Loading...
HomeMy WebLinkAbout09-08-08J 15056041046 REV-1500 EX (05-04) PA Department of Revenue OfFtCtAL USI` OTiLY Bureau of Individual Taxes ~ County Code Year File Number Dept. 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT eZ ~ O 7 ~ (J 8 U ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth l96/~.2S~o 08/Gaoo7 /~~3/9/7 Decedents Last Name Suffix Decedent's First N Ruby (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix N~ A Spe~use's Social Security Number ame MI FLQ~?ENGL. /YI Spouse's First Name MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL. IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death O 4. Limited Estate O prior to 12-13-82) 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required d eath after 12-12-82) ~ 6. Decedent Died Testate O (Attach Copy of Will) 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) b etween 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD B Name E DIRECTED T0: Daytime Telephone Number ~~lA2LEs ~ sH Fi r.y /E~,ps /l/ '/ 7 ~' ~ rm Name (If Applicable) =j a 1 ~,.~ / d _ REGISTER ~{~(f4LS U3fxpNLY ~J. ~ First line of address rri 1 r_ -' ~ CO _-- ' ~ 1 C~7 r'\ Second line of address ~: ~ ~V ~~~ r-rt N / ~ , J ~ D~ City or Post Office State ZIP Code DATE FILED /y1~CE/ANl C S$[~RG PA /'IDS5973S' Correspondent's a-mail address: C2Shie/cl~s 3 ~comeast. net 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, correctp~d complete. Duration of preparer other than the personal representative is based on all information of which preparer has any knowledge SIGNATURE ERSON RES O SIRI f1R Fu mir ocTi ions SIG E O REP ROT HA RESENTATIV _ DATE Q' ADDRE:ss N (,ES ~ . /IE'L. ,s~ S !~V b ~'LaIuSER ~,a-/4D iyj~-~ypN~~sBy~2~ PA /7os.S PLEASE USE ORIGINAL FORM ONLY Side 1 15056041046 15056041046 J J 15056042047 REV-1500 EX C y~ Decedent's Social Security Number Decedent's Name: r ~fCE/1~~. ii(• I~ ~t, ~ y. _ - -.._ _. ' .. ~ _ L I l l ~ ~ 6 ~ RECAPITULATION 10 7 1. Real estate (Schedule A) ............................................. 1. ,3 9 7 ~ D Oq • Q O ....................................... 2. Stocks and Bonds (Schedule B) 2. ~ 9 / ~ O 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. 3. O O 4. Mortgages & Notes Receivable (Schedule D) ............................. 4. • O O 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. S a 7 d ~p • 9 7 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ....... 6. ~ D ~ g D • ~ Q 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property // (Schedule G) C Separate Billing Requested........ 7. ~ ~ r'o l0 3 S • ~ 7 8. Total Gross Assets (total Lines 1-7) .................................... 8. S 7 D ~ ~ ~ 3 9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. ~ ~ 7 ~ 7 . 7 6 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10. ~ 8 / . S 7 11. Total Deductions (total Lines 9 & 10) ................................. .. 11. S3 / / T 9 7 . a. 7 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. S ~ ~ 9 l ~ . ~ 7 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 13 -7 f ~ ~ Q O O an election to tax has not been made (Schedule J) ...................... .. . `. . 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. S ~ Z q / ~ ~ . O 7 TA;K COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .01Z . ~ ~ 15. D o 16. Amount of Line 14 taxable D O 16 0 D at lineal rate X .0 _ 17. Amount of Line 14 taxable /~, ~r ~ 7 ~ rO g 3 ~ '~ 17 ~ ~ y ~ 3 • at sibling rate X .12 . 18. Amount of Line 14 taxable ~ 7 7 ~ 2 / ~ ~ 18 ~ ~ S~ 3 ~ G at collateral rate X .15 . 19. TAX DUE ....................................................... .. 19. 7 ~ ~ ~o b •3 Z- 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C~ Side 2 15056042047 15056042047 REV-1500 EX Page 3 File Number a,~ _ D ?~ 8'r~s Decedent's Complete Address: F~oRF~CE /11. ~2uoy i STREET ADDRESS a~ 3~ ~~~~ G~ ~.~ ciTY E'NoLs~ STATE ~~ ZIP / L ZS i 7 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit ~ t _ __ B. Prior Payments _ `fo_Z 'jS7J.00 C. Discount _ f __ a~ a so. ~~- 3. Interest/Pe!nalty if applicable f (1) 7~, oc6.3z Total Credits (A + B + C) (2) ~~ O~ a ~ D. Interest D E. Penalty __ _ p 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) p (4) D (5) ~d 9, ~~_ 32 (5A) '~63~,zv 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 consitleration? ........................................................................................................ ...... ® ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ........ ...... ^ 4. Ditl decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ...... ® ^ IF THE AN5WER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent (72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate irnposed 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-15.02 EX+ (6-98) SCHEDULE A COIUIMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ~ u Dye t~Lai2ENCF /)?, 02./- 0 7 -- DSOs All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUVUI6ER DESCRIPPTION_ •__' OF DEATH 1. /~ ~~ fltat Cerfa~n ~Gf OT Inn~ai ~ (itcafe GVt Na1'Yj~dLn To~v~s~'r,/n, Cumberland Co u.n ~ , f ern s y I vccnra c~m.d -~¢ i--~t~rnvemeilfis ~r>/o-~ ere~~'eol, hu.v;n~ a,n a.r,~-~res s ©~ ~-~ 35 ~ar~wbs G-a~' -~°ad , ~ nolQ, ~A a ~ ~u~rce-~ nn. ~o -I 3 J7 o a 5 ~ ~ecc,r; n -O/~ ~ ,~L~/I ~~ (~'t'~'Gwalat~y cr!ESG"i~iec~ 099/ ~~ lvl ~ ~ue a~v~ Corr'e~ ~~ of a c~eec~ .tom (,~I C.P.CY enfs e sfU,te -fn ~ ~3 s ~E`VL~zaP/ytL~oit~7 r ~~,1_ G1,T16C.G~G~ rfr.re.~0, df~~~ J~ S be~~y 1 H.e pG(rG~1QS~ p~ h ~r1° o-~, S e~ als© Copy of ~efF~emen t sheet v~ July 3l, ~o~ a~frt.~tiec1 here~~, TOTAL (Also enter on line 1, Recapitulation) $ ~ l ~ QQd, 60 (If more space is needed, insert additional sheets of the same size) Tax Parcel Number: THIS INDENTURE MADE THE ~~,~ day of , in the year of our Lord t~w~~o thousand and eight (2008). BETWEEN DENNIS J. DAMS, as Executor of the Estate of FLORENCE J. RUDY, deceased, late of the Township of Hampden, Cumberland County, Pennsylvania, Grantor, and JSB DEVELOPMENT, LP, a Pennsylvania Limited Partnership with a business address of 1823 Signal Hill Drive, Mechanicsburg, Cumberland County, Pennsylvania, Grantees. WHEREAS, the said Florence M. Rudy, was vested in her lifetime with title to the premises hereinafter described, in the Township of Hampden, County of Cumberland and Commonwealth of Pennsylvania; and WHEREAS, the said Florence M. Rudy, departed this earthly life, testate, on the 16th day of August, ?007, and Letters Testamentary were duly issued to the said Dennis J. Davis, by the Register of Wills of said Cumberland County, docketed to No. 21-07-0$05; and WHEREAS, the lands herein-mentioned were not specifically devised: NOW, THEREFORE, THIS INDENTURE WITNESSETH, that the said Dennis J. Davis, Executor, as aforesaid, for and in consideration of the sum of THREE HUNDRED NINETY-TWO THOUSAND ~tnd No/100ths ($392,000.00) DOLLARS, and other good and valuable considerations, to him in hand paid by the said Grantee, at and before the ensealing and delivery hereof, the receipt