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06-10-10
FAMILY SETTLEMENT AND FINAL RELEASE IN ESTATE OF RETHA M. KEIM, DECEASED KNOW ALL MEN BY THESE PRESENTS, that WHEREAS, RETHA M. KEIM, late of 122 VIRGINIA BEACH AVENUE, CARLISLE, PENNSYLVANIA 17015, deceased, died testate on NOVEMBER 20, 2008. WHEREAS, letters testamentary on the estate of the said decedent were duly issued by the Register of Wills of Cumberland County, Pennsylvania, to the said BETTY J. KEIM, hereinafter called personal representative on APRIL 7, 2009; WHEREAS, the said personal representative has gathered the assets of the estate of the said decedent and the assets consists of both real property and personal property to a total value of $41,838.63 as set forth in Exhibit A, which is a true and correct copy of the Estate Tax Return of the Decedent and Exhibit B, which is a Summary of Distribution to Beneficiaries, and which are both hereto and made a part hereof.; WHEREAS, the debts and deductions, including inheritance taxes in the said estate, amount to $12,539.44 leaving a balance of $27,959.06, remains for disbursement to the heirs. WHEREAS, this agreement may be executed in multiple counterparts, which said counterparts shall constitute a single Agreement. WHEREAS, the balance for distribution as shown in the said statement marked Exhibit B has been reduced to cash and shall be distributed as herein indicated; ~ n ~. ~ _. ~ ...-, _.,.: -k^ht ~ NOW THEREFORE, KNOW YE, that we, ~. _z~ ~ ' - ~ `-~ s-.`.; ~ ~~ F ' ~ i E'1 c~ ~ x ~ ~: ~ T r BENEFICIARY :~ r~ ~ ;.. ~ ,- ~~ ~ s -~ .~ ` f.,~ ~:~ ~ 4 } a.-~ ~ ~ .7 ..~ ~, _ ~ p ; BETTY J. KEIM $9,319.68 ~ ~~~ -~ -~ DONNA K. SEEGER $9,319.69 °' ~ . ~-:~ ~ } ~ CONNIE L. GREEGOR $9,319.69 'A being all of the heirs under the last will and testament of the said decedent and being those persons entitled to inherit under said last will and testament do hereby each of us, acknowledge that we have this day had and received from the aforesaid personal representative, in full satisfaction and payment of all sum or sums of money, legacies, bequests, and devises as are given, devised and bequeathed to each of us respectively by the said last will and testament, the amounts due us under said last will and testament, which amount we shall receive upon the sale of the real estate, which amounts are in the amount set opposite our respective names in the table and schedule of distribution in said statement attached hereto and marked Exhibit A and Exhibit B. AND, we agree with the distribution schedule as set forth in Exhibits A and B; AND, each of us does hereby stipulate that in order to avoid the expense and time involved in the filing of a formal account and schedule of distribution, we each agree that no account is necessary and we do hereby agree that we do consent to distribution being made without the filing of an account and schedule distribution, the same to be with the same force and effect as if they had been filed and confirmed by the Orphans' Court Division of the Court of CUMBERLAND COUNTY. THEREFORE, we and each of us, do hereby remise, release, quitclaim and forever discharge the said personal representative, BETTY J. KEIM, her heirs, Executors, and administrators, the Law Offices of Peter J. Russo, P.C. and assigns of and from the said estate and from all actions, suits, payments, accounts reckonings, claims and demands whatsoever for or by reason thereof, or for any other use, matter, cause or thing whatsoever, touching upon the estate of the said RETHA M. KEIM, and each of us do further hereby covenant and agree that should any liability come due to the estate of the said decedent after the signing of this agreement, we and each of us do hereby covenant and agree with each other and the estate to satisfy any and all claims, demands, suits, or causes of action which may be successfully prosecuted against the said estate of the aforesaid personal representative after the signing, sealing and delivery of this family settlement agreement and final release. IN WITNESS WHEREOF, we have hereunto set our hands and seals. WITNESS: DATED ~ ~ ~ ~ ~~ /mil V, s~~~~C~~ DATED ~~ `r~ / ~ ~~e~ ~~,~~u~. DATED , ~~ -~.s --,~ S e~-r,-~sEa,r.~ BETTY J. KE /, J ~~~~ l-~ ~~ ! ~ ° I EAL l ) DONNA K. SEEGER t ~/ , ~~ (SEAL) CONNIE L. GREEGOR STATE OF PENNSYLVANIA COUNTY OF CUMBERLAND On this the .~ day of ~ ~-~~_.. , 2010 before me a Notary Public, the undersigned officer, personally appeared BETTY J. KEIM (Known to me or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. Notary Pub ' c CgMMQ NN ~.VANIA NatirlN ~I ~hley ~ilpe, Notary Puf~ilc Nempden '11n~p., G'u-nfaerlend County My Commf~fon ~xpfros Ckk i2, 2011 Member, Pennsyl~raNa ~~ciatlon of Notaries STATE OF PENNSYLVANIA COUNTY OF CUMBERLAND On this the _ day of ~ ;•r.~? __ , 2010, before me a Notary Public, the undersigned officer, personally appeared DONNA K. SEEGER (Known to me or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. Notary Public CpMM NNSYLVANiq Ndt~r1~ iii A~rhlMy ~Ip*, Notary ~ubllc Hempd~tn 'T4vp., Cumbe<iand Canty M Commllgian ros Oct. 12, 2011 Member, Pennsylvania Assodadon of Notaries STATE OF PENNSYLVANIA COUNTY OF CUMBERLAND On this the ~ day of ~c.