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Home My WebLink About04-14-10 (3)S M I GE L, ANDERSON HEATHER D. ROPER, ESQUIRE & SACKS LLP PHONE: (717) 234-2401 ATTORNEYS AT LAW TOLL FREE: 1-800-822-9767 FACSIMILE (717) 234-3611 EMAIL: hroyerC~;sasllp.com www.sasllp.com File No. 8960-2-SA April 13, 2010 n -,_.~ Register of Wills Office ~R ~ ~, ~ `' , ~ e F Cumberland County Courthouse - ~~~' ~ .~ ~ -~~ ` -'-.- One Courthouse S uare q ~ ~~~~~ ;~~~ ~`` _ 4 ~ ~:::~ ~_ : ~ ~~=~ , , -~ Carlisle, PA 17013 ~ ~~ ~ `~=' ~" ~ __ ~ _... r ~ ~.._.. -- ~ - ~ -`" _ ~~ ~ RE: Estate of Russella A. Werner ~' ~' ~~' File No.: 21 09 0740 s'v Dear Sir or Madam: Enclosed please find for filing in the above-referenced Estate: 1. An original and two copies of the PA Inheritance Tax Return; 2. Check payable to Registrar of Wills in the amount of $636.38 for the inheritance tax balance; 3. An original and two copies of Inventory; and 4. Check payable to Register of Wills in the amount of $30.00 representing the filing fee for both documents. Kindly datestamp a copy of the Inheritance Tax Return and the Inventory and return them to our office, along with the receipts, in the self-addressed, stamped envelope provided. Thank you for your attention to this matter and please contact our office if you have any questions or need any additional information. Sincerely, L. /alh A L. Haines, Paralegal Enclosures to Heather D. Royer cc: Sharon A. Rose, Executrix (w/out encl.) 4431 North Front Street 3rd Flr Harrisburg Pennsvlvania 17110-1778 A PENNSYLVANIA LIMITED LIABILITY PARTNERSHIP 1505607121 REV-1500 EX (06-05) PA Department of Revenue OFFICIAL USE ONLY Bweau of indivlduai Taxes Po Box 2tlosol INHERITANCE TAX RETURN County Code Year File Numt~er Hartlsburg, PA 17128-0601 RESIDENT DECEDENT 2 1 0 9 0 7 4 D ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 2 9 2 2 8 1 8 1 8 0 7 2 1 2 0 0 9 0 5 1 9 1 9 2 6 Decedent's Last Name Suffix Decedent's First Name MI W E R N E R R U S S E L L A A (If Applicabls) Enter Surviving Spouse's Information Below Spouse's Last Name SuKx Spouse's First Name Mi Spouse's Social Security Number FILL INAPPROPRIATE OVALS BELOW © 1.Original Return ^ 4. Limited Estate ® 6. Decedent Died Testate (Attach Copy of Will) ^ 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS ^ 2. Supplemental Return ^ ^ 4a. Future Interest Compromise (date of ^ death after 12-12-t32) ^ 7. Decedent Maintained a Living Trust 2 (Attach Copy of Trust) ^ 10. Spousal Poverty Credit (date of death ^ between 12-31-91 and 1-1-95) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. 0) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number H E A T H E R D R O Y E R , E S 4 7 1 7 2 ~4 2 4~ 1 -;~::> Firm Name (If Applicable) ~- G, ~,__ J _-..;.,~ REGISTER Ot'`I~~I ~'~ USE ON ' S M I G E L A N D E R S O N & S A C K S T~ --~ ;~ ~, .. -; ._.~_~.~ First line of address ~- r-r-r -- ~ ,--, ; ~ 4 4 3 1 N F R O N T Second line of address 3 R D F L O O R City or Post Office H A R R I S B U R G S T R E E T State ZIP Code P A 1 7 1 1 0 Correspondent's e-mail address: HROYBRCa~SASLLP.COM _. ~.,:r.~ ~ .... ^. ) ~~ ~7~ .fir ` ~ 1 ~ - f ""~`3 ~ ~ i• . .....~. f. ~ ~ ~ ~,. ~.. . 7 DATE FILED ~'`~ 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, N a true, oorrer;t and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PER ON R PONSIBLE FOR FILING RETURN DATE ADDRESS ~ ~ ~ 117 tOTTOK COURT • ~0'e`~ MOON TOWNSHIP PA 15108 m~ufTl C At dneell~w~w 4431 N• FRONT ST.;~RD FLOOR HARRISBUR PLEASE USE ORIGINAL FORM ONLY Side 1 15D5607121 _P-A 171], 0 1505607121 J J REV-1500 EX oecedenYsName: RUSSELLA A WERNER Decedent's Social Security Number 2 9 2 2 8 1 8 1 8 RECAPITULATION 1 2 5 8 0 0 0 ~ 0 0 1. Real estate (Schedule A) • • • • • • • • • • . ............................. • 2 5 4 8 7 9. 4 6 2. .................................. Stocks and Bonds (Schedule B) . 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. • 4. Mortgages 8 Notes Receivable (Schedule D) ........................ 4. • b 6 2 4 4 0 7 . 4 2 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6• ' 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ....... 7. 1 3 3 2 3 1. 2 4 8. ....................... Total Gross Assets (total Lines 1-7) • . , . g. 2 0 7 0 5 1 8 , 1, 2 9. Funeral Expenses 8 Administrative Costs (Schedule H) ................ 9. 9 0 4 3 9 . L 4 3 3 6 L 2 6 9 9 ( ) ............ 10. Debts of Decedent, Mort a e Liabilities, & Liens Schedule I 10. . 11. Total Deductions (total Lines 9 8 10) ........................... 11. 9 3 8 0 0. 4 0 12. Net Value of Estate (Line 8 minus Line 11) ......................... 12• 1 9 ? 6 7 1 7 . 7 2 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) .................. 13. • Ir 9 7 6 7 1, 7 . 7 2 14. Net Value Subject to Tax (Line 12 minus Line 13) .................. 14. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0 0 . 0 0 15. 16. Amount of Line 14 taxable 1 9 7 5 7 1 7 7 2 at lineal rate X .045 . 1 s. 17. Amount of Line 14 taxable 0 0 0 at sibling rate X .12 . 17. 18. Amount of Line 14 taxable ] 0 0 0 0 0 at collateral rate X .15 , . 18. 19. Tax Due ........... ........................... ... ..... ..19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1,505607221, 0. 0 0 8 8 9 0 7. 3 0 0. 0 0 1 5 0. 0 0 8 9 0 5 7. 3 0 Side 2 1505607221 1505607221 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 09 0740 DECEDENT'S NAME RUSSELLA A. WERNER __ _ _______ ____ STREET ADDRESS 310 LAMP POST LANE - - CITY -- ----- T -STATE ZIP - - ------- CAMP HILL PA 17011 Tax Payments and Credits: ~~ Tax Due (Page 2 Line 19) (1) 89,057.30 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments 84,000.00 C. Discount 4,420.92 Total Credits (A + B + C) (2) 88,420.92 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 636.38 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 +5A. This is the BALANCE DUE. (5B) 636.38 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 : ...................................................................... ^ Q b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q 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 decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ^ Q 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? .................................................................................................. ~ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX + (6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER RUSSELLA A. WERNER 21 09 0740 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real ro which is 'oint -owned with ri ht of survivorshi must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 310 LAMP POST LANE, CAMP HILL, HAMPDEN TOWNSHIP, CUMBERLAND 258,000.00 COUNTY, PENNSYLVANIA. SEE HUD-1 ATTACHED. TOTAL (Also enter on line 1, S 258,000.00 (If more space is needed, insert additional sheets of the same size) REV-1503 EX + (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER RUSSELLA A. WERNER 21 09 0740 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. BONDS - VARIOUS E AND EE 54,879.46 SEE ATTACHED CALCULATED VALUE OF BONDS PER TREASURYDIRECT.COM 2. OMEGA FINANCIAL STOCK - 1,890 SHARES -TRANSFERRED TO HERITAGE 0.00 BROKERAGE ACCOUNT 09/05. 3. PENN STATE INVESTORS CORP. STOCK - 200 SHARES -DEFUNCT COMPANY AS OF 0.00 1971. TOTAL (Also enter on line 2, Recapitulation) I $ 54,879 46 (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 RUSSELLA A. WERNER 21 09 0740 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of surv'nrorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1. CITIZENS BANK CHECKING ACCOUNT #610068XXXX 2. CITIZENS BANK MONEY MARKET ACCOUNT #622398XXXX 3. CITIZENS BANK CHECKING ACCOUNT #622398XXXX 4. INTEGRITY BANK MONEY MARKET ACCOUNT #20101 XXXX WITH INTEREST ACCRUED TO DATE OF DEATH 5. ORRSTOWN BANK SAVINGS ACCOUNT #1541XXXX WITH INTEREST ACCRUED TO DATE OF DEATH 6. WACHOVIA BANK CHECKING ACCOUNT #XXXXXX6787 WITH INTEREST ACCRUED TO DATE OF DEATH 7. WACHOVIA BANK SAVINGS #XXXXXX84227 WITH INTEREST ACCRUED TO DATE OF DEATH 8. M & T BANK MONEY MARKET ACCOUNT #XXXXXX84695 WITH INTEREST ACCRUED TO DATE OF DEATH 9. PNC BANK SAVINGS ACCOUNT #51-1200-4025 WITH INTEREST ACCRUED TO DATE OF DEATH 10. HERITAGE WEALTH ADVISORS- MONEY MARKET ACCOUNT, EQUITY ACCOUNT, MUTUAL FUNDS #SHT115060. 11. WACHOVIA BANK SAFE DEPOSIT BOX -SEE ATTACHED INVENTORY LIST. SAVINGS BONDS REPORTED ON SCHEDULE B 12. CITIZENS BANK SAFE DEPOSIT BOX -SEE ATTACHED INVENTORY LIST. 13. CREMATION SOCIETY OF PENNSYLVANIA -BENEFIT TOWARD CREMATION. 14. PENNSYLVANIA STATE EMPLOYEES RETIREMENT PENSION 15. PSECU MONEY MARKET ACCT. #292XXXXXXX 16. PSECU REGULAR SHARES VALUE AT DATE OF DEATH 26,072.78 96,296.55 98.04 56,283.38 13,629.98 104.65 11,355.89 54,014.87 144,648.51 1,208,805.40 0.00 0.00 2,170.00 1,655.60 6,735.86 217.49 TOTAL (Also enter on line 5, Recapitulation) I a 1.624.407.42 (If more space is needed, insert additional sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent RUSSELLA A. WERNER 21 09 0740 Decedent's Name Page 1 File Number Schedule E -Cash, Bank Deposits, ~ Misc. Personal Property ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 17. PERSONAL PROPERTY -SOLD AT ESTATE AUCTION 1,020.40 18. REFUND -TRAVELERS HOMEOWNERS INSURANCE 373.00 19. REFUND -COMCAST 5.58 20. REFUND -FLOOD INSURANCE 86.00 21. REFUND - Q & T PHONE LEASE 7.44 22. AMERICAN EXPRESS TRAVELERS CHECKS 670.00 23. 