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12-12-08
1505607121 REV-1500 Ex (06-05) OFFICIAL USE ONLY PA Department of Revenue Coun Code Year File Number Bureau of Individual Taxes ~ Po sox2sosol INHERITANCE TAX RETURN n ~ o Harrisburg, PA 17128-0601 RESIDENT DECEDENT "~ l7 U ~ 'rL~'.} ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 9 3 3 0 2 7 4 2 0 2 0 8 2 0 0 8 0 1 0 3 1 9 3 9 Decedent's Last Name Suffix Decedent's First Name MI H A R T W I G S E N M A R Y E (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 D 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Eiection to tax under Sec. 3113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number J A Y R B R A D E R M A N E S Q 7 1 7 2 3 3 6 6 3 3 Firm Name (If Applicable) L. A V E R Y F A H E R T Y Y O U N G First line of address 2 2 5 M A R K E T S T S T E 3 0 4 Second line of address P 0- B O X 1 2 4 5 City or Post Office State ZIP Code r -~ -rt '- _ ) ~~ 1 t:, ;~r-, ., H A R R I S B U R G P A 1 7 1 0 8 1 2 4 5 VJ Correspondent's a-mail address: JBRADERMAN@LAVERYLAW .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 ~, true, correct and complete. Declaration of preparer other than the personal representative :s based on all information of which preparer has any knowledge. SIGNATUR F PERSON RES)jONSIBLE FOf~ FIkING RETURN DATE , ADDRESS U ~ ~~ 1517 WOODCREEK DR•, MECHANIC~URG, PA DATE • ~''OX 1245, HBG, PA 17108-1245 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505607121 1505607121 15D56D7221 REV-1500 EX Decedent's Social Security Number Decedent's Name: MARY E• HARTWIGSEN 1 9 3 3 D 2 7 4 2 RECAPITULATION 2 3 2 4 8 4.8 8 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. 4 5 3 2 4 . 8 4 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested . ..... , 6. 6 5 4 7 8 , 3 9 7. Inter-Vivos Transfers $ Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested . ..... , 7. 5 7 8 6 D . 8 5 8. Total Gross Assets (total Lines 1-7) ..................... ...... 8. 4 D 1 1 4 8, 9 6 9. Funeral Expenses & 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. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........ ......... . 13. 1~4. Net Value Subject to Tax (Line 12 minus Line 13) ........ .......... 14. T,AX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 1'i. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2j X.0 _ D D D 15. 16. Amount of Line 14 taxable at lineal rate X .oa5 3 7 4 9 6 8. 6 D 16. 17. Amount of Line 14 taxable D D D at sibling rate X .12 17. 18. Amount of Line 14 taxable D D D at collateral rate X .15 18. 19. Tax Due ................................................19. 2 0. FILL tN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 15D56D7221 2 0 4 5 B• 3 5 5 7 2 2. 0 1 2 6 1 8 D. 3 6 3 7 4 9 6 8. 6 D 3 7 4 9 6 8.6 D D. D D 1 6 8 7 3. 5 9 D. o a D. D D 1 6 8 ? 3. S 9 15D56D7221 J REV-1500 EX Pa~~e 3 Decedent's Complete Address: File Number 0 0 DECEDENT'S NAME MARY E. HARTWIGSEN STREET ADDRESS 415 CANDL.EWYCK ROAD ~IT~' CAMP HILL. STATE ZIP PA 17011 Tax Payments and Credits; 1• Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Interest/Penalty if applicable D. Interest. E. Penalty 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. (1) $16,873.59 Total Credits (A + B + C) (2) $10 526.30 Total InteresUPenalty (D + E) (3) $39.59 (4) $0.00 (5) $6, 386.88 (5A) B. Enter tine total of Line 5 + 5A. This is the BALANCE DUE. (58) $6.386.88 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 : ...................................................................... ^ ^X b. retain the right to designate who shall use the property transferred or its income; ............................... ^ X^ c. retain a reversionary interest; or ................................................ ................................................ ^ 0 d. receive the promise for life of either payments, benefits or care? ....................................................... ^ 0 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... Q ^ 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? .................................................................................................. Q ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE !T 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 dleath on or after July 1, 2000: The tax rate unposed 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 adopfive 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)]. $10,000.00 $526.30 $39.59 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 MARY E. H~4RTWIGSEN 0 0 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 be exchanged between a willing buyer and a willing seller, ne'~ther being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real orooerty which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 415 CANDLEWYCK RD., CAMP HILL, PA 17011 $232,484.88 PLEASE SEE HUD-1 ATTACHED TOTAL (Also enter on line 1, Recapitulation) I $ 232.484.88 (tf more space is needed, insert additional sheets of the same size) REV-1508 EX + (Ei-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPQSITS, & MISC. INHERITANCE TAX RETURN PERSONAL P OPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER MARY E. HARTWIGSEN 0 0 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointy-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 1998 BUICK PARK AVENUE SEDAN $2,000.00 SOLD ON 3/27/2008 (AS IS) 2 CLOTHES, FURNITURE AND FURNISHINGS $6,500.00 3 BANK OF AMERICA IRA $3,004.50 #2742-000001 4 INTEGRITY BANK IRA $2,049.81 #3004881 5 PHOENIX IRA $31,550.00 6 MORGAN STANLEY DIVIDEND PAYMENT $220.53 TOTAL (Also enter on line 5, Recapitulation) ~ $ 45 (If more space is needed, insert additional sheets of the same size} REV-1509 EX + (Ei-98) COMMONV~EALTH OF PENNSYLVANIA INHEF217ANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE F JOlNTlY-OWNED PROPERTY FFLE MARY E. HARTWIGSEN 0 0 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME A. DONNA k;UB1K C JOINTLY-OWNED PROPERTY: ADDRESS 1517 WOODCREEK DRIVE MECHANICSBURG, PA 17055 RELATIONSHIP TO DECEDENT DAUGHTER ITEM NUMBER LETTE'.R FOR JOINT TENAWT 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 °h OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENTS INTERESI 1. A. 1/25/94 SOVEREIGN BANK $3,907.36 50. $1,953.68 #0571124909 2 A 6/22/98 SOVEREIGN BANK $10,213.94 50. $5,106.97 #1051078091 3 A 2/04/03 BANK OF AMERICA $108,335.47 50. $54,167.74 #000574652053 4 A 6/22/98 REFUND FROM SOCIAL SECURITY ADMINSTRATION $8,500.00 50. $4,250.00 FOR MONIES INCORRECTLY TAKEN BY SSA FROM SOVEREIGN BANK #1051078091 TOTAL (Also enter on line 6, Recapitulation) I ~ 65 478 39 (If more space is needed, insert additional sheets of the same size) REV-1510 EX + (Ii-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE G INTER-VIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY FILE NUMBER MARY E. HARTWIGSEN 0 0 This schedule must be completed and filed 'rf the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INQUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF7RANSFERATTACHACDPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION 11FAPFLiccAeL~ TAXABLE VALUE 1. INTEGRITY BANK CHECKING ACCOUNT $17,747.10 100. $3,000.00 $14,747.10 #2030099229 (JT -DONNA KUBIK - 3/31/07) 2 MORGAN STANLEY ACCOUNT $46,113.75 100. $3,000.00 $43,113.75 #19:? 