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HomeMy WebLinkAbout08-13-08 (2)15056041147 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Po Box.2sosol ~' INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 0 6 0 2 3 9 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 182 22 5117 03 03 2006 06 17 1928 Decedent's Last Name Suffix Decedent's First Name MI GRAHAM DOROTHY M {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) 4. Limited Estate ~ 4a. Future Interest Compromise ~ 5. Federal Estate Tax Return Required (date of death after 12-12.82) g, Decedent Died Testate ~ 7 Decedent Maintained a Living Trust Q 8. Total Number of Safe Deposit Boxes (Attach Copy of WiI(} (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 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. O) r CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number RICHARD L WEBBER, JR. ESQUIRE 717 532 7388 r-,a Firm Name (If Applicable) WEIGLE & ASSOCIATES, P.C. First line of address 126 EAST KING STREET Second line of address City or Post Office SHIPPENSBURG State ZIP Code PA 17257 REGISTER OFt3VILLS UONLY ; r.. , - .:~; _ t.~: ___. DATE FILED Correspondent'se-mail address: rwebber@weigleassociates.com 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. ~/~ l~0 /'7`,.,~r71~~jyy` omas Asper Graham, III ~~i~GB` 216 Goodhart Road, Shippensburg, PA 17257 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ~"~ ~/'Z ~--~ __„~1 Richard L Webber, Jr. Esquire ~~~( ~~, ~ 126 East King Street, Shippensburg, PA 17257 Side 1 15056D41147 15056041147 PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF FILE NUMBER Graham, Dorothy Mildred 21-06-0239 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. Signature #2 .~1~ a Sharon Louise Adams Name Address1 Address2 City, State, Zip Date 759 Ridae Road Shippensburg, PA 17257 15056D42148 REV-1500 EX Decedent's Social Security Number oecedenc~sName: Dorothy Mildred Graham 18 2 2 2 5117 RECAPITULATION 1 6 3 x 0 3 0. 0 0 1. Real Estate (Schedule A) .......................................................................................... . 2. Stocks and Bonds (Schedule B) ............................................................................... 2. 3. Closely Held Corporation, Partnership or Sofe-Proprietorship (Schedule C).......... 3. 4. Mortgages & Notes Receivable (Schedule D) .......................................................... 4. 5• Cash, Bank De osits & Miscellaneous Personal Pro a Schedule E P P m'( ) ................ 5. 2 , 2 7 1 . 0 6 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ............. 6. 7. Inter-Uvos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ............. 7. 8. Total Gross Assets (total Lines 1-7) ....................................................................... 8. 6 5 , 3 01.0 6 9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9. 1 8 , 8 9 9 . 2 4 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10. 3 7 , 4 7 1 . 7 2 11. Total Deductions (total Lines 9 & 10) ...................................................................... 11 • 5 6 , 3 7 0 . 9 6 12. Net Value of Estate (Line 8 minus Line 11) ............................................................. 12. 8 , 9 3 0.10 13, Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................................................. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ................................................. 14. 8 , 9 3 0.10 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, of transfers under Sec. 9116 (a)(1.2) X .00 0 . 0 0 15. 16. Amount of Line 14 taxable at lineal rate X .045 8, 9 3 0. 