2009 INCOME TAX REFUND 156.00 SUBTOTAL SCHEDULE E 2,318.42 GRAND TOTAL SCHEDULE E $ 1,624,407.42 REV-1510 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER RUSSELLA A. WERNER 21 09 0740 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACHACOPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OFASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1. PENTAGON FCU SAVINGS ACCT #51-1200-XXXX 5.10 100. 5.10 BENEFICIARIES: SHARON ROSE, DAUGHTER; STEVEN WERNER, SON; AND PAMELA DAVEY, DAUGHTER 2. PENTAGON FCU MONEY MARKET #0-4252465-XX-X 81,341.20 100. 81,341.20 BENEFICIARIES: SHARON ROSE, DAUGHTER; STEVEN WERNER, SON; AND PAMELA DAVEY, DAUGHTER 3. PENTAL FCU MONEY MARKET #0-4260199-XX-X 34,854.72 100. 34,854.72 BENEFICIARIES: SHARON ROSE, DAUGHTER; STEVEN WERNER, SON; AND PAMELA DAVEY,DAUGHTER. 4. PSECU IRA CERTIFICATE 17,030.22 100. 17,030.22 BENEFICIARIES: SHARON ROSE, DAUGHTER; STEVEN WERNER, SON; AND PAMELA DAVEY, DAUGHTER TOTAL (Also enter on line 7 Recapitulation) I $ 133,231 24 (If more space is needed, insert additional sheets of the same size) ~~--~~~~^~_~-~~ REV-1511 EX + (10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER RUSSELLA A. WERNER 21 09 0740 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. PARTHEMORE FUNERAL HOME 4,215.62 2. FUNERAL FLOWERS 227.90 3. FOOD FOR FUNERAL LUNCHEON 776.70 4. MEMORIAL EXPENSES 757.59 B ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) SHARON A. ROSE Street Address 117 COTTONWOOD COURT C;ri MOON TOWNSHIP Year(s) Commission Paid: 2010 State PA Zip 15108 2, Attorney Fees SMIGEL, ANDERSON & SACKS, LLP 3, Family Exemption: (If decedents address is not the same as claimants, attach explanation) Claimant 4. 5. 6. Street Address City State Zip Relationship of Claimant to Decedent Probate Fees REGISTER OF WILLS, CUMBERLAND COUNTY Accountants Fees Tax Return Preparers Fees FINAL PERSONAL AND ESTATE 1041 750.00 7. SENTINEL -LEGAL ADVERTISEMENT 198.16 8. CUMBERLAND LAW JOURNAL -LEGAL ADVERTISEMENT 75.00 9. HUNTINGTON BANK -ESTATE CHECK FEE 18.95 10. D.A. POTTS -APPRAISAL OF HOME 375.00 1 1. DIRTY DOG HAULING -REMOVING TRASH FROM HOME 1,425.00 12. WILLIAM F. DAVEY -REPAIRS TO HOME (REPAIR WALLS/PAINTING) 65.74 13. HAMPDEN TOWNSHIP WATER/SEWER 277.30 14. PP&L -ELECTRIC BILL 676.30 15. RESIDENCE SELLING COSTS -SEE HUD-1 SHEET ATTACHED 9,995.00 16. COMCAST -PHONE BILL 177.30 17. VERIZON 220.55 18. HUNTINGTON BANK -WIRE TRANSFER FEES 72.00 TOTAL (Also enter on line 9, Recapitulation) $ 90,439.14 (If more space is needed, insert additional sheets of the same size) 51,335.40 12,500.00 1,195.00 Continuation of REV-1500 Inheritance Tax Return Resident Decedent RUSSELLA A. WERNER 21 09 0740 Decedent's Name Page 2 File Number Schedule H -Funeral Expenses & Administrative Costs - B7. ITEM NUMBER DESCRIPTION AMOUNT 19. POSTAGE 60.62 20. AMERICAN WATER 89,35 21. CUMBERLAND COUNTY REAL ESTATE TAXES 1,832.96 22. ROBERT MYERS - LANDSCAPE/YARD WORK 1,240.00 23. TAX CERTIFICATION FEE PAID OUTSIDE CLOSING 5.00 24. SHARON A. ROSE -MILEAGE/TOLLS 1,876.70 SUBTOTAL SCHEDULE H-B7 ~ 5,104.63 REV-1512 EX + (12-03) SCHEDULE I COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ~ ESTATE OF FILE NUMBER RUSSELLA A. WERNER 21 09 0740 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. SMIGEL, ANDERSON & SACKS, LLP -FEE BALANCE FOR ESTATE PLANNING SOS.00 2. VILLA ST. JOSEPH OF BADEN -BALANCE FOR PERSONAL CARE HOME 1,705.99 3. DENNIS LACKMEYER -CHECK CLEARED AFTER DATE OF DEATH 100.00 4. BARBARA WERNER -CHECK CLEARED AFTER DATE OF DEATH 100.00 S. VALLEY AMBULANCE AUTHORITY -MEDICAL SERVICES 180.00 6. AARP HEALTH CARE PREMIUM 16.95 7. VERIZON 220.55 8. QLT -PHONE LEASE AUTOPAYMENT 16.36 9. PA STATE EMPLOYEES RETIREMENT SYSTEM -REFUND OF OVERPAYMENT 496.68 10. AMEX CREDIT CARD 19.73 TOTAL (Also enter on line 10, Recapitulation) I $ 3,361 26 (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 ESTATE OF FILE NUMBER RUSSELLA A. WERNER 21 09 0740 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. SHARON A. ROSE Lineal 648,572.58 117 COTTONWOOD COURT MOON TOWNSHIP PA 15108 2. PAMELA J. DAVEY Lineal 648,572.57 17138 WOOD ACRE TRAIL CHAGRIN FALLS OH 44023 3. STEVEN A. WERNER Lineal 648,572.57 12743 PLATEAU CIRCLE NW SILVERDALE WA 98383 4. CHRISTA LAUBACH Lineal 5,000.00 503 SKYPORT ROAD MECHANICSBURG PA 17050 5. ANGELA M. ROSE Lineal 5,000.00 5714 NORTH 6TH STREET ARLINGTON VA 22205 6. DENNIS LACKMEYER Lineal 5,000.00 12323 NE 9TH ST., UNIT Q KIRKLAND WA 98033 7. KATHERINE R. WERNER Lineal 5,000.00 4456 N. KENTON AVENUE CHICAGO IL 60630 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (It more space is needed, insert additional sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent RUSSELLA A. WERNER 21 09 0740 Decedent's Name Page 3 File Number Schedule J -Beneficiaries -1 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS (include outright spousal distributions) 8. TERESA A. ROSE Lineal 5,000.00 50 PADDLEBOAT LANE, APT. 602 HILTON HEAD ISLAND SC 29928 9. JULIA ROSE Lineal 5,000.00 117 COTTONWOOD COURT MOON TOWNSHIP PA 15108 10. ROBERT LACKMEYER Collateral 1,000.00 1025 SENECA TRAIL ST. CLOUD FL 34772 Continuation of REV-1500 Inheritance Tax Return Resident Decedent RUSSELLA A. WERNER 21 09 0740 Decedent's Name Page 3 File Number Schedule J -Beneficiaries -1 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE 1 TAXABLE DISTRIBUTIONS (include outright spousal distributions) 8. TERESA A. ROSE Lineal 5,000.00 50 PADDLEBOAT LANE, APT. 602 HILTON HEAD ISLAND SC 29928 9. JULIA ROSE Lineal 5,000.00 117 COTTONWOOD COURT MOON TOWNSHIP PA 15108 10. ROBERT LACKMEYER Collateral 1,000.00 1025 SENECA TRAIL ST. CLOUD FL 34772 REV-1500 Discount, Interest and Penalty Worksheet Discount Calculation Total Amount Paid within three calendar months of the decedent's date of death Discount: _-_______-___-_-_4 420.92 Interest Table Year Days Delinquent Balance Due Interest this time period this year this period l-- ---- _----- --- ----- -- ---- -- - - ----- ---- i Before 1981 1982 _ _ -- --- ---- 1983 _ - _ _ -- - ~ _ -- ------ -- ---- 1984 - _ _ - - __ 1985 --- ------ ---- -------- -- ------------------- ---------- j1986-_ 1987 -- - -- -- - ',Ir --- __-__--- 1988 through 1991_ __ -- --- 1992 ~ ~- ~ - -- 1993_ throu h 1994 - - - -- 1995 throw h 1998 i- - ---~-------- + -- - -- -- ----- - ---~ ----- - ----- --- _ _ _ ---- _ _ --- - -- '~ 1999 -- - _ -- -_ _ ---- - - -- ', 2000 ---_- _ ~-- 2001 f-----__ _--- -------___- ~~ 2002 _ - _ 2003.... -i - - --- -- - _ _---- ----- ------- ---- - -- - --- ---- -- -- ----1 - - - - -- - I -- -- -- ----_ ---~--- ----- ---- --- ---~ 2004 2005 ~ --- ----- - ---- ----- ---- ----- - _ - - -- - - _ - - r - -- ------ - ----- ---- -- ---------- ----_ -- ---- - ----------- '; 2006 -------- --- ----_------ -- -- -------- - - --- ------------------------ 2007 2008 ---- _ __ - --- i --- - -, ~ - ---- ----- ----- --- +- a ---------- - __- - TOTALS _ - _ - __ __ - -~ -_--- --- ___- -_ 84000..00 Penalty Calculation If the decedent's date of death was on or before March 31, 1993, insert the applicable amount: Total Balance Due on January 17, 1996: _ _ - - Penalty: 8960-1-5/Will/HDR/crm 6/13/06 4:05 F LAST WILL AND TESTAMENT OF RUSSELLA A. WERNER I, RUSSELLA A. WERNER, presently of Cumberland County, Pennsylvania, declare this to be my Last Will and Testament hereby revoking all Wills and Codicils previously made by me. MARITAL STATUS I declare that I am a widow. CHILDREN I have three (3) children, now living, whose names and dates of birth are as follows: PAMELA J. DAVEY born January 24, 1951 SHARON A'. ROSE born December 7, 1955 STEVEN A. WERNER born February 3, 1958 All references in this Will to my children include only the children named above. I have six (6) grandchildren, now living, whose names and dates of birth are as follows: CHRISTA J. LAUBACH born April 22, 1980 ANGELA M. ROSE born February 22, 1983 DENNIS R. LACKMEYER born April 24, 1983 KATHERINE R. WERNER born December 11, 1983 TERESA A. ROSE born November 28, 1985 JULIA P. ROSE born June 20, 1989 All references in this Will to my grandchildren include only the grandchildren named above. SPECIFIC BEQUESTS ARTICLE I A. I give the sum of Ten Thousand ($10,000.00) Dollars to ROBERT J. LACKMEYER, presently of Cleveland, Ohio, provided he survives me by thirty (30) days. If ROBERT J. LACKMEYER does not survive me by thirty (30) days, then this gift shall lapse. B. I give that portion of my net taxable estate that exceeds the federal estate tax applicable exclusion amount in effect at the time of my death to the ROSWELL PARK ALLIANCE FOUNDATION located in Buffalo, New York. PERSONAL PROPERTY ARTICLE II I give all of my household furnishings and tangible personal property to my children and T f~ ~ v w tv ::i j' bruiiuvl:iiur~ii tv vv ui'v iut;u a1i1011~ t11G111 aJ t11Gy ai C dU1C 6Uc1~rCe. lI tney are unaole to agree, then said property and furnishings shall be sold and the proceeds added to my residuary estate. Page 2 of 9 Pages RESIDUE ARTICLE III I give the rest, residue and remainder of my estate not disposed of in the preceding portions of this Will to my children and to my grandchildren in equal shares. If a child of mine should fail to survive me by thirty (30) days, then his or her share shall be divided and distributed in equal shares to