whereof is hereby acknowledged, has granted, bargained, sold, aliened, released, and confirmed, and by these presents, by virtue of the power and authority in him vested by the Fiduciaries Act of the Commonwealth of Pennsylvania, does grant, bargain, sell, alien, release, and confirm unto the said Grantee, its successors and assigns: ALL THAT CERTAIN tract or parcel of land situate in the Township of Hampden, County of Cumberland and Commonwealth of Pennsylvania more particularly bounded and described as follows to wit. BEGINNING at a point in the centerline of Lambs Gap Road at the dividing line between the herein described tract and lands now or late of Jerome D. Wilbert; thence along the centerline of Lambs Gap Road South eight degrees, twenty-six minutes, six seconds East (S 08° 26' 06" E) a distance of fifty feet (50.00') to a point; Thence along the dividing line between Lots 1 and 3 as shown on the hereinafter mentioned plan and being the northern line of lands now or late of Alex L. Tatanish South eighty-one degrees, thirty-three minutes, fifty-four seconds West (S 81 ° 33' S4" T3~ a distance of two hundred ninety-six and sixty-seven hundredth feet (296.6T) to a point; thence continuing along the same and along the western line of Lot 4 being lands now or late of Carl E. and Lorraine D. Wagner South eight degrees, twenty-six minutes, six seconds East (S OS° 26' 06" E) a distance of three hundred feet (300.00') to a point; thence along the southern line of lot 4 said lands of Wagner North eighty-one degrees, thirty- three minutes, fifty-four seconds East (N 81 ° 33' S4" E) a distance of two hundred ninety-six and sixty-seven hundredth feet (296.67') to a point in the centerline of Lambs Gap Road; thence along the centerline of Lambs Gap Road South eight degrees, twenty-six minutes, six seconds Fast (S U8° 26' U6" E) a distance of four hundred eight-one and twenty-four hundredth feet (481.24) to a point; thence continlung along said centerline South twenty-three degrees, twenty minutes, six seconds East (S 23° 20' 06" E) a distance of one hundred fifty-nine and forty-two hundredth feet (159.42) to a point; thence along the northern line of lands now or late of McNaughton Company and land now or late of Joseph A, and Dorothy Davis respectively South fifty-four degrees, thirty-nine minutes, sixteen seconds West (S 54° 39' 16" Gl~ a distance of three hundred twenty-six and ninety-nine hundredth feet (326.99') to a point; thence along the northern line of lands now or late of 1`Iarold W. Shaffer Living Trust and lands now or late of Cumberland Valley School District respectively North fifty-two degrees, eleven minutes, twelve seconds West (N 52° 1l' 12" Ids a distance of fotu hundred sixty-nine and sixty-thi°ee hundredth feet (469.63') to a point; thence along the eastern line of lands now or late of the Cumberland Valley School District and lands now or late of Charter Homes North fourteen degrees, thirty- nine minutes, fifty-seven seconds West (N 14° 39' S7" YTS a distance of seven hundred ninety- eight and seventy-eight hundredth feet (798.78') to a point; thence along the southern line of lands now or late of Thomas E. and Eleanor F. Lehman and lands now or late of Jerome D. Wilbert North eight-one degrees, thirty-three minutes, fifty-four seconds East (N 81 ° 33' S4" E) a distance of six hundred sixty-two and five hundredth feet (662.05) to a point in the centerline of Lambs Gap Road, being the place of BEGINNING. Containing 12.168 acres. BEING Lot No.l, as shown on the Final Subdivision Plan No. 2 of Earl L. and Florence M. Rudy. Said plan being recorded in the Office of the Recorder of Deeds of and for the County of Cumberland, in Plan Book 33, Page 61. SUBJECT to 30' foot right-way for dedication along the western side of Lambs Gap Road, a 40' drainage easement, 30' sanitary sewer easements and a variable width access easement located along the northern line of the herein described tract. THE ABOVE METES AND BOUNDS DESCRIPTION has been prepared by .iohn Walker, of Hoover Engineering from assorted prior surveys and plans, field notes and the like. ALSO, see attached the Draft prepared by John Walker. BEING IMPROVED with a dwelling house and other outbuildings and being known and numbered as 2135 Lambs Gap Road, Enola, PA 17025. BIDING PART OF Tract No. 1 of those same premises which Roy Forney, Executor of the Last Will and Testament of Wilson E. Forney, deceased, by his deed dated July 24, 1953 and recorded in the Recorder's Office aforesaid in Deed Book "I", Volume 15, Page 438, granted and conveyed to Earl L. Rudy and Florence M. Rudy, his wife. The said Earl L. Rudy departed this earthly life on October 19, 1990, whereupon filll and absohite title to the said premises vested in the said Florence M. Rudy by the laws of the Commonwealth of Pennsylvania incident to tenancies by the entireties. Her said Estate is the Grantor herein. TO HAVE AND TO HOLD the said messuage or tenement and tract of land, hereditaments and premises hereby granted and released, or mentioned and intended so to be, with the appru•tenances, unto the said Grantee, its successors and assigns, to and for the only proper use and behoof of the said Grantee, its successors and assigns, forever. AND THE SAID GRANTOR, Executor, as aforesaid, his successors and assigns does covenant, promise and agree to and with the said Grantee, its successors and assigns, by these presents, that the Grantor has not done, committed any act, matter or thing whatsoever whereby the premises hereby granted, or any part thereof, is, are, shall or may be impeached, charged or encumbered in title, or otherwise howsoever. IN WITNESS WHEREOF, the said Executor of the Estate of Florence M. Rudy, deceased, Grantor herein, has hereunto set his hand and seal the day and year first above written. Signed, Sealed and Delivered in the Presence of: (SEAL) DENNIS J. DAMS, Executor of the Est~-te of FLORENCE M. RUDY, Deceased COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS: On this, the day of , A.D. 2008, before me a notary public, in and for the Commonwealth of Pennsylvania, personally appeared DENNIS J. DAMS, known to me (or satisfactorily proven) to be the person whose name is subscribed as Executor of the Last Will and Testament of Florence M. Rudy, and achlowledged that he executed the same in such capacity. IN WITNESS WHEREOF, I hereunto set my hand an official seal. Notary Public My commission expires: (SEAL) CERTIFICATE OF RESIDENCE I do hereby certify that the precise and exact post office address of the within Grantee is: Attorney for Grantee LOT 2 P.B. 27, PG. 124 S8°26'06"E ~,_~~-~^50.00' N81_33~°~_ ~-- o _ - .~ 662,05 S81 33'S4~ - ~ -' 296.67' ` ~O~ 3 ~ i ~ iN 1 ~ 1 °o~ rn m ~ Z ~ - 296.67 f /l C"~ ~ Z ~ ~ ~~~ ~ REVISED LOT 1 ~ ~ ~ ' N ~ P.B. 33, PG. 61 ~' ~ r- ~ 530028.95 SgFt N' o Z 12.168 Acres ~? ~ m I11 i ~ I ~- D \~~ ~ "'° ~ ~~ No ~ ~~~ ~~~'' ~~ 39~~ ~ 5~ `5~'~g ~. \ ~. ~'o1y~~4L//. //~~~Lp./g1~~1~/f~M®2 //~~ b E~~L ~. ac ~L.