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HomeMy WebLinkAbout06-02-1015056051058 REV-150 0 ~ (~-~) OFFICwL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes PO BOX 2806iJ1 INHERITANCE TAX RETURN ~ f /~C~ ~ ~ ® Harrisburg, PA 1712&0601 V RESIDENT DECEDENT C u ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 226-26-9173 09/04/2009 07/27/1925 Decedent's Last Name Suffix Decedent's First Name MI Shufflebarger Mrs Martha H (If Applfcable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Retum 2. Supplemental Retum 3. Remainder Retum (date of death prior to 12-13-82) 4. Limited Estate 4a. Future Interest Compromise (date of 5. Federal Estate Tax Retum Required death after 12-12-82) 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFlDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number William M Shufflebarger (717) 705-2940 Firm Name (If Applicable) REGISTER OF DWI„ ELLS USE ONL~' am ~-~ C .. t.•`. T~ _ ' ' First line of address v ~ < ; = - 1311 Woodward Dr. ~~ rn ~ ~ i . J _ ~ C, r~? .~. Second line of address " ... ~.i `.. ~ ~~ .... ~i i._.~ ~~ ~ ~ G : ,. _ .. i ..- h ~~.~ ~.._. _ . _T..' DATE F L C~ ' - City or Post Office ~ ~ l, ,^ , State ZIP Code Carlisle - PA 17013 G3 ~~ ' Correspondent's a-mail address: WShuffle a~aOI.COm Under penalties of perjury, I deGare that I have examined this return, including acoornpanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of arer other than the personal representative is based on all information of which preparer has any knowledge. SIJLGf~-TUREOF PERSON F~~~~I~SI !%//!l////~~// FILI RN DAT ~ a ~d ~o ADDRESS 1311 Woodward Dr., Carlisle, PA 17013 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE U8E ORIGINAL FORM ONLY Side 1 15056051058 15056051058 J 15056052059 REV 1500 EX Decedent's Social Security Number Decedent's Name: Martha H Sht.lfflebarger 226-26-9173 RECAPITULATION 1. Real estate (Schedule A) ............................................. 1. 140,000.00 2. Stocks and Bonds (Schedule B) ....................................... 2. 99,006.28 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages & Notes Receivable (Schedule D) ............................. 4. 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ........ 5. 54,275.76 6. Jointly Owned Property (Schedule F) Separate Billing Requested ....... 6. 89,377.5$ 7. Inter-Vivos Transfers ~ Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested........ 7. 8. Total Gross Assets (total lines 1-7> .................................... s. 383,159.62 9. Funeral Expenses 8~ Administrative Costs (Schedule H) ..................... 9. 32,081.09 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ................ 10. 2,340.60 11. Total Deductions {total Lines 9 8 10) ................................... 11. 34,421.69 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 348,737.93 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. 348,737.93 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_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 45 348,737.93 16. 15,693.21 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. 15,693.21 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: Flle Numbsr DECEDEN S NAME DECEDENTS SOCIAL SECURITY NUMBER H Shufflebarger 226-26-9173 Martha _ STREET ADDRESS 23 Ridgeway Drive CITY Carlisle STATE PA ZIP 17015 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 15,693.21 2. Credits/Paymerrts A. Spousal Poverty Credit B. Prior Payments 17,000.00 C. Discount 784.66 Total Credits (A+ B + C) (2) 17,784.66 3. Interest/Penalty if applicable D. Interest E. Penalty Total InterestlPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 2,091.45 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A} B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No .......................................................... a. retain the use or income of the property transferred :......................... ....... ^ b. retain the right to designate who shall use the property transferred or its income : ..................................... ....... ^ c. retain a reversionary interest; or .......................................................................................................................... ^ d. receive the promise for life of either payments, benefrts or care? ............................................................... ....... ^ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ...................................................................................................... ........ ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ...... ........ ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ................................................................................................................ ........ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1,1994 and before January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute s n to exem~ 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 benefiaary. 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)J. 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+ (11-08) ~ Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT __ ESTATE OF ~ FILE NUMBER Martha H. Shufflebarger 2109-0860 All real property owned solely or as a tenant in canmon 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 wilting seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real aroaertv that is iointly-owned with right of survivorship must be disclosed on Schedule F. If more space is needed, insert additional sheets of the same size. A. Settlement Statement B. Tvpe of Loan U.S. Department of Housing and Urpan Development OMB Anoroval Nn ~5n~_n~R5 fr~Ynirac 11/3nJ7MQ\ 1. ^FHA 2. ^FmHA 3. ^Conv. Unins. 4. ^VA 5. Conv.lns. 6. File Number 2009-781SWARTZ 7, Loan Number 8. Mortgage Insurance Case Number is rm is urns o give you a s a emen o ac ua se men cos s. moun pai o an y e se emen agen are s own. C. Note: Items marked "(p.o.c.)" were paid outside the closing; they are shown here far information purposes and are not included in the totals. WARNING: It is a crime to knowingly make false statements to the United States on this or any other similar form. Penalties upon conviction can include a fine and im risonment. For details see: THIe 18 U. S. Code Section i 001 and Section 1010. TItIeEXpfess Settlement System D. NAME OF BORROWER: Richard H. Swartz and Mary L. Swartz ADDRESS: 22 Rid ewa Drive Carlisle PA 17015 , E. NAME OF SELLER: Estate of Martha H. Shufflebarger ADDRESS: ' F. NAME OF LENDER: ADDRESS: G. PROPERTY ADDRESS: 23 Ridgeway Drive, Carlisle, PA 17015 . South Middleton Townshi H. SETTLEMENT AGENT: O'Brien, Baric & Scherer, Telephone: 717-249-6873 Fax: 717-249-5755 PLACE OF SETTLEMENT: 19 West South Street Carlisle PA 17013 I. SETTLEMENT DATE: 1212312009 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 rice 140 000.00 401. Contract sales rice 140 000.00 102. Personal Pro ert 402. Personal Pro ert 103. Settlement char es to borrower line 1400 1 797.97 403. 104. ~ 404. 105. 405. Ad'ustments for items aid b seller in advance Ad'ustments for items aid b seller i n advance 106. Cit /town taxes 406. Cit (town taxes 107, Count taxes 12123109 to 12131/09 8.58 407, Count taxes 12123109 to 12131109 8.58 108. School Tax 12123109 to 06!30110 687.11 408, School Tax 12123109 to 06130110 687.11 109. 409. 110. 410. 111. 411. 112. 412. 120. GROSS AMOUNT DUE FROM BORROWER 142 493.66 420. GROSS AMOUNT DUE TO SELLER 140 695.69 Z00. AMOUNTS PAID BY OR ON BEHALF OF BOR ROWER 500. REDUCTIONS IN AMOUNT DUE TO SELLER 201, De osit or earnest move 540.00 501. Excess De osit see instructions 202. Princi al amount of new loans 502. Settlement char es to seller line 1400 1 400.00 203. Existin loans taken sub'ect to 503. Existin loan s taken sub'ect to 204• 504. Pa off of First Mort a e Loan 205. 505. 206. 506. 207. 507. 208. 50$. 209. 509. Ad'ustments for items un aid b seller Ad'ustments for items un aid b seller 210. Cit /town taxes 510. Cit /town taxes 211. Count taxes 511. Count taxes 212. School Tax 512. School Tax 213. 513. 214. 514. 215. 515. 216. 516. 217. 517. 218. 518. 219. 519. 220. TOTAL PAID BYIFOR BORROWER 500.00 520. TOTAL REDUCTION AMOUNT DUE SELLER 1 400.00 300. CASH AT SETTLEMENT FROM OR TO BORR OWER 600. CASH AT SETTLEMENT TO OR FROM SELLE R 301, Grass amount due from borrower line 120 142 493.66 601. Gross amount due to seller line 420 140 695.69 302. Less amounts aid b /for borrower line 220 500.00 602. Less reduction amount due seller line 520 1 400.00 303. CASH FROM BORROWER 141 993.66 603. CASH TO SELLER 139,295.69 IIVV. 1107. Attorne 's fees to O'Brien Baric 8~ Scherer 250.00 includes above items No: 1108. Title Insurance includes above items No: 1109. Lender's Covera e $ 1110. Owner's Covera a 140 000.00 - 1111. 1112. 1113. 1200. GOVERNMENT RECORDING AND TRANSFER CHARGES 1201. Recordin Fees Deed $ 62.50 • Mort e $ • Release 62.50 1202. Cit !Count tax/stam s Deed 1400.00 • Mort a e 1 400.00 1203. State Tax/stam s Deed 1 400.00 • Mort a e 1 400.00 1204. 1205. 1300. ADDITIONAL SETTLEMENT CHARGES 1301. Final Water/Sewer Acct.#016109to South Middleton Townshi Munici al Authori 85.47 1 1400.. TOTAL SETTLEMENT CHARGES enter on lines 103 Section J and 502 Section K 1 797.97 1 400.00 HUD CERTIFICATION OF BUYER AND SELLER 1 h carefu reviewed the D-1 Set nt Sta ant and to the of my knowledge and belief, it is a true and accufate statement of all receipts nd isbursement ade on my account o y me in is t nsaction. f 1 y that I h received the HUD-1 Settlement Statement. c L a w ary wa ~._ cP e o a a e arger WARNING: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE The HUD-1 Settlement Statement which I have prepared is a true and accurate account of this 1 leo~rcr, crn TCC nl.l -ruse no nNV elnnn na cnann PFNGI TIES I IPnN f:nN\/I(:TInN transaction 1 have caused or will cause the funds to be disbursed in accordance with this statement. 11 y•,V uyV U.'S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT File Number: 2009.781SWARTZ PAGE 2 d M °' ~ 0 ~ ~ ~ ~ .. U N U N H N OD 1 01 O O N N z a~ .~ ~ w N .~ .u o F- Z N b N ,r-1 ~ a `~ ~ ~ v rn ~ ~ ~ '~ a ~ c ~ ~ ~ V N W 4d •ri v i ~ W 01 ,L, .~i ~1 W W ~ ~ V ~ ~ •~ N ~ ~ ~ ce W ~ ~ A ~ ~ ~ ~'1 ~ x rn o o w ~ ~ ~ ~ ~ ~ ~ m ~ ~ U ~ a . Z ~ W ~ W W N _ m O ~ H ~ , A ~ ~ a o a tT .~ O r-i U .ri t!1 (~ U rn t0 rn N rn M r-I RIDGE MARKETING ASSOC., APPRAISALS Fig Ho. APPRAISAL OF A SINGLE FAMILY DWELLING LOCATED AT: 23 Ridgeway Drive Carlisle, PA 17013 FOR: Wiliam Shuffieberger, Exect. Go 23 Ridgeway Drive Carlisle, PA 17013 BORROWER: N/A AS OF: September 18, 2009 BY: David Eskin PA State Certified Residential Real Estate Appraiser RIDGE MARKETING ASSOCS., APPRAISALS 464 WOODCREST DRIVE MECHANICSBURG, PA 17050 Uniform Residential Appraisal Report F~IeNo. s9-0930 The ur ose of this summer a raisal re ort is to provide ilia lender/Client with an accurate, and ade aortal su orted, o inion of the market value of the sub act pro art . Pr Address 23 Rid ewe Drive Cit Carlisle State PA Z' Code 17013 Gorr er NIA owner of Public Record Martha Shutfleber er Count Cumb rland L at Desui lion Deed Book 248 P e 1834 Assessor's Parcel ~ 40-24-0748-052 Tax Year 2009 R.E. Taxes S 1 798.88 Nei ttborhood Name C3freen8eld Ma Reference ADC'S 25-H2 Census Tract 3240-125 owner Tartaric vacant s ;at assessments s None Known Puo HOA s NIA er ear r month Pro Ri is aised Fee Sim fe leasehold Othor desuibe Assi merit T Purettase transaction Refir-ance Transaction other (describe Estate Of Martha Shuffleber er Lendegci:ern WiNiam Shuffleber r ExeCt. Address do 23 Rid ewe Drive Carlisle PA 17013 Is thew ' o current offered for sale or has it been offered for sale in the twelve months for W the effective date o(Ittis a raisal? Yes No Report data source(s) used, offering price(s). and date(s). Local MLS data service. 1 did did not analyze the contract for sale for the subject purchase uansaction. Explain the results of the analysis of the conVact for safe or why the analysis was not performed. NIA Conuacl Price S NIA Date of Contract NIA is the seller the owner of ubiic record? Yes Na Data Sources Public RacordS K there any financial assistance poan charges, sate concessions, gift a downpayment assistance, etc.) to be paid by any party on behalf of the borrower? Yes No if Yes, report the total dol,ar amount and describe the items to be paid. 5 N/A N/A Note: Race and the racial c sition of the nei htwrhood are not a raisal factors. Neighborhood Characteristics One•Unit Housing Trends One-UnR Housing Present Land Use % Location tNban Suburban Rural Pro rt Values Mcreasi Stable Declini PRICE AGE One-Unit 100 % Built•U Over 75% 25.75% Under 25% thma~ISu 5ttorte a in Balance Over Su S tlDO 2-4 Unit % Growth Ra id Stable Slow Markelin Time Under 3 mats 3.6 mths Over 6 mths 120 Low 10 MWti•Famii 96 Neighborhwod Boundaries The sub' t is bounded b Todd Rod 1/4 mile north Route 34 2/3 170+ Hi n 20 Commercial % mile east AAarsh Drive 1/8 m to south and Walnut Bottom Road 1 mile was#. 140+ Pred. 15 other ~ Neighborhoort Description See Attached Addendum Market CondRions (including support for the above conclusions) See Attached Addenda Dimensions 116.20 x 4528 x 112.20 x 47.77 x 23.20 Area .15 acre shy e A x. Rattan afar view ResidentiaUAve s circ Zoni CtassiflcaGOn RH Zonin Oescri lion Residential Hi h Densi Zoni Com Hance Le ai L Npnconformi Grand-athered Use No Zoni file I describe Is the highest and best use of the subject property as improved (or as proposed per plans and specJications) the present use? Yes No If No, describe. NIA Utilities Public Other describe) Public Other describe OFf-sitelm ovements-T a Pubtie Private Etecuici 200 Am water Street AS halt Gas Sanity Sewer A!I None FEMA S eclat flood Hazard Area Yes No FEMA Flood Zone X fEMA Ma N 420371-0010C FEMA M Date 1/5/96 Are the uti!ties and oft-site i ro+rernents t ical for the market area? Yes No tf No, descr;be. Are there any adverse s;te conditions or external factors {easements, encroachments, environmental conditons, land uses, etc.)? Yes No iE Yes, describe. GENERAL DESCRIPTION FOUNDATION EXTERIOR DESCRiPTiON materiatskortdition MITERiOR metetiatskonditi0n Units One One with Access Unit Cortuete Slab Craw! S e Foundation Wells BIOCk/Avera a Floors C BYin UFair ~ Of Stories 1 Fu118asement Partial Basement Exterior Walls Brick&Vin UAve Wa1is D alllAvera e T Det. Att. 5-DetJErtd Unit Basement Area 0 tt. Root Surface Com sition/Ave TrimlFinish Paint/Avera e Exis6 Pro sea Under Const. Basement Finish 0 % Gutters & oowns outs Aluminum/Ave Bath Floor Vin /Avers e Deli n St !e TOWnhOUSe Outside En xit Sum Pam Window T DotJble-HUn Ave Bath Wainscot None Year Bu;lt 1993 Evidence of i nfestation Storm Sasivtnsulated Thermo arias/Ave Car Story None Effective A n 8 Dam ness Settlement Sueens Yes/Ave a Orivewa ~ of Cars 2 Attic None Hearin FWA HWBB Radiant Amenities WoodStote(s) N Drivewa Surface A halt pro Stair Stairs Other Fuel Gas Fire face{s ;* Fence X tiara a Not Cars 1 Floor Scuttle Coot Central Air Conditionin Pa-'ro/Deck Porch Ca ort N of Cars Finished Heated lndivdual Cher Poat 01 r An. Dec. Buitt•in A fiances Refri ator Ra van Dishwasher Dis sat Microwave Washer) er Other describe Finished area above ade contains: 5 Rooms 2 Bedrooms 2 Bath s 1 150 S are Feet of Gross Livi Area Above Grade Additional features (special energy eY>cient items, etc.). Textured fo0f era a door o her as water heater. Describe the condition of the property (including needed repairs, deterioration, renovations, remodeling. etc,). The sUb• t is in avers a Condition On both the interior and exterior. The sub ct has a tandard floor Ian and amenities. No evidence of functional or economic obsolescence was observed. The sub'ect does have a strop t odor and needs new floor coverin in most rooms. Are there any physical def~iencies or adverse conditions that affect the livability, soundness. or sVuctura! integrity of the property? Yes No Ii Yes, describe. Does the property generally conform to the neighborhood (functional utility, style, condition. use, construction, etc.)