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HomeMy WebLinkAbout11-30-09 J 1505607121 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 0 9 0 4 4 2 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 9 4 2 8 9 9 3 8 0 3 0 4 2 0 0 9 0 8 0 8 1 9 2 4 Decedent's Last Name Suffix Decedent's First Name MI B R A Z I N S K A S S T A N L E Y (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 0 1. Original Retum ~ 2. Supplemental Return ~ 3. Remainder Return (date of death 4. Limited Estate ~ 4a. Future Interest Compromise (date of prior to 12-13-82) ~ 5. Federal Estate Tax Return Required ® 6. Decedent Died Testate ~ (Attach Copy of Will) death after 12-12-82) 7. Decedent Maintained a Living Trust A 2 8. Total Number of Safe Deposit Boxes 9. Litigation Proceeds Received ~ ( ttach Copy of Trust) 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 CONFID ENTIAL TAX INFORMATION SHOULD BE DIRECTED TO Name : Daytime Telephone Number C H A D J J U L I U S 7 1 7 9 0 9 5 8 5 8 Firm Name (If Applicable) t^~ L E S L I E J A C O B S O N First line of address 8 1 5 0 D E R R Y Second line of address S U I T E A City or Post Office H A R R I S B U R G Correspondent's a-mail address: S T O F F I C E S State ZIP Code REGISTE ILLS US ~iNLY . ,. ; ~ ~ ~ 4 ., .~, ,: r`n tom? ~ : ; . f•", ~ ~ ~ „~ .. '~~~ ~'~ ~ - .__. . , - ^-~ ' • ~. ,-, D'~KTE FILED ~ P A 1 7 1 1 1 5 2 1 2 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 alt information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN © DATE /~ ADDRESS C ~ I ~ (~ 8171 SOMERSET ST HUMMELSTOWN PA 170369316 SIGNATURE OF rRErARER O~T\HF~R TypN REPf3ES NT TjVE. _ ~ _~~ ~~ DATE __~y ,` -L `" _., _,,. ~.., ."r~ ::::-:,~ ~.y+~ .y ADDRESS 8150 DERRY ST SUITE B HARRISBURG PA 171115212 PLEASE USE ORIGINAL FORM ONLY Side 1 1505607121 1505607121 J 1505607221 REV-1500 EX Decedent's Social Security Number Decedent's Name: STANLEY BRAZINSKAS 1 9 4 2 8 9 9 3 8 RECAPITULATION 1. Real estate (Schedule A) ,,,,,,,,,,,,,,,,,,,,,, 1 2 1 5 0 0 0, 0 0 2. Stocks and Bonds (Schedule B) ,,,,,,,,,,,,,,,,,,,,,,,,, 2 2 0 3 2 9 6. 7 8 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages & Notes Receivable (Schedule D) .. . . . . . . . . . ... . ... . . 4 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ....... 5. 1 0 2 2 6 7 . 7 3 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ....... 7. 8. Total Gross Assets (total Lines1-7) ......................... 8 5 2 0 5 6 4, 5 1 9. Funeral Expenses & Administrative Costs (Schedule H) ............ . . . . 9. 7 5 6 0 1 . 8 7 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............ 10. 11. Total Deductions (total Lines 9 & 10) ........................... 11. 7 5 6 0 ], ~ 8 7 12. Net Value of Estate (Line 8 minus Line 11) .................. . . 12. 4 4 4 9 6 2 . 6 4 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ..... . . . . . ....... . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) .................. 14. 4 4 4 9 6 2 . 6 4 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .0 0. 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .0 0. 0 0 16. 0. 0 0 17. Amount of Line 14 taxable at sibling rate x .12 3 3 3 7 2 1. 9 8 17. 4 0 0 4 6. 6 4 18. Amount of Line 14 taxable at collateral rate X .15 1 1 1 2 4 0. 6 6 1 g. 1 6 6 8 6. 1 0 19. Tax Due ................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505607221 5 6 7 3 2. 7 4 1505607221 J KEV-1500 E'X Page 3 File Number Decedent's Complete Address: 21 09 0442 DECEDENT'S NAME STANLEY BRAZINSKAS STREET ADDRESS 523 HERMAN AVE CITY STATE LEMOYNE ZIP PA 17043 Tax Payments and Credits: ~~ Tax Due (Page 2 Line 19) (1) 2. Credits/Payments 56,732.74 A. Spousal Poverty Credit B. Prior Payments 14,400.00 C. Discount Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable 14,400.00 D. Interest E. Penalty 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT Total Interest/Penalty (D + E) (3) 0.00 Fill in oval on Page 2, Line 20 to request a refund. 4 ( ) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 42,332.74 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 +5A. This is the BALANCE DUE . (56) 42,332.74 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: a. retain the use or income of the property transferred; ...................................................... Yes No ^ ^ X ................ b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q c. retain a reversionary interest; or ......... .................................................................. ^ ^ ..................... d. receive the promise for life of either payments, benefits or care? ............................................. ^ ^ X .......... 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ...... .................................................................... ^ ^ X ............. 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ......... ^ Q 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 survivin s ~ouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. 