1 0 16. 17. Amount of Line 14 taxable at sibling rate X .12 0 . 0 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 18. 19. Tax Due ...................................................... .............................................................. . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 15056042148 15056042148 0.00 401.85 0.00 0.00 401.85 REV-1500 EX Page 3 rlpr_prlpnt'c Complete Address: File Number 21-06-0239 DECEDENT'S NAME Dorothy Mildred Graham STREET ADDRESS 121 Walnut Bottom Road CITY Shippensburg 'STATE ~ ZIP PA 17257 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit g. Prior Payments C. Discount 0.00 Total Credits (A + B + C) (2) 3. InteresUPenalty if applicable p. Interest E. Penalty Total Interest/Penalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box 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. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REG/STER OF WILLS, AGENT (1) 401.$5 0.00 401.85 401.85 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 .................................................................................................................. ^ 0 d. receive the promise for life of either payments, benefits or care? .............................................................. ^ ^x^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................................................... ^ ~~11 Lu 3. Did decedent own an "in trust for' or payable upon death bank account or security at his or her death? ......... ^ 0 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 death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disGosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-1502 EX+ (6-98) SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Graham, Dorothy Mildred 21-06-0239 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 jointlyowned with right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH Real estate situate at 8 Enola Road, Newburg, Pennsylvania, Hopewell Township, 63,030.00 Cumberland County, Pennslyvania containing .22 acre, more or less ($63,030.00 assessment value multiplied by 1.00 Cumberland County common level ratio). TOTAL (Also enter on Line 1, Recapitulation) I 63,030.00 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule A (Rev. 6-98) Rev-7508 EX+ (8-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Graham, Dorothy Mildred 21-06-0239 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned wkh the right of survivorship must be disclosed on schedule F. (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) REV-1151 EX+(12-99) gCHEDULE H FUNERAL EXPENSES ~ COMMONWEALTH OF PENNSYLVANIA INR SIDENTDECEDENT N ADMINISTRATIVE COSTS ESTATE OF I FILE NUMBER Graham, Dorothy Mildred 21-06-0239 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: See continuation schedule(s) attached B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Thomas Asper Graham, Sharon Louise Adams Social Security Number(s) / EIN Number of Personal Representative(s): Street Address 216 Goodhart Road city Shippensburg state PA Z;p 17257 Year(s) Commission paid 2007 See continuation schedule(s) attached 2. Attorney's Fees See continuation schedule(s) attached 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 See continuation schedule(s) attached 5. Accountant's Fees 6. Tax Retum Preparer's Fees 11,292.89 3,250.00 3,250.00 177.00 7. Other Administrative Costs 929.35 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 18,899.24 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1502 EX+ (6-98) SCHEDULE H-A FUNERAL EXPENSES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Graham, Dorothy