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HomeMy WebLinkAbout02-25-0915056041046 REV-1500 EX (05-04) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes " ~- INHERITANCE TAX RETURN Dept. 280601 Q ~ C3 ~ ~ ~ ~~ Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~ ( ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~ ~Zo~~~~'~ o~~-7f 4~ Decedents Last Name Suffix Decedents First Name MI (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 Original Return ~ 1 O 2. Supplemental Return O 3. Remainder Return (date of death . prior to 12-13-82) O Future Interest Compromise (date of O 5. Federal Estate Tax Return Required 4a O 4. Limited Estate . death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) Litigation Proceeds Received O 9 O under Sec. 9113(A) ax 10. Spousal Poverty Credit (date of death O 11' . O Attach Sch between 12-31-91 and 1-1-95) ( ) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SrtOUI_u Ist uirctt= i to i v: Name Daytime Telephone Number Firm Name (If Applicable) First line of address l' ~ v ~ ~v c ~ ~- Second line of address City or Post Offce e ,~ .~ P !~ ~ ~ ~ Q k' l ~ ~ r.,~rocnnnriant's a-mail address: !~C L- /'~'C: ~v G State ZIP Code ~,~9 ~ ~~ o REGISTER OF WILLS USE ONLY ~~ _ r~s c~ ':7 a -~ sa `''.7 - C:t.7 ~~ - j C..~f ~ i -'^~ - 3 .. a-. TE FILED`" ; - r.~ - ; .. .::~ .`.r:~ /~ gay <_.•.~ ,_ , ~, , Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my xnowieage anu ueiiei, 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. SIGNATUSIf;i OF PER,SOI nRESPON~I~E FOR FILING RETURN D~}TE ADDRESS / ~~n~~~~.~-. ~.E'/t~c' Ci4.+~i° /~/fit /~j{ r/ICt f/ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY 15056041046 / Side 1 15056041046 J J 15056042047 REV-1500 EX Decedent's Social Security Number Decedent's Name: RECAPITULATION 1. 2~2~'d• 1. Real estate (Schedule A) . ........................................... . 2, `3~ ~~t~s \. 2. Stocks and Bonds (Schedule B) ...................................... . 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. .. 4. 4. Mortgages & Notes Receivable (Schedule D) .......................... . 5. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... . 6. Jointly Owned Property (Schedule F) C Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) C Separate Billing Requested........ 7. o T,..~i r_~~« OcsPts (total Lines 1-7) .................................... 8. 9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9 10 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............... . 11. Total Deductions (total Lines 9 & 10) ............................ . 12. 12. Net Value of Estate (Line 8 minus Line 11) ............................. . t I Be uests/Sec 9113 Trusts for which ~ l 5 358. 23 Sd S. ~~ 2 g /ossy. ~ ~'. <-- ~ ~ . f ~ 13. Chartable and Governmen a q lection to tax has not been made (Schedule J) .................... 13. ... . • an e 14. ........ Net Value Subject to Tax (Line 12 minus Line 13) .......... . ....14. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 ~ 15. • 16. (a)(1.2) X .0_ Amount of Line 14 taxable 16 ~ ~ ~ ~ ~'7 at lineal rate X .0~ 17. Amount of Line 14 taxable ~ 17 • at sibling rate X .12 18. Amount of Line 14 taxable 18 • at collateral rate X .15 ~~ '~ Z~ . ...... .....19. 19. TAX DUE .............................................. O 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15056042047 15056042047 J REV-1500 EX Page 3 Decedent's Complete Address: File Number STREET ADDRESS - CITY _ __ _ __ _ _ _ _ _ _ __ ~~ /~A /~~L.L.. _ STATE~~ ,ZIP l~cU /~ 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 ~~~ ~~ 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. 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) ~ ~~i~~''~~ (3) (4) (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) ~ ~~ ~~~ «~~ Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE AP P ROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No / a. retain the use or income of the property transferred :.................................. b. retain the right to designate who shall use the property transferred or its income : ........................................... . ^ ^ ~ c. retain a reversionary interest; or ......................................................................................................................... . ^ , ~ / fl/J d. receive the promise for life of either payments, benefits or care? ..................................................................... . ^ d 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .................... 3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? ............. . ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ ~ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES YOU MUST COMPLETE SCHEDULE G AND FIL E IT , AS PA RT OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(x)(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 wiwl~ ur FILE NUMBER 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 rlaht of ~~~.,,T~~r~hl., ~.~~~f ~.e.~:....~....~~ __ ~._~_~__._ .. ~~. ~~~~~~ ~Na~c ~~ ~iccucu, nwcn nuuniunai snee[5 OT Ine Same SIZE) REV-1503 EX+ (6-98) ~ SCHEDULE B , COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER T~as(AS F F~larJv€~P ~t - O'~ -12Sa All property jointly-owned with right of survivorship must .lie disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH ,. GE.`'F.29t cGEc.PIc c~ ~ ~~ ' ____- _ _- __- . o~_ .S~!lo/l~ - - , ~a~ ~ Latltl~-~?~ Zo C 3 ~ b _~ ~x~ __v ti __-__ _.. _~.lC_.E~~tJ4 _ / va _~_._, ~_. ~ << a u cc _ ~~ ~DIv~DEa,4 ~~/~~~ _ _.__ _ --- -- _._ _ ~ __. .4~'0.~ vivact ~vAa-~lv~ ~_~.__ 73 S~.P~s ____ ____._ __~_.~N4 2~~6 ,r._ __-- ZZ ZZ1 _ 5. - , _Y.._~, _ ... iV/.!T/av w/,~c /~~O~TN piQd~/.~1.. ~3Lo Sly Crs~r.~t .. _ _. _.u .Pc~s _ - ____~.._._~.. _..___ o.v ._r e~:~s~. .. ~_. _ _... _.- ~ 3Z _ ~ ~~~wE,~o !z/a$ ) ~ ~ l ~I l 7. _ P.~~ Co~F~ - .--___~._._.- ~ _ T .~ ~ ~_~J'082 .SN~I.PcS._Co,tlrl c~ ..:.. ~_~..3 3~ 9s~ _ ~'' C>, 5. SAt?~ n1 Gs Ba.,i!1J5 ~ s~ c ~TT.9 cN~I~E.~T~S~ _~____-__ ..,___~. __.___._ _ 96 9 - __ - `` `~ `` ~ ~ '~~'a.ll' ~.~~ __ _ - -- ----- - ~ mod w TOTAL (Also enter on line 2, Recapitulation) I $ 3 (If more space is needed, insert additional sheets of the same size) REV-1508 EX ~ (7-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. IN RESIDENTDECEDENTRN PERSONAL PROPERTY ESTATE OF T/,~~~G 4S ~" Ntx~vC.~' FILE NUMBER Z ~ o ~ /2 8a Indude the proceeds of litigation and the date the proceeds were received by the estate. All property jointty-owned with the right of survivorship must be disclosed on Schedule F ITEM . NUMBER DESCRIPTION VALUE AT DATE OF DEATH ,. __ p,,,~ ~~K ~~ ~_~_ ice- ~H t /60 dal/n~G ~s( ~ Sr ' ' -. ~ ,~ . o 3a ~ i Z~ 3• rt_ w H ~eri~~~f rE`- Oc~os rr- C 3/ D _ _ _ _ _ __ ______ _ __ ~,3 i9 ~ S3 ~ --- ~ 88 u u ~ --- _-- - ~/F/GTR. QE~~sn~( ~ // .._ "-.i_... ~ .. \ ----- ----__~- _ 5, /~t?Tc.P~/ry ~I~K c~QT~F.1~r~'E~~d~°~rtr~ ooU30o8 G. ~t,OC~ /T /h1sr~ ~sN ~'~to.