9 P 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. I~EV-1502 E'XX + (6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ~~ ~ H i r yr FILE NUMBER STANLEY BRAZINSKAS 21 09 0442 All real property owned solety 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 ro which is ' in -owned with ri ht of survivorshi must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. _ _ 523 HERMAN AVE SETTLEMENT~SHEET ATTACHED LEMOYNE, PA 17043-1823 2 BUILDING LOTS REAL ESTATE TAX STATEMENTS ATTACHED MASSACHUSETTS AVE SPRING LAKE CAMP HILL, PA TOTAL (Also enter on line 1 (If more space is needed, insert additional sheets of the same size) s 95,000.00 215,000.00 REV-1503 e'X + (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER STANLEY BRAZINSKAS 21 09 0442 All property jointty-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1. SEE ATTACHED US TREASURY CALCULATOR SCHEDULE 2 15 SERIES E UNITED STATES BONDS SEE ATTACHED US TREASURY CALCULATOR SCHEDULE 3 264 SHARES BROWN SHOE COMPANY INC SEE ATTACHED STOCK HISTORY PRINT OUT 4 1152 SHARES FOOT LOCKER INC SEE ATTACHED STOCK HISTORY PRINT OUT 5 675 SHARES JP MORGAN CHASE & CO SEE ATTACHED STOCK HISTORY PRINT OUT TOTAL (Also enter on line 2, Recapitulation) I $ (If more space ~s needed, insert additional sheets of the same size) VALUE AT DATE OF DEATH 81,976.40 858.00 9,550.08 13,027.50 203,296.78 aEV-~ 5os ~x + is-ss) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF STANLEY BRAZINSKAS FILE NUMBER 21 09 0442 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 NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. ~ • 2. M & T CHECKING ACCOUNT #950263584 87,624.43 3 1986 LINCOLN TOWN CAR 4DR NDA VALUE ATTACHED 4,000.00 4 HOUSEHOLD GOODS & JEWLERY 4,766.75 SOLD AT AUCTION BY BRICKERS AUCTION 06/15/09 5 CLOTHING TAKEN TO GOODWILL 3,000.00 110 BAGS OF CLOTHING, 9 CARTON OF CLOTHING 5 PEKES & 1 CARTON MISCELLANEOUS HOUSEHOLD ITEMS TOTAL (Also enter on line 5, Recapitulation) I a 102 267 73 (If more space is needed, insert additional sheets of the same size) ~ F2EV-1511 ~X + (10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & IN RESIDENT DECEDENTRN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER STANLEY BRAZINSKAS 21 09 0442 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A• ~. FUNERAL EXPENSES: MUSSELMAN FUNERAL HOME 375.00 B• ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) OTTO ZINK 26,028.23 Street Address 8171 SOMERSET ST City HUMMELSTOWN state PA zip 17036-9316 Year(s) Commission Paid: 2009/2010 2. Attorney Fees LAW OFFICES OF LESLIE JACOBSON 3. Family Exemption: (If decedents address is not the same as claimants, attach explanation) 26,028.23 Claimant Street Address City State zip Relationship of Claimant to Decedent 4• Probate Fees REGISTER OF WILLS 395.00, SHORT CERTIFICATES 40.00 LEGAL NOTICE ADVERTISING 293.15 728.15 5 Accountants Fees FRED H. WEGE, JR. ATP, WEGE ASSOCIATES 8150 DERRY ST., STE B, HARRISBURG, PA 17111-5212 3,200.00 6• Tax Return Preparers Fees FRED H. WEGE, JR., ATP, WEGE ASSOCIATES 8150 DERRY ST., STE B. HARRISBURG, PA 17111-5212 2,000.00 7. CLOSING COST ON HOUSE 8 REAL ESTATE TAXES 2,726.10 9 SEWER FEES 1,255.75 10 ELECTRIC 345.83 11 WATER 131.70 12 INSURANCE 116.00 13 FUEL OIL 576.89 14 MOWING/YARD WORK 88.36 15 PAINTING HOUSE 440.00 16 OTHER REPAIRS AND CLEANING HOUSE 1,039.20 17 STOCK BROKERS FEE 4,549.48 767.30 TOTAL (Also enter on line 9, Recapitulation) I a 75 601 87 (If more space is needed, insert additional sheets of the same size) ~ REV-1513 EX°+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT tJlAlt U STAN L NUMBER I. 1. 2 3 4 II. r .EY BRAZINSKAS NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1. jj LIUDO BRAZINSKO VYTAUTO G. 22-7 4690 DRUSKININKAI, LIETUVA, LITHUANIA ONUTES JUSIENES CIURLIONIO G 87-16 LT 4690 DRUSKININKAI, LIETUVA, LITHUANIA KONSTANCIJOS PALAIKIENES SIMNO G 7 LT 46365 KAUNAS, LIETUVA, LITHUANIA OLGA CEPE WHEREABOUTS UNKNOWN FILE NUMBER 21 09 0442 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) ~ Sibling ~ Sibling Sibling Collateral 111,240.66 111,240.66 111,240.66 111,240.66 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS 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 ~ AMOUNT OR SHARE OF ESTATE (tf more space is needed, insert additional sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent STANLEY BRAZINSKAS 21 09 0442 Decedent's Name Page 1 File Number Schedule H -Funeral Expenses & Administrative Costs - B1 ITEM NUMBER B. 2 airy FRISCO state TX zip 75034-1838 Year(s) Commission Paid: 2009/2010 DESCRIPTION ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) VYTAUTAS RUPINSKAS street Address 5737 FOARD DR AMOUNT 5,205.65 SUBTOTAL SCHEDULE H-B1 ~ 5,205.65 A. Vlf/D IrV. L.7VL-VL~~7 B. TYPE OF LOAN: U.S. DEPARTMENT OF HOUSING 8 URBAN DEVELOPMENT 1.QFHA 2.QFmHA 3.QX CONV. UNINS. 4.QVA 5.QCONV. INS. SETTLEMENT STATEMENT 6. FILE NUMBER: 7. LOAN NUMBER:. s. MORTGAGE INS CASE NUMBER: C. NOTE: This form is famished to give you a statement of actual settlement cosfs. Amounts paid to and by the settlement agent are shown. Items marked "(POCJ"were paid outside the closing; they are shown here far informational purposes and are not included m the Iota/s. 1.0 3198 (FATS-26 GUERS.PFDiFAT9-26 GUERS/40) D. NAME AND ADDRESS OF BORROWER: E. NAME ANO ADDRESS OF SELLER: F. NAME AND ADDRESS OF LENDER: Gail L. Guers Estate of Stanley Brazinskas PA State Employees Credit Union 523 Herman Avenue c% Otto Zink $ Vytautas Rupinskas, Executors 1 Credit Union Place Lemoyne, PA 17043-1823 8150 Derry Stn~et Harrisburg, PA 1 71 1 0-2990 Harrisburg, PA 17111 G. PROPERTY LOCATION: 523 Herman Avenue Lemoyne, PA 17043-1823 H. SETTLEMENT AGENT: 25-1802264 Chesapeake Abstract Company I. SETTLEMENT DATE: S Cumberland County, Pennsylvania PLACE OF SETTLEMENT 17 South Second St., 6th Floor Harrisburg, PA 17101 eptember 4, 2009 J. SUMMARY OF BORR WER'S TRAN SACTION K SUMMARY OF SELLER'S TRA NSACTION . 101. Contract Sales Price 120,000.00 40i. Contract Sales Price 120 102. Personal Pro 402. Personal P e ,000.00 103. Settlement Char es to Borrower Line 1400 4,576.88 403. 