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09-13-08
~++ 1556041147 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Vear File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po eox.2soso~ 2 1 0 8 0 0 0 1 3 Harrisburg, PA 77128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death 112 09 7887 12 25 2007 Decedent's Last Name Suffix VERONIKIS (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Date of Birth 10 15 1915 Decedent's First Name MI JERRY D Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return ;_ ~ 2. Supplemental Return ! _~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~, qa. Future Interest Compromise ~~ ~ (date of deatn aver tz-tz-az) I_ J 5. Federal Estate fax Retum Required g Decedent Died Testate i ~ ~ Decedent Maintained a living Trust 1 8. Total Number of Safe De osit Boxes (Attach Copy of Wilp - - (Attach Copy of Trust) p ~ 9. Litigation Proceeds Received ~ 1 D Spousal Poverty Credit (date of death ' -'I J - I between 12-31-91 and 1-1-95) ~ 1 t Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number JAN M WILEY 717 432 9666 Firm Name (If Applicable) THE WILEY GROUP, PC First line of address 130 W. CHURCH STREET Second line of address City or Post Office State ZIP Code DILLSBURG PA 17019 Correspondent's a-mail address: ~ - , REGIST~I~ODWILLS t ONLY -T ) ,-i - --~ <~ - -.1 r.~ u~ r - - _ -v - =T- -- rte, ~'~I .. DATE 1=ICED ~~ Under penalties of perjury, I declare that 1 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. SI TURE F RSON RESPONSIBLE FOR FILING RETURN DATE ~~~_~ p ~; ~a~~~sCatherine P. Kastanas q ~( ADDRESS _T_ 3 Briargate Road, Me^h~^~^~h.rr,. on ,~ncn S NATURE OF PREPARER OTHER REPRESENTATIVE Jan M Wiley DATE W. Church Street, Dillsburg, PA 17019 Side 1 150561141147 1556041147 PA Inheritance Tax Return Signature of Additional Fiduciaries (ESTATE OF I FILE NUMBER I Veronikis, Jerry D. 21-08-00013 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 prep~rer other than the personal representative is based on all information of which preparer has any knowledge. ,,, ~,...~ /' I ~ Signature #2 Name Address1 Address2 City, State, Zip Dennis S. Veronikis Date 5220 Windsor Blvd. Mechanicsburg, PA 17055 ~~ REV-1500 EX Decedent's Social Security Number ~ecedenrsName_ Jerry D. Veronikis 1 1 2 0 9 7 8 8 7 RECAPITULATION 1. Real Estate (Schedule A) ..................................................... 1 9 2 1 2 5 8 4 .................................. 1. 2. Stocks and Bonds (Schedule B) .................. 7 9 0 2 5 7 6 ............................ 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3. 4. Mortgages & Notes Receivable (Schedule D) ........................................................ .. 4. 5 Cash, Bank De osits & Miscellaneous Personal Pro e P p rty (Schedule E) ............... . 5. 3 8 6 3 0 1 5 4 6. Jointly Owned Property (Schedule F) C ] Separate Billing Requested ............ . 6. ~L 6 6 8 7 1 7 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ............ . 7. 1 7. 0 4 0 3 4 2 8. Total Gross Assets (total Lines 1-7) ...................................................................... . g. 7 8 4 5 4 3 7 3 9. Funeral Expenses & Administrative Costs (Schedule H) ........................................ . 9. E> 2 --- - -- 7 5 6 - 3 2 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................... . 10. 3 2 4 7 4 8 11. Total Deductions (total Lines 9 8 10) ..................................................................... . 11. E~ 6 0 0 3 8 0 12. Net Value of Estate (Line 8 minus Line 11) ........................................................... .. 12. 7 1 8 5 3 9 9 3 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............................................... . 13. `1, 0 0 0 0 0 0 14. Net Value Subject to Tax (Line 12 minus Line 13) ................................................ . 14. 6 q 8 5 3 9 9 3 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(12) X .00 0 0 0 15 0 0 0 16. Amount of Line 14 taxable at lineal rate X .045 0 0 0 16 0 0 0 17 Amount of Line 14 taxable at sibling rate X .12 0 0 0 17 0 0 0 18. Amount of Line 14 taxable at collateral rate X .15 6 9 8 5 3 9 9 3 18 1 Ci 4 7 8 0 9 9 19 Tax Due ..................................._..__...................__.......... ........................................ 19. . 1 0 4 7 8 0 9 9 15056042148 20. FILL tN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ L 15056042148 Side 2 15056042148 REV-1500 EX Page 3 File Number 21-08-0001 3 Decedent's Complete Address: DECEDENT'S NAME Jerry D. Veronikis STREET ADDRESS 49 Honeysuckle Road CITY ----_- -------- - --- - - - -- ----- STATE ZIP Mechanicsburg PA 17050 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit g. Prior Payments C. Discount 3. Interest/Penalty if applicable p. Interest E. Penalty Total Credits {A + B + C) Total Interest/Penalty (D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT (1) 104,780.99 (~) 90,000.00 (3') (4) (5) (5A) (5E3) 14,780.99 14,780.99 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 :.................................. ~~ -~ i c. retain a reversionary interest; or .............................................................__....._...._.............................__ I_ ~ ~XJ d. receive the promise for life of either payments, benefits or care? .................... ( 1 X 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receivin ade uate consideration? ......................._ 1 i x 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?.... .. x' ~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ....................._._ _...................................... ..._...................................... _ _ , x_; 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 exemat 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. §9 t 16 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. 