HomeMy WebLinkAbout09-19-08 (3)J 15056051058
REV-1500 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 20 07 01159
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
___
_ __
183-22-0483 12/19/2007 ' 0 2/1 611 9 2 7
_ __ _
Decedent's Last Name Suffix Decedent's First Name MI
y __ $
Roth Nanc
(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 r„`°°'~ 3. Remainder Return (date of death
~, „"} 4, Limited Estate
;:~ 6. Decedent Died Testate
(Attach Copy of Will)
~"`~ 9. Litigation Proceeds Received
-;a 4a. Future Interest Compromise (date of
death after 12-12-82)
~ 7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
C~"S 10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
prior to 12-13-82)
„~~ 5. Federal Estate Tax Return Required
~.__~.... 8. Total Number of Safe Deposit Boxes
~ 11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
-_; 7
_, _i
---,
,_
,,-,
City or Post Office
,Wormleysburg
_ State.....
PA
ZIP Code
17043
DATE Fll.lD ~ - ~
~=i ..
_-
y, r~
Correspondent's a-mail address: pZUCker@dZmmglaW.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.
ur
F(JK FILING RETURN
ADDRCB'S - - r ~ -- -• - ~
414E teen Avenue, Br ach, NJ 07720
S ATUR P A~2ER .t~.T N ESENT DAT ~ ,../
Duey Zucker Meilton M' er & G' grich, LLC, 1035 Mumma Rd., Ste. 101, Wormleysburg, PA 17043 a,
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056051058 15056051058
J
_ ..~_~
~. _ ,.._~
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~~~
REV-1500 EX
Decedent's Name: Nancy S Roth
RECAPITULATION
Decedent's Social Security Number
..._ ........... ..
183-22-0483
__
1. Real estate (Schedule A) . ............................................ 1.
2. Stocks and Bonds (Schedule B} ....................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. '
4. Mortgages & Notes Receivable (Schedule D) .................. . .......... 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5
6. Jointly Owned Property (Schedule F) ~....? Separate Billing Requested ....... 6, j
7. Inter-Vivos Transfers i?< Miscellaneous Non-Probate Property
(Schedule G) ~..~ Separate Billing Requested........ 7.
8. Total Gross Assets (total Lines 1-7) ...................... . ............. 8.
9. Funeral Expenses 8 Administrative Costs (Schedule H) ..................... 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................ 10.
11. Total Deductions (total Lines 9 & 10) ................................... 11.
12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. I~
13. Charitable and Governmental BequestslSec 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.
153,000.00
11, 355.02 '.
360,323.03
489,899.34
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0_
_ _ ,. a...F..... -_, ....e, . . __
16. Amount of Line 14 taxable
at lineal rate X .0 45 489,899.34
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable ~ w
at collateral rate X .15
___
15.
16.
17.
18.
19. TAX DUE .........................................................19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
15056052059 Side 2
15056052059
~.w~
15056052059
22, 045.47
22,045.47
REV-1500 EX Page 3 File Number
Decedent's Complete Address: '
DECEDENT'S NAME
DECEDENT'S SOCIAL SECURITY NUMBER
Nancy S Roth 183-22-0483
STREETADDRESS -
120 Prowell Drive
CITY STATE ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19) (1) 22,045.47
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments 20,000.00
C. Discount 1,102.27
Total Credits (A + B + C) (2) 21,102.27
3. InleresUPenalty if applicable
D. Interest
E. Penalty
Total InteresUPenalty (D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 943.20
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 943.20
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred :...................................................................................... .... ^
b. retain the right to designate who shall use the property transferred or its income : ........................................ .... ^
c. retain a reversionary interest; or ...................................................................................................................... .... ^
d. receive the promise for life of either payments, benefits or care? .................................................................. .... ^
2. if death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ...........................................................................................
............... ^
....
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ........... ... ^
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ..................................................................................................................... ... ~ ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of 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 imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1502 EX+ (6-98)
SCHEDULE A
COMMONWEALTH OF PENNSYLVANIA REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Nancy S. Roth 2007-01159
Atl 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
exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX+ (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, SANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Nancy S. Roth 2007-01159
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
Personal property of decedent purchased by Alan J. Burleson, Buyer of real estate located at 120 Prowell _
500.00
Drive, Camp Hill, PA 17011
2. Personal property (clothing, shoes) donated to The Salvation Army 200.00
3. .1987 Lincoln Continental 500.00
4. 2000 Ford Explorer (purchased by daughter, Lynda Lee) 5,000.00
5. SERS pension benefits (R. Garrison Lee, son, and Sharon L. Jensen, daughter, designated beneficiaries} 642.83
6. Members 1st Federal Credit Union Account Number 0000013472 (Savings and Checking) 1,190.46
7. Refund from Transamerica for Long Term Care Insurance payment 307.99
8. Refund of car insurance 67.00
9. Refund of homeowner's insurance 251.00
10. :Refund of State tax 12.00
11. Refund from Wells Fargo 39.00
12. Pennsylvania Stimulus Tax 525.60
13. Ameriprise proceeds
__ __ 2,119.14
TOTAL (Also enter on line 5, Recapitulation) $ 11,355.02
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX+ (6-98}
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
Nancy S. Roth 2007-01159
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
NUMBE DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEOENTAND
R THE DATE OF TRANSFERATTACHACOPYOFTHEDEEDFORREALESTATE.
