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HomeMy WebLinkAbout07-09-10'~ 15056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 21 09 1184 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 199-05-7948 12/13/2009 01 /26/1916 Decedent's Last Name Suffix Decedent's First Name MI Scheibelhut Dorothy M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW • 1. Original Return 2. Supplemental Return _ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required death after 12-12-82) • 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 1 8. Total Number of SalFe 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 CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Numk~er Gilbert E. Scheibelhut (717) 732-8836 Firm Name (If Applicable) ~ ~' REGISTER OF~1 USE ONi~ „~,~ ~....f ~` _~~ f- ; '~ First line of address ~ ~ t"" Ca^S .w{ f t°~ ; x l 1820 Hunter Dnve d~ w ~>`:~ :_:_;~ Second line of address C`3 ~ ?~ ~~; ' ~- 0 ;`~~ C 7 City or Post Office State ZIP Code DA~FILE=D © ~,.~ ~ R Mechanicsburg PA 17050 ' Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal r esentative is based on all information of which preparer has any knowledge. SIGNATURE OF PERS~ RESP SIBLE FOR FILING ETUR - DATE= I~ ADDRESS 1820 Hunter Drive, Mechanicsburg, PA 17050 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE: ADDRESS 3601 N. Front Street, Harrisburg, PA 17110 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 150560510:18 r ^i r J 15056052059 REV-1500 EX Decedent's Social Security Number Dorothy M Scheibelhut Decedent's Name: 199-05-7948 RECAPITULATION 1. Real estate (Schedule A) . .......................................... .. 1. 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 14,443.37 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages & Notes Receivable (Schedule D) ........................... .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... .. 5. 46,443.91 6. Jointly Owned Property (Schedule F) Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested...... .. 7. 66,585.81 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. 127,473.09 9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. 13,251.31 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10. 1,200.00 11. Total Deductions (total Lines 9 & 10) ................................. .. 11. 14,451.31 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 113,021.78 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. 113,021.78 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 .045 113,021.78 16, 5,085.98 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. 5,0$5.9$ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 09 1184 DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER Dorothy M Scheibelhut 199-05-7948 STREET ADDRESS 1 Fieldstone Drive CITY Mechanicsburg STATE PA i'IP 17050 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments 4, 833.36 C. Discount 252.62 Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (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) 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) 5,085.98 5,085.98 0.00 0.00 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.......................................................................................... ^ 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, benefits or care? ...................................................................... ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Ditl decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. ^ ^x 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ ^X ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT _-_ ESTATE OF FILE NUMBER Dorothy M. Scheibelhut 21-09-1184 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) REV-1508 EX+ (6-98) ~` SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Dorothy M. Scheibelhut 21-09-1184 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Members 1st Federal Credit Union -- 075797518 Share account 53.54 Money management account 16,557.80 2 M&TBank Certificate of deposit -- 31003914462369 14,438.17 Accrued interest through 12/13/2009 35.82 Certificate of deposit -- 31003915256844 10,044.14 Accrued interest through 12/13/2009 2.44 Checking account -- 75797518 4,031.18 Accrued interest through 12/13/2009 0.04 Savings account 15004206019330 915.87 Accrued interest through 12/13/2009 0.05 3 ~ PNC Bank checking account ~ 64.86 4 Miscellaneous personal property (living with daughter and her family; therefore very little personal