85,500.00 4,500.00 ,' ~r~sk ~tll ttnh (~est~crrcrnk of JERRY D. VE,RONIKIS BE IT REMEMBERED, that I, JERRY D. VERON[KIS, of 49 Honeysuckle Drive, Mechanicsburg, Cumberland County, Pennsylvania, being of sound mind, memory and understanding, do make, publish and declare this as and for my I_,ast Will and Testament, hereby revoking and making null and void any and all Wills and Testarnents and writings in the nature thereof made by me at any time heretofore. ITEM 1: I direct that all my just debts and funeral expenses be ;paid as soon after my demise as may be convenient. ITEM 2: 1 give the sum of Fii'"I'Y THOUSAND DOLLARS (SS0,000.00) to be placed intrust for the benefit of my brother, STEVE VERONIKIS, to be managed by the two Trustees hereinafter named for the purpose of providing proper healthcare for STEVEVERONIK[S. The care forSTEVF,VERONIKISshallbeatthe;;olediscretion of the two Tivstees. [name as the Trustees of the above-named Trust my niece and nephew, CATIIERING P. KASTANAS :1ND DENN[S S. VERONIKIS. If the FIFTS' THOUSAND DOLLARS (550,000.00) is not exhausted at the time of STEVE VERON[KIS' death, the amount ~fcash remaining in the Trust shall be placed in the residuary clause of my Last Will. I [T'Etil3_ 1 give all of my PNC Bank stock to my niece, C.=~"fI{ERINIE P. ~ KAS~TAN_1`i, ins n~ phew, D[?NN[S S. ~~f~:lLONIKIS, :AND FR:y~'CI;S ItARRICK, ii; equal ~h,-gyres, ~~~< <:~a,ita ~~ iTEVI d: 1 ~>i~~e tlic u~u n( "h4VENTY THOUS.~~iD DOLL~~RS ~~ (510,000.0(1) to PI~;NEI,OPI? LASPAL,:alUS_ urovidin~~ she ~;ur~~i~<< ;n~ ~I Wtrnrss ~~'~ ~ ~~ S ~ IL RRY D "V[~;R_ONIKIS ~~ ~~ ITEM 5: I give the sum of TWENTY THOUSAND DOLLARS (520,000.00) to be placed in Trust for THE SAINT GERASIMOS CHURCH on the Island of Cephalonia, Greece. The interest of said Trust shall he paid to THE SAINT GERASIMOS CHURCH once per year, starting with the day of my death, and after the period of twenty (20) years has expired from the date of my death, then the Trustees herein shall tum over the TWENTY THOUSAND DOLLARS ($20,000.00) plus any remaining accumulated interest, to THE SAINT GF,RASIMOS CHURCH, to be used for whatever purposes it deems appropriate. I name as the Tnistees of the above-named Trust my niece and nephew, CATHERINE P. [Ct1STANAS AND DENNIS S. VERONIKIS. ITEM 6: In the event that FRANCES BARRICK shall survive me, i devise and bequeath my homestead real estate situate at 49 Honeysuckle Drive, Mechanicsburg, Pennsylvania together with all household goods and furnishings therein, and all policies of insurance on said real and personal property, to FRANCES BARRICK without liability for waste, Cor and during the term of her natural life, so long as she desires to use such premises as a home and pays all costs of maintenance thereof, including taxes, assessments, insurance and ordinary repairs, said property to be insured in a reasonable among insuring the interest of the remaindermen as well as' herself. Upon the death of FRANCES BARRICK, or at such prior time as she no longer we.s sa.d pr~nus~s as a home for herself, I then g;ve; devise 3nci bequ~~att~ nz~. propery; situate at 49 H~naysuckle Drive, Mechamcsbur~, Pennsylvania unto my niece anJ nephe.w_ CATHF,R[Nh: i'.~[i,4STANAS ANA i)I~;NNIS S. VERONIf~FS, in ecual shares, p~~r c app ta_ ~','(fNI:SS __ _ ~,~ _ - - .a 1 ~~ / ~ JERRY D. V[?(ZONIKFS _ ~_~ ~ ~'~_ ~c l r ~ '-~C ~ ~ <_~, ~ - - ITEM 7: All the rest, residue and remainder ~ `'.ny estate, of whatsoever nature and wheresoever situate, whether it be real, personal or mixed, including property over which I have a power of appointment, I give, devise and bequeath to my niece and nephew, CATHERINE P. KASTANAS AND DENNIS S. VERONIKIS, in equal shares, per capita. [TEM 8: I direct my hereinafter named Co-Executors to pay a!I inheritance, estate, succession and legacy taxes of whatsoever nature and kind, to which my estate or the transfer of any property passing hereunder or otherwise passi ng by reason o f my demise, may be subject and to charge such taxes against my residuary estate, it being my intention that none of the aforesaid taxes, either federal or state, on any property required to be included in my gross estate, under the provisions of any state or federal law new in force or hereafter enacted, sha!! be prorated among the persons interested in my estate to whom such property is or may he transferred or to whom any benefit accr~,ies. ITEM 9: [appoint my niece and nephew, CATf{[TRINE P. KASTANAS AND DGNN[S S. VERONIKIS as Co-hxecutors of this my Last Will and Testament. ITEM i0: I direct that my Co-F.~ecutors or their successor shall not he required to give bond for the faithful perfonnancc of their duties in anv ~~,r,,cjiction. Cih=M 1 L• My Personal Kenresentatives shall have ±h~• following powers in addition to those vested in them by Lava and by other provisions of this, my Last Will and Testament. exercisable without cou~1 apiuova~, and effecti~~~z ~ .u~~ cii~trib~.ation of all properly wf11IESS - =. ~ -, ~ ~ ~ -~= - ~_ - _- =(SETAE) l JERRY D.-VEROVi[i3S To retain any or all of the assets of my estate, real or personal, without restriction to investments authorized for Pennsylvania fiduciaries, as they from time to time may deem proper, ~Nithout regard to any principal of diversification or risk. 2. To invest in all forms of property without restriction to investments authorized for Pennsylvania fiduciaries, as they from time to time may deem proper, without regard to any principal of diversification or risk- 3. 1~o sell at public or private sale, to exchange, or to lease for any period of time, any real or personal property and to give options for sales, exchanges or leases, for such prices and upon such terms or conditions as they from time to time may deem proper. 4. To allocate receipts and expenses to principal or income or partly to each as they from time to time may deem proper- 5. To borrow money trorn persons or institutions, themselves incauded, and to mortgage or pledge any or all real or personal properly as they in their sole discretion shall choose, without regard to the dispositive provisions of this instrument. C. To compromise any claim or controversy asserted by or against my estate or trust estate. 