104. 404. 105. 405. a u r t ~ 106. Coun Boro Taxes 09/05/09 ta 01!01/10 164.25 406 Coun /Boro Taxes 09/05/09 107 School Taxes 09/05/09 t 07/01/ . to 01101!10 164.25 . o 10 108 Sewer/Trash 09/ 802.63 407. School Taxes 09/05/09 #0 07/01/10 802.63 . 05/09 to 10/01/09 34.05 408. Sewer/Trash 09/05/09 t 10/01! 109. o 09 409. 34.05 110. 410 111 . . 411 112. . 412 120 GROSS AMOUNT DUE F . . ROM BORROWER 125,577.81 420. GROSS AMOUNT DUE TO SELLER 200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500 REDUCT10N5 fN AMOUNT DUE T 121,000.93 201 De osit or e t . O SELLER: . arnes mane 10,000.00 501. Excess De asit See Instruction 202. Princi al Amount of New Loans 94,000.00 s 502. Settlement Char es to Seller Li 1400 203. Existin loans taken sub'ect to ne 503 Existin loans tak b' 18,664.77 204 . en su ect to . 504 Payoff of first Mort a 205 . g ge . 505 Pa off of second M rt 206 . o a e . 506 De osit retained b ll 207. . se er 507 10,000.00 208 . . 508 209 . . 509 ustments or terns n ar . a er 210 Count /Boro Taxes ustmen s or ems n ar a er . to 510 Coun /Boro T 211 School Taxes . axes to . to 511 School Taxe 212 Sewerlfrash . s to . to 512 Sewer/Tra h 213 . s to . 513 214 . . 215 514. . 515 216 . ` 516 217 . . 517 218 . . 518 219. . 519. 220 TOTAL PAID BY/FOR BORROW . ER 104,000.00 520. TOTAL REDUCTION AMOUNT DUE SE 300. CASH AT SETTLEMENT FROM/TO BOR LLER 28~~4,77 ROWER: 301. Grass Amount Due From B L 600. CASH AT SETTLEMENT TOIFROM SELLER: orrower ine 120 302. Less Amount Paid B /For Borrower Line 220 y ( ) 303. CASH (X FROM) ( TO) BORROWER 125,577.81 ( 104,000.00) 601. Gross Amount Due To Seller Line 420 602. Less Reductions Due Seller (Line 520) ( 121,000.93 28,664.7 The undersi ned hereb ,-q 9 ~ know dge,re~ipt of axomoleted 21 577.81 coev of nanps ~>z~ 603. CASH (X TO) ( FROM) S LER ~f+tia~ ~+~le..,~..~ ~ .. _ ._«_ 92,336.16 Borrower ~ ~~ ~" ~~~~ Gail L. Guers `~' ~- ;,~''L Seller ~Q,/`r ~W ~ ~ E of t ley Brazinskas HUD-1 (3-88j RESPA. HB4305.2 L. SETTLEMENT CHARGES r z 7 0. To i AL COMMISSION Based o Price ° PAID FROAA pglp FRO DiviS%On Of Commission Jine 700 aS FOIJOWS: BORROWER'S M SELLER' 701. $ t0 FUNDS AT S FUNDS AT 7O2 $ t0 703. Commission Paid at Settlement SETTLEMENT SETTLEMENT 704. to 0. I AY IN NECTiON W N 80i. Loan O ' ination Fee °~ to 802. Loan Discount 1.5000 % to PA State Employees Credit Unio 803. Appraisal Fee to 1,410.00 804. Credit Report to 805. Lender's Inspection Fee to 806• Mort a e fns. A _ Fee to PA State Em Io s Credit Unio 807. Flood Certification t PSECU L o ( Ps Natl Ftoodj 808 Document Preparation t P S 7 ~ . o A tate Employees Credif Unio 809. Application Fee PSECU $300 POC 150.00 810. Underwriting Fee t PA S o tate Employees Credit Unio 811. 100.00 0. T MS R IRED Y L ND R TO BE ID IN ADVANCE 901. Interest From 09/04/09 to 10/01/09 @ $ 14.486300/day ( 27 days %) 902. Mort a e Insurance Premium for months to 391.13 903 Hazard Insurance P i f 1 . rem um or .0 ears to 904 . 905 . 10 0. ESE V D P S TED WITH LEN ER 1001. Hazard Insurance months $ er month 1002. Mort a e Insurance months $ r month 1003 Coun /Boro Taxes . months $ er month 1004 School Taxes . months $ er month 1005 Sewer/Trash . months @ $ per month 1006 . months $ er month 1007. months @ $ per month 1008. months $ er month 1100. TITLE CHA ES 1101. L al fees to Chad Jutius, Es uire 1102. Abstract or T'rtle Search to 1,200 00 1103. Closin Protection Letter to First American Title Insurance Com an 1104. Ex ense Fee to Chad Julius, Es uire 1105. Federal Ex ress to Chesa eake Abstract Com an 1106. Nota Fees to Chesa eake Abstract Com an 1107. Document Preparation to Chad Julius, Esquire includes above item numbers: 35.00 30.00 20 00 116.10 200.00 1108. Title Insurance ~ to Cheasa eake Abstract Com an includes above item numbers: 958 75 1109. Lender's Coverage $ 94,000.00 1110. Owner's Coverage $ 120,000.00 958.75 1111. Endorsements 100, 300, 8.1 to Chesapeake Abstract Company 1112. 150.00 1113. 1200. GOVERNMEN REC RDING AND TRANSFER CHA GES 1201. Recording Fees: Deed $ 38.50; Mortgage $ 66.50; Releases $ 1202. Ci /Count Tax/Stam s: Deed 1,200.00• Mort a e 1203. State Tax/Stam s: Revenue Stam s 1,200.00: Mort a e 1204. UPI fee to Cumberland Couri Recorder of Deeds 1205. 105.00 1,200.00 20.00 1,200.00 1 00. ADDITIONAL SETTLEMENT CHARGES 1301. Surve to 1302. Pest Ins ection to 1303. Tax Certification to Faith Nicola, Tax Collector 1304. 2009 Coll Taxes to Faith Nicola, Tax Collector 1305. See addit'I disb. exhibit to 1400. TOTAL SETTLEMENT CHARGES Enter on Lines 103, Section J and 502, Section K By Signlna Dade 1 of this statamc+nt the ~~.,.,~+„~:e~ .,,.~..,....e..a.._ ____:_. _t _ _ ~ 4,576.88 10,00 558 87 15,379.80 18,664.77 _ __...._...,.,.