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06-06-08 (2)
15056051047 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Cede Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po Box 28oso1 RESIDENT DECEDENT 2' ~ ~ ~ 0 3 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~ I l of ~°o~ 08ot 1~ZI 3riffix D~~ edent's Fir ,t N-une MI per edenCn L+~.t Name SERER 1ST ADE~.~1 0`~ ~ (If Applicable) Enter Surviving Spouse's Information Below MI Spouse's Last Name Suffix Spouse's First N~~me Sl.~cxise ~ Soci~31 Security Number -- THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW O 2. Su lemental Return O 3. Remainder Return (date of death ~ • 1. Original Return pp prior to 12-13-82) O .4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) 7. Decedent Maintained a Living Trust A 8. Total Number of Safe Deposit Boxes O 6. Decedent Died Testate O Attach Copy of Trust) (Attach Copy of Will) ( O .9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11 • Attach SchaOunder Sec. 9113(A) between 12-31-91 and 1-1-95) ( ) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Narrie Daytime Telephone Number g R ~ C F ~ S '~~ ~r 6 (Z 1ST `~ I `1 ~ c~ i G~ 1 ~ 1 Firrn Name (If Applcable), REGISTEH7 ILLS USE ONLY ~ ?.? `C1 - 3 -- ~. ' ~ .~ r ~ c First line of address -- ~ 0 ~ P T. N ~. ~J o o D D ~ 1 V ~ ~ > -~ , ~ Second line of address ~ --i ~ - ~ • ~ ` CJ'i DATE FILED City or Post Office State ZIP Code ~~~~~ m >a In S T o W n P ~• l `1 0 l l C ondent's a-mail address: 4~JYr-~Kti~~ ~ ~u ~-~R~ t C~ orresp Under penalties of perjury, 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 personal representative is based on all information of which preparer has any knowledge. _ DATE SIGNATURE OF SON R~,SPO,NSIBLE FOR FILING RETURN ~~,-` / `~~~ ADDRESS 3~ P1Yt1r,+~ofl~ D 1~~ i /Hl~y,l"~„SGOWY1 ~• ~~OI~ _ DATE SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ADDRESS PLEASE USE ORIGINAL FORM ONLY 15056051047 Side 1 15056051047 ~~ REV-1500 EX ,.. Decedent's Name: RECAPITULATION 15056052048 Decedent's Social 1. Real estate (Schedule A)......+....' ... ~.. ~ ........ '........:.' ...'... ~ .. ~ 1. ' ,:~ .. _ ~ r O 2. - Stocks and Bonds_(Schedule B) ... , ..; .. . .......................... ... 2. 4. ©{~ 3. ~ ~ Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. . ;e. ~ . ~ 4 4. Mortgages & Notes Receivable (Schedule D) .......................... ... 4. b 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... ... 5. ~ Z Q q O ~ g ~( 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. ~ "l ~ 5 7, Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7. ~ ~ ~ Q 8. Total Gross Assets (total Lines 1-7) ............................ .... ... 8. l ~ ` J 3 ~p ~ ~~ 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. ~ L~ti Z S ~ 'Q) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10, ~ 3 ~ (p ~ ~ 3 11. Total Deductions (total Lines 9 & 10) ................................ ... 11. 5 ~ 3 Z S 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. ~ ~ ~ © 3 „ , Q 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election toaax.has not been made (Schedule J) .............. : ...... .... 13. ~ . Q Q 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. y 3 p ~ 3 . ~ '~ TA,X COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 ~ ~ + ' 16. Amount of Line 14 xable at lineal rate X .0 ~ ~ ~ ~ Q ~ ,, Q 16. ` 9 , ` , ' `~ 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 1 g. ~ . 19. TAX DUE .................................:..,..-. .. ..........'.. ....b9. ' '1 1 ~ . 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p /~ e~ ~ ~~ \~ Side 2 15056052048 15056052048 REV-1500 EX P<3ge 3 Decedent's Complete Address: File Number ~~E.t~)~~ Ih. 5~~16R+S3' STREET ADDRESS 5225 ~1tSoh ~,~nF CITY.......... ~Yl~ AY1rCS$tl0.b T -- __ STATE~^ ZIP +~ 11011 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit _ B. Prior Payments C. Discount (1) l,g'~1,~'1 Total Credits (A + B + C) (2) 3. InterestlPenalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E ) 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) O ~O (4) (5) 1 ~g11,17 (5A) O (5B) 11 l1 ~. ~1 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 :.................................................................................... ...... ^ b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ c. retain a reversionary interest; or .................................................................................................................... ...... ^ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........................................................................................................ ...... ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ........ ...... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ...... ^ 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 dE;ath 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 dE;ath on or after July 1, 2000: The tax rate innposed 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 irnposed 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. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (6-98) SCFIEDIJLE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE t)F FILE NUMBER ~~GA~I~~ m • SF~6iuu' ~~~ti6 _b3~t't 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. (If more space is needed, insert additional sheets of the same size) REV-1503 EX ~ (1-97) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ADS ~D€ nn . SE~c~a.