7. To make distribution in cash or in kind or partly in cash and partly in kind, and in such manner as They may determine, and at valuations finally w be fixed by them. IN WITNESS WHERf~~Ol~, T have hereunto set my hand and seal this i day of LUITNESti ~. i~ ~ ~~ ~~ ~ JI RRS' n. V~R(~N[KIS i ~I~l l , COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF YORK We, JERRY I). VERONIKIS, JAN M. WILEY, ESQUIRE and M.ARCY K. RENSHAW, the Testator and the witnesses respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his Last Will and I estament and that he had signed willingly (or willingly directed another to sign for him), and that he executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the ~hestator, signed this Last Will and Testament as witness and that to the best of their knowledge the Testator was at the time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. ~~ .IGRRY U.'VERONIKiS S~.vorn u~ and subscribed i ii be.t;~re me this ,l day of 7 / _ NOT.1iZY PLJI3LIC ' i _~ __ WI-INL:SS _ - __~ ~ - ,J ~~ri ~iJ blot ri i S _a ~ ~~..~ g. pavan Gi c~'r~lte~. ~^iary Pcblic ' Cdisbw ,~ 8oro, York C.ourny ~1y Comm-.Dion E;:plres d:~~y 17, ~p0-~ 1, ~~t ~' ~. ~)~~'T~41S~10~ l.XP1Rl_,~ ~/t2ml):lf. Fonns;,Iv ania nS90Cly?iOn of NDiafles REV-485 Fk « 13-041 ~r COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT_280601 HARRISBURG, PA 17128-O6U1 SAFE DEPOSIT BOX ~I~~EIVTOR Please Print or MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX !S I OC'A7Fn oNn ctGrnnnirn Tn COUNTY CODE ~~ - -- - -- ....~ ..~.....,.~.. ,., FILE NUMBER SOCIAL SECURITY (Required) OR DEATH CERTIFICATE NUMBER { „~,.~~~ .,vuncoo Doty iF SSN is unknown) _- __ 1iz -c~„ -z~~~ _ _ __ DECEDENT'S NAME (LAST, FIRST, MIDDLE) DATE OF DEATH !_ LLL ADDRES S OF DECEDENT (STREET} - (CITY( -t- ISEATEI __ _-_-- (ZIP CODE] NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX ---~ WAME, _ ii r (STREET ADDRESS) (CITY) (STATE) (ZIP CODE) NAME ,ADURESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX PENING a. (NAMEI ~ (RELATIONSHIP) ------------- ---- 1STREET NAME) (CITY) (STATE) (ZIP CODE) ~ b INAMFL --- -- ~ /3/~ f (RELATIONSHIP) ~~~ S v , ~ S S v~'~' J~J ~' (STREf:? NAMEI (CITY) - -_~ - (STATE) ~~z ~ ~ 7 ---- - - ~_ i ,i[ P s o v ~ ~_.~ ~~ . l 7 v s -~ ' ~l P c NA -~- ------ (ZIP CODE) c. ( M e f - {RELATIONSFIIPJ (STREET NAME) (CITY) (STAATE) (ZIP CODE) • NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED -- - (N AM F -- ---- ~~! ~- ~GZ-'YI ~ C- _ (STREET NAME) _--- --_-- t a~ ~ ~~ fCITVI IS rATE) r NAME OF PERSON (ZIP CODEI MAKING ST ENTRY DATE AND TIME OF ST ENTRY /' ~r /t 51,QjtO ~ ~ - ~r~~s ~, ~ --- DATE OF CONTRACT TO RENT BOX NUMBER OF BOX --- -----~---- TITLE UNDER WHICH BOX IS REQUESTED / NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX -- ---- --------- --- a_ i.l i - ------- b. (NAME) --________._ _ \\ '' _.-. _._.____-~v~_~ ~_-__ _._. I:,tREE' ADURESS) __-. __- _.__-_--_.__.-__. -- ISTREIT ADDR~1?51 - - ------ ~' Y' ISTATEI IZP CODEI (CIT V) - (SlalEl - ------ (ZIP CODE) NAME AND TI .LE OF EMPLOYEE TAKING THE INVENTORY -~- -- ~---- ~ ~~ r't, -- - - - _-- WAS A WII E IN THE BOX7 ~ YFS NO If yes, a. Date of wilC ~~v Z- ~ © 6 ---- b. Name and address of personal representative, -rf named in [he will (NAME) !BYRE FT ADURESS) _. _._______-..---... _.. - fCrrv) - -- _ I?TATEI _ ------- QIP CODE) c. ame and address of attorney, rfany - ---- fNAME) (CITYI - - ,ST ATFI _. 21P CDDE;~ rFURn^.I 2C:SOii SAFE DEPOSIT BOX INVENTORY rage °' _-- ----- INSTRUCTIONS __ The Department is authorized under federal law, 42 U.S.C. § 405(c), to use the decedent's Social Security number in administering this state tax law_ The department uses Social Security numbers to establish a decedent's identity and ensure proper credit for tax payments. (1) Cash: 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) Obligations 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 Ronds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, fast date appearing in book, Warne 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_ ITEM NO. - -- ITEM DESCRIPTION l 6' ce t LE ~ ~ - -- ~~~~ -1~ _ _ I l ` oV C1 ~ .~ (~ 4~ .l Q ~ _i-_1 t: E3 1~~-l~C ~~ ~:DC 1C `(:-i ---- ~ ~ ~~-cah-~h~~ ~ ..~-y.v0 _. I ~ ~ ~ i ~ l/l~~ ~ SO UtlO l-~C-~ ~/~t 1 C.L[~i/.t~-TYR.~ r;~l_~C_LC~fP //Q y~ ~ _ ~ o f ~ I> ~- m~ ~ ~ 000 ~ ~ ~ ~ (~~ ~ - ~ ~ c~. j~ -- 1 ~'n ye5f m ~ nfi- f3mt~~ O ~_ ~-~a_~~rp ~ ~ ~~~ ~2-,Cc _ -- - - ~-~jl~i~/~~}' 1( /u ~ /T LS (1 ~.S JJ / t/l S 1 Ct-7~L _ - -- - -----~=~~'i- S t ` - ` `~ ___ ~ C~- ~-~,-i-. ~`f-s ~~n ~ci~~` ~~` t~le~t~r~ t3a~rk Tr ,D~~~~~s~z --~~_~ ~_`_i i GZ ~- -- S ~ ' r _. _ ~ t.1-_1 __C f~ (G ir' F _`_; r T~ f N ~ ! ; (r P ~ ~'t~ 4 ~rG ~G -~ /CO c C? t -- r J __ ICE IFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS P ON RECEIVING COPY OF COR ECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. AF E S!T INVENTORY_ SIGN RF ii URE PRI NAA4t-- T -- f t( ~l+~i 'sV~ ~'1/~ . ~ti.11 - - P NT NAME ANU CHECK APPROPRIA .BOX BEIOW INT TITLE ~~, DATE( Z/~ ~b ~ CHECK APPROPRIA iE HOX_ ^ Executor(trix) ~ Adm~nistratorlrnx) C ^ Estate Aep~esentauve ^ Jofnt owner of safe ileposit box ~~ rvv I r: sartacn aoalUOna1 tip/z" x l 1 " sheet(s) if necessary or use duplicates of this page of form. Rev-1502 EXt (6-98) SCHEDULE A REAL ESTATE COM4.AONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Veronikis, Jerry D. 21-08-00013 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. (li more space Is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule A (Rev. 6-98) ome No. zsoz-ozss A~ 8 TYPE OF LOAN: U.S. DEPARTMENT OF HOUSING 8 URBAN DEVE LOPMENT 1.^FHA 2.~FmHA 3. ~X CONV. UMNS. 4.