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Home My WebLink About05-31-07 -' 15056041147 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes PO BOX.280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death *' County Code Year File Number INHERITANCE TAX RETURN RESIDENT DECEDENT 2 1 0 5 00558 Date of Birth 177226173 05012005 12121929 Decedent's Last Name Suffix Decedent's First Name MI BALLOTS ALBERT (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name BALLOTS PATRICIA MI J 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 D 2. Supplemental Return D 3. Remainder Return (date of death prior to 12-13-82) D 4. limited Estate D 4a. Future Interest Compromise D 5. Federal Estate Tax Return Required (date of death after 12-12-82) [R] 6. Decedent Died Testate D 7. Decedent Maintained a Livin9 Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) D 9. litigation Proceeds Received D 10 Spousal Poverty Credit (date of death D 11. Election to tax under Sec. 9113(A) . between 12-31-91 and 1-1-95) (Attach Sch. 0) ~ORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: ame Daytime Telephone Numberc<' HUBERT X. GILROY 7172433:s41-' (_. ,'~~ . ,,_J Firm Name (If Applicable) MARTSON LAW OFFICES REGISTER OF WU.LS USE-.o~L y I 1 '..' , First line of address 10 EAST HIGH STREET ;1 Second line of address ~ ,-) c~, 0-' City or Post Office CARLISLE State PA ZIP Code 17013 DATE FILED Correspondent's e-mail address:hgilroy@martsonlaw.com ~nder penalties of pe~ury, I declare that,' have examined this return, including accompanying ~chedules and ~tateme!"ts, and t? the best of my knowledge and belief, It is true, correct and complete. Declaration of preparer other than the personal representative IS based on alllnfomnatlon of wlhlch pre parer has any knoWledge. SIGNATURE PERSON RESPONSIBLE ~FILING~ETYRN..# t";,{)E 10 ~ lots I" oad, Newville, PA 17241 OTHER THAN REPRESENTATIVE Hubert X. Gilroy 10 East High Street, Carlisle, PA 17013 Side 1 L 15056041147 15056041147 -' ~ --.J 15IJ5bIJ42148 REV-1500 EX Decedent's Name: AI bert Ballots Decedent's Social Security Number 177226173 RECAPITULATION 1. Real Estate (Schedule A).......................................................................................... 1. 2. Stocks and Bonds (Schedule B)............................................................................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3. 4. Mortgages & Notes Receivable (Schedule D).......................................................... 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E)................ 5. 6. Jointly Owned Property (Schedule F) 0 Separate Billing Requested............. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) 0 Separate Billing Requested............. 7. 8. Total Gross Assets (total Lines 1-7)....................................................................... 8. 9. Funeral Expenses & Administrative Costs (Schedule H)......................................... 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)................................ 10. 11. Total Deductions (total Lines 9 & 10)...................................................................... 11. 12. Net Value of Estate (Line 8 minus Line 11 )............................................................. 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J)................................................. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13)................................................. 14. TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, of transfers under Sec. 9116 (a)(1.2) X ~ 16. Amount of Line 14 taxable at lineal rate X .045 17. Amount of Line 1"'4tiiXable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 75,811.73 15. 0.00 16. 0.00 17. 0.00 18. 19. Tax Due..................................................................................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 L 15IJ5bIJ42148 68,000.00 511.25 38,056.74 106,567.99 25,770.26 4,986.00 30,756.26 75,811.73 75,811.73 0.00 0.00 0.00 0.00 0.00 o 15IJ5bIJ42148 --.J REV-1S00 EX Page 3 Decedent's Complete Address: File Number 21-05-00558 DECEDENT'S NAME Albert Ballots STREET ADDRESS 909 Spring Circle CITY I STATE IZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1 ) 0.00 3,000.00 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits (A + 8 + C) (2) 3,000.00 Total Interest/Penalty (D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 Line 20 to request a refund S. 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. 