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Home My WebLink About97-00944 , klVllow. ("~I \, INHERITANCE TAX RETURN rpn~b\m'LDIA'HAPlU 121~!"1 CHICKItIU ~;\~Jf RESIDENT DECEDENT ~IY~~J~~:rnIHL.~!MID u ~_""'''d cOM::~~nf,~&~~:~~!:H'A (~~T~E IJ~~~T~ g~p~~elE COlll~l~ JOQ~ _ieIR ~~~m ~../,,,.,,. '''m."" " r' .-... ... . ....... ... "'f,l." - ". ""'n, · -- nir~fftn~kuM~{lJ.~..~m,I~Llfi'lfcif uiAlil . ~ ~'li>Alfbll"ill ..... 22 IC11.m11 'l'ra~ 01 ~~~: 1 1'12 09 r.4t\7 .,. Newv,. .13, LA .. ---=_._:?.... ".. .-,." 1()/~~/~I/... .\t(i!7,.lIl\J ~"'~~'r" 1"..a,l1mb.."llann11r------.. 1" """'''II'U'''''''O \PO""1 """'''\1, ,''"'''' "",''' """'" "ltl' "I"li 'WMIl' _ ."Otlll uCI'Y'1>'(Ilf'ln ;IIflTr.nl:l1 I n..__.__.J~Q.at.Qn,.Rutl1 (1,. 1B1..1I\..4UI)6 . .. .nm~_....__..~_H ill (ill I. 0'101"..1 R.lu,,, I I 2 S"""I,,,,.,,'ul R.,",,, I I 3. H.",ulnd., Relu,,, 110' dole' 0' d.olh p,lor 10 12013.021 r"J 4. Llmllecl e""I. I-I ~'L F"lo'~ Inl.'I" COlnp,oml.o I~ I 5, redo,ol Ellole 10' Relu,n Requl,od . .. 1'0' dol.. 0 dO"I. ull.r 12.12,021 ' (~ 6, P:lj:~~nioO~~ll~:rllo 1'1 7, 1~lj~~I~~I.~:'I~I~~'~I'I)" L1vl"O 1'011 .Q.. 0, 10lul Nv",hor 0' Sol. Pep.1II Bo... P__... _..h.' __......__..._..,_.._...~_..._,_".H...n...___.. ..-..--...... .-..,..... -,.- .~'.._---._.~'-,- .--.- ALL CORRIIPONDRNCI AND CONPIDRNTIAL TAX INPORMATlON SHOULP III PIRIClID TOI ~ I HAMI ...-...----,,--- --... n'n__'__'..,...,u....___.__ c'oMlillI'MliilmlAlmilli--.--........---'-...-.-----..--'" n J11T~O~I~I~4.J~L-~~I!-~a..~n.c,i M6!l.fla1.l ( P.C !..~11\ N" Meroer at" SuHe 532 ____._ I? 2Li~~,~9"~"~;;:3,119",,,.,,c'cc. .,..,..", . .~~~,,,~(la,tc~~:,c~~"'"'~c6_\~L~=, 1. R.ol ellol. IOchodulo AI III 2, 510'" ond Oond, ISchodol, 01 I 2 I (i 1 'I, 4 (i O. 94 3, Clo,.ly 1i,Id Sloc,II'ml"o"hlp In'or.1I ISch.ei..'. C) I J I 4, Molto.oe. .nd Notol Roc.lv<lhl. (S,h.dulo P) 1-41 . 5, COlh, Don, Oopo.lh & MII,oli.",uoI I'o"onal P'.porly (5 I ISch.dol. EI 6, Jo'nlly Own.d P,oporly ISc..oeivlo n 7. T,o"l", IS,h.dulo 01 (schodol. 1I 0, '10101.0roll AII.h (10101 tin" 1,71 ;9. Fun.ral eKplln.el/ Aclrl1lnhltallv..Colh, MlscallQneoul EMp'n'" lach.dul. III . 10, O.hll, M.,lgooo Llahlllli", L10", ISchOllolo II 11. 10101 O.duclion, (101,,1 Lln.. 9 & 101 12. Nil Volu. 01 e"olo (Lln. 0 ",Inu, Line 111 13, Cha,lIuhl. and Oovo",,,,onlul oO'lvo", {Schedulo JI ]j, N'LVoluo ~obloc!.L~.la~Jl!".JL"'I~~IJI!!'!..l~L___m. IS, Spo",ollro",I." (lor d.I., 01 d.olh o/io, 6.30,941 S.. Intltuc:t1onl for Applicable Port'DllIaoe un Royorte SId., Ilncludo val~e, Irom Schodvlo K 0' Schod.lo M.I 16, Am~unl 01 LI"o 14 I".ohlo 01 6% ,"10 (Includ. volu., fro", Sdlldulo K 0' Sc..odol. M,I 17, AmouIII.1 L1no 14 11I."hlo "I 15% ,." lI"dvd,"vulu., from Sch.dulo K v, 5,hodulo M,I" 10. P,lndpul'!.. doo IAddl'" 'rom \1110' IS, 16,,,..117,1 19, Cr.dlll Spoulul Povorly ClodU Prlor PUYlllOnh nl\lotllll +~_Q, 5~O,,{)O + .1 ,()80"qq i I i a /5 - ,)...1 1.J - ( (;, =:'-~;,",-"': ~,~ ..1.., {',' " lli .':oil fl) () t: t, 20,050.70 " F' to,J i:::J fl 161 171602,9U6.34 ;_"t \._1 (II ' ( 0 I\A1,l!.4sPr.127..L2Jl c~') 191 .2 7',Ol] 3.60 ~:.J :,__, , ,~. (101 u.27,.ODJ...ao,....., ..... .l,~rt!..diJ.4.JJ1.__ " . 1111 (12) {I31 _____ .__.....n...._~",........, m_m_"'.~" ......., '.n_._" ._~_,___,_, (I,~t;;,J,.~Z1b.6,t:4...:tB (151 _ !l.51, 16S,.!l3 K,OO.., _.u-(l::,__~_.._...... 1161 :)6J, 446.3'\ ,.' K ,06 . ~l,J?..e.Q_!.~Q..___ (171 )( .1.5.. (Iol 21 1..6.11.9.J1Q,.. ... Inhno,1 {I 9) 1201 . 21,6.00.:..00 20, \Ill". IW,eal., Ih.n L1n. 10,0"10' Iho dlllo",,'o an L1"O, 20. 1..III,lho OVERPAYMEN1, 111::1 IIIIII!W;..... '-I-'11f'-IIII-.IIIIIIII-..II~I.I.fllllllll.".~'fllll-...... 'lIll11Tnllll~IJ 21. Ii Lln. 10 h U'o~'" thon lIn. 19, ."101 Ih. dlllo,o"co on L1no 21. Till, 10 IholAX DUE, 1211 A, Enl.ttho 1""'0" on Iho hulo",. ,fuo an Lino 21 A. {21 AI 0, Enl., Ih.lolol 01 L1,,0 21 "n;1.21^ onLl". 210, 1hlo 10 tho bALANCE DUE, 121~1 _ Mole Ch~..k .r..'!y~~I!.LoLJ!gl!.!!!..of ~~Lo'~J!!.I__.,..m.'..mm.'..'_.._u.. ~n_'_ .,,,.... mmnn___..___,,____..."_.. , n ., p'nolil.. 0 porlury,~~lq,~~~~IRI~0~~~I]~J~I~~}1u~?-~~l\~Nr.$n~~~~1~r~~fu~j~'~tt~:1~.~.!~!#f~ .lj.frI~~):f~~owl.do. (;;h;l~l: II It 'dru./ c:brr.ct and c:amp/eID, I dedor. lletl all Ion 0$11110 \('1$ botll\ ropollot (1llruo rnnrkol v(lluo. OodfHilllon ollHoptHOI olhor limn Ihe pOHonal repfo$enlQllvD is beue on alllnformatlon b which pt(lpnrer hat any knowludgo IInHA~~ln1Mql'nNliiln5nn,No Hnmr' ., Ahi>".[Ii' - , - - ~. . , . , Mli .__m._-;-.... ~- ~ ffi,i'Jt A 13.,~:t;,~ l1uth a, nOIlI.on NllwvUlll, P^, 17241 7-('''7-(' f IIOfl^hRfC?~lf~i'Hlrrin{fl~ 11"- ^llhlll\!l' . O^l1 . ...--... -....--......---U.... .- Char]eD y, Monno)], F.alJ~, NBW eMUn, P^ 16101 7-1'l-_?[ .:....6..6,..~O lIVllliU.1/1I1 " l~ SCttlDULlli ~~:if~I~" PUNI~AL &XPINUS, ~clMMOt~WIAltIt 0' mmmVMUA. ADMINISTRATIVIl, COlTS ANP II'lr,r~,' III1~nlL~t\1~ttOMH!e~''',",''''M' 'n ...!!,.'.~~~L~~~~~US IXPE~~~S..._ __ ,..~J.!c::.~~!'!t!rlm! II .,.. I OP . LI NUMIfIr William M. Ooston . 2197-944 .......__ ..;...-..-__".;.,..;....._...___.._~._~__"u._n____~___....._u ~...~~_~._~ "....~ _~...........__......~ _ '__.~_";'~___~..__'T_ , !TIM NUMIIIR 1. A, I'un,,"llHpen..., DISCRIPTlON , II, 1, 2, 3, 4, C. 1, 2, 3, 4, 5, 6, 7, e, 2. R. CunninQham Funeral Home -funeral Day'. Inn - hotel room 3. Funer.al Dinner Ad",lnl.trllllva Cell'" . p,,,onol Ropr..antallva Commllllolll _,.. Social Saeurlly Numbar, of Pa"onal,RoptolonlallvQI ,,__ ....--...----....u.-.--...--.._.-- Voar Commllllotll pald_m..__..~.".~_.m Attorney Fe..' Mansell, White and ManHell, P.C, Family Hxemptlon . Claimant -...-----i-.-'n~;..-------... Relllllc;>nlhlp _..__~~__~_."___ Addre.. of Clalmnnt 01 dac.d.nt'. d.ath Str..t, Addr... __.__.__.:~_..______......._,,,,______.--,-,..____. ________......_..._.__._____..__...._ City _.m.'.... ........................._,.._.L...,. .... _ ... . Stat...... ",____ Zip Cod.. .." 'u...____._____-.. Probate r... Mary C. l,ewia MI.callllneou. Expan.." .. Postage The Sentinel - mat~te Ad Cumberland Law ,Journal - Estate Ad ~ax preparation fee MaryC. LeWis - Fila Inheritence Tax ~eturn and Inventory Lawr.ance m. Welker - Final Account .__.,~--~._-.~________>-~~_+_......~_+"+---+-_+_..._~~_~~~.. ______._r...~__....___~__.____.__.__,...,._. .,_.._ it... TOTAL (Aha onter onllno 9, Rocopllulallonl (If ,no" .pace I. noad,d, In..,t additional .hee" of tn,ne tilt,) '. .. .. .. -,-.... , AMOUNT 6,956.80 60.00 60.00 20,000.00 427.00 33.50 76~50 60.00 60.00 25.00 125.00 $ 27 863.80 ," , "'. ' " I"" ," "..' ~, ' I " " ". . ' \ , "I '., I' I, j , . ":~ ' ' , ' , , "'-, ~ . \ \ , ,I, . 'V' ~ ' 't~l" \ .JII., ( ~ . " ~ \ \.12 .t . ~. . ... " , I-t -", ,i, I )1, " l l' \ i , ' ~, "l" . . !A I ~:: I 1\, . I , " " ,,\ ". ' ,. ~ 1 \)1 " "" " .' " " 1,l\fl'l'd.H 1.111, n.lilL~1'.KflTl\HV;N" 91F W.l4k1J.