~VA S ~jCONV. INS. SETTLEMENT STATEMENT 6. FILE NUMBER: 7. LOAN NUMBER: 99-326.001. ~ 0247844210 8. MORTGAGE INS CASE NUMBER: OLD MORTGAGE INS CASE NUMBER: 6.SOfF/126.42 MMO C. NOTE: This loan is furnished to give you a statement of actual settlement costs. Amoun(s paid to and by (he settlement agent are shown. Items marked "(POC(" were paid outside the closing; they are shown here for informational purposes and are not included in (he totals. f.u ]/aB IMGDADE.R.PFDFJ9-326.001118) D. NAME AND ADDRESS OF BORROWER: Robert B.McDade and - Mabie I. McDade 49 Honeysuckle Drive Mechanicsburg, PA 17050 E. NAME AND ADDRESS OF SELLER: Esta~e of Jerry Veronikis ~ i F. NAME AND ADDRESS OF LENDER: SUNTRUST MORTGAGE INC. 901 SEMMES AVENUE RICHMOND, VA 23224 G. PROPERTY LOCATION: 49 Honeysuckle Drive Mechanicsburg, PA 17050 H. SETTLEMENT AGENT: 68-0510988 Com[rlunity Land Transfer, LLC L SETTLEMENT DATE: Au ust 27 2008 Cumberland County, Pennsylvania PLAQE OF SETTLEMENT 23311 Market Street Camp Hill, PA 17011 , g J. SUMMARY OF BORROWER'S TRANSAC ION K. SUMMARY OF SELLER'S TRANSACTION 100. GROSS AMOUNT DUE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER: 101. Contract Sales Price I 191,000.00 401. Contract Sales Price 191,000.00 102. Personal Pro ert 402. Personal Pro er1 103. Settlement Char es to Borrower Line 1400 4,946.40 403. 104. 404. 105. i 405. Adustments For Items Paid B Seller in advan ce Ad ustmenls For Items Pald By Seller in advance 106. Cit /Town Taxes to 406. Cit /Town Taxes to ~ 107. Count Taxes 08/27/08 to_ 01/01/09 ! ii 152.26 407. Count Taxes 08/27/08 to O1/D1/09 152.26 108. School Taxes 08/27708 Ic 07/01/09 -- I 973.58 408. School Taxes 08/27!08 to 07/01/09 973.58 1D9. _ 409. ~ 11 D. 410. 111. --- 411. 112. ! 412. 120. GROSS AMOUNT DUE FROM BORROWER ~ 197,072.24 420. GROSS AMOUNT DUE TO SELLER ~ 192, 725.84 200. AMOUNTS PAID BY OR IN BEHALF_OF BORROWEF~: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 201. De osit or earnest mone _ ~ ,~ 2,000.00 __ 501. Excess De oslt See Instructions 202. Princi al Amount of New Loan s` -_ ! ' 20.000.00 502. Settlement Char es to Seller Line 1400 15,066.70 203. Existing loan(s) taken subject to _ _ 1 503. Existin loans taken sub' ocl to I 204._ Bridge Loan Proceeds ---- -- ~ ! 177,384.24 _ 504. Payo(i of first Mortgage 205. _, ___ _ __,-,___ ~ 505. Payoff of second Mortg~9? 206. __ _ 506. _ 207._ ___ _ _ _ _ _ _ _ 507. De oslt disb. as proceeds 208. ---~ - 508. 209. - _ ' 509. Adjustments For Items Unpaid By_Setler ~ __ _ Adjus[ments For Items Unpaid By Seller 270. City!Town Taxes to ' _ 510. Cit (Town Taxes to 211. Count Taxes _ tc ~ _ 511. Count Taxes to 272. School Taxes :~ - ----.--- I I _ 512. School Taxes to 213. -~---- 513. ---- 214. - 514. - 1 -- - --- - - ---- 215. - 515. __..--- 216. ~---~- -~. ~, 516. I 217 ! 517. -- 213. _ 518. ' 219. 519. .._. -.- -- 220. TOTAL PAID 8Y/FOR 90RRO W'c ~ ~ 199,384.24 520. TOTAL RED UCT10fJ AMO+JNT DUE SELLER 15.066.70 300. CASH AT SETTLEMENT FROMTfO BORROWER: 600. CASH AT SETTLE ENT -f0!FROM SELLER. M 30t Gross Amount Due From Borrower rLne 127 197,072.24 _ _ 601. Gross Amount Due To Seller !Lme 42D) 192,125.84 302. Less Amount Paid By/For Borrower (!_ ire 220) ~ ( 199,384.24) 602. Less Reductions Due Sef;er 'Line 520) ~,(- 15.066.70 303. Cl+SH ( FROM / (X TO ! ©~4.ROVeFp 2,312.00 603. CASH (X TO) ( FROM) SELLER ~, .77,059.14 e rind erslyned hereby acknowledge er_ pt n` a rorn Dieted copy of pages 1&2 of this statement 8 any attachments referred to herein. Borrower ~ ~l -i -~~~~~~L-6~~, _,{',~ _ Seller Es(ate of Jury Je;onikls Robert 8. McDa.,,. ~'6~~T-o le I McDade i ~a L. SETTLEMENT CHARGES 700. TOTAL COMMISSION Based on Price $ 191,000.00 @ 6.0000 % 11,460.00 anio EaoM auoraoM Division o! Commission Erne 700 as Follows: eoanowER~s sE~LER~s 701_ $ 1?,460.00 tc THE HOMESTEAD GROUP, INC. Eurvosnr FuNOSar 702. $ IO SETTLEMENT SETTLEMENT 703. Commission Paid at Settlement 11,460.OC 704. Transaction Fee to The Homestead Group, Inc. 700.00 100.00 800. ITEMS PAYABLE IN CONNECTION WITH LOAN 801. Loan Ori ination Fee 1.0000 % to Central PA Mort a e, LLC 200.00 802. Loan Discount % to _ 803. Appraisal Fee to Central Penn Appraisals POC: 8350.00 8 -43.00 804. Credit Report to Krotl Factual Dala 12.53 805. Lender's Inspection Fee to 806. Mortgage Ins. App. Fee to 807. Assumption Fee to 808. Mortgaye Broker Fee to Central PA Mortgage, LLC POC:8220.00 809. Administrative Fee to Central PA Mortgage, LLC 600.00 810. JV Processing Fee to SUNTRUST MORTGAGE INC. POC:500.00 CPAM _ 811. Tax Service Fee to Valutree Real Estate Serlvice 83.D0 812. LOL Flood Cert. to First American Flood g.00 813. 814. 815. Principal Reduction Payment to SUNTRUST MORTGAGE INC. 317.32 816. 817. 818. 819. 820. yU U. 11 CMJ KCyU1KCU tlT LCIVUCK I U tlt YAIU IN AU VAN[:t 901. Interest From 08127!08 to 09/01/08 @ $ 3.560000/day ( 5 days %) 17.80 902. Mortga e Insurance Premium for months to 903. Hazard Insurance Premium for 1.0 ears to Slate Farm Ins. POC:B312.00 _ 904. _ 905. 1000. RESERVES DEPOSITED WITH LENDER 1001. Hazard Insurance months $ er month _ 1002. MoR a e Insurance months $ er month _ 1003. Cit (sown Taxes months $ er month _ 1004. County Taxes months $ er month _ 1005. SchoolTaxes _ _ months @ $ per month ~~ _ 1006. months $ er month L1007. months @ $ per month _ _ 1008. months $ er month _ 1100. TITLE CHARGES _1101. Settlement or Closin Fee to _ 1102. Abstract or Title Search to _ _ [o 1103. Title Exarnlnation _ 1104. Title Insurance Binder to _ _ to Communit Land Transfer, LLC 1105. Eleclronlc Document Prep. 50.00 _ ____ 1106. Closing Service Letter to Communit Land Transfer LLC 35.00 _ _ 1107. Attorney's Fees to (includes above f(err. numbers: _ to COMMUNITY LAND TRANSFER 1108. Title Insurance 1 313.75 _ _ _ (includes above ilern nunluers,1102, 1103 & 1104 _ _ $ 28000.00 1109. Lender's Coverage _ __ $ 191,000.00 1,313.75 1110. Owner's C overaye _ _ _ _ i t ? 1. Endorsements 100 300, 8.1 to Commundy Land Transfer, LLC 150.00 __ 1112. Notary Fee to Community Land Transfer 10.G0 to Comrnunlty Land Transfer 1113. Notary Fee 5.0( _ 1114. Overnight Fees & Handling to Cornrnunity Land Transfer, LLC 15.00 , 115. Wire Fee to Community Land Transter, LLC _ 10.00 _ X1116 ---- __ -___. _- ~ 1 1 1 7 ____ ___---______ ~_ _ . ~ , , ,r q I ' 1200. GOVERNMENT RECORDING AND TRANSFER CHARGES _ ' 1201. Recording Fees: Deed $ 38.50; Mortgage $ 68.50; Releases $ j 107.00 ~ ~ 1,91G.OGi _ _'~,202CitylCounlyTax/Sta_rnps:Deed___ 1,910.OOMortgage _______ - 1,910.0( 1203. Stale TaxlStamps. __Deed__ 1,910.00; Murt a e __ _~ 1204. ___ j_ _ _ 1205. l 1300. ADDITIONAL SETTLEMENT CHARGES _ _1301. Survey to _ Cor.trol _ 1307. Pest Inspection to Bowers Pest 5D.0_0 _ _ _ __ _ 1303 Home'Narranty to First Arnerlcan Nome Buyers Protection Plan I 399.0( _ ?3'J4. 2009109 School Taxes to Debra Basehore Wiest, Tax Collector _ _ _ _ __ I 1,130.6t __ __ 1305. Sewer to Silver Spring Township Authority ~ 62.0 1400. TOTAL SETTLEMENT CHARGES (Enter on Lines 103, Soctlon J and 502, Section K) , ~ 4,9a6,40j 15,066.7( 8y srgn,pg page vl In,s slaleii~er,l.:he signaloiies a.knp.Medge recelp! of a completed copy of page 2 0l Lhis rtw page statement. ~.. rti tied to be a true coov Community land Settlement Agent /~ LI_C 99-328 00' / 33 Jl~.ggt. /'9 1 nn,~;~~oos 7s na r,7s ;es 1qn- REar,F~uz.v72r•R ~oD2 A vino nu. taut-YdES7 H. TYPE OF LOAN: U.3. DECARTMENT t7F HOU3~IR b UfffiAN DEVELOPt~}7T 7'^FHA 2.QFnrFtA 3.(~COM/, UN1NG, a.QvA 6_[~CONV. IN9. SETTLEMENT ST EMEN 8. FILE NUMB@R 7. LOAN NL7i4~ER' 91y 6 60 3 AT T - . 2 7. oze7Ba.2TD _ 2 AiOfiTGAGE 114 CASE NUMBER: OLD MOFt'tt3ACiE IN8 CASE NUNBeR: B.so>Fn2e_a2 r~+o C. NOTE: Thlo fomr Lo Alr1N.^.hod ro (~ ydv p statpmanf dl equal se(dBlnenf Co9tL Afnoui7rg peld M onH hY R70 SnNlarfNMr ngnnf ?ro Glrvrvrt Items rnOrMod ~ wnm oaFr outudo . !ta tlonry7g, rhoy nr» yawn n~ ~ Intbrmaudrmfpurfloses end em rmtlnduded M rlta tafefa D. NAME ANU 4ppRESS (X BORROWFF: t~ 7.Ce rmnerrt.rne+eaan.aoin E. NAI.AE AND ACDRE88 OF SELLER; F, NAME 6Np AODRp^-^- OF LENpER' Rotxxt p,~AECDrtdn nne - Ealele of Jcrty Vero~lldg 'UNTRUBT MG`RT13ACtE INC Mpt7M I. McQg6e . 49 Honeyeuekle Dryvn i~7 .SEMk;12S AVENUE kA~xiy:rrtlL;hur77, FA 17060 RICHMOND, vA X3714 G. PROFERrYLOCnnoN: H. 3t~'TLEMEN7ACaEM: g8-4 6 7 0888 ' 48 Honey.•tvnk7n Ortve 1. SET~LEMF,N T DATE: J`4achanineur{7, PA 17066 C Cert~~Y Lvytl TroOnTnr, LLC rrmhertend County. Pdnns}nvenfe ~ PLA1=E OF ETT + Auy7ugt 27. 2008 LE7. IEN7 S 7337 Mafket Sheet Came Hlti, PA 17017 J. BUMNARY OF B(XiRCNVE~'S TRANSACTION 7 t7o. c,'ROSS /u~oulrT WE FROM Ror?Rr>w~e: K SUMMARY OF S r c+w'9 TRANSACTION 707. GoflheCt Sclnz Prim •180, OR098 AYOl/WT DUE 70 SELLER: 707_. Pereontl Pf'erf ~- 1 Pi tU0A0 407,^,ofmac7 Selea price 19!.000.60 103. Setltthtont t~taq.+a to 8orra~n+r tlJnn ' 0 Personal 4 940 40 4A9 104. , . , 705. ate' - I a~ - A rsl7trenra For Irdlns Pero SPUR • by BdVel7ed A xfrncrH9 for hems Feld BBllar M dUVerlCe 10n, C !Town Tracy m ttn. Coon Tazw 08!27/08 to avD !Oa I 4DD, C overt Taxes to 1528 407 1OB. SL1tadlTwrsa PRI7,TroA to 07/01N9 1 . Taxes 08/27 .fo 0!/01A9 1p2,26 973.58 408, :>OIyDW TntRt 08/27/08 to 07101!09 09. 710. _ (773,$8 ~0• 117. 172 aT1. 412, iM. GROSS AMOUNT DUE FROM BORRiJWFR ~ 1137,072.24 420. L7R0.QS AMOLINTDU@TO SELL ER . 192,129.Dh 200• A1N0(114T79 PA>D 6Y OR M 9E}IAt:F <~F 60RROVVEi2: 207. M or rmmmept 6eD. Rrouer7oHS IN Ab10UyVT ixfE TO t36I1ER: 202. PAntl A+nount at Nave LOa a 2,006!76 807. L-xra~e DO t 90o InaUuctidna 203. Eyaatt loe a 7ekM au acX [0 20 0170.1)0 802. Softlemont Ch ea to flatlet Line Ta00 16,08870 ZD4. Drle Lcxrn Pmcdeae 803. Hx7e0 hart a feks+ gb ed to ZOS. 177,30414 604. Po R of tMel 208, P of aamn0 500 207. 2D8, Go7. D eit dltso. 8a ceetts - ZOP. 608. - A srmenta For 8nn+s UrtdMd By SeOer I &ya_ 210. C awn Tnxee - Fa A usmten7a T•dr Hama Un Snt7pr - 2,17. Conn TRw.. t[s 510. CI dyxt Ttixe3 to - 212.:~ahool Taxes ~ blt. CC Tmtas t0 - 213. 572. 3ahool Taxee 1p 27 ~. 613. - 275. l 61<_ - 71 G, ~ 615. - 217. b1B. - 278. 677. 274. ~ G18. sta. 220. TOTAL PAIDQY/FOR90RROWE7? I 199,38414 326. 7T7TALREDUCT10N.dMOUNTAUESELI ~ 300. CASH AT R ETTLEAQCKT FROMITU BORR011agR; . , 15,088.70 301. oroas Atnotrn Due pram Baerower Lue 720 8110. CABH AT BETTI~NfiNT'701PRDY SCLLeR 302. Leas AmeuM Pakf r 9bt7ovcr ,0226} 197 07214 801. t3rasa Amount bus re Salyer o 420 7tY2 125,84 303 CJiStf FR t[J9.31t4.2/1 eV2. Lees Rneudlens pVa adbr (Um 520 t 6,088.76 . ( tJM) (X TO) 80RHOM~R ~ 2,37260 E0.'1_ CAShf (X T'O) ( FROM) SEt L PR 1 4 7 66 T7m imMxalnnwt rv,..w.., ...v.....~..__ __..~, _. _ _ . . , 9.1 7 - ~s~ . ~w „~, ~, ., wmpmteo copy O7 papas td2 d thi7 etetamon~e..agY Nitr+chrnnntA rafsnrad M herein. Sorrawrr Rd~rriB.MdOndp - drJertyvnnxtttnr, ~n 7N1 1. MC'DPrla ,H _ C ~ 1 t~{1~ ~~ ~-f---~ Rev-1503 EX+ (5-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS 8~ BONDS t51Alt OF Veronikis, Jerry D. FILE NUMBER 21-08-00013 All property Jointly-owned with right oT survivorship must be disclosed on Schedule F. ITEM CUSIP NUMBER NUMBER DESCRIPTION 1 1,188 shares of PNC Financial Services Group stock VALUE AT DATE UNIT VALUE OF DEATH 66.52 79,025.76 TOTAL (Also enter on Line 2, Recapitulation) (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. 79,025.76 Form PA-1500 Schedule B (Rev_ 6-98) (Camputershare Computershare Investor Services 250 Royall Street Canton Massachusetts 02021 www.computershare.corn JERRY VERONIKIS C/O THE WILEY GROUP ATTORNEYS AT LAW 130 WEST CHURCH STREET SUITE 100 DILLSBURG PA 17019 January 23, 2008 Company: Registration: Holder Account Number: Our Reference: Dear Shareholder: THE PNC FINANCIAL SERVICES GROUP JERRY VERONIKIS CQ000888231 PNC/0080213034/12/88128 Thank you for contacting Computershare, the transfer agent for The PNC Finandal Services Group. We appreciate the opportunity to be of service to you. On 12/24/07, account number 00000888231 held 1188 shares. On that date, the closing price was $66.52 per share. Transfer instructions for the above registered account have been requested to be sent to you; office under separate cover. Should you have other account related questions, please call us at 800-982-7652 during regular business hours. Sincerely, ~~~~~/N~'\G Service Representative Enclosure: ,Received Documents • Rev-1508 EX+ (6-98) CONAtONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, 8~ MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Veronikis, Jerry D. 21-08-00013 - ~----- -.....~_.._.. . ..... ..... ....... .~~~ N~...,~~~~ w~~~ icn;mveu uy ule esca[e. All property Jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Capital Blue Cross (refund): 409.21 2 Citizens Bank Checking Account Number 6100661415: 23,746.35 3 Legacy Treasury Direct Account: 200,000.00 4 Money found in lock box: 8.00 5 PNC Bank CD Account Number 31500300039: 50,169.18 6 PNC Bank CD Number 31700311374: 50,034.18 7 PNC Checking Account Number 5140473427: 48,365.55 8 Sale of 1996 Buick Station Wagon: 3,000.00 9 The Hartford (refund on car insurance): 25.00 10 United Water (refund): 19.00 11 Wachovia Bank CD Account Number 5712: 10,031.39 12 Wachovia Bank Checking Account Number 6132: 493.68 TOTAL (Also enter on Line 5, Recapitulation) I 386,301.54 (If more space is needed, additional pages of the same size) Copyright (c)~2002 form software only The Lackner Group, Inc. Form PA-~ 500 Schedule E (Rev. 6-98) ~p~CBANK p `v~4rhpnl it iti7tty C~ ~tic•crr~ September I h, 2005 To Whom it May (-'~ncei„ .lerry Vcrtu~ikis {1)rccr~e~l) SS# 112-U9-?SS7 L)Ull 1212 5/2007 ACCOUNT NUi~IBEF ~` DATE (7F DEA`CH Ii,AI AN(:N;+ A(-'t_'KI.1h:U IN I'h:Kh?5"1~ CDn 31~I002921~}~l au,ooo.()o + ~)?.o~l ~?-T ~ 1=rCL,v~c ~/ C . parr, ~ 1~ cr~A :31 ~(;();(x)(.)~~~ so,aoo.oo i 169.15 C'lln 317(}031 1 37a tit),offOU-OU i j .1 1 L~ UDA 5141>47~=1W~ 45,354,55 + 11.UG A member cf the PMC Fu~uricial Services Group 5288 Simpson Ferry Rd McChanic~burg Pn 17050 v~vnv pnrbanh_r_om - ~~ ~~VI~I.~G_VLI~T11I Ii_i 4'~~fl~L YL __ DENNIS VERONIKIS AND CATHERINE KASTANAS REF: SALE OF 1996 BUICK STATION WAGON PRICE AGREED TO: ........ ........ $ 3,000.00 f~ECEIVED DOWN PAYMENT ON MARCH 31, ?_008 _. - 1,000.00 BALANCE DUE ...... 2,000.00 CHECK S IGNA'1'UE?ES NOTE --- --- --~ ,"~' `. ~(~ ,:_~!.~;.r (BUYER ) s ~; ~ - '~ i ~ ~' ~ AGEZEFMENT DISCUSSED THAT BALANCE OWED COUL[~ tip; PAID BY MAY 3I, 2008. '1'tII\NKS '5Pld P°Oti1-Oi;/C:SD/I~inB _1~dE';_ r_5:io r 02/0? 'r-990 -~'--` ~~~~m of '~ara~l Sscur~r,es ~~- -- F d- Box 42t; Porkarsburq. 1NV "Lb i 06•oa 2b 1.800-722-2478 Refer to: 01018547280 January 15, 2008 JERRY VERONlKlS ~~~t~~~~~~~~o~ro~ S DAWN GLADFELTER CIO 7HE WiLEY GRQUP ~-~0 W CHURCH STREET SUITE 100 D1Ll_SBURG PA 17019 Dear Ms- Gladfeiter: ~'Je received Your request for information regarding accounts belongrrrg to Jerry VeroniKis, deceased. This office maintains records pertaining to Treasury pills, notes, and bonds. The rer:orcis are rrtarnra,nen ny t;-;e Taxpayer IgEnt~f-motion ivumber (TIN) of the owner_ We have searched the records of these securities using the TIN you provided, and one Le ac T f3irect® account was ident,fied- g y reasury As of pecember 25, 2007, Legacy Treasury Directei Account No. Berry Veronikis, had a par amoUni of $200,Op0.00 The enclosed TXxa san Hs~orygQr tt~ISd account confirms the gate of death balance. This report also shows the ;slue date and maiunty date of the securities in this account as of the pate of death. i his office does not maintain rec-prds concerning the market value of securittes_ !n oraer to determine the market value ai the time of the owners death, contact a broker or financial rnstttution that handles the buy,ng and selling of marketable securit,es Back [sues of f,nanc,al publications r=antaining these values may also be consulted. When contacting us, please refer to the customer number shown at the top of this Jeti[~r anq furrnsh your daytrme ietephane number. - For genera! quesi,ons about marketable Treasury sec:r,rii,es, call {800) 722-2678 to!!-free or vi s,1 our website at www.treasurydirect.gov If you have questions about this letter, 1 earl be reached at (304) 480-1711 ext. 297439, t~etween the hours of F3:00 a ;,-;_ and 4.3~; ~, „~ E i _ S,ncereiy, Sherry McDbinald Cusiorner Setvrce Specialist Divis,on of Customer Assistance r=nGosure: lransachon History Report For ~nformat;on about Treasury Reta,f s~cwrt~es. ~o [o www-[r©as~rya~rect gov _ _rr _ ;~p4a FRIi~.1-i1j5/f ~jn~~dj,A m O O N a .~ ~O CJ }~ n ~. v CK M s f~ -L (~ ifi f~; C7 r re '" ZJ _ ~ ~~ 7 ;P K :71 C;7 l~ W ., ._ >. Q 'Z .~ S Lr ~ l p c~ w h %. r~ tr~ ~~ ~r~ x x x x h t` ~. G Dl G A N O ~ N ++ N ~ r 3 O - U ~ a d C O w 4~ ~ 4i ~ n ~-+ ra v r+ ip S Q ~~ U (q i; b ~. ~^ 3u4d8~i1Z6 .-6_~~ ;;~i,-~s --~90 w C Q ~ ~ ~ f-1 q q _ [ ~ , N (~ ~ ~ L!1 ~ ~ W _. r ) ~ ~ Q~ ~ l() Cc: N N r.j i_. fY ~ ~ ~ N N _ ~ C1 -~ ~ ri G LJ ~ ~ ~ ~ C~ H U F- ,1 ~ cq ^: FC L _ '~ ~ ~ ~ I u1 ~ 4 !-- ~ ~ ~ ~ a rtiy ~ ~ lq O ~' c~ E-, ~ _ ~ JX ~ r-. r ~ H ~ E~ U '~ ~ u~ r7 E+ ,S cq ~ E~ - ~, ~' ,y ~ ~ E~ ~ n ~ .~ ~ ~ ~ r ' ~ crl z _~ ' z n '" '" ~ H , ~ ~ ~ ~ ~ c c ~ ~ O LK C> !k p ~ ~ ~ ~ O O o p p O U ° 0 0 0 p d Q O p o 0 O o u} O q~ p ~ L O 0 0 0 ° o O O O G o O H O O n p O Vr O 0 J o O U O 0 U} U} rV N ~ ~ CV N .n O N O O ~ O p ~ ily yr ur r` ~ n H o ~ v~ ~ N v} Cq O F~ (r] G F-~ R a ;-+~ 7 Q !~ J ~J :~ ~) U ~~ CJ Ql ti ~' S? Q` In ~ ~) ~ V r ' p O ~ r ~ ~ ~ O ° ~ O O ~ ° ~ O r c v ~ ( , o c~ ~ r 01 _ at N N N N N 4 0 cn o 0 C71 O N N N n ~~ ~ ~ ~ ~ ~ ~ ~ N ~ ~ ~ ~ ~ ~' ~~ ' ' p O R H `~ `~ ~ ~ r v ~7 N ~ N ~ ~ c0 co ~ ~ ~ Z 1 ~, ry ~ . -~ ~"~ ~ N (q , .~ Qi O p m O OD cu ~~ U C. >~ ~ p ~ ~ ° ~ V l V ~ O O !1 }, O p U rd \ ,_ ~ N ~ ~ N N , ~ N w p 0 O J 171 .~ M ~ ;~ ~ ~ ` N CV 4 ~ rV ~ n : ~ .~ ~ ° rv M _ _ O O . b y ~ N v r i ~ c~ f~- ~ O O r O O r-. r, " ~ ~ r- r al r r~ ~ ~ -y ~ ~ o _ O G ru cl U r~ t` :0 C ~~ .v ~ -~ CV N P O ~J ( : O o O G lrJ ( ~ C ~ ~.~ `\ N N J C~ N N N V 'L ~ O o ul (V N ~ ¢> ` ~ ` 1 ,.n ~ ~ C 0 6 O~ ~ O <~ o U ~~ ~ p O N ~ `~ r. ~. \ ~ . -7 ri n ~ ~ rt ~. ~ ~l fV r~ [~ a~ rn W C7] ~~ r, P ,o ~n V ~~ ~, 7 V ~ n _ r t r . N N ` T ~ N ~ ~ t:~ tf) _ ~ ..