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HomeMy WebLinkAbout09-10-10' 150561140 1500 EX (01-10) REV - OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 2 ~ ~, 0 0 2 5 3 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYW 1 5 5 3 0 2 9 4 5 0 8 2 8 2 0 0 9 ], 0 0 5 1 9 4 0 Decedent's Last Name Suffix Decedent's First Name MI H A G E R R O B E R T G (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI H A G E R J A N E T T E L Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW a 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate 0 4a. Future Interest Compromise (date of ~ 5. Federal Estate: Tax Return Required death after 12-12-82) QX 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust ~ 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) GUKKCSF'VIVUCIV 1 - 1 fiW .1t1, I IVIV IVIUJ I CC I.VIYIF'Lt I CU. HLL l.Vl'(KC.~I'VIVUCIVI,C HIVU IiVIVCIUGfV I IHL I HA IfYI-VRIYIHI IVIV i~nVULU DG UIRCV 1 Gv 1 V. Name Daytime Telephone Number J a m e s N C l y m e r 7 1, 7 2 9 9 ? 1 0 1 First line of address 4 0 8 W C h e s t n u t S t Second line of address City or Post Office L a n c a s t e r Correspondent's a-mail address: State P A ~ --- _,_; ®'WILLS U~E'~ON LY ^ ~_ r < "`+ ~_~ m ~~4 _~ ~i ~ ~ „ C3 ~-~~ ~ y ~' ,~ '~ ~- _ -~~ _"" ~ ~ N .. DATES FILED .~" ~ ' ZIP Code L L 7 6 0 3 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 representative is based on all information of which preparer has any knowledge. PLEASE USE ORIGINAL FORM ONLY Side 1 1505610],40 1,5056],01,170 J SIGN~4TURE OF PERSON RESPONSfBLE FOR FILING RETURN DATE r r ~ ~ 3~~3c~/a ADDRESS ~ P-0• Box 14 Carlisle P~- 1,707,E J 1,505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: R O B E R T G• H A L E R 1 5 5 3 D 2 9 4 5 RECAPITULATION 1. Real Estate (Schedule A) ........................................... 1. • 2. Stocks and Bands (Schedule B) ...................................... 2. 6 8 6 1 • ? 6 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. • 4. Mortgages and Notes Receivable (Schedule D) .......................... 4. • 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E}....... 5. ], ? 8 4 5 • D D 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. • 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ....... 7. 9 1, ? 1, 2 . 5 0 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 1, I, 6 4 1 9 . 2 6 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9. 5 1 2 D . D 0 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. • 11. Total Deductions (total Lines 9 and 10) ............................... 11. 5 1 2 D . D D 12. Net Value of Estate (Line 8 minus Line 11) ............................ 12. 1, 1, 1, 2 9 9. 2 6 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... 14. 1 ], 1 2 9 9 . 2 6 TAX CALCULATION -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 4 9 9 5 1. 1 1, 15. 16. Amount of Line 14 taxable at lineal rate X .0450 6 1, 3 4 8 . 1, 5 16. 17. Amount of Line 14 taxable at sibling rate X .12 D . 0 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 0. D D 1 g, 19. TAX DUE .................... ......................... .. ....... 19. 20. FILL IN THE OVAL 1F YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1,50561,0240 D. 0 D 2 ? 6 0. 6 ? o. D D D. 0 0 2 7 6 0. 