~„ ........r. ~, a ...,~~~~,~~~~, wpy ~~ page ~ or trns two page statement. Certified to be a true copy. c;nesapeaKe Abstract Company Settlement Agent ( FATS-26 GUERS /FATE-26 GUERS 136 ) ~ ADDITIONAL DISBt1RSEMENTS EXHIBIT ~ Borrower: Gail L. Guers Setter: Estate of Stanley Brazinskas Lender: PA State Employees Credit Unio Settlement Agent: Chesapeake Abstract Company (717)233-1000 Place of Settlement: 17 South Second St., 6th Floor Harrisburg, PA 17101 Settlement Date: September 4, 2009 Property Location: 523 Herman Avenue Lemoyne, PA 17043-1823 Cumberland County, Pennsylvania r~-YEE/DESCRIPTION NOTE/REF NO BoRROwFFt SELLER 979.80 '14,400.00 ~ 15,379.80 Faith A. Nicola, Tax Collector 2009-10 School taxes Cumberland Co Register of Wills Inheritance Tax Payment Total Additional Disbursements shown on Line 1305 $ 0.00 (FATS-26 GUERS.PFD/FAT9-26 GUERS/30) TAXING AUTHORITY: WEST SHORE SCHOOL DISTRICT TAX YEAR' 2009-10 REAL ESTATE TAX NOTICE LOWER ALLEN TOWNSHIP PAYABLE BONNIE K. INN.LER, T/C (717) 975-7575 PROPERTY ID To. z233 GETTYSauRG Roan 13230549109 CAMP HILL, PA 17011 TAX SCHOOL • I • • • RATE 10.6 ~ o A . ~ ~ ~ ~~ ~~ AFTER PENALTY GATE REBATE 311.64 BY Og/0112Q0g 311.64 FACE 318.00 BY 11/01/2009 318.00 PENALTY 349.80 AFTER 11 /01/2009 349.80 To: BRAZINSKAS, STANLEY 8 STEPHANIE BRAZINSKAS 8171 SOMERSET STREET HUMMELSTOWN PA 17036 FOR: MASSACHUSETTS AVENUE SPRING LAKE BILL DATE - 07101x2009 DELINQUENT BILLS ARE TURNED OVER TO TAX CLAIM ON 12/31/2009 ASSESSED VALUE 30,000 HOMESTEAD EXCLUSION 0 FARMSTEAD EXq.USiON 0 NET ASSESSII~NT 30,000 BILL # 002409 TAXPAYER'S COPY TAXING AUTHORITY: WEST SHORE SCHOO L TAX YEAR: 2009-10 DISTRICT REAL ESTATE TAX NOTICE PAYABLE BONNE K, MILLER T/C LOWER ALLEN TOWNSHIP Cl1~ H75-7575 TO: 2233 GETTYSBURG RO PROPERTY ID AD CAMP HILL, PA 17011 13230549108 ASSESSED VALUE TAX SCHOOL • • ~I ~ 12,000 • HOMESTEAD EXCLUSION RATE 10.6 ~ 0 ~ ~ BEPa~ FACE ~~ REBATE AF's PENALTY w-TE 124.66 sY 09/01/2009 FARMSTEAD EXCLUSION 124.fi6 FACE 127.20 BY 11/0112~g 0 127.20 PENALTY 139.92 AFTER11/01/2Emg 139.92 ~TASSESSMENT 12.000 TO: BRAZINSKAS, STANLEY & STEPHANIE BRAZiNSKAS 8171 SOMERSET STREET HUMMELSTOWN PA 17036 fOR: MASSACHUSETTS AVENUE SPRING LAKE BILL DATE - o7rolrroos BELL # 002408 DELINQUENT BILLS ARE TURNED OVER TO TAX CLAIM ON 12/31/2009 TAXPAYER'S COPY ~~ ~ li ~y ~ `:~ ~~ C Q N (Q (D j O W O W ~V W O W CJ W I~ W W W N W - W ~O N CC N O N OV N O N CJt NNN ~WN NN-~-~ -~OC~OO ~~~~ VOCII,A ~~ WN ~,.., -~O CO QO V O U I~ PW N ~ O m m m m m m m m m m m m m m m m m m m m m m m m m rn m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m m ~ m m m m m m m m m m m ~• O O O O O O O O O O O O O O O O O O O O O O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O O 0 O O 0 O O 0 O O 0 O O 0 O O 0 O O 0 O O 0 O O 0 O O 0 O O 0 O O 0 O O 0 Cn O 0 G1 O ~C7 O 1(n O O 3 « ~ ~ ~ ~ ~ ~ ~ 0 0 0 ~ CO ~ CO ~ ~ 'A ~ G' ~W W ~ W ~ W ~ W ~ W ~ W ~ N ~ N ~ N ~ N ~ N ~ N ~ N ~ N ~ N ~ N ~ N ~ N ~ ~ ~ ~ ~ ~ ~ ~ ~ v ~ v O O ... ~ . ~ ~ ~ ,~ ~ .A N O U N O 7 C1 N O 1 CJ N O 1 CJ N O t N O N O N O O W D a W D 00 W OD W 00 W OD ~ 00 ~ CO .~ 00 .~ 00 ~ OD ~ 00 _ N OD a ... 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C N m m m m m m m m m m m m m m m ~. c~ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 °o o° o° o° o° OO °o o° o° o°° °o °o o°° °0 0° 3 N 0 N 0 N 0 N 0 N 0 N 0 N 0 N 0 ~ 0 ~ 0 ~ o ~ o .~ o .~ o ~ o ~ c~ v w , ~ w ~ w v w , v C~ , ~ 1 W ~ W v W , v N , v N , v N , ~ N ~ N w N v N , p~' ~ 7 C~7 7 W 1 ~ O .A ~ .~ ~ W W 0° °° ~ ~ ~ ~ y ~ +w O w O w O w O w CO cn CG cn ~ -~ m o m co m 00 m ~ m o~ m cn m ~ m . oo rn ~ m vi m cn m ~ m c~ m cn m 3 Q c~ O V O ~I O ~I O V O V O ~1 O ~1 O ~1 O ~I O ~I O ~1 O ~I O ~1 O '~I O ~I CD (O CC CO CO CO CO CO CO CO CO CD CO CC CO ~ C v ~ ~ ~ v v v •i ~ ~ ~ ~ .i ~ ~ v v cn ~ cn ~ cn v cn v cn v cn ~ cn ~ c~ v cn .i cn ~ cn v cn v cn .~ cn ~ cn v cn v cn v cn .i cn ~ cn v cn v cn v ~, ~ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ~ ~ ~ ~ ~ ~ ~ ~A ~ ~ ~ ~P ~ ~ ~ ~ 00 00 OD 00 00 00 OD OD Cn C~7 U1 CJ1 CJ7 Cn V7 ~ 0 0 ~ 0 0 0 0 0 0 ~ ~ ~ 0 0 ~ N 0 0 0 0 0 0 0 0 °0 °0 °0 0° o° o° OO ~ cJ, CJ1 cn U1 cr, C11 cn CJ7 v, V1 cn UI cn CT1 cn CJ7 cn W cn W cn W cn W cn W cn W can W < d O OD 00 OD OD 00 00 OD N N N N N N N C O O O O O C) 0 0 0 0 0 0 0 0 0 ~D O O O O O O O O O O O O O O O ~ i a rn rn a~ rn rn rn rn rn rn rn rn rn rn rn o~ ~ bo co co 0o co ao co 0o c~ o~ o~ o~ vi c~ o~ c~ a a o 0 0 0 0 0 0 0 0 ~ o 0 0 ~ I Z K d ~ ~ ~ T ~ fD ~ ~ .~r ~ n~ • . O v O v O ~ O y O v O ~ O y O y O v O y O v O ~ O v O ~ O v ~ - N N N N N N N N N N ~ N ~ N ~ N ~ N ~ N O ~ 3 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 O 0 ~ p~ ~ ~ r'*''"'' ~l ~l ~I ~I V ~i ~I ~l C 11 c J7 C 17 C J1 G 7 C J1 C J1 ~ CD O W ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ p O D D D D D D D D D D D D D D D ~ o co O d N ~~ fD N CT1 N 0 0 co n ~ < rt ~ O ~ ~ ~ ~ O 3WS: BROWN SHOE INC NEW Historical Prices ~~~a~~.r~~. t~~~~r~~~~~x° i=E~~ w~rs~~:~ ,:. _~ Market Movers .._ ._ ,. ` Y .~ ~ ,_.. ~ http://finaace.aol.comlquotes/brown-shoe-company-inc/bws/nys/histori... BROWN SHOE INC NEW (Bi~'V~ j prices from 02125/2009 through 11/25/2009 ri~: '~C~l :;n ~ tl~; i 911'1 ~'~'TC) s )~ .;~~ sy ~1(l~, ~; ~~ GL f,!"~a~.i~ ;ltltl' Frequency Daity Date 02/25/09 02/26/09 02/27/09 03/02/09 03/03/09 _ __.~.--~-. 03/04/09 03/05/09 03/06/09 03/09/09 03/10/09 03/11/09 Related Resources 03/12/09 i:;,; , :-~,rt~i;~-::~; 03/13/09 .., , t~.;~t.:~ ~ 03/16/09 03/17/09 )I~ P )-~~~~ G =:=r!ci~ Scrtrr;=;~;, 03/18/09 ;t~~;_~ f'~J~:~;°.~:. 03/19/09 cT'r= ~:~.nte. 03/20/09 t~~luii-~~I f=und ~ et~t~=r B,c~~~~~ir~q~t-~~:6a 03/23/09 03/24/09 03/25/09 03/26!09 Volume High Low Open Close 576,730 3.95 3.70 3.93 3.72 672,606 3.81 3.62 3.75 3.73 421,013 3.98 3.57 3.65 3.57 478,428 3.58 3.24 3.57 3.35 712,040 3.46 3.09 3.37 3.17 473,020 3.50 3.16 3.22 3.25 564,380 3.15 2.68 3.08 2.71 885,309 2.81 2.27 2.81 2.27 800,779 2.4059 2.0163 2.2403 2.0845 967,788 2.5325 2.0455 2.1916 2.1526 633,098 2.2598 1.9871 2.1916 2.0747 1.33 M 2.3085 2.0358 2.0747 2.2598 805,774 2.6202 2.2598 2.2695 2.4643 1.17 M 2.6397 2,3962 2.5228 2.4449 557,535 2.7079 2.4546 2.4546 2.6299 730,245 2.91 2.61 2.67 2.84 838,441 3.06 2.85 2.94 3.00 689,857 3.04 2.87 3.00 2.97 548,842 3.20 2.94 3.10 3.19 707,172 3.28 3.10 3.17 3.23 1.12 M 3.55 3.07 3.27 3.29 912,671 4.07 3.32 3.37 4.06 Splits None Available for the Select Timeframe Dividends 03/18/09 [0.0700] 06/17/09 [0.0700] Download Options Choose the forn~at in v~ch you vwuld ike this data to be dowNoaded: Tab separatsed vaiiues {*.tsv} ~' Comma separated values (*.csv) Metastock {*.asc) n_......i__r i 09116/09 [0.0700] T" ar C'fr ~ ~ r ~, ~ i i~ c i~nnn ~ n. c~c ~ 1,, I ~L; FOOT LOCKER INC Historical Prices >ff~rst ,~~~t~c~~=~~, ~. ...flit-.