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HomeMy WebLinkAbout03-29-101505607121 REV-1500 EX (os-05) OFFICIAL USE ONLY PA DepaAmeM of Revenue County Code Year File Number BureaudlndvidualTaxes INHERITANCE TAX RETURN Po sox 2aosot 2 1 0 9 1 1 6 0 Hanistwr9 PA 17128.0601 RESIDENT DECEDENT _ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Daath Date of Birth 2 0 8 4 2 7 3 4 5 1 2 0 8 2 0 0 9 0 2 1 6 1 9 5 5 Decedent's Last Name Suffix Decedent's First Name MI H A M M A K E R J A N S (If Applicable) Entsr Surviving Spouse's Information Below Spouse's Last Name N / A Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW Suffix Spouse's First Name THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS MI Q 1.Original Retum ~ 2. Supplemental Retum ~ 3. Remainder Retum (date of death priorto 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Retum Required death after 12-12-82) 0 B. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 1 8. Total Number of Safe Deposit Boxes (Attach Copy of W iIQ (Attach Copy of Trust) $. 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 CONFlDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number D A V I D R G E T Z E S Q U I R E 7 1 7 2 3 4 4 1 8 2 Firm Name (If Applicable) REGISTER OF WILLS USE ONLY W I X W E N G E R & W E I D N E R First line of address _ ~ ° _ 5 0 8 N O R T H S E C O N D S T R E S T ;::??'v ~ 'C~ ~ ,,, ;_ ~ ' Second line of address f -; ~m N _ t_.. _ P O B O X 8 4 5 . `~~~~ ~D ``' `n C ~ D~6 S. " City or Post Office State ZIP Code _ _; H A R R I S B U R G P A 1 7 1 0 8 0 8 4 ~~ _ r=~~ N t~~~ w Correspondent's e-mail address: DGETZ®WWWPALAW.COM Under penalties of perjury, I declare that I have examined this return, indudng accompanying scF~les and sffitemerds, end to the Hest of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representeWe rs based on all infonnatian of which preparer has any knowledge. OR FILING RETURN SPONSIBLE F SIG ATURE OF PERSON RE D TE ~. (+ ~ ~ DDRESS 1645 REVERE DRIVE MECHANICSBURG PA 17050 SIGNA OF PR ARE THER NqR~.E~P-RESENTATIVE / ~ ~ _ DATE ~~ /~~ ~ ADD~ 508 NORTH SECOND ST/PO BOX 845 HARRISBURG PA 17108 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505607121 1505607121 1505607221 REV-1500 EX Decedent's Social Security Number Decedents Name: JAN $• H A M M A K E R 2 0 8 4 2 7 3 4 5 RECAPITULATION 1. ..................................... Real estate (Schedule A) ... 1 1 3 0 3 7 2. 2 0 2. Stocks and Bonds (Schedule B) ............................... ... 2. D. D D 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 0 • 0 D 4. ..................... Mortgages & Notes Receivable (Schedule D) ... 4. 0 • 0 0 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ... ... 5. 4 8 6 7 6 , 8 3 6. Jointy Owned Property (Schedule F) 0 Separate Billing Requested .... ... 6. 4 0 0 • 0 D 7. Inter-Vivos Transfers & Miscellaneous N -Probate Property ~ 0 0 0 Separate Billing Requested .... (Schedule G) ... 7. • 8. Total Gross Assets (total Lines 1-7) ........................ ... 8. 1 7 9 4 4 9. 0 3 9. Funeral Expenses & Administrative Costs (Schedule H) . ..... ........ .. 9. 7 9 8 1 • 6 1 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .. ........ .. 10. 4 2 7 6 0 • 7 3 11. Total Deductions (total Lines 9 & 10) ............ ..... ........ .. 11. 5 0 7 4 2 • 3 4 12. Net Value of Estate (Line 8 minus Line 11) .......... ..... ........ .. 12. 1 2 8 7 0 6. 6 9 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. 1 2 8 7 0 6 • 6 9 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.o _ 0. 0 0 1s. 0. 0 0 16. Amount of Line 14 taxable at lineal rate x .045 1 2 8 7 0 6. 6 9 16, 5 7 9 1. 8 0 17. Amount of Line 14 taxable 0 0 0 0 0 0 at sibling rate X .12 17. . 18. Amount of Line 14 taxable 0 0 0 0 0 0 at collateral rate x .15 . 1 g. . 19. Tax Due ............................... ..... ........ .. 19. 5 7 9 1. 8 D 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505607221 1505607221 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 09 1160 DECEDENTS NAME JAN S. HAMMAKER STREET ADDRESS 618 PARK RIDGE DRIVE CITY MECHANICSBURG STATE PA ZIP 17055 Tax Payments and Credits: t~ Tax Due (Page 2 Line 19) (1) 5,791.80 2. Cred'llslPaymerns A. Spousal Poverty Credit B. Prior Paymerns 5.000.00 C. Discount 263.15 Total Credits (A + B + C) (2) 5,263.15 3. IrneresUPenatty'rfxpplicable D. Interest E. Penalty Total IrneresUPenalty (D + E) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, erner the difference. This is the OVERPAYMENT. 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) 528.65 A. Erner the irnerest on the tax due. 8. Erner the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (58) 528.65 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 ................................................................................................ ^ ^X d. receive the promise for life of either payments, benefits or care? ....................................................... ^ Q 2. If death occurred after December 12,1982, did decedern transfer property within one year of death without receiving adequate consideration? ....................................................................................... ^ 3. Did decedent own an `intrust for' or payable upon death bank account or security at his or her death? ......... ^ Q 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................. 0 ^ 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 t ,1994 and before January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requiremerns for disclosure of assets and filing a tax return are still applicable even 'rf 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 childtwenty-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(x)(1.2)]. The tax rate impaled 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(x)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(x)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUIWBER JAN S. HAMMAKER 21 09 1160 All reel property owned sok+ty or as a tenant in camrnon must be reported at fair market value. Fair market value is defined as fhe 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. RsY oraosrlr which is k>intN-owned with riaM of survivorehio must ha disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH UPPER ALLEN TWP., CUMBERLAND COUNTY, PENNSYLVANIA, BEING TAX PARCEL NO. 42-30-2110-072 TAX ASSESSMENT VALUE OF 103,470 X 1.26 CLR enter on line 1 (If more space is needed, insert additional sheets of the same size) REV-1503 EX + (E98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER JAN S. HAMMAKER 21 09 1160 All property jointly-owned with right of survivorship must be disclosed on Seheduk F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. NONE 0.00 TOTAL (Also enter on line 2, Recapitulation) ~ $ 0.00 (It more space is needed, insert additional sheets of the same size) REV-7504 EX+(6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP FILE NUMBER JAN S. HAMMAKER 21 09 1160 Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sWe-proprietorship. See insttuctions for the supporting information to be submitted for sde-proprietorships. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH NON TOTAL (Also enter on line 3 Recapitulation) ~ $ 0 00 (If more space is needed, insert additional sheets of the same size) REV-1507 EX+ (6-98) SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES IN RES DAENTEDECEDENT N RECEIVABLE JAN S. HAMMAKER 21 09 1160 All property joirdtyownsd with the right of survivorship must be disclosed on Schedub F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 0.00 TOTAL (Also enter (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER JAN S. HAMMAKER 21 09 1160 Include the proceeds of lifigation and the date the proceed were received by the estate. All jointly-orrrted wdh ri ht of survivorship must 6e diecloeed on Schedub F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. MEMBERS 1ST SAVINGS ACCOUNT 217834-00 5.00 DOD BALANCE: $5.00; ACCRUED INTEREST: $0 VALUATION LETTER ATTACHED 2. SOVEREIGN BANK SAVINGS ACCOUNT XXXX0309 201.10 DOD BALANCE: $201.10; ACCRUED INTEREST: $0 VALUATION LETTER ATTACHED 3. SOVEREIGN BANK SAVINGS ACCOUNT XXXX7908 701.42 DOD BALANCE: $701.42; ACCRUED INTEREST: $0 VALUATION LETTER ATTACHED 4. SOVEREIGN BANK SAVINGS ACCOUNT XXXX3822 1.02.66 DOD BALANCE: $102.66; ACCRUED INTEREST: $0 VALUATION LETTER ATTACHED 5. SOVEREIGN BANK SAVINGS ACCOUNT XXXX7924 100.88 DOD BALANCE: $100.88; ACCRUED INTEREST: $0 VALUATION LETTER ATTACHED 6. SOVEREIGN BANK CHECKING ACCOUNT XXXX2353 1,479.75 DOD BALANCE: $1,479.75; ACCRUED INTEREST: $0 VALUATION LETTER ATTACHED 7. FINAL PAYCHECK RECEIVED FROM HIGHMARK (EMPLOYER) 2,364.66 8. 2000 SATURN (TRADE-IN VALUE) 1 000.00 (BEING ONE OF TWO SATURNS TRADED IN FOR 2010 HONDA (ERRONEOUSLY LISTED AS ONE SATURN TRADE-IN ON MV-1 ATTACHED); OTHER VEHICLE IS A SATURN OWNED BY THE DECEDENT AND LINDSEY HAMMAKER, SET FORTH ON SCHEDULE F) 9. BENEFICIAL INTEREST IN THE ESTATE OF VIOLET BEARLEY 0.00 10. BENEFICIAL INTEREST IN THE ESTATE OF EDWARD N. NAYLOR 41,951.36 11. ORDINARY HOUSEHOLD GOODS AND FURNISHINGS 660.00 (AUCTIONEER SUMMARY ATTACHED) 12. ESTIMATED REFUND FOR 2009 PERSONAL INCOME TAXES 110.00 TOTAL (Also enter ort line 5, Recapitulation) ~ $ (If more space is needed, insect additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF FlLE NUMBER JAN S. HAMMAKER 21 09 1160 Han asset was msds joint within one year of the decedent's deb of death, it must be roported on Sehedub G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. LINbSEY A. (MATEER) HAMMAKER 917-A SOUTH YORK STREET DAUGHTER MECHANICSBURG, PA 17055 e C JOINTLY-0WNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTn'UTION 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 DECEDENPS INTERESI t. A. SATURN SEDAN (TRADE-IN VALUE RECEIVED) 800.00 50. 