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HomeMy WebLinkAbout10-30-0915056051058 REV-15®0 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO Box 2sosot 21 09 ' 0693 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 043-'I6-9921 ' 07/14/2009 04/2411912 Decedent's Last Name Suffix Decedent's First Name MI Casey Janet E (If AppNicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW ;~,, 1. Original Return THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS ""? 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 Reqwred 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) 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 John M. Eakin ' '; (717) 766-3172 Firm Name (If Applicable). REGISTER OF WILLS USE ONLY r.~ - ' ~~ "~ First line of address ^; ' ~ ~ a i ~, , .'t ~- . • :.._.) Market Square Building ; ~ ''i . : Second line of address ~.. ~ ... . , _".,t _ - .-.~ - ~ i City or Post Office State ZIP Code :., DATE FILED t-. ~ ,, - , .. -, •- , 'Mechanicsburg ' PA 17055 ' ' ° ' , c.a 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. SIGPJATURE OF P~E.RSO/N RESP/O)N~S~I,BjLE FOR FILING RETURN /. ~ y, r----~ ~~,, DATE ~'~"~,~~ l~iL~.' x'.csi-G...~r~ .~ /~ ~-/r ~'1 /L it ~! n ~ ~ 1. 2 ~ i. ~ y ADDRE S 951 W. Trindle Road, Mechanicsburg, PA 17055 SIGNATUR F PREPA O HER THAN REPRESENTATIVE DATE _ %G rzz~2~; r ~~ ADDRESS Market Square Building, Mechanicsburg, PA 17055 -' PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 ~ ) J 15056052059 REV-1500 EX Decedent's Social Security Number Decedent's Name: Janet E Casey 043-16-9921 RECAPITULATION __._ _. ~„_ ........ .....~_.....,~ 1. Real estate (Schedule A) ........................................... .. 1. ' 149,000.00 2. Stocks and Bonds (Schedule B) ..................................... .. 2.' 7,975.00 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. ' 668,829.10 6. Jointly Owned Property (Schedule F) Separate Billing Requested ..... .. 6. ', 30,005.67 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested...... .. 7. l . Total Gross Assets (total Lines 1-7) .................................. .. 8. ' 855,809.77 9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. 70,151.29 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10. 9,354.39 11. Total Deductions (total Lines 9 & 10) ................................. .. 11. ! 79,505.68 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. ' 776,304.09 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... .. 13. 10,000.00 ' 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. ' 766,304.09 1'AX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES ~^ ^ ~ ,.~._„~m..,,~ * } 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 __ __ (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. ' 17. Amount of Line 14 taxable at sibling rate X .12 ', 17. ~~s. Amount of Line 14 taxable 766,304.09 at collateral rate X .15 18. 114,945.61 '19. TAX DUE ....................................................... .. 19. 114,945.61 :?0. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 09 !:0693 DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER Janet E Casey 043-16-9921 STREET ADDRESS CITY STATE ZIP Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InterestlPerialty if applicable D. Interest E. Penalty 110,000.00 5,789.30 114,945.61 Total Credits (A + B + C) (2) 115,789.30 843.69 Total Interest/Penalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4} 5. If Line i + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (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 APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................... ...... ^ b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ c. retain a reversionary interest; or ................................................................................................................... ....... ^ (~ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........................................................................................................ ...... ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ........ ...... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ...... ® ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1,1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9111; (a) (1.1) (ii)]. The statute does not exem,~t 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. §911E~(1.2) [72 P.S. §9116(a)(1)]. The tax rate unposed 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)J. 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. RELf-150< ET ~ ~ 1 ~08 pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE Oi' FILE NUMBER Janet E. Casey 21-09-0693 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 that is jointly-owned with right of survivorship must be disclosed on Schedule F. If more space is needed, insert additional sheets of the same size. ~~ CenVal Penn Appraisals, Inc. (717) 737-4600 Uniform Residential Appraisal Report File No. WCOOVER201 Pa a #2 Flle# WCOOVER201 b ose of this summa a sisal re ort is to rovide the lender/client with an accurate, and ade uatel su orted, o inion of the market value of the subject roe Pro a Address 201 W. COOVER STREET Ci MECHANICSBURG State PA Zi Code 17 5 Bonower N/A Owner of Public Record CASEY Coun CUMBERLAND Le al Descri Pion DEED BOOK 0023K PAGE 00933 Assessor's Parcel # 20-24-0787-011 Tax Year 2007 R.E. Taxes $ t 860 Nei hborhood Name MECHANICSBURG BOROUGH Ma Reference ADC PAGE 18 J-7 Census Tract 0115.00 Occu ant Owner Tenant Vacant S ecial Assessments $ 0.00 ^ PUD HOA $ er ear er month Pro a Ri hts A raised Fee Sim le Leasehold Other describe Asst nmentT a Purchase Transaction Refinance Transaction Other describe PRIVATE Lender/Client PRIVATE Address Is the subject roe cunenti offered for sale or has it been offered for sale in the twelve months riot to the effective date of this a raisall Yes No Re ort data sources used, otterin rice s ,and dates . 