property) Estimated estate auction value 300.00 TOTAL (Also enter on line 5, Recapitulation) $ I 46,443.91 (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (08-C9) ~ ~ Pennsylvania SCHEDULE G DEPARl-MENT of REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Dorothy M. Scheibelhut 21-09-6114 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes, ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND 7HE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (lF APPLICABLE) TAXABLE VALUE 1. Allstate Life Insurance Company Non-Qualified Fixed Annuity Contract 40,040.81 100 40,040.8 Number GA17064027 2 Western Southern Life Assurance Company Non-Qualified Fixed Annuity 12,545.00 100 12,545.0( Contract Number W0020582959 3 Cash transferred within one year of death to son, Gilbert E. Scheibelhut 10,000.00 100 3,000.00 7,000.0( 4 Cash transferred within one year of death to daughter, Susan K. Massie 10,000.00 100 3,000.00 7,000.0( TOTAL (Also enter on Line 7, Recapitulation) $ ~ 66,5$5.81 If more space is needed, use additional sheets of paper of the same size, REV-.1.51 1. EX+ (l0-Q~l) ~ pennsylvania DEPARTMENT UFREVENUE INHER[TANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Dorothy M. Scheibelhut 21-09-1184 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Funeral Home -- funeral expenses 8,165.00 2. Luncheon after funeral 1,998.50 3 Cemetary plaque 405.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address _.. City __ _ _ __ Year(s) Commission Paid: z 3 4, 5. 6. ~. s. State ...........ZIP __. Attorney Fees: Family Exemption: (If decedent's address is not the same as claimant's, attach explanation,) Claimant Street Address City __ _ ____ _ __ _ State Relationship of Claimant to Decedent _ Probate Fees: Accountant Fees: Tax Return Preparer Fees: Cumberland Law Journal -- leagl advertising The Patriot-News Co. -- legal advertising ZIP 194.50 1,750.00 500.00 75.00 163.31 TOTAL (Also enter on Line 9, Recapitulation) I $ 13,251.31 If more space is needed, use additional sheets of paper of the same size, REV-i 512 EX+ (12~-0181 ~ Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Dorothy M. Scheibelhut 21-09-1184 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. REV-].513 EX+ (i s -Q8} ~ pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE; NUMBER Dorothy M. Scheibelhut 21-09-1184 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1,2).~ 1. Susan K. Massie 1 Fieldstone Drive, Mechanicsburg, PA 17050 Daughter 50% of residue 2. Gilbert E. Scheibelhut 1820 Hunter Drive, Mechanicsburg, PA 17050 Son 50% of residue 3 Lewis C. Massie 1 Fieldstone Drive, Mechanicsburg, PA 17050 Son-in-law Nil 4 Joshua Massie 105 Hillside Road, Mechanicsburg, PA 17050 Grandson 2,000.00 5 Jason Massie 111 June Drive, Camp Hill, PA 17011 Grandson 2,000.00 ENTER DOLLAR AMOUNT5 FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A 5 APPRC)PRIATE. II NON-TAXABLE DISTRIBUTIONS: A, SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE BENEFICIARIES ESTATE OF: FILE NUMBER: Dorothy M. Scheibelhut 21 ~•09-1184 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. 6. Jeana Longenecker 140 Ridgehill Road, Mechanicsburg, PA 17050 Granddaughter 2,000.00 7. Cynthia Taylor Reeser Road, Camp Hill, PA 1701 Granddaughter 2,000.00 8 Pamela Dougherty 7245 Shannondale Road, Mechanicsville, VA 23116 Granddaughter 2,000.00 9 Gilbert E. Scheibelhut, Jr. 9167 Witt Lane, Argyle, TX 76226 Grandson 2,000.00 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE, II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN; 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ If more space is needed, use additional sheets of paper of the same size. REV-1513 EX+ (01-10) ~ pennsylvania DEPARTMENT OE REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ~ BENEFICIARIES ESTATE OF: FILE NUMBER: Dorothy M. Scheibelhut 21-09-1184 RELATIONSHIP TO DECEDENT ~4MOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).J 1. 10. Jo Ann Youkers 1810 Willow Road, Camp Hill, PA 17011 Granddaughter ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. 2,000.00 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ If more space is needed, use additional sheets of paper of the same size. REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA No . 2009- 01184 CERTIFICATE OF GRANT O F LETTERS . PA No . 