The URL can be used to link to this page

Home My WebLink About02-07-07 . --.J 15056041125 REV-1500 EX (06-05) PA Department of Revenue *' Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 Harrisbu ,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death OFFICiAl USE ONLY County Code Year ~l File Number 710 Date of Birth 20116 263 7 o 8 0 7 2 006 08241926 SHANK BETTY MI J Decedent's Last Name Suffix Decedent's First Name (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI NON E Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW I:&l 1. Original Return o 4. Limited Estate I:&l o 2. Supplemental Return o o 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Retum Required 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death 0 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 o o o o o 8. Total Number of Safe Deposit Boxes C H A R L E S J D E H ART I I I 232 -76 () REGISTE 6J = Second line of address -u -,.,,- _j.1'~ Firm Name (If Applicable) 3 6 3 1 NORTH FRONT STREET ILLS US~NL Y _ rr, () OJ I -...J C A L D W ELL & K EAR N S First line of address City or Post Office State ZIP Code w C) DATE FILED en H A R R I S BUR G P A 17110 Correspondent's e-mail address: Charles J. DeHart, ill 1 North Front Street HarrisburQ Pennsylvrlni;:l '711 () PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056041125 15056041125 --.J . -.J 15056042126 REV-1500 EX Decedent's Social Security Number Decedent's Name: BETTY J. SHANK RECAPITULATION 201162637 1. Real estate (Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. 152900.00 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. 1 1 7 4 4. 9 4 ...... . 6. Jointly Owned Property (Schedule F) D Separate Billing Requested . . . . . . . 6. 1 4 0 8 7 . 8 2 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 8 1 9 7 3 . 3 0 (Schedule G) D Separate Billing Requested . . . . . . . 7. 8. Total Gross Assets (total Lines 1-7) 8. 2 6 0 7 0 6. 0 6 .......................... . 9. Funeral Expenses & Administrative Costs (Schedule H) 9. 2 1 6 6 1 4 5 ............... . 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . . . . . . . . . . . 10. 5 1 7 . 4 6 11. Total Deductions (total Lines 9 & 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 2 2 1 7 8. 9 1 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . 12. 2 3 8 5 2 7 1 5 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. 2 3 8 5 2 7 1 5 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.O _ o . 0 0 15. o . 0 0 16. Amount of Line 14 taxable 2 at lineal rate X .O~ 3 8 5 2 7 . 1 5 16. 1 0 7 3 3 . 7 2 17. Amount of Line 14 taxable o . 0 0 O. 0 at sibling rate X .12 17. 0 18. Amount of Line 14 taxable o . 0 0 O. 0 at collateral rate X .15 18. 0 19. Tax Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 1 0 7 3 3. 7 2 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT D ~~~ Side 2 L 15056042126 15056042126 .-.J REV-1500 EX Page 3 Decedent's Complete Address: File Number o 0 DECEDENT'S NAME BETTY J. SHANK STREET ADDRESS 1485 SIMPSON FERRY ROAD CITY 1 STATE I ZIP NEW CUMBERLAND PA 17070 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 10,733.72 8,550.00 450.00 Total Credits (A + 8 + C) (2) 9,000.00 3. Interest/Penalty if applicable D. Interest E. Penalty T otallnterest/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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 0.00 1,733.72 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (58) A. Enter the interest on the tax due. 4>~'-;~ 1,733.72 ~,: 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 No a. retain the use or income of the property transferred; ...................................................................... D 00 b. retain the right to designate who shall use the property transferred or its income; ............................... D 00 c. retain a reversionary interest; or ................................................................................................ D 00 d. receive the promise for life of either payments, benefits or care? ....................................................... D 00 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... D 00 3. Did decedent own an 'in trust for' or payable upon death bank account or security at his or her death? ......... 