HomeMy WebLinkAbout12-21-06
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15056051047
REV-1500 EX (06-05)
PA Department of Revenue
Bureau of Individual Taxes
PO BOX 280601
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
County Code Year
File Number
Date of Birth
Decedent's Last Name
Suffix
Decedent's First Name
MI
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
_ 1. Original Return
C)
2. Supplemental Return
C)
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
C)
C) 4a. Future Interest Compromise (date of
death after 12-12-82)
C) 7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
C) 10. Spousal Poverty Credit (date of death C) 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
8. Total Number of Safe Deposit Boxes
4. Limited Estate
C)
C)
C)
ZIP Code
REGISlEll OF WILLS
(-
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First line of address
:;3~~
State
:Do
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--4 ..
)~ATE FILED 0
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Second line of address
P A
1 7 0 5 5 0
1 4
Correspondent's e-mail address:
17055
Mechanicsburg, PA 17055-0314
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056051047
15056051047
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15056052048
REV-1500 EX
Decedent's Name:
RECAPITULATION
1. Real estate (Schedule A). ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1.
2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3.
4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5.
6. Jointly Owned Property (Schedule F) c:::> Separate Billing Requested . . . . . .. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) c:::> Separate Billing Requested.. . . . . .. 7.
8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8.
9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I). . . . . . . . . . . . . . . . 10.
11. Total Deductions (total Lines 9 & 10)..... .............................. 11.
12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . .. .. . . . . . . . . . . .. .. . . 12.
13. Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14.
TAX COMPUTATION. SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .045 5 8 5
16. Amount of Line 14 taxable
at lineal rate X.O_
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
19. TAX DUE. . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
/:J!(2I/a
NAPtJ
~
Side 2
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J.o.::JU.:Jl:Iu..JL.J48
15.
16.
17.
18.
-
15056052048
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REV-1500 EX Page 3
Decedent's Complete Address:
DECEDENT'S NAME
File Number 21- 06-00315
FAYETTA K. PAGE
STREET ADDRESS
100 Mt. Al~~~~~-"_,___~~s8i~l:1_Vill_age ____
CITY
STATE
PA
Mechanicsburg,
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
[ZIP
17055
(1) $ 26,335.25
.. $-Z7;S-~--o-o---- ...
1 , 316.} 6____ ___ _
TotaICredits(A+B+C) (2) $ 28,816.76
3. Interest/Penally if applicable
D. Interest
E. Penalty
-- - ------- Total Interest/Penalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4) $
2.481.51
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(5)
(5A)
(5B)
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;.......................................................................................... D
b. retain the right to designate who shall use the property transferred or its income; ............................................ D
c. retain a reversionary interest; or..............................................................,........................................................... D
d. receive the promise for life of either payments, benefits or care? ...................................................................... D
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. D
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ D
No
=
I
.
Il
II
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (3) percent [72 P.S. ~9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent
[72 P.S. ~9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in
72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
~-1503 Ex + (1-9;'\
'*
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
21-06-00315
FAYETTA K. PAGE
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
VALUE AT DATE
OF DEATH
DESCRIPTION
Putnam Premier Income Trust C0710730485369182
5,058. Shares @ $ 6.12 / share $
Franklin-Templeton U.S.Government Securities Fund
Class A - #110-101611409460
634.207 Shares @ $ 6.41 / share $
National Retail Prperties, Inc.
formerly Commercial Net Lease Realty, Inc.
113400216119
100 Shares @ $ 22.715 / share $
Wachovia Securities Brokerage Account #6558-2929
A. Vanguard Fixed Income Securities Fund - GNMA Inv.
13605.629 Shares @ $ 10.17 / share $
B. Vanguard Fixed Income Securities Fund shtm inv.
7507.686 Shares @ $ 10.47 / share $
C. Vanguard Bond Index Fund - Inter term
5882.353 Shares @ $ 10.11 / share $
D. Vanguard Bond Index Fund - Long term
5571.031 Shares @ $ 11.29 / share $
E. Vanguard Bond Index Fund - Long term port
7225.09 Shares @ $ 11.17 / share $
F. Nuveen Municiapal Value Fund
9000 Shares @ $ 9.70 / share $
G. Putnam Premier Income Trust
5058 Shares @ $ 6.12 / share $
H. Evergreen Money Market $
United States Savings Bonds - Series E
12 Bonds issued from March 1976 thru February 1977 $
( see attached itemized schedule )
30,954.96
2.
4,065.27
3.
2,271.50
4.