8. Enter the total of Line S + SA. This is the BALANCE DUE. (3) (4) (S) (SA) (S8) 3,000.00 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;.................................................................................. D ~ b. retain the right to designate who shall use the property transferred or its income;.................................... D ~ c. retain a reversionary interest; or.................................................................................................................. D ~ d. receive the promise for life of either payments, benefits or care?.............................................................. D ~ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?... ........................ .................................... ................ .......... ................ ............. D ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... D ~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation?..................................................................................................................... ~ D IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. ~9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. ~9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~9116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.S) percent, except as noted in 72 P.S. ~9116 1.2) [72 P.S. ~9116 (a) (1 )]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. ~9116 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-1502 EX+ (6-98) . SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Ballots, Albert FILE NUMBER 21-05-00558 All real property owned solely or as a tenant In common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which Is jolntly-owned with right of survivorship must be disclosed on schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Real estate - 974 North Locust Street, Hazleton, Luzerne County, PA, being recorded in Luzerne County, PA, Deed Book 1836, Page 1004. Actual sale price 68.000.00 TOTAL (Also enter on Line 1, Recapitulation) 68.000.00 (If more space is needed. additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA.1500 Schedule A (Rev. 6-98) Rev-1508 EX+ (6-98) . SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Ballots, Albert FILE NUMBER 21-05-00558 Include the proceeds of litigation and the date the proceeds were received by the estate. All property Jolnlly-owned with the right of survivorship must be disclosed on schedule F. ITEM NUMBER DESCRIPTION 1 Miledys Hernandez - Real estate tax proration received at settlement VALUE AT DATE OF DEATH 511.25 TOTAL (Also enter on Line 5, Recapitulation) 511.25 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev.1510 EX+ (6-98) . SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Ballots, Albert FILE NUMBER 21-05-00558 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM IIUNOF 'VI ,-", , y DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER INCLUDE NAME OF TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. 1 IRA Merrill Lynch Acct 87270766 - Beneficiary: 6.823.50 6.823.50 Patricia J. Ballots, wife 2 IRA Morgan Stanley Acct No. 433064714074- 31.233.24 31.233.24 Beneficiary: Patricia Ballots TOTAL (Also enter on Line 7, Recapitulation) 38.056.74 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) REV.1151 EX+ (12.99) . SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Ballots, Albert FILE NUMBER 21-05-00558 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. FUNERAL EXPENSES: DESCRIPTION AMOUNT See continuation schedule(s) attached 11,600.65 B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Social Security Number(s) I EIN Number of Personal Representative(s): Street Address City Year(s) Commission paid State _ Zip 2. Attorney's Fees Martson Law Offices 4,500.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Patricia J. Ballots Street Address 909 Spring Circle City Mechanicsburg 3,500.00 Relationship of Claimant to Decedent State Spouse PA Zip 17055 4. Probate Fees 193.