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Home My WebLink About08-24-07 --.J 15056051047 REV-1500 EX (06-05) 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 INHERITANCE TAX RETURN RESIDENT DECEDENT County Code Year ~ \ \) '1 File Number ti l\ '-\ 0 Date of Birth I) C'---' f) L1 :7) '0' ./)1 Decedent's Last Name ~ ::) 1/ 0 C Lj.jD j)D (''I Suffix / / / /\ / C;' -3 ~-; Decedent's First Name MI r C I I..) I ( K rJ ( ( ( IV /-J (If Applicable) Enter Surviving 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 C) 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10, Spousal Poverty Credit (date of death 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 If S PJ:: e.l'j R c' E r) ~~ [/ J q .3~ '7 :i: D'.S y.. 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received --L 8. Total Number of Safe Deposit Boxes 4. Limited Estate L / I\J /) /+- tl1 Firm Name (If Applicable) ;:~ ~~~ :p" {J First line of address LI J ~..' I-I iLL ( 12_t: ;" r ;?u .~ I.J Second line of address ( .) \',) J\ PE. V AI 'I (j ZIP Code :1- 75 () ..L.~ City or Post Office State i /-"" r( . ,'!" Correspondent's e-mail address: U ~ cLt:J i.~ /.- bLL{s0Cklh . I) C~ Under penalties of perjury, I declare that I have examin d this retum, including accompanying schedules 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. S'GNA1f;:;c.::tn\jt~A4-A:'1?I"Ldt "j ?/.:;DA"/iJ 7 AD DR j ~I/l) !-lJQ(~l/2{( /]/2CAI-1 fl1' G J-J:~:{I . SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L. 15056051047 15056051047 ...J ---I 15056052048 REV-1500 EX Decedent's Name: 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) . . . . . . . 6. Jointly Owned Properly (Schedule F) Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properly (Schedule G) Separate Billing Requested.. . . . . .. 7. 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .' 8. 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . 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, or transfers under Sec. 9116 (a)(1.2) X .0_ 16. Amount of Line 14 taxable at lineal rate xo;-I< - .1-' ~: / I q J .:L 2 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 I" ,(J" /. f it'J' I " /1 u,) v'" -'1 1- .~) L.f l' / l ':5 L. '- (2. ,-,I C ( C , ,,_/ . 1__....,.:,../ l C. l.. l 5. ~7 ,/ .." /, I /~--J "\ . L . L. L; ,. ~. / \ /. (\ ,-..'e L.' L 9. J. / '" I ,f >" , ] .- .). r.. c, ~i .-" /\.:.J - r-' \ j -' ~ . j', , ,} ..~-1 )( ~; . -;;. / ., , . , /':J I U I / ' 7 :Z, '-li lL... . { ,I / . , (~\ I ,--\ S" / ;' i , t ..../ . c.~ / 0: I / c) ) . ~2~ ~~ (). (. D 15. 16. ",'. \- 1.,0" i__~ 17. 18. \ L/ ~\ 15056052048 . , ..... / L i 1 1.--/. ! /1 .-, C . ,! ..:) --.J REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENTS NAME I .1 i-\, hh i 'I ~h !---fel{i~1 I--t f-' i~.n-L ( 1::- /, '\ I '\ ,/, I r: t: ". /) L( ,.', i-f' '(I i ( i --, / rr, ,.,.., ~'i I U l.' .....- '~ ' ~"f-J / "L. ~ j \...~ L. ,,<-'-". ' ) STREET ADDRESS CITY \jl/'(ij'l{U ';! /5' bCL-ill STATE /2+ ZIP ! -I( ,c_, (. ; . L. J Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2, Credits/Payments A. Spousal Poverty Credit B. Prior Payments C, Discount (1) i C fl r, ,"'~) /-"~ \.1 [ : . (j ~\ \L. "..J ,1..... ~~_~I Total Credits ( A + B + C ) (2) {i, (' C 3. Interest/Penalty if applicable 0, Interest E Penalty 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) (I I (\ ,- /._; , L ( L , fe, r .... .--< \ if( (/ .J --- /' L .. ( c_ ( /'~ C :? L err" .~ / --' /' ) TotallnterestiPenalty ( 0 + 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) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) A. Enter the interest on the tax due. 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 []I b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 C'll. c. retain a reversionary interest; or.......................................................................................................................... 0 CZJ d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 E;Zl 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 flI 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 !1J 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 iZJ 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 disdosure of assets and filing a tax retum are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~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 orfor 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+ (6-9* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF j .. ! .,\ .r ii::..J( I! f-! I" }-\( ./ ...::> c I FILE NUMBER 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 jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH III ::)kjJ/tL/ L ,- / C r(',,':{)/lLCj .. i) ,. .. [L'llar) I C~J)L crt} I/A / 7C.'