010002 025 (JTWS -DONNA KUBIK - 4/01/07) TOTAL (Also enter on line 7 Recapitulation) ~ $ 57 860 85 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES ~ INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER MARY E. HARTWIGSEN 0 0 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. S. J. GRONTKOWSKI FUNERAL HOME, 530 W. MAIN ST., PLYMOUTH, PA $7,100.00 2. PASQUALES RESTAURANT $644.63 3. FUNERAL FLOWERS $503.20 4 DEATH CERTIFICATES $218.00 5 GRAVE OPENING $800.00 6 FUNERAL SERVICE $125.00 7 M J MONUMENT COMPANY -GRAVE MARKER $550.00 B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Street Address City Year(s) Commission Paid: State Zip 2 Attorney Fees LAVERY, FAHERTY, YOUNG & PATTERSON 3. Family Exemption: (If decedents address is not the same as claimants, attach explanation) f :laimant 4. Street Address City State _ Relationship of Claimant to Decedent Probate Fees CUMBERLAND COUNTY REGISTER OF WILLS 5 Accountants Fees 6. Tax Return Preparers Fees 7. THE SENTINEL -LEGAL ADVERTISING 8 CUMBERLAND LAW JOURNAL -LEGAL ADVERTISING $9,800.00 $444.00 $198.52 $75.00 TOTAL (Also enter on line 9, Recapitulation) I $ 20,458.35 Zip (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS ~ RESIDENT DECEDENT ESTATE OF FILE NUMBER MARY E. HARTWIGSEN 0 0 Report; debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. DISCOVER CARD $647.64 2 JOHNS HOPKINS UNIVERSITY -MEDICAL BILL $141.16 3 MSHMC -MEDICAL BILL $251.35 4 PP&L (ELECTRICITY) $301.36 5 PAWC (WATER) $83.42 6 COMCAST $178.89 7 VERIZON $135.72 8 MONTOUR HOME COMFORT (HEATING OIL) $800.24 9 MARK ULSH (LAWN SERVICE) $540.00 10 TOM HAYDEN (MASONRY) $263.00 11 OVERHEAD DOOR (GARAGE DOOR REPAIR) $99.04 12 RADON SYSTEM $454.18 13 DONEGAL MUTUAL (HOME INSURANCE) $431.00 14 LOWER ALLEN TWSHP GARBAGE COLLECTION $175.00 15 WEST SHORE INCOME TAX $30.90 TOTAL (Also enter on line 10, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent MARY E. HAIRTWIGSEN Decedent's Name Page 1 File Number Schedule I -Debts of Decedent, Mortgage Liabilities, 8 Liens ITEM NUMBER DESCRIPTION AMOUNT 16 FEDERAL INCOME TAX $280.00 17 LOWER ALLEN TWSHP REAL ESTATE TAX $884.61 18 LOWER ALLEN TWSHP PERSONAL TAX $24.50 SUBTOTAL SCHEDULE I $1,189.11 GRAND TOTAL SCHEDULE 1 $ 5,722.01 REV-1513 EX + (9.00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MARY E. HARTWIGSEN ~ ~ RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TA;~(ABLE DISTRIBUTIONS [nclude ouVight spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. DONNA KUBIK Lineal 1517 WOODCREEK DRIVE 50% MECHANICSBURG, PA 17055 2 SUSAN KWIATKOWSKI Lineal 12:9 BRIARPATCH DRIVE 50% CARLISLE, PA 17013 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II, NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. 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) DEPARTMENT OF REVENUE BUREAU OF= INDIVIDUAL TAXES DEPT. 280601 H ARRISBUFIG, PA 1 7128-0601 PENNSYLVANIA ECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 009649 KUBIk: DONNA 1517 WOODCREEK DRIVE MECI-IANICSBURG, PA 17055 ------ told ESTATE IIVFORMATION: ssrv: is3-3o-2742 FILE NUMBER: 2108-0284 DECEDENT NAME: HARTWIGSEN MARY E DATE OF PAYMENT: 05/02/2008 POSTMARK DATE: 05/02/2008 couNTY: CUMBERLAND DATE OF DEATH: 02/08/2008 REMARKS: CHECK# 101 ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ 510, 000.00 TOTAL AMOUNT PAID: 510,000.00 INITIALS: AKK SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER S.J. GRONTKOWSKI FUNERAL HOME DONNA M. GRONTIlCOWSKI, F.D. 530 West Main Street - Plymouth, Pennsylvania 18651 Phone (570) 779-2014 or 779-3435 STAT~ME~1T OF FUNERAL GOODS AND SERVICES SELECTED Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will explain in writing below. If you selected a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you did not approve iLg u selected arrange nts such a direct cremation or immediate burial. If we charged for embalming, we exp am why b ow For the Scrwic-e of l ~ ;~ 1`- i ..~ ~ ~' ~ ,~ 1 ~ t (l~~^Y i Datr of Death _~-E=~-~ ~~~ ~` ~. Charge to: /~G' /« Name A. CHARGE FOR SERVICES SELECTED: l . PROFESSIONAL SERVICES ' ~~ ,~~ ~ Services of Funeral Director/Staff .... f ~ `' ` ~ Embalming ...................... E Other preparation of body ~-} f-~, r/ ............................... E SUB-TOTAL OF PROFESSIONAL SERVICES......... AI i FACILITIES AND SERVICES Use of facilities and services for { viewing (Visitation/Wakej...... ... i J Use of facilities and services for funeral ceremony ......... ... f Use of facilities and services for Memorial Service ............ ... E Use of equipment and services for graveside service .......... ... E Other use o~ facilities . ,c,.-, ~ ............................... E -, SU$-TOTAL OF FACILITIES/EQUIPMENT ........... A2 E~ 3. AUT0INOT[VE EQUIPMENT Vehicle to transfer remains to Funeral Home. Local ..................... ......E Hearse (Casket Coach) _ J' ;;,,~ i ~~ Loca[ ..................... , ...... E Limousine Local ..................... ...... E Family car Local ..................... ...... E Flower car or floral disposition Local ..................... ...... f Lead carlclergy car ''~+ ~} ~-~^ Local ..................... ...... S ~''J/~,_.~] Car fcrc pallbearers Local ..................... ..... E Out of town transportation ... > ......E z- ` ~~ E SUB-TOTAL OF AUTOMOTIVE EQUIPMENT....... . City Other clothing Cremation urn .. , ....... . (Description) OTHER i ~~ -': E ~=•, ~ TOTAL MERCHANDISE SELECTED .................. B E C. SPECIAL CHARGES: Forwarding of remains to E {Funeral Home) Receiving of remains from S (Funeral Home) Immediate Burial ................. E Direct Cremation ................. E SUB-TOTAL OF SPECIAL CHARGES ................ C E D. CASH ADVANCED Opening Grave .................. E Cemetery Equipment .............. E Lot and Deed .................... E Newspaper Notices-Local ......... S Newspaper Notices-Out-of-town .... E Telephone & Telegrams ........... f Airfare ......................... f Clergy/Mass Offering .............. i Pallbearers ...................... i Certified Copies of the Death Certificate ...................... E Police Escort .................... i Flowers ........................ f Vault Service Charge .............. E i~ -,,,/ f i ~ i i SUB-TOTAL OF ADVANCES.......... ~............ D E ~~~• C3C A3 f ~4 ~ E~We charge you for our services in obtaining: (specify cash advances tbat are marked-up) TOTAL ~OF PROFESSIONAL SERVICES, FACILITIES AND AUTOMOTIVE ~~ f~ EQUIPMENT ................................... A E B. CHARGEE OR MERCHf~ND[SE SELECTED: ' R;, ~'-:,'~i Caske[ k`E~.4).~.~:.'~` ~E.r!'. f. r~1~ rt . E f r _~ (.~.~,; (Description) ~:~ r ~'~` r~ ~ r .lit -r~ _ss1 ~ ~ _- '.J L% Otha; Receptacle ................. E (Description) -ti ---- ~~ _~ SUMMARY OF CHARGES A . Professional Services, Facilities and Equipment, and Automotive j I~~ p~ Equipment ..................... . E $ . Merchandise .................... . E C . Special Charges ................. D. Cash Advances .................. .E tG~ . S~ ~ ~ 1 ~ TOTAL OF ALL SECTIONS ....... .............. ...E ~ ` PAID AT TIME OF OR PRIOR TO S ....... E Use of equipment and services for Rnvexide service ............. f Other use oft~ f~~acilitie~s ~ ~ L l 1 / y:-~J / lit 1 t~?"'~• ~,I --~ ............................... f ttu i~~ SUBTOTAL OF FACILITIES/EQUIPMENT ........... AZ t 3. AUTOM07"IVE EQUIPMENT Vehicle to transfer remains to Funenl Horoe. Local ........................... f Hearse (C:uket Coach) r" ~; ~ ~- Local ... ........................ f~ ....- Limousine Local ........................... f Family car Local ..... ...................... f Flower estr or floral disposition Local ........................... f Lead carlclergy car '~+ ~'} s~~"'" Local ........................... t; ~jj-~. .~ Car for pallbearers Cocal ........................... f Out of town transportation ......... f ` , ~~ f j~ ~j SUB-TOTAL OF AUTOMOTIVE EQUIPMENT........ A3 f ~`~ `f E~ TOTAL OF PROFESSIONAL SERVICES, FACILITIES AND AUTOMOTIVE ~,l ~` ~ EQUIPMENT ................................... A f J B. CHARGE,I;OR MERCH~ISE SELECTED: ' -` ; -'-~;%' Casket; .L~.(.-.+.~~. _.:.L, i:-1 ~. G ~l" ;:f t':-+ f / '~; ~~ (~ ,. (Description) ~._}'~"':d ~ t ~ -r' ; ~-r'-.-.f~.-~~_- J ~. Other Receptacle ................. f (Description) Outer burial containeiT? '. '.. t .~ t . ~.. (Description) f s Direct Cremation ................. i f SUB-TOTAL OF SPECIAL CHARGES ................ C i D. CASH ADVANCED ~ Opening Gnve .................. f Cemetery Equipment ............ . . f Lot and Deed .................... S Newspaper Notices-Coca! ....... , . f Newspaper Notices-0ut-of-town .... i Telephone & Telegrams ........... f Airfare .................... ....f ClergylMass Offering .............. i Pallbearers ...................... i Certified Copies of the Death Certificate ...................... f Police Escort .................... E Flowers ........................ f .autS e>;vice Ch~rge_ . ............ f f _,..rl i s f SUB-TOTAL OF ADVANCES ....................... D f We charge you for our services in obtaining: (specify cash advances tbat are marked-up) SUMMARY OF CHARGES A . Professional Services, Facilities and E ui ment, and Automotive ~ ~~~ Equipment ..................... . . f B. Merchandise .................... . f~~ C . Special Charges ................. D. Cash Advances .................. . f . E,~ , TOTAL OF ALL SECTIONS . . ..... .............. ... i PAID AT TIME OF OR PRIOR TO ARRANGEMENTS ............... .............. ... f BALANCE DUE ................. .............. ... Y Acknowledgement cards ........... f ___M REASON F • R,~EMBALMI~iG ;' Register book(s) .................. f,~ / ... ~~ ~`,~Lr'`ri~,..i!..,? ~, .' _~1,_~ . ,,` Memory folders .................. f If any law, cemetery, or cremato ' equirgnts have required a purc~iase Prayer cards ..................... f ~ of any of the items listed above the taw or requirement is explained below. i d % N Temporary grave marker ...........E ~' r Burial clothing ........ I agree that 1 have examined the items of goods and services selected above and found them to be correct and according to the arrangements I have requested. I ~ekrto~iedge receipt of a copy of this Statement of Funeral Goods and Services Selected. I represent that 1 have sufficient Funds available for payment of the cash price for the goods and services selected. I also agree to make payment of f within days. I agree to be jointly and severally liable with anyone else who signs below. A fate charge off per month amounting to f per year will be applied to the ynpaid balance beginning days from the date of this agreement. i will also pay to the Funenl Director all reasonable costs paid by the Funenl Director to collect amounts I owe under this agreemrnt. Thost costs may include attorneys' fees, court costs and othtr costs. Any additiort1l services or merchandise ordered or requested after the date of this agreement will be considered art of th~is~ a~greeme t nd the cost thereof will be reflected on tht frnal bill or 3tatctnettt. ~ `-'~;' i %7 ~~ (Seat} ~ ~..~...~`',aL ,1.>f-.~-' ( ~~ ~ !~r_.1.`.%' ii ~_t f't.t s`~ • l -= t 1t-/ ! ~ .~ ~ (Purchaser) _ (Date-), - (i ,% ,~ r, (Purchaser) ', (Licensed Fu eral Director) '~ Pennsvh•ania Funenl Directors Association WHITE Funeral Director PINK Customer form - 600 Revised 4/94 ..r S. J. GRONTK~WSKf - Fu~erai Home -.__~_-__--_:~ _---- _--__- .;~n:n,sC.ti.T1V~ri~r~: Ji~t~.T DI'~;Apt;~`;7r+ 'f+. '~i`.,.. ~-- ~ f ~) Z~)~}c ~` ~3~~ is~ ~~ ~cc2cp C~'J ~'"`'°~u ~ ~ Sao - Q ~u-e ~~~ ~B~O o0 ~~~n~~~~ O ~.~~~ ~a ~~ r'~ ,l~ A~~~c~f 2 ~ . ,: ~~~,L9~. ~- ~,~, , ,~-~~ ~~ ~ _ J ~1~..Q~ TQ REORDER CaL! MELL tu~t~J CO!!?,4.Nr ~,~j~ ~~~J -CR! FSitt • 7-000 15L~63SS _, .~ :60 1 _ ~ r 5 E 7 1 / ~~ ` f 4 1 ~, ~ 12 ~ l s 1 t3 id ~~ ~ 1 f !, T N1i~k ~~~~ .~ .~ ~~ 'I r ~4 3 6Yy' ~s~~di~ s > -~~- "° °°" 633483 1 ~s d ~ ~~ 5 g~ 6 f 7 r S ~y ~/ 9 l 1a 11 +v~~ 12 13 1a 15 16 Tea Milk F04D ~~nC~ Q BEVERAGE SUB TdTAC TAX TGTAL ; :~ ~/~ ~~ RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Sgware Carlisle, PA 17613 HARTWIGSEN MARY E Estate File No.: 2008-00284 Paid By Remarks: DONNA KUBIK AJW Fee/7'ax Description PETITION LTRS ADM SHORT' CERTIFICATE RENUNCIATION JCP F~ EE AUTOMATION FEE Chec}~# 530 Total Received......... Receipt Date: 3/14/2008 Receipt Time: 08:57:47 Receipt No. 1051924 Receipt Distribution ------ ------- ------- ---- Payment Amount Payee Name 360.00 CUMBERLAND COUNTY GENERAL FUN 24.00 CUMBERLAND COUNTY GENERAL FUN 5.00 CUMBERLAND COUNTY GENERAL FUN 10.00 BUREAU OF RECEIPTS & CNTR M.D 5.00 ---------------- CUMBERLAND COUNTY GENERAL FUN $404.00 $404.00 Glenda Farner Strasbaugh Register of Wills and CIerH; of Orphans' Court Marjorie A. Wevodau First Deputy Kirk S. Sohonage, Esq Solicitor Register of Wills and Clerk of the Orphans' Court County of Cumberland One Courthouse Square Carlisle, PA 17013 (717) 240-6345 FAX (717)240-7797 ~_ INVOICE Bill To: InvoiceNo: 1954 Invoice Date: 3/31 /2008 L2~VERY SAHERTY YOUNG & PATTERSON Estate of: Marv E. Hartwi~sen 225 MARKET STREET Estate No: 21-08-0284 CJ HARRISBURG, PA 17108-1245 Qty Fee Description Fee Total 10 Short Certificates 4.00 $40.00 Total: $40.00 Checks should be made payable to the Register of Wills. Terms: Net 30. Please return one copy of this invoice with your payment. Thank you. Sovereign Bank March 26, 2008 The Estate of Mary J Hartwigsen C/O Donna M Kubik 415 Candlewyck Rd Camp Hill Pa 17011-8426 Subiect: U.S. Treasury Reclamation for Federal Payment(s) On March 19, 2008, Sovereign Bank received a notice of reclamation from the U.S. Treasury for Federal payment(s) deposited to the account of Mary J Hartwigsen. The Treasury advises us that Mary J Hartwigsen date of death 02/08/07, and that all payments made after that date must be returned to the Treasury. Please be advised that the following amount(s) have been debited from the account(s) listed below and returned to the Treasury on the date shown. Date of debit: 03/25/08 Account(s) debited: *******8091 Amount(s) debited: $8,492.00 If you have any questions or need any additional information, please feel free to call Sovereign Customer Service, toll free at 1-877-768-2265: .Thank you. Sincerely, Nancy ACH Department Sovereign Bank Enclosure Donna Kubik 1517 Woodcreek Drive Mechanicsburg, PA 17055 The Honorable Arlen Specter Hart Senate Office Building Washington, DC 20510 Dear Senator Specter: I am writing to request your assistance in a matter that has significant financial impact on my family due to an error in the date of death of my mother. A human error at the Social Security Administration Office resulted in my mother's death being dated February 8, 2007 instead of the actual date of February 8, 2008. As a result, the government seized $8,492.00 from a bank account because the error treated Social Security payments post 2/8/07 as incorrect. My mother's death was the result of cancer and many expensive medical bills are being refused for payment by Medicare due to the error. A copy of the Death Certificate, the release form from your Harrisburg office, and my Short Certificate from Cumberland County are attached. Your help to resolve this matter as quickly as possible will be much appreciated. Sincerely, ~_~~/~ ~QJ C~J(,J~'~ Donna Kubik (Daughter of Mary J. Hartwigsen/Administratrix) Contact Information Donna Kubik Phone: 717-697-1744 FAX: 240-235-1523 ©3f 31 ~' 2©D8 ©4:52 Dear Friend: ?1?-?61-8265 C ARTHUR & CD .Arlen Specter . U:S. Senator~Pennsylvania Thaak you for your rtquest tfiat I contact the gppropriata Federal agency for infarmatian that mnght prove he[FifuL I will be very" glad to be of assistance in this matter. Under the Privacy Act of i974, whirdt went iato e~oet in September of 1975; I must have writtea . ptantnission of the ittdividuaI whose records will be disclosud 'Ibis law was wriboen to protect every AmrrFean cities from anauthorixed disclosure of gersorial irtfortr~tian without his or her consent. • If tip person wha~see file is involved wiII ~ the rdease form below aad return it to n~}r Iioaisburg oifioa I wild da~what I can bo obtain the necessary inforrn~ation. . S' Ar1at ^/~//////~^~////////.//////////f//////t///////f/^at./////////////•/s/~^/tom/t•///ai Pletue complete this: form snd retain lt, along wlth any sapportlog documentation aad/or correspondeace, to ~P.O. Boz 102, gserrlabitrg, PA I7I(38 or faz to (717) 782-49?A. I graant perrnisaciun to release information requosted in mY behalf fA U.S. Sv[tatar Ariexi Specter. PAGE D2 Ni~14~: ~OI~11~IPt KUCSIK ~p~uGtt"t~2 O~ 'DE~/~sE~ ~1A~Y.