6 ? a 1505610240 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 10 0253 DECEDENT'S NAME ROBERT G. HAGER _ _ STREET ADDRESS 20 Sunset Drive CITY Carlisle STATE PA ZIP 17013 Tax Payments and Credits: ~ • Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 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. (1) 2,760.67 0.00 (4) 24.29 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 2,784.96 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : ...................................................................... ^ ^X b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q c. retain a reversionary interest; or ................................................................................................ ^ 0 d. receive the promise for life of either payments, benefits or care? ....................................................... ^ Q 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ^ ^X 3. Did decedent own an "intrust for" orpayable-upon-death bank account or security at his or her death? ......... ^ Q 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? .................................................................................................. 0 ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan.1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 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 requiremE:nts 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 21 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 0 percent [72 P.S. §9116(a)(1.2)I. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 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 12 percent [72 P.S. §9116(a)(1.3)J. Asibling is defined, unde Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Total Credits (A + B) {2) (3) REV-1503 EX + (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ROBERT G. HAGER ___ 21 10. 0253 All property jointlyowned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Citigroup - 1,312 shares @ $5.23 6,861.76 TOTAL (Also enter on line 2, Recapitulation) I $ 6, 861.76 (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. IN RE811 ENT DECEDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER ROBERT G. HAGER 21 10 0253 Include the proceeds of litigation and the date the proceeds were received by the estate. Afl property jointly-owned with right of survivorship must be disclosed on Schedule 1=. _ ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 1999 Dodge Ram Wagon 3,050.00 2. 2001 Toyota Avalon XLS 7,165.00 3. 2003 Toyota Camry 7,630.00 TOTAL (Also enter on line 5, Recapitulation) $ 17.845.00 (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (08-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER ROBERT G. HAGER 21 10 0253 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 THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST E>CCLUSION jIF nP~Llcne~E- TAXABLE VALUE 1. Orrstown Bank -IRA Certificate of Deposit No. xxxxx0108 15,920.28 100.00 0.00 15,920.28 Beneficiary: The Evergreen Trust for the Robert G. Hager Family 2. Orrstown Bank -Roth IRA Certificate of Deposit No. 8,503.03 100.00 0.00 8,503.03 xxxxx0112. Beneficiary: The Evergreen Trust for the Robert G. Hager Family 3. The Bank of Landisburg -Checking Account No. xxx5723 987.55 100.00 0.00 987.55 4. The Bank of Landisburg -Savings Acct. No. xxxxx0479 1,000.83 100.00 0.00 1,000.83 5. Members 1st Checking Acct. xx3004 985.05 100.00 0.00 985.05 6. Members 1st Savings Acct. No. xx3004 27,335.51 100.00 3,000.00 24,335.51 7. Orrstown Bank -Checking Acct xxxxx1208 39,980.25 100.00 0.00 39,980.25 TOTAL (Also enter on Line 7, Recapitulation) ~ $ 91,712.50 If more space is needed, use additional sheets of paper of the same size. REV-1517 EX+ (10-09} pennsylvania DEPARTMENT QF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ROBERT G. HAGER 21 10 0253 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. 