? Yes No If No, describe. rreUO~@ Mac ram !l MafCli [UU~ rrotr_.ea'.5 "5 RC;1 wRwxe. tl00 ell tllll ^.WYe aCwO^ Coen ra,^^e more run, ,un rvwt„ cwa Page t d6 too{ oaoGZ~oa Uniform Residential Appraisal Report FtteNo. s9-0930 There are 5 com arable ies currents offered for sate in the subject nei hborhood re i in ice from S 105 000 to S 150 000 There are 14 ctxn ratite sales in the sub' t ne i hborhood within the st twelve months ran i in sate ice from 107 000 to S 149 900 FEATURE SUBJECT COMPARABLE SAlE NO.1 COMPARABLE SALE N0.2 COMPARABLE SAlE N0.3 23 Ridgeway Orive address Carlisle 51 Greenfield Drive Carlisle 67 Greenfield Drive Carlisle 3 Briarly Drive Carlisle Proxima to su ' t .1 mile NE .1 mice N .1 mile S Safe Price S N!A S 145 000 S 147 900 S 167 000 Sale PricelGross L+v. Area S 0.00 . ft. S 105.99 s . ft. s 114, 03 . ft. S 121.37 ft. oats saxce s Ins coon MLS/Stab Re s MLS/Stab Re -ts MLSlSteb Re rts Verificata~ Source s Public Records Public Records Public Records P brie Reootds VALUEADIUSTMENTS DESCRIPTION DESCRIPTION +t-tsA ustmerR DESCRIPTION +-13 ustmera DESCRIPTION .t-)s ugtme~t Sate a Financing concessions N/A N/A Cash None Known Conventional Nane Known Cash None Known Date of Sale/Time NIA 4!9/09 7!15109 6/19!09 location Suburban Subu an Suburban Suburban LeasehotdlFee Si le Fee Sim le Fee Sim le Fee Sim le fee Sim le site .15 acre .10 acre .17 acre .11 acre view ResidentiaUAve Residen ' UAve ResidentiaUAve ResidentiaUAve Da ' n fe Townhouse-End Townhouse-Ctr 1 500 Townhouse-End Townhouse-Ctr 1 600 Qtrali of Construction Brick&Vin I/Ave Brick&Vin UGD -3 000 Brick&Vin ilAve Brick&Vin UGD -3 000 Actual a 16 15 14 7 5 condition Averse Averse Averse Aver e Above Grade Tatat Bdnas 6adas Total Bdrtn 8eritis Total Bdrms Baths Trial Bdrtns Baths Room Count 5 2 2 5 2 2 5 2 2 5 2 2 Gross ' ' Area 15.00 1 150 . ft. 1 368 . ft. -3 300 1 297 ft. -2 200 1 376 . ft. -3 400 Basement rt Finished Rooms Below Grade Slab Unfinished Stab Unfinished Slab Unfinished Siab nfinished Funcbonat ubt~t Aveca Averse Averse Avers e Neatin Coot. FA/CA HP/CA FA/CA FA/CA Ener Etfcient Items Thermo apes Similar Similar Similar car car ort 1 Car Gara e 2 Car Gara a -2 000 1 Car Gara e 2 Car Gara a -2 000 PorchlPatiot0eck Patio Porch Patio Porch EnGosed Porch -1 000 Patio Porch Fire laces None None None None Net Ad' tment otat S 6 800 t S 3 200 S 6 900 Adjusted Sate Price !es Net Adj. -4.79~o t3rass '. 6.8% s 13$ 2 0 Net Adj. -2.295 Gross 2.295 s 144 700 Net Adj. -4.1 % GrossAd'. 5.9% S 1 0 100 1 did did not research the sate or transfer history of the subject property and tbmparabte sales. It not, explain M research did did not reveal an for sates or Transfers of -he sub' ct ro for the three ears ' r to the effective date of this a sisal. oats sources Tax Assessment Office M research did did not reveal an for sales or Uansters of the com rabie sates for the ear for to the date of sale of the com rabie sale. Data sauces Tax Assessment Office Re the results of ttte research and ana is of the for sate a transfer his of the sub-act ro rt and com arable sates e rt additional for sales on a ITEM SUBJECT COMPARABLE SALE N0.1 COMPARABLE SALE N0.2 COMPARABLE SALE N0.3 Date of Prior Satetfranster No Tranfers 36 Months No Tranfers 12 Months No Tranfer812 Months No Tranfers 12 Months Price of Prior SalelTranster N!A NIA N/A N/A Data source s Tax Assessment Office Tax Assessment Office Tax Assessment Office Tax Assessment Office Effective Date of Data Sourc s Date of Ins action Date of Ins lion Date of Ins CtiOn Date of Ins n Analysis of prior sate or vansfer history of the subject properly and comparable sates The sub has not tranfered in the ast 36 months nor has the sub' t been listed for sate with in the st 12 months. All com arables had not tranfered in the st 12 months exce t as noted as recent sales data. C rabie #1 did transfer as re rted and is current relisted for sale for 5169 900 er the local MLS data service. summary of sates comparison approach. All sales are closed transactions. All sales are considered avers a indicators of value. In the final reconciliation most wei ht is iven to com arable #2 house the feast ad ustments and bash most similar in deal n uali and market a al. Co rabie #1 and #3 both are su rbr ual' to the sub'ect with vaulted ceilin sand other u rades and were ad usted acxondi t .The sub"act is sl' h smaller than com arablea selected and several dated sales were reviewed for GLA ad'ustments selected. The sub'ect is in need of floor coverin in most rooms due to dams a and this was considered in the final reconciliation and the sub t is a raised in "as-is" condition. Militated Value b Sales Com i n A roach S 140 000 tndicat value b : Salsa Com orison roach S 140 000 Cost A roach d devet e E 111 600 Income roach if devefo ed) s N!A The sales a roach is the best a teach for this of ro .The costa roach is not a livable due to the a of the ub'ect. The income a roach was not t~nsidered since the seal bu er of this of ro is for owner occu n and not an investor urchase. This appraisal is made "as is,' subject to completion per plans and spec;ficalions on the basis of a hypothetical condition that the improvements have been completed, subject to the following repairs of alterations on the basis of a hypothetical cord+tion tftat the repairs or alterations have been completed, or Q subject to the folbwitlg required inspection based on the extraordinary assumption that the condAion or deficiency does not require alteration or repair. Based on a complete visual inspection or the interior and exterior areas of the subject property, defined scope of work, statement of assumptions and limiting conditions. and appraiser's cert~ftcation, my (our) opinion or the market value, as defined, or the real property that Is the subject of this report is 5 140,000 as of O9/1 S/2 O9 , which is the date of ins lion and the effective date of this a raisat. rrepoe Mae rvrm rv aurcn [un Prot:cet s:~g ~e;~so.;wxe apo za~eru www xmea [cm ramie enae ram iur Mau~ewa Page 2 d 6 toad os oetio5 Ridge Marketing Assocs, Appraisals Uniform Residential Appraisal Report File No, 89-Q930 COST APPROACH TO VALUE {not r wired b Fannie Mae) Provide ode uate information for the lenderlclient to re ticate the below cost F sand calculations. Support for the opinion of site va'ue {summary of comparable land sales or other methods for estimating site value) The C05t a roach is not a IitaDle due to the e of the su 'ect. Three lot sales were reviewed with sale ricer from $29 900 to $50 000 and lot sizes from .40 acre to .50 acre. No towr-house or semi-detached lot sates were discovered. EST{MATED REPRODUCTION OR REPLACEMENT COST NEW OPINION Of SITE VALUE .......................... . ............. > S 24 000 source of cost data Marshall and Swifts Cost Handtaook Dwell; 1 150 s Ft. ~ s 75.00............ = s 88 250 Quafi ratio from cost service AVefa 8 Effective date of cost data 3/2007 5 Ft. ~ S ............ = S CommeMS on Cost A oath ( ors iivtn area cakuiaGons. de eciation, etc. Built-ins Porch Patio fence 9 025 Gar e/Ca on 276 S . Ft. ~ S 25.99............ = s ? 173 Total Estimate of Cost-New ........... , = S 102 448 less P icat Functional External De eciation 16% = S 16 392 De eciated Cost of Im ovements ............ .................... = s 66 056 -As-is° Value of Site t rovements ................................ _ ~ 1 500 Estimated Remaini Economic lice HUD and VA onl 42 Years UVDICATED VALUE BY COST APPROACH ...................... S 111 600 INCOME APPROACH TO VALUE (not wired b Fannie Mae} Estimated Montht Market Rent S X Gross Rent Multi tier = S Mdicated Vakre Income ach Summary °f Income Approach (including support tot market rent and GRM) PROJECT INFORMATION FOR PUDs (if applicable} Is ltte devei eribuitder in corNrol of the Homeowners' Association HOA Yes No Unit s Detached Attached Provide the foilowi information for PUDs ONLY if the deve ertbuikfer is in control of the HOA and the sub~ect is an attached dwellin unit. L 1 name of 'ect Total number of ores Total number of units Total number of units solo Total number of units rented Total number of units tot sale Data sourc s Was the o ect created b the conversion of an exisGn buildi 5 into a PUD? Yes Ho tt Yes. date of conversion. Does the ct contain an mufti•dweliin units? Yes No Data source s Are the units, common elements, and retteation facilities complete? Yes No I( No. describe the status of completion. Are the common elements leased to or by the Homeowners' Association? Yes No ii Yes, describe the rental terms and options. Describe common elements and recreational tacildies. t R°OY@ NBC ipi11 ly NIdR'1 LIRA i'(UW.iM LS~.'fj ACf 50*.WMP. tlW t![ 9111 MW W K YRO c411 rai~C 11~Ctl rum 1µn [min cwa Page 3 °f 6 t]O<_l+5 O6i~6 RIDGE MARKETING ASSOC., APPRAISALS file No. s9-0930 i I i ********* INVOKE ***'***** j File Number: 59-0930 f i William Shuffleberger, Exect. i c!o 23 Ridgeway Drive Carlisle, PA 17013 I Borrower : NlA Invoice # i Order Date : 09/14/2009 ReferencelCase # PO Number i 23 Ridgeway Drive Carlisle, PA 17013 ~ 200.00 5 ~ Invoice Total S 200.00 State Sales Tax ~ 0% S O.oo j Deposit (~ ) ' Deposit ($ ... ..........) Amount Due i S 200.00 t ~{ Terms: Net 30 Days. i Please Make Check Payable To: l l RIDGE MARKETING ASSOC., APPRAISALS ` 464 WOODCREST DRIVE i MECHANICSBURG, PA 17050 j Fed. I.D. #: 193-58-2956 ! i 464 WOODCREST DRIVE MECHANICSBURG, PA 17050 ~. 3 w ~~ 0 w SD ~rn ~~ ~~ ~a a ~~ `a ~~ 1 ~~ r ~tfj~ F C b ~~ g° -~ Nm ~~` o ~~ ~vc~~~ nNCn ~o~orOaN~a aovaa =r'''ip D'`"'= mm O~ac~watn OOU zN~z ~~a~ cnQimm~-,o~ ~co~ rno0~ ~~~n m~ .~~~vz~„ ~07mo ,~ mm r~~ Z~-~-~ OOtn G7x--t N~~~ a~~ r~ ~. ao~ ~ C7 ooy4p wpm ~pp o~~A~ ~ ~ ~~~~ o~~ ~ ~ ~~ ~ ~ ~ og c"m~ ~ mo~ n ~ m O~ ~l i ~ N ~ pc'a '~ D j'y p n z -v , ..~ ~ ~ 1 rn~ ~ ~r-~.t ' --f l Hw ~a ~a ~ o L ~~ O O O ~~i~ O O O O K7 N N !n O1o v'o:'~w N ~F"tH ~ NO OONOO~ ~~~!'IIM ~ NO W ONO O ~ wa ~ ~~°~aa C o ~1 3 a F ~ ~i~~ "'7 1-+N J M M ~ o . O~ O V C .o o lh a ~ $` ~; m ~ ~~~ ~F ~ o~ ~~ W O ~ N 0 0 $ N W N ~O ~O op O dlr ~) dp n ' ~ 01 VI W O ~~N N ~ ~Nj ,,,,~ ~ o o O O ..~ ~n pu W ~O W ~i --~J C1 8 O N W W N O ~ .P N o pp~ a o r., o v a ~D N O .r+ N do M 0 0 0 0 O N N N W W 04 Q1 w 6 10 ago N N \O N Oo N ~ N W N o N .A N ~ Y O 'C3 n ~ (gyp 01 O O ~'f 0 D x A m z 0 A 0 0 m O ~, D ~, ... o ~ ~ W N OD '~ w O f..~ . , s Z~~ ' x m~0 =m,~ ~~°m mAC~cD ~"'~$ m p~ X-+ o •~ N ~~ Q O 'S. m 9 c ~'v -< ~~~a~ ~~ ~^ ~ .. ~: - ~ ~ . v~v~ c~ . ~~~ ~~. ~~a=~ ~ ~x ~. ~ ~ ~- ~' ~ o o ~= ~~ ~ c~~~cn c~~Qm~m to p w -~ ~ ~ Q K '~ C ~ 3 ~ ~ " Y m~~Q~m -, ~ ~~'~ r ~~ x ~Q~O ~ f9 ~ y 4,s CD ~p ~ , nO.C~1 ~ ~ f ,~oao- ~., ^, ~ -v 3 m ~~~N~ ~~°w ~~ ~' o o _~: ~ ~ :~ ~r~. a ~ ~' ~ w ~ - ~ :~ '~t D A1~c mks (~ ..y ~a' ~ ~"'~ r~.. ~^. ._,~•. y ?~~ D. () Q nw~~ ~~ ppDw~ tDnm OOC~~ cr-n~~` m~ `'zv'G°~~ ~ cn~ ~~ ~~ ~ ,v -n ~~? xm ~.. rn~~ ~ z ~n o c~ nZ,~ DW--~j 1'A r _ -~ ~ 7D D v~ ~W ~oN o~~ t3 o A ~ ~ _ 7° u -o m~ ~m~ p 4' ~ < ~, ~ A ~ _ o~ ~ j o ~ ~ ~ t n ~ r ~- Q n`i ~ O m ~ 0~0 ~ a ~~~~' . ~~ ~ ao-v~ G~~ ~~0m~ o~o~ o ~_ v 2 f ~~ ~. o~ Q CV.1 A REV 1503 EX+ (fs-98) SCNEpVLE B COMMONWEALTH of PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Martha H. Shuftlebarger 2109-0860 All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) ~~ a ~ °° ~ ~~ ~ v v ~. ~ p ~ ca at ~! p ~ U"i :A W ~ N r G ~ ~* ~ ~ t"''D cp • 3 ~ ~ ~ ~ D ~ S ~ ~ Q ~ 3` ~ ~ E n ~ N ? ~` ~ ~ ~ ~ ~ "' ro Q, c C7 ~' p, ~ c C7 Q, ~ w < ~ p -• ~ ~ -. -' ~ L c o c a 4s >> w ~ ~~ ~ a .•- a > > ~t `Q ~ ~• C m l11 ~ ~ ~ .. 7 tip C ~ 4~3 c ~ ~ ~ ~. a C p• e~ GL ~ .~, d w Q N .. ~~ ~, ~; .. ~ w ~. ~ p ~ A ~ ~~ ~° ~ ~~ ~ a ~~ ~ ~o ~ > > ~ ~ _~ ~~ =~, a (~~j x ~o a~ ° ,Q ~ ~ ~ w ~ ~a ~~~' ~ o `D ~ ~.~. ~ ^ ~ V~ •r ~o ~~' to o a ~ ~ ~~ fli 3 ~ ~ ~' vi c ~. ~~ ~~ o =• ~ .. ~ C G C ~ ~ to ~1 a lV (~ _~ n• ~• ~, o- a O 4~ C a lJ ~ c ~ n ~ _O ~ ~ ~g c~ v ~b' ~ - N W ~Q ~) m D d m D z~ Z ~, ~ w m •~ m c~ ~~ ,~ O a p/ «« 0 m O O m D Q'' CJ1 0 Q c~ ~I~ rn w N m N ~D- ~R.r t0 to ~~~ ~. N ~ ~ ~ c ~ K N s~ g ~~ om ~ ~ v o~ v, i~ w n~ = o co cn .v a~ cn ;~. w ~, ~ m -p6 wc~ x ~~ ~ ,A ~NQjf to ~ ~ (u p j ~ to ~ O ,f~H N N ~0 !,a C~"~ V NCVi1 N ~ ~ N _C~Tt 4J 41 ~ ~ W Oo CD O) O Ut v c.1 w !mob ~ N f.1 W ~I N ~ ep rn tJi h~i ~v Irv v Iii ~Ci ~p ~' N V 0~ ~ 6D 0 N -+. CD N '~I N V A ~ ~. .. (O ~ rmrt D ~ ~ -~o ~ Q O ~ 'moo D D S °o O A ~ ~ cA z O ~ `D V~ ~ ~ $ 0 ~ ~ 4 O Q r" ~ ~ S ~ ~ ~ ~ n D - ~ 70 r ~ z ~ ~ c C,7 G Q ~ -~ J p C ~ N ~ O ~ ~ < ~ Qo ~ D rv '~+~ '~. ~ oD ~ ~ ~ R1 ~ 1 D s Z ~ '~' (7 (y ~ (~j n g `C ~ -~-~ rn a ~ ~ ~ ~ n ~ v c~ X k~ av ~ a r.., L. .~ b O ~. rn ~ ~- z ~ ~ c~ ~ p ?~ ~ ~ ~ ~ ~ z ~ ~ rn '~ m ~ a. ~~ ~ ~ ~ v ~ ~ ~ ~ ~ a ~~ ,~ o ..~ ~ o „ ~~ w C ~~ ~ y .D ~ o 'O ~_ ~ w ~° °~ m ~~ ~ ~ ~ oa ; ~ ~' ~ ~ ,~ ~- ~ ~ ~ o R' ~~ ~ ~ ~ E9 E~ ~! EA ~A fA to 69 Ef'i iH 63 E!~ Efl EA to EA EA ~ v- O ~ .~ o~ ~ ~ W ~ ~ N ~ .. ~ _ _ N ~_ ~ Cri (O (~ W t~ O s c.~+ a .A U1 U1 -W+ N Q O W ~CNO ~ ~ ~ W~ 1 N 4~d ~ c~0 O Q -J ~ O~iD ~ CNT~ ODD W CN~1 c0 of '~ a ~ ~ c~ t~ ~ ~ ~ to ~ ~ ~n ~ ~ ~ ~ ~ ~ ~ ~ ~c -, ~~ m t ~ w -~ e y' ~ ~ Cif VI W W y '~ "'~` !I --~ ~ ~• -+~ N W cC7pp'~ ~-pp~ V ~ W C11 ~i b Al Q ~N~+1 cp ~ C7'~ ~ m cp QD 'V O cC~ ~o ~ ~ ~ 0~ co O ~ Q .C. ~ N ~ v W N ~ ~ ~ fJ~i i W GTi CO A --- V ~ ~ ? y C~ -' C!t m ~ ica ~ io cf =.1 o N -~ ~p ~ ~ ~ ..a A ~ ~ GH bA EA 69 EA ~A FA 69 b4 69 d- ~F! 6H to EH ffi EA ~ -- `~ ~ a ~ a o~~~ ,~ o c~+ ~' ~ ~ $ ~ ~m cn m c y ~_ ~ y ~ Z ~. '~! 01 A~ tD •.. O a a ~ z ~ 7 1 V .~ :O y REV 1508 EX+ (6-98) SCI~IEpULE E CoMMONwEALTH of PENNSYLVANIA CASH BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Martha H. Shufflebarger 2109-0860 Include the proceeds of atigation and the date the proceeds were received by the estate. All property Jolnty-ovmed with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Checking Account 194856-11, Members First FCU,1166 Walnut Bottom Rd., Carlisle, PA 17013 15,541.87 Dividends YTD 9/4/09 17.60 2 Money Management Acct. 194856-05, Members First FCU,1166 Walnut Bottom Rd., Carlisle, PA 17013 21,824.38 Dividends YTD 9/4/09 110.23 3 Regular Savings Account 194856-00, Members First FCU,1166 Walnut Bottom Rd., Carlisle, PA 17013 59.77 Dividends YTD 9/4/09 0.25 4 Personal Property 1991 Toyota Camry, Fair Cond., Kelly Blue Book, $750/ Disc. to $650, in need of muffler and piles 650.00 Furnishings 7,060.00 Jewelry 300.00 Miscellaneous glass, pictures, accents (6 plastic tubs); matress and box springs (2) to Vols of America 0.00 Piano 25.00 5 Unearned Premium Return/ Genworth Longterm Care 3,991.44 6 Returns/ Newspaper Subscription, Tem~inex, and Comcast 257.15 7 Final Payments (2), WV Public Employee Retirement Benefits 545.88 8 Unearned Premium Return/State Farm, House Insurance 221.87 9 State Farm Auto/ Uneamed premium return 85.63 10 Fed Inc Tax Return 2009 Form 1040 2,330.00 11 Pa State Inc Tax Return Form 40 559.00 12 South Middleton Twp School Taxes/ Credit at House Closing ~ 687.11 13 Cumberland County Tax/ Credit at House Closing 8.58 TOTAL (Also enter on line 5, Recapitulation) ~ 54,275.76 (If more space is needed, insert additional sheets of the same size) Account Detail ~~ ~ -__ - ~~ l~ Fage 1 of 2 F:^ _ -'.ii LS CC'1I;;Ll r7C^ „~':,v&r,;c;:i5 Fi:__•,,.~~i~..._-Fiu...~.ri.._:i Account Sumttmry Transfers eStatements Bilt Payer Services Visa Loan AppPtcations My Profile Messages ' ~fiev,~ Acccrcir~c Fiaiory ~ . ,:...,i r .: Account: Sii -CHECKING ~hanae A~cQunt De~S,r~t~i 8alalACe: $1~2$ i ~, RAE;.>~ ~f/~ ~ f r'`i l.ArF. ~ ~ ~ ~y'~ 8~ , ..,~~ Available: $15,531.28 Lat;t Activity Date: 9/6/2009 e a ~; ,- Dividend Wet Year: $30.87 / ,. Dividend YTD: $17.60 / '~' Phase Note: The use of inappropriate langusge in personal account descriptions v/rtH resuit in the removai of this privilege. <.'t ~•vi.. ~ : ..>', •~ Y.... \~iy:^: Arco+.