~.I~I~Tw~~s~ns~ AI»~xl3ss: t ~ i 7 woo C2 fir ~ ~R N iC . MEct~~Nl,cs~u2 c , Ply »0~5 . ~~eHOrl~: -i t ~ - C~~l?- 1~ y-4 soctAl, ssevltrtyt~ttnv~~: of D~er~s F.o : t g 3 - 30: Z7 ~k~. ANY (xAIM or ID NUl4lBBR: ~ . DATF:ofBIRTH:OF i/EC~.1~'3~rA .lP~t•~uA~zY~ 3rJ939 FEL?BRAL A(~BNCY LNVOLYBD: ._ ~Ct Rst, •~ EC.~121~ [y ~JM! tJ t t'T 2h'[ 1 ~tJ BR1Bl? DESCRII''l'tON OF STiVATION AAID llBSIRBD OVPC011+18: Q SbGrht. SECt.~R,l'hf ERROtt D1°k't~.0 MaTt~s Ds;~h-rw lot zoo? n3o-ir ~co8 ~~ .Tt~ ~"TT$~f~'~O Crc.2TtFteh~iF. CoRre~GT ErttroR; 2~TUR_~ #$.~qZ.-• 71~1tsN Ic'rtclMr~ Ct~:wi.14 RrC.t~JaT tw+4AR.cxi-~ colt~.e~ M~Oteat~ Ft4Fss to l~u.cw PhYn~+rs _~,Q.. ~. S~F~ ~Ra++- X13 S ,~ ?~ 7 -n ~ 1=E8 S moo $ . • DATE. 3~ I / OS STGNAITJRS: /S ~ {~~r`rRtc lar+~E.l~res LOCAL REGISTRAR'S CERTIFICATION OF DEATH - WARNING: It is illegal to duplicate this copy by photostat or photograph. c fir this crrlifir.:uc. Sfi.tHl C~crtilicatiun Numtxrr ;u.tttr agar RF I rlMf N +errtBa . NAG(N. This is to certify that [hc information here given rurrectly copied from an original Certit3cate of De: duly t71ed with ille aS Local Registrar. The origi[ certit7cute will he forwarded to the State Vi e •ords U - ~ •e f ~r perms ent tiling. 1 U~ L.ural Rcgistr:u- Date Issued COw1oN1NF~t7H of PENNSYIYANtA • DEPnR7LE1fT OF 1iEAU)i • vRAI RECORDS CORONER'S CERTIFlCATE OF DEATH fs« p+sEnciions end.xamWas on eeversal srr. 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O ;~~oooooao~ .°oar Ty ~ _ N T o 0 0 0 0 0 0 .O 0~-0 0 0 0 0 0 0; ~ It1'O 0 0 0 0 0 0; n M' ~ ~' w w E "' w r, _N m -w Q U•- ~Om m C~~O-C O: o m r.. c ~ ~~ o~ ~ R Ox..fD ow m m~m3~~` c `O~E~mmm mY U O ~' ~~ 7 V'.U•C ~~+~ ~~ C ~~~C°~C°7~~UQ }- A N O M '. v 1 ~ rl p p . 0 h . 7~`: m s..~..: 'C U_ a ~ ~~ ~oooooooo~ ~o z~~ N O O O O O O O O N N o !A ~O ~ 0 0 0 O O O O~ ~~ ` ~ ~ ~ ~ ro w an. y ~, N I In i °' t ~ U~ ~ D N k V w C N w w ~ w E° my ~ ~' Q. V= 3 0 N G. o w-`~ F'a~i E U~ Y '~ C _ U ~~ ~ ~° oI m oxN.o~° m pC `~I ,D o 00 mmm3yd E cQ- c amE~>~a " maEi m `°Y;v`oE~cc~~. ~~ ;a li ° C Q m 3 M }, ~~ N Active Assets Account Application April 1, 200 For Morgan Staley Use Only ~. To open an Active Assets Account (the "Account") with Morgan Stanley & Co. Incorporated {`Morgan Stanley"s, please complete all applicable sections below. The Active Assefs Account Client Agn~ement ('Agreement`s and the•accompanying Ac#ive Assets Account Fees and Charges Schedule ("Fee Schedules set forth the terms and conditions of the Account and provide important information about Account services and fees. Terms not otherwise defined in this Application are defimed in the Agreement. Please note that you are automaticalh+ requesting margin prnnleges unless you check the "NO MARGIN box in Section 4 of this App~Cation. if you are not a U.S. Person; you must also complete the Morgan Stanley Irrtematianal Client Letter of Eligibility and return d with this Application. You may not be efig~le to participate in the Bank f)eposd Program in Section 3 of this Application or the services in Sections 4, 5, 6 and 7. Ask your Financial Advisor for detats and a copy of the lntemational Client Letter of Eligibility. It you are opening a Custodian, Estate or Guardia account, the services in Sections 4 and 5 of this Application are generally not available to you. If you are opening an Irrevocable Trust accourd, the services in Section 5 of this Application are not available to you. 1. Account Registratioe ^ Indlvldual ^ Custodian (UGfiAA/UTMAI D Persons Trust (Complete Section 91 iPkase note that cGerds who are trot U.S: Persons' may open a custodal account only for a minor who has a U.S. Social Security rpunber.) Joint Account Registration (tile following are the most common forms of joint ownership. Available fomts of joktt ownership may ary by state, and the selection of the form of joint ownership can have important legal and estate•planning consequences. se consult your attorney if you have any questions regarthng the appropriate form of joint ownership for your Account.) / Joint Tenants with Right ^ Tenants by the Errthety ^ Tenants in Corrnaon D Community Property f Survhrorshrp If one owner rtes, tds/Irer if are owner r6es, lis/her For married couples in It one owner des, tas/her interest Passes to the interest passes to his/her AZ, CA; D, tA, IVAt, tW, 7X, interest passes to the survvng owner(s). Laws estate (50/50 unless WA, VN and PR only. Laws surviving owner{s). vary by state. Please otherwise noted). vary by state. consult your attorney. Other Registrationsz O Guardian D Sole Pmprietorsbrp D Famiy- Partnership or D Estate ^ Employee Stock Purchase Plan Family Limited Partnership 2. Account.lrnformation For joint accounts, alt individuals must be named as Account Owners. ti there are more than three individual Account Owners, please provide the requested information on a separate page and attach it to this Application. • For Trust accounts, the name of the Trust is the Primary Account Owner and must match the full name of the Trust in Section 9 of this Application. Please provide the Trust's tax 1D number and mating address . Far sole proprietorships, famtly partnerships or family l'mtited partnerships, the entity is the Primary Account Owner. Please complete and sign the appropriate Certification form and return it with this Application . For Custodian (UGMA/UTMAs and Guardian accounts, the full name of the custodianship or guardianship (e.g., John Smith, Custodian for Jane Smiths is the Primary Account Owner. Please provide the Date of Birth of the Beneficial Owner . For Estate accounts, the estate is the Primary Account Owner . For Custodians, Guardians or Executors, please provide the requested 'reformation where designated. ff there are more than two Custodians, Guardians or Executors, please provide the requested information on a separate page and attach it to this Application Morgan Stanley Pagel.ofl2 (~ ~ ~~ 192-010002-APP-008 007 ss 2n ~~- ~-~`1~~ C~ i ~ ~ X39 Soda) Securty Hgrdrer ar U.S. ~ ~ ~ ~~ Taxpayer tdentibcation Number ht aryl Resderrte: stree- Addrrss _l ~ 7~- 7Jr [1 Yes ~ ~'as oH~ o~ us, e~inn us. ~aeo< he Can only) ~/' /~'^'/' 1 ~V'! Cdv, State era oc Postal cone (and ceunln d outsde the )baled stags) Email Address far Or~dne Aecaurt Access? Ma,'to8 Address Id ddlereat 6om pamary msidencek SUeet Address Giy, Stale and ZP ar Postal Code land coudry d outside the (bated stales) NmU.S. C PassP~ - ~ of Expiation (mm/dd/yyyy} . Passport lssued 6y lCorarbyl~ Fist Addtionar Atcoure uxmegwsmawvuw~av~„a+•~•,• ..-•.~. 1 l 1 ~ U/ ll ~ ~ 3~~ ~1 "1 / rr ,~ S ~ ~, u~.,s R 'age amerstaa Peroen-a~e ~ ~ DaR: of t~rfl- krm~dd/YYyYi ~O- Termds in camrNn or+ty! ~lyand 2P a Postal Code teal outtside the tbrted 5~tesl Pmnary Resdente~s Home Plnrra ~ business Pborre E~mml Address Uequied for Onfire Account Access) ltontf.Se C.'diaerrz: Passport t~rrrrber Date of Fspiration trryrrlddMaM Passport Issued 6Y R:ourrhY}r Secaa Adddiorral Accaert Owrrer/41r tienre ^ Yes O Yes ~ ~ ^ Pb ^ No - Soda) Securely tkrrrrber or U.S. ~ d Beth tmm/dd/yyyy) U.S. (~lizen ~ ll.S. Resident t)rmersli4 Perce~ge Taxpayer Iderdibcatron lkrtr~er (d any) )tor Tenants in Common Drily) Primary Residence: Street Address Coy. State and ~ or Postal Code land cwdry ~ owside the lkrited states) ttorne Phone Business Plrooe Hnad Address IrnNried for Orr6re Accourd Access) Nontt.S. CrT'aens: Passport Nxr~.r Date of Exrxration irten/dd/yyyJl3 Passport Issued by lCourdryl3 Morgan Stanley Page 2°f 12 ,~~~~ Bank~fAmeri~ ®~ •`' ~~5= Bank of America, N.A. Deposit Product Operations P.O. Box 2518 Hoaslon, TX 77252-2518 ~u~~~n~~~~tnn~~ln~ll~ulu~n~n~~~~l~un~ll~~~~n~n 00011323 O1 AT 0.334 13 01132 001 STM500 MARY J HARTWIGSEN 415 CANDLEWYCK RD CAMP HILL PA 17011-8426 Quarterly IRA Statement ~ October 1 through December 31, 2007 Page 1 of 2 00226: Customer Service Information F'or additional information or ser~~ice, ;~o~z may c~ L: 1.888.827.1812 Customer Service 1.800.288.4403 TDD/TTY Users Only 1.800.688.6086 En Espanol egular :IRA Number XXX-XX-2742-000001 Or yvu rray wz-ite to: ® Bank of America, N.A. Deposit Product Operations P.O. Box 2948 Wichita, KS 67201-2948 ie ending balance shown on this statement is the Fair Market Value of your IRA as of the ending to of this; statement. This will be reported to the Internal Revenue Service. This Quarter's Activity ginning IRA Balance as of October 1, 2007 ...................................................................... $2,975.2. ~ney Adcled 31/07 IntE~rest This Period ..........................