400.00 TOTAL (Also enter on line 6, Recapitulation) S 400.00 (If more space is needed, insert addtional sheets of the same size) REV-1510 EX + (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN OF SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY FILE NUMBER JAN S. HAMMAKER 21 09 1160 This schedule must be completed and tiled 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 INCWOE7HENAAIEOFlFE7p/NSFEgEE,7HEIflPElA7gNSHFT00ECE0EMMlD '"E°"1E°F'avurEfl"T'"°""cow°fln~cEE°F°"fl~xEST"h. DATE OF DEATH VALUE OF ASSET °h OFDECD'S INTEREST EXCLUSION (FAPPIICI&E) TAXABLE VALUE 1. HIGHMARK RETIREMENT 0.00 0.00 DECEDENT, DURING HER LIFETIME, DID NOT HAVE THE RIGHT TO POSSESS, ENJOY, ASSIGN, OR ANTICIPATE THE PAYMENTS MADE THROUGH THE RETIREMENT PROGRAM AND, AS THUS, IT IS NOT SUBJECT TO PENNSYLVANIA INHERITANCE TAX TOTAL (Also enter on Iine 7 Recapitulation) ~ $ 0 00 (If more space is needed, insert additional sheets of the same size) REV-7511 EX+(10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF _ FILE NUMBER JAN S. HAMMAKER 21 09 1160 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. MICHAEL SHALONIS FUNERAL HOME, MARYSVILLE, PA 2,116.47 B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Street Address City State Zip Year(s) Commission Paid: p, attomeyFees WIX, WENGER &WEIDNER (ESTIMATED) 4,850.00 3. Family F~cempfion: (If decedents address is not the same as claimants, attach explanatlon) Claimant Street Address City State Zp Relationship of Claimant to Decedent 4• Probate Fees CUMBERLAND COUNTY REGISTER OF WILLS 323.50 5 Accountant's Fees 6. TaxRetumPreparer'sFees WIX, WENGER &WEIDNER 125.00 7. CUMBERLAND COUNTY LAW JOURNAL (ADVERTISING) 75.00 8. SENTINEL (ADVERTISING) 240.64 9. SOVEREIGN BANK -DATE-OF-DEATH VALUATION PROCESSING FEE 20.00 10. DELL AUCTIONEER 231.00 TOTAL (Also enter on line 9, Recapitulation) I $ ~ (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS JAN S. HAMMAKER 21 09 1160 Report debts incurred by the decedent prior to death which remained unpaid as of dire dam of death, including unreimtwrsed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. MEMBERS FIRST (FIRST MORTGAGE) 22,539.42 2. ISECOND MORTGAGE 3. I W ELLS FARGO 4. IMEMBERS 1ST VISA ACCOUNT 5. IAAA FINANCIAL SERVICES VISA TOTAL (Also enter on line 10, Recapitulation) I $ (If more space is needed, insert addiUOnal sheets of the same size) 9,643.72 1,068.82 3,199.68 6,309.09 73 REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE) BENEFICIARIES JAN S. H AMMAKER 21 09 1160 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 outd t spousal distdlwlions, and transfers under Sec. 9116 (a~(1.2)] 1. LINDSEYA. (MATEER) HAMMAKER Lineal 1,060.00 917-A SOUTH YORK STREET MECHANICSBURG, PA 17055 2. TRUST FOR LINDSEY A. (MATEER) HAMMAKER Lineal 127,646.69 1645 REVERE DRIVE MECHANICSBURG, PA 17050 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, O N REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OP PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (n i nine space u neeuea, Insert aaamonal sneers of ttte same size) r~ LAST WILL AND TESTAMENT OF JAN S. HAMMAKER I, Jan S. Hammaker, of Mechanicsburg, Upper Allen Township, Cumberland County, Pennsylvania, being of sound and disposing mind and memory, do make, publish and declare this my Last Will and Testament, hereby revoking all other Wills and Codicils by me at any time previously made. Provision for Taxes ITEM I: I direct that all inheritance and estate taxes becoming due 6y reason of my death, whether such taxes may be payable by my Estate or by any recipient of any property, shall be paid by my Executor out of the property passing under this Will, that is not specifically devised or bequeathed, as an expense and cost of administration of my Estate. My Executor shall have no duty or obligation to obtain reimbursement for any such tax paid by my Executor even though on proceeds of insurance or other property not passing under this Will. Specific Bequests ITEM II: I give and bequeath all of my household furniture and furnishings, automobiles, books, pictures, jewelry, china, .linen, silverware, wearing apparel, and all other like articles of household or personal use and adornment to my daughter, Lindsey A. Mateer, per stirpes. ITEM III: I give my real estate located at 618 Park Ridge Drive, Mechanicsburg, Cumberland County, Pennsylvania (the "Property"), or any other property I may be using as a residence at the time of my death, to my Trustee, hereinafter named, to hold INTRUST NEVERTHELESS for the benefit of my daughter, Lindsey A. Mateer, as follows: (a) I request that my Trustee hold my said Property as a residence for my daughter as long as she chooses to occupy it. In the event my daughter predeceases me, or in the event she no longer desires to use the Property as her residence, my Trustee shall sell the Property and distribute the net proceeds thereof in accordance with Item IV of this Will. Page 1 of 9 (b) I recognize that the Property is anon-income-producing asset. Therefore, I direct that in the event my daughter chooses to occupy the Property as her residence, she will be solely responsible for all costs of maintenance, utilities, repairs, real estate taxes and any interest or penalties thereon, insurance premiums for the real estate and its contents, any mortgage payments and special assessments. If my daughter fails to make such payments within the time period provided by the creditor, then my Trustee may sell the Property and discharge said debts thereby as Trustee, in her absolute discretion, shall determine. (c) My Trustee may, in her absolute discretion, enter into agreements for alterations and renovations of the Property and pay for same either by assessing my daughter or securing a mortgage loan on the Property, or a combination of both, to pay the charges therefor. (d) I direct my Trustee to transfer title to the Property to my daughter when she reaches twenty-eight (28) years of age, if the Property has not been sold. In the event my daughter predeceases me, or in the event she no longer desires to use the Property as her residence, my Trustee shall sell the Property and distribute the net proceeds thereof in accordance with Item IV of this Will. ITEM IV: I give, devise and bequeath unto my Trustee, hereinafter named, all the rest, residue and remainder of my property, real, personal and mixed, not disposed of by the preceding portions of this Will, to be held INTRUST NEVERTHELESS, for the benefit of my daughter, Lindsey A. Mateer, to be distributed as follows: (a) Upon my death, the Trustee shall divide the principal of the trust into as many shares or parts as there are then living children of mine and then deceased children of mine represented by then living issue. The Trustee shall hold one such share as a separate trust fund for the benefit of each then living child of mine and one such share as a separate trust fund for the benefit of the living issue of each such then deceased child of mine. (b) In each trust thus established for a child of mine or the issue of a deceased child of mine, the Trustee shall have, hold, manage, invest and reinvest the principal thereof and shall, if the child has not attained twenty-three (23) years of age, pay to or for the benefit of such child in not less than quarterly installments so much of the net income and principal of said trust as the Trustee, in the Trustee's sole discretion, shall deem necessary and appropriate to maintain said child in the proper station in life, Page 2 of 9 including proper support, maintenance, medical, hospital, nursing and nursing home care, and high school, vocational, college, university and post-graduate education. Any undistributed income shall be accumulated. Upon such child's attaining the age of twenty-three (23) years, he or she shall, upon written request, be paid one-half (112) of the then assets of the trust. My Trustee shall thereafter pay and distribute the net income of the trust, not less frequently than quarterly, to or for the benefit of that child, upon written request. Upon such child's attaining the age of twenty-eight (28) years, he or she shall, upon written request, be paid all of the remaining assets of the trust. If, at the establishment of the trust, said child has already attained an age at which he or she would have been entitled to one or more distributions of assets, as above provided, the portion(s) that would have been distributed at such prior age(s) shall be paid to such child upon such child's written request. Should such child of mine die before final distribution of the assets of said trust, the provisions of Item IV(c) herein shall control. (c) If a trust beneficiary shall die before final distribution of the trust assets to which the beneficiary would otherwise be entitled, said assets shall be divided into as many equal shares as there are then living children of said deceased beneficiary, and are to be distributed to said living children under the same terms and conditions asset forth herein. If a beneficiary-dies before final distribution of the trust assets to which the beneficiary would otherwise be entited and not be survived by living children, then the Trustee shall divide said assets into as many equal shares are there are then existing trusts created under this Item IV, and one such share shall be added to each such then existing trust. Provided, that if any of said trusts herein created has previously been terminated by payment of all of its principal to its beneficiaries, said beneficiaries who received payment of the principal of that trust shall collectively be considered an "existing trust" for the purposes of this Item IV(c), and one such equal share shall be paid directly to each beneficiary in the same proportion by which he or she received the principal of the trust or, if deceased, to his or her issue, per stirpes. If, at the'time of termination described in this Item IV(c) there is no then existing trust, or if at any time before final distribution of assets under this Item IV, none of my issue is living, the trust shall terminate, then all of my property, real, personal and mixed, not disposed of by