my surviving children. If a grandchild of mine should fail to survive me by thirty (30) days, then his or her share shall be divided and distributed in equal shares to my surviving grandchildren. If all of my children fail to survive me by thirty (30) days, then their respective shares shall be divided and distributed in equal shares among my surviving grandchildren. If all of my grandchildren fail to survive me by thirty (30) days, then their respective shares shall be divided and distributed in equal shares among my surviving children. If all of my children and all of my grandchildren should fail to survivie me by thirty (30) days, then I give the rest, residue and remainder of my estate not disposed of in the preceding portions of this Will to ROSWELL PARK ALLIANCE FOUNDATION. EXECUTRIX ARTICLE IV A. Appointment. I appoint my daughter, SHARON A. ROSE, as the Executrix of this Will. In the event of her death, resignation, renunciation or inability to act in that capacity, then I appoint my brother, HARRY W. ADAMITZ, presently of Mount Vernon, Washington, as the Executor of this Will in her place and stead. Page 3 of 9 Pages B. Bond. No bond or other security shall be required of any Executrix or Executor appointed in this Will. C. Compensation. The Executrix or Executor shall receive reasonable compensation for her or his services performed as determined by the Court in which this Will is admitted to probate. EXECUTRIX POWERS ARTICLE V I give my Executrix in addition to and not in limitation of the powers given by law or by other provisions of this Will, the following powers with respect to settlement of my estate, to be exercised from time to time in the discretion of my Executrix without further order or license of the Register of Wills or of any Court: A. Investments. To retain any property, pending distribution hereunder, to invest in or purchase any property without restriction to legal investments for fiduciaries, to compromise claims, and to sell any property at public or private sale; B. Securities. To hold shares of stock or other securities in nominee registration form, including that of a clearing corporation or depository, or in book entry form or unregistered or in such other form as will pass by delivery; C. Litigation. To engage in litigation and compromise, arbitrate or abandon claims; Page 4 of 9 Pages D. Distributions. To make distributions in cash or in kind at current values, or partly in each, allocating specific assets to particular distributees on a non-pro rata basis, and for such purposes to make reasonable determinations of current values; E. Tax Return. To make elections, decisions, concessions and settlements in connection with all income, estate, inheritance, gift or other tax returns and the payment of such taxes, without obligation to adjust the distributive share of income or principal of any person affected thereby; F. Loans. To pay off any loans I may have taken against life insurance policies owned by me that remain unpaid at the time of my death; G. Borrowing and Encumberin,~. To borrow money from any person including any fiduciary acting hereunder, and to mortgage or pledge any real or personal property; H. Property Management. To manage, control, repair and improve all personal and real property; I. Insurance. To procure and carry at the expense of the estate, insurance of the kinds, forms and amounts deemed advisable by the Executrix to protect the estate and the Executrix against any hazard; J. Employment of Attorneys, Advisors and Other Agents. To employ any attorney, investment adviser, accountant, broker, tax specialist or any other agent deemed necessary in the discretion of the Executrix; and to pay from the estate reasonable compensation for all services performed by any of them; Page 5 of 9 Pages K. Business Operation. To conduct alone or with others any business in which I am engaged or in which I have an interest at my death, with all the powers of any owner with respect thereto, including the power to delegate discretionary duties to others, to invest other property held hereunder in such business and to organize a partnership or corporation to carry on such business; L. General. To do all the acts, to take all the proceedings, and to exercise all the rights, powers and privileges which an absolute owner of the property would have, subject always to the discharge of her fiduciary obligations. The enumeration of certain powers in this Will shall not limit the general or implied powers of the Executrix. The Executrix shall have all additional powers that may now or hereafter be conferred on the Executrix bylaw or that may be necessary to enable the Executrix to administer the provisions of this Will, subject to any limitations specified in this Will. NO ALIENATION ARTICLE VI No interest of any beneficiary under this Will or any codicil hereto shall be subject to anticipation or voluntary or involuntary alienation. Page 6 of 9 Pages NO CONTEST ARTICLE VII If any beneficiary or remainderman under this Will in any manner, directly or indirectly, contests or attacks this Will or any of its provisions, any share or interest in my estate given to that contesting beneficiary or remainderman under this Will is revoked and shall be disposed of in the same manner provided herein as if that contesting beneficiary or remainderman had predeceased me without issue. LEGALITY OF ARTICLES ARTICLE VIII If any provision of this Will or of any codicil thereto is held to be inoperative, invalid or illegal, it is my intention that all of the remaining provisions thereof shall continue to be fully operative and effective so far as it is possible and reasonable. TAXES ARTICLE IX All estate, inheritance and succession taxes, together with any interest and penalties thereon, payable as a result of my death and imposed with respect to any property, whether or not disposed of by this Will, shall be paid out of the residue of my estate. Page 7 of 9 Pages IN WITNESS WHEREOF, I have hereunto set my hand and seal and caused this my Last Will and Testament, consisting of nine (9) typewritten pages, including this attestation clause, to be executed, declared and published this ~'~ ~1 day of ~e~_,t~` , 2006, at River Chase Office Center, 4431 North Front Street, Harrisburg, Pennsylvania. t I ~ ~ ll~c . C~Zt~-s.~- (SEAL) RUSSELLA A. WERNER Signed, sealed, published and declared by the above named RUSSELLA A. WERNER, Testatrix, as and for her Last Will, in the presence of us and each of us, who, at her request and in her presence and in the presence of each other, have hereunto subscribed our names as witnesses thereto the day and year last above written. Residing at 1 G!~ ~j Tc~d.(,~~,, ,C~ ~ ~~ ~ 0~ ~ ~, Residin at ~ ~. •• ~k ~~. ~ , g L n, ~~rn ~~ ~~~~~ ~~c~~t t ~ ~ Residing at t~ ~~~ a ~p~~.J~ww ~'lc.. Ilf' ~..s 1 ~~`i ~ I ~~ Page 8 of 9 Pages COMMOI~fWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN SS. We, RUSSELLA A. WERNER, the Testatrix, and ~-~- ( ~_ ~ and ~ ~~ ~.. ~ the witnesses, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will; that the Testatrix 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 Testatrix signed the Will as a witness and that to the best of his or her knowledge the Testatrix was at that time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. RUSSELLA A. WERNER Witness S Witness Witness Subscribed, sworn to and acknowledged before me by RUSSELLA A. WERNER, the Testatrix, and subscribed and sworn to before me by I `~~ ~ ._ ~~ e..r- , ," ~~-~' • ~ ~ - J..~ ~ and c~ ,witnesses, this _~ ~ ~ ~~, ~~~~ day of ~ ~ ~~... , 2006. ~~ Nota y Public ' My Commission Expires: Page 9 of 9 Pages 8960- I -~/Codici I/H DR/tmc 7/8/09 12: i7 P1v1 FIRST CODICIL TO THE WILL OF RUSSELLA A. WERNER I, RUSSELLA A. WERNER, presently of Cumberland County, Pennsylvania, having made my Last Will and Testament dated June 14, 2006, do hereby make, publish and declare this ~~ ~~,:1 __ to be a First Codicil to my said Will. ~ ~ ~-, ~ , : -~ ~; ,. .,.. . _ .: •.._ -• _.. ti ... ~ ~' ~ `~: Substitution of Provision ~~ ~' ' ~? -~ } Article I on Page Two of the aforesaid Will is hereby revoked and the foll~vmg is W ` ="=-~~; .~ substituted in its place: SPECIFIC BEQUESTS ARTICLE I A. I give the sum of Five Thousand ($5,000.00) Dollars to each grandchild of mine who survives me by thirty (30) days. B. I give the sum of One Thousand ($1,000.00) Dollars to ROBERT J. LACKMEYER, presently of St. Cloud, Florida, provided he survives me by thirty (30) days. If ROBERT J. LACKMEYER does not survive me by thirty (30) days, then this gift shall lapse. C. I give that portion of my net taxable estate that exceeds the federal estate tax applicable exclusion amount in effect at the time of my death to the ROSWELL PARK ALLIANCE FOUNDATION located in Buffalo, New York. Article III on Page Three of the aforesaid Will is hereby revoked and the following substituted in its place: RESIDUE ARTICLE III I give the rest, residue and remainder of my estate not disposed of in the preceding portions of this Will to my children in equal shares, per stirpes, such that any issue shall represent and take their deceased parent's share. If all of my children fail to survive me and leave no surviving issue, then I give the rest, residue and remainder of my estate not disposed of in the preceding portions of this Will to ROSWEI.L PARK ALLIANCE FOUNDATION. Article IV on Page Three of the aforesaid Will is hereby revolted and the following is substituted in its place: EXECUTRIX ARTICLE IV A. Aupointment. I appoint my daughter, SHARON A. ROSE, as the Executrix of this Will. In the event of her death, resignation, renunciation or inability to act in that capacity, then I appoint my daughter, PAMELA J. DAVEY, presently of Chagrin Falls, Ohio, as the Executrix of this Will in her place and stead. Page 2 of 4 Republication of Will In every other respect, I hereby confirm and republish my Last Will and Testament dated ,tune 14, 2006. IN WITNESS WHEREOF, I have hereunto set my hand and seal and caused this First Codicil, consisting of four (4) typewritten pages, including this attestation clause, to my Last Will and Testament dated June 14, 2006 to be executed, declared and published this ~ ~h'day of 2009, at _ ~ C~ 3 ~ _~~-_ ~,~-~-~=.,r~,~~.