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Home My WebLink About04-04-08 -.J 15056051058 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 Securtty Number Date of Death OFFICIAL USE ONLY County Code Year INHERITANCE TAX RETURN RESIDENT DECEDENT 21 07 File Number 0698 Date of Birth 220-10-3798 07/12/2007 10/02/1914 Decedent's Last Name Suffix Decedent's First Name MI NICHOLS DORIS G (If Applicable) Enter Surviving Spouse'. Infonnatlon Below Spouse's Last Name Suffix Spouse's First Name MI N/A Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ,.j 1. Original Retum ...-....... 2. Supplemental Return ..._''''''~\ 3. Remainder Retum (date of death prlor to 12-13-82) 5. Federal Estate Tax Return Required ca-! '::~.::> 4a. Future Interest Compromise (date of death after 12-12-82) C) 7. Decedent Maintained a lMng Trust (Attach Copy of Trust) C-;;) 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 SECnON MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number t':~ ,::,,') (717) 243-37~ 0 ~: ......:;:J .-.,\ REGISTER OF~lU~l)SE oNt? ,~ 2~)~l 1- '. ! "--j,') -0 -, ~:"..2 >\~\ 6. Decedent DIed Testate (Attach Copy of WID) 9. litlgaUon Proceeds Received 8. Total Number of Safe Deposit Boxes 4. Umlted Estate .._.~......., ,.~.-.,..... c:,:) Landis & Black ~J ; \;,~'3 i" .) . 1 '. oJ -" 1 \_-) Robert R. Black Firm Name (If Applicable) First line of address c"'.) -'"1 . 1 __~"\ 36 South Hanover Street :\:" :-4 ''0 'Y' ~ en -J -""J 10,;, ~~:~ C) -i" Second line of address City or Post Office Carlisle State ZIP Code DATE FILED PA 17013 Correspondent's e-mail address:ROBTRBLACK@COMCAST.NET Under penalties of petjury, I declare that I have examined this return, 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 penonal representative Is based on all informatlon of which preparei' has any knowledge. SIG~ERSON R~NSIBLE FOR FILING RETURN DATE ...& A A2.L-'-' 1../- () 3 - 0 g ADDRESS ' 40.._Carii~~ SI1 E~ RE SENT. AD~RESS 36 South Hanover Street, Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY dJjo 8 Side 1 L 15056051058 15056051058 -.-J .....J 15056052059 REV-1500 EX Decedent's Name: DORIS G NICHOLS 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) C:) Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) C::) Separate Billing Requested.. . . . . " 7. 8. Total Grou 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 APPUCABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (aX1.2) X .0_ 16. Amount of LIne 14 taxable at lineal rate X.O~ 198,127.85 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 5,000.00 15. 16. 17. 18. 19. TAX DUE..... ... . " .,. ...... .... . .. .. ............ '" ., . . ..... . . .. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 15056052059 Side 2 220-10-3798 Decedenfs Social Security Number 127,000.00 26,397.84 72,032.08 225,429.92 20,380.04 1,922.03 22,302.07 203,127.85 0.00 203,127.85 8,915.75 750.00 9,665.75 15056052059 --I REV.1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME DORIS G NICHOLS 'stREET ADDRESS 7 Abbey"" COt-l K'T FUe NI!mber 21 .' ".. 07 0698 DECEDENT'S SOCIAL SECURITY NUMBER 220-10-3798 ._-- -- f--. CITY Carlisle r STATE PA --.---.,-:;;;--...------ , ZIP i 17015 Tax Payments and Credits: 1. Tax Due (Page 2 Une 19) 2. CreditsJPayments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 9,665.75 7,000.00 368-:-~ Total Credits ( A + 8 + C ) (2) 7,368.41 3. InterestlPenalty if applicable D. Interest E. Penalty TotallnterestlPenalty ( 0 + E ) (3) 4. If Une 21s greater than Une 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. 8. Enter the total of Une 5 + SA. This is the BALANCE DUE. (5) (SA) (58) 2.297.34 0.00 2,297.34 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;.......................................................................................... D ~ b. retain the right to designate who shall use the property transferred 0/' its income; ............................................ 