1. 2. 3. 4. 5. 6. 7. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: Attorney Fees: Clymer, Musser, Brown & Conrad, PC Family Exemption: (lf decedent's address is not the same as claimants, attach explanation.) Claimant Janette L Hager Street Address 20 Sunset Drive ~;ty Carlisle state PA zIP 17013 Relationship of Claimant to Decedent wife Probate Fees: Register of Wills Accountant Fees: Tax Return Preparer Fees: TOTAL (Also enter on Line 9, Recapitulation) I $ If more space is needed, use additional sheets of paper of the same size. 1,500.00 3,500.00 120.00 5.120.00 REV-1513 EX+ (01-10} pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ROBERT G HALER ~d do n~~~ 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. 91.16 (a} (1.2).J 1. Janette L. Hager Spousal 49,951.11 20 Sunset Drive Carlisle, PA 17013 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS 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. $ n rn~re space is neeaea, use aaaiuonai snee>s or paper or the same size. REV-1647 EX+ (02-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE (Check Box 4a on REV-1500) ESTATE OF FILE NUMBER ROBERT G. HAGER 21 10 0253 This schedule is appropriate only for estates of decedents who died after Dec,12,1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interE;st vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument that created the future interest and attach a copy to the tax return. ^X Will ^ Trust ^ Other I. I Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY ~ • Janette L. Ha er wife 10/10/1946 63 2. 3. 4. 5. II. For decedents who died on or after July 1,1994, if a surviving spouse exercised or intends to exercise a right of ~vithdrawal within nine months of the decedent's death, check the appropriate block and attach a copy of the document in which thE: surviving spouse exercises such withdrawal right. ^X Unlimited right of withdrawal ^ Limited right of withdrawal III. Explanation of Compromise Offer: Assets transferred to the Evergreen Trust for the Robert G. Hager Family $111,299.26 x .4488 (3.4 table) = 49,951.11compromise offer $ 111,299.26 { 49,951.11) 61,348.15 future interest value IV. Summary of Compromise Offer: 1. Amount of future interest .................................................. $_ 61,348.15 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (Also include as part of total shown on Line 13 of REV-1500.) ...... $ 3. Value of Line 1 passing to spouse at appropriate tax rate Check one. ^ 6°/a, ^ 3%, ^ 0% ................ $ (A1so include as part of total shown on Line 15 of REV-1500.) 4. Value of Line 1 taxable at lineal rate Check one. ^ 6°/a, 0 4.5% ...................... $ 61, 348.15 {Also include as part of total shown on Line 16 of REV-1500.) 