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HomeMy WebLinkAbout10-27-10 (2)J 1505607121 REV-1500 Ex (Dt;_D5, PA Department of Revenue Bureau of Individual Taxes County Code Year File Number POBOx28oso1 INHERITANCE TAX RETURN Harrisbu PA 17128-0601 RESIDENT DECEDENT 2 1 1 0 0 2 1 8 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 9 2 1 4 5 4 2 7 0 2 0 4 2 0 1 0 0 9 2 5 1 9 2 5 Decedent's Last Name Suffix Decedent's First Name MI M O N G H E L E N E (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 Retum ~ 2. Supplemental Retum [~ 3. Remainder Retum (date of death 4. Limited Estate ~ prior to 12-13-82) 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Retum Re uired d th © 6. Decedent Died Testate A q ea after 12-12-82) ~ 7. Decedent Maintained a Livin Trust g Q ( ttach Copy of WII) 9 Liti ati P 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust) . g on roceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec 9113 betw A 12 . ( ) een -31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED ALL Name . CORRESPONDENCE AND CONFIDENTUIL TAX INFORMATION SHOULD BE DIRECTED TO: D A V I D H Daytime Telephone Number R A D Firm Name (If Applicable) C L I F F E S Q 7 1 7 2 3 6 9 3 1 8 R A D C L I F F L A W O F F I C E P REGISTER OF WILLS USE ONLY first line of address C r•.a n o 1 0 1 1 M O M M A R O A D ~%u=~ ~~ Second line of address c', ~ n -~-i .7~r ~ -- S U I T E 2 0 1 xt. ~~ ~ '-' ~-- City or Post Office State ZIP Code LSD ~ L E M O Y N E _ ~-~ -- ~ =- ~~ P A 1 7 0 4 3 ~-I •• ;~~ ~ , o --, Correspondent's e-mail address: DHRAp~ w IX.NETCOM COM Under penal8es of perjury, I dedare that I have examined this return, induding accompanying schedules and statements, and to the treat of m kn it is true, oared and complete. Dedaration of preparer other than the personal representative is based Y owledge and belief ll i f , on a n ormation of which NATO OF PERSOORESP SIBLE FOR FILING RETURN preparer has any Imowledge. DATE ADDRESS /~ .rg` 70~a 5203 BRIGHTON LANE ENOLA SI RE OF PR ER E ~ NTATNE P A 17 0 2 5 L,L~[ L. ADDRESS DATE ~D 1 S ~,~ 1011 MOMMA RD ST 01 LEMOYNE PLEASE USE ORIGINAL FORM ONLY P A 17 0 4 3 L 1505607121 Side 1 1505607121 J J 1505607221 REV-1500 EX Decedent's Social Security Number Decederk's Narne: HELEN E• M O N G 1 9 2 1 4 5 4 2 7 RECAPITULATION 1. Real estate (Schedule A) ...................................... .. 1. 1 0 2 5 0 0, 0 0 2. Stocks and Bonds (Schedule B) ................................ .. 2. 5 7 ? 6 1 , 8 ? 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages 8 Notes Receivable (Schedule D) ...................... .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ,..... .. 5. 7 7 2 4 , 7 0 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. 5 9 3 , 5 7 7. Inter-Vivos Transfers 8~ Miscellaneous N n-Probate Property (Schedule G) ~ Separate Billing Requested ..... .. 7. 1 4 8 9 6 4, 9 8 8. Total Gross Assets (total Lines 1-7) ......................... .. 8. 3 1 7 5 4 5, 1 2 9. Funeral Expenses & Administrative Costs (Schedule H) .............. .. 9. 1 D 5 4 6 , 1 3 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .......... .. 10. 2 D 2 D . ? 7 11. Total Deductions (total Lines 9 & 10) ......................... .. 11. 1 2 5 6 6 , 9 D 12. Net Value of Estate (Line 8 minus Line 11) ....................... .. 12. 3 D 4 9 7 8 , 2 2 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................ .. 13. 2 5 D 0 0 . 0 0 14. Net Value Subject to Tax (Line 12 minus Line 13) .............. . . . . 14 2 7 9 9 7 8 , 2 2 TAX COMPUTATION - 3EE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2)x.00 0. 