~~ i ; z;!: ~e,Cl~t~C~4+:~#: ,.. ;a - ,.. . \I~f VC ~~~lti G,:~ Mark,,11et Movers lmp://finance.aol.com/quoteslfoot locker-inc/fl/nys/historical-prices?t.. FOOT LOCKER INC (1=~) prices from 02/25/2009 through 11/25/2009 i t~!•~ :?r~~ 3t~t tam 9rt1 Y"Ti~~ 1 y 3Y ~~a 1 CJ~~ 15y GOy P.~~~.ir~tirr~;~l -__ . Frequency ' wiry __ Date 02/25!09 'L'ICJC)~~~! r~f~t (`.-X31!"'e:' :'a Related Resources :~ • -~ - ;'~~r3 ~~'~. 02/26/09 02/27/09 03!02/09 03/03/09 .~------~-~;` 03/04/09 03105/09 03!06/09 03/09!09 03!10/09 03/11/09 03/12/09 03/13/09 ~) 03/16/09 03/17/09 03/18/09 03/19/09 03/20/09 03!23!09 03!24/09 03/25/09 03!26/09 Volume High Low Open Close 4.16 M 8.36 7.87 8.12 8.10 1.82 M 8.30 7.91 8.22 7.93 3.85 M 8.45 7.70 7.80 8.31 3.74 M 8.50 8.12 8.21 8.19 5.73 M 8.45 7.75 8.38 7.83 4.05 M 8.51 7.94 8.06 8.29 7.87 M 8.97 8.11 8.28 8.19 5.42 M 8.51 8.20 8.32 8.39 5.25 M 8.9403 8.1321 8.2799 8.7333 4.25 M 9.5613 8,9009 8.9798 9.4431 3.66 M 9.8275 9.2952 9.5121 9.4036 3.97 M 9.7191 9.1868 9.5219 9.6303 3.05 M 9.7486 9.3642 9.7191 9.5416 3.09 M 9.7486 9.1769 9.7486 9.2558 4.36 M 9.5022 9.0685 9.2163 9.4726 3.59 M 9.7289 9.1769 9.4233 9.6008 2.72 M 9.6895 9.1079 9.6599 9.2656 4.49 M 9.6303 9.2755 9.2755 9.6008 3.90 M 10.6456 9.5022 9.7782 10.5569 4.34 M 10.547 9.8275 9.926 9.8866 4.20 M 10.1725 9.3741 9.9458 9.7881 2.92 M 10.685 9.9458 10.0049 10.5372 Splits None Availa~fe for the Selec# Tirrieframe Dividends 04!15/09 [0.1500) 07/15!09 [0.1500] Download Options Choose the format in which you wand ike this data to be dowrdoaded: Tab separated vakies (4.tsy Corrrna separated values (*.csy (quicken (*.qif) Mletastock (".asc) 10/14/09 [0.1500] Download y ~ ~ - ~~ FPM: JPMORGAN CHASE & CO Historical Prices http://finance.aol.com/quotes/jpmorgan-chase-and-co/jpm/nys/historical... ~~ ~ Q ~ ~ ~~ ~ l~ ~~ ~ ~ ~~ JPMORGAN CHASE 8 CO (J P €~) prices from 02/2512009 through 11 /25/2009 C~;r ;~i<_~ .~. ~9i~, ~irrr ?rn :3na ~f11 9n'1 `r`F~~ iy 3y° :~y 1G~; 15y~ ~?Oy i=:1~~xrr'tuti? __ Frequency Daily ~ ~ ~~ ~ ~„~ ~ ~ ~ ~ ~ . Fla+.:~,~._., Si~._~-t , f~lccrr:'~~ ::;i2t,~::~~.:3r~', Date Volume High t_ow Open Close I~~ r~ ~~ ~ ~ .=, t i ~ ~ s ~ 02/25!09 135.75 M 23.22 20.12 20.83 21.73 r ; ,; .~< - ,_ E:, c :, ~ c~;~~ 02/26/09 125.00 M 24.18 22.80 23.32 23.05 r ~ ; -: n c:;::, i t I ~ ~s s ~ rv 02!27/09 109.86 M 23.60 21.55 21.63 22.85 03/02/09 94.97 M 22.43 21.07 21.70 21.16 NNarket Movers 03/03/09 85.58 M 21.90 20.6009 21.68 21.01 t,, i ~~ ~~ t =~.i i~ tip, ~-~--~- 03/04/09 144.97 M 21.74 18.80 21.74 19.30 E, i `~~ ,' -,t ' ~ ~ i r C 's 03/05/09 153.79 M 19.00 16.04 1$.50 16.60 ~i r;~-st r_ase~ s =~ .~ ~~ ~ ~t ~~ ~_ + C~ a i ~ ~ ~ r 03/06/09 155.14 M 17.67 14.96 17.19 15.93 ~~ 03!09!09 132.85 M 17.2592 14.9932 15.3426 15.8716 ~= ~ ~ ~ ~ ~'~ ~ -~= r ~ ~ ~ % r ~ ~ i 03!10/09 148.77 M 19.4652 17.0995 17.3191 19.4652 03/11 /09 155.34 M 20.8727 19.0859 20.3137 20.3636 Related Resources 03/12/09 151.93 M 23.2884 19.9644 20.1141 23.1587 i'` `" ': ~ ~ t±:= ~ ~ ? ~ 03/13/09 120.46 M 24.2866 22.8692 23.548 23.7077 ;' ~. ~~ a> s ~ 03/16/09 124.88 M 25.225 22.9191 24.2667 23.0488 `' ~ ~: `" ',ta ~ ~ac,~ ~:~~~r 03/17/fl9 99.72 M 25.1751 22.2303 23.2585 25.0952 ~= ~.: ~~: r; ~ S ~~r ~~ e ; ~ ~. r 03/18/09 141.98 M 27.2813 24.1369 24.7758 27.0617 E "~_ :~crr:.~nF:'~ ~.,~-_ ;:_a ..y,,,.,::: 03/19/09 124.26 M 27.3612 24.5462 27.2014 24.9055 '=":~E= Car~i::r 03/20/09 108.91 M 24.7358 23.1087 24.6161 23.1087 P~E.rt~~~!.~-iir~~tl Ct-itt~r ,~ i,-,t7,a ~;.~~,~ ~~,a~.~; ~ 03/23109 146.78 M 29.118 25.0852 25.2549 28.8086 03/24/09 133.19 M 29.2478 26.1533 28.00 26.353 03/25!09 149.47 M 28.6588 25.8838 27.1416 28.5091 03/26/09 133.69 M 29.5473 27.6007 28.9982 29.0482 Splits None Avaik~ble for the Select Timeframe Dividends oa/ovo9 [a.osoo] o7rov09 [O.ooSO] 08!26/09 [0.4361] 10/02/09 [fl.0500] Download Options Choose the format in which you would eke this data to be downloaded: Tab separated values (*.tsv) Comma separated ~ak,es (*.csy Chticken (".qif) Metastock ('.asc) rlr,um~n~r1 > > » c i~nnn > > . nn ~ t-. ACCOU~~T rya, ACCOUNT TYPE ~ STATEMENT PERIOD _ ----~-- - PAGE _ 9'i02~>3584 M8T SELECTNITH INTEREST FEB.26-MAR.25,?_009 1 OF 2 00 0 06113M NM 217 -' 4049 STANLEY BRAZINSKAS 523 HERMAN AVE LEMOYNE PA 17043-1823 INTEREST PA:[D YEAR TO DATE 88,041.60 HIGHLAND PARK .S4 ~ 3.30 ~ 85,853.01 11.51 ACCOUNT SUMMARY ITS 8 IOITIONS CHECKS PAID 9tJ AMOUNT NO. AMOUNT tom, 1j798.27 5 3,737.32 3 ACCOUNT ACTIVITY P05TI 6 bAt'E TRANSACTION~'OfSCRIPTI DEPOSITS,INTEREST CHECKS 8 OTHER - DAILY ON f!: QTNER ADDITIONS SUBTRACTIQNS BALANCE 02--26-09 'i BEGINNING BALANCE 02--27-09 CHECK NUMBER 1084 ~ 588,041.60 03-02-09 CNiTRL PEN MON PF CKS 1,935.00 86,106.60 678.00 03-•02-09 CITIBANK N.A. LO PENSION 03-03-09 US TREASURY 303 SOC SEC 66.27 86,850.87 1,054.00 03-03-09 UNITED AMERICAN INS. PREM 03-03-09 CIHECK 181MBER 1082 208.00 03-03-09 ~ PAM'C PAYMENT 60.00 ~ 03-05-09 CHECK NUMBER 1087 12.44• t 87,624.43 ~ ~--------' 03-05-09 UNITED AMERICAN INS. PREM 148.98 __T__. 