~~..~1~ /-~ `~~c,,~;.~.,,,;.~ Crr `~ ... (SEAL) RUSSELLA A. WERNER Signed, sealed, published and declared by the above named RUSSELLA A. WERNER, Testatrix, as and f'or her First Codicil for her Last Will, in the presence of us and each of us, who, at her request and in her presence and in the presence of each other, have hereunto subscribed our names as witnesses thereto the day and year last above written. Residing at ti \ ~ ti ~p~ ~ Pry ~ Residing at ~~ ~.1.)~,~r~U-Q,I~ ~`r`y~-Q ~--- _. ~ _ Residing at N~e~es R,oc~L.s, ~A 1513 b ~on3 W~N~~V ~ ~w~ ~~GI~ES ~c.4~.S ~ 1S13~ Page 3 of 4 COMMONWEALTH OF PENNSYLVANIA COUNTY OF SS. c We, RUSSELLA A. WERNER, the Testatrix, and and ,the witnesses, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as the First Codicil to her Last Will; that the Testatrix 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 Testatrix signed the First Codicil as a witness and that to the best of his or her knowledge the Testatrix was at that time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. ,`JC~il~~u-~--i ~~~~ yrC . J I /~. M All ~ -~- ~.~ RUSSELLA A. WERNER Witness Witness ~ r Witn Subscribed, sworn to and acknowledged before me by RUSSELLA A. WERNER, the Testatrix, and subscribed and sworn to before me by v and `'1~" witnesses, this day of ~1.~,~ 009. ~~ Notary Public (SEAL) c~~„r.~c; y ~r~ h,L; , i o~ ~~r~~~Y~v~~vi,a i`.I^iarf-~ii a~~l ~%i.!?~,^.1 Ni. F~Crw, ~do~ary Public G;;y lat 'i;i~~~air~r.i.:~lF~h~t~y Ccuniy Page 4 of 4 nay c.~;~;,Ys~;,f~,:~;, __,,; ~,an~ii 2~, 2011 b,~~n~st, r~n~~aylv~nia Asso~:iafi~:n of t+lcta~le; nuiw tin ~sn~_n~as T A• B. TYPE OF LOAN: U.S. DEPARTMENT OF HOUSING & URBAN DEVELOPMENT 1.OFHA 2. QFmHA 3. QCONV. UNINS. 4. ~VA 5. ~CONV. INS. SETTLEMENT STATEMENT 6. FILE NUMBER: LEPLEY 7. LOAN NUMBER: 6800285212 8. MORTGAGE INS CASE NUMBER: C. NOTE: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked (POCJ" were paid outside the Dosing; they are shown here for informational purposes and are not included in the totals. 1.0 3/9B (LEPLEY PFD/LEPLEYlt7) D. NAME AND ADDRESS OF BORROWER: CHARLES C. LEPLEY and STEPHANIE S. LEPLEY E. NAME AND ADDRESS OF SELLER: SHARON A. ROSE, Executrix of the Estate of RUSSELLA A. WERNER F NAME AND ADDRESS OF LENDER: MEMBERS 1ST FEDERAL CREDIT UNION 5000 LOUISE DRIVE MECHANICSBURG, PA 17055 G. PROPERTY LOCATION: 310 LAMP POST LANE CAMP HILL, PA 17011 H. SETTLEMENT AGENT: 20-1624913 GUARANTEED ABSTRACT SERVICES, INC. I. SETTLEMENT DATE: November 30 2009 HAMPDEN TWP, CUMBERLAND CO. PLACE OF SETTLEMENT PRUDENTIAL THOMPSON WOOD REAL ESTATE 3813 Market St, Camp Hill, PA 17011 , J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION 100. GROSS AMOUNT DUE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER: 101. Contract Sales Price 258 000.00 401. Contract Sales Price 258 000.00 102. Personal Pro eri 402. Personal Pro erl 103. Settlement Char es to Borrower Line 1400 8,361.23 403. 104. 404. 105. 405. Ad ~usfinents For Items Paid B Seller in advance Ad ustments For Items Paid B Seller in advance 106. Count fTw Taxes 11/30/09 to 01/01/10 46.05 406. Count /Tw Taxes 11130/09 to 01/01/10 46.05 107. Cit Tax to 407. Cif Tax to 108. School Tax 11/30/09 to 07/01/10 1069.65 408. School Tax 11/30/09 to 07/01/10 1,069.65 109. 4TH QTR SEWER/REFUSE $138.65 11/30/09 to 01/01/1 48.23 409. 4TH QTR SEWER/REFUSE $138.65 11/30/09 to 01/01/ 48.23 110. 410. 111. 411. 112. 412. 120. GROSS AMOUNT DUE FROM BORRO WER 267,525.16 420. GROSS AMOUNT DUE TO SELLER 259,163.93 200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 201. De osit or earnest mono 5,000.00 501. Excess De osit See Instructions 202. Princi al Amount of New Loans 206,400.00 502. Settlement Char es to Seller Line 1400 9,995.00 203. Existin loans taken sub'ect to 503. Existi loans taken sub ect to 204. 504. Pa off of first Mort age 205. 505. Pa off of second Mort a e 206. 506. 207. 507. De osit dish. as roceeds 206. 508. 209. 509. Ad ustments For Items Un aid B Seller Ad ustments For Items Un aid B Seller 210. Count /Tw Taxes to 510. Count /Tw Taxes to 211. Cd Tax to 511. Cit Tax to 212. School Tax to 512. School Tax to 213. 513. 214• 514. 215. 515. 216. 516. 217. 517. INHERITANCE TAX ESCROW to GUARANTEED ABS 10000.00 218. 518. 219. 519. 220. TOTAL PAID BY/FOR BORROWER 211,400.00 520. TOTAL REDUCTIONAMOUNT'DUE SELLER 19,995.00 300. CASH AT SETTLEMENT FROM/TO BORROWER: 600. CASH AT SETTLEMENT TOIFROM SELLER: 301. Gross Amount Due From Borrower Line 120 267,525.16 601. Gross Amount Due To Seller Line 420 259,163.93 302. Less Amount Paid By/For Borrower (Line 220) ( 211,400.00) 602. Less Reductions Due Seller (Line 520) ( 19,995.00 303. CASH (X FROM) ( TO) BORROWER 56,125.16 603. CASH (X TO) ( FROM) SELLER 239,168.93 The undersigned heretry acknowledge receipt of a completed copy of pages 1 &2 of this statement 8 any attachments referred to herein. Borrower CHARLES C. LEPLEY Seller SHARON A. ROSE, Executrix of the Estate of RUSSELLA A. WERNER STEPHANIE S. LEPLEY Pa°e Z L. SETTLEMENT CHARGES 700. TOTAL COMMISSION Based on Price $ 258,000.00 2.5000 °~ 6,450.00 PAID FRCM PAID FROM Division 0/ Commission line 7O0 aS FO/IOWS: BORROWER'S SELLER'S 701. $ 6,450.00 to PRUDENTIAL THOMPSON W000 REAL ESTATE FUNDS AT FUNDS AT 702. $ to PRUDENTIAL THOMPSON WOOD REAL ESTATE SETTLEMENT SETTLEMENT 703. Commission Paid at Settlement 6,450.00 704. SETTLEMENT DEPT MGMT FEE to PRUDENTIAL THOMPSON WOOD REAL ESTATE 200.00 200.00 800. ITEMS PAYABLE IN CONNECTION WITH LOAN 801. Loan Ori ination Fee 1.0000 °k to MEMBERS 1ST FCU 2,064.00 802. Loan Discount % to 803. Appraisal Fee to 804. Credit Report to 805. Lender's Inspection Fee to 806. Flood Cert Fee to 807. Tax Service Fee to 808. Document Prep Fee to MEMBERS 1ST FCU 305.00 809. Application Fee MEMBERS 1ST FCU $375 POC 810. Underwriting Fee to MEMBERS 1ST FCU 150.00 811. 900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 901. Interest From 11/30/09 to 12/01/09 $ 28.666700/day 1 days °~) 28.67 902. Mort a e Insurance Premium for months to 903. Hazard Insurance Premium for 1.0 ears to POC 904. 905. 1000. RESERVES DEPOSITED WITH LENDER 1001. Hazard Insurance 3.000 months $ 43.00 r month 129.00 1002. Mori a e Insurance months $ r month 1003. Count R Taxes 10.000 months $ 42.90 er month 429.00 1004. Cit Tax months $ r month 1005. School Tax 6.000 months $ 152.75 r month 916.50 1006• months $ r month 1007. months er month 1008. AGGREGA?E ADJUSTMENT months $ er month -558.69 1100. TITI ~_ %'t~A' vES 1101. Set; ,:iosin Fee to 1102. E-M4 ;e.:ument Retrieval to GUARANTEED ABSTRACT SERVICES INC. 50.00 1103. Title Examination to 1104. Title Insurance Binder to 1105. Document Pre ration to SMIGEL ANDERSON 8 SACHS DEEDlPOC 1106. Nola Fees to NOTARY CLERK 30.00 1107. Attorney's Fees to includes above item numbers: 1108. Title Insurance to GUARANTEED ABSTRACT SERVICES INC. GA8.09-140 1 648.75 includes above item numbers:1101 1103 -BASIC RATE 1109. Lenders Coverage $ 206,400.00 8230738-79333159 1110. Owner's Coverage $ 258,000.00 8222638-79333215 1111. PA EN0:100, 300, 900 to GUARANTEED ABSTRACT SERVICES, INC. 150.00 1112. 1113. Insured Closin Letter to LAWYERS TITLE INSURANCE CORPORATION 75.00 1114. Overni ht Fee/packa a to GUARANTEED ABSTRACT SERVICES, INC. 12.00 1115. Tax Cert Fee to GUARANTEED ABSTRACT SERVICES, INC. 5.00 1116. 1117. 1118. 1200. GOVERNMENT RECORDING AND TRANSFER CHARGES 1201. Recording Fees: Deed $ 62.00 ;Mort age $ 90.00; Releases $ 152.00 1202. Cit /Count Tax/Slam s: Deed 2,580.00 Mort a e 2,580.00 1203. State Tax/Stam s: Revenue Stam s 2 580.00: Mort a e 2 580.00 1204. RECORDER OF DEEDS 1205. RECORDER OF DEEDS 1300. ADDITIONAL SETTLEMENT CHARGES 1301. Surve to 1302. Pest Ins action to POC 1303. RADON MITIGATION to ENVIROQUEST 760.00 1304. 1305. 1400. TOTAL SETTLEMENT CHARGES Enter on Lines 103, Section J and 502, Section K) 8,361.23 9,995.00 Certified to be a true copy. GUARANTEED ABSTRACT SERVICES, INC. Settlement Agent (LEPLEY/LEPLEY/17) Calculated Value of Your Paper Savings Bond(s) http://www.treasurydirect.gov/BC/SBCPrice Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 07/2009 Total Price Totai Value Total Interest YTD Interest 19 106.25 54 879.47 35 773.22 895.22 Bonds: 1-190 of 190 Serial # Series Denom Issue Next Final Issue Price interest Interest Value Note Date Accrual Maturity Rate L378764100EE EE $50 . 08/1988'., _ 08/2009_, 08/2018 . $25.00'. $46.18 4.00%' $71.18_:._„ L351692039EE EE $50: 06/.1988 12/2009 06/2018 : $25.00 $47.60'. 