•---._..__.........-..--......_................--•--•--...................._....................................................$29.3 TOTAL MONEY ADI?ED ............................................................ + $29.3: iding IRA Balance as of December 31, 2007 ...................................................................... $3,004.5 Your Investment Summary ivestmen't Account Interest Opened/ Interest Curren ype Number Rate Renewed Matures This Period Balanc EA-National Education Association 1.800.348.4632 -Customer Service xed Term :IRA 681 004 5154 4535 3.89 04/10/03 04/10/08 29.32 3,004.5 UTAI.S ....•..• ........................•--........ ................................................................. .........$29.32 ................. $3,004.5 ie,BNA .4r„eric<a B~,nt:- t.A rI~'aditional Individual Retirement Account P.O Box 17270 ~A Plan Application/Agreement u e a , c a• LVitmin;;ton. Delaware 19h50-7271! ~aoo-3as-o3'n IRA SIMPLIFIER"~' MEMBER FDIC This docunrertt car:rtot he altered or nmdified. Please prier! all infannation clearly. For Bank Use Only t!_ AltinitV Code r' REA Plan Typc ~ `-- IRA HOLDER'S NAME AND ADDRF,SS IRA CUSTODIAN'S NAME, ADDRESS AND PHONE ,~ MBNA AMERICA BANK, N.A. -~=•f` ; - .=. -_ _ _ P.O. BOX 17270 WILMINGTON, DE 19850-7270 L'' , -' ~_ ~ 1-8(f0-345-0397 Social Security Number Date of Birth Home Phone Business Phone Contribution Type Contribution For Tax Year 1 i _-~ ~ ' ;/ F~~ Regular or Spousal ~ - ` ~ " l SEP (Sintplilicd Employee Pension) Transfer IRA. Account Identification Opening llate Rollover (inrhrdirr,4 a duce! m!/aver lmm an ern lurer' lan) c '~ ~ p p . ^ R h i i _ , y _ - ec artctcr zat on ^ Cltcck here~if this is an amendment to an~e xisting ]RA. DESIGNATION OF BENEFICIARY(ies) The following individual(s) or entiq'(irs) shall he my primary and/or contin~cnt bcncliciary(ics). It' neither primary nor contingent is indicated, the individual or entity will be deemed to be a primary beneficiary. tf more than one prinru't' bencliciary is designated and no distribution percentages are Indicated, the beneficiaries will he deemed to own equal share percentages in the IRA. r~4ultiplc contingent beneficiaries with no share pcreauage indicated will also he deemed to share cyually. [f any primary or contingent bencliciary dies before I do, his or her interest and the interest of his or her heirs shall terminate rnmplelcly, and the percentage share of any remaining beneliciary(ies) shall he increased on a pro r.zta basis. If no primary heneliciary(ies) survives mc, the contingent heneticiary(ies) shall acquire the designated share of my IRA. MESNA dcx not accept "per stirpcti • or "per capita" hcnciiciary designations. If no bencliciary is designated. the estate of the owner will he deemed the beneficiary. This designation applies to all suhseyucnt accounts opened within this plan. No. Name and Address Date of Birth SocNumbernty Relationship Contingent Share % 1 ~ Primary % // /~ L' _ ^ Contingent `CQ ~ ®Primary % Sl 5 I l]~ / ~- l~ _ J C~ ~ ^ Contingent ~~ 3. ^ Primary ^ Contingent ~. ^Primary % ^ Contingent 5. ^Primary ^ Contingent SPOUSAL CONSENT This sectir~n noes! he conrplek•d r% citlrer the, n-ust or the residence r,f the IRA lrrrlder is !orated in rt connrrtntity nr nunital propem• state and lire /RA /rnlder is nrrrrr-ierl. Conrntrurih• nrnun-itnl prz,prrh•.rtcrtes are AL, CA, ID, Ul, NV, NM, TX, WA, AK, and WI. Doe to the inr,norrarrt lrtr cnusc•yuerrces u(~irin,S rep one's cnnunmriry propem> interest, indirirhur/s sil;rrin,t; this section .clrorrlrl rnarrr!! u•ir/r cr c•nnrpek'rtt feu ar le;al nrh•isor: CURRENT MARITAL STATUS I Am Not !Married - I understand that if 1 become married in the future, I must complete a new IRA Desi~~nation Of Beneficiary form. ^ I Am l~ilarried - I mtdcrstand that it 1 choose to designate a prunarv bencliciary outer than my spouse. my spouse nulst sign below. CONSENT OF SPOUSE I am the spouse of the above-named IRA holder. [acknowledge that I have received a fair and reasonable disclosure of my spouse's property and frnancial obligations. Due to the important tax consequences of giving up my interest in this IRA, I have. been advised to sec a tax professional. I hereby give the iRA holder- any interest I have in the funds or property deposited in this [RA and consent to the beneficiary designation(s) indicated above. 1 assume full responsibility; Ibr any adverse consequences that may result. No tax or Ie,>al advice was ~,iven [o me by the Custodian. t Signmurc n( Sryniscl SIC=NATURRS 6apnrtanC Plc'rtsc rend be~nrc .ci,~nin,{. I understand the cligihilit}' requirentcnts li>r the type of IRA deposit 1 am making and I s4uc that 1 do yualily to make the deposit. I have received a copy of the Application, 5305-A Plan Agreement, Financial Disclosure and Disclosure Statement I understand that the terms and conditions which apply to this Individual Retirement Account are contained in this Application and the 5305-A Plan Agreement I agree to be bound by those terms and conditions. 1'irithin seven (7) days from the date i open this IRA I may revoke it without perialh~ by nriilim~ or delivering a written notice [o the Custodian. 1 assume; complete responsibility for 1. determining that [ am eligible titr an IRA each year I make a contribution; 2. insuring that all contributions I make are within the limits set forth by the tax laws; and 3. [he [ax consequences of any cvntrihution (ine)udine rollover contributions) and distributions. k~~2 , j~~ _/ = 0.3 r.' ui.:i u~,r~ren roalei lAuth,uized Signature nl Cuau,dian~ rUate~ (Date! INTEGRITY BANK NEW CUMBERLAND BRANCH, 440 Market Street. New TIME CERTIFICATE OF DEPOSIT NONTRANSFERABLE AND NONNEGOTIABLE PA Account Tale Account Type Taxpayer ID Number ~ MARY J HARTWIGSEN 6 - 11 MONTH IRA 193-30.2742 4~ ~ Payable On Death Beneficiary(les) DONNA M KUBIK ~ Account IVumber Amount Date of issue Maturity Date Tenn 0000000003004881 S 2,000.00 March 26, 2007 September 26, 2007 6 Months 1 Automatic Renewal ~ Interest Rafe Per Annum 4 89 % with a l i ld f Interest Payment Frequency . n annua percentage y e o 5.00 %. Monthl y ~ ° ~ ® Interest Payment Dlspasi6on ~.~ Interest will be capitalized to this ~, certficate. TIME CERTIFICATE OF DEPOSR Agreement_ This Time Cert~cate of Deposit is a part of, and governed by, our Time Deposit Agreement. Among other things, this means that all terms defined in that agreement have the same meanings here. You have received a copy of that agreement, the Truth in Savings disclossires (if applicable), and the fee schedule. You have read them and agree to them. Early VNithdrawal Penalty. We do not have to permit early withdrawals from the account. On each one we do permit, we can charge a penalty calculated as follows: If the term is under 30 days interest will be waived if the accout is Go sed before maturity. If the term is between 30 days and under one year a penalty of one month interest will be assessed. If the term is one year and over, a penalty of three monts interest will be assessed. If there is enough accrued interest to cover the penalty, we deduct the penalty from it. If not, we deduct the remaincler of the penalty from principal. If the account is a variable rate account, we will calculate the penalty using the interest rate being applied at the time of withdrawal. If the account is an Individual Retirement Account, the early withdrawal penalty will be in addition to any penalty imposed under the Individual Retirement Account (IRA) Disclosure Statement. The minimum early withdrawal penalty is seven days' simple interest on any amount withdrawn (a) within the first six days after the account is opened, or (b) within six days after a previous early withdrawal. ,`+,~~ Nontransferable. This Time Certfiicate of Deposft is nonnegotiable and nontransferable. All purported holders or assignees of it agree that t our right of setoff will have priority over any of their claims. .. *** RENEWAL NOTICE *** Inte~7ity ~-~ ~~ ,~larket.chrer DATE 10/05/07 B A N K C.