DATE OF DEATH
VALUE OF ASSET
% OF DECD'S
INTEREST
EXCLUSION
(IFAPPLICABLE)
TAXABLE
VALUE
1. Oppenheimer Funds (IRA), OMB No. 1545-0119 (R. Garrison Lee, son, and 12,749.28 100 12,749.28
Sharon L. Jensen, daughter, designated beneficiaries)
2. Ameriprise Financial (Annuity) (R. Garrison Lee, son, Lynda Lee, daughter, 133,196.30 133,196.30
and Sharon L. Jensen, daughter, designated beneficiaries)
3. Union Central (Annuity), Account No. A61121224C A64000778S (R. 113,798.55. 113,798.55
Garrison Lee, son, Lynda W, Lee, daughter, and Sharon L. Jensen,
':daughter, designated beneficiaries)
4. Lincoln Benefit Life Company (Annuity) (R. Garrison Lee, son, Lynda Lee, 100,578.90 100,578.90
Ildaughter, and Sharon L. Jensen, daughter, designated beneficiaries)
TOTAL (Also enter on line 7 Recapitulation) $ I 360,323.03
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (12-99)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Nancy S. Roth 2007-01159
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' Neill Funeral Home, Inc. 4,123.15
2. Our Daily Bread, funeral luncheon 406.25
B. ADMINISTRATIVE COSTS:
1. Personal Representattve's Commissions
Name of Personal Representative(s)
Social Security Number(s)IEIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees 2,750.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
. 3,500.00
Claimant .Lynda W. Lee
street Address 414 Evergreen Avenue
city'Bradley Beach '.state NJ .z;p 07720
Relationship of Claimant to Decedent Daughter
4. Probate Fees 185.00
5. Accountant's Fees
6. Tax Retum Preparer's Fees 194.00
7. Additional short certificates (6) 24.00
s, Cumberland Law Journal, publish Estate Notice 75.00
s. The Sentinel, publish Estate Notice 143.64
~o. Federal Express fee 18.19
~ t Copying costs 1.50
(SEE ADDITIONAL ADMINISTRATIVE COSTS CONTINUED ON SEPARATE SHEET)
TOTAL (Also enter on line 9, Recapitulation) $ 11,420.73
({f more space is needed, insert additional sheets of the same size)
SCHEDULE H
(continued)
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Nancy S. Roth 2007-0 1 1 59
ITEM
NUMBER DESCRIPTION AMOUNT
BALANCE FORWARD 11,420.73
12. Keystone Oil 342.18
13. Pennsylvania American Water 38.40
14. Comcast (cable) 42.26
15. AT&T (long distance) 203.23
16. PPL (electric) 178.25
17. Verizon 67.09
18. Classified Ad, sale of vehicle 97.52
19. Repairs to 2000 Ford Explorer 154.98
20. Fuel for vehicles 37.00
21. Postage 14.22
22. Food and beverages while preparing house for sale (12/07) 220.70
23. Food, beverages, Turnpike tolls for Executrix (01/08 and 02108) 327.00
24. Lodging and meals for Executrix (2/1/08 - 2/4/08) 1,262.46
25. Closing costs related to sale of real property at 120 Prowell
Drive, Camp Hill, Cumberland County, Pennsylvania 11,842.52
1
SCHEDULE H
(continued)
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Nancy S. Roth 2007-0 1 1 59
ITEM
NUMBER DESCRIPTION AMOUNT
26. Pennsylvania Department of Revenue (2007 State Income Tax) 269.00
27. U. S. Treasury (2007 Federal Income Tax} 4,829.00
TOTAL $ 31,346.54
2
REV-1512 EX+ (12-03)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
Nancy S. Roth 2007-01159
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, includ(ng unreimbursed medical expenses.
(If mare space is needed, insert additional sheets of the same size)
REV-1513 EX+ (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEf{CfARIES
ESTATE OF FILE NUMBER
Nancy S. Roth 2007-01159
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)1
1. R. Garrison Lee, 2656 Mable Lane, Lexington, KY 40511 Son 1i3
2~ Sharon Lee Jensen, 17040 E. Carr Avenue, Parker, CO 80134 Daughter 1 /3
3• Lynda W. Lee, 414 Evergreen Avenue, Bradley Beach, NJ 07720 Daughter 1i3
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS;
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NO7 BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
LAST W[LL
OF
NANCY S. ROTH
I, NANCY S. ROTH, now domiciled in Cumberland County, Pennsylvania, declare this
to be my Last Will. I revoke all other wills and codicils that I may have previously made.
ARTICLE 1
My just debts and expenses of my last illness, funeral, and administration of my estate
shall be paid by my Executrix from the principal of my residuary estate as soon as practicable
after my death.
ARTICLE 11
All inheritance, estate, and succession taxes (including interest and penalties thereon, but
nat including any generation skipping tax) payable by reason of my death shall be paid out of
and be charged generally against the principal of my residuary estate without reimbursement
from any person. This provision is not a waiver of any right which my Executrix has to claim
reimbursement for any such taxes which become payable as the result of any property over
which I have the power of appointment.
ARTICLE 111
I give, devise and bequeath all of my property, real, personal, and mixed to my beloved
children, R. GARRISON LEE, SHARON LEE JENSEN and LYNDA W. LEE, in equal shares,
Page 1 of S
provided they survive me by thirty (30) days. In the event that R. GARRISON LEE, SHARON
LEE JENSEN or LYNDA W. LEE fail to survive me by thirty (30) days, I give, devise and
bequeath their share of my property, real, personal and mixed, to their issue, per stirpes, or if
there is no issue, then the share shall be equally distributed to my remaining children, or their
issue.
ARTICLE IV
I have made no provisions in this Last Will for my daughter, SANDRA LEE SMITH, as I
do not wish her to share in my estate for personal reasons known to her.
ARTICLE V
In addition to the powers conferred by law, I authorize my Executrix, in her absolute
discretion:
A. to retain in the form received and to sell either at public or private sale, any real
estate or personal property except that which I specifically bequeath herein;
B. to manage real estate;
C. to invest and reinvest in all forms of property without being confined to legal
investments, and without regard to the principal of diversification;
D. to exercise any option or right arising from the ownership of investments;
E. to compromise claims without court approval and without consent of any
beneficiary;
F. to file any federal income tax return for any year for which I have not filed such
return prior to my death;
Page 2 of 5
G. to make distributions in cash or in kind, or in both, and to determine the value of
any such property;
H. to employ any attorney, investment advisor, or other agent deemed necessary by
my Executor, and to pay from my estate reasonable compensation for all their services; and
I. to conduct along with or with others, any business in which I am engaged or have
an interest in at the time of my death.
ARTICLE VI
I nominate, constitute, and appoint LYNDA W. LEE, Executrix of my Last Will and
Testament. In the event of her renunciation, death, resignation, or inability to act for any reason
whatsoever as my Executrix, I nominate, constitute, and appoint R. GARRISON LEE to act as
my Executor. I hereby relieve my Executrix or Executor, whether original, substitute, or
successor, from the necessity of posting security in connection with her or his duties as such in
any jurisdiction in which she or he may be called upon to act so far as I am able by law to do so.
