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Home My WebLink About07-07-09 (2)1505607121 '~ REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Counly Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 RESIDENT DECEDENT 2 1 0 9 0 0 3 7 Harrisbur . PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth I O 16 2 0 0 8 0 9 0 4 1 9 3 4 Decedent's Last Name Suffix Decedent's First Name D U N K L E B E R G E R M R B E N D AM I N (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS MI R MI FILL IN APPROPRIATE OVALS BELOW Original Return 1 ~ 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. Election to tax under Sec. 9113(A) O) h S h Att between 12-31-91 and 1-1-95) c . ac ( CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Daytime Telephone Number Name J O H N H B R O U J O S E S Q U I R E ~ I ~~ 4 3 ~,,, 5 7 4 Firm Name (If Applicable) ~ -x-> , ILLS USE ONLY ~~ ! --j ~ REGIST~ . ~'%_-~'~ "~ C7 I'~-- ~~ ; Icy First line of address ~~m I ale ,, I - '^-~ ~ ~ r i 4 N O R T H H A N O V E R S T R E E T I; `~ ~" O -~ `- ~`~~` i__ ~, < _ -rt _ ~ Second line of address - ~~ f`J ~ ~ h-i N ~ ..: -'~i; DATE FILED ~; City or Post Office State ZIP Code C A R L I S L E P A l ~ 0 l 3 Correspondent's a-mail address: Under penalties of perjury.. I declare that I have examined this return, including accompanying schedules and statements,. and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGN/~CI`URE OF yP~E.~R~SONrRESPONSIBL_E FOR FILING RETURN DATE r-, ADD62ESS ~ s~Q~ RTnc;F,VIEW DRIVE CARLISLE PA I~013 SIGN URE O ~j REPAREI~THER THAN REPRESENTATIVE DATt 4vN~TH HANOVER STREET CARLISLE PLEASE USE ORIGINAL FORM ONLY 1505607121 Side 1 PA 1013 1505607121 }- 1505607221 REV-1500 EX Decedent's Social Security Number Decedent's Name: BENJAMIN R . DUNKLEBERGER, MR . RECAPITULATION 1 4 0 0 0 0, 0 0 1. Real estate (Schedule A) ~ ~ ~ 1. 3 1 3 0 1, 0 3 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. ' 2 3 6 8 8 0, 3 6 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . .. 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 0 0 0 (Schedule G) ~ Separate Billing Requested .. .. 7. , 4 0 8 1 8 3 1 9 8. Total Gross Assets (total Lines 1-7) ~ ~ ~ ~ 8. , 5 J ~ 3 0 2 6 9. Funeral Expenses & Administrative Costs (Schedule H) ..... ....... .. 9. , 4 0 0, 0 0 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ... ....... .. 10. 5 6 1 3 0 2 6 11. Total Deductions (total Lines 9 & 10) ........ .... ........ .. 11. , 12 3 5 2 0 5 1, 1 3 12. Net Value of Estate (Line 8 minus Line 11) ........ .... ........ . .. Charitable and Governmental Bequests/Sec 9113 Trusts for which 13 . an election to tax has not been made (Schedule J) ... ........ .. 13. 3 5 2 0 5 1, 1 3 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 0 0 0 15. 0, 0 0 (a)(1.2) X 0 16. Amount of Line 14 taxable 0 0 0 O , 0 0 at lineal rate X 0 16 17. Amount of Line 14 taxable 3 5 2 0 5 1 1 3 17 4 2 2 4 6, 1 4 at sibling rate X .12 18. Amount of Line 14 taxable 0 0 0 18 0, 0 0 at collateral rate X .15 . 4 2 2 4 6, 1 4 19. Tax Due ........................ ..... ....... 1s ... 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1505607221 Side 2 1505607221 REV-1500 EX Page 3 nnrpripnt'c Cmm~lete Address: File Number 21 09 0037 DECEDENT'S NAME BENJAMIN R. DUNKLEBERGER, MR. _ _ __ ____ _ __- __ _- - STREET ADDRESS ;1842 RIDGEVIEW DRIVE, BASIN HILL HEIGHTS _ _ ___ ____ _- _ __ __ CITY STATE ZIP CARLISLE PA ' 17013 Tax Payments and Credits: 1 Tax Due (Page 2 Line 19) (1) 42,246.14 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments 10,000.00 C. Discount Total Credits (A + B + C) (2) 10, 000.00 3. Interest/Penalty if applicable D. Interest E. Penalty 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. (3) (4) 0.00 0.00 (5) 32,246.14 (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 32,246.14 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 :................................................................. .... ~ O X b. retain the right to designate who shall use the property transferred or its income : ........................... .... ^ c. retain, a reversionary interest; or .......................................................................................... .... ^ d. receive the promise for life of either payments, benefits or care? .................................................. .... 