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs See continuation schedule(s) attached 5,976.61 TOTAL (Also enter on line 9, Recapitulation) 25,770.26 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev.1502 EX+ (6-98) *' SCHEDULE H-A FUNERAL EXPENSES continued COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Ballots, Albert FILE NUMBER 21-05-00558 ITEM NUMBER DESCRIPTION AMOUNT 1 Krapf and Hughes Funeral Home - Funeral expense 8.880.83 2 St Peter & Paul Lutheran Cemetery, Hazleton - Grave opening 450.00 3 St Peter & Paul Lutheran Cemetery, Hazleton - Monument 780.00 4 St. Peter & Paul Lutheran Church, Hazleton - Funeral service 800.00 5 Thomas Ballots - Reimbursement, funeral clothing 40.89 6 Thomas Ballots - Reimbursement, Rev. Ohara 100.00 7 Thomas Ballots - Reimbursement, funeral reception 548.93 Subtotal 11.600.65 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-A (Rev. 6-98) Rev-1502 EX+ (6-98) *' SCHEDULE H-B7 OTHER ADMINISTRATIVE COSTS continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Ballots, Albert FILE NUMBER 21-05-00558 ITEM NUMBER DESCRIPTION AMOUNT 1 Broujos & Gilroy - Attorney fees 500.00 2 Martson Law Offices, costs advanced - Short certificates 12.00 3 Martson Law Offices, costs advanced - Stock valuation report 9.30 4 Real estate - Settlement charges to Seller 5.365.31 5 Register of Wills - Filing fee, inheritance tax return 15.00 6 Register of Wills - Additional Probate fee 75.00 Subtotal 5.976.61 Copyright (c) 2002 fOnTI software only The Lackner Group, Inc. FOnTI PA-1500 Schedule H-B7 (Rev. 6-98) Rev-1512 EX+ (6-98) . SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Ballots, Albert FILE NUMBER 21-05-00558 Include unrelmbursed medical expenses. ITEM NUMBER DESCRIPTION 1 Broujos & Gilroy, costs advanced - Income tax preparation, Boyer & Ritter VALUE AT DATE OF DEATH 90.00 2 Manor Care Health Services-Carlisle - Claim 4.896.00 TOTAL (Also enter on Line 10, Recapitulation) 4,986.00 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) REV.1513 EX+ (9-00) . SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF NUMBER Ballots, Albert NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal Clistributions, and transfers under Sec. 9116(a)(1.2)] RELATIONSHIP TO DECEDENT Do Not List Trustee(s) FILE NUMBER 21-05-00558 SHARE OF ESTATE AMOUNT OF ESTATE (Words) ($$$) I. 1 Patricia J. Ballots 909 Spring Circle Mechanicsburg, PA 17055 Wife Merrill Lynch IRA 6,823.50 2 Patricia J. Ballots 909 Spring Circle Mechanicsburg, PA 17055 Wife Morgan Stanley IRA 31,233.24 3 Patricia Ballots Trust 909 Spring Circle Mechanicsburg, PA 17055 Wife Entire residue 37,754.99 IDl'E: See attached staterrent Total 75,811.73 Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA.1500 Schedule J (Rev. 6-98) Thomas A. Ballots, Executor and Trustee under the Will of Albert Ballots dated February 21,2005, hereby certifies that pursuant to Item 1 in such Will, the residue of the Estate of Albert Ballots was held in an account (Morgan Stanley Account No. 433 072440074 ) for the priority benefit ofthe spouse of Albert Ballots, Patricia J. Ballots, until her death on September 2,2006. No principal or income was distributed to son, Thomas A. Ballots or daughter, Debora J. Ballots Humberston. Such account is included as an asset in the Estate of Patricia J. Ballots, Estate No. 21- 06-1068. Nonetheless, an inheritance tax payment in the amount of $3,000 was paid from the settlement proceeds ofthe decedent's real estate on or about October 7,2005, as a requirement of the buyer, as evidenced by the copy of Settlement Statement attached as an exhibit to the Inheritance Tax Return. ~~ 6-g~~ Thomas A. Ballots, Executor/Trustee Sworn to and subscribed this :ao-M dayof rrJllf ,2007. L~ f1tr'.L Notary Public COMMO~Df OF PENNSYLVANIA NOTARIAL SEAL ~ne L. Myers, Notary Public CarlisJe ~ugh, CumbcrIaDd County ~ex' 27,2011 F:\FILES\EST A TES\ 12383\2.intx.Slalemenl PC-I \ My Documents\Deeds\Ballots]aul Estate to Ballots_Albert DEED PREP ARA nON ONLY BY: Frank Bognet, Esquire 21 North Locust Street Hazleton, P A 18201 PH: (570)459-1700 Fax: (570) 459-1221 PIN: T8 NWll B7 L2 THIS DEED MADE, this /5 ''f1.. day of ~ v I.J ~ ,2005. BETWEEN: RONALD KUTCHMARICK, Executor of the Estate of PAUL BALLOTS, late of the City of Hazleton, Luzerne County, Pennsylvania GRANTOR and THE ESTATE OF ALBERT BALLOTS, late of 909 Spring Circle, Mechanicsburg, Pennsylvania GRANTEE WITNESSETH, That in consideration of One ($1.00) Dollar, in hand paid, the receipt whereof is hereby acknowledged, the said Grantor does hereby grant and convey to the said Grantee, his heirs and assigns, ALL that certain lot or piece of ground situate on the West side of Locust Street between Twentieth and Twenty-first Streets, in the City of Hazleton, Luzerne County, Pennsylvania, being lot Twelve (12) of Square No. Twelve hundred and two (1202) on the Plan of the Diamond Addition to said City of Hazleton, bounded and described as follows, to wit: BEGINNING at a point being the Southwest corner of Locust and Twenty-first Streets; THENCE (1) extending Southwardly along the West side of Locust Street a distance of thirty-two (32') feet to the Northern line of Lot No. Thirteen (13); 800k 3005 Page 152964 U1 .::.., !