~c-y MA.~'h'ET-,,.~~iv_c. ~, 7, Zoo ,Bl~/CK Ct~rJ?c.r•P~/- S_z~tloa ~it~5 ~i~EGC~,~UF /~a~sc /~~, ,o ~- ~ Gtr 5 /J~1 A ~v.~.rlisf~/.JGS .e; 9. CA 5 ~f o.~ ~A~v,~ 3.7t.~?...~,. ._- Zoo ____ __ Piu c /N v~ s% r~t~TS 9a% Gvc~~?-- Gd vc"%~%vvf~ ~P.o .~.P1~Y ~ /~ 33 r/ TOTAL (Also enter on line 5, Recapitulation) I S 2 ~~ 3~ (If more space Is needed, Insert addltlonal sheets of the same size) REV-1510 EX • (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF TJ-f ~.~'(/t'S ~` float ITEM 1MBE ._~' __ SCHEDULE G INTER-VIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY FILE NUMBER Zi-a~-/2$0 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY % OF INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH DECD'S EXCLUSION VALUE OF ASSET INTEREST IF APPLICABLE J~P.4 C~~ iavEr,-.~rE,~-r.~ .4cc~'°4~~8.~-~3~~~ 'Z3, 503' /o~~; o TAXABLE VALUE ~.3, ~~ TOTAL (Also enter on line 7, Recapitulation) 13 ~ ?, . ~~ ~- REV-1511 EX+ (10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER _ TfIa~S ~ No~c1E-P 2f - o~ ° 1 Zgo Debts of decedent must be reported on Schedule I. ITEM A. FUNERAL EXPENSES: t. ~.~1i2%y~MO.P~"' ~v~tJc.~,~I~. ~t~+!tE ~•r?.4_-C.c~~.tTla.J 5~~`.ccs _ lid ~ '~~JG_c _.~_.. •2.?c c~ _ ._3.E~~ ~ _ S'T tllc, W CU,~/,Bc ~4gtlf B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City ~ Year(s) Commission Paid: State Zip ~i~yS.S~ ~S c n Vic!/,tlct~i 89S ~k~ A-~--~ cv,•rc-,~7- t 2. Attorney Fees 2 Ac'~~iDs -~J,/~t3SE _/,~gM4,~~ fc~CG~f~ly~ ~Er~'$,} /~f~T.'~~'y~ecs 398 3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) /~ ~ 3,500 Claimant !l DQ~ s 1, ~-/00 IJ aer~ Street Address ~ ~,{1,/'~~,'t ~"',~, "~~~'" City ~) ~t~° 1t//LL. State ~~ Zip ~T4 // Relationship of Claimant to Decedent So n1 4• Probate Fees GTiPf ?EST ~ i sd„~S~O~E'T" C~~-; - 2~„~~~~~~y~ ~ ~P Ate, ~ , ..__ _,.__ __,~_~.~.._~_ ._~...._._- ~. Yo 5. Accountant's Fees 6. Tax Return Preparer's Fees ~. PoST~Ct'~ i9r~© /NS. CSAU/NO'S /~th?d ~~~ef~'T/Q~J 8. A~/J/1~1 ! say fiEE - ,~a ~ s ~ Z 7~. 9 ~~,eAisa~. _ fi~E__- _ _ _ _ ~.9wo _ __----- - - 3~a TOTAL (Also enter on line 9, Recapitulation) $ l Q,j S (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ 02.03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH ~. Mgt STi~2GkQ.0 ~A•t.4NC ~ ~/~/D /2 ! 07~~g ___.._.._.____ ~r SS TOTAL (Also enter on line 10, Recapitulation) E I 5~~"" n (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER T awls ~ ovE~ 2/ - 08 -/~~a RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions and transfers under , Sec. 9116 (a) (1.2)] ..~.~ ~_ _ ,_.~w.~. 56 5 A~P~I a2 y /20AO !.c?!-1 ~~E'ft 5NM i 5~ 37 ---L~(~l5 Dc..4_ eta vaTi9i.J,C'.4 GJ~LGS tlt ~cE~-. />3 .Vo7E L/~S%_tJI[C.AN,tl ~r-cS~ANEv~ G~O'tr-.~~5~4.a, ~~ ~d AND-.~ ~~A_ ~ L~o./,9,lcE ~T~._~sEO -1JA~v L _...~_To SffA2~"S o f` F5't"~fTE /Ics~cTia~_ ~ v!~E~toA~ A•arovt97'~ N' _ ~ _~~.. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMENT OF THOMAS F. HOOVER I, THOMAS F. HOOVER of, 1 Cornell Drive, Lower Allen To:L~rship, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking all other Wills and Codicils previously made by me. ITEM I: I direct that payment of all m y just debts, expenses of my last illness, funeral expenses, and the costs of administering my estate from my estate as soon after my death as conveniently may be done. ITEM II: It is my will that my body be cremated. ITEM III: I give, devise and bequeath to Robert L. Hoover, my son, my house and lot at 1 Cornell Drive, Lower Allen Township, Cumberland County, Pennsylvania with his 1/3 .share of total distributive share as hereinafter mentioned to be charged at tax assessed value of said house and lot. ITEM IV: I give, devise and bequeath to Donald R. Hoover, my son, all my land of approximately 10 acres in Warrington Township, York County, Pennsylvania with his 1/3 share of total distributive share as hereinafter mentioned to be 1 charged the tax assessed value of said land. ITEM V: I give, devise, and bequeath all of my distributive property equally to Robert L. Hoover, Donald R. Hoover and Thomas F. Hoover, Jr., my sons, except if the said house at 1 Cornel Drive and/or my acreage in Warrington Township, York County, Pennsylvania is/are an estate asset then they shall go as above set forth with the 1/3 distributive share of Robert L. Hoover and Donald R. Hoover to be charged as set forth so that all three sons are equal in computation. ITEM VI: I nominate, constitute and appoint Robert L. Hoover, Donald R. Hoover and Thomas F. Hoover, Jr., my three sons as sole executors of this my Last Will and Testament, to serve without bond. IN WITNESS WHEREOF, I Thomas F. Hoover, have, to this my Last Will and Testament, set my hand this ~~~~day of ~' ~, tA,IU~ 2007. ~~ ~ (SEAL) THOMAS F. HOOVER Signed, sealed, published and declared by THOMAS F. HOOVER, the above named Testator on the ~7-~-{ day of J ~ ~~ 2007, as for his Last Will and Testament, in the presence of us, who, in his presence, and in the presence of each other, have, at his request, subscribed our names as w' sses he eto. i _ residing at /,S (iyNLyy ~~y~ DR.X .4 V~ PA / 73 7d 2 ff! / {.-~~~ ~- ~ - ."'~il~~-~¢.~"''~`-~ residing at ~~ ~y JZ-- Name ! ? _ ~ ~I - 3 is'~ residing at Name COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS WE, the undersigned, the Testator and the witnesses, respectively, whose names are signed to the foregoing instrument, being first duly sworn and qualified according to law, do hereby declare to the undersigned authority that we were present and saw the Testator sign and execute the instrument as his Will, and that he had signed willingly 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 Testator, signed the Will as witnesses and that to the best of their knowledge, the Testator was at that time eighteen years of age or older, of sound mind and under no constrain or undue influence, and I, the said Testator, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament, that I signed it willingly, and that I signed it as my free and voluntary act for the purposes therein expressed_ Sworn to and subscribed before me this ~-~-~- day of ~~ 2 0 G '~ ' Notary Public My Commission Expires : ~ _ ~Q_~ saueroN ,, 6002 6' , ..,.~ yaqu,eW !4U. ~~r'c~ t COMMQNWEAl.TH OF PENNSYLVANIA Notarial Seal Robert E. Myers, Notary Public 3 Fairview Twp., York County MY Commission Expires Jan. 19, 2009 htiem5ar, Parers~!~.