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 why the analysis was not rformed. „ Contract Price $ NIA Oate of Contract N/A Is the ro seller the owner of ublic record? Yes No Data Source s - Is there any financial assistance (loan charges, sale concessions, gift or downpayment assistance, etc.) to be paid by any party on behalf of the bonower? ^ Yes ^ No ti Yes, re ort the total dollar amount and describe the items to be aid. N/A Note: Race and the racial composRion of the neighborhood are not appraisal factors. e(ghbo`~icbd,Clt adte,stlcs ,_ _,~.` , :', 'qAQ-URJtH1l~taingTterid"s -`_~~_ ~ { -OneUr~fYHb. '-,?i~ ~~ R se':°~'' Location Urban Suburban Rural Pro a Values Increasin Stable ^ Declinin PRICE AGE One-Unit 85 % Buih-U Over 75% 25-75% Under 25% Demand/Su I Shorts a In Balance Over Su I $ 000 rs 2-4 Unit 5 % ;Growth Ra id Stable Slow Marketin Time ®Under 3 mths 3-6 mths Over 6 mths 90 Low 10 Multi•Famil 0 % Nei hborhood Boundaries THE HOME IS LOCATED BETWEEN YORK AND MARKET STREET SOUTH 350 Hi h 100+ Commercial 5 % OF KELLER STREET IN MECHANICSBURG BOROUGH. 150 Pred. 60 Other 5 % Nei hborhood Descri lion This suburban town has relative) eas access to em to ment and services and is com etitive with other net hborhoods in the eneral area. Most have similar amenities. No unfavorable factors were observed which would adverse) effect marketabilit . Market Conditions includin su ort for the above conclusions There are no foreseeable economic trends which mi ht si nificantl influence market conditions in this area. The current mort a e market offers a wide varlet of conventional loans with com etitive rates. As a result the terms of financin have little if an im act on sales vices. If interest rates remain reasonable ro art values and marketabilit should be stable. IJimensions SEE LEGAL DESCRIPTION Area .16 ACRES Sha e RECTANGULAR View AVERAGE S ec'rfic Zonin Classification R1 SINGLE FAMILY RESIDEN' Zonin Descri lion SINGLE FAMILY RESIDENTIAL Zonin Com liance Le al Le al Nonconiormin Grandfathered Use No Zonin ilia al describe Is the hi hest and best use of subject roe as im roved or as ro osed er tans ands echications the resent use? Yes No If No, describe Utllltlea Public Other (describe) Public Other(descrlbe) Ott-sftelm rovements-T Public Private Electrici Water Street ASPHALT Gas Sanita Sewer Afle NONE FEMA S ecfal Flood Hazard Area Yes No FEMA Flood Zone X FEMA Ma # 4203620005D FEMA Ma Date 3/3/1992 Are the utilities and off•site im rovements ical for the market area? Yes No B No, describe Are there an adverse site conditions or external factors easements, encroachments, environmental conditions, land uses, etc. ? Yes No K Yes, describe G~ M t19a r._,.,., ' s.,F~.uA atlJJ `- "-"` ~. Facte~l9 ,~4a1( Ibn ~ ~~tR#i~>~~C ~130,,, ~ '~ e! p _ Units One One with Accesso Unit . Concrete Slab Crawl S ace Feundation Walls STONE/AVE: Floors WOODNINYL/AVE # of Stories 2 Full Basement Partial Basement Exterior Walls BRtCKAVE Walls PLASTER/AVE T e Det. Att. S-Del./End Unit Basement Area 1 018 s .tt. Root Surface SHINGLE/AVE Trim/Finish WOOD/ AVE Existin Pro osed Under Const. Basement Finish 0 % Gutters & Downs outs ALUMINUM/AVE Bath Floor VINYL/AVE Desi n S le 2 STORY Outside En /Ezft Sum Pum Window T e DOUBLE HUNG/AV Bath Wainscot FIBERGLASSlAVE Year Buitt 1930 Evidence of Infestation Storm Sash/Insulated STORM/AVE Car Stor a None Effective A e rs 25 ^ Dam ness ^ Settlement Screens YES/AVE Drivewa # of Cars 1 Attic None Heatin FWA HW66 Radiant Amenities Woodstove s # Drivewa Surface ASPHALT Dro Stair Stairs Other Fuel OIL Fire laces # Fence Gara e # of Cars 1 Floor Scuttle Coolin CenVal Air Conditionin Patio/Deck Porch Ca ort # of Cars ^ Fnished ^ Heated ^ Individual ^ Other Poo! ^ Other ENCPCH ®Att. ^ Det. ^ Built-in A liances ^ Refri erator ^ Ran a/Oven ^ Dishwasher ^ Dis osal ^ Microwave ^ Washer/D er ^ Other describe Finished area above rade contains: 7 Rooms 3 Bedrooms 2 Baths 1 676 S uare Feet of Gross Livin Area Above Grade . Additional features s acts/ ener efficient items, etc.. NATURAL WOODWORK 200 AMP ELECTRIC . Describe the condition of the roe includin needed re airs, deterioration, renovations, remodelin ,etc.. These im rovements are of averse ualit frame desi nand reflect avers a maintenance with no re airs needed. The home is older and could use some kitchen and bath u radin as well as some fresh aint. YOU MUST GO THROUGH ONE BEDROOM TO GET TO ANOTHER. Are there an h sisal deficiencies or adverse conditions that affect the livabili ,soundness, or structural tote r' of the roe ? Yes No ti Yes, describe Does the roe enerall conform to the net hborhood functional utili , s le, condition, use, construction etc. ? Yes No tf No, describe Freddie Mac Form 70 Match 2005 Page 1 of 6 Form 1004 - "WinTOTAI" appraisal software by a la mode, inc. -1.800-ALAMODE Fannie Mae Form 1004 March 2005 File No. WCOOVER201 Pa a #3 Uniform Residential Aaaraisal Report Fneu wrnnvrR~n1 ere are 1 com arable ro cities currentl offered for sale in the.. subject nei hborhood ran in in rice from $ 179 000 to $ 179 000 There are 4 com arable sales in the subject nei hborhood wiUtin the ast twelve months ran in in sale rice from $ 150 000 to $ 169 500 FEATURE SUBJECT COMPARABLE SALE # 1 COMPARABLE SALE # 2 COMPARABLE SALE 3 Address 201 W. COOVER STREET MECHANICSBURG_, PA_17055 _ 605 S YORK STREET MECHANtCSBURG PA 17055 106 E MAPLEWOOD AVE MECHANICSBURG PA 17055 210 W MARBLE STREET MECHANICSBURG PA 17055 Proximi to Subect _ ,_ 1022 miles S Sale Price $ - NrA' €! ?