~J8ZE8tl`iE M. ~US~~ ~ 2~0' RAMP®E11~ T'®VI/IVS~OIP, CUMEE62L~C911~ ~®., ~'~4 JUNE 29, '978 OMB NO. 2502-0265 r A: B. TYPE OF LOAN: DEPARTMENT OF HOUSING & URBAN DEVELOPMENT U S 1.QFHA 2.QFmHA 3.^X CONV. UNINS. 4.QVA 5. QCONV. INS. . . SETTLEMENT STATEMENT 6. FILE NUMBER: JSBDEVELOPMENT 7. LOAN NUMBER: 8. MORTGAGE INS CASE NUMBER: C. NOTE: This form is famished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked "(POCj" were paid outside the closing; they are shown here for informational purposes and are not included in the iota/s. 1.0 3198 (JSBDEVELOPMENT.PFDIJSBDEVELOPMENT/16) D. NAME AND ADDRESS OF BORROWER: JSB Development, LP 1823 Signal Hilh Drive Mechanicsburg, PA 17050 E. NAME AND ADDRESS OF SELLER: Estate of Florence Rudy F. NAME AND ADDRESS OF LENDER: INTEGRITY BANK G. PROPERTI' LOCATION: 2135 Lambs Gap Road PA 17025 Enola H. SETTLEMENT AGENT: 68-0510988 Community Land Transfer, LLC I. SETTLEMENT DATE: July 31 2008 , Cumberland County, Pennsylvania PLACE OF SETTLEMENT 2331 Market Street Camp Hill, PA 17011 , J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION 100. GROSS AMOUNT DUE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER: 101. Contract Sales Price 392,000.00 401. Contract Sales Price 392,000.00 102. Personal Prope 402. Personal Prope 103. Settlement Charges to Borrower (Line 1400) 10,430.75 403. 104. 404. 105. 405. Adjustments For Items Paid 8 Seller in advance Adjustments For Items Paid (3 Seller in advance 106. City/Town Taxes to 406. Ci /Town Taxes to 107. Coun Taxes 07/31/08 to 01/01/09 159.24 407. Coun Taxes 07/31/08 to 01/01/09 159.24 108. School Taxes 07/31/08 to 07/01/09 1,218.72 408. School Taxes 07/31/08 to 07/01/09 1,218.72 109. Refuse Pro Ration 07/31/08 to 10/01/08 29.82 409. Refuse Pro Ration 07/31/08 to 10/01/08 29.82 110. 410. 111. 411. 112. 412. '.'120: GROSS AMOUNT DUE FROM BORROWER 403,838.53 420. GROSS AMOUNT DUE TO SELLER 393,407.78 's00. AMOUNTS PAID BY OR iN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 201. De osit or earnest mone 45,000.00 501. Excess De osit See Instructions 202. Princi al Amount of New Loan s~ 300,000.00 502. Settlement Char es to Seller Line 1400 3,930.00 203. Existing loans taken sub'ect to 204. 503. Existin loans taken sub'ect to 504. Payoff of first Mortgage 205. 505. Pa off of second Mork a e 206. 506. 207 507. Deposit dish. as roceeds) 208 508. 209. 509. Adjustments For Items Un aid 8 Seller Adjustments For Items Un aid 8 Seller 210. Ci /Town Taxes to 510. Ci !Town Taxes to 211. County Taxes to 511. Coun Taxes to k 212. School Taxes to 512. School Taxes to ~213. 513. :! 11 4 514. ~1~ 5 515. 216 516. 217. 517. 218. 518. 219. 519. 1220. TOTAL PAID BY/FOR BORROWER 345,000.00 520. TOTAL REDUCTION AMOUNT DUE SELLER 3,930.00 300. CASH AT SETTLEMENT FROMffO BORROWER: 301. Gross Amount Due From Borrower Line 120 403,838.53 302. Less Amount Paid By/For Borrower (Line 220) ( 345,000.00) 600. CASH AT SETTLEMENT 70/FROM SELLER: 601. Gross Amount Due To Seller Line 420 393,407.78 602. Less Reductions Due Seller (Line 520) ( 3,930.00 303. CASH (X FROM) ( TO) BORROWER 58,838.53 603. CASH (X TO) ( FROM) SELLER 389,477.78 t~ ~5 The undersigned hereby acknowledge receipt of a completed copy of pages 1 &2 of this statement & any attachments referred to herein. 8orrovrer JSB Development, P BY: Seller ~ ~~ .. ~ ('C'. Es to of F ore a uiiy Page 2 L. SETTLEMENT CHARGES 700. TOTAL COMMISSION Based on Price $ % PAID FROM PAID FROM Dly%5!011 Ot COfT71111SSlOn ~Ilne ~OO~ aS FOIIOWS: BORROWER'S SELLER'S 'O1. $ t0 FUNDS AT FUNDS AT 702. $ t0 SETTLEMENT SETTLEMENT 703. Commission Paid at Settlement 704. to 800. ITEMS PAYABLE IN CONNECTION WITH LOAN 801. Loan Origination Fee % to :802. Loan Discount 1.0000 % to INTEGRITY BANK 3,000.00 803. Appraisal Fee to INTEGRITY BANK POC:B2750.00 804. Credit Report to 805. Document Preparation to INTEGRITY BANK 300.00 806. Mort a e Ins. A .Fee to 807. Assumption Fee to 808. 809. 810. X911. r{.000. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE E101. Interest From 07/31/08 to 08/01/08 @ $ /day ( 1 days %) A02. Mortgage Insurance Premium for months to 903. Hazard Insurance Premium for 1.0 ears to 904. -905. 1000. RESERVES DEPOSITED WITH LENDER 1001. Hazard Insurance months $ per month 1002. Mortgage Insurance months $ per month 1003. Ci flown Taxes months $ er month 1004. Coun Taxes months $ er month 1005. School Taxes months @ $ per month 1006. months $ per month 1007. months @ $ per month ;1008. months $ er month ~N~•100. TITLE CHARGES -x;101. Settlement or Closin Fee to '1102. Abstractor Title Search to 1103. Title Examination to 1104. Title Insurance Binder to 1105. Electronic Document Pre to '1106. Closin Service Letter to Communi Land Transfer, LLC 35.00 •1107. Attorney's Fees to Reager & Adler, PC 500.00 includes above item numbers: 1108. Title Insurance to COMMUNITY LAND TRANSFER 2 318.75 includes above item numbers.1102, 1103 & 1104 1109. Lender's (:overage $ 300,000.00 1110. Owner's Coverage $ 392,000.00 2,318.75 1111. Endorsements 100, 300, 910,710 to Community Land Transfer, LLC 250.00 .1112. Notary Fee to Community Land Transfer 10.00 1113. Notary Fee to Community Land Transfer 5.00 ?~i200. GOVERNMENT RECORDING AND TRANSFER CHARGES ' Mi . s '201. Recordiny Fees: Deed $ 40.50; Mortgage $ 56.50; Releases $ 97.00 -1202. City/Count Tax/Stamps: Deed 3,920.00• Mort a e 3,920.00 1203.. State TaxlStamps: Deed 3,920.00; Mortgage 3,920.00 1204. 1205. 1300. ADDITIONAL SETTLEMENT CHARGES 1301. Surve to 1302. Pest Ins ection to 1303. Tax Certification to Marie Huber, Treasurer 5.00 1304. 1305. 1400. TOTAL SETTLEMENT CHARGES (Enter on Lines 103, Section J and 502, Section K) / 10,430.75 3,930.00 By signing page 1 of this statement, the signatories acknowledge receipt of a completed copy of page 2 of this two page statement. Certified to be a true copy. L~ Community La' Transfer, LLC Settlement ent (JSBDEVELOPMENT/JSBDEVELOPMENT/16) REV-1503 EiX+ (6-98) .. ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS --_ ESTATE OF FILE NUMBER ~R u.n y, ~Lo,i2~ivCE m ~ a-1 - a7- 8oS 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) ~~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER ~ D~, ~Lo~'E'NCC n1. a.~-o7- BcoS Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 ~ a. 3. ~~ ~: G- 8: q /o. !/. /~. /3. Cred-~'s c~rtd Rey -nbu.rs eme>,7's o n ,Scale o~ r~ct,r! 25~u,t~ ~ r 5~~en~tent Sl~eef a~ziclitc~ ~' se,(1eal. f}~. , ,~. ~,;no lflo?, Coun7if Truces 8. line ?fig, school ~t~ C. ~~ ne `f0`~, reuse prn ra.~'oh m ~ T (~ A~ ~K ,/~. ChecrlC~-~c, /~-~'. No. 730 X72 9~{ C . SQVi~S Acct: No , D /s ODD ot./~f 08'D ~27~ ~D. Tnt. fi~Cr:r, ~' ~ • o. d . off i }em C . CSee ~aluah'oh /effe,r u lfacheol~ ~vF/2E16N ,(~3A~NK etrzT~F. o~ i~~oSIT #~ a~~ soy a,~oG .Z`N%, i¢-C C~, l0 8ov O/U / TE=ry1 /tb.3 (See /a~uaho,~ /efI`er a ~Zcclled~ ~Qy„,e~t ~~ t~~5 C'o:ns ~r asso~t~d coins a.nrl old G.e.r~^e,n.~ aSu~ ~G~oos~t ~oX ,i¢. /~iylerr~an Cu.rr~Nc~ ~ Coy na..g~ (included •n d~,o• D~JCo%ns ~ , n~oK-descrpf {bNe,~r1 Gins o~ C~.da S M exi co C . did l~uSfri ah ,~~ex' m~~ ~' Ct~or{d I.