My Executrix or Executor shall receive reasonable compensation for services rendered to my
Estate.
IN WITNESS WHEREOF, I, NANCY S. ROTH, hereby set my hand to this, my Last
Will, on this _ ~~~ day of ~ 2007, at Harrisburg, Pennsylvania.
N Y S. H, Testatr'
Page 3 of 5
In our presence, the above-named Testatrix signed this and declared this to be her Last
Will, and now, at her request, in her presence, and in the presence of each other, we sign as
witnesses.
N Address:
/o.~ ~o, ~T~I`3
I, NANCY S. ROTH, Testatrix, who signed the foregoing instrument, having been duly
qualified according to law, acknowledge that I signed and executed this instrument as my Will,
and that I signed it willingly as my free and voluntary act for the purposes therein expressed.
NANCY S. R H, Testatrix
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF DAUPHIN
SS.
On this, the ~~' day of _~GZ'f? b~ r , 2007, before me, the undersigned
officer, personally appeared NANCY S. ROTH, known to me (or satisfactorily proven) to be the
person whose name is subscribed to the within instrument, and acknowledged that she executed
the same for the purposes therein.
IN WITNESS WHEREOF, I hereunto set my hand and public official seal.
COfi~MpNWEMLTH OF PENNSYLVANIA
NOTARIAL SEAL
SUSAN M. HUDSON, Notary Public
Lower Paxton Twp., Dauphin Courtly
idly Commission expires Oct. 12, 2010
• Nom[-[7'C.~'
Notary Public
Page 4 of 5
We, the undersigned witnesses who signed the foregoing instrument, being duly qualified
according to law, depose and state that we were present and saw the Testatrix sign and execute
this instrument as her Will; that she signed and executed it willingly as her free and voluntary act
for the purposes therein expressed; that each of us, in her sight and hearing signed the Will as
witnesses, and that to the best of our knowledge, she was at that time eighteen (18) years or more
of age, of sound mind, and under no constraint or undue influence.
~~ ,
TNESS W SS
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF DAUPHIN
SS.
On this, the S~ da of ~. I~ , 2007, efore me, the undersigned
officer, personally appeared ~CY'° ~(,~~i~and V1t°__ ~..r~~,
known to me (or satisfactorily proven) to be e persons whose names are subscribed to the
within instrument, and acknowledged that they executed the same for the purposes therein.
)N WITNESS WHEREOF, I hereunto set my hand and public official seal.
/yJ~
Notary Public
COMMONWEALTH OF ~~NNSYLYANiA
NOTARIAL SEAL
SUSAN M. HUDSON, Notary Public
Lower Paxton Twp., Dauphin County
iUh- Commission expires Oct. 12, 2010
Page 5 of 5
A. Settlement Statement
B. Type of Loan
U.S. Department of Housing
and Urban Development
OMB Approval No. 2502-0265
1. [ ]FHA 2. [ J FmHA 3. [ ]Conv. Unins. 6. Fila Number: 7. Loan Number: 8. Mortgage Insurance Case Number:
4. [ ] VA 5. [ J Conv. Ins. I 400800117-SK
C. NOTE: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items
marked "(p.o.c.)" were paid outside of the closing: they are shown here for informational purposes and are not included in the totals.
D. Name and Address of Borrower I E. Name~and Address of Seller F. Name and Address of Lender
ALAN J. BURLESON I ~
LYNDA W. LEE ,EXECUTRIX OF
II ESTATE OF NANCY S. ROTH
497 WOODCREST DR{VE
414 EVERGREEN AVENUE
MECHANICSBURG, PA 17050 BRADLEY BEACH, NJ 07720
G. Property Location H. Settlement Agent
.CFf`I IRFf1 I ANTI TRA NCFFRC - MF(`HANI(:SFI IRCi
CAMP HILL, PA 17011 Place of Settlement
COUNTY: CUMBERLAND 485 ST. JOHNS CHURCH ROAD„
PARCEL ID: 10-20-1848-138 SHIREMANSTOWN, PA 17011
TOWNSHIP: HAMPDEN TOWNSHIP 1. Settlement Date 02/20/2008
Disbursement Date 02120/2008
J. SUMMARY OF BORROWER'S 7RANSAGTIONS K. SUMMARY OF SELLER'S TRANSACTIONS
100. Gross Amount Due From Borrower 400. Gross Amount Dua To Seller
101. Contract Sates Price $153,000.00 401. Contract Sates Price $153,000.00
102. Personal Property 402. Personal Property
103. Settlement Charges to Borrower $2,859.25 403.
Adjustments For Items Paid By Seller In Advance Adjustments For Items Pald By Seller in Advance
113. CityfTown Taxes 413. City(rown Taxes
114. County Taxes 414. County Taxes
115. School Taxes 1,201.61/yr 2/20/2008 to 7!1/2008 $433.37 415. School Taxes 1,201.61/yr 2/20/2008 to 7/1/2008 $433.37
118. Assessments 418. Assessments
119 419.
121. Sewer/Refuse 138.65lgtr for 2120!2008 to 411!2008 $62.47 421. Sewer/Refuse 138.65/gtr for 2/20/2008 to 4/112008 $62.47
120. Gross Amount Due From Borrower I $156,355.091420. Gross Amount Due To Setter I $153,495.84
e_:.. o., r,. ... a..ti~lr ru a...r.,...o~ 5D0. Reductions In Amount Due To Seller
201. Deposit or Earnest Money $10,000.00 501. Excess Deposits
202. Principal 502. Settlement Charges to Seller $11,842.52
203. Existing Loan(s) Taken Subject to 503. Existing Loan(s) Taken Subject to
Adjustments For Items Unpaid By Seller Adjustments For Items Unpaid By Seller
210. 510.
211. 511.
212. 512.
213. Cityffown Taxes 513. City/Town Taxes
214. County Taxes 332.67/yr 1/1/2008 to 2/20/2008 $45.45 514. County Taxes 332.671yr 1/11200810 2/20/2008 $45.45
218. Assessments 518. Assessments
219. 519.