$__ _1_5.0_ .000 Sate Price/Gross Liv. Area 5 ~ ~ 3 105.63 sq.ft~ Data Sources w r ,ti ASMT RECORDS/MLS/AGENT/ n 4 miles_E_ _ __ I$ 154 900 ~ $ 127.38 sq.ff. ~ ~ ASMT RECORDS/MLS/AGENT/ 0 12 miles S ~_ ~ g,'-T S 158,900 $ 108.84 sq tt i ~ :'~ 'e r ~`' " ASMT RECORDS/MLSIAGENT/ Verification Sources _ . r~+,~ rI SETTLEMENT DEPT. SETTLEMENT DEPT. SETTLEMENT DEPT. VALUE ADJUSTMENTS 6: , h'~ T i(N I DESCRIPTION + - $ Ad'ustment DESCRIPTION + - $ Ad'ustment DESCRIPTION + - $ Ad'ustment Sales or Financing ~' .T ASH , h ~r ,NONE KNOWN Concessions ~ CONVENTIONA NONE KNOWN CASH NONE KNOWN - r. Date of Sale/time __ __ _ __ 8-31-06/8 7-6-07/15 6-28-07/49 Location AVERAGE AVERAGE AVERAGE AVERAGE Leasehold/Fee Sim le FEE SIMPLE FEE SIMPLE FEE SIMPLE FEE SIMPLE Site 16 ACRES 11 ACRES 22 ACRES .17 ACRES View AVERAGE AVERAGE AVERAGE AVERAGE Desi n S le 2 STORY 2 STORY 1.5 STORY 1.5 STORY Ouali of Construction AVERAGE AVERAGE AVERAGE AVERAGE Actual A e 77 YEARS 80 YEARS 57 YEARS 53 YEARS Condition AVERAGE BTR THN AVG -8 000 BTR THN AVG -8 000 BTR THNAVG -8 000 Above Grade Total Bdrms. Baths Total Bdrms. Baths Total Bdrms. Baths Total Bdrrns. Baths Room Count 7 3 2 6 3 1 +2 000 6 3 1 +2 000 7 3 1.5 +1 500 Gross Liv' Area 1 676 s .tt. 1 420 s .ft . +3 800 1 216 s .tt. +6 900 1 460 s .tt. +3 200 Basement & Finished Rooms Below Grade FULL BMST UNFINISHED FULL BMST UNFINISHED FULL BMST UNFINISHED FULL BMST REC ROOM -3 000 Functionalll6li " AVERAGE AVERAGE AVERAGE AVERAGE Heatin Coolin HW/ NO CA HW/ NO CA FA/CA -4 000 HW/ NO CA Ener Efficient hems TYP FOR AREA TYP FOR AREA TYP FOR AREA TYP FOR AREA i Gara a/Car 1 CAR GARAG 1 CAR GARAG NONE +2 500 1 CAR GARAG - PorcfVPatio/Deck SUN ROOM PORCHES SUN ROOM PORCH/PATIO +1 000 NONE 1 FIREPLACE -3 500 1 FIREPLACE -3 500 1 FIREPLACE -3 500 NONE NONE NONE NONE N_ONE___ __ NONE NONE NONE + - • Net Ad'ustment otal $ -5 700 + - $ -4 100 + - $ -S 800 _ Adjusted Sale Price ~- Net Adj. 3.8 % of Com arables ~ I Gross Ad . 11.5 % $ 144 300 Net Adj. 2.6 % Gross Ad . 17.4 % $ 150 800 Net Adj. 5.5 % Gross Ad'. 12.7 % $ 150 100 i did did not research the sale or transfer histo of the subject roe and com arable sales. If not, ex lain M research did did not reveal an rior sales or transfers of the subject roe for the three ears rior to the effective date of this a sisal. Data Sources LOCAL MLS & COUNTY ASSESSMENT RECORDS ONLINE M research did did not reveal an rior sales or transfers of the com arable sales for the ear rior to the date of sale of the com arable sale. Data Sources LOCAL MLS & COUNTY ASSESSMENT RECORDS ONLINE Re ort the resuhs of the research and anal sis of the rior sale or transfer histo of the sub act roe and com arable sales re ort additional rior sales on a e 3 . ITEM SUBJECT COMPARABLE SALE #1 COMPARABLE SALE #2 COMPARABLE SALE #3 Date of Prior Sale/Transfer NO PRIOR SALE NONE KNOWN TO EXIST NONE KNOWN TO EXIST 2-16-07 Price of Prior Sale/Transfer IN THE PAST 3 YEARS OTHER THAN ABOVE OTHER THAN ABOVE 123 550 Data Sources COURTHOUSE RECORDS COURTHOUSE RECORDS COURTHOUSE RECORDS COURTHOUSE RECORDS Effective Date of Data Sources 7-16-07 7-16-07 7-16-07 7-16-07 Anal sis of rior sale or Vansier histo of the subject roe and com arable sales NO UNUSUAL CHARACTERISTICS IN SALES HISTORY OF SUBJECT OR COMPARABLES Summa of Sales Com arison A roach All five sales are considered to be reliable indicators of value and are wei hied similarl in the final reconciliation.tn order to find com arables sales it was necessa to use less recent sales. All five com arable sales are located in the same market area as the sub'ect roe and would be considered b the same ers active urchaser if all were on the market at the same time as the sub act. Com arables sales used are all closed sales. Indicated Value b Sales Com arison A roach $ 149 000 Indicated Value b :Sales Com arison A roach S 149 000 Cost A roach (tt devel ) S NIA Income roach (Ii develo d) S N/A • This appraisal is made ®"as is'", ^ subject to completion per plans and specifications on the basis of a hypothetical condition that the improvements have been completed, ^ subject to the following repairs or aherations on the basis of a hypothetical condition that the repairs or aherations have been completed, or ^ subject to the • tollowin re aired ins action based on The extraordina assum lion that the condition or deficiene does not re uire aheration or re air: Based on a complete visual inspection of the (nterfor and exterior areas of the subiect property, defined scope of work, statement of assumptions and limiting conditions, end appraiser's cerbficatlon, my (our) opinion of the market value, as defined, of the real property that is the subject of this report is S 149 000 as of 7-74-07 which (s the date o1 ins coon and the effective date of this a sisal. Freddie Mac Form 70 March 2005 Page 2 of 6 Fannie Mae Form 1004 March 2005 Form 1004 - "WinTOTAL"appraisal software by a la mode, inc. -1-800-ALAMODE File No. W OOVER201 Pa a #4 Uniform Residential Appraisal Report Fue# wcoweR~n, ENDMENT TO SCOPE OF WORK: THE INTENDED USER OF THIS APPRAISAL REPORT IS THE LENDEFUCLIENT. THE INTENDED USE IS TO EVALUATE THE PROPERTY THAT IS THE SUBJECT OF THIS APPRAISAL FOR A MORTGAGE FINANCE TRANSACTION SUBJECT TO THE STATED SCOPE OF WORK PURPOSE OF THE APPRAISAL REPORTING REQUIREMENTS OF THIS APPRAISAL REPORT' FORM AND THE DEFINITION OF MARKET VALUE AS DEFINED BY FANNIE MAE OR FREDDIE MAC. THE REPLACEMENT COST IS USED FOR NEW CONSTRUCTION OR HOMES LESS THAN 5 YEARS IN AGE ONLY. THE INCOME APPROACH IS USED ONLY WHEN THE SUBJECT IS TO BE A SINGLE FAMILY RENTAL PROPERTY. _ ' _ _ _ COST'APPRd,ACH TO~VALUE?