~wr ~ Cas{~ ~~pos-f -~,r'o,~r~ 'r}..ums •~ut~,nc~ '~n pu.rSe unneQ ~nccs~ ~b~~~ ~„n ox-d cas~- C as ti a~,,d Coin z n ~e~s~ ~~ ~~ ~i e~ccnd Pa frrot -/(/BLt!U LvOSe CDir) ~1re.1~.~~ 6~ ~ h~!>° ~.~. a. /'i efwn ~ G'e.~~vorf~' .sfs. Lo . - Lam ,~1 y' ~, 2 1 $, 7Z ~a9, ~'z 13~ 4.1Q. 9q ~ O. 3/0 ~/7, 9Z~ ~o "1 z.lol >~ jf, O v0, ov t 7. 36 ~3 3 S• !O ~/~ - o -' D '_' ~73f!O, 00 ~2s~.oo ~'i ~z,sv f/ 3.4~5~ '~S- ~ ~'~~ /6 TOTAL (Also enter on line 5, Recapitulation) , $ Sg, 7gg, ^i --^-^ ^^^^^ •^ ^....a.,a ;~~~h odrlifinnet choe4e of 4he mme ci~el ~~ ~Ch'~17 , ~~ C-d~tt~c~ - -- --- -~~s% D~ ~G1'~~- FGO~?E®l/('~ %1!l, - - F/L.F ~IID- ZI -D7- 8'oS _ -- _ _ - _ -_ _ -- - - - ___w - -"` 4 "- -E° _ /~ ~~ axe Qss s.~`-- - '~ao •~- --_ --- - - ~ _- - --- /? _ _-._~~`_/~'l%~iCtt~_B~_6/~ ~s_-__~r Suu~'a°%m ---Sar -___ _ _ ---- 3586 _ ---__ ------ l_8. ---_~'1-~mr~aa~__~~u!eLr ~r__-_~u%%i_? -s©1_~ ~r__~ns~~r1-~_ -- --- - #3so. ~D --- e-u ~ ~~ r9 J~.L/~ - -- --w - n - ~ __ _ -- - - c_~-~~ -- - - _ -- ~~"_--~x,~.S_,'oh __. DF -_ T1/}tQ---- -mil ~t -- - --- - ------- - _ ------- o~i-STD. _- _ ----- ~. _ W~af__~Sla_o-~__ ~s~S_/~~a~y __~~'~in</_~r_wP~GOa~~~%r?~ _ ___ _ ~_~da.ad - - ------ --®2L.- --('n~~r___~r_ K;c~~ ,D,_s_e~se_~/_yy/~err1e_~t2s• -hQ!~r_ou~~a~~~.a,~' --239.-9~0 - -- - p~,~ - _ _ ~T~~~r~_ __..1x---all%f pl~ja_~ a/~Q~c! k~i1Ge --~r__~~r_r-~-c%t_y___ ~s ~.S ~ h - - __ _ ___ _ _ -- ~j oa.oo _ _ - - -_- - •c_'_`~. -- Gf _S._ _ /r~a.~ct rY - _ ~Cono/1tu; ~SIS~ttclc~s __C.'Ji~~.- -_-_ __ _ --- - --- --- _-- - - - _ _ -_- - - - - _ _ as.-- - --`$u/c -8~- /~saira/t d/_ _C',luck _,Q~.ckU~, _/~tcr.~ionecr__~~ss sale ---- - _ - _ ----- ----- CJ~_~~,103. ~s. DF-fP~%s---F lqu,-,~,_~GO.eO cis __de~crrcd_~zr~ t~{r•9r _- - _ ~-~_d __ke!!y, __ ~!r_e__~o~ o~ --Subs_e$-~c~~ly--~us__~_in_~as~i_ %_ ___- ~' -- -- -- << ~ - -- !3 0513.75- Sec q'o n etr^s -~{~, f ewtl~_ - ~r~on~t__ Chuck B~~ cKe~'- _~}a_chec~-~ - _ -- - ,a~, - Tn3wr. - f1'1GtLt_-_fD_r__~rz-Ca,s~e.ol _ o~d_ChC_ck,---nec.~ _re ~ssu.zof--- b Ili ont,t,- _ __ - r - ~ -_ I -- __ ~ - -_ -- - - -- ~ --- I -- - L - _ _-_ - I - _ - _ rip,'rin/~r'iri~~ r~~ri~ .-1lrpr~1~r~~ C~1°.:il_Y.th': _~ hl_I'_;i1'J(`I I-'i-i~_a v11 ~~' ~ ~~ ~ ~ Bi~I~~Ef~S AUGTIO~ ~~~,,,~;~ buy & Sell on Commission - Complete Sale Service 93 Texaco Rd., Mechanicsburg, PA ~ 705 7~b~5785 ~.~ ~--- ~ f ~~ _ Personal Propet~ of ~- ~~ U1t~~v ~ ~ 1~;~v' ~ ~./ ~ Address ~~ Sold At Public ' Sale ~~ v , ~ -- ' ~ av~ t~utstanding __~ :..____~?~.. Total ~t~le_ Y ) .3,1 ~~3, ~~ ~_ ~ ~, ~. u ~ Total Checyks ~.a ~ ~, ~ .. TOt ~... u i..-- ..,~. ~... Gosh Ater Pray©ut (~ ~. ~ ~ a .._T ~~nses~y._._.. _.~ .. ___.~..-_ _. Auo~ioneer ~c Cle~k~oo, o __._...- _.--- W~~_ _ _ .M...._._~ - w~--~ Adv. ~os~ _ ~3 rte. ~ ~ .~.~.-..__..__.........- ~- Pr~~ ._~ Sale Setup or l~4elp ~-' u , ~~ _ ___._ _w.. -~ Total expenses --- ~ ~ ~ ~~ ;/o~~ ,~~ r K-Ff' ~'/"x~, Thank You For S~alsafln~ Chunk Brkskor, Auatiarloor & Shoff CHARLES E. SHIELDS, III ATTORNEY-AT -LAW 6 CLOUSER ROAD. Corner of Trindle and Clouser Roads MECHANICSBURG, PA 17055 GEORGE M. HOUCK (1912-1991) September 24, 2007 Mr. Al Forlizzi, District Administrator PA Dept. of Revenue, Harrisburg District Office Lobby, Strawberry Square Harrisburg, PA 17128-0101 TELEPHONE (7I7} 766-0209 FAX (717) 795-7473 In Re: Estate of Florence M. Rudy, Deceased File No.: 21-07-0805 Dear Mr. Forlizzi: Please find enclosed the original inventory report of the Safe Deposit Box we made on September 10, 2007 for your records. Thank you for your kind attention to this matter. Very truly yours, C~ ~, £ of ~~ Charles E. Shields, III Attorney-At-Law CES/mjj Enclosw•e J 48500041046 REV-485 EX (05-04) SAFE DEPOSIT BOX INVENTORY PA Department of Revenue PLEASE USE ORIGINAL FORM ONLY :iocial Security or Death Certificate Number Date of Death County Code Year File Number l 9~ /~{ ~~'Io0 D~l~2Oa7 ~,/ 07 OD8'QS~ Decedent's Last Name Suffix First Name MI R U Dy lY]~S ~LD~ENC~ /yJ ® ADDRESS OF DECEDENT STREET: CITY: STATE: ZIP CODE: I a. ~ 3 S ,F}- GA' P 12~ ~' ND Ll~1- Pft 170 ~ P ENING OF THE SAFE DEPOSIT BOX DRESS OF PERSON REQUES TING THE O NAME AND AD Ll A ~ + NAME: C H~2G ~ ~. -S/I~~J ~ ~ !~ STREETADDRESS:A~ ~/~ /~/f~'/~ Y ICI AI.sJ ~ ,~i! ~~~/S/,/ ~ ~ ,,/ /~ CITY: ~/~'~[.-5~~~~ ~~ STATE: ZIP CODE: ~~O.SS ~ . NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING a. NAME: RELATIONSHIP: DENNrS ~J,~yis ~v~tiE-w/ExFeuTn.Q STREET ADDRESS: CITY: STATE: ZIP CODE: !o D ~ !.y • .gY4'~¢Dy C~¢NE' CNOG,f~ /~i~ / 70 ~ b. NAME:`/ n, ~ ,~/ .~ /~ ~• ~- 7~ RE~LIATION~S-H-IP-: STREET ADDRESS: (o CL OGlS~7~ /u0_ CITY: /~I E'e+Y~.it~lCSLi'G~ STATE: !°,~ ZIP CODE: /7oss c. NAME: RELATIONSHIP: STREET ADDRESS: CITY: STATE: ZIP CODE: NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME ~ ~ ~ ~~~ STREET ADDRESS: ss~• C~ sGE' /~lkE CITY: ~'1F'CiY~~elcs,~3~r~G STATE: ~°•¢ ZIP CODE: /7asS~ NAME OF PERSON MAKING LAST E RY DATE AND TIME OF LAST ENTRY J-- ~ FO/1 G!JlLL S I Q~,IV ~j4~ }~lS C~.H cNLY ~ ~ 2Z a7 /a : oa s~.ii ~ DATE OF CONTRACT TO RENT BOX ' NUMBER OF B OX 1 TITLE UNDER WHICH BOX IS REQUESTED S 3 97 f.~- i iL C'S . NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX a. NAME: ~(~~NL"E~ itr, ,~2.uD y b. NAME: STREET ADDRESS: ~~.~s /~~tds ~~ ,~.a. STREET ADDRESS: CITY: SQTATE: ZIP CODE: CITY: STATE: ZIP CODE: NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY ~ 1 /~S ~+ [~! C~ D~ Z_ ~~ ~ ~ ~j2 E~ -~ WAS A WILL IN THE BOX7 ^ YES I~ NO ~ If yes, a. Date of will: b. Name and address of personal representative, if named in the will ~ w' ~ S~ ~~ /'~p..~i~'~"L~ ~t/~/~7 NAME: ,~/,Q W/LL Wi¢•S l2FTl2LElr~ TJti/Cif/ STREET ADDRESS: CITY: STATE: ZIP CODE: c. Name and address of attorney, if any NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: 48500041046 48500041046 RFV-4R5EX Jl~~C ®Cr®~~ 1 ~O~ I6V ~/ G1tl~06~ i Page of INSTRUCTIONS (1) Gash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) ©bligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.~e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount; serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. . (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 ITEM NO. ITEM DESCRIPTION ~-u!~ t,as'ly ,. ~ Z ~~.DD 4 Z •~ 3 ~' • ~ ~ ~.. ~ .h~ GG'~ f b . 3~ r /~z I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS CORRECT AN) COMPLETE TO THE BES MY KNOWLEDGE AND BELIEF. PERSON RECEIVING COPY OF SAFE OSIT BOX I NTORY: SIGNATU ''` r.-~~- x ~° ~~ SIGNAT R x . PRINT NAME CH~t-~5 E, SHIM-~S T ,,g-%7Y PRIN NAME AND CHECK PP O IA BOX BELOW: '~~i-l~V(S AA-/I's PRINT TITLE Cy/~lllL~'S F ~h'/t21~ S!~` ~T rJ ~y w- ~ ,~ I /~ ~/` ~.