-j ;:: '.~I: ::l~"'" :::l:Z: ........ ":c ~~ '-, :.." .:c:: 'Jj ~ '..iJ:?= i,r; ::::.':J:::: z ,.5 i::j ,3 ..) '::-1 '~L .l.J .-1 ::r:: Ii'; ~ ;CJ::: ,;:. 1: W~l '-0 :i:: t<') '::: il. ,;:. 0-. "~' ~ ';0 ~ N ,;:: \"'j :,~, .z: i:'i a ':' (<') it! ~ :z ;''''l ~ ... ':' " 1""4 ._"" i..u c:::: , ....... >.::: ',f .:::;> ','4 II :J::: II ~ ;~ -0 ;:J ':"~ 1).:) W 3 ':r.;J~I'::':: IJ~I ':::J I..:) .::= .~ c: II .:J.j <I :;j l"'~ Jl. .:;:;, ..J ...> :;:;, .:;:;, "::J ...> :;:;, u-:, '::0 -' ::) ." :;:;, .=. ..!.... '..J .::. 'j'''') c"" l~"-t f<) i""~J (4.' .... ....... .~ .,. ..... .... .... .t- .... .... ... ,,," fl .~ i..l..J :c: ::;::l w '..1J lJ.... :-- :-l.L..:- !:::t ~ 1::::r ,-I..U ,- - ::c:: __~,_ ':>< 5~ ~3 St:J 3tt: 3~~ :=:~ '3,.;1 13 ~ I~ L.\- :~ !.,I- '3:= '..l.J :Z".J:: ',IJ ',I") ;::; .;3 t3 '~~ '~,::: '~~~.~ ~~ '~~:E r:t::: ~..z:--f L:' r:c::: ':t:::: ,:.t:J ':..::: \--1 _~,...... .x: <--1 -I :.2: ...... 1- '..I.J,::) '.J..J.-f '_u:..:c: '..u::r: ...LJ.on J: .J"');~ ...... ':.:' ,.....II~ ,"..' ,"', .........". ,'_.,....... sc.f/. A TJ.e-.A.../ THENCE (2) extending Westwardly along the Northern line of Lot No. Thirteen (13) a distance of two hundred (200') feet to the East side of an alley; THENCE (3) extending Northwardly along the East side of said alley a distance of thirty-two (32') feet to the Southern line of Twenty-first Street; THENCE (4) extending Eastwardly along the Southern line of Twenty-first Street a distance of two hundred (200') feet to a point, the place of BEGINNING. CONTAINING 6400 square feet of surface, strict measure. SAID PROPERTY is commonly known as: 974-976 Locust Street Hazleton, PA 18201 BEING the same property conveyed to Anna Ballots, Widow, a1k/a Anna Baloc, and Paul Ballots, her son, as Joint Tenants With Right of Survivorship, by deed of Anna Baloc dated September 16, 1974 and appearing of record in Luzerne County Deed Book 1836 at Page 1004. The said Anna Ballots died on June 18, 1984, whereupon title to the subject property vested in her son, Paul Ballots as Surviving Joint Tenant With Right of Survivorship. The Estate of Anna Ballots, a1k/a Anna Baloc, is filed in the Register of Wills Office at Estate No. 1054 of 1993. The said Paul Ballots died on July 1,2004 and Letters Testamentary were issued to the Grantor herein by the Register of Wills of Luzerne County, Pennsylvania, on July 20, 2004 at proceedings filed to Estate No. 1191 of 2004. In clause THIRD of his Last Will and Testament dated June 13, 2002, Paul Ballots specifically devised the subject property to his brother, Albert Ballots, the Grantee herein. The said Albert Ballots died on the 1 st day of May, 2005 and his Estate is filed in Cumberland County at Estate No. 2005 - 00558. TOGETHER with and under and subject, however, to such rights, privileges, benefits, easements, obligations, conditions, restrictions, reservations, terms, provisions and covenants, if any, as appear in prior instruments forming the chain of title to the herein conveyed property. TOGETHER with all and singular the buildings, improvements, ways, streets, alleys, passages, waters, water-courses, rights, liberties, privileges, hereditaments and appurtenances whatsoever thereunto belonging, or in any wise appertaining, and the reversions and remainders, rents, issues and profits thereof, and all the estate, right, title, interest, property claim and demand whatsoever of the said Grantor(s), in law, equity, or otherwise howsoever, of, in, and to the same and every part thereof. Book 3005 Pa!le 152965 2 THIS DOCUMENT MA Y NOT SELL, CONVEY, TRANSFER, INCLUDE OR INSURE THE TITLE TO COAL AND RIGHT OF SUPPORT UNDERNEA TH THE SURFACE LAND DESCRIBED OR REFERRED TO HEREIN, AND THE OWNER OR OWNERS OF SUCH COAL MA Y HA VE THE COMPLETE LEGAL RIGHT TO REMOVE ALL OF SUCH COAL AND IN THAT CONNECTION DAMAGE MAY RESULT TO THE SURFACE OF THE LAND AND ANY HOUSE, BUILDING OR OTHER STRUCTURE ON OR IN SUCH LAND. THE INCLUSION OF THIS NOTICE DOES NOT ENLARGE, RESTRICT OR MODIFY ANY LEGAL RIGHTS OR ESTATE OTHERWISE CREA TED, TRANSFERRED, EXCEPTED OR RESERVED BY THIS INSTRUMENT. THIS IS A CONVEYANCE pursuant to the terms of a Will and is therefore exempt from all Pennsylvania Transfer Taxes. See: Revenue Regulation 91.193(b)(7). AND THE SAID Grantor will Warrant Specially the property hereby conveyed. IN WITNESS WHEREOF, the Grantor has hereunto set his hand and seal the day and year first above written. Signed, Sealed and Delivered in the presenc f: ~ {SEAL} RONALD KUTCH ARICK, Executor of