(not reGu~r`er,(by Fanrile'Ma_e) - _ Provide ade uate informaton for the lenaer/client to re licate the below cost fi ures and calculations. ~:: - Su ort for the o inion of site value summa of com arable land sales or other methods for estimatin site value ESTIMATED REPRODUCTION OR REPLACEMENT COST NEW OPINION OF SITE VALUE ........._...__._.._...__......__...._.....__.... _.__. _$ Source of cost data MARSHALL & SWIFT COST VAUTATION SERVICE DWELLING S .Ft. $ __ __.__ _$ Quali ratio from cost service AVE. Effective date of cost data 09/2006 S .Ft. @ $ _$ __ - Comments on Cost A roach ross livin area calculations, de reciation, etc. _ _.___. _$ Gars a/Ca ort S .Ft. $ _$ Total Estimate of Cost-New _ =$ _-.-_. Less Ph sical Functional External De reciation =$ De reciated Cost of Im rovements ..._.....__........__.....__.__... ......_.. _$ "As-is" Value of Site Im rovements .._....__..._......._....__....__ __.._. _$ Estimated Remainin Economic Life HUD and VA onl Years INDICATED VALUE BY COSTAPPROACH ....._...,_.._.______.._.____ ___.____. =5 _ _ INCOME APPROACH TO VALUE (not requl(ed by Fennle'Mae) ~ _ _ ~ "' Estimated Monthl Market Rent $ N/A X Gross Rent Muld tier N/A = $ N/A Indicated Value b Income A roach Summa of Income A roach includin su ort for market rent and GRM _ _ _ _ Pf30JECT.INFORMATIONFOHPUDs{if,appJlcahej _ _ Is the develo er/builder in control of the Homeowners' Association HOA ? Yes No Unit e s Detached Attached __ __~`? ~ __ Provide the followin information for PUDs ONLY'rf the develo er/builder is in contol of the HOA and the sub'ect roe is an attached dwellin unit. Le al Name of Pro'ect Total number of haws Total number of units Total number of units sold Total number of units rented Total number of units for sale Data source s - Was the ro'ect created b the conversion of existin buiidin s into a PUD? Yes No B Yes, date of conversion. Does the rri ect contain an multi-dwellin units? Yes No Data Source Are the unRs, common elements, and recreation facilities com lete? Yes No If No, describe the status of com fetion. Are the common elements leased to orb the Homeowners' Association? Yes No B Yes, describe the rental terms and o lions. Describe common elements and recreational facilities, Freddie Mac Form 70 March 2005 Page 3 of 6 Fannie Mae Form 1004 March 2005 Form 1004 - "WinTOTAL" appraisal software by a la mode, inc. -1-800-ALAMODE REV-1503 E~:+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYU/ANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF~ FILE NUMBER Janet E. Casey 21-09-0693 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBEI~ DESCRIPTION OF DEATH ~ ~ 470 shares Bank of America @ $17.08 = $8,027.60 less transaction fee $52.60 7,975.00 TOTAL (Also enter on line 2, Recapitulation) $ 7,975.00 (If more space is needed, insert additional sheets of the same size) REV-1508 E}(+ (6-98) SCHEDULE Ep COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE Of= FILE NUMBER Janet E. Casey 21-09-0693 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. Citizens Bank CD# 6244376191 Principal $50,000.00, Interest Rate 3.45%, Issue Date 8/2/2008 50,056.71 Maturity Date 8/2/2010 2. Citizens Bank CD# 6251642476 Principal $100,000.00, Interest Rate 2.72%, Issue Date 6/11/2009 100,231.00 Maturity Date 6/11/2014 3. Members First Federal Credit Union CD# 57451-42 Principal $100,000.00 Issue Date 9/11/2007 100,143.53 Maturity Date 8114/08, see attached 4. Members First Federal Credit Union Savings Account # 57451-00, see attached 65,639.50 5. Omega Bank CD# 173-0047755 Principal $100,000.00, Interest Rate 4355%, see attached 100,124.66 13. Soverign Bank CD#1685426502 Principal $50,000.00, Interest Rate 3.25%, Issue Date 7/28/2008 50,128.07 Maturity Date 7/28/2009 7. Metro Bank CD#802444 Principal $180,000.00 180,210.00 8. Citizens Bank Account #6422 22,295.63 TOTAL (Also enter on line 5, Recapitulation) $ I 668,829.10 (If more space is needed, insert additional sheets of the same size) -, _ z a O N N m ° --~ * !2 N ro~ n ~ ~ c°'ia --~ ~m~~o~ m Z M O ~ a '~c ~ ~m . ~cm7 cu~ao c~ rn ~' ~~ ~ ~ m ~ ~ Z . ~m Q y. ~~, ~ N ~ ~ ~ 3~" cd c ~3co."~' "'~ -"' ~' ~k v m ~ a~ o d ~ a, v 6 ~ n~o C m~?~„ 0 . ro ' 3. N O 0 N ~ 0 ~ O 4 ~ O N W a~~ a-~~ ~ ~ ~o ~:~ p m ~a "~ Z ca $ ~ ~ y~~ ~~~ tii?~~~~o --~ :'~ p Cs ~ o a coo ~~ v pn~ ''K ~' O d- ~ c"'O a ~~ Nym a-oo~<~n Z G c ~ ~ ~ ~ p ~ .,, y . .N-~ O ~ O. 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Z m-1 m n N ~~ ~yy rD t/- • ~ ~. ~ ~ ~ ~ ~o ~ -+, ~ ,~ ~ O ~" rn ~~ ro ~ ~° -o -~ (D VN c m o ~~~ ~b~ ~ ~' 3 N vi ~ rs ~o rt ~ ~ c ~~o o~ N O G Cp LD 0 N O oQ 01 7 7 N N y .• rn ~ -~ z Z 'L ~' ,~~ ~N roo~~: N ~ g ~ ~ ~ 3 3 ~ o-o ~ 'C ~ a ~ ~~m tea. '~o~fl- O z ~ o ~~~- ~ o o ~;N o o o~ ~ an 3 ~~ c~ ~ N •- N N C7 O ON N N N N C9 ~ ~« 91 ~ 01 tD N* <q ~`' O' f~'~ C~ ? N ~ CO's ~!„ ia1 ~1 N r O p7 .