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Home My WebLink About06-11-07 (2) ~ 15056051047 REV-1500 EX (06-05) PA Department of Revenue Bureau of Individual Taxes PO BOX 280601 Harrisbur , PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Securit Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT Date of Birth Decedent's Last Name Suffix Decedent's First Name MI (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW .. 1. Original Return ~ 2. Supplemental Return 1:) ~ 4. Limited Estate c;:) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required C) c::) 4a. Future Interest Compromise (date of death after 12-12-82) ~ 7. Decedent Maintained._'Living Trust (Attach Copy of~~ . C) 10. Spousal Poverty Cre-aft (date of death C) 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes = Correspondent's e-mail address: Under penalties of pe~ury, I declare that I ave examined this return, including accompanying s edules and statements, and to the best of my knowledge and belief, it is true correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. 07 170() DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051047 15056051047 ...J \ ~ .-J 15056052048 REV-1500 EX Decedent's Name: . ~ 'G4-\Olc;oJ 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) t=) Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) t=) 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/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ... . . . . . . . . . . . . . . . . . . . . . 14. TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 16. Amount of Line 14 taxable at lineal rate X.O ~ 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 19. TAX DUE. . ., . . . .. . . . .. . .. . .. . ..... .. . .. .. . . ., ... ................ 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15056052048 Decedent's Social Security Number 15. 16. 17. 18. t=) 15056052048 .-J REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME () . ---~~+\aL~ "-^.. STREET ADDRESS (\ riP, 3 o~ ~~___ \ lJjq~1 ~~ CITY File Number .~\(,~Q-~~-----_. S',~<t<C-1 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount t..f () 3.. (, )., (1 ) 3. InteresUPenalty if applicable D. Interest E. Penalty Total Credits ( A + 8 + C ) (2) -----~--~.- TotallnteresUPenalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. ,-\o~. (Q'l- B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5) (5A) (58) A. Enter the interest on the tax due. 401.. ~1... Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. ~klr:=:tu:: ~n:~::f ~~::property transferred;.......................................................................................... 0 Er' b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 g.....- c. retain a reversionary interest; or.......................................................................................................................... 0 ~ d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 c:;}- 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 W 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 G:J,/ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 [J/ 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 exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116{a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. 99116{a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~ :-f '"' ca.. ~cr REV-l508 EX. (1-97) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly+owned with the right of survivorship must be disclosed on Schedule F. ~ '<-&-to L"'O~ FILE NUMBER ITEM NUMBER 1. DESCRIPTION W~(H"OVI P.l BA~~ CoO~ ~S"1 \-\IGoU S1~~~1 ~o..US\. 