220. Buyer's Total Credits $10,045.45 520. Seller's Total Charges $11,887.97
300. Cash At Settlement FromlTo Borrower 600. Cash At Settlement To/From Seller
301. Gross Amount Due From Borrower (line 120) $156,355.09 601. Gross Amount Due To Seller (line 420) $153,495.84
302. Less Amounts Paid By/For Borrower (line 220) $10,045.45 602. Less Deductions In Amt. Due To Seller (line 520) $11,887.97
303. Cash [ X ]From ( ] To Borrower 1 $146,309.641603. Cash [ X j To ( ]From Seller 1 $141,607.87
a
40D8C0117 - SK
I Rofflamanf Sfafomant
Page 2
700. Total Sale Commission 153000.00 Q 6 % = 9180.00
Division of Commission (line 700) As Follows: paid From Borrower's Paid From Setter's
701. $9180.00 to ERA-NRT, Inc. Funds At Settlement Funds At Settlement
702. Commission Selling
703. Commission paid at settlement $9,180.00
708. Broker Administration Fee to ERA-NRT, inc. $165.00
709. Broker Administration Fee to ERA-NRT, Inc. $165.00
803. Appraisal Fee
804. Credit Report
Rn5 l endwr Insnection Fee
900. Items Requiretl 6y lender To 13e Paid In Advance
901 . Interest
902 . Mortgage Insurance Premium
903 . Hazard Ins. Premium
1000. Reserves Deposited With Lender
1001. Hazard Ins. Reserve
1002. Mortgage Ins. Reserve
1003. City Property Taxes
f nee r~~ ~.,r., p~..nort,~ ra„a~
1100. Title Charges
11Dt. SettlemenUClosing Fee
1102. Abstract or Title Search
1103, Title examination
1104. Title Insurance Binder
1105. Document preparation Prepare Deed to Daley, Zucker & Gingrich $125.00
1106. Notary fee to Shirley Keys, Notary Public $2.00 $5.00
1107. Attorney Fee Legal Fees to Daley, Zucker & Gingrich $200.00
1108. Title fns. Total to Secured Land Transfers -Mechanicsburg $1,123.75
1109. Lender's Coverage $ ($)
1110: Owner's Coverage $153000.00 ($1123.75)
1138. Processing/Tax Cert. to Secured Land Transfers -Mechanicsburg $10.00
1200. Government Recording And Transfer Charges
1201. Recording Fees for Deed 38.50; Recording Fees for Mortgage $38.50
1202. CitylCounty Tax/Stamps 1530.00 $1,530.00
1203. State Deed Tax 1530.00 $1,530.00
1300. Additional Settlement Charges
1302. Pest inspection (POC-Buyer)
1303. Home Warranty to American Home Shietd $475.00
1305. Home Inspection (POC-Buyer)
1306. SewerlRefuse 1/2/3 to Hampden Township Sewer Authority $152.52
1400. Total Settlement Charges $2,859.25 $11,842.52
i nave cerewuy ~eweweu uie nuu- i ae[uemem aiaiemem gnu w u[e ues[ o[ my xnuwieuge ono oeuer i[ is «ue and accurate s[a[emen[ o[ an receip[s ono aisoursemen[s
made on my account or by me in this transaction. I further certify that I have received a copy of the HUD-1 Settlement Statement.
BUYERS- ~ SELLERS
+ Est a of Nancy S. Roth
Ala J.Burleso
By: Lynda W. Lee ,Executrix
The HUD-1 Settlement Statement which I have prepared is a true and accurate account of this transaction. I have caused or will cause the f~ disbursed in
accordan t this statement.
Set ent nt Date
02!2012008
SE URED LAND TRAN RS - MEC NICSBURG
Rnn_ Items Payable in Connection With Loan
'V
January 02, 2008
Statement Date:
Account Number:
Director Name:
January 02, 2008
741100200073
Kevin J Shillabeer
7411 -Neill Funeral Home, Inc.
3401 Market Street
Camp Hill, PA 170114428
(717)737-8726
Lynda Lee
414 Evergreen Ave.
Bradley Beach, NJ 07720
The following is a detailed bill for the professional services andlor merchandise arranged for:
Nancy S. Roth
Date of Service: December 28, 2007
Funeral Dir & Staff Srvc
Basic Professional Service Fee $1,710.00
Page 1 of 1
Total Funeral Dir & Staff Srvc $1,710.00
Transportation
Funeral Vehicle/Hearse $395.00
Lead Vehicle $395.00
Service Vehicle $395.00
Transferring Remains to Funeral Home $495.00
Total Transportation $1,680.00
Cash Advance
Certified Copies $120.00
Clergy /Religious Facility $125.00
Flowers $318.00
Newspaper Notice $170.15
Total Cash Advance $733.15
Total Service, Merchandise and Cash Advance Charges $4,123.15
Cash Received $0.00 \
i
Unpaid Balance Due
$4,123.15 ~
r~ !/
~~~ `~'
~ j ~V
t
209 KELKER STREET • STEELTON PA 17113 • 717-986-1913, • FAX 717-986-i 914
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11
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~~ ~~.~ / ~
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Name & Address
LEE,LYNDA
414 EVERGREEN AVE.
BRADLEY BEACH, NJ 07720
US
C1~
~'
-
~ One North Second Street • Harrisburg, PA 17101
Hilton Phone (717) 233-6000 • Fax (717) 233-6271
Reservations
HBrriSbutg~ www.hilton.com or 1 800 HILTONS
Room 1509/K1T
Arrival Date 02/01/088:16PM
Departure Date 02/04/08
AdulUChild 1/0
Room Rate $179.00
RATE PLAN L-AA
HH#
AL:
BONUS AL: CAR:
Confirmation: 3297866754
02/04/08 PAGE 1
DATE REFERENCE DESCRIPTION AMOUNT
02/01/08 2311366 *MOVIE $12.99
02/01/08 2311366 SALES TAX $0.78
02/01/08 2311378 *ROOM SERVICE $89.40
02!01/08 2311725 *VALET PARKING $20.00
02/01/08 2311726 GUEST ROOM $179.00
02/01/08 231.1726 HOTEL OCCUPANCY ROOM TAX $10.74
02/01/08 2311726 LOCAL TAX $5.37
02/02!08 2312628 *THE GOLDEN SHEAF $330.53
02/02/08 2312636 *MOVIE __ $13.99
02/02/08 2312636 SALES TAX ~ $0.84
02/02/08 2312972 *VALET PARKING ~, $20.00
02/02/08 2312973 Gt)EtsT~RF~OM $179.00
02/02/08 2312973 HOTEL b(',},CUF~ANCY ROOM TAX _
:, $10.74
02/02/08
2312973 _
~
LOCAL TAX
$5.37
02/03/08 2313594 *RASPBERRIES $150.00
02/03!08 2313653 *ROOM SERVICE $18.60
02/03/08 2313771 *VALET PARKING $20.00
02/03/08 2313772 GUEST ROOM $179.00
02/03/08 2313772 HOTEL OCCUPANCY ROOM TAX $10.74
02/03/08 2313772 LOCAL TAX $5.37
WILL BE SETTLED TO VS *2634 $1,262.46
EFFECTIVE BALANCE OF $0.00
DATE OF CHARGE FOLIO NO.lCHECK NO.