~an:a gssarialion of Notaries 48500041046 ~~~~ %S~,t~ ~~~~ y REV-485 EX (1-07) SAFE DEPOSIT _. BOX INVENTORY PA Department of Revenue Social Security or Death Certificate Number Date of Death PLEASE USE ORIGINAL FORM ONLY _ County Code Year File Number ~T ~~ Decedents Last Name Suffix First Name ®ADDRESS OF DECEDENT STREET: CITY ~~'~ •C1~~~ ~,S.~~g (' -,i'~~,~ `\ \~~ ~~ STATE: ZIP CODE: NAME AND ADDRESS OF PERSON REQUESTING THE PEENING OF THE SAFE DEPOSIT BOX \~ ~e t NAME. STREET ADDRESsS: \ ITY~ ~ ~ \ \ a STATE: ZIP CODE: • NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEbENT, OF PERSON(S) PRESENT AT THE BOX OPENING ~. ~.,.~•,~ `~~\ _ ~~~ ~ \~ ~ ~V ~ RELATIONSHIP: STREET ADDR SS t ~ ~~~ ~„~ \ ~~ ITY STATE: ZiP CODE: b. NAME: RELATIONSHIP: STREET ADDRESS: CITY. STATE: ZIP CODE: c. NAME: RELATIONSHIP: STREET ADDRESS: CITY: STATE: ZIP CODE: as •°••••- --••-• ^~~••~~~ ~-• • •••~••~.~.+~ Irv ~ . ~ ~ ~ wrv rvncrct i nt SgFE DEPOSIT BOX IS LOCATED IVHIVI C. ~~ ~~~~ STREEF~DDRESS: V ~~\\ \ ~ `''\ STATE: ZIP CODE: ` ~ 1 NAME OF PERSON MAKING LAS7 ENTRY DAVE AND TIME OF LAST ENTRY ~ `s~ \ DATE OF CONTRACT TO RENT BOX ' NUMB OF BOX 1 TITLE UNDER WHI ,BOX IS REGISTERED ~ ~ ~c~ .. _ NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX a. NAME: b. E:. STREEThADDRESS: STREET ADDRESS: Y: STATE: ZIP CODE: '~ `~~ , ~ ~ STATE: Zip CODE: ~t ~ - - NAME AN TITLE OF EMPLOYEE TAKING THE ITQR WAS A WILL IN THE BOX? ^ YES NO If yes, a. Date of will: b. Name and address of personal representative, if named in the will NAME: STREET ADDRESS: c. Name and address of attorney, if any NAME: STREET ADDRESS: 48500041046 ~~~ _ ~~. CITY: STATE: ZIP CODE: CITY: STATE: ZIP CODE: 48500041046 J REV-485 EX ~7/Y~` C ®CPD~f i !"S[7X ~~~/~~'Tr1QV Page of INSTRUCTIONS (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 f name o company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock . (3) Obligations of V.S. Government: Number of items, date of issue, face value, names in which registered and type of ownershi p, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book name of bank , and branch, and balance. {6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG, PA 17128-0601 ITEM NO_ ITEM DESCRIPTION I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECEIVING COPY OF CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. ~~~ ' SAFE DEPOSIT BOX INVENTORY: SIGNATURE ~~ "" "` ` ~`~ ,.J.r,__-._._ SIGN RE PRI NAM~~ ~~~~~~0~~ ~^~ ~ P I TAI ~ ~ ~ K AP~ RIA~ G ~ // \ `,1 PP L ©~ 4 I DATE CHECK APPROPRIATE BOX: ~ ' \ ~ xecutor(trix) ~ Administrator(trix) ^ r~~. ~ ~ ~ ~ ~ Estate Representative ~ Joint owner of safe deposit box NOTE: Attach additional 8'/z" x 11" sheet(s) if necessary or use duplicates of this page of form. The Department is authorized by law, 42 U.S.C. §405 (c)(2)(C)(i), to require disclosure of Social Security numbers in connection with administering state tax laws. The Department uses the Social Security number to identify the decedent and personal representatives of the estate. The Commonwealth may also use the information in exchange of tax information agreements ' with Federal and local taxing authorities. The state law prohibits the Commonwealth s personnel from disclosing confidential tax information except for offcial purposes. The u ose of this summa a praisal report is to n~dOmmnResidential Appraisal Report 117011 ~~ ~~ Pro a Address 1 CORNELL DR. /Bent with an accurate, and ode uatel su orted Flle# 117011 Borrower ESTATE OF THOMAS HOOVER , o mion of the market value of the subject roe Ci CAMP HILL State PA Zi Code 17011-7638 Le al Descri lion COUNTY TAX PARCEL # 13-23-0545-383e DEED'COPY WqS~ NAVAILABLE TO APPRAISER Assessor's Parcel # 13-23-0545-383 Coun CUMBERLAND Nei hbofiood Name CEDAR CLIFF MANOR Tax Year 2008 Occu ant Ma Reference 13-23-0545-383 R.E. Taxes $ 1 711 ® Owner ^ Tenant ^ Vacant S ecial Assessments $ 0 Census Tract 109.00/3240 ' Pro a Ri hts A raised Fee Sim le ^ Leasehold Other describe ^ PUD HOA $ Assi nment T e ^ Purchase Transaction ^ er ear ^ er month Refinance Transaction ®Other describe ESTATE Lender/Client ESTATE OF THOMAS HOOVER Address 1 CORNELL DR. CAMP HILL PA 17011 Is the subject roe current) offered for sale or has ft been offered for sale in the twelve months riot to the effective date of this a raisal? Re ort data sources used, offerin rice s ,and dates . CENTRAL PENN MLS. ^ Yes ®No i ^ did ^ did not analyze the contract for sale for the subject purchase transaction. Explain the results of the analysis of the contract for sale or wh the an erformed. Y alysis was not Contract Price $ Date of Contract Is there any financial assistance (loan charges, safe concessions, gift or downpayment ose tanceW etc.) to bel~paid bydany pa~ onsbehaif of the bo ower? s If Yes, re ort the total dollar amount and describe the items to be aid. ^ Yes ^ No Note: Race and the.raclal composition of the neighborhood are not appraisal factors. h~~~ffa rre~Utii~:tioUsirt d ,-~~•; Location Ufian ®Suburban ^ Rural Pro a Values Increasin ' h -: ~` 0 nft Houain ;.. , ~ present Land Uae>°,6 Built-U Over 75% ®25-75% Under 25% Demand/Su I Shorts a Stable ^ Declmm PRICE AGE One-Unit ^ Ra id ®In Balance Over Su I $ 000 rs 2-4 Unit 55 % Growth ®Stabie Slow Marketin Time Under 3 mths 3-6 mths Over 6 mths 80 Low 10 Multi-Famil Nei hborhood Boundaries ROUTE 581 TO THE NORTH THE SUSQUEHANNA RIVER TO THE EAST 250 Hi h 120 Commercial 10 % ,: ROUTE 76 TO THE SOUTH AND ST. JOHNS CHURCH RD. TO THE WEST. 20 % Nei hborhood Descri lion SUBURBAN ARF~4 WITH AVERAGE ACCESS TO SCHOOLS SHOPPING RECREATION AND EMP OYMENT. VC.10 % SUBJECT NEIGHBORHOOD IS WITHIN 20 MINS. DRIVING TIME OF THE MAJOR JOB MARKET OF HARRISBURG THE STATE CAPITAL. Market Conditions includin su ort for the above conclusions THE SOUTH CENTRAL PENNSYLVANIA HOUSING MARKET REMAINS RELATIVELY HEALTHY DUE IN PART TO THE STATE CAPITAL COMPLEX AND SUPPORTING AGENCIES & BUSINESSES PROVIDING AMPLE EMPLOYMENT. VALUES ARE INCREASING. AVERAGE MARKETING TIME CURRENTLY 60-120 DAYS. SEE ADD'L.COMTS. PG. 3 Dimensions 0.25 ACRE S ecffic Zonin Classification R_1 Area 0.25 ACRE Sha a RECTANGLE M/L View AVERAGE Zonin Descri lion RESIDENTIAL SINGLE FAMILY Zonin Com Hance ®Le al ^ Le al Nonconformin Grandfathered Use No Zonin Ille al describe Is the hi hest and best use of subject roe as im roved or as ro osed er loos and s ecifications the resent use? ® Yes ^ No If No, describe Utliltles Public Other (describe) °~ Electrici ^ Public Other (deacrtbe) Otf-site Im rovements - T Water ® ^ Street MACADAM public Private %~ Gas ® ^ Sanita Sewer ® ^ ® ^ FEMA S ecial Flood Hazard Area ^ Yes No FEMA Flood Zone C Alle N/A ^ ^ Are the utilities and off-site im rovements ical for the market area? FEMA Ma # 42101600028 FEMA Ma Date 9/30/1977 Are there an adverse site conditions or external factors