[Il17/J //1//. /~-l / t)// PD~uxc• -! --910- i 900 YOUR CERTIFICATE OF DEPOSIT HAS RENEWED AS DESCRIBED BELOW. ''vJE THANK YOU FOR YOUR BUSINESS AND LOOK FORWARD TO PROVIDING 'YOU WITH EXCELLENT SERVICE AND HIGHLY COMPETITIVE RATES. MARY J HARTWIGSEN 415 CANDLEWYCK ROAD CAMP HILL PA 17011-8426 THANK YOU ACCOUNT NUMBER 3004881 PREVIOUS BALANCE 2 41.33 INT PYMT DATE 0§g26/07 INT CAPITALIZED 8.48 NCE RENEWAL DA E 0§%26%07 NEXT MATURITY DATE 03/26L08 RENEWAL RATE 4.410000 RENEWAL TERM 6 MONTHS 3UY -SELL - 7-BADE CROSSROADS MOTORS HOURS: 10 A.M. TO 7 P.M. USED CARS NOTARY SERVICE • T TAGS !LL NOTARY SERVICE 700 SANS SOUCI PARKWAY - HANOVER TWP. MONDAY THRU FRIDAY TEMP TAGS WILKES-BARRE, PA 18706 12 NOON TO 5 P.M. SATURDAY . PHONE & FAX (570) 825-7988 E-Mail: alicekwiatkowski(~yahoo.com HASER'S NAME- SOC. SEC. ~~~ ~~n$~Sj'Q~!~' Pkitte'I/i! - NO. c~ - ~~ DATE , HASER'S ADDRESS Fta~iv~~~ Twp., ~A 1 ~70r3 D/O/B PHONE NCE ~5 J j 6s-957 BUSINESS STATE & ZIP LIC. NO. PHONE VEHICLE BEING PUR NASED CASH DELIVERED PRICE OF VEHICLE $ 2 ~, ~~ ,~ ^ EW CAR SE ENTER MY ORDERUSED ^ TRUCK STOCK NO. THE FOLLOWING: ^DEMO^ i 4KE MILEAGE ~. ADDITIONAL EQUIPMENT (Options) $ .L OR BODY /' ES ~' /~ TYPE RIM )R LL~ 7 - f%^ T ~~~~ /_ ~{ f NOR C~,tY Y~ ..YJ ~"/ TYPE ~ I E DELIVERED SALESMAN )R ABOUT ~~ f .NEW VEHICL-E SALE ... ff d b th i hi h hi l ere y e c e are t ose o ng to t s ve only warranties apply ufacturer. ~~ ~ ISED VEHICLE SALE-CHECK APPROPRIATE BOX " " by us. This motor vehicte is sold as is as is 4S IS: this Vehicle is sold .without any warranty. The purchaser will bear the entire expense of or correcting any defects that presently exist or rhat may occur airin •e g p in the Vehicle. OR The only Dealer Warranty on this vehicle is the Limited Warranty whicfi is issued with ancf made a part of this order form. UTRACTUAL DISCLOSURE STATEMENT FOR USED VEHICLE ONLY le information you see on the window fprm for this vehicte is part con- w form overrides an th ind ti I f y e w on on o orma n :his contract. y provisions in the contract of sale: ' USED VEHICLE TRADED IN AND/OR OTHER CREDIT AR MAKE OF TRADE-IN MILEAGE DEL OR BODY 21E5 TYPE LOR TRIM /.t.OR ENG. R. NO. TYPE :ante Owed To: (dress: Casfi Price of Vehicle & Accessories ~. ~: ~v ed Trade-In AIloettance ~ STATE AND LOCAL TAXES (If anyi lance Owad on Trade-tn Documentary Fee tt Allowance on Used Trade-In $ License, License Transfer, Title, Registration Fee aposit or Credit Elalance rsh With Order $ TOTAL PRICE OF UNIT OTAL CREDIT (Transfer to Right Column! $ TOTAL CREDIT (TRANSFERRED FROM LEFT ` COLUMN ~ ~ ~lJQ EMO: UNPA{O CASH BALANCE DUE ON DELIVERY ~- J 'urchaser agrees that his Order on the face and reverse side hereof and any attachments hereto includes alt the terms and conditions, that this Order cancels and upersedes any prior agreements and as of the date hereof comprises the complete and exclusive statement of the terms of the agreement relating to tlfA subject natters covered hereby, and that THIS ORDER SHALL NOT BECOME BINDING UNTIL ACCEPTED BY DEALER OR HIS AUTHORIZED REPRESENTA- 'IVE. Purchaser by his execution of this Order acknowledges that he has read its terms and conditions and has received a true copy of the Order, IF A D000- JIENTARY FEE OR PREPARATION ARGE IS~ADE, YQU HAVE: A RIGHT TO A WRITTEN ITEMIZED PRICE FOR EACH SPECIFIC SERVICE 'ERFORMED, Cleatersppmay ndt har~st mers for w vuhi paid for by the manulacturer. 4ccepted By::~ ~ D- ~ ~ ~ ;~L Date ,_ - ~ er. r His t ed Re(5resentative Date Purchaser's Signature ••-•.-.~.. vnrt _ wF APPRECIATE YOUR BUSINESS" REV. 10/1 CROSSROADS MOTORS 86-9457CR 700 SANS SOUCI PKWY. WILKES-BARRE, PA 18706-1331 60- 3 5086. 1 r~ 717 5 r. nm cros~oaes Once i ~' %~ ~:03~302955~: `~-8f7~6!"27~i'7L75 Nov-18-08 06:36A Hewlett-Packard Company PENNSTlYA1'11A lt'ttt>rRi I a+ni.= i ~+.. INFORMATION NOTICE OUREAU Olc INDIYIDUAL TAXES AlID Po BDx a~eosol TAXPAYER RESPONSE HARRISBUIRG PA 17126-0601 asr-°su sx irv cea-n° I DONNA KUBIK 1517 WOODCREEK DR MECHANICSBURG PA 17055 P_02 FILE N0. 21 08-0284 ACN 08151733 DATE 11-04-2008 EST. OF MARY J HARTWIGSEN SSN 193-30-2742 DATE OF DEATH 02-08-2008 COIINTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT ® SAYINGS CHECKING [] TRUST CERTIF. LJI.K/w'.c- t~l ~ ~G~ BANK OF AMERICA Provided the Department with the infereatian bolow, which has boon usod n cslculatinp the potential tax duo. Records indicate that at the death of the above-nered decedent, You wer• a ioint owner/beneficiary of this account. If you foal the information is incorrect, please obtain written eorreetien from the financial institution, attach a copy to this form and roturn it to the above address. This account is taxable in sceordance with the Inheritance Tax laws of the Cowaonwaalth of _ _ Pennsylvmia. Plaasa call C717) 717-8321,1Litb quastiens. - _ -_._ ._ -- -- COMPLETE PART 1 BELOW * SEE REYERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 000574652053 Dato 02-04'2003 To ensue proper credit to the account, two Established copies of this notic^ oust accoopenY psyment to the Ropister of Ylills. Make check Acc:aunt Balance S` 335.47 108, payable to ^Reeister of Wills, Apent". Percent Taxable X 50.000• NOTE: if taz payments ere nsde within three Amount Subject to Tax ~` 54,167.74 ronths of the decedent's dat• of death. Taff Rata X . 045 deduct a 5 percent discount on the tax due. Anv Inheritance Tax dua will bacow• delino~ent Po1[ential Tax Dua $ 2, 437.55 nine months after the det• of death. PART TAXPAYER RESPONSE ^ ~ ~ -.:~ - A. ~ Th• above infonation and tax due is correct. Rea it paysent to the Ropister of Wills with two copies of this notice to obtaln C H E C K a discount or avoid interest, or chock box "A^ and roturn this natico to the Ropister of Mills and an official assessment will be issued by the PA Department of Revenue. C DNE a L C CK B. The above asset has boon or will be reported and taz paid with the Pennsylvania Inheritance Tax roturn ON L Y to be filed by ifi• estate representative. C. ~ The above inform ion is incorr et and/or debts and deductions zero paid. Coaplote PART ~2 and/or PART ~ below. PART If SndicatSn9 a differont tax rate, please state ° ~ ~'~ »~ %Y" ralatlonship to decedent: ri ~`1 ~~ a ~_. ~ ~ , ~ ~~ TAX RIETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS g ~~{'e' a eg ",'Ft~:"~~- .o .. _ _.. LINE 1.. Bata Established 1 2,. Account Balance 2 ~ ~~'' ~~- - ,~. r~ a~; 3.. Percent Taxabl• 3 X "~~ a~3~u~ - ~~ ~'lla ~. . '-'1~. sa m "3'.i 4. Amount Subject to Tax 4 5. Debts and Deductions 5 _ -' 6. Amount Taxabl• 6 6 t ~A ~ l 6 1~ ' a i ~.y. A` '7~ 7. T a x R a t e 7 X „ '"' ~ ~ ~~ihr"iY$ L 3 ' -... 8. Tax Due 8 +~ ~ ~ ._a. "}' - ,_ .:.:. aaRr DEBTS AND DEDUCTIONS CLAIMED Under penalties of perjury. I declare that the facts I have reported sbova era true, correct and complete to the bast of my knowledge and belief. HOME C ) WORK c ) TAXPAYER SIGNATURE TELEPHONE NUMBER DATE DATE PATD PAYEE DESCRIPTION AMOUNT PAID Aug-06-08 01:56P Hewlett-Packard Go)npany P_02 CDMMOtME:ALTH OF PENNSYLVANIA DEPARTNF:NT OF REVENUE INFORMATION NOTICE BUREAU Of INDIVIDUAL TAXES AND FILE N0. 21 08-0284 DEPT. 21SD601 ACN 08135498 NARRISBURG, PA 171za-o6~1 TAX P AY E R R E S P O N S E DATE 08-07-2008 acv-ISba EX srr (09-00] TYPE OF ACCOUNT EST. OF MARY J HARTWIGSEN ~ SAVINGS S.S. N0. 