+ Sv 0 ~ ~ ~ 3~' Q. fD ~ o ~ ~ ~ ~' .yi n O i r m G G G N P ~~ ^ . CD ~ ~ fD ~ `~ 7~ R tOA ~ ~ j ~ ~~- ~• ~ u -. O n ~ ~ ~ _ ~ N ~..0 ¢~ ~~' ~ ~o~a• ~, ~~ x-03 ~~~ ~~ ~Q ;.~ ~3~o z i ~ Q u o ~~ ,. o - ~ z rn o s~ o~~ g~ ~ . wmN~ ~ rn ~a G v~ ~ mC~ No ~~ 'a A ' N' ~' °' N-~ ~, ~ ~' ~ o ~ ~ ~ °' a 7a m m ° o N ,~-,w ~ ~ ~ cv a N 0~~~ ~ ~ ~~ ~ N N ~ v~ N S 3 • N~ N O C~ 7 ~ ~ o N 7 ~ ~? v .~, O ~ O N C9 ~..~ ,~ "'" O ~ n to t N N :~ ~ ~ • n 7.. O 4 ~ O~ N ~ ~^y CD O ? N N tD C'~ ~+i a^ 4 `C n 4 CD C ~ ~ ~ ~ O m ~` ~ a ` ~ ° ~ -r~ ~ ° v ~' ~ ~ W ?;. v w a ~. < -G ~; Nom; x ~pO ~. a o ~~ ~ ~~o~ ~ sv m ~a W m ~ g ~ N ~' ~ ~ ~~ ~ ~ ~ ~ v _. o L c .•-y ~ " , ~ ~~~ ~ O ~ ~ ~ N ~ ~ ~. O N C3.~ ~ -o o~ g o ~ ~ Ci. n a tv ~ ~ ,P ~: o- ~ m -~ N N Z rn n N -~ ~~ n, N~ 9~ .+1~ """" C ~ ~ ~ y CD t~3 CD ..y "iI ~t T~ 5000 Louise Drive MEMBERS 1't ® Mechanicsburg, PA 17055 rauEn~u.cnenrrurroN (800)283-2328 CERTIFICATE APPLICATION AND RECEIP'~ \ UWe hereb a 1 for a Members 15L Certificate in the amount and term listed below Y PP Y Please Print: Member Name: JANET E CASEY Street: 951 W Trindle Rd Maturity Date: 03/14/2010 Account #: 0000057451 SSN: 043-16-9921 Extra Address: City: Mechanicsburg State: PA Zip Code: 17055-4080 .T(ITNT nWNF.RS Last: First: MI: Suffix: 1 Street: City:.. -_ _ _ _ ~tate:_ ~i __~ode;_ _ ----- - Extra Address: Date Of Birth: --/--/---- SSN: - - Last: First: MI: Suffix: 2 Street: City: State: Zi Code: Extra Address: Date Of Birth: --/--/---- SSN: - - Last: First: MI: Suffix: 3 Street: City: State: Zi Code: Extra Address: Date Of Birth: --/--/---- SSN: - - Last: First: MI: Suffix: 4 Street: City: State: Zi Code; Extra Address: Date.Of Birth: --/--/---- SSN: - - ^ Deposit Amount: $ Transfer Amount $ 100 , 000.00 From Account: 0000057451 Share ID: 41 - 12 MONTH CERT MONz !"F.RTTFTCATF, i)F.TATLS Certificate Type Minimum Amount Original Deposit Amount Annual Percenta a Yield Dividend Rate Share ID 19 t~NTH CERT $500.00 $100,000.00 4.110$ 4.030 42 Dividends Payment Method: By: By Check To: Account Number: Share ID: Member's Signature: ~~'~"'"" h ~~VI~~~ Date: 08/14/2008 This is to certify that the above named person(s) is (are) the owner(s) of a Certificate account at Members l51 Federal Credit Ur The Certificate is in accordance with the terms of the Membership and Account Agreement and the Credit Union's current Trut~ Savings Rate and Fee Schedule which shall accompany the receipt of deposit for this Certificate and is incorporated by this referee St MEMBERS 1St FEDERAL CREDIT UNION SAVINGS ACCOUNT: Account Number/Suffix 57451-00 Date Account Established 09/17/1964 Principal Balance at Date of Death $65,627.81 Accrued Interest to Date of Death $11.69 Total Principal and Accrued Interest $65,639.50 Name of Joint Owner None CERTIFICATES OF DEPOSIT: Account Number/Suffix 57451-42 Date Account Established 08/14/2008* Principal Balance at Date of Death $100,000.00 Accrued Interest to Date of Death $143.53 Total Principal and Accrued Interest $100,143.53 Name of Joint Owner None *Rollover from certificate 57451-41, originally established 09/11/2007. M BERS 1ST FEDERAL C~RE~DIT~UNION C1~-~~~ ~- ~.Q~c~~- Danielle A. Kline Insurance Services Specialist August 5, 2009 Estate of: JANET E. CASEY Date of Death: 07/14/2009 Social Security Number: 043-16-9921 5000 Louise llrive !?O. Box 40 Mechanicsburg, Pennsylvatua 17055 (800) 283-2328 wwwmeinberslst.org Omega Bank N. A. Receipt for Number 173-0047755 PAYABLE TO JANET E CASEY 201 W COOVER ST CERTIFICATE OF DEPOSIT NON-NEGOTIABLE NON-TRANSFERABLE This certificate is subject to aft applicable existing and future rules and regulations of this Bank. RELATIONSHIP CUS7 TYPE TX IND TIN SELF F Y 043-16-9921 MECHANICSBURG, PA 17055-6411 PHONE # H 717-697-1379 W THE SLIM OF One hundred thousand and xx / 100 PROD TYPE DEP TYPE 1099 OFFR CD BRANCH ACCT CLASS ISSUE DATE T256 Ol I 798 225 03 04/04/2005 INT PAYMENT FREQ DISPOSTTION OF INTEREST PAYMENT RENEW INFO Monthly 04 Mai12 3 0 000 TYPE OF CERTIFICATE Automatic Renewal DOLLARS $100,000.00 MATURITY DATE 1NT RATE FUNDS SOURCE 04/04/2010 4.55% Check Drawn on Other 07 `t _""'" BANK REPRESENTATIVE SIGNATURE STANDARD TERMS PROMOTIONAL OFFERS AND CHANGES IN INTTIAL CERTIFICATE OF DEPOSIT TERMS UPON RENEWAL: For information as to your interest rate, annual percentage yield, special promotional offers, maturity date and other pertinent information of the certificate you have purchased or have authorized for subsequent renewal with a revision and/or change in the original or prior term, refer to the "Certificate of Deposit Disclosure" which will be delivered or mailed to you at that time. BASIC OWNERSHIP TERMS AND CONDTTIONS: If this certificate is issued to two payees, a certificate will be held by them as joint tenants with right of survivorship, and shall be payable to either of them or the survivor. Each payee shall be the agent for the other to receive interest, to give or receive any notice, and to take any action affecting this certificate or rights hereunder, including but not limited to receiving and receipting the proceeds thereof. By opening this account you hereby agree to keep your funds on deposit with the above identified bank until the due date specified above and for the full maturity of any subsequent renewals. Any withdrawal made prior to the maturity of this contract may be made only with the bank's consent and with a substantial penalty. This certificate is not negotiable, not subject to check, and may not be assigned without acceptance of such assignment by the bank. The