> l' I / E DATE ~A/O/O ~] ` ` / CHECK APPROPRIATE BOX: ~ Executor(lrix) ^ Administrator(trix) ^ Estate Representative ^ Joint owner of safe deposit box NOTE: Attach additional 8'/~" x 11" sheet(s) if necessary or use duplicates of this page of form. The Department is authorized bylaw, 42 U.S.C. §405 (c)(2)(C)(i), to require disclosure of Social Security numbers in connection with administering state tax laws. The Department uses the Social Security number to identify the decedent and personal representatives of the estate. The Commonwealth may also use the information in exchange of tax information agreements with Federal and local taxing authorities The state law prohibits the Commonwealth's personnel from disclosing confidential tax information except for official purposes. I t ;" . j'` .. .:(Z" A...J\. © M&TF~~nk 499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12 Phone (888) 502-4349 Fax (302)934-2955 September 27, 2007 (:harles E Shields Attorney At Law fa Clouser Road Mechanicsburg, Pennsylvania 17055 Re: Estate of Florence MRudy Social Security: 196-14-2560 Date of Death: Au,~ust 16, 2007 Dear Sir or Madam: F'er your inquiry dated September 24, 2007, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: l.. Type of Account Checking Account Account Number 73027294 Ownership (Names o~ Florence MRudy Opening Date 08/28/64 Balance on Date of Death $13,416.99 Accrued Interest $ 0.36 Total -------------------------------------------------------------------------------------- $13,417.35 2.. Type of.]ccount Savings Account Account Number 015004214080274 Ownership (Names o~ FlorenceMRudy Opening Date 07/30/06 Balance on Date of Death $17,921.60 Accrued Interest $ 12.67 Total $17,934.27 Type of Account Certificate of Deposit Account Number 031003917117846 Ownership (Names ofi Dennis JDavis Florence MRudy Opening Date 06/05/07 Balance on Date of Death $20,000.00 Accrued Interest $ 176.19 Total $20,176.19 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 Summerdale Plaza Office # 717-255-2261. Sincerely, ~ ~~ ~~ Plancy Clagett F:ecords Management ~ '~.%~ .~~~~:`tii' ~ t"~'J~~~'`Yc'~C'.1~~~'~:'. ~t~•~;' ~~~jE ,FBI::-'~jl'J }'C~7'~i~,~:.:~ Fr~.~!'"~'rw Court Ordered Processing / MA1 MB3 02-10 P.O. Box 841005 Boston, MA 02284 September 27, 2007 Charles E. Shields, III Attorney at Law 6 Clouser Rd. Mechanicsburg, PA 17055 RE: Estate of: Florence M. Rudy Date of Death: August 16, 2007 Dear Mr. Shields: ~~~ ^j~,. Per your request, enclosed please find the account information as of date of death for the above-named decedent. Please note the balances do not include accrued interest. If you should have any further questions, please do not hesitate to call. Very truly yours, ~~`~ ~. Linda Spavento Team Leader Court Order Processing (617) 533-1789 (617) 533-1931-fax Sovereign Bank ESTATE OF Florence M Rudy SOCIAL SECURITY #: 196-14-2560 DATE OF DEATH: August 16, 2007 Account #: 2475012106 Type: CD Open date In the name of: Florence M Rudy Date of Death Balance: Int.(YTD) from 1/1/2007 Accrued interest to date of death: Other Info: 4/2/ 1999 $4,000.00 to 7/31 /2007 $7.36 $83.88 Page 1 of 1 REV~1509 EX•IL91) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER U.17 y, ~'~btQEN C~ /~'~ • ;Z-l - 0 7- ~ O S'r If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. -~~nr,v'is ~A-~~s !a o y cu. sha~~y Lane, k n.Q,la, P~ ~ ~~zs- ~ epl~e~ B C JOINTLY-OWNED PROPERTY: 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. 6~SJo7 M ¢T /3ank, C~~-f••f of D~ios~t # ~ap oc~, oo ~~~° s/o, oao.e~ 031 D03 q/7 //~ $`Ko ~ ' Sal /D ~~1~ ~• ,~• u/R' ?nt ,/}CCr. tv d.o•c~. ors .~•{cnal 174.19 . e . (See Ya/ua~ioti stie2~ q{taGJ,etJ ~ Sched ~'. ,fl-lso, see en ~Y 1. on S~heo! G. ) TOTAL (Also enter on line 6, Recapitulation) $ /0 Q ~~ ~~ III ......., ~...,..~ .o necae~l inmrr arirlirinnal cheers nI the came ci~e\ kEV-1510 EX . E1d7~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER ~z,lt a y, ~~ot2 E r~e.E nn . a r - o ~ - 80~ 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, THEIRREIATIONSHIPTODECEDENTANDTHE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE . DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IF APPLICABLE TAXABLE VALUE 1. pN~'-M M. F C/i) ~~ TE7~ ~T /~Ie. C~'72 TI F o~ ~FPoSIT 03i a.~3 X117 ll7 S'-l~ /~T /)'1 ~ T 13 i} N/< Div O TtIE" /,/YT~72~3T /~e~2U.ED T~~E'o~ (o,oao•~ p,r~nu~oal ~D, DBS./D ~Do fo ~ 3,000 Rs 7, D8d'.~O ~d ~~ & ~ 10 INTEt2-~T~ G l I/ F,~U To ~ E/V/U~S ~fFt~/S , ~ a µ b~ . Shad Lane, ,k nolcz,~ IPf~ 1 ?OZS Q iVe,~~ieu>~ 2. /'1'1et~~,(e lnUCS'~vl'S USA ~Su,r• (.o. /~-nnu,~t'~ ~ nhnict ~~D/Y~79SZ x`30. y3l,Sy /b0/a -o- 30, S~3/.S9 P~,yuble fa ~Sf~ s~ ~lan°`tce Aq• I~~~ ~SCc ~~/KalSo/~ ll~c G~q~ 3• /~~~ s~ar~ L~~G .~i1ur. (~. ~r~nk~t ~'o~~ru ct G,~l /6 9 ~9a 7~ ,2 ~le ~ ~S{u~ o~ ~~ F/~/L°Lt('.Q ~ ~~G~ ¢ ~'~, bOQ. ~ ° /OD~ ._.p- Z, DOD • 00 (fee l% ~udh o,~t ss~' d~~;~l~~ T`iG ~arttbrt.~~ /~hnu/ty (.o,~?l~'aG~ No. # ~ o ~ ~ i75 aib /6~ 2g5 ZZ /c+a~ - a - 6, Z yY.22 ~ay~ ~/t ~ ~5~~ e~ f-/oiYsu~ ,/~j, ,~~ ,C7, ~ia~G~ ~r /Pes~~~rary ~1 `yi !tii// See 1/alica~vh shet~s Q/~ac~ta~/ ~ . /Y1P~ L,~e A-nnu~ fiy Con~r`ur.~" Na. /h X Ofl ~ A/(o, 9~/Q, y2 /oo ~o ~ o - %`, 9`fo, ~Z 97~ 1~enn is ~av ~ s , ~ovla.;lr,~ Payable J f/(~~ ~~f0, / Z /00 90 ' D " ~/6 5~'yo.~,- ~ ' o roi~er ~ (~IG,ggo~ii ~,) ~ s . (z -1,r~l.ew~, 1 %(o, 9~f0./~ /oo Po - o - ~ %G, q5~o, y~ Sq~ Ya(u.a.~'o vt s1, tars a..~ TOTAL (Also enter on line 7, Recapitulation) I $ / / 6, 4 3 ~ • ~ 7 llt ...,.............. ~........a.,a ~.,.....4 .,.+.+i+f.,.,.,1 nV. m+c of +{,~ come ci~o1 MetLife Investors P.O. Box 295 Des Moines IA 50301-0295 MetLife October 9, 2007 ESTATE OF FLORENCE RUDY C/O DENNIS DAMS 61)4 WEST SHADY LN ENOLA, PA 17025 RE: METLIFE INVESTORS USA INSURANCE COMPANY CONTRACT 940147952 OWNER Florence M Rudy Dear Executor: We have processed slump-sum distribution representing the proceeds payable to the Estate of Florence Rudy under the above- referenced annuity. We are sending a check in the amount of $30,431.59 to the above address under separate cover. The table below details how your check amount was calculated: Portion of account value at death, due the above-referenced beneficia $30,371.21 Plus interest credited at 3.35%, from date of death $60.38 Less federal taxes withheld: $0.00 Less state taxes withheld: $0.00 Check amount: $30,431.59 The taxable portion of your proceeds is $431.59. An IRS Form 1099-R will be mailed to you by January 31, 2008. If you have any questions, please contact our Customer Service Center at (800) 343-8496 Monday through Thursday between 8:30 a.m. and 6:30 p.m., ET and Friday from 8:30 a.m. until 6:00 p.m., ET. Siincerely, Bethany Hopper Sr. Annuity Representative -Post Issue Processing MetLife Annuity Operations and Services ^ VOID D CORRECTED PAYER'S name, street address, city, stale, and ZIP code 1 Gross distribution OMB No. 1545-0115 Dlstrlbutlons From Pensions, Annuit(es, Allstate Life Insurance Co Retirement or s 12,042.70 2007 Protk-sharing P.O. Box 80469 NE 68501-0469 2a Taxable amount Plans, IRAs, Lincoln , Insurance s 42.70 Form 1099-R Contracts, etc. 2 a e amount ~ d ® CO B t li ib PY on s r u ~~t~~un~tt~ttt~~~ 3 noldelermined ncome ax i i cl d d ~~~ ~ ~ ~ ~ ~ ~ ~ ~~~ ~~~ ~ i ~% 2 ; n ( n u e t nu t ut ut nut t t t nt nt Report this income wilhheld ESTATE OF FLORENCE M RUDY on yourtederellax 604 W SHADY LANE S 0.00 S 0.00 return. II this term 5 Employee contributions unrea ize apprecia ion irl shows federal ENOLA PA 17025-2053 or insurance premiums employer's securities i ai ~ is b adh ox 4, i l Fl n S 12,000.00 S 0.00 copy to your return. 