193-30-2742 ® [NECKING DATE OF DEATH 02-08-2008 ~ TRUST COUNTY CUMBERLAND ~ CERTIF. REMIT PAYMENT AND FORMS T0: *~ DONNA M KUBIC REGISTER OF WILLS 1517 WODDCREEK DR CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055 CARLISLE, PA 17013 ~~ INTEGRITY BANK has provided the Departwent with the inforwation listed bolox which has boon used in calculatiing the potontisl tax due. Their records indicate that at the death of the above decadent, you wore a joint owner/beneficiarv of this account. ]f you fool this inforwation is incorrect. please obtain written correction frow the financial institution, attach a copy to this forty and roturn it to the abovo address. This account !s taxable in accordance with the Inheritance Tax Lavs of the Cowaornroalth wt Ponnsylrenta. Questions way be artmred try Gelling-(717] 737-8327. COI+IPLETE PART 1 BELOW tF * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 2D3009229 Date 03-31-2007 Tg insure proper credit to your account, two Established (2) copies of this notice roust accowpany your Account Balance 17,747.10 paywent to the Ropiztor of Wills. Nako check payable to: "Register of Wills, Agent^. Percent Taxable X 100.OD - NOTE: If taz paywents are wade within throe Amount Subject to Tax 17~747.1D (3) months of the decedent's date of death, Tax Rate X )(~~~ you way tleduct a 5X discount of the tax due. Any inheritance tax due will bacowe delinquent Potential Tax Due 2-66~~ nine (9) wanths after the data of death. PART TAXPAYER RESPONSE ~ikTi ditltr'.''t# ds+QOiia~i-: E~'r~:t--~ia~{~~~.":R~i~akli'is~~rfi"~~r~~:i~s~;~i~~a~ae~~ii~~:s~e~~._~..,:r~':_v~rfr~.~`;~~ A. ~ The abovo inforwation and tax due is correct. 1. You way choose to rewi4 paywent to the Register of Wills with two copies of tfiis notice to obtain C HE C K a discount or avoid interest, or you way cheek box "A" and roturn this notice to the Register of C ONE J Wills and an official assesswent will be issued by the PA Dspartwent of Revenue. B L DC K D.~ 7ha abovo asset has bran or will ba reported and tax paid with the Pannsvlvania Inheritance Taz return D N L Y to be filed by the de codent•s reprosantative. C. ~ Th^ abovo inforwation is incorrect and/or debts and deductions ware paid by you. Vou must coeplete PART 2~ and/or PART Sa below. PART If you indicate a different tax rata, please state your ,,~ F~y''~ ~~~~+~~~ ~4~~~~ ^Z relationship to decedent: .,,4...@9{,.} ;,a.~~~i.:.:_.,..,_.'~~~ f-__,:;z:~ ~ .-...-,,.~...: TAX RETURN - COMPUTATION LIRE 1. Date Established ^ 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rwte 8. Tax Due PART OF TAX ON JOINT/TRUST ACCOUNTS s ~ s$k 3 X *e$ t:, y ~, 3, R' 4 . =~Y~,.. ,,'. R ~ ' 3 F ~ ' ~ ' ~ i 5 - . s : n ., i i r .' ' ~.w. $+c~s~~.c~K 6 ;~ „t~~M. ;y~yn ' i;,a,s. DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID TOTAL [Enter on Line 5 of Tax ComputatiorU • Under penaltiws of perjury. I declare that the facts I have reported above aro true, correct and coapleta to the best of wy knovledga and belief- H ONE C ) WORK C ) TAXPAYER SIGNATURE TELEPHONE NUMBER DATE PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE AND FILE NO. 21 08-0284 BUREAU OF IIJDIVIDUAL TAXES ACN 08145713 PO BOX 280601 TAXPAYER RESPONSE HARRISBURG PA 17128-0601 DATE 10-08-2008 REV-1543 IX I1FP COB-OB) TYPE OF ACCOUNT EST. OF MARY E HARTWIGSEN ^ SAVINGS SSN 193-30-2742 ® CHECKING DATE OF DEATH 02-08-2008 ^ TRUSr COUNTY CUMBERLAND ^ CERTIF. REMIT PAYMENT AND FORMS T0: DONNA M KUBIK REGISTER OF WILLS 1517 WOODCREEK DR CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055 CARLISLE, PA 17013 SOVEREIGN BANK provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvaniai. Please call (717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0571124909 Date 01-25-1994 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Accoulnt Balance $ 3, 907 • 36 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 1 , 953.68 months of the decedent's date of death, X `~ deduct a 5 percent discount on the tax due. Tax Ftate Any Inheritance Tax due will become delinquent Potential Tax Due $ 293.05 nine months after the date of death. PART TAXPAYER RESPONSE FAILURE TO RESPOND WILL RESULT IN AN CIFFICIAL TAX ASSESSMENT The A above information and tax due is correct. . ^ Remit payment to the Register of Wills with two copies of this notice to obtain discount or avoid interest, or check box "A" and return this notice to the Register of C H E CIC a Wills and an official assessment will be issued by the PA Department of Revenue. C ONE $ L D C K ^ The B above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y' . to be fil ed by the estate representative. C. ^ The above informs ion is incorrect and/or debts and deductions were paid. Com plete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RE1fURN - COMPUTATION LINE I. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS ~ 1 z $ 3 X 4 $ 5 - 6 '~ 7 X 8 $ PAD OFFICIAL USE ONLY ~ AAF PA DEPARTMENT OF REVENUE I 2 3 4 5 b 7 8 PART DEBTS AND DEDUCTIONS CLAIMED ____ ... _.. OAVCC DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. HOME C ~ WORK C __-__ ___...r...,~ TELEPHONE NUMBER DATE PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU CIF INDIVIDUAL TAXES AND FILE N0. 21 08-02$4 PD Bax 2BB6ol TAXPAYER RESPONSE ACN 08145712 HARRISBURG PA 17128-0601 DATE 10-08-2008 REV-1543 EX AFP f08-Oel TYPE OF ACCOUNT EST. OF MARY E HARTWIGSEN ^ SAVINGS SSN 193-30-2742 ® CHECKING DATE OF DEATH 02-08-2008 ^ rRUST COUNTY CUMBERLAND ^ CERTIF. REMIT PAYMENT AND FORMS T0: DONNA M KUBIK REGISTER OF WILLS 1517 WOODCREEK DR CUMBERLAND CO COURT HOUSE MECHANICSBURG PA 17055 CARLISLE, PA 17013 SOVEREIGN BANK provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 1051078091 Date 06-22-1998 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 10,213.94 payable to "Register of wills, Asent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to TaX $ 5, 106.97 months of the decedent's date of death, Tax: Rate ~( ~-'` G('~J deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due $ 766.05 nine months after the date of death. PART TAXPAYER RESPONSE ~ FAILURE TD RESPOND WILL RESULT IN AN OFFICIAL TAX A55E55MENT A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. ONIE B L D C K B. ^ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ^ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3^ below. PART If indicating a different tax rate, please state QFFICIAL USE ONLY ^ AAF relationship to decedent: PA DEPARTMENT DF REVENUE TAX RE TURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1. Date Established I I 2. Account Balance 2 +~ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 5 6. Amount Taxable 6 $ (, 7. Tax Rate 7 X 7 8. Tax Due 8 $ g PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE F'AID PAYEE DESCRIPTION AMOUNT PAID TOTAL CEnter on Line 5 of Tax Computation) $ Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. H OME C ) WORK C ) TAVDAVCD CT!`61A TIIDC TCI rDUnur uuunrn .~.rr- A. Settlement Statement U.S. Department of Housing and Urban Development OMB Approval No. 2502-0265 (expires 11/3012009) B. Type of Loan 6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number: 1, ^ FHA 2. ^ FmHA 3. ^Conv. Unins. A06-038297-STG 0089155352 101060597386 4. ®VA 5~ ^Conv. Ins. 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 the closing; they are shown here for informational purposes and are not included in the totals. D. Name & Address of Borrower: E. Name 8 Address of Seller: F. Name & Address of Lender: Kevin S. Lush Estate of Mary J. Harfwigsen Wells Fargo Bank N.A. 521 Pennsylvania Avenue 415 Candlewyck Road One Home Cam us, MAC X2303 04U, Des York, PA 17404 Camp Hill, PA 17011 Moines, IA 50328-001 Lyanna L. tu:ak 521 Pennsylvania Avenue York, PA 174(14 G. Property Location: 415 Candlewyck Road Camp Hill, PA 17011 Cumberland County H. Settlement Agent: Rescission Date: Law Office of Darrell C. Defhlefs T1N: 25-1727631 Place of Settlement: 2132 Market Streef Camp Hill, PA 17011 I. Settlement Date: 07/25/2008 J. Summary of Borrower's Transaction K. Summary of Seller's Transaction ~no_ Gross Annount Due From Borrower 400. Gross Amount Due To Seller 101. Contract :sales price $250, 000.00 401. Contract sales price S250, 000.00 102. Personal property 402, Personal property 103. Settlement charges to borrower (line 1400) $lI, 816.96 403. 