easements, encroac®ents, environmentaNconditionselanduses, etc. ? NONE NOTED DURING INSPECTION. APPRAISER IS NOT EXPERT IN ENVIRONMENTAL MATTERS. ^ Yes No If Yes, describe -- < ' . F.xtarid 'tfo :, tit~(t~ryd f Units ®One ^ One with Accesso Unft Concrete Slab ®Crawl S ace Foundation Walls BLOCK/AVERAGE Floors ~-=R ,; md~~l~/~d~o # of Stories 1 ^ Full Basement ®Partial Basement Exterior Walls P.STN/ALU/WD/AVG Walls PLASTE/R/AAVG Type Det. ^ Att. ^ S-Det./End Unft Basement Area 576 s .ft. Roof Surface VG ® Existin ^ Pro osed Under Const. Basement Finish FIBER GL.SHIN/AVG Trim/Finish WD/STN/PNTD/AV .Design S le RANCH 0 % Gutters & Downs outs ALUMINUM/AVG Bath Floor CERAMIC TILE/AV ® Outside En /Exit Sum Pum Window T e HOP/CSM/DH/AVG Bath Wainscot CER.TILE/AVG Year Built 1965 Evidence of Infestation Effective Age rs 20 Storm Sash/Insulatetl DBL.PANE/AVG Car Stora a None At4c ^ Dam ness ^ Settlement Screens YES None Heatin FWA HWBB Radiant Amenities Drivewa # of Cars 2 ^ Dro Stair ^ Stairs ^ Other Woodstove s # Drivewa Surface ASPHALT ^ Floor Fuel GAS fire laces # 1 Fence ® Scuttle Coolin ®Central Air Conditionin Patio/Deck PATIO Porch Gara e # of Cars ^ Finished ^ Heated ^ Individual Ca ort # of Cars ^ Other ^ Pool ^ Other 1 Appliances ^ Refri erator ®Ran a/Oven ®Dishwasher ^ Dis osal ®Att. ^ Det. ^ Built-in finished area above rode contains: ^ Microwave ^ Washer/D er ^ Other describe 5 Roams 3 Bedrooms 1 Bath s Additional features s ecial ener efficient items, etc.. VINYL REPLACEMENT WINDOWS. 1 074 S uare Feet of Gross Livin Area Above Grade ivrar n ~ ~ca.nn wn , ~cu~ a_uauw .~r~„ LAND APPRAISAL REPORT ~- ~~ l~ ~ ~`"~^~~ Z ~ n,. . ~,__ c:re u.. .,~~ . --...~.. • ,vv~v~ ~ nvnlas r./ vOfIS U. - ---• ~+~~ ~.wurnanl Census Tract Map Reference 49-000-MD-0017-TO ,operty Address Old Mountain Road ,city Wellsville county York State PA Legal Description Not Available Zip Code 17365 Sale Price NA Date of Sale NA Loan Term Actual Real Estate Taxes yre• Property Rights Appraised X Fee Leasehold (yr.) Loan charges to be paid by seller NA De Minimus PUD Other sale concessions NA LendedClient Donald R. Hoover Address 1445 Old Mountain Road Wellsville PA 17365 occupant Unimproved Land Appraiser Mark W Heckman CGA . Instructions to Appraiser Provide Opinion of M arket Value Location Urban Suburban X Rural Built Up C'O ^ Over 75% X^ 25% to 75% ^ U Em lo m t St O F ir poor . p y en nder 25% ability Growth Rate ^ Fully Dev. ^ Rapid ^ Stead Conve i X^ gl a ^ y n ence to Em to ^ ow p yment Property Values ^ Increasing X^ Stable ^ Declining Convenience to Shopping ^ 0 O ^ ^ Demand/Supply ^ Shortage X^ In Balance ^ Over Supply Convenience to Schools ^ Marketi Ti Q ^ ^ ^ ng me ^ Under 3 Mos. X^ 46 Mos. Ade uac of Public Transportation ^ Over 6 Mos. q Y Present 40 O ^ ^ ^ % 1 Family _ °/, 2-4 Famil 7 % _ ° C _ o C Recreational Facilities Land Use y _. APts /° ondo 3 /° ommercial % I d t 5 ^ ^ ^ _ n us rial ~ % Vacant _ % Adequacy of Utilities Change in Present Land Use ^ Not Likel Lik ^ ^ y ely X Taking Place(•) Property Compatibility ^ ' O ^ ^ ( )From Vacant To Residential Protection from Detrimental Conditions ^ Predominant Occupancy X^ Owner T P 3 Q ^ ^ enant ° olice and Fire Protection ^ /o Vacant Single Family Price Range 120 to 350 0 ^ ^ Predominant Value 180 General Appearance of Properties ^ Single Family Age 5 ^ ^ yrs. to yrs. 100 Predominant Age 15-50 yrs. Appeal to Market Comments including those factors fawrable or f O ^ ^ , un awreble, affecting marketability (e.g. public parks, schools, view, noise) The subject property of this r iori. A substantial ortion of the surroundin land in the area is a riculture and woodl d M is in a rural portion an s. arket activit indi or better acre tance in the market lace. No unfavorable factors were observed which w ld cates a vera e ou adverse) affect marke Dimensions Irregular tabili =10 Acres*` zoning Classlficatlon Rural A rlcultural Corner Lot Present Improvements Do Do N Hi t C h f o g on orm est and Best Use X Present Use Others ( pacify) to Zo ning Reg ulations Public Other (Describe) Elec. ^ None Gas ^ None water ^ None San. sewer ^ None ^ Underground Elec & Tel Topo Level/ Slight Slope size Typical for area Shape Irregular view Average Drainage A ears ade uate Property located in a HUD identified Special Flood Hazard Area? Yes X No Comments (favorable or unfavorable including any apparent adverse easements, ericroachments or other adverse conditions) See Attached Addendum The undersigned has recited three recent sales of properties most similar and proximate to the subject and has to be considered these in the market analysis. The description inGudes a dollar adjustment, reflecting market reaction to those items of significant variation between the subject and comparable properties. If a significant item in the comparable property is superior to, or more fawrable than subject property, a minus (-) adjustment is made, thus reducing the indicated value of the subject, if a significant in the comparable is inferior to or less fawrable than the subject property, a plus (+) adjustment is made, thus increasing the indicated value of the subject. ITEM SUBJECT COMPARABLE NO. 1 Address Old Mountain Road Wellsville 1543 KBS Road Jacson Townshi Proximit to sub'ect 12.9 miles SE Sales Price $ NA Price $/ . Ft. Acre Data Source Assessment Rec Date of Sale and DESRIPTION DESCRIPTION Ave 1 To o ra h Level Level Clean & Green Yes Qualifies Parcel # 33-000-GF-012S Sales or Financing concessions Cash equivalent None known Net Ad'. otal X + _ Indicated Value Gross: 0.0 COMPARABLE N0.2 Susquehanna S Trail 12 547 Assessment Re adjust. DESCRIPTION 4-11-2008 Rural/ Fair 13.04 Acres/Ave Am le Level Qualifies 47-000-EI-0032 Cash equivalent None known 0 X+ _ Gross: 29.9 'S 500 Ner 10 0 COMPARABLE N0.3 Thundergust Mill Road Warrington Township 3.5 miles East v 1 vvv 10 046 1~ MLS & Assessment Recor \djust. DESCRIPTION +(_) Adj 9-15-2008 2 000 Rural/ Ave 10.01 Acres/Ave -1 000 Am le _1 Rollin Q ualifies 49-000-07-0014 Cash equivalent None known 1 000 + X - $ 1 Gross: 8.1 Comments on Market Data See Attached Addendum '~ ~ 10 500 Net: -8,1` $ 113 000 comments and conditions of appraisal According to records provided by county assessment office the subject property HAS NOT transferred in the ast 3 ears. This a raisal has been re ared with the ro art In 'as Is" condltlon. Final Reconciliation See Attached Addendum I ESTIMATE THE MARKET VALUE, AS DEFINED, OF THE SUBJECT PROPERTY AS OF February 12, 2009 to be $120.000 Appraiser Signature ~~k~~ /~ Supervisor Signature (ff applicable) Appraiser Name Mirk W._Heckman, Certified General Appraiser Supervisor Name Did Did Not Physically Inspect Property Date Report Signed 02/15/2009 Date Report Signed State Certification # GA-000666-L State PA State Certification # State License # State State crflm 1 L.e..