~nt History Sll -CHECKING PJra '1Yansactia;~s Peri,lir~0 •:-~~, iii.^i~'e'r V~eG~~~ Accor~nt Detail Account History: S11 -CHECKING Cleared Dates Ail Last 30 Days o Last 60 Days .Last 90 Days Last 120 Days Date Range: ~_.__._~__.._.__....__~_.~ - C_..~__.~..____~ . Show Oniy: Any type of transaction Description: Check Number: - Amount: Search Ciear~ '-/Printer Friendly Download fort-Money/Quicken 99 & later -Quicken 98 irSpreadsheet -Web Conn ect (OFX/QFX) O#~e D~crip 1t_4r~ A2~9ij0.ti OS?I~S~ C~~iS' 9/6 2009 SOLI THE HOME DEPOT 462585 CARLISLE PA %% Card iS #56008 $-10.59 $15,531.28 ~ D~ g ~ /4/200 .Check #000633 - ~w Sheck #633 -+ Uuy~C-Q,.. $-205.40 $15,541.87 ¢~ ,~ 4 /3/2009 From Share 00 $1,395.00 $15,747.27 9/1/2009 0006320035107491 Processed Check - Embarq :BILL PYMT Ib: ~-54.24 $14 352.27 632 2202975500 oaTA: i-888-723-8010 9'0% ACH ECC ARC , 9/1/2009 0006300129868938 Processed Check - UGI UTILITIES : UTIL PMT ID: $_17,87 $14,406.51 630 231174060 %% ACH ECC ARC %% ACH Trace 011500129868938 9/1/2009 From Share 00 $322.51 $14,424.38 8/31/2009 APY Earned 0.15% 08/01/09 to 08/31/09 APYE Avg Daily Bal 15,376.61 $1.96 $14,101.87 8/31/2009 Check #000622 -View Check #~72 $-439.99 $14,099.91 f~ 8/31/2009 #006610 MEMBERS 1ST FCU 1166 WALNUT BOTTOM RD CARLISLE PA c~_40.00 $14 539.90 %% Card 15 #56006 , 8/29/2009 Deposit $100.00 $14,579.90 #005801 MEMBERS 1ST FCU 1166 WALNUT BOTTOM RD CARLISLE PA 8/29/2009 °Yo% Card 15 #56006 ~ /fj $-100.00 $14,479.90 ~'1/ ~ 8/28/2009 0006280023284038 Processed Check - ICPENNEY/GEMS : CNECKPAYMT y_153.05 $14 579.90 628 ID: 0301200401 %% ACH ECC ARC %9~o ACH Trace 021000023284038 _ , ~ 8 _ _ ,iEsinr~h k # _u~ . , - ~ - 14,732.95 ~~ . • .. 8~7j2II09 Check #000629 - Vfew~h c~k #~f 2~ 8/25/2009 From Share 00 8/25/2009 From Share 00 8/24/2009 #004161 MEMBERS 1ST FCU 1166 WALNUT BOTTOM RD CARLISLE PA %% Card 15 #56008 8/23/2009 GIANT FOOD #112 CARLISLE PA o10% Card 15 #56008 $-58.07 $15,032.95 6~.~ 1 ~L ~y,,. $389.48' $15,091.02 ~ ^~i $155.90 $14,701,54 V $-40.00 $14,545.64 $-24.78 $14,585.64 Dig 0 ~~~ Detail 8/22/2009 NELL'S -WALNUT BOTTOM CARLISLE PA %% Card 15 #56008 ~-12.9b $14,610.42 8/22/2009 NELL'S -WALNUT BOTTOM CARLISLE PA 96% Card 15 #56008 $-10.31 $14,623.38 8/22/2009 Check #000627 -View Cheek #62j $-16.50 $14,633.69 6~ ': 8/21/2009 6260216406641 Processed Check -MET-ED :BILL PYMT ID: $-94.34 $14 650.19 626 2258580002 % r6 ACH ECC ARC 9696 ACH Trace 053000216406642 , 8/21/2009 CNS RITE AID CORP. 432847 CARLISLE PA %% Card 1S #56008 $-37.19 $14,744.53 ' 8/19!2009 #002573 MEMBERS 1ST FCU 1166 WALNUT BOTTOM RD CARLISLE PA $-b0.00 $14 781 72 %% Card 15 #56008 , . 8/17/2009 Check #000625 -View Check #62~ $-1,000.00 $14,841.72 rt~5 8/17/2009 Check #000624 -View Check ~4 $-10000 $15,841.72 ?~4 8!17/2009 Check #000623 - V<ew Check. #6?~ $-s.61 $15,941.72 6~3 8/12/2009 Check #000618 - V~~w Chick #618 $-65.72 $15,947.33 61$ 8/12/2009 0006160019223190 Processed Check -AMERICAN EXPRESS :ARC PMT $-93.22 $16 013 05 616 ID: 9133133497 9696 ACH ECC ARC °!o% ACH Trace 091000019223190 , . 8/11/2009 Check #000617 -Vie eck #617 ~-45.75 $16,106.27.617 8/10/2009 Check #000612 - VLe~h~ck.#6~2. $-10000 $16,153.02 6~2 8/10/2009 Check #000620 - ViP~~~Q $-5000 $26,233.02 639 8/10/2009 Check #000603 - li~w.~i~~ #~Q3 $-50.00 $16,303.02 ~p3 8/8/2409 Deposit $317.94 $16,353.02 8/8/2009 Deposit $46.44 $16,035.08 8/7/2009 Check #000613 -View ~teck #613 $-50.00. $15,988.64 fly 8/7/2009 Check #000609 - Y1ew C~ec~S #6QQ $-8.00 $i6,038.6a ~ 1 8/6/2009 0006100038227192 Processed Check - Embarq :BILL PYMT ID: $.62.71 $16 046 64 610 2202975500 DATA: 1-888-723-8010 96% ACH ECC ARC , . 8/5/2009 Check #000615 - Vlew Check #~5 $-200.00. $16,109.35 6~ 8/5/2009 Check #000611 - Vigw CheClc #~~ $-72.10 $16,309.35 ~1 8/5/2009 Check #000614 - y~,Qy~C eck.~~4 5-x9.00 $26,38i.a5 ~]4 8/5/2009 Lifeline Systems :DIRECT PAY ID: 1042537528 DATA: 985435 CO: $-40.87 $16 430 45 Lifeline Systems 9'0% ACH ECC PPD 9696 ACH Trace 011500126948407 , . 8/4/2009 S MIDDLETON TWP :DIRECT DB ID: 2231881662 CO: S MIDDLETON $-103.50 $16 471 32 TWP °1696 ACH ECC PPD %Wo ACH Trace 022000044056594 , . 8/4/2009 0006080016303932 Point of Purchase Check - WAL-MART STORES ~-26.31 $26 574 82 608 Termina{ City & State -CARL PA :PURCHASE ID: 9037012574 , . 8/3/2009 0006050026906973 Processed Check -STATE FARM RO 27 : PYMT ID: $-309.00 $16 601 13 605 9000307003 %% ACH ECC ARC °Ib% ACH Trace 021000026906973 , . 8/3/2009 From Share 00 $1,395.00 $16,910.13 8/3/2009 From Share 00 $322.51 $15,515.13 7/31/2009 APY Earned 0.1596 07/02/09 to 07/31J09 APYE Avg Daliy Bal 15,623.46 $1.99 $15,192.62 7/30/2009 Check #000604 - V'ew h ck #6Q4 $-48.00 $15,190.63 ~iQ4 7/30/2009 0006060129408987 Processed Check - UGI UTILITIES : UTIL PMT ID: ° $-15.20 $15 238 63 606 231274060 °k, ~ ACH ECC ARC %% ACH Trace 011500129408987 , . i~ Return to Previous Pape Page 2 of 2 Page 1 of 1 i-,~ .. ...~liit.a ta,.!rAfi,r, ._..S&E1lc~,TS PG.._.,';T:'.,... R. .,C}.. ._., It Summary Transfers eSteteme:ris Biq Payer Services Vise Loan Applications My Proble Messages ~~ .~, 7 - Month Term .~,;sr '`;`~, vie•r; Accou>>t i-fistcry Account: SOS -MONEY MANAGEMENT ~~Q4.~4~ount~~pt9n a Balance: $21,824.38 t/' •Af'Y Avallat>rle: $21,824.38 15 -Month Term Last Activity Oate: 7/3/2008 Dividend Lsst Year: $360,30 a Dhridsnd YT'D: $110,23 / 'APY Rty-D (VY~t at_is~teg_4?j: 0 transfers, 6 remain Rey-D Transfers: 0 Rey-O Checks; 0 PNatM Note: The use of inappropriate language k1 personal aOCOUt1t descriptions N6iI rosutt in ttte rortwval of this privilege. i,; '~i~'+9 ~`}.:r, °.4iz,r;,= vies;; Account tllstary S05 -MONEY MANAGEMENT t~,c: Transactions i~ercri~ic~ ?~.~,r,>+_ara~. tii~:f~'~~r Jie'.vF+CCOUntDetail Account History: S05 -MONEY MANAGEMENT Cleared Gate: All -Last 30 Days o Last 60 Days Last 90 gays Last 120 Days Date Range: (~.___~...~._._.._.._..___~ I ~.__.._____.____.__~~ Show OMy: Any type of tranaactiort ' Description: Check Numbter: - AmouM: Searcit~ Clear Printer Friendly llownfoad for:-MoneylQuictcen 99 ~ Later -Quicken 98 tSpreadsheet -Web Connect (OFX/QFX) D~t~ Q~SS~Rt1Qr! Amour ~O.S~~ 8/31/2009 APY Earned 0.60'16 08/01/09 to 08/31/09 $11.12 $21,824.38 7/31/2009 APY Earned 0.60% 07/01/09 to 07/31/09 $11.11 $21,813.26 1 _____ r_Return to Previous Paye~^_`~ .. ._.. ..' J - . nt Detail Pale 1 of 2 ' ?;.,... _a~i ~+S C•v,:i, ^Tt~:, ..~.., c: •_b<;:i5 ~ ..'..4Ti..,~~ fit_._J'.,,__ Account Summary Transfers eStatements Bill Payer SeMces Visa Loan Applicatbns My Profile .Messages ,.: r.•~;:. i Vic,r: Ac+:~ur~t itistot'Y Account: S00 -REGULAR SAVINGS ~h~n.9R~~o.~Dt D~~crip~ion Balance: $59.77 {/~ Available: $54.77 Last Activity Date: 9/3/2009 Dividend Last Year: $0.60 Dividend YID: $0.25 Req•O (~-hai:s Rag-C~?)s 0 transfers, 6 remain ReB-D Transfers: 0 Rep-D Checks: 0 Ptsasa Note: 71w use of tnapptopriate language in personal ao00unt descriptions wiN resuk in the remove! of this prtviiege. ,'r i : ~' ° '+. Vi~•,: Account Nistor}~ 500 -REGULAR SAVINGS Pdo i'rr.~~s=srii~JiIS Pertdi~» ~~.~~ ,.. t'i ,~,~~~'~ V~~~~.~ Ncc~:,~ir2tDetail Account History: S00 -REGULAR SAVINGS Cleared Date: Alt Last 30 Days ra Last 60 Days last 90 Days Last 120 Days .. _ Date Range: ~ ~_ . _ .___.___ ___._ - - ~~.__. __~~__ __-- ~ Show duty: Any type of transaction Description: Check Number: - Amount: Search Ciear~ Printer Friendly Dot„m{oad for:-Money/Quicken 99 & Later -Quicken 98 -5preadsheet -Web Connect (OFX/QFX) Date Oescl:IRtiosl Amount $a1~st: 9/3/2009 To Share 11 $-1,395.00 $59.77 9/3/2009 SOC SEC ID: 3031036030 CO: 50C SEC $1,39S.00 $1,454.77 ~^ 9/1/2009 To Share li $-322.51 $59.77 9/1/2009 BENEFIT PAYMENTS :PENSIONS ID: 9186063000DATA: BPP3291524 CO: $322.51 $382.28 BENEFIT PAYMENTS : 8/31/2009 APY Earned 0.59% 08/01/09 to 08/31/09 $0.03 $59.77 . 8/25/2009 To Share 11 $-389.48 $59.74 8/25/2009 WVTREASURY : TR-PENSION ID: 1556000814DATA: WV CPRB CO: $389.48 $449.22 WVTREASURY 8/25/2009 To Share 11 ~-155.90 $59.74 ; 8/25/2009 WVTREASURY : PR-PENSION ID: 1556000814DATA: WV CPRB CO: $155.90 $215.64 WVTREASURY 8/3/2009 To Share 11 ~ $-1,:395.00 $59.74 8/3/2009 SOC SEC ID: 3031036030 CO: SOC SEC $1,395.00 $1,454.74 8/3/2009 To Share 11 $-322.51 $59.74 8/3/2009 BENEFIT PAYMENTS :PENSIONS ID: 9186063000DATA: BPP3291524 CO: $322.51 $382.25 BENEFIT PAYMENTS 7/31/2009 APY Earned 0.59% 07/01/09 to 07/31/09 $0.03 $59.74 7/24/2009 To Share 11 $-389.48 $59.71 7/24/2009 WVTREASURY : TR-PENSION ID: 1556000814DATA: WV CPRB CO: $389.48 $448.19 WVTREASURY 7 -Month Term °' .~ 'APY 1S - Month Ternt s~ •APY ~ ~ ~ e ~-~'a~ng~+~ -6 o G(nec.~: tv~ ~ s ~ c~y 1~u._ _. /I.._ 7 _1' 1 1 In 1• T 1 • f • ./'f 1 • .rte •• .. •i •w.+.+.. Page 2 of 2 7/24/2009 7o Share 11 $-155.90 $59.71 7/24/2009 WVTREASURY : PR-PENSION ID: 1556000814DA7A: WV CPRB CO: $155.90 $215.61-.. WVT'REASURY 1 ~ .~ _ w Return to Previous Paga~ _.._ - - -- - - ..., .. ..,. .. ... r . .r. •, n i~ innnn J ~. t '~s~+t}t~)ic~r,~t~ii~;t~~~i-~r un~~t~a~ nut Bottom 6 Walnut Bottom Road lisle PA 17013 uiriea Call: 717-249-4666 t XXXXXXX435 ESTATE OF MARTHA : 10/03/09 Date: 10/03/09 0398 Time: 10:04am osit to CHECKING 11 v Bal: 14,449.53 unt: 650.00 Bal: 15,099.53 #243748 ck Received 650.00 Authorized by CERTIFICATE~OF TITLE FOUR-A VEHICLE ~ ~< ~- -.DATE SECOND LIEN FAVOR OF: -ODOMETER STATUS - 'D .=~AGTUAL`:MiLEAGE t.a MILEAGE EXCEEDS TFIE~MECHANiCA! LIMITS, . -2 m NOT THE ACTUAL MILEAGE ` '- -3 =NOT THE ACTUAL M![:EAGE•000hi>=TER =_ TAMREHING-VERIFIED - 4 =EXEMPT FROM ODOMETER DISCLOSURE TITLE BRANDS A =ANTIQUE VEHICLE C =.CLASSIC VEHICLE D =COLLECTIBLE VEHICLE F = OU7 OF COt7NTRY O'. ORIOINALL'f~MFGt7~.~FORNON-U.S. DISTRIBUTION H =AGRICULTURAL VEHICLE L =LOGGING VEHICLE P = ISIWAS A POLICE VEHICLE A > RECONSTRUCTED . S =STREET HOD T ~ RECOVERED THEFT VEHICLE V ~ VEHiCLE'CONTAIN5 REISSUEDsViN w _ FLOOD VEHICLE . X =' i31WAS-A TAXI If a second iienholder is listed upon satisfaction=of the-first lien; the -first ' Iienhoider. must farvvard this Tftle?sto-the':@ureau of -Motor Vehicles -~~ith the - appropdate form and fee. ' - _ - SECOND LIEN RELEASED AUTHORIZED REPRESENTATIVE Source: Drv Lic SigCard ©~'9Q~ Known ~ ~ 5~~~~~~~~-~~~s~~ other ?G~~fA~f #3~ tnafar your balances to a Members 1st ~;-~ ~~~ ~'~~~~ ;A Credit Card and receive a low 3.99~a t introductory rate! Ask for details. sue, the official records of the Pennsylvania Department ATE OF MARTHA J HAYNES SHUFFLEBARG ne person(s) or company named here{n Is the Lawful owner rtc~,irs-ars . (f .~~ `w.la~ ~..l~ V 1 BY. DATE AUTHORIZED REPRESENTATIVE j Secretary of Transportation 3 a-vl:, 9 ~ If a co-purchaser other than your spouse is fisted and you want the title to ):BEFOIRE ME: t) SWORN ~~-- , ( I be listed as "Joint Tenants With Right of Survivorship" (On death of one _ Mo. Y owner,=title,gbt3s to urviving owner.) CHECK HERE O. Otherwise,•the title :wilt-be.issued as "Te~anis in Common" (On death of one owner, interest of } ~ jcr t,~,c' , ~ deceased owner goes' to his/her heirs or:estate). SIGNATURE OF pERBON ADMINISTERiWO OATH 1ST GEN DATE: ~ tF NO UEN, CHECK t Commonwealth .af Pennsylvania NOtar>taI Seal 1ST LIENHOLDER ~t DOf7Vx811 /A+~-. REt211iIIg /~ . STREET C~arligl~`$orough, :Cumberland COU~11~ I CITY :STATE ZIP ~:My>Commiseion Expires:Febrtuary 4, ~20I0 1 FINANCIAL INSTITUTION NUMBER .'The underaigrwd Mraby :makes apptiplion for. Certificate of Titfe to the vehicle descrioed above. Subje[t to U78'ltICURlbr8fIC8S and other legal G81rn5serlprth here. 1 ~~!/ ~:SIGNATUHE OF APPLICANT-OR AUTHORIZED SIGNER 2ND LIEN DATE: 2ND LIENHOLDER STREET cITY -.R IF NO LIEN. CHECK _~ ..' STATE _ ZIP '_ ; _ ~ y FINANCIAL INSTITUTION NUMBER . SIRNATURE OF; CO.APPLICANTRITtE OF AUTHORIZED SIGNER I Sc~ Ids t s ~~ V~~~n ~- c ~~ ~. ~~- ~ , a ~ ~ /1 ~r~ G~~~ r~ V 1 ~~ O ~y~yy ~.J~./ ~. ;. .. w -` - CERTtFICATE,C7F=T TLE F~~R-p- AEI-ttCLE ~,. ~.~ ~~ REGISTERED OWNER(S) { z, fa~~ _ ir#A`~R"~~'~A 'H ~~HU~i~I~~~~~~~R'ttr~~r~ , ~3.1~1t .}t,,z:r , t ~ to , ;. - , -. ,_ FIRST.LlEN FAVOR DF: FIRSTliEN RELEASED :DATE BY AUTHORIZED REPRESENTATIVE MAILING ADDRESS SECOND LIEN FAVOR OF: if a second : llenholder is listed _upon satisfaction -ot the airst lien, he 'first lienholder. must :forward this Title'<t0=the'Bureau `of: Motor -Vehicles -with the - ' appropriate form and fee. - SECOND LIEN RELEASED DATE ~~~ Q~~ - ~A~tTHA ,H 5~i3#~~Fl.~8~4R~~R ~3 ~ I tl~E~l<A~Y ~fR GARLI`Sl~ .~'A _~7L1~,~3 I certify as of the date of issue, the official records of the Pennsylvania Department of.Transportetion reflect that the peroon(s) or company named herein ie the lawful owner of the said vehicle. ~DONIETER STATUS ' t3.-~ AC=TUAL: MIL@A4E 1s MILEAGE EXCEEDS THE-MECtfANSBAC LIMfTS-. ' 2 =NOT THE ACTUAL MILEAGE _ - '- - 3 =NOT THE ACTUAL MILEAGE-ODOMETER TAMPERiNt3-VERIFIED - 4 =EXEMPT FFtOfd ODOMETER DISCLOSURE TITLE BRANDS A = ANTfOUE VEHICLE C =CLASSIC VEHICLE D =COLLECTIBLE VEHICLE F ='OUT OF COUNTRY Q' = ORIGINALLY-MFGD: FOR NON-U.S. DISTRIBUTION H =AGRICULTURAL VEHICLE L =LOGGING VEHICLE P = ISANAS A POLICE VEHICLE -R = gECONSTRUCTED S =STREET q00 T = gECOVERED THEFT. VEHICLE V = VEWICLE CONTAINS'gEISSUEO-VIN VI= FLOOD:VEHICLE X =:ISNJASA'TAXI BY AUTHORIZED REPRESENTATIVE Secretary. of Transportation SUBSCRIBED AND SWORN .3 a'0C7 ~ ~ If a co-purchaser other than your spouse is fisted and you want the title to be listed as "Joint Tenants With Right of Survivorship" (On death of one TO BEFORE ME: M ~ av ~ vFJ1 - owner, title goes fo; ul'Vivirtg owner.) CHECK-HERE O. Otherwise;~the tide' ~ / .will bt3.issuetl as "Tenants in Common" (On death of one owner, interest of , ~y~--~~j-'C/'~' ~ :. deceased owner gees to his/Yter heirs or:estatej. ' 'SIGNATURE OF PEgSON AOMtNtSTEAtNO OATH - ' !, CHECK 1ST GfEN DATE: ~ IF NO LtEI ealth ofPennsylvania _ 'Commonw ~t .NOtanai Seal ~ 1ST LIENHOLDER .,~ ,:. ,c . Deborah A: Railing STREET ;A ~ ,t Carliale,Borough, ;Cit~mbCrlattd County f CITY STATE ZIP My ~Commisaion ExpiresFebruary 4s r2U I0 I FINANCIAL INSTITUTION NUMBER r the urbersigned .hNeOy tnehes epptiption for l:ertUicate .col Title M the vehicle tlesc6bed shove, sub~j~~t two the er>cbmbrartces anN oUUar regal Geinte sellonh here. ~( ~,~;/ t 1 L-~' SIGNATURE Or PPpUL'ANT OH AUTHORIZE!) SIGNER 2ND LIEN DATE: IF NO LIEN. CHECK -2ND l1ENHOLDER STREET crrY STATE ZIP r slowt~uRt: OF.CAdpPUCANTrTtTLE of AUTHORIZED SIGNER FINANCIAL INSTITUTION NUMBER TYPE OR PRINT) Certificate of Title must be submitted within 20 days, unless the' purchaser is a registered dealer noltl~ ,. 4 ,, _ _ 1NAR N I N G - ro'co~Pl~ op PH01Y b Na A AL'S'E STA?NTsMAY pESIJLT~N~~NESdifJDfC~R MPRISONMENT. x}IE TRA~tBFER Rsgbtered d9'Rlsrs ~muai COmplete'tptft~'M427A 6YY2TS , ~ ? _ LAST ,~ ASSIGNM1AENfi OF-TITLE- ' id1 ~ ~°'{"~' ~ ' o n~i ``~ m t~; . ro tu a , s. p PUR6HA9Eii~7R FULL ~'~~/\ !" ! `•~/~ Jtr< t= A N SSN ME IANe certdy t the beat of m /out' knowledge•that the otlometer reading Is = sUS1 TENTHS ' CO~PURCHA5ER ~ ~ ~,,~ miles and reheols the-actual mileage Ot.ltle veh~fe, „ ..::,..~' ., : ~ /'' 1, STREET -` ~ L+C./ ~~ /~ G , uhlpse one of theioUowing bones is checked: ADDRESS ~R6[fleotg^tg6"!>Rwutftltfv~f(Iegge ~IS'NOTthe actue! mileepe"" CITY ~ 1 ~> ^ ' WARNING: Odometer discrepancy l EJl ^ f ' . mits its meehan ca ,Irt exc9ss o V1Ne turther;aert-lythpt ttle.wehicle,lstAee of anyencumbranceand that ownership is hereby ~_ PURCHABE'PRiCE g - c- n ZIP ; ~ (~~~" ~ OR +-~0 , STATE ~ DIN . : ~ p J v . : ; ~trartslevBd W lhb:~~rooR(9] oYthe~e8ter liat~d. SUBSOt~[~~fl~Af~YDfi~If~E3N~ ~ ~~ ~ , ,.. ~~ t VDU ~ _ ,~ _ X ~ TO BEFOi~E E: :DAY Y AR / PURCH SI A RE ~ _ _ _ ~ ~_ `~ ` M is OATH RCHA$EA ~ _ ~~`'~`' - - ; ,i~~: ! z ;°' } ` l , PIJRCHASGR AND/O ~ _ ~ ~r ~ - - CO•PURCNASER"MUST ;/i d' _~vl~',~ ~~ ,~~ . ~ ~~ ~~V> U _ - ` _ _ ~~ C J i~ 4 ~~ I II'~~~1-q'ElHtila ~ _ _ ry f~ .. ai'i 'b ~ ~ ~ ` =; _ --_ SI TURE'OF (vY3S EA (, ' ~ ~ ~'(~~~ ~~ a+ ° ~ z" ~( N Q ~ """F - ~ _ ' rr~~ ~ .MUST C ELt: ~ c ~ ~ ~CQyN IV-1 ..,A!