~{\ <L'I. i I. .C /_'1(1, (" (I / \'-- ._' / ( l J r} /'-..... (i~)L-l! TOTAL (Also enter on line 1, Recapitulation) $ / {c,.5, l {( I (0 (, (If more space is needed, insert additional sheets of the same size) REV-1503 EX+ (6-98. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF l.:.icL 1-( FILE NUMBER {' f' ?-Ie It(\ {1 ((~-jl~ (' All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1, DESCRIPTION 1\1 L /l~ TOTAL (Also enter on line 2. Recapitulation) $ (If more space is needed, insert additional sheets of the same size) VALUE AT DATE OF DEATH /~/ ~, / If ~) REV-1504 EX+ (6--98* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF II e {-ell /-1. /"', :~)ILt (/ Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. FilE NUMBER ITEM NUMBER NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH IV {'J;LL_ [lJ. TOTAL (Also enter on line 3, Recapitulation) $ (7) {If more space is needed, insert additional sheets of the same size) REV-1507 EX+ (6-98) *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF FILE NUMBER I ( , I ' "1 /-Llt! It {\t.:")lJLr All property jointly-owned with right of survivorship must be disclosed on Schedule F_ ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH !\Je Ill_ ,0 //)\ TOTAL (Also enter on line 4, Recapitulation) $ ;- (If more space is needed, insert addijional sheets of the same size) REV-1508 EX+ (0.98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER l~ f~j {Ii l-t t-- (~) \.L {/ Include the proceeds of litigation 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 VALUE AT DATE OF DEATH I //1 (" '.; i#'~//rl-l;3 .~' { /] '7\ ' /~ [ C C ( (( c~ ! t)LC(CL l'-,-.- + ~ ,-), j/} - f ,-( e t c (( S" (~JC+- ) I l-t, I t\J. (, , "- " . . )(. I"~ \... i,L/_' _A. [ ,-" ! '... I"~ Il' l ";:lJ ,^ 1/' l iLl, \..1 r' -',-. i, .\... v l '" ": f' ~ ,...., ' (,t /:c.: L U ~ L lit. A, 71J-:/ v.. /'.~ ~-) [)(( /ll( - e.(\J C .K:-( /\tj' ,. ('. ..' .; rt / ) l~'.Yl (( I/tu k /(/C7(/ S~) [I ' ( ( . (( / \vC I 1 U ( 11-( nl ,./i {{ c I i { ^ '/, .;. L/ (: '\--/~ .--).- c ./ \ _' l'.~.<' { ~~/{( Ie /"7 '7 < ~ . (-0 (.~,/.-- ' TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed. insert additional sheets of the same size) REV-1509 EX+ (6-98* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF rlef!..'l I~\ ,'/)lu( FILE NUMBER If an asset was made joint within one year of the decedent's date of death. it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. B. f\} J II C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEA1H ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSllTU1l0N AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEA1H DECD.S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER ATTACH DEED FOR JOINllY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1. A. TOTAL (Also enter on line 6, Recapitulation) $ t (If more space is needed, insert additional sheets of the same size) I REV-1510 EX+ (6-98. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF J j/) i {>/ .'1 rl (.IC FILE NUMBER A D., ~.. II I 1/ ! 1_, "J... This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INClUDE THE NAME OF THE TRANSFEREE. THEIR RElJ\TIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. {\ I l _. I \ I ! -It..___ ,j C I I - TOTAL (Also enter on line 7 Recapitulation) I $ \/ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) f,j '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF ITEM NUMBER A. 1-,1 tie II IJ ,'-"', I ~. {sttX (' FILE NUMBER Debts of decedent must be reported on Schedule L FUNERAL EXPENSES: 1. DESCRIPTION " I I\/! lLC~{~ e \ (Y\.~Li \- ___ . I '[-, L U-\.L-(cJ h D (){-"--- 1. B. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: 2. Attorney Fees State _Zip 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Retum Preparer's Fees 7. ClC511 (JJ C [C~t-. Lll ,~~ l\\e,~L; C.Ll( fA J ~) , " l( lk::pLC I ( A Ic/ { 'I- pu \l-;(.. C ': :JJ l.c L+/ (- " ~Cl~l C f. State _Zip lV./:.;DC l.Lt[cll H 6/yli__ HDIVU..". AMOUNT ef';" I " . I' L.~. .- '-.....'J :.,__m ~. ,..j I j. \.j/ o (j C/ (2; r{ "I) 1el35,Co i~3Cl J.L'\ ".L, . .I J.' C t"'\ ~~'lf) i. L C, TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) I . C ~~'" -- ,'r-D5 ,--:I~ . ~ ") ~ I ,.... "",,/"j REV-1512 EX+ (12-03) '* SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~-Ie\en .-~ rl~I'lL( FILE NUMBER Report debts inculTed 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 1. C t -t I e~tl1\L- N'kL~)k(' C(Lf L~ j ::5 I I L)' J, ,.:;)... . \\/ ~?.J t- S J lc r t ~~"'(lJ vt-clCf [)Q.I l tl ~) iTl) { .::::..:; -} L-). <.,) , J--... 