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death ^ 0 without receiving adequate consideration? ................................................................................ d th? ..... ^ ^X .... ea 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her ..... Did decedent own an Individual Retirement Account, annuity, or other non-probate property which 4 . contains a beneficiary designation? ........................................................................................ ..... ~ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX + (5-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER BENJAMIN R. DUNKLEBERGER, MR. 21 09 0037 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 roe which is 'ointl -owned with ri ht of survivorshi must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 1842 Ridgeview Drive, Basin Hill Heights, North Middleton Township, 140,000.00 Cumberland County, Pennsylvania. Description attached Appraisal by William A. Bassett, GCA. Decedent sole owner TOTAL (Also enter on line 1, Recapitulation) ~ $ 140,000.00 (If more space is needed, insert additional sheets of the same size) REV-1503 EX + (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER BENJAMIN R. DUNKLEBERGER, MR. 21 09 0037 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. TYCO International LTD -- Common Stock -- 75 shares/$20.80 per share 1,560.00 CUSIP 205 102 G9143X20 2. (TYCO Electronics LTD -- Common Stock -- 75 shares/$27.58 per share I 2,068.50 CUSIP 205 102 G144P10 3. Pioneer Small Cap Value A I 5,288.21 Acct No. 00663800704 4. Dreyfus Find 18,952.32 Acct No. 0026-0002571701 5. ICovidien LTD -- Common Stock -- 75 shares/$45.76 per share I 3,432.00 CUSIP 205 102 G2552X10 TOTAL (Also enter on line 2, Recapitulation) I $ 31,301.03 (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (6-98) SCHEDULE E CASH, BANK DEPOSITS, ~ MSC. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER BENJAMIN R. DUNKLEBERGER, MR. 21 09 0037 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Sovereign Bank Checking #1691015717 5,384.29 2. Sovereign Bank Certificate of Deposit #169541233 18,488.70 3. F&M Bank Money Market #70-75081 92,786.36 4. M&T Bank Checking #410411 17,392.39 6. M&T Bank #31003913026885 13,559.51 7. M&T Bank #31003917741009 27,877.80 8. M&T Bank #31003917741059 13,603.94 9. Automobile - 1999 Buick Park Avenue 11,025.00 10. Automobile - 1999 Chevrolet Tahoe 10,400.00 11. U.S. Savings Bonds 24,844.36 12. Coins and Currency in safe deposit box. Appraised value 1,225.11 13. Transamerica Life Insurance/Tax deferred annuity 292.90 TOTAL (Also enter on line 5, Recapitulation) I $ 236,880.36 (If more space is needed.. insert additional sheets of the same size) REV-1510 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER BENJAMIN R. DUNKLEBERGER, MR. 21 09 0037 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACHACOPYOFTHEDEEDFORREALESTATE DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST EXCLUSION pFAPPLICABLE) TAXABLE VALUE 1. M & T Bank, Individual Retirement Account 26,855.60 0.00 AN 35004200211437 Beneficiary -- Janet R. Dunkleberger TOTAL (Also enter on line 7 Recapitulation) $ 0.00 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+(10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER BENJAMIN R. DUNKLEBERGER, MR. 21 09 0037 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Hoffman-Roth Funeral Home & Crematory, Inc. 8,089.26 2. Osiris Holding of Pennsylvania/Internment Fee 1,335.00 g. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Janet R. Dunkleberger street Address 1842 Ridgeview Drive city Carlisle state PA zip 17013 Year(s) Commission Paid' 2 Attorney Fees John H. Broujos, 4 North Hanover Street, Carlilse, PA 17013 3 Family Exemption. Qf decedent's address is not the same as claimant's,. attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees Petition Itrs adm, Automation fee, Renunciation, Short Certificates, JCP fee 5 Accountant's Fees 6. Tax Return Preparer's Fees 7 TOTAL (Also enter on line 9, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) 23,000.00 23,000.00 306.00 55,730.26 REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER BENJAMIN R. DUNKLEBERGER, MR. 21 09 0037 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 1. Wolfe & Shearer Appraisal Services -- Real Estate Appraisal 33 South Pitt Street Carlisle, PA 17013 2. John Tartamella -- Consultation and Coin Appraisal 637 Grahams Wood Road Newville, PA 17241 VALUE AT DATE OF DEATH 300.00 100.00 TOTAL (Also enter on line 10, Recapitulation) I $ 400.0( (If more space is needed, insert additional sheets of the same size) REV-15'13 EX + (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA .BENEFICIARIES INHERITANCE TAX RETURN ESTATE OF FILE NUMBER BENJAMIN R. DUNKLEBERGER, MR. 21 09 0037 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) (12)] 1. Janet R. Dunkleberger Sibling 1842 Ridgeview Drive Carlisle, PA 17013 2. Mary Jane Mentzer Sibling 3235 Rosemont Road North Jackson, OH 44451 3. Pauline D. Hollenbaugh Sibling 261 North Middlesex Road Carlisle, PA 17013 4. Robert D. Dunkleberger Sibling 151 Shughart Road 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: 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 I $ (If more space is needed, insert additional sheets of the same size) I ~fO1 DEED-IND. '1~ 0 ~ ORVST-1 j L3 i~: i-ti S ~ ~YONE COMMENCE DNIVE,CMNF0ND N~JrO7O 6 d ~ _ .~ L . '~ J ,''• ,,~~ rY J '81 ACT 30 Pii 3 C6 Made the 3a~ day of October , ix the year Nineteen hundred and eight-seven (1987) ~Ef1UP~II r:ICNAEL J. NETTO and LINDA L, NETTG, husband and xife, of North liiddleton Township, Cumbariand County, Pennsylvania, hereinafter called Grantors AND BF.NJAI9IN R. DUNHLEBERGER, single man, of North Middleton Toxnehin, Cumberland County, Pennsylvania hereinafter called Grantee ~~tt~~,~e~, That in consideration of One ($1.00) and 7io~z00tha--------^-_----~ 1-•~.. -------------~ ------------------------------------------ ---------- -Dollars, in hand paid, the receipt whereof is hereby ack»owiedged, the said grantor a do `- hereby gr'a'nt and convey to fhe said granter. his heirr and assigns. ALL that certain tract of land with the improvements thereon erected, situate in North Middleton Township, Cumberland County, Pennsylvania, bounded and described as follows: BEGINNING at a point on the Eastern-line of Hill Street, on the Plaint of Lots known as Basin Hill Heights,. as reoorded in the Office of the Recorder of Deeds Por Cumberland County; thence along the Eastern line of Hi11 Street, 208 feet to the Southern curb line oP s proposed street 50 feet wide;, thence by the Southern ourb line of said proposed street, in an Easterly direction, 108 feet, more or less, to a point; thence by land no1+ or formerly of"John C. Rasp and wife in a Southerly direction, 208 Peet, more or. Iesa, to a point; thence by land' now or formerly of Verne S. Ressler and wife, and Theodore A. Young and wife, in a Westerly direction, 125 feet 6 inches to the Place of BEGINNING. BEING improved with a dwelling house known as 1842 Ridge View Drive. THE WITHIN property is conveyed subfect to'certain restrictions upon use as set forth at length in prev~oias conveyances for said tract of land. BEING the.Eame property xhich Richard James. xidoxer, of !forth Middleton Town- ship, Cumberland County, by deed dated October 16, 1980 and recorded in the Office of the Recorder of Deeds in and for Cumberland County at Carlisle, Pennsylvania in lleed Book "D", Volume 29, page 922 granted and conveyed to I:ichael J. NAtto and Linda L. Netto, his xife, Grantors herein. (/~ nla ~~;~, !•vWip •r ••••• School Dirt. CuRib. Ce., P~. Cup,b. Co, ~Po. _{-7G M.4 61•r• Tnnf•t Tr ~ ~ R••f Ed.4 Tr,mi•r Tn v o.r ti•r. e.»