the preceding portions of this Will, shall be distributed as follows: Page3of9 -> (i) Fifty percent (50%) thereof to my aunt, Violet Bearly, of McVeytown, Pennsylvania; (ii) Twenty-five percent (25%) to my cousin, Gina L. Steele, of Mechanicsburg, Pennsylvania; and (iii) Twenty-five percent (25%) to my cousin, Carol E. Arnsden, of Marysville, Pennsylvania. (d) Notwithstanding the foregoing, any trust created hereunder shall automatically terminate and the principal and income be distributed twenty-one (21) years from the death of the last surviving beneficiary living at the time of my death. (e) Except as otherwise may be provided, during the continuance of any of the trusts created under the provisions of this Will, and thereafter until the property is distributed to and received by a beneficiary hereunder, the principal sums thus held in trust for any beneficiary, and the income thereof shall not. be subject to or liable for any contracts, debts, engagements, liabilities, or torts of such beneficiary now or hereafter made, contracted, incurred, or committed, including, without limitation, attachment, levy, and seizure by any creditor, spouse, assignee, trustee, or receiver in bankruptcy, but shall be absolutely free from the same, and such beneficiary shall have no power to sell, assign, anticipate, or encumber all or any part of the principal sums of such beneficiary's interest therein, or the income thereof. Appointment of Fiduciaries ITEM V: I hereby nominate,, constitute and appoint Gina L. Steele to be my Trustee. In the event of the death,. resignation, refusal or inability of Gina L. Steele to serve as Trustee, I nominate, constitute and appoint Carol E. Arnsden to serve as Trustee in her place. ITEM VI: I hereby nominate, constitute and appoint Gina L. Steele to be my Executor. In the event of the death, resignation, refusal or inability of Gina L. Steele to serve as Executor, I nominate, constitute and appoint Carol E. Arnsden to serve as Executor in her place. ITEM VII: If at any time, any minor child or mentally incapacitated person shall be entitled to receive any. assets hereunder, my Trustee shall act as Guardian of the assets payable to such person and shall have full authority to use such assets in any manner as such Guardian shall deem advisable for the best interests of such Page4of9 person, including proper support, maintenance, medical, hospital, nursing and nursing home care, high school, college, university, post-graduate or other education, without securing court order. ITEM VIII: My Executor, Trustee, and Guardian are specifically relieved from the duty or obligation of filing any bond or other security. Powers of Fiduciaries ITEM IX: In the settlement of my Estate and during the continued existence of the foregoing trusts, my Executor and Trustee of each trust shall possess, among others, the following powers to be exercised for the best interests of the beneficiaries: (a) To retain any investment I may have at my death, so long as my Executor or Trustee may deem it advisable to my Estate or trusts to do so. (b) To vary investments, when deemed desirable by my Executor or Trustee, and to invest in such bonds, stocks, notes, money markets, real estate mortgages or other securities, other than options or futures, and in such other real or personal property as my Executor or Trustee shall deem wise, without being restricted to so-called "legal investments." (c) In order to effect a division of the principal of my Estate or a trust or for any other purpose, including any final distribution of my Estate or any trust, my Executor or Trustee is authorized to make said divisions or distributions of the personalty and realty, partly or wholly in kind. If such division or distribution is made in kind, said assets are required to be divided or distributed at their respective values on the date(s) of their division or distribution. (d) To sell, either at public or private sale, and upon such terms and conditions as my Executor or Trustee may deem advantageous to my Estate or trusts, any or all real or personal estate or interest therein owned by my Estate or trusts, severally or in conjunction with other persons, or acquired after my death by my Executor or Trustee, and to consummate said sale(s) by sufficient deeds or other instruments to the purchaser(s) conveying a fee simple title, free and clear of all trust, and without obligation or liability of the purchaser(s) to see to the application of the purchase money or to make inquiry into the validity of said sale(s); also, to make, execute, acknowledge and deliver any and all deeds, assignments, Page 5 of 9 ,' options or other writings that may be necessary or desirable to effect any of the bequests or devises made in my Will or in carrying out any of the powers conferred upon my Executor or Trustee in this Item IX(d) or elsewhere in my Will. (e) To mortgage real estate and to make leases of real estate. (f) To borrow money from any party to pay indebtedness of mine or of my Estate or trusts, expenses of administration, or inheritance, legacy, estate and other taxes. (g) To pay all costs, taxes, expenses and charges, except as herein noted, in connection with the administration of my Estate or a trust. My Executor shall pay expenses of my last illness and funeral expenses. (h) To vote any shares of stock that form a part of my Estate or a trust and otherwise to exercise all the powers incident to the ownership of such stock. (i) To assign to and hold in a trust an undivided portion of any asset. (j) In the discretion of my Trustee, if the size of any trust herein established shall become so small that it is impractical or uneconomical to continue said trust, my Trustee may distribute all accumulated income and principal to the then income beneficiaries. in proportion to their income interests. (k) The right and discretion to elect the most appropriate settlement options for any pension plans, individual retirement accounts or other employee benefit options payable to my Estate or any trust, assuming such election shall be in accordance with procedures established by the plan's administrative committee or administrator, as the case may be. (I) The right to engage accountants, attorneys, appraisers and other agents, as deemed necessary by my Executor or Trustee, to render advice to and/or to represent my Executor or Trustee, as my Executor or Trustee deem necessary or appropriate to the administration and preservation of my Estate or the assets of any trust. (m) To do all other acts in the judgment of my Executor or Trustee necessary or desirable for the proper and advantageous management, investment and distribution of my Estate. Page 6 of 9 4~ Miscellaneous Provisions ITEM X: Any person who shall have died at the same time as me, or in a common disaster with me, or who shall fail to survive me by ninety (90) days, shall be deemed to have, predeceased me. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, consisting of this page, the next two pages, and the preceding six pages, this_ day of ~~1Q ~ , 2003. an S. a er SIGNED, SEALED, PUBLISHED AND DECLARED by the above- named Testator, Jan S. Hammaker, as and for her Will, in the presence of us, who, at her request, in her presence and in the presence of each other,-have hereunto subscribed our names as witnesses in attestation thereof. ` Address ~`t0 ~~.,., ~v1`~ Address ~ p~ ~~i l ~ ~ ~ - dress FO14-Ib ~~ca t/~V~- ~c_~ntcss~.tra ~~ 11~ Page 7 of 9 •' .L, COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN SS. I, Jan S. Hammaker, the Testator 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 instrument as my Last Will; and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by Jan S. Hammaker, the Testator, this ~~,~ day of cQ~rtbo e . , 2003. c~noFw~seuaa.a ~~ My CommMNm . Page 8 of 9 My Commission Expires: (SEAL) .• COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN SS. e, ~ ~ l ~iCfand the witne es whose names are signed to the a ached or foregoing instrument, being duly alified according to law, do depose and say that we were present and saw the Testator sign and execute the instrument as her Last Will; that the Testator signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness, in the hearing and sight of the Testator, signed the Will as a witness; and that to the best of our knowledge the Testator was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. om to or affirmed and subscribe to before me, 1 (A. _, ~ ,and l Y ,witnesses, this day of b e~ ~ , 2003. F:\dbw\Wills\HammakerUan - Wlll.doc ._.,:. noua~ al~u. ~ ~ c~a~e cmrcFr~uwo•~ My calnlelnrMa~ rwo a nom Page 9 of 9 My Commission Expires: (SEAL) ~~.. ~.y ~~«~~HBA1~~ !34:5 tJ; January 21, 2010 Wix, Wenger & Weidner, Attorneys at Law Attn: Denise B. Williamson 508 North Second Street PO Box 845 Harrisburg, PA 17108-0845 RE: Jan S. Hammaker Dear Ms. Williamson: On December 8, 2009 Jan S. Hammaker, did not hold any accounts with Kishacoquillas Valley National Bank. She had a safe deposit box that was inventoried and found to be empty. If you have any questions regarding the above information, please don't hesitate to call me at 667-9208 Ext. 368. Sincerely, Darla S. King Branch Service Support Specialist Sr e MEMBERS 1rt FEDERAL CREDIT UNION SAVINGS ACCOUNT: Account Number/Suffix 217834-00 Date Account Established 06/032002 Principal Balance at Data of Death $5.00 Accued Interest to Date of Death $.00 Total Principal and Accrued Interest $5.00 Name of Joint Owner None VISA ACCOUNT: Account Number 4572090000205674" Date Axount Established 05/022008 Balance on Date of Death $3,199.68 Joint Cardholder None •Contractual Pledge of Shares. LOAN ACCOUNT: Accourit Number/Suffix 217834-02• Date Loan Established 02262003 Princpal Balance at Date of Death $22,539.42 Unpaid Interost Accuued fr 1 2/01 2 009-1 210820 09 $49.95 Loan Type Home Equity/Contractual Pledge of Shares Collateral Secured 618 Park Drive, Mechanicsburg, PA 17D55 Interost Rate 6.49% Name of Co-Borrower None 'Loan does not have life coverage. LOAN ACCOUNT: Account Number/Suffuc 217834-03• Date Loan Established 09212007 Principal Balance at Date of Death $9,643.72 Unpaid Interest Aceured fr 11272009-12/082009 $31.21 Loan Type Home Equity/Contractual Pledge of Shares Collateral Secured 818 Park Drive, Mechanicsburg, PA 17055 Interest Rate 10.74°~ Name of Co-Borrower None "Loan does not have Ilfe coverage. BERS 1~ FEDERAL CR IT UNION ~. ~-~- Danielle A. Kline Insurance Services Specialist December 24, 2009 Estate of: JAN HAMMAKER Date of Dsath: 12!08!2009 Social Security Number: 2082-7345 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 w~vw.membersl st.org _> , Sovereign ;Cpurt Order~d:Processing FDecedents - MAl-MB3-02-10 - P. O. Box 841005 -Boston, MA 02284 December 31, 2009 i Wix, Wenger ~ Weidner ~ Attorneys at Law. ~ P.O. Box 845 Harrisburg, PA 17108-0845 RE: Estate of Jan S. Hammaker ~ Date of Death: December 8, 2009 Dear Ms. Williamson: Per your request, enclosed please find the account information as of the date of death for the above-named decedent. For your information, accrued interest is not included in the date of~death~baiance: , Please feel free to contact me if I can be of any further assistance. Very truly yours, Linda Spavento Team Leader 617-533-1789 Sovereign Bank ESTATE OF SOCIAL SECURITY #: DATE OF DEATH: Account #: 0574120309 Type: Savings Open date: 10/31/2001 In the name of: Jan S Hammaker Date of Death Balance: $201.10 Int.