~sr 2~-06--o~~t1 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL (Also enter on line 2, Recapitulation) I $ ~~~ (If more soave is needed, insert additional sheets of the same size) REV-1504 EX+ (1-97) CONIMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDI~ILE C CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER A~DguA~tDE ~. SElg6~iS~ ~.i-d8~-o3y'~ 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. (If more space is needed, insert additional sheets of the same size) _ REV-1505 EX+ (6-98) SCNEDIJLE C-1 COMMONWEALTH OF PENNSYLVANIA CLOSELY HELD CORPORATE INHERITANCE TAX RETURN STOCK INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER A~DE4~IDE ~1 • S~A6tU~' 21-0'~ X03 ~1 1. Name of Corporation State on Incorporation Address City 2. Federal Employer I.D. Number 3. TypE~ of Business 4. Product/Service Business Reporting Year STOCK TYPE TOTAL NUMBER OF PAR VALUE NUMBER OF SHARES VALUE OF THE Voting/Non•Votng SHARES QUTSTANDING OWNED BY THE DECEDENT DECEDENT'S STOCK Common $ Pneferred $ Provide all rights and restrictions pretaining to each class of stock. 5. Was the decedent employed by the Corporation? ................................. ^ Yes ^ No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? ................................... ^ Yes ^ No If yes, provide amount of indebtedness $ 7 Was there life insurance payable to the corporation upon the death of the decedent? ..... ^ Yes If yes, Cash Surrender Value $ Net proceeds payable $_ Owner of the policy 8. Did i:he decedent sell or transfer an stock in this company within one year prior to death or within two years if the: date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....^ Yes ^ No If yeas, provide a copy of the agreement. 10. Was the decedent's stock sold? ..................................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? .................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ............. ^ Yes ^ No If yeas, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • • ~- • ~ ~ A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. Date of Incorporation State Zip Code Total Number of Shareholders ^ No (If more space is needed, insert additional sheets of the same size) REV-1506 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ACNE®!!!E ~@2 PARTNERSIiIP INFORMATION REPORT ESTATE OF FILE NUMBER ~FuA~10~ ~1- S~~~US~'= 2~-O'~~03~1 1. Name of Partnership „' fit- N ~ A`A~, ~, Date Business Commenced Address ' ' `- V, ~'Cl"~~+fJF~w ~ Business Reporting Year City 2. Fecleral Employer I.D. Number 3. Type of Business Product/Service State Zip Code 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. PARTNER NAME _ PERCENT OF INCOME PERCENT OF OWNERSHIP BALANCE OF CAPITALACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................. ^ Yes ^ No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ..... ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferred/sold Transferee or Purchaser Consideration Attach a separate sheet for additional transfers and/or sales. Date 10. Was there a written partnership agreement in effect at the time of the decedent's death? ...... ^ Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? ....................................... ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ................... ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? .................................... ^ Yes ^ No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? .............. ^ Yes ^ No If yeas, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • ~ ~- • e e A. Detailed calculations used in the vaiuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX+ (1-97) ~~~ ~ SCNEDIJLE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER ~-'D~.~.+~10~. ~v1. 5~1~46~J1~ ~,1 ~-o3y1 All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1508 EX ~ (1-97) SCHEDULE E p ~^ ~+ COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & IIflISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER K}~Ea.aa~-pE gyn. SE~c~ls, ?tea--o3yl Include the proceeds of litigation and the date the proceeds were received by the estate. All property joiMlyowned with the right of survivorship must be disclosed on Schedule F. 4TEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ,. ~tVC gwr~~C. 'DinTSr~u' t~.~,r-b St-V ors - ~el~ ~.o. Lox coq T Q~3B~0.wµ, P+A~ 1SZ~~q~~g - _--~ 9, iQ,3,3q Z PN ~ ~rEW~~. PQ~t~nn mcm~ M~X-~ ~'~-3o~e- 3~`y P, o , troy. (coq Q;c~~os~~, P~. tsar-a~3a 3z, qo~ ,y.~ TOTAL (Also enter on line 5, Recapitulation) I $ ~z f O4 ~ .~ (if more space is needed, insert additional sheets of the same size) REV4509 EX a (1-97) SCHEDULE F COMNIONWEALTHOFPENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ~1DE.L,r~~E- hl. 58,14(ail.ISi ~~-A8.,03~1Z If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURV'IV1NG JOINT TENANT(S) NAME A. ~~~ ~. sir ADDRESS Sob PIY~~WOOD DR1vF_ ~1~1REM'A~-S?' ©`ilil~ ~ ~ . 1011 RELATIONSHIP TO DECEDENT So-n a. l,p~Ri~`~ ~~12150' c. 3 t(~ So~~t ~ odl~ 53~+~ Mf~t p~-tCS4vRb, ~~1. 1105 .InINTLY-AWNED PROPERTY: Sov~ ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name of financial institution and bank account number or similar identifying number. Attach deed for jointly-held real estate. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. log-~cy ~c~1C ~nx~ncv,A~, Ss~G~ ~c.