~'~~--- , 2010, before me a Notary Public, the undersigned officer, personally appeared CONNIE L. GREEGOR (Known to me or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. .~ ~ ,_ Notary Pub~i CpMMC~NW NN Yl,'VNV~A Aip~n'I~1 ~~~ Publk A~ohlay Sips, NQtarA/ HampQen TVvp., Cum ~~ ~2~ 2011 My Gommlaslon Member, PenrsSc;~rart~a gssodation of (~arles EXHIBIT A J 15056051058 REV-1500 EX co6.os) PA Deptrtrr~rtt of Retrerwe BuremladumTaxes o~,~,,,,,. ~~ oH~Y code Yep. ~ ~ PO eox 2eosol INHERITANCE TAX RETURN 21 09 0326 Harri:36trrp, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Sodal Security Number Date of Death Oate of t3irth 179-12-3492 11/20/2008 01/21/1923 Decedent s last Name Suffix Decedent s Flrst Name MI Keim ~ Retha M (If Appilcable) Enter Surviving Spouse's tnt~ntat[on Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Soaal Security Number ,- THiS RETURN MUST 6E FILED IN DUPLICATE WITH THE REGISTER OF WILLS flLL {N APPROPRIATE OVALS BELOW - ~>~; 1.Original Return C~ 2. Supp~mentaf Return C=.'s 3. Remainder Return {date of death prior to 12-13-82) _~.~ 4. Limited Estate t~ 4a. Future Interest Compromise {date of C: 'r 5. Federal Estate Tax Return Required death agar 12-12-82) •'t 6. Decadent Died Testate u 7. Decedent Maintained a Living Trust __-._. 8. Total Number of Safe Deposit Boxea (Attach Copy of Wiil) (Attach Copy of Trust) .,_ • 9. Litigation Proceeds Received ~:~~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sea 9113(A) between 12-31-91 and 1.1-95) (Attach Sch. O) CORRESPONDENT - THIS 8ECTtON lBUST BE COMPLETED. ALL CORRESPONDENCE AND CONFlDENTULL TAX INFORMATION SHOULD 13E DIRECTED TOc Name Daytime Telephone Number Elizabeth J. Saylor Esq (717) 591-1755eVcy ~ . .. .. Fimr Name (if Applicable). .. ... .. .. ... ~~ .. .._ ....... ... -.REG18T'ER OF _..._ LYE.: ~ SSE ON ., ..r <'~','~ i~ Law Ofcs of Peter Russo T i~ ~ ~n n t:~. ~ ~'' ~. t i First line of address • • ~7 .tr ~ -. n ~' ~ rJ 5006 E Trindle Road ... - - , .. ~ c :~ ~ ~ ~ ~-~_' '~~ ~~ . ~ ~ ` ! ~ - - ` ~ Second line of address ' :77 fV ` r i _r_r Suite 100 -~ cn City or Post Office State ZIP Code _ .. DATE FtLEq iV Mechanicsburg PA 17050 Correspondent's e-ntaq address: LSeylOr@pjrlaW.COm Urxb- psnaltles of perjury. I dedarY that 1 have examined thia return. irxtudirrg accompanying scheduba and statements. and to tha best of my knowledge and belief, it is true. cored and compote. DederaUon of preparor curer than the personal nPmsents!!ve is based on eU information of wtdch preparer has any knoavlsdQe. St RE PERS Sit3LE FOR FIL ~ Rtc71JRN ~ - T SS 12_2 Vrginia Beach Avenue, Carlisle, PA 17015 _ _ _ SIt,NA ~OF PREPARER~OTF'lE^R_TtiJW REPRESENTATIVE /~DAT `/. ADDRESS 5006 E. Trindle Road, Suite 100. Mechanicsburg, PA 17050 PtLE:ABE U8E ORlt31NA1. FORM ONLY side 1 15056051058 15056051058 ,~ .- J 15056052059 REV 1500 EX Decedent's Soda) Security Number Retha M Kt;im 179-12-3492 Decedent's tyame: r~~__ .._. RECAPITULATION 1. Real estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. 288.33 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. . _^ , 4. Mortgages 8 Notes Receivable (Schedule 0) ............................. 4. _. .. . 5. Cash, Bank Deposits 8~ Miscellaneous Persona! Property (Schedule E) ........ 5. 500.00 6. Jointly Owned Property (Schedule F) t~ Separate Bailing Requested ....... 6. 41,050.30 7. Inter-Vrvos Transfers 8 Miacelianeous Non-Probate Property (Schedule G) ~-'':~ Separate Raping Requested........ 7. 8. Total arose Assets (total Lines 1-7) ......................... . .......... 8. 41,838.63 9. Funeral Expenses 8 Administrative Costs (Schedule H) ..................... 9. 12,539.44 10. Debts of Decedent. Mortgage Liabilities, 8 Liens (Schedule I) ................ 10. 11. Total Deductions (totM Unes 9 b 10) ................................... 11. 12,539.44 12. Net Value of Estate (Line 8 mtnus Line 11) .............................. 12. 13. Charitable and Governmental Bequests/Sec 9113 Tn~sts 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. _` a _ 29,299.19 7AX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax cats, or transfers under Sec. 9116 (a)(1.2) X .0_. 15. 16. Amount of Une 14 taxable at Nneal rate x .0 45 29,299.19 1 g. 1,318.46 17. Amount of Une 14 taxable _ .._ .. . at sibling rate X .12 .. __ . _ . ..... 17. .. . .... . . 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE RECUESTING A REFUND OF AN OVERPAYMEN3 15056052059 Side 2 1,318.46 15056052059 REV 1500 EX Pape 3 , _. _. ,,. Fih Number 1'1~~~~1~.-~l~ n~r~rlw~w Aw~~rw~~• 7'~ nQ ~' n~7r1 V~V~Yrr~~• ~ VV~~~~/~~~V I"1MM~~VV• DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER Retha M Ke'un 179-12-3492 _ "snz~irnooRESS _ ___.. _ _. 122 Virginia beach Avenue __~ _ ______.______ _ _ _ . t;frY _..- --- ~- Carlisle -- ---~---------• - .-r ZIP _.. _ .. pA ~ 17015 Tax Payments and Credits: 1. Tax Due (Page 2 line 19) 2. Cn3ddslPayments A Spousal Poverty Credit ~.. B. Prior Payments __._ C. Discount 3. InteresUPenalty if applicable D. Interest E. Penalty (1) 1,318.46 Total Credits (A + B + C) (2) 0.00 21.67 .. ,.~___~.~ Total InterestlPenalty (D + E ) 4. If Lure 2 is greater than Line 1 + line 3, enter the dNferenoe. This is the OVERPAYMENT. Fill in Duet on Page 2, Une 20 to request a refund. 