138,369.25
78,605.47
59,470.59
62,896.94
80,704.26
87,300.00
30,954.96
22.26
5.
6,406.00
TOTAL (Also enteron line 2, Recapitulation) $ 582,021. 46
(If more space is needed, insert additional sheets of the same size)
6-,
PUT NAM INVESTMENTS
Putnam Invcstor Scrvice"
Post Office Box 41203
Providence, Rhode Island 02940-1208
www,pulnaminlJ.cnm.
May lO, 2006
ALBERT Z BOGERT
ATTORNEY AT LAW
PO BOX 314
MECHANICS BURG PA 17055-0314
Account No.: C07lO730485369182
Registration: Fayetta K Page
Reference No.: 0451894529
Dear Attorney Bogert:
Thank you for your letter regarding the above-referenced closed-end fund account.
The table below provides the value of the account as of April 5, 2006:
,~<.:Sh'relial"'ee .
5,058.000
Market.SharePriee
$6.12
. :M'" ~...a.. V..' 'i.i.'Iii.:.
'. .. _1\..., .... _e:
$30,954.96
The account is registered as a personal investment account and is invested in the Putnam Premier
Income Trust, a closed-end fund.
All dividends distributed from the account are reported under social security number
183-03-6933.
The account was originally opened on May 15, 1996 in the Putnam Master Income Trust account
number C061183036933BBBC. This fund merged into the Putnam Premier Income Trust on
February 28,2005 and the new account number is C07lO730485369182.
To reregister the shares, we require the following additional documentation:
· A letter of instructions signed by the legal representative. A signature guarantee
is required to prove that the signature is genuine. This guarantee may be obtained
from an investment dealer or a bank. We cannot accept notarization in place of a
signature guarantee because it does not provide the complete legal protection
necessary to process this transaction.
· Certificate number U-0081429 for 5,058 issued certificate shares. As a protection
against loss, we suggest that you return the certificate by registered and insured
mail.
.
--------.
8-2..
rw.
JUL.
Franklin Templeton Investor
Services. LtC
100 Fountain Parkway
St Petersburg, FL 33716-1205
lei 800/6322350
frankli nlemplelon .com
FRANKLIN TEMPLETON
INVESTMENTS
May 15,2006
Albert Z. Bogert, Esq.
Attorney at Law
P.O. Box 314
Mechanicsburg, PA 17055-0314
SUBJECT: Franklin U.S, Government Securities Fund - Class A
NC #110-10161409460'
Fayetta Konn Page
Dear Mr. Bogert:
We are writing in response to your recent correspondence concerning the transfer of shares held
by the late shareholder, Fayetta Konn Page. We would like to confirm that the referenced
account held in Ms. Page's sole name was opened on March 15, 1986. The earnings for this
account were reported under Ms. Page's Social Security Number.
According to our records, the referenced account held 634.207 shares on April 5, 2006. The net
asset value ofthe Franklin U.S. Government Securities Fund - Class A at the close of market on
April 5, 2006, was $6.41 per share, for a total dollar value of$4,065.27.
We welcome any questions that you may have regarding this matter. You may contact a
Customer Service Associate, Monday through Friday, 5:30 a.m. to 5:00 p.m. Pacific Time, toll
free at 1-800/632-2301 and refer to identification number: 0413-25APR06.
Sincerely,
~Eranklin Templeton Investor Services, LLC
,it{
\ essica M. Hall
Associate
Customer Operations
8-3
~...... American Stock Transfer
~. & Trust Company
Operations Center
6201 15th Avenue
Brooklyn, NY 11219
www.amstock.com
(866) 627-2644
May 30 2006
ALBERT Z BOGERT
ATfORNEY AT LAW
PO BOX 314
MECHANICSBURG, PA 17055-0314
Re:
Company:
Account:
FA YETTA KONN PAGE
NA TIONAL RETAIL PROPERTIES INC
3400216119
Dear Sir or Madam:
We have received your request in respect of the above-referenced account.
As of the date of death, the account held a total of 100 shares. As transfer agent, we do not track prices.
In order to determine the market value of the shares as of the date of death, we suggest contacting a stock
broker for assistance. You may also refer to a financial newspaper, such as the Wall Street Journal or
your local library.
A signed letter of release by Anita Bogert is required to provide account specific information to your firm.
The following documents are being returned to you:
1. Court Appointment of Anita Bogert
In the future, you may communicate with us by visiting our Web Site at: www.amstock.com. or you may
e-mail medirectlyatDPucel@amstock.com
We trust the above information is helpful.