7 Distribution tAAI 8 Other This information i code(s) SEP/SIMPLE being furnished lc 4 ~ S 0.00 % the Internal 9a Your percentage of total 9b Total emp(pxee contributions Revenue Service distribution % S U UU PAYER'S Federal idontitiralion number Customer Service Number 10 State lax wilhtreld 11 Slate/Payer's slate no. t2 Slate distribution 36.2554642 1-800-755-5275 s----------------------------- PA_1846_8744------------____-- s ______-----__-- s s Account Number (sae inslruclions) RECIPIENTS idenliticetion number 13 Local lax withheld 14 Name of local ly 1b Local distribution AC1035297A0001 XX-XXX9401 s ------------------------------ -------------- -- --- - s s Form 1099-R Department of the Treasury -Internal Revenue Service Q CORRECTED (t dledced) Dlstrlbutlons From PAYER'S name, street address, cl1y, slate, and ZJP code t Q-oss distribution OMB No. 1545A11s pensions, Annukles, Allstate Life Insurance Co Retirement or s 12,042.70 2007 Protk-Sharing P.O. Box 80469 a ax a amoun Plans, IRAs, NE 68501-0469 Insurance Lincoln , S 42.70 Form 1099-R Contracts, etc. a e amoun ~ Total not determined distribution Copy C 3 Capital n (included a er Income ax in box 2a~ withheld Far Recipient's Records ESTATE OF FLORENCE M RUDY s 0.00 s 0.00 604 W SHADY LANE 5 Brrployee conlrlbulions s Net unre ized appreciation in or insurance premiums employer's securities ENOLA PA 17025-2053 s 12,000.00 s 0.00 7 pislribution IRA/ s Other This information is code(s) SEP/SIMPLE ,~, ~ being furnished to 4 ~ s 0.00 % the Internal 9a Your percentage of total sb Total erOp(pxee contributions Revenue Service. distribuhon % S U UU PAYER'S Federal identification number Customer Service Number 10 Stale lax withheld 11 SlatelPayer's stale no. 12 Slate distribution s isag s?aa rn s 36-2554642 1-800-755-5275 ----------------------------- _ ------------------ --------------- s s Account Number (see instructions) RECIPIFldT'S idenlificelion number 13 Local lax withheld 14 Name of locality 15 Local distribution AC1035297A0001 XX-XXX9401 s ------------------------------ ------------------------------- --------------- s s Form 1099-R (Keep for your rocords) Department of the Treasury - internal Revenue Service __ _ _. _ __ ____ _ . CORRECTED (f checked) OMB No. 1545-ot15 Dlstrlbutlons From PAYER'S name, straet address, city, stela, and ZIP code 1 C;(io$s ilislribution Pensions, Annukles, Allstate Life insurance Co r 2007 Retirement 9 s 12 042.70 Protk-sharln P.O. Box 80469 a ax a emoun Plans, IRAs, Lincoln, NE 68501-0469 Insurance etc. 1099-R Contracts F , orm s 42.70 a e amount Total not determined distribution COPY 2 3 Capital gain (included a ra mcome lax in box 2a) withheld File This copy with your stale, ESTATE OF FLORENCE M RUDY s 0.00 s 0.00 citY.orlocal income lax 5 Employee contributions s Nel unrealized aepppprreciation in 604 W SHADY LANE or insurance premiums employer's securities return, when required. ENOLA PA 17025-2053 s 12,000.00 s 0.00 7 Distribution IRA/ a Other code(s) SEP/SIMPLE a D s o.oo 9a Your percentage of total 9b Total employee contributions distribution % S PAYER'S Federal idenlificelion number Customer Service Number 10 Stale tax withheld 11 Stale/Payer's stale no. 12 Stale distribution 36-2554642 1-800-755-5275 £----------------------------- PA_ 1846 8744------------------ S _____________-- S S Account Number (see inslruclions) RECIPIENTS identification number 13 Local tax withheld 14 Name of locality 15 Local distribution AC1035297A0001 XX-XXX9401 a_____________________________ ____________________ s THE HAR'I'I'ORD #BWNGSGR #V19XESECJSR04# FLORENCE RUDY 2135 LAMBS GAP RD ENOLA PA 17025 joss Date: November 12, 2007 Contract Number: 000012058/47175210 Type of Contract: Non-Qualified Owner Name: Florence Rudy Annuitant Name: Florence Rudy N _~ ~_ N ~ (] ~ (~ ~U Z p W °_ O o o =o N Your CRS' Generations fixed annuity financial confirmation 'The total value of your annuity on November 12, 2007 is $0.00 Your Contract Details Contract Effective Date: October 13, 2004 Interest Rate: 3.45% Duration: 5 year(s) Gross Contributions were: $14,676.85 Details of your transaction(s): Full Surrender -Death Proceeds Transaction Date: November 12, 2007 Rate Duration - `Amount `'~2ate Guaranteed until FROM 3.45% 5 year(s) -$16,294.22 For assistance For general information on Hartford products or services: Visit www.HartfordInvestor.com or call 1-800-862-6668 (Monday -Thursday 8:00 a.m. to 7:00 p.m., Friday 9:15 a.m. to 6:00 p.m. Eastern Standard Time) or write to The Hartford, P.O. Box 5085, Hartford, CT 06102-5085. ""I'he Hartford" is The Ilarlford Finattc•inl Sct~~ices Croup, Inc., audits Subsidiat•ies, including the issuing contpaxies of Hartford Life htsurance Contmm~~ mtd Hartfi~rd Life and Anititittt_ Insutance Comnnnv. Details of your surrender Your surrender will be distributed separately. Gross Surrender Amount $16,294.22 Net Surrender Amount $16,294.22 The Taxable Amount for this surrender is $8,294.22 The Taxable Amount provided is for it formational purposes only. In the case of an LR. C. section 1035 exchange, Direct Transfer, or Direct Rollover, Hartford Life will not report the Taxable Amotrjrt provided as taxable to the IRS. For custodian accounts, the Taxable Amount provided may be different than the taxable amount determined and reported to the IRS by the custodian. Hartford Life recommends consulting with a qualified tax advisor regarding the tax consequences of your transaction. Payee Information Payee Name: Estate of Florence Rudy Under the terms of the Contract, if the contract value falls below the required minimum as the result of a partial surrender, we will close your Contract and return to you any surrender value. Reinstatements are not allowed. Please promptly report any inaccuracy or discrepancy in your account to us and your brokerage firm. Any oral communications should be re-confirmed in writing to further protect your rights, including rights under the Securities Investor Protection Corporation (SIPC). We are issuing this cor firmation statement on behalf of the selling broker-dealer. Hartford L ife ~!nsurartce ~"ompany -Issuer; Hartford Securities Distribution Company, Inc. -Principal ~'Inderwriter. - -- -- • ~Ii'PZ~~Cii~~i~ 47175210 PAGE 2 OF 2 000013 00003 OD 0 0 0101000100 0001000010000{f 7 II I I~ I II I III II I I I I II I II I II I II I II I II I II I II I II I II I II I I'II I ~IIII'l~ MetLife P. O. Box 10342 Des Moines, IA 50306-0342 DENNIS J DAVIS 604 W SHADY LN ENOLA PA 17025 00003 RE: ANNU{TY DEATH CLAIMS DECEASED FLORENCE RUDY CONTRACT MX008976 Dear DENNIS J DAVIS MetLife Your claim for the death benefit under the above contract was processed March 19, 2008. Your share of the settlement totaled $16,940.42. The payment details for your share of the proceeds are as follows: Settlement Amount $16 , 94 0.4 2 Cost Basis Amount $ 0.0 0 Less Federal Income Taxes Withheld $1, 694.04 Less State Income Taxes Withheld $ 0. 