5. If Lure 1 + Line 3 is greater than line 2, enter the difference. This ~ the TAX DUE. A. Enter the interest on the tax due. 8. Enter the total of Une 5 + 5A. This is the BALANCE DUE. (3) 21.67 (4) (5) (5A} 21.67 (gg} 1,340.13 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. n~fain the use or income of the property trans(erred :.......................................................................................... ^ b. retain the right to designate who shag use the property trans~rred or its income :............................................ ^ c. retain a reversionary interest; or ............................................... ....................................................................... .... ^ d. receive the promise for life of either payments, bertefds a care? ...................................................................... 2. If death occurred after December 12,1982, d'rd decederd transfer property within one year ~ 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, annrirty, ar other non-probate property whidr contains a beneficary designation7 ........................................................................................................................ © ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS 1S YES, YOU MUST COMPLETE SCHEDULE G AND FILE R AS PART OF THE RETURN. For dates of death on or after Juiy 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)j. 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 (O) percent [72 P.S. §9116 (a) (1.1) (i~j. The statute des not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disdosure of assets and filing a tax return are stilt applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent (72 P.S. §9116(a)(1.2)J. The tax rate imposed on the net value of transfers la or for the use of the decedent's lineal benefidaries is faun and one-half (4.5} percent, except as noted in 72 P.S. §9116(1.2) (72 P.S. §911ti(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 (t2) percent [72 P.S. §9116(a)(1.3)j. Asibling is defined, under Sectieon 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV 1503 EX+ (6-88) SCHEOVLE B COMMONVVEAITH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Retha M. Keim 21-09-0326 IW oronerty Inlntlv~oMmsd w6h right of survh-orshtp must be dlsdosed on Schedule F. (II mas space is rteedea, insert aaantonai sr-ea~s or -ns same s~i -~ ~omputershare Compu#ershare Investor Services 2S0 Royall Street Canton Massachusetts 02021 www.computershare.com LAW OFFICES OF PETER ~ RUSSO PC ATTORNEYS AT LAW ATTN: AMBER L SOUTHARD 5006 EAST TRINOLF ROAD SUITE 100 MECHANICSBURG PA 17050 ]uly 31, 2009 Company: Registration: Holder Account Number: Our Reference: Dear Ms. Southard: PRUDENTIAL FINANCIAL INC RETHA M KEIM 00001444361 PRU/0002821679/2/ Thank you for contacting Computershare, Prudential's transfer agent. We appreciate the opportunity to be of service to you. On November 20, 2008, account number 00001444361 held 21 shares. On that date, the closing price was $13.73 per share. Information regarding the other account will be mailed under separate Dover. Should you have other account related questions, please call us at 1-800-305-9404 between the hours of 8:30 AM and 6:00 PM Eastern US time, Monday through Friday. A te%vmmunKations devlae for the hearing impaired (TTYITDDJ is also avafifable at 1-80~-619.28.37. ~X ~~ Service Representative Enclosure: None REV 1508 EX+ (g-98j COMMONWEALTH OF PENNSYLVANW INHERITANCE TAX RETURN RESIDENT DECEDENT SCMEDVLE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY E8TATE OF FILE NUMBER Retha M. Keim 21-09-0326 Include the proceeds of hligalbn and the date the proceeds were rooefved by the estate. Ali pn-pertt- joiMfy~oMmed with fight of aun~irorship must be dbciosed on Schedule F. (It moro space is needed, inseA additional sheets of the same size) REV 1509 EX+ (6-98} COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT QECEDENT SCHEDVLE F JOINTLY-OWNED PROPERTY ESTATE OF FILE NUAABER Retha M. Keim 21-09-0326 K aen asset was made joint wEtbin one rear of the decedent~a dab of deeth~ It mu:t be reported ort Schedule G. SURVMNG JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A• Betty J. Keim 122 Vrginia Beach Avenue Daughter Carlisle, PA 17015 8. C. JOINTLY-0WNED PROPERTY: IT'F.i~l HUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCWPTION OF PROPERTY u~cwoE wucE OF FWANCIAL tNSTTTUT1oN AND eANlt ACCOUNT NU1(BER OR SIAaLAR f0@ITIFYINO NUUBER. ATTACH DEED FOR JOINRYdiELO REAL A DATE OF DEATH VALUE OF ASSET x of oECO's INTEREST OATS of DEATH VALUE OF DECEBENT'S INTEREST t • A. p7~ 1995 Skyline Mobile Home -VIN 2G111125HB 44,600.00 50% 22,300.00 2• A. 01101/06 Citizens Bank Chedang -Aooourtt No. 6100767418 6,171,83 50"/, 3,085.92 3• A. 01/011106 Citizens BaMt Time Deposits • Aooamt No. 6140876508 31,328.75 50% 15,664.38 TOTAL (Also enter on lire 6, Recapitulation) ~ s 41,050.30 (!t more space is needed, insert additional sheets of the same size} _~ iJew Mobile Homes For Sale pennsylvania Used Mobile Homes For Sale pennsylvania Page 1 of 4 Cam par able MHBay.com Phone: 800-950-1364 The Ultimtrte Place tD Buy ~ Sal{ a New or Used Manufactured Home or Mobile Hotro! 