3 S L l<:::'C[ L uJ\JL /l1lI-L -r u) e ~. AD J('. _ CU 1.1 TOTAL (Also enter on line 10, Recapitulation) $ J\ 0&;, 3' 7 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) '* SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF r! Litt' I~ l-~ S tlL/~ FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS pnctude outright spousal distributions, and transfers under Sec, 9116 (a) (1,2)] H ~f'qC(\ r.f) L{fj(' . 5D 0-; () ~J($J~ eta, t uy.JCI/ '1i'\c ()V(f~ r' "'-'(j r\ ~ 0 tile'; Y-1~JLLr '-"'\...,~ "- ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A, SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE ,/ J /) ,.-_._~, 1\ ,/ ! L " L.\ , , .f 1 \jl I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS /$ 1\ I r.t Gi 'J I TOTAL Of PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0 (If more space is needed, insert additional sheets of the same size) / REV-1514 EX+ (12-0. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN Check Box 4 on REV-1500 Cover Sheet ESTATE OF ~~ ~(€(l A '""' . r'IS/Ut~ RlE NUMBER This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. o Will 0 Intervivos Deed of Trust 0 Other LIFE ESTATE INTEREST CALCULATION NAME(S) OF LIFE TENANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH LIFE ESTATE IS PAYABLE r'lll U- o Life or o Term of Years - o Life or o Term of Years - o Life or o Term of Years - o Life or o Term of Years - o Life or o Term of Years - 1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Actuarial factor per appropriate table ........................... Interest table rate - 0 31/2% 06% 010% 0 Variable Rate % 3. Value of life estate (Line 1 multiplied by Line 2) ......................................$ ANNUITY INTEREST CALCULATION NAME(S) OF LIFE ANNUITANT(S) DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH ANNUITY IS PAYABLE i\ (' :--)UL-- o Life or o Term of Years - o Life or o Term of Years - o Life or o Term of Years - o Life or o Term of Years 1. Value of fund from which annuity is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ 2. Check appropriate block below and enter corresponding (number) Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26) o Quarterly (4) 0 Semi-annually (2) 0 Annually (1) o Monthly (12) o Other ( ) 3. Amount of payout per period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _ . . . . . . . . . . . . . . . . . . . . . . .$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 ................................... 5. Annuity Factor (see instructions) Interest table rate - 0 3 1/2% 06% 010% 0 Variable Rate % 6. Adjustment Factor (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Value of annuity - If using 3 1/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 . _ . . . . . . . . _ . . . _ . . . . . . . . . . .$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 ............................... _ . . _ _ . . _ . . . . . . . . . . .$ o -.I I l~ 'tj.,' NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed, insert additional sheets of the same size) ~ LAST WILL AND TESTAMENT OF HELEN A. FISHER I, HELEN A. FISHER, presently of Hampden Township, Cumberland County, Pennsylvania, being of sound mind, memory and understanding, do make and publish this my Last Will and .' Testament, hereby revoking and making void all former wills by me at any time heretofore made. ITEM I. I direct that all my just debts, funeral expenses and inheritance taxes which may become due as a result of my death be fully paid and satisfied out of the residue of my estate as soon as conveniently may be after my decease. ITEM II. I give and bequeath to my son and daughter the following items of tangible personal property, to wit: A. To my son, Thomas C. Fisher, presently residing in Bartlett, Illinois, the brass bed which came from his father's side of our family, and the grandfather clock which my son had gifted to me. B. To my daughter, Linda M. Hergenroeder, presently residing in Harrisburg, Pennsylvania, the three-piece cherry bedroom suite which was handmade by the Smith family, any -.- -.".,.---- .-...~_..-.."..,~~-- ._'-",~'---'-'.""""-"'~~ -~."..,-,--~-.,.........