~S ~OR~~,P 3~o SHIM-~S ~ ~ ~~.80 -M+~~3' U 14W ti, No~w- @ti1: 1, Zo No~D~CtL IA[~u~r tnvw-~. ooo48ZtS~o3 ~ZZ.,33~°° 3333 - 7,y~1~.~~1 ~ TOTAL (Also enter on line 6, Recapitulation) I $ 1~~US~3~1 (If more space is needed, insert additional sheets of the same size) REV-1510 EX i (1-97) COMMONWEALTH OF PENNSYLVANIA IPJHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER ~~FL~Q~ID~ M• SEi~ ~1-o~~o3y1 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER, ATTACH A COPY OF THE DEED FOR REAL ESTATE . DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION iFAPPUCneLE TAXABLE VALUE t TOTAL (Also enter on line 7, Recapitulation) I $ ~~' (If more space is needed, insert additional sheets of the same size) REV-1511 1.X+ (10-06) SCFIEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER AD~t~iO~ M. S~~iS) ~,1-oB --o3V~~ Debts of decedent must be reported on Schedule I. ITEM NUMBEI3 DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. YYl~1L'~FZZ.~ Fvv~~.Q~~. h}orh~ m~,~n,cs ~o~b, P-~, 17oss ~ B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name 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 ~. R~~~t. of Dtities- C~4v4u,a~ eoo~~y, P~tnns~~vw~-~,A i~ty .o~ 8• -t1~t, 5~11t~'~t~ ~ 11S~ab ~~~ 1~cSTIA„n~unilwU{ IZb.1o TOTAL (Also enter on line 9, Recapitulation) $ ~,y~,s,~~, (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNED~ILE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER A~?F.uAr10~ 1M. S~tAfc'N-R' '1.~.A'a-~3~t'l 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 ~t v~wa~., Yv-~cs$ut~k,, PA . SK~u.4~ I~'~i ~4 ' 0(~o~R„ '~,~o~ ?,u ~V1~LL~t~AlV~1 ~M~{ PH~yY1'IAb~ CI~IA~bfL - ®~0~, ~.oA9 ~ • ~~~ ~~1 C~~ m~c~Dt~4c, ~Sv~, . TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) ~'~'i,So ~.9~~~ t~`t.o~l l,~oc~.~t3 REV-1513 EX+ (9-00) SCHEDULE J COt~AMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~E~D~ W1. S~{A6RKi FILE NUMBER ~1-0A..e3411 NUMBEfi NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] ~'~ ~0.R1~`I SF~~ si 3-b So~~t ~o~ g~~ ~, ~1~1QrV~vCSP~v~R.b ~ PEA. 1`to~~ S0 v1 ~O~o 0~ ESi1 ~~lvc~ ~. SFaA~tU~p' 3nb ~lvttiwo~D DlLlvk. SWtR~.~Mrq~Stia,~-- I ~Ip-. t1o~- Sov~ So ~ o~ ~,ii ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 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 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ ~`~ (If more space is needed, insert additional sheets of the same size) REV-1514 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDVLE K LIFE ESTATE, ANNUITY & TERM CERTAIN heck Box 4 on REV-1500 Cover Shei ESTATE OF FILE NUMBER taAfr~uA~o~ M. S~61MS~' 2~-oe-o3~1 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. ^ Will ^ Intervivos Deed of Trust ^ Other NAMES} OF LIFE TENANTS} DATE OF BIRTH • NEAREST AGE Afi DATE OF DEATH TERM OF YEARS LIFE ESTATE IS PAYABLE ^ Life or ^ Term of Years ~01 ~ ^ Life or ^ Term of Years ~ ~ ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which life estate is payable ..........................................$ 2. Actuarial factor per appropriate table ................................ . Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 3. Value of life estate (Line 1 multiplied by Line 2) ......................................$ NAME(S) OF LIFE ANNUITANT(S) DATE OF BIRTH. • NEAREST AGE AT DATf OF DEATH TERM OF YEARS ANNUITY IS FAYABLE ^ Life or ^ Term of Years ~~' ~ ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which annuity is payable ............................................$ 2. Check appropriate block below and enter corresponding (number) ......................... . Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^ Semi-annually (2) ^ Annually (1) ^ 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 - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor (see instructions) ................................................. . 7. Value of annuity - If using 31/2%, 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 ..................................................$ 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) REV-1644 EX ~.Is-oaf INHERITANCE TAX SCHEDULE L COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN AS P FILE NUM I ~"O3y~ ~ RESIDENT DECEDENT OR INV ON OF TRUST P INCIPAL .. BER I. ESTATE OF SF.IA~~Utg: ~DEI,IQ~tp~ ~, (Last Name) (First Name) (Middle Initial) This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal. II. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) of election or annuity is payable C. Assets: Complete Schedule L-1 ~~ ~~~ 1. Real Estate ...............................$ 2. Stocks and Bonds ..........................$ 3. Closely Held Stock/Partnership ...............$ 4. Mortgages and Notes .......................$ 5. Cash/Misc. Personal Property ................$ 6. Total from Schedule L-1 ......................................................$ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities ...........................$ 2. Unpaid Bequests ...........................$ 3. Value of Unincludable Assets .................$ 4. Total from Schedule L-2 ......................................................$ E. Total Value of trust assets (Line C-6 minus Line D-4) .................................$ F. Remainder factor (see Table I or Table II in Instruction Booklet) ........................ . G. Taxable Remainder value (Line E x Line F) .........................................