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New Loan Rod Shingh sktlno ~~ Fireplace ~ Gam or ~D~ None Propane Coapng No<a Ovwap Caution of Motrlls Home: Average App Refrlgsrahr, Otshwaaer. Washer. Dryer Other Faatwes o- Comments About thb Used Mobih Home For Sah: This 3 bedroom 2 batlu~oom bona Is tocatsd in a aloe quiet park outside d AbboltsWwn. The home hss a Mce ktk:hen wpb lots d cahlrab. The stove. rehiperator and washed dryer come with the rah of title homy Located elf Ua kitchen h s separsle dining room with Pogo poct{r-0 and a built in glass toted bufht. Them b kks a< space in this horns because you can use the eying room a the separate tempt' room. This 1-ona has 2x8 oonstruWott far better Insuhtlat, new wpetbtp bedrooms in 2007 and s new root 2005. You can go outside b en{oy the covered porch an one side or the built h porch an the other. Aho b>cbtdsd in tM ssh is a one year tirapsd vrarrang-. Gies us a cell to take a took. This home b lorded to a land lease oonaawtdy. CALL PARAN~UNT HOME SALES AT 1-888-747- 8481 FOR ADOITtONAL INFORMATION AND UPDATED PRICINt3. INFORMATION HEREIN BELIEVED TO BE ACCURATE BtJT NOT Gl1ARANTEED. VMan resportdng by email, pleas irtckrde a photo #. Rnd New or Used Manutaewmd Homq For Sale ..-+ BOOt Camp Uctoher 23-25, 2009 ~gkino for a MoWle . Hone P~?_ sae o~rr Nstbnal List of over 40.000 Communities How to make money buvlrtsr p~,obile home Qom! View commenb end testimonials from ourcustomeTS - httn:/iwww.mhbav.com/home for salelpennsvlvania/pa 114-abbottstown-pennsvlvania.htm 10/6/2009 aR Citizens Bank July 20, 2009 AMBER L SOUTHARD 5006 EAST TRINDLE ROAD SUITE 100 MECHANICSBURG PA 17050 Estate of RETI3A M ICEIM Date of Death: Nov 20, 2008 SSN: 179-12-3492 Dear Sir/Madam: ~ ' 1 525 William Penn Place Suite 153-2618 Pittsburgh, PA 15219 In accordance with your request, the attached information sheet has been provided in the above decedent's name as of his/her date of death. For IL or LC accounts, contact our Loan Department at i-800-708-6680. For all other inquiries, please ca11888-999-6884 Sincerely, Pfeil, Marnie Operations Services :~ ~~ titizensBank~~ .-~ Account Number 6100767418 Account Title RETHA. M KEIM BETTY J KEIM Date O ned 8/20/1990 Account T Checkin Princi al Balance as of DOD $6171.83 Interest from Last Postin to DOD $ .00 Account Balance as of DOD $6171.83 Y"I'D Interest to DOD $ .00 ,. a~ Citizens Bank- Account Number 6140876508 Account Title RETHA M KEIM BETTY J KEIM Date ened 10/15/1990 Account T Time De osits Princi al Balance as of DOD $31260.24 Interest from Last Pos ' to DOD $68.51 Account Balance as of DOD $31328.75 YTD Interest to DOD $1033.65 OCT. 30.2009 3 : 01 PM N0.611 P. 2 •~~ ~ ~ ~~~ g~IlO{i GD 01 ~ 3~ ~ YLVJOtii~ p9AC7iS8 ~ 07/i7/06 ~- 060 !IIi ~ fit' p~~y ~ 07/17/08 >gI1Q 7110) >-~S: Ci1~: --~Of~ ~~8 ~ ]ICGOaI~ ~.~ safal~SS ~0~'1'~--• ~~ i7P~ t ~4 ~„~ TY • ft~rtrt•ttsr*f•f~-N~*ft'+fRffftstt*ftf1Tt lS f f70Q ~ r~Rf4wrt*s*trtitffrrtfstetwNfftrs*sts++e+w *rrsrt*ttittet 610076-?al-e i 1 as~- k~ s Z 1 2 s0:r~- ~ r~ 93zZx J GSM 1 1 33•'1r!'Y J 10;~ Z 1 7073 ~~ p7~ >-P~ '~ Z 3 7073 GWSSLti PZ~ 7i0'~ 87 3 1 CAlt1.T8~ ~ 17013-9739 17018 1 CAitLlSLE ~ DJ-~ O~ ug? : 03/07/05 SOO~it t~ 07!17/o6 10.65 REV 1510 EX+ {6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETW2N RESIDENT DECEDENT SCHEDVLE G INTER-vNOS rRaNSt=ERs ~ MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Retha M. Keim 21-09-0326 This schedule nwst be oon>pleted and tiled ~ the answer to any of questions 1 tluough 4 on ttre n3verse side of Ore REV 1500 COVER SHEET is yes. REM NUMBER DESCRIPTION OF PROPERTY watroe THE NAAiE OF THE TRANSFEREE, THEpt ~ TO DEC®61TAND THE oATE aR TRANSFErt ATTACH AOOP1f OF illE 0~ FOR REAI ESTATE. DATE OF DEATH VALUE Of ASSET' % OF DECD'S INTEREST EXCLUSION ~ TAXABLE VALUE ~ • Betty J. Keim, daughter -12!18108 2 513.53 0 00 0 Stonetxidge Life Insurance Policy Na. 74L3770308 p , . 2. Betty J. Keim, daughter -11!26108 1 793.14 0 0 00 Prudential Life Insurance Policy No. D50257021 p , . 3. Donna K. Seeger, daughter -11/26108 1 793.14 0 0 00 Prudential Life Insurance Po!'icy No. 050257021 p , . 4. Connie L. Greegor, daughter -12110!08 1 795.34 0 0 00 Prudential Life Insurance Policy No. D50257021 , . 5. Betty J. Keim, daughter -11!26108 703.36 0 0 00 Prudential Life Insurance Pony No. 75698624 p . 6. Donna K. Seeger, daughter -11126108 703.36 0 00 0 Prudentlai Life Insuranoe Poflcy No. 75698624 p . 7. Connie L. Greegor, daughter -12110108 704.16 0 0 00 Prudential Life Insurance Policy No. 75698624 p . TOTAL (Also enter on line 7 Recapitulation) s I Q.00 iIf more space is needed, tnsert additional sheets of the same size} REV 1511 EX+ (12.99) SCHEDVLE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8c INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT OECEOENT ESTATE OF FlL,E NUMBER Retha M. Keim 21-09-0326 Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~. Myers Funeral Home - Mewing 5,044.00 2. Woodlawn Memorial Park & Funeral Home -Burial 3,990.