bank specifically reserves the right to refuse to accept or acknowledge any assignment thereof. Deposit Accounts will be governed by and interpreted in accordance with federal law and the laws of the Commonwealth of Pennsylvania. Deposit Accounts are accepted by bank in the Commonwealth of Pennsylvania. If there is a lawsuit, depositor agrees upon bank's request to submit to the jurisdiction of the courts of Centre County, Commonweaith of Pennsylvania. The bank has the right to mature this certificate upon notice of any attachment, levy or right of setoff exercised under Pennsylvania or federal law. This certificate is payable with interest to the registered holder(s) hereof in cun'ent funds upon proper receipt and acknowledgement. Unless presented for redemption within the ten day grace period following any maturity date or you provide written, e-mail, or verbal recorded telephone instruction to change the original term or product offered; your certificate, including accumulated interest, if compounded, will renew automatically for an additional period equal to its original term at the then prevailing bank interest rate offered for a like term certificate and product. Unon such renewal anv special interest rate adiustment ontion or promotional offer attached to the initial term shall have exaired. Accumulated interest, if applicable, will be added to the principal at each renewal date and as such will be subject to penalty if withdrawn before the next maturity date. Compounded interest earnings, however, credited to this account during the immediate prior teen may be withdrawn without penalty at any time before the next maturity date of the certificate. Bank will pay no interest on your deposit after its maturity date unless your deposit is automatically renewed. If bank renews your certificate, you will receive written confirmation and bank will pay you interest from the prior maturity date to the new maturity date at the then prevailing interest rate. The rate of interest payable hereunder upon renewal and all other terms and conditions are subject to change by bank's regulations and/or to comply with applicable banking laws and regulations. The bank reserves the right to redeem this certificate upon notice at any maturity date. This receipt need not be presented to redeem or change the certificate at maturity. OPTIONS AT MATURITY: You may take any of the following actions within 10 days after the maturity date of your deposit (1.) Withdraw your deposit; (2.) Transfer the deposit to a new or existing account; (3.) If your deposit is automatically renewable, you do not have to take any action. BALANCE COMPUTATION METHOD: Bank uses the daily balance method to calcuiate the interest on your account. This method applies a daily periodic rate to the principal in the account each day. EARLY WITHDRAWAL PENALTY: See your Certificate of Deposit Disclosure for Early WIthdrawl Penalties that may apply. SIGNATURE CERTIFICATION: By my/our signature(s) below, Uwe certify acceptance of the Terms and Conditions, Early Withdrawal Penalty and the accuracy of the W-9 Certification contained in this Certificate of Deposit agreement. W-9 CERTIFICATION: Under penalty of perjury, Uwe certify (1) that the number shown on this form is my correct taxpayer identification number (TIN) and (2) that I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report ail interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding. I understand that the tax identification number that I am certifying at this time will be used for tax reporting purposes. Instructions: Strike out item number 2 in the certification if you have been notified that you are subject to backup withholding and you have not received a notice from the Internal Revenue Service that backup withholding has terminated. If this account is exempt from backup withholding; you should check the space below. The Internal Revenue Service does not require your consent to any provision of the document other than the certifications required to avoid backup withholding. "EXEMPT" T'RI W-8 Signed ID PA 13277304 (PRI) Depositor's signature ^ (Co-H) W-8 Signed Depositors signature Signature to follow W-8 Signed Name Added Depositors signature TRI Change DATE J~1 ~lai~ln~ ~. Sovereign Bank Certificate of Deposit Receipt inci al Transactions ONLY Addition to Principal /Withdrawal from Pr p This receipt is issued to: JANET E CASEY 951 W TRINDLE RD MECHANICSBURG PA 17055 The account evidenced by this receipt is subject t e went and thec ertific atetof depositt ds closure. conditions as contained in the deposit account ag Principal Dollar Amount Balance before Addition/Withdrawal $50,000.00 Addition to Principal $0.00 OR $0.00 Withdrawal from Principal Penalty Amount $0.00 If not during grace period. New Certificate of Deposit Amount $50 Account Details IRA Account: ^ Yes®No Account Number: 1685426502 Date Opened: 07/28/2008 12 MOS Term: Maturity Date: 07/28/2009 __ _._ _ - Interest Rate: 3.25 Annual Percentage Yield: 3.30 Interest Disbursement: CHECK Interest Payment Frequency: MONTHLY Dater 07/2812008 Office # 168 Comp e d DEBORAH B ECKERD or Desi ate Signature of Sn Print Name This account is not negotiable and not transferable. Effective 12110/02 • L,' e ~ " ;~~ ~ ~ ormation for your records: Please retain this inf 0.00% , ~ ~ ~ ~ Interest Rate• tR0 Date: gp,N1'~ Prr uct [] Checking ___ .. __. ga~mgs a~ ~~ [Certificate -Term Account # ~ O ~ ~ 5032 Simpson ~ PA R Q d ,Gaines RBPresentatiVe 55 ~yneiie M er SeNlce Meonanresburg. 