$ (Also enter on Line 7, Recapitulation) III. INVASION OF CORPUS: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) corpus or annuity is payable consumed C. Corpus consumed ............................................................$ D. Remainder factor (see Table I or Table II in Instruction Booklet) ........................ . E. Taxable value of corpus consumed (Line C x Line D) .................................$ (Also enter on Line 7, Recapitulation) P,EV•t6d5 EX+ (7.85) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE L-1 REMAINDER PREPAYMENT ELECTION IFILE NUMBER ~.1~-'a3~~ -ASSETS- I. Estate of 5~~~~ ~~ m• (Last Name) (first Name) (Middle Initial) I1. Item No. Description Value A. Real Estate (please describe) Y1oT ~QP~lC~yl,~ Total value of real estate $ (include on Section ll, Line C-1 on Schedule L) B. Stocks and Bonds (please list) V~0'`1 ll4p~l.l.@J~l~/ Total value of stocks and bonds S (include on Section ll, Line C-2 on Schedule L) C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2) (please list) h~ mil}/ Total value of Closely Held/Partnership $ (include on Section {I, Line C-3 on Schedule L) D. Mortgages and Notes (please list) har 14PPucd4b~ Total value of Mortgages and Notes $ (include on Section II, Line C-4 on Schedule L) E. Cash and Miscellaneous Personal Property (please list) NO ~ t4~IPclCr4bt~ Total value of Cash/Misc. Pers. Property $ (include on Section II, Line C-5 on Schedule L) I11. TOTAL (Also enter on Section II, Line C-6 on Schedule L) $ (If more space is needed, attach additional 8'/z x 11 sheets.} REV-1646 EX+ )3-84) INHERITANCE TAX SCHEDULE L-2 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN REMAINDER PREPAYMENT ELECTION h A~ RESIDENT DECEDENT -CREDITS- FILE NUMBER f.~' I. Estate of ~~~~ ~~~~~ M~ (Last Name) (First Name) (Middle Initial) II. Item No. Description Amount A. Unpaid Liabilities Claimed against Original Estate, and payable from assets reported on Schedule L-1 (please list) Y1oB' I4~t~Pu~!'~bt~-- Total unpaid liabilities $ (include on Section II, Line D-1 on Schedule L) B. Unpaid Bequests payable from assets reported on Schedule L-1 (please list) N~1 ~~~~1,~-~ Total unpaid bequests $ (include on Section II, Line D-2 on Schedule L) C. Value of assets reported on Schedule L-1 (other than unpaid bequests listed under "B" above) that are not included for tax purposes or that do not form a part of the trust. Computation as follows: ~~ ~~~~ Total unincludable assets $ (include on Section II, Line D-3 on Schedule L) III. TOTAL (Also enter on Section II, Line D-4 on Schedule L) $ (If more space is needed, attach additional 8'/s x 11 sheets.) REV-1647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE Check Box 4a on Rev-1500 Cover Sheet ESTATE OF FILE NUMBER A~srJUac~~ rh. S~tA~~-4fi ~-oe~o3~c1 This Schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. ^ Will ^ Trust ^ Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. ~~ 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. ^ Unlimited right of withdrawal ^ Limited right of withdrawal III. Explanation of Compromise Offer: 1V. Summary of Compromise Offer: 1. Amount of Future Interest .........................................................$ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) ......$ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One ^ 6%, ^ 3%, ^ 0% ......................$ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One ^ 6%, ^ 4.5% ...........................$ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ......$ 6. Value of Line 1 taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ......$ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ......................$ (If more space is needed, insert additional sheets of the same size) REV-1648 EX (11-99) SCHEDULE N ..r ~ SPOUSAL POVERTY CREDIT COMMONWEALTH OF PENNSYLVANIA (AVAILABLE FOR DATES OF DEATH 01/01/92 TO 12131/94) INHERITANCE TAX DIVISION ESTATE OF FILE NUMBER This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet. 1 . Taxable Assets total from line 8 (cover sheet) ............................................ 1 . 2. Insurance Proceeds on Life of Decedent ................................................ 2. 3. Retirement Benefits .................................... ~... ~~T.. ~ :'^`r?:d`.+!'. '. 3. 4. Joint Assets with Spouse ......................................... c.... ~ ..... 4. 5. PAL_ottery Winnings .............................................................. 5. 6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a. 6b. 6c. 6d. 6. SUEITOTAL (Lines 6a, b, c, d) ........................................................ 6. 7. Total Gross Assets (Add lines 1 thru 6) ................................................. 7. 8. Total Actual Liabilities .............................................................. 8. 9. Net Value of Estate (Subtract line 8 from line 7) ........................................... 9. !f line 9 is greater than $200,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part II. Income: 1. TAX YEAR: 19 a. Spouse ........... ia. b. Decedent .......... 1 b. c. Joint ............. 1c. d. Tax Exempt Income .. id. e Other Income not listed above ........ ie. f. Total ............. if. 4. Average Joint Exemption Income Calculation 4a. Adcl Joint Exemption Income from above: (1 f) + (2f) _ + (3f) 1 (- 3) 4b. Average Joint Exemption Income ..................................................... _ If line 4(b) is areater than $40.000 -STOP. The estate is not eliaible to claim the credit. If not. continue to Part 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less ..................... I 1 2. Multiply by credit percentage (see instructions) ........................................... ~ p 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet . ............................... 