the Estate of Paul Ballots COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF LUZERNE Jf\ : ~ On this, the 15.:. day of -S UN, 2005, before me, the undersigned officer, a notary public, personally appeared RONALD KUTCHMARICK, Executor of the Estate of Paul Ballots, known to me to be the person whose name is subscribed to the within instrument and acknowledged that he executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. -- "1~= Ifcai~8tI7._ $~a./~1- ;X} fl-<h'k (Notary pu&H-c1 ' I; Book 3005 Page 152966 3 1("' I CERTIFY that the precise address of the Grantee herein is: c/o JOHN H. BROUJOS, ESQUIRE BROUJOS & GILROY, P.C. LJ. NORTH HANOVER STREET -{ CARLISLE, PA 17013 CERTIFIED PROPERTY IDENTIFICATION NUMBER MUNICIPALITY City of Hazleton PIN: Map T8 NW11 Block 7 Lot 2 Transfer ~ G'-2~- ~~ O.~ . " ping Clerk Date 800k 3005 Page 152967 -. 5- ~. .~. .''> ~pi>J','_._;:'!:.-O':3 cr:/ :0.,.~. ... '._ , , . I! ~ _~J:,~ ()~~,;..~..._..,~-:~~,,<S.~~~~ docun~'3nt is (f}corded in it1-.:: ....t:}-/ ~ ~\~'0~ R'" ~-:) fO'~-' ",\,-. H) : ~ r",c';~" .. 5=', : . ecoru...r 0 . t:eds ()rf:ce of ~ .J. ~...4-~~.' , .~ - Lu"erno r: t p ~ ~. -Y~1-..,.~;.(' ,?: '.' ..< Joun. y, ennsylvani2 ':. \~ ",;~" '~:'-. 'J J .:7 ,~ . ..,-~.,%~.,;, : ~.. ~"'''''---'~~~: C"':'f'/.'_.," ('\,. t1 n 1 ..<"(~\il\I~~\".."" ,,"_".lJ.-. . '''_''\(~.Y4/:'_J!)'^ ..~~~_~,,-.~~w).... :.. If :1,' ,",' \ ;;Y'SlESKI (;F DE1~n_',~ 4 A. Settlement Statement B. Type of Loan 1. 0 FHA 2. 0 FmHA 3. 0 Cony. uninsfFile Number -05-076 4. 0 VA 5. 0 Cony. Ins. C. NOTE:This form is fumished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked .p.o.c. were paid outside of closing; they are shown here for informational purposes and are not included in the totals. OMS No. 2502-0265 U.S. Department 01 Hou.illA and Urban Development ~ 1r Loan Number Mortgage Insurance Case Number D. NAME AND ADDRESS OF BORROWER: Mlledys Hernandez 6tU W. 17Bth Street Apf Basement, New York, NY 10032 E. NAME AND ADDRESS OF SELLER: Estate of Albert Ballots 16 Quarry Hili Road, Newville, PA 17241 Noe Hernandez ~~)r 17Bth Street Apt Basement, New York, NY F. NAME AND ADDRESS OF LENDER: Countrywide Home Loans 1017 Wyoming Avenue, Wyoming, PA 1B644 G.PROPERTY LOCATION: 974 N Locust Street Haz/eton, PA 1B201 H. SETTLEMENT AGENT: PLACE OF SEmEMENT: TIN: Can Do Abstrect Company 21 North Locust Street, Haz/eton, PA 1B201 23.1916400 I. SETTLEMENT DATE: 10107/2005 RESCISSION DATE: J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION 100. GROSS AMOUNT DUE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER: 101. Contract Sales PrICe "'68 ono.no 401. Contract Sales prtce $68 000.00 102. Personal Property 402. Personal property 103. Settlements charges to borrower: 403. (from line 1400) $3,861.21 104. 404. 105. 405. ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE: ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE: 106. Cltyltown taxes 10/07/2005 to 01/01/2006 $40.02 406. Cilyllown Taxes 10/07/2005 to 01/01/2006 $40.02 107. County Taxes 10/07/2005 to 01/01/2006 $94.83 407. County Taxes 10/07/2005 to 01/01/2006 $94.83 106. Assessments 10/07/2005 to 07/01/2006 $364.48 406. Assessments 10/07/2005 10 07/01/2006 $364.48 109. Sewer Tran.sm'l-10-7 to 12-31-2005 $11.92 409. Sewer Tran.sm'l 10-7 to 12-31-2005 $11. 92 110. 410. 111. 411. 112. 412. 120. GROSS AMOUNT DUE FROM BORROWER: $72,372.46 420. GROSS AMOUNT DUE TO SELLER: $68,511.25 200. AMOUNTS PAID BY OR IN BEHAlF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 201. Deposit or samesl money $1,000.00 501. Excess deposit (see instructions) $1,000.00 202. Prtndpal amount of 11M Ioan(s) $68,000.00 502. SelUemenl charges 10 seller (line 1400) $8,365.31 203. ExlsUng Ioan(.) laken subject to 503. ExisUng Ioan(s) laken subject to 204. 504. Payoll of first mortoage loan 205. 505. Payoll 01 second mortgage loan 206. 506. 207. 507. 208. 506. 209. 509. ADJUSTMENTS FOR ITEMS UNPAID BY SELLER: ADJUSTMENTS FOR ITEMS UNPAID BY SELLER: 210. Cltyllown taxes to 510. Cityllown laxes 10 211. County taxes to 5". County taxes to 212. Assessmenls to 512. Assessmenls 10 213. 513. 214. Garbage - 10-1 to 10-7-05 $2.72 514. Garbage - 10-1 to 10-7-05 $2.72 215. .. 515. 216. 516. 217. Seller to Pay Water to day of! Clsg 517. Seller to Pay Water to day of! ClsQ 218. 518. 219. 519. 