4.00% $72.60 L351663840EE EE $50 05/1988' 11/2009 05/2018 $25.00 _ $47.60. 4.00% „ _ $72.60 L351625694EE EE $50 03/1988 09/2009 03/2018 _ ' $25.00 $47.60 4.00% $72.60 L227225169EE _EE _ _ $50 O1/1986 _ 01/2010 _ O1/2016 _ _ __ _ $25.00 $64.14 _ 4.00% ._ $89.14: L214223738EE EE $50 05/1985 11/2009 05/2015 $25.00' $65.94 4.00% . __ _ $90.94. L214230337EE __ EE $50 __ 06/1985. 12/2009 06/2015 , $25.00 $65.94 4.00%' $90.94; L217625150EE EE $50 06/1985', 12/2009 06/2015 $25.00 $65.94 4.00% $90.94: L217633165EE EE $50; 07/1985 01/2010 07/2015 $25.00 $65.94 4.00%; $90.94 L217541125EE EE $50 07/1985 01/2010_,_ 07/2015 $25.00_ $65.94 __ 4.00% _ $90.94 L182469339EE EE $50 _ 08/1985 _ 08/2009.:_ _ 08/2015_ $_25.00;._ $.64.14 4.00% $89.14 L226736431EE EE $50. 08/1985 08/2009 _ _08/2015 $25.00:. $64.14:,, 4.00% $89.14 L226744465EE EE $50 08/1985 08/2009 08/2015: _. $25.00 $64.14 4.00% $89.14: L226752490EE EE $50 09/1985 09/2009, _ _ .09/2015. $.25.00:_ _$64.14 4.00% $89.14 l_226760424EE EE _ $50 _ 09/1985__, , .. _,09/2009:. _ . _ . _ 09/2015,: _,_ _.. _ , ,$25.00.:. _ _ ..$64.14 . . , _ _ _: . . 4.00% $89.14; L228369299EE EE $50 10/1985 10/2009 10/2015' . . $25.00 . , $64.14 4.00% _ __, $89.14. L228377081EE EE _ $50 _10/1985 10/2009' - _ 10/2015_ _„ _ $25.00- $.64.14:, 4.00% $89.14 L228385141EE EE _ $50_, 1.1/1985 _ 11/2009.:., 11/2015.' $25.00 $64.14 4.00,% .. _ X89.14 L227185928EE EE $50; 11/1985' 11/2009; 11/2015 $25.00 $64.14 4.00% $89.14 L227193710EE EE $50 12/1.985 12/2009 12/2015_. ,_ $.25.00_:. $64.14'._ _ .4.00% .. $89.14.,, ~i L227202342EE EE $50 12/1985_ 12/2009_._ _ _12/20.15.'., .._ _,$25.00.._ $64.14:. 4.00%' _ $89.14'_ _ ~ L227209888EE EE $50' 01/1986. 01/2010:. 01/2016 $25.00 $64.14 4.00% $89.14; L227217524EE EE $50 01/1986 0.1/2010 .01/2016 : $.25.00. . _ $64.14 4.00% $89.14. L263768807EE EE $50,. 02/1986 _ _ „08/2009 _ _02/2016 . , $25.00: $62.40 _ 4.00% $87.40; L263776726EE EE $50 02/1986 08/2009 02/2016 $25.00 $62.40 4.00% . $87.40; L263784520EE EE $50 03/1986 _. .09/2009_ , _ . _ _03/2016 _$25.00' _ $62.40._ ..4.00% $87.40._ L263792175EE., EE _ $50 03/1986 ___09/2009_;. _ 03/20.16,,; _ . $25.00. _ $62.40 4.00%; $87.40;.__. L263799727EE EE $50 04/1986 10/2009 04/2016 $25.00 $62.40 4.00% $87.40' L263807272EE EE $50 04/1986 10/2009 04/2016 $25.00 $62.40 4.00%' $87.40 L263814844EE EE _ $50 05/1986 _ 11/2009 „ _05/2016 $25.00 $62.40 _ ,4.00%' $87.40 _ L263822217EE EE $50 05/1986 11/2009 05/2016 $25.00' $62.40 4.00% $87.40 L263829698EE EE $50 06/1986 12/2009 06/2016' $25.00' $62.40 4.00%' $87.40 L263837039EE EE $50 06/1986 12/2009 _ _ ,06/2016.'. ,,.$25.00:_ $62.40 4.00.% $87.40 L267610498EE: EE $50' , 07/1986 01/2010' 07/2016'. $25.00 $62.40 4.00% $87.40' L276672647EE EE $50' 07/1986. 01/2010 07/2016'.. $25.00. $62.40.. 4.00% $87.40 L276680724EE EE $50 08/1986 08/2009 08/2016 $25.00' $60.68' 4.00% $85.68 L276688810EE EE $50 08/1986 08/2009. 08/2016 $25.00 $60.68 4.00%' $85.68. L284825587EE EE $50 11/1986:: 11/2009: 11/2016. $25.00 $52.04' 4.00% $77.04 L276697567EE EE $50 08/,1986 08/2009._. 08/2016' _,$25.00 $60.68; _._ _ 4.00% __. $85.68 L276706651EE EE $50 09/1986, 09/2009' 09/2016' $25.00. $60.68:. 4.00% _ $85.68 L276716266EE EE $50 09/1986 09/2009; 09/2016 $25.00 $60.68. 4.00% $85.68 _ L276725809EE EE $50 _ 10/1986 10/2009 10/2016_:, $25.00 _ $60.68 4.00% __ $85.68 L276735115EE EE $50 , 10/_1.986 .. _ _ .10/2009 _ 10/2016 ,_ $_25.00 .,_ $60.68,_ _ u, 4.00 /o $85.68 L284816788EE EE $50' 11/1986: 11/2009 11/2016' $25.00 $52.04 4.00% $77.04 L284834930EE EE _ $50 _ 12/1986... 12/2009 _ 12/2016' $25.00 $52.04 4.00% _. $77.04. L284844303EE EE _$50 _ 12/1986 12/2009.„ 12/2016 _ $25.00 $.52.04 _ 4.00% ___ $77.04 L284853404EE EE $50 01/1987 01/2010 01/2017 $25.00 $52.04 4.00%' $77.04 L284862675EE EE $50 0.1/1987 01/2010 ._ _, ., 01/2017 ; $25.00 $52.04 o__ 4.00 % $77.04 L291559180EE' EE $50 01/1987 01/2010 01/2017 .$25.00'_.. $52.04 4.00%' _ $77.04 L291568412EE EE $50 02/1987 08/2009 02/2017 ;, $25.00 ,$50.52 - 4.00% ., $75.52 L291577254EE: EE $50' . 02/1987 08/2009, 02/2017: $25.00. $50.52 4.00% $75.52 _ L315665240EE EE $50 06/,1987 12/2009 _ 06/2017 $.25.00 $50.52 4.00% __ $75.52' L291586360EE EE $50 03/1987 09/2009 03/2017 $25.00- $50.52' o ' 4.00 /o $75.52 L291595109EE EE $50 03/.1987 09/2009 03/2017. $25.00. $50.52.' 4.00% $75.52: L291603478EE EE $50 04/1.987 10/2009 04/2017 $25.00: $50.52: . o 4.00 /o $75.52 L291612418EE EE $50' 04/1987 10/2009 04/2017 $25.00 _ .,, $50.52 4.00% $75.52'. L315639920EE EE $50 05/1987 11/2009 05/2017; $25.00. $50.52 o 4.00 /o $75.52: l_315658653EE EE $50 05/1987 .11/2009. 05/2017: $25.00;,_, $50.52: 4.00% . . $75.52: L315656742EE EE 50 06 1987' 12 2009. 06 2017 25.00 50.52 4.00% 75.52 1 of 3 9/4/2009 10:52 AM Calculated Value of Your Paper Savings Bond(s) http://www.treasurydirect.gov/BC/SBCPrice L315676429EE EE $50 07/1987: 01/2010 07/2017 $25.00 .$50.52. 4.00% $75.52 : L315682850EE EE $50 07/1987 01/2010 07/2017 $25.00. $50.52 4.00% $75.52 ' L35169144EEE EE $50 07/1987 01/2010_;, 07/2017 $25.00 $50.52 4.00% $75.52 L315700136EE EE $50 08/1987 08/2009 08/2017 $25.00 $49.04 4.00% $74.04 ,. L336748191EE EE $50 09/1987 09/2009 09/2017 $25.00 $49.04 4.00% $74.04 L336767606EE EE $50 09/1987 _09/2009.._ 09/2017,. . $25.00 $49.04 4.00,% $74.04 ., L336767832EE EE $50 10/1987 10/2009_._. 10/2017 $25.00 $49.04 4.00% $74.04 L336777419EE EE $50 10/1987 10/2009;,, 10/2017 $25.00 $49.04 4.00% $74.04 L336787437EE EE $50 11/1987 11/2009 11/2017 $25.00 $49.04 4.00% $74.04 L336797194EE EE $50 11/1987 11/2009 11/2017 $25.00 $49.04 4.00% $74.04 L336817343EE EE $50 12/1987;_. 12/2009,,. 12/2017 $25.00 $49.04 4.00% _ $74.04 _ L336807533EE __ EE $50 12/1987: 12/2009 12/2017. $25.00 $49.04 4.00% $74.04 L336827105EE _ EE $50 _.12/1987 _ _ _ _12/2009' _ __ .12/2017.:. $25..00 _ .$49.04 _ ..,4.00% _ $74.04 L336836970EE EE $50 01/1988:, _..01/2010__, 01/2018 $25.00 _ $49.04 4.00% ,. $74.04 _ _ _. L351596508EE EE $50 01/1988 01/2010 01/20 18 $25.00 $49.04 4.00% $74.04 L351606836EE __ EE _ $50 02/1988 08/2009.;_ , _ 02/2018 $25.00 $47.60 4.00% $72.60 L3515153,77EE _ EE $50 _ 02/1988 . ,,,,,,08/2009 02/20.18. .. _ ...$2.5.00. _ $47.60 4.00% $72.60 L351635142EE EE $50 03/1988: 09/2009 03/2018 $25.00. $47.60 4.00% _ $72.60 _..,_ L351644792EE EE $50 04/1988 10/2009: 04/2018 . $25.00. $47.60 4.00% $72.60 L351654382EE EE _ $50 _ _ 04/1988 _ _ __ 10/2009 _ , ..,04[20.18 _ . _ _ _ _$25.00: _ $47..60. _ _ _,. 4,00% _ _ $72.60. . .,_ . L351673448EE EE $50 05/1988, 11/2009„ .05/2018 $25.00 $47.60 4.00% $72.60 L351682990EE _ _ EE $50 _ _ 06/1988;,_ 12/2009: _ _ 06/2018,: $25.00 $47.60 __ 4.00% $72.60, _. L351704357EE EE ; _ $50 07/1988'_ ___01/20,10__ . 07[20.18 _ $25.00. $47.60 _ _.4.00% _ _ $72.60 __ _ ___ __ L378737758EE EE $50 07/1988 01/2010 07/2018 $25.00 $47.60 4.00% , $72.60 , L378746886EE _EE _ $50 07/1988 _ 01/2010,:_ _ 07/2018 ._ _ 25.00, $ $47.60 _ _ _. 4.00% $72.60 L378755504EE EE $50 _ _ 08/1988 _ . ...,..08/2009'., . 08/20.18. _ . .,_, _._$25.00 $46.1.8, _ _ 4.00%_ $71.18__ __ .. L378772684EE EE $50 09/1988 09/2009; 09/2018 $25.00 $46.18 4.00% $71.18' L378797560EE' EE _ $50 09/1988 , 09/2009_;,.. 09/2018 _ $25.00 $46.18__ 4.00% _ $71.18,. . L378782286EE _ EE __ $50 _ 10/1988' _ _ 10/2009 _ __10/2018., ___ . _..$25.00.. ., _$46.18 , __ __ .4.00% _, _ __ $71.18 _.. __ L378790491EE' EE $50 10/1988. 10/2009, 10/2018 $25.00 $46.18' 4.00% $71.18 L378807228EE: EE $50 11/1988 _ 11/2009'. 11/2018. _ _ $25.00 . $46.18 4.00% $71.18: ~, L378815658EE EE _$50 .11/1988 11/2009„ 11/2018.'. $25.00 __ $46..18 _ 4.00% _ , $71.18 L378824159EE' EE $50 12/1988: 12/2009;: 12/2018 $25.00 $46.18 _ 4.00% . $71.18. ____._ L378832242EE' _ EE _ $50 _12/.1988'._ 12/2009,:_ _ 12/2018_ $25.00 $46.18 4.00% $71.18 L378840669EE EE $50 12/1988;,. 12/2009_:, 12/2018 _ $25.00:, $46..18 _ 4.00%' $71.18. L378848907EE: EE $50 _ 01/1989' _ 01/2010: 01/2019 $25.00' $46.18. 4.00% , $71.18. L404617139EE EE $50 02/1989;;_ 08/2009,_ ___.02/2019 $25.00 _ _ _,$44.78 4.00% $69.78- Q6135730134E E $25 11/ 1976 . _ _ _ ,.11/2006 _$.18.75 _ _ . _ $118.90 $137.65 MA Q6135741397E E $25 11/1976 11/2006 _ . $18.75 _ . _ _ $118.90 _ ,, _ . _ _ _ $137.65 MA Q6135752734E _E $25 12/1976 _ _ _ 12/2006 $18.75 _ $119.29 $138.04 MA Q6135763761E E _ $25 12/1976- _ _ _ , ,__12/2006 _ $18J5 _ $119 .29 _ _ $138.04 MA Q5126828858E _ E $25 02/1974. _ 02/2004_ _ _ $18.75 , ,,,$109.73 _ . $128.48 MA Q5126846423E; _ E _ _ $25 02/1974 02/2004 $18.75 $109.73 $128.48 MA Q5126855678E _ E _ $25 0.3/1974:_.. __ .. __03/2004_ $18.75 _ $109.73 $128.48 MA Q5125865575E E $25; 03/1974 03/2004 $18.75 $109.73 _ $128.48 MA Q5140748863E E $25 04/1974 04/2004 $18.75 .$109.73 $128.48 MA Q5140753930E E $25 04/1974 04/20.04_ _ $.18.75 . $10 9.73 $128.48 MA X2409060EE EE $10,000 02/1993 _ _ 08/2009 02/2023 $.5,000.00 , $6,912.00 4.00% $ 11,912.00 Q5140761434E E $25 05/1974 05/2004 $18.7.5 .$110.96 $129.71 MA Q5140772353E E $25' 05/1974, . 05/2004; 18.75 -$ $110.96 _ ~ _ $129J1 MA Q5176341422E E _ $25,,. ..05/1974;_,. __ _ 05/2004' __.$18.75.., ., _,$110.96_.,._ ._.,__,_..__ $129.71 MA Q5176354229E'_ _ E $25 06/1974_,._ ___. _ _._.06/2004.:,_ .._._.$18.75 _$111.27' $130.02 MA Q5176363365E E _ $25' 06/1974'.. _ _ 06/2004 ... .........$18.75 $111.27 $130.02: MA Q5176375648E _ E $25'_ 07/1974;, _ _ _ 0.7/2004' $18.75. ,.