2 7' - 09- ~ 184 Estate Of : DOROTHY M SCHEIBELHUT (First, Middle, Lastl Late Of : SlL VER SPRING TOWNSHIP CUMBERLAND COUNTY Deceased Social Securi ty No : 199-05-7948 WHEREAS, on the 22nd day of December 2009 an instrument: dated July 6th 1999 was admitted to probate as the last will of DOROTHY M SCHEIBELHUT IFirst, Midd/e, Lastl late o f S/L VER SPRING TOWNSHIP, CUMBERLAND County, who died on the 13th day of December 2009 and WHEREAS, a true copy of the wi 11 as probated i s annexed' hereto . THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wi 11 s in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: GILBERT E SCHEIBELHUT and SUSAN K MASSIF who have duly qualified as EXECUTOR(RIX) and have agreed to administer the estate according to 1 aw, all of which ful 1 y appears of record in my office a t CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 22nd day of December 2009. '~ ~~ Register of W!lls / .~ Dep y * *NOTE* * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) L1~ST tiui1LL AND TESTr~T~TLNT OF' DOFIOT:riY I~~I. SCx3EII3JL71ITT I, DOROTI--TY T~Z. SCIiETBTLIlUT, of the Toz•mship of Silver Sp_rin~;, County of C1.1r1L~erland a.nd Utate of Penns ~r~ var_i ry, bei n of sound and disposing mind, Memory and understanding, do male, publish and declare this my Last ldill and Testament, hereby ~. ~-~ ~.~ revoking and making void anv and all prior ti~Jills by rr~~:r~.t and _ .~~_ ;, time heretofore made . ._.,_,_~~ rv ..:. I direct the pa~,~rlent of all my just debts and funeral ~..~.ti ~~ el~pens©s as soon after mfr decease as the same can be conveniently done, including the payment out of the principal of ~r~y general estate, of all inheritance, estate and succession taxies, which may be assessed in consequence of my death. 2. I give and bequeath my personal bedroom suite, consisting of my bed. and mattress, my bureau, chest of drawers, night stand and t~•1o (2) lamps to my grandson, JASU~t T~TASSIE. 3• Z give and bequeath my desk and my eight (n} plates and frames, presently located in my bedroor.~~, to my granddaughter, JEAN LOT~IGEZTECIiEPt . ~• I give and bequeath my Television Set and Stand, together Frith my rocking chair and cedar closet, to my grandson, JOSHUA l~7ASSIE . 5. I give and bequeath my cedar chest to my granddaughter, C I TJDY T A'E'I, OR . 6, 2 give and bequeath my personal jewelry, if I have not otherUrise disposed of the same during my lifetime, to my three (3) granddau€;hters, to zrit, JEAT~? LOITGFT~ECI~R, CIZ•TDY TAYLOR and PAi~2ELA DOUGHERTY, share and share alike . 7• I give and bequeath all the rest, residue and remainder ox"' my household furnishings, including tools, equipmant and appliances, to my daughter SUSAN I~;.. 't~2ASSIE and to her husband, L~:rIS C. I'~L4SSIE, share and share ali'_-~e . ~. I give and bequeath the sum of T~~ro Thousand (~2,000.00~ Dollars apiece, to my seven (7) grandchildren, to ~,rit, JOSHUA 1~ZA.SSIE, JASOT~1 T~~ZASSIE, JEATd LOT~tGENECIT~, CII~IDY TAYLOP, ~AT~IELA DOUGI3EF'~TY, GILBERT E, SCHEIBELHLTT, JR. and JOAl~,TdE YOU~ERS. ^ 9. I give, devise and bequeath all the rest, resid~.~e and remainder of my estate, of ~~rhatsoever nature and ~rheresoever the same lnay be situate , t o my son, GILBLI~T E . SCI-IEII3ELHUT and to my daughter, SUSAN I'~. P-ZASSIE, share and share alike, per stirpes. L1~STLY, I nominate, constitute and appoint my son, GILBERT E. SCHEIEELHUT and my daughter, SUSAN N. T~ZASSIE, Co-Executors of this my Last ti'~ill and Testament, and direct that they be excused from posting bond or other security for the _f_ aithfu~. performance of their duties in a.ny ,~urisdicti ot~. IN WITTTESS ~°dHEREOF, I have hereunto set my hand and seal tl~.is ~~ day of July, A. D. , 1999. c C .[~..u Q,~Gc(,,~( (SEAL Do othy T~2. Scheibelhut Signed, sealed, published and declared by the a~>ove named, DOROTHY T~I. SCI~IBELHUT, as and for her Last ti°J 1.11 and Testament, in the presence of us, who have subscribecl our names hereto as tiritnesses, at the request of said testatrix:, in her presence and in the presence of each other. S COMMONWEALTIi Or PENNSYLVANIA ) COUNTY OI' CUr1BERLAND ) I, SS. DOROTHY T~I. SCI~iEIBELI-]UT the testatri.'!~ whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do Hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and volun- tary act and deed, for the purposes therein contained. Sworn and affirmed to and acknowledged before m~•b~ DOROTHY I~'~. SCHETBELH"tJT the testat x-i$ this ~(l ~` day of~ July ~ A• D• ~ 1999. Dorothy P~~~. Scheibelhut Notary Public Natzrial :;eei COMNIONWEAL'TH or PENNSYLVANIA ) Ma~Yn~E• H-~iiams, Ndary public S S . r Boro, C~um-~~and County t~~'~ g. ~ ices Nov. 6, 2001 COUN'T'Y Or CUMBERLAND ) ~,,~~ Commisswn P 1AemBes, pp~~ylvetua Assoc-ttwa ~ ~r~es We , the undersigned , J. P~OBF~RT STAUFFER and SUSAT? A. A'IcCOY the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, depose and say that we were present and saw the testatrix DOROTHY ~~~. SCI~E_T_BELI-iUT sign and exe- cute the instrument as ~~ller Last Will and Testament; that the said testatrix ~ DOROTHY h2, SCI-IEIBELI-iLTT _~ executed it as ~~Yher free and voluntary act for the purposes therein expressed; that each of us, in tl~e hearing and sight of the testatrix signed the Will_ as witnesses; and that to the best of our knowledge, the testatY'1X was, at the time, eighteen (18) or more years of age, of so»nd mind, and under no constraint, duress or undue influence. Swort2 anti subscribed to before me this ~ `~ day of July ~ 1999 a / /.~' ~ C./L' cam/ _~.. "~~~ Notarial Sezl Pubiic ~rilyn E. y~{Itiams, Notary Mecnanic~bur9 goro, Cumberland Camry Ivey Commission Expires Nov. 6, 2041 Member, PeransyJvania Assoelativn of Notaries COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES A N D PO BOX X80601 HARRISBURG PA 17128-0601 TAXPAYER RESPONSE REV-1543A AFP C7-DO) FILE N0. 21 09-1184 ACN 10500111 DATE 01-22-2010 GILBERT E SCHEIBELHUT 1820 HUNTERS DRIVE MECHANICSBURG PA 17050 TYPE OF ACCOUNT EST. OF DOROTHY M SCHEIBELHUT ® SECURITY S . S . N0 . 199 - 05- 7948 ^ sEC ACCT DATE OF DEATH 12-13-2009 ^ sTDCK COUNTY CUMBERLAND ^ soNDs REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE= CARLISLE PA 1701:1 AMERIPRISE FINANCIAL has provided the Department with the information listed below which has been used in calculating the potential tax due. 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. 4uestions may be answered by calling (717) 767-627. COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRU(:TIONS Account No. 1 0 1 0 942225 To insure proper credit to your account, two CZ) copies of this notice must accompany your DOD Valuation 14,443.35 Payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax 7 ~ 221.68 (3) months of the decedent's date of death, Tax Rate X . 0 4 5 you may deduct a 5Y. discount of the tax due. Any inheritance tax due will become delinquent Potential Tax Due 324 • 98 nine C9) months after the date of death. PART TAXPAYER RESPONSE ~:>~c~ t. l~ i~'<E Yfl< ; Rr~'~P.~~?1"t~~~;L L ~i~~~i~ T~ ~I hl a~ Q FF~~~.A~4 ~Ts~~ `'$ ~~~~.E ~`R~S~~~ B.~l~'~I~ ~l~ ~ 'C"H"'I S` .NCI~~'+,~ : A. ^ The above information and tax due is correct. I. You may choose to remit payment to the Register of Wills with two copies of this not::ce to obtain C H E C K a discount or avoid interest, or you may check box "A" and return this notice to the Register of 0 N E Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K H. ^ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y 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 2^ and/or PART ^3 below. PART If you indicate a different tax rate, please state your ay ~_ ~L~ ~~ k ~~'~"BxLn~' ~;~ f=`,~ ' ~~~ © relationship to decedent: y,~yLt~L`~~~` PA D ~ ~` ~'~ ~~ ~, ~ ~,~ TAX RETURN - COMPUTATION OF TAX ON ABOVE ASSET(S) `F~~A1l - _~~:n, .~• =xz~u~...r:...~~.~~ ~:<~~t LINE 1 . DOD Valuation 1 b'~ ^~~ ~#~ 2. Percent Taxable 2 X 2 ~•Y ~n ~<~;~~ ~ ar~'r.~ ~.;.: 3. A m o u n t S u b j e c t t o T a x 3 ~ ~`~~ ~fl~„~~„~ _= r ~' ~%~ _~ °•lt '3~.ee.' `>~~ zxieeu ~„, ...;,~ . 4. Debts and Deductions 4 - ~ ~•~ ~:~:'~4Le~r ,~,~~•~".'~ _~ >~' 5. Amount Taxable 5 ~;.,, ~. wR~ 2~;~~~ ,'~~i ~~A ., '~ ~` .'~L , 3s~4 ..df t3Y 6 . T a x Rat e 6 X g ; ~_ ~~.::~<~:~: ~::xx= FL: , ~, :. " e~ 7. Tax Due 7 ~~'er~;°..... ~~~t'':„~. s. ~ z $ t t~~tkfs 3. Vz~ ~, :k ~ »S <.mft>»'~£is} ., ., :s uc '~ .~yY:"3-: Via. v.,''~. ~r"3fi`.,~.. .. tt3F~€ct,??- PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID WORK C ) TAXPAYER SIGNATURE TELEPHONE NUMBER DATE TOTAL (Enter on Line 5 of Tax Computation} S Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. H 0 M E C ) GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the transfer agent. 2. Inheritance tax becomes delinquent nine months after the decedent's date of death. 3. Assets held by a decedent "in trust for" another or others are taxable fully. REPDRTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, Plata an "X" in block "A" of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with your check for the! amount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Farm REV-1548 EX) upon receipt of the return from the Register of Wills. Do not use the envelope provided. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" :section. Sign one copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept 280601, Harrisburg, PA 17128-060]. in the envelope provided. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check block "C" and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REY-1548 E}:) upon receipt of the return from the Register of Wills. Do not use the envelope provided. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the total balance of the account including interest accrued to the date of death. 2. The percent taxable assets owned by the decedent but held in trust for or payable to another individual(s) (beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF BENEFICIARIES X lOD - PERCENT TAXABLE Example: Assets registered in the name of the decedent in trust for two other persons.., 1 DIVIDED BY 2 (BENEFICIARIES) _ .50 X 100 = 50% (TAXABLE FOR EACH BENEFICIARY) The amount subject to tax Cline 4) is determined by multiplying the account balance Cline 2) by the percent taxable Cline 3). Enter the total of the debts and deductions listed in Part 3. The amount taxable Cline 6) is .determined by subtracting the debts and deductions Cline 5) from the amount subject to tax Cline 4). Enter the appropriate tax rate Cline 7) as determined below. A. For dates of death occurring after 6!30/94, the tax rates for transfers to spouses are as; follows: 1. Dates of death on or after 7/1/94 and before 1/1/45 the rate is 3%. 2. Dates of death on or after 1!1/95 transfers to spouses will be taxed at 0% tax rate. Note: For dates of death prior to 7/1/94 transfers to spouses are taxable at 6%. B. Transfers to lineal descendants including father, mother, son, daughter, grandchildren, son-in-law, daughter-in-law, stepchild and their issue are taxable at six percent C6%). A date of 7/1/2000 and after are taxable at four and a half percent C4.5%) . C. Transfers to siblings will be taxed at twelve percent C12%) for dates of death on or after 7/1/2000 . D. Transfers to all others including Uncle, aunt, nephew, and niece are taxable at fifteen percent C15%). E. For dates of death on or after 7/01/2000, transfers from a child Cage 21 or under) to a natural parent, adopted parent or step-parent are taxable at 0/,. F. If you change the tax rate, please specify your relationship to the decedent in the area provided. The amount of tax due Cline 8) is determined by multiplying the amount taxable Cline 6) by the tax rate Cline 7). CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED 3 4. 5. 6 7. Allowable debts and deductions are determined as follows: A. You legally are responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use plain paper 8 1/2" x 11". Proof of payment may be requested by the PA Department of Revenue. RR-~1w ~.1..L l RC~> y, ~#ARRISBURG - A7 C:7 ~~.~ 'd ~.ty.;sstl''3k7~"~ ~s '~',~`~ 7 'A''~1r ~ ~ ~3k~ s Y~ ~ a~'~'~~ ~'f ~ `Y c 3 ~t~ ~ FaJJ~i~'`~~~:r`/~5~`~~~~1j9]~~~~ 11}5>I ~3~ s £~ ~.AANY ~~7 ~I {.. L S ~ Q : D~~~k~~~ d~ bf f~E ~~~ 4YI.& ~ ,•. `~~~~ .; ~~~ x~~~~ ~~ ~~~I~~~~`~"~~~f~~3~s~ T~iX '~u '~i~c~~~~,~r u~~T z~ X87 83~~,.t~ ,T~13i~#'`_ 1 -~Cl~-~~4?`~;:3gr~tl.; C~~~Z'~;.~~GE' `F 0R T~:~#;XPAYE~F ~'-°' Tt~.? S~~~I,~1`a:~'~li'~~N~G AND ;S~~A.T~IC`~N~~13.5~~~.. ., ;~""' ': ..,, ~~X1 499 Mitchell Road, Millsboro, DE 199b6 Mail Code DE :rvlB-12 Phone (888) 502-4349 Fax (302j934-2955 December 29, 2009 filbert ~ Scheibelhut 18201iunter Dr Mechanicsburg, Pa 17050 Re: Estate of: Dorothy M Scheibelhut Social Security: 199-05-7948 Date of Death: December 13, 2009 Dear Sir or Madam: Per your inquiry, please be advised that at the time of death, the above-named decedent had nn deposit with t]us bank the foLlowin~: Type of Accou~u Certificate of Deposit Accoauit Ntcrnber 31003914462369 O~a~nership (Nantes ofl Dorothy M Scheibelhut Opening Date 10/17/94 Balance orz Date of Death. $ 14838.17 Accnced Interest $ 35.82 Total $ 14873.99 2. Tjjpe of Accor,~at. Certificate of Deposit .9ccount Number 3100391525b844 Ownership {Names of) Dorothy M Scheibelhut Opening Date 07/11/05 Balance on Date of Death $ 10044.14 Accrued Interest $ 2.44 Total $ 10046.58 3. Tipe of Account Checking Account Account RTUr~ther 73797318 OHjnersl7ip {Names of) Doroth}• M Sclieibelhut Opening Date 08i'?8/64 closed 1222/09 Balance on Dare of Death. $ 4031.18 i __. Accnced Inter est .. _ _.... . ~ 0~ 04 ._ . _.. __-_ __- __ Total $4031.2? i 4. T}pe of Account SavingsAccount Account Number 15004206019330 O1ti~tership fNames of) Dorothy M Sclteihethut Openi.fag Date 1028184 closed 121?2/09 t: Balance on. Date of Death $ 915.87 Accrued Interest $ 0.03 i Total -- --.