220. TOTAL PAID BY/FOR $69,002.72 520. TOTAL REDUCTIONS $9,368.03 BORROWER: IN AMOUNT DUE TO SELLER: 300. CASH AT SETTLEMENT FROMITO BORROWER: 600. CASH AT SETTLEMENT TO/FROM SELLER 301. Gross amount due from borrower (line 120) $72,372.46 601. Gross amount due to seller (line 420) $.",511.2S 302. less amount paid bylfor borrower (line 220) $69,002.72 602. Less reductions in amI. due seller (line 520) $9,368.03 303. CASH ( 181 FROM) ( DTO) BORROWER: $3,369.74 603. CASH ( o FROM) ( 181 TO ) SELLER: $59,143.22 HUD.1 (3-86) - RESPA, HB 4305.2 SC H. A. ;:r:-Je.w-, I SCJ.I. C" .I~ I SCf-J. H. 1)-7 ~ ~ PAGE 1 H'lD-l (ROY 3186) L. SETTLEMENT CHARGES OMBNo2S02-o26S 700. TOTAL SALES/BROKER'S COMMISSION PAID FROM PAID FROM BASED ON PRICE $68,000.00 0 6 'II. $4,080.00 BORROWER'S SELLER'S FUNDS FUNDS DIVISION OF COMMISSION (LINE 700) AS FOLLOWS: AT AT 701. 10 SETTLEMENT SETTLEMENT 702. $4 080.00 10 Prudential LaJldDJark ProDertie. $1000 POC 703. SO.OO 10 704. $0.00 10 705. eommiuionpoidol--" ( $1,000.00 P.O.C.) $3,080.0c 708. 800. IIEMS I'AYABlt: IN GuNNt:G11",N vvllM LOAN: 801. Loon orig_ "'" 'II 10 Coun tzyvide HOfIUJ Loan.s 802. Loon diIcount 0.3750'11 '0 Countrywide HOfIUJ Loan. $255.00 803. ApprlliNl "'" 10: Landaa.te ($385 POC) ( $320.00 P.O.C) ($65.00) 804. CrodiI roporllo: Lancba.te < S35.00 PDq 805. L_."-ion roo Countrywide HOlDe Loan. 806. Mongogo ina<nnco oppIicoIion fwlo Countrywide HOIU LaaIa 807. Aooun1Jljon "'" Countz:yvide HOlDe L...... 808. Flood Certi.tioation - LaDCba.te Flood $26.00 809. 2'... Serrioe F_ - Countrywide 2'... Serrioe $90.00 el0. DoOUlUDt Preparation - Countzyvide HOllIe Loan. $375.00 900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE. l101.Inl....trom 10/07/2005 10 10/31/2005 0 902. MonO. inIur.-.ce prwnium for moa. 10 803. - inlu'1InOI premium lot 1. 00 yro. 10 Fa.r::mer. Fire In. 904. Flood inlurMCe premium for yr.. to 905. $12. 81/day $320.25 $559.00 1001. Hazard inlu-1InOI 1002, MorI~ 1lIU'.... 1003. City ptOpO<ty ,_ 1004. C"""'r ",-,y '-.. 1005. Amuae .....amenII 1006. Fbod ina..nnc. 1007. 1008. 1008. Aggregate Accounting 1100. 3.00_0 months 0 11.001llOlllh.O 11 . 00 monlh. 0 6.00_0 monlhs 0 -0 months 0 Escrow Adjustment $46. 58 1* IIlOIlIh $36. 831*monIh $13.961*_ $33.291* monIh $41. 371* monIh 1* monlh 1* monIh per monlh $139. 74 $153.56 $366.19 $248.22 ($439.00) 1101. SettIemMltordoling'-to Can Do Abatract C any - Electronic Pkge 1102. Abotrodotlillo_1o 1103. Title uarnfl8IQ\ to 1104. Title inannce binder 10 1105. Docum_ ~"jon to 1108. Notofy _10 1107.AItomoy._1o John H. Broujos, Esquire <-_item. Numbora: 1108. nloina<nncolo Can Do Abstraot Campany <-_,I....~: 1109.L_....... $68,000.00 1110. Ownot'...... $68,000.00 1111. Endors_ts 100, 300 7 8.1 1112. Lu.ze.rne Count 2Ir...urer - Tax Carti.t'ication "13. Portno.t'.t' WV Asaoe - School Tax CartiLication $50.00 Cloat Service Letter John Doyle P1Ulllbing Servioe - Un-rinted",e hOlU Can Do Abstraot C "n $35.00 $133.10 $300.00 $10.00 . ( $68,000.00 ) $68,000.00 ) $450.00 V M IN AND T FER HARG S: 1201. Rooording f_, ~ $43.50 : Mon_ $73.50 ; R.Ie.... 1202. Cdylalunty loxI.,ampa: ~ $680.00: Mongago 1203.S....IoxJ.'-: ~ $680.00 :Mon_ ;0_ 1~, Luzezne Count Treasurer - PIN Cert 1205. lIPS - OVernite Loan Pkge I OVemite Proceeds Cheok 1 .A I I L M N HA E: 1301. St.<voylo InoClllling Wire Fee 1302. _inopodionto Ha",leton City 2'... OLfioe - Dup 2'..... bill 1303. Gtr Ha",leton Jt Sever Autb - Final Sever 1304. CUmberland County Regi.ter o.t Wills - P"yment on Aoot - E.t o.t Albert Ballot. 1305. Ha",leton Ci t 2'..... O.tfioe - 2005 Sohool 1308. Ha",leton Cit 2'... O.t.tioe - 3rd , 4th Qrt Garba e 1307. John _0 - Lawn Maintenanoe $117.00 $680.00 $680.00 S20.00 $20.00 $20.00 $8.50 Borrower: $5.00 $12.31 $3,000.00 $496.40 $38.50 $150.00 $35.00 ~/ 105- Borrower: Date: The HUD-l Settlement Statement which I have prepared is a lrue and accurate account 01 this transaction. I have caused or will cause the funds 10 be disbursed In accordance with this statement. Date: Selllement Agent hu.l rh. ..J- {JIj Frank Bognet a Dala:/D /.~15- WARNING: It Is a aime to knowingly mel<e false statemenls to the United Stales on this or any olhsr similar form. Penalties upon conviction can includa a fine and imprison. ment. For de\aJIs sse: TiUe 18 U.S. Code Section 1001 end Section 1010. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA IN RE: ESTATE OF ALBERT BALLOTS, Deceased. ORPHANS' COURT DIVISION No. 21-2005-558 PROOF OF CLAIM Manor Healthcare Corp. d/b/ a Manor Care Health Services - Carlisle files this claim against the Estate of Albert Ballots in the sum of $4,446.00, for the value of nursing care and services provided to Mr. Ballots within six (6) months of his death, plus accruing interest at the highest rate permissible at law, and attorneys' fees and costs in the amount of $450.00. Respectfully submitted, SCHUTJER BOGAR LLC Dated: rlt~f05 By: C dwick . B ar Attorney J.D. No. 83755 (717) 909-5920 Rodney Alan Myer Attorney J.D. No. 89381 (717) 909-8160 441 Friendship Road, Suite 102 Harrisburg, PA 17111 SC:H. .I.;> -L ~ .x.. , I I ! \. Will r I, Albert Ballots, of909 Spring Circle, Mechanicsburg, Cumberland County, Pennsylvania, declare this to be my last will and revoke any will previously made by me. Item One: I direct that all my debts, medical expenses and funeral expenses including my g~.avemarker shall be paid from my residuary estate as soon as practicable after my decease as a part of the expense of the administration of my estate. Item Two: I give, devise, and bequeath my entire estate, both real and personal and mixed, to my son Thomas A. Ballots, in trust for the following purposes: to hold, manage, invest, and reinvest the income therefrom, to be administered in accordance with the following terms: --[ 1. All the net income and so much of principal as is necessary for the following purposes thereof from the trust during the lifetime of my wife Patricia J. Ballots, for her priority benefit and applied for her health, care, medical and mental care, long term nursing care, insurance, and maintenance, and for the health, medical, and mental care, and customary insurance benefits and maintenance of mobile homes and rental units of my son Thomas A. Ballots, and for the health, medical, and mental care, and customary insurance benefits of my daughter Deborah J. Ballots. with the priority of allocation of benefits among the two remaining beneficiaries determined by my Trustee. Upon the decease of my wife Patricia]. Ballots after my death, then the following disposition: ~ ~\J ,) ')j \; "- "~ (A) Trustee shall give and bequeath to Deborah J. Ballots a sum to be determined by my son "::.,. in his sole and absolute discretion to be identified as the "discretionary trust", not to be less than one-fourth nor to be more than one-third of the trust estate remaining at the time of my wife Patricia's death; he shall further determine how he shall distribute the sum in Trustee's absolute discretion; for instance, he may distribute the sums in a larger or smaller share over a period of time, not to exceed over ten years after the death of my wife Patricia J. Ballots, at which time my daughter Deborah J. Ballots shall receive the balance of her trust share; and the trust shall be closed. '1 (B) At the time of my wife's death, the remainder of the trust not identified as the "discretionary trust" shall be paid over to my son Thomas A. Ballots. (C) In the event that my son dies prior to the distribution of his share, his share shall be distributed to his wife Kathy Renee Ballots. Guardian shall establish separate guardianship accounts. Item Three: I appoint my son Thomas A. Ballots Executor and Trustee of this my last will. Should he fail to qualify or cease to act as Executor, I appoint my daughter-in-law Kathy R. Ballots, of 16 Quarry Hill Road, Shippensburg to act as Executrix and alternate Trustee with the same rights, powers, and duties. - "-., "'-.:.::::, ~ .. ':~ , .\ .,~, " .,....;, .,,~ .'~ -~ , ~. ~ Item Four: In addition to the rights and powers given to the fiduciaries by law or elsewhere in this Will, I give to my personal representative and Trustee, without any order of court and in their sole discretion, the following rights and powers: A. Retain any property owned by me at my death and to invest and reinvest in any property without restrictions to legal investments. B. Keep reasonable amounts of cash in bank and uninvested, as deemed advisable for the protection of principal. C. Purchase investments at premiums and charge premiums to income or principal or partly to each. D. Subscribe for stocks, bonds, or other investments; join in any plan of lease, mortgage, merger, consolidation, reorganization, foreclosure or voting trust and deposit securities thereunder; and generally exercise all the rights of security holders of any corporation. E. Register securities in the name of a nominee in such manner that title shall pass by delivery. F. Vote, in person or by proxy, securities held by it and in such connection to delegate its discretionary powers. '~~ G. Repair, alter, improve or lease, for any period oftime, any property, and give options for leases. H. Sell at public or private sale, for cash or credit, with or without security, and exchange or partition property and give options for sales or exchanges. I. Borrow money from any person, including my Trustee or personal representative, and mortgage