0 D 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate x .oa5 2 7 9 9 7 8. 2 2 1s. 1 2 5 9 9. 0 2 17. Amount of Line 14 taxable at sibling rate X .12 D. D D 17, 0. D D 18. Amount of Line 14 taxable at collateral rate X .15 D D D 18. D. D D 19. Tax Due ................................................ 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1 2 5 9 9. 0 2 Side 2 L 1505607221 1505607221 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 10 0218 DECEDENTS NAME HELEN E. MONG STREET ADDRESS 298 SAMPLES BRIDGE ROAD CITY MECHANICSBURG STATE Zip PA 17050 Tax Payments and Credits: 1 • Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments 11,000.00 C. Disr~unt 578.93 Total Credits (A + B + C ) 3. Interest/Penalty 'if applicable D. Interest E. Penalty Total Interest/Penalty (D + E ) 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. A. Enter the interest on the tax due. (1) 12,599.02 (2) 11,578.93 (3) 0.00 (4) 0.00 (5) 1,020.09 (5A) B. Enter the total of Line 5 +SA. This is the BALANCE DUE. (56) 1,020.09 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. Did decedent own an "in trust for" or payable 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 benefiaary designation? ............................................................................................. ..... ® ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE R 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 ff the surviving spouse is the only benefiaary. For dates of death on or after July 1,2000: The tax rate imposed on the net v~ue of transfers from a deceased child twenty-0ne 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 p2 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-1502 EX + (e-gg) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT t,lAlt Vh FILE NUMBER HELEN E. MONG 21 10 0218 All real property owned soby or ~ a Lenard in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seNer, neitller being oompelbd to buy or sell, both having reasonable knowledge of the relevant fads. Real whk:h is ' i -owned with ht of survivorshi must be disclosed on Schedub F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. RESIDENCE AT 298 SAMPLE BRIDGE ROAD, MECHANICSBURG, PA 17050 102,500.00 PIN 38-14-0847-020 TOTAL (Also enter on line 1 Recapitulation) ~ s 102,500.00 (If more space is needed, insert additional sheets of the same size) a/z9rz01o z:zz:o5 PM lament Statement U.S. Department of Housing OMB Approval No. 2502-0265 and Urban Development B. Type of Loan 1.^ FHA 2.Q FmHA 3.0 Conv. Unins. 6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number: 4.^ VA 5.0 Conv. Ins. ^ Other 20100348 C. Note: This form is famished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are sho " " wn. Items marketl (POC) were paid outside the closing by either the: Borrower (POCB), Lender (POCL), Mortgage Broker (POCM) O h , t er (POGO), Real Estate Agent (POCR), or Seller (POCS); they are shown here for informational ur o p p ses and are not included in the totals. D. Name 8 Address David Schweitzer, 15 Natures Crossing, Enola, PA 17025 of Borrower: Jennifer D. Schweitzer, 15 Natures Crossing, Enola, PA 17025 E. Name & Address The Estate of Helen Mong, deceased, 5203 Brighton lane, Enola, PA 17025 of Seller: F. Name & Address of Lender: G. Property Location: Property Address 298 Sample Bridge Rd. Mechanicsburg, Pennsylvania 17050 PIN 38-14-0847-020 H. Settlement Agent: James A. Miller, Esq., 1-Great Road Settlement Services, LLC, 765 Poplar Church Road, Camp Hill, PA 17011, (717)731-1040 Place of Settlement: 765. Poplar Church Road, Camp Hill, PA 17011 I. Settlement Date: 4/18/2010 Proration Date: 4/16/2010 Dtsbureement Date: 4/16/2010 Ff.