HomeMy WebLinkAbout04-23-07
.-J
15056051058
REV-1500 EX (Q6.05)
PA DeparlmenI of Revenue *'
Bureau of IndMduaI Taxes
PO BOX 280601
HanisbUIg, PA 17128-0601
ENTER DECEDENT INFORMAnON BELOW
Social Security Number Date of Death
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
County Code Year
21 07
File Number
00084
Date of Birth
183-09-0096
01/23/2007
07/27/1908
Decedent's Last Name
SuffIX
Decedent's First Name
MI
Burkholder
Hazel
N
(If Applicable) Enter SuJViving Spouse's Information Below
spouse's Last Name Suffix
spouse's First Name
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
.. 1. Original Return
2. Supplemental Return
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
..
48. 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 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 CONFlDEN11AL TAX INFORIIATlON SHOULD BE D1RECl'EP TO:
Name Daytime TeIe~~umber '"
___J
(731) 394-3453
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
1
8. Total Number of Safe Deposit Boxes
4. Limited Estate
Robert F. Burkholder
Firm Name (If Applicable)
f---}
REGISTER OF W1LL~~E O~Y)
-! c.~
First line of address
-'J
749 Boundary Blvd
Second line of address
City or Post 0fIlce
Rotonda West
State
FL
ZIP Code
DATE FILED
33947
07
749 Boundary Blvd Rotonda West, FI 33947
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056051058
15056051058
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--I
15056052059
REV-1500 EX
Oecedenfs Name:
RECAPITULATION
Hazel
N Burkholder
1. Real estate (Schedule A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1.
2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2.
3. Closely Held Corporation, Partnership or SoIe-Proprietorship (Schedule C) . . . .. 3.
4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5.
6. Jointly Owned Property (Schedule F) Separate Billing Requested .. . . . .. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) Separate Billing Requested.. . . . . .. 7.
8. Total Gross Assets (total Unes 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8.
9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9.
10. Debts of Decedent, Mortgage UabiIities, & Liens (Schedule I). . . . . . . . . . .. . . . . 10.
11. Total Deductions (total Unes 9 & 10). ... .. ... . . . ... . . . .. .. . . .. ...... .. . 11.
12. Net Value of Estate (Une 8 minus Une 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.
13. Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J) .. . . . . . . . . . . . . . . . . . . . . . . 13.
14. Net Value Subject to Tax (Une 12 minus Une 13) ... . . . . . . . . . . . . . . . . . . . . . 14.
TAX COMPUTATION - SEE INSTRUCTIONS FOR APPUCABLE RATES
15. Amount of Une 14 taxable
at the spousal tax rate, or
transfers under See. 9116
(a)(1.2)X .0_
16. Amount of Une 14 taxable
at lineal rate x.045 147,618.93
17. Amount of Une 14 taxable
at slbHng rate X .12
18. Amount of Une 14 taxable
at collateral rate X .15
15.
16.
17.
18.
19. TAX DUE............................. ."...........................19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
15056052059
Side 2
L
183-09-0096
Decedenfs Social Security Number
158,297.12
158,297.12
10,326.74
351.45
10,678.19
147,618.93
147,618.93
6,642.85
6,642.85
15056052059
-.J
REV-1500 EX Page 3
Decedent's Complete Address:
21
File Nlllllber
07 00084
DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUt.eER
Hazel N Burkholder 183-09-0096
STREET ADDRESS
129 Walnut Bottom Road
CITY I STATE TZlP
Shippensburg Pa 17257
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. CredilslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
6,642.85
332.14
Total Credits ( A + B + C ) (2)
332.14
3. InterestlPenalty if applicable
D. Interest
E. Penalty
TotallnterestlPenalty ( 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, Une 20 to request a refund. (4)
B. Enter the total of Line 5 + SA This is the BALANCE DUE.
(5)
(SA)
(58)
6.310.71
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
6,310.71
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;.......................................................................................... 0 [iJ
b. retain the right to designate who shaD use the property transferred or its income; ............................................ 0 [iJ
c. retain a reversionary interest; or.......................................................................................................................... 0 [iI
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [i]
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ............................................................................................................... 0 [i]
3. Did decedent own an oin trust for" or payable upon death bank account or security at his or her death? .............. 0 (iJ
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0 (iJ
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE rr 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. S9116 (a) (1.1) 0)).
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. S9116 (a) (1.1) (ii)]. The statute does not exemDt 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-ooe 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. S9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedenfs lineal beneficiaries is four and one-half (4.5) percent except as noted in
72 P.S. S9116(1.2) [72 P.S. S9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedenfs siblings is twelve (12) percent [72 P.S. S9116(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-1508 8<+ (6-98)
*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Hazel N Burkholder
FILE NUMBER
2007-00084
Include the proceeds of Htigation and the date the proceeds were received by the estate.