5. Value of Line 1 taxable at sibling rate (12%) (Also include as part of total shown on Line 17 of REV-1500.) ...... $ 6. Value of Line 1 taxable at collateral rate (15°/a) (Also include as part of total shown on Line 18 of REV-1500.) ...... $ 7. 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Et~h1RkK ^• "[l _. Estimated Payments S1R2 /mo Ct~ 4.39% APR Click for Details Get aPre-Owned Loan from 3.99% APR Get Your Credit Score Now Get a Free Insurance Quote advertisement 1i ~ s r'` Camry Titt/Telescopic Steering Wheel ~, - !~ ~~ ~... .. .T y. VF'i '.F a rt.:~~~Y;:~. '~ r D°k~NE°nD ERO~:HVRE i V1EU1 PHO1D5 - ,6° 'i IEWS s+NO 401C~R5 i_-~._-_.~ __--~ ~ShtQPPtNG 7pO1S r euaD v~wRs - ESi,NriTE FFYt~1E1~JT h FIND A DEALER F~:t~. -`; EF HEFE Fv~ .._:.' fir: F,'~ Or Search by Category Or Change ZIP Code ., ~~~~~~~~~~~ Traditional I:R.A $~~~~~~ S o c. Sec . XXX _. XX - 2 9 4 5 ~1 ~'raditiv'i of Excellence Customer Tax Year H024184 2 0 0 9 Robert G Hager 20 Sunset Dr PO Box 181 Carlisle PA 17013 The Fair market Value on 12/31/09 was 16,001.68 This statement represents activity on your retirement account. Please review and contact us if you have any questions. "1~h1.~i information is being provided to tine IRS . THANK YOU FOR ALLOWING US TO BE YOUR BANK. ACCOUNT BALANC E INFORMATION Certificate Current Accrued Maturity Interest Year-To-Date Number Balance Interest Date Rate Interest 606000108 15,964.02 37.66 0/00/00 1.09 144.57 15,964.02 37.66 144.57 ACCOUNT ACTIVITY Number Date Amount Description 606000108 1/14/09 33.80 Interest Added Back 606000108 4/14/09 24.29 Interest Added Back 606000108 4/15/09 6!000.00 Prior Year Contribution 606000108 4/16/09 1.0900000 New Rate 606000108 7/14%09 42.74 Interest Added Back 606000108 10/14/09 43.74 Interest Added Back P LAN ACTIVITY Description Amount BEGINNIi~TG BAi.~ANCE 9 , 319.4 5 CONTRIBUTIONS PRIOR TAX YEAR 6,000.00 INTEREST EARNED 144.57 ENDING BALANCE 15,964.02 BENEFICIARY INFORMATION Name Soc.Sec. # Birth Date Level Spouse The Evergreen Trust for the Robert G SN* R O/00/00 PRIMARY NON-SPOUSAL 1' C). E3c~x 250 • Shil:~perisbt.~xy, PA 172.57 • 71.7.530.3530 • 7 17.53?,.=1143 i`ax ~ i ~ ~ ~ ~~~~~~~~~~~r~ ~~~~~~~ Roth IRA . Soc. Sec. XXX-XX-2945 A ~'rnc~~ti©~ a~~~ccell ence Customer H 0 2 418 4 Tax Year 2009 Robert G Hager 20 Sunset Dr PO Box 181 Carlisle PA 17013 The Fair market Value on 12/31/09 was 8,542.91 This statement represents activity on your retirement account. Plea se review anal contact us if you have any questions . This information is being provided to the IRS. THANK YOU FOR ALLOWING US TO BE YOUR BANK. ACCOUNT BALANCE INFORMATION Certificate Current Accrued Maturity Interest Year-To-Date Number Balance interest Date Rate Interest 606000112 8,524.46 18.45 0/00/00 1.00 92.46 8,524.46 18.45 92.46 ACCOUNT ACTIVITY Number Date .Amount Description 606000112 1/14f09 29.02 Interest Added Back 606000212 4/14/09 20.87 Interest Added Back 606000112 7/14/09 21.14 Interest Added Back 606000112 10/14/09 21.43 Interest Added Back PLAN ACTIVITY Description Amount BEGINNING BALANCE 8,432.00 INTEREST EARNED 92.46 ENDING BALANCE 8,524.46 BENEFICIARY INFORMATION Name Soc.Sec.# Birth Date. Level Spouse The Evergreen Trust for the Robert G SN*P. 0/00/00 PRIMARY NON-SPOUSAL (?C7. Bc~~c 2:i0 • Shi~~}~c~rZSts~irg, 1'A 1 1257 • 7~17.:i:30.:i530 • 1;.5:32,-~1~3 lark Y, .,k ~. i'1.``1DiSFsURG • ~I.