$111.27 $130.02 ' MA Q5176385089E E $25 07/1974 _ _ 07/2004' $18.75. $111.27 _ $130.02 MA Q5176397622E E $25_. 08/1974__ _ 08/2004 .;. $18.75 _ $111.27. _ _ $130.02 MA Q5176406973E.. ...E _ $25, 08/1974:.. _ _ __ 08/2004 $18.75 _ _ . ,,,$111.27 ;130.02, MA Q5192567956E E $25 09/1974 09/2004 $18.75 $111.27 , $130.02: MA Q5192577843E _E $25 _ 09/1974, 09/2004. _ $18.75. $111.27 $130.02. MA Q5192587244E _ E $25 10/1974:_ __ _ 10/2004_ $18.7.5;.. $111.27. $130.02 MA Q5192596433E E $25 10/1974 10/2004 $18.75, $111.27 $130A2 MA Q5192618755E E $25,_,. .11/1974._. _ _ 11/2004' $18.75 $112.51 $131.26 MA ~5192628511E` E $25_ 11/1974 _ 11/2004 $18.75'. $112.51 _ $131.26 MA Q5192634652E E $25 11/1974' 11/2004 $18.75: _ $112.51: $131.26 MA 6084281937E E $25 07/.1976:_ _ 07/2006 _ . $18.75 _ _ $117.57'. $136.32 MA 6084292930E E $25' 07/1976,;, _ ,07/2006_.,,, $18.75 _ _ . _ $117.57: _ _ _ $136.32; MA 26107884262E E $25' 08/1976. 08/2006' $18.75 $117.57 $136.32 MA 26107895825E E $25 08/1976 08/2006 $18.75' $117.57 $136.32- MA 26107905585E E _ $25 09/1976 _ 09/2006,_ _.$.18.75 $117.57 $136.32 MA 26113930914E E $25 09/1976 _ 09/2006..._ $18.75' $117.57. $136.32 MA 26124073538E E $25' .10/1976 10/2006_, $18.75 $117.57 . $136.32: MA 26124083601E E $25 10/1976.. 10/2006 $18.75:. $117.57. „ $136.32' MA 26124092553E E _ _$25' 10/1976 10/2006 $18.75 - $117.57 ; . $136.32 MA 26135776721E E $25 __ 01/1977 01/2007 _ $18.75_ _ $119.29 _ $138.04 MA 26135786156E E $25 01/1977 01/2007 $18 75 $119.29 . 5138.04 MA 2 of 3 9/4/2009 10:52 AM Calculated Value of Your Paper Savings Bond(s) http://www.treasurydirect.gov/BC/SBCPrice Q6135799959E E $25 02/1977_. 02/2007. $18.75 $119.29 _ $138.04 . MA Q6145852690E E $25 02/1977 02/2007 $18.75. $119.29.. $138.04 MA Q6145865499E E $25; 03/1977... ., __03/2007,.. _ $18.75 $119..29 __ $138.04 MA Q6145874245E E $25 03/1977 03/2007 $18.75 $119.29 $138.04 MA Q6170855246E E $25 04/1977 04/2007. $18.75 $119.29 $138.04 MA Q6170862822E _E _ $25_ 04/1977_.. _ 04/2007 _ $18.75 $119.29 $138.04; MA Q6170871263E E $25 04/1977 04/2007 $18.75 $119.29 _. $138.04 MA Q6170881988E E $25 _ _.05/1977. _ 05/2007_,. _ $18.75_ $120..65. $139.40 MA Q6170892784E E $25 05/1977 05/2007.. ... $18.75, _ $120.65_ _ __$139.40 MA Q6170905211E _ E $25 06/1977.,_ . ... _ _. .__ 06/2007 _ _ $18.75. __ _ $120.95. _ _._ _ _ _$139.70 _MA Q6170914385E E $25 06/1977 06/2007 $18.75 $120.95'. _ $139.70 . MA Q6179242570E E $25 07/1977 _ 07/2007 _ _ $18.75 $120.92 $139.67 MA Q6179250105E _ E $25 07/1977 _ 07/2007 $18.75_ $120.92 _ $139.67 MA Q6179266289E. ...E $25 08/1977 08/2007 $18J5 $120.92: $139,67 MA Q6179277069E E $25 08/1977 _ _ 08/2007 $18.75 _ $120.92. __$139.67 __ MA Q6197925935E E _ _ $25 09/1977' _ _ 09/2007 $18.75... _ $120.92 _ _ $139.67' MA Q6197939304E E_ _ $25 09/1977 _ 09/2007. _$18.75 $120.92' _. _ __ $239.67 _MA Q6197937064E . E $25 09/1977 09/2007 $18.75' $120.92' $139.67 MA Q6212982340E _ E _ $25 ,10/1977,..,_ _ 10/2007,'._ . _.___,.$18.75:. _ _ _.. _.$120.92., _ $139.67' _ MA Q6212993483E E $25 10/1977._ 10/2007 $18.75; $120.92 __ _ $139.67 MA Q6213004543E E _ $25, 11/1977 _, 11/2007; _ _,. , $18.75. $109.34 $128.09- MA Q6213013983E E $25; 11/1977._ _ _ 11/2007 :: . .75: $18 ..._ $109.34: .. _ _ $128.09: MA Q6226377527E E $25. 12/1977 _ ,, _ 12/2007. . . _ $18.75 $109.70 _ _,$128.45 _MA Q6226388160E _E _ $25 12/1977 12/2007 $18.75; $109.70 $128.45 MA Q6233928602E _ E __ $25 01/1978 _ _ _ _ _ _ _ 01/2008 _ $18..75. _.$109.70 $128.45` MA Q6233937923E E _ $ 25 01/1978 _ _ 0 1/2008 ' $18.75 $109,70 _ . _ $128.45 MA Q6233951219E E $25;_ 02/1978 _ . 02/2008 ; _ $18.75 $109.70 _ $128.45' MA Q6233961728E E $25 02/1978 _ . 02/2008 , _ .. $18.75' $109.70 $128.45; MA Q6233971066E E $25 _ 03/1978 _ _ _ _ _ ._ _ 03/2008 . . _,, . , ._ $18.75_ _ _ _ $89..79 _ $1016.54 MA Q6233981211E E $25 03/1978'_ . _ 03/2008 $18.75' _ $89.79 $108.54' MA Q6233989322E E $25' 03/1978._ 03/2008 ' $18.75. $89.79 _ $108.54 MA Q6233999584E E $25 04/1978 _ _ 04/2008 _ _ $18.75 _ $89.79 _ $108.54 MA Q6256702019E E $25 04/1978 04/2008 _ $18.75 $89.79' _ $108.54. _ MA Q6256710929E _ _E _ $25 05/1978: _ 05/2008. _ $18.75. $87.92 $106.67 MA Q6256721282E E $25 05/1978 _ _ __ 05/2008 _ $18.75 _ . _ $87,.92 _ __ __ _ $106.67;; MA Q6256733260E E $25 06/1978 _ ._ 06/2008 _ __ _ $18.75 _ $88.19 _ . $106.94 MA Q6256743427E E _ $25 06/1978 06/2008 . $18.75. $88.19 $106.94' MA Q6256755972E E $25 07/1978 _ ___ , _ 07/2008 $18.75 $88_.22 $I06.97; MA Q6256765973E E $25 07/1978 __ 07/2008 _ $18.75 $88.22 _ $106.97: _ MA Q6217881510E E _ $25 08/1978 08/2008. $18.75 $88.22 $106.97; MA Q6271890342E E _ $25 _ .08/1978 _ 08/2008 18.75 $ $88.22 _ _ _ $106.97; MA Q6271905458E E $25 09/1978 _ 09/2008 , . $18,75 _ $88.22. _ $106.97 MA Q6288885603E E _ $25 09/1978 _ , 09/2008 18.75 $ $88.22 $106.97 MA Q6288888047E E $25 _ 0.9/1978 09/2008 . _ $18.75 $88.22 $106.97 MA Q6288898280E _ E $25. 10/1978 _ _ 10/2008. _ _ _$18.75, _ _,$88.22 _ $106.97; MA Q6288908551E E $25 10/1978 . . 10/2008, _ 18.75 $ $88.22 ., $106.97; MA Q6288918590E _E $25 _ 1.1/1978',_ _ _11/2008 ,_ . _ $18.75 _ $89.23 _ _ : $107.98„ MA Q6288928683E E _ $25 11/1.978,, _ 11/2008: $18.75 $89.23 , _ _ $107.98' MA Q6288941040E E _ $25 , 12/1978;.. ., _ 12/2008 $18.75 . , $89.52 : $108.27.- MA Q6288949950E E _ $25 12/1978 - __. 12/2008 . _ _ ' $18.75 . , $89.52 $108.27 MA Q6306975256E _ E $25' . _01/,1979:_ _ _ .... _ _ 0.1/2009: _ _ $18.75' _ $89.53 _ _ . $108.28, . MA Q6306985003E _ E $25 01/1979: 01/2009 $18.75' $89.53 , $108.28 MA Q6306998572E E $25: _ __ 02/1979._.. _ _ __ 02/2009. . $18.75: $89.53'. $108.28 MA Q6307007791E E $25 02/1.979:.. _ .. __ 02/2009 _ _,. _ $18.75',. _ $89.53 _ $108.28. MA X2409061EE EE $10,000'. 02/1993: 08/2009. 02/2023' $5,000.00: $6,912.00: 4.00% $11912.00 X2409060EE EE $10,000; 02/1993 08/2009': 02/2023;, $5,000.00. $6,912.00 4.00% $11,912.00: _ ._ _. Totals for 190 Bonds 819,106.25 $35,773.22 554,879.47 Notes NI Not Issued NE :Not eligible, for payment.,,,.. _ _ P5 Includes 3 month interest penalty MA Matured and not earnin interest 3 of 3 9/4/2009 10:52 AM From: Neff, Maynard (Wayne) (IFC) [mailto:mwayne.neff@investfinancial.com] Sent: Thursday, September 17, 2009 5:43 PM To: Amy L. Haines Cc: SHARANNROSE@aol.com Subject: RE: Werner Estate Hi Amy, Sharon was correct about the Omega Financial stock. Omega Financial was acquired by F.N.B. Corp in 2008 & the stock was exchan ed for shares of F.N.B. Cor ella's account. However, the Penn State nvestors s oc our digital files show copies of the 4 certificates that you reference) is a different story. Our contemporaneous note system shows that Russells brought theses certificates to us on 9/7/05 (prior to her trip to Australia), we copied them for reference and returned them to her. She indicated that she believed the company to be "defunct." Our Broker Dealer cor orate research de artment to d us Se t. 1995 that the company merged . vith Penn Pacific (possibly a Delaware corp.) in 1971, that the shares were now considered "wort ess an would not be eligible for safe keeping in her brokers a account. I suggested that she could either es rod y tfiem or ITave~ e~m~rame as memen os. ope that this has helpe ase let me know if I can be of further help. M. Wayne Neff, CFP Heritage Wealth Advisers, LLC 635 N 12th Street, Suite 102 Lemoyne, PA 17043 717-614-6100 Ext. 214 (Voice) 717-614-6220 (Direct Fax) Securities and Advisory Services offered through INVEST FINANCIAL CORPORATION (INVEST}, member FINRA, SIPC. A Registered Investment Advisor. INVEST is not affilliated with Heritage Wealth Adviser, LLC. 9/18/2009 Aug. 24. 2009 11:52AM ~~ Citizens ~~nk Smigcl, Anderson & Sacks LLB' Heather D. Royer, Bsquire 4431 North front Street 3'~ Floor Harrisburg, PA 17110 To Whom Yt May Concern: No. 2389 P. 1 2001 Market Street Suite 600 Philadelphia, PA 19103 August 24, 2009 This letter is in response to your request dated August 11, 2009 in reference to Bstate of Russella A. Werner. Please be advised that at the time of her death of July 21, 2009 the balance in her accounts vS-ere as follows: 6100683559 - $26,072.7$ 6223987335 - $96,296.55 6223987378 - X98.04 The accounts were all titled as Russella A. 'Werner and were individual accounts. The accounts were established on the following dates: 6100683559 - 06/06/1966 6223987335 - 01/02/2009 6223987378 - 01/22/2009 There is one safe deposit box listed in the customers name located at branch #291. Should you require further information pertaining to this situation, please contact our office at {717) 540-7314. rdially Andy L. A r Branch Manager 1Gf RBS Integrity B A N K August 17, 2009 RE: Estate of Russells A. Werner Heather, 5... l M1.{ RI 'f 0"l.1 d 1~ + ~,~~ Here is the information which you request about the late Russella A. Werner's account. 1) The registered owner(s) of the account is only Russella A Werner. 2) The account was established on March 31, 2006. 3) No changes in the ownership of this account have occurred. 4) The Year-to-Date interest accrued as of 07/21/2009 on the account is $583.23. ~' 5) The Date of Death balance is $56,283.38.' 6) The customer had no safe deposit boxes with our bank. If you have any further questions please call me at the phone number below. Sincerely, .