\M.J1..,.JIQ.I,I'1'QJi I, WILLIAM M, aO~ToN, of Neshannook Township, Lawrenoe County, Pennsylvania. being of sound mind and memory, do make, ~ublish and deolare thia to be my Laat Will and Testament, hereby revoking and making void any !lnd all [OL'mea: Wills and Codioils by me at any.time heretofore made; J1'JMTJ.. 1 dlreot that the expenses of my last illness and funeral expenses be paid out of my estate all soon all may be oonvenient after my death, f,l.EQQrID.!. 1 give and bequeath all my tangible persohal property, inoluding any vehiole 1 own, unto my wife, RUTH S. BOSTON, if she should survive me for a period of thirty (30) days, 'l'lilRIU. 1 give, devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wheresoever situate unto FIRST W!tSTERN TRUST SliJRVIOES OOMPANY, IN TRUST, NEVERTHELESS I to the folloWing uses and purposes I (a) To hold, manage, invest, reinvest and kee~ invested t he same in suoh seouri ti es as are authori ~ed by the laws of the CommonWealth of Pennsylvania, t MANS1:I,t, WIIITr. <0,<1 MANSr.u" pc AIIoIMV.<<ILow <'\1 t~\l tkrlklfl'11 "'llIk I\IU~IIl\li1 NowConlln, I'A 16101 Alod Cod. 412 65?,,74'IO 6M.,14'19 speoifioally authod~e my Trustee to retain any investment that I miQht own at the time of mY deAth, ,\ I nu;; I "''I "Ti',!". I j~"~ "J !;'"-,, In /,?<.~_l_\'h '"r<" - _{ ~ I ' .' " - , 'f1JJ'i!'~"':l'~' ,~, <'I":, ,',' I " !PI ,f' ,,': ;';",I.':H'1 1 . ~ ' . , I , " '/;1" ,VI TH\ i, ':il~tt,L"I' I': 'f,[ .. t~c~-~l r.I.'~!-lV,\', p',l-:).,ytrVJJj,U(t!,r){tj-. Cfull\ III III (.',1)1\1.11'" ()')\J1t q C;;WlIll(/tlnnrl C\~'llly 083093RlllS&Cl l"IUllSIlY'l'llln:rAN lIOMlllS, rNO ./GRlllIllN RIDqE VILtJ\GE lUJ:SIOENClll AND CARIll AQRllllllMIllNT PHAN 1 PAGl!l 2 19~~ t~~~:=~N~Rm:~c\;I5g~sVIL~~1ll/PR~~~V~~RI;~ '114oMES, -, INCdR~ORATEO, a '~ennQYlvania non~profit corporation, hereinafter callel1 "CORPORATION, II and Mr. & Mrs. William M. Boston, hereinafter oallel1 "Redclantll for ac\miss.ion to 22 1!l1m Tres Cirol/il; WHI!JRI!JAS, Oorpora'don Clonrtuots at the faoility, a oontinuing-oare oommunitYI ' W~ERI!JAs,ReQidGnthaH applied for admission, whioh applioation haa been reoeivel1 by corporation I NOW, TIIERIllFORE, the parties, intending to'be legally bound hereby, agree astollowSI SIllCTION 11 OIllFINITIONS OF WORDS AND PlIRASIllS ADMINISTRATOR I meanS the person who i$ l1esi<;1nated to al1minister the faoility and to whom every mamber of the staff is aooountable. APARTMENT/COTTAGIll INVESTMENT FEEl means the portion of the Residenoy Investment Fee for the living unit. ASSrGNMEN';J'OF INSURANOEI authorizlltion to faoility to llpply for anl1oolleot Mectioare or other insuranoe benefits from Resil1ent's in~uranoe oarrier for servioes furnished to Resident or on Resident's behalf by faoility. BOARD OF Rl!lVIEWI consists of the Administratcr, Mel1ioal' Direotor, Oireot9r of NUl:'sing-, and Sooil\l service Representative. CO-RESIDENT I means one of two persons who sign as residents to occupy o,ne living aooommodation. , ' ,. OOl1MUNITY I~VESTMEN'r I"Em, me,ans the entrenoe investment made by Bao~ ~e~il1ent ~or the oommunity tlGnter, land oost and oommon space. POUBLE OCCUPANCY I means occupanoy of one' Uving aooommodation\lY co-residents. , HIllALTH CENTl!lRI means the onMsite nursing- oare faoility or, when no vacanoY, an alternate faaility approved by corporation. HEALTH SERVICE INVlllSTME~'l,' FEE! means the advance investment for a portion of the health oare ,oosts provided by this agreement. INSURANCE I means Medioare (A and B) Blue Cross/alue Shield 65 speCial, or equivalent, whioh Residant Is required to oarry. OB3093RES&Cl l'R\!)SIlY'l'mIUlIN, HOMms, I'NO ./OIUllJJN RIPGl!l VILW\GE HmaIPElNCI~ AND CAHI~ AQRF.JEMElN'r PW\N 1 PAGlil 3 ~IVING ACCOMMODATION, means the living unit or nUrs~ng beq provided for, exo1usive oooupanoy by Rasiaent. MEDICA~ DIRECTORI means tho physioian designated by the Administrator to supervise tha meaioal affairs of the faoi1ity and of the residents of said faoility. OOCUPANCY I means the aotual possesaion or use of a living accommodation, or immediate right to suoh Posslll$$ion or use. PROBATIONARY PERIOD I means thf;i first three months of ooo\1panoy 9f a living accommodation. R~SIDENCY INVESTMENT rEEl means the payment by the Residant prior to ooo\1pancy whioh is comprised of the total of the community Investment Fee, the Health Service Investme~t Fea and the Apartment Investment Fee. RESIDENTI Applies to person or persons exeouting this agr~ement and residing at faoility. ' Masouline adjeotives or pr~nouns are sometimes used therein in referring ,to the resident, but the word RESIDENT applies equally to a woman. REMAINING RESIDIllNT OR SURVIVING RESIDENT,I means the resident who oontinuas ~o occupy a living aooommodationafter the death Or withdrawal ofa co-resident or the' pel;'manent transfer of a, c!;l-rfiilsident to a health olanter, or to any other fa(JUity authorized under this Agreement. , SURRENDE"I .means tooease to ,oooupy a living aooommodation/ to remove all possessions therefrom, and to turn in all keys therefor. TERMINATE THIS AGREEMENT I means the end of Reaident's right of occupancy, whether in a living accommodation or in a health oenter. , SECTION 21 ACCOMMODATIONS PROVIDED av CORPO"ATION A. ~iving Accommodation - From and after the date when Resident takes ocoupancy in, accordanoe with" the terms of t~is Agreement, Corporation will, provide Resident with living , . acoommodation and facilities, i, n inaependent living, perso,nal. care or n\.1rsing for and during the palance of Resident's life or for suoh shor~er period as shall apply under this Agreement. corporation shall have the right at all reasonable times to enter and inepect the ~iving aooommodation. B. ,FUrnishings - corporation will furni$h self defroeting refrigerator, stove ~ith self oleaning oven, garbage disposal washer and dryer, garage aoor opener in the living acoommodation. All other furniehings shall. be provided by Resident sUbjeot to supervision of and approval by the A,aministrator. 