~ jJ ~ ~ p N Ul % (~~ ~ ~ ~fI ~ ~ ~ [V N n ~ ry ~ N N (~ (v N r` n n (_ ti "~ ~~ ~~ r-, ti N N r V ~ ~ is Account Number 6100661415 Account Title-_ __ ____ _ ___ JERRY VERONIKIS Date Opened - -_ - -_- -------- -- 1 /9/2002 Account Type Principal Balance as of DOD _ __ Checking $23746.35 Interest from Last Posting to DOD _ _ _ $ .00 Account Balance as of DOD __ _ $23746.35 YTD Interest to DOD _ __ $176.77 F~~x '1'ransrnittal 9/17/200f3 9:54:00 AM I?AGL 2/003 Fax Server \\~:1Ch 0'73 61171; 1~~./\. F331a~ue Con17ru13tion Szt~~iczs Y o I~;,~ :IOO~s R,,lnoke- vA ~aoz~-%; 1; ianuan~ ~-3. ~OOti W[LEY GROUP A7TN: S DAWN GI_ADFE1_TER 1 ,0 ~~` CHt'RCH STREI~I SUITE 100 DIL.LSBURG, PA 17019 Reference ID: ? ~Oei'_i9 SUBIEC°T: Veriticatitu~ 1 Collfirntation of Account and Balance I1~ii~rmation pr~ivided for: Customer: JERRI' D V>:RO1VIIilS (SSN# ?C.til-?Ct-7887j Date of Death: December 25, 2007 Deposit Account Information Aciount Account Dare u1 Death Ave~aoe Date [~larnniy- Lnelest Acuved 1'-ID Date Tvpe Number Bal:ulce Balance" Opened Dare Rate Interest In~ere~t Pa1d Closad CERTIFICA"f 3:OI L ~-~~.';X~l?+R)i5~1'_ $LGA00-OU ~I:l;/3ii06 $3139 $4~15 G~! IP3lZ00S DEPOSIT . LEG.~LTII I.E: IE~Ry D VFRONIKI.S CLOSING B-A1_V'~CE: $100?7_ri9 _._ __ _ _ ERTIFICA"17?OF ?L~,'}i~~:_~l'.l'~`LXS,II - $20,000.pO ~r'Si?00~ $'.b~i g99bb~a 5119^Dpg DEPOSIT I_EGALTICIF_: 1~R}' D VEI:ONIKLS ;1"I"I FR_\NCES ( B:\RRICK CLOSING 8;11 ^NCF: X20061.43 __ _ CHECKIIJG }L~X?:?;X_~~~;r~132 $49±.61 Sn.il'OOi $0.01 50.04 Ill~tr?003 LEG:~L Tf]'ly~: I t,RP,} D \rE~'ON1filS CATl~R[NF i' K.~S~i:ANAS POA CL05ING B,aI ~WCE: ~t,l LSu Rev-1509 EX+ (6-98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Veronikis, Jerry D. 21-08-00013 ff 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. Catherine P. Kastanas B. Dennis S. Veronikis C. JOINTLY OWNED PROPERTY: 5220 Windsor Blvd. Mechanicsburg, PA 17055 Nephew 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&B 3/20/2002 Citizens Bank CD Account Number 50,062.02 33 333% 16 687 17 6140859204: . , . TOTAL (Also enter on Line 6, Recapitulation) 16,687.17 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98) 3 Briargate Road Niece Mechanicsburg, PA 17050 ~~~ Account Number ~ 6140859204 Account Title __ ____ _ _ _ _ JERRY VERONIKIS OR DENNIS VERONIKIS OR CATHY VERONIKIS Date Opened _ ____ _ 3/20/2002 _ Account Type _ __ _ _ Time Deposits Principal Balance as of DOD __ __ __ _ $50000.00 Interest from Last Posting to DOD _____ _ ___ $62.02 Account Balance as of DOD _ ___ $50062.02 YTD Interest to DOD __ $2506.36 • Rev-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN RESfDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Veronikis, Jerry D. 21-08-00013 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 DESCRIPTION OF PROPERTY DATE OF DEATH % OF DECD'S ExcLUSioN TAXABLE NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLII'AHLE) VALUE THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. 1 Citizens Bank Account Number 6245825372 - 50,027.56 50,027.56 Jerry Veronikis TTEE for Dennis 8 Cathy Veronikis: 2 I Penn Treaty Stock (TOD to Frances Barrick): ~ 281.16 3 I PNC CD -Jerry Veronikis ITF Frances C. Barrick: ~ 40,092.03 4 ~ Wachovia CD Account Number 8311 -Jerry D. I 20,002.67 Veronikis ITF Frances C. Barrick: 281.16 40,092.03 20,002.67 TOTAL (Also enter on Line 7, Recapitulation) 110,403.42 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) Fax Transmittal 9/17/2008 9:54:00 AM PAGE 2/003 Fax Server 'i'1TAGHOEVIA Reference ID: 230(1239 ~~'acho~ is Batik ~'.A. Balance Confinuatiou Services P O Bos 40025 Rouiuke. VA 2402-7;13 .lanuary 24, 2005 WILEY GROUP ATTN: S DAWN GLADFELTER 1 ~0 W CHl'RCH STREE`f SUITE t00 DILLSBUKG, PA 17019 SLBJF,CT: Verification i Confirniation of Account and Balance Information provided fi)r: Customer: JERRY D VERONIIiIS (SSN#t X3kk-X.Y-7887) Date of Death: December 2S, 2007 Deposit Account Information Account Account Pate of Death Average Date [~4atnrity Lrterest Acal~ed YTD Date Type Number Balance Balance" Opened Date Race Interest Interest Paid Closed CFRTIFICATE OF }~l~X~~i;xXX5712 $ I OpOQ.00 4; t 7/2006 $31.39 $445.64 I "3/ZOOS - nF~'OSIT LEGALTITI_E: JERRY"D VEP.ONIKIS CLOSING BALANCE: $ IOOZ7.ti9 -- CEhT~1CATFOF / )i,>;XX?;?;};.~X?L~;S311 $?O,Obp.00 ~I!5l?005 ` - - -- $2.67 $~996.G4 3I197ZOOS DEPOSIT ~/ LEGAL "CfCLE: i;~Y D VERONIKIS 'CI7= FRANCES C B.ARRICK CLOSQG BALANCE: $2n061.43 c~FLECK[rIG k?iJUiXX~~bI~Z $493.67 S/'4!'007 $0.01 $0.04 I t4''.OOS LEG:ALTiTLE: TERRI' D \fL:I:ONll;IS CATHERINE P IC.ASTANAS I'O.A CLOSING BALANCE: $'~6LlSO Q P1V C BAN K I q WhOlil It 1~1ay Cplrt;crn September l fi, 20()5 To V~~hom it May (-'nnce~„ .Jerry Ver~-mikis (Dcc%asrd) SS# 1 12-U9-7887 UUU 12/25;2007 ACCOUNT NUMBER * UATF.. {)FT)FA`ITtf ti,At.AV<:1-:+ A('(_'kl.)H:I) IN I F-:Kf":5'f' CD~1319U02121.09 40,(.)00.00 + 92.03 ---TT ~ f=r~1/~nc>vJ, C ~CI,K'r ~ c K- CDA 315(tO3O{)039 50,000.00 ~ 169.1£ Ci~A 317(1031 1371 50,0000 00 i }:.1.18 UUA 5140473427 48,354.5~ + 11.00 A member of the PPJC Fuianuial Services Group 52A8 ;impson Ferry Rd Mechanicsburg Pn 17050 www pnrb~nk.n~m ~. ~ Account Number _ 6245825372 Account Title r _ _ JERRY VERONIKIS TTEE FOR DENNIS & CATHY ------- --------- Date Opened VERONIKIS --- ------- _ _____ _ - ~ 5/23/2005 _ Account Type __ _ Time Deposits Principal Balance_as of DOD $50000 00 -Interest from Last Posting to DOD . _ $27 56 Account Balance as of DOD _ . $50027 56 _YTD Interest to DOD . $2412.23 ''~ "American Srock Transfer & Trust company January 29, 2008 THE WILEY GROUP ATTORNEYS AT LAW A`I'T"N: DAWN GLADFELTER 130 W. CHURCH ST, SUITE l00 DILLSBURG, PA 17019 ~/ ~ Operations Center i t i ;~ fi201• 15th .Avenue i; Brooktyns ?VY 11219 www.amstock.com (800) 937-5449 Re: JERRY" VERONIKIS TOD FRANCES C BARRICK SUBJECT TO STA '1'OU RULES Company: PENN TREATY AMERICAN CORPORATION Account: 4001410650 Dear Ms. Gladfelter: We have received your request regarding the above-referenced account. Please be informed as of the date