~IN Sr'ER~~1;a~`~iS C1PLE EVERGREEN TRUST FOR ROBT G HAGER FAMILY REVOCABLE LIVING TRUST DTD 07/14/2009 20 SUNSET DR PO BOX 181 CARLISLE PA 17013 ACCOUN'~ NUMBEl~~ i 3725723 Sep 7, 2009 Pg 1 o f ]- 0 We would like to take this opportunity to say that we really appreciate serving you and your banking needs. Some products that might interest you are Internet Banking, ATM services, & 24 Hour Banking Power. MEMBER FDIC 08/10/2009 Beginning Balance Regular DDA 1,000.00 0 Deposits/Other Credits + .00 1 Checks/Other Debits - 1-2:45.` 09/07/2009 Ending Balance 29 Days in Statement Period x987.55 ~ --------------------------------- Other Debits ---------------------------------- Oa/12/2009 ACH Payrnen~ 12.45 HARLAND CLARKE CHK ORDERS ----------------------------- Daily Ending Balance ------------------------------ 08/10 1,000.00 08/12 987.55 ~~c~n~ o~~.~nrii~l~irr~ ~~ ~. ,~r~~~i~eu~c~ ~ ~~~aii~~ • .HFR~n,ar~5 ~~a~F 3 6 6 9 5 0 4 7 9 `~LFPNc'_~i~~,E~ (717) ;~9 3?13 ,~ Sep 7, 2009 Pg 1 of 1 EVERGREEN TRUST FOR ROBT G HAGER FAMILY REVOCABLE LIVING TRUST DTD 07/14/2009 20 SUNSET DR PO BOX 181 CARLISLE PA 17013 We would like to take this opportunity to say that we really appreciate serving you and your banking needs. Some products that might interest you are Tnternet Banking, ATM services, & 24 Hour Banking Power. a MEMBER FDIC 08/10/2009 Beginning Balance Stmt Savings 1,000.23 1 Deposits/Other Credits + .60 0 Checks/Other De bits - ,00 09/07/2009 Ending Balance 29 Days in Statement Period 1,000.83` 08/10/2009 Beginning Balance 1,000..:...23--~ u9i07i2GG9 Accr Earning Pymt .60 1,000.83 ~ ~ Added to Account ~'~ ----------- -------------------- Earnings Summary ---------------- ---------------- ** Below is an i temization of the Earnings ** ** paid this period. ** Interest Paid This Period 0.60 Annual Percentage Yield Earned 0.76 0 Interest Paid YTD 0.83 Days in Earnings Period 29 Earnings Balance 1,000.23 've ,;~ ..:•~; PO Box 40 Mechanicsburg, PA 17055 ~t `` www.membersi st.org ~. Main Switchboard: (800) 283-2328 ~' - EZ Call: (717) 697-4372 or (800) 283-4372 Ya. TDD: (717) 697-5312 or (800) 283-2328 ext. 5312 ~ TeleBranch: (800) 237-7288 MEMBERS 1St FEDERAL CREDIT UNION 4477 1 AV 0.335 4477-4477 - - I~~~Ill~r~lll~~~~~~ll~~ll~ll~„~~~III~~I~~~~Ill~~l~~~~lll~l~~l THE EVERGREEN TRUST FOR THE ROBERT G HAG - C/O ROBERT G HAGER PO BOX 181 "- CARLISLE PA 17013 > __ r - Statement of Accounts Aug 25, 2009 thru Sep 24, 2009 Account Number: 363004 Balances at a Glance Checking : 985.05 Savings : 27,335.51 Certificates : 0.00 Loans: 0.00 Money Management : 0.00 Swipe 5 YTD Reward : 0.00 F'age : 1 of 1 Your aggregate balance as of September 1st is $28,320.56. An aggregate balance of $2,500 and having 3 products will place you in the Silver MLR level. _ Send Inquires to 5000 Louise Dn We are celebrating International Credit Union Day on October 15, 2009. Please see the enclosed insert for more details. CHECKING ACCOUNTS 11 -CHECKING Date Transaction Description Additions Subtractions Balance Aug 25 Ba/ance Forward 985.05 Sep 24 Ending Ba/ance gg5.05 SAVINGS ACCOUNTS 00 -REGULAR SAVINGS Date Transaction Description Additions Subtractions Balance Aug 25 Balance Forward 27 ; 323-~ 91 - Aug 31 Deposit Dividend 0.500% 11.60 27 335.51 Annua/ Percentage Yield Earned 0.500% from 08/01/2009 through 08/31/2009 ~ =_ ~ - - -- Sep 24 Endinq Balance 