083093RIllS&Ol PRmSBV'l'IlHIAN IIQMmS, INO ./ORml!:N lUOGE VILLAGE: RESIDIlNom AND CARE AORmmMmNT PLAN 1 , PAGE 4 O. oommon Faoilities - Resident may Ulile" in oommon with other./ the dining room, aotivities areas and other faoilitilillil , p~pvided by corporation for all residents. O.Availability - oorporation anticipates promise) that the liVing aooommodation ahaU be beginning on 6/17/94. Corporation sha~l notify two months in advanoe of the date when resident (b\,\t doel not re~dy for oooupanoy Resident: at le~st may take ooo\'\panoy. SIllOTION 31 SERVICES PROVIDED BY CORPORATION A. utilities - corporation will provide wateri sewer, trash' oOlleotion, and in house TV I;lervice. Electrioity bi led to eaoh unit with ex, pense paid by resident. Telephone service will be made available in eaoh unit when desired at Resident's expense. B. Housekeeping - Rssid$nt will maintain the liVing aoo,ommodation in olean sanitary, and orderly oondition and will perform all," usual light hO,usekeepin9 taeks in oonneotion ,therewith. ' Corporation w, iUprovide houseoleaning servioe on an annual basis to eaohunit. If Resident does not perform housekeeping tasks to ' maintllin the living l\poommodation in a proper manner f corporlltion, after notioe to Resident, shall have the right 'to malntain the aooommodation and the oOlSt of ,such maintenanoe shall be oharged to Resident. Additional housekeeping service will be provided upon . Resident/s req~est at Resident/s expense, 0'. ,Maintenanoe and Repair ~ Corporation will perform and provide groUndskeeping, snow removal, necessary repairs, and maintenanQe and replaoement of corporation/~ real p~operty and equipment. Repairs, maintenanoe and l:.'eplacement of Resident / s persol'lal prQperty will be the .,responsibility of Resident. D. otller Servioes - Assigned parking is provided for resident/ s own oar pursuant to prccedure established by Corporation. E. Struotural Ohanges - Any etr~otural or physical ohange of any kind withi~ the livinq aooommodation will be made only after aPproval by tile Administrator and thereafter will be subjeot to Administrator/. super.'vision. The cost, of any ohange.requeeted by Resident will be borne by Resident, unless otherwise, agreed to in writing by corporation. options are not considereq part of the Residency Investment Fee. . ll'. Redecoration - Redeooration of liVing aQoommodation in addition to or other than that soheduled by qorporation will . requi,re the approval of the Administrator and will be at Resident's expense.Any change or replaoement by Resident of the furnishin~s provided by Oorporation in the livingacccmmodation v,ests tit~e thereto in Corporation unless otherwise agreed to in wr.itinq by Oorporation. , G. Food .and Meals "., PRlllllllY'l'DlRl:A" ,Il0MIDS, INO ./OnIllIllN RIDOIil VILLAOl!l RlllSIDENOID AND CARIll AOREEMENT PLAN 1 PAOIl1 IS Oinin9 Room,/3epvicei- one meal per perfion per day ia available as, a part of the 11'onthly fee. Additional. meals and 9~sst meals may be pUrohased at additional Cloet to Reddent in aOClordanoo with Corponti'on'a oost sohed~le. Resident may apPlY tOr oredit for mined msalq when absent fr.om the facility fOr mOre than seven days. Tray Servioe - Tray servioe, approved by the Medioal Direotor will be provided at no additional oost to Resident on a temporary basis. other servioe - Meals oontaining substit~teor alternate diets (,speoial) will be provided When Ordered by the Medioal Direotor at no additional ooat to Resident. . H. Health Oare servioes 0830P3RtllS&Cl 1. 2. 3. pr, ovided bY,Qorporation " Corporation will provide, when preeoribedby the Medioal Direotor aseieted living1,semi"pl:'ivate (or Private, at additionCll 00, at to Res dent) oare in a health oenter, and home health servioes. 2. Phyeician SlllrviCles, - Resident at his own e)Cpenee may employ the servioe'of any o~tside physioian Or surgeonl, but cOrPoration m~y require reimburs,emen,t for its oost in oaring for any oomplioations resulting from suoh servioes and for.the oost of medical, surgioal, hospita.l and nursin9,care ordered by any such outside Physician or surgeon not approved by the Medioal Director. 1. \' 3. Trimster to Hospital or other, Faoility - The Mect!oal Direotor m~y tranSfe,r ~esident to a hospital or oth,~r facility ashe deems best~ndr it he determines it to be advisable, he may require that Resident be ret~rn~d to a hea,lth oenter Or other level of oare. Resident may indicate his preference of hospitals from among those with whom transfer agreements have been a~rangedl hOWeVer, no guarantee of bed availability at the preferred hOB~ital can be made ~y Corporation. paY11'ent for.hospital serviqe is not covered by oorporation and is the responsibility of..Resident. 4. corporation's Right to Insurance Proceeds ~' Resident aoknowledges ,the right of Corporation to reoeive prooeeds to wh,ioh, Resident is enU tled 'un,d!!r insuranoe GIld benefit programs required by the A~reement, and hereby assigns and transfers over t6 corpo~ation all right, tit~el and interest of Resident to suoh pUblio and privata nsuranoe and,benefits to the e~tent necessary tc pay Corporation fOr services provided in 083093RES&O:L PllESln!'l'I~(U1\N HOMES, J:NC. /OIlEEN IUDGE VIL,LAOE RESIDENCE AND CAllE AGREEMENT PLAN 1 PAGE 6 seotion 11.1. Res~denthel:'eby authorizes cOt'poration to make any and ,,11 olaimsfor 'Eluoh insuranoe and ' benefits and a<;Jreesto, eXBcute all clocumenh necessary to enable corporation to oollect or enforoe s,~lch olaims, If for anY reason Corpot'ation oannot apply directly for such benefits, Resid, ent agrus tio make "uch applicadon indivictually anct to pay to " corporation the prooeeds reoeived. 6. Resident Not ~iable for Servioes Rendered Under Agreement - Rssident shllll not be lillble to a health care provider for servioes rendered under the Agreement. In the event a he,lIltl1oare provider seeks pa~ent from Resident, corporation shall assume liability for payment of the health oare servioe" rendered, .if the health onr&set'vioes renclered, are services whioh corporation agrees to furnish under 'A<;Jreement, I. Exolusions - corporation does not pay for refrllotions, eye,-glasses, hearinq aide, presoriPti"on medioations, pOdiatry, dentistry I chmtures ,inlays, orthopedio IIpplillnoes, IImbulance __rvice, therapy for psychiatrio disorders, hospihliution, Phy,.ician servio,es, any services not provided in Seotion H.l. and the cost of oare for pre-existing conditions. When approved in w~itinq by Administrlltor, oare for pre-existing conditions shall be provided at the current daily rate for nursing care a~ a health center. ,.. pre-existing condition is a disease, "i:Llness, sickness or physical condition for whioh medioal care, adv~ce or treatment ,was reoommended bY or reoeived from a physician within the five year periOd preceding the date of admission. Pre-exist!nq oondit;l.ons ' Which constitute an exolusionare as followsl William Boston is totally exoluded due tome,dioftl history. J. Illness or Aocident away from Facility - If Resident Butfers an accident or illness while away from the facility/ Corporation shall have no responsibility to pay for Resident's medical, surgical, hospital, or nursinq care incurred or resultinq therefrom, until RelOlident returns to the lIotualoare of the Medioal Director, " K. Merital Illness - The faoility is not desiqned to oare for persons who are afflioted with mental illness. If corporation determine. that Resident's mental condition is such that Resident's cont;l.nued living in any acoommodation in the facility is either dangerous or detrimental to,th~\ life, health, safety or peace of Resident or other residents, t,nen corporation may transfer Resident to an institution Of corporation'S Choosing, sUbjeot to the Board of RevieW's deoision. SECTION 41 FEES 083093RlDS&C1 1'1~ESI3V'l'lmrllN HOMES, l:NC./OIUil\i1N RIDGE V;II..LAGE