0 ~ c. retain a reversionary interest; 0/'.......................................................................................................................... D [iJ d. receive the promise for life of either payments, benefits or care? ...................................................................... D [i] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 ~ 3. Did decedent own an ain trust for" 0/' 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? ........................................................................................................................ 0 [i] IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. FOI' dates of death on 01' after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or fOl' the use of the surviving spouse is three (3) percent [72 P.S. ~9116 (a) (1.1) (ill. 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) (iill. 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 decedenfs 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 decedenfs siblings is twelve (12) percent (72 P.S. ~9116(a)(1.311. 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+ (6.9W COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE DORIS G. NICHOLS FILE NUMBER 21-07 -0698 ESTATE OF All real property owned loIely or ala 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 wiRing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant fads. Real property which Isjolntly-owned with rtght of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION All that certain lot of ground with the improvements erected thereon designated as Lot B-5, VALUE AT DATE OF DEATH 127.000.00 PB 52, Pg. 124 in South Middleton Township, Cumberland County, Pennsylvania, known as 7 Abbey Court, Carlisle, PA 17015. Tax parcel No. 40-24-0759-001-UB5-1. Assessment $120,340.00. See Attached HUD 1. TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed. insert additional sheets of the same size) 127.000.00 Rev..1508 EX+ (6-98} *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISe. PERSONAL PROPERTY ESTATE OF DORIS G. NICHOLS FILE NUMBER 21-07-0698 Indude the proceeds of litigation and the date the proceeds were received by the estate. All property jolndy-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1. M & T Savings Account. No. 015004204224907. See attached letter. 2. Sprint. Refund 3. Proceeds. Sale of 1997 Mercury Sedan, VIN ZMELM75WZVX706840. See FMV attached. VALUE AT DATE OF DEATH 19.56865 96.38 4.000.00 4. Hartford Co.. Refund auto insurance 73.09 5. Public Sale of household goods. See attached. 6. Appraisal of jewelry in Safe Deposit Box from the Jewel Box, Inc. 1.636.50 23600 7. Internal Revenue Service. 1040 tax refund 350.00 8. Peerless Ins. Co. - Refund of home insurance 340.84 9. Health Insurance Rebate 96.38 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 26.397.84 RI:V-1509 EX" (6-98. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF DORIS G. NICHOLS FILE NUMBER 21-07-0698 If an asset was made Joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVMNG JOINT TENANT(S) NAME A. Shirley A. Kiser ADDRESS RELATIONSHIP TO DECEDENT 400 Sutton Drive, Carlisle, PA 17013 Daughter B. Shirley A. Kiser 400 Sutton Drive, Carlisle, PA 17013 Daughter C. Shirley A. Kiser 400 Sutton Drive, Carlisle, PA 17013 Daughter JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY .)/~ OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE or NUMBEH TENANT JOINT IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY-HELD REAL ESTATE VALUE OF ASSET INTEREST DECEDENTS INTEREST 1. A. 02105104 2,408 Shares of the common stock of Carlisle Companies, Inc., Cusip No. 116,667.60 50% 58.333.80 142339oo@ $48.45 per share. See share Certif. 110966 dated Feb. 5, 2004 attached hereto for 1,204 shares together with Computershare Registration Statement dated March 19, 2007 for 2 for 1 stock spltt for an additional 1 ,204 shares or a total of 2,408 shares 2. B. 09101167 M & T Checking Account 430986. See attached letter. 