-. teapots which I may still possess at the time of my death, and any personal jewelry which I may still possess at the time of my death. c. All other tangible articles of personal property located within my household at the time of my death shall be divided equally between my son and my daughter as they may agree between themselvesj however, if they cannot agree, such personal property shall be sold at public auction and the net proceeds therefrom shall become part of the residue of my estate. ITEM III. All of the rest, residue and remainder of my estate, of every nature and wherever situate, I glve, devise and bequeath in equal shares to my son and daughter, above named, subject, however, to the following conditions and limitations: A. The one equal share of my estate for the benefit of my son shall be paid to him directly, but, if my son shall have predeceased me, then his share shall be distributed to his lssue, per stirpes, subject to the provisions of "TRUST FOR ISSUE" hereinafter set forth. B. The equal share of my estate which shall pass to my daughter shall be subject to the following limitations and conditions, to wit: 2 1. In the event the qross value of my estate for Pennsylvania inheritance tax purposes shall be in excess of One Hundred Ten Thousand '($110,000.00) Dollars, I direct that fifty (50%) percent of my daughter's share of the residue of my estate be paid to her and that the remaining fifty (50%): percent shall be paid to her only if such remaining sum is utilized by her for the purpose of purchasing a primary residence or is applied to a direct reduction of mortgage principal upon a primary residence of which she is the owner or co-owner. In the event my daughter does not own or co-own a primary residence, or does not choose to use the aforementioned gift to purchase a primary residence, then, I direct that the aforementioned fifty (50%) percent of her one-half share of my estate be paid to Dauphin Deposit Bank, Trustee, In the LINDA M. HERGENROEDER TRUST, and further direct that Trustee shall pay all income from said trust to my daughter In convenient, but no less than quarterly, installments for the remainder of my daughter's lifetime, and, upon her death, that the Trustee pay the principal of said Trust, In equal shares, to the living issue of my daughter, subject, nevertheless, to the terms and 3 ~... ""l conditions of the provision for "TRUST FOR ISSUE" hereinafter set forth. 2. In the event the value of my qross estate for Pennsylvania inheritance tax purposes shall be less than One Hundred Ten Thousand ($110.000.00) Dollars, then, the entirety of the gift herein provided for my daughter shall be paid to her only if the entirety of the gift is utilized by her for the purchase of a primary residence of which she is the owner or co- " owner, or lS utilized in the direct reduction of principal of a mortgage loan upon a primary residence of which she lS the owner or co-owner. In the event my daughter cannot use or does not choose to use the gift for the intended purposes, then I direct that the entirety of my daughter's gift shall be paid to Dauphin Deposit Bank, Trustee of the LINDA M. HERGENROEDER TRUST, to be held and administered by the Trustee In accordance with the provisions set forth in the immediately preceding paragraph of this ITEM IV of my will. 3. In the event my daughter shall have predeceased me. then her share shall be distributed, In 4 . - ;._,: ~}J.~,; equal shares, to her issue, subject to the provisions of "TRUST FOR ISSUE" hereinafter set forth. ITEM IV. TRUST FOR ISSUE. In the event any of the issue of either my son or my daughter shall be entitled to any share of my estate/ either at the time of my death/ or thereafter, by reason of any distribution to be made from the LINDA M. HERGENROEDER TRUST, and any of such issue shall be under the age of thirty (30) years/ then direct the share of such issue shall be paid to Dauphin Deposit Bank/ Trustee/ IN TRUST/ for each of such issue who shall be under the age of thirty (30) years/ with the further direction that Trustee shall: A. If the issue of the trust shall be my grandchild/ Trustee shall payor apply all of the income and as much of the principal of the trust as, In the sole discretion of my Trustee/ is deemed necessary and appropriate/ to provide for the health, comfort/ and education of that grandchild. B. Upon the attainment of the issue who is my grandchild to the age of thirty (30) years, the trust of that grandchild shall terminate, and Trustee shall pay to that grandchild the entire remaining balance of the Trust/ together with any undistributed lncome. C. In the event the issue entitled to a share of any trust created hereunder shall not be my grandchild/ but 5 shall be a great-grandchild, or great-grandchildrenl I direct my Trustee to terminate the trust and to paYI In equal shares, to my great-grandchild or great-grandchildren the equal share of the trust to which each of them is entitled (principal plus undistributed income) I orl if any of them shall be mlnorSI payment shall be made to the natural guardian of each. ITEM v. TRUSTEE POWERS. Notwithstanding the normal provisions of trust responsibilities imposed upon Trustees in accordance with the provisions of the Pennsylvania I Probate, Estates and Fiduciaries Code I I hereby direct that my Trustee shall have the following powers and duties: A. To retain any or all of the assets of my estate, without regard to any principle of diversificationl risk or productivity. B. To invest In all forms of property without restrictions to investments authorized for any type of fiduciary. C. To compromlse any claim or controversy. D. To loan money to or to purchase property from my probate estate. 