03-06-09 CIHECK NUMBER 1088 32.40 87,k43.05 03-Ob-09 CHECK NUMBER 1086 1,543.34 03-25-09 ~ INTEREST PAYMENT ` 50.00 85,849,71 i 3.30 ~ 85,x53.03 ENDING BALANCE 585,853.01 _. . .: :::CHECKS PAID: SUMMARY .::.: 1082 03-03-09 66.00 1084* 02-27-09 1,935.00 1086* 03-06-09 1087 03-05-04 148.98 1088 03-06-09 1,543.34 50.00 ANNUAL PERCENTAGE YIELD EARNED = 0.04 .., - ~. LOQBA f 6~(-7) E NA i ~ ~ I D ~ ~ Vehicle Pricing & fnformai>ion #~.~.as NADAguides.com 11/2/2009 • • ! i • f t k • • k • i r • L.. Passenger Car ... ~`~~~ ' 1986 Lincoln Town Car 4 Door Sedan PRICING Original MSRP: $20,764 Low Retail Average Retail Value High Retail Base Price $1,350 $3,025 $5,850 Options Designer Series $600 $975 $1,350 TOTAL PRICE $1,950 $4,000 $7,200 Low Retail Value This vehicle would be in mechanically functional condition, needing only minor reconditioning. The exterior paint, trim, and interior would show normal wear, needing only minor reconditioning. May also be a deteriorated restoration or a very poor amateur restoration. Most usable "as-is". Some of the vehicles in this publication could be considered "Daily Drivers" and are not valued as a classic vehicle. When determining a value for a daily driver, it is recommended that the subscriber use the tow retail value. Note: This value does not represent a "parts car", Average Retail Value This vehicle would be in good condition overall. It could be an older restoration or a well-maintained original vehicle. Completely operable. The exterior paint, trim, and mechanics are presentable and serviceable inside and out. A "20-footer". High Retail Value This vehicle would be in excellent condition overall. It could be a completely restored or an extremely well maintained original vehicle showing very minimal wear. The exterior paint, trim, and mechanics are not in need of reconditioning. The interior would be in excellent condition. Note: This value does rl4~ represent a "100 Point" or "# 1" vehicle * "100 Point" or "# 1" vehicle is not driven. It would generally be in a museum or transported in an enclosed trailer to concourse judging and car shows. This type of car would be stored in aclimate-regulated facility. pCopyright 2009 NADAguides.eom. AY Rights Reserved 1 of 1 11/2/2009 3:01 Pl' PENNSYLVANIA REGISTRATION RENEWAL APPLICATION My-1os {os-o7~ _- .~ Step 1 -ODOMETER AND INSURANCE INFORMATION: Detach the appNcation below at the perforation. Please provide the vehicle's current odometer reading and insurance information in the spaces provided. The NAIC number is a five digit, unique number assigned by the National Association of Insurance Commissioners Central Office and used to identify the insurer. !f the NAIC number is on your insurance card, please fist in the space provided. tf your number is not Hsted on your I.D. card, contact your insurance agent. k sel#-insured, enter "SELF-INSURED" in the Insurance Company Name block and your self-insurance certificate number in the Policy Number block. Vehicle insurance must be maintained at aH times on aN valid vehicle registrations. A lapse in insurance coverage could result in suspension of vehicle registration privileges for three months. Step 2 -ORGAN DONATION AWARENESS TRUST FUND: You have an opportunity to contribute an additional $1 to the Organ Donation Awareness Trust Fund (ODTF}. Your contribution to the Fund will M help increase public awareness of organ donation and help save lives. Since this additional $1 is not ~ part of the renewal fee printed on your application #orm, please add it to your payment. Also, be ~ sure to check the proper block on the form to make sure your contribution is handled properly. o _ _ ___Step 3 - CHAt~IGE OF ADDRESS INFOSMATION:....Please note .that the~hange of .address in#ormation M block need only be changed when your address listed below differs from your actual address.. ~' NOTE: P.O. Box numbers may be used in addition to the actual address, but cannot be used as the only address. You may also change your address online at Online Services Center at W W W. DIIJIV. STATE. PA. U S . Step 4 -COMPLETING YOUR RENEWAL APPLICATION: You must sign the form bebw exactly as your name(s) wears. ff the vehicle is in the name of a company/corporation, the signature of an authorized representative is required. Use the enclosed envelope to return your completed renewal application, along with your check/money order made payable #o the "Commonwealth of Pennsylvania." If the envelope is misplaced, mail to the Bureau of Motor Vehicles, Harrisburg, PA i 7104-2516. Detach At Perfaratitan PLEASE DO NOT STAPLE, BEND, FOLD, OR fYtUT1LATE Detach At Perforstior 386'rwe Nwnber ~ ~ VeNde96w~tliailion Number i v~ 1 ape ~ Yepr ~ w~teOMumber ~ Expiration Zoae91 Reg. cir. vl-t. ~ c~orab. Gr wt. ?dometer Rearing ~ rr~ ~ ris h~staanoe Co. Name NAIC No. tnwraaee Papry iiutnber - - - ~ Popcy 0fectlve Date Paper Expiratfoa{ Date FEE: indicatetf of ~ ~p,gan Donation Mrarettesa ~ ~ 36.00 sts t~wei Trust ~ ; 901t906]t1t2738639454003600 STANLEY BRAZINSKAS 523 HERMAN AVE ~ ~ ~~ LEMOYNE PA 17043 to'in~'rdauo mat r~ (insucar~) an the arrenty meter le for the per~+od of rcgw~t tratione Owner/Co-Owner Sign Here Phone # 'r ~: f __y....___ __ _.___ .. 1 ~ G ~ ~` 5 ~- ~ s~~~ tail ~i4t111't1tSS~~1t1 - ~.e'Ci~'1~~~'t@ ~,~~~ ~,!'yrjC#' ~ 43 50 ~ . ~ ~ 5 u -; xacv i~+d.~ .~+~ha~~cs~au~rg, ~~-- 1 ~'~!~~ ?'~~i-~?~5 5~~ `r~+ ~o~~o~- a~ ~ ~u-,- 3 2 ~ ~ Cl t~ ~- ~~7u~t~u~ -- 5~ ~ UU-=- "%~_~ 92 ~ uu-+ '~~ 1 6 2 y 2~ -_ "1 0 ~1 ° U U 62'~l4UU~- ~i o ~ - +69 2-' V ~~I.~ji ~ 4 J~ U ~~- ~~Yi / ~ ~ f / ~ : ~~O~UU-r- 16i~uU:- 2v2 ~ ~ 0-s ""' 0 2 5 ____-~--- .. _ ,,,~, 4~'1~ay:E~: ..,.... Tiartatl $a~e ? -' ~ ., Totat~ s • Tort~tl Cash ~ ~~ ~~ ~ ~~ ~~ ~ ~~ C. ~ Cash j#tt'~ey' Patyrou# ~~~ ~-actiot~s~er ~ G`1~ks Ad~r. Cost ,i,~.'