Sincerely, /J
l1'AA-LIM/
DONNA PUCEL
Shareholder Services Department
1111111111111111111111111I
AST15255923400216119
[>a~ker H. Kuhnll II (Skip)
"WC Pn'sidcn!
St'nim Fil1ilnri;lI ..\dvisOf'
~ MellUI Lyncb
(;I(JI)all)riv01t~ Client (,1'<;110
:21.1 .'it~l1ille . \v<~nlle
SlIill" :)0)
~il~nl~~lill. Pennsylvania : ~!Jj ~
,I, <),.) .lIi.n Din'ct
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1'\.\ 717 <)7:)11;(;:;
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22.790 +
22.640 +
45-430 ()
45-430 .
2 . ::
22-715 *
-
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iIiir.-.:= 4'01 'S~Ulh Tryon Street
- Charlotte. NC 28288
WACHOVIA
a."f
June 21, 2006
Albert Z. Bogert
Attorney At Law
P. O. Box 314
Mechanicsburg, P A 17055-0314
RE: Ms. Fayetta K. Page
Dear Mr. Bogert:
Thank you for contacting Wachovia Securities, LLC regarding the account(s) of Ms. Fayetta K.
Page.
Attached is the information regarding the date of death valuation requested.
If you have any questions regarding this matter or if you need further assistance, our Estate
Processing Specialists are available 8 a.m. to 6 p.m. Monday through Friday at 1-866-874-2717.
Sincerely,
OJ') CA
c71u}k ~ /he;.MH
Rick Shinn
Estate Processing Specialist
Wachovia Securities
Securities and Insurance Products:
Not Insured By FDIC Or Any MAY LOSE VALUE Not A DeposIt Of Or Guaranteed By
Federal Government A enc A Bank Or An Bank Affiliate
Brokerage services offered through Wachovla SecuritIes., LLC. a registered broker-dealer and a separate. non-bank
affiliate of Wachovia Corporation. Member NYSE and SIPC.
BKOQA.rtf 510552130 8060294 65582929
~
"
Estate Valuation
Fayetta K. Page
Date of Death: 04/05/2006
Valuation Date: 04/05/2006
processing Date: 06/21/2006
Shares
or Par
Security
Description
High/Ask
1)
13605.629 VANGUARD FIXED INCOME SECS FD (922031301; VFIIX)
GNMA INV
Mutual Fund (as quoted by NASDAQ)
04/05/2006
2)
1507.686 VANGUARD FIXED INCOME SECS FD (922031406; VFSTXI
SHTM INVGR INV
Mutual Fund (as quoted by NASDAQ)
04/05/2006
3)
5882.353 VANGUARD SD INDEX FD INC (921937306; VBIIX)
INTER TRM PTFL
Mutual Fund (as quoted by NASDAQ)
04/05/2006
4 )
5571.031 VANGUARD BD INDEX FD INC (921937405; VBLTX)
LONG TERM PTF
Mutual Fund (as quoted by NASDAQ)
04/05/2006
5)
7225.09 VANGUARD MUN BD FD INC (922907308; VWLTX)
LONG TBRM PORT
Mutual Fund (as quoted by NASDAQ)
04/05/2006
6)
9000 NUVEEN MUN VALUE FD INC (670928100)
COM
New York Stock Exchange
04/05/2006
9.72000
7)
5058 PUTNAM PREMIER INCOME TR (746853100)
SH BEN INT
New York Stock Exchange
04/05/2006
6.14000
81
22.25 EVERGREEN MONEY MKT FD CL A (CASH)
Accrual
Total Value:
Total Accrual:
Total: $538,323.73
Portfolio Endnotes
Title:
FAYETTA K PAGE
2630 ARCONA RD
MECHANICSBURG PA 17055-6701
Low/Bid
10.17000 Mkt
10.47000 Mkt
10.11000 Mkt
11. 29000 Mkt
11.17000 Mkt
9.68000 H/L
6.10000 H/L
THE INVESTMENT ACCOUNT 6558-2929 REPORTS TO TAX ID 183-03-6933.
THE INVESTMENT ACCOUNT 6558-2929 OPENED AS AN INDIVIDUAL ACCOUNT ON 10/21/1988.