Mildred 21-06-0239 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-A (Rev. 6-98) Rev-1502 EX+ (6-98) SCHEDULE H-B1 PERSONAL REPRESENTATIVE'S COMMISSIONS COMMONWEALTH OF PENNSYLVANIA continued INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Graham, Dorothy Mildred 21-06-0239 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B1 (Rev. 6-98) Rev-1502 EX+ (8-98) SCHEDULE H-B2 ATTORNEY'S FEES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Graham, Dorothy Mildred 21-06-0239 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B2 (Rev. 6-98) Rev-1502 EX+(6-98) SCHEDULE H-B4 PROBATE FEES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Graham, Dorothy Mildred 21-06-0239 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-64 (Rev. 6-98) Rev-1502 EX+ (6-96) COMMONWEALTH OF PENNSriVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H-B7 OTHER ADMINISTRATIVE COSTS continued ESTATE OF (FILE NUMBER Graham, Dorothy Mildred 21-06-0239 ITEM NUMBER DESCRIPTION AMOUNT 1 Cumberland County Register of Wills -Filing fee for inheritance tax return 15.00 2 Cumberland County Register of Wills -Reserve for filing of First and Final 200.00 Accounting 3 Cumberland Law Journal -Legal Advertisement 75.00 4 Dan Hershey's Auction Service, LLC -Commission and Expenses 485.13 5 News Chronicle Company -Legal Advertisement 92.75 6 Thomas Asper Graham, III -Paint for cellar door 27.44 7 Thomas Asper Graham, III -Reimbursement for parts for front door 34.03 Subtotal 929.35 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-67 (Rev. 6-98) Rev-1512 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF (FILE NUMBER Graham, Dorothy Mildred 21-06-0239 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 2006 CountylTownship Real Estate Taxes 146.82 2 Ambulance Bill 30.00 3 Blair 28.16 4 Chambersburg Imaging Associates, P.C. 34.45 5 Commonwealth of Pennsylvania Dept. of Public Welfare -Medical Assistance claim 26,469.25 6 Everett Cash Mutual Insurance Company 435.75 7 Fingerhut 327.07 8 Kough's Oil Service 774.99 9 M8r,T Bank -Visa Credit Card 779.07 10 M8~T Bank -Loan 5,632.61 11 Mobile Flex 5.02 12 Penelec -Electric Bill 32.00 13 Shippensburg Health Care Ctr. 1,924.25 14 Timmons Oil 527.61 15 Timmons Oil 303.00 16 Waste Management 21.67 TOTAL (Also enter on Line 10, Recapitulation) I 37,471.72 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF Graham, Dorothy Mildred NAME AND ADDRESS OF NUMBER PERSON(S) RECEIVING PROPERTY I~ TAXABLE DISTRIBUTIONS [nGude outright spousal distributions, and transfe under Sec. 9116(a)(1.2): Sharon Louise Adams 759 Ridge Road Shippensburg, PA 17257 - Brenda J. Graham Marysville, PA Thomas Asper Graham,lll 216 Goodhart Road Shippensburg, PA 17257 Kimberly A. Johnson 14275 West Creek Road Newburg, PA 17240 II. FILE NUMBER 21-06-0239 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE DECEDENT (Words) ($$$) Do Not List Trustee(s) Daughter Daughter Son Daughter One-Fourth One-Fourth One-Fourth One-Fourth 2,232.52 2,232.53 2,232.52 2,232.53 Total I 8,930.10 Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet 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 II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98) ICC LASI I~~NV Jirtcci, _.