RlilSIOlilNC1U AND CARlilAGRElDMlllNT PLAN 1 Ii'AGlll 7 A. RlDSlPlDNOV INVlDSTMlDNT FElD ~ Resident shallp~y to ~copporation a ResiaenoyInvestment Fee comprised of the total of the ,\~ community Investment, HE!alth Servioe Investment, and , ,~~ Apartment/ccttage Investment. The total Residency Investment Fees 'of " ':,-1 ~,\I.:J, '. '18-9/'1l00"'00 is, made as ,follows I $1',000,.00 deposit made 12/8/93, II ~ 27,600.00 payment upon return of this agreement to corporation, and d, "'1 U J~~ U.,.OOOTOO upon oompletion of unit. If, two persons sign this " ,'-' ',' ,.... A9reem~nt as co-residents, the sums stated in this paragpaph oover , both persons. All funds, beginning with the reoeipt of the initial Of.WI?," payment, shall ear,n passbook savings rate interefilt until the final Y~llt \~~ payment is made. corporation reserves the right to reduoe or \_ II inorease the interest rate based upon market oondi tions. The lJ.' interest shall be paid in lump sum thirty (JO)dIlYs after ooo\,\pl1nl;JY. \1~\tJ' No in,terest shall be paid if oocupanoy ifil not ,taken when offered. No ~l"'\~ interest shall be paid on any deposit until the initial monthly I . payment is maae. The deposit will be refunded in full if the applioant resoinds tlli,s Agreement within seven days ,in aooordanoe with the terms of seotion 18 of this Agreement. If the Agreement is not resoinded within seven days, the deposit beoomes part of the entrance fliile and Oan only bliil, refunded in acoordancliil with ,.the terms d'f seotion B of this Agreement. B. MONTHI..'t FmlD - RE!sident shall pay to corporation monthly in advl1noe/ a Monthly Fee of $1,395.00. payment of the Monthly Fee is due on the established ocoupanoy date and upon reoeiptof a monthly liIt,atement fro\1l Oorp.oration.. Upon at least thirty days writteh noticet the,Monthly Fee may be adjusted to refleot. ohanges in,the o~st or doing business by corporation. The statement shall show the . amount due for the Monthly Fee and any other sUmS whioh are ohargeable to Resident. If any Monthly Fee or oharge is not paid within, sixty (60) days of delivery of statement, then corporation, subject to its subsidization policY and the provisions of seotion 4C o~ this agreement, may terminate this Agreement. Upon reasonable notioe, I1n allowanoe shall be made against'the Monthly Fee when Resident, while visiting or traveling, is away from the faQility for a period of at least seven, (7) oonseoutive days. It 'is the intent of Corporation that th~s MohthlyFee, with any adjustments thereto authorized under this AgreemC:lnt, shall remain In effect whether Resident remains in the living aooommodation or is permanently transferred to a health oenter or other facility authorized under this Agreement. Monthly fees may be inoreased or adjusted in aooordanoe with changes in the oost ,of providing the required servioes to Resident. C. Finanoial Indbility - ,To the extent funds ~re available, it is the pOlioy of Corporation to furnish finanoial assistanoe and, '&I\.\bj eot to tfl,e aooureoy of Resident's representations regarding his finanqial oondition, Resident shall not be dismissed nor this Agreement terminated$olelY beoause of Resident's finanoial inability to pay t,he monthly fee or, other oharges, provided Residant ire.ents to Oorporation faots which in corporation'S opinion, . ustify speoial finanoial oonsidera'ion. In,suoh eventj,oorporation n Oorporation's sole disoretion, shall partly or whollY subsidize Resident's mOnthly fee and other oharges, pr.ovided that suoh subsidy PREliI3Y'I'ERIAN 1I0MES, INC. /GHEEN RIDGE VIr..r..'\GE RESIDENCE AND CARE AGREEMENT Pr..AN ~ . ' PAGE 8 . can bl! liJrantect without impairing the ability of corporation to provide care to ,its other Residents. . D. Reduotion of Inoome - Resident shall make every reasonable effort to meet his financial r~sponsibilities to corporation. Resident represents that he has made no gift prior to the date of his applioation and will make no gift thereafter/ other than to corporation, whioh would substantially impair his ability or the ability of his estate to satisfY his finanoial responsibilitiss to Oorporation. If Resident's sources of income are inadequate to meet hb fiflanoiol responsibilities to Oorporation / he will make every reasonable effort to obtain assistanoe e~~ewhere and/ if he can qualify, shall take all neoessary steps to obtain federal, stat./ or munioipal aid or assistance. E. Subsidy by corporation - In the event Corporation sUbeidiz.s partlY or wholly Resident's Monthly Fee and/or other oharqes, any property of Resident which remains in his possession or oontrol at his death shall be transferred by Resident's personal representative, heirs, devisees and assigns, to corporation for the purpose of reraYing to Corporation (to the extent of the value of such property the subsidy ,fUrnished Resident by Oorporation. Thill Aqreement sha l,'operate as an assignment, transfer, and oonveyance to oorporation of such property, and may be enforced as a claim against Resident's estate. corporation may from time to time request finanoial statementlil from any Resident whose Monthly Fee is subsidized by Corporation. 1his subparagraph shall apply whether or not Resident is in residenoe at the faoility. . F. Co-Resident's Responsibility - In the oase of co-Resictents, each of them shall be jointly and severally liable for all payments whioh shall. be due hereunder. If one of the Co-Residents dies or leaves the faoility,the remaining resident shall be'responsible for the Monthly Fee as a single oooupant. G. Cost of Medioal Examination - Eaoh applioant for residenoy must be examined by the Medioal Direotor or other physioian . , dssignated by the Administrator and must make the results of the examination available to corporation. The cost of the physical . sxamination must be paid by the applioant. H. Shared Living Arrangement 083093RIDS&C1 1. Resident/Former Non~resident - In the eVent of a shared living arrangement or marriage of Resident, where a new partner dosires to beoome a Resident of the faoility, the new Resident shall be required to exeoute a separate Residenoe and Care Agreement and pay the differenoe,batween the Residenoy Investment Fee paid by the original Resident of the living unit and the our rent Residenoy Investment Fee. Further, the new Resident of the shared living arrangement shall be resp6nsible for paying the differenoe between ,. 