Page 1
Estate of: Fayetta K. Page
Account: 6558-2929
Report Type: Date of Death
Number of Securities: 8
File ID: 65582929
Mean and/or Div and Int Security
Adjustments Accruals Value
10.170000
10.410000
10.110000
11.290000
11.110000
9.700000
6.120000
138,369.25
78,605.41
59,470.59
62,896.94
80,104.26
87,300.00
30,954.96
22.25
0.01
$0.01
$538,323.72
This report was produced with EstateVal, a product of Estate Valuations & Pricing Systems, Inc. If you have questions,
please contact EVP Systems at (818) 313-6300 or www.evpsys.com. (Revision 7.0.4)
u.s. Savings Bond Redemption Receipt
Branch ID: 1
Transaction Number: 06-426181612751
FAYETTA K PAGE 183-03-6933
2630 ARCONA RD.
MECHANICSBURG, PA 17055
Redemption Date: 04/26/2006
Teller ID: fbkCPcsr2
Issue Interest Redemption
Serial Number Series Denom Date Issue Price Earned Value
. 04/1976
C2019842877-E E $100 $75.00 $464.04 $539.04
C2017377003-E E 100 03/1976 75.00 464.04 539.04
Total number of bonds redeemed: 2
Total Total Total
. Price Interest Value
$150.00 $928.08 $1,078.08
Customer Signature
...
..1M
.1'.
~:r
Fulton Financial Corporation
1695 State Street
East Petersburg, PA 17520
800-752-9580
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104/2006
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Issue Date
I~.~~~~...____B
sl~~~__.
l__.______.___j
L______'
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Results
Leiend
Note Description
NI Not Issued
NE Not Eligible for Payment
P5 Includes 3-month interest penalty
MA Matured and Not EaIning Interest
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7/27/2006
~'~a'"". ..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
FAYETTA K. PAGE
FILE NUMBER 21- 06- 00315
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of sUNivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
DESCRIPTION
VALUE AT DATE
OF DEATH
Premium refund - Erie Insurance Co. $
Personal Property Policy
Premium refund - Life Investors Ins. Co. of America $
Accidental death benefit and travel policy
Dividend - Putnam Premier Income Trust $
Dividend - Vanguard Fixed Income Securities Fund GNMA $
Dividend - Vanguard Fixed Income Securities Fund STC $
Dividend - Vanguard Bond Index Fund Int-term $
Dividend - Vanguard Bond Index Fund Long-term $
Dividend - Vanguard Municipal Bond Fund $
Dividend - Nuveen Municipal Value Fund $
Dividend - Putnam Premier Income Trust $
Dividend - Franklin-Templeton U.S. Govt. Sec. Fund $
Pension Benefit Guaranty Corp. - Distribution $
Bethlehem Steel Retiree Benefit
48.00
45.17
151. 74
586.40
278.11
247.65
285.53
317.78
351.00
151. 74
16.49
77.50
TOTAL (Also enter on line 5, Recapitulation) $ 2 ,557 . 11
(If more space is needed, insert additional sheets of the same size)
REV-.1511 EX+ (12-99) _
. *
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
21-06-00315
FAYETTA K. PAGE
FILE NUMBER
ITEM
NUMBER
A_
Debts of decedent must be reported on Schedule I.
DESCRIPTION
AMOUNT
FUNERAL EXPENSES:
Myers - Harner Funeral Home, Inc.
2. Rolling-Green Cemetary, Camp Hill, PA
3. Isaac's, Camp Hill, PA - Bereavement dinner
L
$ 3,233.30
920.00
130.53
B. ADMINISTRATIVE COSTS:
4.
5.
6.
7.
8.
9.
10.
1.
Personal Representative's Commissions
Name of Personal Representative(s) Anita L. Bogert
Social Security Number(s)/EIN Number of Personal Representative(s)
2630 Arcona Rd.
Street Address
$ 8,000.00
City Mechanicsburg,
Year(s) Commission Paid: 2007
State PA Zip 17055
2.
Attorney Fees Alb rt Z B t E q
e . oger, s.
$ 15,000.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
State _ Zip
Relationship of Claimant to Decedent
Probate Fees
$
460.00
54.00
Additonal misc file fees
Accountant's Fees
Harvey Danowitz, CPA
Tax Return Preparer's Fees
$
800.00
Publication of Grant of Letters:
The Sentinel
Cumberland Law Journal
File Fee - Inheritance Tax Return
Fulton Bank - Check printing cost
Short Certificates - 5 Additional
$
129.77
75.00
15.00
24.60
20.00
$
$
$
TOTAL (Also enter on line 9, Recapitulation) $ 28, 862 . 20
(If more space is needed, insert additional sheets of the same size)
MYERS-HARNER FUNERAL HOME, INC.