5,953.90 50% 2.97695 3. C. 01106106 M & T Certificate of Depostt No. 031003913122047. See attached letter. 21,442.66 50% 10.72133 i TOTAL (Also enter on line 6, Recapitulation) $ 72.03208 (If more space is needed. insert additional sheets of the same size) REV-1511 EX+ (12-99) *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H fUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF DORIS G. NICHOLS FILE NUMBER 21-07-0698 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Mt Olivet Cemetery - Services Ewing Bros. Funeral Home. Services 68250 2,28760 2. e. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)IEIN Number of Personal Representative(s) Street Address City . State Zip Year(s) Commission Paid: 2. Attomey Fees 6.350.00 3. Family Exemption: (If decedenfs address is not the same as claimant's, attach explanation) Claimant NONE Street Address City State . Zip Relationship of Claimant to Decedent 4. Probate Fees 5.. Accountant's Fees 6. Tax Retum Preparer's Fees 7. Settlement charges as per HUD 1 attached 8. Met Ed . Invoice 9. LaVilla Homeowner's Asso. 10. Met Ed - Invoice 11. LaVilla Homeowner's Asso. 12. South Middleton Township - Water & Sewer 350.66 8.181.95 56.43 85.00 31.93 89.00 99.00 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets ollhe same size) 18.214.07 (Carried l:'orward) SCHEDULE H FUNERAL EXPENSES & ADMINISTRA TNE COSTS Continued - Page 2 ESTATE OF DORIS G. NICHOLS FILE NUMBER: 21-07-0698 ITEM NUMBER DESCRIPTION AMOUNT (Brought Forward) 18,214.07 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. Met Ed - Invoice LaVilla Homeowner's Asso. Met Ed - Invoice LaVilla Homeowner's Asso. LaVilla Homeowner's Asso. Schlusser's Painting - Services South Middleton Township - Water & Sewer Met Ed - Invoice Peerless Ins. Co. - Homeowner's Ins. LaVilla Homeowner's Asso. Brian Eshenour - Roof Repairs Med Ed - Invoice LaVilla Homeowner's Asso. La Villa Homeowner's Asso. - Roof Rebate Met Ed - Invoice Reserve for closing and filing releases 25.83 89.00 43.31 89.00 89.00 117.50 99.00 129.82 409.00 89.00 125.00 64.27 89.00 164.80 42.44 500.00 TOTAL 20,380.04 R&V-1512 EX+ (12.Q3) .. Cot.lMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE UABIUTIES, & UENS DORIS G. NICHOLS FILE NUMBER 21-07-0698 ESTATE OF Report debts Incurred by the decedent prior to death whlcl\ remained unpaid as of the date of death, including unreimbursed medical expensn. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Met Ed - Invoice 61.88 2. FIA Card Services - Invoice 181.18 3. LaVilla Homeowner's Asso. 8500 4. Embarq - Telephone Invoice 12193 5. Comcast . Invoice 5087 6. The Hartford Co. - Auto Insurance 79.09 7'. Judy Campbell, Tax Collector - Real Estate Taxes 1.342.08 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 1.922.03 REv.1513 EX' (9..00) SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT DORIS G. NICHOLS FILE NUMBER 21-07-0698 ESTATE OF 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 pnclude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. Shirley A. Kiser, 400 Sutton Drive, Carlisle, PA 17013 Daughter 500;0 SSN: 179-38-4782 2. Lawrence D. Kiser, 400 Sutton Drive, Carlisle, PA 17013 Son-in-law 50% SSN: 175-40-6401 3. Nancy L. Miller, 307 Coffeetown Road, DiIIsburg, PA 17017 None 5.000.00 SSN: 230-64-0582 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 1\ - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REY-1500 COYER SHEET S 0.00 (If more space is needed, insert additional sheets of the same size) ~~r~ LAST WILL AND TESTAMENT OF DORIS G. NICHOLS I, DORIS G. NICHOLS, of South Middleton Township, Cumberland County, Pennsylvania, declare this to be my Last Will, hereby revoking all prior wills and codicils. FUNERAL EXPENSES FIRST: I direct the payment of my funeral expenses, including my gravemarker, as soon as may be convenient after my death. PAYMENT OF DEATH TAXES SECOND: I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as apart of the expense ofwnnurlstrationofmyestate. BEQUESTS THIRD: I