0 0 Claim Payment Amount $15 , 2 4 6. 3 8 You can expect to receive the settlement in the next few days. This contract is non-qualified and all proceeds over the cost basis are considered taxable in the year received. The cost basis is listed above. If you have any other questions, please feel free to call our toll-free number at 1-800-638-7732. One of our Customer Service Consultants will be happy to assist you. Sincerely /'Gi 13Q!L7.C%1~ Patty Brackett Annuity Death Claim Unit .Annuity Administrative Operations MARCH 20, 2008 R00352. SCRE (01/06) PD LTR-NQ 000050000500000000000MX008976 1 ~et<ef~ For more information MetLife or to address any P • D • BOX 10342, Annuity inquiries DES MOINES, I A 50306-0342 write or call: TEL : 1- (800) 638-7732 Check Payee DENNIS J DAVIS G/O METLIFE 56L 1 Ci 1 EicFORu" R^u STE 200 CAMP HILL PA 17011 Contract/Certificate Mxo-o89-76 Transaction Date o3/19Izoo8 REMARKS: THIS CHECK REPRESENTS THE AMOUNT OF DEATH CLAIM PRCICEEDS FROM THE ABOVE ANNUITY CONTRACT NUMBER. STATEMENT TO BE SENT UNDER SEPARATE COVER. Ck Blk/Num Ck Date -Net Payment 0147/003514177 03/19/zoo8 $15246.38 Type of Transaction DEATH CLAI Detach stub before cashing P90G27.SCRE (G6/Ot) ~~~~ ~ Void After 12Q Days ~ ~ Metropolitan Life Insurance Company 62-35/311 If not cashed, mail to P.;O. BOX 103:42, DES M01 NES, I A 50306-0342 n Ch1eck Num~b]er O ~ ~ CreLiit Account Number /Name: " i ~ ~ ` MX008976 Not Valid Eefore personal Endorsement Required 03/79/2008 Pay to the. order of : DENN I S J DAV'I S Amount ~ Dollars Cents Cj0 MfTL l FE 56L The Bank Of New York (Delaware) 1.01 ERFORD RD STE 200 $ 1.5246' 38 Newark, Delaware CAMP HELL PA 1]07.7 000030000300000000000MXOD8976 1 ~tl~f For more information or 9o address any Annuity inquiries write or cal{: A (• 1~ MetLife P.o. Box 1o34z, DE'S MOINES, IA 50306-0342 Tf L : 1- {800) 6'38-7732 Check Payee DONALD J DAVIS C/0 METLIFE 56L i v 1 ~Ri' DIiD R"u JTE 20 CAMP HILL PA 17011 Contract/Certificate Mxo-oB9-76 Transaction. Date o3/lg/2008 REMARKS: THIS CHECK REPRESENTS THE AMOUNT OF DEATH CLAIM PROCf:EDS FROM THE ABOVE ANNUITY CONTRACT NUMBER. STATEMENT TO BE SENT UNDER SEPARATE COVER. Detach stub before cashing Ck Blk/Num 0147/003514175 Ck Date 03/lg/2008 filet-Payment $15246.38 Type of Transaction DEATH CLAI P90G27.SCRE (06!01) 000040000400000000000MX008976 1 ~i°~tf~~ For more infiormation MetLife or to address any P .O, BOX 10342, Annuity inquiries DES MOINES, I A. 50306-0342 write or call: TEL 11- (800) 638-7732 Check Payee JOSEPH W DAVlS C/0 METLIFE,756L ~ U ~ [KC• 1.1 rt 1.1 1\U JTE LVv CAMP HILL PA 17011 Contract/Certificate Mx0-089-76 Transaction Date 03/19/2008 REMARKS: THIS CHECK REPRESENTS THE AMOUNT OF DEATH CLAIM PROCEEDS FROM THE ABOVE ANNUITY CONTRACT NUMBER. STATEMENT TO BE SENT UNDER SEPARATE COVER. Detach stub before cashing Ck Blk/Num 0147/003514176 Ck Date o3/ 19/2008 Net Payment $15246.37 Type of Transaction DEATH CLAI P90G27.SCRE (06/DY) REV-1511 EX+ (10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Ruby, FLoRC-'NCB //I"I. ~1-o7-ADS Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. FuNC~~G ~//PS P~EP~~Id. pt. G i~19/~i'c~1 fY/Bitto~ia/s , r'n-tLt/e ~}rna i rtsc:ri~~'on ~/ Z S, Oo B. I ADMINISTRATIVE COSTS 1. Personal Representative's Commissions ¢ Name of Personal Representative(s) ~E ~ ~-~+ ~ 5 ~~' ~/s -- -- -- - -- -- / ~ 7 S~l~. OD ~ r1 Street Address ~DT ~~SI ~~I~.~ L..Lt,YIC __~_ n City ~hD~G( State ,l'A Zip ~70 xS Year(s) Commission Paid: ,olDDb' _ _i !_ _` 2. Attorney Fees C~4.1" ~~$ ~. d~' f~~uS ~ ~! ~, s-QO~ ~D 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant ~j lV F ~G~6//3L~ ---- - /Vo/IJ.L~ Street Address City State Zip _ _ ___ Relationship of Claimant to Decedent 4. [~ l (' L Probate Fees (,~ ~h 1 Q I n~ ~t SS lAG aT S~(^t C.e,T"1 r 77,GQ.I¢S (J ~~ y 9 , OQ 5. Accountant's Fees r MQ,r~'in ~~avtner~ ~ Assocs, [.LP clauoutlo~Fd i 7bp, 00 1 6. ~o~~, PA ~~ a~ Tax Return Preparer's Fees ~~~ N. ~nola Dr, , Ennla, P19 ~7o zS ~2 sr.7~ /y~ars~ . 7. l~Gdu.~~+ohs umc! Pa~ m P,+~-fis as s ~o wn o h ~-~le.m~rt~ .s ~ua,#' a,~- Scud. ~. r~ : sa,l>/ ©~ r~a-J e s+a~~ /Q~. L~n~ Il/3 Nott~ry fee {a L~DM~Iun,fiiJ Lpmr,~ Ti'~57~'er f5',OD g, ~,; n e I a.d3 ~ ealty Trans{~r ~uac ~ 3, 5'~ D . 0 0 _ C. l.;ne 1303 Twc Cer~~~. Fee '1'a n"lUrie }-lklaer, jtMc Coll, x S-, oD $. ~Q~i ~i'ona/ ,,Or~hafe few 3~0.6~ 11 (~/?Ti h TOTAL (Also enter on line 9, Recapitulation) $ ~~~ 767 76 ~sT. o/= f~ (~ O Y, ~ Lo t2FN C.~ I-'1, F7~E' ivv. ZI -07- 8'oS y. : /¢ddi~o~rd/ S~or~ Cerfi~ta~~S ~~,4. 00 /D. /~d~ert-~;r.~ ih ~arl,'s/e ~it:;ne/ /1/~j~a~or /l d', 7.Z Jl, /~Gt~l/E,/'~i.Si/?q %i7 ` u/r) ~u-~a/?v~ ~trw Sur,~ta/ fi7$'; as (.?. ~r%itZy Fce ~ ~c~ciJ~r o~ GU.%/s ~/S', DD l3. J~~~~tdursenjeytts ~ Charles E. ~h-'eids ~ ~~- ~hmr~emp,'~, ~i1oS~itG~e., e.erf;~ec~ ~'lQ,~,i~ys, ~. ~6~.so ly, Costs aM.d Co;~miss;ons pa~~1~ ~D C~l(.[./C (3r~ckcr, atcr.~'nhe~r; ,9, /l~i'us~o~eer usrc/ G=/erks 9 !, 3©0. °° ,Q. f~Cly. Est q boo , eo ~ . cf~c~ ~f t{~ q7f r/ ~e~ ~`f8d . ~ tSee G!ccr.1/ip~Ire~s a7~~rll~tt a1~~~ ~ S~erl. E~ IS, X1'1 un~rta s ~~va~ ~i~-K - ~pprais~/ ~~ dlCtv~/ry ~a~ 00 l~r. %~'ataf~,~ ~: yi~9tr, L~eu~n Fare / ¢20.00 J 7 J ~o bcf-Z~ ~l4ri~9, 7r~esi~i /~emo~~ ~yt ~~~ Fvr ~u./e ~7s. ov c S, ~t'ruc (n~ . ~ r~rr~tf' I~ea.~ £',~a.~ l~raisa.~ ~3so, a~0 /`l. ~ /~5soa,a~d ,G~ib~~s~ ®or~a-~r~ES ~-o'~ 1~ioh ~99.zz Z°- ~~r/~arr~ %u,~,, % Asti ~~ 5~. Zs ai , Ta~/e/%rr ?-ncltm. ~ /~~i~% , f/~,tteowriecr~r -~s. ~SSz~ .LS ~~ 5; ?3 /~.~. N.S. /"Osl7l ~ o~trl'.~ce ¢~. Zo ~Y, Gl4 ss/ll4s~ rl -- /~yv/ ce c~r~r .~or' Gt~tss ~~i!~~?~°~ a~ etQ.le . r~3G . Z G a5. -T:mof~fy yil~cr, Lr~urr~ CQre ~ L~f ~cr~1orQls. ~cf 60 , too a6. /~,~L . ~'lec~%~ Wyo. 33 ~~ 7QYL~/CAS .~l~lAf . ~ ~~~~, ~'/e~y~eow~u`s ~i1s. ~Sb.2S' ~°~` ~ ~ SCfIC=J, hl~ Gc~t~`i~ _ __ _ - ST. a~ - ~U..~y~ ~Lo/?EN~ /l'L _ ___ _ - Z (~ 0 7~ d'os F'~ ~E- No. -__ ay PAL ~/C~,~ __- - _ ~ --- -- _____ -- - --- _ 3~.3z _ ~ ~ -- ~~, ta?~cL. _ChG_C.~S ,_ - ~r~-er- u.c~ ~' _.~ _ _ _ - -- _ _ _ _.. - _ _ - _ `j. S7J - - --- - _ 3 ~,. i Ti~ave~/cyr _ _ ~icj~.~yn~`, s ~~'l ~ _ ~lo/~oc~i~rr ~yisur. _ _ - _ - _ Asa . 2S~ 33. PPG E/eCfi^ic_ _ ____ - _- ~ z ra ~~~ ~ ----- ---- _- - _f-~eove~' ~~ i1?eerii2-_!/__~YiG~S. .~ .C.DCrt`~ufC____!'ea2lN^G~ _ - _ -- re: e7~ _ - _ __ _-- --___. _- -- 4 -_de2r,~ a~t¢l ~pd_~ndQry- -~pSeh%~~B~u_ - -- --- _- '17S.oo -- - - - - _ - 33,' - ira Ye ~~~yS _ ~"n Clem _,~ f~~~ ~_,- iY_6_/_heoc~nerr_ ~i s ~ r - _ _ _ -_ _ __ - - _ _ "so, as' _ ____ _~. _ ~~L, ~/~~iL - - ---- ~3 3. 3z _ - - _ - ----- - 37. ~-~!l -D_,Ope/. - ©i/_ ~c/i!_ _ _ 336.57 _ _~_ - - -/_L_DO{~L1'__~~~iI1Ge/'~!2y--~/Y~G~S~ ~k ~- ~~_UJo1?~' ~--_~t'G ~l a~pJ___E?7Y1~11~- - _ _ _ -- _--- - _ ------ _-, e5 ~- -~ ---_ ------- ----- ------ - ---- ___ -- 7D. 00 ~ -- - _ __3g __7~/~f~8_!~S-_ ~!~_tG~j.-_~ /~fi~~f__~fOdlP.at/~!/'S'_____±~r?SUr.._---- __ - ---- __ - ~SD.2S `~~. f1~'tie /yu ber, /~ ~/f _, _ l.