1903 MARKET STREET
CAMP HILI.. PF.NNSYLVANIA 1701 J
ROBERT H. HARNER
SUPF.RVISOR
LOCALLY OWNED AND
OPERATED
TELEPHONE
717-737-9961
April 29, 2006
Mrs. Anita Bogert
2630 Arcona Road
Mechanicsburg PA 17055
Services for Fayetta K. Page
April 15, 2006
Cremation with Service
$ 2,225.00
...
Charges for Merchandise Selected
Vault
Cremation Container
$ 225.00
125.00
$ 350.00
Cash Advanced .
Newspaper Notice/Local
Clergy
Certified Copies
Flowers
Coroner Fee
$ 143.00
100.00
120.00
270.30
25.00
$ 658.30
$ 3,233.30
Total due within thirty days, please:
?DUfNG 1~f'fN r!=Mf''f''v
,......~ "IlW' Ie . (;AM" "114 ". 'JI::'I . '171 ,~
!\,..
8"3-102
THIS AGREEMENT PROVIDES FOR ENDOWMENT CARE
CEMETERY INTERMENT RIGHTS, MERCHANDISE AND SERVICES PURCHASElSECURITY AGREEMENT
Date: 1-\ (\ t:\ r
~2.4 No.
The undersigned, referred to as "Purchaser", hereby agrees to purchase the Interment Rights, Merchandise and Services described
berein, subject to acceptance and approval of the above named cemetery, hereinafter referred to as "Seller".
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PURCHASER
ADDRESS _,'\
TELEPHONE:
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SIreet
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Name of Deceased t I' -1'" \, :',
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Description of Interment Rights:
Issue Certificate or Interment Rights to:
Address
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City
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INTERMENT RIGHTS, MERCHANDISE AND SERVICES
Interment Rights (including Endowment Care ofs ~----- ) s -------'--
...................................................................
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Interment Fees ... ...................,.. .... ......... ..................... ............. ............... ..... ...... ........ ...... .............. ..................... ......... i
I Memorialization - T )'pe ............................
Size Design ...........................
,
I Memorial Base - Type ...... .......~.. ........ ....
Size Color . .....~........... ..~......
I Memorial Endowment Care of ..................................................................................................................................
I Memoriallnstallationllnspection Fee ....................................... .......... ............................ "'~"""""'"'''' ......... ...........
I Outer Burial Container - Material _ .............................
Supplier .-.
Model. ............................
CreDl&tion Charge ...................... ....... ..... ........... ....... ....... .............. ......... ........... ......... ........ ..... ....... .............................. -
Urn - Type. Size . '~'. .,. ..
...........................
Flower Vase- Type .-'
... ..~........., ............
Nameplate ......................... ....................... ......,............................................................,................................................ - .-..
Lettering .-'
.................................. .... ...~................................................................,.~....... ... ............... .... ............... ..... ........ '. ..,,-.
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Other . \ \ . , \ ........................... :A ~
Other ..
-- --............................
I Sales Tax -~." -
...........................................................................................................,......................................................... -
TOTAL CASH PRICE ....... ....................... ............................ ................................................................. I .- ,. , I'
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LESS: . i //'. t' ,..- ',' I
Down $ , i )( ( (
Payment Casb;-:)........ .I...j:'",........ 'uJr.~... ./........... ....,..........................
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Other Credit ..... .................. .............. ................. .............. .~..... ... .................. -
-.
TDtaI Down Payment $< "I :)L ,.. .C) >
......................................................,...................................................................... l
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i UNPAID BALANCE OF CASH PRICE ......................................................,...................................... $ ~
I REMARKS: -
-
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TERMS - CASH SALE
The Total Cash Price is due and payable as of the date of this Agreement. A delinquency charge of __ percent will be
assessed monthly on an}' balance not paid within 30 days of tbe date of this Agreement. If less than full payment is received, Seller
shall deduct the accrued delinquency charge from the amount received, and credit the remainder of the payment received to the
Unpaid Balance.
SECURITY INTEREST: Seller (or its assigns) will have a security interest in the Interment Rights and Merchandise being
purchased as described above. Seller will retain title to said Interment Rights and Merchandise until the Total Cash Price,
together with any delinquency charges thereon have been paid by Purchaser to Seller.
Purchaser agrees that all rights conve}'ed under. this Agreement are subject to, and Purchaser agrees to at all times comply with,
... - ' I.. .JI - - .___~.:L" 1...__.....~,.,._~ -..a..,,_.~_... n.......o_..Io..i n... Q~fo..._":I\ D~.I&\~ DA~!.lQf;^nc_~:u...l R.tlt:n.,~ 1\' ~.n"r ahi,.h A,"P "vAn.hl..