3 4. For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the deardent's gross estate ............................................................. 4. 5. Mulltiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal Poverty Credit .Include this figure in the calculation of total credits on line 18 of the cover sheet....... 5• 2. 2c. ~ ~ 3c. 3f. REV4fi49 EXi (7-97) SCHEDULE 0 COMMO'NWEALTHOFPENNSYIVANIA ELECTION UNDER SEC. 9113(A) INHERITANCE TAX RETURN (SPOUSAL DISTRIBUTIONS) f2ESIDENT DECEDENT ESTATE OF FILE NUMBER IP~D~d~ M, sE~~~u~r ~-_oa -o3y~I Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the Trust (marital, residual A, B, By-pass Unified Credit etc.). If a trust or similar arrangement meets the requirements of Section 9113(A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transfE;ror's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0. The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 9113 (A) trust or similar DESCRIPTION U1o~ Y~'Pw~~ PART B: Enter the description and value of all interests included in Part A for which the Section 9113 (A) election to tax is being made. DESCRIPTION VALUE Part B Total ~ (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMENT OF ADELAIDE M. SEAGRIST I, ADELAIDE M, SEAGRIST, of Shiremanstown, Cumberland County, Pennsylvania, being of sound mind, memory and understanding, do hereby make, publish and declare this as and for my Last Wi11 and Testament hereby revoking and making void any and all other wills by me at any time heretofore made. I. I direct that my Executor hereinafter named shall pay all my just debts and funeral expenses as soon as conveniently may be done after my decease. II. All the rest, residue and remainder of my estate, whether real, ~, ~ personal or mixed, and wheresoever situate, I hereby give, devise and bequeath ' unto my husband, RTCHARD L, SEAGRIST, if he survives me by a period of thirty ~~. days. If my said husband does not survive me by a period of thirty days, ____ then this gift to him shall be divested, and I then give, devise and bequeath my entire estate unto my two sons, LARRY SEAGRIST and BRUCE E, SEAGRIST, in ,,-, equal shares. III. I hereby nominate, constitute and appoint CUMBERLAND COUNTY \~'" NATIONAL BANK AND TRUST COMPANY as Guardian of the estates of any minors who may take a share under this Will. IV. I hereby nominate, constitute and appoint my husband, RICHARD L, SEAGRIST, as Executor of this, my Last Wi1I and Testament. If the said Richard L. Seagrist should predecease me, or otherwise fails to qualify, or ceases to act as such, then I nominate, constitute and appoint my two sons, LARRY SEAGRIST and BRUCE E. SEAGRIST, as Coexecutors. V. No fiduciary acting under this Will shall be required to post bond in this jurisdiction or in any jurisdiction in which he may act. IN WITNESS WHEREOF, I, Adelaide M. Seagrist, the Testatrix, have unto this, my Last Will and Testament, set my hand and seal this day of February, A. D., 1970. ~: ~ ~ , !(SEAL) SIGNED, SEALED, PUBLISHED and DECLARED by Adelaide M. Seagrist, the above-named Testatrix, as and for her Last Wi11 and Testament in the presence of us, who have hereunto subscribed our names as witnesses at her request, in the presence of the said Testatrix and of each other ,:: -•, a JON I 317 T~ 105.905MS REV. GlOG This is to cenify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records in accordance wick Act 66, P.L. 304, approved by the General Assembly, June 29> 1953. Military Status l WARNING: It is illegal to duplicate this copy by photostat or photograph. U Calvin B. Johnson, M.D., M.P.H. Frank Yeropoli Secretary of Health State Registrar 126U42~. No. NOV 0 92007 Date COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (See instructions and examples on reverse) STATP FIt F NumeeR INK 1. Name ai Decetlent (First, middle, last, suaix) 2. Sex 3. Social Becudry Number 4, Date M Death (Month, tlay, year) 03 7867 Nov 2007 le 204 1 F Adelaide M. Seagrist - - . , ema Age (Las[ 6ldhtlay) UMer 1 year Under 1 day B. Dale of Birth (Month day. year) ]. Bldhplace (City antl state p forego country) /)a. Place of Death (Check only one) 5 . Morena aYS Hours Minuses Hospkal: Omar: 86 vra August 1, 1921 Millersburg, PA ^mpaueM ^ERlanpauent ^DOA ~NUr$Irig Home ^Residance ^Other-Speciry Twp. of Death City. Bono url of Death & Bb D Btl. Facilhy Name (b nW indiNign, gva street and nunber) 9. Was Decedent of Hispank Origin? ['~ No ^ Vas tp. Race'. Parrerirzn IMian, Black, WMe, etc , . y . o pr yea, specM cubes. (spedM Ctiunbexland Lower Allen map. Bethany Village Mexico^. Puenb Rican. Np.l ?~ihite 1 i. Decedan'.s Usua{ Occu algn Kkg o1 vepk done Mom most M workin lice. Do not slate retired 12. Was DecetleM ever In 10e 13. Decetlenl's EtlUCation (Specify only highest grade compleletl) 14. Ma"tat Sglus: Married Never Monied 15. Surviving Spouse (II wire, give maiden namef Witlowed Diwrwtl (Spaciy) K,rd of Work Kintl M Busirgss I Intlustry U.S. Armetl Forces? Elementary / Secondary (D-12) College (1-4 or 5+) a W d Cl Controller Banking ^Yaa $J¢m cx e l 12 18. Deceiient's Mailing Atltlress (Street, dly i town, state, ziP cotlel OecedeM's 17 R S Penns 1Vania ~ve mecaetlenf p~ T l Decedent Lived-m TAWer Allen Twp. y 1]c z Yas 5225 Wilson Lane a. Actual esitlence tale om . p , TownshlP7 1]tl. ^ No, Decedent Lived wahin Gtiamberland Me.