-~,~ ~ ~ tr.~ ;) ~~"t7- ~+so ___._._ ~ ~ ;? Jt~~_ ~ ~. ~~ ~- ~ ~; __ ..y )' ~ ~ `~ ~~ Your donation is important. The money earned from your donation will fund programs that promote employment and self sufficiency for individuals with disabilities and other barriers to independence. For more information, visit yourgoodwill.org DATE ` 1 ~ 1 ~ ~ LOCATION ~ ~ '~"^ ~~ ATTENDAftT S WITIALS ~tAME OF DONOR PkONE ADDRESS cm E-MAIL ADDRESS Z1P CODE ~~ uuwue~ t5 >KtSPOM5IBLE BUR ~SSIGNlNG idALUf 1'0 DOW,4TIONS. EST#MATED VALUE ~ OF DONAT#ONS i X SIGNATUAE OF DOkOR ,. ~Ceys~O ~ ~ A ~e ~ ~ ~-, ~ ~ ~1 Goodwill Industries Keystone Area 1150 Goodwill Drive Harrisburg, PA 17101 P: 717.232.183 ~ Tofl Free: 1.800.432.4483 F: 717.232.0115 BAGS PCS. CTNS. DESGRtPTtoN CLOTHING FURNITURE M{SCELLANEOUS i GOODW{LL HAS NOT FURN{SHED GOODS OR SERVICES TO THE DONOR {N EXCHANGE FOR THIS CONTR{BUT{ON. °~. f3 ~~~~~~~~v~, ~ ~ ~ a Your donation is important. The money earned #rom your donation will fund programs that promote employment and self sufficiency for individuals with disabilities and other barriers to independence. For more information, visit yourgood~Jvi!l.org DATE ~ ~ Z 5 ~' ®C, ~OCATtoN i t 2.. NatitE OF DONOR fiTiENUMJT'S INfE W1..5 PHONE ADDRESS CITY 2iP CODE E•PAAtL ADDRESS ~ YTIfC tl~~~~~t~ ~a~ It~~~if"svi'~~IO~i: t~9J~ i9~?a?~1iI{19~Y. ~,~~n.~~ ! d ~~1~t~Y IVl~a7. ESTIMATED VALUE OF DONATIONS $ X SIGNATURE OF DONOR s Goadwilt Industries Keystone Area 1150 Goodwill Drive Harrisburg, PA 17101 P: 717.232.1831 Toll Free: 1.800.432.44$3 F: 717.232.0115 '~ GOODWILL HAS NOT FURNISHED GOODS OR SERVICES TO THE DONOR IN EXCHANGE FOR THIS CONTRIBUTION. ~~ Y' Your donation is important. The money earned from your donation will fund programs that promote employment and self sufficiency for individuals with disabi{hies and other barriers to independence. For more information, visit yourgoadwill.org i DATE P L ...~" LOCATION ~ ~ ~.. ~~ arrENDANrs INITIALS NAME OF DONOR PHONE ADDRESS cITY E-MAIL ADDRESS ZIP CODE ~~ uu~~t~ f~ ~Iri'~fbSi~LE FDfi A~IGNtiYG VALUE TO DDl~ATID~9S. ESTIMATED VALUE ~ OF DONATIONS X SIGNATURE Of DONOR ~~ ~ a~; y v as ~eys~o~~ Aria ~ ._~_~~~ ----- E Goadwiff Industries Keystone Area 1150 Goodwin Drive Harrisburg, PA 17101 P: 717.232)831 Toll Free: 1.800.432.4483 F: 717.232.01 i 5 GOODI~VILL HAS NOT FURNISHED GOODS OR SERVICES TO THE DONOR IN EXCHANGE FOR THIS CONTRIBUTION. Your donation is important. The money earned from your donation will fund programs that promote employment and self sufficiency for individuals with disabilities and other barriers to independence. For more information, visit yourgoodwill.org ~q GATE _ ~ ~ ~ ~ LOCATION NAME OF DONOR ADDRESS CIri E-RAAII ADDRESS ~ ~ ~~ ATTENDANTS tNlTWIS PHONE 21P CODE f~i= D®t~9Di~ tS ~E~€~DN~[GLE EDR 1Gt~~!>'~G V~L#lE TD DQ~Tt01~S. ESTIMATED VALUE ~ OF DONATIONS y , - - - ~:T- - - ! _, r ~e~s~c0~~ A~~~ ~~'-fit Goodwill Industries Keystone Area 1150 Goodwill Drive Harrisburg, PA 17101 P: 717.232.1831 Toll Free: 1.80D.432.4483 F: 717.232.1)115 BAGS PCS. CTNS. DESCRiPTtON ~- CLOTHING FURNITURE MISCELLANEOUS X GOODWILL HAS NOT FURNISHED GOODS OR SERVICES SIGNATURE OF DONOR TO THE DONOR iN EXCHANGE FOR THIS CONTRIBUTION. .. -. r„,c t~ r • ~ ,. y~ L~ mow-:.: ~~~~ j a° ~ ~ Your donation is important. The money earned from your ~~ ~~Olr1~ ~, - __ donation wi!! fund programs that promote employment and T self sufficiency for individuals with disabilities and other Goodwi!! Industries Keystone Area barriers to independence. 1150 Goodwiq Drive Harrisburg, PA 17101 Q: 717.232.1831 For more information, visit yourgoodwilLorg Toll Free: 1.800.432.4483 F: 717.232.0115 OATEN ~ 1 ~ t LOCATION' ~ t """ NAME Of DONOR ATTENDANT'S UrITtALS PHONE ADDRESS CITY ZIP CODE E-ldAll ADDRESS rl~i1= ®0-~'OR f3 RESPUNSiBIE FOR tGN1~IG t9~i.UE TO DtlI~AFiU~S. ESTIMATED VALlJE ~ OF DONATIONS X SIGNATURE OF DONOR t'=~ GOODWILL HAS NOT FURNISHED GOODS OR SERVICES TO THE DONOR 1N EXCHANGE FOR THIS CONTRIBUTION. • ~Y ~ Your donation is important. The money earned from your donation wiff #und programs that promote employment and self sufficiency for individuals with disabilities and other barriers to independence. For more information, visit yourgoodwiH.org I ~~-~--~ I DATE ~ P ~ t L ~ LOCATION ~ ~ ~ 7..._1 ATTENDANTS lNfT1AL$ NAME OF DONOR PHONE ADDRESS GTY 21P CODE E-MAIL ADDRESS Y~E ®fJ~IOR IS r~ESPC11~Si~L~ FOR ASSIGNING VALUE TO DO~iAT'IQNS. ESTIMATED VALUE OF DONATIONS X SIGNATURE OF DONOR ~ ~~ ~ } ~ I LL f -._~.~ ',mss-..4 7:- /4--'~ ~ ~r~ ~ r.Y_ ~~ J ~ -~ 1.' ' _ ;_ --- Goodwill Industries Keystone Area 1150 Goodwill Drive Harrisburg, PA 17101 P: 717.232.1831 To8 Free: 1.800.432.4483 F: 717.232.0115 BAGS PCS. CTNS. DESCRtPTlON ~--' CLOTHING FURNITURE ~., MISCELLANEOUS GOODWILL HAS NOT FURNISHED GOODS OR SERVICES TO THE DONOR IN EXCHANGE FOR TH15 COr1TRl6UTION. -~i BRAZiN~Kf~5. ?~ttst 3~Ii11 rzn~ ~estrzment OF STANLEY BRAT-'LiSKA3 I, STANLEY BkAZINSKAS, of the Borough of Lerioyne, Cumberlanu County, 1?enX~s-cl.vania, being of scunci arsd di.sr.~c~s.;.ng, Xrii7d, mer:~or_y and un=lerstandng, d,? ~~a~Nby m~k.e, publish anal declar~`_his as and for my Last Will and Teti_~r;F~?Xr, ~'it?r°bV revOh_i g 1I1C~ II?c1~.2n~ ~Ic~1d ~Tt~' a;-.~1 31 7 ;.J~~ ~.£ Or .