(YTD) from 1/1/2009 to 9/28/2009 $0.35 Accrued interest to date of death: $0.00 Otherlnfo: Account#: 1054017924 Type In the name of: Jan S Hammaker Date of Death Balance: Int.(YTD) from 1/1/2009 Accrued interest to date of death: Other info: In the name of: Jan S Hammaker Jan S Hammaker 208-42-7345 December 8. 2009 Savings Open date: .9/26/1989 $100.88 to 9/28/2009 $0.88 $0.00 Account #: 1201752353 Type: Checking Open date: Date of Death Balance: Int.(YTD) from 1/1/2009 Accrued interest to date of death: Otherlnfo: $0.00 6/26/2001 $0.47 Account #: 1684013822 Type: Savings Open date: 2/22/2003 In the name of: Jan S Hammaker Date of Death Balance: $102.66 Int,(I'TD.) from 1/1/2009 to 9'/28/2009 $0.75 Accrued interest to date of death: $0.00 Otherlnfo: Account#: 2334017908 Type In the name of: Jan S Hammaker Date of Death Balance: Int.(YTD) from 1/1/2009 Accrued interest to date of death: Otherlnfo: $1,479.75 to 11/27/2009 Savings. Open date: 2/5/1993 $701.42 to 9/28/2009 $0.32 $0.00 Page 1 of 1 ~-I~GHMnRKo P. O. Box 090009 Camp Hill, PA 17089-0089 eN5336 NNN1 NNal Pay Group: P8S 37.5 Exaapt Cbeck ~!: 0 02171962 Pay Begin Data 11/28/2009 Pa End Date: 12/11/2009 Check pate; 12/18/2089 Ha~akar,Jan S Employee ID: 0062% ~ <);1;rIZE + .~' :. .-..~~.~~ - :. ~~ ~~ 618 Park Ridpa Driw Cosl Center. Tastlnp Cantor of Exeal lanes Marital Status: SINGLE SIN6LE Yaehanics6urp PA 17055 Location: CNSQI Allowances: 5 0 Job Title: Oafaet Yanapaaant Analyst 2 Addl. Pct-: Pa Rate: 64,487.000000 Amwl Addl. Amt.: 100.00 ::: ,: :::. ...._ ..: ##M k#i Current "•*V'I'U••+ Dascri ion Rate Hours Earoie Nours Eamin Uescri lion Curteot Rapular Pay Vsx:ation 33.070256 7.50 1,488.16 1758.75 248.03 123.75 57,910.92 4.082.65 FED OASDI/Dissb 217.04 FED FICA Nad Ho 50.76 4,156.83 972.16 Vacation Payout Parsonel Pald T Flax Tiaa Off 33.070256 55.63 1,839.70 55.63 0.0• 30.00 0.00 15.00 1,839.70 992.11 4%.06 FED Yittdwldlnp 590.84 PA Yithholdinp 107.47 PA lkwploy0sn 2.10 9,115.66 2,051.83 40.10 Incantiva Coap 0.00 0.00 3,464.95 PA U ALLEII T 59.51 1,136.17 PA E PENNSB T 2.00 52.00 • 63.13 3,575.89 1,983.13 68,786.39 I: 1,029.72 17,524.75 Descri ion Currant YTD Desch tioa Current YTD Dsscri ion Currart Y'ID FMai th Dental 401K Rap NOpas 71.93 1.862.58 3.41 88.66 104.17 3,808.99 Naalth PAC 2.00 52.00 401K Rp YaBaa Lila x 62.50 2,285.31 0.00 210.45 Total: 179.51 5,760.23 Total: 2.00 52.00 • Taxable ` Currant: YTU: :: 3,575.89 68 786.39 3,3%.38 63 236.61 1,029 72 181.51 17 524.75 5 812.23 -. -<:: f 2,364 66 45 449.41 .. . . . . - Stag Balanos: + Available - T k 0.00 167.50 Start Balance + Awllable 0.00 37.50 Start Balance + Available: 0.00 0.00 ADVICE N: CIECK N: a en: +/- Adjustments: 187.50 0.00 - Takeo: + - Mjustmentr. 30.00 .0.00 - Takao: - Sdd: 0.00 0 00 Total: EM Balance: 0.00 End Balance 7.50 t/-Adjustments: . 0.00 Document N: 000 000005336 End Balance 0.00 MESSAGE: ' -IiGHnw~wC® P. O. Box 890089 Camp Hill, PA 17009-0009 DEPOSIT AMOUNT S 2, 3 6 4. 6 6 Hantmaker,Jan S 618 Park Ridge Drive Mechanicsburg PA 17055 BwG S 0900 LOCATION CHSEN DEPT 1651 DEPOSTI' NOTICE ONLY -- NON-NEGOTIABLE DATE 12/18/2009 No. 002171962 cc~:::~1RP8sIr.>nilsr~CRyRIIrYOIV ;::> - :: .. Account T e Axouot Number De osit Amount Ctwek irp 1201752353 2,36y,~, Total: f 2364.66 DEPOSTI' NOTICE ONLY -- NON-NEGOTIABLE (Y" ~ R f'"4 ~: ~• ~.j ~,,~ ,a ,~, ,~; ~. www.dmv.state.pa.us M V - 1 5-05 I. TAX /FEES A. MAKE OF VEHICLE VEHICLE IDENTIFICATION NUMBER (VIN). IF TRACING BODY TYPE (SDN, TK, MODEL YEAR PDRG#IA$E REQUIRED, TAPE SECURELY TO REVERSE OF THIS COPY BUS, ETC.) PRrC~ P GROSS VEHICLE WT. FUEL TYPE: ^ GASOLINE ~ I B <AUTHORfZED NOTAflYP OR.CER71F) ~ LESS "- ' ' ' ` RATING ^ DIESEL O ELECTRIC ~ PROPANE 11JSPECTION'MECNANIC.(PRINT NAME) TRADE-IN •t > m ^ HYBRID ~ OTHER t . f ° CHECK THE APPROPRIATE BLOCK IF THE VEHICLE ~ yB IlWe ~ a SIGN NBRE TAXABLE ~' L' '" • /~' IS TO BE USED OR WAS FORMERLY USED AS A J1pNId iNd 1(r:~ll ~yyw1110 WiOM AMOUNT TAXI ~ OR A ~ POLICE VEHICLE (IF APPLICABLE) iaNm~R tea aa,la N.aKdM f n men. ~' . . 8. LAST NAME (OR FULL BUSINESS NAME) FIRST NAME MIDDLE INITIAL DATE AC.f]UIRED! X 8% (.OB) SALES TAX - t . L..p i.., s .;g. PURCHASED 'X 7% (.07) 1~. f t~5" •'-~ fit. ~ '(See note on reverse) i i% ~ i C0.P R M ' - "' . "'-- ' "" LEFf1 NUMBER LESS TAX (IF APPLICABLE) CREDR '6 STREET CITY STATE ZIP COUNTY CODE t. a ~ SALES TAX a ~ .<~ -r. t ea n - F o ri- .-r DUE ~~ryry ~-~'~l ~. ? NOrt7=: If a co-pur'cha`ser of er than your spouse is listed eii~'you >3n f~ e o be listed as JointTe arS Wkh ~ TA• ReaeDn Right of Survivorship' (On death of one owner, tkle goes to surviving owner.) CHECK HERE ^. Olflerwise the tkle REFER TO COUNTY Code (11106[ bi a , will be issued as 'tenants in Common" (On death of one owner interest of d d t hi /h h i CODES LISTINp ON nU1r1I1Br If0111 1 10 26,01 O) , ecease owner goes o s er e rs or REVERSE SIDE OF t8 BXEMPTWNNO estate.). YELLOW COPY NOTE IF THE VEHK:LE LR TO BE USED AS A DAILY RENTAL OR LEASED VEHICLE, CHECK THIS BLDCK ^ . IF BLDCK IS CHECKED, COMPLETE AND AT TACH FORM MV-IL _ C' ^ REFLECTS THE AMOUNT OF MILEAGE IN EXCESS ^ IS NOT THE ACTUAL MILEAGE ODOMETER READING 1C. (PTA) ND. o OF ITS MECHANICAL LIMBS WARNING: ODOMETER Q q DISCREPANCY °1+ S ~ WARNING: FEDERAL AND STATE LAWS REQUIRE THAT YOU STATE THE MILEAGE IN CONNECTION TE ® 2. z WITH THE TRANSFER OF OWNERSHIP. FAILURE TO COMPLETE OR PROVIDING A FALSE TITLE - 3TATEMENi MAY RESULT IN FlNES ANDlOR IMPRISONMENT. - - - - - FEE .,.r , ~a(.I D. 1ST LIEN DATE: • IF NO LIEN, CHECK 2ND LIEN DATE: • IF NO LIEN, CHECK^ 3• z 0 1ST UENHOLDER 2ND UENHOLDER LIEN FEE • ~- w ~ STREET STREET 4. REGISTRATIO O ° ~ z CITY STATE ZIP CITY STATE ZIP N R PROCESSING FEE ~jy ~i) - FINANCIAL INSTITUTION NUMBER FINANCIAL INSTITUTION NUMBER FN F~np1 NamWf ~ IF THIS IS AN ELT, CHECK HERE NOTE: FIN IS REQUIRED IF THIS IS AN ELT, CHECK HERE ^ NOTE: FIN IS R~(,1i11RED by ~ Bweau ° MAKE OF VEHICLE^ `[' 6 WN ~ -) IG' s[ r i t- MODEL YEAR 5. DUPLICATE REG. p ~ BODY TYPE (SDN, BUS, TK, ETC.) ~ CONDRION OF VEHICLE ^ GOOD ^ FAIR ^ PODR FEE NO. OF CARDS • F, PASSENGER pgSSENGEF; AXI ^ LIMOUSINE ^ H L ^ M~ N rc ^ THER ^ SEATING CAPACITY S. CYLINDER CAP TY BMK ^YES ^NO E 1 5 OR 1 6 TO ^OVER 5 0 ^ ^ TRANSFER MOTORCYCLE OR LESS HORS . EPOWER LESS 50 FEE • AACYO~DRIVEN PE LL ^yES ^NO E R ~ M ED ^YES 7 J D A I S ^NO MPH OR LESS ~ ~ ~ MOPED gUTOMATIC ^YES ^NO D I NED/ALTERED ^YES ^NO INCREASE ~ TRANSMISSION FOR ROAD USE FEE • i ~ MOTOR HOME CHASSIS MFR: BODY MAKE: e. ~ 7 R . -NUMBBR OF AXLES: - A I~~ REO: REGISTERED GROSSWT. (INCLUDING LDAD) FEE~CEMENT ° V E H . S BELOW 'SUM OF GAWR'S P 9 : ~ UNLADEN WT. (EM TY) . ~ ~ RED. REGISTERED GROSS COMBINATION WT. GROSS COMBINATION Wi. RATING TOTAL PAID t~p G' ORIGINAL PLATE / Check One ^ TRANSFER OF PREVIOUSLY ISSUED PUTE ^ TRANSFER 8 RENEWAL OF PLATE Send One RCII9pA ~ ~f sC y I ^ PLATE TO 8E ISSUED BV ^ TRANSFER 8 REPLACEMENT OF PUTE TRANSFER OF PLATE & REPLACEMENT OF ^ In This Amount y BUREAU (PROOF OF INSURANCE MUST BE ATTACHED ) STICKER ~ . P~~ ~ , REASON FOR REPLACEMENT ^ EXCHANGE PLATE TO BE ISSUED BY BUREAU EXPIRES ^ LOST ^ STOLEN ^ DEFACED ^ NEVER RECD LOST IN MAIL TEMPORARY PLATE ISSUED ( ) g Y FULL AGENT (NOTE: THIS - LATE WILL EXPIRE 00 DAYS MDMh Year NOTE: If "NEVER RECEIVED" block is checked, Ilcarrt must com late Form MV-44. aPp ~ ~ FROM DATE OF ISSUANCE.) TRANSFERRED FROM TITLE NO. VIN ~ v • t)._ 7( ,:,. r~~~r .'rv" $'.142 .+-, ~ ,~ --77 SIGNATURE OF PERSON FROM WHOM SIGN HERE RELATIONSHIP TO APPLICANT a EEK ~?.~~~ PLATE IS BEING TRANSFERRED (IF OTHER TEMP:PLATE NO.. THAN APPLICANT): INSURANCE COMPANY NAME NAIC NO. POLICY NO. (OR POLICY EFFECTIVE POLICY EXPIRATION ai - ~ ATTACH BINDEF~)~ i){• ~i II , ~. .1 DATE ...:r ~ ^ ..; DATE - s t :. + t ~ a , + ~ . ,~... ISSUING AGENT (PRINT NAME) " ' ~ '-' AGENT NO. IN DING I CERTIFY THAT ON MONTH DAY a• ~ ~ YEAR ^ ^ I H ~ I ' AVE CHECKED TO DEI E THAT THE VEF IRiCE IS INSURED - T .