00 D 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................. 00 D 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. 99116 (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. 99116 (a) (1.1) (ii)). The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum 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. 99116(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. 99116(1.2) [72 P.S. 99116(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. 99116(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. REV-1502 EX + (6-98) '*' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER BETTY J. SHANK 0 0 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real DroDertv which is iointly-owned with riaht of survivorshiD must be disclosed on Schedule F. SCHEDULE A REAL ESTATE ITEM NUMBER 1. DESCRIPTION Residential dwelling known and numbered as 1485 Simpson Ferry Road, Borough of New Cumberland, Cumberland County, Pennsylvania, indexed at Deed Book G, Volume 24, Page 947. Gross sale proceeds - see attached Deed VALUE AT DATE OF DEATH 152,900.00 TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 152.900.00 REV-1508 EX + (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BETTY J. SHANK SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER o 0 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION 2002 Toyota Sedan automobile - Net proceeds from sale VALUE AT DATE OF DEATH 9,000.00 2. Miscellaneous household goods and furnishings: (a) Net proceeds from public sale 1,360.45 (b) Desk, wall clock and 3 wall pictures - Appraised value 270.00 3. Refund checks: (a) Verizon - Telephone service 0.97 (b) Auer Memorial Funeral Home 6.06 (c) Nationwide Federal Credit Union 12.36 (d) Toyota warranty refund 282.80 (e) Hartford Insurance - Accident insurance 48.05 (f) State Farm homeowners insurance 384.56 (g) State Farm auto insurance 379.69 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 11 744.94 REV-1509 EX + (6-98) '* SCHEDULE F JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BETTY J. SHANK FILE NUMBER o 0 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. Karen L. Rolko 538 Magaro Road Enola, PA 17025 Daughter B 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 DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 1996 Members 1 st regular savings account - See attached 31.95 50. 15.98 statement 2. A. 1996 Members 1 st checking account - See attached 11,203.30 50. 5,601.65 statement 3. A. 08/1996 Members 1 st money market account - See attached 16,940.37 50. 8,470.19 statement. This account was established by transfer of funds from savings account #161300-00, which was a joint account established from August, 1996. TOTAL (Also enter on line 6, Recapitulation) $ 14087.82 (If more space is needed, insert additional sheets of the same size) REV-1510 EX + (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER.VIVOS TRANSFERS & MISC. NON.PROBA TE PROPERTY ESTATE OF BETTY J. SHANK FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST VALUE (IF APPLICABLE) 1. Gartmore Funds Investment Trust Account #2409716000, 4,423.13 100. 4,423.13 payable on death to Karen L. Rolko, daughter - see attached statement 2. Aviva Life Insurance Company Individual Retirement Account 77,550.17 100. 77,550.17 Contract #30AB738032, payable on death to Karen L. Rolko, beneficiary - see attached statement TOTAL (Also enter on line 7 Recapitulation) $ 81,973.30 (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 FILE NUMBER o 0 ESTATE OF BETTY J. SHANK ITEM NUMBER A. 1. 2. B. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Debts of decedent must be reported on Schedule I. DESCRIPTION AMOUNT FUNERAL EXPENSES: Auer Memorial Funeral Home Gilligans Too - Funeral luncheon 1,431.60 758.78 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Karen L. Rolko - Waived Social Security Number(s)/EIN Number of Personal Representative(s) Street Address 538 Magaro Road City Enola State P A Zip 17025 Year(s) Commission Paid: Attomey Fees Caldwell & Kearns 4,250.00 Family Exemption: (If decedenfs address is not the same as c1aimanfs, attach explanation) Claimant Street Address City Relationship of Claimant to Decedent State Zip Probate Fees Register of Wills 400.00 Accountanfs Fees Tax Return Preparer's Fees Clauser Real Estate Appraisals - House appraisal Keystone Land Transfer - Real estate settlement costs for sale of house (See attached statement) Duty's Lock Service - Household security Bower's Pest Control - Termite inspection for sale of house Miscellaneous home repairs for sale of house U-HaulNince Mitchell - Furniture/trash removal Pechart Lawn Service - pending sale Utilities - pending sale, including electric, water and heat Postage and advertising State Farm Auto Insurance premium pending sale (refund on Schedule E) 325.00 12,415.92 136.62 40.00 390.21 212.19 318.00 512.03 57.03 414.07 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 21,661.45 REV-1512 EX + (12-03) '* SCHEDULE. DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BETTY J. SHANK FILE NUMBER o 0 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. Cingular Wireless - Cell phone 48.82 2. Comcast Cable 7.68 3. Moffit Heart and Vascular - Unreimbursed medical 15.07 4. WSO Imaging Center - Unreimbursed medical 30.96 5. Hematology and ONC Associates - Unreimbursed medical 22.61 6. Partners in Women's Healthcare - Unreimbursed medical 135.00 7. Internists of Central Pennsylvania - Unreimbursed medical 46.45 8. Hershey Kidney Specialist - Unreimbursed medical 2.31 9. Holy Spirit Hospital - Unreimbursed medical 142.82 10. Pulmonary and Critical Care Medical Associates - Unreimbursed medical 65.74 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 517.46 R~-""~.l* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BETTY J SHANK SCHEDULE J BENEFICIARIES FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. Karen L. Rolko Lineal 538 Magaro Road 100% residuary Enola, PA 17025 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) REV-1500 Discount, Interest and Penalty Worksheet Discount Calculation Total Amount Paid within three calendar months of the decedent's date of death: 8.550.00 Discount: 450.00 Interest Table Year Days Delinquent Balance Due Interest this time period this year this period Before 1981 1982 1983 1984 1985 1986 1987 1988 throuah 1991 1992 1993 throuah 1994 1995 throuah 1998 1999 2000 2001 2002 2003 2004 2005 2006 TOTALS Penalty Calculation If the decedent's date of death was on or before March 31, 1993, insert the applicable amount: Total Balance Due on January 17, 1996: Penalty: 1Ln~t Will nub '(lI:e~tnnletlt 1, BErry J. SHANK, of the City of New Cumberland, State of Pennsylvania, do hereby make my Last Will and Testament, and revoke all Wills by me at any time heretofore made. I. 1 give, devise and bequeath all my estate, real and personal to my daughter, Karen L. Rolko, conditioned, however, that in the event of her death in my lifetime, or in the event of her death within six1y (60) days after my death, the said devise and bequest shall lapse or be divested, and in either event, I give, devise and bequeath my estate to my grandchildren, Michele Lynn Rolko and Kristin Marie Rolko, then living. I declare it to be my intention that should my daughter be living at the expiration of sixty (60) days from the date of my death, the estate hereby devised and bequeathed to her shall vest in her absolutely and in fee simple, free of all conditions. 2. A I authorize and empower my executrix, for the payment of debts or for any purpose of administration or distribution, at any time within two years from the date of my death, to sell aJl or any of my real estate, at public or private sale, for such prices and upon such terms as to cash and credit as she may deem best, and to execute deeds of conveyance thereof, without liability on the part of the purchasers to see to the application of the purchase moneys. This power shall not be construed to work a conversion of my real estate, unless and until the power is actuaJly exercised, nor shall this power be construed to extend the lien of debts. B. I authorize my executrix to retain aJl stocks, bonds and other investments made by me for distribution in kind, or in her discretion to seH and transfer the same, either in person or by attorney, without liability on the part of the purchasers to see to the application of the purchase moneys. 3. I direct that aJl legacies andaJl shares and interests in my estate, whether principal or income, while in the hands of my executrix or trustee, shall not be subject to attachment, execution or sequestration, for any debt, contract, obligation or liability of any legatee or beneficiary, and shall not be subject to pledge, assignment, conveyance or anticipation, and the personal receipt by such legatee or beneficiary shaJl be the sufficient and only discharge of my executrix or trustee. 4. I direct that a]] estate, inheritance, succession, and transfer taxes, whether state or federal, which may be levied or assessed by virtue of my death, shall be paid out of the principal of my general estate to the same effect as if said taxes were expenses of administration. In the absolute discretion of my executrix, she may pay such taxes immediately, or she may postpone the payment of taxes on future or remainder interests until the time possession thereof accrues to the beneficiary. 5. I nominate, constitute and appoint my daughter, Karen L. Rolko, to be and act as my sole Executrix of this my Last Will and Testament. In the event of renunciation, death, resignation or inability to act for any reason whatsoever of my daughter, I nominate, constitute and appoint my granddaughters, Michele Lynn Rolko and Kristin Marie Rolko, as co-Executrixes of this my Last Wi]] and Testament. No personal representative or fiduciary appointed herein shall be required to post bond or give any security. 'last Will anb mestanll~nt IN WITNESS WHEREOF, I, the said BETTY J. SHANK, have hereunto set my hand and seal to this my Last Will and Testament, which consists of two (2) pages to which I have affixed my signature thisA~ "tr'f'day of November, A.D. 1999. i.-" Signed, sealed, published and declared by the above named Testatrix as and for her Last Will and Testament in the presence of us, who, at her request, and in her presence and the presence of each other, have hereunto subscribed our names as witnesses. "J- i'7 n /,l'/ ,'H" , '<' '. I L'~(. . - '; c~n./- /" "-- ';. . >' . -, ~Y/~.l:'tVN' i",+ IN . V1 \1/ - /1 " '/ /(,' ~"/ '/':'J/ltfe'-lb/7u/ irl \, / 7c1 ;;, C) ~, ,~. ~, '~~~::::" .,,-~~~~\ " \ "'~\5~-,--"~'S:-b"'~~~\. \(~ ~~'--~ ~~,~~~."\,,,\,,~ ~~ "'\'\l.I~ -2- OMS NO 2502 0265 ~ - .,.. -_. A. t:!. I JAN' - -~.... U.S~ DEPARTMENT OF HOUSING & URBAN DEVELOPMENT 1.0FHA 2.0FmHA 3.