{(~ 1: s~CC~ ~IAM E-~ NAI1DPRlM ~ ,; _ ; ' a ~ ' ~ ~ ~ ~ ~ ~ Q Cet`tlfy~o'ttte`bestrof my/our krl0wletlpe tt~t~the bdometer reading is ~ x . LAST FIRST M.I. . TENTHS ` ? ,:,•_,>~,,..,~.:,,t.~_,1,.~, .,~: „~~-miles=artd reflects the actual mllea,!)e of the vett3cle, a PURCHASER OR FULL BUSINESS NAME r unless oiis~it ltte totbvrlny'.boxetrls,checked +e~a[>Nxmt of ~i~ ~~ Is<f>tOT~ the aca,at milespe " (('~''~ R911eotsa`tl CO•PURCHASER r C , LJ+~in~~wceB6°nt ktt'mei~enicel kmlts~+ ~..^ WARNINC3: Odometer~BisCrepanoy' 'STREET . I/YVe turtfteT~'dAtNf~+`thaMhe V9hl~t1A',3s free~oY~njr encumbrance end that theiovJnership;js hereby, 'ADDRESS G tranafertedLU~~ltltl~perepn(s};t~GYtfeiliealerafBted: CITY ( SUBSGRIBEDtAND SWORN '- <; . 'TQ'BE~RE~NIE: - ~ _ ~BtyR A E ~ ~' =6N SEP{ -~--- .,STATE 21P ~ ~ ( - °'.; - .:,:DAY R s~ ~ ~ : ~ ~ ~ g =~ ~ _~ _ _ ~ MI ING OATH L _ S1~ _ _ _ ~ a. ~ __ - - q ~- ~_ F U SI T R ttJ -; ~ -- .~ - - _ r :~ F _` 4 ~ __ '`~ - i•8 ATURE OF E R C I' _ _ ~_ =FfAAfDPR/f~'1xNAME~ERE=i ~ 11 ~ ~ , c ~ElWt1 osttffy to thtt.bstEt of my/DUfJcnowledgeithat'tfte odometerreadlrtg-is - - LAST FIRST ML: r . > TENttls , ~ r~,.~..o~~ ~VECPf.~.~.,.a,;:°,,f;° ~~,~,,ar.~ mlles~dreflects the actual mllettge`of the vetlide, ` ~ gUSIRNE~SSERNMIE~~ ( ' ~uruess nne of ~g bozes:.is cr,edieii r Fiefleota~the-arrxtlmt.ot mtl@t-9e ~~~ 'Is'fJOT the actual mileage" ~ CO~PURCHASER `^ sWARNING:Otlometer.disCnepaACy . ^ inexceBSOtkentechat~lpalllrtilts . BTREET F UWe lurthe-.t,f[y ttwt"thetvt9i'11dB>is~Nee of Rtiy 9~/~1 th8t the'owner911ip~ts hereby. ;AODAESS ~'. ~ e ttansterred to"the'person(9j ordhe`dealer listed. Ct1Y ( 'S3UBSL~IBED ~VD Sk4fL~#~N TO"B&'~`C~RE+1dE> ~ °' - ~~"~~~~ASE ~ }Y~- BTATE ZIP ~ ~ r s O.. :DAY Y 'R ~ °~ - - _., - ~ TURE. Fr=PERSONA hiIN18TERINf3DATH ~ -- E'R St PUR M R S AT --~ ~_ ' ppi~pp ~~R ~ R~iEU~ ® i - ~ ~ - ~~I.LER L i ~ _ HANDPRIM'NAME F+EAE~ EiWe certity,:to'the beAt of my/our~krWtivladge'UtaE~,the.odometerteatSing is ~ >' LAST FIRST ~M.(. p TPJViHS ,,: ., - - ~, ,x..3~:P ~~yT,~3"~°~ tio,~,:~ ;~~ rriNea~HDd r&Iletks"the~ttCtUal mileage;of the vEhlcle, '~ ' ~ ~ PURCFIASERDA FULL BUSINESS NAME . unless',onebf ms'~Ilmyitlg twxea~i~cheokec( ~ ~ ~ ~~> ~ ~ ~~ Is NOT the actual mUea je~ (~ f~idfbdta'dte atratxtt of Ireleage ~-PURCHABER ^ S . in~axcesS;of its rtlsdienk;aE-emits . WARNING: OdorneUardisq{epartcy . L STREET _ IM{e furthEr:cettfty that the iVehlcle iti free of airy encumbrance and tttat:th8 ownerehip~s heroby, . .ADDRESS tt'ettsfetrodtOlhA person(s).or:tt)atleeler lYstetl. cITY .SUBSCRIBED AND SWORN TO B~Pt)RE ,fvlE: = '~?tIHCHABE Pfl[GE ~'~ STATE ZIP- 3~f~7)IN M <DAY YEAR = z r x -__:- ~ ~ ~° ;'BFGtdI. F . ADFAtNI ING OATH -_ ~ t Rt#fASER A`EU E _ _ =-° ~ -_- ~<~ = _ }fir -~ - -- ~ _ - R IQNATURE ~ _ €- _ URCHASER'AND/O_$~ ~ PUR YCSHR M . ~ .~ . ~ " . ~ ~ f G ,~ ~ Z ~ ~ ` ~ e tY r,. `r ~- ~ _ _ ~ __ ~ 81 TORE OF S L ' ~ ~ ~ _ r , _ ~SfiLt.ERA4 ~uT = ~ ~ - ~ ~ ` NAMECd~E , _ ~i4NDPRf w~ 1- TI'YIdiC <ON 1 nutnv uaoC .te wnbt tl+w'RTIf'-wl .Cl1D 11CA1tCQ f1 f:AlU1D1''st=7iR QCP`TIt1N'R T{TIi1N1': RFF~'~ ' ~ ~~ u RONALD W. MOORE DONNA M . MOORE 60-8111/2313 i 928 WEST TRINDLE ROAD MECHANICSBURG, PA 17055 ~1 ~ ~~ 1' .DATE PAY TO THE ~ ^S r ~ QT ~ ~ "~ ~ ~ ~., ~, ."~,`,~ ~ ~jF r.~,. ~ ,-I~. ~~~, 5_ ORDER Of ~+ ~. ~-r---~~--- d,=' ' U S~curir~ g r r DOLLARS 1 oiu~ia on PSEC HARRISBURG, PA 17110-2990 _ ~,~` FOR ~ ~ ~ ~ 1 U~y n ~ ~1. ~'' _.~..__ _..__...._ ___~_.._..-.--.-..- ~:23 i~38 L L L6~:2660 ~~~04 546 5 2686++' ,~, ,1991 Toyota Camry -Trade In Value, blue book value -Kelley Blue Book SEARCH T~TRU5TED RESOURCE ...___~,...._...._,._•..w.w.,_._ .._.__.,.._ ,.~.~' iloFrlr~ New Cars Used Cars ResAarch & Explore News & Reviews [)eaters & Inventory Classifieds loans & Insurance KSB Y Green llsci f;ar Prices i Searih Used Czar List;nyc ~ Certified Prn U:+ned ~ Cmrrpare Vehkles ( Perfect far Finder ~ Rost Researched Vr_hicles ~ CARFAX Vehicle Ffistory 4'J!!!come Back ~ 5i:~n Fn ~ C'rrate ftre:~unt. ~ Dty K86 2IP Code: 17013 ~ latest Car News HC~?' ~ > .V..~`~ L;d.'S > :?y~ T`Y.~Sd > Solllry > .Sedan 4D 1991 Toyota Camry Sedan 4D Trade-in Value BLUE 8O0K°~ 1'RADE•Et$ VALUE'' ,r:, Private t7arty Value __ uuc~geste:d ?etail Value (>irpt'O Gafi~ry ~, Condition . ~ : -_ .,. ~ Value Corllpar"VP.hICIP.;i ve..+t K!~.` Bide i;c1ol~ F'~evia::~ Excellent #1,225 Consumer Ratings Good $1,t15t) Find Your Next Car Fair X750 SpecifiCiitiCr)S ~ tdare Photos Shopping Tools ~ ~ ~~ ~~ Price Neav Cars Free CARFAX Re~r+rd t'heck Autn Loan from S.4ri':u AF', G~~S a Free Insurance Quote local Listings: Find a C?eatr-r '~h View Toyota Camry ') Search all Classifieds in 170F3 s BtiY A USEQ CAR . i On Blue Book Classifieds'" ~ Avera a Consumer Ratin 9 9 (128 Reviews) R<:<+d Ra±vi:'_.es Toyota r `: $+I~`I"~; 4.6 out of 5 Review this Veh:rie ` Camry r so Rites ~ Similar New Vehicles _ -... - { 2010 Toyota Camry 2010 Mazda MAZDA6 IiP Cnde. 176.13 ~ ': Ta View Ads, Click ~ P.Jz°tQS QlFUta~ ~ ~,gyrl~w R i .w ' ~ Fri 'le Prielna , FINQ INE RlGNT UR More Resorts Compare tfsed vs. New Under SS,ODQ ~ B~rih Nely and used r Vehicie Highlights Sedan r i Mileage: 98,UU0 Engine: 4-Cy1. 7.6 l..iter To View List, Crick Transmission: Automatic Drivetrain: F4'1G YfEW ANaTHER YENf(~E Seletl Year... r ;, !+ ,,. ; t. ~ r Seieeted Equipment Change Equipment .;rrie~;+ c.-.,=_-f ~ 's Standard Air Conditioning Power Steering AM/fM Stereo O~ C:~S~n~tei~`l~~tel~~ry .:Blue Book Trade-In Value i Trade-in Value is what consumers can expect to raceive from a dealer for a i trade-in vehicle assuming an accurate appra+sal of conditron. This value will likely be less than the Private Party Value because fhe reselfiitg dealer incurs tha cost of safety inspections, reconclitioniny and other costs of doing [ business. Vehicle Condition Ratings Check Vehtcle Titre F!istary _ _ ~'~ Save Vehicle Print ?~wa~ Email .`,~ Bo171O'1fiRIC f .':; ~._. .__ add:.il enurrt+. ._._......... Page 1 of 2 r'~ t y, c~~Q vco,,.~" ~ ~~~cu' ~ ~ rr ~~ whet v~-e..QQcY (yt u~ ~c~~- ~ r 6 ( ~p ~ fig `"~"`~ ~ ~~ ~.I C ~~ , http://www.kbb.com/kbb/UsedCars/PricingReport/1991_Toyota_Camry Trade-In Excelle... 10/8/2009 INVENTORY REGISTER OF WILLS OF ~~^^-~X'~Q~n-o~ COUNTY, PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA ~ SS COUNTY OF C u w~ ~.n,r t c~vti o~ File Number ~ ~ ~ ~ "' ~ ~ ~-~ Personal Representative(s) of the Estate of ~1/1ct p-E-tn~ ~ • s ~t.u-~-~~-e~a~. deceased, depose(s) and say(s) that the items appearing in the following inventory include all of'~he personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I verify that the statements made in this Inven- tory are true and correct. I understand that false state- ments herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. G%C~~-u ~G ~•Attorney -- (Name) ~""'" (Supreme Court LD. No.) ~~3~ (Address) ~ `~ llJ e 5-E- ~~`~~ ~•~2rt" C o--r ~ c s 1 ~ _ ~ ~? l 7 ~ (.~ (Telephone) ~ (-? 7 ~~, ~~S"? ~ DATE OF DEATH LAST RESIDENCE DECEDENT'S SOC. SEC. NO. ~ f . ~ 2oa~ ~~ ~~ee ~~. C~d~ts(e f c~A t 7d Ems" 226 -Z~6 - 4 X73 FIGURES MUST BE TOTALED House Mutual Funds /Acct.896-13448-1-2/Edward Jones Money Mkt./Edward Jones Stocks, Mutual Funds/Acct. 896-08529-1-4/ Cotenant/Edward Jones Stocks, Mutual Funds/Acct.896-08538-1-3/ " Stocks, Mutual Funds/Acct. 896-08537=4/ US Savings Bonds Mutual Fund/Acct. 896-09501/ Edward Jones Checking Account, Members First FCU plus Dividends Money Market, Members First FCU plus Dividends Savings Members First plus Dividends Personal Property Auto: 1991 Toyota Camry Furniture Jewelry Piano Unearned Insurance Premiums, Tax and Misc. Returns (Attach additional slTeets as needed) 140,000.00 98,949.80 56.48 35,672.56 35,587.80 35,554.16 7,329.61 32,305.50 15,559.47 21,934.61 60.02 650.00 7,060.00 300.00 25.00 8686.66 TOTAL: 1439,731.67 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative include the value of each item, but such figures should not be extended into the total of the Inventory. (See 20 Pa. C.S § 3301(6)) Forn: RGf/-09 rev. 10.13.06 Martha H. Shufflebarger/ Furnishings, Jewelry Vanity and Mirror: 200 Oval Mirror: 75 Dresser and four drawers: 50 Two steel bedframes; one wooden bedframes 60 Cedar blanket chest: 200 Two analogue TVs 20 Composite board TV stand 10 Coffee table and two small end tables 200 Reproduction china, four settings 100 Doughboy 150 Walnut Hutch (damaged) 200 Single drawer stationery table 50 Two captain's chairs 300 Two dining room chairs 100 Four old table lamps (cords not code) 20 See addl. attached: 5325 Total Furn. 7060 Jewelry Assorted costume jewelry 250 Two zirc, Fake diamond rings 50 Total Jewelry 300 HIGH VALUE INVENTORY FORM ATLAS VAN LINES, INC. ~ " t~c7S® 1212 ST. QEORGE ROAD, P.O. BOX 509 EVANSVtLLE INDIANA 47703-0509 At~~~g i~~b U.S, DOT No. 125550 (800) 252-8885 / (8i2j 424-2222 -""""- • Customer ~ Be sure, to complete the description and estimated value sections on this form fdr al! items in your shipment idered to be of high value or that may require additional attention, special packing, crating or handling. If no items are considered to be of high value or in need of additional attention, write NONE. Examples of High Value Items or items needing additional attention -Antiques, Art (wall or standing), CDs or DVDs (quantity), clocks, collectibles, collections, computer hardware or software, customized items, designer clothing~or wardrobe accessories, exercise equipment, fine china, firearms, high end appliances/furniture, home audiolvideo system, hot tub, memory foam mattress, piano/musical instruments, silverware, tanning bed, or other high value goods exceeding $1000.00 in value. INVENTORY N4• " DESGRIPTION OF HtGH VALUE ITEMS ESTIMATED VALUE NOTES / CONDiTION* ~ i ~ ~..~ ~. ~ct~EJS i~ ~ i~ fl~K~4 ~ ~ ~ ~}CJ R~'~5 -~ 2. c~~~ Q~ ~Q~v~~~ a - ~- C~U~ cc~~-rz cv~ e~r~.~ ! c~ • - ~~xc~~~~~ C - -- sou i ~ uL ~'~~ ~ 34 D ~ , , ,. 'Z PLUS t i C ~ v~5s o~' Gt..~~S ~ ;~r~*S ~ Ctzc-~,~s - -cz dLL --A~ ~~ Cod - ~ s I ' ~,~ nf~• Urn ~,Lv ~ ~. ~~ ~ ! v~ W~ ~ ~ .~~0 2. •~ r~ c ~.~e Irv (,~,~ ~;=-~ ~ _~ . ~ ~d ~• .; ~m s ~Zc~C.~C.i ~ f, ~. ~ - ~, 2 ~~ O l~ 1 ~ t tJ&~ ~ S - ~4~ ~ ~i h~ \ -----~ . ~- ".rte BE COMPLETED BY TOTAL ~ $0.0~` ~ ~~ ~" ATLAS REPRESENTATIVE. / AT ORIGIN i CERTIFY THE ABOVE LISTED INFORMATION TO BE TRUE, CORRECT AND COMPLETE TO THE BEST OF MY KIttOWLEOGE. 1 HAVE READ AND UNDERSTAND THE STATEMENT OF CUSTOMER RESPONSIBILITIES FORM. St(iNATURE OF CUSTOMER OR S REPRESENTATIVE DATE S10MATURE OF ATLAS REPRESENTATIVE AQENT/PVO CODE GATE AT DESTiNATIC)N I ACKNOWLEDGE RECEIPT OF ALL: rtEMS LISTED ABOVE. ALL ITEMS ARE IN THE SAME COINDITION AS WHEN TENDERED TO ATLAS, UNLESS EXCEPTIONS ARE NOTED ABOVE, StONATURE OF CUSTOMER OR CUSTOMER'S REPRESENTATIVE GATE SIONATUflE OF ATLAS flEPRESENTATiVE AOENT/PVO CODE DATE ESTIMATED VALUE DOES NOT DETERMINE THE ACTUAL VALUE OF THE GOODS. SHOULD A LOSS OCCUR, THE ACTUAL VALUE MUST BE ESTABLISHED BYTHE OWNER OFTHE GOODS.THE PURPOSE OFTHIS FORM IS TO ASSISTYOU IN DETERMININGTHETOTALVALUE OF YOUR SHIPMENT AND TO ASSIST ATLAS IN DETERMINING WHICH R'EMS NI:1?D 8PECIAL HANDLING AND PROTECTION. Dc 225009 Rpv. 2/07 ATLAS A Community Service of Volunteers of America 675 Silver Spring Rd • Mechanicsburg, PA 17050 PHONE 717-766-2999 • FAX 717-766-7505 ~VWW.VOAPA.ORG .Name: Patty Shufflebarger f No: 8481 Address'! : 23 Ridge Way Drive Donation Date: 9/28!2009 Address2: Pickup Date: 10/20/2009 City: CARLISLE ~ Pickup Phone: (717)245-2140 State: PA Picked Up By Postal Code: 17013 Delivery of Items: Pickup Special Instructions (if applicable): Category Description of Items Donate Furniture swival chair, mattr ~... c=~~ FOR INCOME TAX PURPOSES. This slip will serve as your receipt, in case you wish to use your contribution for purposes of income tax deductions. The Internal Revenue Department advises us that it is up to the contributor to estimate the fair market value of his contribution. Volunteers of America has provided no goods or services in consideration of this donation. ~ Estimated Value of Donation ~ $ ~ ----~ iw viv c ~+-T riiunn t _~1 A.M. u P.M. Thank You! ,.._-- n _ ~ c u~ ~ ~ ~- ~ ~. ~ (~ d x. ~.. r; .- ~,:~ `/lye''"/~'-/ ~/''~ ~ `~~ G `~~ ~~.~ ~,~_ - __ ,, if ~ ~,~ ~_~ ~.x I _~ ~~ .„,, w=.~ -~- <_ t .: ~, ,~ .\ ~% Genworth Financial ; ~= f I, , a8]I'M+ORTH LII~ I~tBVRA~1~ t~dI~PANY W , P O H00[ 40005 ~~Z~ LYNCHBURQ VA 24506 000000002 4400034673 1 1 0445 022 ~n~~~~~u~~~~~n~~~~n~~u1~~~~~n~n~~~~~l~~u~~~u~~~u~~~~ TO THE ESTATE OF MRS MARTHA H SHUFFLEBARGER C/O WILLIAM M SHUFFLEBARGER 1311 WOODWARD DRIVE CARLISLE PA 17013-4712 DEATH POLICY - UCG 364 CASH PAID 3991.4 DAT - 04 S We have received notification of the insured's death. Please accept our condolences. The long term care insurance contract has been cancelled as of the above date. If you have any questions, please call our office toll free at (800) 456-7766. A Customer Service Representative will be available to assist you Monday through Friday, 6:00 a.m. to 5:00 p.m., Pacific time. Sincerely, Policyholder Services ~~i'f~J~1~Y13~`wllt~~~~/h~r x.11:7 ~~~1~7 Carlisle Crossing 321 York Road Carlisle PA 17013 Inquiries Call: Acct XXXXXXX435 Eff: 10/06/09 Tlr: 0676 717-254-1100 ESTATE OF MARTHA Date: 10/06/09 Time: 12:24pm Deposit to CHECKING 11 Amount: New sal: Seq: Check Received 3,991.44 #257569 3,991.44 Authorized by ID Source: ^ Drv Lic SigCard ^ Known ^ Other Transfer your balances to a Members 1st VISA Credit Card and receive a low 3.995 APR introductory rate! Ask for details. TKO<°5 ~~-z, ~ Please detach before negotiating chec ESTATE OF MARTHA J HAYNES SHiJFFLEBARG Check Date: 09/17/2009 THE PATRIOT-NEWS PO Box 2265 I-Iarrisburg, PA 17105 Vendor Number: 9999999999 Check No. 090004038b Invoice Number ~ Invoice Date Voucher ID Gross Amount Discount Taken Paid Amount 007167923 ,2009-09-15 09/15/2009, 00127655 93,61 0.00 93.61 Newspaper Subscriber Refund SUBSCRIBER REFUND I~ a~ Questions regarding this check contact the AP Dept 717/255-8260 Total Total Total Check Number Date Gross Amount Discounts Paid Amount 0900040386 09/ 17/2009 $93,61 $0.00 ^ ` $93.61 am>po n#e o>n_ a! ~ yc 'RtcAtw urchl~aue$y e~le ` .I~e~ ,~E55 Senor Member ~' ~~ Statement of Account you u:~e~ the Ciard. ,Visit www>amencanexpress.com/rev~ Prepared For Account Number Closing Date M H SHUFFLEBARGER XXXX-XXXXXO-72005 10/p1/09 Page 1 of 2 New Act;vrty $ credit Payment Not Previous Balance $ Payment Activity $ Inc. Adjustments B8i811C@ 115.42 -115.42 -10.47 ~ li ~ Required _•__ - Please refer to page 1 for important informati regarding your accour An existing Credit Balance on your Due in Full account will be applied to your Flexible Minimum Amount Due. Any remaining Credit Balance can be applied to your Flexible Payment Optian Account (Sign.& Travel and/or Extended Payment Options Balance, against future charges or you may request a refund. To manage your .Card account online or to pay your bill,. please visit us at www.am®ricanexpress.com. For additional contact information, please see the reverse side of this page. Aetiv~ty 'Indicates posting date Amou 09/j0/49''< PAYMEhfT REC~IVEF~`P;CFi -;'THANK YUU . ~~ =115 .. Due in Full Activity for M H SHUFFLEBARGER Amou cars xxxx-xxxxx .. , . . Q9/~8C©9 ~ TEFtMINE?~ iNT:'224f-~84~0=$~~-64r6A~ ~ >': _ _ - - ~ t~5 ,,,, _. M.I NAT : ~ . ..... .. .: ~~r TER, ,. >. , ..... , ,,, .. >. ,, , ,: Total Due in Full Activity -105. Important Notice Information on Flexible Payment Features Please refer to page for further important You may have access to one or more Flexible Payment Features. as part of your Card account. The current Annual information regarding Percentage Rates (APRs) and Daily Periodic Rates (DPRs) for the Flexible Payment Features are as follows: your account For Sign & Travel®, the APR is 15.24%, the DPR is 0.041896 Sign & Travel, the APR is 15.2496, the DPR is 0.0418% Do not staple or use paper clips Account Number To Pa Com ter Payment Not Required Y by pu , Payment Coupon 3730-704360-72005 americanexpress.com, Enter account number all documents. Make check payable tc I~I~"'Il~l~lr~~r~llll~l~l'1'Illlti~lllll~l~l~l~~'~~1'~'I~1'II"" ~ American Express. M H S H U F F L E B AR G E R Amount Due See Finance Charges 2 3 R I D G E WAY D R ~•00 section on reverse sad. CARLISLE P A 1 7 01 5- 7 61 4 a description of when additional Finance Charges are not asses on Features. Check here if address phone number has changed. Note changE II"II"I11i1'IIIIII'111111"'I'111""I~~IIIII'I'III"III'IIIIII rse side. AMERICAN EXPRESS P.O. BOX 1270 NEWARK NJ 071 01 -1 270 DETAILS OF PAYMENT ~~~ l~ DATE CHECK NO. RATE ACCOUNT BATCH /SEQUENCE ~ 71408992 XXXXXXXXXX72005 4173*702 REFERENCE _, GROSS DISCOUNT NET AMOUNT CE REFUND r '~~ $105.47 TOTALS $105.47 ~mpany Inc. 