~e.~ Produced using ACI software, 8(10.234.8727 www.adweb.com LAND2 08082005 Mark Heckman Real Estate Appraisers 24. If this appraisal report was transmitted as an "electronic record" containing my "electronic signature," as those terms are defined in applicable federal and/or state laws (excluding audio and video recordings), or a facsimile transmission of this appraisal report containing a copy or representation of my signature, the appraisal report shall be as effective, enforceable and valid as if a paper version of this appraisal report were delivered containing my original hand written signature. 25. Any intentional or negligent misrepresentation(s) contained in this appraisal report may result in civil liability and/or criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, et seq., or similar state laws. SUPERVISORY APPRAISER'S CERTIFICATION: The Supervisory Appraiser certifies and agrees that: 1. I directly supervised the appraiser for this appraisal assignment, have read the appraisal report, and agree with the appraiser's analysis, opinions, statements, conclusions, and the appraiser's certification. 2. I accept full responsibility for the contents of this appraisal report including, but not limited to, the appraiser's analysis, opinions, statements, conclusions, and the appraiser's certification. 3. The appraiser identified in this appraisal report is either asub-contractor or an employee of the supervisory appraiser (or the appraisal firm), is qualified to perform this appraisal, and is acceptable to perform this appraisal under the applicable state law. 4. This appraisal report complies with the Uniform Standards of Professional Appraisal Practice that were adopted and promulgated by the Appraisal Standards Board of The Appraisal Foundation and that were in place at the time this appraisal report was prepared. 5. If this appraisal report was transmitted as an "electronic record" containing my "electronic signature," as those terms are defined in applicable federal and/or state laws (excluding audio and video recordings), or a facsimile transmission of this appraisal report containing a copy or representation of my signature, the appraisal report shall be as effective, enforceable and valid as if a paper version of this appraisal report were delivered containing my original hand written signature. APPRAISER C L R. NT Signature Name MICH E • Company Name RE/MAX REALTY ASSOCIATES INC. Company Address 3425 MARKET ST. CAMP HILL PA 17011 Telephone Number (717) 730-3010 Email Address MENT(a~CAPITALAREAHOMES COM Date of Signature and Report DECEMBER 11, 2008 Effective Date of Appraisal DECEMBER 09.2008 State Certification # RL001676L or State License # or Other (describe) State # State PA Expiration Date of Certification or License 6/30/2009 ADDRESS OF PROPERTY APPRAISED 1 CORNELL DR CAMP HILL PA 17011-7638 APPRAISED VALUE OF SUBJECT PROPERTY $ 142,000 LENDER/CLIENT Name ROBERT HOOVER EXECUTOR Company Name ESTATE OF THOMAS HOOVER Company Address 1 CORNELL DR.~CAMP HILL PA 17011 Email Address N/A SUPERVISORY APPRAISER (ONLY IF REQUIRED) Signature Name Company Name Company Address I elephone Number Email Address Date of Signature State Certification # or State License # State Expiration Date of Certification or License SUBJECT PROPERTY ^ Did not inspect subject property ^ Did inspect exterior of subject property from street Date of Inspection ^ Did inspect interior and exterior of subject property Date of Inspection COMPARABLE SALES ^ Did not inspect exterior of comparable sales from street ^ Did inspect exterior of comparable sales from street Date of Inspection Freddie Mac Form 70 March 2005 Page 6 of 6 Fannie Mae Form 1004 March 2005 Form 1004 - "TOTAL for Windows" appraisal software by a la mode, inc. -1-800-ALAMODE Uniform Residential A raisal Rer~ort- 197011 The , --~,_ P P P Flle # 117011 ~~~~~~ u,~ J VVI11 GIUUIG IU cnlca ~~~~~„u There are 9 com arable sales in the subjec FEATURE SUBJECT Address 1 CORNELL DR. CAMP HILL PA 17011-7638 Proxim' to Sub'ect Sale Price $ Sale Price/Gross Liv. Area $ s .ft. Data Sources V ifi ti S une~eu wr sale m me suoeCt nei nnom t nei hborhood within the ast twelve mon COMPARABLE SALE # 1 17 AMHERST DR. CAMP HILL PA 17011 0.20 miles $ 150 000 $ 109.17 s .ft. MLS/ CO.TAX RECORDS ooa ran in in rice from $ 130 000 ths ran in in sale rice from $ 130 00 COMPARABLE SALE # 2 1295 STRAFFORD RD. CAMP HILL PA 17011 0.43 miles $ 143 000 $ 152.29 s .ft. MLS/ CO.TAX RECORDS to $ 160 000 0 to $ 160 000 COMPARABLE SALE # 3 1198 LOWTHER RD. CAMP HILL PA 17011 0.30 miles $ 147 600 $ 103.07 s .ft. z : :,,.:,_<.` MLS/ CO. TAX RECORDS er ca on ources VALUE ADJUSTMENTS DESCRIPTION Sales or Financing Concessions Date of Sale/Time Location SUBURB/AVG Leasehold/Fee Sim le FEE SIMPLE Site 0.25 ACRE View AVERAGE Desi n S le RANCH Qual' of Construction AVERAGE Actual A e 43 20 Condition AVERAGE Above Grade Total Bdmts. Baths LISTING OFFC. DESCRIPTION TOM: 1 DAY CONV. 06-02-08 SUBUR/EQUAL FEE SIMPLE 0.24 ACRE AVERAGE RANCH AVERAGE 49 20 AVERAGE Total Bdrms. Baths 10163273 + - $ Ad'ustment LISTING OFFC. DESCRIPTION TOM: 31 DAYS CONY. 11-14-08 SUBUR/EQUAL FEE SIMPLE 0.14 ACRE AVERAGE RANCH AVERAGE 55 20 AVERAGE Total Bdrms. Baths 10169699 + - $ Ad'ustment -5 500 LISTING OFFC. DESCRIPTION TOM: 17 DAYS CONV. 03-27-08 SUBUR/EQUAL FEE SIMPLE 0.18 ACRE AVERAGE RANCH AVERAGE 58 20 AVERAGE Total Bdmts. Baths 10157998 + - $ Ad'ustment -2 750 Room Count 5 3 1 6 3 2 -1 500 5 3 1 6 3 1 Gross Livin Area 1 074 s .ft. Basement & Finished PARTL&CRWL Rooms Below Grade UNFINISHED Functional Util' TYPICAL MKT Heatin Coolin GAS HW/CAC Ener Efficient Items STANDARD Gara a/Ca ort 1C.CARPORT - Porch/Patio/Deck PATIO • FIREPLACE FIREPLACE 1 374 s .ft. FULL UNFINISHED TYPICAL MKT OIL FAlCAC STANDARD 1 C.ATT.GAR. PATIO FIREPLACE -6 000 -2,500 1 500 939 s .ft. FULL PARTL.FINISH TYPICAL MKT GAS FA/CAC STANDARD 1C. CARPORT PATIO NONE +2 700 -2,500 -1 500 1 000 1 432 s .ft. CRAWL SPAC N/A TYPICAL MKT GAS FA/CAC STANDARD NONE PATIO FIREPLACE -7160 +2,500 2 000 • Net Ad'ustment Total Adjusted Sale Price of Com ambles - I did did not research the sale or transfer hist ^ + - Net Adj. 7.7 % Gross Ad'. 7.7 % o of the subject ro $ 11 500 $ 138 500 e and com arable ^ + ®- $ 5 800 ^ + ®- $ 5 410 Net Adj. 4.1 % Net Adj. 3.7 % Gross Ad'. 9.2 % $ 137 200 Gross Ad'. 