of death and the current date the account held a balance of 44 shares. These shares are represented by the following certificates which should be in the shareholder's possession: Certificate # Issue Date # of Shares PTA0000623 08/15/2005 44 ~ ~~l The closing market value on was 6.39 er share. As of the current date, the closing market value is $5.84. The company trades on the NYSE and the symbol is PTA. Share prices are as of close of business the business day preceding this letter and are provided by a third party. AST' does not guarantee the accuracy of such information and neither AST nor its provider will be liable for any informational errors, or for any actions taken in reliance on such prices. In the event an original certificate is lost, please inform our Lost Security Department in writing to the above address or on-line from our web site. Please be sure to provide all pertinent information and the certiticate number which is lost, so we may properly initiate replacement procedures. F,nclosed please find a transfer instruction package providing necessary requirements needed to effect the transaction. The following documents are being returned to you: 1. Death Certificate 2. Court Appointment In the future, you may communicate with us by visiting our Web Site at: www.amstock.conz, or you may e-mail me directly at SStern@amstock.com ~V61~IlhVIIYflV~IINI~INI~IfNMW~!IU~IINllhlllN!~IIIIII We trust the above information is helpful. 't~eere~l Shana Stern ~~' Shareholder Services imiiquiiu~~oii~~iiiu~i~ini~immiiNmuii~oru~uu REV-1151 EX+(12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESIAIEQF Veronikis, Jerry D. Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES: See continuation schedule(s) attached B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Social Security Number(s) / EIN Number of Personal Representative(s): Street Address City State Zip Year(s) Commission paid 2. Attorney's Fees The Wiley Group, PC 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent FILE NUMBER 21-08-00013 AMOUNT 930.00 40,000.00 4. Probate Fees The Wiley Group 622.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 21,204.32 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 62,756.32 SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS Copyright (c) 2002 form software only The Lact<ner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1502 EX+ (6-98) COA4.10NWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER 21-08-00013 Veronikis, Jerry D. ITEM NUMBER DESCRIPTION AMOUNT 1 Saint Catherine Philoptochos Society: 830.00 2 Sophia Kaldes (server @ memorial service): 100.00 Subtotal Copyright (c) 2002 form software only The Lackner Group, Inc. SCHEDULE H-A FUNERAL EXPENSES continued 930.00 Form PA-1500 Schedule H-A (Rev. 6-98) Rev-1502 EX+ (6-98) COMMONWEALTH Of PENNSYLVANIA INHERITANCE 7AX RETURN RESIDEN7 DECEDENT SCHEDULE H-B7 OTHER ADMINISTRATIVE COSTS continued ESTATE OF Veronikis, Jerry D. FILE NUMBER 21-08-00013 ITEM NUMBER DESCRIPTION AMOUNT 1 Andy Moyer (grass cutting): 645.00 2 Castle Clean: 120.24 3 Closing costs from sale of real estate: 15.066.70 4 Cumberland Law Journal (advertise estate): 75.00 5 Dept. of Veterans Affairs: 95.00 6 Greg Ritter (carpet stretched): 375.00 7 Home helper: 95.00 8 House painter: 1,800.00 9 Krehling Industries (replace countertop): 530.25 10 Lowe's (new door/lock): 120.99 11 Lowe's (vanity, sink, supplies): 419.70 12 Nicole Jastron (house cleaning): 295.00 13 Pig Pen House (junk removal): 300.00 14 PNC Bank (Social security payment returned and outstanding checks): 954.88 15 Register of Wills (add'I short certificates): 24.00 16 Register of Wills (filing fee): 30.00 17 The Sentinel (advertise estate): 182.56 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-67 (Rev. 6-98) Rey-~sD2 ex+ ~s-sad SCHEDULE H-B7 OTHER ADMINISTRATIVE COSTS CONPAONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN continued RESIDENT DECEDENT ESTATE OF Veronikis, Jerry D. FILE NUMBER 21-08-00013 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-67 (Rev. 6-98) Rev-1572 EX+ (6-98) COMMONWF_A1.TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF (FILE NUMBER Veronikis, Jerry D. 21-08-00013 Include unrelmbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 ADT Security System: 9.43 2 Carey Associates: 119.00 3 Debra Basehore Wiest (real estate taxes): 429.25 4 Griswold's Special Care: 274.75 5 Lucille Phillips (Aide): 242.87 6 PA Department of Revenue (2007 state tax): 450.00 7 Penn Waste: gg,70 8 PP8~L Electric: 435.38 9 Silver Spring Township Authority: 257.10 10 U.S. Treasury (2007 tax): 854.00 11 United Water: 87.00 TOTAL (Also enter on Line 10, Recapitulation) ~ 3,247.48 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Veronikis, Jerry D. 21-08-00 013 NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY Do Not List Trustee s (Words) ($$$) I~ TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116(a)(1.2)] 1 Frances Barrick Estate Friend 86,601.55 c/o James M. Bach, Esquire 352 S. Sporting Hill Road Mechanicsburg, PA 17050 2 Catherine P. Kastanas Niece 295,969.19 3 Briargate Road Mechanicsburg, PA 17050 3 Penelope Laspalakis Other 20,000.00 29 Skytop Ridge Oakland, NJ 07436 5 Dennis S. Veronikis Nephew 295,969.19 5220 Windsor Blvd. Mechanicsburg, PA 17055 Total 698,539.93 Enter dollar amounts for distributions shown above on lines 1 5 through 18, as appropr iate, on Rev 1500 cove r sheet II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS See continuation schedule(s) attached 20,000.00 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I 20,000.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98) • •. Rev-1502 EX+ (6-98) SCHEDULE J - I I B CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS CorxaONWEALTH OF PENNSYLVANIA I continued INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Veronikis, Jerry D. 21-08-00013 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-'1500 Schedule J-IIB (Rev. 6-98)