~CONV. UN INS. 4.0VA 5. OCONV. INS. J SETTLEMENT STATEMENT -0. : 17. LUAN : 06571 30000000602371 ) 8. MORTGAGE INS CASE NUMBER: I C'l NOTE: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. ! Items marked "(POC]" were paid outside the closing; they are shown here for Informational purposes and are not Included in the totals. i 1.0 31118 (06571106571136) D'INAME AND : E. NAME AND A ;OF ,-, . F. NAMI= OF LENDER: Stephen A. Pearson and Estate of Betty A. Shank Fremont Investment & Loan I . 555 Taxter Road, Suite 220 Je~slca R. Pearson 345 Iroquois Trail Elmsford, NY 10523 YOrk Haven, PA 17370 G$~rROPERTY LOCATION: H. SETTLEMENT AGENT: 25-1878915 I. SETTLEMENT DATE: 14 5 Simpson Ferry Road Keystone Land Transfer, Ltd. I N~w Cumberland. PA 17070 October 26, 2006 cu1mbertand County, Pennsylvania PLACE OF SETTLEMENT 3421 Market Slreet I Camp Hili, PA 17011 J. Ut- ,... "IUN K. VI" ,____. ,_ ,~, ,nON 10C " GROSS ' DUE FROM : 400. GROSS AlAnl uue : 101,. Contract Sales pnee 401. Contract ::sales ,",nce 1o;l,9UU.UU 102. Personal Property 4U~. ....ersonal ....roperty 103: -Seltrement l;harges to Borrower (Line 14UU) 5,873.08 403. 104. 4U4. 105. 405. I Adjustments For Items f"alO tly ::iel/er In aovance AOjUSCmenes ,..or ICems Pala tly ::ieller In aovance 106. CltyfTown Taxes to 406. CityfTown Taxes to 107;. County Taxes to 99.81 407. County Taxes IV/"O/VO to """ ,,,, 99.81 108. School Tax to 734.88 408. SchOOl I ax IV',,"V/VV to VflV IV' '34.68 109. Trasn IV/':O/VO to V IIV "'" --z8TI 4U9. I raSh IV/"O/VV to UIIUI/UI 28.11 11U. 41U. 111,'. 411. 112. 412. 12q. GROSS AMOUNT DUE FROM BORROWER 160,635.88 420. GROSS AMOUNT DUE TO SELLER 153,762.80 200. ~... BY OR IN 'OF : 500. UUl; 1U SI:LLI:R: 20':. Deposit or eamest money 1 ; 50lJ.00 I 5U1. t:xeess Deposit (:see Instrucuons) :lU;,!. t-'nnclpal Amount ot New LOan(S) , I 502. Settlement Charges to ::seller (Line 14UU) . 203. EXisting loan(s) taken subject to 5U3. t=xlsung 10an(S) taken SUbject to 204. Secondary Financing 30,122.58 504. Payoff of first Mortgage 205. 5U5. t-'ayonOf secono Mongage :lU5. 505. 20('. 507. (Deposit disb. as proceeas) 208. OU8. 209. Seller Concessions 3,000.00 509. Seller Concessions I AajuSCmenCs For ICems unpala /jy ::ieller Adjustmenes For /Cems Unp810 tly ~ell9r 210. CilylTown Taxes to 01 U. (,;Ityll own I axes to 211. county I axes to 511. County Taxes to 212. Sch06lTax 10. 51~. ::iChool Tax to 213. Sewer to IV/':O/VO 7.12 01J. ::sewer ""VII"" 0 ''''''''''V 7.1;,( 214. 514. I 21 !,i. 515. 1~15. 515. 121",. 011. 1218. 518. 121lr. 519. 220. TOTAL PAID BY/FOR BORROWER 156,949.70 520. TOTAL REDUCTION AMOUNT DUE SELLER 12,415.92 I' 309. CASH AT SI:T . ; 600. ;:U:I ,_... : 301. \3i"oss Amount uue t-rom tlorrower (Line 1 ~U) , bUl. l;;ross Amount uue 10 :Seller (Line 4GU) 103,70G.80 302. Less Amount Paid By/For Borrower (Line ':':U) 100,949.70 002. Less Reductions Due ::seller (Line O~U) I':,'n o.~.: 30~. CASH ( X FROM) ( TO) BORROWER 3,686.18 603. CASH ( X TO) ( FROM) SELLER 141,346.88 T,~e undersigned hereby acknowledge receipt of a completed copy of pages 1 &2 of this statement & any attachments referred to herein. ) Borrower RIA0- p..~n ~J Seller E~lalrof,etty A. S~k (). () c' L , .. . L. SETTLEMENT CHARGES .. 700. rOT AL-.;OMMISSION Based on Price $ 149,900.00 @ 5.0000 % 7,495.00 PAID FROM PAID FROM UIVlSlon OT c..;ommlsslon (line IUU) as r-OIlOWS: BORROWER'S SELLER'S rU1. :Ii 4,4f:.!.UU to KerMax KeallY ASSOCiateS, inC. FUNDS AT FUNDS AT rU"L. :l> J,U"LJ.UU to I ne HomeSteao \.:>roup SETTLEMENT SETTLEME~T (,U,j. 1.0mmlSSlon t' ala at ;:,eUlement r ,4~!::>.UU (U4. I ransactlon ree to Ke(MaX KeallY ASSOCiateS, inC. '<;;JV.UU BOO. ITEMS PAYABLE IN WII H LOAN I llUl. Loan unglnation Fee U. UUUU '10 to 802. Loan Discount % to : BUJ. Appraisal t-ee to Amencan 1'\ovantage IVlongage r-UI.:C,jUU.UU I tlU4. l.reoll Kepon to Amencan Aovamage