~~ r~ Ronak R. Patel Integrity Bank Customer Service Representative 3345 Market Street Camp Hill, PA 17011 Phone: (717) 920-4900 3345Mcrrket Street, Camp Hill, PA 17011 • Phone: 717-~20-4900.877-I-HAVEIT • Fax: 717-920-4904 • www.integritybankonline.com ORxsTOwiv B~ A Tradition of Excellence August 18, 2009 To: Smigel, Anderson and Sacks 4431 North Front Street 3rd Floor Harrisburg Pa 17110 From: Traci Yohe Orrstown Bank Customer Service Center PO BOX 250 Shippensburg, Pa 17257 Re: Estate of Russella A Werner Date of death July 21, 2009 ,~ 08- ~~~'~~~ IT IS HERERBY CERTIFIED THAT THE ABOVE NA~I~IED DECEDENT, ON THE ABOVE DATE, HAD THE FOLL O WING A CCO LINTS WITH ORRSTO Wl ~T BANK.• CHECKING ACCOUNT Account # Title of Account Date opened Princi al Accrued Interest,,/ 15412864 Russella A Werner 09/14/06 13623.38 6.60 Int. YTD 12.63 SA VINGS ACCOUNT Account # Title of Account Date opened Principal Accrued Interest CERTIFICATE OF DEPOSIT Account # Title of Account Date Opened Principal Accrued Interest P.O. Box 250 • Shippensburg, PA 17257. 717.530.3530. 717.532.4143 fax ~ ~i Lax Transmission 8/21/2009 il: 3:43 AM PAGE 1/002 Fax Server ~~~~~A Wachovia Bank N.A. Balance Confirmation Services P O Box 40028 Roanoke, VA 24022-7313 August 21, 2009 SMIGEL ANDER50N 8t SACKS LLP ATTN: HEATHER D ROPER ** Refenaroe ID: 2773497 SUBJECT: Verification / Confirmation of Account and Balance Information provided for: Customer: RUSSELLA A WERNER {SSN# ~~QC-XX 1818) Date of Death: July 21, 2009 Deposit Account Information Acaourrt Aoeourrt Date of Death Average Date Maturity Interest Accrued YTD Date Type Number Balance Balanoe* Opened Date Rate Irderest Irferrst Paid Closed CHECKING XXa~7~X6787 5104.65 10/24/1989 NA LEGAL TITLE: RUSSEL.LA A WERNER SAVINGS XX7~D~~4227 811~SS.n LEGAL TITLE: RUSSEILA A WERNER 12!111989 X0.17 sa.n Uther Account Information Account Aecaud Date of Balance Date Date Lodger Collected Type Number Opened Closer/ SAFE DEPOSIT 090 6/1!1996 BOX LEGAL TITLE: RUSSEILA A WERNER LOCATION: 5201 SIMPSON FERRY ROAD MECHANICSBURG PA 17030 7177938731 ~~~ ~~ L, ANDS R S OAT HEATHER D. ROYTR. ESQUIRE & SACKS LLr 1'HON3E: (7l7) 83x2401 ATTORNEYS AT LAW 'TOLL FREE: 1-500-8Z2-9757 FACSIMILE (717) 234-3811 LN~AXX~: hroyer(~'sasllp.oom wwvr.easllp.com bile No. s~~az-~A August 11, 2009 M & T flank 3805 Trindle Road Camp ~-zzll, i'A. 17011 RE: lrstate of Russetla A. 'Werner Died: July 21, 2009 Acct. No.: 150042132$4695 Ladies and Gentlemen: I represent the above referenced estate. At the time of her death, the decedent had at least one account with M & T Bank. For Ynheritarlce xax purposes, we are requesting a statement from you including the followiztg infgrmation for alI accounts in which decede t had an interest: 1. The registered owner or owners (exact title of account}. ~~-~~"r ~~ J 2. The date on which the account was established. /~~1'zr ou-T~ 3. if there was a change of ownership or registration of the account within one year prior to the date of death, please prow de the date of such change and the title of the account prior to the change. ~ ~/dn/~' 4. The amount of any interest accrued to date of death for the c lendar year, oN s'T~~~-~ S. The date of death balance (plus accrued interest, if any}. ~ aN ~T~~e~N~ nt' name. a 8~ E~ 6. V~hether there were 2uRy safe deposit boxes In the decede S -1S ~ I am enclosing a photocopy of the Letters Testamentary for your records. Thank you for your assistance. HDR/alh Enclosure cc: Sharon A.. Rose, executrix Sincerely, Heather D. Royer Z00 'd 4431 North Front Street. 3~d Flr.. Harrisburg Penn$ylvania 1711 -177$ A PENNSYLVANIA LIMITED LIABILITY pA14'TNk;1tSITIP `~__~ 606ZL6GGiL~Xdd }INdS-Z~ 9Z~EI I8d 6002-8I-ddS r Page: 1 Docwmez~t Name: untitled CUP1 1 CIS INDIVIDUAL CUSTOMER PROFILE 09/09/18 11.43.3' CULO CO 96 OF EBRN MS 64282 INDIVIDUAAL CUSTOMER DISPLAYED OUST NO. 7729643 C'UST SEG STATUS-- COID 96 SSN TID: 1~0 292281818 CD 0 COST CENTR 4350 BRN-- 435c N ~2USSELLA A WERNER TIE 1 OPENED 7112 OJ. OFFO1 A 310 LAMP PAST LN CLOSED OFF02 C CAMP HILS, PA 17011-1460 LST MAIN 1070618 MAR STATS • BRTHDATE 260519 SEX--'--- DECEASED ADVERTIS? BANKRUPT EMPLOYEE? S EMPLOYER RETIRED OCCUP CD HH# t BK REL PRG HOME PHOI~TE 717-761-0376 CUST TYPE T6 SENS CODE c BK SVC BUS. PHONE LANGUAGE REFER? 1 R. E M A R K S NATIONA,LI~'Y NEXT PLACED EXP. DATE PLACED EXP. DATE LIST HIST ACCTS? N LIST CLOSED ACCTS? Y ACTN: ACPR A,CDT x3 C C O U N T R E L A T I O N$ F~ I P S NEXT: SEA- COID- PRDSF ACCOUNT---------------- OPEN $T CURR ------BALANCE------ RE] 0001 96 DD,Ar9M Q15004213284695 10611 99 ~4, 014 .87 IN1~/ Date: 9/18/2009 Time: 11:44:1~k AM 000 'd 000ZL0GLiL~X~d X~dd-Z'81~ 9Z~01 Idd 6002-SI-d~S Page: 1 Document Name: untitled ,ACDT 2 CYS D}7A ACCOUNT DETAIL 09/09/18 11.43.5: C'U'LO CO 96 OP EBRN MS ACTION SUCCESSFUL ACTION: INQ (INQ NXT} COID 00096 PRODUCT DDA ACCOUNT 01500421328~k695 }***** ACCOUNT CORES ****** ~'~~~~*'~**** ACCOUNT B.A.LANCE DATA ~~~******** SLTB PRODLIrCT CODE........ 9M CURRENCY-----......-•--•- A000UNT ST.A.~'US.......... 99 LINE AMOUNT .............. 0.00 SERVICE CHG TYPE CODE... 9M OPENING DEPOSIT.......... 50,986.39 SERVICE CHG WAIVE CODL.. 00 CURRENT BALANCE.......... 54,014.87 INTEREST CODE........... 9M CLT,RRENT COLLECTED BALANCE 54,014.87 INTEREST WAIVE CODE..... AMOUNT OF RESTRAINTS..... 0.00 LATE CHARGE CODE........ LAST DEBIT/CREDIT AMOUNT. 9.18 LATE CHARGE WAYVF CODE.. 00 ACCT RECON PROCESSING CD. SHORT NAME........ WERNER RUSSELLA A ZERO BALANCE ACTION CODE. 0 SL~A,R.Y POST CODE........ ******** ACCOUNT DATES ******** DRIVER PROCESSING........ 0 DATE OFENED..._...... 106/11/1.0 DATE REOPENED........ DATE OF LAST DEPOSIT. 109/09/l0 DATE OF LAST W/DRAWAL 106/12/08 DATE OF LAST MAINT... 106/11/10 DATE CLOSED.........- Hate: 9/18/2009 Time: 11:44:28 AM ~00'd 608ZL8LLjL~Xdd XNdS-Z~~I 9Z~8I Idd 6002-8I-d~S Sep. 8. 2009 12:23PM PNC BANK 412-705-2741 No. 8375 P. 1/1 d4~o _2_s7+ ~~~ LElWING 7HE WAY September 8, 2009 Amy L Haines Heather D Royer, I/sq. 4431 N Fxaz~t St 3`~ Fl Harrisburg, FA 17110-1778 RE: Russella A Werner SSN: 292-2$-1$1$ DOD: 07-21-2009 Dear 1VYs, wines: In response to youx request for Date of Death (DOD) balances for the customer noted above, our records show the following: ' Savings Account Account # 5112004025 Established: 09-18-2006 RUSSELLA'A WERNER DOD balance: $ 144,554.59 + 93.92 accrued interest Interest paid 01-012009 thru 07-21-2009 $ 1,371.50 YTD Please note that this office provides date ofdeath balances for deposit accounts (IRAs, CDs, Checking and Savings}. We do not process any fins~ncial transactions or provide statements. If you need assistance with any of these items, please call 1-888-PNG-BAN.K (1-888-762-2265) or stop by your local PNC Bank branch office. Sincexely, National Financial Services Center PNC Bank, N.A. Member FDI C Page 1 0l' 1 Holdings by Product Type as of 07I21J2009 ~ Acct# : SHT115060 Cash and Eeuivalan+c ~,,.,• } ~- .. ,- :2 ~.~1' ~. SHT115060 5HT 72M MONEYMR KT FEDERATED CAPITAL RESERVES 96,989.00 8.02 5HT115060 5HT 72M S 5HT115060 Eauitv 5HT 72M U D USD999997 MONEYMR KT CASH FEDERATED CAPITAL RESERVES - Purchase 96491 -964.91 08 -.08 5HT115060 5HT 72M PE SHT115060 5HT T2M P FN 713448108 PEPSICOINC 1,785.5400 100,704.41 8.33 SHT115060 SHT115060 5HT115060 5HT 5HT 72M 72M B YUM DTV 302520101 988498101 25459L106 F N B CORP PA COM YUM BRANOS INC COM OIRECTV GROUP INC COM 5,732.0000 864.0000 106.0000 34,735.92 28,840.32 2,641,52 2.87 2.39 .22 SHT115060 5HT SHT 72M 72M CMCSA 20030N101 COMCAST CORP CL A 73.0000 1,044.63 .09 5HT115060 5HT 72M MTLQO D 62010A105 MOTORS LIQ CO COM 366.4400 176.44 .01 5HT115060 5HT 72M PHIO A 247126105 DELPHI CORP COM 263.4100 13.96 .00 Mutual Fund LU 013904305 ALCATEL LUCENT SPON ADR 5.0000 12.45 .00 SHT715060 5HT 72M PTE PX 746852102 PUTNAM PENNSYLVANIA TAX EXEMPT INCOME FUND CLASS A 31,085.6100 271,066.49 22.42 5HT115060 SHT 72M F RPAX 354723801 FRANKLIN PENN TAX FREE INCOME FUND CLASS A 25,938.4800 256,790.95 27.24 5HT115060 5HT 72M VKMPX 920902103 VAN KAMPEN PENNSYLVANIA TAX FREE INCOME CL A 15,421.0000 229,464,50 18.98 SHT115060 5HT 72M D ELIX 233216100 DELAWARE TAX FREE PENNSYLVANIA FD CL A 20.830.0500 159,349.85 13.18 SHT115060 SHT 72M ETT GX 277911830 EATON VANCE TAX MANAGED GROWTH FUND 1.1 CLASS A 1,100.6000 20,471.07 1.69 5HT115060 5HT 72M ESBAX 299909614 EVERGREEN CORE BOND FUND CLASS A 645.7800 4,836.92 .40 5HT115060 5HT 72M PH IGX 746782101 PUTNAM HIGH-YIELD TRUST FUND CLASS A 257.6500 1,666.97 .14 otal 104,474.5600 1,208,805.40 100.00 M. WAYNE NEFF, CFPT"' SENIOR PARTNER HERITAGE WEALTH A D V I S E R S 635 N. 12TH STREET SUITE 102 ,.,~ ,~ ,; , LEMOYNE, PA 17043 PH: 717-G14-6100 x214 FAX: 717-614-6200 EMAIL: MWayne.Neff@investfinancial.com Iii-.C~ISII.Itl-1l I~f('ItI:tiENr;\I-I\/F l)F ANII SF('ItRITIFS nNl> A()VI~I.)R\'til:RVIC:F C)Fk~I:Rrf) 1-IIRI)UC~I-I INVEST FINANCIAL CORPORATION IIN\/ESTI. M LM Ii IIt INR/~. SII'C. n rtlC;I1I~FR[C) INVrtiTMFNl nl)VItiC)R INVEST I5 Ntrr nffn_Im!'r) w . rrfl Iler.lnu;r: wenlln AnvlsfR> I_li PSEC~ January 25, 2010 Account # 02923CX~~~X SMIGEL, ANDERSON & SACKS, LLP ATTORNEYS AT LAW 4431 N FRONT ST 3RD FL HARRISBURG, PA 17110-1778 Dear MS HAINES ~~~~~n~~ The following is the status of RUSSELLA A WERNER's account with PSECU as of the date of death. Joint Owner's Name NONE Date of Death 07.21.2009 Date of Birth 05.19.1926 Share Description Open date Balance Accrued Dividend S O1 Regular Shares 08.29.1984 $ 217.49 $ .04 S 07 Money Market 10.08.1991 6,732.02 3.84 C50 60 Month IRA Certificate * 01.08.2009 16,989.18 41.04 * Designated IRA Beneficiaries - STEVEN A WERNER, SHARON A ROSE, PAMELA J DAVEY The dividend earned from January 1,2009 through the date of death was $51.71. The decedent had no loans with us. We do not have safe deposit boxes for our members. If you have any questions, please ca11234-8484 in Harrisburg or our toll-free number, (800) 237-7328. At the menu prompt, enter 6 and then extension 2227. Sincerely, ~ w Jo lbin Me ber Service Representative Finance Support Unit Pennsylvania State Employees Credit Union Main Address: 1 Credit Union Place, Harrisburg, PA 1 71 1 0-2990 • 717.234.8484 • 800.237.7328 Mailing Address: P.O. Box 67013, Harrisburg, PA 17106-7013 • 717.777.2100 (TDD) • 800.472.1967 (TDD) psecu.com This credit union is federally insured by the National Credit Union Administration. Equal Opportunity Lender '`' ~ Penta on Federal C ' '°° g redit Un1on Superior Rates. Proven Service: PO Box 247009, Omaha, NE 68124-7009 1-800147-5626 www.PenFed.org September 15, 2009 ,,~; ,~~..