°`• f+ ~. irk r -. AGENT ORMATION ISSUED TEMPORARY REGISTRATION TO THE ABOVE APPLICANT, IN ISSfiI AflENT RE TEL E'NO: COMPLIANCE WrTH ALL APPLICABLE PROVISIONS OF THE VEHICLE CODE , _ AND DEPARTMENT REGULATIONS. - ( ) H. VYVE ACKNOWLEDDE THAT VWE NAY LCISE NY/OUR OPERATING PRIVILEGE(S) OR VEHICLE REGISTRATION(S) FOR FAILURE TO MAINTAIN FINANCIAL RESP 1 DN"THE CURRENTLY REGISTERED VEHICLE FOR THE PERIOD OF REGIBTRATN)N. VWE FURTHER ACKNOWLEDGE THAT VWE MAY BE SUBJECT TO A FINE NOT EXCEEDING :5 000 AND , IMPRISONMENT OF NOT MORE THAN TWO (2) YEARS FOR ANY FALSE STATEMENT THAT VWE MAKE ON THIS APPLN:ATION, AND VWE CERTIFY THAT VWE HAVE EXAMINED AND r SIGNED TFBS FORM AFTER TI'S CONPLETKIN• AND THAT IF AN EXEMP110N FROM PAYMENT OF SALES TAX IS CLAIMED, I AMIWE ARE AUTHORncn TO CWN TFUS E7rENPT10N. UWE o SUBSCRIBED AND SWORN ~ - ., _ FURTHER CERTFV THAT ALL STATEYENfS HEREW ARE TRUE AND CORRECT AND MAKE APPLICATK)H LL 1 ~ ~ ~ ~ ~ z -° - - ~'-- ~ SIGNATURE OF INDIVIDUAL OR AUTHORIZED SIGNER TELEPHONE NO. - SKiNATURE`flFPERSON ADMINISTERING OATH ''' ' 1 ~` . ~ . : ~ SIGNATURE DF CO-OWNER?RLE OF AUTHORIZED SIGNER ° `S E N A SIGN IN PRESENCE OF NOTARY If your registration documents are not received ~ ~;~~ ~~,(~~~~ within 90 days, please contact PennDot. o wnor rrwr.IT•c rnevrrcwenewev rJ 1505607121 REV-1500 EX (t76-OS) OFFICIAL USE ONLY PA Departrnent of Revenue Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN Harrisbum, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 2 0 7 0 3 0 1 6 8 1 0 2 4 2 0 0 8 0 3 0 3 1 9 2 1 Decedent's Last Name Suffix Decedent's First Name MI Bea r I e y V i o I e t s (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 8E FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW O 1. Original Retum ~ 2. Supplemental Retum ~ 3. Remainder Retum (date of death © 4. Limited Estate ~ 4a. Future Interest Compromise (date of prior to 12-13.82) ~ 5. Federal Estate Tax Retum Required 6 D d Di death after 12-12-82) . ece ent ed Testate (Attach Copy of WiIQ ~ 7. Decedent Maintained a Living Trust A 8. Total Number of Safe Deposit Boxes .( ttach Copy of Trust) 9. Lftigation Proceeds Received ~ 10. Spousal Poverty Credd (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 V i n c e n t M. M o n f r e d o E s 7 1 7 2 4 1 6 0 7 0 Firm Name (If Applicable) Romi nger & Associ at es First line of address 1 5 5 S H a n o v e r S t r e e t Second line of address City or Poat Office Car I i s I e Correspondent's e-mail address: 8 b~trrre ~rrect ~ ry' I declare tllat I have examined this rehrm, conrpbte. Decleva8ar of paperer other than the SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETLRi State ZIP Code P A 1 7 0 DATE FILED 1 3. sand statements, and to the best of my on aB informatbn of rArieh preparer has 155 South Hanover Street Carlisle PA 17013. SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ~~ ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505607121 1505607121 J 1505607221 REV-1500 EX Decedent's Social Security Number DecedenrsName: Violet s. Beal•ley 2 0 7 0 3 0 1 6 8 RECAPITULATION 5 0 0 0 0 0 0 1. Real estate (Schedule A) 1. . 2. Stocks and Bonds (Schedule B) ..................... .......... .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages 8 Notes Receivable (Schedule D) ..................... .. 4. 1 8 9 9 5 4 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... .. 5. • 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous N Probate Property ~ (Schedule G) Separate Billing Requested ..... .. 7. 8. Total Gross Assets (total Lines 1-7) ..................... .. 8. 5 1 8 9 9. 5 4 9. Funeral Expenses S Administrative Costs (Schedule H) . ....... ..... .. 9. 5 4 7 8 • 6 0 7 6 5 4 7 5 4 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 10. , 11. Total Deductions (total Lines 9 & 10) ............ ....... ..... .. 11. 8 2 0 2 6. 1 4 12. Net Value of Estate (Line 8 minus Line 11) ........... ....... ..... .. 12. - 3 0 1 2 6 . 6 0 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) .... ....... ..... .. 13. 14. Nat Value Su6jeet to Tax (Line 12 minus Line 13) .:.... ..... .. 14. 3 0 1 2 6 • 6 0 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.o _ 0. 0 0 1s. 0. 0 0 16. Amount of Line 14 taxable 1 0 0 0 0 0 0 0 0 _ at lineal rate x . . 16 . 17. Amount of Line 14 taxable 0 0 0 0 0 0 at sibling rate x. t 2 . 17. . 18. Amount of Line 14 taxable 0 0 0 0 0 0 at collateral rate X .15 . 18. • 19.Taz Due ................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505607221 1505607221 0. 0 0 J Decedent's Complete Address: 0 0 DECEDENTS NAME Violet s. Bearley _ _ STREET ADDRESS CITY ,STATE ZIP Tax Payments and Credits: t. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit 8. Prior Payments C. Discount 3. InteresUPenalty if applicable D. Interest E. Penalty (1) 0.00 Total Credits (A + B +C) (2) 0.00 Total InteresUPenalty (D + E ) 4. If Line 2 is greater than Line 1 +~ne 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Une 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. (3) 0.00 14) 0.00 (5) 0.00 (5A) B. Enter the total of Line 5 +5A. This is the BALANCE DUE. (5B) 0.00 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : ...................................................................... ^ ^X b. retain the right to designate who shall use the property transferred or its income : :.............................. ^ ^X c. retain a reversionary interest; or .......................................................................................:........ ^ d. receive the promise for I'de 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 consideratian? ....................................................................................... ^ Q 3. Did decedent own an "in trust for' or payable upon death bank account or security at his or her death? ,........ ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contans a beneficlary designation? ........................................................................................... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE R 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 a 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 (O) percent [/2 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 beneficlary. 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. §9118(aK1.2)]. 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(aK1)]. The tax rate imposed on the net value of transfers to or for the use of fhe decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood ar adoption. SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN Violets. BearleV 0 0 All real property ovrrred solely or as a tenant in common must be reported at fair market value. Fair market value Ls defined as the price at which property would be exchanged between a wiling buyer and a wiling seller, neitlrer being canpelled to buy or seN, both having reasonable knowledge of the relevant facts. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 105 Cutman Drive, McVeytown, PA 17051-Sales Agreement- Pending TOTAL (Also enter on line t (If more space is needed, insert addkbnal sheets of the same size) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS Violet s. Bearlev 0 0 Ait propeAy Joimly~owned with right of survnrorehip must be disclosed on Schedule F. ITEM I VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL (Also enter on line 2, Recapitulation) ~ _ (If rtwn; space b needed, insert additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN RESIDENT DECEDENT scHE®u~E c CLOSELY•HELD CORPORATION, PARTNERSHIP OR SOLE•PROPRIETORSHIP Violet s. Bearley 0 0 Schedule C-1 or C-2 (including all supporting in(amiation) must he attached for each closetyfield corporatioNpartnership interest of the decedent, other than a sole~proprietorship. See instructbns for the supportng in(orrnafion to be submitted for sak-proprietorships. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH TOTAL (Also enter on line (H more space is needed, insert additional sheets of the same sae) REV-1505 EX + (6-98) COMMONWEALTH Of PENNSYLVANIA INHERITANCE TAX RETURN scHEOU~ c-~ CLOSELY•HELD CORPORATE iTOCK INFORMATION REPORT ESTATE OF FILE NUMBER Violet s. Bearley 0 0 1. Name of Corporation State of Incorporation Address Date of Incorporation Clty State Zlp Code Total Number of Shareholders 2. Federal Employer I.D. Number Business Reporting Year 3. Type of Business Praduct/Service 4• STOCK TYPE Votl Non-V TOTAL NUIIN3ER OF SHARES OUTSTANDING PAR VALUE NUMBER OF SHARES OWNED BY THE DECEDENT VALUE OF THE DECEDENTS STOCK common $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? ....................................... ^ Yes ^ No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? ....................................... ^ Yes ^ No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ............... ^ Yes ^ No If yes, Cash Surcender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer stock in this company within one year prior to death or within two years 'rf the date of death was prior to 12.31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Number of Shares Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ............ ^ Yes ^ No If yes, provide a copy of the agreement. 10. Was the decedent's stack sold? ................................................. ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the dint s death? .. ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ..... . ....... . . . . .. . ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or G2 for each interest. A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of finandal statements or Federal Corporate Income Tax returns {Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete addressles and estimated fair market valuels. ff real estate appraisals have been secured, attach copies. D. List of princpal stockholders at the date of death, number of shares held and their relationship to the decedent E. List of officers, their salaries, bonuses and any other benefits received from the krporation. F. Statement of dividends paid each year, List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. (If mkxe space is needed, insert additional sheep of the same size) ___ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT EST SCHEDULE C-2 PARTNERSHIP INFORMATION REPOR Violet s. Bearfev 0 0 1. Name of Partnership Date Business Commenced Address Business Reporting Year City State ZIp Code 2. Federal Employer I.D. Number 3. Type of Business Produd/Service 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited paMer, provide initial investment $ 5. PARTNER NAME PERCENT OF INCOME PERCENT OF OWNERSHIP BALANCE OF CAPRAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ................................ ^ Yes ^ No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the paMership upon the death of the decedent? ........ ^ Yes ^ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to de~h or within two years if the date of death was priarto 12-31-82? ^ Yes ^ No If yes, ^ Transfer ^ Sale Percentage transferredlsold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's deathl........ ^ yes ^ No If yes, provide a copy of the agreement 11. Was the decedent's partnership interest sold? .................................. ^ Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the paMership dissolved or liquidated af6er the decedent's death? ^ Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? ................................ ^ Yes ^ No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? ................. ^ Yes ^ No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest A. Detailed calculaticns used in the valuation of the decedent's partnership interest B. Complete copies of finandal statements a Federal Partnership Income Tax returns (Porto t065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete addrass/es and estimated fair market valuels. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. REV-1507 EX ~ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES 8 NOTES RECEIVABLE All P-opertY lolntlY'o~ed with tiro right of survivorship must be discbsed on Schedule f. ITEM VALUE AT DATE OF DEATH ~ v r nr. AISO Enter 0r1 (If more space is needed, insert additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ATE SCHEDULE E CASH, BANK DEPOSITS, 8 MISC. PERSONAL PROPERTY Include the proceeds of litigation and the date the ~ Properly jointly-owned with right of survivon ITEM NUMBER DESCRIPTION 1. Kish Bank -Account #346070 were received try the estate. 6e discbsed on Schedub F. - I VALUE AT DATE Of DEATH 1, 899.54 TOTAL (Also enter on line 5, Qf more space is needed, insert additional sheets o(the same size) S 1 __. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER Violet s. Bearley 0 0 Nan asset was made joint vrithin one year of the decadenCs date of death, it must be reported an Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS TO DECEDENT A. B C JOINTLY-0WNED PROPERTY: ITEM NUMBER ~~ FOR JOINT TENANT ~~ MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HEED REAL ESTATE. DATE OF DEATH VALUE OFASSET 96 OF DECD'S INTEREST / DATE OF DEATH VALUE OF DECEDENTS INTEREST 1. A. TOTAL (Also enter on line 6, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) ~v-ao/ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDt1LE G INTER-VIVOS TRANSFERS ~ MISC. NON-PROBATE PROPERTY 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. ~r.- . rvrv yr rRUrtK I Y I- M INCLUDE THE NAPE OF THE TRANSFEREE. THEIR REIAilONSHIP TO DECEDENT ANO JMBER TNEOATEOFTRANSFER.ATTACHACDP/DpTWEDEEDFORREN.ESTATE DATE OF DEATH %OFOECD'S EXCLUSION I VALUE OF ASSET INTEREST (IFAPPL~DAgLE) TAXABLE VALUE TOTAL (Also enter on line 7 (If more space a needed, invert additional sheets of fhe same size) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & IN RES DENT DECEDENTRN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Violet s. Bearley 0 0 Debts df decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION .AMOUNT A. FUNERAL EXPENSES: t. Harshbarger Funeral Home 2,271.60 B. ADMINISTRATIVE COSTS: t , Personal Representative's Commissions Name of Personal Representative (s) Street Address City State Zip Year(s) Commission Paid: 2. AltomeyFees Vincent M. Monfredo 3;051.00 3. Family Exemption: (If decedenfs address is not the same as claimants, attach explanation) Claimant Street Address Oily State Zip Relationship at Claimant to Decedent 4• Probate Fees Mifflin County Register of Wills 156.00 5 Accounfanfs Fees 6. ~ Taz Retum Preparefs Fees 7 TOTAL (Also enter on line 9, Recapitulation) I S (If more space is needed, insert addltlonal sheets of the same size) REV•1512 EX ~ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE / DEBTS OF DECEDENT, MORTGAGE LIABILITIES, ~ LIENS ESTATE OF FILE NUMBER Violet s. Bearley 0 0 Report debts incurred by the decederrt prior to death which remained unpaid as of the date of death, including unraimburtted medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. Pennsylvania Department of Public Welfare 75,063.70 2. (Kish Bank to open safe deposit box 3. ~Retum last social security check 4. (Valley Rural Electric 5. (Lewistown Sentinel-Advertising 100.00 1,046.00 149.00 188.48 TOTAL (Also enter on line 10, Recapitulation) I ; (If more space S needed, Insert additbnal sheets of the same size) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Violet s. S earle O u RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY fM Not List Truatee(s) OF ESTATE ~ TAXABLE DISTRIBUTIONS [include outright spousal distnbutbns, and transfers under Sec. 9116 (a] (1.2)] 1. Jan Hammaker Lineal 100.00 Lineal ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE L B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS t TOTAL OF PART [I -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET S pt more space Is neeaeo, insert a~ihonal sheets or Ine same size) . -.t , IN RE ESTATE OF EDWARD N. NAYLOR, Deceased IN THE ORPHANS' COURT OF THE 9sT JUDICIAL DISTRICT OF PENNSYLVANIA CUMBERLAND COUNTY NO. 21-09-0055 c~ ° c o - NOTICE ~~ ~ ~ ~ _:; '` ~Q~1 ~ ._ Notice is hereby given to all persons interested that Steven ly, Ex~~°cutai;gf ~kte cn .., Estate of Edward N. Naylor, late of Upper Allen Township, Cumberland County, Pennsylvania, deceased, has filed a First and Final Account of said Estate, together with a statement of proposed distribution of the balances shown by such account, in the offices of the Register of Wills and the Clerk of the Orphans' Court of said County, which account ,and statement will be presented to said Court on March 2, 2010, at 9:30 a.m., in Courtroom # 1, when the same will be confirmed and approved and a decree of final distribution as proposed will be made, unless written exceptions thereto are filed prior to said confirmation. WIWAM R. BUNT -IRYSTAL L. PROSSER ATTORNEYS AT LAW 109 S. Carlisle Sfreet New 8loomfleld, Pa. 17068 l~ 2'~.~ Chrys I L. Prosser, Esquire Supreme Court ID # 77396 LAW OFFICE OF WILLIAM R. BUNT 109 S. Carlisle Street P.O. Box 336 New Bloomfield, Pennsylvania 17068 (717) 582-8195 Attorney for the Estate of Edward N. Naylor Tel. (71 ~ 582-8195 FAX (71 n 582-7521 IN THE COURT OF COMMON PLEAS OF THE 9T" JUDICIAL DISTRICT OF PENNSYLVANIA CUMBERLAND COUNTY NO. 21-09-0055 FIRST AND FINAL ACCOUNT AND STATEMENT OF PROPOSED DISTRIBUTION OF Steven C. Daly, Executor w for the ~ - ; ESTATE OF EDWARD N. NAYLOR, Deceas ~ ~ ~ r `-~ ~ :~ ~, ,, Date of Death: December 30, 2008 `_;~~ s~ c ; -~ Date of Executor's Appointment: January 20, 2 `Od9o~ ~ ~ __ '~~- 11"Tl Account stated through: December 15, 2009a~ to ~~' < v WILLIAM R. BUNT :HRYSTAL L. PROSSER ATTORNEYS AT LAW 109 S. Cadlsle Sheet New Bloomfield, Pa. 17068 Dates of Advertisement: The Sentinel Cumberland Law Journal January 26, 2009; February 2, 2009; and February 9, 2009 January 30, 2009; February 6, 2009; and February 13, 2009 Purpose of Account: Steven C. Daly, Executor, offers this Account to acquaint interested parties with the transactions that have occurred during the Administration. The Account also indicates the proposed distribution of the Estate. It is important that the Account be carefully examined. Requests for additional information or questions or objections can be discussed with: Steven C. Daly Chrystal L. Prosser, Esquire 622 Elliott Drive Law Office of William R. Bunt Lewisberry, PA 17339 109 S. Carlisle Street (717) 938-5464 P. O. Box 336 New Bloomfield, PA 17068 (717)582-8195 Tel. Q17) 582-8195 FAX (717) 582-7521 SUMMARY AND INDEX Paae PRINCIPAL Receipts Cash .....................................................2 ........... $996,739.94 Tangible Personal Property .................2 ........ _ $ 5,662.50 Total Receipts ................................2 ....................................$1,002,402.44 t Adjustment to Carrying Value ...............3 ......................................... -$3,260.76 ins and Losses .......................:................3 .............................. .......+ 1 056.84 Total Adjusted Principal Receipts..3 .............................................. +$1,000,198.52 Less Disbursements Federal & State Taxes .........................3 ............ $115,249.07 Fees and Commissions .......................3 .............. $40,000.00 Administrative Expenses ......................4 ................ $7,541.39 Funeral Expenses .........................:......4 ................ $4,035.42 Medical Services ..................................4 ................ 8 384.19 Total Disbursements .................................4 ............................ .....- $175,210.07 ................. Total Income ..........................................5,6 ........................... ....+$4,286.32 ...................... BALANCE INCOME & PRINCIPAL .............................................$829,274.77 Proposed Reserves ..................................7 ..................................... 32,200.00 Proposed Distribution to Beneficiaries..:7,8 .................................... 797.074.77 DISTRIBUTION AND RESERVE ..................................................$829,274.77 WILLIAM R. BUNT :HRYSTAL L PROSSER ATTORNEYS AT LAW 109 S. CarlBle Street New Bloomfield. Pa. 17068 Tel. (717)582-8195 FAX (717) 582-7521 1 RECEIPTS OF PRINCIPAL 1. 12/30/08 PNC Bank N.A. Checking Account .........15,248.95 2. 12/30/08 PNC Bank N.A. Money Market Account ..36,138.83 3. 12/30/08 Morgan Stanley Account. (#036-140) ... 204,384.47 4. 12/30/08 Morgan Stanley Account (#664-140)..... 653,301.18 5. 12/30/08 Bank of America Certificate of Deposit ....24,378.64 6. 7. 