'i ffi \101 J ~"1'c of / U"""1\l ~~t'\)C. ct. ~ A PA (l. -'1 M (N1 ~JLNI S-" '~<:,.s (. ~f~/ Ctttl).l~J \<.<(('L(~ ~j) ~~'7~N#Ac,tVT W. '"1\ VALUE AT DATE OF DEATH It I C\ '-I.). ~.O I 11 YtlD.OD ~. ~l t...\> ~ \)O.......A{).S -i \-\ ~Lf ~~L-A{l.~ f'l\u"", ~A~~7~ {)~te~17 (>0'( $ i!.So TOTAL (Also enter on line 5, Recapitulation) (If more space is needed, insert additional sheets of the same size) $ 19 903. s. , REV-1511 EX+ (12-99) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF CA,.", tl\'w\')~ ~.. N\<+to ~oJ Debts of decedent must be reported on Schedule I. FILE NUMBER ITEM NUMBER A. DESCRIPTION FUNERAL EXPENSES: '\ , .ffJ ,.. q Hot'f'~A"" RO"1" ~"'W~~ NO~~ - ~I 1.>."1. l.f ~~ N 1Ct\)uo..J (~(.w~".... fo~ ~41""" lJJ ~ ~7-j1."1O(. Cti""~ ..,~~ f"On. U3t(fe~ OM....Ht'\I~ "GI-Q~~w" OF GtA\)'e ANi} 6A-",,^,..,IC:.c:... F()lC. ~\~~.L W\4u. ~~ f"UM~A.&. Ittf;tcr~\.hV [...."1,S l-~30) A1 <1'I'.J 6/04.. 4:) ) ~, Wl~'7"'N"",^ ~1M.' (~~llo...) - f)'t:16~11 ,.... 1^cc""".fhA.c.. l'-'-~<~ '-t, W~MI*-"l~ C~ti.,M-'t 0.-131'0:"')- TN1CCA..~......, ~y..ll';.....u.CC..l p(h{j <C. \^-,h'\"7Li'\''''",''L ~Il~" (o"Io.J}q,,) ~ (b~\)~ SP~c.cr.. .)vr4A.&. VA-ua..'1 1. ", B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State _ Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State _ Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. P~UL. ~~tiM (~\)~L J ~'U L l-'\~"1<1-^. (~f~U~C{ HA-u\..~~ ?l. AMOUNT ~ ~ 7~q_ qLf 1!/ \ ) '3 OS.. , 0 If <},~.ao ~ S la, 00 ~ l, , !""l). aU ~ lP fl.J: Clb ..., ~/O. TOTAL (Also enter on line 9, Recapitulation) $ 10 7 ~7.() LJ If more space is needed, insert additional sheets of the same size / REV-1512 EX+ (12-03) SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Ctrn'~,.v~ ~. N '~OL&oJ Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 3. ~p l. ... ~~c...1.e..( c. ~C>~ __ \>~ N~ ~t \,..~ t'~~ ~t(j) l <Ac... (1o.{b(tt\'TluJ ~t.L.\l~O~C( M~t{A'" ~6M7(j /I. 7~ ,:J l-J 1. ~. q 3 9 . ~"3 (6 "" S. ~'1 Y. 4. Sta" , t TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) ~ C'1C'1 ....roe ~ ~trl S trlZ (j ~o~e ~ ... I"l ,.... '1C":1'1~O =:cS""':l"I'l"I'l ~~~s.~~~ 'ti:::r'C":I>~Z >oozCtrl ==CI.ll.,.. ~ [/)::1 ~ CI.l,... 8 ~q n ~ ~ w,QC":I~n~ '=0'-<.... W~=.,..l W'1'1.....trl ~1"lg.--3e~ o ~> ~ OL: I"l "I'lC'1 --3~ ~ trl trl [/l .... ~ .... It Z o N ....... I o --.J I o N Vl u~ .... [/l [/l ::: It ~ ~ .[:; ri ::T ....... .0\ N o o --.J n en '1:1~> mt:O?:' zmt""' z?:'cn 1Zlt""'t""' >-<::J>tTJ t""'ZI;)j <00 :J>n?:' zoo -c:;c >zo -3:r: >-<: roe ~ .... It o ~ n ~ ~ trl ~ Z trl ~ Z .... n ~ o roe CI.l o Z ~ [/l ,... ll: .... ~ o ~ r- ~ ~ ,1) ;;0 'J) tT: 'J) ....J ~ ~ ~ z )> ;:;:; -< ,. - ......... .-' ,---- REGISTER OF WILLS CUMBERLAND County, Pennsylvania CERTIFICATE OF GRANT OF LETTERS ,J / ..1~"'~ ',. ~, d~ '-", ' ,', ,'-. \ ::~ 'r '.). :; .,{ '.... . .. ,,,' J w ". .. .....,> ,. } , ..... to, ~ Pillt No, 2007-00253 PA No. 21-07-0253 Esta te Of: CA THERINE M NICHOLSON (First, Middle, Last) I '; 41 ~, "- " Late Of: CARLISLE BOROUGH CUMBERLAND COUNTY Deceased Social Securi ty No: 204-01-3358 WHEREAS, on the 16th day of March 2007 an instrument dated June 24th 1978 was admitted to probate as the last will of CA THERINE M NICHOLSON (First, Middle, Last) la te of CARLISLE BOROUGH, CUMBERLAND County, who died on the 12th day of March 2007 and, WHEREAS, a true copy of the will as probated is annexed hereto, THEREFORE, I, GLENDA FARNER STRASBAUGH Register of wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: GARY L NICHOLSON who has duly qualified as EXECUTOR(RIX) and has agreed to administer the estate according to law, all of which fully appears of record in my office a t CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 16th day of March 2007. JjJ~flrfa ~UlM , ~nd-a,~ Regis'ter 0 ills _~~/\ C~. (t ~ Deputy * *NOTE* * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) .