766-00 Custom 7~~' 78244 Senior FerN FaX: i17- SimPson n,etrobank,~orn yyne11e.9aings~ mY Date: 1 ~ ~ I ~ ivlitLl~rlty Tiered Rates APY Intere~ e Ballan_ce To: ~~ ----- Commerce Bank America's Most Convenient Bank® 1-888-937-0004 commercepc, com Balance information reflects transactions through 6:00 PM on that business day. Some deposits may not be available for immediate withdrawal. Checks and other items era received for deposit s,,{ubJect to the prorv~is))ions of ~ut{he Uni(rfry}or (m'~~ Co jm}}mercial Code or¢ayny applicyable collection agreement. 'EJ J' ~J ~1! H ~lJr~*J~t ~~UV L ~~T~[.'{~'['T \ ~ ~: ixE-y is,iG i~r's'alt L'~YS..'31 SVVI UtJ +L.~_i ,, ~`- t i~ 7Ff E_.~ ~., BR-17 3.3MM 2108 AC a"k f3 REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY OWNED PROPERTY ESTATE OF FILE NUMBER Janet E. Casey 21-09-0693 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 ADDRESS RELATIONSHIP TO DECEDENT A• Beulah J. Atkinson e' Chester L. Wolf C JOINTLY-OWNED PROPERTY: 951 W. Trindle Road I Niece Mechnanicsburg, PA 17055 5830 Lincoln Highway W. Nephew Thomasville, PA 17364 ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST t. A. 01/24104 Susquehanna Bank CD#48152724, Principal $100,000.00 100 018 90 1/3 30 005 67 , . , . Interest Rate 3.45%, issue date 1124104, maturity date 1/12/2014 TOTAL (Also enter on line 6, Recapitulation} I $ 30,005.67 (If more space is needed, insert additional sheets of the same size) Certificate of Deposit Receipt This receipt is issued to: ~JRNET E CASEY CHESTER L WOLF i BEULAH J ATKINSON 951 W TRINDLE RD ~MECHANICSBURG,PA 17055 ~, Account Number: 3 4 8.15 2 7 2 a IRA Number: Amount $ 100. 000. o0 Date Opened 0/~ 2/. n 0 4 Term 60 Month(s~ Maturity Date 0 ~ / T ~ / . 0 ~ q Interest Rate r 4 5 0 0 0 0 Annual Percentage Yield 3.45°b 01 - Susquehanna Bank Camp Hi11 Office 201 St Johns Church Road _. _ _ _ _ _ Camp Hi11,PA 17011 The account evidenced by this receipt is subject to and further explained in the terms and conditions contained in the account agreement and account disclosures. The account is Not Negotiable and Not Transferable. Only the items checked apply. ^ Fixed Interest. Rate ® Variable Interest Rate ^ Additions Permitted ® Automatically Renewable ^ Single Maturity (not automatically renewable) ^ Callable Interest will be: ® mailed to the owner(s). ^ added to principal (compounded). O paid to account No. ® to be bald every 1 Month(s) ~ ©1894 Bankers Syctams, Inc., St. Cloud, MN Form CDREC-BK-IAZ 8/7/2002 ^ Notice Account (pye 1 of 1) REV-1510 EX+ (6-96) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Janet E. Casey 21-09-0693 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. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE ~ ~ Western National Annuity FJ204223 100,347.40 TOTAL (Also enter on line 7 Recapitulation) $ I 0.00 (If more space is needed, insert additional sheets of the same size) AMERICAN READ YOUR POLICY CAREFULLY American General Annui[y This policy is a legal contract between the policy owner and Insurrnce Com ny the Com an GENERAL A~ ~~3~~~ ~ p y. ~' ~ r;~ t ~ ANNUITY T l h e cp enc 6 a2s.a The Company will provide written notice of the Initial Interest - Rate with delivery of your policy. ,' ~ ~r Policy Number F,! ~~4~~3 Initial Premiu P PolicyD~~l30/1999 i m ayment 100035 ~ 78 Annuity ate ANNUITANT FUJI Name . Marital Status S~EMALE CA.~F~ JA~iET E r¢ s4 Social Secures 31 ti9 9 21 Date of Bi ~ 1 W COOVER ST r~i4 ~ 2 4 ~ 1912 Age 7 Phone No. (Horr~76971379 MECHANICSBURG gA ~~'p55 Phone No. (Business) OWNER Full Name Marital Status Sex , Social Security Address Date of Birth Age Phone No. (Home) Zip Phone No. (Business) ~; BENEFICIARY `-` On The Life Of Annuitant: Prim~gf,UL~ ATKINSON Contingepn{' RelationsECE Relationship On The Life Of Owner, If Applicable: Primary Relationship Contingent Relatianship The Right To Change The Beneficiary is Reserved To The Owner r ANNUITY APPLIED FOR Plan: Flexible Premium Deferred Annuity. Non Participating .. Type of ~4nnuity; Non-Qualifie~ IRA Transfer $ Rollover $ , (attach endorsement) Deposit Year $ Other Deposit Year $ Will any insurance or annuity now in force be replaced or changed by the annuity applied for on application? Yes _ ~fo : . If yes, give company, amount, year issued and reason. ~ = I understand this annuity is not federally insured. On behalf of myself and any person who may claim any interest under this policy, I represent that all statements set fcrth are full, complete and true as written and correctly recorded to the best of my knowledge. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to civil and criminal penalties. CHECKS MUST BE MADE PAYABLE TO AMERICAN GENERAL ANNUITY INSURANCE COMPANY, DO NOT MAKE CHECKS PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK. this 0 day1~JGUST ~ d J . ~ ' . ., ~ Y"y.,a.a ' Joint Owner)( .Licensed Agent and Numbgz 0 3 - 01417 i~ income'at age ~ qq ,paid for life with 10 year period certain, will be ~ 04.45 based on a representati~7e~nnual premium of $2;OOQ.00. This is based on the guaranteed'cash values, assuming no withdrawals and that only the~guaranteed interest rate of 3.5% is paid. FOR AGENT To the best of your knowledge, is this insurahce being purchased to replace or change~any existing insurance or annuity? Yes If yes, give company, amount, year issued and reason, SBDA-96-A-PA. WHITE -Customer Copy ~ELLO. -Home Office Copy __~~ PINK -Agency Copy .GOLD -Agent Signed7CSBURG PA Signature s Annuitant if age 18 or over Owner if different from Annuitant licensed Agent Slg' naT-ure E CAS~,~'` go 538559 EV-1511 EX+ (12-99) SCHEDULE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Janet E. Casey 21-09-0693 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1 ~ Gingrich Memorials, inscription in tombstone 135.00 Malpezzi Funeral Home- death certificates 9.