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Conut~Ons Name of Petsonai Representative(s) Social Security NuHiber(a)<EiN Number of Personal Representative(s) Street Address C;ty .State Years) Commission Paid: z. Attorney Fees 3. Family Exemption: {lf decedent's address k nol the same as cialmaM's, attach explanation) Ctahnar-1 Street Address ~y State Relationship of Claimant to Decedent 4. Probate Fees 5. AooouMant's Fees 6. Tax Return Preparer's Fees 7. Preparation and Filing of Rev-1500 ~R .gyp 2,760.32 595.12 150.00 TOTAL (Also enter on line 9, Recapitulation) ~ $ 12,539.44 m more space is Headed, insert addfionaf sheets of the same size) • t ~~, fir` fOW titAf/Ol1pjL« ._. Cr~eb/aIIpRL/fR'FIOiN~rIA[(7YWlQia~nie .- .~~-.......•..,-..-.--„ K-. ,-.._.,.,..~_..__ 1~ C1 BOYD L. MYERS, 7R, Supert+ttor JJ~~y~ 37 E MAIN SfRfiE'I' ~~,p~~~~ MECttANtCSBURO,PFNNSYLVANlA 17053 ~~ c~~o'eeme, ~C (717)766.3421 STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Charges are only fa [box items that you selected or that are required. If ae are required by law or by a cemetery or aematory to use any items, we wW e:phia is writing below. Uyou selected a futleral that may requir:earembalmiag, such as a furtecal you may have to pay for embalmittg. You do not have to pay for embalming yon did not approve R yo ~ected tg,7/`i is a direct itpmadiate burW. if we charged for embafmitrg, we wW exp wb bebw. For the Service of ~ !' f //! Date of Death ZO 2.v v '$ Charge tos Name Address City State A. CHARGE FOR SBRVICBS SELECTED: Other clothing 1. PROFESS10NAl SERVICES f Services of Funeral Director/Staff .... f~ f EmMlraiag ................... f ~ Cremadoa urn ....... f Other preparation of body (pacrlption) ........... . SUBTOTAL OF PROFESSIONAL SERVICES......... Al fT.~ty~ 2. FACILITIES AND SERVICES Ux ties sad services for iewi tatiodWake)......... T r f .l.N[.~ Ux of faciUtks sad servkes for funeral ceremony ............ f•~Ncl+ Ux of facilities and services for McHwrhl Service ............... f ~' Ux of equiprtteat and xrvices for graveside xrvia ............ . a Other ux of facWties OTHER f f f ~~ TOTAL MERCHANDISE SELECTED .................. B f C. SPECIAL CHARGESc Forararding of remains to (Fnnenl Home) Receiving of remains from . f (Funeral Hoax) Immedlatc Burial ................. f ----. __.._.._........ ... fT.- _ SUB-TOTAL OF SPECIAL CHARGES ................ C a D. CASH ADVANCED f Opedag Grave .................. f SUBTOTAL OF FACILITIES/EQUIPMENT ........... A2 f Cemetery Equipment .............. f 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral H a, .oral.......... ................ f A Local .. ~.t?a.Ct~t~-. P °~`~.... .,,._ o f.i,.e~~ Limousinc Lorai ........................... f Family car Local ........................... f "' Flower car or floral disposition Local ........................ . E ._ Lad car/ ~j car .~.. Loal ... ~,~ a,~~''r,ry~~r..1~ i-"'""'" Car for pallbearers Lod ........................... S Out of town tratlaportation ......... f 5 f SUBTOTAL OF AUTOMOTIVE EQUIPMENT....... Lot and Deed .................... f ..NcavsQaper Notices---local ........: f ! q f .~ -~ Newspaper Notices-Out•of-town.... f Telephone do Telegrams ........... : Airfare ......................... f ClergyMass offering .............. f 1rw _ ~2. Pallbarers ...................... f Certificd Copies of the ~ ' ~ ~ ~~ CeNficatc ..... /. ~-. P....... f Polio Escon .................... Flowers ........................ f ~l Z. '~[ Va !t S ~rvice large .............. s, f f ~ f_$~ f f f f 5 U~ O SUB-TOTAL OF ADVANCES ......... A3 ~ We charge you for our services in obtainhlg: ~. .............. D f I ~' (spenjy cart adaancts that one ,rtarlerd~np) ¢~ , ~ ~ SUMMARY OF CHARGES ~ ~~ A . Professional Services, Facilities and ~ l: Equipmxnt, and Automotive ~ 8 ~S ~ ~~{ .BC Equipment . A~'~_ e . Macltandtsc ..................... f ~ ''"A C. special charges .................. f ~ ` G D. Cash Advances ................... ff~s- ~L~u a TOTAL OF ALL SECTIONS ..... _[ ~ PAID AT TUI[8 OF OAP OB T p"""'er'"" 1c O`= Z • 6 ARRANGEMENTS ...... `F ..~,1-~!k! : ~.'.. f ~~+Yr I BALANCE DUE ......... ....................... f ~ t .~vt A` EMB c ,~ (~_ . y t G...u C•~~ if any law, cemetcry, or crematory requiremetus bare required the- p- u- rZ~ise. of say of the items listed above the law or tequitmtent is tzplained below. TOTAL OF PROFESSIONAL SERVICES, FACILITIES AND AUTOMOTIVE EQUIPMENT ................................... A B, CHARGE FOR MERCHANDISE SELECTED ; Casket .. ........................ f (Description) Otba Recepaclc ................. i (Description) Outer bnrtal container ............. s (DescrlptiOA) Acknowledgement cards ........... S Register book(s) ............... . Memory folders ................. . Prayer ards ..................... f Temporary grave [Harker ........... f Burial ciotbhtg ................... s I agree [bat I have exaatUtcd the items of goods sad servioa selected above sad fonad them to be rnrrat and xcortWtg to the amngenteau 1 have requested. I aduwwkdge receipt of a copy of ibis S[ateatatt of Funeral Goods attd,~rvicead. I tepresettt tb I ~re suiiidettt funds avaihible for paymetu of the cash a for the and services selected. I also agree tp t~,payment of Y N wi days. I agree to be )oktdy attd scveaUy liable with n who signs below. A late cbare o l [i per month amountWg to ~ Per year wiq be apptkd w the unpaid balsaoe beginning days from the date o[ this agr 1 wiU abo pay to the Funeral Director aU rasombk coos paid by the Funeral Dilator to collect amormq 1 owe under this agtteat<nt. Those costs may iru~attoraeys' fees. court tests and other coca. Any additioml services or merchandise ordered or d after the date of tbi: agreement wiU be coasidaed part of this agreement sad the cost tbercof wiU be reflected on the Rnal biU or statement. (sue) ~ ° Z~ S6 cs<ai) ~~ Y`1 (~~) ( enscd F hector) wwrrn _ w.