--~ 1!Ictst ~ill cttth 'Q}tstctmtttf I, CATHERINE M. NICHOLSON, or the Borough or Carlisle, Cumberland County, Pennsylvania, do make and publish this as and ror my Last Will, and Testament, hereby expressly revoking any and all Wills and Codicils heretorore made by me. 1. I direct my Executor to pay all or my debts, runeral and administrative expenses as soon as convenient arter my decease. 2. Allor my property, real and personal, I give, devise and bequeath to my husband, PAUL R. NICHOLSON, ir he shall survive me. 3. In the event my husband, PAUL R. NICHOLSON, shall predecease me, then I give, devise and bequeath all or my property, real and personal, to my son GARY LEE NICHOLSON or Carlisle, Pennsylvania. Ir my said son should predecease me, then his share or my property shall pass to his issue who shall survive me, per stirpes. 4. I direct that ror the purpose or construing this Will, a person shall not be deemed to have survived me ir such person dies within sixty (60) days or my death. 5. I appoint my husband, PAUL R. NICHOLSON, as Executor under this my Will; or ir my said husband shall predecease me, rail to qualiry or rail to complete his duties as such Executor, ror any reason, I appoint GARY LEE NICHOLSON as alternate Executor under this my Will. I give to my Executor rull power and authority to sell and dispose or any and all property, real and personal, owned by me at my death, either at public or private sale, and upon such terms as he shall deem ror the best interests or my estate, and to make good and surricient conveyances in the law thererore; and rurther, I direct that no bond shall be required or my Executor ror the administration or my estate in any jurisdiction. I 6. I suggest that my personal representative retain the services of Irwin, Irwin & Irwin, Carlisle, Pennsylvania, as attorneys in the Isettlement or my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this .J'II:':: day of June, 1978. (I -J '~'7~) j i . ,rtj__Il.l-l A""-"--' ,y) , :L!!- (UI- -,-<tv 1C- . CATHERINE M. NICHOLSON (SEAL) Signed, sealed, published and declared by CATHERIN M. NICHOLSON, the testatrix above named, as and ror her Last Will and Testament, in the presence or us, who at her request, in her presence and in the presence of each other have subscribed our n es as witn~_f? es hereto. (} Iv.~ (,-(r..vv~ C], l7~<'4._., """ ~"""<"'~,,-~ , ... ACKNOWLEDGEMENT AND AFFIDAVIT We, CATHERINE M. NICHOLSON JOHN K. CURRIE and MARCUS A. McKNIGHT, III ,the testatrix and the witnesses, respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her Last Will and that she had signed willingly, and that she executed it asher free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testa~ix , signed the Will as a witness and that to the best of their knowledge the testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. I- L~~Jk.t~ '/)7.. .v;'1""c.I'-LI:..