--- -- -----~----- $ .915.92 I! Please be advised, there was a safe deposit box found for the above deredent Box 71 at the Hampden branch. ~ * If upon res~iewing the information above, you believe there are additional accounts not referenced, please provide us with an account number and/or name of any possible joint account holder. For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds, etc., please contact ~ our Hampden branch, 5528 Carlisle Pike, Mechanicsburg, PA 17050. Uffiice # 717-255-2293. ~! Sincerely, ~ r- ~-- Ndrissa Sears t., Adjustment Services N CD ~ cD ° °a a? ~ rn , ~ ~ ~ ~ ~ ~ ~- ~ C W 7 N v ~. ~ O t!') cd 7"' Z D f +~ ~~ Jd Cn W Z . 7m O ~ ~ ~ ~ ~ J G p~ ~ 0 U U~ 2 m N ~ o~ Q ~ ~~ U ~ M ~ N G . ~ ~ C~ Q CU .g ~ ~ = i- +~'' v ~ ~ C~ o m p o 3 ~ ~ ~ c ~ ~© r N ~~ ~ N ~ ~ ~ ~ ° N ~ ~ N ~ ~ ~, ~ .v ~ ~ `~ k` ~ C ~ ~ c J ~' C.3 d t3? ~ Z '~ ~ , ~ a- ~ ~ ~s ~ m ~ ~Q, ~ ~ > > ~ ~ ~ ~ a ~ ~ ~ ~ ~ ~ ~ ~ _ ~~ ~'':s [L ~T ~ rs yr- ~ y ~ ~ ~ ° ~ `~ ?' m ° v ~ ~C -d dr -~.~...w ~ ca 4 N ~ o ' ~ ~ v Q, .~ ~ ~ d e U ~ CY a.. 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'j v ° ~ ~ i ti ~~, ° s $ -3 ~ ~.5 ~ ~ m m ~ o ~ 'a- 'may .~ ~ ~ ~ ~ ~ ~ ~ m ~ -~ rT1 ? ~• ~ `1 c'~ `~ V m `~ - °J v 'dm m `a~i 'd ~° v 'y. .~ of r,,,, m O R y .r ~ r, .d r °r~, ~ 'O A' r' Fes" u- ~ :~y fy. ~ O m II G ~ nn a~ ~d ~ ~ ~ m ~ c`ai ~ ~ y ~ ~ .tom. v o A ° y d d o v A so ,4• ~ci .°.3 cc ~ ~` ~ ~ ~. ca " Or ~ ~ O ~' d m ~ O ~ .~ O +, d s°' ~ O ~ yd .°3 ~ ,;~ G ~ ~ ~ m ~ ~_ .~ ~ :y T Z E~ C' ~ bn -' AO °' ~ ~ s ~ ~ ~ d, ° 9 U ~ aUi v ~ ~ ~-'. c`~d ~ .~ -U m L ~, $ - m a"`i w 'd >+ '~.~ '~. ~ ~ ? » 9 ~ ,~ ~'..~ ¢` co @ ..mv. 7 O G O ~, OC "~ d °,~' ~ y, ~ ~ co ~, .vr-, ~ m ~ c f' m m3.+ ~ ~ d ~ `•~ d ie c ,~ ~-' ~ 3 a o u -.~ ~ ~~ m o '> o m~ .aJ' c a~ t o m ~ m m .~ t„i d a A o y, u~ ~a .~ ,2 -p ~ ~ G y . ~"' o ~ ~ •~ ~ T ry ~ ~ d ~ o ~ o ~ emu" ~ ~_ ~ ~ 1 .-°• ~ e ~ ~ ~O .° -c o m ~ > ,~ m o m V °.t ~ ~ '... Y m~ 0°5 `~ p,, ¢ ~ ~ ~ w, c m ~ i ~ F ,m„ p m ~ _A Ci ~m ~ rc +y, . M, O ~ 4 ~ r o v v ~ s`^ ~ O ~ ,. p °~ .~ ~ ° d'oo .y m N m ~ A. a ~ ~ ~ v 3 ~ O 'O o ~ ~ - J = G °.r.' ~ ~ d ~ -~ .~` *~CS, i y ~ ?, ~, A °~ .>..' ~ '~' m v ~ - ~ ~ C ~ ° ~ u~c, ~i o ~ ~ •~^~, .~ bo ~ ~ m ~ ° .. a. ~ 3 y-. A ~ _ m V .>.. ~ v. ~ ",1 d ~ v m y p ~o o .z~'' q '~ m °~° ~ O ~r `y ~ ~ .~ cs _ c'` y, y d .~' ''r^. y °~ ~'~ •_o J~ '~G~ ~ ~~et m ~ ap ~o ~ w° o~v c a ~p r ;j ~ P m~ ~~ ° 3 •~ ~ V d :..~ m y Li m m a~ ~a~ 'v '-c2 c Z' v m y = ~ ~ r. Y `. .-. Allstate Life Insurance Company P.O. Box 94212 Palatine, IL 60094-4212 Telephone: (877) 499-6418 Facsimile: (866) 635-4523 December 23, 2009 Susan K. Massie 1 Fieldstone Drive Mechanicsburg, PA 17050 Re: Dorothy M. Scheibelhut Contract No: GA17064027 Dear Ms. Massie: ~~ ~ ~ ~ 'k~ Yau`re in goad hands. The purpose of Form 712 is to provide an estate or donor with the value of a life insurance contract or its proceeds as of a certain date (usually the owner's date of death or date of transfer of the contract). Because this contract is an annuity, it is not reportable on IRS Form 712. I can, however, provide the following information for estate purposes: Date of Death: December 13, 2009 Annuity Value as of Date of Death: $ 40,040.81 Cost Basis: $ 40,000.00 Named Beneficiary: Susan K. Massie & Gilbert E. Scheibelhut *The actual amount paid may differ due to Market Value Adjustments and/or any applicable Surrender Charges. If you have any questions, please contact me at 1-877-499-6418 Ext. 86184. Sincerely, Donna Gray Sr. Claim Examiner Printable Front and Back Images Page 1 of 1 SdgS~ERN,S+~U~'~ILRfi~I ~.TFE ~4SSURAI~ICE CSk~1P'A~tY K~~-rn~~4r+at.~nlK s,-••nsa WINO°,y~i, CT G{!t'''"FZAC'.E' TTl A~S~ ~-QS-2~~1~ OC ~~6'~~~Q~ Wt~Q~~l58~295~9 '~$~} R'igr161F.eord~'u6 E~iACT.~Y '~~~'~~1~, ~92~ L~f~~,L~AEtS ANI3 87 CANTS GILBE~T S~i381F~EIYH~T?' . ~9EGHAIyICSB~FR~ ~A ~7~50 j~'066g25~5jj' ~:0~'9J04~S~. 6r0fi~jj' ~~~~ ~= C ,~ ~ ,~ . ~~i fir., y ~.~ p ~ ' ~ .T ~^ ~ i..s.+'-'y t.~n~~.-~~ ~ t ii ~ h L a J C%I 1.~. ~y5] 11 ff '7 * ~ k~ ``~~ ~ ~ ii ' ~~ ~"' ~, •? ~_ .i. ty 1~1 ~ ..a 1 ~ ~ ~ r h ~ {`~, u ~ c kf~+ ~7 ' r \ L rx l G9 ~ ' ~ u Sy' a. C.r r~ ~ ~i ~~-'i ~ ~' "1 ~ Si cS ~' .I' ~ ~y a ., T j ~.