~...i rw...~.. vet I.f1w _ nwn~. . ~)"t • ~. ~~ ~~ WOODLAWN FUNERAL MOMS 4200 No.0018'[ 11 Po gox 585627 ORLANDO, FL 32858-5627 IlVDIVIDUAL CASH RECEIPT 407-293-1361 DATE t ~, ?.~ ~ ob ACCOUNT N0. /~ a Y~9 s r ~ 4 ~~ '` D-~ ACCT/CONTR NAl1~ ~7NA K•E tM ACCT/CONTR NO. Q tG Y S ~~ ~ 1.9 ~ R~CBIVED FROM LFTT ~ I CEO A. CB #/ C.C. iIPPBONAL # C.C. TYPB DE4CR1'pTION TRUST NO. S ' G/L ACC'D S ~ c~c (Yr3 ^ case sY ^ ca~T c.,~D ^ Dssrr TorraL ,3 4 Ro C3trN s~01(3lOS) Whloe - Cop~- Yelloar - Coat~act Rile Finl~ - Can~+cl Cow ~~~ Y~U a4~~. VYa>~wn Malaorisl Park dt FgnCral Holm dlasw f C~teiety Rodd . ~O~Wa O l Gbrolrtwt, +7.420441Q024,i_ `_ .. ~~ yy~~ p ~ ~~.'Y ~7.7'. Cato. x - i r r~~ x~ui s~tlt I~ Fa~~ooQ 9u~iats+ac Lioearo tr~si+b.r F1i10u Front ooa Tbroo ~tecuont of Ib>Itctre and Se>r'vfc~ Seloct~ed/1'nreh p e ~ent 1~ o! n«nb 11 /201,~Q08 ~ ~/29/ZO08 1Va:no o! tiooosseat RaRlta YCtsim _.__ ~..~...~..~~ + ~,« DMta of Sicth Old IlI9:t3 Daeaasad's Last Addtear 12Z Vit~o~irtie BC~Ch Avaltu~e C itr ~e Stmo ~A xtp Gode ><?OI~_ Pgrel~pre~s Noatol4ettY JKelm ,. ._..... ..^.... Phoaa Nvatbar__ (71?) 76b-6571 Pgnbaocr's Homo Addrett _~ Yiti'~ittie~ Beach Avenue Citr ~atlixlc tttara P~ Zip Cod• I7Q15 Co•lbeoltaar'e Namo Fifono Nwttbos - Co'P~ NO'o0 ~-dd~ C{tl- Stale Zip Codo tp 6tootaant o a-o poq a yogr BOO P r, t ouy. s ~ t tt wprae~aent. o wo • wo. ~ as oar to v tow ar Soifer wlteso a~ttte and sddrorr rapoar sDova Fos snod sad vdgabM wn~rideralioa, trbiah aaeh prty- aotcawvladges eoastvlsg, yod tgros to bwy she asodt sad sarvieas doror~bod below. Yeu sutbAt{~cr of to pt+opue ~d eato fet tho ftody o[tfto dose6oat aamad fa tlut Ap~reaaoat sad to aoadoet tlsr flraerd sad eer+-iaos .ad iaoar tbd obor et fitted i aid g s s Agrootetoat. Wo luno tho rich! b oolleat tbo tatd atngatttt dva gadoethb ASroemoat Qiom as pvrrpa Mho y sisal thta A`reatnCat at Pnrobssor of Co-Pgrsbascr. (N/1l aadtaetiri •re OIl t'eea Too of t aye t'o~ tro ars ~ or It oamNet~- or ssasetas~r to ens aw~r lrms. we We rosaoRt Ia treldnS 6olou-. K T~ t>eloaead a llrttesal lftst ntyr rogatrs eaMsia~itgt, ttneb as s that:tel sNeh riowlaF. Too flaw m pdq- lion awbalattag. Yeti do not flees ro twT tiw easiro.tro~l yaa ald ~l •pptere If lroo aeleeted •rrao~eslr roab ar . dUrrat eresu~tlos or lmraellate bwial. itwe obr<eyted tb. ostbst:atng. wo wilt euptei» w~t,y Mtlow. Ruf+lf#aA~ olaeeTOR afyD aTAI~ saeviees e~looe oe Altomoti~o Coat+~sr: Sato Fro1'tssiotttl Sotvioo Foa ..-•---..._...... i ........... s >ae! Maate~npplier PAOKAQQ O~RfNQ6 _ Oltma C.rotaatioa ......_.... __.._........r.__...._..---• • a,.~,__,. Mvdsi Ntana/Ngfat>ot .E45..~ taaa.if{dt. 6ur{ol ................... s ForwordMS ILcamior .......................~ ....... «.... ~ .... IN~urtol °/" .~~.. Spea3et oar Wood L!! ._ Roaeir{aS Rea-siar ._....... ............. .............. __ Z~ i ,, .. ~.__ Tj-pa of ~.at ~ ,,,:OD ~ ~-- ...........................................................».....- _.._ ~ ~ tatosior CARE AND PR8PARATION OF Rf:MAiN$ ' Cunt Svrfal Coataiasr: Sasbdm{a ..........._. _-S Ns MaAplletutat/Sgppllot Otber 1-teparation (rpanifr} Modal Nattto/Ngmber tvtnwrirl ~ a/R ........................... Urn: ..................»....----.......»......«...~.....»..... ~.~ _~~ Moaohoturerl>soppiior Ji D b F FACILITIt~B AND R6LATE0 8ERV1C8S _ ....._«» ..... ~ -+~ ~. ) t Vt~itotion .... . .... .. ... .ice- .............. .. .. ~~ .....~~ __LL ~•r~~~ ..._..«..... ..«.. ~ ~ Fgaetd Coro ..............».............. "•_"+ • ........»« _ .r . • ~.. ^ r ~ . ............. ; te .r M waor i { ! Ser v ce ~ -t __ a • .`~ TOTAL SECTION 1 ...~ Zt19S.tM .. .H/4 , ~ y , // !~ tt ~~ Vr~~r ~ YQ ff'Or~ieC . ...... ... .........«._.~ _. ...._.. ....... ~ ~~~W//~~/. _~'~Y/~f~~'.~~V~~{ ~ / ' _ ~~~~ ~ /.~~ ` `~~I ~ • VVR ~~7Arr S~.w.YN~ ~p~ ~~wi~YQ ~~v~ //~1~/~ •.ra vw ,rott ~ owaorio I Ml b4 S t ...........-• ...........................»...._.._......... es ~ n v r tta tew oattto .............. .._«...___._....__.._..___._... L.........«. _ ~ fl/p rRANISPOwTATioN . Ttat>s8relnSRoaminstaPnaatalHoiaa_..« ...:............ S Fq~ Yettiotd~toarse....... .... .. .. .. C+dbt (r o i~: . -;~~. ~.. Mm ~.~ p o TeNlstl~[~ORACXrOliLA1t1~OC_.».....».......»........_ i Iact t f ................ ..............................:........... ...................... .. .. . ~ a a s~ .. . .. ............................. ~TNt$R <i00DS AND 8ER'NICEB ..__.. _._ _ ~osvla Fotdoet .. s ~... AdorOwldd~sateas Cam ... p~gp.. : .~..._ i ._,BC$ .... :. ..... ~ ......... .£~.. _..Iff~_ ............_. ..................... «................. w ~ ..~............_..._~._...~ .......... .. .... ..... .... s ~. 1~3....._ 77.i0~Nl1[t7 ............ .......................». _.........__. or 3in~ers .......... . . Co+gtkd Copies .............»............. Navrrpoper Notiner .... .... . ...........».......» .......................... ~~..r5~ TaTAt SECTION N......... ...............................~..~ 0.