'hoenix. Arizona 85027 use paper Clips account Number :oupon 3730.704360-72005 I~I~I~~II~I~II~~Illlll~l~l~l~llllrllil~l~l~l~l~~'~~1'~'I~I'~I"" M H SHUFFLEBARGER 23 RIDGEWAY DR CARLISLE PA 17015-7614 REMITTANCE ADVICE DETACH BEFORE DEPOSITING Payment Not Required To Pay by Computer, visit: americanexpress.com/pbc. Enter account number on all documents. Make check payable to American Express. Amount Due See Finance Charges $0.00 sect;on on reverse side for a description of when " additional Finance Charges are not assessed on Features. II~III~~II~11~11111~i111111"'('111"IIII~IIII~~~II~~~~~~I~II~~~I AMERICAN EXPRESS P . 0 . BOX 1 270 NEWARK NJ 07101-1270 Check here if addressor phone number has changed. Note changes on ~rse side. COMCAST 1555 SUZY STREET ATTN: LEBANON SUPPORT SERVICES LEBANON, PA 17046 ~~''C~/~ v i~ SHUFFLEBURGER 26870 0630-53-10-3DG 1311 WOODWOARD DR CARLISLE, PA 17013-4712 ~comcast, .PAYMENT SLTMII~ARY CHECK No: 0003179820 ACCOUNT NO: 09547 -37 841302 CHECK DATE: 10/20/09 Dear.SHUFFLEBURGER, The attached check represents a subscriber refund for account number 09547-37841302 in the amount of $58.07. If you have any questions or concerns regarding the refund check you can write us at the address above or call Comcast's toll free customer service number at 1-888-COMCAST. DETACH AND RETAIN THIS STATEMENT THE ATTACHED CHECK IS IN PAYMENT OF ITEMS DESCRIBED ABOVE. IF NOT CORRECT, PLEASE NOTIFY US PROMPTLY. NO RECEIPT DESIRED. .. _. (Datach Herel ..................................................................................................................... State of West Virginia Consolidated Public Retirement Board 4101 MacCarkle Avenue, SE, Charleston, West Virginia 25304-1636 Tlelephone: 304-558-3570 or 800-654-4406 Fax: 304-558-1394 or 304-558-5455 CPRB C~ wv~tirement.com www wvretirement.com TO: Martha Shufflebarger, Estate C/O William Shufflebarger 1311 Woodward Dr. Carlisle, PA 17013 DATE: Oct. 30, 2009 FROM: Derek A. Bailey RE: Estate Check Enclosed is a State Warrant in the amount of $155.90. a As Administrator of the Estate of Martha Shufflebarger, we are forwarding this final payment to you for distribution through the estate, ., If you have any questions concerning this account, please feel free to contact our office and speak with the Death Benefits Coordinator. enclosure , _... ._._ ~ i ~ . ~ ~.~,. __. ,_~: __ ~ , ~.~ ..__ __~ t .___ _.. __.. ~.. __ ~ r~.. __, w.__ ._ _. _._ ~ i i _._~ ___ i I ~... ___ __. ~..~_ .~..___ _... _.._... __ ~~~>n -f ' _, MARTHA ESTATE gHUFFLEBARGER OF 226-26-9173 10/30/2009 1007536.6E GROSS: $389.48 RET ~ MISC4 FED TAX BONA ~~ MISC5 S T TAX CRUN K `_ :~ FICA TAX GARN NET $389.4 MED TAX CH AD ~ , MISC3 ~` ~ '~ w ~~ k~~ ~ i REMOVE DOCUMENT ALONG THIS PERFORATION ACKNOWLEDGEMENT OF 00456 fTA/l fARM n® 32107-5-E AI-NONPI ,- Insurance and Financial Services CANCELLATION. REQUEST INfYRANGS Farm Dr DATE OCT 07 2009 le PA 19339 ., POLICY NUMBER 14 5199-F11-38A 6271 5 52E ..AUTO :BARGER, MARTHA H MULTICAR POLICY ~EWAY DR _E PA 17015-7614 EFFECTIVE DATE OF CANCELLATION PREMiuM REFUND OCT O4 2OO9 l2:Ol A. M. STANDARD TIME *****85.61 AGENT GREG LUNDE' - quested, this policy has been canceled as of the effective date shown. thank you for having given us an opportunity to provide this insurance. •~r •g~ u. pa~u~~~ ZODZ-9'-6L~'naa E•G LtOt~6-E96 k, ~~ . . ~. -~_~~ {Y ,~~ ~. ~ _ -~ i~~st Filing Instructions Form PA-40 - PA Individual Income Tax Return Taxable Year Ended December 31, 2009 Name: MARTHA H SHUFFLEBARGER Date Due: April 15, 2010 Remittance: None is required. There is a total overpayment of $559, which is to be refunded in its entirety. Signature: You have signed your electronically filed return with a Personal Identification Number (PIN). Sign and date Form PA 8879, Pennsylvania a-file Signature Authorization. Return it as soon as possible to: COHICK & ASSOCIATES 390 Alexander Spring Rd Carlisle, PA 17015-9129 Other: Your return is being filed electronically. Do not mail Form PA-40. Initial and date the copy of the return and retain it for your records. o ~ ~ _~a~ ~n ~, ' y ~ ~ .~ ~, ,~ ct p tf tt ~ rra o~mClrn b n .q E ~ < O Fi rh Q ~ a f+ h ~ C ~. iv :s a .. •- cr ~ ~rn~ • • ~~ ~ • ~ ~" ~ oon ~ K ~ Or t'' A ~ ~'' ~ On rt 0 o x W A x K ~ ~ • m cr r• F o o O ~ ~ _ ~ r x ~ ~ car ~ ~.. ~ ~ ~ ~' ~ O ~ F+ aJ ~ Y } ~ O O n ~ i ... N ~ GJ cr, .. p ° . ~. i ~-~ A. w ~ .. o H ~ ;,. K ~ ~ ~ ~ ;~ °' ~ c o ~ ~ 1-1 ~ jf; Q .,~ ~ G ~' a c n --` H A 7yw a ~ ~ - ~ ~ t~- V.t '- v: y.~ A ~-' f+ O O ~ .. O ~ -v FJ .1~ ~' ~t . ~ b ~ ?s' st ~ N Oti (n f•+~ ~ A A b c~+ to ~D ~ W O ~ pi ~ O -•+ ~D iV J ~ ~. O K -i O O m ~ O to ~ ~O ~' H Q1 f]. •J J t0 O t0 ~ O~ Q1 Filing Instructions U.S. Individual Income Tax Declaration for an IRS a-file Return with Electronic Filing Personal Identification Number Taxable Year Ended December 31, 2009 Name: MARTHA H SHUFFLEBARGER Date Due: April 15, 2010 Remittance: None is required. The return shows a•total overpayment of $x,330, which is to be refunded in its entirety. Signature: Your electronically filed return is not complete without your signature. You have signed your electronically filed return with a Personal Identification Number (PIN). Sign the IRS a-file Signature Authorization and mail it as soon as possible to: COHICK & ASSOCIATES 390 Alexander Spring Rd Carlisle, PA 17015-9129 Other: Initial and date the copy of the IRS e-file Signature Authorization and Form 1040, and retain them for your records. % O O 0 C~~I + ~ LJ J d ct A~ K tt O ?C ilI d (!~ ~ a ~~c K io ac ~ ~" {p K ~ IY L"' (! K r• A ~ b ~ Q C ~ A p ~ ~ o K 6'! K m ct C H ~ ~ b a ~~ H O ~ ~ ~ 7S' Ct t~ d K K iL .~ Your return is being filed electronically with the IRS and is not required to be mailed. If you mail a paper copy of Form 1040 to the IRS it will delay processing of your return. h` G ~ x • O ^.. K rCC- A ``.c~~~ ¢ ~.\., tr '~,~. ~ ~`:: O O~ K f~Jl Q A A O~ K 'a xc°A<~KO'~~c<`~ ~ fi ~ Li7 ~ C~t' p ct Obi ~ .. ~..+ O .. H N .. rh x ft .. X O rR ~ W ~ ~ ~ ~ Y~ 70 H (Z ~ r u i J N A A O W 01 cn N W ~O t+rOr W • ~ ~ O W N 1p O tp O h11 O r H ~~ tp N H (!! A t7~ W m O V1 O W W O ~ is O A 00 01 ~ O OD H Q1 O 01 H [+7 ?~ r rh A K M t! r O ~C 01 A ~C W '~. ?>CC ~ N X O QxD W A b C ~ A tom' o •• c~ ~~ o A N ~ N N ,`Li 1p ~ O H H (1 r $ ~ p r p C ~ ~ ~ r• N• ~ K a ~ tt F'• 1-i S11 ~ o ~ o p b ~ ~ r r W ~ r ~1 O •. O R W O O il. r i N tp 1 A rn 01 ~. ~' .'~`: ~. ~' ~~ ~' ~~ _~ '~ . REV 1509 EX+ (g-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEf~ULE F JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER Martha H. Shufflebarger 2109-0860 Han asset was mada joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVMNG JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A• IAfilliam M. Shufflebarger 1311 Woodward Dr., Carlisle PA 17013 Son B' Thomas E. Shufl9ebarger C. John V. Shufflebarger JOINTLY-OMYNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTIMION ANO BANK ACCOUNT NUMBER OR SIMILAR fDENTiFY1NG NUMBER. ATTACH DEED FOR JOINTLY~i~IELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECO'S INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1. A. 07/01/01 Stock and Mut Fund Co-Tenant Account#896-08529-1-4, Edward Jones 35,672.56 50 17,836.28 2 A 11/17/99 Five Series EE and 16 Series E US Savings Bonds, RI FRB Richmond 2,609.43 50 1,304.72 3 B 07101/01 Stock and Mut Fund Co-Tenant Aaount#896-08538-1-3, Edward Jones 35,587.80 50 17,793.90 4 B 11/17/99 Four Series EE and 14 Series E US Savings Bonds, RI FRB Richmond 2,215.23 50 1,107.62 5 C 07/01/01 Stock and Mut Fund Co-Tenant Acoount#896-08537-1-4, Edward Jones 35,554.16 50 17,777.08 6 C 11/17/99 Five Series EE and 16 Series E US Savings Bonds, RI FRB Richmond 2,504.95 50 1,252.48 7 A 07101/01 Mut Fund, Oppenheimer, Edwd Jones Acct. #896-09509-1-6 4,849.91 100 4,849.91 8 A 07/01/01 Money Market, Edward Jones Account #896.09509-1-6 5,918.59 100 5,918.59 9 B 07/01/01 Mut Fund, Oppenheimer, Edwd Jones Acd. #$96-09509-1-6 4,849.91 100 4,849.91 10 B 07/01/01 Money Market, Edward Jones Account#896-09509-1-6 5,918.59 100 5,918.59 11 C 07101/01 Mut Fund, Oppenheirr~r, Edwd Jones Acct. #896-09509-1-6 4,849.91 100 4,849.91 12 C 07/01/01 Money Market, Edward Jones Account#896-09509-1-6 5,918.59 100 5,918.59 Attachments 1518 Auburn Oak Circe, Auburndale, FL 33823 Son 6 Olde Stone Bridge Path, Westboro, MA 01581 Son TOTAL (Also enter on line 6, Recapitulation) I ; 89,377.58 (If more space is needed; insert additional sheets of the same size) - --~'clwar_ ones Payer's Federal Identification Number 43-0345811 ~~ ~ ~~~~~a.~~ ~ ,~A~~' Edw Y Jones Account Number : ~` (Includes 1099-INT, 1099-DIV, 1099-8.) 96-08529-1~,4,,.,......~..~ . ~..,. _ --~.__....~.... _~..:.._,-,-, FIGURES ARE FINAL Recipient's Identification Number : Printed on Janua 12th, 2002 226-26-9173 ,_„ .- ry Investment Representative : 7~r~f~ ~:w;~ ` Page 1 SEAN FERGUSON Telephone Number 717-731-5432 ~-~-~ Recipient's Name and Address ~.Q-~ ~ ..-~~ C~IJ~' I~~~IIl~~~tll~~~~~~ll~~ll~l~~~l~ll~~~~~ll~l~~l~~l~l~~il~~l~l~l MARTHA H SHUFFLEBARGER 007192 WILLIAM M SHUFFLEBARGER '~`~ a ;, 23 RIDGEWAY DR ~~~ ;r,~ CARLISLE PA 17013-7b14 THIS IS IMPORTANT TAX INFORMATION AND IS BEING FURNISHED TO THE INTERNAL REVENUE SERVICE. IF YOU ARE REQUIRED TO FILE A RETURN, A NEGLIGENCE PENALTY OR OTHER SANCTION MAY BE IMPOSED ON YOU IF THIS INCOME IS TAXABLE AND THE IRS DETERMINES THAT f7 HAS NOT BEEN REPORTED. ;. ... . , ;; .. :: , ~ 499-1NT INTEREST: ~NCaM~ - ZOQ'~ Statement fc-r. cecp~er~ts (OMB: N0. 1545-0112). Box 1 Interest Income not Included in Box 3 .07 Box 2 Early Withdrawal Penalty .00 Box 3 Interest on U.S. Savings Bonds and Treasury Obligations .00 Box 4 federal Income Tax Withheld .00 YOUR TOTAL REPORTABLE INTEREST IS THE SUM OF BOXES 1 AND 3 .07 _. .. ,. ; ~Q99-D~ D~1I~t~N~ DiSTRIBUT'(QNS - ~0~~ Sia~+~rr~en~ for re~ip~ents . (CAM . .. ...: .. ~ ~.: ......... ............... . .........:...... .:........: ..:............... , ......:. ::.... ..: ~;1'~C~.` 1545-f1~<'i 4~..:.. ,. ; Box 1 Ordinary Dividends (including short-term capital gains) 778.31 Box 2a Total Capital Gain Distr. .00 Box 2b 28% Rate Gain .00 Box 2c 6~uallfied 5-year Gafn .00 Box 2d Unrecap. Sec. 1250 Gain .00 Box 3 Nontaxable Distributions .00 Box 4 federal Income Tax Withheld .00 5er~~iu~~~ l~adi~~i~iua4 lm~i•~tm~~ Shire 75~~ 201 Progress P~.~ ~t:^.~~ y, :V~2ryiar~d ~~{nights, °`r';0 630~+3~3042 i •~C~~282.08?9 v~:^, vt.ed~~d~rd~ot~es,CGt~n ____ - --_ __. ~dwarcTjones /~~~ Recipient's Name ~--~ and Address ~~~~ t ©~ ~ I,,, i 11,,, I1 i,,,,,, I i„I i, I,,, I, I I,,,,,1 I, i„ I„i, I„I I„i, I, I d~ ~ MARTHA H SHUFFLEBARGER 007194 THOMAS E SHUFFLEBARGER Ilt r ~:~' 23 RIDGEWAY DR ' CARLISLE PA 17013-7614 ~~,~~'~ THIS IS IMPORTANT TAX INFORMATION AND IS BEING FURNISHED TO THE INTERNAL REVENUE SERVICE. IF YOU ARE RE6IUIRED TO FILE A RETURN, A NEGLIGENCE PENALTY OR OTHER SANCTION MAY BE IMPOSED ON YOU IF THiS tNC~ME IS TAXABLE AND THE IRS DETErtMiNES THAT IT HAS NOT BEEN REPORTED. ;~ 1 Q'~9-iNT ~NT~~~ST #NCON~E - ~Qa~ ~tat~meni' fic-r rec#p~en#s ~t~MB NO ~ 545.0 ~:2)' Box 1 Interest income not Included in Box 3 .01 Box 2 Early Withdrawal Penalty .00 Box 3 Interest on U.S. Savings Bonds and Treasury Obligations .00 Box 4 Federal Income Tax Withheld .00 YOUR TOTAL REPORTABLE INTEREST IS THE SUM OF BOXES 1 AND 3 ,p~ `'tt~99tDlW QIYI~IU Dfi~TRt~UT~ONS - 20Q~ Stafement for rec#p#ents (t:7MB NO. 9545.0`1 ~ 0~'. Box 1 Ordinary Dividends (including short-teen capital gains) 777.71 J Box 2a Total Capital Gain Distr. .00 Box 2b 28% Rate Gain .00 Box 2c 62ualified 5-year Gain .00 Box 2d Unrecap. Sec. 1250 Gain .00 Box 3 Nontaxable Distributions .00 Box 4 federal Jncome Tax Withheld .00 S~~r~inr Inrl,iciilual [n~~e~tur, Since ~~ ~~ ~_~~ - ~ ____ 7z ?_01 Progress Park+:ra;~, ;~'~ ry!arcf t-+e~~~ its, wv~~ 6304-3042 _ '` +~ ~ - ~. + ~,,,; .8.~i)~7~~~~)~7~ .J,'.1.. ~+..~;r'nlnnnC rn~Yr ~c~war~~Q11~S Payer's Federal Identification Number 43-0345811 ~~ ,~~~°`'"~ ~ and Jones Account Number ~. 896-08537-1-4 ..... ,.. Recipient's Identification Number 226-26-9173 Investment Representative SEAN FERGUSON Telephone Number 717-731-5432 L~k7~ MRD~ eb ~ r~tr (Includes 1099-INT, 1099-DIV, 1099-B.) FIGURES ARE FINAL ~o ~,~~_~r~-:,~t, f~. ,~. ~ ~'~,~'> Printed on January 12th, 2002 ?t/r /~,~ ~,.~ ,~ Page 1 Recipient's Name and Address ~~~I11~~~111~~~~~~11~~11~1~~~1~11~~~~~11~1~~1~~1~1~~11~~1~1~ MARTHA H SHUFFLEBARGER 007193 JOHN V SHUFFLEBARGER ' 23 RIDGEWAY DR CARLISLE PA 17013-7614 ~~~ ~''' THIS IS IMPORTANT TAX INFORMATION AND IS BEING FURNISHED TO THE INTERNAL REVENUE SERVICE. IF YOU ARE REAUIRED TO FILE A RETURN, A NEGLIGENCE PENALTY OR OTHER SANCTION MAY BE IMPOSED ON YOU IF THIS INCOME IS TAXABLE ANA THE tRS DETERMINES THAT IT HAS NOT BEEN REPORTED. .. . . . lNCCiME = ~op`~ Statement for recipients 'tQ9~9-tNT INTEREST,... .. .. .. .. BOMB 1~0. '1 ~4~-~3~ ~ ~) ..., Box 1 Interest income not Included in Box 3 .01 Box 2 Early Wifihdrawal Penalty .00 Box 3 Interest on U.S. Savings Bonds and Treasury Obligations .00 Box 4 federal Income Tax Withheld .00 YOUR TOTAL REPORTABLE INTEREST IS THE SUM OF BOXES 1 AND 3 .01 . ;, . ,,. , ~: 'IQ99-Dtv ~DIVIDENt3 DfSTRIBUTI4NS i 20t}~1 ~tatet~ent tOr recipfient~ _ (Ol~n~ N~?. "545-~~.~o~ ... Box 1 Ordinary Dividends (including short-term capital gains) 777.21 -,1 Box 2a Total Capital Gain Distr. .00 Box 2b 28% Rate Gain .00 Box 2c 6~ualified 5-year Gain ~ ,00 Box 2d Unrecap. Sec. 1250 Gain .00 Box 3 Nontaxable Distributions .00 Box 4 federal Income Tax Withheld .00 ~~~°r~ ins Ituli~~idfial In~~e~,tor~ Sizir~e ~8 ~ i X01 Prn~r•ess P~rkt~,rav. tV;~rvl~ nd }-!ei~'r~is, i4;0 6 X043-304?_ 1 800.282-0829 :~~~~~.v.edvrard;ot ~eS.com N d C O Z .~: _~ R r~ /^a rw1 0 0 ~~ .~ I W O , N to Q N O v N O 00 «.~ C Q W r ~ C ~ BQ Z ~ W W J LL J m y~ N C _~ Q~ t w E N '~ C 0 .n ~V1 O ~ y V .-.' O ~ o O v .... ~ '~ ... a~ a~ ~ c _ e`? ~ ~ ~ C ~ .~ 3 ~ p ~ ~ a ~ ~g o t '~ U >. o cr, ~ c~ ~ o° o 4S c ~ c~ c G ~ cep , c o ~=• ~ to N d_ ~ N C ~ ~ -~ ~ aD ~- U ~ C _ ro E € ~ ~' ~ ~ ~~ N 3 °~ ~' U ~ Q + ~ ~ } ~ '~ N ~ ~ « iA E9 to 69 E9 d9 dq d3 ~? 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E9 6F! t~ d9 tfJ t~ E9 e~ E9 69 <9 ~ ~ ~ 4 ~ = a o G ~ ~ ~ ~ a or ~ ~a ~? ~ ~ ~ ~~ .L A W N ~ ~ a ao ~ ° ~ ~ ~ c ~ ~, ~~ o ~ ~ ~ ~ ~- ~ o~ U ~. $ 'r a ~ am ~ cm ~ ~~ ~ ~ U ~ ~ C ~ Q W ~ }' O o w ? ~v ~ o ~ ~ ~. ~~ ~- v p O v~ C V Q m i m:" . ~ o ~ O a o' r.r ~ ~ ~ o r ~ O ~ ci ~ y ~ W T VI C ~•+ y ~ D '~ N U ~ y ~ ~C LLI r- c~i c~ v +.c~ c~ r~ ~ vi ti ~- .- r,i r~ ~t . Sri ce r: ~ ~ W r .- T- .- •- ~' ~ o W U ~. ~ aD O~ 'S a, ~ j oa y 4~ O i i i r c u a c a +r v Y ' ~. O .~ t0 w 0 0 .V VJ H 1 t H ~ W ~ ~ .~ ~O 0 o ~ o uo~ a ...~ _a ~ ~ O O ~ ~ ~ ; ,~ ~° C v ~ ~~ ~ y d s t~ b9 ~ eg Eg ~ ~ bi g ~ ~ E9 6 9 ed3 b9 b R 69 d~ Hh ~ n o~ c-~ c'~ o°, c~ o O°, o o O o O° O O o°° D o coo ~ ~ '' M G1s N O O O O G O O O O , O D O , O O , Q `-' a ~ d Q' 01 ap ~ m N Q .S' ~ ~ .~ td Q .~ Ctl U O '~ w. A ~- ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ s~ ~~ , E N ~ ~ ~ a ~ ~ ~ .n V ~ ~ LL '~ ~ ~ a rq ~ cd ~ ~ ~ ~ ~e ~ ~ a ~ ; ~ ~ i ri 69 d9 69 E9 to EH ~? 6F! &~? E9 ER E9 E9 cfi ~ ~} -- ~ 0 vi ~ O ` ~ e L. L G w E- a Z ~ ~ U ~q~' 'a C ~ E ~ a. ~ w ~' o v ' ~ o ~ a "~ ~ a~ ~ ~ _ o ~ , .