-,, ~~ .~~., ta ,. Heather D. Royer Q~-- ~~ RE: Russella A. Werner Attorney at Law un~r 2. ~;~. File # 2985359 4431 North Front Street U I 3'd Ftoor Harrisburg, PA 17110-1778 Dear Ms. Royer: Please find below the date of death values for Ms. Werner's accounts per your request: Account Nnmher Princiga! .Balance Dividend Accrued Taal DnD Balance Share Svgs 2985359-01-3 $ 5.10 $ 0.00 $ 5.10 Certificate 4252465-56-4 $ 81,287.13 $ 54.07 $ 81,341.20 Certificate 4260199-56-9 $ 34,831.55 $ 23.17 $ 34,854.72 The Beneficiaries of these accounts are: Pamela J. Davey, Sharon A. Rose and Steven A. Werner. The share savings account was opened on 1/29/07. The two certificates were opened on 1/31/07. If you have any questions, please call us toll-free at 1-800-247-5626. Sincerely, ~~ .-, ,. ,:;~ ~ . %~,~~..•~G-lit ~~~ L_ // Laurel Dunning ~~ Estate Accounts Specialist 48500041046 REV-485 EX (1-07) % ~.:Y SAFE DEPOSIT ..: BOX INVENTORY PA Department of Revenue PLEASE USE ORIGINAL FORM ONLY Social Security or Death Certificate Number Date of Death County Code Year File Number - _ ~ ~ ~- Decedent's Last Name ~-- Suffix First Name MI ,. e~ ~ ~ e ~ I c~ . ~~5~~~' _ _ _ _ .. ADDRESS F RECEDE~L~ STREET /1 CITY: . ~1 i n n KY~ ~ .Y,~ C .-~ ~Z~ 1 ' it r~~ ~ l~ i ~ ~ ~E. 2~P COOEt: ~..~ t..u y I I~--I I /v + . j NAME A ADDRE S OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX NAME: ~ r--r STR TADDR S: _~--.------ ---._...__ .------------- y ~ - -- - NAME, ADDRESS AND RELATIONS IP IF ANY TO RECEDE ( ) NT, OF PERSON(S) PRESENT AT THE BO PENING a. NAME: RELATIONSHIP: ----~~! ~ C..U ~-~_.____~7 ~_ -~-~__---_ ...__ STREET ADDRESS: - - CITY: STATE: ZIP CODE: b. NAME: ------------ ------------------- --- RELATIONSHIP: TREET ADDRESS: CITY: STATE: ZIP CODE: c. NAME: RELATIONSHIP: --- STREET ADDRESS: - CITY: ~~~~~~~ Hrvu aooRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED CITY: - IV/11VIt: (/ '---- ~v"l-"'_ STR TAD RE S~ ~~g fit' NAME OF PERSON N ;ING LAST ENTRY Vv~l~.lV DATE OF C NTR CT TO RENT BOX NUMBER OF BOX ~ ~ .-' ~ (~ NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO-~6=0=X-~ a. NAME: STREET ADDRESS: CITY: STATE DATE AAID~TIME OF LAST ENTRY TITLE UNDER WHICH BOX IS REGISTERED ZIP CODE ZIP CODE,.^ GI ~-. r b. NAME: STREET ADDRESS: ZIP CODE: CITY: STATE STATE WAS A WILL IN THE BOX? ^ YES ~ o If yes, a. Date of will: b. Name and address of personal representative, if named in the will -~~~'-'-'--'---- NAM E: STREET ADDRESS-------------- ---- ------ _..------ CITY: ------- c. Name and address of attorney, if any ~-- - NAM E: STREET ADDRESS: CITY: __ . .. .................... .... STATE: ZIP CODE: ZIP CODE: STATE: ZIP CODE: 4850041046 48500041046 Page 5~~~ ~~~oSiT BOx iNVENTOR~r _ __.._ _Or . REV-485 EX INSTRUCTIONS (1) Cash: Report total only, (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG, PA 17128-0601 ITEM NO. ITEM DESCRIPTION `, , .. ---- ~--- -----• ---------- -~ ------J'~----•-•-- I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECEIVING COPY OF CORRECT AN COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SAFE DEPOSIT BOX INVENTORY: SIGNATURE .._ SIGNATURE ~_ PRINT NAME ) _._------ ~~~~ ~.- ~ ._ ~~r . '~_~_~-~-!__.. PRINT NAME AND CHECK APPROPRIATE BOX BELOW: __ ...__ .. ... -~ ---. _.. . -~ --- - --- .. _...---_..._ .. ~ - PRINT TITLE r" DATE C 1.1~~ ~ 1-L-~ f ~ (1; . I t~ r ~ 1t ~~ ~, L ~ CHECK APPROPRIATE 80X: ~ Executor(trix) ~ Administrator(trix) ~ Estate Representative ~ Joint owner of safe deposit box NOTE: Attach additional 8'1~" x 11" sheet(s) if necessary or use duplicates of this page of form. The Department is authorized by law, 42 U.S.C. §405 (c)(2)(C)(ij, to re:luire disclosure of Social Security numbers in connection with administering state tax laws. The Department uses the Social Security number to identify the decedent and personal representati~~es of the estaie. The Commonwealth may also use the information in exchange of tax informmation agreements with Federal and local taxino authorities. The state law prohibits the Commonwealth's personnel from disclosing confidential tax information except For official purposes. W a h Z U H U z z 0 U _Z ~W LL j O w m Q O ~ F- W H 0 li 1~ H W [0 z W _J '" O W Z .. _Q Z Q .- w ~~ ~ ~w 4 z ~ ZWO~ ~-~, nW, a o ~:~ • ~ J w m ~~a~ Za g p Q ~ _ O U 0 X W w LL O N fA W a~ mZ in ? YO UW oa ~- W fq F- _N t7 W W CG z F- U W J a U W N N O W Q fr W m Z D z 0 m a U F L1C W U W a z }• z a 0 U w a W N N g U to O_ ~ ~ _ ? NO Oz 2 WQ .~ J 48500041,046 REV-485 EX (1-07) ; •• SAFE DEPOSIT ~; ,~ BOX INVENTORY PA Department of Revenue PLEASE USE ORIGINAL FORM Social Security or Death Certificate Number Date of Death ONLY ... • Z ~ l ~~__~~ ~'-o~z~~ ~~~ ' County Code Year ~~~' ~_~z~- ~ ~ File Number off' ' Decedent s Last Name ~ - Suffix First Name .; . Mi ~~~-tr (1C,~~ ~~.~~SC'l•~ -C~. ® ADD ESS OF DECEDENT TR ET: _ ~il~ t (~ Of14 ~ ~/S~ ~ ~ It~r~ _ - `. ~~~~44 CI11 ~ _ . 171~TATE: - _ ZIP CODE: _ _ NAME AND ADDRESS OF PERSON REQUESTING THE OPENING O . NAME: ~ F T HE SAFE DEPOSIT BOX STRE TA RE ~~ -~.. _ ,. Si. z d _ - - ~%/ ---~•- --CITY: -----------•--- M ----5 -- E/'~ ----- - ZIP CODE: NAME ADDRESS AND REL , ATIONSHIP ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE X OPENING a. NAME: ---D~ ~ i Ste. ~ d ~ V ~ S _ --------_ __.._.- _. ---- RELATI^"'°~'~• ~/L_:- '~ i.~ STREET ADDRESS: ~. `'~ f ~ ! C.~4-2.~ i S• ~~ ~ 1 ~ b _ CITY: ~-c~'V1~ -l-f -~, Lam. __ ~rarF• ~~- _ ~~a ~n~nc. ~~1~ ~ ~ . NAME: RELATIONSHIP: --- I ,. ~~'' STREET ADDRESS: CITY: - STATE: ZIP CODE: ' c. NAME: RELATIONSHIP: - -•- -----•------------- STREET ADDRESS: ---------- -------- CITY: ----------- _--STATE: ZIP CODE: ~~~+~^~~ hrvu AuuKt55 of FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME: STREET ADDRESS: ~-~~ ~ Cc~ I~~I~ ~~K~ NAME OF PERSON MAKING LAST ENTRY DATE OF CONTRACT T ENT BOX NUMBER OF 80~; ~ .~ NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX T~Y:-~-I ~ ~U r® DATEI TITLE UNDER WHI V SS ~C:• L-L. AsTATE: IT ENTRY C:S i'fti~ ISTERED a. rvrrrvit: b. NAME: STREET ADDRESS: STREET ADDRESS: CITY: -----~---------- STATE:--- ZIP CODE: CITY:---V--____ NAME AND OF EMPLOYEE TAKING THE INVENTORY ' Vim. N t5~= ~, ~ ~;. ~(~' C~ D TIME - F L ~~ ~ ~ H BOX IS RI ~. l ~:. l,` WAS A WILL IN THE BOX? ^ YES ~NO If yes, a. Date of will: b. Name and address of personal representative, if named in the will NAME: ~ i rcCC ~ AUURESS: c. Name and address of attorney, if any NAME: CITY: STATE: ZIP CODE: STREETADORESS: CITY: STATE:- ZIP CODE: STATE: ZIP CODE: 48500041046 48500041046 SAFE DEPOSIT F30~ INVENTOf~~' Page ___. _ _ of _ REV-485 EX , INSTI~U1CT10NS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG, PA 17128-0601 ITEM NO. ITEM DESCRIPTION .. C u~ Nc:~r'. i t # ~ z ~ ~ :7 t~~~~E_~1.. ~ - -~- l - --~----- _ ~ _ ~~~~_C~_C~ N~- ~`~~t~t~~t`~Gi~l 1~-- ~i-~:._~~__!~Zz~~'1.~:---~---~~YLC'ffr~~---~-~-5---~-~-~~~;--- -- r.... ~ ~-iiN ! ~ L ~1~Ja~ i i ~ \. ~rY `G ~t LM. • YI Y ~ ~-- - -.- ~ - ~ ~ 3~i ~.7 ~ ? CYO ~t 1 ~1~~ .-- 1~ 1L ~ 1~~ ~ l~~lv I~~~ ~ _ ~ ...., . _ _ _ -- _ ---. --~ 1 CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD iS CORREC~ AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BE!_IEF. PERSON RECEIVING COPY OF SAFE DEPOSIT BOX INVENTORY: SIGNAT R SIGNATURE PRINT AME z- ~ ~ ~~- /~. PRINT NAME AND CHECK APPROPRIATE BOX BELOW: _._--... .---- .---.-._ _. PRINTTITLE DATE ~~~2 ~~ ~ ~ ~{ ~ s ~; ~ ;--~~ . `3 ~~ c C~ 1 ....__ ._. _.._ . CHECK APPROPRIATE 60X: ~ Executor(trir.) ~ Administrator(trix) '~ (( r (l `1C~ ~. (.• ` ~ ~'-.Z (~;t~:i•~ 11 ~ Estate Representative ~ Joint owner of safe deposit box MOTE: Attach additional 8'/:" x 11" sheet(s) if necessary or use duplicates of this page of form. The Department is authorized by law, 42 U.S.C. §405 (c)(2)(C)(i), to require disclosure of Social Security numbers in connection with administering state tax laws. The Department uses the Social Security number to identify the decedent and personal representatives of the estate. The Commcrn+vealth may also t.lse the i^formation in exchange of tax information agreements with Federal and local taxing authorities. The state law prohibits the Commonwealth's personnel 6~om disclosing confidential tax information except for official purposes. ;~~'~~ v i ~., ~~ ( . 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