Mongage ;:,ervlce LLI. 14.10 tlU::>. Lender s Inspection t-ee to BUti. Mortgage Ins. App. t-ee to I Bur. ASSUmption t-ee to , I tlUtl. ! BU!J. ! tl1U. I Bl1. tl1"L. tlrOKer ree to Amencan Advantage IVlongage ;:,ervlce LL.1. l,"L"LJ.UU B 1 J. processing t ee to Amencan Aovamage Mongage ;:,ervlce LLI. OOU. UU , tl14. unaerwrltlng ree to rremont Investment 01 L.oan I,UIO.UU i 11l15. Tax Service t'ee to Lan01'\menca 4tl.UU : I tllb. rlooa c..;ert t-ee to LanaAmenca r.::>u I tllf. Y lelO ;:,preaa t-'remlum Amencan Aavamage palo oy rreemmont Investmem 'll ~~ , Itlltl. I Bl!J. I Itl"LU. 1900. ITEMS - TO BE PAID IN A !! 901. Interest From 10/26/06 to 11/01/06 @ $ 26.780000/day ( 6 days %) 160.68 I I ~U"L. Mortgage Insurance t remlumTor momns to 1903. Hazard Insurance Premium for 1.0 years to Electnc Insurance c..;ompany 4JU.UU I 1904. 1905. I 1000. ._. ~_.. _~ WITH I I""'n""~ I 1001. Hazard Insurance months $ per month I 100:.!. Mortgage Insurance months :l> per montn . 1003. City/T own I axes montns :l> per month lUU4. (,;ounty Taxes months :Ii per monm 1005. School Tax monms :l> per montn I lUUO. monms @ ~ per monm ! luur. months @ :) per montn , 1008. Aggregate Adjustment months @ :) per month 1100. TIT I" : 1101. Settlement or Closing Fee to I 11102. AOstract or 1I11e Search to , 1 103. Tille Examination to I 1104. IltIe Insurance ~inder to I 1105. Document Preparation to (,;alaweu & Kearns "LUO.UU 1 106. Notary Fees to (,;ASH 25.00 1'5.00 1107. Attorney s rees to . (lnclUaes aoove /Cem numoers: ) 1108. Tille Insurance to Keystone Land rranster, Ltd. 1,123.75 I (Includes above item numoers: ) 11 Ul:I. Lender s l.overage ~ 1 "L"L,J"LU.UU ! l11U. uwnersl.overage :l> 10":,tlUU.UU 1111. t:naorsements lUU,JUU,B. I ,f IU to t<.eystone LanD I ranSIer, 1.1U. ":UU.UU 111"L. (';Ioslng t-'rotectlon Leuer to t<.eystone LanD I ranSier, L.\a. JO.UU 111 J. I ax (,;ertlT/catlons to Keystone Lana I ransTer, LtD. b.UU 1114. uvernlgm to KeYStOne Lana I ranSIer, Lta. :.!U.UU 111::>. KetrleVe t: Mall Uocumems to KeYStOne Lana I ranSIer, L.ta. 25.00 1110. I 11lf. 111 tl. I 1200. GOVERNMENT AND I 1201. Recording Fees: Deed $ 39.50; Mortgage $ 74.50; Releases $ 114.00 , : 1 "LU:.!. (,;Ityr(,;oumy 1 ax(;:,tamps;::; l,o..:~.uu; IVlongage 1,::>Ll:I.UU 1203. State Tax/stamps: Kevenue stamps 1,529.00: Mongage 1,549.00 1204. I 1 :.!05. I 1300. .SETT ! 1301. Survey to 1302. Pest Inspection to I lJUJ. sewer (U7I01-9/30/06) to New Cumoenana tlorougn 46.20 , :.(.Cl4. r::t.~h'1 nln' _ y" "1.cU.' Ill""nh.or ."nrt U"PI"\' .,..... gartmore Funds 9/1912006 Karen L Rolko 538 Magaro Road Enola, P A 17025 RE: Account Number: 2409716000 Reference Number: G9JOOJ Dear Karen Rolko: Thank you for contacting Gartmore Funds. We are writing to confirm the following infornlation: DATE OF DEATH VALUE 2409716000 660.168 Net Asset Value as of August 7,2006 6.70 Dollar Value $4,423.13 Fund # 21 Account # Share Balance Additionally, please be advised that the above referenced account was registered as a Beneficiary Trust account which is like a Transfer on Death (TOO) Account. Should you require additional assistance, please feel free to call our Customer Service Team toll-free at 1-800-848-0920. We appreciate the opportunity to assist you any way we can. You may also obtain current information on the Gartmore Funds from our internet homepage at www.gartmorefunds.com. s~ Karin Magowin Shareholder Services LC Enc!.: Copy of Original Document Friday. September.... 