0012
Server : KELLY K
04/15/06 12:59, SWiped
ISAAC'S RESTAURANT&DELI
1200 MARKET STREET
LEMOYNE, PA 17043
(717) 731-9545
MERCHANT #:
CARD TYPE ACCOUNT NUMBER
VISA XXXXXXXXXXXX8194
Name: ANITA BOGERT
00 TRANSACTION APPROVED
AUTHORIZATION #: 028913
Reference: 0415010000012
TRANS TYPE: Credit Card SALE
Rec : 18
Termina 1: 1
CHECK:
TIP:
TOTAL:
105.53
..l 5'. t!5D
_J.3ZJ.~3
x__________
PHONE: ( )
***DuPlicate COPV~**
CARDHOLDER WILL PAY LARO ISSUER ABOVE
AMOUNT PURSUANT TO CARDHOLDER AGREEMENT
Sign One Copy & Keep a Copy for
Your Records
~EV~1512 EX. ('~97)
ESTATE OF
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
,
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FAYETTA K. PAGE
FILE NUMBER
21-06-00315
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
1.
$
2.
3.
4.
5.
6.
7.
8.
Messiah Village
Alert Pharmacy
Verizon Final Phone Bill
Humana - Prescription Drug ( Part D ) Ins. Premium
Neurology Center, PC - Medical Bill
Capital Area Health Assoc. - Medical Bill
Wachovia Securities Brokerage Fees & Commissions
Ameriprise Financial - Brokerage Fees & Commissions
7,420.00
89.03
9.02
33.88
95.66
76.84
1,319.64
154.08
TOTAL (Also enter on line 10, Recapitulation) $ 9,198.15
(If more space is needed, insert additional sheets of the same size)
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Form PB-01
100 MOUNT ALLEN DRIVE, MECHANICSBURG, PA 17055
ANITA L BOGERT
2630 ARCONA ROAD
MECHANICSBURG, P A 17055
QUESTIONS? CALL: (717 697-4666
RESIDENT # f UNIT STMT. DATE
100009 I 084W 03/31/2006
RESIDENTCS)
Mrs. FA YETTA K. PAGE
TOTAL AMOUNT DUE $6,572.00
DATE DUE 04/30/2006
$
DATE DESCRIPTION RATE UNIT CHARGES CREDITS BALANCE
Balance Forward 5,974.80
03/24/06 PAYMENT RECEIVED - THANK YOU!!! 5,974.80 0.00
*** Nursin~ Care ***
03/24/06 RM/ BRD - NURSING - SEMI-PVT 212.00 24.00 5,088.00 5,088.00
03/01-03/24
03/28/06 RM/ BRD - NURSING - SEMI-PVT 212.00 4.00 848.00 5,936.00
03/25-03/28
03/31/06 RMI BRD - NURSING - SEMI-PVT 212.00 3.00 636.00 6,572.00
03/29-03/31
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D MAY 1 Z 2000 V
fi.~--J4.
RESIDENT # CURRENT OVER 30 OVER 60
OVER 90 OVER 120 TOTAL AMOUNT DUE
100009 6,572.00 0.00 0.00
0.00 0.00 $6,572.00
RESIDENT NAME Mrs. FAYETTA K. P
A ,% Onanee cha",. may he a",..,.., on accou~~~, which paym.nt ha, nnt been Re.i..., by 'b. due date Th k ,
If . an you.
you have any questions or concerns about your bill I
· P ease address them d' tl .
aree y to Fiscal Services at 790-8220 Th
. auk You!
Form PB-01
N/A
:}/1tKJ
. WACHOVTA. SECtJRITIES
CONFIRMATION
DATED 09/27/06
Account Number 1438-5429
YOUR fiNANCIAL ADVISOR
MARK STRUBE
888-243-1422
800-:159-9297
001769
111111111111111111.1"1.11111,, 1111111'1111.11.111.11" ..1.1.1
ESTATE OF FAYETTA K PAGE
ANITA L BOGERT EXECUTRIX
2630 ARCaNA RD
MECHANICSBURG PA 17055.6701
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SOLD
NUVEEN MUNICIPAL VALUE
FUND tNC
SYMBOL
SECURITY NUMBER
CUSIP
UNSOLICITED
NUV
2822-713
670928-10-0
QUANTITY PRICE PRINCIPAL
7,60000000 10.11000 76,83600
1,40000000 10.13000 14,182.00
9,00000000 1011311 91,018.00
i:ll/$raye pnce
ACCOUNT TYPE CASH CHARGE/COMM ISSfON" 1,(>71 .8.1.