~/ CATHERINE M. NICHOLSON COMMONWEALTH OF PENNSYLVANIA ss: COUNTY OF C~lBERLAND Subscribed, sworn to and acknowledged before me by CATHERINE M. NICHOLSON , the testat rix , and subscribed and sworn to before me by MARCUS A. McKNIGHT, III June, 19 78 . JOHN K. CURRIE , and , witnesses, this Jytl-- day of /.~3 c0.,,-. r:I)I,:'".\ (.C,j( <',I t IVI'( (.1,,:':,(/11,:\:';' ~ II : ! ( i " . ~ I) i,L1ACHC:VIA E~~it.~K} J...L:...JiL ".,., .- ~ .l"!"ldncia 1 Center 1151:2: DEPOSIT TO ACCT# ri1110Ut'4T >',:XXXXX 1293 $19 .' 400~ '!"~ :, . '=""'.'-; _ '-' ~ '_ i; '..t....;, -- ....;::.,::.'; :- ~ - ~ - - -" '-'" '- ~, 't ':-. ' nK VOL For iY\Jur Busine::i::3 tJa_cho\J ia !, ",I l' ; . ~?.. WACHOVIA Business Checking 01 2000018111293 752 130 o 138 35.649 - - 0000787902 AT 0.54502 3DG 34 111,111",111"""11,,11,1,,1,,,.11,,11.,.11,11...,1,1.1,,1.1 ESTATE OF CATHERINE M NICHOLSON GARY L NICHOLSON EXECUTOR 105 LONG VIEW CARLISLE PA 17013 -- CB Business Checking 3/31/2007 thru 4/30/2007 Account number: Account owner(s): 2000018111293 ESTATE OF CATHERINE M NICHOLSON GARY L NICHOLSON EXECUTOR Account Summary Opening balance 3/31 Deposits and other credits Checks Closing balance 4/30 $18,032.12 33.99 + 257.27 - $17,808.84 Deposits and Other Credits Date 4/27 Total Amount Description 33.99 DEPOSIT $33.99 Checks Number Amount Date "osted Number Amount Date "ostea Number Amount Date "os ted 0993 0995* 38.93 28.34 4/05 0996 4/05 Total 190.00 $257.27 4/10 * Indicates a break in check number sequence Daily Balance Summary Dates Amount Dates Amount Dates Amount 4/05 17,964.85 4/10 17,774.85 4/27 17,808.84 WACHOVIA BANK, N.A., CARLISLE page 1 of 3 WACHOVIA Deposit Account Close Confirmation (Debit) WACHOVIA BANK, N.A. Date Customer Name(s) and Address Taxpayer 10 Number 05/31/2007 CATHERINE M NICHOLSON 8204013358 ONE WEST PENN APT 305 ONE WEST PENN ST CARLISLE PA 17013 ACCOUNT NUMBER: 1000294102085 Available Balance $28.01 Otg/Serv/Acct: 0751 DDA 1 2000018111293 PA Amount: $28.01 Name1 : ESTATE OF CATHERINE M NICHOLSON + Accrued Int : $0.00 - Fed W/Hd Due: $0.00 - Admin Fee: $0.00 - Outstanding Db : $0.00 - Transfer Total: $28.01 - Closing Fee: $0.00 U-- ~/ ~~. !'~ / '.. ~ .9caY- r:' .? ~~ i 1/- C/ >>",1"- . ~>V~ y~ ~.., . IV \ (~, "0; C7J 0\ '\^ ,j Paid To Customer: $0.00 5665)6 CUSTOMER COpy - ~,.,. ~~Z~ WACHOVIA Club 50 Checking 01 1000294102085 752 30 o 3 82,127 0002372401 AT 0,30801 3DG 83 ,," J" ","',"",",,",',',',,",,',',,',,",,', J'" ,,",,' CATHERINE M NICHOLSON ONE WEST PENN APT 305 ONE WEST PENN ST CARLISLE PA 17013 PB Club SO Checking Account number: Account owner(s): 1000294102085 CATHERINE M NICHOLSON 3/07/2007 thru 4/06/2007 = Account Summary Opening balance 3/07 Interest paid Checks Other withdrawals and service fees Closing balance 4/06 = $19,722.14 0.64 + 289.77 - 19,414.00 - $19.01 - - - - Deposits and Other Credits - - - iii - - - ~ - ~ !!1!!!!! -- Date 4/06 Total Amount Description 0.64 INTEREST FROM 03/07/2007 THROUGH 04/06/2007 $0.64 -- ~ ~ Interest Number of days this statement period Annual percentage yield earned Interest earned this statement period Interest paid this statement period Interest paid this year 31 0.10% $0.64 $0,64 $5.25 Checks Number Amount Date Number 1774 30.00 3/13 1778 1776 * 136.43 3/07 1779 1777 32.45 3/07 1780 Amount Date Number Amount Date 35.15 10.00 4.90 3/08 1781 3/20 1782 3/14 Total 12,50 28.34 $289.77 3/14 3/14 * Indicates a break in check number sequence WACHOVIA BANK, N.A., CARLISLE page 1 of 3 RF-485 EX + (3-04) '* SAFE DEPOSIT BOX INVENTORY COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 Please Print or Type MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS COUNTY CODE FILE NUMBER SOCIAL SECURJTY (Required) OR DEATH CERTIFICATE NUMBER (only If SSN is unknown) DECEDENT'S NAME ( ST, FIRST, MIDDLE) I 'N 't. ~. fJ, C-k....Ils. oA..i . ADDRESS OF DECEDENT (STREET) lJ (CITY) 10 5 LoN~ f~ ~,~IL NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX (NAME) DATE OF DEATH - /2-~'" MATE) (ZIP CODE) Vcz. " (STREET NAME) ~ ,c...,z.y L.,;\.I; cJ-. l S" '" I 0 5 L,,,, c. l}, €w (CITY) ~0;.1 <<t.. A.