give the sum of Five Thousand and nolI 00 ($5,000.00) Dollars to Nancy L. Miller, 307 Coffeetown Road, Dillsburg, Pennsylvania 17019. If the said Nancy L. Miller does not survive me, this bequest shall become a part of the residue of my estate. DISTRIBUTION OF RESIDUE FOURTH: I give the rest of my estate to my daughter and son-in-law, Shirley A. Kiser and Lawrence D. Kiser, or their issue, per stirpes, who survive me for a period of thirty (30) days. PROTECTION OF BENEFICIARIES (Spendthrift Provision) FIFTH: No interest in income or principal shall be assignable by a beneficiary or available to anyone having a claim against a beneficiary before actual payment to the beneficiary. Provided, however, any beneficiary may assign any part or all of the beneficiary's interest in my estate to anyone or more of my descendants or to anyone or more of the beneficiary's descendants. ' /1 h initials MINORS AND INCAPACITATED BENEFICIARIES SIXTH: If any income or principal shall be payable to any person who shall be a minor or who shall be incapacitated for any reason, my executor as trustee shall hold such income and principal during minority or incapacity and shall be entitled to apply such income and principal to the health, maintenance, support and education of such person during minority or incapacity without the appointment of any guardian or committee or any authority of court. My executor as trustee shall be entitled to make direct application hereunder or to make application by payment of income and principal to the parent or other person in charge of such minor or incapacitated person, or to his or her guardian or to a custodian under the Uniform Transfers to Minors Act. Any remaining income and principal to which such person shall be entitled shall be distributed to such person upon the termination of minority or incapacity. My executor as trustee shall have the same powers as my executor. POWERS OF EXECUTOR SEVENTH: I confer upon my executor the right to sell or otherwise convert any real or personal property at public or private sale, at such time or times, in such manner, and for such price or prices, and on such terms and conditions as my executor shall determine, and to execute and deliver good and sufficient conveyances, assignments and transfers of the property, without liability of any purchaser for the application of any consideration; to borrow money and to secure its payment by mortgage of real or personal property, pledge of investments, or otherwise, without liability on the part of the lenders to see to the application thereof; to retain any investments at discretion; to invest and reinvest at discretion, without restriction to so-called "legal investments"; to make distribution in cash or in kind; to allocate and distribute different kinds or disproportionate shares of property or undivided interests in property among beneficiaries, in cash or in kind, or partly in each; and to do all other acts and things necessary or appropriate in the management, administration and distribution of my estate. APPOINTMENTOFEXECUTORnUX EIGHTH: I appoint SHIRLEY A. KISER or LAWRENCE D. KISER, or the survivor thereof, as Executors of my Will. WAIVER OF BOND NINTH: I direct that no fiduciary hereunder shall be required to furnish bond in any jurisdiction, and if any bond is necessary, no surety shall be required. ,,",, -1 /fJ V\ <::f-' " initials INTERCHANGEABILITY OF LANGUAGE TENTH: Words used in the singular may be read to include the plural or the plural may be read as the singular. Similarly, the masculine form may be read to include the feminine and neuter; the feminine may be read to include the masculine and neuter; and the neuter may be read to include the masculine and feminine. HEADINGS ELEVENTH: The headings used on the various paragraphs of this will are included for convenience only and shall have no legal significance. I have signed this will this ~ 1ft- -.f2 ~ (P day of frUI t[/!.{,.f ,2006. ;h(jYl1cA~ -.A . r~.-, 1';.' ~ .'j/ Doris G. Nichols, Testatrix . / /?-~ Ie? '-:1A/t~4-~_ t. 1V"~r. '\ Witness I \.' ACKNOWLEDGMENT and AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ) SS. COUNTY OF CUMBERLAND ) We, Doris G. Nichols, the Testatrix in and the undersigned witnesses to the will, the attached or foregoing instrument, who have signed the instrument, having been qualified according to law do depose and say: (a) (b) that I, the Testatrix, do hereby acknowledge that I signed the instrument as my will, that I signed it willingly and as my free and voluntary act for the purposes therein expressed; and that we, the witnesses, were present and saw the Testatrix sign and execute the instrument as her will, that she signed it willingly and executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the will as a witness and that to the best of our knowledge the Testatrix was at that time eighteen or more years of age, of sound mind and under no constraint or undue influence. jO~ r )uc/~ ~ Doris G. Nichols, Testatrix /' r? ,,--;Y-. '-1~/~ z 1V'___... -.. I _ Witness ' -" -J0--G-0 ttl/Lv'Z Notary Public COMMONWEALTH OF PENNSYLVANIA Notarial Seal Robert R. Bfack, Notary Public Carlisle 8oro, Cumbeflarld County My Commission Expires Sept. 28, 2009 ..-J REV-485 EX (O5-04)~- SAFE DEPOSIT ~ BOX INVENTORY PA Department of Revenue Social Security or Death Certificate Number Date of Death .~&5000~10~6 PLEASE USE ORIGINAL FORM ONLY County Code Year File Number '1-1- 'D { 0 J 1 q 8 Decedent's Lasl Name Nl &EfOt-S () '1 I .z. -z,O 0 -1 Z ( IJ -1 0 (PC( ~ Suffix First Name MI (). (j (<. S' G- I a. NAME~ I-h L1. 1./ ~ ..), It<.Letj Fl. ~ be< STREi:{06ss: S--a.lf16tJ 0-(<1 V~ b. NAME: ZIP CODE: 1"7 (] t.3 STREE) ADDRESS: CITY: STATE: ZIP CODE: c. NAME: \/6 r< NON - STREET ADDRESS: w_ N l C,ffO '- s fRG (L}e: ~S~9 fits CITY: WIF~ STATE: ZIP CODE: NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME: WAS A W1U IN THE BOX? 0 YES NO If yes. a. Date of will: b. Name IflCI address of persona' repreaentetlve, If named In the will NAME: STReET ADDRESS: CITY: STATE: ZIP CODE: ITY- t.-i <; L 12 L 48500041046 48500041046 ....J Page of REV-485EX SAFE DEPOSIT BOX INVENTORY INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List In detail every common or preferred certificate,,WSrrant 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, I.e., jolnUy held, payable on death, etc. (4) Bonds: Designate by name, amount, selial 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. Current Insurance Policies or other evidences of Indebtedness: list and describe as fully as possible. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DMSION DEPT. 280601 HARRISBURG, PA 17128-0601 ITEM NO. ITEM DESCRIPTION \ CEiZr( ~6C:= 1(1L l q tf..., - Vvl ~(Zu\ 12 $w -Z vx' 'loft> '\ff,1 ~ '3. H-{ G-r,J. Sc ~ fA ~ Pili NOTE: Attach additional 8'/l' x 11* sheet(s) if necessa or use duplicates of this page of form. The Deparlmenl is aulhorized by law, 42 U.S.C. ~ (c)(2)(C)(i), to require disclosure of Social SecuriIy numbers in connection with administering state tax laws. The Department uses the Social SeaIrily number to identify !he decedent and personal representatives of !he estate. The CommonwealIh may also use the information in exchange of tax ilformalion agreements with Federal and JocaI ' authorities. The state law prohibits the CommonweaIIh's personnel from disdos' confidential tax information except for ollicial purposes. A.. SETTLEMENT STA.TEMENT u.s. OEPARTMENT OF HOUSING AND URBAN DEVELOPMENT HUD-1 OMB No. 2502-0265 .T of n 1.0FHA 2.0FmHA 3. DConv. Unlns. 6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number: 4. OVA 5.DConv.'ns. RE08.15 C. NOTE: This form is fumlshed 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 the closing; they are shown here for Informational purposes and sre not included in the totals. D. Name and Address of Borrower(s): Evelyn Osborn E. Name and Address of Sellerts): Estate of Doris G. Nichols F. Name and Address of Lender: G. Property Location: 7 Abbey Court, Carlisle. Pennsylvania 17015 South Middleton TownShip,-Q1.lmberland County 40-24-0759-001 UB5 Place of Settlement: Irvine Row, Carlisle, PA 17013 H. Name of Settlement Agent: Orchard Settlement Services. LLC I. Settlement Date: 3-13-2008 Funding Date: 3.13-2008 . ..,. ~...: \ .