6 E. To borrow money from any person, including any Executor or Trustee, and to mortgage or pledge any real or personal property. F. 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 all for such prices and upon such terms and conditions as it deems proper. G. To allocate receipts and expenses to principal or income or partly to each as it deems proper. H. To repalr, alter or improve any real or personal property. I. To distribute in cash or in kind or partly in each at valuations fixed by the Trustee. J. To purchase investments at premlums and to charge premiums to income or principal or partly to each. K. To subscribe for or to exercise options for stocks, bonds or other investments; to join in any plan of lease, mortgage, merger, consolidation, reorganization, foreclosure or voting trust and to deposit securities thereunder; and to generally exercise all the rights of security holders or employees of any corporation. 7 L. To register securities ln the name of a nominee or In such manner that title shall pass by delivery. M. To assume continuance of the status of any beneficiary with reference to death, marriage, divorce, illness, incapacity or other change in the absence of information deemed reliable, without liability for disbursements made on such assumption. N. To add to the principal of any trust created by this instrument any real or personal property received from any person by deed, will or in any other manner. O. To exercise all power, authority and discretion given by this instrument after the termination of any trust created herein until the same is fully distributed. P. My Trustee may commingle the assets of any trust estate created by this will in anyone or more common funds for greater convenience and flexibility. Q. To employ attorneys, accountants, engineers and such other persons, professional or otherwise, as may be necessary for the proper administration of this estate or trust, and to pay their compensation from such funds. R. I authorize the Trustee to pay from the income or principal of any trust fund an amount which it shall determine as proper and reasonable to compensate the 8 guardian of the person of any minor beneficiary. It is my desire that whoever should assume this responsibility of raising minor children should be properly compensated from the trust estate herein provided. s. I authorize the Trustee to purchase from the trust fund or funds any type or manner of insurance which it deems to be in the best interest of the beneficiary. T. I authorize the Trustee, ln its sole d~scretion, to " advance funds from the trust fund to my probate estate for the payment of any part or all of the death taxes or costs of administration of any obligations that I may have at my death. u. To carryon any business owned or controlled by me at my death for whatever period of time the appropriate fiduciary shall think proper, and the appropriate fiduciary shall have the power to do any and all things he or she deems necessary or appropriate, including the power to incorporate the business, the power to borrow and to pledge assets contained in my estate as security for such borrowing, and the power to closeout, liquidate, or sell the business at such time and upon such terms as the appropriate fiduciary shall deem best. 9 ';'~....:,-._,.~,.:~ ,'.......o..J:.:;.:.~.~_ ..;;}..~'~,.i:..,,:;.,~~.ii...-::,:-,4~. ""'.:"':,:,'.;.i:,,..,..;,;.. . ','" ,',~.." .....___.c.__.. . .,....:...~.~4..'-- ",.,,";;;" ITEM VI. All principal and income shall be free from anticipation, assignment, pledge or obligations of beneficiaries, and shall not be subject to attachment, execution or other legal process. ITEM VII. I appoint my son, Thomas C. Fisher, and my daughter, Linda M. Hergenroeder, to be and act as Co- Executors of this, my Last Will and Testament. In the event one of my children shall predecease me, or otherwise fails to qualify as Co-Executor, I appoint the survivor as sole Executor or Executrix, as the case made be. No bond shall be required of my Trustee, my Co-Executors, my Executor or my Executrix in Pennsylvania or any other jurisdiction. this IN WITNESS WHEREOF, I / d day of I have hereunto set my hand and seal ..r; /--:' ..