~$??~Sui~rrt " ~ . 4 y~u £~I~~lf, • yF~i§ ~ zH:a_~SG'mma ry~of~elj9r'sTrarlsa tl 100 ~JG r`de ~~~• 4 .~.~ ii>{(~t'~ .y i. ,, f ~~~~~~ c on f; /_:~ 1 i ~ ~: ,- '- 400 ~.{ °~ ~N~,211 't0}Sellei'~a .;,` 101. Contract sales price $102,500.00 401. Contract sales price 102. Personal property $102,500.00 402. Personal property 103. Settlement charges to borrower (line 1400) $2,499.75 403. 104. 404. 105. 405 AdJt~hnenti.locJteiris'Ppldby"~Ife~dn'advaFcega.. ~ ; *:: d '. t 7 F. .+S F ~ . Ad~uat a 'ts;fop tams= Paled byneelfeT`~1rl.ietlvante ; I ~ ~ ?t - 106. Cityftown texe8 . . + - ; .. . 406. City/town taxes 107. County taxes 4/1 612 0 1 0 to 1/1/2011 $223.49 407. County taxes 4/16!2010 to 1/1!2011 108. Assessments $223.49 408. Assessments 109. School Real Estate Tax 4!16/2010 to 7/1/2010 $167.11 409. School Real Estate Tax 4/16/2010 to 7/1/2010 110. 410. $167.11 111. 411. 112. 412. 120. Gross Amount Due from Borrower $105.390.35 ~ 420. Gross Amount Due to Seller 200:1 ?Amo nh•, - '~ - ~1 ..P4 o~~r~$pfde(f~f•8pf7pwer~, ?l, ~, , r ;-p;~,- $102,890.60 500.1 ~.. buctloneRn`A oun'tLue tO Seller 201. Deposit or earnest money $2 500.00 501. Excess deposit (see instructions) 202. Principal emountof new loan(s) 502. Settlement charges to seller (line 1400) 203. Existing loan(s) taken subject to $2.671.25 503. Existing loan(s) taken subject to 204. 205. 504. Payoff of first mortgage loan 206. 505. Payoff of second mortgage loan 506. 207. 507. 208. 508. 209. Adjtmtmen4 fe~R~~r1`s,u~psldby,ieller.=' 7: _ - ',~~ 509. Adj uelmer~fa for Items unpattk~5y;peYler- 210. City/town taxes 510. City/town taxes 211. County taxes 511. County taxes 212. Assessments 512. Assessments 213. 513. 214. 215. 514. 216. 515. 516. 217 517. 218. 518. 219 519. 220. Total Paid byHor Bonower $2,500.00 , .... 520. Total Reduction Amount Due Setler ~ . 0': dS~fdYVlP~j i _' - .: .: t i . x ~.l~.; } . _ ,;: r~ 1 52,671.25 600'..Cis ' eY$ettlemerit foJfrotn Seller ~ - 301. Gross amount due from lwnower (line 120) $105,390.35 3 601. Gross amount tlue to seller (line 420 ) 02. Less amounts paid by/for borrower (line 220) ($2,500.00) 3 $102,890.60 602. Less reductions in amount due seller (line 520) 03. Cash ®From OToBOrrower $102,890.35 ($2,671.25) 603. Cash ®ToOFromSeller $100,219.35 "7~/' ~. _ ~ 4/29/2010 2:22:05 PM File Number: 20100348 :' ertt"C1~er~ea;~.~z~;,:s- a~~~=~=:• :~ ti r si-', ,..~?.s,. - i' d ,oca+ aaresioroxers commission Dase0 on puce $702,500.00 @ 1.000000% _ $1,025.uu Paid From Paid From Division of commission (line 700) as follows: Borrower's Seller's Jt. $1,025.00 to Straub 8 Associates Real Estate Group,lnc. Funds at Funds at 702. 703. Commission paid at settlement $1,025.00 704 Settlement Settlement $1,025.00 705. Broker Fee to Straub & Associates Real Estate Group, Inc. $295 00 706. Broker Fee to Straub 8 Associates Real Estate Group, Ins $295 00 . . .. ,.. , 800i;Jtemf P,eylble;i~ Connep{fon!withCoari ~"~-"r ~~ ; -.+ ~' :., _ 9 i ... r; ; .. .. 801. Loan origination fee 802. Loan discount 803. Appraisal fee 804. Credit report 805. Lender's inspection fee 806. Mortgage insurance application fee 807. Assumption fee 808. 809. 810. Bt 1. 812. 813. A00: ~ltem~'FaquireC ty Lep~lei~to Be Pald irk-A`UVa[rCe;' - +.:1 ~ j„, got. Interest from 902. Mortgage insurance premium for 903. Hazard insurance premium for 904. 905. tOtl0,!Resetves'Deposlted,'(tti 1~'nder 1001. Hazard insurance 1002. Mortgage insurence 1003. City property taxes 1004. County property taxes 1005. Annual assessments 1006. 1007. 1008. 1009. ~ 110Q:;TttIe Clisrgoe'+i; ,~^~~- z ,. ~ 1101. Settlement or closing fee ' 1102. Abstract or title search 1103. Title examination 1104. Title insurance binder 1105. Document preparation to Great Road Settlement Services, LLC $250.00 1106. Notary fees to Cash t 107. Attorney's fees to $2.50 $2.50 Includes above item numbers: 1108. Title Insurance to Great Road ettlement Services. LLC $873.75 Includes above item numbers: 7109. Lenders coverage 1110. Owner's coverage - $105.000.00 $873.75 1111. Tex Certification to Great Road Settlement Services, LLC 1112 $10.00 1113. 1200:GoYern~`6y~R~'dording~and_TransterGt~argoa`{'; ~ - 1201. Recording fees: Deed $53.50 $53.50 1202. Citylcounty tax/stamps: Deed $1,025.00 7203. State tax/stamps: Deed $1,025.00 1204. $1,025.00 1,025.00 1205. 1206. ~ . .. .. 1300jA-. (lone LSe erpent Charges y~;is.,. ,~~,,. rr. ~". _ ~';,~ - . - 1301. Survey - I 1302. Pest inspection 1303. 2010 County/TOwnship Tax to Debra Basehore Wiest, Tax Collector 1304. 2009-10 School Tax on 7/7/2009 to Debre Basehore Wiest, Tax Collector POCS $802.5 $313.75 1305. 1306. 1307. 1400. Total Settlement ChargeE (enter on Ilnes 103, Saetlon J and 50T, Saetlon K) 52,499.75 $2,871.25 ~t V 4/29/2010 2:22:05 PM File Number: 20100348 .PION: I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, it is a true and accurate statement of all receipts antl ments made on my account or by me in this lasnsaction. I further certify that I have received a copy of HUD-1 Settlement Statement. The Settlement Agent does not rt or represent the accurecy of information provided by third parties, including information wnceming POC items antl information supplied by the lender in this transaction ,caring on the HUD-1 pertaining to "Comparison of Good Faith Estimate (GFE) and HUD-1 Charges' and "Loan Terms', and the parties hold harmless the Settlement Agent ~s to any inacc ies of such matters. Oavitl Schweitzer The Estate of He Q Mong, decea ed Jennifer D. Sweitzer To the List of my knowledge, the HUD-1 Settlement Statement which 1 have prepared is a true and accurate account of the funds which were received and have been or will be disbursed by the undarsigrpd as part of the settlement of this transaction. ~1 i~. s~~l ~r0 James A. Miller, Es . Date r WARNING: a cri(J1a to knowingly make false statements to the United States on this or any other similar forth. Pen ties upon conviction can include a fne and imprisonm t. For ~ gils see: Title 1e: U.S. Code Section 1001 and Section t010. REV-1503 EX + (8-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS ~ BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER HELEN E. MONG 21 10 0218 All property jointly-owned with right of survivorship must be d'aclosed on Schedub F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 29 SH PRUDENTIAL FINANCIAL ~ $49.14 1,425.06 2. 977.9870 SH BLACKROCK GLOBAL ALLOCATION FUND C ~ $16.21 15,853.17 3. 1264.4670 SH AMERICAN BOND FD AMERICA CL C @$11.97 15,135.67 4. 278.6680 SH AMERICAN CAP IN CBLDR FD CL A x$46.00 12,818.73 5. 402.9990 SH AMERICAN FUNDAMENTAL INVESTORS CL A x$31.09 12,529.24 TOTAL (Also enter on line 2, Recapitulation) I s 57 761 87 (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 RESIDENT DECEDEN RN PERSONAL PROPERTY ESTATE OF FILE NUMBER HELEN E. MONG 21 10 0218 Indude the prooseds of litigation and fhe date the proceeds were received by the estate. All property jointly-owned with right of survivorship moat be diadosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ML BANK DEPOSIT PROGRAM 103.77 2. CMA MONEY FUND 477.00 3. REFUND -BENT CREEK 2,453.70 4. PNC BANK, NA ACCT#5005299526 638.30 5. 