TRADE DATE 09/27106 OTHER FEE" 280
SETTLEMENT DATE 10/02/06
NET AMOUNT $89,943.36
"INCLUDES $6.00 TRANSACTION FEE
"SEE ITEM 16 ON PAGE 2
MARKET NEW YORK STOCK EXCHANGE
TRADE INFORMATIOH:THE PRICE DISPLAYED IS AN AVERAGE PRICE. FURTHER INFORMATION REGARDING AVERAGE PRICE
AND REMUNERATION DETAILS ARE AVAILABLE UPON REQUEST.
SECURITY INFORMATION: MONTHLy' PAY
SOLD QUANTITY PRICE PR,NOPAL
VANGUARD FIXED INC SEe 13.60562900 10 20000 138,777.42
FUND INC GNMA PORTFOLIO
SYMBOL VFIIX ACCOUNT TYPE CAS~ TRANSACTION FEE 6.00
SECURITY NUMBER 3718.595 TRADE DATE 09i27106
CUSIP 922031-30-7 SETTLEMENT DATE 09/28/06 NET AMOUNT $138,n1.42
UNSOLICITED
SECURITY INFORMATION: MONTHLY PAY.
SOLD QUANTITY PRICE PRINCIPAL
VANGUARD FIXED INCOME 7,507 68600 10 55000 79,206 09
SECURITIES FUN[) SHORT
TERM CORPORATE PORTFOLIO
SYMBOL VFSTX ACCOUNT TYPE CASH CHARGE/COMMISSION" 46.00
SECURiTY NUMBER 3718-611 TRADE DATE 09i27106
CUSiP 922031 .40-6 SETTLEMENT DATE 09/28/06 NET AMOUNT $79,160.09
UNSOliCITED 'INCLUDES $6.00 TRANSACTION FEE
SECURITY INFORMATION: MONTHLY PAY
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rCGl3270 00116'J 27W()ln0213 NNNNN NtlNNN NNNNNNNN rUJOOl
Page I 01 3
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. WACHOVYA SEClJRITIES
CON F ] R ;VI A TI 0 N
DATED 09/27/06
AceT No.
1438.5429
ESTATE OF FAYETTA K PAGE
ANITA L BOGERT EXECUTRIX
2630 ARCONA RD
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-
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SOLD
VANGUARD BOND INDEX FD
INTERMEOIA TE- TERM BOND
PORTFOLIO
QUANTiTY
5,882 35300
PRICE
10 27000
PRINCIPAL
60.41177
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SYMBOL
SECURITY NUMBER
CUSIP
UNSOLICITED
SECURITY INFORMA lION: MONTHLY PAY
VBIIX
3718-719
921937-30-6
ACCOUNT TYPE
TRADE DATE
SETTLEMENT DATE
CASH
09/27/06
09/28/06
CHARGE/COMMISSION'
46.00
NET AMOUNT $60,365.77
.INCLUDES $6.00 TRANSACTION FEE
SOLD
VANGUARD BOND INDEX FD
LONG-TERM BOND PORTFOLIO
QUANTITY
5,57103100
PRICE
11.58000
PRINCIPAL
64.51254
SYMBOL
SECURITY NUMBER
CUSlP
UNSOLICITED
SECURITY INFORMATION: MONTHLY PAY.
VBLTX
3718-721
921937-40-5
ACCOUNT TYPE
TRADE DATE
SETTLEMENT DATE
CASH
09/27106
09/28/06
CHARGE/COMMISSION'
46.00
NET AMOUNT $64,466.54
.INCLUDES $600 TRANSACTION FEE
SOLD
VANGUARD MUNICIPAL
BOND FD LONG. TERM PORT
QUANTITY
7,225.09000
PRICE
11 33000
PRINCIPAL
81,860.:<'7
SYMBOL
SECURITY NUMBER
CUSIP
UNSOLICITED
SECURITY INFORMATION: MONTHLY PAY
VWL TX
3718-856
922907 -30-8
ACCOUNT TYPE
TRADE DATE
SETTLEMENT DATE
CASH
09/27,106
09/28/06
TRANSACTION FEE
NET AMOUNT
6.00
$81,854.27
Also:
Ninety-five ( $ 95.00 ) dollar fee to close account and
transfer assets to Ameriprise Financial account.