^_iu~. ~' 1;:~ d~ c:.X"~~ 3 ![iP heretofore made by me. ARTICLE I I direct the payment of all my legal debts, the expenses of my last illness anal funeral, and the expenses of administering my estatz as soon after my death as conveniently ?nay be done . I direct that all taxes that may be assesse3 3.r? consequence of my clealh, of whatever nature and by whatever jca,risdicticn .imposed, shall by paid from :ny Residuary Estate as part of the expense of ttie adm~niscrativn or my Estate. ARTICLE II I direct my Executors or successor to bury my remains in St. Casimir L.it-.huanian Cemetery, 111th Street and Cicero Avenue, Chicago, Illinois, nest tv my deceased wife, STEFANIJA. My executors or successor are directed to carry out such direction regardless of the expense in transporting my remains to said cemetery, and I further direct that my remains not be cremated. ART IC.LE T I I I give, devise and bequeath all the rest, residue and remainder of my rstaL-e, of_ whatsae~ver nature arXd wheresoever situate unto my brother. , 1.IUDAS BRAZZNSK'1S, my sister, NAS'rUTE Z.ILINSKIENE, my sister, KASTULE PALATY.i.ENL, my sister, ONUTE JUSIENE, all of Lithuania, and my sister--in-law, OLGA CEPE, of .. ,BRAZINSKAS, Yugoslavia, in equal shares, provided that should any one named in this article predecease me, I give, devise and bequeath such person's share unto those named in this article who survive me, in equal shares. ARTICLE IV I name, constitute and appoint OTTO ZINK, Hummelstown, Pennsylvania and RUDY BRINJAC, Enhaut, Pennsylvania, Co-Executors of this my Last Will and Testament. Should either fail to qualify or cease to so act, I direct that the other shall complete the administration of my estate without the necessity of appointing a Co-E:~ecutor. IN WITNESS WHEREOF, I have hereunto set my hand and seal, this ~S day of 1989. ~-r ( SEAL ) r' ST 1LE` BRAZI SKAS Signed, sealed, published and declared by the above-named Testator, as and fcr tiffs Last Wild and Testament, in the presence of us, who a~ his request, in his ~-resence and. in the presence of each other, have hereunto subscribed our names as witnesses. A y BRAZINSKAS. ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA , . ss: COUNTY OF CUMBERLAND We, STANLEY BRAZINSKAS ~ ~~° ~~' °~. ~~`~~`~.....~ ~ and ~.... >, `~`"~,._..~: `~ ~ `•~''y-~-~- ~ the Testator and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that thz Testator signed and executed the instrument as his Last 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 witness and that to the best of his/her knowledge the Testator was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. ANL Y B ZIN S Witness Witness Subscribed, sworn to and acknowledged before me by STANLEY T3RAZINSKA__S, Testator, and subscribed and sworn to before me by ~,,,.,,~,,,,.~„~, ~~~, ~~ and ~'"~?~---~ ~~~ti-~.~-.. --' witnesses, this ~~~ ~`~ day of ~~`~ i~ 1989. ~ ' ~,,` _-'c,-. yam. r• f Notary lic NOTARIAL SEAL OIANNE LENI6, ND?ARY Pt181.IC LENOYME Ia0R0. CtA%ERtAMD CO. Mfr Cq!MISSION EXPIRES DEC. 21. 1989 s .. 09999°:00013/March 28, 1997/EGM/NLBI62201 CODICIL TO ?rrzst 3~i11 ttnil ~nstrzmPnY O~ STANLEY BRAZINSKA5 I, STANLEY BRAZINSKAS, of the Borough of Lemoyne, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this to be the sole Codicil to my Last Will and Testament dated May 25, 1989. ITEM I. I hereby revoke Article IV of my Will and in lieu thereof provide as follows: ARTICLE IV I name, constitute and appoint OTTO ZINK, Hummelstown, Pennsylvania and VYTAUTAS RUPINSKAS, Clarendon Hills, Illinois, Co-Executors of this my Last Will and Testament. Should either fail to quality or cease to so act, I direct that the other shall complete the administration of my Estate without the necessity of appointing a Co-Executor. If both fail to qualify or cease to so act, I name, constitute and appoint PNC BANK, N.A., Camp Hill, Pennsylvania, Alternate Executor to complete the administration of my Estate. No fiduciary appointed herein shall he required to post bond for the faithful administration of the duties required in any jurisdiction. ITEM II. In all other respects, I hereby ratify, confirm and republish my Last Will and Testament dated May 25, 1989, together with this Codicil as and for my Last Will. • .. 09995-00013/March 28, 1997lEGM/NLB/62201 1 IN WITNESS WI-IEREOF, I have hereunto set my hand on this ~~~ day of _ ~~`;~ , 1997. r i ~..,. (SEAL) ~iTA EY B INSKAS 7 ~~ ti S t Signed, sealed, published and declared by the above-named T~tatc~r, as and for his Codicil to r his Last Will and Testament dated May 25, 1989, in the presence of us, who, at his request, in his presence and in the presence of each other have hereunto subscribed our names as witnesses. ~u~ -2- ` 099'.199`00013/March 28, 1997/EGM/NLB/62201 ACKNOWLIDGMENT COMMOr1WEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS. We, STANLEY BRAZINSKAS `- '~ ~`~,~ ,. ~ . ~ =~ -`Y-` ~ , ,..., ; and r.,, r ' ' ~ ~`` -~ ~ ~ ,the Testator and the witness respectively, '<__.~ whose names -are signed to the attached or foregoing instrument, being- first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his Last Will and 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 witness and that to the best of his/her knowledge the Testator was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. f STANLEY RA INS~;A~ Witness -~. ~ _ Witness Subscribed, sworn to and acknowledged before by STANLEY BRAZINSKAS, Testator, and _~ ~~_~~'~._-~,~-Y-.~.~--; ::~_ ~~ . -~-~-, ,.,; :.,~ and ~'~~ witnesses, this ~ ~~ day of ~y-~~a.,.~. , 1997. ~~~--- ,~ ~~ ~` ~-- , _~ ;~- .. Notary Public - " ~' ~ ~~ My Commission Expires.:, _3_ S~OTAR(Al. SEAL D(ANNE LEt~(G, Nctar~~ ~ubtc Lemayns Sorou~i~ C~mber(~r,~ Ca. My DCmR?isSt~r~ ~x~=r~s Dec. 21, i9~7