~ C~ ° a ~ o c m 4. C eel p ~ N •- U E ~ a ` W LL 4 e~ O ~ D v ~ ~~ ir' ~ LL ~ ~ ~ m ~ W ~ ~ ~ ~ C ~ ~ ~ C ~. td O ~ a ~ N ~ ~ G ~ ^ M ~ ~ Q a N ~ ~ N ~- . l N C ~ ~tl cD r~ cp t7~ O y'_ ~ T~ N ~• c7 ~t 1. AA ~ ~ ~ 3 a T ~~ w $ ~~ °05 cv ,~ A ~ ~a r.,. + 1 Calculate the Value of Your Paper Savings Bond(s) :~~?~r~e~t~ • , • Pale 1 of 1 C, ,~', f ~ , kixrca , Ir•~lwiQ~.ial ?cas t._i_u!ate rive V.alua of Yc~.rr payer Sa•/i ::?s B~;=d(s'. Calculate the Value of Your Paper Savings Bond(s) SAV1NCiEi BOND CA1Ck7t.A'rCrR !'si~tt itsa'ir.iu; Yalue as of: 09,2004 __ IUP6AT ~~ t to U c ti,~ ~,+ings 8~~;~ri E~ . c a i::etn N~Ip Series: Denomination; Bond Serial Number: Issue D ate: x! EE BOndS 50 NI Not Issued ___. _ NE Not eligible for payment PS Includes 3 month HOW TO SAVE YOtlR INVENTORY Interest penalty MA Matured and not earning interest f~.;r1iC1?~i'i~'fi'r" ~;w'St1~i'~~ ~'y.a ~ ~q'i?a;ialip~i="a€'1 ~rsl~;? ~~`~j ."~.4~~3ti? Total Price ~ Tots! Value Iota! Interest $425.00 ~ $2 609 43 $2 1$4 YTD Interest , . . , .43 $35.49 Serial # Series penom issue Next Date Accrual Final Maturity issue Price interest Interest Value Nate 0579777577 EE $50 09/1981 03/2010 09/2011 $25.00 $110.70 Rate 4.00% $135.70 0574777578 EE $50 12/1481 12/2009 12/2011 $25.00 $108.04 4.00% $133.04 _ 0579777580 EE $50 04/1982 10/2009 04/2012 $25.00 $105.44 4.00% $130.44 _ 0579777579 EE $50 01/1982 01/2010 01/2012 $25.00 $108.04 4.00°+6 $133.04 r 0579777581 EE $50 07/1982 01/2010 07/2012 $25,00 $105.44 4.00% $130.4; 6414244715 E $25 11/1979 11(2009 11/2009 $18.75 $89.70 4.00°k $108.45 6419244702 E $25 07/1976 07/2006 $18.75 $117.57 $136.32 Mt, _ 6419244701 E $25 04/1976 04/2006 $18.75 $116.01 $134.76 MA 6419244703 E $25 10/1976 10/2006 $18.75 $117.57 $136.32 htA r 6419244705 E $25 05/1977 05/2007 $18.75 $120.65 $134.40 h1A 6414244716 E $25 02/1980 02/2010 02/2010 $18.75 $89.70 4.00% $108.45 _ 6419244704 E $25 02/1977 02/2007 $18.75 $119.29 $138.04 MA 6419244706 E $25 08/1977 08/2007 $18.75 $120.92 $139.67 h1A _' 6419244707 E $25 11/1977 11/2007 $18.75 $109.34 ;128.09 ~•1A 6414244708 E $25 02/1978 02/2008 $18.75 $109.70 $128.46 h1a _ 6419244709 E $25 05/1978 05/2008 $18.75 $87.92 $106.6? h1A _ 6419244710 E $25 06/1478 08/2008 $18.75 $88.22 $106.97 htA _ 6419244711 E $25 11/1978 11/2008 $18.75 $89.23 $lOT.98 h1A _ 6419244712 E $25 02/1979 02/2009 $18.75 $89.53 $108.28 MA _ 6419244713 E $25 05/1979 05/2009 $18.75 $90.58 $109.33 MA _ 6419244714 E ` $25 08/1479 08/2009 $18.75 $90,84 $109.59 P1A CALCULATE AfYOTHER BOi•JD How would you rate this tool? Excellent Good Fair Poor Frca~unr of In~or~niation Act ~ Lav+_€c Guidance ~ Privacy ~ Leaal tvotices ~ Websitz Terms' & Conditions ~ Accessiui!ity ~ C)ata Quality U,S._Det~artr~r~ nt o` the Treastiry,_Burtau o~_tiie P~rblrc !?ebI ~,,,. !~ ~~~ INTEREST GEA5ES 30 Y~AR9 - FRQR1 1S$lf ~~ DATE ~~. „, _,_ 26 9173: _;. _ 226 04 1~$-~: ._ ~- z ~ , e _, ~;, MARTHA J SHUFFLEBARGER -- . . ,, _. _ , ~ R $ ~ ~t ~ N .. -~ .~~~-~~~06 HAGEMAN ST ~ ~ ~ ;~ ;~,1~,~,~~~~,~,~°~ ~; ~~~~~~KELEY SP INGS wV X541 I --16T 0 ~~ t ~~~ ~t°, WI LRAM M+~~HF~ - GF~^_ ;~ F R~,,a~9~~~o7a. _ool ool ~ - ~ ~D"37~7775 _ . . ~. 41r_: .. ,~..a.ry /'n{. iwrwy 905?9???5?8~~• al, - - ' - - - -mot:: ,,; ,`~; > FRB ~Y~kl ~~. F 11=17'-99 i ~ ~ t ,.FB~i~~Il~ACitJlra ~. . S, ; '~- ~ ~ ~W1/_ X5411-1610 ,~ -<.: ~ 1 l~ - _~ j l1Xr Try _ ...__ ~ ., s M M ~H~F~L G z. ~ { ~ ~, ?8 _:DO1 001 ~ '~~`' `~~~57~777~ \, Y _ ~ ~~~ Calculate the Value of Your Paper Savings Bond(s) ,•.~~re~tt Page 1 of 1 ,r td:;rr,:= > F~riivitlc.:~a ~ Tnois Ca',~utata [he Va!ue oi' 1'oar Pate; Savings Errt1~5~ Calculate the Value of Your Paper Savings Bonds} sAtrxsv~s BnND cAi.cui.af<~tx Value as of: 04P20~9 UPDATE} ._.._ _,_.. Series: Denomination: H _'~ Bond Serial Number: Issue Data: EE Bonds 50 HOW TU SAVE YOUR INVENTQRY t,•v~."t %viiF~g.3,~. ~+??6.l,alT~:s j~>, ~~,.."~.~'~.~i".~.''+°:iCJfr ~~~ta~.» Q~.~~y~~'1~~ Total Price otat V aluef $362.50 $2,215 .2 ' E:erJi:{i-::t :it+' t>;' It Serial # S°ries Dencm Is Next Final Date Accrual Maturity 0579777576 EE $50 06/1982 12J2009 06/2012 0574777575 EE $50 03/1982 03/2010 03/2022 ~ 0579777574 EE $50 11J1981 11/2009 11/2011 0579777573 EE $50 08/1981 02J2010 08/2011 6419244686 E $25 02/1980 02/2010 02/2010 i 6419244685 E $25 10/1979 10/2009 10/2009 6419244684 E $25 07/1979 07/2009 6419244683 E $25 04J1479 09/2009 fi419244682 E $25 01/1979 01/2009 i 6419244681 E $25 10/1978 10/2008 6419244680 E $25 07/1978 07/2008 6419244679 E $25 04/1978 04/2008 ', 6419244678 E $25 01/1978 01/2008 6419244677 E $25 10/1977 10/2007 6419244676 E $25 07/1977 07/2007 li 6419244675 E $25 04/1977 04/2007 ' 6419244673 E $25 09/1476 09/2006 6419244672 E $25 06/1976 06J200b Total Interest $1,852.73 Issue Price Interest Interest Rate Value Note $25.00 $105.44 4.00% ;130,44 $25.00 $108.04 4.00% ;133.04 $25.00 $108.04 4.00°l° ;133.04 S25.OD $110.70 4.00% ¢135.70 $18.75 $89.70 4.00% ;108.45 #18.75 $88.69 4.00% ;107.44 $18.75 $90.84 #109.59 MA $18.75 $89.53 ;108,28 MA $18.75 $89.53 ;108.28 i~tA $18.75 $88.22 ;106.97 P•tA $18.75 $88.22 ;106.97 f~A $18.75 $89.79 ;108.64 rta $18.75 $109.70 ;128.45 ~tA $18.75 $120.42 ;139.87 t~tA $18.75 $120.92 ;139.87 Mgt $16.76 8119.29 ;135.04 r~A $18J5 $117,57 ;136.32 htA $18.75 $117.59 ;136.34 hiA tor; ~~~ l.tsc the 5;,:ir~r.~s f;o:~rt Ca:.cu;:.'or NI Not Issued NE Not eligible fnr payment P5 Includes 3 month interest penafty MA Matured and not earning . Interest YTD Interest $30.40 CALCIiLATE ANOTNiR 50fVD . : ~ . ~ t i r b r . ,, How would you rate this tool? Excellent Good Fair Poor _ i y '~1 Fro gum o; Infgrn~atipr~ Act ~ Lbw & Guidance ~ ~riv$~y >x Legal 6Jotice> ~ ~Nz6site '~ern~; i, Conditions ~ACC~'SSIJi{ily ~ Deta Quality U.S.. Department of tite Tt egsury, 9ureau of the Pubi c Debt SERIES E p d' ~_, ~~ ~ ~;x:~ ~~ ~ _ ~ ~~ a= ~~, >_ ~-. ,\ _ ;: ,~ ~~~ ' SERIES E ~~;~L,~ ~=v ti SERIES E _. 1 `~ ~ f1~- L ~l ~~~~~~(~~\~~~h~~ ~C1lL~':~~ ` _~~1jy: M;,~ •" ±f 3'# 3,`1 !T I.1p ':i J~".l~i' .t 1%\U %:1~~~~ ~/~"?1..~~-ti..../". ~~~~1~~ ~4a~' .1~~ t ISSUE DATE WHICH IS THE FIRST DAY OF 226 26 9173 06 1976 T~,MARTHA J SHUFFLEBARGER FRB RICH 11-17-99 106 HAGEMAN ST 1 BERKELEY SPRINGS WV 25411-1610 I„I, t, i, I„I„I,,, i i,,, I1,,, I I, I I,,,,, I I11,,, i I,,,,11,,,, I I, I OR THOMAS E SHUFFLEBARGER III RI 993140077 001 001 6419244672 °~~~.~~. Q64192446~2E DEPARTNC NI DE THE TNEA$UPY dir.. ~~.r~w/~~r ~...x~+~~ WASM+N(iiON W 4 9 24,67 2~~' x'00009000 7~:6 2 ~ L6 ~ ~> r.-1J E~";- _i ~ .,~» r a ~ ~,n~ mvs , :~s:~, rS:.~wR c^a~.v:ncv~.tads~:viafia3~.ti.m~e~+ J,~r.~a~'; • t ~i ' ,~~ 11. ,1 ~ : ' h W _:. f r ~..~~ ~~~ \3 I5SUE DATE WHICH IS THE FIRST DAY OF 09 1976 226 26 9173 T„MARTHA J SHUFFLEBARGER FRB RICH _1Y-17-99 106 HAGEMAN ST 1 ~ BERKELEY SPRINGS WV 254;1-1b10 _. I„i, I, i, I„I„I,,, I I.,, I I,,, I i, I I,,.,, i l i I,,, I I,,,, i i,,., i I, OR THOMAS E SHUFFLEBARGER III 6419244673 RI 993140077 001 001 A DEEAPTNENT Oi THE TPEASNRY ~ ,~:r.rl..r~n/I/r /~i•arN!4 wA6N~NGTON ' • ~ 264 i,9 2446 7 3~~' ~- . ., ,xew. Fva.,~~lrM5c.5:.5-.fx,~fr3:a.,;.~3:~ _•, ~~''',` V ~`-r-[~al~~; ~~ ISSUE DATE 4 i~;~~` WHICH IS THE fIRST DAY OF 226 26 9173 04 1977 T,MARTHA J SHUFFLEBARGER FRB RICH 11-17-99 106 HAGEMAN ST 1 BERKELEY SPRINGS WV 25411-1610 _ I,.I, i, I.I„I., I,,, I I,,, i I,,, i I, I I,,,,,11 I I,,, I I,,,, I I,,,, I I, i OR THOMAS E SHUFFLEBARGER III 6419244675 RI 993140077 001 001 ~~~ Qb'+192446~SE DEPA~TNENI OE 1NE TPE ASURY ~ ,\~rr, /,rr~~/'//r jrr, R.~~ir,~ WASNiNGTON '"~' 6t,i92446?5~~' x:00009000 7~:6 2 y y 4 "~i~xp:',.u'xtt},wL~sCa'~/3~ohlrr"' ~ f e scyy^:.t.,r.r~..~.n,{ya'~~~~ r. ,~~ d t t f ~^` tic n Ar" ~i_`tlc.~ xor 6^B 'af's.+~ nfm6~.7flifll~iC;IG <,, ^~~ a~ ~.- r ~~~ ~~ Calculated Value of Your Paper Savings Bond(s) Calculated Value of Your Paper Savings Bond(s) Calculator Results for Recta-,nption Date 09/2009 Page 1 of 1 R .. . , / v i cta / ,r, ~,~ I Total Price '~6ta1 Value Total Interest ~ YTD Interest $425.00 f $2,504.95 _~~'_ $2,079.95 $30.89 Bonds: i-21 of 21 Serial # Issue Series Denorn Date Next Final Accrual Maturity Issue Price Interest Interest Rate Value Nate 0579777568 EE $50 04/1993 10/2009 04/2023 $25.00 $24.16 2.63% $49.16 0579777569 EE $50 08/1982 02/2010 08/2012 $25.00 $105.44 4.00% $130.44 0579777570 EE $50 05/1982 11/2009 05/2012 $25.00 $105.44 4.00% $130.44 0579777571 EE $50 02/1982 02/2010 02/2012 $25.00 $108.04 4.00% $133.04 0579777572 EE $50 10/1981 10/2009 10/2011 $25.00 $108.04 4,00% $133.04 6419244654 E $25 04/1980 10/2009 04/2010 $18.75 $87.58 4.00% $106.33 6419244655 E $25 12/1979 12/2009 12/2009 $18.75 $89.70 4.00% $108.45 6419244656 E $25 09/1979 09/2009 $18.75 $90.84 $109.59 MA 6419244657 E $25 07/1979 07/2009 $18.75 $90.84 $109.59 MA 6419244658 E $25 03/1979 03/2009 $18.75 $89.53 $108.28 MA 6419244659 E $25 12/1978 12/2008 $18.75 $89.52 $108.27 MA 6419244660 E $25 09/1978 09/2008 $18.75 $88.22 $106.97 MA 6419244661 E $25 06/1978 06/2008 $18.75 $88.19 $106.94 MA 6419244662 E $25 03/1978 03/2008 $18.75 $89.79 $108.54 MA 6419244663 E $25 12/1977 12/2007 $18.75 $109.70 $128.45 MA 6419244664 E $25 09/1977 09/2007 $18.75 $120.92 $139.67 MA 6419244665 E $25 06/1977 06/2007 $18.75 $120.95 $139.70 MA 6419244666 E $25 03/1977 03/2007 $18.75 $119.29 $138.04 MA 6419244667 E $25 11/1976 11/2006 $18.75 $118.90 $137.65 MA 6419244668 E $25 08/1976 08/2006 $18.75 $117.57 $136.32 MA 6419244669 E $25 05/1976 05/2006 $18.75 $117.29 $136.04 MA Totals for 21 Bonds 425.00 2 079.95 2 504.95 Notes NI Not Issued NE Not eligible for payment P5 Includes 3 month interest penalty MA Matured and not earnin interest 1.~..~._.//_'-..~_'~'.-____.-_J'.__-a ----lTl/`t/ClT/'lT--~-- C/1A/n/~1l~ SERIES E tt rl / try '~P111~, i tr/'i r~ r~ r~ (~~~ rl, J! 'J~•~l.l~~~ : 'S~ ~t!'iJ JSI s {!S'am` r~ ,5Y rT+rt~~~' ~ E,~~ IJ '~J ~~ ~~~.'~ TaMARTHA J SHUFFLEBARGER ..10.6 HAGEMAN ST BERKELEY SPRINGS WV 2541.1-16.10 111111/1/1111111111111UI11111~i'IIIIIIIIIIIIIi111~111111/11111 OR JOHN V SHUFFLE$AROER RI 993140012 001 001`` ~~~` ?64 it9 24466?~~• ~.~ -- SERIES = 1 ~ I3SUE DATE - WH{GH IS THE FIRBT DAY OF ~- =- ;226 26 9173 - 08 1976 ,, , -~- ~ ~o MARTHA J SHUFF<LEBARGER -' FRB RICH '. ,. 11-17-99 10.6 HAGEMAN ST ~ 1 .~ ~ $ERKELEY SPRIN~('~ ~WV 25411-1610 ~ h11i111iIIIIf11/11111111111111"~I~IIi1111111111111111111111111 , ._ OR JOHN V SHUFFLEBAR~ER ''''+ HtN°sO"• ` RI 993140012 001 DO1 6419244668 OAANTYENi OE THE iAEATJNY ° ~-:.-~.... Q 6.419 2 4 4 b 6 8 E wASNwGTON ~ •S:n.I ry•/Y/r %..,arn~y x:00009000?~:6 2 ~` 864 L9 244668~~• SERIES E ~_._s ~'° HIIdG'tO~ T„MARTHA J SHUFFLEBARGER 106 HAGEMAN ST BERKELEY SPRINGS ~WY 25411-1610 /~111~1/I II IIJ11J111111~i111~11~~~~1111111t~~1~~~i~11~1~11iJ OR JOHN V SHUFFLEBARGER RI 993140012 001 0.01 pNANTYENT OE THE TIIEASUIIY wA51MNGTON x:00009000 7~:6 2 ~~~ WHICH IS THE.FtRST OAY OF 05 I976 F.RB RICH 11-17-99 1 .. 6419244669 Q6419244669E _-ISSUE -©ATE WHICH IS-THEr flRBT. DAY OR 11 `1976 FRB-.RICH 11-I7-99 1- 6419244667 Q6419244b6~E was ~~ DE/ANT wNASN~NGTON11EA8Ully ~ .~i.-,rrrry~/l~i~~%vu'u y x:00009000 ?~:6 2 ~ 96~, it9 244669~~' 16/04/2009 22:24 7177720412 INHERITANCE TAX PAGE 02/02 October 5, 2009 WILLIAM M SHUFFLEBARGER 1311 WOC)DWARD DRIVE CARLISLE PA 17013 (717) 7e7-62o1 jwatts~state.pa.us Re: Estate of Martha H Shufflebarger File Number 2109-0860 Social Security 22626-9173 Dear Sir: The Department issues this waiver for the following security held in beneficiary format by the decedent. The security will be subject to Pennsylvania inheritance tax. The Department will issue an information notice to the transferee of the potential Pennsylvania inheritance tax due for this asset. A copy df this waiver Is to be used by you to notify the transfer agent that the reporting requirements of Section 6411 of the Probate Estates and Fiduciaries Code (Title 20, Chapter 64, Pennsylvania Consolidated Statutes), have been satisfied. Name of Company; EDWARD JONES Type of Account: ^ Capitol Stock ^ Registered Bond ^ A Security Asset ®A Security Account ID Number: 89609509 Account Balance: $32,3Q5.49 Sincerely, Judy Watts Tax Examiner 11 Inheritance Tax Division COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPARTMENT 280601 HARRISBURG, PA 17128-0601 , Telephone COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES FILE ND . 21 0 9 - 0 $ 6 0 Po Box zso6ol AND ACN 09504668 HARRISBURG PA 1712a-o6o1 TAXPAYER RESPONSE DATE 10-13-2009 REV-1543A AFP (7-00) TYPE OF ACCOUNT EST. OF MARTHA J SHUFFLEBARGER ~ SECURITY S.S. N0. •226-26-9173 ®sEC acct DATE OF DEATH , 09-04-2009 ~ STOCK COUNTY CUMBERLAND ~ BONDS REMIT PAYMENT AND FORMS T0: WILLIAM M SHUFFLEBARGER REGISTER OF WILLS 1311 WOODWARD DRIVE CUMBERLAND CO COURT HOUSE CARLISLE PA 17013 CARLISLE, PA 17013 3 EDWARD JONES has provided the Department with the fni ormation listed below which has been used in calculating the potential tax dua. Their records indicate that at the death of the above decedent, you were a beneficiary of this asset. If you feel this information is incorrect, please obtain written correction from the transfer agent, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania puestions may be answered uy calling (717) 787-8327. COMPLETE PART 1 BELDW * * ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 89609509 To insure proper credit to your account, two C2) copies of this notice must accompany your 32, 305.49 payment to the Register of Wills. Make check DOD Valuation payable to: "Register of Wills, Agent". Percent Taxable X 33.333 NOTE: If tax payments are made within three Amount Subject to Tax 10, 768.39 (3) months of the decedent's date of death, Tax Rate X .045 you may deduct a 5% discount of the tax due. Anv inheritance tax due will become delinquent Potential Tax Due 484.58 nine C9) months after the date of death. PART TAXPAYER RESPONSE ® .S'~',C~^'' . •;5~+:. > :~ ' ~ . ,f .,..:>.,'k:'../r'% ~,, : i / r .:t't.'45ER' ~: `+?` C>'' :x . 3i i~:a}%n:. :' ~" '>/.. ~:;« .: ~ ' :'%/,.. .:>C: ~:.yc % + ., .• . i .. Yi .. . ~: :. .. U A. ~ The above information and tax due is correct. ~^ ~ ~,• 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest. or you may check box "A" and return this notice to the Register of ONE ills and an official assessment will be issued by the PA Department of Revenue. BLOCK B. The above asset has been or will be Feported and tax paid with the Pennsylvania Inheritance Tax return ONLY to be filed by the decedent's representative. C. ~ The above information is incorrect and/or debts and deductions were paid by you. You must complete PART Q and/or PART ~ below. PART If you indicate a different tax rate, please state your ''"'`~''~``~~'"'"'"~~` ~:"~' relationship to decedent: k:~l` "' "`' ,Y 4Yf %Y,`'7'`~~j'~: iY~}~ > .C~ > . ~ `,Q,u• .~~. V h;32 . ~: ~"S' ~:'E':`!. TAX RETURN - COMPUTATION OF TAX ON ABOVE ASSET(S) ~~~~ ~~'`,' .~; ~ ~ ~; ;:~~: ',~~~) , ~a ~~ry }° :. }xt~ia~Yr LINE 1. uatfon 1 ;,`:~~3r~ '~`~ G,~~ s. ~ ^~~~~Jr~~ ~', y' ''`~"~ 2. Percent Taxable ~ .h~~ ''~'~s}~ • } ~ :~ '>'~.~.• '`~~aA•' ,~•,.• x: 2 X ~`U> TA,~ ':cx, < )a`r ~:.~'°': ~IH ' S"y:~'':~,`•!.;~i.."%~~ ~"•, l xx. 3. Amount Subject to Tax 3 '~yss3'~',,.•~>'X• ~`~ f ~••f~`~> !''~ f `~'' y ~ >.z;;~:";:r y~x.:,.,>.:,,i...',u,. '" . rs : ~>~'X?i~"' ' .~fN,~,F'..' %s:£ <s'f.' >' 'r .~S> . <t~l.":fz:: 4. Debts and Deductions ''~`» ,.; ~ 'f "~ f' ''~ '` ~.~1, ; fa- ~ ~. „'.;.`:. ';'S> r~ d*%d 'i?yay ''";%.f;3.`:f'?lF, .r'i»3`';;a'~. .,~~~' zxs::r . s .f ~;s;~s:<` ~: 'tom . :.> ~ ~ : ~'" ,. ~T>.: ` ~: < . :. ' d:» : •~:~,~.-`: r% 5 . Amount T a x a b 1 e 5 ... f t,;;:~~a. ; •,;,: ~ .~.~. ~.~. . ~;~ , +;.~~:~ ~;~ ~ ~ '»r..r•;,;~, ,:;:. :~r~x:7':xr"l.`.q? ':z;: ".:'~:: :k>, ..,w:c~c :NNE<o;:zr TaX Rate 6 X ;rz`~y~;¢i:' ,;y,: ~lr" ~. .< ~ •.,ry3~:.To!!'' f~. 2.v~`s•`'`xr ..5,;. ~ .~~'=, 7 . Tax Due : ~:>vr" .f:: ~' :F~~ ,~,~ ~~'+ "' rry~ , ') ~'fi :~ 2.:~s: . PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and c e be f my_ kn edge and. HOME t?r? ) 7C~ S- ~- r S~C~ ~ /// WORK C'"7(~7 ) ~.