~~, .. ~. ShttPPENS6t.JRG, PA 17257 LAST WILL AND TESTAMENT ~- I, DOROTHY MILDRED GRAHAM, being of sound :mind, memory and understanding, do make, publish and declare this my Last Will and Testament, .hereby revoking all prior wills and codicils made at any time before by me. FIRST: I direct that all my funeral expenses and just debts be paid as soon as practical after my death. SECOND: I give, devise and bequeath my property, be it zeal, mixed or personal, wherever situate to my children, Thomas Asper Graham, III, Sharon Louise Adams, Brenda Jean Graham and Kimberly Ann Graham, in equal shares, share and share alike, per stirpes. I direct that my children may receive property in kind, according to value. THIRD: I direct that my hereinafter named. Executors give to my children the right to purchase my residential real estate at the fair market appraised value. The right of purchase shall be extended to my children in the following order: Brenda Jean Graham,. Kimberly Ann Graham, Sharon Louise Adams, and Thomas Asper Graham, III. FOURTH: I nominate, constitute and appoint Thomas Asper Graham, III and Sharon Louise Adams, as Co-Executors of this, my Last Will and Testament. IN WITNESS WHEREOF, I, DOROTHY MILDRED GRAHAM, to this my Last Will and Testament, set my hand, and seal, this ~~~ day of January, X994. ~9 ~, ,Cr~d..T HX c., .. I f't ~Gi~f ~ <~~i.~.•.->~ -~ ( SEAL ) Dorothyr'Mildred Graham Sworn to and subscribed, declared and published by Dorothy Mildred Graham, as her Last Will and Testament, and so ;`~~~~ ~~ done in the presence of we the r------ witnesses, who sign at her request, ~,. and in her presence, and in the ~ ~ ? presence of each other . 1~~~.~"' ~ ~" ~ t - < ,'" y'r-~~--~ '•..~ COMMONWEALTH OF PENNSYLVANIA: :SS COUNTY OF CUMBERLAND I, DOROTHY MILDRED GRAHAM, whose name is signed to the foregoing instrument, having been duly qualified according to law,. do hereby acknowledge that I signed and executed the instrument as my Last Will and .Testament; and that I signed it willingly; and that I signed it as my free and voluntary act for the purpose therein expressed. ~, Dorothy Mildred Graham Sworn to and acknowledged, before me, by Dorothy Mildred Graham, the Testatrix, 's ~ day of Ja uary, 1994. otary Public fi~~`T'~,~t~Al. S~~AL QP,WN Iv~FRii= S~OrJP, hiatary Public ShipNensb~rg, Cumberland CQUniy, PA l~iy Ccmm+ss+on Expires P'eb. 5, 1995 COMMONWEALTH OF PENNSYLVANIA: :SS COUNTY OF CUMBERLAND We, H. Anthony Adams and Sharon Coleman Adams, the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we saw the Testatrix sign and execute the instrument as her Last Will and Testament; that she signed willingly and that she 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 witnesses, and that to the best of our knowledge and understanding the Testatrix was at the time at least eighteen (18) or more years bf age and of sound mind and under no constraint or undue influence. H. An Sharon Coleman Adams Sworn to and subscribed before me by, H. Anthony Adams and Sharon Coleman Adams, the witnesses, this L fSt day of January, 1994. Q;~..~'~'L 1' ~~... Notary Pu}~lic - DAVdN MARiF_ SifiCXJP, Ptotary Public Shippensburg, Cumberland Caunty, PA My Commission Exp;tas Fats. 5, '199E~ FacetWin Screen Print for recdeeds, from "LAMA Login" 4/4/2006 11:10:01 AM CUMBERLAND COUNTY ASSESSMENT OFFICE 2004 BASEYEAR NEIGHBORHOOD: 1100 CONTROL # 11000397 DISTRICT: 11 - HOPEWELL TOWNSHIP SD: 7 PARCEL: 11-07-0497-015. SPEC ID: LOT: ~---~ Tback: Short Name GRAHAM, DOROTHY M -~ LAST NAME GRAHAM I I PROPERTY TYPE: R (FIRST NAME DOROTHY M r ~ ~ ~ +C/O NAME I ~ SALES (ADDRESS( : 8 ENOLA ROAD ~ I DEED BK/PG.....0025T-00276 ~ADDRESS2 I ~ DATE OF SALE...08/21/1974 (POST OFFICE: NEWBURG ~ I SELLING PRICE: 1 ' STATE & ZIP: ~ PA 17240 i l i Situs: 8 ENOLA ROAD __ r---CURRENT VALUES Prop Descrip .: ~ Assessed Fair Market LAND DESC: L AND LESS THAN 1 ACRE ~ FMV - 63030 L - 20400 LAND USE TYPE: 101 ~ C&G - B - 42630 DEEDED ACRES: .55 ~ approved? -> T - 63030 Screen 1 Enter Selection > Record: 8368 Number -Switch Screens, X -Exit, J -Jump Mode, F -Forms, I -Image Down Arrow -Next Entry, Up Arrow -Previous Entry, ? -Screens, B -Browse HO'L© DRRt1MENT TO LIGH'i"T¢ UlERti,/Y \NATE~fi1+6AFSK~ .. .,. . : 00000 002 018 071806 62040017 442609 60-14~ 00°BO9 ~ 85 53296986 °313 CDC FUND DEPT PREP DATE VOUCHER WARRANT ID CMECK NUMBER FULTON BANK "f ~ ne .