9.8 % $ 142 190 sales, lt not, ex lain M research ^did ®did not reveal an riot sales or transfers of the subject roe for the three ears nor to the effective date of this a raisal. Data Sources CUMBERLAND COUNTY TAX RECORDS. M research ^did ®did not reveal an riot sales or transfers of the com arable sales for the ear riot to the date of sale of the com arable sale. Data Sources CUMBERLAND COUNTY TAX RECORDS. Re ort the results of the research and anal sis of the riot sale or transfer h isto of the subject roe and com arable sales re ort additional riot sales on a e 3 . ITEM Date of Prior Sale/Transfer Price of Prior Sale/Transfer Data Sources Effective Date of Data Sources Anal sis of riot sale ortransfer histo SUBJECT NONE WITHIN PREVIOUS 3 YEARS COURT HS. RECORDS 12-11-08 of the subject roe and com ara COMPARABLE SALE #1 NONE OTHER THAN ABOVE COURT HS. RECORDS 12-11-08 ble sales NO PRIOR TR COMPARABLE SALE #2 NONE OTHER THAN ABOVE COURT HS. RECORDS 12-11-08 ANSFER OF SUBJECT WITH COMPARABLE SALE #3 NONE OTHER THAN ABOVE COURT HS. RECORDS 12-11-08 IN PAST 3 YEARS. Summa of Sales Com orison A roach AFTER A THOROUGH SEARCH OF THE SUBJECT MARKETPLACE THE THREE SALES SELECTED ARE CONSIDERED TO BE THE BEST INDICATORS OF VALUE. ALL SALES SELECTED HAVE UTILITY SIMILAR TO THE SUBJECT AND ARE LOCATED WITHIN THE SUBJECTS MUNICIPALITY & SCHOOL DISTRICT. COMPARABLE SALES SEARCH PARAMETERS WERE EXPANDED TO INCLUDE THE PREVIOUS 10 MONTHS IN ORDER TO OBTAIN SALES WITHIN CLOSE PROXIMITY TO THE SUBJECT. SIMILAR MARKET CONDITIONS HAVE EXISTED DURING THIS PERIOD. AN ADJUSTMENT OF $20./ SQ.FT. WAS USED FOR GLA DIFFERENCES. SALES PRICES/ GROSS LIV. AREA MAY VARY WIDELY FROM SALE TO SALE IN THIS AREA FOR THIS STYLE DWELLING DEPENDING UPON MARKET APPEAL OF THEIR FEATURES & AMENITIES THAT HAVE BEEN ADDED OVER THE YEARS. Indicated Value b Sales Com orison A roach $ 142 000 Indicated Value b :Sales Com orison A roach $ 142 000 Cost Approach (If developed) $ Income A roach (If develo d) $ ADEQUATE MARKET DATA IS AVAILABLE WITH SEVERAL SALES IN THE SUBJECTS PRICE RANGE AND MARKET AREA. THEREFORE • THE SALES COMPARISON APPROACH TO VALUE IS THE BEST METHOD FOR THIS APPRAISAL. This appraisal is made ®"as is", ^ subject to completion per plans and specifications on the basis of a hypothetical condition that the i t h mprovemen s ave been completed, ^ subject to the following repairs or alterations on the basis of a hypothetical condition that the repairs or alterations have been completed, or ^ subject to the • followin re wired ins ection based on the extraordina assum 'on that the condition or deficient does not re wire alteration or re air: Based on a complete visual insppeecction of the Interior and exterior areas of the sublect property, defined scope of work, statement of assumptions and limiting conditions, and appraiser's certiflcatlon, my (our) opinion of the market value, as defined, of a real property that Is the subject of this report Is $ 142 000 as of DECEMBER 09 2008 which Is the date of fns ctlon and the effective date of this a raisal Freddie Mac Form 70 March 2005 Page 2 of 6 Fannie Mae Form 1004 March 2005 Form 1004 - "TOTAL for Windows" appraisal software by a la mode, inc. -1-800-ALAMODE Calculated Value of Your Paper Savings Bond(s) ~ ~~ ~~. ~ 1 Page 1 of Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 01/2009 _ _ ~ 1 425.00 8 157.04 $6 732.04 $0.00 Bonds: 1-38 of 38 ~'~= ~` ~'~~ /,~ ~ /~ /~~ 12213625415e. E }- _ . $5012/1978 _ _,,_,.12/2008: __...,, $37 .50 $179.04 $216 ! ~ 12213625414e _.,_... _._ .,.. E .. ,~ .., $50ti 12/1978x_..__... ~ ;_12/2008 . -_ .$37.50 ~ , .04 _. $179 ., , .. ~ $216 12213625413e . 12212325071e E _. E _. $50;..12/1978...... $50 12/19 78 ..x..12/2008, 1 2008 . _ . _. $37.5C . , .,..., .. .__.,$179.04; ...__. .,. _ ~.. $216.. .. _ 12212325070e ... E 78 - ._ ~~ $50.12/19 ~ ~ ;__ 2 12 2008, ~ ` $37. $3750,_ _ ~ 50 ,$179.04, $179.04; $216.! $216 ! 12212325069e _. _ __ E __. .._ .._ $50 ~ 12/1978;... ._,.12/2008 ~ . „ ;,. ~ __ __ $37.50 ` ,,,,..,. ~ - $179.04 . ~- -- $216 1221232506 _.__ .. -_.., 8es._ 12212325067 ,E _";~_ _ $50.11/1978 . - _ 1/2008 ~ ~ _ ._ $37..50 _ _ £ . ___$178.46 . $215.! e, _._.. 12213625412e - E _ E __ $50 ~ 11/1978 ~ $5011/1978 11/2008.; 11/2008 _ $37.,,50 ~ ~~ $37.50 _ ..,,.$178.46 ~ ~ ~~~~~ $178 46 ~ . .. _. ~ _ $2.15.. ~ 12213625411e _ ....... ....... :.. E ._.._ ... ._ .. $50s 11/1978.. , ~ 11/2008 ~ ~ __ $37.50 . - $178.46' ,-.. $215.! $215 ! 12213625410e . ... E .._ . t.. ~._ $5Qy10/1978.,...... ~ 10/2008 `~ _ _ . ~ _... $37.50 ....... . ~ - 176.44 $ .,, , . - $213 ! 12213625409e E _~ 50,:.10/1978_ _ ~ .. 10/2008 _ . ~ ~ ~~ $37.50, , ..._. ~` $176.44; . ~ $213 ! 12212325066e _ E ..._ _. ._. $50~10/1978y 10/2008 _„ $37.50 $176.44 . $213 ! 12212325065e~ .... ..~ .... ,. E ,...., ,...__ _ $5Q 10/1978;._,.. .. ` 10/2008,,.. ,_„ ..._.....$37.50 , $176.44 . _. $213 ! 12212325064e E $50~09/1978..,....__ ,_09/2008= ... ..,.._.._$37.50 ,..., ,.._., $176.44 . ... $213 ! 12212325063e E $50 x 09/1978 _. 09/2008: _ ___... $37.50 = ... $176.44 . $213 ! 21332506 2e ~ E $50 , 09/1978 _ ~ ~ 09/2008 ~ . . _ $3,7.50 ,..,. ,... $176.44 . ., $213 ! 12213625408e . E ..~ .~ .. .. __ $50 09/19.78 _ 09/2008.. ~~ $37.50 _ ~ ___ $176.44 . $213 ! 12213625407e E 50 09/1978 09/2008 ._ $37.50 • ,.., $176.44 , $213 ! 12213625406e... . E _ $50 09/1978 _.._. _ 09/2008 .. _ $37.50 ._ $176. 44 . ~.. $213 ! 22136 25405e: ~~ ~ ~ _.. . E ___. r.._ ....$50~08/1978 ____ ~ _ _ 08/2008 ._.__.$37.50, , $176.44; . -- $213 ! 122126 25404e. _ .... 12212325 61 _E _ E ,_ $50.x.08/1978:,_ ° 08/2008_ _ _ .. _„_$37.5.0; _ __ _„$176.44- ~ . ~~ $213.! e .... 122123250 060e ~ _, ~._., _. _ E _ _ ._ $50 .08/1978 ___ _ $50 x08/1978 ~ ;._08/2008 . 08/200 8 ; _ ....__$3.7..50 "..~ $37 50 _. $176.44 - $176 44 _ _ $213.! 13 ! i2212325059e - E _ ,.~ ,_ ._. $50 67/1978 , , 07/2008.;.. ~ _ . . $37.50 ~ . X176.44 _. , X2 . $213 ! 12212325058e E . $50 07/1978 ._ _.,_,.7/2008: 0 .,_ __$37.50 . _ $ 176.44 . ~~--$213 ! 12213625403e .~_._~ .... E . _ ,... ._. $501.07/1978 07/2008 y. _ _ $37.50 _ , $176.44 . _. . $213 ! 12213625402e . _E_ _ ,,,.$50_x_07/1978 07/2008 $37.50 ... $176.44 ., ,__ $213 ! 12212325057e E_ „__ _ _$50 ~ 06/1978 __ _ 06/200,8 .._,_...$37.50 t , $176.38: . $213 1 12212325056e . 1221362540i E .. . __ _....$50'.06/1978.:. _ .. .. 06/2008 . ___ _......$37.50 .._... _...$176.38 ~~ . -- $213.1 _ e .. ~.E _ . $50x06/1978 _ `.06/2008 _ $37.50 $ 176.38 .. 3 1 $21 12213625400e ..... _. ~ .._ ~ ~_ _ E ...... _..$5006/1978.` 06/2008, _ .... ~ .....$37.50_ _ _ , $176.38 . , . __ $213 1 12212325055e _, . _..,_, E _,., -,$50:05/1978... . ,..05/200.8.. . ~ $37.50 . . -- $175.84. _ . - ~~ - $213 ; 1221 2325054e _ _ _.. E_y _ _ _ _$50 ~ 05/1978 ~ 05/2008 ~. _ ., ] ._ X37.50 : _ . $175.84 ; . .. .._. $213 ; 12213625399e E _ 50 .05/1978 ; x.05/2008' _ __..$37.50 F .__. $175.84 . ~ - .._ ._ $213 : 12213625398e_ E _.