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pet. 13270 \JO J Ie\) 2101J92/2(), 13 NNNNN N",NNIl NNNNNNNN 0??oo2
Page 3 01 3
~1.1509 EX + (1~7)
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNS\ LVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FAYETTA K. PAGE
FILE NUMBER
21-06-00315
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. Myrna A. Morgan
9009 Laurel Hurst Place
Ft Wayne, IN 46835
Daughter
8. Anita L. Bogert
2630 Arcona Rd.
Mechanicsburg, PA 17055
Daughter
c.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 4/02 Fulton Bank Money Market $ 82,743.42 1/3 $ 27,581.1
Acct II 9904-85003
B. 4/02 Fulton Bank Money Market
Acct II 9904-85003
2. A. 2/01 Wachovia Checking Account $ 7,225.61 1/3 $ 2,408.5
Acct. II 101000823511
B. 2/01 Wachovia Checking Account
Acct. II 101000823511
3. A. 1/98 Wachovia Money Market $ 26,159.94 1/3 $ 8,719.9
Acct. II 1010008235291
B. 11/98 Wachovia Money Market
Acct II 1010008235291
TOTAL (Also enter on line 6, Recapitulation) $ 38,709.66
4
4
8
(If more space is needed, insert additional sheets of the same size)
FultanBank
LISTENING.
April 20, 2006
Albert Z. Bogert
P.O. Box 314
Mechanicsburg, Pennsylvania 17055
Dear Mr. Bogert:
RE: Fayetta K. Page, deceased April 5, 2006
In response to your recent inquiry concerning the accounts maintained in the name of
the decedent, please be advised that the foHowing accounts were open at the date of death:
Money Market # 9904-85003, open 4/24/2002, balance $82,719.85
and accrued interest $23.57, joint with Anita L. Bogert or Myrna
A. Morgan.
If you should have any further questions, please do not hesitate to contact me at (717)
291-2437.
v cry truly yours,
~0Nu...~ ~cQ)
Karen D. Hil1eg~ G
Credit Inquiry Processor
CONFIDENTIAL
!hts ifYformltion is furnished IS a matter of business courtesy
In answer t~ .~u~ inquiry, and i~ for your confidential u..c;e only.
No res~nsibillt~ IS aSSUn1C<1 by the; lldflk CT a!l)' of its offirers.
Any OplIllon herein CXDh!!':~t:.. .'. ......oJ..,;\.; l::; (;;k)n~e ~..,thoull>;:'::c.e.
POBox 4887
Lancaster, P,A. 1 7604
fullonhnnk (nm
800-FULTON-4
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WACHOVIA
Relerenee 10: 1597871
Wachovia Bank N.A.
Balance Confirmation Services
POBox 40028
Roanoke, VA 24022-7313
April 25, 2006
ALBERT Z BOGERT
A TTORNEY AT LAW
PO BOX 314
MECHANICSBURG, PA 17055
SUBJECT: Verification / Confinnation of Account and Balance Infonnation provided for:
Customer: FA YETTA K PAGE (SSN# 183-03-6933)
Date of Death: April 5,2006
Deposit Account Information
Aecount
Type
Account
Number
Date of Death
Balance
Average
Balance.
Date
Opened
Maturity Interest Accrued YTD Date
Date Rate Interest Interest Paid Closed
CHECKING 10]0008235811
LEGAL mLE: FAYElTA K PAGE
MYRNA A MORGAN
ANITA L BOGERT POA
$7,209.33
12/17/200]
$16.28
$107.37 4/1212006
CHECKING 1010008235921
LEGAL TITLE: FAYElTA K PAGE
MYRNA A MORGAN
ANITA L BOGERT
$26,157.03
11/9/] 998
$2.91
$6.13 4/1212006
· Due to system limitations, we can only provide a twelve month average balance on depository accounts.
Revolviu Credit Information
Account
Type
MASTERCARD
Account
Number
Date of Death
Balance
Credit
Limit
Date
Opened
Date Times Legal Title
Closed late
5329037332303978
MBNA - Revolving credit accounts are no longer serviced by Wachovia Bank. Please contact MBNA at 800-477-9131.
. REV:1~13 EX+ (9-00*,
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
FILE NUMBER
FAYETTA K. PAGE
21-06-00315
1.
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
MYRNA A. MORGAN Daughter Fifty (50%)percent
9009 Laurel Hurst Place
Ft. Wayne, IN 46835
NUMBER
I
2. ANITA L. BOGERT
2630 Arcana Road
Mechanicsburg, PA 17055
Daughter
Fifty (50%)percent
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRiATE, ON REV-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX is NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)