~.;.-.,L..-' ."'.".... . .......'.kX::.!, ':y~;.::' , '~.', to 3-13-2008 to 12.31.2008 254.19 to 3-13-2008 to 12-31-2008 254.19 3-13.2008 to 6-30-2008 3-13.2008 to 3- 1-2008 400.79 51.68 3-13-2008 to 6.30-2008 3.13-2008 to 3-31.2008 400.79 51.68 130008.91 u To Seller 106. 6 ..1 8181.95 205. 505. Payoff of second mortgage loen 206. 506. 208. 209. 508. 509. 11;~,L:':,J-"":"",'" . 10. Ci /town taxes 211. Count taxes 212. Assessments to to to 510. Ci /town taxes 511. Coun taxes 512. Ass ssments to to \0 I II I I t" --' (.\, ,,'1;,'(.] "Mti:{&li!1:Ii.l~1~~~~~li1liiH'f-~\(~1~'__~_~ _ , - -'- ,",L~""""'" ~ ~.~...........- __",L_ _' _ __~_ -l ~.J. ...-.:....~__ ,~:...... ~ ~_"'>.1.~ ~~....... ~t... Paid From Paid From based on price S 127000.00 II'Il 5 % = 6 350.00 Borrowers Seller's .. . Funds at Funds at 701. S 3 200.00 to ERA-NRT Ine. Settlement Settlement 702. S 3 150.00 to Hooke Hooke & Eckman 7n,> fi 350 00 704. Tra Fee to ilNRT Ine. 165.00 ". \ "f,;;'::< 801. Loan OriQlnatlon Fee % to An? . n' O/. In 803. 804. 805 806. 807. 808. Ano 810. 811. A1? 813. 814. ~.,I'. '1,;lky!.t'~'~-d :\"" 901. Interest from to (//} S 0.0000 Idav 902. Mortgage insuranCUlremium for months to 903. Hazard insurance Dremium for vear/s) to llO4 ~i~~f;fJi(tllill1D;;~*..~ ~, o. ['"" .~_~_II ~:1~2-"-~< ~~"~~l~~'LJ~,"~ ,-- .0 .." -~.. - , - ~ --'"-'~ ~ ~--'....- 905 1107. Attorney's fees to Robert Black. Esquire POC includes above item numbers: 1108. Title insurance to Orchard Settlement Services. Agent for United General Title 993.75 Premium Premium 993.75 38.50 1 270.00 1 270.00 1302.2008 CDun 316.65 1303. 1305. 1400. Total Settlement Cha 8S enter on line. 103 Section J and 502 Section K 2302.25 8 181.95 CERTIFICATION: I have carefully reviewed the HUO-1 Settlement Statement and to the best of my knowledge and belief. it is a true and accurate statement of all receipts and disbursements made on my account or by me in this transaction. I further certify that I received a copy of the HUO.l Settlement Statement. -t Pt:~ ()~ ..J);jJj~ /I ~/A~ Signature Borrower Signature of Borrower Signal re of Sel er Signature of Seller WARNING: It is a crime 10 knOWingly mak lse slalemenls 10 the United States on this or any other similar form. Penalties upon conviction can include a fine and Imprlslonmenl. For details see: Tille 18 U.S. Code Section 1001 and Section 1010. I ..-1 I . rm M&fBank _~) i. : . i . :'6/ ! (1\ -'1' I . it 499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12 Phone (888) 502-4349 Fax (302) 934-2955 August 9. 2007 Law Offices Landis & Black 36 South Hanover Street Carlisle, Pennsylvania 17013 Re: Estate Qf: Daris G Nicholas Social Security: 220-10-3798 Date of Death: Julv 12. 2007 Dear Sir or Madam: Per your inquiry dated August 03, 2007, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: L Type of Account Checking Account Account Number 430986 Ownership (Names of) Doris G Nichols * Shirley A Kiser * Opening Date 09101167 Balance on Date of Death Total $5,953.82 $ 0.08 "$f953:"96"' ... .......' ""'" .......... .......... .... Accrued Interest .. .... "..- '.' H............ ~-,. __......_... _ ......_.., ... _. .,.... _ _"'''' ....M ......." 2." -'TypeojACcQulit ~avlngs Account Account Number 015004204224907 Ownership (Names of) Doris G Nichols * Opening Date 12118103 Closed 07127107 Balance on Date of Death $19.552.06 Accrued Interest Total $ 16.59 --$/9368."65".---.-.--.---.-.--....--..-.. ...... ""'--'-'- ...-...... .--....... .~. -.. ....___.__...M __.. ______._ ____, 'M _.___ -- -- -.-----.----.-------.--------. -..-.. 3. Type of Account Certificate of Deposit Account Number 031003913122047 Ownership (Names oj) Shirley A Kiser * Doris G Nichols * Opening Date 01/06/06 Closed 07/27/07 Balance on Date of Death - $21,000.60 Accrued Interest $ 442.06 Total ..~.~._. "-~-".".""-.".".'''..' .....-.... ............-.........-............--..... -..- .--........--....--- ..-- .....-.......... $21,442.66 ..........-----....---.................-..-....-.......-.................-..-............-------..-------..-----.......---.......-- Please be advised, there was no safe deposit box found for the above decedent. * IT upon reviewing the information above, you believe there are additional accounts not referenced, please provide us with an account number and/or the name of any possible joint account holder. For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds, please caU the Stonehedge Office # 717-240-4524. Sincerely, ?4r~ .. . Nancy Clagett Records Management _ -v \ v I -\J.;I) MOTOR VEHICLE VERIFICATION OF FAIR MARKET VALUE BY THE ISSUING AGENT 'TIonwealth of Pennsylvania Irtment. of 'i"ransportation .U of Motor Vehicles sburg, PA 17104-2516 This form is used in conjunction with Forms MV-1, MV.4ST, MV-217A and an on-line processing Applicant Summary Statement. TYPE OR PRINT ALL INFORMATION AS REQUESTED FOR DEPARTMENT USE ONLY VEHICLE DESCRIPTION N PURCHASE PRICE .co a current edition of a Agent Number .. . .. e3-\2~ I ~~ L-a'Jo~a. ! ' i MHni~al L Explain In detail Why the purchase ptlC9listedon Form MV,-1, MV-4ST or MV-217 is less than 80% mthe avarage Fair Jv1ari<et ValuEI'; orifihe vehicle is over 15 years old and ."., he purcl1ase price is less than $500. explain haw the purchase price W8! determined, or if the vehide. is not listed in a PENNDOT 8ppl'tlved.publlcatlon,'explain' now the ' lurchase price as listed In Section A was determined. Please use additional paper if more space is required. NOTE TO PURCHASER: An addltlona' audit otthlsvehlcle .ale bv the Oeoartment of Revenue mav occur. Pleu. retain QQpln of this form. your canceUIId:.i:!leck' or original cash' receipt; and your receipt from the seller of' - his vehicle, along with either your copy of the Application for Certificate of TItle (MV-11. the Vehicle Sales and Use Tax Return/Application for Reglstnrtlon (MV-4ST)' Irthe Appllcatlonby FlnanclalInstitutions for Certificate ofiltleAfterOefaultbyewner (MV-21TA). ,. . '. :...'0.'....'. .,'. .:. . ..: '\\J\~D\( 'oo~daVV\~. . i. SEAL. AND SIGNATURE OF SellER. NOT REQUIRED FOR veHICLSS:-PURCHASEO O'UT..oF.sTATE: JBSCRIBED AND SWORN I~e state- that I/we:have'.read' and' signed this form after its completion, and l/we j B FORE ME: sytear or a1!lrm thatthe:$itements made herein:are true and correct,. and that any.. statement-made-on or pursuant to this form is. subject to the penalties 01.1 a PI. C.S. . _ Section 4903(a)(2)(relatlng to false swearing), which shall include punishment of a' - fllie not exceeding. $5,000, or to a term 'or imprisonment.of not morejhanJwo years, or bo1tl. Signa e of eller .. .~ Telephone Number ( EAL AND SIGNATURE OF PURCHASER IBSCRIBED AND SWORN EFORE ME: W P 00 ~~E UNLESS SUZ~"t8a:oB\'tJE~R I CARLISLE BOPIR_lU.1I1B!RI1A.CSlaA:~~TY MY COMMISSION EXPIRES MAY 10. 2008 (We state that Ilwe have read and Signed this orm a er Its completion, and I we ear or affirm that the statements made herein are true and correct. and that any tement made on or pursuant to this form is subject to the penaltles of 18 PA C.S. Sectlon 4903(a)(2)(relatlng to false swearing), which shall InClude punishment of a fine not exceeding S5.000, orto a term or imprisonment of not more than two years, or both. Signat X. Telephone Number ( I i I Messenger No. I THIS FORM MAY BE PHOTOCOPIED Income 42.25 226.75 90.50 64.75 30.75 60.75 65.00 16.75 152.25 67.75 122.75 160.00 26.50 34.50 49.75 83.50 1,082.00 2,376.50 Expenses AuctlClerks Adv. Total Income Expense Balance 550.00 190.00 740.00 2,376.50 Z4UllQ 1,636.50 nD~C Sa/~ ') ,1fcJ/Jda.; IJ fp 1. / () TJ-, 3- ? /I) 7 flJ3I3E7 CT Co! /;J Ie PA- f~rvlL CI3 ..--#-' ciLp~~ ,t- 9)107