$50_.0,5/1978 05/2008_:_ $37.50 $175.84 _ . $213 : 12212325053e E-. $50 ~ 04/1978 A 04/2008. _., .. $37.50 __, $ 179.58 . ~ $217 1 12212325052e _. E $50 04/1978, ._ 04/2008 $37.50. , - $179.58 . - - $217 Totals for 38 Bond s $ , 1,425 00'$6,732.04; $8,157.1 http://www.treasurydirect.gov/BC/SBCPrice ~ i~i~nnn Calculated Value of Your Paper Savings Bond(s) Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 01/2009 825.00 650.52 3,825.52 00 Page 1 of 1 Scc~ ,~ ~ Sc ~~ ~. ~~Nc INVESTMENTS Member NASD and SIPC January 12, 2009 Robert Hoover 1 Cornell Drive Camp Hill. PA 17011 Re: Date of Death values for Thomas Hoover as of 12/02/2008 Dear Bob, Account 22548290 # Price as of Security Shares 12/02/2008 Value Calamos Conv Opp & Income 1300 $7.14 $9,282.00 Eaton Vance National Muni Fd 2986.73 $7.44 $22,221.27 Nationwide Health Prop Inc 320 $20.10 $6,432.00 PPL 1082 $31.38 $33,953.16 Account 46854373 IRA UST 7.5% 11/15/2016 15000 $136.53 $20,479.50 Money Market 3025.45 1 $3,025.45 Since ly, d 1 Allot CIO S~IIiOr ~II'lanCial COn~trltant The information contained herein has been obtained from sources we believe to be reliable but do not guarantee it to be accurate, correct, complete, or timely, and shall not be responsible for the results obtained from its use. Calculated Value of Your Paper Savings Bond(s) Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 01/2009 Page 1 of 2 ~ $2,250.00 $13,916.04 $11,666.04 $37.12 Bonds: 1-45 of 45 c621907856ee EE $100 12/1980;06/2009 12/2010 $50.00; $23348r ,4.00% $2 c63627793ee, EE $100:12/1980 06/2009 12/2010 $50.00' $233.48: s 4.00% $2 c63627792ee. _- EE $100 12/1980:06/2009 12/2010 $50.00 . $233.48: 4.00% ~ $2 c62907855ee EE $100 11/1980 05/2009 11/2010 $50 00; $233.48f 4.00% $2 c63627791ee EE $100 11/198005/2009 11/2010 $50.00 $233.48: 4.00%, $2 c62907854ee EE r $100 ~ 10/1980 04/2009 10/2010: $50.00 $259 32 4.00% $3 __ 2907853ee c6 EE $100 10/1980.04/2009. 10/2010 $_ 50 00: $259.32; ° 4.00 /o _. $3 Cfi 3627790ee _ EE $100 10/1980 04/2009 10/2010' $50 00 259.32 ` .° 4.00 /o _. $3 c63627789ee _ _ EE - $100 10/1980.04/2009 10/2010 X50 00: ~ $259 32 4 00%: $3 c63627788ee EE $10009/1980 03/2009 09/2010 $50 00 $259 32 4 00% $3 c63627787ees EE r $-100 09/1980403/2009;09/2010 $50.00 $259.32: 4.00% $3 c62907852ee EE T X100 09/1980 03/2009r 09/2010 $50 00 $259.32 4.00% - $3 c62907851ee EE ~100y09/1980 03/2009 09/2010 $50.00 $259.32 : 4.00% $3 _c63627786eeh, EE __ _ x,100 08/1980 02/2009y 08/2010; __ $50.00 r . - $259 32 ; . 4 00%. $3 c63627785ee : EE $100 08/1980 , 02/2009 : 08/2010: $50 00 _ . $259.32 :4 - 4.00% : _ $3 c63627784ee w w, EE $100 08/1980 0,2/2009 08/2010 $50 00 r $259 32 4 00% $3 c62907850ee EE $100 08/1.980 02/2009, 08/2010; $50.00 r $259.32 - : 4.00%. . $3 c62907849ee EE $100 08/1980 .02/2009 08/2010} $50.00 $259 32 _ 4.00% .... _ $3 c62907848ee EE $100 08/1980 02/2009; 08/2010 r $50 00 $259.32 4.00% _. $3 c63627782ee EE _ X100 07/1980 07/2009, 07/2010: $50 00 $,265 48 ` 4.00% $3 c62907847ee~ EE $100 07/1980;07/2009 07/20104 $50 00s $265 48 4.00% $3 c62907846ee -_.. ~ ... ____. ~.. EE $100 07/1980; _07/2009 07/2010: _ .r_ ._ $50.00 $265 48 ~ _ _ ° 4 00 /o _ $3 c63627783ee ~ EE $100 07/1980 07/2009. 07/2010; $50.00 $.265 48 r 4.00% $3 c62907845ee _ _EE _- ;.,. ~? 00 05/1980 06/20:09 06/2010.4 _ - $50.0 X265„48 4 00°io $3 c63627781ee EE . $100 06/1980 a 06/2009 06/2010 - $50.00. $265.48 , 4.00% $3 c62907842ee, EE ~ $100. 05/1980 ; 05/2009 ~ 05/2010 $50 00 , $265.48: _ 4.00% ~ $3 c62907844ee EE $100 05/1980 05/2009 05/2010= ... r r $50 00: $.265.48 _ 4.00%; ... $3 c63627780ee EE $100, 05/1980 05/2009 05/2010 $50.00 _ $265 48 y 4.00% _ $3 c63627779ee- EE $100 05/1980: 05/2009 05/2010: , $50.OOY $265.48:. __ 4.00%, $3 c62907841ee ._ EE $100 04/1980:04/2009; 04/2010; $50 00~ $262 36 4.00%y $3 c63627778ee EE $100 04/1980 04/2009 ~ 04/2010 $50.00 ; $262.36 4.00% _ $3 c62907842ee EE $.1.00 04/1980 , 04/2009 : 04/2010 ; .. $5,0.00 ; $262.36 4.00% $3 c63627777ee EE $100 04/1980 t 04/2009 :04/2,010 ~ $50.00 $262.36 4.00% $3 -c62907840ee _ EE $100 03/1980.03/2009; 03/2010 $50.00 _ $262.36 4.00% $3 c62907839ee EE $100 05/1980`05/2009:05/2010 ` $50 00 ~ - $265.48 ~ ° ? 4.00 /o $3 c63627776eev EE ~ $100.03/1980:03/2009 03/2010 $50.00, $262.36; , 4..00% . $3 c63 5ee EE ~ $100 03/1980 = 03/2009 a 03/2010 $50.00: _ $262.36 _ 4.00% $3 c6290783 Bee; EE $100 02/19800 /2010 $50 00 $262 36 4.00% $3 c62907837ee EE $100 02/1980 02/200902 ,010 r $50 00 $262 36 4.00% _ $3 http://www.treasurydirect.gov/BC/SBCPrice 1 /6/2009 N w O N ~ cC Llr 00 00:00 O' 00 00:00 00' 00 i 00 00 00:00 00 i 00 00'00 00 `00:00 00' 00 00 O ~ 00 r, , ~ 00 00; 00 00 00 00 00 00 00' 00 ~ 00.00 ; 00 00 ~ O 00: CO 00 O; O O O O; O O O O O O: O O~ G; O O O O O; O O: 0? 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U` U; U; C1 ,Sy Total Banking Statement cJ. ~ ~..~ ~~ ~ PNCBANK PI~~ C Back For the period 11/08/2008 to 1Z/09/2008 THOMAS F HOOVER c 1 CORNELL DR CAMP HILL PA 17011-7638 Primary account number: 51-4003-0132 Page 1 of 4 Number of enclosures: 0 [[~]] For 24-hour banking, and transaction or interest rate information, sign on to '~ PNC Bank Online Banking at pnc.com. For customer service call 1 IIG6-PNC-4000 between the hours of 6 AM and Midnight ET. Para servicio en espan"ol, 1-866-HOLA-PNC Moving?! Please contact us at 1-866-PNC-4000 ~ Write to: Customer Service PO Box 609 Pittsburgh PA 15230-9738 Vi51t US at nnr..cnrn We value your relationship with PNC. For questions about your account, ~ TDD terminal: 1-800-531-1648 please call 1-866-PNC-4000. For neau,, ;,,,pa;red ~ISer,r, or,t~ Relationship Averviow Bank Deposit Accounts Description Account Number Deposit Balance Interest Checkim~ ,(_-}p0!_01~;~> Premium ~Ionec Market 51- ,007-1F,35 Certificate(s) Of llefaosit 'Total of 1'otat Deposits :~,92f_i,$I ri 1,12.31 95,`il I.Ori 155,36f,.67 Did you know that every purchase mlde wit}t your PNC Bank ~"isa Credit or Check Card through the end of the yev could mean a chance for you to help yourself and Sesame ~~orkshop? Ciet a lot -Ind give a lot with PNC. ~~isit pnc.cont%visasweeps for promotional details. Did you know it is possiUle to have significantly more than $250,000 in deposits at PNC Bank FDIC insured? Stop in any Uranch to review your account or call 800-PNC-BANK. Or go to PNC.com or http://tivww.fdic.gov/edie/ for more information. ~erfOrnlance CheCking Thomas F Hoover Interest Checking /account Surn~nlary Account number: 51-4003-0132 Balance Summary Beginning Deposits and Checks and other Ending balance other additions deductions balance 6,363.94 2,~46.i0 2,728.53 ri,92G.81 Average mentlily Charges balance and fees 6,139.56 .00 Transaction Summary Checks paid/ Check Card POS Check Card/Bankcard ~vithdrav~als signed transactions POS PIN transactions =1 0 0 Total ATM PNC Bank Other Bank transactions ATM transactions ATM transactions 0 0 0 Interest Summary Annual Percentage Yield Earned (APYE) 0.20% Please see the Activity Detail section for additional information. As of 12/09, a total of $5.51 in interest was paid this year. Number of days Average rollected Interest Paid in interest period balance Tor APYE this period FORM953R-1005 Integrity B A N K 3345 Market Street, Camp Hill, PA 17011 (717) 920-4900 THOMAS F HOOVER 1 CORNELL DR CAMP HILL PA 17011-7638 Time Deposit 6 -11 MONTH CD ACCOUNT NUMBER 0003008484 ~SCN E~ Page: 1 Enclosures: 0 Statement Date: 02/09/2009 Account Number: 3008484 CLOSED PREVIOUS STATEMENT BALANCE .... .. .... . .. ........... .00 PLUS 9 DEPOSITS AND OTHER CREDITS .. . .'