~earfl, '' ~.z ° ~ ~ LANCASTER, PA ,, ,,,c ~-°" ~~~~,_ ?„o..,y ~,~,r,,,.,~ ``~~ 08/01 /20C OD :VERIFICATION AVAILABLE - "POSITIVE PAY" PROTECTED onTE 0 o - - ` ~ ~ ° TSC rs ~ ~ c ONI~ _ ° VOID AFTER 180cDAYS TO THE ORDER OF ° ° ~ ~ 000809 _. pp ~ ~k 1t';k: * ~ * >>k ~ ~ ;~ ~~ SO{/: R/~ DOROTHY M GRAHAM r ~ DLN 057000376411 REV REBATE ° 126 E KING ST ° C/O WEIGLE ASSOCIATES P ° o SHIPPENSBURG PA 17257-1326 IJ~IL~~~LI~IL~I~~LI II IL LIJ I„ LI III I I . -~- ~ ~~ ~~ ~~~ ~ ~~~ ~~ ~~~ TREASURER OF RENNSYLVANIA 11'5329698611' ~:03L301422~: L2L9 5384711' .. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE REV-16 9 EX (5-06) We are pleased to send you this check for your 2005 Property Tax/Rent Rebate.The Property Tax/Rent Rebate program is one of the many benefits that the Pennsylvania Lottery provides to older Pennsylvanians. I am proud to say that the Pennsylvania Lottery remains the only state lottery that designates all its proceeds to programs that ben- efit older residents. You may be familiar with some of the other programs that the Lottery helps provide: the low-cost prescription drug programs PACE and PACENET; free and reduced transportation services; senior centers; and the Area Agencies on Aging. All of these services are part of our commitment to ensuring a healthier, happier life for Pennsylvania's 2.4 million older residents. If you have questions or would like more information about other Lottery-funded services, please call your local Area Agency on Aging. If you have any questions about this check or your claim, call toll-free 1-888-222-9190.: CAL ~-~C Edward G. Rendell Governor NOTICE: Your 2006 Property Tax/Rent Rebate form will be mailed at the end of January 2007. Please do not call or order a claim form before February 2007. ''1~ ~.._._r. `.. ~,,.~ DAN HERSHEY'S AUCTION SERVICE, LLC - 532-4647 y ~ Steve Ege Chris Bream ~, ,~,..-.,, Cell: 717-385-5438 Cell: 717-226-1920 ~~ t. ~ ~ . ~ ~, ~~•. ~-r ~~~`r, ... ~ F~1 "} ~~~. S ^r ` f ~t~"S . ~ t'~ (,r ~~c,,~ DATE SELLERS NAME ' - ^ ~, ADDRESS ' ~ '~`~~ `~" '~-''` ~ `~r)"'r~''~ ~' `t`om` PHONE ~ ~ '~ } OTHER ! > ~ r `--~.-j"~ s~C~! ~~V/~`P'-€- L;iir ~~''~~>fi%~'j ~"~~J''~! C~E~'AUCTIONEER % ~ `~' AUCTION DATEILOCATION °``~ ~"~ 1l ~ ~' ~ ~~~'~ CLERK % ,. l DESC,rRIP~(TI[/ON~yOF MERCHAN/'DI(SE~p p { r, ~,~ '~ '~' ( {~ 0' ' ~} t~ ~,r ~ i/ ~ U t.~t ~ f ,!~ ~ ~ `~ J ~ . ~~ '~(~ ( L^ f 4 ~'l 4 ~ ~~d 9 ~..~t ~` t € ~ ~ r l^. ~' ~t 1 ~ r ~ ~4V ~~ _.1 !r ~"~.trl a' ~' ~it'~~ •,..._ R /1 l'~"°? d ~ ~~?r...~i l~L~'~ ~ 1 ~~ ~ " V .~,~ / I ! ~f f t ~,~° ~i 1 !„r~ i `, .~ ~. 4t ti .: ~ )~ ~'~'i, a 1 td ~ ~ ~~'rC_.r~ V .~'1 i/ ?`rII K I~ ~;Ur "' ~",f ti...3'~~ ~:`~v i (, ` ;`4.. (_ri ° t '~- ~, .... - .! * `~.v '~ .'~"'4~~ ~,~'-f•.: ,,^t t'' i ~ ~f~ ~ `~ (,rt ,ry~ ! ~ .~ 1 i~' ~ .`^ i/%~ ~ 1~,4'! r^ ~'e~ i j'.~a`~. ;j~.;~r. ,f'~ ~ ~~ _; L.6 , ~/ .,f irk`) ' ~ . ~ ~-' ~ ,~ ~ ~ r`• ~ ' ~ L r i '1'l r.- t~ ~ ~ r ~~ ~. ~ l ~ ~o f ~ r ~:h~ G ~ ~,.~ ~, i6'.`. r:,, J 7~ ` t i ~ y ~ ~ t i t~~ i-'~ ± F :l i~,1 L''~ L. ~ ~ r'j~ (JE~ ~ { r^' art C.~~•, i/"t~, G'~ '~-~,r ~ ~~ r"'~ p ~ ~. '~ ~ i./ ( (_ f i a e' ~ ~ f „k.:- ,. r~ J t ',d ~~h~ Vr' E'. e.•'} 4.'~ ~ ~' ~ i ~~ \ t ,;~~ Y/~ k F~`.'`~ r ~'F '~i - ~,r r ~~,~ p; t {~ n t ,fir.