~.... T'aTAL SBCTiON 1 QMARQf3S ...._.....----•--•--_-_-•• s . ?~a~. TOTAL, ~3C7'iON p CHAROfSS .... _ . _ 3 ~ 4 OQ TOTAL 88C?ION 1 ANO SECTION p CNAROHS . -t - x.eS~•W- r - IY1lCw-rRK'R 1.i ANp >sAT1t M-ITlrbiJ' iNtTlALi ANO 13 Chaepea a+a Daly ~•• tboao iteasa thwt are ttteb. U the type aTlMoero! sdetled rsgrfb+p~ ewes lteatM aui eacpbasAao wNi be y~irea. . news rbrn i l+esrt 't'wo oY't7~rprr Na=ss ',Vary v~' ~vasad Redha Keim Coattat:{. I< • d?.4~ l ~~ w..~.w•YY~. St8*4'm~Cnt pt ~'Yl. GOOds ~{d Sei'vfC~3 StiltfCled/PYnthali{s A~C'1`IfIC'>I>Et TOTAL t3ECTiON 1 ANO t3EGT10W !1 CMARC~ ._...._._»...---...--_-----.... __. .. ..._..- -----. .............. .. ...................... s a.~+s.on i~cTloN to • Auowa~lees ..................................... .........----.N.N...N ...N....---...N.....wN»..._........ .. ............_....----..._.......s nrti . .............---......_.................__ ..........................N.........._...NN.......N.....w.N.................... s ---------~..---. ......•..•..........•.... •...•..... ...... ....... ... _.. ...__.• ... ....... .......• .........._...•w........•..... _.. •.......... .. • .•..........5S ~ i..~~ .. ....... ..... .......••.......... • . • •...................•w.t.....•.....•.............w•.•..w.....M..1.w.•.... •.. • .... ...~~.~..~. - ...... .................«................N.._...._.......N............... ... .. .. 3 TOTAL AU.O?INANCHB ................ ..........................._.................».................................. 3 0.00 SECTION IV • TA7p"aS Tipcebla Items boetioe t * or • l3oadoa 11t i ....... ............... . ...........................•......_ ................~...~~.r.. NLI......~ Lars Dedirotibleu._......» ..... ........................wN......Nw..----------..N....»._............... .. ..................... s n/a roTal. cwnl~ls: s.alle~r tq • p4 + e~ ~tnn + t1+7........~.---.N...ww...w_....... ..............w............. . _._... s z.r,es.oA Left. (7uth 1i;00ip11-ed ._.....«..............-..-.».....__..w....._-.............._.__.....____..._._...... .......................• .............~~ ~lir t.a+ts na~eldtna+nes ot............. ..............1 ..............w......_._.w~....---...................._.............~....... ...._.......... * *+~ . ~ . r•~ ~ ~. •iiilTi iT~ •..... , ..._•..........1...M•...•..........M_....MN..••...•..... •.•.......... ...... ........_...•.. ~V7i.V./ pAYMINNT T!elt~B: Yaw mnderxtand that ea ot~iic by b l~osteral 1K ated8 dhalOetNe. imtadleaetd elder. o~ other » tsradit sgetttoei, is ~1 ab by tllitt Apweaoelt. Yaw haw Iw d~ delae psymest nc+~- ueOODUK dnt: eta >b6t Alp~ewteetc. Yoa a~ dwc Feu a+e !y li^ far paq-a~eot of tl,e q~~iedtk balaoee dns Idevw ar tie :meeateat of r+aand Goods end tlavtea sdaeeed try d+s daa deae indkeeedl ae- tha 9te~aeeat. s~palraner~t .rip be awdo ~ ve ax tM tddteee eat ~bed- itt tltts Agaanaiis. whew Ste lbil ttraowtc aoe wm sat br paid Ixios b t1,e prtlbaohw e!'tlta eaeviveN 1wUad fbr br Iitia Al~ooutertt. ydtt atalrot-ito w ba ittgrtia~t nto Fes' ~ biatoty. OBNTIRIGATIOMI ANO.OtBSGRIPTlON O!r NANOATpRY tTt~ ANp ~t.ANJ1?!O!i OF F~ROALdliNfi CHARaGt Wo hnva Ind and detaribsd babes any add. aeas0t+oE- aK ~vaaa0ou0- aotldtoatenb that ooenPe! rho pta+eheee auteuo- itsnw ~Ird ht Pad Grre and wv helve acplaltted wlty wo obatedad !br ~ Yost selotowled8a and +Sree tbaL nritbalaria8 and/or p~maiiew vtibe rarrdns n~rgr bo pafor+ned ai tlto ltoodtty ot'tito ltsrsrd borne ea at +rathee lltaility that ix duly liefae~sd msd squipp0d m ps+o~rldo stteb serviooe. . . foa oartt'lten tltsc you bavo aaeattbiad ttty eacviasaatd taerdtoatllee itwas lheo4 b Putt Ono aad Lottad Ihrm m br aat,uet end eoepding to the Is*ta~ontartte sotea0a+d and ba pHs o 6 tie . i"~:ewswod attd a ~A~ egpp- of thb ~ttaatt Yon shto ootdleta that yat it>hy bran bbea.od of yaa right to Neleat emly saoh savtoos std ttaetoltettdiee m yort detra+o. mid dart you larva qte ltbtd ridltt co ~ pa tlmorai ~ietvlose ibr the dooewnd raoned abava. Aclarawlod~elmea! taf Disc~os~arre~llDialalabacr 7s0 ItOdO~i11 TtadO t~at++rltesbn Trade R0dW0doa Ro1v en "FtaelOfd P~80tlOp~ ~pl~ OOttaln ~QJOeII{M eff~ ptQllibl~ff gfNROpeeMCetSYdORUt. ~t7lO ~bil0'Mbt$ ii a 011C01dift ro eek tltoeo we ttot~ oo head and ttigtt IP t-asity tbd the tWtorel str aortsi~eaos wa ooude+sked la aemplitetoe whb die lttrle. Yeet who made dta ataetto ibr rho weoral trod Baal dhmoe:tion oTtbs eboro~asmedNboederA. do hrrab!- etJoet b Ws lbNowht~ . Yaw we<e glwstt a Clattaai PMoe t.bc alQn oassrlme .,~. p'ior ~ dbtmteieid lEenord ~ oc t!w raleotion oteny f (moral doods or servtaee. :. Yaw vwRe ahovrn a< tZtsdret Psiaa LlNt Islteetive<ono9,rts/=o0lt PiOr to disotash~g asloete. . You ware ala~wrr Vn Ouser Besid Coalearv Pius L.irt etlSetiYO o1i ~ prl~>n dh~usgtg outer Dnrial OOneehfCA. •. Yoa vwse odviNad lhat the 1a+v doa~ sot sv~iru etnbebrhgl a~oospt ~ oaraiw apw,a'~'!wees. Yoa writs Aal odrlMd tha umbaLoi~~~~~d !iw dneat a~uorisu~, aaetsr~als bvrid ar a alsa~+d udart Aa~a1 wilitout vlao-Ing or vlehetion K eoo is avaitsbla. +>tere NtitlNl aT leoal faw does sot eagrie~s la suaA aarec s Ywr wets sot advised part tttty laMr requietat s aendrst !be dhttat memmlea or thra a tt»eloet; odror thnei ltft d0ta1aailve Otalssbtes. V aoqulrcA the dintot a~wiiatkNr. '. YQO wqo advleed tlNtt t-ptb Itwn dop t+ot regt~3ev tlt0 paroltaee of en oetot Ootiai ootRaittat of ally of the tttaold gtlods ar ean-ieaN yeu . eaoopt ae Nat !