. ` ....:......... 15,365.31 LESS 1 WITHDRAWALS AND OTHER DEBITS . CTTR R F.NT CTnTRfvTb'TTT RnT.DNCF nC nF n7 /nQ /ng ... .:............ 15,365.31 nn • Account Transactions 05/01 DEPOSIT AT 3.59000 _ 15,000.00 06/01 INTEREST PAYMENT 45.74 07/01 INTEREST PAYMENT 44.40 08/01 INTEREST PAYMENT 46.01 09/01 INTEREST PAYMENT 46.15 10/O1 INTEREST PAYMENT 44.80 11/O1 INTEREST PAYMENT 46.43 12/01 INTEREST PAYMENT 45.07 01/01 INTEREST PAYMENT 46.71 01/02 PENALTY FREE WITHDRAWAL 15,365.31- PAYER FEDERAL ID NUMBER ................. 52-2389022 INTEREST PAID YEAR TO DATE.............. 46.71 ~~I/~ `` /~ a A Family Tradition Of Caring° PARTHEMORE Funeral Ho Mr. Donald R. Hoover 1445 Old Mountain Ro Wellsville, PA 17365 1303 Bridge Street P.O. Box 431 New Cumberland, PA 17070 (717)774-7721 (Fax)774-5546 www.parthemore.com Gilbert W. Parthemore, Founder Gilbert J. Parthemore, Supervisor Stephen K. Parthemore, CFSP Bruce R. Parthemore, Pre-Need Coordinator, CPC Professional Memberships: NFDA • PFDA DCFDA • CCFDA G ~~>>LDEN ULE The Rule You know, The People You Ti~us( For the service of Thomas F. Hoover Cremation Services, Inc. 12/5/2008 We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. The following is an itemized statement of the services, facilities, automotive equipment and merchandise that you selected when making the funeral arrangements. ~ Tsrms Due Date Account # Net 30 1/4/2009 2008108.3 Description Amount SERVICES & MERCHANDISE Cremation with Memorial Service 3,890.00 Wildflowers Stationery Set 135.00 Cherry Finish Memory Chest Urn 188.00 Total Services and Merchandise 4,213.00 CASH ADVANCE TI'EMS Death Notice, Harrisburg Patriot 211.02 15 Certified Copies of Death Certificate 90.00 Cumberland County Coroner Fee, Cremation Authoriza tion 25,00 Total Cash Advances 326.02 Immediate Pay Discount -Thank you! -84.26 Total $4,454.76 Payments/Credits $-4,454.76 Balance Due $O.oo Fox Eichelberger Veterans of Foreign Wars Post 7415 109 Third Street New Cumberland, PA 17O7o-2107 Phone (717) 774-6554 Fax ('717) 774-6566 NAME/ADDRESS Don Hoover 1g45 Old Mountain Road Wellsville, PA 17565 C-717-a97-lgn H-717-432-2722 EVIIVT: Remembrance Luncheon 5 ~ N N .~ i~/` Z DATE: 12~10~2008 INVOICE# 12102008-1 ~~ PRICE QTY. AMOUNT `' Li1NCKBONBUFFET $ 9.95 58 $ 577.10 Deli sliced meats & cheeses $ assorted breads & rolls, lettuce, tomato $ _ pickles, clops $ _ baked potato & beef vegetable soup $ _ Full sheet cake $ 69.95 1 $ 69.95 $ - $ - TOTAL $ T9.go 59 $ 647.05 BEVEiA(3ES ° PRICE _ 'QTY. AMOUNT Coffee 1Ced tea, included $ _ $ - $ - TOTAL $ - $ _ ALt7DHOL ~ TOTAL The final count must be equal to or greater than the minimum guarantee stated in the agreement If attendance falls below the final guaranteed number, the pafron wi7i1 lie charged for the final guazanteed number. The Club will set for 5% over the guaranteed number. All checks should be made payable to "Fox-Eicheiberger YFW Post 74~" Should you have any further questions concerning this invoice, please feel flee to contact Harry Young, Manager at (717) 774-6554 ~~ ~ ~~ AMOfJNT ~~ ~ - $ - $ - $ - $ - $ - $ - !k _ Misc Fees: (incl. Set-up, linens, & janitorial fees) ~ 5,00 6% SALES TAX 43.32 20% GRATUITY ~ 129.41 TOTAL $ 894.78 LESS DEPOSIT (s) 150.00 AMOUNT' DUE >~ 7dd.7R ~Ii~iank You For amour mousiness! ~:s~~~ ~ ~ Opening/Closing Date: 10/18/08 - 11/17/08 CUSTOMER SERVICE CHASE ~ Date: Payment Du 12/07/08 In U.S. 1-800-945-2000 ~ Minimum Pa ment Due: $13.00 Espanol 1-888-446-3308 TDD 1-800-955-8060 Pay by phone 1-800-436-7958 Outside U.S. call collect Minimum Payment Due for Credit Access Line , , $13.00 1-302-594-8200 Total Nk?'rimum Payment Due $13.00.. ACCOUNT INQUIRIES P.O. Box 15298 Wilmington, DE 19850-5298 WORLD MASTERCARD SUMMARY Account Number: 5544 5303 02904170 PAYMENT ADDRESS P.O. Box 15153 Previous Balance $422.11 Credit Access Line $8,000 Wilmington, DE 19886-5153 Payment, Credits -$422.11 Available Credit $7,345 Purchases; Cash, Debits +$654.71 Cash Access Line $8,000 VISIT US AT: New Balance $654.71 Available for Cash $7,345 www.chase.com/creditcards Your next AutoPayment for $654.71: will be deducted from your account and credited on your due date. Should you make a payment prior to your due date, thatamount will be deducted from the AutoPayment amount identified above. :REWARDS SUMMARY __ _____ _______ _-_ To redeem your points, call 1-800-603-2265 or Previous Points Balance 5,845 log on to www.chase.com/creditcards. Points Earned On Purchases 655 Points Expired This Period D Points Redeemed this Period 5,000 Current Points Total 1.500 422 Points Due To Expire on Statement in September, 2011 TRANSACTIONS Trans Date Reference Number 10/17 b5547508292123099Q .10/18 554203682934651201 1 1 1 10/28 10/28 11/02 11/01_ 11/03 11/06 11/07 11/06 11/10 11/11 1 61231 0000001 FIS33335 D 9 X 03711NS126891NS73460 Amount `Merchant Name or Transaction Description Credit Debit 0434 CULHANES'STEAK HOUSE NEW CUMBERLAN PA $33.04 5348 TLF'ROYERS%STEPHENSNS LEBANON PA _ ___ 15.89 9107 ARMITAGE GOLF CLUB MECHANICSBURG PA 22.00 - XXONMOBIL 45461498 MECHANICSBURG PA` - --- _ 15.38 ;ARLI GOLF HOUSE CARLISLE BARB PA ___ _ _ 18.00 _ iOCKBASS GRILLE WORMLEYSBURG PA _ 62.42 NINE & SPIRITS 6708 NEW_C_UMBERLAN PA 13.77 MANGE END GOLF CLUB DILLSBURG'PA 22.00 3P-(QIL- - --A5760764 DILLSBURG PA _ _ _. _ 10.75. _. BOBBIN HOUSE RESTAURAN GETTSBURG PA 31:90 iHEETZ 00002329 MT HOLLY SPR_G PA _ 15.32 TAVERN ONTHE GREEN IN FAIRFIELD PA _ 1_9.71 ~AEDCO HEALTH FT WORTH 8008887010 TX _ ____ 30.00 ;ARROL VALLEY RESORT FAIRFIELD PA 118.81 ~ULHANES STEAK HOUSE NEW CUMBERLAN PA ___ __ 38.74 PICKET TURTLE 866-788-7853 OR, _ 36.00 =AIRVIEW GOLF COURSE LEBANON PA _ ___ __ 21.00 AUTOMATIC PAYMENT -_THANK YOU _ _ _ 42.2:11 _ __ TILL SIDE CAFE ETTERS PA _ __ 58.50 _ _ _ _ aULLIFTY'S CAMP HILL PA __ _ _ 32.03 _ _ ONTANA MAGAZINE HELENA MT N _ ___23.00 __ _ -IESS 38256 038 LEMOYNE'PA 16.45 000 N Z 77 08!11/17 Page 1 of 2 05686 MA MA 38079 32210000090453807901