( `-., , `,, (•' !r! ;. ~ E` \F ~'~ ~ '. "~t Rr,, t i "i ~ ~..~ ~..> C" ~ ~,' ./ ©{ ~' G~F ~ Lid ~'1 ~ ~.' ~ r--r¢`r¢ f~ ~a ~i ~rj``, L~ °~?~ i~ a', /" ~,r 'r~Ci ...~k' ~~ Cd t/'~ ! t '~~' ~~~w'~F~,f ~~!J` tJ6, "~ 1jY~ ~,J ` r'~ ~ f~ ~^~ ~ ,t J~~ f :} ` ~ I Commission the Auctioneers to sell the merchandise to the highest bidder by Public Auction. Merchandise `-' ~` ' to be sold as is & grouped as necessary to obtain bids. I certify that I am the owner or authorized represen- ,,, tative of the merchandise, goods and or property and have good title and the right to sell and that they are free ~ `''~ a ~ t from all incumbrances. I agree to accept all responsibility for providing merchantable title and for delivery of title to the purchaser. I agree to hold harmless the Auctioneers against any claims of the nature referred to in this agreement. - - AUCTION SIGNAT'L'TRE` SELLERS SIGNATURE Total Sales (Clerking Tickets Attached) $ ~ ~ ~ ~ = Z '%~ Less Sale Expense: % Commission Auctioneer $ f ~~ ~ ~ % Commission Clerks $ ~ ~/ ~A f ,: ~y4 OTHER: d~, ,- t ~ ~~ is `~~p'~~-,-~ -fit ~~ ;~ ; ~.~~' ~ f , TOTAL SALE EXPENSE DEDUCTED $ ~'~~~ :'~=' SELLERS NET $ ~ /~~~ ~~ r°' F f ~r f 't AI~CTION SIGNATURE SELLERS SIGNATURE 0 MSTBanIi 499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12 Weigle & Associates PC Attorneys At Law 126 East King Street Shippensburg, Pennsylvania 17257-1397 Re: Estate o : Dorothy M Graham Social Security: 182-22-5117 Date of Death: March 3, 2006 Phone (888}502-4349 Fax (302) 934-2955 October 2, 2007 Dear Sir or Madam: Per your inquiry dated October O1, 2007, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type of Account Checking Account Account Number 97266302 Ownership (Names o~ Dorothy M Graham Opening Date 01/28/80 Closed 05/02/06 Balance on Date of Death $667.80 Accrued Interest $ 0.01 Total $667.81 2. Type of Account Installment Loan Account Number 100 0019125665 0001 Ownership (Names o~ Dorothy M Graham Opening Date 09/15/98 Closed 07/25/06 Balance on Date of Death $4,872.87 ** This amount is not to be used for payoff purposes. For a payoff balance, please caU 1-800-724-2440. Current Balance $4, 834.51 ** This amount is not a payoff balance. Please be advised, there was no safe deposit box found for the above decedent. * If 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 call the King Street Office # 717-532- 4132. Sincerely, j~. `/~ Nancy agett Records Management / i Eby Granite Works ~'~~~-- ~~'`~~ _ ~' ,y P. O. Box 187, Newville, Pa. 17241-0187 ~-~~r~'~1 ` ~'=r"°'~~~;~' set ..Phone: 717) .776-5118 ,. ~~- ~-~ - , ~:~..=~~-:~ ~,~~~,., _ _ ,,~,. "_ _ .~ _ c.. F... C ~{~ ~~'1"' ~~. /.. Name:..'~~2..../~f r, ~?"~~.-~~~2.~ . ,-, Date ,,~/~~ -'~'~'~ ;~',~ ,- , Address _~=r'"~F~ ~ .. ~.~ ~ .;.~= ,~r_.~.-~~~....~~~ Zip _ / ;%._ -- ;, ~/ ,... _ ~~' Phone ~.~'t.~ ~~ ~1-~~ ~ C~orne Post ^ Monumentc.~`'- C'~ .~/~ -~f=. ~ ~-~ ~ f'~ ~~ ~~?,y ~"~f~Ower Vases ^ Slant ~~ ~._ .. Base `~ _ ~;' ~ /-, ~ ~ ~' <~ --~~ ° ' _~ r` ~`.<<~ y'~ _ ~; Bevel Grass Marker Design Kind of Granite]~~,:1 ~;~~.; , ,~; .;' ,~~,.,:.,,,, ,/ Cemetery `~,~, .k> ~ ,~.,,~~,r.~ r p Name on back FOUNDATION Yes No WARRANTY I ................................................................ take full responsibility for the accuracy of the above spellings and dates. ^ Check How to Letter Letter this way -opposite Unit Price $~ G. Sl Flower Vase $ Corner Post $ Misc. $ - $ Total ~~~t~ ~'' Deposit $ , r,'.