Z1~J-Out Check-Out® 439814 A
Good Morning'. We hope you enjoyed your stay. With Zip-Out C7teck-Out® AUTHORIZATION INITIAL
there is no need to stop at the Front Desk to check out.
Please review this statement. It is a record of your charges as of late last PURCHASES @. SERVICES
evening.
For any charges after your account was prepared, you may: TAxs
+ pay at the time of purchase. s
the Front Desk for an
our account
then sto
b
+ char
urchases to
e
y
y
,
p
g
p
updated statement. Ttrs ~ nalsc.
+ or request an updated statement be mailed to you within two business days.
Simply call the Front Desk from your room and tell us when you are ready to
depart. Your account will be automatically checked out and you may use this TOTAL. AhtovNT
0.00
statement as your receipt. Peel free to leave your key(s) m the room.
Please call the Front Desk if you wish to extend your stay or if you have any
questions about your account
~['
~T
__
Secured Land Transfers, inc. PNC Bank, N.A.
485 St. John's Church Road CENTRAL, PA
Shiremanstown, PA 17011 152604
(717) 901-8342
FILE # DATE 60-1273/313
400800117-SK 2120/2008
AMOUNT
PAY One Hundred Forty-One Thousand Six Hundred Seven and 87 /100 Dollars
$141,607.87
TO THE Estate of Nancy S. Roth
ORDER OF
PA
PROP ID 10-20-1848-138
MEMO Ref #
AUTHORI D SIGNAT RE Me
11'00 1 5 2 60 L~11' 1I:0 3 1 3 1 2 7 38~: 500 4 3 1 78 1 711'
ALAN J BURLESON
497 WOODCREST DR.
MECHANICSBURG, PA 17050-6854
8 313956109 /'~ 10 5 3
DATE ^'`~®~ S
w
q PAY TO THE ~~~~T~ O1- Iy!`~V~ ~i ~`.'T~ ~ ~ ~~~~ ~:!
ORDER OAF) I~ ~ryp~ C ~y A ~~ ~/ C~ ,,,,+ ,
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c
3
®MBTBank
~~ MvMecWlweeMTretlms Truer„
~ Hampden DlACa
MEMO
-~:0 3 130 29 5 5~:
984 1 23989111' 1053
~.. DEPOSIT TICKET
NANCY S ROTH ESTATE
-- LYNDA Vl/ LEE EXECUTR{X
414 EVERGREEN AVENUE
BRADLEY BEACH, NJ 07720
~
DATE - ~J~~~~
g DEPOSIT S MAY N T BE AVAILABLE FOR IA4MEDIATE WITHDRAWAL
- EIVCG (IF REQUIREGI :Y
EC
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S
SIGN HER
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7
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Wachovia Bank, N.A.
wachovia.com
Lv 1-J CASH ~
3-50/310
~~~1~ l~l~oyl~ ,7
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5118 TOTAL »
x LESS GASH ~
RECEIVED
U
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~:54 7 50 5 2 59r': 200001 295738511'
COMMONWEALTH OF PENNSYLVANIA
PUBLIC SCHOOL EMPLOYEES' RETIREMENT SYSTEM
Mailing Address
PO Box 125
Harrisburg, PA 17108-0125
January 9, 2008
LYNDA W LEE
414 EVERGREEN AVE
BRADLEY BEACH NJ 07720
Toll-Free - 1-888-773-7748
(1-888-PSERS4U)
Local-717-787-8540
Web Address: www.psers.state.pa.us
RE: Nancy S. Roth
S.S.# XXX-XX-0483
Dear Ms. Lee:
Thank you for your correspondence:
Building Location
5 North 5th Street
Harrisburg, PA
A prorated payment of $642.83 ($678.80 minus $35.97 federal withholding tax) for the
period of December 1, through December 19, 2007, was due Nancy S. Roth, and is now
payable to Sharon L. Jensen and R. Garrison Lee $339.40 each, as the designated
beneficiaries.
Please provide the current addresses for the two beneficiaries.
Because payments are prepared well in advance, the payment dated December 31,
2007 for $1,015.53 has been issued and must be reimbursed this office. Total
reimbursement due PSERS is $1,015.53. Please make your check or money order
payable to PSERS and send to the mailing address shown.
The December 31, 2007 payment will have Federal Withholding Tax (FWT) of $56.82
deducted and paid to the Internal Revenue Service (IRS). Since this information will be
reported to the IRS for the tax year 2007,. PSERS must be reimbursed for the FWT of
$50.82. Make your check or money order payable to PSERS and send to the mailing
address shown.
Enclosed is PSERS Health Options Program information sheet which applies to any
surviving spouse or dependent(s) of the deceased member.
A 1099-R will be sent which will report the deceased member's income. This form will
be necessary for the preparation of the final income#ax return. 1099-R's are generated
and issued at the'end of the calendar year.
There will be no further benefitsJpayable from this account.
Please include the decedent's name and social security number-with all
correspondence.
If you have any questions, please contact the Member Service Center by calling toll-free
1-888-773-7748 (focal calls 787-8540). If you prefer, you may reach PSERS by FAX at
LYNDA W LEE
RE: Nancy S. Roth
S.S.# ~:XX-XX-0483
Page 2
January 9, 2008
717-772-3764. For your convenience, the Member Service Center is staffed each
business day from 7:30 a.m. to 5:00 p.m.