(J r:O ct', y>cfJ,yy( ,-fX.-f:/l ' 1999. i '. Ii , l' // ;::.',,' /) /..v~__,i:.L.-t, /7, .f _/4:.L./1", (JA / Helen A. Fisher The preceding i~strument, consisting of this and nine (9) other typewritten pages, was on the date thereof signed, published and declared by HEL~N A. FISHER, the Testatrix therein named, as and for her Last Will, in the presence of us, who at her request, in her presence and in the presence of each other, have subscribed our names as witnesses hereto. Ijo5.~~(\':.. C:l2C <7"-L9-s:-- " r 7 J ~J!t!~: . (~ ~'-{C1 ~\'AJ~:~,t L"'t>d 103166-1 Residing at ., h ' 'I \ L(JC1L'~, c./..---t;.U ".,L \...c-.c: " ~c('~ ?<:) /~ C '1 , u /', I! J j'",d1--eJ( CV' [if} Residing at z z.. (d' Cl 3:. 10 ,'; .. " .:: 'r:'.'/, .,..... " EV 11/2005 RltHtN "~E1Si KINK COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH (See instructions and examples on reverse) STATE FILE ""'UMBER 4. Dile 01 Death {Month. d;y. ~u) I\pr.30,2007 5. Age (l3!.tBl:thCaYl Nov.12,1933 ad. Fao:ty Name: {ll net instdU'liCrt.. 9ive stleel8Ji.d flUIt1hcrl Lebanon,PA Olhe< o \r,p,"'n1 0 ER I o.tp"UOnl 0 OOA 0 N,rsing H""" 0 R..",ence ilIOlher. ~ ;-1.65 p /c e.- 9. Was Qecedtm1 01 P.ispani::. Oriqn' JKl No 0 Yes . Illycs.sllOOlyC"",,,- Resldence LI,~.I'1...n'R"'n."'.1 14. tI.arrtal SlaIus: Marrial. Neve' Mar~. \'(_.IJM>.'tedlS~ widowed 1N!.":'Ieot[)ecetefl1.tFusl.~,laSlsuffiJ) 6. Data of Birtll ~.Ion~. day. yw) 73 VIS Dauphin 11. Dece<le:CJUsual Susquehanna Tw c.c. Slane Hospice 13. _.s ElluCa"'" lSpoOly onti ..;g,eSl ga<e oompIele<l) Elementary I Second.ry [O-12} College \1-1 Dr S<l 12 4 pennsylvania cumberland 17C.~ Ves.OtceCIer.tLNeda 17d. 0 '~o.Oec2<!EnlLi'/ed~ >.dU21 Uml'.s 01 Hampden I.... l)b. Ccun~ cl Dealt\ mgt. analyst KhdclWcrk 12. Was [)eeodenl evot in Ihe U.S. Armed R:lrteS1 DYes )gNO Decedents J.ctuaI ResUaN:e 1101. Stt~ Crty/Bo:o 17b. tcuntf = 19.1.\othef"s Nama IFU!J. middle, mal;jen svmamel May Haas 2Ob.lnlorman\'s lI.aii:ng ~ {Street. crty 1 1a1lT!. state. ziti c;ode) 416 Hillcrest Rd., Apex,NC 27502 2tc. PbCe cl O~ (uame ol ttme~er1. erema~f or o\tlel pla::e\ Resurrection cemetery 21d. Lcce1icn (City J ta...n. gale, rip code) arrisbUrg,PA17112 Hummel Ave.,LemOyne,PA17043 23b. Ucense Number 23::.. Date Signed (MO<\!h. day. ~-ear) M. 26. Was Case Referred to Medcal Examiner' Coroner leI a Reason Other U\afl Ctemation Cf {)cnation" DYe!>. "9it'NO Part It: Er,lel cW ~o.rJ ~.J1i:)l'\,mnlrih..!tir,!] lodi!a\h. WI roOl resul'.1',t) in t!'Ie u:-.do!:rtftoQ cause: ~ in Pal1!. 2B. o:d 1:t'~ Use c~...,:.~~c \:J Oc~~", 0./0$ oPnbo::t/ ot,,01)(1:"'"1O"";'I 29. II FemaJ.e o Not p-egr.anl ",...:n.o, past ~1!a: o Pf~r.ant 2\ tm9 01 dea:!\ o N"?l'egnanl bit. ~rE9W" 'fIo~':.:\ Ai Cilj'S tl team o Not ~W"'"t "" pI=' 4J "''' to \ ,,,, belate oea:h o ~if~rJ'llo~1hG;w:ye;lI 32c. Pl3cc o! lr~ Home. Fl.t1tI. ~ r2::.wry. O\fia>&"""I!..1<.fSpcolyJ CAUSE OF DEATH {See Instructions and examples) no",27 Part" En:or~' ~ -Os........ _es." comp{"'_ - ""'_:I'{ C3~'" dc.!h. 00 I'OT enlor termnal..''''b ",d> as cWac on'''- rC!pratory arrest C'l ~ 1ibfJ.1~'Otl v.'lIttO'Jt shcW'.t:9 tt'.e etiok)qy. lisl ~y coo CZluse on e3d1 eM. f Ap;y,orirniUeinler.Ill: Qnse110 Qealh =~~s~~~)~~ SfVlJ"rU, UU- Que \i) {Of as a COl\$eQUence on: CfWl-C.-.iWDW)/) 0'::: LI/N6 ,f) ?,L/l1Il1: , . , , . , , . o o ~~1lr~le~~C-='~~ a ~.e UNOERlYDIG CAUSE ,; (6se1Se or injly 1hal in3ia1ed the ~ IlSU:t1'l91n ~attll LAST. b. Due 10 tor as a ~oence of)~ Oueto(OfaSa~ol): 303. Was an kN.(tsJ Ptrf~.erj? d. :Jrb.\'I...A\JU;1SY~;S Ava3.a!ft Prlcf 10 ComP!~1i::tl cl Cause 01 Oea\tl' :t2d.T""'ol""'''' 32t.ll TraMportabon tnj!sf (~J o Qrio;er 1000ta\01 0 Passen~l OPeeest:iiJ;n oo-.he<.Sj;.o1y: J3bSi DYes ~I.b oVe< 0'" 31,JAarviefo10catl\ ~N'_ 0 t'omi6de o AcCOenl 0 P"'''''l'.'e<L'9''''''' o s.;tille 0 CD<J\d Nol L~ o.t,nrm<!d I 32a Date 01 ~ (Monltl. day, ywi ,.. ~~~ L o?t /, Ot I / V -.J ~ I j3: M[)'^OJ rJ0lfJi!S-/z7iO';? J.S.N~~"jM::t~se!PmMy{t.3Ccl'17e:e:::~Ca oIOe~(\lemZ7) T~/pml A. THO>'>'lAS P rz,b""'!>, tl117 '3l1 ,....... T'tL,>'V u,e- o.~T1ff" c..rr;v1 P If}"' l,.. ,1"t' I'" tJ)} 3Ja_ ~I (d'<<i<.onlvoo~) c.<tllylng physitun IP~i"t.n ,,~ti"'l C1",' 01 Ilea:.,..... anD"'" .",=an nos """"""'" <eo'" "" -'" ncm 23) Io \he bes'ol my loMWled9'.d,,1h occtlfT.d d" '0 !h. ""stI.)and mann" .. ".,"'_ _ _ _ _ _ - - - - - - - - - - - - - - - - - - - - - - - - - - - 0 ~o:,,::;~~r':' =~.~~ .;~~ ::=~::~.~~~~~o~=~':......, os ,ta'cd.. _ _ _ _ - - - - - - - - - - - - - 6cl l.~ttll Euminfll Coronet On \he ba'" 01 esemlna11cn and I D. \n'Ie<'gallon.ln my oplnlon. deslh occu~t< aI\he time. dale, and piau. and due to \he ",onc{s} and ........ as ,b'cd.. 0 STATE OF PENNSYLVANIA COUNTY OF CUMBERLAND SHORT CERTIFICATE I, GLENDA FARNER STRASBAUGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 7th day of May, Two Thousand and Seven, Letters TESTAMENTARY es ta te of HELEN A FISHER in com~on form were granted by the Register of said County, on the , la te of HAMPDEN TOWNSHIP (First. Middle. Last! in said county, deceased, to LINDA M HERGENROEDER (First. Middle. Last! and THOMAS C FISHER (First, Middle. Last) and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 7th day of May Two Thousand and Seven. File No. PA File No. Date of Death S.S. # 2007-00440 2 1 - 07- 0440 4/30/2007 208-24-4340 \ .~ i .' Register Of Wilts t 'i i Deputy NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL REV.... ""I"" '* COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 SAFE DEPOSIT BOX INVENTORY 1 - J 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 SECURITY (Required) OR DEATH CERTIFICATE NUMBER (onlY If SSN Is unknown) 07 (ZIP CODE) I 7 /)~O h .N &e &sErJ f2-oE- D73i2. IUIIG4..~T ~ ,4-Pck (C~TY) tJc... (STATE) (ZIP CODE) ~7~();).. NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING a. (NAME) L "(V ....... -n 11 (RE~S~I~.1 -+--~ C) l..> n" H ~{~ €IU f20~t::e. ~ "Z. I ~ (STREET NAME) .0 ~ (CITYl1,,- 4l & I+t I [ C(2..42&; T ~'d.. F\fe4. fV l.- b. (NAME) (RELATIONSHIP) (STATE) d. 7 ~-o)... (ZIP CODE) (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 BfW K. Cft1Z-U s Le C?,'r<:E: 1..- (CITY) J I"1;(:::C:I4fMJ I '2:St:J;//U- ?~) (ZIP CODE) 17DSO b. (NAME) (STREET ADDRESS) S-O~ (CITY) (STATE) (ZIP CODE) . NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY ~ Lv ''',4 L- 1=01 fg r1 WAS A WILL IN THE BOX? 0 YES 'fyes, s. Date of will: b. Name and address of personal representative, If named In the will (NAME) (STREET NAME) (CITY) (STATE) (ZIP COOE) c. Name and address of attorney, If any (NAME) (STREET NAME) (CITY) (STATE) (ZIP CODE) SAFE DEPOSIT BOX INVENTORY Page INSTRUCTIONS ;}.. of :3 The Department is authorized under federal law , 42 U.S.C. ~ 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. (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 and class of stock. (3) 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. (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 of 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, CllITent Insurance Policies or other evidences of Indebtedness: List and describe as fully as possible. (8) All ,other contents. rrEM NO. ~_. i<- . rrEM DESCRIPTION /lA~ PRINT TIRE CHECK APPROPRIATE BOX: &/' <;! ( r1 ~ecutor(lrix) 0 Admlnistrator(trix) ."2. 00, 0 Eslale Representative I Joint owner of safe deposit box NOTE: Attach additional 811." x 11" sheet(s) if necessary or use duplicates of this page of form. L .=Ft> I ~~ H<Od PRINT PRINT NAME (c(!{Lcr DATE . ? SAFE DEPOSIT BOX INVENTORY Page INSTRUCTIONS of :3 The Department is authorized under federal law , 42 U.S.C. ~ 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. (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 and class of stock. (3) 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. (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 of book, last date appearing in book, name of bank and branch, and balance. (6) Jew~lry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. rrEM DESCRIPTION {~~ HE ABOVE RECORD IS OWlEDGE AND BEUEF. --. '" ~(SfIHJT tf2- f/."y NOTE: Attach additional 8'/zn x 11n sheet(s) If necessary or use duplicates of this page of form. . ,,~ER'S BUSINJlf RF.L~~lITK tA LICENSED BROKER BROnR(com...~'- ~ ;.~ ~ PJ-ON', ../p.!l.1.s'_~ '187 ADDRESS '/; ./ !.f1o. l.? i ~ ~A.'X -' '=' C,1 - CJ c.{' 9-0--. ~-- L1CENSt;t;(S)' !~ ___'___'.'--'--- .'_ ..._.__ Designatw Ag~nt'~ DYes 0 No BROKEB IS Tift AGENT FOR SELl;ER. OR (if chccked below): Broker is NOT th~ Agent rOf Seller and is alan: 0 AGENT FOR BUYER JL':"-d'l-dkl~:rt 1~;44 n "-' WHL"C.r:. r;.CML-' , ! ; I , I __J 1 i o No I I 1 .- -"" When the same BrOker is Agent for SeUer and Agent ror Buyer, Broker is II Dual Agent. All of 8roker'~ lic:to~ecs are also Du:!l Aj{ents lINt.~SS there arc separate Desl~uaftid A~ents ror BI'yer :lnd Seller. (f the ~,"ne LieellSec is desq,aoted ror Seller lInd 811Yl!r. the Licensee is It J)ulll.A~enr. 1 J. <<bt5 ~grtement, dllted "1/ ,;J ~ I ~ I ~._-- SELLER~): f~~ of J.IeI-t1/i. n)'hLr , . .'.~ .... ... . .._........_..___ -.- -rr..... - - ..-. --. ..... . -. ....- o 'raANS,.\CTION LICENSEE IP WITH "PA UCENSED BROKER. PHONE f., 'If r - ~f1'7 ~"'11D.s.5" - fAX__~ i - '1 a _Designated Agent? 0 Yes BROKER (Com ADDRESS LlCENSEE(S) i r. ~ f. ~ ~ v- BROKER IS TH* AGENT FOR BUYER. OR (if checked below): i NO' B d' aI 0 ACENT. FOR SELLER 0 SUBAGENT ).'OR SELLER 0 TR.