27 , 3.5.51 YTD SUMMARIES TOTAL DIVIDENDS PAID 00 REGULAR SAVINGS 13.19 11 CHECKING 0.00 Total Year To Date Dividends Paid 13.19 NOTE : Total includes closed shares Don't forget about our new Member Loyalty Rewards Program. The more products you have with us, the more benefits you'll receive. Ask an associate for details or visit our website at www.members1st.org for details. OARS ORRSTOWNBANK _--1 Tr~rditiorz of'Excelle~ice P. C7. Bot ~>0 Shippensbura. PA 17^~7 Temp-Return Service Requested Date 9/18/09 Frimary Account: Enclosures er F ~ii~~~~~~~~~~~~~~~~~~~i~~~~~~~~ii~`I~~~~~i~~~~li~ti~~~~~l~l~r~ 000003 0.4500 AV 0.335 TR00001 Evergreen Trust for the Robert G Hag PO Box 181 Carlisle PA 17013-0181 Page 1 143001208 Building? Buying? Remodeling? We can help! 1.888.ORRSTOWN - orrstown.com C H E C K I N G A C C O U N T S Account Title Evergreen Trust for the Robert G Hager F Free Checking Check Safekeeping Acc.~unt Number i 43nn12p8 Statement Hates 8/21 /na t:hru 9; 20/09 Previous Balance 39,980.25 Days In The Statement Peric>d 31 Deposits/Credits .00 Average Ledger 39,980.25 Checks/Debits .00 Average Collected 39,980.25 Service Fee .00 Interest Paid .00 Current Balance /39,.980.25_ .' M "' Daily Balance Information ~,., Date Balance °0 0 0 8/21 39,980.25 0 rn rn THANK YOU FOR BANKING WITH ORRSTOWN BANK 0 rn 0 0 0 0 0 0 c~ 0 0 0 o r+ 0 0~ ~ ~ ~ ~ o ~-+ 0 0 M C /') r--~ ~ O O ~ LAST W~1,L AND '1'I:S'I~'A.MF~NT I, ROBERT V. IIAGER, of the County of Cumberland and Commonwealth of Pennsylvania, hereby make, publish anal declare the following to be my I.aSt Will and "l,estament, revoking an~r and ail Wills anal Codicils by me at any time hei-etofo~-e made. FIRST: Pa~xnent of Debts: I direct that all r~~y just debts and funeral expenses be p~}id 4~s soon alter any demise as may be practicable. I fu.rthex• direct that all estate, transfer and in.lleritance taxes assessed with respect to my estate herein disposed of, or any pars` thereof, o~• any bequest or devise contained in this my Will be paid. out of my residuary estate as adn2inistration cxper~ses writhout proration or apportionment. SECUI~ID: Forgiveness oI' Debts: I direct that any Ioans I have mlde to nZy son Jonathan Mager or debts he may otherwise nave to me shall be forgiven. ".1"I-II<R.D: Bequest -Residue: l give devise v~d bequeath all the rest, l-esidue Vinci remainder of nay estate, of whatever t~aturc and vahereve.r situate, to Che "Trustee of the EVERCJR.I±;EN 'TRE~S'T FOlZ '1'HE iZt)I3E1Z'T C~. HAGER I~'AIVIIL~'` established under Declaration dated Julr~~ I~_ 2003 to be held, administered, and disbursed in accordance with the terms thcreo#: FUCTIZ'TH: Ct~ntin~ent Be ~ uest - Residue:.ln the event the Trust referenc;cd in tl~ie preceding article is no longer in existence or the Trustee cannot take the bequest for any reason. give devise and bequeath all the rest* residue and ren~airader ol`rny estate. to nt}~ wiff~, JANETTF. ~.,. ~I,~~T R, my son, .N.~AT"~'.€~EV~' ;,I. I~iA~Exi, ar~d my dau~;I-itcr, ~'L?IZABE"1'I~~ _~~. ~-~A«E ~, or to the survivor(s) olthem, in equal shares. f FIrT~_: Appointment of I~xecutor: I nomic~ate, constitute and appoint niy tarife, JANE'I'TF, L. HAG.EI2, and my daughter, ELIZABETH A. HAGER, and my so~~:. 