083093RES&cCl 2. ,PRESB'{'l'ERIAN 1I0MES, INC ./GREEN RIDGE VILJ.,AGE: RESIDENCE AND CARE AGREEMENT Pl~N 1 PAGIll 9 the one and ,two person monthly fees for maintenanoe and servioes at said living unit. Resident/Former Resident .. In the event of marriage or other shared living arrangement between two Resiaents of the facility, an addendum shall be signed and attaohed to each Residence ahd Oare Agreement providing for, the fallowing I a. Resident vacating his/he,r living uni,t ehall receive any refund due in acoord with the original Residence and Care Agreement. b. The new Res,ident in the shared liVing arl;'angement being entered into shall pay the differenoe between the entrance fee paid by the original Resident of the liVing unit and the current Residency Investment Fee. ' " c. The new Resident of the Iilhared living arr~ng.l1I.nt shall be 'responsible for Paying the difference between,the one and two person Monthly Fees for maintenance and service with all other applicable maintenance and servioe fees then currsntfor two persons Sharing said accommOdation. SEOTION 51 TERMINATION OF AGREEMENT A., By Resident "At any time prior to occupanoy, Resident may terminate this Agreement upon delivery by Resident of notice to oor,p, oration. At any time during the probatiotiarY periC,d, ! ,Resident may,terminate th,is Agreement by delivery of written notlce to Oorporation and surrender of the living accommodation, such t.rminati~n to be effective upon suoh surrender. Resident rnayalso terminate this Agreement at any time after the conolusion of the probati,onar,y, peri,o,d bY, delivery of notioe at least thirty" (30) days prior to termination to Oorporation. In the event of termination after occupancy, any refunds will be made in acoordance with section 8 o~ this Aqreem~nt~ . . , , B. By oorporation - At any, time prior to Ocoupanoy, Oorporation may terminate this Agreement by delive~y of written nctlo,e to Resident. At any time duri,ng the probatio, nary periOd, or at any time if Resident is found td,have made any material , misr.presentation or omission in his application, Corporation, may terminate this Agreement by delivery of written notipe to Resident ettectivethirty (30) days atter delivery or upon the sooner !!Urrende, r of the liVing acoommodation. Corporation may termi"nate thi_ Agreement upon delivery of such written notioe. !f the ,Board of Review f, inds, t, hat: continued occupanoy of the living aocommodation Py Resident creates a serious threat to. the life, health, safety or peace of Re.ident or other residents or, persons on the premis.s, immediate termination of this Agreement may be neoessary. ,/ PRmSln"l'I~IUAN 1I0MES, INC. I GREEN RlDGEl VILLAGE \U1JSIDENCE AND CARE AGRInEMENT PLAN 1 PAGE 10 C. By Death - Unless sooner terminatec\ by Resident or, by oorporation, anc\ exoept: as to enforoing rights qrantec\ herein, this Agreement IIhall terminate at the c\eath of Res, ident and aUrrenc\er of living aooommodation. Any unused portion of a Monthly Fee shall be refuhc\ecl to the estate of Resic\ant. Ifthill Agreement has been siqn~~ by co-Residents, it shall remain in full foroe anc\ effeot as to th~ surviving or remainin9 Co~Resident. ' 083093RES&OI SECTION 61 SURVIVING OR REMAINING RESIDENT'S OPTION TO MODIFY AQ\UlEMlllN'l' . Upon the termination of th!SA9reement as to a co-relilident, the surviving or remaining Resident shall,have the option for a perioc\ Of sixty clays thereafter to eleotl A. TO retaih the same living aooommoc\at!on and payt:he Monthly Fee'for single ot;loupancy thereof, or B. To move to a smallerlivingaooommodation, if anc\ when available, and, after moving, to pay the Monthly Fee for single oocupa,noy in SUOh, living aooommodation. Failure to mak,8 an election within the option perioq shall be deemed an election under A. above. NO, option shall be given to a surviving or 'remaining Resic\ent who haa been permanently transferred to a health oenter or other authorized facility. SEOTION 71 TRANSFER TO OTHER LIVING ACCOMMODATIONS After oonsultation with the Resident andlor Resic\entls family or designatedrepresentativel Corporation may transfer Resident to another living accommodat on if it de~ermine~ th~t such ~ move ~hould be m~de for the benefit of Reeident, or for the proper operAtion of, the facility, or to. meet the requirements of laW. If ~e.ic\ent is transferred permanently to a health center or to any other faoility authorized under this Agreement, corporat~on m~y deolare Res qent's living accommodation vacant. The decision !!IS to the permanenoy of the transfer shall be mac\e by the Board of Review. SECTION 81 .REFUNDS OF ALL OR PART OF RESIDENCY INVESTMENT FEEl Upon ter!\lination of this Agreement, corpor!!ltion Shall):'efund the Residenoy Investment Fee in aooorc\ance with'the following provisions I I'; A. Refund During cotl~truction \' In tho event Resident ter,minates this Agreeme,n, t during cons~ruotion of apartment phase to Which the Resident hasappliec\ for ac\missiotll no refund to which Resident ie entitled ,lIhall be made until an equal number of apartment h~mes .has beenrellerved all the number reserved at the time Resident gave noticG of withdrawal to Corporation. In the event . that the refund is made more than ninety (90) clays after termination ")L . \~ ;f OB3093RES&Cl. . PIU1SU,/'!'WIUAN 1I0MlilS, INO./GHIl1\:1N RIDGE VILLAGlil RESIDENOE AND OARE AGREEMENT PLAN 1 PAGE 11 interest at the rate of the 2G week United states Government Treasury aill will be paid on deposits made to oorporation. . a. Termination by Death - In the event of death and surrender of the living accommodation during the first fifty (50) months of residency, the Residency Investment Fee shall be refunded less two (2) percent times .the number of months ocoupied plus any cost incurred by the health protection plan. After fifty (50) months of occupancy, there ahall Qe no refund. , C. other Termination - In the event either party terminates this Agreement prior to occupanoYl all moneys shall be refun~ed. If this Agreement is terminated by ether party after ocoupancy, all . money. .hall be refunded less a sum equal to ten (10) percene of Re.idency Inve.tment Fee or two (2) peroent of the Residenoy Inve.tment Fee per month of residenoe until surrender of living aooommodations, whichever is greater. After fifty (60) months of ocoupancy, there shall be no refund. D. Termination after Transfer - In the event a transfer of Re.ident to a health oenter or other facility authorized under this Agreement, prior to fifty (50) months of oooupanoy, the refund shall bel the balanoe of the unamoreized Residency Invesement Fee at the termination of this agreement less any cost inourred by the health' proteotion plan. E. Oo-Residents - If the entranoe fee has been paid on behalf of CO-Reeide~tsl one-half of the Residency Investment Fee shall be deemed to be pa d on behalf of eaoh Co-Resident. Unless (1) co-residents specify otherwise in writing, or (2) a court order is .erved upon corporation stating otherwise, any refund required to be made to co-residents under this Agreement shall be paid by a cheok made payable to Co-residents. . F. Due Date for Refund Payments - Any refund of the Residenoy Investment Fee shall be payable only when the living aooommodation of Resident has been surrendered and when oorporation has aooepted and entered into a Residence and Care