->,f ~ Balance $~~/f ~,~ ~! /ti's ~ / I L> I agree that said memorial, with title thereto and right of possession thereof, shall remain your personal property until I have paid for it full. In default of any payment hereunder, I license you to repossess and remove the said memorial, without guilt or trespass or other wron i and authorize and empower you, in my name and on my behalf, to apply to the management of said cemetery or other premises for a pern for its removal and to take any other steps you may deem necessary or expedient and further agree to save you harmless from any entr repossession and removal; you may retain said memorial or dispose of it at your own discretion without being answerable to me for it or ai proceeds therefrom. Orders subject to cancellation. All contracts contingent upon strikes, accidents, and other causes beyond our control. I understand that 30 days after placement of the memorial a FINANCE CHARGE will be entered on the billing date. It is computed by a perioc rate of 1 %2 % per month which is an annual percentage rate of 18 % applied to the previous balance before deducting credits, payments or addii purchases appearing on this statement. To avoid FINANCE CHARGE pay the "New balance" before the billing date next month. I AGREE THAT ALL LETTERING AND DATES GIVEN ON ABOVE ORDER ARE CORRECT. I ALSO HAVE BEEN INFORMED AND UNDERSTAND THAT THERE WILL BE A CHARGE FOR ANY LETTERING DONE AFTER TI MEMORIAL HAS BEEN ERECTED IN THE CEMETERY. I ALSO ACKNOWLEDGE THAT 1 HAVE BEEN GIVEN MY FOUNDATION GUARANTEE, IF APPLICABLE. P Name Addre: Phone Phone: (717) 776-5118 Monument ~~ ~~''.~ ~' /-:~ ~i~. -% Flower Vases ^ Slant Kind of Granite ~~~/~ .~ ~ • '~` Cemetery ' ,-f ~-~ ~~ ~...a ..~~? ..~~ ~ ~ ~~ Name on back FOUNDATION Yes No WARRANTY `~ ~" •Bevel Grass Marker Design ~- Eby granite Works P. O. Box 187, Newville, Pa. 17241-0187 G R ~+ ~ ~ m ~~ ~~- V r~~ r~ ~ ~ ~7 /~~~ l~~ ~ ,n .~; ~:. ; ~,~a-~.:...:. ,.~:(.t,X~r'.' ...................... take full responsibility for the accuracy of the above spellings and dates. ^ Check How to Letter Letter this way -opposite Set .-~-- r Date/:!~ ~~' _,;, ~~' Zip ,/ '°'.~ ~` ;;"~ '~~_ , r ~ ORD. P.O. # POS GRA VAS POSTS GAR S COM B&J Unit Price $~C,~/ Flower Vase $ Corner Post $ Misc. $ - $ Total $ '` ~' ~ Deposit $,~~v /~ Balance $ ~'`~r-='r.,.:~-~ ~.~:= /~ I agree that said memorial, with title thereto and right of possession thereof, shall remain our personal property until I have paid for it full. In default of any payment hereunder, I license you to repossess and remove the said memorial, without guilt or trespass or other wron )and authorize and empower you, in my name and on my behalf, to apply to the management of said cemetery or other premises for a perr for its removal and to take any other steps you may deem necessary or expedient and further agree to save you harmless from any enti repossession and removal; you may retain said memorial or dispose of it at your own discretion without being answerable to me for it or ai proceeds therefrom: Orders subject to cancellation. All contracts contingent upon strikes, accidents, and other causes beyond our control. I understand that 30 days afterplacement of the memorial a FINANCE CHARGE will be entered on the billing date. It is computed by a perioc rate of 1 ~/z % per month which is an annual percentage rate of 18 % applied to the previous balance before deducting credits, payments or addii purchases appearing on this statement. To avoid FINANCE CHARGE pay the "New balance" before the billing date next month. I AGREE THAT ALL LETTERING AND DATES GIVEN ON ABOVE ORDER ARE CORRECT. I ALSO HAVE BEEN INFORMED AND UNDERSTAND THAT THERE WILL BE A CHARGE FOR ANY LETTERING DONE AFTER TF MEMORIAL HAS BEEN ERECTED IN THE CEMETERY. I ALSO ACKNOWLEDGE THAT I HAVE BEEN GIVEN MY FOUNDATION GUARANTEE, IF APPLICABLE. a ~' `~ o ~~ -~o O ~ ~- O N ~ b N ~ N '~ E O ~' ~- ~ rn tD d O N h ~ G In ~ i C rt ~ w N x rt~ O v m N (A fL C ~ fD ~+ W Ti fD N G cD rt n N ry W W n O ~ ~ 1 ~ to ' 0~ ~ I (f CT N CJ c0 ~ ~~ ro m ~ m r rj -+ a ~ rS ~n o ~ ~ 'm m co ~ n ~ m n ~ rt rt N• C] ~? g c. a > ra ~ p~ N n ~ w ~ O ° ~ ~ ~ b > ~ ~n ~ a b rt v o ~ a~ ~ n m b l-J r ~ ~ o a t m K w m ~ .