(STATE) (ZIP CODE) II CJ I NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING a. (NAME) /" (RELATIONSHIP) G:::>AIL-{ L. ;U I ~k.. l ~ cJ ;oJ Sa'/ (STREET NAME) (CITY) (STATE) (ZIP CODE) b. (NAME) (RELATIONSHIP) (STREET NAME) (CITY) (STATE) (ZIP CODE) c. (NAME) (RELATIONSHIP) (STREET NAME) (CITY) (STATE) (ZIP CODE) . NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED (NAME) wA-.J-..c 1) I A- (STREET NAME) &o~ I NAME OF PERSON MAKING LAST ENTRY &,Afl- l. N,~lS(j.AJ NUMBER OF BO~ "2.. ~<Y" NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX a. (NAME) g~ I(. EJ-, c,,*,- c; r- /,(CI'!:), 0TATE) (ZIP CODE) L,.ACvt. ,s/~ r~ ,')c)/ ~ DATE AND TIME OF LAST ENTRY ~ '-'-~-o, , TITLE UNDER WHICH BOX IS REQUESTED i~. AJ I c.~I~II...... ~~ b. (NAME) (STREET ADDRESS) (STREET ADDRESS) (CITY) (STATE) (ZIP CODE) (CITY) (STATE) (ZIP CODE) . NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY :j"; I \ ^,,+,.Jl ~ V\A.-b IL WAS A WILL IN THE BOX? 0 YES ~ NO If yes, a. Date of will: b. Name and address of personal representative, If named In the will (NAME) ~~ cu "i k{ ~:.-..-cu'i.i) - ~ I nJ 0 ., (STREET NAME) (CITY) (STATE) (ZIP CODE) C. Name and address of attorney, If any (NAME) (STREET NAME) (CITY) (STATE) (ZIP CODE) ------I ~>' (1 ) I (2) I (3) (4) (5) (6) (7) (8) ITEM NO. .I SAFE DEPOSIT BOX INVENTORY page-LofL INSTRUCTIONS The Department is authorized under federal law , 42 U.S.C. S 405(c), to use the decedent's Social Security number in administering this state tax law. The Department uses Social Security numbers to establish a decedent's identity and ensure proper credit for tax payments. Cash: Report total only. 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 l1umber of shares and class of stock. Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, Le., jointly held, payable on death, etc. Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) Bank and Savings and Loan Passbooks: State name of depositor,number of book, last date appearing in book, name of bank and branch, and balance. Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. Deeds, Mortgages. Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. All other contents. ITEM DESCRIPTION -~(?l.t.~ p(l~, If""I<.'\./ .01 S; u<;,.L DATE I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SIGNATURE PRINT TITLE CHECK APPROPRIATE BOX BELOW: L "A-.F ~l.s.q.;oJ NOTE: Attach additional 8'1z" x 11" sheet(s) if necessary or 'Use duplicates of this page of form. ~ .A-b~ ~(u. tJl CHECK APPROPRIATE BOX: ~xecutor(trix) 0 Administrator(trix) o Estate Representative D Joint owner o( safe deposit box April 24, 2007 Gary L. Nicholson 105 Longview Carlisle, P A 17013 Hoffman-Roth Funeral Home & Crematory, Inc. 219 North Hanover Street _-----~_ Carlisle, P A 17013 r- ' -----, ""j (717)243-4511 (f' i,\ ~ C) 'to ,"\ ,,,Q) c.. " ,,\cP C\" .'\ )- O~:x L .y ~:J, The Funeral Service for Catherine "Katie" Nicholson 14993-65 We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. OUR SERVICE: Traditional Funeral Service Package . . . . . . FUNERAL HOME SERVICE CHARGES $3990.00 $3990.00 SELECTED MERCHANDISE: Viceroy Caske\ . . . . . . . . . . . . . . . . . . . . . . THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THATYOUHAVESELECTED . . . . . . . . . . . . . $1060.00 $5050.00 Cash Advances Newspaper Obituary Notice- Sentinel . Newspaper Obituary Notice - Patriot News Clergy Offering . . . . . . . Certified Copies of Death Certificates. Flowers-Caslet Spray. . . . . . Hairdresser. . . . . . . . . $100.80 $218.14 $100.00 $48.00 $183.00 $30.00 TOTAL CASH ADVANCES AND SPECIAL CHARGES. $679.94 Total Total Cost . $5729.94 TOT AL AMOUNT DUE $5729.94 This statement is net and payable in full within 30 days of receipt. ::l o .... ~Q:; Q,l . .... .. Q,l- S .!!l ~i:~ U c:l~ t . ~ t; ." ~ .: !::; si:l:.... .... .. "'= Q,l .- ~ ; .. z "" :!.! - Q z ... o '" - <( S e - ... !: Q z z: ~ 0 Q <( i!: ~ Q Q z <I: Z o ;:: <I: N ;a o '" I- ;, <I: I- Z ... :;; III :;; i: z ... f:; Z '" :;; lZ '" l- i!: i ! I J '6 tj '. ~ I '.'~ i g, '~. t{) cy.p (~~ 0- r/'? <" . ~ 'j, {~:,~ .Q (~ ..::> ? ~ (oJ, ~ \0..;.- ~I/~~ ~~ ~ \''''~(j ~ 4-~ ~ l' /~^ /'/' / ,..... ~ 'f-----..---.. +- '\. .~ \.rt "'" z ~ ~ ~ ~ ~ I~, k~l) I "JI I .", ~ ! ~~ e ~!k I I ~Ir-I! z: ~ '"\J I ~ \~~I I ::;: \.i ~~ ~ ~~@ , o '" < .. z: ~ z: ... ~ ... I- i5 ~ ~ ~ ! ~ ~ z ~ ., o " S o ~ <5 ~ ! 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'..' - Osiris Holding of Pennsylvania ~~~~~~I:~~~~~:c.~?I~n~on~~~n~~~ ~~~~~ity A~reement 740 WVlltlallll"rC Road IIW NCWVlllt' Road Lcwl~hc'Tv, P^ 17.1.1<) C;lrl;.~k, PA J701~ 717-9.18-.1'435 717.249-2029 THIS AGREEMENT. made hy and hclween Seller nod . 81';flt I ~ tJ. 1l4.'t:4t.iJ:;;;~---- (l'le:t~l'rinl) (ocreinafter call1.!d the "Purchaser") WITNr:SSEllI THAT Pun.~ha.,('r agrees to huy and Seller agrees [0 ~dl to Pun:hascr, or his deslgnall'tl hcncficlary In accordance with the terms hl'n'Of, the fnllnwlll~ items 10 he providL-d or IlS00 allhe ahovc chcdcd location (heremafter called ''Cemetery''). In consideration for Seller hinding il!>Clf 10 provide the iicms with. 0111 rC~<lrd 10 the actual (ost and pnee of said ilt'ms preVailing at the time of performance ncreunder. Pun.:ha.';Cf agrees thallhis AgrCt~m('nt shall ~ irrevocahlc. I. DRlolCRIPTION OF RURIAL RJ(an'S. The BlJnal RI~hls covef~d hy the Al-->recm~nt ;m: ~h()wn hy the map of \UI:h gardenlhUlldmg on file in the office of lhe CEMETERY, and ;Irc mllfe particularly dC\i:rihcd helow. The pllrrha~ pril"t' of Rurial RiJ=ht~ does not include InlermentIF.ntomhlllt'ntllnumment Fm (opt'nin~ and dosin~ eost5). _ flurial Ri~hls in _ (;rave Space(s) _ Lawn Crypt: Douhle D('fHh SJdc-hy-SHJC SIngle Developed Prcclm~lrllCflOI1 lUtlOt'r!<lnd Vall~'v Memorial (j;IflI~'m 11121 Ritnef Hlghw.1Y l'arli~lt., PA l70n 717-~41..l.'i!l1 *:\1ausfJleum: ~iche: 1st Choice 2nd Choice (janJcn Section Lol Spacc(s) 2. MERCHANDISE Check here if merchandise is hcing purchased for llSe at another cemetery Cemetery's Name: A. VAULT(S) #1. Deseriplion__ __.~_~_~__ #2. De'iCnplinn 8. URNeS): #1. Dc!\cription #2. Description C MEMORIAL INFORMATION: Memorial Design: Vase: Y IN Bronze Size _ X _ Granite Size _ X _ Location (Seclitln, Clc.) D. MONUMENT INFORMATION: Type: Color: Size: Die: Base: P 4.;1...} -Ocl'j~-:U Contract' ('hare] Gard~'n Tandem Sldl',-hy-Slde Smgle D~velopcd Preconslfuction Chapd Garden Single Compamon Developed .,tfrlllmum ''''/(1'1 diml'rrmm, lift II'''Rth X5' w,d/II 29", /i,'Ii!h/2f1" Precllnslrucllon 1st Choice 2nd Choice Building Section No.(s) Level ______ 3. ITEMIZATION OF CHARGES (A) Burial Rights (a.HIe~ribed in Para. J above) _ $ (B) Perpetoal Care $ ____ (C) Less Certificate Discount S ____ (0) Second Right of lntermenl $ (E) Vault(s) ~__ $ IF) Urn(s) _____ $___ (G) Mausoleum LeUeringlCryrt Plate $ ~___ _____ (H) MemoriallMonument $ ____~_ (l) Granite Base(s) '_'__ $ (l) Installation Charge __ $ ____ (K)Caskets __ $ (L) Initial Fee for Interment -/-_ $ h I ~ ,OU (M)FinallntcrmentJEntomhmentllnurnmenl Fee s.. I ~~ . ()f') (N) Permanent Records & Processing Fee ~CjL (0) Olher __. $ (Pl Sales Tax $ -~-r- 4. TOTAL CASH PURCHASE PRICE (A THRU P) $ 4i-~ ITEMIZATION OF THE AMOUNT FINANCED Ff It) CO (I) Total Cash Price $ (2) A. Cash Down Payment $ '1 I au B. Trade In: $ Old Agreement No. <;JJqa~ c. Tolal Down Payment (2A + 2B) $ (3) Unpaid Balance of Cash Price (I . 2C) $ (4) Finance Charge $ (5) Total Unpaid Balance (3 + 4) $ r7~q ao E. CASKET(S): I. Model: Type: Model #_ 2. Model: Type: Model #_ S. PAYMENT. The Purchaser shall pay SELLER for such rights in accordance With the follOWing dIsclosure statement: AHNUAL HRCENTAGE RATE flNAHCE CHARGE AMOUNT FINANCEO TOTAL OF PAYMENTS TOTAL SALE PRICE The cost of your credit The dollar amountlhe credit will The amount of credit provided The amount you wil have paid The tolal cosl ~rchaS8 as a yearty rate cost you 10 you on your own behalf :Ze:c~~~~~aK~~ts ~y='~S l~t~j G- _% S 0-_. .. s r7lvCl C~_ S ;- 7tt1(..1 ...:\.J S 61ll~ YOUR PAYMENT SCHEDULE WILL BE: NU~b~~~:__~ Amount of Payments First Payment Due Date Thereafter, Payments Are Due_ _ " h $ { 11 ,-\ \ U't:, -CO 'l:)C;P-u:~-- ~onthlY on the (,j'l-- $ {" I I \I~ . SECURITY: You are giving a ~eCuf1ly intcrt~t in the good~ or property being purcha~ed or in part of the fUnd~ paid under thi~ Agreement held in a Mcrchandi.~e Trust Fund. PREPAYMENT: If you payoff early, you will not have to pay a penally and you may he entitled to a refund of part uf lhe Finance Charge. NOTICE: See the remainder of this Agreement (including Gt:neral Provisions on the rever:e side hereof) for at.lditional information aboul nonpayment, default. delinquency charge, '-ccunty mlcrClil,-. any required payn1l:nl in full t.efore the "ch~'~luled dale, and prepayment refund~ .lnd penaltil'~. Ir ,. do DOt - 1fIIJr - GbIlpdonr, 100 lllaY .... tbe ftmds plIId UDder lblo Axr-nem beId ill tbe MerdwIdioe TnIIt F1IDd. nus AGREEMENT ARISES OUT OF A CONSUMER CREDIT SALE AND IS SUBJECT TO THE ADDmONAL GENERAL PROVISIONS CONTAINED ON THE REVERSE SIDE OF nus AGREEMENT, WHICH ARE A PART OF THIS AGREEMENT. Seller reserves the right to refuse to accept this Agreement within ten (10) days of the dale hereof by notifying the Purchaser in writing of this refusal. The Agreement shall be binding upon the heirs, executors, administrators, successors and assigns of the parties hereto. THIS AGREEMENT AND THE FAMILY PROTECTION CERTIFICATE, IF APPLICABLE, CONTAIN ALL THE COVENANTS AND PROMISES BETWEEN THE PARTIES, AND NO AGENT, SALESPERSON, OR OTHER REPRESENTATIVE OF EITHER PARTY HAS AUTHORITY TO MODIFY, ADD TO OR CHANGE ANY OF THE TERMS AND CONDITIONS CONTAINED IN TIDS AGREEMENT AND/OR THE FAMILY PROTECTION CERTIFICATE. NOTICE TO ASSIGNEES OF SELLER Any holder of this consumer credit contract is subject to aU claims and defenses which the debtor (Purchaser) eould assert against the Seller of goods or services obtained pursuant hereto or with the proceeds hereof. Recovery hereunder by the debtor (Purchawr) shall nol exceed the amount pald by the debtor (Purchaser) hereunder. LC) z:-",v' /,uLe. /. ~ 0.3 NOTICE TO THE PURCHASER r ~ (I) Do not sign this Agreement before you read it or if it conrains any blank spaces. ' (2) You are entilled to a completely filled in copy of this Agreement at the time you sign it. (3) Under the law, you have the righl to payoff in advance the full amount due and under certain conditions to obtain charge; to redeem the property if repossessed for a default; to require, under certain conditions, a resale of the prope PURCHASER'S RIGHT TO CANCEL If thi~ Agreemenl was solicited at your residence and you do nol wantlhe goods or services, you, the Purchaser, may cancel this Agreement at any lime prior to midnight of the third business day aller the date of this Agreement. (For an explanation of Ihis right, see Ihe attached Noliee of Cancellation form. ) Recovery Fund: A Real Esrate Recovery Fund exists 10 reimhurse persons who have suffered monetary loss and have obtained an uncollectible judge. ment due 10 fraud. misrepresentation. or deceit in a real estate transaction by a Pennsylvania licensee. For eomplele details call (717) 783.3658 or 1.800. 822-21\3. SEE REVERSE SIDE FOR ADDITIONAL TERMS AND CONDITIONS IN WITNESS WHEREOF, PURCHASER has executed this Agreement this .3~ day of no- {);;:J.. . By executing this Agreement. haseraeknoWledgesreceiP)-!(~ae~p:ofthisAgreement. GPu h. "~;U-<4""';,1,~ (J. c?-'i -' '~o . . '. '3/ "L. t... ~ . ~ ~ ~~LC(;I--:S-3-;::-; ale -I1Lt_.~___ Counselor 'H_._ ..- ...-..... ---.---.-..._.___ So,,"! Seeunly NO.____~._--'_.o..1=.1._. Dale of Birth _._._n_ 19nature 2 Purcha~r __________ _ Dale ___.___~.._.__ SOClaJ Secunty No __ __ _ _ _ _ __ _ Date of Birth ___ _ ___ ---- - ~AddrcSS_J ik) ~~~ .~__ _'__ and apprm'ed by an AIII/lI"'zed - _ _ C~1'l 120i~_.__.___ City ~lale Zip If Huri.11 Ellj!hh('rrtlfi(arl" ro I't In N3rrlo."(~1 nth,'rlllan I'm.(hJ....r<\J l"..~ jlH'lI1 k NJlIld'll[ru Home Phone Nllmhcr c.Q. 4. ~2 (;)...L ,S? ) - ~ <:J~ '-.' /.'~) " , '.-./ '\ (:7 ?~\' ::::::!;'~. ,) ~lIer: --I. ~ \ B~ PPL Electric Utilities Electric Service For: CATHERINE NICHOLSON 1 W PENN ST APT 305 CARLISLEPA 17013 Questions about this bill? Please contact us by Mar 26 at 1-800-342-5775 (1-800-DIAL-PPL) or "rite to: Customer Service 827 Hausman Rd. Allentown, P A 18104-9392 www.pplelectric.com \. !i ~ c "..." J P P>':..i":~~: ~- ~'t; ....~\. ~~:ge 1 '" ' '-')' ~ , '0 ~ ,).~ /\~' --<>>>>::>Y!:i1li->~i_:: 658~ - --- --- ->UMf-- Balance as of Mar 5, 2007 Char~s: TotafPPL ELECTRIC UTILITIES Charges Total Charges $ 0.0 $ 73.2 $ 73.2 Account Balance Electric Use This graph shows your electric use over the last 13 months. Types of Meter Readings: Actual _ Estimated Ef0l%i\'J Customer D KWH - Average Per Day Meter Reading Inform 24 20 Actual Actual 16 KWH Blllt Average - Mar 2 12 TWAjrature K Per Day 8 Yearly Use: 4 Apr 2005 - Mar 2006 0 Apr 2006 - Mar 2007 MAMJ J ASOND J FM 2006 Months 2007 Other important information on .....M cc15G; ~E~ o :;l 00 -::~ cO> CII 25 ~ g'g~ c..<(r:: 1: CII EI"- ClIO 1;;0 Ui~ >M -- .cor; 1: '" o ..... :iE~ i;j ~ ~1Il III CII CIIl:l'l )( .. III III ~i3 .. :l (/) i;jlll C Ql Ol:l'l .- .. :6~ "CU < Ql U C IV C; < I < III Ql C) ... IV .r. (,) +' C Ql ... ... ::s (,) III CII u 'S: .. Ql (/) E" III ~ E w ~ .E 1:) IV III +' Ql C < Cl Ol (,). .. 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