Agreement with a new resident who has aooepted the living aooommodation formerly oooupied by R.sident. In the event of Co-Residents, refunds are made only upon withdrawal or the death of surviving resident. In the event of transfer, refunds are made after withdrawal or death of Resident, or in the oase ofOo-residency, upon the withdrawal or death of the survivinq resident. . . G. Release of Obligation - Upon termination of .this Agreement, Corporation shall be reloased from any further obligations to Resident except for payment of any refund due under this'Section 8. H. Taxation Disolosure - Tax oode ohanges enacted by congress may affect Resident's taxable inoome. The Internal Revenue Servioe may .1.nterpret the new law, pertaining to below-market interest rate loans, a. impo.ing an inoome tax liability on the refundable portion of the Residenoy Investment Fee paid to oorporat:l.on. The IRS might OB3093RES&Ol PRESnV'l'rnIUAN 1I0MES, INC./GnEEN RIDGE VILLAQIl RESIIlENCE AND cAnE AGREIlJMEN'l' PLAN 1 PAGE 12 tnat therefundab1. portion of this foe liS a loan from Ruident to QOFPoration and attribute to Resident reoeipt of interest inoome on the outstanding bahnoe of the fee, even though Resiclent cloes,' not. recei ve interest payments. Residem:, should oonsu1 t with hls , aoaountant Or attorney to determine how ohanges in the tax laws m~ght be applied. SECTION 91 ARRANGEMDlN'J'S FORlllSTATE A. Will and Funeral Arrangements Required - If not previously made, Resident, within one (1) month after the date of this ' Agre.ment, shall make a Will prOViding for the disposal of his furniture and possessions and/or appointment of an exeoutor of hi. estate, and make funeral and burial arrangements. , ., SECTION 101 RIGHTS AND OBLIGATIONS OF RESIDENT ~. Right of Self-Organization - Residents of the faoility shall have the riqhtof self-organization. The faoi1ity.shall hOld quarterly meetings whioh Resident may attend for the purpose of free disous.ion of sUbjeots whioh may ino1ude income, expenditure. and finunoial matters as they apply to thefaoility and proposed ohanges in pOliaies, programs, and servioes. At lsast seven (7) days' notice of eaoh quarterly meeeing shall be given. . 8. Right to Receive Disolosure Statements - corporation shall deliver to Resident at the time of the exeoution of this Agreement ana at least annually thereafterl the disOlosure statement ,requi, red by Aot No. B2 of 1904. (see Seot on 16) . C. Guest. Privileges - Resident shall have the right to have quests in his liVing aooommodation, provided that the period of visitation of any guest shall not exoeed two (2) weeks. D. ~iqhts to Property - The rights and privileges granted to Realdent by this Agreement do not inolude any right, title or inte!\~.,t i, n any part of the personal property, land, builcUngsllncl improvem~~ts owned or administ~red by corporaeion. E.Responsibility for Damages ... 'Any losElor damage to real or P.rsolla~ ,p,roperty of Corpo;t'aticn oaused by the fault, negligence, or Intentional misoonduct of Resident shaUbe paid for by Resident. At the,effeotive date of",termination of this Agreement, Resident shall vaoate the livinq acoommodation and leave it in good condition exoept forr~asonable wear and tear. In the event of the death of R..~dent, the estate of Resident "hall be liable for any 10118 oX' dame, g... If any fault, neg1igenoe or. intent, ional mi'sQondUct of ~8sident results in injury, illn~ss, or damage to any otheX' relic1ent, cQrporation a.ssl.\melil no responsibility therefor, and Rellident herebyre1eues and dlHohar?es Corporation trom any injury or damaqe to Resident or to Resident s personal proper~y oaused by the fault, neqUgenoe or intentional misoonduot of other residents. l'RmSO'/'l'mUAN 1l0MIUS, INC ./OnmmN IUDGE VILLAGE IWSIDENOEJ AND OAIUU AGREIilMENT PJ..AN 1 PAGE 13 F. RellPondlJi li tyfqr Protecticn of neliident' s Property - cot'poration shaUll9t be responsible for the loss of any property belon~ing to Resident or to n~dident's estatel for any oause, unless the oare and oontrol of said property is speo fioa1ly aooepted in writing by corporation, and then only for'laok of ordinary cars to eafeguard and aocount forsuoh property. Resident shall have the responsib, ility, at his own eXpense, of providing any insura,noe d..,irec1 by him to protect against any such loss. If Resident has . become unable to ocoupy the living aooommodation, or has died, or . this Agreement has been terminated tor any other reason, . Corporation , at Relilident , s o"ost, ma,' y remove all property t;lf ~esident from the' living accommodation and store the lIame, in whioh oase oorporation shall ,exeroise ordinary oare ,to proteot such proper,ty against theft or other loss While litored. If the property should be stored in a oommeroial litorage safehcuse, corporation shall have no rellponsibility for suoh propert,y thereafter. In the event of Rellident's death, any property of Resident in the living aooommodation or held .in storage lihall be delivered to ~esident'li perllonal representative, or if none qualifies within one (~) month after Resident's death, to any of Resident's next of kin. ' corporation will hold suoh property for suoh periOd at the risk of Reeident's estate orperaonli entitled thereto, subjeot ,to ordinary care by Oorporation in safeguarding the same until delivery oan be made. 083093RmS&C1. G. The parties named in this Agreement herelJy agree ,as followsl each party hereby releases the other from any claim or reoovery for any loss or damage to any of its property ,whi.oh ia insl.lred under valid and oolleotible insuranoe polioies to the sxtent of any reoovery oolleotib1e undersuoh insurance. It is further . agreed that this waiver shall apply only when permitted by the applioable pOlioY,of insurance. ' . H. Rights Cif.Resident a2;e Personal and Non-transferable - The rights and priVileges of Resident under this Agreement to the living aocomm~dation, faoilities, servioes, and medioai care provided for , herein are personal to him and oannot be transferred or assigned by aot of Resident, or by any prooeeding at law, or otherwise. No person other than Resident may occupy or use the living aooommodation cOVered' by this Agreement, except with the approval of corporation. I. ,Obligation to Obtain Insuranoe - Resident is ob1i9ated. to obtain and maintain insuranoe ooverage under the following planel Weclioure (A and a) and Blue oross/Blue Shield.G5 speoial, or the equivalent. If the eq\livalent plan benefit is less than ehe aforementibl1ed standard, Resi'dent shall pay the qifferenoe when claims are inourred. If Resident fails to, maintain this insuranoe, corporation has the right to terminate the Residen.ce and Oare Aqreement oonsistent wi,th the termination provisions,oontained her,in. In the event Resident laoks insurance ooverage, the costs of _killed nursing care shall be ,the responsibility of Resident. 