1VIATTI-IE~'~ D. H~.t~E12, or the survivor ol'them, as Cv-Executor(s) of this my I.:ast V~'ill and F "i'estament. I direct that my I.:~xectrtor(s) shall not be required to file bond in a~1y court for his or- ~~r faithful crformance ai dut~T. whether he or she should be anon-resident of this state or foi• I~~ p ~- ~~ arty other reason. '_ ~t f ~~ ~ ~I:k'T'l1: C~efinitions: A. As used in fibs Vv'i.ll, the masculine, feminine or muter gender, and the singular c7r pl~.~r~tl number, shall each be deemed to include the others uthenever the context so indicates. 1:3. Caption4 and paragraph headings used herein are f~~r convenier~cc only, anti are nut ~i part o:(' this ti'v'ill, and sh~311 not be used in construing it. ,. _..,~" Tti ~4~'1":lNfaSS Vv'I-I~:;RE01=, I have hereunto set my hand and seal this f` `,~'c..~da~~ c~l~ ~-,~~~.., , 2U09. `l "~ RUl~ER7, G. l ~f1CxER Sl(:i.1t~lI), sealed, published and declared by t11e above-named '1'esti~tor, R~~BI~,R"l~ Ca. ~-1t'~(~EIZ; as ~.sid t~or .his Fast V-lill and `I`est~trr~ent, in the presence of t~s, why, at his request., in his presence and. in the presence oCeach other, have hereunto sub;SCribed our. names as ~vitnesse4 thereto. r ~ 1 .~" .!f ~r f w-. _... ~w ~! ~~" :~``"~ °--•-x=. `1'~Sidln~ clt t! d j t1.,.' ~= -~ ~-~" f" . ~ ~.~_.. ~• t ,~ ~. ~} , ~_..~.c~ .,Y Y ~~ ~, s,?,<~^: C~~-~ residing; at ~'.i~~. ~~`~ ,~ _ ~ ~:~~ r ',,, i ~.1 ._ t:~;t)~~INIONVtii~~.I.,7.'H C)Ti' PENNS'YT.aVANI~ } ~S: C't:)L;fN"1'Y OT~ I,~1IvTCAS"l`lR } ... -- ..~ ~: ,.., ;: ~ ~ V4'F., Rf)I3T-~.T2"T~ ti. T-1~1{-il~~k, .IA11f1T~S N. CI,YIt~El~ and c=~- • ~_#-~-~ , ,..,; ,.,, ~_. 43 ~' thi; 'I'estatar• and the r~•itn~sses, respectively, ~~lu7se n~~rnes tu-e signc~cl~to the attacl~cxi or forc;goiilg instrurZ~ent_ being first duTy~ affir~~3ed, do hertt~y declare to tl~e undersigned authority, a Nt~tar4~ 'I I'ublit;, that the "I~estatc~r signed ru}d executed the instru7nerrt as his Last ~~ill, and that he' had signed willingly, and that he executed it as his Exec and voluntary] act fir the pur~o.~cs therein expressed, and that each of the tiuitnesses, in tl~e presence a.nd heaxiz~g of the Testator, signed the Fill as ~.vitness, and that to the best of his ur her knawledge the Testator vas at that time eghteert ('.l ~} years cif age or older, of Sound mind and under nU ccjnstra.int or uiadu~~ influet~cc. -, I ~ ~~r' , ~j~ ~ ~ .~ ~ . e! _,._. 6^ l .... ~ ~~ Y \` `~ t ~t..f~3SC~RI.I3FI~, affirmed to and acknowledged before me, aNatary Public, by Rt)T3F.,~2T Ci-,-~iAG~:R, e "I~estator, an subscribed and affirmed to before ~xae by~fiA.~.1~1~5 N. {:'i,~'i'vI:~R and 1 ~~ ~-~ r ~ ~ ~. -~~ _ witnesses, tl~2s ~'~`~- day of '~--~+~- ~' ,~- - 2OC)9. t Uf3~f'atUhYt`A!fi:i CF :~NA~S'~LVANIA / ... ~''~ ~ ~ ~i ~ :fit ~... ~.,..!L'' ~ 1~4 ~... ?~~~~cc~ ~. ~Nitmer-~cta~} Pt4blic Notary Public C!'CY ~F E.Ah~1C~ST~R, L1~dC#tSTER CC~tIM`f 11~1y Comm. Expires: f ~ - ~. (- Z~ t ~ ~Y eo~r~~ss~c~r~ ~xpr~~s rev 21, 2UI I ._ -z ~.. MEMORANDUM OF TRUST THIS MEMORANDUM OF TRUST dated this day of ~C,~L _ , 2009, acknowledges and certifies the creation of a Revocable Living Trust by a DECLARATION OF THE EVERGREEN TRUST FOR THE ROBERT G. HAGER FAMILY dated July I~t' `, 2009. The principal components of declaration of mist are as follows: A. Name of Trust: THE EVERGREEN TRUST FOR THE ROBERT G. HAGER FAMILY B. Type of Trust: REVOCABLE LIVING TRUST, becoming IRREVOCABLE upon