~ cat your ~aanetrt adF»paat aooti: and Satvioes BakrJOd. . No attw»e wars ate~dr m yor- es b Wit ~e or eervibss (aeabahdng. fit. avtor 6wisf so fhv ttl>bot that oaabtJmind ar the tree ot'miy ttt~nhaadbtr ovdlable rom its would d~uer the dNVae~roeitean of tles:eeroios !br a Ivag tam er iaiaflntts tlms. aT that aa~~-r e~itolt araobndia prober the body iYottr b Iwbslru+ese. IQs ads~enadotss a~weersweles weee tatrtde sb yat shoat rho petxeaiva pieatroa ol'eaeloes ar awmr anew ootttataet+t anbee ~ male by rho nw~nw~r0tta~sr. Yaw waits ardvfaed that tits !lutatal tlrtn~t sat ~ dta !tams llst0d (n Pert Otte. Saetloa 12. arhY m dlliee+era bat~rd a~a vd~aAr nr oeed+ ~tievawtpt ar vihos p~tottal/attde otttrtw»s fiam perlnit0od by et~o aK load law. NOTICQS TO :BH PART TMR6EE iROR T6RlMi AND t301~IWTiO1+IQ TWIT /11!!! PART OF T!~ At3Ri~NT. DO NOT s10N TtilE AN7' ®BFORL~ YQti READ t oR !ia tr aoNTwa~ Al'tY euNle spaces. You let;o®I~ oR AN ~xaoT copv oR TN18 aOa~weMr. 11f iKiMbiii TN1>i A~iMtiliT• YDV ARB AAA TW-T ANY CIAIt11 YQU liAY MAVB AQAMIST TtiB ~{.L.ER SHALL BS Y@D BY .RI~R'RATION AMO 1fOV ARQ btMNO NPIYOf,IR g10M!'I' TO A t~tilZT OR JNRlI TR1Jt1.. Ali tN81.t. Ai YOYR R10MT R7R 4PPOA-L. y% Type is Nmne t,loonn Nuniba 8 rM! Manrs: I~t+ot ExoQUeod dtlt ~,... ~ ul' j~ati-et~sbgl' 2008 Perdmeo~"s Nmaw P+tircbaa.r's Sitpa~ae `Jovial QI N CvAa'!r Natre _ Co-Auebaors S Cv-A Sooid 4eourity ar / atieeta Mnot /Nova ttlt~fs do~rt as ~gWlnrd by tars wrlr'S Sgl(Kb' Cvnthtf GNo~s Tttla; Oahe: t il~en7gc IG:t6:W < < • ~ 1fa00~iAWP1 1pARK a ~~ , pia oooc stomas • ova. R me...~ • ~+~-~w 114 _ 8 x.14 35 . ~•- I t ~» ~~ ~ >~~ C'r~xr Ylw~rsx~errr! `~ ~ rv .~,~ui7r -- - - - _~aQcs _ ~ Ttw m~aa~,.d...nsa M ar 'lra~eba~'. M~ yna io pordws~ w. >b.t..+~wt Ry~6r Iwue6reitl.t ,.«t 1~.~.raen OMieslb~l ttrasist. areas so se~.ptaps~ sad appr+r,~ .d tYe aulaa+ae aaaaaaaNd . char s~Aen~d a i ~'. j/~~f`(tli'/d~~ ~ ~a 1 t 1 1 1 1 1 I 1 M~"~ t 1 1 1 1 t 1 7>:Npitooes lsl~a ter ~_ / tlnaaib /lddetattt ~ ~ '$ 3eoox ~ • ... 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Cetaat~ory. tltdnd Cb>nsnlovl>pc Sarvsocs ae c8ooy 3i3i~7. i IsiavAer ~ ~ee~~ o~r~ ~~ i~we~ a ad eltst aapr dsim Pucdss~ar aaep- lasre a~alaae tlta Selke ~dtslt bo r~tvad b0- a~biceasion scut Pezt~ehaRar 1R 8~~8 W+ Sfsoad tbtis e~ aslpr of l~~r/ ~ 20~~ _.,__ dbo W~OOOLJ-WN IIIImWO QIt~• 1 ~ P. Q YOlit ~7 • QP10e~1101r F0. 9~99'Si~ii00R Y'arcita~s ~ ~~ aKiaaship; s Co-ta'arohascr: ~„Relsttitmshlp: Aaonpwd by; ( .ainl t a~.e Gir Nes~reaos awd ... trouwtek>r: r # Dads: ~,.J.._1__.~. ~. 1VOTICE: ~ Ufl~er ~ tar Additiosrwl lbrstts~ urtd Cottd&hn~ whitb attt~ Fat t v~This Amt . PATR1: 2Q.3-Pf. lfl2/071 ~ nawfrRaaatfan IialMdWl~t wf.l~w.rrnMtK+r e7anva Ye11a+w-.. e~+wfna++~. ~'.n~,n- TnTAr. F- nna e ;~ .~ ~ • ~ REI!-1513 EX+ (il-t-S) ~~ ;..r~ :;~ Pennsylvania DEPARTMENT Of REVENUE iNHERITANCE 7AX aEniaa RESIDENT DECEDENT SCHEDULE ~ BENEFICIARIES ESTATE OP FILE NUMBER Retha M. Keim 21-09-0326 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE i TAXABLE DISTRIBUTION5 (Include outright spousal dlstributlola and transfers under Sec. 9116 (aj (1.2).] 1. Betty J. Keim, 122 Virginia Beach Ave., Carlisle, PA 17015 Daughter $9,318.68 2. Donna K. Seeger, 120 Virginia Beach Ave., Carlisle, PA 17015 Daughter ~ $9,318.69 3. Connae L. Greegor, 1606 Trindle Road. Carlisle, PA 17015 Daughter $9,318.69 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. ~ NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO YAX IS NOT TAKEN 1. B. CHARRABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON TAXABLE DISTRIBUTIONS ON LUVE 13 OF REV•1500 COVER SHEET. # If more space is needed, inset additEonal sheets ~ the same site. E~IBIT B DISTRIBUTION OF ASSETS FOR THE ESTATE OF RETHA M. KEIM SUMMARY OF DISTRIBUTION TO BENEFICIARIES ENTIRE ESTATE $27,959.06 BETTY J. KAIM $9,319.68 DONNA K. SEEGER $9,3_ 19.69 CONNIE L. GREEGOR $9,319.69 (r \~ PETER J. RUSSO, ESCZUIRE ASHLEY R SIPS, PARALEGAL LAW OFFICES OF PETER J.RUSSOP.c. ATTORNEYS AT LAW ELIZABETH J. SAYLOR, ESCZUIRE AMBER L. SOUTHARD, PARALEGAL Wednesday, June 9, 2010 Register of Wills Cumberland County c~ ~° Y 1 Courthouse Square, Room 102 ~ ° ` ,=~' 'µ='y> Carlisle, PA 17013 `.~~~ ~ ~' . ~ ... .cam i"R .--. ~~_~ r ~a ~~ c , RE: Estate of Retha M. Keim C~ ~~`~- ~' -v ~ ,~ ~:~~' Y-w , ~ -i _ t`V .. s ' _'~ ~~ V~ t"j~ ~/ ""''i ~ Dear Sir or Madam: Enclosed please find two original Family Settlement Agreements. Kindly file one original and return the other time-stamped original in the envelope provided. Should you have any questions please feel free to contact our office. Thank you for your assistance in this matter. Very truly yours, . }~ Amber L. Southard, Paralegal Enclosure 5006 EAST TRINDLE ROAD, SUITE 100, MECHANICSBURG, PA 17050 PHONE: (717) 591-1755 FAX: (717) 591-1756 y Q ~ ~ 4 ~ M O ~ III g w 'M 1~1 .~ ~. 1 ~y .~J ~ ~ ~' :~.~ ~:~ 0 '.... _.- . ..,:~ ~~~~: 1 ~ .t ~ ..P ~:~" ~'~~ ~~~ _~ U ,~ a o o ~ ~' ~°n ~ ~ o '' cn h ~ ~ ~~ ~ ~ -+- ~ ~ ~ ~- ~~~ ~ ~ ~~ ~ r... ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~ ~ _ ,..• ~- ~~ ..- J ~ ~ --- 1 a v