01/02/09 01/02/09 Verizon Pension ..................................... Social Security Payment ....1,872.82 1 11 ........................ .... , 6.00 8. 01/13/09 Morgan Stanley Rebate ....................... 13 69 9. 02/02/09 ... Morgan Stanley Rebate of quarterly fee ......... . ....1,510.91 10. 02/02/09 Direct Deposit Pension ........................... ....1,783.12 11. 02/06/09 U.S. Department of Treasury - Government Life Insurance Policy......... ..30,945.30 12. 02/19/09 Morgan Stanley Rebate .......................... ... 13 61 13. 03/06/09 Verizon Life Insurance Policy ...... . through Prudential .................................. ..22,500.00 14. 03/12/09 Morgan Stanley Rebate .......................... ...........0.62 15. 04/03/09 Verizon Refund ........................................ ........59.80 16. 05/08/09 2008 Federal Individual Income Tax Refund ................................. ...2,400.00 17. 05/02/09 2008 Pennsylvania Individual Income Tax Refund ................................. ......872.00 18. 06/25/09 Verizon Pension Refund ......................... ......200.00 Total Cash ................. $996,739.94 Tans~ible Personal Proaertv: '/ 1. Akoya Cultured Pearl Necklace ....................................160.00 2. 2.64 Carat Diamond Solitaire Ring ....:....................... 3,500.00 3. 1.37 Carat Diamond Solitaire Ring ............................ ...800.00 4. 6.72 ctw Diamond Tennis Bracelet ........................... 1,000.00 5. Man's Ring Onyx w/ Diamond 10 k ........................... .....47.50 6. Man's Ring with 3 Diamond 14k ................................. .....77.50 7. Man's Ring with Diamond 14k ................................... .....77.50 Total Tangible Personal Property .................$5,662.50 WILLJAM R. BUNT :HRYSTAL L. PROSSER ATTORNEYS AT LAW 109 S. Carlisle SfreeT New 8bomfleld, Pa. 17068 Tel. (71 ~ 582.8195 FAX ply 582-7521 TOTAL RECEIPTS .......................... 1 002 ....................................................... $ ,402.44 '/ Prices are the date of death value from the Pennsylvania Inheritance Tax return and are the market value as determined by the sale by Cordier Antiques. 2 2/ 1. 12/31/08 Morgan Stanley Account(#036-140)..........+806.70 2. 12/31/08 Morgan Stanley Account(#664-140)........-4,167.46 Net Adjustment to Carrying Value ..........................-$3,260.76 1. 01/31/09 Morgan Stanley Account (#036-140) ...........-906.70 2. 01/31/09 Morgan Stanley Account (#664-140) .......+3,267.74 3. 02/28/09 Morgan Stanley Account (#036-140) ..........+249.52 4. 02/28/09 Morgan Stanley Account (#664-140) ..........+733.58 5. 02/28/09 Morgan Stanley Account (#162-140) ........-2,409.90 6. 03/31/09 Morgan Stanley Account (#162-140) ..........+123.30 7. 04/30/09 Morgan Stanley Account (#162-140) ...............-0.70 Net Gains and Losses ...........................+$1,056.84 TOTAL ADJUSTED PRINCIPAL RECEIPTS .................................$1,000,198.52 DISBURSEMENTS OF PRINCIPAL Federal and State Taxes: 1. 03/03/09 Pennsylvania Inheritance Tax.........110,000.00 2. 06/12/09 Pennsylvania Inheritance Tax .............5,249.07 Total Federal and State Taxes ............................... $ 115,249.07 Fees and Commissions 3/ 1. 06/03/09 Partial Payment of Attorney Fee Law Office of William R. Bunt ....20,000.00 2. 06/03/09 Partial Payment of Executor Fee Steven C. Daly, Executor ............20,000.00 Total Fees and Commissions...........40,000.00 WILLIAM R. BUNT :HRYSTAL L. PROSSER ATTORNEYS AT LAW 109 S. Carlisle Sheer New Bloomfield, Pa. noes Tel. (71 ~ 582-8195 FAX (717) 582-7521 2/ The Morgan Stanley accounts were reported on the Pennsylvania Inheritance Tax Return as of 12/30/08. The adjustment to the carrying value is the difference between date of death value and the next statement of 12/31/08. - a ! The fee reported on the Pennsylvania Inheritance Tax Return for both the Executor and the Attorney was $31,100.00. Said Inheritance Tax Return was accepted as filed. The unpaid balance is included in the reserve and will be paid at the time distribution is made to the heirs after the confirmation of this Account. 3 1. 01/13/09 Veterans Insurance .... . 13 20 2. 01/15/09 ....................... ... Morgan Stanley Quarterly Fee ............... ........ . ...1,510.91 3. 01 /20/09 Register of Wills -Probate Fee- ............ ......730 00 4. 02/02/09 Morgan Stanley Term Fee .................... . ......537.11 5. 02/06/09 Refund of Social Security Payment........ ...1,116.00 6. 02/13/09 AAA Annual Service Fee on Morgan Stanley Accounts ..................... ......150.00 7. 02/14/09 The Sentinel .......................................... ......142.66 8. 02/23/09 Morgan Stanley Wired Funds Fee ......... ........30.00 9. 02/23/09 PNC Bank Wired Funds Fee ................ ........12.00 10. 03/03/09 Short Certificates ............................. 20 00 11. 03/03/09 ...... Bank of America - ........ . Research Verification Fee ..................... ........20.00 12. 03/23/09 Cumberland Law Journal ...................... ........75.00 13. 04/04/09 Barbara Ann John -Accountant Fee...........335.00 14. 04/19/09 Cordier Antiques -Commission ....... .............30.39 15. 05/22/09 Cordier Antiques -Commission .................819.00 16. 06/02/09 Refund - Verizon Pension Overpayment ..1,985.12 17. 06/12/09 Filing Fee for Inheritance Tax Return .... .......15.00 Total Administrative Expenses .......................$7,541.39 Funeral Expenses: 1. .01/23/09 Myers Funeral Home .................4,035.42 Total Funeral Expenses .................................$4,035.42 Medical Services: 1. 01/27/09 Alert Pharmacy Services, Inc. .......147.79 2. 02/09/09 Alert Pharmacy Services, Inc. .......112.50 3. 01/21/09 Messiah Village ..........................8,123.90 Total Medical Services ........................$8,384.19 TOTAL DISBURSEMENTS OF PRINCIPAL ............... $175,210.07 WILLIAM R. BUNT :HRYSTAL L. PROSSER ATTORNEYS AT LAW 109 S. CaAlsls Sheet New Bloomfield, Pa. 17068 Tel. Q17) 582-8195 FAX (717) 682-7521 4 RECEIPTS OF INCOME A. Morgan Stanlev Account Income and Dividends a/ 1. Dividend 12/31 /08 ....................................193.66 01 /02/09 ........................................2.25 01 /30/09 .................................... 208.14 01 /30/09 .................................... 308.61 01 /02/09 .................................... 240.40 01 /02/09 ...................................... 81.12 02/06/09 ......................................98.31 02/27/09 ...................................... 57.42 Total Morgan Stanley Dividends.. $1,189.91 2. Taxable Interest 01 /02/09 ..........................:.........169.44 01 /11 /09 ....................................135.89 01 /14/09 ....................................122.30 01 /29/09 ....................................160.52 01 /29/09 ........................................ 3.69 02/02/09 ....................................169.44 02/04/09 ........................................0.45 02/26/09 ......................................49.56 02/26/09 ...................................... 23.41 03/02/09 ...............:....................153.04 03/30/09 ......................................41.97 03/30/09 ......................................24.16 04/02/09 ....................................169.44 04/29/09 ......................................44.90 04/29/09 ......................................20.14 05/28/09 ......................................43.97 05/28/09 ......................................19.46 06/29/09 ...................................... 48.52 06/29/09 ................:.....................21.48 07/30/09 ......................................47.02 WIWAM R. BUNT ;HRYSTAL L PROSSER ATTORNEYS AT LAW 109 S. Carlisle Street New Bloomfield, Pa. 17068 Tel, p17) 582-8195 FAX (717) 582-7521 4/ As of the date of death, Mr. Naylor had two Morgan Stanley Accounts in his name alone. Said accounts were combined on or about February 2, 2009. Due to the format of statements by Morgan Stanley, all income and dividends whether for the individual accounts or the Estate account are combined hereunder. 5 ' 07/30/09 ...................................... 20.81 08/28/09 ......................................43.98 08/28/09 ......................................19.47 09/29/09 ......................................48.55 09/29/09 ......................................21.48 10/29!09 ...................................... 45.51 10/29/09 ......................................20.14 11 /27/09 ......................................44.00 1127/09 .......................................19.46 Total Morgan Stanley Interest..$1,752.20 3. Tax Exempt Income/Dividend 01 /29/09 .................................... 568.24 01 /30/09 .................................... 456.17 02/26/09 ........................................2.50 02/27/09 ....................................103.19 Total Morgan Stanley Tax Exempt Income ..................$1,130.10 B. Bank of America Certificate of Deposit 03/27/09 ....................................205.77 Total Bank of America Interest ..$205.77 C. PNC Bank 01 /06/09 ........................................ 5.18 01 /06/09 ........................................ 0.49 04/17/09 ........................................ 2.67 Total PNC Bank Interest ... ..............$8.34 'OTAL INCOME ................................................................................ $4,286.32 WILLIAM R. BUNT :HRYSTAL L PROSSER ATTORNEYS AT LAW 109 5. Carlisle Sheet New Bloomfleid. Pa. 17058 Tel. p17) 582-8195 FAX (717) 582-7521 6 SCHEDULE OF PROPOSED DISTRIBUTION TO BENEFICIARIES WIWAM R. BUNT ~HRYSTAL L. PROSSER ATTORNEYS AT LAW 109 S. CarlWe Street New Bloomfield. Pa. 17068 Tel. (717) 582-8195 fAX (717) 562-7521 Balance per account ..........................................................$ 829,274.77 Reserve for taxes, miscellaneous bills, filing fees, balance of Executor Fee and Attorney fee and for filing of Account ...................................................