5. :200607:13:56 ~ Gartmore Funds PO Box 182205 Columbus, OH 43218-2205 September 12, 2006 RE: Betty Jane Shank Account # 2409716000 Date of Death: August 7, 2006 To Whom It May Concern: Upon my Mother's death I provided your office with infonnation which allowed the transfer of the above referenced account into my name. Based on the Trade Confinnation Statement dated 9/5/06 that I recently received from your office, the account has been transferred to new account number is 021-2101015034 indicating a market value of $4607.97. As the Executrix of her estate, I have been requested by legal counsel to obtain from your office the date-of-death balance for account number 2409716000, along with the nature of the ownership of the account and the date the account was originally established for purposes of Pennsylvania inheritance tax. Your prompt attention to this matter is greatly appreciated. Thank you for your cooperation. Karen L. RoIko, Executrix 538 Magaro Road Enola, P A 17025 717-571-6341 cc: Charles 1. DeHart, III Esq. Caldwell & Kearns D.AGOSTI NO . BRISELLI ALBERT D'AGOSTINO. CFP. CSA ANTHONY BRISELLI Financial Consultants September 6, 2006 Attorney Charles J. Dehart, 3rd CaldweH and Kearns 3631 N. Front Street Harrisburg, P A 17110 Re: Betty J. Shank A viva Life Insurance Company Contract Number 30AB738032 Please be advised that the date of death value (8/7/06) for the above referenced IRA was $77,550.17. The primary beneficiary on the account was Karen L. Rolko. A Claimant Statement and Certificate of Death were sent to Aviva via US mail on August 30th, 2006. If you have any further questions, please do not hesitate to call my direct line at 796-1790 extension 11. Sincerely, Albert D. D' Agostino, CFP, CSA 5006 East Trindle Road, Suite 102, Mechanicsburg, PA 17050 . (717) 796-1790 Toll Free (877) 625-2378 Fax (717) 796-0484 bdagostino@pfginc.com . abriselli@pfginc.com Securities OITeted through registered representatives ofWalnur Street Securities. Inc. (WSS). Member NASD. SIPe. Advisory Services through PFG Financial Advisors . Branch Office: 270 Walker Drive. State College PA 1680 I. (8 J 4) 238-0544 Neither D&B nor PFG are subsidiaries or affiliates ofWSS . A VIVA Life Insurance Company PO Box 55172 Boston, MA 02205-5172 Payee: KAREN L ROLKO Policy Owner: BETTY J SHANK Insured/Annuitant: BETTY J SHANK Policy Number: 30AB738032 Claim Number: V A2213 Please refer to the account numbers listed above for all correspondence FOR QUESTIONS PLEASE CALL 1-800-343-5660 SEP 14,2006 I Check Number 541518 Transaction Date Summary of Transaction Dear KJ\REN L ROLKO: The following is a detailed summary of the attached check, which represents the proceeds due you under the above referenced policy/contract. If you have any questions please call the telephone number listed above. Net Check Amount 77 ,550.17 -19,387.54 58,162.63 Annuity Benefits Policy Withholdings-Federal Taxable Amount (if applicable): Tax Cost Basis (If applicable): 77,550.17 76,054.81 For annuity contracts, a form 1099 will be distributed in January. Detach this confirmation and retain for your records before cashing or depositing check IN FULL SETTLEMENT OF ACCOUNT PER STATEMENT ~tJ.\;?f.;; 1~',~;r_'fJiC;LF3ilfl~!1IIrJ~I[niEi;[;mID'~lliJfG~J~la}!:llti!II.lt.~J~~~'tj~li~El.~l!lTIEJ;]l!lBilWii1[ill;ZL~ e .'.r.. A VIVA Life Insurance Company PO Box 55172 Boston, MA 02205-5172 Check No. 541518 52-153 112 Date September 15, 2006 Amount ********$58,162.63 Not Valid Over 180 Days Fifty eight thousand one hundred sixty two and 63/ J 00 Dollars PAY TO THE ORDER OF: KAREN L ROLKO 538 MAGARO ROAD ENOLA, P A 17025-2945 ~5~' Two Signatures required if Amount is Over $10,00 L/ ~? //~.; .--0 Vd,..:.7~ZA~-- - ./' Fleet Maine, NA ./ South Portland, ME .. .. REGULAR SAVINGS ACCOUNT: Account Number/ Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established CHECKING ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established MONEY MANAGEMENT ACCOUNT: AccountNumbe~Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established tv 1st MEMBERS 1st FEDERAL CREDIT UNION 161300 -00 08/19/1996 $31.95 $.00 $31 .95 Karen L. Rolko 08/22/1996 161300 -11 08/19/1996 $11,202.85 $.45 $11,203.30 Karen L. Rolko 08/22/1996 161300 -05 06/17/2006 $16,934.86* * $5.51 $16,940.37 Karen L. Rolko 06/17/2006 *' "Account established by transfer of funds from 161300-00 Estate of: BETTY J. SHANK Date of Death: August 7,2006 Social Security Number: 201-16-2637 ~~BEHS 1STJYD~RAl C7DIT UNION ~cUc ?