~C~ ~- ~ t~+~ ~ ` 2 7//'~ : w:A~ ~tncer on une 5 of i ax computation) S C Q ~, ^d Q~ Y 0 ,O 7 ~' 0 ..,. V L ~1 Y 1 ~ .~ Vf W O N m 4 w ao E Z c a W o (aj J LJ. ~ ~ ~' ~ ~a W M N to O ti Q a LU U ~_ c t C 3 w E c b O 1] vi ~~ 7 vi ~ U C O U cd d~ .~.i w ~ C 0 ~ ~ ~ ~ ~ _C 3 ~ ~; ~ ~ 'O = o .`o~ '~ U 'v ~ v '~ ~ m .0 .. c ~ ~ € a~ a~ -r o v ~ Z5. N _p ~ d V ~ p a ~ ~ N N N ~ ~ ~~ ~° -- ~~ ~ ~~ c `~ G ~ ~ ~ " ~ ~ .~ ~ ~ ~ c~~~~ r N L C ~ ~ ~ °o o ~ a '„ V A '~ o ~ q~ ~ 0 o d^ ~~ ~a Q d EAI .= ti ~ o ~ ~ $ 0 o 0 fi3 69 fA d`i ty9 b? (~9 Ef! ~ ~ m N _ w ~ v~ '~ ~' ~ ~ ~ U 0 P7 V ~ p `~ ~ ~ LL `~ 7 tt j m t _ ~' W ~' ro ~ co d r+ ~ ~ ~ _~ ~ ~ !ll~~~ .~ ~ O !~ N a, C ' ~ U ~ t`~ ~ ari ~ ~ ;a ~ t/~ -v 3 LL t~ ~i cTi m v ~~ c 0 ;~ '~ _~ O r 'D c cti a U !r C }. o ~~ ai N b U :... •~ O ~ ~. ~ N ~^ ~ yO V .~ C ~ O ~ ~ O o~ .~ i 0 U ~ O ~ ~ ~ o ~~ °' ~ a~~i `t ~ ~' ~r; o ~~ r~ ~ °' c °c a~ a ~ v E cn V O ~ s R! ~~ ~ C C ~~ ~U d C d o ~ Q a1 ~ ~°c ~ ~ O ~ C ~ ~ v ~ O `' °' ~ ~a ~ E p wo c°~ °' o '$ N ,,,, ~. ~~ ~o,~ a .~ C~~ w~v ~ m ~ O o Q ~ ~~ ?` b~ o -o ~ ,o ~ '_~ c o ~' ° 4 4 ~ o N ' ~ ~ rte',' O O 0 0 D O O © ~ o o O O p O O Q O O O ~ ~ ~ C 0 0 ~ c 0 0 o a o o c o v o 0 o •r o rn ~ A ,d; ~ w ~ e- ~ a v ~ ~ ~ ~ ,~ • N ~ 1U ~, iii tf3 d! ER 6~! fH ER 69 ~ E9 ~} to EA E9 d! ti9~ 64 69 EA ~ ~ iUI C7 ~ ~- ~ O N c- ~ ~ ~ V . ~ A tt~ ~ ~ a W ~ c ~ ~ ~ ~ cq c m ~ ~ a~ ;~ ~-- ~ .. ~ ~ ~ ~ w ~ ~ cA ~ c~ c~ ~ ~ ~ ~+ ~ ~ ~ E~., • '~ o ~ ~ ~ , t a G J F- O ~.r ~ C ~ W U ~ •~ Qi d .. ~ ~ ~ ~~ ~ v 4 d `o o ¢ LN ° ~ ~ ~ ~ ~ ~~ C o. ° ~;' ~ ~ ~ M ~~ ~ . . U ~ . a~ o t0 ., ~ ~ ~ v° E ~ tv o .~ ~ ~ . ~ ~ a E a ~ "" O °~ a z .~ p v ~ cc ~ ~ 4 E w $ ~ ~ ~ u ~ m '4"j V ~ ~ ~ ~i O o ~ ~o ~ ~ ~ ~ OD a, ~ c ~ to p ~ a ~ ~ C N ~ ~ ld ~ 7 ~ ~ ~ W W ^ N c ~ ui cG f~ Gp Oi o •- .= T- N ~ c-i ~. v ~ ~i ~. cG .- I~• ? ~ w~ r~ ~ a ~~ N ~ A ~ c~C oa .~ EV•1511 EX+ (12-99) SCMEp11LE M COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT --- ESTATE OF FlLE NUMBER Martha H. Shufflebarger 2109-0860 Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t' Ewing Brothers Funeral Home, Carlisle, PA: Transport, Viewing, Cremation, Death Cents 2,301.78 Helsley-Johnson Funeral Home, Berkeley Springs, WV: Reception, Service, Burial, Headstone 2,672.11 Minister Gratuity 100.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 11,000.00 Name of Personal Representative(s) William M. Shufflebarger, exec. Sodal Seaxity Number(s)/EIN Number of Personal Representative(s) 232-80-4119 27-6219989 street Address 1311 Woodward Dr. city Carlisle .state PA zip 17013 Year(s) Commission Paid: 2009-2010 2. Attorney Fees 2,000.00 3. Family Exemption: (If decedent's address is not the same as daimant's, attach explanation) Claimant Street Address City State _ Zip Relationship of Gaimant to Decedent 4. Probate Fees 344.00 5. Accountant's Fees 150.00 6. Tax Return Preparer's Fees 1,005.00 7. Decedent's Home: Repair 8,945.46 t3 Decedent's Home: Maintenance 529.75 s Utilities through December 23, 2009 656.44 1 o Care and Transportation of Mom's two dogs to son Tom's home in FI. 744.00 11 Estate Checks from Bank and Postage Stamps for bills 32.55 12 House Appraisal /Closing costs 1,600.00 ---- TOTAL (Also enter on line 9, Recapitulation) ~ 32,081.09 (It more space is needed, insert additional sheets of the same size) Executors Fee: William M. Shufflebaraer, executor Administration of Estate: Prepared PA 1500 Inheritance Tax; Constant communication and meetings with Attorney, Tax Accountant, Brokerage Representative, and County Courthouse; regular communications two brothers; sell decedent's car; arrange appraisal of house; and sell the house. Three-months, repair and maintenance of House: Daily maintenance in house; repair plumbing, replace pipe in both bathrooms, sand and re-finish wood floor; tape drywall cracks in garage ceiling; paint floor interior of garage; power clean, strip, etch, and repaint large outside patio with masonry paint; clean and repair 500 surface feet of six-foot vinyl fencing; bring several electrical outlets to wiring code; replace damaged light fixtures; replace out of code dryer duct; and all daily maintenance due any home; cared for dogs for a month, then transported decedent's two dogs from Pennsylvania, to Florida, to new home with decedent's son. Made Funeral arrangements and maintained estate account; and consulted Judy Watts at Dept. of Revenue numerous times for advice. Miscellaneous other tasks as well, including the transference and closing of the decedent's accounts. Attorney Fee, Rob Obrien: His fee included six office visits, one for four hours; numerous phone conversations about estate; probated will; letters of administration; E1N filing; house closing; authorized County inventory list; as Mom's attorney, I consulted with him on a weekly basis. Tax Accountant Prep and Fee, Jeff Cohick: He was Mom's tax accountant; He helped me setting up estate account, reviewed final PA 1050; Federal 1040; PA 40; Local Taxes; Fed 1041; and PA 41. He provided advice, consultation, and many phone calls. Attorney Robert L. O'Brien 19 West South Street Carlisle, PA 17013 Tax Accountant Jeff Cohick Cohick and Associates 390 Alexander Spring Road Carlisle, PA 17015-9129 Explanation for B-10: Care and Transportation of Mom's two does to Tom's home in Florida My mother was concerned about the care of her two dogs, should she die. In October 2008, my brother Tom and his wife, Barbara, told Mom that they would adopt the pets should that happen. When Tom and Barb came up for Mom's funeral, we discussed the matter of transferring the pets as quickly as possible, not only for humane purposes, but to facilitate the repair of the house. This was an immediate need, since the dogs had destroyed the carpet throughout the house (note: $4,442 of line B-7 is carpeting expense). A realtor agreed that the house would not be marketable with the condition (especially odor and tearing) of the carpet; that it would need to be changed. We agreed, sons Bill, Tom, and John, that we would pay out of pocket; then charge the estate for reimbursement. Our attorney and tax accountant both agreed that the process qualified as a legitimate estate expense; first, from the practical standpoint of preparing her house for sale; and second, since it was public knowledge that the agreement existed between my mother and Tom and Barb. To ship the animals by air from Dulles to Orlando would have been about $1200. So we agreed, Tom and Barb, and my wife and I, that I would rent a van in Pennsylvania, drive the dogs to Florida, and rest overnight on the two day trip in a "pet friendly" motel. Tom made all reservations since he travelled a good deal and enjoyed discounts that we did not have. We would return the van to Orlando Airport on the third morning, and we would return to Harrisburg by air. The total cost was $744. William M. Shufftebarger, Exec ..---- ~_. ~~, r._~`. ORLANDO INT'L AP(OFF AP) RR 524984040 *61 TCJM SHUFFL,E~BARGER VEHICLE: 02198 / 1888395 085NE8 LIC: CO 8335IT FUEL: 8/8 OUT 8/8 IN CDP:00014 -AAA AUTO CLUB SOUTH ~ RES: E5031759256 /ICAL / L COMPLETED BY: 1262 /FLORLI6 RENTED: HLE, MECHANIC5BURG, PA j RENTAL: 09/18 /09 07:55 RETURN: 09/20 / 09 08:03 PLAN IN: ICAL RATE CLA55: L PLAN OUT: ICAL MILES IN: 31103 TR-X MILES MILES OUT: 30026 hIIlES ALLOWED MILES DRIVEN: 1077 hIILES CHARGED DAYS 2 f~ $ 145.99 /DAY $ 291.98 SUBTOTAL 1. $ 291.98 DISCOUNT - R 15 95 $ 43 , 80 SUBTOTAL 2 T$ 248.18 LDW ACCEPTED E~ $ 19.99 UAY T$ 39.98 LIS DECLINED PAI, PEC DECLINED PA SURCHARGE $ 4 ~ ENERGY SURCHARGE T~._ 1.03 TAX 8.0009 n...-!~---.~._:-289...::19. $ 23':"13 NET..-~DUE._ ; 316.3~~~ ,.PAID BY VISA XXXXXXXXXXXX4231 .:~ ~ ,, r ~~~ 1~,~ __ ___ ., _~_ i HOW WAS YOUR EXPERIENCE? WE'D LIKE YOUR FEEDBACK. 1) Calt 1-800-278-1595, or Visit WWW.HERTZSURVEY.COM 2) Enter Access Cade: 05867 3) Take Brief 4 Question Survey THANK YOU FOR RENTING FROh1 HERTZ Ramada Hotel & Suites Florence 1819 West Lucas Street Florence, SC 29501 . Tel: (843) 665-4555 Fax: (843) 665-4577 na_~ a_na William Shufflebarger Folio No. 4288 Room No. 311 1311 Woodward Dr A/R Number Arrival 09-18-09 Carlisle, PA 17013 US Group Code Departure 09-19-09 Com an P Y Conf. No. 64244977 Wyndham Rewards : Rate Code S3A Invoice No. Page No. : 1 of 1 Date Description Charges Credits 09-18-09 Pet Fee Pet Fee 09-18-09 Room Charge 09-18-09 State Tax-6% 09-18-09 County Tax 2% 09-18-09 Occupancy Tax "s% 09-18-09 Local Tax 1 09-19-09 Visa XXXXXXXXXXXX4231 As a Wyndham Rewards member you could have earned 612 points for this stay. 10.00 61.20 3.67 1.22 1.84 0.61 78.54 Total 78.54 78.54 Balance 0.00 Guest Signature: Please contact the Manager about and issues with your stay. Ramada or affiliates may contact you about goods and services unless you call 877-222-3297 or write to Wyndham Worldwide Hotels, Inc. 1 Sylvan Way, Parsippany, NJ 07054 to opt out. View our Ramada website about privacy. _:` ,~ ~~.~:,~ r ~l ~~ ,/~~ / ~ ~ ,~/ ~~~. Thank you for slaying with us. It was our pleasure to serve you. ~, '°~`° ,~ t -~ ~ . x~~l ~.~~~~ ~t ~ics~Ke~c~: ~C w~5~~ t ~,~.. ~~. ~i:{~. it ~~ ~~ p~t~ ~ii~rT~ j i~~~ `~'~E~~C~~~ 1 J i~f~ %t] ~. F R~a~.~13.i' ~.~, ~i~~ ;ELF ~ ~~; ~t~~f.. ~~~4ti. ~~Lw I :i ~ r fi~ jt7rJk i ~~~~~3 34 ., ~~"~~~~ ~~ `~~ ~: ~~. 3 ~-- ~"~ r '?~ w,~ .~#~ W,:#, •~ ~~~c~~ ` ,tee #6'e'$ tnton 4``4ad ,ksbu~9~ u~ ~K~~K~K~K~K~K:~ :~K~K~~K ~'9/ a $/Cl-9 6`~ ~4~5 Y' O ~lA G t: ~t~ a ~dtA f1 t• ~1FILE~I~~. ~~ ~ ~ 7 . ~4 Tot~a 1 z~~r. l e ~ ~ ? . ~4 ~~~~~~K:~~~K3K~K~kjK~K~K=r ;~C~1C~1c~K Thank 'y'ou FQr~ Fuo l i rry at Waw~s ~~c~K~c3K~K~c ,~~K~Ic~~Ic~K~K~K~. ~~~~ `~ - ~ WilcaHees #3969 K i ngs land, Gib Ticket: 16$4453 V I Sid 9cct # : ~1t ~1c ~ ~K ~Ic aK ~k ~Ic ~inK * ~K 4 2 31 89/19/89 12:99:08_. approval: 6918$9 Reference : 899262582 1?5983?M5K rump Ga11on~ Price 11 19.856 2.239 I Rroduct Amount Unleaded #24..33 j Tatal: # 24.33 (~ Have a Nice Dayt Dcn't Drink ~ Drive ~` ~~~ r ~i \ /l./...~ ~~~~5 ,JC,,`, 3 ft i 4~• ,f ~+ We 1 come To L.a~e~#~~t3 188 Highway h~9 Polk City i~L Date : 89~28-,fU9 Time : ii #; ; hq I n+~a f ~e # 4Ug41 VISl~ Card dale j 4########~###4~~5.1. Pump Ga11on~ Prue ~ 8.~r~ ~~.~9i9 Prod~u~ct. Un 1 e.acfed I Ti~1'At, Sfi~.E ~ ~#~ .'~7 i rerr~iinal ~pPr+~ued# fi9~~~h REF: Thank S~QU * # ~ F: ~: ~~ NaUI HIRING 5h1ILING FAt:FS! APPLY AT WW~J.MCMARYLAND.COMJ545G 313 FAST POTOMAC S~fREET WILLIAMSPORT, Mq 21975 THANK YOU ~JILLIAMSPORT ' 8B KS#03 STORE# 5456 ~r~er #~~ 1 FILET--0--FISH MFAI_ 2 CHEFSFBURGER 2 ONLY MUSTRq 1 MELT hRENCH FRIES z M~q caK~ SUB TOTAL TAKE OUT TAX TEf.# (301)223-9011 Sep.18'09(Fri)1G;45 TO GO 3.90 1.98 1.79 2.98 10.65 U.64 11.29 CASH TFNgERFp '~NGE fi~ ti 20.00 j SHONEY'S #333684 I []r~c~~~r # ~lt~l~~3 ~fBL#01 'I P:IY#(l l Name Tracy 1 BRKFST 1 CTR 1,g6 1.97 lbs, ~ 3,99 per lb 1 WATI.R ONLY ua 7.86 TAx a ~ ~, ~ TaIAL ;~ ~ ~ ~ CASH 20.00 CHANCE qUF 11.59 8,30 U1 O1 9/19/09 New I: gs to Order witr~ ,~reakfast Buffet (,attiring Available ftir Large nr Small Groups _.- 8.71 ~I ~~~ '`~~ ~~ ,.p,~ ~~,. cYa o ao N ~ I~- m ~ ~ 1`~- ~+,' r-'- X L V rn ~ :~ ~ -;-~ ; -~-~ o :CJ N ci. ~ ~ oo ~n .. ~ co ;--. :~ ~x~ ~`L ~c~ ~ n~ w~ s' ~ t:~ ~ ~ ~~Q J ~ ~ ~ ~ ~ o~w i-- n. cn ~~~ w ~ c~ *- r- J ~ ~C I- r"t ~. , 1- :~ ~ J ~ ~ ~ 0o H I O ~ 1I- ~ I E ~- -~ ~ ~ C~ <C ~ l t~1 T ~1 ~ ~ WHh- ~~1L O H W !Y (~ ~w (0 I- ~ Ora ~~ ~' ~~WH~ 3.iL~ ~C°a 1 { Q W +- W ~ to ~' ~ ~ ~' '"'1 ~ W ~ ~r~t~ ~~ I ~~ ~~'.~ I W r~i ~ (D E ~ U.i ~:'~ ~ ~¢ I ~ H ~,.. I- ~ I ~ oa~~~c~ l~ rs~Hr~ ~~y H C1jJ I n ~,W~f7r- '~- Ll. ~ ' ' ~ ~J W ~' ~~ i ~ U1 U c. ~- ~; HMSHUST MACARONI GRILL ORLANDO INT'L AIRPORT 10149~Neetu_M_W_.Y___________.___ 1 1 1 5/1 833 GST 1 SEP21'09 1:30PM *~~~ SEAT 1 **~* ~~ 1 SODA BAR 14 2.59 FIRST ROUND SBEV ICE TEA 1 SPAG ~ MEATBALLS 11.69 MEAT SAUCE ~ SUBTOTAL 14,18 TAX 0.93 AMOUNT 15.11 ~~~~ SEAT 2 **** 1 SODA BAR 14 2.59 f FIRST ROUND SBEV ICE TEA 1 CHIX CAESAR SALD 10.49 / SUBTOT~.~ 13 , 08 TAX ;.85 AMOUNT 13.94 , SUBTOTAL 27.36 TAX 1.78' AMOUNT ~; 2 9 1 4 *~~ GRATUITY NOT INCLUDED ~** Customer Comments call or email (407) 851-1334 x145 MCOCustomerService~HMSHost.com HMSHOST RUM BAR CHARLOTTE INT'L AIRPORT ..,478 ;;AYLA ~ 81`1 1 ~ ~-~ GST 2 SEP21'09 6~C4Pr1 1 **** sEAT 1 ~~-. 1 BCP,Ci GOLD PINA =.~ .?^ 1 ULTIMATE i~Ar~Y ;(~ 1 ir`AG~!OS ra , NO CHOICE ADD GUACAMOLE NO JALAPENOS 1 CALAMARI SUBTOTAL ._~;: TAX 3.73 AMOUNT 4~ t:~8 SUBTOTAL 40,35 TAX 3,73 AMOUNT ~ 4 ,4 t~ 8 THANK YOU, H~•1SHOST COhfP*1ENTS, QUESTIONS OR CONCERNS? PLEASE CONTACT 704-359-4316 OR LLTCUSTOh~ERC~H~~SHOST , COM t;, ~ r t- , ~~- .~. ~ ~.. , ,`~, r~~ ~' indows Live Hotmail Print 1Vlessage r.1"6 i ~ -J http://byl l 1 w.bay111.mail.live.com/mail/PrintShell.asp~?type=mesa --7 .u Travelocity Confirmation From: The Travelocity Team (travelocity@travelocity.com) Sent: Tue 9/15/0912:55 PM To: TSHUFFLEBAt~GER@MSN.COM ~~ Il ,.n..;~.:w a.~'wT+new:~xvn R ~' .r.w.+wA'~!. -^t°1aF~•"~ ~.rr~«,rw.yi !~y.x+~;rj '7 l~SZ91~'. ' ~r_.ra~-Me+s.ww.. W11118m, -. . ~.. . Thank you for booking your travel with Travelocity 1` ~~` ~~~ ~. Your Travelociiy Trip ID is: 3925 8678 1519 You can view your Trip Details by logging onto Travelocit~r.com If any issues arise with your reservation before or during your trip, please contact us immediately. Customer Support In the US 1.888.872.8356 24 hours/? days a weak flow to change ~ trip Outside the US 1.210.521.5871 24 hours/? days a week _~._..~_ ..How to cancel my trip En Espanol 1.866.828.3933 lam - 10pm CST Emaif Tra~.~elocit~,~ Flights ~ ~- ~ ~~~'~-- ' 2 One-Wa Tic t .----~ l ~ l ` J ~ ~ ~ ~ ~`- y ke s ` \ All flight times are local to each city. ~ ....~ ,~ ~,~~ ~. Mon, Sep 21, 2009 (•~-~ ~ ~` Online check-in de: A3NXKZ \ ..;. Depart: 03:30 pm Orlando, FL (MCO) US Airways, Flight Arrive: 05:07 pm Charlotte, NC (CLT) Travel time: 1 hr 37 mins 1 Stop -change planes in Charlotte, NC (CLT) Connection Tirr~: 2 hrs 48 mins Depart: 07:55 pm Charlotte, NC (CLT) Arrive: 09:22 pm Harrisburg, PA (MDT) Travel time: 1 hr 27 mins Passengers E ticket Numbers WILLIAM SHUFFLEBARGER 0377705049807 ~~ ~ ~ ~ ~ ~ ~ /~ .~ ,,~~ C~ j`~ ~~C~~ US Airways, Flight 816 Frequent Flier Information Add your number at the airport. \~ _..., ;. ""~ Hotmail Print Message r PATRICIA SHUFFLEBARGER 03777450490$ Flight policies Pricing http://by 111 w.bay111.ma.il.live.com/mail/PrintShell .aspx?type=mesa Add your number at the airport. 2 Adults: $118.00 ($59.00 per person) Taxes & Fees: $39.40 Total: , -$157.40 J We charged a total of $157.40 to your American Express® Card x~ooc x~ooc xx~oc 2001. The Travelocity Guarantee We look out for you all trip long, and even before you go. The Travelocity Guarantee is our commitrr~nt to you that we are here for you. We stand behind everything we sell, everything about your booking will be right, or we'll work with our partners to make it right, right away. Leam more Complete Your Travel Plans for Harrisburg Add a Hotel 2-Stars: Howard Johnson Harrisburg from $74 /night 2-Stars: Hershey Travel Inn from $45 /night Nlore hotel deals 3-Stars: Hotel Carlisle & Embers Convention Center from $73 / night Add a Car From compacts to SUVs, we've got cars well-suited for your time behind the wheel. More car deals REV-1512 EX+ (1Z-08) ~ pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Martha H. Shufflebarger 2109-0860 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 • South Middleton Township School Taxes 879.99 2 Rite Aid (JCP Credit Card) 184.98 3 American Express 115.42 4 Precision Mowing and Maintenance 131.44 5 Pennsylvania Dept of Revenue/ PA-40ES 125.00 6 Internal Revenue Service/ Estimated Income Tax 250.00 7 West Shore EMS 287.90 8 Cumberland Goodwill EMS 75.00 9 Betra in-Home Care 250.00 10 Phillips Lifeline (auto withdrawal) 40.87 TOTAL (Also enter on Line 10, Recapitulation) I $ 2,340.60 If more space is needed, insert additional sheets of the same size. Check Image Page 1 of 1 r ~rrr:. r «.-u r u:; r., ~raTkCr ~ Es ra~~a°s ~ Gverrr:> ~-`ur3~~c~r~~NS ~~so~.