$ 32,200.00 Balance available for distribution ................................................... $ 797,074.77 Total Distribution to Beneficiaries: Per Paragraph FOURTH, of the Last Will and Testament of Edward N. Naylor A. Five percent (5%) of the residuary estate unto the Salvation Army B. Ten percent (10%) of the residuary estate unto his nephew, Steven C. Daly C. Five percent (5%) of the residuary estate unto his nephevJs wife, Delores A. Daly D. Five percent (5%) of the residuary estate unto his great nephew, Matthew Daly E. Five percent (5%) of the residuary estate unto his great niece, Melissa Daly F. Five percent (5%) of the residuary estate unto his great nephew, Marc Ban•ick G. Five percent (5%) of the residuary estate unto his friend, Jan Steele Hammaker H. Five percent (5%) of the residuary estate unto his friend, Lori Nast I. Five percent (5%) of the residuary estate unto his sister, Marguerite Henderson. And in the event that the said Marguerite Henderson predeceased Decedent said share of Decedent's estate is divided pro rata among the remaining beneficiaries named in Paragraph FOURTH of the Last Will and Testament of Edward N. Naylor J. Five percent (5%) of the residuary estate unto his brother, Raymond Naylor K. Seven percent (7%) of the residuary estate unto his niece, Dorothy Holley L. Five percent (5%) of the residuary estate unto his niece, Ruth Ann Wright M. Five percent (5%) of the residuary estate unto his niece, Barbara Jean Fry N. Five percent (5%) of the residuary estate unto his great niece, Patricia Kissinger O. Five percent (5%) of the residuary estate unto his niece, Di~ae Steigleman P. Three percent (3%) of the residuary estate unto his niece, Diane Gutshall Q. Five percent (5%) of the residuary estate unto the Gavin Horting Trust, Steven C. Daly, trustee R. Five percent (5%) of the residuary estate the Zachary Criswell Trust, Steven C. Daly, trustee S. Five percent (5%) of the residuary estate unto the Joshua Criswell Trust, Steven C. Daly, trustee 7 Distribution to Be Made to Beneficiaries: ~ i A. Salvation Army ................................ . $41,951.36 B. Steven C. Daly ................................ . $83,901.67 C. Delores A. Daly ............................... . $41,951,36 D. Matthew Daly .................................... $41,951.36 E. Melissa Daly ..................................... $41,951.36 F. Marc Garrick ..................................... $41,951.36 G. Jan Steele Hammaker ..................... $41,951.36 H. Lori Nast ........................................... $41,951.36 I. Raymond Naylor .............................. $41,951.36 J. Dorothy Holley .................................. $58,731.69 K. Ruth Ann Wright .............................. $41,951.36 L. Barbara Jean Fry ............................. $41,951.36 M. Patricia Kissinger ............................. $41,951.36 N. Dixie Steigleman .............................. $41,951.36 O. Diane Gutshall ................................. $25,171.01 P. Gavin Horting Trust ......................... $41,951.36 Q. Zachary Criswell Trust .................... $41,951.36 R. Joshua Criswell Trust ...................... $41,951.36 Total Distribution To Be Made ........... ................................$797 074 77 , . alance remaining (excluding reserve) ............. .............................. $ 0 00 .......... . WILLIAM R. BUNT ;HRYSTAL L PROSSER ATTORNEYS AT LAW q ~ The amount listed includes the pro rata share of the five percent (5%) of the residuary estate that 109 s. carllsle sr~eef would have otherwise been distributed to decedent's sister, Marguerite Henderson, who predeceased New sioomeeld. Pa. decedent. 17068 Tel, (717) 582-8195 FAX (717) 582-7521 STATEMENT OF THE REASONS FOR THE PROPOSED DISTRIBUTION WILLIAM R. BUNT :HRYSTAL L. PROSSER ATTORNEYS AT LAW 109 S. Carlisle Street New Bloomfield, Pa. 17068 Tel. Q17) 582-8195 FAX (717) 582-7521 The above distribution is proposed due to the completion of all matters pertaining to the Estate of Edward N. Naylor. e Steven C. Daly, Executor COMMONWEALTH OF PENNSYLVANIA COUNTY OF PERRY ss. STEVEN C. DALY, Executor under the Last Will and Testament of Edward N. Naylor, deceased, hereby declares under oath that he has fully and faithfully discharged the duties of his office; that the foregoing First and Final Account is true and correct and fully discloses all significant transactions occurring during the accounting period; that all known claims against the Estate have been paid in full; that, to her knowledge, there are no claims now outstanding against the Estate; and that all taxes presently due from the Estate have been paid. C. . Steven C. Daly Executor Sworn and subscribed to before me this /,S~ day of December , 2009. My com ssion expires: COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL CHRYSTAL L. PROSSER, NOTARY PUBLIC MEW BLOOMFIELO BORO., PERRY COUNTY MY COMMISSION E%PIRES MAY 15 212 9 Michael J. Shalonis Funeral Home 206 Maple Avenue Marysville, Pennsylvania 17053 Fax (717)-957-2077 Michael J. Shalonis, Owner Phone (717) 957-3451 We Care About Service To You Friday, January 8, 2010 Miss Gina L. Steele 1645 Revere Drive Mechanicsburg, PA 17050 Dear Gina, Thank you for selecting ow funeral home to provide services for your family during yow time of bereavement. 1 hope that you found ow services, so far, to be of the highest standards that we always try to achieve. The following is a summary of the service charges as previously explained and provided in written form. on the services for. JAN STEELE HAMMAKER 2. Use Of Facilities, Staff Aod Equipment Staff & Equipment For Church Service $ 395.00 $395.00 TOTAL OF PROFESSIONAL SERVICES, FACILITIES AND AUTOMOTIVE EQUIPMENT $395.00 Acknowledgement Cazds $ included Register Book $ included Memorial Folders 200 $ included Cremation Urn _ $ included SPECIALSERVICES Direct cremation $ 1450.00 TOTAL SPECIAL CHARGES $1,450.00 CASH ADVANCES Paid Newspaper Notice $ 206.47 Chwch or Clergy $ Famil Y Certified Copies of Death Certificate 15 $ 90 Flowers $ 50.00 Cumberland Co. Coroner's Cremation Permit $ 25.00 $371.47 TOTAL FUNERAL CONTRACT $2,216.47 LESS: Credits ganted $100.00 Discount allowed $100.00 BALANCE DUE $2,116.47 If there are any questions or concerns that remain unanswered, please call me. Sincerely, Michael J. Shalonis Owner ~~ /a l3 ,la~l~o i o Michael J. Shalonis Funeral Home 206 Maple Avenue Marysville, Pennsylvania 17053 Fax (717)-957-2077 Michael J. Shalonis, Owner Phone (717) 957-345 ] We Care About Service To You Thursday, January 28, 2010 Miss. Gina L. Steele 1645 Revere Drive Mechanicsburg, PA 17050 Dear Gina, Thank you for selecting our funeral home to provide services for your family during your bereavement. I hope that you found our services to be of the highest standards and that they met your needs and those of your family and friends. The following is a summary of the service charges as previously explained and provided in written form and herein indicated as PAID-IN-FULL. Jan Steele Hammaker SUMMARY OF EXPENSES TOTAL OF SERVICE RENDERED 52,216.47 LESS: Credits granted 100.00 LESS: Total Payments 2,118.47 CURRENT BALANCE 60.00 Credits Granted: $100.00 Discount allowed If there are any questions or concerns that remain unanswered, please call me Sincerely, ~~ Michael J. Shalonis Owner LOT # L=~1'f~ , RECEIVEi) $Y' DATE'': . ONSIGNOR'S NAME ~~~.y ~'> y~ ~'~,~ ~9'l~w ' '"1 "~r~``s`- ~'`"^, £ ry •'"' ' - HONE ~/.'s . ZIP CODE '~I ~.~ `; r ~ ~ ( ._. (.J. ..,. ~ ~7 __ ' E ~ HEET # OF TOTAL SHEETS I (consignor) hereby commission you to sell the items listed above 8 on the attached sheets to the highest bidder by public auction. I certlfy that I am the owner of the above listed items and have good tftle and the right to sell them. I certi}v that the items listed are tree from all incumbrartces. I agree to accept al responsibility for providing good thle and for delivery of title to the purchaser. It is agreed that the consgnee is not responsible for the loss of any item due to fire, theft, damage, etc. I understand drat a °h commission will be deducted from the gross sales of my items. "NO Bid" items will be disposed of at the discretion of the ' Auctioneer/Auction Mouse. Payment will be made to the consignor xrithin days from date ~f sale. .. , o r 9 . .__ ..`~ ~ Date, ~~ ~V Auction io gnature CONSIGNOR'S CHECK IN COPY ' 1 BUYER ITEM "-` LOT # t-~ ~ S i~-CZC-kf-~~L.. ^~, , ,,~, 2 ' ~~ i ~ BUYER 4?~'~ ITEM ~ ~ ~~'~ `~-~' `~ ® _ $ _,. ~ 1 -__ BUYER ITEM LOT # __ _ _ 5 BUYER ~ ~} , ~} ITEM ~"`"` „i t~"~,.d, ;~ LOT # ~ ~ BUYER +•'l: ITEM .~--N ~ ~ {-~,N ~'(i. i tv",'~ LOT # ® _ $1 ~ ,~® BUYER j ~ITEM`~,~..~~ ~,tti1 ~--~-~ LOT # ~ , ._ . ~i 1B ~~ y.BUYER ITEMP" Y '~~ ~siR-L k+~ ~1„UW.~t.~ LOT # ® _ $~~ J 15 - ~ _. ~~_~~_ BUYER ITEM '"'.T. ~~1 C-- S ~.., ~ ~~~~ LOT # ~ _ $~ LOT # ® _ ~ ,.. 4 - - -- --- BUYER '"~ ~ ~ ~7 ~~ ITEM ~~T ~se~ i~"'4,.~r'~.T~`C„i ~, LOT # ~ _ $~~~ BUYER„, ~ f ITEM \ 4..~~~'~~°'1 r~ ~~.-~ ~ J~.~ ~ LOT # I ~~ ~ i 12 BUYER ~~~ :- ITEM ~~~ .~/-~'l.Q ~-'~ \~~~ LOT # t E. ~-^~~ f,_...__.... ~ , ~ 14 ~~ .. T. ~ BUYER ,~. ~ M~ ~, rte? f ITEM ~~ 1"-'~' ` "1"e-,~"` C-c~ \r-t!L"Q ~,,f ' ~'N 4 LOT # ~ BUYER -ITEM ~L'~"V1''~"~'~..." '~ `-y!('Y1-iC. LOT # ~ _ $ l! ~ - iHEET`# SHEET TOTAL RUNNING TOTAL $ • BUYER !'~ ~, ~` ; '~ i 10 y /'' ~ '~r t ,~ ~`~~'~ ~ ~ II BUYER "...' `'-i ~. ~~,s~ ITEM ~i~"~ `-~ ~.~. ~..' ~6"-~11~ ~-' ~) 'il) C3 P,~ LOT # l LOT # t ~.s -r..~ ~-------- _ $ ~ ~-~. ~ I ,. _.._ ~ ....,__, _.__ __ _ _ i 12 _ ___ BUYER ~ '~ I _ .--s __ --- ITEM ~~.. ~C~ ~C., I BUYER ~ ~ ~ - _ ~~ I LOT # ~ ITEM ~ ~~-- ~~ _t~'\f~ C~l`~ Ili '~' J LOT # ~- C~~S ~ lLt3\<{~ ~~- _ $ ; .. _ .__ i ~ .. _ 14 °~- ~ BUYER ,~, ,p F~~1 ~-~ I 'p : BEM `~-~°+~ ~~ ~,.,~ «-`i•-~ ' ~'ai) 7-t,'~LS -J" _ ~ LOT # ~ I 5 ,~( r-- - -_ _ -- - $~~ ~ ' BUYER ~'""~~ t 18 -.. - _ ._ _ - LOT ~~_ _ i -~_ BUYE{R'~' J ~ ~' ~ f ITEM ` "tt,~~`~ ~ ~ `~-'~'._ s~-~-(~..y1C,Q LOT # ~~~ ITEM `--~C-2. ~t~-~-t.,'+(Z,.~'CC~ LOT # BUYER. '~".~ t ITEM LSD • ~'h~~ 1,~~_,,©^'S-~~ P LOT # "'1 e~ ,.~. ~.