death of Grantor C. Grantor: ROBERT G. HAGER D. Original Trustees: ROBERT G. HAGER, JANETTE L. HAGER, ELIZABETH A. HAGER and MATTHEW D. HAGER E. Successor Trustees (to serve as Co-Trustees with remaining original Trustees): ANNA M. HAGER and SARAH A. HAGER F. Primary Beneficiaries: ROBERT G. HAGER and JANETTE L. HAGER G. Secondary Beneficiaries: ANNA M. HAGER, ELIZABETH A. HAGER,, MATTHEW D. HAGER, and SARAH A. HAGER, and to the survivin€; issue of any named Secondary Beneficiary H. Remainder Beneficiaries: Same Class as Secondary Beneficiaries I. Dispositive Provisions: Distribution of income and principal at the sole discretion of the Trustee but is strictly limited to the named beneficiaries J. Corpus of Trust: Corpus of the Trust consists of real and personal property transferred to the Trust by the Grantor or by others with full power c-f revocation by Grantor during Grantor's lifetime. IN WITNESS WHEREOF, of the Grantor certifies the foregoing to be an accurate representation and summary of the Declaration of THE EVERGREEN TRUST FOR: THE ROBERT G. HAGER FAMILY. ~~ -(SEAL) RO RT G. HA E , G antor Signed, sealed, published and declared by the above-named Grantor, ROBERT G. HAGER, as and for the preceding instrument, in the presence of us, who, at his request, in his presence and in the presence of each other, have hereunto subscribed our names as witnesses thereto. ~r `~--`^i( ~ '~ residing at ~ - ~`~ ~_._ residing at ,Cc.~x. -2- STATE OF PENNSYLVANIA: COUNTY OF LANCASTER: Before the undersigned personally appeared ROBERT G. HAGER who acl~:nowledged himself to be the Grantor of the Evergreen Trust for the Robert G. Hager Family and that :he executed the Memorandum of Tnlst as his free act and deed, before me this I~day of S'~-~~_ , ?009. Notary Public Commission Expiration Date: ~/-2f-ZOtI CDMMDNWEALTFI DF PENNSYLVANIA N OTARtAL SEAL Rebecca S. Witmer-Notary Public CITY OF LANCASTER, LANCASTER GOUKfY MY COMMISSION EXPIRES NOY. 21, 2011 (SEAL) -3- CLYMLR MUSSER BROWN ~ CONRI~D, P C ATTORNEYS AT LAW JAMES N. CLYMER 408 WEST CHESTNUT STREET 203 coMMERC~ DR,su1TE A MUSSER ROBERT F POST OFFICE BOX 1766 QUARRYVILLE. PA 17566 ' . 17) 786- 0500 (% LEONARD G. BROWN, ID LANCASTER, PA 17608- 1766 F.~iX r7v~ ~~as-2111 DAVID R- DYE (717) 299-7101 21Q NORTH ST"ATE STREET JEFFREY A, CONRAD FAX <717) 299-5115 EFHRATA, PA 17522 DAVID W MERSKY cmbclaw.com www . DIRECT ALL CORRESPONDENCE STEPHANIE E. LOMBARDO E-MAIL 1awC~cmbclaw.com TO THL- LANCASTER OFFICE August 31, 2010 Register of Wills Cumberland County Courthouse 1 Courthouse Square, Room 102 Carlisle. PA 17013 Re: Estate of Robert G. Hager No. 21-10-0253 Dear Sir or Madam: Enclosed are the following: l . Origina. with exhibits, and two copies of PA Inheritance Tax Return. The original is for the PA Department of Revenue, one copy is for your office and the other copy is to be time-stamped and returned to me 2. Original and one copy of Inventory. The original is for your copy and the copy is to be time-stamped and returned to me. -~ ~ l^ n !~-~ ~; ~;, 4. Self=addressed stamped envelope to return copies to me. If you have any questions regarding the enclosed, please do not hesitate to ontact mew e.; _- JNC/mh Enclosures `~ =` ' , U _.~~- ~ tom`-` ~' , rn ~~'~ ~..~ , ~ ~ - ~, c~' ~ a, ~~ : ry ~ -,p C: . Ja er i l - -_: _~ v .~.' .,-- ,