~Rr.F. Account Summary Transfers ? eStetements ;Bill Payer Services Visa Loan Applications MY Profile ; fNessages Check Image Clnse Front of Check• ESTATE OF MARTHA J HAYNES SHUFFLEBAR p-a~z,~a 10 2 0 WILLIAM M SHUFFLEBARGER p1°'~"~' 1311 woovwARV ~~ GIB 1NILLIAM M SFIVFFLEBARGEK Here (')at a ~ z~ CARLISLE, PA 17013 t ^ //1~ PA~_~A~~sn'G" `- _ C..dtJ~U1s ~'4 C ~ .t I_I~2LS'L~'tI` I ~ ~~ .QL~J e 1 f ~ ~~ ~~ue.on 33 R ~ "-~'L~L. ~ ,~l . G3 ~ __.__ ~:23i38224i~: 2L836?4353' X020 ,..,.... Back of Check: w n~ 1- J. . ~ G l~ ~ ~; ~co~~ 1r '~'; r U c~ ; m ~ U' W Q ~ 7~Y ; ~ ~ o c~ ~ • - Q ~ . H LL ~ ~ ~y 6 i f a _ :~ W ~~ ~l ~. i . - - ~. 5 - ~. }, N , ~ ,,~ ~ 3 ~ I C - c ~: _'„ -, 4 ; _ ~ ~? L ` `'n ~y t:€ . E, > Y ~ ~~ l.~/j .av~~i} jrf lti : ~~ii_ .. ~..s` ~`~~ „~ ~G - f, j`1~w _ ~~ .t - C ~ u ~. _ ~. _~ltts~..Win~gvv ~ .....................:........... . https://m 1 online.members 1st.org/OnlineBanking/AccountSummary/CheckImage.px?acco... 10/30/2009 Check Image Page 1 of 1 6i'; 4,A F; i•.l?!,`~vT ii:i f;t'i~lTHti:T US 1'lEi~N:i: & E:VEPITS F''JBLiGn'T~ONS RL'i;C~tJRCE`3 Account Summary :Transfers eStatements ' Bili Payer Services ?Visa :loan Applications My Profile 'Messages Check Image Close Front of Check: ESTATE OF MARTHA J HAYNES SHCTFFLEBAR eo-a~wx+~a 10 O 1 WILLIAM M SHUFFLEBARGER 2t°'6"'~+a~ ,~I q ]371 WOpDWARD DRIVE DA't9G~«~'~'~i, ~C.~~ C/+O WIU.IAM M StiUFFLEBARGER CARLISLE, PA 17013 ~/ ^ , pAVTO ~~,Q/~T G.. ~Q//"~S. `...~~r'`r' ~~ $ I-39. Qq ~ 7~OItDER OF ~ f ~St ~~~ /1.rr~a? Owt~/~ ~ ~~DO4uRS ~ ~.4 . i' ~ R~n~1ON ~~ • ,. ~:2 3 138 2 24 1~: 21836?4353M 1001 ... ..._ .. _wira.w Back of Check: ~~~.-L~~Y sA1~K..~ _:. W , _x fi~ t r ~ ~ C7 )z „ 7' _ % r, M ' 4_ , a ~ % ` L~T~ r ~ T o. 2 .f7 ' . ~ ~, ; .~ . 0 'y = 0 ~ W ~ t, ,^ -.4. { .~.. ~_ .arty. _ _ _ .. _ r~ ~_...r_ ...u Q ~' ' L ' • ~J 3 a ' ............................... _.............,..,...E ~Io~~ W.nd4w;t _ .. https:/fm 1 online.members 1st.org/~nlineBanking/AccountSummarylCheckImage.px?acco... 10/30/2009 jc;a.c,ca,i~ plus, receive an additiona115% Off your entire portrait purchase when you use your JCPenney Card additional traditional portrait sheets 3.99 each (Reg. 9.99) JCPenney Portraits can be found in most larger JCPenney stores. Schedule appointments at jcpportraits.com or 1.800.59.SMILE for studio locations. Offer expires 1 /31 /10. Free sitting fees. Present coupon at time of sitting. !P Not valid on reorders, studio events, with other offers or online oniers. 181Y198 One tree traditiona18x10pen family. Account Number 477-623-008-0 Minimum Payment Due X15.00 Pnvlous Balance X153.05 payment Due Date 10/09!09 „ e, (-) Payments A Credfts x153.05 Crodit t_imit x2,200.00 Available Crodit ' w (+) Charges X184.98 X2,015.00 w ~ Billing Dats 09H 6/09 (+) FlNANCE CHARtI<ES (NET1 X0.00 pays in Bluing PeNod 31 New Balarroe X184.98 ir,r,,~~c,,~ s"i?i ~.. r~ t~ .~ PACE 01 OF Oi For account infom~a8ion Call 1800-b27 7717 Writs P O BOX 881131 EL PA80, TX 78988 OnNns jop oom T~ ~ Referonoe Number ~ ~Batanoe Type Rem Description ~ Chafes (.. Payments 3 CredRs 08-23 P8118007tZ00XTT81G R RITE AID DRUGSTORES DRUG STORE MERCHANDI8E 08-24 P81 f 9007EOOXTT8H7 R RITE AID DRUG8TORE8 DRUG STORE MERCHANDISE 08-27 P8118007F010FWE16 PAYMENT -THANK YOU 09-01 P9118007MOOXTTFXV R RITE AID DRU08TORE8 DRUG STORE MERCHANDISE ...1 ..f» .......... .....{: ....}.............~.... ::.r............ : ..:. ..r.... ...:?:........ . .~. v.. ~yp,~yyRy ...r............... . .. .. ........ ..........................3......: ......... ......................:.. , .......:................... . • ik... ..s . r .........................................., ....: ............ ... BALANCE I COMPUTED ON PERIODIC RATE(8)% TYPE AVERAGE DAILY BALANCE REGIULAR E 0.00 .06261 dally 22.85 ~ Your Bahnoe ConHxttatlon OAethod Is indicated above. See nwene side for an exphnatbn. ANNUAL PERCENTAQE RATE t:OR TH18 BILLINQ PERIOD 22.8SOX TOTAL PERIODIC FINANCE CHARD, E ,00 JCP REWARDS EARN ~ f0 REWARDS MONTH AFTER MONTH S/GN UP FOR YOUR FREE MEMBERSHIP GO TO JCPREWARDS. COM MONITOR YOUR ACCOUNT 24/7. ENROLL IN FREE ESERV/C/NG AT JCP.COM AND TAKE ADVANTAGE OF THE EASY WAY TO: VIEW RECENT TRANSACTIONS, CHECK YOUR BALANCE, UPDATE PERSONAL INFORMATION AND MUCH MORE. 74.91 33.34 183.06 76.73 ..4..». ~ ~... r: iii3': i:s ~ `:ri:;:i:; ..:fib:; ':;r. tt'r.~ "i 'Yi ~':•. ''. ...:•.1 i ................... i»~.»......................».......t... -............ CORRESPONDING ANNUAL PERCENTAttEE RATE(S) ~f. PNasa note your malted payment must be roeeiwd by 5PM (ET) or your in-storo payment must be rocelwd during stony hours on the due date. Your payment may be converted into an sleohonio debit. Bee nwrse for details. am po nts on .all of your '''~~` ""~'"~ - purchases, everywhere ~~~~=ty~~ Senor Member you use the Card. Statement of Account Visit www.americanexpress.com/rewards P,epa,ed Fa Account Number Closing Date M H SHUFFLEBARGER XXXX-XXXXXO-72005 09/01/09 Page 1 of 5 New Aoti~ny $ New Please Pay By n Previous Balance $ Payment Achv,ty $ Inc. AdjusU»ents Balance $ 09/16/09 93.22 -93.22 +115.42 Please refer to page 3 for important information regarding your account 0 Z __ __ _ --- o To manage your Card account online or to pay your bill, please visit us at www.americanexpress.com. For additional contact information, please see the reverse side of this page. a z r ~ ~` ^ o ~,.~ r~ 0 0 Activity ' I~~a1es,~r„~, date ____._- _-- 08/11/09* PAYMENT RECEIVED ACH -THANK YOU Due in Full Activity for M H SHUFFLEBARGER c:~d xxxx-xxxxxoa?oas Amount S -93.22 Amount 4 08!08/09 NELL'S -WALNUT BOTTCARLISLE 33.83 7172492345 08/29/09 NELL'S -WALNUT BOTTCARLISLE 60.76 7172492345 - - --_ _- 08/29/09 KMART 7746 KMART #07CARLISLE 20.83 CARLISLE PA Total Due in Full Activity 115.42 Please fold an the pe,to,at,on Flow, det.~h and ,etu,n wdh you, payment + Continued •eciszon l~toufin~ c'~.I~Iairifex~ax~ce 95 ~ti1.c:C'11~•s I~Iill Road '~~'})tl1°b, PA 17240 7-6~9-0777 Bill To artha Sftllf1:11~ar~~1. Ridge~~-~l}- Drit-~ lrlisle. 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Q J w cn ~w '~ ~ U -.-'+ w a cx ~~ 0 a 1 t~- ru ~ ~. ~cla Q N o w r~ Q ~ r-+ ` ` i~ ,~ ~a. ~ r'u f1J ~~Q QQ~" G ce ~+~~~~ m ~ ~ E"+ F--r p0 J ~ a x ~ .-O ~~~ ~ ~" W ~ ~' O w ~C1U ~ :: 3.t:N~i•^7 b~~131~Y:•i 3v ~li0 v I i i ~.._ 7 r \\ ~~ 4~ ., WEST SHORE EMS -CARLISLE ~ 205 GRANDVIEW AVE STE#211 CAMP HILL, PA 17011 ~~ Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 PATIENT NAME: MARTHA SHUFFLEBARGER INSURANCE: 9006311 MARTHA SHUFFLEBARGER 23 RIDGWAY DR CARLISLE, PA 17013 PATIENT NUMBER: CALL NUMBER: DATE OF CALL: TIME OF CALL: CALLER: FROM: TO: REASONS} FOR TRANSPORT INVO/CE ~~~ 83416 REJ 9006311 NONE 09/04/2009 07:53 AM 23 RIDGWAY DR TREATED @ SCENE NO TRANSPORT Unresponsive Patient Respiratory Failure DESCRIPTION OF CHARGE QUANTITY UNIT PRfCE AMOUNT ALS TREATMENT -RELEASE/REFU: A0998 1.0 275 63 EKG ELECTRODES (4PK) A0396 1.0 . 5.19 275.63 5.19 GLUCOSE BLOOD A0394 1.0 7.08 7.Q8 Total Char es 287.80 . Cumberland-Goodwill FireRescue PO B4X 12910 PH1LA, PA 19176-0910 Phone #: (800j 367-0512 Federal Tax ID: 23-2298422 MARTHA SHUFFLEBARGER CG0903591 MARTHA SHUFFLEBARGER 23 RIDGEWAY DR CARLISLE, PA 17U13 BLS RESPONSE AND TREATMENT A0998 t y~ , 1 R'~ t~~ ~~ ~k ~` , ~S 13fi21 PRIV CG0903591 A 09/04/2009 07:52 AM 23 RlDGEWAY DR TREATED @ SCENE NO TRANSPORT Unresponsive Patient SHORTNESS OF BREATH 1.0 75.00 75.00 r^~ ~. _-.~ Total Charges 75.00 Total Credits 0.00.. $75.00 BETRA In Home 1026 Ritner Highway Carlisle, PA 17013 717-258-3881 BILL TO Martha Shufflebarger 23 Ridgeway Drive Carlisle,Pa. 17015 Invoice DATE INVOICE# 9/14/2009 3674 PATIENT NAME M. Shufflebar... DESCRIPTION HOURS ~ RATE. SERVICED AMOUNT PC~-IA/1~EW PATIENT 10 25.00 9/3/2009 250.00 . ~~ A 11 • • _ _. n~~ wvjn la cump~eiet r~ease accept our sympathy. ~ TOta~ $250.00 ~ ~ , Lifeline Systems, Inc. 111 LawrenceStreat Lifeline Care Plan Agreement Framingham, MA 01702 Page 1 of 2 ^ This is a PARTIAL Install ^ This is a FOLLOW-UP Install; (Bust complete all dumber of pages included: fields outlined in bold) 1 ^ or 2 ^ Program Name ' ; ,.: .. ~ . w.-. Program Phone Number Program Code Model Type Unit # Household Phone # ( ) V Installation Date Salutation Subscriber Last Name First Name Middle Suffix Preferred Name Last Name Sounds Like Language Need'? ^ Spanish ^ Other Gender ^ Male [l Female Date Of Birth Household Information Emergency Phone Numbers (Do not list 911 or 800 #'s) Residential Street Address~Apt.# CEXTKAI. DISPATCH ( ) POLICE ( ) City. State ' . _' Zip Code _ FIRE ( ) Township/ Municipality COUtity A1IBGLA\CE ^ Check if t'ri~"ate ALTERNATE A3IBQLANCE ( ) ( Household Hidden Key Location Directions Ta Home (Must Be Provided If PO Box Listed) Additional Services ^ Healthcare Directives ^ Inactivity Alarm Service Special instructions ^ State Funded ^ Lifeline Smoke Detector Drug Allergies Medical Conditions andlor Diseases Household Warning Responder O ne Responder Two Responder Three Name (First/Last) ~, ~ • Name (FirstlLast) Name (First/Last) • Language Need? ^ Spanish ^ Other Language Need? ^ Spanish ^ Other Language Need? r ^ Spanish ^ Other Street Address Street Address Street Address City, State, Zip Code City, State, Zip Code City, State, Zip Code Family Relation ^ Have Key ^ Family Caregiver ^ Notify ^ Reminder Contact Family Relation Q:.Have Key •^ Family Caregiver ~ ^ Notify - ^ Reminder Contact Family Relation ^ Have Kcy ^ Family Caregiver =• ~ ^ N'otif y ^ Reminder Contact Phone ^ Home ^ Work ^ Cell _. Phone Q Home ^ ~'Vork ^ Cell Phone (~ Home ^ RTOrk ^ Cell s E, ( ) ~ ~ a Phone ^ Home [] Work ^ Cell ( ) A P Phone ^ Home ^ Work ^ Cell ( ) Phone ^ Home ^ Work ^ Cell ( ) Phone ^ Home ^ Work ^ Cell Phone ^ Home ^ Work ^ Cell Phone ^ Home ^ Work ^ Cell All information contauied in this repot is considered private and confidential, and is intended solely for use by authorized Lifeline Systems, Inc. representatives. PN 0930334 Rev. 03 (BMS) . ~ . Liteline8yatems,inc, Lifeline Care Plan Agreement 111 Lawrence Street Framingham, MA 01702 Page 2 of 2 Program Code Subscriber Last Name First Name Household Phone # Program Namc '~ ( ) Notify Notify Name (First/Last) Family Relation Name (First/Last) Family Relation ^ Family Caregiver ^ Family Caregiver ^ Reminder Contact ^ Reminder Contact Phone ^ Home ^ Work ^ C'eli Phone ^ Home ^ Work ^ Cell Phone ^ Home ^ work ^ Cetl Phone ^ Home ^ R'ork ^ Ceti Primary Physician Third Party Notify Name (Fit•st/Last) Name (First/Last) Fax Number ( ) Phone Name (First/Last) Fax Number r ~ ,, i ( l ) Preferred Hospital Referral Source Hospital Natne . Name (First/Last) Phone ( ) City, State r Phone txEQctRfDl ( ) ~` Organization/Agency Name Position/Title ^ Multiple Subscriber Household Street Address City, State, Zip Code (Yore «r«st complete a separate Care Plan Agree«rent for ~«c!r Subscriber) Name of Additional Subscriber Coupon Code ~ . Referral Source Code Aromotion Code Subscriber Notes Paver Information First Name (1('appl~rnhle orga«iwarrea„ ,~cr«re) Last Name Home Phone # Street Address Wot•k phone # ( ) City State Zip Code Social Security Number Medicaid Number Monthly Fee(s) One Time Fee(s) Payment Frequency Payment Method Monitoring Service S - Enrollment Fee S ^ Monthly _ ^ Ltvoice Inactivity Service s ~, ^ Quarterly ^ Credit Card S Shipping & Handling S ^ Z'early ^ Debit Card Card Type Name (as it appears on Card) Card Number Expiration Date ^ Visa ^ Master Card ^ American Express ^ Discover For Program Use Only (Not to be Entered by Data Entry) Signature Of Subscriber Date Signature Of Payer (If Different) Date All information contained in this teport is considered private and confidential, and is intended solely for use by authorized Lifeline Systems, Inc. representatives. PN 0930334 Rev. 03 (BMS) ~~ MEMBERS 1St FEDERAL CREDIT UNION Send inquires to: 5000 Louise Drive PO Box 40 Mechanicsbur8, PA 17055 www.membersl st.org Main Switchboard: {800) 283.2828 EZ Call: (717) 697-4372 or (800) 283-4372 TDD: (717) 697-5312 or (800) 283-2328 ext. 5312 TeleBranch: (800) 237.7288 2164 1 AV 0.3'35 7536-2164 ~~~~~~~itt~l~t~t~i~l~ii~~~~~~~~~~i~~~~~~~ n ~~~i~~~~~i~ll~~~~~~ MARTHA H SHUFFLEBARGER C/O WILLIAM SHUFFLEBARGER, EXECUTOR 1311 WOODWARD DRIVE CARLISLE PA 17013 Statement of Accounts Aug 25 , 2009 thru Sep 24 , 2009 Account Number: 194$56 Balances at a Glance Checking : 60.00 Savings: 5.00 Certificates : 0.00 Loans: 0.00 Money Management : 0.00 Swipe 5 YTD Reward : 0.00 Page : 1 of 3 Your current Member Loyalty Rewards level is Platinum. Your aggregate balance as of September 1st is $36,308.53. An aggregate balance of $75,000 and having 3 products will move you to the Titanium level. We are celebrating International Credit Union Day on October 15, 2009. Please see the enclosed insert for more details. CHECKING ACCOUNTS 11 -CHECKING Date Aug 25 Transaction Descriation Additions Balance Forward Subtractions Balance Aug 25 Deposit Transfer From Share 00 155.90 14,545.64 14 701 54 Aug 25 Deposit Transfer From Share 00 389.48 , . 15 091 02 Aug 27 Check 000629 Tracer 0001242298 58.07- , . 15 032 95 Aug 27 Check 000631 Tracer 0001545112 300.00- , . 14 732 95 Aug 28 Check 000628 Tracer 0023284038 153.05- , . 14 579.90 Processed Check - JCPENNEY/GEMB , TYPE: CHECKPAYMT ID: 0301200401 Aug 29 Withdrawal at ATM #1005801 100.00- 14 479 90 MEMBERS 1ST FCU 1166 WALNUT BOTTOM RD CARLISLE PA , . Aug 29 Deposit by Check 100.00 14 579 90 Aug 31 Withdrawal at ATM #006610 40.00- , . 14 539.90 MEMBERS 1ST FCU 1166 WALNUT BOTTOM RD CARLISLE PA , Aug 3'I Check OU0622 Tracer 0003421175 439.99- 14 099 91 Aug 31 Deposit Dividend 0.150% 1.96 , . 14 101 87 Annual Percentage Y~e/d Famed 0. 150% from 08/01/2Q09 through 08/31/2009 , . Based on Average Dally Balance of 15, 376.81 Sep 01 Deposit Transfer From Share 00 322.51 14 424 38 Sep 01 Check 0630 Tracer 0129868938 17.87- , . 14 406.51 Processed Check - UGI UTILITIES , TYPE: UTIL PMT ID: 231174060 Sep 01 Check 000632 Tracer 0035107491 54.24- 14 352.27 Processed Check - Embarq TYPE : BILL PYMT ID : 2202975500 , DATA : 1-888-723-8010 Sep 03 Deposit Transfer From Share 00 1, 395.00 15 747 27 Sep 04 Check 000633 Tracer 0001209177 205.44- , . 15 541 87 Sep 06 Withdrawal POS #121117 10.59- , . 15 531.28 SOU THE HOME DEPOT 462585 CARLISLE PA , Sep 08 Withdrawal at ATM #/000257 200.00- 15 331.28 MEMBERS 1ST FCU 321 YORK RD CARLISLE PA , Sep 08 Witftid~tti ANk Li~~ 6~mrs 4(1.87- 15 290 41 TYPE: DIRECT PAY ID: 1042537528 , DATA: 1017421 CO: Lifeline Systems `~ ~" _ _ _ (`.nntirn ~t~t nn fnllnwinn Wane _ _ _ REV-1513 EX+ (11-08) Pennsylvania SCHEDULE ] DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ---- ESTATE OF FILE NUMBER Martha H. Shufflebarger 2109-0860 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. William M. Shufflebarger Son One-third 1311 Woodward Drive, Carlisle, PA 17013 2 Thomas E. Shufflebarger Son One-third 1518 Auburn Oak Circle, Auburndale, FL 33823 3 John V. Shufflebarger Son One-third 6 Olde Stone Bridge Path, Westboro, MA 01581 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON TAXABLE DISTRIBUTIONS; A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. N/A B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. N/A TOTAL OF PART II -ENTER TOTAL NON TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 0 If more space is needed, insert additional sheets of the same size. COMMONWEALTH OF PEPJNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 DECEIVED FROM: ~- PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 01 1907 SHUFFLEBARGER WILLIAM MINOR 131 1 WOOODWARD DRIVE CARLISLE, PA 17013 ~ ~--°° fold ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ $17,000.00 NES ~ ESTATE INFORMATION: SSN: 226-26-9173 FILE NUMBER: 2109-0860 DECEDENT NAME: SHUFFLEBARGER MARTHA J_ DATE OF PAYMENT: 10/ 28/ 2009 POSTMARK DATE: 10/28/2009 COUNTY: CUMBERLAND DATE OF DEATH: 09/04/2009 REMARKS: SEAL CHECK# 1024 A TOTAL AMOUNT PAID: REV-1162 EX111-96) $17,000.00 INITIALS: SAP RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER