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08-12-10 (4)
1505610142 ~ REV-1500 ex(°1-'°' ' OFFICIAL USE ONLY PA Department of Revenue pennsylvanla County Code Year File Number DENINTNENT OE NEVENUE Bureau of Individual Taxes INHERITANCE TAX RETURN ~ ~ ~ ~~, PO BOX 28o6oi RESIDENT DECEDENT Harrisbur , PA i'Ji28-o601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 162225634 10252009 01131926 Decedent's Last Name Suffix Decedent's First Name MI PALMER DORIS L (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 Q 2. Supplemental Return Q 3. Remainder Return (date of death prior to 12-13-82) Q 4. Limited Estate Q 4a. Future Interest Compromise (date of Q 5. Federal Estate Tax Retum Required death after 12-12-82) Q 6. Decedent Died Testate Q 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) Q 9. Litigation Proceeds Received Q 10. Spousal Poverty Credit (date of death Q 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 T0: Name Daytime Telephone Number FRANK H KELLY, EA 7177747536 First line of address 400 BRIDGE STREET, SUITE 34 Second line of address City or Post Office State ZIP Code NEW CUMBERLAND PA 17070 ~., LLS USE REGISTER ~111 QY U ~~ C ETn _ Cl ~> r- _' =~ ~ N - _ ~7~:' ~=' J' ~ ~ ° ~ DP 19 E FILED ( J N Correspondent's a-mail address: FRANKKELLY@KELLYTAX . COM 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. SIGN OF PERSON RESP,OMSIBL~fj~R~ILJ1jIGD~ URN DA~ ~ I Z~- t ~~ 400 TBRIDGE STREET, SUIT~Er #4, NEW CUMBERLAND, PA 17070 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS 400 BRIDGE STREET, SUITE #4, NEW CUMBERLAND, PA 17070 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610142 1505610142 J REV-1500 EX 1505610242 Decedent's Name: DORI S L PALMER RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1 2. Stocks and Bonds (Schedule B) ....................................... 2. 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. 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ......... ..... 10. 11. Total Deductions (total Lines 9 and 10) ............................ ..... 11. 12. Net Value of Estate (Line 8 minus Line 11) ......................... ..... 12. 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. 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.o45 93, 598. 15. 16. Amount of Line 14 taxable at lineal rate X .0 . 16. 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. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Decedent's Social Security Number 162225634 115,000.00 • 15,352.00 130,352.00 33,665.00 3,089.00 36,754.00 93,598.00 93,5.98.00 4,211.91 4,211.91 O Side 2 1505610242 1505610242 REV-1500 EX Page 3 nwwwil~n~~c ~AFI1 HIDtA ArI /'IIPpCC' File Number 21- 2 0 0 9- 010 3 6 ............~..~- -----r---- - --- DECEDENTS NAME Doris L Palmer _ STREET ADDRESS 4006 Old Gettysburg Road CITY STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. Total Credits (A + B) (2) (3) (4) (5) 4,211.91 0.00 4,211.91 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 : ...................................... ...... ^ ^x c. retain a reversionary interest; or .................................................................................................................... ...... ^ ^ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death 2 . without receiving adequate consideration? ........................................................................................................ ...... ^ ^X 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ........ ...... ^ X^ Did decedent own an individual retirement account, annuity or other non-probate property, which 4 . 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 Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 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 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 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)]. • 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)]. • 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)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (11-08) ~ Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Doris L Palmer 21-2009-01036 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is aermea as the pace at wmcn property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common, VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. House - 4006 Old Gettysburg Rod, Lower Allen Twp, Camp Hill PA - sold on June 11, 2010 115,000 TOTAL (Also enter on Line 1, Recapitulation.) I $ 115 , 0 0 0 . 0 0 If more space is needed, insert additional sheets of the same size. REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RPCInFNT r1FCFI~FNT ESTATE OF FILE NUMBER llnri c T, Pa1mPr 21-2009-01036 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~~ None TOTAL (Also enter on line 2, Recapitulation) ~ $ (If more space is needed, insert additional sheets of the same size) REV-1504 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RFRIDFNT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Doris L Palmer 21-2009-01036 Schedule C-1 or C-2 (including all supporting information) must be attached for each closety-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 None TOTAL (Also enter on line 3, Recapitulation) ~ $ (If more space is needed, insert additional sheets of the same size) REV-1505 EX+ (6-98) SCHEDULE C-1 CLOSELY-HELD CORPORATE COMMONWEALTH OF PENNSYLVANIA STOCK INFORMATION REPORT INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Doris L Palmer 21-2009-01036 1. Name of Corporation None State of Incorporation Address Date of Incorporation City State Zip Code Total Number of Shareholders 2. Federal Employer I.D. Number Business Reporting Year 3. Type of Business ProducUService 4. 5. Was the decedent employed by the Corporation? ........................................ Yes ~ No If yes, Position Annual Salary $ Time Devoted to Business 6. Was the Corporation indebted to the decedent? .........................................QYes ~ No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? ............QYes ~ No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer any stock in this company within one year prior to death or within two years if the date of death was prior to 12-31-82? Yes ~ No If yes, Transfer Sale Number of Shares Transferee or Purchaser Consideration $ Attach a separate sheet for additional transfers and/or sales. 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....... Yes ~ No If yes, provide a copy of the agreement. 10. Was the decedent's stock sold? ...................................................... Yes ~No If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? ......................QYes ~No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? ....................QYes ~No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. Date (If more space is needed, insert additional sheets of the same size) Provide all rights and restrictions pertaining to each class of stock. REV-1506 EX+ (9-00) SCHEDULE C-2 PARTNERSHIP COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN INFORMATION REPORT RESIDENT DECEDENT ESTATE OF FILE NUMBER Doris L Palmer 21-2009-01036 1. Name of Partnership None Date Business Commenced Address Business Reporting Year City State Zip Code 2. Federal Employer I.D. Number 3. Type of Business Product/Service 4. Decedent was a ^ General ^ Limited partner. If decedent was a limited partner, provide initial investment $ 5. A. • ~ • • • B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? ......................................... ^Yes ^No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? ............ ^Yes If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? ^Yes ^No If yes, ^Transfer ^Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? ......... ^Yes ^ No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? .......................................... ^Yes ^ No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? ...................... ^Yes ^ No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? ........................................ ^Yes ^No ~~. ..~~ ~~ ~...., ,,,.r._... _. 14. Did the partnership have an interest in other corporations or partnerships? .................... ^Yes ^No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. • • •- • ~ ~ A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. ^No REV-1507 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN aGCinFNT nFCFI'IFNT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF FILE NUMBER n,~,r; c T. Palmar 21-2009-01036 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM I VALUEATDATE NUMBER DESCRIPTION OF DEATH 1 (None TOTAL (Also enter on line 4, Recapitulation) ~ $ (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER T)~ris L Palmer 21-2009-01036 Include the proceeds of litigation and the date the proceeds were received by the estate. All oroaertv 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-1509 EX+ (6-98) SCHEDULEF COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Doris L Palmer 21-2009-01036 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule tx SURVIVINGJDINTTENANT(S)NAME I ADDRESS I RELATIONSHIPTODECEDENT A. None JOINTLY-OWNED PROPERTY: REM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANKACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER.ATTACHDEED FORJOINfLY-HELD REALESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1. A. TOTAL (Also enter on line 6, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Doris L Palmer FILE NUMBER 21-2009-01036 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENTAND NUMBER THE DATE OF TRANSFER. ATTACH ACOPY OF THE DEED FOR REAL ESTATE. None DATE OF DEATH I % OF DECD'S I EXCLUSION VALUEOFASSET INTEREST (IF APPLICABLE' TOTAL (Also enter on line 7, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) TAXABLE VALUE REV-1511 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Doris L Palmer 21-2009-01036 Debts of decedent must be reported on Schedule [. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~~ Mussleman Funeral Home, Lemoyne, PA 7,426 2 Rolling Green Cemetary, Lower Allen Twp, Camp Hill 1,345 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 6 , 517 Name of Personal Representative(s) Ka r e ri L Ke 11 y StreetAddress400 Bridge Street, Suite #4 CityNew Cumberland state PA zIP17070 Year(s) Commission Paid: 2 010 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant StreetAddress City State ZIP Relationship of Claimant to Decedent 4. Probate Fees 314 5. Accountant's Fees 6. Tax Return Preparer's Fees 7 , 4 2 5 7. Wake Expenses 378 8 Real Estate Costs 10,048 9 New Family, Dillsburg - Trash Removal 212 TOTAL (Also enter on line 9, Recapitulation) $ 3 3 , 6 6 5 . 0 0 (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-08) ~ Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT FILE NUMBER ESTATE OF Doris L Palmer 21-2009-01036 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medVALUE AT DATE ITEM DESCRIPTION OF DEATH NUMBER i. Frank H Kelly 1,800 2 Chase Financial - Credit Card Balance 48 3 AAA Financial - Credit Card Balance 46 4 Bonnie Miller - Lower ALlen Twp Tax Collector 22 5 Lower Allen Twp - Sewer Bill 190 6 Verizon - Telephone 108 7 UGI - Gas Heat 387 8 PPL - Electric 183 9 PA American Water 288 17 10 Comcast TOTAL (Also enter on Line 10, Recapitulation) I $ 3 , 0 8 9. 0 0 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (11-08) ~ Pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Doris L Palmer NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] i. Karen L Kelly 400 Bridge Street, Suite #4 New Cumberland, PA 17070 2 Kathryn Leib ~517b Florence Drive Lower Allen Twp, Camp Hill, PA 21-2009-01036 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE Daughter Daughter 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. 50% 500 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ If more space is needed, insert additional sheets of the same size. REV-1514 EX+ (4-09) ~~~,3, Pennsylvania DEPARTMENT OF REVENUE Bureau of Individual Taxes PO Box z8o6oi Harrisburg PA 1~1z8-0601 ESTATE OF n~ris L Palmer SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN (CHECK BOX 4 ON REV-i5o0 COVER SHEET) FILE NUMBER 21-2009-01036 This schedule should be actuar al falctorgslforifsingle life calculationslcan be obtained f om t ei Department of Re venue of death prior to 5-1-89, Actuarial factors can be found land n A elph Volume four dates of death fromh5-1-99 and thereafter. death from 5-1-89 to 4-30-99, Indicate below the type of instrument that created the future interest and attach a copy of it to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other DATE.OF BIRTH I NEAREST AGE AT NAME OF LIFE TENANT DATE OF DEATH None 1. Value of fund from which life estate is payable ................... • . • • • • • • • • • • • • • • • • • • • •$ 2. Actuarial factor per appropriate table .............•....•..••••••••••••••••••••••••••• Interest table rate - ^ 3.5% ^ 6% ^ 10% ^ Variable Rate 3. Value of life estate (Line i multiplied by Line 2) ................. • • . • • • • • • • • • • • • • • • •$ NEARE5T AGE AT NAME OF LIFE ANNUITANT DATE OF BIRTH DATE OF DEATH 1. Value of fund from which annuity is payable ...............••••••••••••••••••••••••••••$ 2. Check appropriate block below and enter corresponding number ................ . Frequency of payout - ^ Weekly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^Serni-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per period ........................................................$ 4. Aggregate annual payment, Line 2 multiplied by Line 3 .................................. . 5. Annuity Factor (see instructions) Interest table rate - ^ 3.5% ^ 6% ^ 10% ^ Variable Rate 6. Adjustment Factor (See instructions.) ................................................ . TERM OF YEARS LIFE ESTATE IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years TERM OF YEARS ANNUITY IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 7. Value of annuity - If using 3.5, 6, or 10%, or if variable rate and period payout is at end of period, calculation is Line 4 x Line 5 x Line 6 ............. • • • • • • • • • • • • • •$ If using variable rate and period payout is at beginning of period, calculation is (Line 4 x Line 5 x Line 6) + Line 3 ...............................................$ NOTE: The values of the funds that create the above future interests must be reported as part of the estate assets on Schedules A through G of the tax return. The resulting life or annuity interest should be reported at the appropriate tax rate on Lines 13 and 15 through 18 of the return. If more space is needed, use additional sheets of the same size. REV-1644 EX+ (3-04) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE L REMAINDER PREPAYMENT OR INVASION OF TRUST PRINCIPAL FILE NUMBER 21-2009-01036 I. ESTATE OF pAT.MFR n(~RIS L II. (Last Name) (I-first Named ~~^~~~~~ ~°^~•~ This schedule is appropriate only for estates of decedents dying on or before December 12, 1982. This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of _ .. ,.. _~ .~_ :_~,._:.......e ~.,a G~~*o TaY Ort of 1961 or to report the invasion of trust principal. REMAINDER PREPAYMENT: A. Election to prepay filed with the Register of Wills on None B. Name(s) of Life Tenant(s) or Annuitant(s) (Date) Date of Birth Age on date Term of years income of election or annuity is payable C. Assets: Complete Schedule L-1 1. Real Estate ........................... ... $ 2. Stocks and Bonds ..................... ... $ 3. Closely Held Stock/Partnership ........... ... $ 4. Mortgages and Notes .................. .... $ 5. Cash/Misc. Personal Property ........... .... $ 6. Total from Schedule L-1 ................ .................................... $ D. Credits: Complete Schedule L-2 1. Unpaid Liabilities ..................... .... $ 2. Unpaid Bequests ..................... .... $ 3. Value of Unincludable Assets ............ .... $ 4. Total from Schedule L-2 ................ .................................... $ E. Total Value of trust assets (Line C-6 minus Line D-4) ............................... $ F. Remainder factor (see Table I or Table II in Instruction Booklet) ....................... . G. Taxable Remainder value (Line E x Line F) .. .................................... $ (Also enter on Line 7, Recapitulation) III. INVASION OF CORPUS: A. Invasion of corpus (Month, Day, Year) B. Name(s) of Life Tenant(s) Date of Birth Age on date Term of years income or Annuitant(s) corpus or annuity is payable consumed C. Corpus consumed .......................................................... $ D. Remainder factor (see Table I or Table II in Instruction Booklet) ....................... . E. Taxable value of corpus consumed (Line C x Line D) .............................. $ (Also enter on Line 7, Recapitulation) REV-1647 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE Check Box 4a on Rev-1500 Cover Sheet FILE NUMBER ESTATE OF Doris L Palmer 21-2009-01036 This Schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. ^ Will ^ Trust ^ Other I. Beneficiaries RELATIONSHIP DATE OF BIRTH AGE TO NAME OF BENEFICIARY NEAREST BIRTHDAY 1. None 2. 3. 4. 5. II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 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. ^ Unlimited right of withdrawal ^ Limited right of withdrawal III. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of Future Interest ...................................................... $ 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 Cover Sheet) .. $ 3. Value of Line 1 passing to spouse at appropriate tax rate $ Check One ^ 6%, ^ 3%, ^ 0% ................. (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One ^ 6%, ^ 4.5% ........................ $ (also include as part of total shown on Line 16 of Cover Sheet) (a 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) .................. $ 5. Value of Line 1 taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) .. $ 6. Value of Line 1 taxable at collateral rate (15%) Iso include as part of total shown on Line 18 of Cover Sheet) .. $ (If more space is needed, insert additional sheets of the same size) REV-1648 EX (02-09) ii pennsylvania DEPARTMENT OF REVENUE Bureau of Individual Taxes PO Box z8o6o> u~..~~ti~~n. GA »»R SCHEDULE N SPOUSAL POVERTY CREDIT FOR DATES OF DEATH 01/01/92 TO 12/31/94 FILE NUMBER ESTATE OF llnri c T. Palmer 21-2009-01036 This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sneer. 1. TaxableassetstotalfromLine8(coversheet) ...........•••••••••••••••••••••••••••"""' 1' .......... 2. 2. Insurance proceeds on life of decedent ..................•••••••••••••••••••••• ....... ..................~ 3. 3. Retirement benefits ,...........••••••••••••••••••••~••••• C- 4. Joint assets with spouse ..................... . .... . ................................... ~ 4. 5. PA Lottery winnings .... . 6a. Other nontaxable assets: Li 6. SUBTOTAL (Lines 6a, b, c, 7. Total gross assets (Add Lin 8. Total actual liabilities .. . 9. Net value of estate (Subtr If Line 9 is greater than $2 .,. ~ ~- •~• Income: a. Spouse ............ b. Decedent ....,..... c. Joint ............. d. Tax-exempt income .. . e Other income not listed above ........ . f. Total 4. Average joint exemption income calculation 4a. Add joint exemption income from above: (if) + (2f) + (3f) 4b. Average joint exemption income ........•••••••••••••••••••••••••••••"""""""""' If line 4(b) is greater than $40,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part III. 1. Insert amount of taxable transfers to spouse or $100,000, whichever is less .............. • • • • • • • • • • i 1, 2. Multiply by credit percentage (see instructions) .. , .. , .... • . • • • • • • • • • • • • • • • • • • • • • • • • • • ' ' ' ' ' ' ~• 3. This is the amount of the Resident Spousal Poverty Credit. Include this figure 3 in the calculation of total credits on Line 18 of the cover sheet . ........ . 4. For nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the 4. decedent's gross estate ................................................... . 5. Multiply Line 3 by Line 4 and enter the total here. This is the amount of the Nonresident Spousal S Poverty Credit. Include this figure in the calculation of total credits on Line 18 of the cover sheet.......... . ... ....................... ~ 5. stand attach schedule if necessary .. 6a. ~ ~ { :~ - 6b. 6c. 6d. ............................................. ) 6. ............. ................................................ ;slthru 6) 7. ... .................................................. 8. .......... ................................ Line 7) 8 f 9. ............ rom ct Line )0,000 -STOP. The estate is not eligible to claim the credit. If not, continue to Part II. ~ ~~ 1. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19 la. 2a. 3a. lb. 2b. 3b. 1c. 2c. 3ci ld. 2d. 3d. le. 2e. 3e. lf. 2f. 3f. d REV-1849 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Doris SCHEDULE O ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) Palmer FILE NUMBER 21-2009-01036 Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance 8 Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. Trust (marital, residualA, B, By-pass, Unified Credit, etc.). This election applies to the If a trust or similar arrangement meets the requirements of Section 9113(A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specificalty identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule 0. The denominator is equal to the total value of the trust or similar arrangement. pert a~ Fnter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse 105.905 REU.(3/09) r This is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance with the Vital Statistics Law of 1953, as amended. WARNING: It is illegal to duplicate this copy by photostat or photograph. a ~. ~%a- Linda A. Caniglia State Registrar NOV 0 3 2009 X105.144 REV 1712008 '. TYPE/PRINT IN PERMANEM BLACKINK `~ 5265439 No. COMMONWEALTH OF F HEALTH • VITAL RECORDS CORONER'S CERTIFICATE OF DEATH _ rte..,... M...nc onA nrnrnnlsa nn MVPafAa) .._..' Date $ 32-130 z. sex 3. Sadel Secunry Nan08r 4. Date a Death (MOMh, day, year) .Nameal7acedmlt(Rrst,mxae.tam,aallk) October 25, 2009 Palmer Female - 22 - 5 34 Doris L s. Age (Lam Biroway) um« 1 rear ulam t s. Dam a Bann IMOntn, m . ear 7. Bamplere Ic. am mate « CamMl ea. Pence a Deem cl,aae m me) Haepilal: Omar 83 `""~"" ~~ Haw, M~ January 13, 1926 Lemoyne,PA ^Irpaeent ^ER/OUtpaaeM ^DOA ^NUreingHOme Resident. paher-Baaar: vre. a Death ry. 9. Wee DBCedeM a Hiepenk Orlgin? yes 10. Rare: Amadwn Ineiu, SIe k, While, xc. Im. Ci Bo a Dum Be. Fa Ary Name (lf na1 ir~smunon, give mraet one nunber) ^ SP?cek1 spectl CuOan ( (If es M • 6e C Q , w h y , y y . ou Cumberland Lower Allen 4006 Gettysburg Road M~lt~n,Pwrro Rican, xu) t DereOem'3 Uswl t'en KiN a wok tlae tlun mom a wwdxl Itle. Do ml smte retired 12. Wee DecetleM ever in the 13. Decetlant'8 FAUCaem (Spaz1ry only highest greee mnplemtl) /4. Marital Satw: Mertmd, Never Maned, 15. SurviNng Spouse Ili wife, give meitlen name) Wxaved, Diverted (Specd7~ • 11 . U.S. Armed FO s Eremanmry /Secondary (0-t2) Gollega (1J or 5.) Klm a Worn Klntl a Bumnus / IMumry ' widowed housewife own home ^Y~ "° 12 D.tamrn,MetlirgAeaaaalswm,an/mwn.amm,zpreae) DeretlBM'a Pennsylvania °W1tlalD1 ~/ r.~~~~,- pl ~ ~, 17c.~~Yle,, Deueem Livetl in - re'P. . ,s . Aaux Rmidence 17e. Slate Townmip? ,7d. ~l_Ned wlhln City/8ao 4006 Gett sbur Rd. Y 4 ,7b.ct~try Cumberland C 3m' Hit P A 17 011 ts. Monier s Name (Brat, middle, maven aumame) 18. Femefa Name (FlrsL mkNe, 1981, suflk{ Grata Orn~r M . Chrst~r 3. D2ci:mal 20b. IMormant's Meiang Adtlrew (SIreeL CnY /town. mxe, tip catle) ~7 u ., I Pnn T ' ype 6 Name ( NM. InrolmaN 9 4517 Florence Av~.,~nt.l3,~lachaoic~our;~ pA ';Z3thr a G. L..=_iv ositlm ^Cremetlm ^ DOrmaat 21 b. Dale a Dbpwem lMmm, day, yor) 21c Plaza a Olspoeieon (Name a cemetery, crematory a oMer place) 21 e. Location (City / bwn, mate, zip code) d a g h sp 21 a. Met o Oct.29,2009 '.tollin~i G.r~aen Cam=_t-pry .Campo Hi 11,P.~ 17011 Ike" ^Remwalh«nSmm " h°"mtl ° "" ^vaa^NC i ca~a: ~M,dmr,m,, i t~ix ~ sPea'N: ' Nre a F Service Licensee (a person acting assort) 22b. Liarea Number 22c. Name aM Atltlress a FedNy t•Y~~ FD-013173 7. ussalma;~ FHS<CSS,324 Hu(~m~l ?wa.,Lzmoyn~,P~ 17043 4r+~1 hams 23ac alN when CmaTM9 23a. To Vie been a my NMNeeg9, death otCUnetl et the line, dale erle P~ smled. (Slgwture arq mk) 23b. Liceroa Number 23c. Dam Sgned (MOnm, deY• year) plgeiden n ml avaimbm m mm a seam ro CeraY reuu «de~m. 24. T a Death p rX . 25. Dam Pmwunced Duo IMamn, eaY, Year) 26. was Case Retuned ro Meeiul Examiner /coroner for a Reason O[her man cremation or Domtion? . ueme 24-28 rnwl m rempmme 0Y Parson ^ October 25, 2009 Vas "° M 8:00 A d m . . ea . wnpprtnamrea CAUSE OF DEATH (See IraWdioru sM examples) r Approzinlate iM«val: Pan II: Erax Omer 28. Dq 7obacm Uae Cgnldbum to Daxh7 ^ Yes ^ Pmbebly Pan I i i d . vu n N"A cause g nem 27. Pan I: EMx me amin a evelle - dusau, injunu, a more -nix 6recdy causetl tM Oeatll.170 NOT enter t«minal eveMS such as cardiac arrest, Onsm ro DuM ba not reueng in ttm Mme ^ No ^ Unknam reepiretory emam, a venMtumr flbdletlOn wmba xwwing ma etiology. Llm only one caws on each line. ANMEOIATE CAUQE 1Feel muese « 29. II Female. aMOOn rosunhW in dexh) _,~ Occlusive Coronary Artery Disease ^ Na PregrMnl wimn peen rex Dw m (« as a axmagwrxx al: ^ PregneM x ems d demh xy lm rerxnbne, a x+r, b. ^ Na pegrwnt, ba pregnaM wmia 4z says o 1erg tlm cause timed on 1me 6. Dw ro (« as a conaequena or): , Enmr ale UNDERLYING CAUSE - of deeM ONeaw a gin.' nix ins"pxad ma ^ Nm pmgna"t, ben pregmM 43 days to 1 year mh) LAST d c . eeulailg In a baron eemn Due m (a as a cansaQUence oQ: d ^ unmtwn n IxaTut warm me yam rear • 30e. Was en Aaepsy 30b. Were Autopsy Rndings 31. Mama a Dum 32e. Date a Inlury (Month, day. Yurl 32D. DesaiOe Fbw mpry Otcunetl 32c. PWre a mWry: Hans, Faun, S1mL Faaay, Omre BuMdinq, enc. (SpeaN) PeAOnred? Availaae Prior m Compmeon NeNm ^ lionnlx'tle a Cux a Deem? J-'l ^ Accident ^ Pendaq Invesegaewl 32e. Time a Ir(ay 32e. Iryury a1 Work? 321. If Trenspamem mNry (SP~~N) 329. L«atbn a injury (Scram. city I town, mate) V ~ ^ u ~ V ^ ~ ^ es ^ Ves ^ No ^ Driver / Operela ^ Pwsen9er ^Petlestnan ^ Suidde ^ COVtl Nabs Dmerminetl M Otlrer - Spe«N: 330. Sgmlae am C 33a. Cenni« (check aaY one) • Cenlyirp p0yeiden (PhYaician wrnfYin9 reuse a deem wh« ammar plrysician has prawaeae dexh antl camplmed Imm 23) ___________________ ^ e(elub moms,u,Med rom ~ Co rove r .._____________ e nw To Um bexamy aaowled9e, umll eeeurre0 tlu a d th 33e. licmim Number 330. Dale Sigred IMCMh, day. year) ea ) • ponameirq erW uAbMY PMxefen IPhvaidan bosh prenoundng deeel aM cmtlrymq ro rouse eM dwroma auulp and mennerr etmtL --'---"--------- ^ erx pleu d.n m etarrteaxm.Ilme d October 26, 2009 • , , ee To me butamy lmoNedpe, Wdieel Examinxl C9NMr On iM peeb a sxelMnetlaa arm / or Nuetipetlan, m my oplttlorx dxm Cecume x to tNrm, rime, arm Plau, and due ro the ovate) erW manner u aMad_. ~ 34. y~~~ peppn WM.CamWad Cawe oLDeelh_(tlem 2~IY7YPe /Pmt Oil d 35. Regisuer's Signxu Dielnct Numb' I >~ I ~ I ~ ~ I ~ I 36. Dam Imo Y, Yeee pp ~o ~j( , Suite 6375 Basehore Roa Mechanicsburg, PA 17050 ~ p Di,pwNion Permit No. V ~ b !D 7 eS w7 _ Estate of Doris L Plamer 21.2009.01036 Living Room Sofa/Love Seat 100 Recliner 35 Coffee Tables - 3 65 Television 75 Lamps 20 Floor Lamp 15 Kitchen Refrigerator 0 Sold/House Tables/4 Chairs 45 Pots/Pans 50 Dishes 50 Dining Room Table/4 Chairs 75 Hutch 45 Master Bedroom Bed 75 Dresser 75 Chest 35 2nd Bedroom Bed 35 Dresser 35 3rd Bedroom Bed 35 Dresser 35 Other Items: Linens 100 Clothing 275 Washer 0 Sold/House Dryer 0 Sold/House Total 1275 ~ ~~ ~~~ ~ ~ O ~P W C~ ~ ro~ ~o ~ x~~ d a .~ ~ ~~'o O~a~ o ~ ~ b t!1 (n C7d ~: ~ o ~~~~ ~~ ~~~~~~c~ ~, ~ ~ ~ ~ o ~o~~ .o ~ ~ c~ n ~ ~ ~~~~ ~ k~ c~ ~ ~ ~ v~ 'd ~ ~ Oro. C a ~ ~o~~a~~ c~ W ~ ~ p,, ~ ~ CD O ,~~ ~~£" ~~c~y ~ ~o ~~ ,pCrNOWN,pO`P~PW~P r~~~CO ~ ~~CflNN~~W NO.POCDO.POC~OWOWCD ~oa~oo~ c~ ~ v cn ~ ~ n ?~~~ ~~~ ~ ~~ ~ ~ ~ ~ ~ ~ 0 a ~, ~CJ~CTiWW`PWWN~ CTr ~ Clo -~ ~l ~ ~ ~ 67 ~, ~ ~ o c ~~o ~~ d©~ oS.S~ro~~ ~C t~ ~~ ~~ ~~ ~ A _ O~j1~~CrCN3tO~]O '0~OO0 C7 N ~ ~ N ~ i i r+ r-+ i r~+ ~ ~ ONC3~Npp,..~~v~l~N~1N Z OWOC3~OC3~000OCJ~OCJt ~J o ~ o~~ o° o o~~~ o c a ~~ ~ ~ as ~ ~ ~ ~~ ~ c~n~ p' ~ ° ~ ~ n ~ ~ ~ ~o ...o ~ ~ A. -~o c~u o ~ n'",G~ CD`~o p c~ _ -~ oa ~~_ ~~~ox~a ~ ~ ~ ~ ~~ ~ ~ ~o ~ ~~ fD '~i' ~ ~ p ~ 'd ~ r* ~ ~ O C rt ~~ ~ ~ ~r~~~ ~o~ ~~~ ~~~ ~ ~ ~ ~~~ o ~ ~ a o d N W N W O N N N r~ ~ OCPOCPO ~~,~~ ~o c ~~ ~'~d~c c ~ do C7~ c C~~~~C ~ ~ ~ ~ ~ ~ n° ~ ~ ~~~ c~ ~~~ ~ ~ i ~ ~' ~* ~ n ~ WNW' 000 W-~-rCO7~N'"'CTC3NC3NCrC~CrWO O U- CT- Cp N C,J W O CJi C3i O ~ O N ~„_, ~,, Cj1 ~, ~ ~ N ~--~ ~ ~' 000 WCJ~C3~OOO~~PCW3~O~O0OO~OCN3lU-00 G7O~tntnU~ ~~~~~~ `~o~~r'c~n~ O O ~P O Cr ~C~~P~-'CflN CaOCnrPCAW 0 K ~~~~ xb~ ~~'~~'© ~, a ~ C7 U. 0 W O C3- C3~ ~ N N N N~ N OCOCrW~I.PW AUG 11,2010 08:11A ~u~t+elm7tmn ~uncral ~orracf I C,s~enta,~ion ~ i~crvice~, ~n~;. Established 1895 Brian C, Musselman, F,O. Supervisor William G. Pegan, FD. P0.8ax 137 324 Hummel Avenue Lemoyne, PA 11043-0137 (717}763-7440 fax: 717-730.9798 www.musselmanfuneral.com 7177309798 page 2 To Funeral Expenses of DORIS L. PALMER Nav.17,2009 Kathryn G. Leib 4517 Florence Ave., .Apt. B ~ [~ Mechanicsburg, PA 17055 2009 October 29 PROF. SEK'VYC1rS,FACILITIES,AUTOS $9,090.00 "Whitmire" Poplar casket 2,075.00 Basic concrete vault 95p.00 $7,115.00 Cash Advance Items: Flowers $169.60 Paid newspaper notice 129.12 Minister's gcatuity 100.00 Conies of death certificate 12.00 1410.77_. TOTAL ..........................................$7,525.72 (Cumberland Co. widow of veteran allowance) 100.00 SUB-TOTAL ......................................$7,425.72 a ~ ¢~ liar ~ ~~ FpR ApppINTMENT PHONE 717-763-7440 __,-,~..,r,, _._....~ _- - .~..~,.~ :.._.__.~,...~..,w .... ~ ~~ 1 PRENEED COUNSELOR SALES RECEIPT _ --'''~ ~EMETER~ C~a~viP~tvY bL4 ivo.t~OG77~8 au 1811 CAftlISlE RDAD v CAMP Hlll~ PA 11811 886911512 YEEa~ AH ND ~ 2376635538 AMEN xxx1021 SALExxxxxx INVOICE 818497 BATCH 888318 TIME: 16:53 ppTE: OCT 26~ 89 AVTH N0: 581433 51345.0@ TOTAL CUSTOMER COPY .. _. _.. ~.. n r ~,~ptETTERY DATE ~ ~- - ~ ~ ~ . ~ oAM ©ul'er uriet ainer Description Manufacturor Provided By ~..~- Memgr7at Deecripticsn- t --- ~..-.kr~. ., :_•d ~ ~ x~--~: ~ - ~ el ion-;,;,,;~ ufacturer Provided . (r - k _~^ v~ Q~^ ~Q~t 1 Vl Q ~ 1~,'', SCn~l0r1. ~ 8n aGtufEr fOY . tip. ~. ~ v REMARKS ..,r ' -..._ t fit. ,~ . ~""!~ interment Fee ~p- ,~~~ ~~~ Overtime Gfiarges ~ Z3fher Ct'targe& ,*'` rota! ,%~ ~2LF ~ _ ~~ Family Verification. ~C ~~'~ ~ ~.~~g,,~ Date TFte u igned hereby ceriNy that they are the next-of-kin of the above named Deceased, or otherwise have the full legal thoriiv tb dived the interment, entombment or t h ith i h h M f h d ma e rema ; arx 6re ry aut mr irxtrnmeo r~ of t e Decease ze t e a~jove-named cemetery to make di of the te inan of tt~e Deceased as Indicated above. Fhe undersigned hereby further certify and represerrt that tf~ey are the owr~r(§1 op autharizec# representativ s) of the owner(s) of the above-described Irrtermerrt Flights and hereby autitorize trse of the said irrtertrserst Rights for the interment, errtom eM or inumment of the remains of the Deceased. Cemetery is hereby authorized to install any outer burial container purchased in connection with this interment. in the interment space described herein. The undersigned hereby agree to indemnity and hold harmless the cemetery, its affiliates, and their respective a~errts, shareholders, oificers, directors and employees from arty and all lasses, costs, or Ii~bUity Inducting reasonable attorney`s fees; it or any of them n-aY sustain in connedton with any misrepresentations, misstatements,. negligence, intentional aCtsor misconduct by t}te undersigned as it relates to the intemtent; entombment`or inurnrnent au~uirized hereunder. The undersigned agree that; at i!s own expense, the cemetery has the right to Correct any error in the interment; entombment; or inumment. 17ris fgmtmrist be?srgned ~y (1) the Prol~nY own ,4N© (2) the closestnext -kin. 9 A n e Sig Date P t N Relationsh' Address ~ ~ City State Zip Telephone Number DATE ~~~~~~~ 1,- l~ Name of Purchaser ~ • ' I - - -'... ° - - O Grt. ~(#'t l ~-- r1 DOLLARS (5 ~ 34S , C,C~I REGULAR PAYMENT ^ CREDIT CARD CHARGE L-~ ` CHECK CARD TYPE ^ FERMENT RIGHTS AND/OR MERCHANDISE AND SERVICES FROM THE ABOVE NAMED CEMETERY. SALES COUNSELOR I l ~ BY NAME i _,,,.,~.-~--~-~~ ~~~..-_ -_~• -rho ~eTP~Me"'a"yoe OMB Approval No. 2502-0265 'i A. Settlement Statement (HUD-1) `!~*`~ ~q~ra °e~Er d! Tvnn of I nnn 1. Q FHA 2.0 RHS 3. Q Conv. Unins. 4. ©VA 5. Q Conv. Ins. 6. File Number: 10-261 7. Loan Number: 1004149462 8. Mortgage Insurance Case Number: 10-10-6-0612037 C. Nate: This form is famished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent ere shown. Items marked "(p.o.c.)"were paid outside the closing; they are shown here for informational purposes and are not included in the totals. D. Name and Address of Borrower: Cole Thomas Taylor and Shannon Margaret Taylor 4006 Gettysburg Road Camp Hill, PA 17011 E. Name and Address of Seller: Estate of Doris L. Palmer 400 Bridge Street, Suite 4 New Cumberland, PA 17070 F. Name and Address of lender: USAA Federal Savings Bank 10750 McDermott Freeway San Antonio, TX 78288 G. Property Location: 4006 Gettysburg Road Camp Hill, PA 17011 Cumberland County, Pennsylvania H. Settlement Agent: 68-0510988 Community Land Transfer, LLC 2331 Market Street Camp Hill, PA 17011 Ph. (717)909-6949 I. Settlement Date: June 11, 2010 Place of Settlement: 2331 Market Street Cam Hill, PA 17011 J. Summary of Borrowers transaction K. Summary of Sellers transaction 100. Gross Amount Due from Borrower: 101. Contrail sales rice 115,000.00 400. Gross Amount Due to Seller: 401. Contrail sales rice 115,000.00 102. Personal roe 402. Personal ro 103. Settlement Cha es to Borrower Line 1400 3,856.85 403. 104. 404. 105. Ad'ustments for llama Id Seller In advance 405. Ad ustments for Items Id b Seller in advance 106. C' flown Taxes to 107. Coun Taxes O6/11/10 to 01/01/11 304.35 406. Ci /Town Taxes to 407. Coun Taxes 06/11/10 to 01/01/11 304.35 108. Assessments 06/11/10 to 07/01/10 55.49 408. Assessments O6/11110 to 07/01/10 55.49 109. Refuse 2nd Otr. 06/11/10 to 07/01/10 110. Sewer 2nd Otr. 06/11/10 to 07/01/10 9.67 11.86 409. Refuse 2nd Qtr. 06/11/10 to 07/01/10 410. Sewer 2nd Otr. 06/11110 to 07/01/10 9.67 11.86 111. 411. 112. 412. 120. Gross Amount Due from Borrower 119,238.22 420. Gross Amount Due to Seller 115,381.37 200. Amounts Pafd b or In BehaH of Borrower 201. osit or earnest mone 202. Prins al amount of new loans 1,000.00 115,000.00 500. Reductions in Amount Due Seller: 501. Excess de osR see instructions 502. Settlement cha es to Seller line 1400 10,047.74 203. Existin loans taken sub'ect to 503. Existin loans taken sub'eil to 204. 205. O ~ ination Fee Credit 350.00 504. Payoff First MoR age 505. Pa off Second Mort a e 206. Lender Crt 10°k tot. -rec. tee 21.58 506. 207. 507. De osit disb. as roceeds 208. 508. 209. Ad ustments for hems un id Seller 509. Ad ustments for llama un ald b Seller 210. C' /Town Taxes to 510. C' /Town Taxes to 211. Coun Taxes to 511. Coun Taxes to 212. Assessments to 512. Assessments to 213. 513. 214. 514. 215. 515. 216. 516. 217. 517. Escrow for Inheritance taxes to Rea er 8 Adier, PC 7,762.50 218. 518. 219. 519. 220. Total Paid Ifor Borrower 116,371.58 520. Total Reduction Amount Due Seller 17,810.24 300. Cash at Settlement fromtto Borrower B00. Cash at settlement to/from Seller 301. Gross amount due from Borrower line 120 119,238.22 601. Gross amount due to Seller line 420 115 381.37 302. Less amount paid b lfar Borrower (line 220) ( 116,371.58) 602. Less reductions due Seller (line 520) ( 17,810.24 303. Cash X^ From To Borrower 2,866.64 603. Cash ~ To ~ From Seller 97,571.13 The undersigned here I ge 1P o leted py of this statement & any attachments referred to herein Borrower ~ Seller Esta f Dor' J le o o ~ / B T i ,Executrix r'S nno M et or TM Pubtlc Reporlelg Baden br dNS collecaen of infanneeon is eeemete0 at 35 milWtes per rosponee for colhaing, reviewing, entl roportmg Ina tlei9. Th18 agenry may not collect Uua infortnetion, end you ero not roquired to cortpbte dsa form. uNess it displays a artanUy valid OMB control number No conhtlentislity is assured: Chia discbsure is mandatory. This i9 designed to provide the peniee to a RESPA coveretl transaction with information Wang trb aetllement Process Page 1 of 3 HUD-1 (TAYLOR. COLE.SHANNON.PFD/10-261 /29) L. Settlement Charges 700. Total Real Estate Broker Fees 7,100.00 PaiA From PaIC From Division of commission (line 700) as follows: Borrowers sallera 701. 7 100.00 to THE HOMESTEAD GROUP INC. FwWa at F~m1a at 702. to THE HOMESTEAD GROUP INC. settlement Setaement 703. Commission aid ai settlement 7 700.00 704. Bu er Commission to The Homestead Grou Inc. 295.00 705. 800. Items Pa able in Connection with Loan 801. Our on ination char a Includes Ori inafion Point °h or $ 685.00 $ 685.00 from GFE #1 - ° • +' >~~ 802. Your credit or charge (points) for the specific interest rate chosen $ -1,581.25 (from GFE #2) c' ~ , '?' - . 803. Your adjusted origination charges from GFE #A ro " -89625 804. A raisal fee to Freeman Real Estate from GFE #3 375.00 805. Credit Re ort to CSC from GFE #3 14.00 - 806. Tax service to (from GFE #3) 807. Flood certification to First American Flood Data Services (from GFE #3) 5.25 808. Origination Charge is m. made up of USAA Processing Fee of $685.0 (from GFE #3) .> .` 809. (from GFE #3) ~ g10_ (from GFE #3) . 811. (from GFE #3) 900. Items Re aired b Lender to Be Paid in Advance 901. Daily interest charges from O6/11/10 to 07/01/10 20 ~ $16.770800/day (from GFE #10) 335.42 , ~'-'c.,: ' 902. Mort a e insurance remium for months to from GFE #3 903. Homeowner's insurance for 1.0 ears to Travelers Home Ins. from GFE #11 POC:B387.00 a ; a. , ~; t.+~' 904. from GFE #11 _- 905. (from GFE #11) 1000. Reserves De fled with Lender 1001. InRial deposit for your escrow account (from GFE #9) 1,174.68 1 omeouvne s tnsurance mon s per mon 1003. Mort a e insurance months $ er month $ 1004. Property taxes $ •• >' r County Taxes months @ $ per month Assessments months $ r month 1005. $ 1006. Counry/Twp Taxes 5.000 months @ $ 45.38 per month $ 226.90 1007. School Taxes 13.000 months ~ $ 84.39 per month $ 1,097.07 1008. $ 1009. Aggrogate Adjustment $ -246.04 1100. Title Char es 1101. Title services and lender's title insurance from ) 1,243.75 5.00 1102. Settlement or ctosin fee $ 1103. Owner's title insurance to COMMUNITY LAND TRANSFER INSURANCE ACCT. from GFE #5 1104. Lenders tRie insurance to COMMUNITY LAND TRANSFER INSURANCE ACCT. $ 933.75 1105. Lenders title oli limit $ 115 000.00 'T 1106. Owners title oli limit 3 115,000.00 1107. A ant's artion of the total title insurance remium to Communi Land Transfer LLC $ 821.7 1108. Underwriters ortion of the total title insurance remium to COMMUNITY LAND TRANSFER INSUR $ 112.05 1109. 1110. 1111. 1112. 1113. 1200. Govemment Recording and Transfer Charges 1201. Govemment rocordin cha es to Recorder of Deeds Office from GFE #7 160.00 r~r,' 1202. Deed $ 62.00 Mortgage $ 98.00 Releases $ Other $ 1203. Transfer taxes to Recorder oT Deeds Office (from GFE #8) 1,150.00 1204. City/Countytax/stamps $ 1,150.00 $ 1205. State tax/stam s $ $ 1,150.00 1206. 1207. 1300. Additional Settlement Char es 1301. R aired services that ou can sho for from GFE #& 1302. 2010 Coun R .Taxes to Bonnie K. Miller Tax Collector 544.54 1303. Insect Troatment to Bowers Pest Control 821.50 1304. Sewer Fee to Lower Allen Townshi Auihorit 426.70 1305. 1400. Total Settlement Cha es enter on Hoes 103, Section J and 502 Section K 3 856.85 10047.74 By agnlrq page 1 a ova statement ma agnatonea atxnownsoge raw~pt m a c°mprete° mpy m page ~ or mis nao papa aoasmem. 'I f _ ~ Community Land Transfer, LL ettlement Agent CeR~ed to be a true copy. ~ Page 2 of 3 HUD-1 (TAYLOR.COLE.SHANNON.PF0/10-261129) ~ Comparison of Good Faith Estimate (GFE) and HUD-1 Charges Good Faith Estimate HUD-1 Char es That Cannot Increase HUD-1 Line Number Our origination charge # 801 685.00 685.00 Your credit or charge (points) for the specific interest rate chosen # 802 -1,581.25 -1,581.25 Your adjusted origination charges # 803 -896.25 -896.25 Transfer taxes #1203 2,300.00 1,150.00 Char es That in Total Cannot Increase More than 10 % Good Faith Estimate HUD-1 Government rewrding charges #1201 90.00 160.00 Appraisal fee # 804 375.00 375.00 Credit report # 805 14.00 14.00 Flood ceAification # 807 5.25 5.25 Total 484.25 554.25 Increase between GFE and HUD-1 Charges $ 70.00 or 14.46 Charges That Can Change Good Faith Estimate HUD-1 Initial deposit for your escrow account #1001 1,662.04 1,174.68 Daily interest charges # 901 $ 16.770800/day 402.50 335.42 Homeowners insurance # 903 216.20 387.00 Title services and lender's tkle insurance #1101 225.00 1,243.75 Owners title insurance to COMMUNITY IAND TRANSFER INSU #1103 903.75 oan Terms Your intial loan amount is $ 115,000.00 Your loan term Is 30 years Your initial interest me is 5.2500 Your initial monthly amount owed for principal, Interest and $ 635.03 includes any mortgage insurance is Q Principal ^X Interest ^ MoRgage Insurance Can your inteest rate rise? ^X No ^ Yes, it can rise to a maximum of °h. The first change will be on and can change again every _ months after Every change date, your interest rate can increase or decrease by %. Over the life of the loan, your interest rate is guaranteed to never be lower than % or higher than %. Even k you make payments on Ume, can your loan balance rise? ^X No ^ Yes, it can rise to a maximum of $ Even k you make payments on Ume, can your monthy ^X No ^ Yes, the first increase can be on and the monthly amount owed for principal, Interest, and mortgage insurance rise? amount owed can rise to $ The maximum it can ever rise to is $ Doea your loan have a prepayment penalty? ^X No ^ Yes, your maximum prepayment penalty is $ Does your loan have a balloon payment? ^X No ^ Yes, you have a balloon payment of $ due in _ years on Total monthly amount owed including escrow account payments ^ You do not have a monthly escrow payment for items, such as property taxes and homeowners insurance. You must pay these items directly yourself. ^X You have an addkional monthly escrow payment of $162.02 that results in a total initial monthly amount owed of $797.05. This includes principal, interest, any mortgage insurance and any items checked below: ^X Property taxes ^X Homeowners insurance ^ Flood insurance ^ ^X School Taxes ^ Note: If you have any questions about the Settlement Charges and Loan Terms listed on this form, please contact your lender. Page 3 of 3 HUD-1 (TAYLOR.COLE.SHANNON.PFD/10-261 /29) HUD-1 Addendum Borrower(s): Cole Thomas Taylor and Shannon Margaret Taylor 4006 Gettysburg Road Camp Hill, PA 17011 Lender: USAA Federal Savings Bank Settlement Agent: Community Land Transfer, LLC (717)909-6949 Place of SetGement: 2331 Market Street Camp Hill, PA 17011 Settlement Date: June 11, 2010 Property Location: 4006 Gettysburg Road Camp Hill, PA 17011 Cumberland County, Pennsylvania Seller(s): Estate of Doris L. Palmer 400 Bridge Street, Suite 4 New Cumberland, PA 17070 Additional Adjustments For Items Paid By Seller In Advance (Borrower Debit) Description Amount FromlThrough Prorated Amount Refuse 2nd Qtr. 44.00 04/01/10 through 06/30/10 9.67 Total Line 1091409 9.67 Sewer 2nd Qtr. 53.95 04/01/10 through 06/30/10 11.86 Total Line 110/410 11.86 Additional Disbursements from Broker's Commissions Listing Selling Other Payee/Description Note/Ref No Broker Broker Broker Total THE HOMESTEAD GROUP, INC. THE HOMESTEAD GROUP, INC. $ 7,100.00 The following persons, firms or corporations received a portion of the real estate commission amount shown above: Bowers Pest Control 25.00 Total $ 25.00 Adjusted Origination Charge Details Origination Charge USAA Processing Fee to USAA Federal Savings Bank Origination CrediUCharge (points) for the specific interest rate chosen CrediUCharge to USAA Federal Savings Bank 25.00 0.00 0.00 $25.00 685.00 Total $ 685.00 -1, 581.25 Total $ -1,581.25 Adjusted Origination Charges $ -896.25 WARNING: k is a crime to knowingly make false statements to the United States on this or any similar form. Penalties upon conviction can Include a fine and imprisonment For details sae: Title 18 U.S. Code Section 1001 and Sectfon 1010. (TAYLOR.COLE.SHANNON. PFD/10-261 /29) HUD-1 Addendum - Continued Reserves Deposited with Lender Homeowner's Insurance 96.75 3.000 at 32.25 per month 90 226 Countyliwp Taxes . 5.000 at 45.38 per month 097.07 1 School Taxes , 13.000 at 84.39 per month Aggregate Adjustment -246.04 month Total 1,174.68 Title Services and Lender's Title Insurance Details BORROWER SELLER Closing Service Letter Community Land Transfer, LLC Electronic Doc. Preparation Community Land Transfer, LLC Wire Fee Community Land Transfer, LLC Notary Fee Community Land Transfer, LLC Overnight Fees Community Land Transfer, LLC Endorsements 100, 300, 8.1 Community Land Transfer, LLC Total 75.00 50.00 10.00 10.00 5.00 15.00 150.00 $ 310.00 $ 5.00 Owner's Title Insurance BORROWER SELLER Owner's Policy Premium 933.75 to COMMUNITY LAND TRANSFER INSURANCE ACCT. Total $ $ Lender's Title Insurance BORROWER SELLER Lenders Policy Premium to COMMUNITY LAND TRANSFER INSURANCE ACCT. Total 933.75 $ 933.75 $ WARNING: It is a crime to knowingly make false statements to the United States on this or any similar form. Penalties upon conviction can include a floe and imprisonment. For details see: Title 18 U.S. Code Section 1001 and Section 1010. (TAYLOR.COLE.SHANNON.PFD/10-261 /29)