All property jolntly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION
1 M&T Bank King Street Office Shippensburg, Pa
Checking Acct # 20274270
CD# 4397079
CD# 4452360
CD # 31003915780413
CD # 31003915780405
2 Orrstown Bank King Street Office Shippensburg, Pa
CD # 4??oo12039
CD # 4??oo13847
CD # 4??oo13368
3 Personal Property
All personal property was sold at auction in September, 2006
VALUE AT DATE
OF DEATH
18,404.32
5,000.00
20,000.00
42,779.25
45,336.24
15,000.00
5,001.13
6,776.18
0.00
TOTAL (Also enter on Une 5, Recapitu/ation) $
(If more space is needed, insert additional sheets of the same size)
158,297.12
REV-1511 EX+ (12-99>.
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RElURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Hazel N Burkholder
RLE NUMBER
2007-00084
FUNERAL EXPENSES:
FogeIsanger-Bricker Funeral Home Shippensburg, Pa
Spring H~I Cemetery - Grave opening Shippensburg, Pa
Tim Wyrick - weekend fee- CemeteIy
Premier Events -refreshments for 90
rrEM
NUMBER
A.
1.
2
3
4
Debts or decedent must be reported on Schedule L
DESCRIPTION
B. ADMINISTRATIVE COSTS:
1. Personal Repl'8S8n1ative's Commissions
Name of Personal RepresenlBtive(s)
Social Security Number(s)lElN Number of Personal Repl'8S8n1Btive(s)
Str8et Address
City
Year(s) Commission Paid:
2. Attomey Fees
State
3. Family Exemption: (If decedenfs address is not the same as claimanfs, attach explanation)
Zip
Claimant
Str8et Address
City State . Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountanfs Fees
6. Tax Return Preparer's Fees
7. Postage, mMing, copies
TOTAL (Also enter on line 9, Recapitulation)
(If more space is needed, insert additional sheels of the same size)
AMOUNT
322.00
10,326.74
REV-1512 EX+ (12-03) ..
COMMONWEALTH OF PENNSYlVANIA
INHERrrANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENr,
MORTGAGE UABIUTlES, & UENS
ESTATE OF
Hazel N Burkholder
RLE NUMBER
2007-00084
Report debts Incurred by the dec:edent prior to death which remained unpaid as of the date of death, Including unreimbuned medal expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
PEBTF Medical Insurance Premium for January 2007
283.73
48.72
2
3
Chambersburg Hospital- final invoices
Choice Critical Care Pharmacy - final invoice
19.00
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
351.45
REV-1513 EX+ (9-00) *'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX REnJRN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
Hazel N Burkholder
FILE NUMBER
2007-00084
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS Of PERSON(S) RECEMNG PROPERTY Do Not LIst TI1IIt8e(I) Of ESTATE
I TAXABlE DISTRIBUTIONS [include oubighl spousal dislributions, and transfers under
Sec. 9116 (a) (1.2)]
1 Lisa Trampler 23925 Crescent Parte Ct Fernandina Beach, FL 32034 Granddaughter One half of 1/4
2 Timothy Burkholder 13904 Spring MiD Ponds Cir Carmel, IN 46032 Grandson One half of 1/4
3 Steven Burkholder 409 Westover Road Shippensburg, Pa 17257 Grandson One half of 1/4
4 Scott Burkholder 4593 North Isle Royale St Moofpark, CA 93021 Grandson One half of 1/4
5 Carole Crusey 90 White House Road Shippensburg, Pa 17257 Granddaughter One third of 1/4
6 Greg Jones RR 1 Box 765 McAlisterville, Pa 17049 Grandson One third of 1/4
7 Unda Keen 30 Clay Road Carlisle, Pa 17013 Granddaughter One third of 1/4
8 Robert Burkholder 749 Boundary Blvd Rotonda West, FI 33947 Son 1/4
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
n NON-TAXABlE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABlE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART n - 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)
~
~
~
JRZ - 5.1 burkholder.2 November 30, 2000
LAST WILL AND TESTAMENT
I, Hazel N. Burkholder, of Southampton Township, Franklin
County, Pe~nsylvania, being of sound and disposing mind, memory and
understanding, do hereby declare this to be my will, hereby
revoking any and all former wills and codicils thereto by me
heretofore made.
1'.)
C) =
I. SO ~
"." :0 c...
'- "~ :=~ ,....... '2::
).;..;..-~ c.:;... -...~,j
.~:~~~ ~ ;~~
I direct that all my just debts and funer~}c>~ycpenses(,-) r;
,)0"1'1 ~ -:l"'r,
,--'.r- -...;;. _.
including all expenses of my last illness, shall be :~~d fr~ ~y;~~
N .d
estate as soon as practicable after my decease as a part ~ the
expense of the administration of my estate.
II.
I give, devise and bequeath the residue of my estate of every
nature and wherever situate in four equal shares to be distributed
as follows:
A. One equal share to my son, Paul S. Burkholder;
B. One equal share to my son, Robert F. Burkholder;
C. One equal share to the children of my deceased son, Roy
L. Burkholder, namely Steven R. Burkholder and Scott A.
Burkholder, equally.
4
D. One equal share to the children of my deceased daughter,
Lois B. Jones, namely Carole Jones Crusey, Greg Jones and
Linda Jones Keen, equally.
E. Should any of the above-named beneficiaries predecease me
or die on or before the thirtieth day following my death,
their share shall be distributed to their issue, per
stirpes, living on the thirty-first day following my
death, and in default of any such then-living issue,
their share shall be distributed equally among the
remaining shares with beneficiaries surviving.
III.
Any fiduciary under this will shall have the following powers
in addition to those vested in them by law and by other provisions
of my will applicable to all property whether principal or income,
including property held for minors, exercisable without Court
approval, and effective until actual distribution of all property:
A. To retain any and all of the assets of my estate, real or
personal, without regard to any principle of
diversification of risk.
B. To invest in all forms of property including stock,
common trust funds and mortgage investment funds without
restriction to investments authorized for Pennsylvania
fiduciaries as they deem proper, without regard to any
principle of diversification of risk.
Page 2
~
~
c. To sell at public or private sale, to exchange or to
lease for any period of time any real or personal
property and to give options for sales, exchanges or
leases, for such prices and upon such terms or conditions
as they deem proper.
D. To allocate receipts and expenses to principal or income
or partly to each as they from time to time think proper.
E. To compromise any claim or controversy.
F. To distribute in cash or in kind or partly in each.
G. To hold property in their names without designation of
any fiduciary capacity or in the name of a nominee or
unregistered~
IV.
I direct that all taxes that may be assessed in consequence of
my death of whatever nature and by whatever jurisdiction imposed,
shall be paid from my residuary estate as a part of the expense of
the administration of my estate.
V.
I appoint my sons, Paul S. Burkholder and Robert F.
Burkholder, as co-executors of this my will.
Page 3
VI.
No bond shall be required of any fiduciary hereunder in any
jurisdiction.
IN WITNESS WHEREOF, I hereunto set my hand and seal to this my
last will and testament, consisting of five typewritten pages, the
first three of which bear my signature in the margin for the
purpose
of
identification
this
_Id~
day
of
~~ ef'~_-
, 2..tliM.
~y i/.B~ct.-
(SEAL)
Signed, sealed, published and declared by the above-named
testatrix as and for her last will and testament in our presence,
who in her presence, at her request and in the presence of each
other have hereunto set our hands as attesting witnesses.
/l/III &JfU,~/J~ kic/1,
9.V/J. !iaMklrw3ti~~{fA
We, Hazel N. Burkholder,
a/ f ft~~,
0e;/ /Zfir and
testatrix and the witnesses
the
respectively, whose names are signed to the attached or foregoing
instrument, being first duly sworn, do hereby declare to the
Page 4
undersigned authority that the testatrix signed and executed the
instrument as her last will and testament and that she executed it
as her free and voluntary act for the purposes therein expressed
and that each of the witnesses, in the presence and hearing of the
said testatrix, signed the will as witnesses and to the best of
their knowledge, said signer was at that time eighteen years of age
or older, of sound mind and under no constraint or undue influence.
jh~/iili~~
Subscribed, sworn to and acknowledged
before me by the above-named signer and
subscribed and sworn to before me by the
above-na~es this ~ day of
~ ,1~
. ;::~-
Not~y Public
Notarial Sea.
CIrIn L Wder, Notlry Public
Chlmb....burg Boro, Franklin County
My Commission expires May 13, 2001
Page 5
Welcome to M&T Online Banking
JANUARY 26, 2007
l\l&l 'v\eb Banking
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Accounts
Transfers
Bill Pay
ACCOUNT SUMMARY> CHECKING DETAIL
M& T Select Checking wi Interest
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Retated links: Transfers & Loan Payments I Upcoming Transactions ($O.OO)
View Statements I Sian UP for Electronic Statement Delivery
E~port Data I Qrder New Checks
Account
Select Checking 4270
rot,,1 Balance $18,120.59
Available Balance $18,120.59
View Calendar
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.111
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Last 10 Transactions . _ or _
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vDate Transaction DescrlptlQO
01/24/2007 CHECK NUMBER 2318
01/23/2007 TRANSFER FROM ACCT 031 003915780413
01/23/2007 TRANSFER FROM ACCT 031003915780405
01/22/2007 INTEREST PAYMENT
01/19/2007 WEB PMT EMBARQ
01/1712007 CHECK NUMBER 2317
01/0812007 CHECK NUMBER 2315
01/08/2007 TRANSFER FROM ACCT 031003914397079
01103/2007 US TREASURY 303 SOC SEC
01/02/2007 CHECK NUMBER 2313
CredltslDeblts
-$283.73
$182.77
$193.69
$1.55
-$25,64
-$26.00
-$19,91
$13.40
$1,127.00
-$1,875.00
$18,120.59
$18,404.32
$18,221.55
$18,027.86
$18,026.31
$18,051.95
$18,077.95
$18,097.86
$18,084.46
$16,957.46
Total Balance
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".T I.STATEMENTS
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Q 2007 Manufacturers and Traders Trust Company. Users ofthis web site agree to be bound by the provisions of the M&T Web Banking Terms and
Conditions. View the Terms and Conditions, Privacy Poficv or Securitv Information.
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Welcome to M&T Online Banking
JANUARY 26,2007
l\1&I\\eb&nking
Accounts
Transfers
Bill Pay
8kCO.!.!NT SUMMARY> CD DETAIL
12-13 Month CD
QHELP
Related Links: View Statements
Account CD (12-13 Month) 7079
Current Balance * $5,000.00
Interest Paid YTD $13.40
APY 3.200%
Current Term Opening Date 02/0812006
Current Term Maturity Date 02/08/2007
History for Current Term
vegst Date
01/08/2007
01/0812007
12/08/2006
12/08/2006
11/08/2006
11/08/2006
10/06/2006
10/0612006
09/0812006
09/08/2006
08/08/2006
08/08/2006
07/0712006
07/07/2006
06/08/2006
06/08/2006
05/0812006
05/08/2006
04/0712006
04/07/2006
03/08/2006
03/0812006
02/08/2006
Transaction Description
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
"RENEWED AT 3.15%, MATURES ON
02108/07
Amount
-$13.40
$13.40
-$12,96
$12,96
-$13.39
$13.39
-$12.96
$12.96
-$13.40
$13.40
-$13.39
$13.39
-$12.96
$12.96
-$13.40
$13.40
-$12.96
$12.96
-$13.39
$13.39
-$12.10
$12.10
$5,000.00
"Current Balance includes interest paid (not accrued interest).
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~ Mltl'Bank
C 2007 Manufacturers and Traders Trust Company. Users of Ihis web site agree 10 be bound by the provisions of the M& T Web Banking Terms and
Conditions. View the Terms and Conditions, PrivacY Policy or Security Information.
https://onlinebanking.mandtbank.com/history/HistoryCD. aspx?Id=2
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Accounts
ACCQUNT SUMMARY> CO DETAIL
Select Rate Certificate of Deposit
Related Links: Viel/l{ St~tements
Account Select CD 2360
Current Term Opening Date 10/0412005
Current Term Maturity Date 0410412007
History for Current Term
vPo_st Date
01/04/2007
01/04/2007
12/0412006
12/04/2006
11/03/2006
11/0312006
10/0412006
10/04/2006
09/0112006
09/01/2006
08/04/2006
08/0412006
07/0512006
07/0512006
06/0212006
06/02/2006
05/0412006
05/04/2006
04/04/2006
04/0412006
03/03/2006
03/0312006
02103/2006
02103/2006
01/04/2006
01/04/2006
1210212005
12/02/2005
11/0412005
11/0412005
10/06/2005
10/04/2005
Transaction Description
INTEREST PAID BY CHECK (DEBIT)
INTEREST PAYMENT
INTEREST PAID BY CHECK (DEBIT)
INTEREST PAYMENT
INTEREST PAID BY CHECK (DEBIT)
INTEREST PAYMENT
INTEREST PAID BY CHECK (DEBIT)
INTEREST PAYMENT
INTEREST PAID BY CHECK (DEBIT)
INTEREST PAYMENT
INTEREST PAID BY CHECK (DEBIT)
INTEREST PAYMENT
INTEREST PAID BY CHECK (DEBIT)
INTEREST PAYMENT
INTEREST PAID BY CHECK (DEBIT)
INTEREST PAYMENT
INTEREST PAID BY CHECK (DEBIT)
INTEREST PAYMENT
INTEREST PAID BY CHECK (DEBIT)
INTEREST PAYMENT
INTEREST PAID BY CHECK (DEBIT)
INTEREST PAYMENT
INTEREST PAID BY CHECK (DEBIT)
INTEREST PAYMENT
INTEREST PAID BY CHECK (DEBIT)
INTEREST PAYMENT
INTEREST PAID BY CHECK (DEBIT)
INTEREST PAYMENT
INTEREST PAID BY CHECK (DEBIT)
INTEREST PAYMENT
TERM CHG = 3.97%, MATURES ON 04104/07
'RENEWED AT 2.81%, MATURES ON
10/04/06
, Current Balance includes interest paid (not accrued interest).
Transfers
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rl:1 M&fBank
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Current Balance. $20,000.00
Interest Paid YTD $67.55
AP'( 4.050%
Amount
-$67.55
$67.55
-$65.36
$65.36
-$67.55
$67.55
-$65.36
$65.36
-$67.55
$67.55
-$67.54
$67.54
-$65.37
$65.37
-$67.54
$67.54
-$65.36
$65.36
-$67.55
$67.55
-$61 .00
$61 .00
-$67.55
$67.55
-$67.54
$67.54
-$65.36
$65.36
-$67.54
$67.54
$0.00
$20,000.00
Q 2007 Manufacturers and Traders Trust Company. Users of this web site agree to be bound by the provisions of the M& T Web Banking Terms and
Conditions. View the Jerm.lLamLQ.onditions, PrivacY Policv or Security Information.
https://onlinebanking.mandtbank.comlhistory!HistoryCD.aspx?Id=3
1/26/2007
Welcome to M&T Online Banking
,J.A,NU,A,RY 26,2007
M~r\\kb Banking
.....
ACCOUNT SUMMARY> CD DETAIL
12 Month CD
Related Links: View Statements
Account CD (12 Month) 0413
Current Term OpenIng Date 08/23/2006
Current Term MaturIty Date 08/2312007
History for Current Term
VPost Date
01/23/2007
01/23/2007
12/22/2006
12/22/2006
11/24/2006
11/24/2006
10/23/2006
10/23/2006
09/22/2006
09/22/2006
08/25/2006
TransactIon Description
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
DEPOSIT
. Current Balance includes interest paid (not accrued interest).
Accounts
Transfers
Bill Pay
Page 1 of 1
Sign Off
Customer Service
Can I View My
Account Statements
In Web Banking?
Yes, using Sta~ment
Y~w you can view,
print, and download
your recent
statements, including
your CD account
statements.
g IfEU'
Current Balance. $42,779.25
Interest PaId YTD $182.77
APY 5.148%
Amount
-$182.77
$182.77
-$176.86
$176.86
-$182.77
$182.77
-$176.86
$176.86
-$182.76
$182.76
$42,779.25
m M&I'Bank
C 2007 Manufacturers and Traders Trust Company. Users of this web s~e agree to be bound by the provisions of the M& T Web Banking Terms and
Conditions. VieN the Terms and Conditions, PrivacY Policy or Security Information.
https://onlinebanking.mandtbank.com/history/HistoryCD. aspx?Id=5
1/26/2007
Welcome to M&T Online Banking
JANUARY 26. 2007
M&r\\eb Banking
ACCOUNT ~UMM~RY > CD DETAIL
12 Month CD
Related Links: View Statemen~
Account CD (12 Month) 0405
Current Term Opening Date 08/2312006
CUrrent Term Maturity Date 08/23/2007
History for Current Term
vPost Date
01/23/2007
01/23/2007
12/22/2006
12/22/2006
11/24/2006
11/24/2006
10/23/2006
10/23/2006
09/2212006
09/22/2006
08/25/2006
Transaction Description
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
INTEREST TRANSFER OUT
INTEREST PAYMENT
DEPOSIT
. Current Balance includes interest paid (not accrued interest).
Accounts
Transfers
aillPay
Page 1 of 1
Sign Off
Customer Service
Can I View My
Account Statements
In Web Banking?
Yes, using ~l~t~ment
View you can view,
print, and download
your recent
statements, including
your CD account
statements.
\}HElP
Current Balance * $45,336.24
Interest Paid YTD $193.69
APY 5.148%
Amount
-$193.69
$193.69
-$187.44
$187.44
-$193.69
$193.69
-$187.43
$187.43
-$193.69
$193.69
$45,336.24
rsg M8tlBank
l!:l 2007 Manufacturers and Traders Trust Company. Users of this web site agree to be bound by the provisions of the M& T Web Banking Terms and
Conditions. View the Terms and Conditions, Privacy Policv or Security Information.
https://onlinebanking.mandtbank.com/history/HistoryeD. aspx?Id=4
1/26/2007
Orrstown Bank
King Street Office
77 East King St
Shippensburg, PA 17257
TRUTH IN SAVINGS DISCLOSURE
FOR TIME ACCOUNTS
D The interest rate will not be less than
or more than %.
D The interest rate will not
Terms following a rn apply only if checked.
Acct: 6-11 Month CD
Acct #: 4000013847
Date: NOVEMBER 07, 2006
~ The interest rate and annual percentage yield stated below
are accurate as of the date printed above. If you would like more
current rate and yield information please call us at
(717) 530-3530
This disclosure contains the rules which govern your deposit
account. Unless it would be inconsistent to do so, words and
phrases used in this disclosure should be construed so that the
singular includes the plural and the plural includes the singular.
~ FIXED RATE:
~ The interest rate for your account is 5. 05 % with
an annual percentage yield of 5.05 %. We will pay
this rate until first maturity
D The interest rate and annual percentage yield for your
account depend upon the applicable rate tier. We will pay
these rates
D VARIABLE RATE:
D The interest rate for your account is %
with an annual percentage yield of %.
Your interest rate and annual percentage yield may change.
D The interest rate and annual percentage yield for your
account depend upon the applicable rate tier. The interest
rate and annual percentage yield for these tiers may change.
Determination of Rate:
D At our discretion, we may change the interest rate on
your account.
D The interest rate for your account
D The fixed initial rate is not determined by this rule.
D The initial interest rate on your account
Subsequent rates
Frequency of Rate Change:
D We may change the interest rate on your account_
D Your initial interest rate will not change
We may change the interest rate on your account at that time
and thereafter.
Limitations on Rate Changes:
D The interest rate for your account will not
by more than each
~ Q 1992 Bankers 5ystems.lnc" St. Cloud, MN Form TSD-TIME 6/17/2005
1f
./
~tJ~/, I '3
0:..-
~ Ci. CL Va IvLL
%
the interest rate initially disclosed to you.
COMPOUNDING AND CREDITING:
rn Frequency - Interest will not
compounded monthly
Interest will be paid monthly
by check
rn Withdrawal of Interest Before Maturity. The annual
percentage yield assumes that interest remains on deposit until
maturity. A withdrawal of interest will reduce earnings.
rn Required Interest Distribution. This account requires the
distribution of interest and does not allow interest to remain in
the account.
rn Effect on Closing an Account. If you close your account
before interest is credited, you will
the accrued interest.
be
receive
MINIMUM BALANCE REQUIREMENTS:
rn To Open the Account. You must deposit at least
$ 5, 000 . 00 to open this account.
D To Obtain the Annual Percentage Yield Disclosed.
D You must maintain a minimum balance of
$ in the account each day to obtain
the disclosed annual percentage yield.
D You must maintain a minimum average daily balance of
$ to obtain the disclosed annual
percentage yield. The average daily balance is calculated by
adding the principal in the account for each day of the period
and dividing that figure by the number of days in the period.
The period we use is
BALANCE COMPUTATION METHOD:
rn Daily Balance Method. We use the daily balance method to
calculate the interest on your account. This method applies a
daily periodic rate to the principal in the account each day.
D Average Daily Balance Method. We use the average daily
balance method to calculate interest on your account. This
method applies a periodic rate to the average daily balance in the
account for the period. The average daily balance is calculated
by addin~ the principal in the account for each day of the period
and dividing that figure by the number of days in the period.
The period we use is
ACCRUAL OF INTEREST ON NONCASH DEPOSITS:
D Interest begins to accrue no later than the business day we
receive credit for the deposit of noncash items (for example,
checks).
rn Interest begins to accrue on the business day
you deposit noncash items (for example, checks).
MATURITY DATE:
rn Your account will mature on 08/07/07
rn Your account will mature in 9 MONTHS
D We may accelerate the maturity or call this account, at our
option,
(page 1 of 2)
Orrstown Bank
King Street Office
77 East King St
Shippensburg, PA 17257
TRUTH IN SAVINGS DISCLOSURE
FOR TIME ACCOUNTS
D The interest rate will not be less than
or more than %.
D The interest rate will not
Terms following a [}9 apply only if checked.
Acct: 6-11 Month CD
Acct #: 4000013368
Date: OCTOBER 04, 2006
~ The interest rate and annual percentage yield stated below
are accurate as of the date printed above. If you would like more
current rate and yield information please call us at
(717) 530-3530
This disclosure contains the rules which govern your deposit
account. Unless it would be inconsistent to do so, words and
phrases used in this disclosure should be construed so that the
singular includes the plural and the plural includes the singular.
~ FIXED RATE:
~ The interest rate for your account is 4. 99 % with
an annual percentage yield of 5.11 %. We will pay
this rate until first maturity
D The interest rate and annual percentage yield for your
account depend upon the applicable rate tier. We will pay
these rates
D VARIABLE RATE:
D The interest rate for your account is %
with an annual percentage yield of %.
Your interest rate and annual percentage yield may change.
D The interest rate and annual percentage yield for your
account depend upon the applicable rate tier. The interest
rate and annual percentage yield for these tiers may change.
Determination of Rate:
D At our discretion, we may change the interest rate on
your account.
D The interest rate for your account
D The fixed initial rate is not determined by this rule.
D The initial interest rate on your account
Subsequent rates
Frequency of Rate Change:
o We may change the interest rate on your account _
o Your initial interest rate will not change
We may change the interest rate on your account at that time
and thereafter.
Limitations on Rate Changes:
o The interest rate for your account will not
by more than each
~e '" 1992 Bankers Systems. Inc., St. Cloud, MN Form TSD-TIME 6/17/2005
11 ~ ?7~.1 ~
~t\ Q v' C\/IIU
%
the interest rate initially disclosed to you.
COMPOUNDING AND CREDITING:
[3 Frequency - Interest will
compounded monthly
Interest will be paid monthly
added back to the certificate
[3 Withdrawal of Interest Before Maturity. The annual
percentage yield assumes that interest remains on deposit until
maturity. A withdrawal of interest will reduce earnings.
o Required Interest Distribution. This account requires the
distribution of interest and does not allow interest to remain in
the account.
[3 Effect on Closing an Account. If you close your account
before interest is credited, you will
the accrued interest.
be
receive
MINIMUM BALANCE REQUIREMENTS:
[3 To Open the Account. You must deposit at least
$ 5, 000 . 00 to open this account.
o To Obtain the Annual Percentage Yield Disclosed.
D You must maintain a minimum balance of
$ in the account each day to obtain
the disclosed annual percentage yield,
o You must maintain a minimum average daily balance of
$ to obtain the disclosed annual
percentage yield. The average daily balance is calculated by
adding the principal in the account for each day of the period
and dividing that figure by the number of days in the period.
The period we use is
BALANCE COMPUTATION METHOD:
[3 Daily Balance Method. We use the daily balance method to
calculate the interest on your account. This method applies a
daily periodic rate to the principal in the account each day.
o Average Daily Balance Method. We use the average daily
balance method to calculate interest on your account. This
method applies a periodic rate to the average daily balance in the
account for the period. The average daily balance is calculated
by addinlil the principal in the account for each day of the period
and dividing that figure by the number of days in the period.
The period we use is
ACCRUAL OF INTEREST ON NONCASH DEPOSITS:
o Interest begins to accrue no later than the business day we
receive credit for the deposit of noncash items (for example,
checks).
[3 Interest begins to accrue on the business day
you deposit noncash items (for example, checks).
MATURITY DATE:
[3 Your account will mature on 07/04/07
[3 Your account will mature in 9 MONTHS
D We may accelerate the maturity or call this account, at our
option,
(page 1 of 2)
Orrstown Bank
King Street Office
77 East King St
Shippensburg, PA 17257
TRUTH IN SAVINGS DISCLOSURE
FOR TIME ACCOUNTS
D The interest rate will not be less than
or more than %.
D The interest rate will not
Terms following a ~ apply only if checked.
Acct: 6-11 Month CD
Acct #: 4000012039
Date: AUGUST 10, 2006
~ The interest rate and annual percentage yield stated below
are accurate as of the date printed above. If you would like more
current rate and yield information please call us at
(717) 530-3530
This disclosure contains the rules which govern your deposit
account. Unless it would be inconsistent to do so, words and
phrases used in this disclosure should be construed so that the
singular includes the plural and the plural includes the singular.
~ FIXED RATE:
~ The interest rate for your account is 5. 00 % with
an annual percentage yield of 5.00 %. We will pay
this rate until first maturity
D The interest rate and annual percentage yield for your
account depend upon the applicable rate tier. We will pay
these rates
D VARIABLE RATE:
D The interest rate for your account is %
with an annual percentage yield of %.
Your interest rate and annual percentage yield may change.
D The interest rate and annual percentage yield for your
account depend upon the applicable rate tier. The interest
rate and annual percentage yield for these tiers may change.
DeterminlJtion of RlJte:
D At our discretion, we may change the interest rate on
your account.
D The interest rate for your account
D The fixed initial rate is not determined by this rule.
D The initial interest rate on your account
Subsequent rates
Frequency of RlJte ChlJnge:
D We may change the interest rate on your account_
D Your initial interest rate will not change
We may change the interest rate on your account at that time
and thereafter.
LimitlJtions on RlJte ChlJnges:
D The interest rate for your account will not
by more than each
~ C> 1992 Bankers Systems. Inc.. St. Cloud. MN Form TSD-TIME 6/17/2005
1IJS; 000,00
\" , .
-'r-C\ GL 'vaJ u.J.---
%
the interest rate initially disclosed to you.
COMPOUNDING AND CREDITING:
~ Frequency - Interest will not
compounded monthly
Interest will be paid monthly
by check
~ WithdrlJwlJl of Interest Before MlJturity. The annual
percentage yield assumes that interest remains on deposit until
maturity. A withdrawal of interest will reduce earnings.
~ Required Interest Distribution. This account requires the
distribution of interest and does not allow interest to remain in
the account.
~ Effect on Closing IJn Account. If you close your account
before interest is credited, you will
the accrued interest.
be
receive
MINIMUM BALANCE REQUIREMENTS:
~ To Open the Account. You must deposit at least
$ 5, 000 . 00 to open this account.
D To ObtlJin the AnnulIl PeTCentlJge Yield Disclosed.
D You must maintain a minimum balance of
$ in the account each day to obtain
the disclosed annual percentage yield.
D You must maintain a minimum average daily balance of
$ to obtain the disclosed annual
percentage yield. The average daily balance is calculated by
adding the principal in the account for each day of the period
and dividing that figure by the number of days in the period.
The period we use is
BALANCE COMPUTATION METHOD:
~ DlJily SlJllJnce Method. We use the daily balance method to
calculate the interest on your account. This method applies a
daily periodic rate to the principal in the account each day.
D AverlJge DlJi/y SlJllJnce Method. We use the average daily
balance method to calculate interest on your account. This
method applies a periodic rate to the average daily balance in the
account for the period. The average daily balance is calculated
by addinf.! the principal in the account for each day of the period
and dividing that figure by the number of days in the period.
The period we use is
ACCRUAL OF INTEREST ON NONCASH DEPOSITS:
D Interest begins to accrue no later than the business day we
receive credit for the deposit of noncash items (for example,
checks).
~ Interest begins to accrue on the business day
you deposit noncash items (for example, checks).
MATURITY DATE:
~ Your account will mature on 05/10/07
~ Your account will mature in 9 MONTHS
D We may accelerate the maturity or call this account, at our
option,
(page 1 of 2)
~
cO.....ONWe....u.H 0' 'eNNSYlV..N'....
ge""UMeNT 0' .!VeNue
INH"ITAI'4C1 TAl[ DIVISION
I'OST O'''ce lOX 1317
H.....lIIS.U.C. ,.. 171C!.l,'U7 Pleas. Print or Type
MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETuRNED TO ABOVE ADDRESS
COtlNTY CODE FILE NUMBER SOCIAL SECURITY Q.J DEATH CERTIFICATE NUMBElt
':>00' I g ~- ()g - 009 \,a
DATE OF DEATH
lh
SAFE DEPOSIT BOX
INVENTORY.
.3 - c:F]
(STAT!)
PA
NAME, ADDRESS AND RELATIONS (IF ANY) TO DECEDENT, OFPERSON(S) PRESENT AT THe 80X opeNING
a. (N....ME) I (R~ONSH'P)
D l') 61 J\ ~ (:' f3...LU-J.~J.....(jJJ\. ~
(STRE~AOORESS) I ,
-..T::L q G<S\N~O---v., BJ v ~
10. (N....ME) 0-
Rokk W~
(STATE)
r::
(C/TYJ
R i) to~ l,0
(RELA TrONSHlp)
(STATE)
PI
(ZIP CODE)
3"?>Cf4]
(STREET ....~ORESSJ
(CI"N)
(STATE)
IllP CODE)
c. (NAME)
(RELA nONSHIp)
(STREETAQORESSl
-(Cl"N)
(STATE)
(ZIP CODE)
NAME AND 'ADDRESSOflFINANCIAI. INSTTT1JTJON WHeRE THE SAFE DEPOSIT 80X IS LOCATED
(NAME)
OA TE OF CONTRACT TO RENT BOX
3-,- q
NAME AND ADDRESS OF PERSON(S) HAVING ACc:E.SS TO BOX
a. LN.... E) 11..
~ A-tA~~
(STREET ....0 SS)
ISTp/1
(ZIP CODE)
17;).s
,. '1!n-6o "J. f g 1--<-.Y L ,J},j. ,
(snEET ....OORESSI
(CfTY)
(STATE)
(ZIP COD e) (CITY)
(STATE)
(ZIP CODe)
NAME AND mL; OF EMPLOYE TAKING J'HE INVEN ORY
AjOJv~
b. Nom. and add,... of personal '.presentative, if nam'" In tft. will
{N....ME} N I It
(STREET AOORESS,
(CITY)
(ST A TEl
(ZIP CODe)
C. Nom. and add,... of otto,ney, if any
(NAMEJ I\J 1ft
(STREET ....OORESS)
(CITYI
(ST MEI
Ill' COOE)
Page
SAFE DEPOSIT BOX INVENTORY
INSTRUCTIONS
(1) Cash: Report total only.
(2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are
to be designated by name of company, certificate number, date of certificate, name in which stock is registered,
and number of shares anddass of stock.
(3) Obligations of U. S. Gov.mm.~t: Number of items, dote of issue, face value, names in which registered
and type of ownership, i.e., jointly held, payable on death, etc.
(4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds)
(5) Bank and Savings and Loan Passbooks: State name of depositor, number ~f book, last date appearing in
book, name of bank and branch; and balance.
(6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as Fully as possible.
(7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: Ust and describe as
Fully as possible.
(8) All other contents.
\:
of
\
ITEM
NO.
ITEM DESCRIPTlON
I.
e<.
M. e \, .> ~ L. \f lS\...If' i")eI
Print Nam. and Titl. ^ A ~ .
-'~.l,,,, '. ,vlC-Jl\.~,
orrect, q,nd corppJete to the" best of my knowledge
,ii' \-j+e.J- LJ~Lf-
''}xi::. b i Id L h' kL Dot.
~~S
Signature
NOTE: Attach additional 8Y:z" x 11" sheet(s} if necessary or use duplicates of this page of form.
Robert F. Burkholder
749 Boundary Blvd.
Rotonda West, FL 33947
731 394 3453
February 27, 2007
Billing Department
Cbambersburg Hospital
PO Box 897
Chambenburg, Pa 17201
Re: Estate of Hazel N Burkholder
To whom it may concern:
Please find a check enclosed for $48.72 to pay for the balances due on accounts H 26716308
(October 20, 2006) and H 267 13057 (October 19, 2006) for Hazel N Burkholder.
According to your phone call today, there are no additional outstanding balances due from the estate.
Thank you for your response to my letter.
~
G:> ~ '1
Robert F. Burkholder
749 Boundary Blvd.
Rotonda West, FL 33947
731 394 3453
March 16, 2007
Choice Critical Care
10 South Sixth Street
McSherrystown, Pa 17344
Re: Account for Hazel Burkholder
To Billing Department:
Enclosed is a check for $19.00 to pay the final balance due for Hazel Burkholder. Today was the
fIrst time I had seen this bill, and you were kind enough to waive the $1.00 finance charge.
It is my understanding that there are no other charges pending.
Thank you,
.-... ..............-)
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