^.hanicsburg, PA 17055 . Counry t gdual umim Pf cll. Bom 18. Father's Name (First, middle, last, suMu) 19. Molners Norte (RrsL mklrle, maitlan samame) Wa ner M tl M Elmer E. Hoffttlart g . yr e 20a. Infbnmenl's Nang (Type! PnM) 20b. Informants Nailing Address (Street. Cay i town, stale, zip code) PA 17011 Shiremanstown 306 Pinewood Drive Bruce Sea ist , , 2t a. Medrotl of Disposition 4~ Cremadan ^ Donation 210. Dag of Disposhion (Month, tlay. year) 21 c. Place of Dispdsilion (Name of cemetery, cre,glory or other pWCej 21 tl. Location (City I town. state, zip code! % tnon:ee ^ aerial ^ Remwaltrbmslam n'N EZ ~ m D Nov. 2 2007 Hollinger Crematory Holly Springs PA Mt a r ^vea^Nd aO N i ^ Other - Specify , . , 5'g aMy$GFunaral Servae L~pensea (or person acing as Such) J c / 220. license Number 22c. Name antl Address of Fadhty g Market Plaza Way rS`'/~ G~/~-ma ` FD-011667 Mal 2zi Funeral Home Mechanicsb PA 17055 Comp.' g Items 23ac oMy when cad .g physn4 s not available at tme M deem to 23e. T best my edge. Beam at the time, dMe ant place stated` (Sgnature antl titg) /~ ~ / 1 23b. License Num08r i ~ ~ ~ ~ v C 2 .Data Signed (Month, ay, year) ' tiTT rerMy reuse of tleam. , \ N V 26 Time N Death 25. at onouacetl Deatl IMO m, tlay, year) 26. Waa Case Referred to Metlkal Examiner /Coroner far a Reason Other Ivan Cremation er nation? his 2426 muss be competed by person w . 0 ^Ves ^~ ho pmneunces death. M. CAUSE O EATH (See instruetl sand examples) r Approximate interval: Pad II: Eller other g^;f I Mldl Mdbua t de m, 2R. Did Tobacco Use CmldOUte Ib Death? Item 27. Part I: Enter the ch ' d g -dseases, Injuries, or Wmp6wliore -1hN drecdy caused the death. DO NOT enter lemvnal events such as car iac arrest, pn, t to Death but not rewllug in the undedyirrg cause given in Pad I. ^ Yes ^ PrcbaMy rasprztory anesl, a veMricuhr fibrillation wi11gN showing me Niology. List only one cause on each line (~ ^ Ne ~ Unknown IMMEpATE CAUSE Final disease or /a , (^ x~' ~t N contldion resulting m ~aathl I N "y ~ s ~ O ~/~~~[~fl)~w l }'~'~ N - •"~ -'1 29_ If Femag: t nant ithin r ^ N t ~ e. DMe tP pr a5 a pOn nenre p~l}w~lvt.~..fl b - r1y1M~ d anr dNy hs rn,dr s b (~vJ, mOrxltnn,l ~r~-.~,~. preg pas o w Yea ^ P,agnam ai trine m deem , • eq . leadirgp to ;he cause listed on line a. Due to (or as a~~ EMSr the UNDERLYING CAUSE (tllseese or injury mat inkietetl me ^~ ~ ` - ^ Nolrepalegrgm. Out pregnant witNn a2 dens o vents revslting m dean) LAST. c ^ Not pregnant, but pregnant 63 tlays l0 1 year Duero (or as a consequenre oQ: d. bNOre death ^ Unknown if pregnant wihin me pall year 30a. Was an Autopsy ?Ob. Were Autopsy Findings 31. Manner d Deam 32a. Date oI In;ury (Month. Day, year) 326. Describe How Injury Occunetl 32c. Face of Injury: Home. Farts, Street Factory OflCO Building, etc (Specify) Performed? Available Prior to Compleson f C f D m? 4/^`0rural ^ Homicide o ause o ee ^ Acddent ^ Pending Invasligation 32d. Tine M Injury 32e. Injury a1 Work? 32f. II Transponation Injury (Specify) 32g. Emotion of Inlury (Sireel. city /town, Siatej ^ Yes [~b~ ^ Vas ^ No ^Ves ^ No ^ DMer! Operator ^ Passenger ^Petlasinan ^ Suicide ^ Coultl NM be Determined M ^~&. Specify' 33a. Cen'rfiar (check only one) 33b. Sg a n0 Title of Ce her r • Cenilying physlclen (Physician certltying cause of death when another physician has prorgunced Oealh antl mmpletetl Item 23f x as WlM _ the eausa(s)arM mAnM d d l d kNh ________________ ^ - ______________ _ . ge,r xeurre ue s To tM best of my Nnowla =e of death) edi in to au m nt _ License Number 33c 33d. Date gnetl (Monet, tlay, year) y g _ a c • Prorwuncng arM crvlifying phyeicbn (Physician both pronouncing tlea To the beN of my knowlatlge, deem occurred N the time, date, and place, and due to the cause(s) and manner as statetl_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ . w ,a ~ ` ~ ~ 3~ `/ ~ ~ L ry-~ v dlcN Examirrer)Cororgr • M ~ ' 1 O- T e On me basis of examinetlon and / or investlgatitm, in my opinion, dnm ocwrretl N the time. date, and place, and due to the cause(s) and manner as steted_ ^ 34.tNan~e anxtl `Atldtr~esls at Person Wvho C~mpl led tCa~use of Deals (I:am 271 Type /Print ~ ~ ~ ~~ ~ Data F,gd (Month y ar( 3fi daY l~ ~`~.A ,v, ` ~ 1`^ - ` to umber I/ 35. Reg Inv' naiU tl I ~I -l I r2~ I ~ I ~I ~ ~ , ` , . . nf i/ N er "j ~C'1 3 ~ ~ -~-t~l.~ ~ ~'0 l1 V / M.L ~ LxC I (, a e Disposilicn Permit No, ~~~Q I ~I Total Eanking Stateme~ ~ PNCBANK PNC Bank v Primary account number: 51-4005-6121 Page 1 of 4 Number of enclosures: 0 p For 24-hour banking, and transaction or interest rate information, sign on to 'a' PNC Bank Online Banking at pnc.com. For customer service call 1-888-PNC-BANK between the hours of 6 AM and Midnight ET. Para servicio en espaliol, 1-866-HOLA-PNC Moving? Please contact us at 1-888-PNC-BANK ® Write to: Customer Service PO Box 609 Pittsburgh PA 15230-9738 Visit us at pnc.com TDD terminal: 1-800-531-1648 For hearing impaired clients oiily Relationship Overview Bank Deposit Accounts Description Account Number Deposit Balance Interest Checking 51-4005-6121 ~.~1~~ bN Premium Money Market 51-3016-3564 QM•!'~~1C11k~ ~- Total Deposits 9,184.45 32,997.76 42,182.21 Give the gift of PNC Bank Visas Gift Cards this holiday season. Perfect for everyone and availablevt whole dollar amotmts up to $500. Stop by a narticinatu~e PNC Bank branch for more details. Senior Premium Plan Adelaide M Seagrist Interest Checking Account Summary Account number. 51-4005-6121 For the period 10/06/2007 to 11/06/2007 ADELAIDE M SEAGRIST 5225 WILSON LN STE 325 MECHANICSBURG PA 17055-6663 Balance Summary Beginning Deposits and Checks and other balance other additions deductions 3,081.34 1,518.17 415.06 Ending balance 9,184.45 Charges and fees .00 Average monthly balance 8,106.32 Transaction Summary Interest Summary Checks paid/ Check Card POS Check Card/Bankcard withdrawals signed transactions POS PIN transactions 3 U 0 Total ATM PNC Bank Other Bank transactions ATM transactions ATM transactions 0 0 0 Annual Percentage Number of days Average collected Yield Earned (APYE) in interest period balance Tor APYE 0,15% 32 3,106.32 Please see the Activity Detail section for additional information. As of 11/06, a total of $11.35 in interest was Interest Paid paid this year. this period L06 E FORM953R-1005 Total P>anking Statemer. For the period 10/06/2007 to 11/06(2007 For 24-hour information, sign on to PNC Bank Online Banking ADELAIDE M SEAGRIST on pno.com. Primary account number: 51-4005-6121 ~<• Account number: 51-4005-6121 -continued Page 2 of 4 ti,ctivity Detail Deposits and Other Additions Jate Amount Description l1;'Ol 1,517.11. Direct Deposit. - RR Ret try Treasut-)~ 303 ~lraZS,ttis4905 1 ll/OG 1.OP_i Interest Paj'ment Checks and Substitute Checks check Date Reference Check lumber Amount paid number number ??43 ?06.06 10%19 0:;65?.5573 2?45 ??4=1 150.00 l0i 17 OT572-ts2~t ' Gap in check sequence Daily Balance Detail )ate Ba!anc=_ Date Balance Date Balance l)jOr_, 3,031.31 10.'19 7,6f-,6.`23 11jOC, 9,134.45 1(1;'17 7,37.'.34 11;'01 9,183.39 There were 2 Deposits and Other Additions totaling $1,513.17. Date Reference Amount paid number 59.00 1O,%'17 Og602uii3 There were 3 checks listed totaling 5415.06. Take your holiday shopping easy and re~~-arciing this year ~rhen yot.t use your PNC Bank ~'is1 R~ Check Carci or PNC Bank `'isa R~ Platinum :'t~edit Card..~ccented at inoiti than 20 million locations «-orld~cide acid onlitte. Ha~~e a goal'? Get a plan. Come in for ~•otar complimentary financial assessment. You have a better chance of realizing your goals when you write them down. That includes financial goals. A PNC Financial Consultant can Delp you. create a. plan for education expenses, a new house, retirement and any dream you have. Call 1-800-P`C-6111, visit us at pnc.com or stop by the nearest PNC Bauk Branch. Vnt. FDIC Insured. :11ay Lose Value. \n (tank Guarantee. 6npnrtant Investor Information: Securities and bmkernge senices are pro~~ded by PNC Invesimcnts LLC ll2lllht:•1' £I\R.'1 allCl SIPC:. :~lllltti$z$ and OtI121' 1115R1hllC2 pr(XI71CtS alt offel'ecI t)}' PNC. Ill$IDhllBZ $0ri1C0S. LLC, a IICZll$2(I IllSlll8llC0 a42llC~'. Premium Plan Adelaide M Seagrist Premium Money Market Account Summary 4ccount number. 51-3016-3564 Balance Summary B=_ginning Deposits and Checks and other balance other additions deductions 43,473.33 291.83 15,767.50 Average monthly balance 3 7, 7?4.?4 Transaction Summary Ghecks paid/ Check Gard POS Check Card/Bankcard withdravrals signed transactions POS PIN transactions i O o Total ATM PNC Bank Other Bank transactions ATM transactions ATM transactions 0 !) 0 Interest Summary Annual Percentage Number of days Average collected Yield Earned /APYEj in interest period balance for APYE 2.7G% 3? 37,7?4.24 Ending balance 32,997.7(1 Charges and fees . ('0 Please see the Activity Detail section for additional information. As of 11/06, a total of $1,970.79 in interest Interest Paid was paid this year. this period 90.? 3 E Total Banking Stateme_ For 24-hour information, sign on to PNC Bank Online Banking on pnc.corn. Account number: 51-3016-3564 -continued PNCBANK For the period 10/06/2007 to 11/06/2007 ADELAIDE M SEAGRIST Primary account number: 51-4005-6121 Page 3 of 4 Activity Detail Deposits and Other Additions Date Amount Description 10/24 201.60 Direct Deposit - Divpde0710 The PNC Financia C~:tiua1503PNC 11/06 90.23 Interest Payment Checks and Substitute Checks Check Date Reference number Amount paid number 191 15,767.50 10/16 027016570 There were 2 Deposits and Other Additions totaling $291.88. There is 1 check listed totaling $15,767.50. Daily Balance Detail Date Balance Date Balance Date Balance Date Balance 1Oj06 43,473.33 10,/16 32,705.33 1.0/24 32,907.•13 11/06 32,997.76 E FORM953R-1005 PNC The PNC Financial Services Group Computershare Trust Co., Inc. 2 North LaSalle Street Chicago Illinois 60602 Within the US, Canada 8 Puerto Rico: 800 982 7652 Outside the US, Canada b Puerto Rico: 312 360 5235 Facsimile: 312 601 4335 For a change of address please call the above number. Holder Account Number ADELAIDE M SEAGRIST & LARRY SEAGRIST & BRUCE SEAGRIST JT TEN 213 W COURTLAND AVE CAMP HILL PA 17011 PNC Irrrlllr~rlllrrrrrrllr~~ll~llr~rlrlrllrrrlr~l~r~rllr~llrlrrrll C 0009821503 Uncertified accounts are subject to withholding taxes on dividend payments and sales proceeds. CUSIP Number 693475105 Company ID PNC SSN/TIN Certified Yes The PNC Financial Services Group, Inc. -Direct Registration Advice Transaction(s) Date O6 Oct 2004 Transfer Total Shares/Units 320.000000 Account information: Date: 06 Oct 2004 (Excludes transactions pending settlement} Certificate Balance Held by You 0.00 Transaction Description Current Dividend Reinvestment Balance ~ Current Direct Registration Balance 0.00 320.00 Total SharesNnits 320.000000 F IMPORTANT INFORMATION RETAIN FOR YOUR RECORDS. This advice is your record of the share transaction affecting your account on the books of the Company as part of the Direct Registration System. It is neither a negotiable instrument nor a security, and delivery of this advice does not of itself wnfer any rights on the recipient. it should be kept with your important documents as a record of your ownership of these shares. No action on your part is required, unless you wish to deposit your existing certificates, sell or request a certificate, or transfer your book-entry shares. To do so, please complete and mail the Direct Registration Transaction Request Fonn enclosed. Upon request, the Secretary of the Company will furnish to any shareholder, without charge, a tul{ statement of the designations, rights (including rights under the Company's Rights Agreement), preferences and limitations of the shares of each class and series authorized to be issued, and the authority of the Board of Directors to divide the shares into series and to determine and change rights, preferences and limitations of any class or series. Assets are not deposits of Computershare and are not insured by the Federal Deposit Insurance Corporation, the Securities Investor Protection Corporation, or any other federal or state agency. G ENCOMMTAPNC.NSPFUL_48 tl000003/000010 FU HOME Michael J. Malpezzi, Owner • Jeremy J. Slaartzer, Funeral Director 8 Market Plaza Way • Mechanicsburg, PA 17055 PJzone: (717) 697-4696 Larry Seagrist 316 South York Street Mechanicsburg, PA 17055 The Funeral Service for Adelaide M. Seagrist 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. i. PROFESSIONAL SERVICES Services of Funeral Duector/Staff , $3265.00 FUNERAL HOME SERVICE CHARGES $3265.00 SELECTED MERCHANDISE: Pecan Haz~dwood Urn, _ $495.00 Register Package . $135.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED $3895.00 AT THE TIlvIE FUNERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. CASH ADVANCES Certified Death Certificates , $60.00 Newspaper Notices -Sentinel $119.88 Flowers -altar vases $84.80 Flowers -family piece _ $79.50 Flowers -rosebuds $15.90 TOTAL CASH ADVANCES AND SPECIAL CHARGES . $360.08 CONTRACT PRICE $4255.08 HISTORY 11/23/2007 Cumb. Co. VA , _ $-100.00 TOTAL AMOUNT DUE $4155.08 p~~ ~.o'~ ~'~'~ , ti~ H www_mnlnv;--ifiinornlhni~~o rnna November 25, 2007 Comments $0.00 I $822.50 ~ $0.00 ~ $0.00 ~ $0.00 $822.50 --_ Date 10/16/07 - 10/16/07 10/08/07 - 10/08/07 10/14/07 - 10/14/07 10/15/07 - 10/15/07 10/31/07 - 10/31/07 10/31 /07 - 10/31 /07 10/31 /07 - 1 U/31 /07 10/31 /07 - 1 U/31l07 - - - Descriptior- Balance Forward Check # 141 Simple Wound Care Complex Wound Care Beauty/Barber Shop Charge Catheter Care Mobility Alarm Specialty Mattress Incontinence Care -Mod/Heavy `Daysl Rate Charged I_ Payments F Balance Units ~ ~ (Credit) ~, $15,767.50 8 $6.50 $52.00 5 $10.50 $52.50 1 $16.00 $16.00 31 $6.00 $186.00 2 $18.00 $36.00 31 $10.00 $310.00 17 $10.00 $170.00 $15,767.50 TOTAL BALANCE DUE: $822.50 P ~ ~,~ l FACILITY NAME RESIDENT NAME ACCOUNT NUMBER BETHANY SKILLED NURSING ADELAIDE M SEAGRIST 2467 T MILLENNIUM PHCY.SYS INC. 2 8 8 0 BERGEY RD . , STi.. AA HATFIELD, PA 19440 A FINANCE CHARGE OF 50 PER MONTH (AN ANNUAL PERCENTAGE SATE OF 18.0%) WILL BE CHARGED ON ALL AMOUNTS 30 DAY5 OR MORE PAST DUE STATEMENT OF ACCOUNT DTJE BY:l~f29/07 k3ILL~NG.: xottRS ~tcaN-FRI 9AM-sPM I30TIFY MPSRX OF CHANGES TOLL FREE 1-866-466-7779; STATEMENT DATE: 10/31/2007 PHONE: 866-466-7779 SEAGRIST (NC), LARRY SEAGLAR a DAYS , 312 .65 (ADELAIDE SEAGRIST) GRP-BVNC FACILITY 316 S YORK ST PAGE 2 MECHANICSBURG PA 17055 AMOUNT PAID DUE_. b09.84' PLEASE DETACH. HERE AND RETURN TOP PORTION WITH YOUR PAYMENT ---------------------------------------------------------------------------------------------------- MTLLENNIUM PHCY.SYS.,INC.2880 BERGEY RD., STE. AA HATFIELD, PA 19440 DATE NU~'IBE QTY. DESCRIPTION DST / D AMOUNT sus TAx ITEM To~AL * ACTIV TY FOR S GRI T(H), ADELAIDE M - EAGRADE -X 10/29/07 6508367 WARFARIN SODIUM 2 O1 * 4.88 .00 4.88 51672-4028-01 10/29/07 6508368 WARFARIN SODIUM 3 O1 * 5.00 .00 5.00 51672-4030-01 10/30/07 16002360 ATROPINE 1% EYE D 01 * 4.55 .00 4.55 61314-0303-O1 10/31/07 6519199 12 ACEPHEN 325 MG SU O1 * * 4.90 .00 4.90 00713-0164-12 10/31/07 2037013 0 MORPHINE SULF 20 Ol * 10.00 .00 10.00 58177-0886-01 10/31/07 6519291 12 ACEPHEN 650MG SUP O1 * * 5.07 .00 5.07 00713-0165-12 10/31/07 6427458 3 ISOSORBIDE MN 30 O1 * 5.00 .00 5.00 58177-0222-04 10/31/07 6427480 3 GABAPENTIN 100MG O1 * 5.00 .00 5.00 00228-2665-11 10/31/07 6427405 3 DIOVAN 80 MG TABL O1 * 67.06 .00 67.06 00078-0358-34 10/31/07 6511082 2 CRANBERRY CAP 250 O1 * * 3.35 .00 3,35 03504-6007-51 10/31/07 6427452 3 ASPIR-LOW 81MG TA O1 * * .55 .00 .55 00904-7704-80 10/31/07 6427499 6 OYST-SHELL W/VII O1 * * 1.58 .00 1.58 00904-5460-80 1 PA'-p ~~~ ~- 2 292. 5 MED DED FOR MONTH PREVIOUS $ALAt3CE. 518.71 r 247.22 45.28 LEGEND NON-LEGEND FOR MONTH FOR MONTH ' TOTAL CFiARdES -''T{3TAL ~:: .. PAXMEDITS & CK~DITS = 815.90 - 206.06 ~roTAL TAx 'AMOUNT DUE 609.84 PLEASE REMIT PAYMENT T0: MILLENNIUM PHARMACY SYSTEMS, INC. 12450 PERRY HIGHWAY, SUITE 200 WEXFORD, PA 15090