Deceased Processing Center
klh
Enclosure(s)
The Union Central
Life Insurance Company
1876 Waycross Road
Cincinnati Ohio 4i2a0
(513)SIS-2200
www. unioncenh~aLcom
~~~~~~
[nsurunce and Inveshneuts
A UNIFt Company
LYNDA W LEE
414 EVERGREEN AVE
BRADLEY BEACH NJ 07720
January 23, 2008
Re: Nancy S Roth
A61121224C A640007785
Dear Ms. Lee:
We wish to inform you that the claim you submitted for benefits has been approved.
Your third of the benefit proceeds of $37,932.85, less Federal Income Tax Withholding of $3,126,62
along with interest earned in the amount of $72.75 have been deposited into a Union Central DIRECT
ACCESS ACCOUNT. The total amount deposited into the Direct Access Account was $34,878.98.
Interest was calculated at a rate of 2% from the date of death to the date of payment. The Direct Access
Account is your personal checking account designed to provide immediate access to your funds, while the
balance earns a competitive bank money market interest rate from the time your claim was approved.
Within the next few days, you will receive a packet providing a supply of personalized checks, a
certificate of confirmation and a brochure outlining the Direct Access Account along with instructions on
how to use it.
Once you receive your benefit proceeds in the form of your Direct Access Account, you have the option
to write a check at any time, just as you would with any personal checking account, for the entire benefit
amount. (Do not send this checkbook back to Union Central). However, if you need time to decide how
to invest these funds, you can simply keep the money in the Direct Access Account and use it as a
checking"account while you receive a competitive interest rate.
These deferred annuity policies were designed to provide annuity income benefits upon election;
however, the annuitant died prior to this election and, as a result, the value of the contracts are now
payable in a lump sum.
Under the current Internal Revenue code, that portion of the value of Annuity A61 121224C which
exceeds the cost of the contract -the net prelrliums paid - is taxable to each recipient as ordinary income.
We calculated this excess or profit as $34.26. Under the current Internal Revenue code, the proceeds of
Annuity A64O007785 will be taxable to the recipient as ordinary income. Each recipient will receive a
tax notice, Form 1099R, near the end of next January.
The Forms 2791 that you requested will be sent under separate cover.
After receiving your packet, if you have any questions, please don't hesitate to contact this office.
Respectfil I ly,
Diana Kortekamp, ACS, FLHC
Senior Claim Examiner
Individual Life Claims
cc: Agency: # 1691 Michael J Garofalo Jr
Securities oflered fhrou~h Ameritas investment C'orp.,
member NASD/SIPC.. an ttf~iliate of "rhe Union Central
LSt'e Insurance Company, 187fi W:,vrr~~-~ m•,,,,
The ITnton Ccntril
[.ife Insm•stnce Company
1876 Waycross Roud
Cincinnati nhio 45240
(513)5J5-2200
www. unioncentral.com
V Ivf1~11t1a1
insunmce anJ Invesbneuts
A UNIFl Company
SHARON L JENSEN
17040 E CARR AVE
PARKER CO 80134
January 23, 2008
Re: Nancy S Roth
A61121224C A640007785
Dear Ms. Jensen:
We wish to inform you that the claim you submitted for benefits has been approved.
Your third of the benefit proceeds of $37,932.85, less Federal Income Tax Withholding of $3,126.62
along with interest earned in the amount of $72.75 have been deposited into a Union Central DIRECT
ACCESS ACCOUNT. The total amount deposited into the Direct Access Account was $34,878.98.
Interest was calculated at a rate of 2% from the date of death to the date of payment. The Direct Access
Account is your personal checking account designed to provide immediate access to your funds, while the
balance earns a competitive bank money market interest rate from the time your claim was approved.
Within the next few days, you will receive a packet providing a supply of personalized checks, a
certificate of confirmation and a brochure outlining the Direct Access Account along with instructions on
how to use it.
Once you receive your benefit proceeds in the form of your Direct Access Account, you have tl~e option
to write a check at any time, just as you would with any personal checking account, for the entire benefit
amount. (Do not send this checkbook back to Union Central). However, if you need time to decide ho~v
to invest these funds, you can simply keep the money in the Direct Access Account and use it as a
checking account while you receive a competitive interest rate.
These deferred annuity policies were designed to provide annuity income benefts upon election;
however, the annuitant died prior to this election and, as a result, the value of the contracts are now
payable in a lump sum.
Under the current Internal Revenue code, that portion of the value of Annuity A61121224C which
exceeds the cost of the contract -the net premiums paid - is taxable to each recipient as ordinary income.
We calculated this excess or profit as $34.28. Under the current Internal Revenue code, the proceeds of
Annuity A640007785 will be taxable to the recipient as ordinary income. Each recipient will receive a
tax notice, Form l 099R, near the end of next January.
TIZe Forms 2791 that you requested will be sent under separate cover.
After receiving your packet, ifyou have any questions, please don't hesitate to contact this office.
Respectfully,
Diana Kortekamp, ACS, FLHC
Senior Claim Examiner
Individual Life Claims
cc: Agency: # 1691 Michael J Garofalo Jr
Securities offered through Amcritas Imesunem CorP.,
member NAS1:)/S1PC.. an alliliate of T'he Union Central
t_i1c Insurance Company. 1876 1Wuycro,.c Road.
The Union C'entril
bite Insurance Compnnv
IR76l~~aycross Rond
Cincinnlti Ohio 4524Q
(513) 5J5-22(lQ
www. unioncentral.com
~n~rr~Ce~nrral
Insurance and hn•esUnents
A UWIFI Company
R GARRISON LEE
2656 MABLE LANE
LEXINGTON KY 40511
January 23, 2008
Re: Nancy S Roth
A61121224C A640007785
Dear Mr. Lee:
We wish to inform you that the claim you submitted for benefits has been approved.
Your third of the benefit proceeds of $37,932.85, less Federal Income Tax Witl}holding of $3,126.62
along with interest earned in the amount of $72.75 have been deposited into a Union Central DIRECT
ACCESS ACCOUNT. The total amount deposited into the Direct Access Account was $34,878.98.
Interest was calculated at a rate of 2% from the date of death to the date of payment. The Direct Access
Account is your personal checking account designed to provide immediate access to your funds, while the
balance earns a competitive bank money market interest rate froth the tithe your claim was approved.