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Beulah J. Atkinson and Donald L. Atkinson Social Security Number(s)lEIN Number of Personal Representative(s) street Address 951 W. Trindle Road city Mechanicsburg state PA Zip 17055 Year(s) Commission Paid: 2009 and 2010 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees ~. The Sentinel, estate notice a. The Cumberland Law Journal, estate notice s. Citizens Bank -Clark American Checks ~ o. Citizens Bank -Service charge 1 ~ . Register ofWills -Filing Fee TOTAL (Also enter on line 9, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) 34,500.00 34,500.00 630.00 208.75 75.00 43.95 34.59 15.00 70,151.29 RE~I-1512 ~X+ (12-Q8; ~ Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Janet E. Casey 21-09-0693 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (11-08; pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Janet E. Casey 21-09-0693 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. First United Methodist Church 135 W. Simpson St., Mech., PA 17055 10,000.00 2. Beulah J. Atkinson 951 W. Trindle Road, Mechanicsburg, PA 17055 Niece 1/4 of net residue 3. Sarah Weidenhoft Brookdale Cypress Village, Jacksonville, FL 32224 Niece 1/4 of net residue 4. Martha McEnany 106 Harrington Drive, Rising Sun, MD 21911 Niece 1/4 of net residue 5. Chester Wolf 5830 Lincoln Highway W., Thomasville, PA 17364 Nephew 1/4 of net residue ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. 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. ~~~# ~i1I ~~th 'C .e~~~tme~tt OF JANET E. CASEY I, JANET E. CASEY, of the Borough of Mechanicsburg, County of Cumberland, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this my Last Will and Testament. 1. I direct the payment of all my just debts and funeral expenses as soon after my decease as,the same can conveniently be done. 2. I direct that there shall be paid out of my residuary estate all estate, inheritance and like taxes together with any interest or penalty thereon imposed by the Government of the United States, or any state or territory thereof, or by any foreign government or political subdivision thereof, in respect to all property required to be included in my gross estate for estate, inheritance or like tax purposes by any of such governments, whether the property passes under this will or otherwise. 3. I give and bequeath Ten Thousand ($10,000.00) Dollars to the First United Methodist Church of Mechanicsburg. - 1 - 4. I give and bequeath Sixty Thousand ($60,000.00) Dollars to my sister-in-law, CLARA CASEY SIMMONS. 5. All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, I give, devise and bequeath as follows: A) One-fifth (1/5) of the residue to my niece, SARAH ALVERTA EFCEVITCH, B) One-fifth (1/5) of the residue to my niece, BEiJT.AH ATKINSON, C) One-fifth (1/5) of the residue to my niece, MARTHA M. McENANY, D) One-fifth (1/5) of the residue to my niece, DOROTHY MILLER, and E) One-fifth (1/5) of the residue to my nephew, CHESTER LEROY WOLF. 6. In the event a specific or general legatee predeceases me, his or her share shall lapse and fall into the residue for distribution to the residuary legatees who survive me. 7. Lastly, I nominate, constitute and appoint my niece, BEULAH ATRINSON and DONALD ATKINSON, her husband, to be Co-Executors of this my Last Will and Testament and in the event either should be - 2 - unwilling or unable, for any reason, to act as such, I then direct that the other shall serve as sole Executor. I further direct that no bond or other security be required of my personal representative to guarantee faithful performance of her or his duties. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~.<:~ day of December, 1995. t ~ `~..,6tc2%~'' "' ~.~,~' t ( SEAL ) Janet E. Casey Signed, sealed, published and declared by the above named JANET E. CASEY as and for her Last Will and Testament, in the presence of us who have subscribed our names hereto as witnesses, at her request, in her presence and in the presence of each other. COMMONWEALTH OF COUNTY OF SS I, JANET E. CASEY, the testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the same instrument as my Last Will and Testament; that I signed it willingly, and that I signed it as my free and voluntary act and deed, for the purposes therein expressed. ~ ( SEAL ) Sworn and subscribed to before me this ~~- day of ~~ ~:. ~_ : ~ 1995. l 1~ ~ - 3 - COMMONWEALTH OF PENNSYLVANIA COUNTY OF SS We, the undersigned, JOHN M. EAKIN and J. ROBERT STAUFFER, the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, depose and say that we were present and saw the testatrix, JANET E. CASEY, sign and execute the instrument as her Last Will and Testament; that the said testatrix executed it as her free and voluntary act for the purposes therein expressed; that each of us, in the hearing and sight of the testatrix, signed the Will as witnesses; and that, to the best of our knowledge, the testatrix was, at the time, eighteen (18) or more years of age, of sound mind, and under no constraint, duress or u Sworn and subscr~ed~to before me this "; day of December, 1995. ~~ ~~l~~~l0otti'~W d - 4 -