and pledge any property. J. Loan money to, borrow money from, sell property to, buy property from, and exchange property with, and inter vivos or testamentary trust created or established by my wife *. K. Compromise claims. L. Add to the principal of any trust created hereunder and any property received from any person by deed, will, or in any other manner. M. Pay premiums on any life insurance, annuity, or endowment policies, which may have been retained or purchased herein and exercise any right, option or privilege thereunder. N. In the exercise of Trustee's discretion with respect to the use of principal for any beneficiary, taking into account other property and income available to such beneficiary; and in so doing, Trustee may conclusively rely on written representations made to it by such beneficiary, and judgment of my Trustee as to the amount of principal so used and the extent to which other resources are considered shall be conclusive as to all parties and interest. O. Advise in the use of expenses an losses as deductions for federal income tax or estate tax purposes, or partly for each, as they shall be deemed advisable, without adjustments between' income and principal in consequence of the exercise of such discretion. P. Make distributions in cash or in kind or partly in each. Q. The Trustee shall exercise all power, authority and discretion given by this instrument as to termination of any trust created herein until the same is fully distributed. Item Five: All estate, inheritance, succession, and other taxes, imposed or payable by reason of my death, and interest and penalties thereon, with respect to all property comprising my gross estate for tax purposes, whether or not such property passes under this will, shall be paid out of the principal of my residuary estate, without apportionment or right of reimbursement. In the event that a substantial portion, as determined in the sole and absolute judgment and discretion of my Executor, of any non-probate assets, such as an annuity or mutual funds, are directed to be paid to a beneficiary or beneficiaries, so that the taxes referred to herein would be paid out of the probate residue passing to the beneficiary or beneficiaries of this will (whether or not the same as the beneficiary or beneficiaries under the non-probate assets), my Executor, in the Executor's sole and absolute judgment and discretion, shall direct or have the right to allocate a full or partial payment of the taxes to the beneficiary or beneficiaries of the non-probate assets. Item Six: I direct that my personal representative or guardian shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand this b</ day of February, 2005. Signed ~ M{~ Albert Ballots The preceding instrument, consisting of this and three other typewritten pages each identified by the signature of the Testator was on the day and date thereof signed, published and declared by the Testator therein named as and for his last will, in the pr sence of us, who at his request, in his presence and in the presence of each other have subscribed, ur n es. t \ COMMONWEALTH OF PENNSYL VANIA ss COUNTY OF CUMBERLAND We, John H. Broujos and J})Cit10j m&V~, witnesses whose names are signed to the attached or foregoing instrument bemg duly qualified according to law, do depose and say that we were present and saw the Testator sign and execute the instrument as his last will; that he signed willingly and executed it as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testator signed the will as witnesses; and that to the best of our knowledge, the Testator was at the time 18 or more years of a e, of d minan der no constraint or undue influence. I U , ! i . . Notarial Seal Michele L. Portney, Notary Public Catli~le ,B(1f(i, CUn.'bcrland County My Comlnihlol/ Bxpll'C5 Apr. 17, 2006 Amoor, o(JnnB\l']l~~~;r. '1~~::'. .'ofNotaries Sworn and s}lbscribed to before me this ,}I day ofFe~""". 2005. ttJk~ ./ ;Z~c/ . NOTARY PUBLIC ~ COMMONWEALTH OF PENNSYLVANIA ss COUNTY OF CUMBERLAND I. Albert Ballots, whose name is signed to the attached document, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my last will; that I signed it as my free and voluntary act for the purposes therein expressed. ft)fIKj)-+ 6u!~-1;; Albert Ballots, Testator Sworn and affirmed to and acknowledged before me this d / day of February, 2005. /" . / ;to ~' , did , ~ V , NOT AR Y PUBLIC Notarial Seal Michele L Fortney, Notary Public Carlisle Borc. Cumberland County My Commission Expires Apr. 17, 2006 Member. fJe,m\r.(!var,;g JI..,,;sQf.;llltion of Notaries