Within the next few days, you will receive a packet providing a supply of personalized checks, a
certificate of confir(nation and a brochure outlining the Direct Access Account along with instructions on
how to use it.
Once you receive your benefit proceeds in the form of your Direct Access Account, you have the option
to write a check at any time, just as you would with any personal checking account, for the entire benefit
amount. (Do not send this checkbook back to Union Central). However, if you need tithe to decide how
to invest these funds, you can simply keep the money in the Direct Access Account and use it as a
checking account while you receive a competitive interest rate.
These deferred annuity policies were designed to provide annuity income benefits upon election;
however, the annuitant died prior to this election and, as a result, the value of the contracts are now
payable in a lump sum.
Under the current Internal Revenue code, that portion of the value of Annuity A61121224C which
exceeds the cost of the contract -the net premiums paid - is Taxable to each recipient as ordinary incorne.
We calculated this excess or profit as $34.26. Under the current Internal Revenue code, the proceeds of
Annuity A640007785 will be taxable to the recipient as ordinary incorne. Each recipient will receive a
tax notice, Forin 1099R, near the end of next January.
The Forms 2791 that you requested will be sent under separate cover.
After receiving your packet, if you leave any questions, please don't hesitate to contact this office.
Respectfully,
_~
Diana Kortekamp, ACS, FLHC
Senior Claim Examiner
Individual Life Claims
cc: Agency: #1691 Michael J Garofalo Jr
Securities offered tlu•oueh Americas Investment Colp.,
mcmherNASDlS1PC., an afriliate trf "rlu Clnion Ccnn'ai
L710 iI1Sll rilnCN COinnanv IR7F ~u.,,.,. _...... ,~.. ,
LINCOLN BENEFIT LIFE
C O M P A N Y
A Member ofAllstate Financial Group
' Lincoln Benefit Life Company
PO Box 80469
Lincoln NE 68501-0469
R GARRISON LEE
2656 MABLE LN
LEXINGTON KY 40511-8622
Telephone: 1-800-LBL-WAYS
Fax: 1-877-525-2689
www.accessallstate.com
January 4, 2008
Your Representative
MICHAEL J GAROFALO JR
2951 WHITEFORD # 301
YORK PA 17402-7618
(717)755-2119
RE: Original Allstate® Treasury-Linked Annuity #LBF1224494
Your New Allstate® Treasury-Linked Annuity #AC7042334A
Dear R Garrison Lee:
Your claim has been processed. As you requested, we have deposited your death benefit funds directly into your bank
account.
The first table represents the entire benefit value under the original contract as of the date of settlement, as well as any
transactions that may have occurred on that date.
Transaction
Date
01 /03/08
CONTRACT VALUE AS OF 01/03/08 ON
Transaction
Type
Investment
Alternative
Total Claim
5 YEAR T LINK FUND
E ORIGINAL ANNUITY #LBF1224494
Units for this Transaction
Transaction Unit Value
N/A N/A
Transaction
Amount
$-100,578.E
The second table confirms the investment alternatives to which your portion of the benefit value has been allocated.
Please review the information below. If you have any questions concerning these allocations, please contact us at
1-800-LBL-WAYS.
CONTRACT VALUE AS OF 01/03/08 ON YOUR ANNUITY # AC1042334A
Transaction Transaction Investment
Date Type Alternative
01/03/08 Transfer To 5 YEAR T LINK FUND
Your Total Annuity Value as of 01/03/08 $0.00
Units for this Transaction
Transaction Unit Value
N/A N/A
Transaction
Amount
$33, 52637
D0962YJS.N01
1
~;~8 8Y80002D0982YJ500%2YJSOOpOp
~3A~ID S. BABOIAN, CPA, PC
4350 CARLISLE PIKE
CAMP HILL, PA 17011
(717) 763-8044
Estate of NANCY S. ROTH
C/O LYNDA W. LEE
C/O 414 EVERGREEN AVENUE
BRADLEY BEACH, NJ 07720
Home: 732-322-1215 Work: 732-974-7409
March 21, 2008
FEDERAL FORMS
Form 1040 2007 U.S. Individual Income Tax Return $ 154.00
Form 1040-V Payment Voucher
Schedule B Interest and Dividend Income
Schedule D Capital Gains and Losses 15.00
Form 8879 IRS a-file Signature Authorization
1099-R Charges 30.00
PENNSYLVANIA FORMS
Form PA-40
Form PA-V
Schedule W-2SlMC
Schedule A/B
Schedule D
Form REV-1630
Form PA-8879
2007 Pennsylvania Income Tax Return
Pennsylvania Payment Voucher
Wage Statement Summary
Taxable Interest and Dividends
Sale, Exchange or Disposition of Property
Underpayment of Estimated Tax
Pennsylvania a-file Signature Authorization
FEE SUMMARY
Preparation Fee
Dividend income $5 each
Social security calculation $10
Amount Due
$ 199.00
30.00
10.00
00
1`~`I
Asbury Park Press
Classified Ad Receipt
{For Info Only - NOT A BILL)
Ad Number 0100619470
Payment Method Credit Card - Visa:1031
Amount $ 97.52
Run Times 10
Run Dates 1112/2008, 1/13/2008, 1/14/2008, 1/15/2008,
1/16/2008, 1/17!2008, 1/18/2008, 1/19/2008,
1/20/2008, 1/21/2008
The Asbury Park Press Classified
3601 Highway 66
Neptune, NJ 07754
LEE,LYNDA
414 Evergeen Ave
Bradley Beach NJ 07720
Text of Ad:
FOADSXPLORIa"Et XLT
'00. Exc cond, l owner,
16,570 orig mi, White
wMsray Sthr int, fu0y
loaded, 512,000, cat)
732-322-125/732-4747409
AUTO REPAIR ORDER_-
A i M SERVICE CEM7Ei!
t~04 Market St. Camp HiN, PA NAME ~ L ~,, --
~'" `'~-~
717.761-7898 ADDRESS
CITY, STATE
~~~
• • • •
QATE ~, ~c.~y CUSTOMER'S ORDER NO.
` •- •
WHEN PROMISED ~ ,~
y
,~ YEA • MAKE • MOD SERIAL
NO
r~
~ U ~-~ ~ 't~
~i .
MOTOR
NO.