1 . ii 2. 3. 4. 5. 6'. 7. 8. 9. 10. 11- 12. .13. 14. ;;J:NVElS{TO:aX State File Numoerl 2197-00944 Illstate of WIJ.LIAM M.BOSTPN, deoeased, late of Newville, Cumberland County, Pennsylvania. TO THill REGISTER OF WULS OF CUMBIllRLJ\ND COUN'!'\,, PIllNNSYLVJ\NIAI The following is a true inventory of all of the real and . peraonalestate of the above-named decedent (exoept for real estate outside the Commonwealth of Pennsylvania), taken and made by the und~rsiqned personal representative as required by chapter ,33 of the Pennsylvania Probate, Illstates & Fiduciaries Cqde, its amendments and supplements, (Aot. No. 164 of 1972, 'as amended) pursuant to Letters granted on Deoember 2, 1997., P!m.BONAL PROPERTY 1~0 shares Bell Atlantic @ 83.875 --~--~-----____$ 8,387.50 19,051 shares First Western Banoorp, Ino. @.,2"1.25 - ------..- - ---- ~ - - ------- -----__ - --$519,139.75 i. 200 shares Ford @ 48.125 -------------~---------_$ 9,625.00 200 shares Johnson & Johnson I 59.938 ------~---_$ 11,987.50 100 shares. Ohio Illdison @ 23.438 -'~-------------_$ 2,343.75 10,000 shares. Dauphin Cnty.@ 102.31 ------------$ 10,231.00 IRD on Item #6 -_--______~____________--------~__$ 154.90 10,OaOshares Jefferson Morgan PJ\ @ 102.77 -----.$ 10,277.00 IRD on It em # 8 - - - - -- - - - - - - - - - -- - - - - - _ - - - - - - - _ __ _ $ . 32 . 34 Presbytarian Homes, Inc. - refund -.__-___~---___$ 1,286.00 R. Cunningham Funeral Home - refund -------------$ 1,825.10 Blue CrpsS/Blue Shield - refund ------.;.---~-_____$ 1,785.56 2,170.767 shares Federated Max. Cap. @20.a6 ----$ 45,282.20 15,095.13 shares Cash Management' @ 1 ------------$ 15,095.13 HAKI CHIOK PAVAB~I AND RIMIT PAVMINT TCI REBISTER OF WI~LS CUMPERLAND CO COURT HOUSE CARLISLE, PA 17013 OUT AL.ONG, THIS L.ZNI ~ RITAZN L.OWIR PORTION POR VOUR, RICORDS ... 'iW:I.W~ij('-A~1I'-r&l':nrlQ&Yia',UtWYNHiRifI1ld'I-YAR-'iill'j1~'AYI.MI, NT-;-Ati.-cS, WAiJi, tl'I,-'llIf------------'-_.- DzsALL.oWANOI OP DIDUDTZOHS ANb ASSISsHINT OP ,TA~ ' ISTATIOF BO$TON WILLIAM M PZL.I NC. 21 97-0944 ADN 101 DATI 12-21-1998 TAX RETURN "ASI ( ) ACCePTED AS F~LeD (XI CHANGBD SEE ATTACHED NOTICE RISIRVATXON cbNOIRNINO PUTURI INTIRIST - SI. RIVIRSI APPRAISID VA~UI OP RITURN BASID ONI ORI6INAL RETURN 1. R.,l e.t.t. ISah.dUI. Al a. Stoak. ond Sand. (Sah.duI. B) I. Clo..ly H'ld staak/P.rtn.r.htp ~nt'r'lt ISoh.dul. C) 4. Hartg.g.I/Nat.. R.a.lv.bl. (Sah,dul. 01 S. C..h/8.nk D,pa'ltl/Hllo. P.rlan.l Prap.rty (Soh.dul. E) 6. ~ointlY Own.d praporty (Sah.dul. FI 7. Trln.f.r. (Sah.dul. 01 B, Tot.l AII,b APPROVID DIDUOTIONS AND IXIMPTIONSI 9. Fun.r.l BMP.n,"./Ad." COlh/Hha, bp.h... lBoh.dul. HI (9) 27,883.80 10, D.bb/Hortg.g. LhbUiUII/Lhn. ISohldul. ~I (101 .00 11. Tot.l D.duaHan. (11) '7 .RRll. RO lB. N.tVl1u.'OfT'MRlturn (2) 1,212,614.1B 11, Ch.rlt.bl./Oay.rn~'nt.l B.qu..t.) Non-.l.otld 9111 Tru.t. (Soh.dul. ~) (III .00 14." N.t Volu. of hht. Sub.l.ot to T'M 1141 1.212,614.18 NOTI. If.n ......m.nt w.. i'.U.d pr.viou.ly, lin.. 14, 18 and/or 16. 17 .nd 18 Will refl.ot figurll th.t inoludl the totel of 6kk rl~urne .......d to det.. ASSISSMINT OP TAXI 18, A"ount of Lln' 14.t Spall..l r.t. tl8) 847,076.23 X .00. 16. AMOunt of Lin. lq t.M.bl. .t Lln..l/Cl... A r.t. tl6)_ 365 ,1138,95 x' 06. 17, A"ount of Lin. l4t.M.bl. .t Call.t.r.l/Cl..I 8 r.t. (11) ,00 x.l~. IB, Prinoip.l T'M Du. tlsl TAX ORIDZTSI PAVHEHT DATE 15/ ,) Ie, ,,/ BUREAU Of INDIV~DUA~ TAXES IWI","I1INCI' lAM P1Y1811lfl UNit. n060 1 IIAHMIHlIJllO, "A 11111-0101 COMMONWIA~TH OF PINN8YLVANIA DIPARTHINT OF RIVINUI NDT~CE Of INHERITANCe TAX APPRA~SEHENT, ALLOWANCE DR DISALLOWANCE Of DEDUCTIONS AND ASSESSHENT Of TAX I r I . , DATI ISTATI OP DATI OP DIATH PI~I NUHBIR OOUNTY ACN 12-21-1998 BOSTON 10-22-1997 2l 97-0944 CUMBERLAND 101 AMount R.lliHed MANSELL Wij,TE AND MANSELL SUITI! 532 I 14 N MEROlER S T N6W CASTLE PA 16101 u,; '" :h -,,- .,J '-.) C~ (11 (2) , (5) (4) 18l (61 (71 .00 617.460.94 .00 ;00 201050.70 .00' 602,986.34 181 07-18-199B RECEIPT NUHUR 2 2 AA296441 AHOUNT PAID INTEREST IS CHARBEDTHROUBH 01-0B-1999 AT THE, RATES APPLICAB'LE AS OUTLINED ON THE REVERSE SIDE'OF THIS FORM TCTA~ TAX ORIDXT aALANOI OP TAX DUI INTIRIST AND PIN. TOTAL DUI . If PAID AFTER DATE INDICATED, SEE RBVERSE fOM CALCULATION OF ADDITIONAL INTeREST, " r *' ,~ u~.tt., U '" en.", WILLIAM M l NOTE I Ta in.ure proper oredit to yaur eooount, eubllit tho upp.r portion of thl. forM with your t.~ p'YMent. 1,240,497.98 .00 21, 932,34 ,00 21,932.34 21.686.90 248.44 10,06 288,80 ( IF TOTAL DUE IS LESS THAN .1. NO PAVHENT IS REqUIRED, If TOTAL DUE IS REfLECTED AS A "CREDIT" (CRI, VOU HAV BE DUE A REFUND. 8EE RBVERSE SIDE OF THIS FORH fOR INSTRUCTIONS.) ,- ~VREAU dF INDIVIDUAL TAKES llilltNl1IHCn TAM DIVISION fIt!,II. Ift06DI IIAHRlB~IIRO. I'A mll-OnDl OOHHONWEALTH OF PENNBYLVANIA DIPARTHINT OF REVINUI *~/ NouaE OF lHltERlTANCE TAK APPRAISeHENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAK UNItf".'~I".m MANsELL WHITE AND MANSELL SUITE B32 14 N MERCER ST NEW CASTLE PA 16101 DATE IlBTATE 1)11 DATR OF PlATH FUll NUHBIR OOUNTY AON 12-21-199B BOSTON 10-22-1997 l!l 97-0944 CUMBERLAND 101 A~OU"t R.~I U.d WILLIAM M L j MAKIOHIOK PAYABLI AND RIMIT PAYMINT TOI RE~IsTER OF WILLs CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 OUT ALONG THIS LINI .. RITAIN LOWIR~ORTION FOR YOUR RI00RD8 .. RW:I.W"''li"~W-f~'lf:n,)""A~Yf6'-, "6'If"Willlfff,l i"YIii!"~lI'jl~AYilW" A'--"~t'L1SQlWI"'liIi"""""."~'""""""-- DISAI.LDWANoj"oli DlI:P OTIOHS ANb ABBlI:ljSHlI:NT 0' 'fAX- . , IlSTATIl OF BOSTON WILLIAI~ M FILII NO, 2197-0944 AON 101 DATIl 12-21-1998 , TAK RETURN WASI I ) ACCEPTED AS FILED I X) CHANGED SEE ATTACHED NOTICE ~RIl~lhVATION CONORRHINO FUTUhR INTIRI8T'" BII RIVIRSI, ~,sAIBID VALUI OF RIl'l'URN IiASID ONI, ORIGINAL RETURN (.- I. R..I Bot-t. ISoh.dul. A) ~O':'I 2, sto.k. ."d Sond. IS.h.dull SI J ~;::l B, Clo..ly H.ld st.ok/p.rtn.rihlp Inhr..t (S.h.dul. C) ~4. Hortg.,../N.t.. R...lv.bl. (S.h.dul. 01 o a. C.lh/BlnkDIPo.HI/H,Io.. Plrl.nll Pr.P.rty ISohldul. E) _ 6, Jointly OW""dProp.rty (a.hldul. Fl. ~ ,~7. Tr,""f.r" (S.h.dul. G) ~ O. ' Tot.1 A...to APPROVID, DRDUOTIONS AND RXIlHPTIONSI 9. Fun...l Swp'"""/Ad~. COlto/Hho. SMP.nl" ISoh.dul. It) 191 10. D.bh/HortOlO. LllbUltll"/LI."" ".hldui. 1) 110) . 00 11. TotllD.duotl."" Ill) ~7.A93.RD 12, N.t Volu. of Tlk R.tUI'n 112) l,2121614.1B 15. ch.rUlblI/GOVor"".ntl1 Slquuh, 'N.n-.I..hd 9115 Trultl lS.hldull J) I1B) .00 14. N.t V.lu. of Bot.t. SUbj..t to TI. 1141 1 ,212,614.18 NOTE I If II, n .......m.nt Will :1.1', ued prev:l.IlUllly, l:l.ne. 14, 18 .nd/llr 16,17 .nd 18 w:i.11 r.fbot f:l.liIurll th.t :l.nlllude the totll1 Qf 6IJ.. return. ..,.....d ta'd.te. AS818SMIlNT OF TAXI 18. A".unt .f Lln. 14 It Sp.U.11 rata 11&1 847,01~.23 K ,00. 16. A..unt ofLlh. 14 bx.bl' .t LI"..I/ClI.. A rota 116) 36B , 538."