+ l: 1 ., f http:// 10.94.5.201 /ICWebServices/BBResearch/PrintableImages.aspx?sys_id=18353073 &t... 5/21 /2010 48500041046 REV-485 EX (05-04) SAFE DEPOSIT BOX INVENTORY PA Department of Revenue PLEASE USE ORIGINAL I:ORM ONLY Social Security or Death Certificate Number Date of Death County Code Year Fiie Number 199 05-7948 ~ 12/13/2009 09 Decedent's Last Name Suffix First Name __.._.~..___._._, ._____.__.~ .__ ~. M! i Scheibelhut ~ ..., ... . 4 `Dorothy _._._ _ _ .......... M __ ADDRESS OF DECEDENT STREET. ~~ CITY: STATE: ZIP CODE: 105 Hillside Rd Mechanicsburg PA 17050 NAME AND ADDRESS OF PERSON REQUESTING THE OPENIN G OF THE SAFE DEPOSIT BOX N~E~ Gilbert E Scheibelhut STREET ADDRESS; CITY: STATE: ZIP CODE: 1820 Hunter Dr Mechanicsbur PA 17050 NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING a. NAME: RELATIONSHIP: Gilbert E Scheibelhut son STREET ADDRESS: CITY: STATE: ZIP CODE: 1820 Hunter Dr Mechanicsburg PA 17050 b. NAME: RELATIONSHIP: Susan K Massie daughter STREET ADDRESS: CITY: STATE: ZIP CODE: 1 Fieldstone Dr Mechanicsburg PA 17050 c. NAME: RELATIONSHIP: STREET ADDRESS: CITY: STATE: ZIP CODE: NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME: M&T Bank STREET ADDRESS: CITY: STATE: ZIP CODE: 5528 Carlisle Pike Mechanicsbur PA 17050 NAME OF PERSON MAKING LAST ENTRY DATE AND TIME OF LAST ENTRY Gilbert E Scheibelhut 10/27/09 1:40 pm DATE OF CONTRACT TO RENT BOX NUMBER OF BOX 1 TITLE UNDER WHICH BOX IS REQUESTED 08/12/1968 71 Doroth Scheibelhut or Gilbert Scheibelhut NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX a. NAME: b. NAME: Dorothy Scheibelhut Gilbert Scheibelhut j STREET ADDRESS: STREET ADDRESS: 105 Hillside Rd 1820 Hunter Dr CITY: STATE: ZIP CODE: CITY: Mechanicsbur PA 17050 Mechanicsbu CITY: NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY Margie Fealtman, Personal Banker WAS A WILL !N THE BOXT ^ YES NO H yes, a. Date of will: i b. Name and address of personal representative, Nnamed In the will ~ NAME: STREET ADDRESS: i c. Name and address of attorney, If any NAME: STREET ADDRESS: 48500041046 CITY: STATE: ZIP CODE: PA 17050 STATE: ZIP CODE: STATE: ZIP CODE: 48500041046 J REV-485 EX SAFE DEPOSIT BOX INVENTORY Page_ of INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred Cert~cBte, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) ObNgations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. - (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. ~ (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies yr other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 ITEM NO. ITEM DESCRIPTION I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD tS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. PERSON RECENING COPY OF SAFE DEPOSIT BOX I VENTORY: SIGNATURE SIGNATUR 7 .,ll~J ~ /dL , PRINT N E PRINT NAME A D CHECK APPROPRIATE BOX BELOW: PR(IN~T ~E~{` ~/~v ~ ~- YI.kJU1U~ !.(J'~i1..~ DATE 1~~~ ~O CHECK AP O RIATE BOX: ~Executor(trix) ~ Administrator(trix) Estate Representative ~ Joint owner of safe deposit box NOTE: Attach additional 8'/z" x 11" sheet(s) if necessary or use duplicates of this page of form. The Department is authorized by law, 42 U.S.C. §405 (c)(2)(C)(i), to require disdosure of Saaal Security numbers in connedton with administering state tax laws. The Department uses the Sodas Security number to identify the decedent and personal representatives of the estate. The Commonwealth may also use the information in exchange of tax information agreements with Federal and local taxing authorities. The state law prohibits the Commonwealth's rsonnel from disdosin confidential tax information except for official urposes. 05-?1-'1D 10;56 FFO~I-Hollinger FH _ -. , December 22, 2009 Susan K. Massie 1 Fieldstone Drive Mechanicsburg, PA 17050 The Funeral Service for Dorothy M, Scheibelhut: 71'4863433 T-834 P00~10a2 F-y55 ' We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can_ Please feel free to contact us if you have any questions in regard to this statement. THE FOLLQWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIl3MENT, AND MERCHANDISE THAT YQU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. Professional Service Traditional Package $448;0.00 Merchandise Casket -Haven line Poplar 2495.00 Memorial Package ~ Hummingbird Book, Memorial Folders, Acknowledgement Cards, Bookmarks No (:barge A7 THE TIME FUNERAL ARRANGEMENTS WERE MADE, V1/E ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLpWING IS AN ACCOUNTING FOR THOSE CHARGES. Cash Advances Newspaper Notices -Patriot-News $408.92 Certified Copies of Death Certificate (ZOC~ $6~ 12,0.00 aeverend David A. Watkins 200.00 Organist 75.00 Flowers -Casket Spray 21.2.00 Flowers -Vase 47.70 Clothing -Blue Dress with Sweater 12:5.00 Current Balance: ,~81fi3.fi~ Funeral account is paid in full: bated Dec. 29, X009 Contract File Folder Name/Number CEMETERY INTERMENT RIGHTS, MERCHANDISE, AND SERVICES PURCHASE/SECURITY AGREEMENT TRTC Af_RF.F.MFIVT PRnVT11FC F(-72 PFl?DTl'I'iTn r i~'>`trinxxrn,rL'~rm r,t nt: The undersigned, referred to as `Purchaser', hereby agrees to purchase the Interment Rights, Merchandise and Services described herein, subject to acceptance and approval of the above named cemetery, hereafter referred to as `Seller'. -- ,_ Purchaser: Last Name: I~: I ~' hr" I~ I •. PC. L" h, I`~ I, x j~`: I I ... I"' I I I I First: i(~ .I , l I ••')I C I; I~" 1 1 1 1 1 1 1 Middle: I I I I I I I Telephone: ~_ i ~'I ^: ~! - ,,-i `?..(c SSN: t _~ ~....-~ DOB: / / Email: Address: i', 't:~ h~I_>;I h''41~- I^~ I` 'I" I t{:, i' I 1 < t~'j-~ I I I I I I I I Cityay `,.I' 1- EF. d.~l i c I __I ~a,..~ ~ l cl State ~ , I, .~ Zip: ~ j _ ,i::7 ~.J Co-Purchaser: Last Name: I I I I I I I I I I I I I I I ~ I ~ First: ~ I I I i l l l l l l i l ~ Middle: I I I I I I I Telephone: ( ') SSN: DOB:.. / / Email: ,, . _.. _. Address: I I I I I I I I I I I I I I I I I I I I i l l l l l C'ty' I I I I I I I I I I I I I State: I I I Ztp. Deceased: Last Name: ( I~' I~~ ~ I~ I, V-. Ir I `t ~V~ •~. I~ ~.1 i 1 1 1 1 1 1 1 Ftrst.~ ~ =~1 ^ Is IC~,;1'~ Ir~~. t~ 1 1 1 1 1 1 1 Middle: ~~ I I I I I DOB: I /ry1 lw, / t i DOD: I ~ / ~ ;" / _ ~ Burial Date: i ~ / , 7~. / 14,i 4 ` Veteran: Description of Interment Rights to be used: __ _i ~- k4 ,- Memorialization Rights: Issue Certificate of Interment Rights to: Address: City: State: Zip: INTERMENT MERCHANDISE & SERVICES • Interment Rights $ Urn ~~ (Includes Perpetual/Endowment Care of ~ ) Supplier • Interment and Recording Fees Type/Color • Outer Burial Container Design/Size ', Supplier Admin/Processing Fee (,iJ. (~.-C~ ', Model/Design Other ---- Material/Color Other - • Outer Burial Container Installation Other MEMORIALIZATION Other - - • Memorial ~ Other Supplier Other Type/Color TOTALS, ALLOWANCES & TAXES Design/Size -- Interment Rights ............................................................... ( ) • Memorial Base Reason - Supplier r--- Merchandise/Service ........................................................ ( ) Type/Color Reason Design/Size Apply to • Memorial Perpetual/Endowment Care Merchandise/Service ........................................................ ( ) • Memorial Installation Fee Reason • Memorial Inspection Fee Apply to _ • Nameplate/Scro11E'~,"' ~. "`. _.-~ ~ i -'t..EC~ _ -;~ C; r ~l_,l l! ~ Sub Total , :~.. '~- .. _ • Lettering "~ ~ Total Taxable "" - • ower Vase _ ------ _ Sales Tax (if applicable) .................................................... Supplier TOTAL CASH PRICE $ L(/.1 C-~ ~ t.'~1 t Type/Color Less: Down Payment Design/Size Other • Vase Base ~ Total Down Payment ( ),,. Sizt:/Material Unpaid Balance of Total Cash Price $ Notes & Payment Terms (where applicable): TERMS The Total Cash Price is due and payable as of the date of this Agreement. A delinquency charge of _~ percent will be assessed monthly on any balance not paid within 30 days of the date of this Agreement. If less than full payment is received, Seller shall deduct the accrued delinquency charge from the amount received and credit the remainder of the payment to the Unpaid Balance. Security Interest: Seller (or its assigns) will have a security interest in the Interment Rights and Merchandise being purchased as described above. Seller will retain title to said Interment Rights and Merchandise until the Total Cash Price, together with any delinquency charges thereon, have been paid by Purchaser to Seller. NOTICE: By signing this Agreement, Purchaser is agreeing that any claim Purchaser may have against the Seller shall be resolved by arbitration and Purchaser is ivin u his/her right to a court or jury trial as well as his/her right of appeal. g g p ! F~+1~s`rF.~~4kotf~s C"tfi~C~lE~4~ She Signed this '"? "~~ day of ~~ "~•: r~ ; , 20 i ~'~; ~ ~'~~ '~~`~~ 3'urchaser: ti .l ~ ~ 1~~-' ~''s r;,P,t`l~~.t~".' Relationship: . ".,%-~~ Accepted by: ~ ~ V - I attest that I have reviewed this document for accuracy end completeness. Co-Purchaser; Relationship: Date: / / I~ ~ Counselor,. a/ R ~~ ~. r, t .. _`/ r _ _ # ~M ~ ~`~A14TICE:- See Other Side for Additional Terms and Conditions which are Part of This Agreement FOrm: 220-PA (05/07) Distribution Schedule: While =Cemetery Copy; Yellow =Customer Copy