LICE NO. OD METER WRITTEN BY
LOBE ^ CHANGE ^ TRANS. ^ 07 ASH ^ MASH ~ POLISH
v
~`yJ
• LABOR ONLY
GALS. GAS PARTS
TOTAL PARTS OTS. OIL - CCESSORIES
® ~ • • LBS. GREASE IL RASE
TOTAL GAS MIS . M RCA LSE
OIL &
GREASE
S,yBL T RE AIR
RETAIN PARTS
DESTROY PARTS T CESSORIES TAX
ESTIMATE AMOUNT • PARTS & LABOR ~ji AurHORIZED sv ~"' TO'T~ L
1 HEREBY AUTHORIZE THE ABOVE REPAIR WOflK TO BE DONE ALONG WITH THE
NECESSARY MATERIAL, AND HEREBY GRANT YOU AND/OR YOUR EMPLOYEES PER-
MISSION TO OPERATE THE CAR, TRUCK OR VEHICLE HEREIN DESCRIBED ON
STREETS, HIGFIWAYS OR ELSEWHERE FOR THE PURPOSE OF TESTING AND/OR
INSPECTKNl. AN EXPRESS MECHANIC'S LIEN IS HEREBY ACKNOWLEDGED ON
ABOVE CAR, TRUCK OP, VEHICLE TO SECURE THE AMOUNT OF REPAIRS THERETO.
~tadems GT3870
YOU ARE ENTITLED TO A PRICE ESTIMATE FOR THE REPAIRS YOU HAVE AUTHORIZED. E RELAN~ 7. I request an estivwt ~ iiin h you begin repairs.
PRICE MAY RE LESS THAN THE ESTIMATE, BUT WILL NOT EXCEED 7NE ESTIMATE WITH YCUR
PERMISSION. YOUR SIGNATURE WILL INDICATE YOUR ESTIMATE SELECTION. 2 please proceed wilh repairs. but can a+e helore contimiiry A Me pace win exceed 8
TEARDOWN ESTIMATE ~ I UNDERSTAND THAT MY CAR WILL BE REASSEMBLED WITHIN--,--DAYS ~ I ~ not rrem an estimate.
OF THE DATE SHOWN IF I CHOOSE NOT i0 AUTHORIZE THE SERVICES RECOMMENDED.
AUTO REPAIR ORDER
PROOF OF PUBLICATION
State of Pennsylvania, County of Cumberland
Troy Whitesel, Classified Advertising Manager, of The Sentinel, of the
County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL,
a newspaper of general circulation in the Borough of Caxlisle, County and State
aforesaid, was established December 13th, 1881, since which date THE SENTINEL has
been regularly issued in said County, and that the printed notice or publication
attached hereto is exactly the same as was printed and published in the regular editions
and issues of THE SENTINEL on the following day(s):
January 18, 25, 2008, February 1, 2008
COPY OF NOTICE OF PUBLICATION
ESTATE NOTICE
NOTICE IS HEREBY GIVEN that letters testamentary...
have been granted. in the following Estate: Ali persons
indebted to the said Estate are required to make `'
payment, and those having claims or demands to
present the same without delay to the administrators,
executors, or their attorneys named below.:
ESTATE OF NANCY S. ROTH, late of Camp Hill,
HampdenTowiiship; Cumberland County PA, Died ~-
Decembec19,.2007, Execufor: Lynda,tN .Les ,,,.,..-,., °'
Attorney: Patricia Carey Zucker, Es uiret Dafey_Zucker
Meilton Miner & Gingrich, LL"C; i0351G1umma (a~oai~;''
Suite 101, Wormleysburg, Pennsylvania 17043.
Affiant further deposes that heJshe is not
interested in the subject matter of the
aforesaid notice or advertisement, and that
all allegations in the foregoing statement
as to time, place and character of
publication are true.
_....-
Sworn to and subscribed before me this
1st. da,~of February Zoos.
~~
Notary Pub
My commission expires: ~ ~1 [ v `
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Christina L. Wolfe, Notary Public
Carlisle Boro, Cumt>Extartd County
My Commission Expires Sept 1,2008
Member. Pennsylvania Association Ot Notaries
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16, 1929), P. L.1784
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
ss.
Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and
State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law
Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid,
was established January 2, 1952, and designated by the local courts as the official legal
periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly
issued weekly in the said County, and that the printed notice or publication attached hereto is
exactly the same as was printed in the regular editions and issues of the said Cumberland Law
Journal on the following dates,
viz:
January 25 February 1 and February 8, 2008
Affiant further deposes that he is authorized to verify this statement by the Cumberland
Law Journal, a legal periodical of general circulation, and that he is not interested in the subject
matter of the aforesaid notice or advertisement, and that all allegations in the foregoing
statements as to time, place and character of publication are true.
~s arie Coyne ditor
SWORN TO AND SUBSCRIBED before me this
8 day of February 2008
Notary
Roth, Nancq 3., deed.
Late of Camp Hill, Hampden
Township.
Executrix: Lynda W. Lee.
Attorneys: Patricia Carey Zucker,
Esquire, Daley Zucker Meilton
Miner & Gingrich, LLC, 1035
Mumma Road, Suite 101, Worm-
leysburg, PA 17043.
~__.~.~~~~.~NOtARf.4l SEPd
GE80RAH A COLLINS
Notary Public
CARLISLE BORO, CUMBERLAND COUNTY
My Commission Expires Apr 28, 2010
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 1 7 1 2 8-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 009421
LEE LYNDA W
215 MORRIS AVE
SPRING LAKE, NJ 07762
Fold
ESTATE INFORMATION: ssN: Asa-22-o4sa
FILE NUMBER: 2107-1 159
DECEDENT NAME: BOTH NANCY S
DATE OF PAYMENT: 03/18/2008
POSTMARK DATE: 03/17/2008
couNTY: CUMBERLAND
DATE OF DEATH: 1 2/ 1 9/2007
REMARKS: RECEIPT TO ATTY
CHECK# 1021
SEAL
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
10 i ~ SZO,OOO.GO
TOTAL AMOUNT PAID:
INITIALS: CJ
REV-1162 EX(11-96)
$20,000.00
RECEIVED BY: GLENDA EARNER STRASBAUGH
REGISTER OF WILLS
TAXPAYER