~NSACTl()N I.J(:J::NS~E B~ker $! :r thf Agent tor uyer an IS an: 2 3 4 5 7 10 11 12 13 14 IS 16 17 18 19 10 21 22 23 ,4 , is between BUYER(S): -l!.i~ ~ W.Li'XJ s-trOUf 7lI . ., ' caned "Seller," and 1!Ji'<.~ r(..i>fri-~t~~ ,.called "Buyer:' -"-'- :;' ...-.;-....--..- 2. PROP.ERJrV (9-0S) Seller bcnby agrec~ In gell and cOllvey to BUYel; who hereby agrees to purchase: AU. THAT CERTAIN lot 1)9iec~ 1)( ground with buildin tI and illlprovemenls thereon encted, if liOY. known a~: ___...~..~.'-~ I - /YLLv~" _..0-.. ; .' . in tbe . 01' County' of . ..~bC:CICl n"ol'" in the' CIJlJ1mulJwcalth of penn!;Ylva~ Identification ..Lot, BlnC\'; Deed BO.ok,.Pagt; Recording ~te):. 3. TERMS (9-05) <A) purc)uase Priee f5Yu h <<\ ~_.~ -tA~ ______._ U.S. Dollars. .....,---. (B) whidt wm be paid to Seller by Buyer II!! follows: I. ~shoreheckat5igllingthisAgreement: S _~..L..90 '2-.. 2. ~ash or check. within _ days of the execution of this Ag.l,\..ement: $ 3. ' --....---.--- $ 4. ~t1Sh or cashier's check ut rime of settlement: S / b 3 led t? . TOTAL S ___ ..I-.la.5:;._oJ)O Dcpqsits paid by Buyer within .-:ill..- DAYS of settlcme:11 wi II be by cash Or cashier's check. Deposits, l'egardless of the fonn of payment and tilt: person designated 8S payee, will be paid in U.S. Dollllr.; to Broker (or Seller (\lnle~S Olherwise staled here), . ___.-.-.---......--------' who will tl:tain depo~it5 in an escrow account until consunuDauon or tcnninonon of this A.grcc:ment in conformity with allllpplicable ,"w..s ami regulali'lns. Any chec~ tendered il.$ deposit monies may be h~ld unca.c:bed ~nding th~ acceptance of III is Agreement. Se1l1's wrinen approval to be on or bs.(o , Settlement to he on ~ I () , or before if Buyer and Seller agree. SC:lllrmcnt will occur in the county wh . the 1:> pcrty is located or in an adjacent CO\l:1ty. dllting nonnal b;l~incss hours.. unless Buyer Bnd Sella DgrCC otherwise. Co~cyancc from Seller will be by fee simple deed of special warranty unless otherwise stated here: -. -"- -----------..-- 2.5 26 ?1 2S 29 30 31 32 3.1 (C) (0) (E) (1:') (<.i) PllYrVc:nt oftransfcr tuxcs will be 4ivi<led equally bClWCCl\ Buyer Ilnd 5cUcr unlcs~ otl1crwise stilted /lerc: ~r, ; (H) ~; ~e of settle;~~;~;;-i~lowing will be adjUSled.p;~.rata -;;-ad;j'Jy basi;~;-~.~~-B~y;.~~;d--;ii~;:_ ;~;'b~;;~g where';ppli~~: n:nt ~lIxes (see: InfonnatioD Rcgurding Real Estate Taxes); rents; interest on mOl1gage lISsumptions; condominium fccs and bomcowncr asso- ciation fees; water and/or sewer fees, together with any other lienable municipal service. All chal'ge.~ will he 'p1'O-rated for the period(s) cov- ered~ Seller will uy u to a i 'lucJing the cJalc IJf sc:tllc:mc:ntllnd l3uyer will pay 111r all day~ folll)wing settlement, un lc:ss uthc:rwi'ic stilt- ed here: . Buyer Initial~: ---'--AiS-R p~;l:;i~_.._n. --.--.- n."_ --- Seller 'Initlllls: :_IiF~~' n.~,: --..-- , n / Revised 9/05 COPYRIGHT PElIo"NSYLVANlA ASSOCfATION OF REA,tTORS'" :Q05 9105 35 36 37 38 39 40 41 ID ",,,,,,,,,, p.~"anl;a Assocflltion of REALTORS- ....__.......c-...~.. :; 5 S ~~ ~"! ~~ '" 14 !~ ~e :7 lS 19 2C ,~ 22 2~ 24 2~ 26 t? 29 29 3C 31 32 33 :!.: .l~ !5 3? _1~ )S :0 ,..... ,,"~"'."'" : "" ~~~1;:'~L~i :_.- ,,~..ar..;7~ :"\"; . ,.. . L,j ,,,. .. r.'~~'.' ", ....,;.. 'ilJ;;~ " '. ...... "-' ~~'SR , rluJr_ ..... ~ .11........ ')II Musselman . ._----~--,~_.._---,-- . Funeral Home & Cremation Sernces! be. Established 1895 Brian C. Musselman, ED. Supervisor William G. regan, ED. PO. Box 137 324 Hummel Avenue Lemoyne, PA 17043-0137 (717) 763-7440 Fax: 717-730-9798 www.mussefmanfuneral.com To Funeral Expenses of HELEN ANN FISHER May 22,2007 Linda Hergenroeder 416 Hillcrest Rd. A?ex, NC 27502 2007 May 4 PROF. SERVICES, FACILITIES, AUTOS "Winston" Solid Cherry Casket Wilbert "Continental" Lined Vault Slippers $3,745.00 3,300.00 1,350.00 15.00 $8,410.00 Cash Advanced Items: Certified copies of death certificate Newspaper death notice Tent & grave servicing Honorarium for celebrant Cantor & organist fee $72.00 205.15 125.00 100.00 100.00 $602.15 $9,012.15 TOTAL No. 1005 ~ WACHOVIA Wachovia Bank, N.A. wachovia.com PAY -! b~~~~ OF / i: t.t .J,>_ . -; ;..', i\. i)\ :.; " U:.~.L ., -i V, \, j U " 3-50/310 I , ( ) I DATE . / I ~_~J~-~.1~~ ~_i(l (_LL~__~._L (._t_~__~l__~_~~ '" .J $ I ~j . \ ! '.... .. ..t-:~,_.t.-( ( L.; i~ .i /'.,--:" /. ' ~_. -.' '~--~_.~--- ; \- ------------- -DOLLARS FOR , '/1 r '_ _' (......._ : ' ESTATE OF HELEN ANN FISHER LINDA HERGENROEDER, CO-EXECUTOR ., ., .... -' ---- ...- - ~ l\:? -( M' II. 0 0 0 0 . 0 0 5 II. I: 0 3 . 0 0 0 50 31: 20 0 0 0 . 2 CJ 5 b q . 7 II.