........ _ ~.l~ ~.. /~~o BO0!;A vv ~6i ~;~ c.b~ c. a.a c.i. na+. ~R`, ~ G•. pl•r. Vii. ,~ .~ rv 11/05/2008 2:47:40 PM CUMBERLAND COUNTY Inst.# 198705417 -Page 1 0~ ~•~~ .grid ~ the said graxtar s do hereby generally the property hereby conveyed. ~ri ~itriE~ri ~II~Erfnfa said grantors have hereunto set their and seats the day dnd year first above written. SfgneD. SeteleD unD ~elfuertD Jn tfle ~1reu nce of a o ~- r7 U/! 6 L G/L/ i L _ .. _ ..... CC)thMCNWC:A:TH 11 ^@fJ`•;~~'CJA't~;ik -- iar.r:ssER _ ~n.~4~,,~.,1 ; g '% ;:. J ~ I bonds (dnminnnwealfll of ~enn,agluunfu es. (IIIIUtttg Df' CU!•i3GRLAND Onihia,the ~'hdayof October Is87 .bgforeme tluunderxigttado,QSter.peraonallyapptared IiIC:HA:'L J. P1^TPO and LIidII.1 L. ~E7T0 knovm to me (or aatigfaetorily proverb to De the ysraon suhoae names are subscribed to the within inatrvs+cnt, and acknowtcdyed that tlu y executed the sane, for the purpose therein contained. . IN i{rITNESS WHEREOF. ! have bsrsunto eat my hand and ,n ofcLJL ~/c~cJ' aeaL o ,/ "~ ~,, ~ ~ ~ ~° - KINBEdiY A. BURRHOICCR NOTARY PUeIIG - = ~ ~ ~ .' •~ ~- CF•~.i;LE 60 W, tJ!dSERtbKO COUNTY V ~' ~ rr MY OONNISSION El(PIRESJIPR$ 2.1940 _ ~ ~•' ' : t.: RIav:Yar, raBBL raw socudon of Nohdea '>,`~8vaf/m~~taieu[tll of ~Ennsgluenfa ss. (Quuntg of On this. tlu day of 19 , before me the undersigned o„picer, personally appeared known to mt (or aati~faetorily pr•ovtt~l to be the person where name subscribed to the within instrumsnt, and acknowledged that hs executed the same for the purpose therein contained. IN WITNESS WHEREOF. I Anus hereunto set my hand and seal. ,.1 ~erCh~ ~P~fif~ that the precise address of the gra>ttQe(e~( ` • herein is •` ~ V ~"w ~ V \~~ 800?(A ~~ ~~Cf 2~j, WIICr81Tf i 1/05/2008 2:47:40 PM CUMBERLAND COUNTY Inst.# 198705417 -Page 2 I ruJ.lu es pay _ , - _ .., ~ - ~" ~ - ~ RECVRDER^S USE ON[Y REALTY TRANSFER TAX toMMOteweAUNOrnNNSYlVAN1A STATEMENT OF VALUE v .r DErARTMENT W efYENVE °ae eU%!AU O! IMgY1W AL TAXK eOST OfFKF t0%te10 NA%MSWEO, rA vtolevw ~• Rw•rf• for InRtructiona ' /p/3~/P7 Complels each section and file in duplicate wkh Recorder of Deeds when (f) the full value/consideration k not sN forth in the deed, {2) when the deed Is without considarotion, ar by g$t, or (aJ a tax uempHon is claimed. A StaNmenl of Value Is not required if the trensf~r ii wholly exempt from tcx bared on: (1) family relmtonship or (Z) public Ylility~sasement, I(more span B needed, attach edditiolrol theet(s). - Bro'ous Gilro & Houston P.C. Ar.eced.l717 ! 243-4574 . SIreN A dne Ciry frme zip ce 9 rvorws nanover ~creet C:arllsl.e P - A 1 1 ....:.- • •:: ~: ~ ; ~ e .. . ~ .. .... - Dms Aneptenp o Daumeel , Grenlor(rhluwrl'I GroMes(QMwe(sJ Mi ha L n Sn.« Addnrl ~ Slrs« Addre« 1 4 i Ciry frogs Zip Gh - Prole .p Cod. Carlisle, PA 17013 Carlisle PA 17013 _ • e e ~ ~ ~ - _ slr.« Aadr.rr c'ny, rowslhip, I{or,r,ph 1842 Rid ewe Drive o ~ddleton Z. Check Apprepdero Bex frolow Ter IacempHon Cfolmed ^ Will or intsrlote wansion w irsr. Nen.6e I1 ^ Trandar to Industrial DevdopmeM Agenry, 11 1 ^ Transfer too ent or straw oA Attach of p sn !show a reemeM t 9 P Y• ( COPY 0 cY PortY g ). y ^ Tromfsr bNween pdndpd and agdM. {AHoch wpy of agency/craw (rust ogreemenl). tax pdd prbr deal $ ' i { ^ Ttansfen to 1M Commonwealth, the UnRed Stobt, and Inslrvmenfaatles by giN, dedlcotfon, eerrrlemnation or In IAu of condemnmion. 1 {AHOCh copy of rasolulion), " ^ Transfer kom mongogor to a holder of a mortgage In default. MoAgoge Book Number ,Page Number ^ Correpivs deed (Anach copy of the prior dwd), - ^ Statutory mrperele consolidation, merger or dirufon. (Attach copy of eAklo). I f ^ Other (Please expbin exempfien ckimed, tf odrer than listed above,) i , i i - ~ 1 Under penalties el few, l dedere thef 1 hoveyx Ssrsroslserst, indudksy eccetnpenykq Mhrmesbn, and ro she Msf of my knewledpe ~ and Mllef, h is srue, oerrecs end late. ` flxnalurs Consspen scK er R.rp sib! Perfy Dae~ 1 (SEE VERSE 8'OOK Ai3E3 PACE 2%~ 0 [7 0 CUMBERLAND COUNTY Inst.# 198705417 -Page 3 11/05/2008 2:47:40 PM