~ ca/ %cs - _ - _ - - _ '~3?0, 8'~ _ -- - -- - y%_ ~a~p~~ _ = gip.,- _~•~s~ -- _ __ - -- - _------ --- --__ - -- _ - - - -- -_ ~~~. zs - -- - --/ --- -- _ _- -_ _ ---- ~~_- - Tav~Ilc~s _~ic~e/N-x-%?FFl_~_f`,!e!~o~r!,/ut"S_ ~js~tr___ _ -__-- - ~sn.Zs --- ----------- --ys._. ___ PPL,_~lec1`r-~~_--- ---_ ------- -- - _--- - - ---- - --- - ---_ __ _ _ - -_- --.?703_ __-. ____ ___-- _-___ ~~•_ _ '' -- ~~ ~~ // ~~ __~~2_ .fl.~/lv~_~r_ ~c~ _ a~ ~i__ Gert!T!_c_aa`4S.- - - -- -- - - - - __ _ __ _ -~36 , a o - _ _ - -~-- - 'Y~- _ _ APL f/c~~'r~~ -_- - -- -_ __ _ -- day. ~'~ ___ ___- __-_- _ ~_ -_ _%~~e/lfs_.T-n~l~, ~ ~~i~~~ f~rX?~[J~--,1jts.--- _____ _ _ _ sa 2S - _ _ -_- ,~Z. ~- --/ha~~e _yu err, --/R.~c_- ~'D/l _, ~Sc.~.__ _T~c~?!'es, _ _ _ _ ~ _ _ - _ __ /,_.~/. ~o - - ,.3.~-_ _ 7 ~,i'YIiYPi~~G/'S _'~1 jl~C/Ij, -.~_ ~~f% ~_. ~G1~IL°~!/:~tfS' _ d~?S. _ - _ ~/ O. O b _ _ _ sib. _ P!'G__ -~"/ec~/rrG - _- _ - _ _- - - - z z. 9 ~ _ _- , - - - _ _ - -_ REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF ~ ~~y, r"~C.Ot~NC.E /H. FILE NUMBER oZl-a 7- 8oS' 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 1' C.In c~,r{~5 ~. Shy ~~dS ~ ~ /¢ffarn t~j 'Tnr Se-WiGeS hP~7CfG'I~ ~ n Conne~l~'a~- w- ~ Sewer P1tSP.~tr~nt GLCr,oss a~ecec~enfs ~/ 8's , 2~ ~,r-d p e r~'y q?. 9/4~~n9- C~ieck c%a/rd oh ~iid 4/afi 4~i4~ do.u! tvri~ fxe{,~te /, 33 9, ~~ 3. 7i%ytOIJ`jy E. f ii?9u~ Lawn auq~ cf~ira/ Ca.r~ '~,?loS. ~o 5~ P~. DEp % ,Q~'I~FNa F - ~'s fi:N /~`dnn~tl S,~,e,a~ Tax . '°sod, o0 S. f~v/~i~I` ~P4.~f ~ ~SCw~ar G~~ncc~o ~la7.6S' ~ . f~erifit~e ,//1~i;' :ta/ G.r»~~ C t.d S'6.6 E' ~1est Jho~ ~rtes~esi4 ~¢ssncs. '~,7.r ob 8. gaanfum =MaU ~ fi ~erq~eu~i~ ~soes. ~ ~s.38 q, yeovEr ~h~ineeniny ~r~.ces, -Znc., ~'r ~{'t~a~wo~'k, ~~. 3s ~ 9y /o . F• /!!, op~O~l - ,~//urne~" ~rv. c e ~ 6 9.00 l~ q cc4 n ~~ 1 ntia.~ i nq ~' r77t.~.s-a pcu~.t.~ /.~sso~s. f~6 . Ba /~. /i/G~GIiCu~ ~SOG$, C1T c. ~~D /..33 1,3. ~en)`Gr ~~ f(i'r,~,ncy ~i~feQ~ ~ '~yPu"~s~'°~ a3y Flo ~ , pa. f. ~~n,u.e, Esfi•~ G~~~ .~,~,~ r.~ ¢~ ao.oo l.~; C'Q.n~ H:/! ~rner~en,u~ Phy~/~;ans ~~o, sz /6, u, s. %gSl1y 2Do~ ~ ~irc. % ~~~a.oo TOTAL (Also enter on line 10, Recapitulation) $ ( T, ~$ q• s/ (If more space is needed, insert additional sheets of the same sizel REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ~ ~.S~y, t`LoI~C--,~ CF m . ~l - 0 7 - goS NUMBER 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)] DF 2E5/IDtt,~ I~ h1 ~21on1 ~>aNCt~n< s+ran9er ~ blsed AFB ~Tr~ /~,l; C/D Lucille Nusz Pre.r~e~e,ased /»s. NoAI~ -L~PSEL X509 ,/tlorf~I ;Rna.c~ Gaudy. Share lap ~a,rrisburq, PfE 1?l09 ~, J~DSP.~h lt.! . ~txvt s _ bro~er ~~~l 6 04 ~ . ~hct~1.~ LcaJne Cnola, PA~ (~o ~ S 3, 'I~w~ r(~aclaba~n~h s~s~r.r yip 55D0 G1r~~tzV~ ale (>2nad ~'no1Q, PA /7aas ~, CafihQrine yea.q~r s;s~{ ~~ $~s t~ati~ fit. ~ i"jo 2S ~no~cc~ P Ceo nt d 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' C u~rnbcr~and Cn~,nty of~i'ce oi~ l~i~ i~ c~. N; yti ~t. ~a r~i s ~e~ p~F / 7013 FF o0 02, Doo. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more sdace is naarlarl incart a~~ta~~n~~ ~hoot~ of fhn ................~ z SCH~D. ~ e.ent~d. ~s7 n r- Rum y, r--r.~~eENCE Nl. (.~; lhur DUNS N3 ~ 4SfiZfe cS~'. yes/ ~ ir~iuv~ Pi4 /70 2S 6 • Cr. ~Qmes ~x,v%s ~~io werrfLV;IJe (~'d. Cnola ~ pf} l ? o zS 7 Ronald ~tuv;s 3 Easy Wood lamd 1~r. h'1 echan i c sbrt r~, P~4 ~7osS //?%cha e l ~~v,'s ~ !v lS We,rfzv'i~/le /Pig ono/a, off l~D aS 9, ~ottala/ QANi~S a~35 ~'hermaas lla //u~ load ~/lioffs~hry, PA loo ~~ /o- Dennis ©avis (o o ~ h~. ~Sha dy Lane ono/a, ~A~ (?o aS ~e~htd~ ~lL~ND. ~l-U7-80S ~l ~/JAGk~ y, ne~~e~ ~~hew n eptieul nG~luw `/r~ y~ yl yi ~a-~e.- 3 ~ C NE~'v. T, ~nf'd ST o~ 2uD y, ~o,e,EMeE- /IJ. //. Gary UT~a.c~a,bau5l~ 131 Salem Chu,rG~ /coat/ l~1 ~c~hanicsbur~, P~ l7osa ~2. RusSe11 ~ ~u.dab~~ S~fyO (,UPn~tLV~~Ie ~a~ ~'n of ct ~ Pi4 / 7o Z~' F/LENO• Z! -D 7- 80S rt ya,~uw ~i i ~~~~ y, ,w~ x LAST WII I, AND TESTAMENT OF FLORENCE M. RUDY I, FLORENCE M. RUDY, of Hampden Township, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all prior Wills by me at any time heretofore made. 1. I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can conveniently be done. I hereby give and bequeath to the Cumberland County Office of Aging the sum of Two Thousand ($2,OOO.QO) Dollars. 3. All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, is to be converted into cash and distributed to the following persons: Marion Duncan; Joseph Davis; Ruth Radabaugh; Catherine~Yeager; Wilbur~Davis; G. James Davis; Ronald Davis; Michael It7avis; Donald Davis; Dennis Davis; Gary Radabaugh; Russell Radabaugh, Jr. Each of the above-named persons who survive me shall have an equal share. In the event any of the above-named persons fails to survive me, his or her share shall be proportionally divided amongst those above-named persons who do survive me. 4. I nominate, constinite and appoint my nephews, Dennis Davis and Donald Davis, to be the Co-Executors of this my Last Will and Testament. I further direct that they shall not be required to Mlle bond Or other security in the Office of the Register of Wills for the purpose of administering my Estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this alt ~~ day of ~.. ~~Ll/. , A.D. 1999. f .~ ~ /~,,~-: (SEAL) ~; ~,,~~2.~.~i~v iii ~ FLORENCE M. RUDY .~.~ ~j i LAST WILL AND TESTAMENT OF FLORENCE M. RULIY I, FLORENCE M. RUDY, of Hampden Township, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all prior Wills by me at any time heretofore made. 1. I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can conveniently be done. 2. I hereby give and bequeath to the Cumberland County Office of Aging the sum of Two Thousand ($?,000.00) Dollars. 3. ' All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, is to be converted into cash and distributed to the following persons: Marion ~' ~ Duncan; Joseph Davis; Ruth Radabaugh; Catherine•Yeager; Wilbur Davis; G. James Davis; Ronald Davis; Michael Davis; Donald Davis; Dennis Davis; Gary Radabaugh; Russell Radabaugh, Jr. F ;,; Each of the above-named persons who survive me shall have an equal share. In the event any of j the above-named persons fails to survive me, his or her share shall be proportionally divided ~i ', ~ amongst those above-named persons who do survive me. 4. 1 I nominate, constitute and appoint my nephews, Dennis Davis and Donald Davis, to be the I Co-Executors of this my Last Will and Testament. I further direct that they shall not be required to ,' file bond or other security in the Office of the Register of Wills for the purpose of administering my Estate. ' IN WITNESS WHEREOF, I have hereunto set my hand and seal this a 7.~ _- day of ~~~ , A.D. 1999. ~ - ~ ` ~r ,,_..~. (SEAL) FLORENCE M. RUDY Signed, sealed, published and declared by the above-named FLORENCE M. RUDY as and for her Last Will and Testament, in the presence of us, who at her request and in her presence, and in the presence of each other, have hereunto subscribed our names as witnesses. ~` Is is __