104. 404. 105. 405. Adjustments for items paid by seller in advance Adjustments for items paid by seller in advance 106. City/town taxes to 406. City/town taxes to 107. County taxes 07/25/2008 to 12/31/2008 $386. 72 407. County taxes 07/25/2008 to 12/31/2008 $386.72 108. Assessments 07/25/2008 to 06/30/2009 51,868.58 408. Assessments 07/25/2008 to 06/30/2009 $1,868.58 109. Sewer,: 07/25/2008 to 09/30/2008 $23.65 409. Sewer: 07/25/2008 to 09/30/2008 $23.65 i10. Trash: 07/25/2008 to 09/30/2008 541.02 410. Trash: 07/25/2008 to 09/30/2008 541.02 111. 411. 112 412. 120. Gross Amount Due From Borrower 5264, Z36. 43 420. Gross Amount Due To Seller $252, 319.97 200. Amounts Paid By Or In Behalf Of Borrower 500. Reductions In Amount Due To Seller 201. Deposit or earnest money S3, ooo. 00 501. Excess deposit (see instructions) 20Z. Principal amount of new loan(s) $295,150.00 502. Settlement charges to seller (line 1400) 519, 835.09 203. Existing loan(s) taken subject to 503. Existing loan(s) taken subject to 204. 504. Payoff of first mortgage loan 205. 505. Payoff of second mortgage loan 206. 506. 207. 507. 208. 508. 2pg. 509. Adjustments for items unpaid by seller Adjustments for items unpaid by seller 210. City/town taxes to 510. City/town taxes to 211. County taxes tO Si 1. County taxes to 212. Assessments to 512. Assessments to 213. 513. 214. 514. 215. 515. 216. 516. 217. 517. 218. 518. 219. 519. 220. Total Paid By/f=or Borrower 5248,150.00 520. Total Reduction Amount Due Seller 519, 835.09 300. Cash At Settlement From/To Borrower 600. Cash At Settlement To/From Seller 301. Gross amount due from borrower (line 120) 5269,136.43 601. Gross amount due to seller (line 420) 5252, 319.97 302. Less amount paid by/for borrower (line 220) ( 5248,150. oo) 602. Less reductions in amt. due seller (line 520) 519, 835.09 303. Cash ®From ^ To Borrower 515,986.93 603. Cash ®To ^ From Seller 5232,x84.88 Section 5 of the Real Estate Settlement Procedures Act (RESPA) requires the following: HUD must develop a Special Information Booklet to help persons borrowing money to finance the purchase of residential real estate to better understand the nature and costs of real estate settlement services; Each lender must provide the booklet to all applicants from whom it receives or for whom it prepares a written application to borrow money to finance the purchase of residential real estate; Lenders must prepare and distribute with the Booklet a Good Faith Estimate of the settlement costs that the borrower is likely to incur in connection with the settlement. These disclosures are mandatory. Section 4(a) of RESPA mandates that HUD develop and prescribe this standard form to be used at the time of loan settlement to provide full disclosure of all charges imposed upon the borrower and seller. These are third party disclosures that are designed to provide the borrower with pertinent information during the settlement process in order to be a better shopper. The Public Reporting Burden for this collection of information is estimated to average one hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number. The information requested does not lend itself to confidentiality. form HUD-1 {3/86) Previous editions are obsolete Page 1 of 2 ref Handbook 4305.2 L. Settlement Charges 700. Total Sales/Broker's Commission based on price $ $250, 000.00 @ 6 %= S15, 000.00 Paid From Paid From Division of Commission (line 700) as follows: Borrowers Seller's Funds at Funds at 701.$ $15,000.00 tp Re/Max Realty Associates, Inc. Settlement Settlement 702. $ to 703. Commission paid at Settlement $15, 000.00 704. Transzrction Fee to Re/Max Realty Associates, Inc. $195.00 $195.00 800. Items P<ryable In Connection With Loan 801. Loan Origination Fee % Wells Fargo Bank N. A. 802. Loan Discount 0.2500 % We11s Fargo Bank N.A $612.88 803. Appraisal Fee to RE'S Direct ( $325. 0o P.o.c.l 804. Credit Report to RELS $19.89 ( $5. 00 P o.c l $9.84 805. Lender's Inspection Fee RES Direct $100.00 806. Mortgage Insurance Application Fee to wells Fargo sank N.A. 807. Assumpl:ion Fee wells Fargo Bank N.A. 808. Flood Life of Loan Fe to WF Ins. Inc. $19.00 gpg.Processing Fee to WFBNA $395.00 810. VA Funding Fee (Financed) $5,150.00 811. 812. 813. 814. 815. 816. 817. 818. 819. 820. yUU. Items KegUlrea t3y Lender ro tse Pala In Advance 901. Interest from 07/25/2008 tp 08/01/2008 @$ $92.82 /day 5299. 79 902. Mortgage Insurance Premium for months to Wells Fargo sank N. A. $10.00 903. Hazard insurance Premium for 1.00 years to state Fawn ( $515.00 P.o.c.> 904. years to 905. 1uuu. rcesenres ueposrtea with Lender 1001. Hazard insurance 3.00 months @$ $92.92 per month $128.76 1002. Mortgage insurance months @$ per month 1003. City property taxes 7.00 months @$ $19.88 per month $139.16 1004. Count} property taxes e. 00 months @$ $38.99 per month $307.92 1005. Annual assessments months @$ per month 1006. months @$ per month 1007. months @$ per month 1008. School Taxes 2.00 months @$ $171.89 per month $393. 68 1009. Aggreciate Accounting Escrow Adjustment ($373.27) $o. 00 ~ ~uu. r rcre charges 1101. Settlerent or closing fee to LAW OFFICE OF DARRELL C. DETHLEFS 1102. Abstract or title search to 1103. Title e:camination to 1104. Title insurance binder to 1105. Document preparation to Re/Max Realty Associates, Inc. $125. 00 1106. Notary fees t0 Law Office of Darrell C. Dethlefs $25. 00 $5. 00 1107. Attorna~y's fees to (includes above items numbers: ~ 1108. Title tnSUranCe t0 Security Title/Law Office of Darrell C. Dethlef; $1, 758.75 (includes above items numbers: Basic - 3 End. ) 1 109. Lender's coverage $ $295, 150.00 ( $295,150.00 ) 1110. Owner's coverage $ S25o, ooo. oo ( $250, ooo. oo ) 1111. C1os.inq Service Letter Fee to Security Title $35.00 1112. 1113. i zuu. ciovernment Kecoraing and 7 ransrer charges - -. - 1201. Recording fees: Deed $ 538.50 ;Mortgage $ $70.50 ;Releases $ 5109.00 1202. City/county tax/stamps: Deed $ $2,500.00 ;Mortgage $ 52,500.00 1203. State i:ax/stamps: Deed $ S2,5o0. 00 ;Mortgage $ 52,500.00 1204. 1205. 1300. Additional Settlement Charges 1301. Survey to 1302. Pest inspection to 1303. Overnight Fee to Law Office of Darrell C. Dethlefs (UPS) $26.00 1304. Law Office of Darrell C. Dethlefs (email Doc Fee) $25.00 1305. Bonnie X. Miller (Tax Cert Fee) $10.00 1306. Bonnie K. Miller, Treasurer (2008-09 School Tax Bill) $2,000.09 1307. 1400. Total Settlement Charges (enter on lines 103, Section J and 502, Section K) 511, 816.46 $19, 835.09 form HUD-1 (3/86) Previous editions are obsolete Page 2 of 2 ref Handbook 4305.2 Certification (continued from HUD-1) I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, it is a true and accurate statement of all receipts and disbursements made on my account or by me in this transaction. I further certify that I have received a copy of the HUD-1 Settlement Statement. Borrower: ~~ ~~ KevirJ.13. Lusk Seller or Date: ~`~i~ ~' Agent: ~~~ (.(/J~ ~ .Date: - ZS'- G~ Donna Kub ,Executrix Estate of Mary J. Hartwigsen 1 ~~ ( Seller or Borrower l Date: ~~ ~jb Agent: y nna L. Lusk i Date: Estate of Mary J. Hartwigsen The HUD-1 Settlement which i have prepared is a true and accurate account of this ra saction. I have caused or will cause the funds to be disbursed in accordance with this statement. Date: Settlement Agent: Date: ~ ~~"~ f' Da . Dethlefs, Esquire WARNING: It is a crime to knowingly make false statements to the United States on this or any other similar form. Penalties upon conviction can include a fine and imprisonment. For details see: Title 1$ U.S. Code Section 1001 and Section 1010.