~ - s' = a a ~' u, w ~ `~ a ~ m a ~ -, ~ co p, h rt - = ~ SL n ~ r, tD O rt n W ~ ~ ~ i9 ~ rt 8 QI rt G ' G fD a r N• ~ ~ o ri r ~ ~ c n ~ o =, ~ 3 H N O ~. S a ~ n w a~ n Q ~ cD `C O. ~ O 9 m ~ (p rh (D p, .'3 YYl .7 ~ y ~ rt N• rt N (l • (D O - ~ ~n w w m rr N ~' 1 N W N O Ul N O O ro ~ r~+n a n ~~ o n'= ym , o- m o N ~ ri M `G O ~ ~ n ~ o m rn ~, c't !A W W c>7 ~ C>, ~` ~ °' t ~ o d G+ O Gl >v _ ~° 2 ~ N e o ~ n °' F~ l0 U) r'! 'C3 a Ip hj = b rt N r- n m ~ m ~ ~ ~ a ~ ~ ^' ~ m w w ~ I ~tD ~ o O nx~ ~ w o ~ n - ~ r K a ~ 3 ~ ro ' ~ c to to to to to ~ ~ cn y ~ m A ~ ~ c ^3 .. 'p ~ ~ B er' o ~ ~ O~ ~A ~1 O o ~. ~D O lJi O N N ~ p , ~ m ('~ p ~ O~ O 9 O O O O ~ 07 O O O O O O O tG O O O O O O O rt to iA ~ {n {~ N tT J ,J ~ t.~ N O N N O 0~ O O ~ O ~ ~ O COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 MAR 2 9 2006 HARRISBURG, PA 17105-8486 March 27, 2006 WEIGLE & ASSOCIATES PC RICHARD L WEBBER JR ESQUIRE 126 EAST KING ST SHIPPENSBURG PA 17257-1397 Re: DOROTHY GRAHAM CIS #: 001654607 SSN: 182-22-5117 Date of Death: 03/03/2006 Dear Mr. Webber: Please be advised that the Department of Public Welfare maintains a claim in the amount of $26,469.25 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $25,443.98, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $1,025.27, is to be entered as a priority Class 6 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may. be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, .Q. ~.~ Debra A. Wiest TPL Program Investigator 717-772-6713 717-772-6553 FAX Enclosure j~ I ~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF P~18LIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 March 27, 2006 STATEMENT OF CLAIM SUMMARY NAME Estate of GRAHAM, DOROTHY I D 001 654 607 hdEDICAL CLASS 3 CLASS 6 TOTAL INPATIENT 912.00 .00 912.00 OUTPATIENT 98.01 22.97 120.98 LONG TERM CARE 23,894.10 979.35 24,873.45 DRUG 539.87 22.95 562.82 REIMBURSEMENT TO DPW 25,443.98 1,025.27 26,469.25 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE -' EIN - 23-6403113 ~SBLILNO Customer Service Workstation 10:56:50 EBRN6MU I/L ACCOUNT BALANCE 05/09/02 Account #: 10000191256650001 Product: ILN SubCode: M&T BANK Title 1: DOROTHY M GRAHAM SSN/TIN: 182225117 2~ Package: Rate 8.9900 Maturity: 08/10/13 Status ACTIVE Loan Type: SIMPLE INT Org Note Amount $ 13,500.00 Payment Term/Made: 121 / 82 Gross Discount $ .00 Pre-Payment Penalty: .00 Outstanding Balance: $ 5,632.61 Auto Deduct From NO AUTO DEDUCT Current Payment Due: $ 171.99 Current Due Date 05/09/13 Regular Payment Amt: $ 171.99 # Of Extensions 0 Last Tran Amount $ 171.99 Code: 30A Date: 08/09/05 Late Charge Code 1 Late Charge Paid $.00 # ofi NSF 0 Late Charge Unpaid; $.00 Payoff Ca1c Date F2 Options F3 Main Menu F6 Referral F11 Title F12 Previous STATEMENT SHIPPENSBURG HEALTH CARE CTR 121 WALNUT BOTTOM RD SHIPPENSBURG, PA 17257 AUG 1 1 2a0~ Phone: 717 Statement Date: 08/06/08 the Dorothy M. Graham Estate Resident: DOROTHY M GRAHAM c/o Weigle ~ Associates 126 East King Street Shippensburg, PA 17257 Date Service Throucah ~ Descriation BALANCE FORWARD TOTAL AMOUNT DUE »»»»»»> PAYMENT DUE UPON RECEIPT Amount 1,924.25 1,924.25 Page 1