[/X .04~: 17. A~.u"t of Lln. lq bw.bll It Con.brll/CI... P r.t. 1171 ,,60~K .lIS.' IS. PHno!pll' Tlx oU' 110) ;'1 TAX ORIDITSI ',1 PAYHHNT RECUPT DISCOUNT l+ I AHDUNT PAID .. : OATS NUHSER INTERHBT IPSN PAID (-) 1Ol~9 A^24267' I,OBO,OO 20,B20.00 07-18-1998 AA296441 .00 86.90 11) (el (8) (4) IS) 161 171 .00 NDTEI T. Inluro pr.p.r oradlt t. your ....unt, .ub~lt tho UPP'r p.rtl." of thll far" with y.ur tox p'y.'nt. 617.460.94 ,00 .00 20.0BO.70 .00 602',986.34 18) 1,240,497.9B 27,883.80 .00 ,~n19li2. 54 ,00 21. 932.34 , , r--) INTEREST IS CHARGED THROUGH 0~~OB-1999 AT THE RATES APPLICA8LE AS OUTLINED ON tHE REVERSE SIDE OF THIS FORM TOTAL TAX ORIlDrT BALANOI OF TAX DU. INTIRI8T AND PIN. TOTAL DUll 21,686..90 248.44 10 1,06 2S!l.80 · IF PAID AFTER DATE INDICATED, SEE RDVERSE FOR CALCULAtION CF ADDITIONAL INTERSST. IF TOTAl. DUE IS LESS TitAN U, NO PAYNENT 19 REQUIRSD. IF TOTAL DUE IS REFLECteD AS A "CABO IT" tCRI, YDU HAY 1& DUE A RnFUND, nap. RF,VERS& RtOP. OF TIllS FDRN FOR1NRTRUCnONs.) PA\'HIItT, 1It1"" tho lop ~rUon .f Ihll HoU.. ond .uboll .1Ih ~OlI' P.VlIIflI .ode p.~IIII. I. lhe n.. ond ~ru. prlnl'" on tho r.""r. .h... -- ~f IlIIl!IlIl!t lltlC8lllHt "",. Oheot< or _~ .td.r P'VO!!I. I., RaGISTeR Of WILLS. AlleNT. --If IIDll-ltll'IIlIHT lltlClllleHT Ilk. llho<lk 'r ....~ 'rlltr p.~IIII. 101 COHHONWaAL TH Of I'BHH'VLVo\lIU. ~ (ClIl' A rtfUnd .f . It. .r"'lI, llhlOh ... nol r.quellld on lhe T.. p.lurn, "V be ..""".11d b~ 0....1.11", on "AfltlII..t1on for Pof\lnll of P_.~IYonl. l\'herll..... ond 1lI1.1. T.." (Pll\I-ISISl. ApjlIl..t1onj... .Y.III11I. t\ \l1t DIll.. .f lhe P..I.I.r .fWlllt, onv .f lhe is P.v",", Pl.lrlol oW... .r fr.. lhe PtfIIt\ttnI'. 14-hour tnllfOrl.... "NIl.. nuobtrt for 'o!'ll. .rlltrll1fll, In ,Ptnn.VIYonl. 1-'DD-S41'IOID, OlIldllt P"".vIYtnlo ond .,I\hln 10001 Htrrlllllurg .r.. (717) 767-1094, TPO.' (7171 771'UII CHoorl", IoP.lrt'H>nI~'. RliPLV TO' Ou..\lon. r...rdll1fl orrol. .onlolned .n Ihll noli.. .hoUld be Ild1Ir....d I., PA Dop.rl..,,1 oU.v.""" aU"1II .f IndlYldutl T..... AtTM' po.1 'A......"'I k.vl... Unll. Dopl. teD601, Horrl.bur., PA 1711N601, P_ (7) 717-611I. ' PIICOUIIT, If on. It. duo I. p.ld "liMn Ihr.. (5) o.l.nd., .onth. ./tortho lIto.dont'. do.th. 0 fl"" Por....1 ('~) dl.oount 0' u,. \tII pold It .1Ill!ftC1; PlHAL TV. Tho IIIl( I" _.tv non-p.rtlolpoUon Ptn.lt. 10 ....ut.. on tho 101.1 .f lho tow ond Intor.ot .....Itd, tnd nol p.ld befol. "",""r~I', 19'16, the t1rlt 1It~ ./tor lho .nd,o' lho I.. _01. porltd. IHTIllllIT. Inlor..t II ohtr.... bttlnnll1fl .lIh flratd.. .1 d.llnqu'no~, or nln. c.) "nth. ond one II) d.~ fr.. tho IItt. .f dtoth, t. tho 1It1. .1 P."""I. T.... Nhloh beo_ IItUnquenl be'or., J""u..~ 1. 1.11 b..r Intor..1 .t tho r.t. .f II. ('~I po,....t por onnuo ..Ioul.tld .t ,,'d.lI. r.l. .f .000164. All to... "hloh beo_ d.lI_t "11 ond .lter Jonuorv I' I." .,111 ....r Inlor'.1 .1 0 rol. llhloh "IU yorv,'r.. o.londor .... to o.l.niI.r v..r "lth thot rot. -..oOIf b~ tho, PA Doport_t Of P'Y"hUt. Th.ot>pllo.bh Into...1 rot.. f.r 1911 throutll1 1m .... YOIrlnt,".t A.t. IloIlV Ihlor..1 P'otor - V..r Intirtlt Rat, ballv tntar.lt Faator - 1'$8-1991 IIX ,000501 1991 .X ,000147 1995-1'" 7X .0001.1 199&-I99a 'X .000147 1999 n .010191 1"1 lOX .001141 ItIS lOll .0004S1 1944 lit .OOOSII 1911 ISle ,OODlIl6, 19116 lOX .000174 lM7 OX .000141 --IM.r..t It olloulotld ._ f.II..., J~r · IALAHCBDF TAX UHFAJD M HU"JBR OF,DAYS DBLXHqUIHT M DAILY IHTBRBST FACTOR -'An~ Hotl" 1..uId .her tho t.. ........ 1It1l_1 .111 ,.".ot tn lnl"ut o.loul,"on 10 IIft_ (161 do~_ baVOndtho dot. of tho ......_1. If P.v_t It aid, .lIlr lhO Ihl"..' ....ut.tlon dot. __ on tho NOUN, .dcUUctnal tnt.rllt tIlt,t bt a.loullt*d, P\lRPo,a OF H<lTlCa, p~'I1\l!Hl' ~aF\lHO (C~II QaJtiCll\IH1I ~DHIH- l'l~mya CllllRaCll\IH., paH~L lY I IHla~asl, 10MIlII tho "qulr_nl' 0' "o\lon _146 (b) of Ih. Inhorll.noo .nd a.l.to 11. ~ol' ~.I n .f 19'6. (7E P.', ,.oUnn 91911. o.".h I'" I.p po,U.n 01 Ihl. HUUO' .nd ."".11 Wllh your p.y..nl 10 Iho Rogl.tor of will' prlnl.d "" tho rIY'''''', ,ide I ' __ w"" oh.ok 0' ,on.y ordor p,~.bl' I., RBOI,TRR Of MILL", AaaHT. ~ ,,11MIil .1 . \.. ."dlt ..y b. "qu..\.d bY .o.pl.ung .11 "~ppllo.Uon fo, Hofund of ponn.yl..nl, Inhorll""o, ond a.l.lo 1'." (~ay-mll. ~ppUo.\lon' or. ...llollI' .1 tho of/loo of tho HOIlIlor 01 Willi. .nY .1 tho as ~o..nu',nl.trlo' Ofll.o, .r fr.' Iii' n.p.rl..nt" 24-h.ur .n.w.rln, ..,vlo. nwob.r. '0' ,Dr.' .rd.rln" In p'M.ylv.nl. \_,o.-S"'2U., .ulOld. ponn.ylv,nl. .nd within 10..1 lIorrl.buro .ro. tll71 711-,.94, 10" (717) 171-UBI tII..rln,~ 1"".lrad,O,M). ~nY porty In Inlor..1 nol ..\I.fl.d wlW Iho ........nl of I.. .. .hown .n Ihll n.Uoo ..Y obl..t .lthln .I.IY (601 d'Y' .f i,o.\pt .1 thll ..Uoo bY, ' , --.,Itton pro\..t \0 tho p~ o.port..nt .1 ~...nuo. Boord .f ~pp..l.. n.pt. aal01l. ,,,rrhbur,. p~ 17121-1011, all __.\.o\lng \0 h.Y' th. ".ttor d'''"ln.d .t .udll pf \ho por..n.1 "pr...nt.II.., OR, ....pp.al to th' orphan,' Court poo\u.1 ."o,,"dl.oo.or.d on thll ........nt 'h.Uld b. .ddr....d In wrlUno tOI p~ o.p.rt..nt of H...ilIJ" ,ur..u .1 Indlvldu.1 I...., AHII' P..t A.......n\ R.vl.. Unit. n.pt. 16060\, lI.rrllburo, PA 17121-060\, PIID'" ,(117) 111-680a. '"' p.oo a .f th. bODkl.t "In.tr..u.n. I.r lnllorltln.o 1.. Hoturn I.r · H..ldont n...d.nt" (Hay-\aOl) lor an 'MPI.n.tl.n of .d.lnl.tr.tlvoIV ..rr'Dt.bl',.rrD'" lh. laX t.. .""oitY non-portl,lp.U.n p.n.IIY II .."".tod on \h. tDtol of tho t..'""d Intor..t .......d, ond not pdd bolora J""uorY ta, 1996, tho flrot d.y oltor thv ond 01 tho t.. ..nOlty p.rl.d. lhll non-p.rtlolp.llDn pon.IIY 10 .ppo.lobll In thl .... ..nnor .ndln th' tho .... UOI porl.d .. Y.u w.uld '.pp..1 thl to. .nd III\oroot that ha. heft' .,.Iued It 'ndlaattd 'on 'hh noUOI. Iddl\l.nol p.on.ylv.nl. a.\.to 10. .......d .. . ,.,ult .f . .hono' on tho Fld.,.1 a.t'I' 1'. olo.lno hUor b.o.... d.Unquon\..1 tho ..pl"U.n .f on. (1)' ..ntll f'Ob tho d.to tho fln.l nollo. of tho Inoro... in Fadere,l Blt.t, 'ax 11 ...atlVldi ,1'." ~hlDh b.....'d.llnqU.nl b.f.t'. J.nuarY I, 1911 bo.' lntor..t .llh' roto.f .1. t6X) po,oonl p.r annil' .,l.ul.t.d .1 . d.IIY rol.o,I .000I4~. All t.... wIlloh b..... d.llnqU.nt on .r .lIor J.nuarY I, "02 will boo' Inmoot " . rot. .hloh will vorY Ir.' ..Iond" y..r t. o.l.ndor y... .lth Ih., rolo announ..d by tli. PA n",lrt..nt of AIVI"UI, lnl IPppolbh int.r..t rlt.. for .9U through 1999 ,rll U!t lnt'tllt R.'tl pat1Y lnt.~..t F~ot(lr V,lr tntir..t Rltl pIny tnt.r..t Plotor - 190t 10~ I oooa~a 1900-1991 11i1, .000SOI 19a5 I6X .000.$0 1992 9X .000207 19M 1IX .000501 1905-199. 7X ,000192 , 190a U~ .00OS66 1990-1990 'IX .000207 1916 lOX .00017. 1999 7X .000192 1m 'X .00ot~7 ....In'.....t 11 ollou1tttd I' fol~WI1 ~HT~llaaT . 8ALAHoa OP TA" HPAIO " HU"8~R OP DAVS D~LIHqUBHT " DAILV IHTBIlBSTf~CTOIl -'Any H.UO' I..wod, ./1" tho t.. b...... dOlln".ont ,~lIl rofl,ol .n Inlor"l ..10.I.tI.n 10 I IIt.tn '(\0) doY' b.yonci Ih' d.to 0' Ih. ........nl. If ptYOInl II ood. ."" tho Intor"l ooooilt.Uon d'I' tho.n on 11\0 Mot1ae. ~ltlan.l l~t.r..t IUlt bl,OllGut.tadl