(/{;dZ::~ enise A. Wolfe Insurance Services Su ervisor September 28, 2006 5000 Louise Drive' Po. Box 40 . Mechanicsburg, Pennsylvania 17055 . (717) 697-1161 . \vww.memberslst.org ...... -, REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA INVENTORY Estate of Betty Jane Shank No. 2007 rES -7 PH:1: n6 , Deceased Date of Death 8/7/2006CLEiT< Oi" Social Security ~~181'6~~6'3V): ;RT ~~/\ also known as Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I/We verify that the statements made in this inventory are true and correct. I/We understand that false statements herein made are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Personal Representative: Name of Attorney: Charles J. DeHart, III, Esquire I.D. No.: 15617 ~n.~o{212- ted Jill!,,),? Address: 3631 North Front Street Harrisburg Telephone: (717) 232-7661 PA 17110 Description Real Estate - Residential dwelling known and numbered as 1485 Simpson Ferry Road, Borough of New Cumberland, Cumberland County, Pennsylvania, indexed at Deed Book G, Volume 24, Page 947. Gross sale price Value 152,900.00 Personal Property - 1. 2002 Toyota Sedan automobile - Net proceeds from sale 9,000.00 2. Miscellaneous household goods and furnishings: (a) Net proceeds from public sale 1,360.45 Total (Attach Additional Sheets if necessary) 164,644.94 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory. RW-4 Continuation of Inventory Betty Jane Shank Page 1 Description of Inventory Description (b) Desk, wall clock and 3 wall pictures - Appraised value Value 270.00 3. Refund checks: (a) Verizon - Telephone service 0.97 (b) Auer Memorial Funeral Home 6.06 (c) Nationwide Federal Credit Union 12.36 (d) Toyota warranty refund 282.80 (e) Hartford Insurance 48.05 (f) State Farm homeowners insurance 384.56 (9) State Farm auto insurance 379.69 Subtotal $ 1,384.49 164,644.94 Grand Total $ ~ --.J 15056042126 REV-1500 EX Decedent's Social Security Number Decedent's Name: BETTY J. SHANK RECAPITULATION 201162637 1. Real estate (Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. 152900.00 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 Properly (Schedule E) 5. 1 1 7 4 4. 9 4 ...... . 6. Jointly Owned Property (Schedule F) o Separate Billing Requested . . . . . . . 6. 1 4 0 8 7 8 2 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properly 8 1 9 7 3. 3 (Schedule G) 0 Separate Billing Requested. . . . . . . 7. 0 8. Total Gross Assets (total Lines 1-7) 8. 2 6 0 7 0 6. 0 6 .......................... . 9. Funeral Expenses & Administrative Costs (Schedule H) 9. 2 1 6 6 1 . 4 5 ............... . 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . . . . . . . . . . . 10. 5 1 7 . 4 6 11. Total Deductions (total Lines 9 & 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 2 2 1 7 8. 9 1 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . 12. 2 3 8 5 2 7 . 1 5 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. 2 3 8 5 2 7 1 5 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.O _ o . 0 0 15. o . 0 0 16. Amount of Line 14 taxable at lineal rate X .O~ 2 3 8 5 2 7 . 1 5 16. 1 0 7 3 3. 7 2 17. Amount of Line 14 taxable o . 0 0 at sibling rate X .12 17. o . 0 0 18. Amount of Line 14 taxable o . 0 0 at collateral rate X .15 18. o . 0 0 19. Tax Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 1 0 7 3 3. 7 2 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT o L 15056042126 ~~7 Side 2 15056042126 --.J