2009 FEDERAL INCOME TAX REFUND 3,592.00 6. FARMERS INS CO -REFUND PREMIUM 459.93 TOTAL (Also enter on line 5, Recapitulation) ~ S 7 724 (If more space is needed, insert additional sheets of the same size) REV-1509 EX + (8-98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN ESTATE OF NUMBER HELEN E. MONG 21 10 0218 Nan asset was made joint within one year of the decedents date of death, k must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME A. CAROLYN A BRUAW 5203 BRIGHTON LANE ENOLA, PA 17025 C JOINTLY-0WNED PROPERTY: ADDRESS TO DECEDENT DAUGHTER ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENTS INTERESI 1. A. 4/30/07 PNC BANK, NA ACCT #5000089896 1,187.14 50. 593.57 TOTAL (Also enter on line 6, Recapitulation) I S 593.57 (If more space is needed, insert additional sheets of the same size) REV-1510 EX + (g-ga) COMMONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN ESTATE OF SCHEDULE G INTER-VIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY FILE HELEN E. MONG 21 10 0218 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. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE TIENMEOFTHE7RANSFERff,Tl~IRRELATIDNSFNPTODECEDENiAND TNEDA7EOF7MNSFEft. ATTACHACDPYOFiNEDEEDFDRREALE5TA7E. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST EXCLUSION QFAPPUCABLE) TAXABLE VALUE 1. ALLSTATE ANNUITY #GA0679067 62,064.57 100. 0.00 62,064.57 2. AXA EQUITABLE ACCUMULATER CONTRACT 86,900.41 100. 0.00 86,900.41 #303743774 TOTAL (Also enter on line 7 Recapitulation) I S 148 964.98 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES Sr INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER HELEN E. MONG 21 10 0218 Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. AVER CREMATION SERVICES 51.70 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Street Address Ciry State Zip Year(s) Commission Paid: 2, AttomeyFees RADCLIFF LAW OFFICE, P.C. 8,925.00 3. Family Exemptan: (If decedent's address is not the same as daimant's, attach explanation) Claimant Street Address Ciry State Zip Relationship of Claimant to Decedent 4. Probate Fees 324.50 5 Accountant's Fees PARK FINANCIAL SERVICES 364.00 6. Tax Retum Preparers fees 7. FILING FEES 30.00 8. ANNUAL FEE -ESTATE ACCOUNT 125.00 10. DAVID SCHWEITZER 162.93 11. CUMBERLAND COUNTY CORONER 25.00 12. JUNK REMOVAL 538.00 TOTAL (Also enter on line 9, Recapitulation) S 10.546.13 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, ~ LIENS ESTATE OF FILE NUMBER HELEN E. MONG 21 10 0218 Report debts incurred by ~e decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ALERT PHARMACY 41.54 2. PENN WASTE 44.35 3. PPL 113.90 4. ROSA LUCIDON 1,150.00 5. FARMERS NEW CENTURY INSURANCE - O/S CHECK #2526 580.72 6. COUNTY/TOWNSHIP REAL ESTATE TAXES 90.26 TOTAL (Also enter on line 10, Recapitulation) I S 2,020.77 (If more space is needed, insert additional sheets of the same sae) REV-1513 EX + (9-00) SCHEDULE) COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT NGI Gti G rwntir_ ~~ ~n n~~c 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 pndude out~M spousal distribu6ans, and transfers under 9116 S 1 2 ec. a . 1. CAROLYN A BRUAW Lineal 279,978.22 5203 BRIGHTON LANE ENOLA, PA 17025 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. YOE FIRE COMPANY 10,000.00 36 EAST GEORGE STREET YORK, PA 17313-1202 2. THE SALVATION ARMY 15,000.00 50 EAST KING STREET YORK, PA 17401 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET S 25 000.00 (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMENT KNOW ALL MEN BY THESE PRESENTS, that I, HELEN E. MONG currently residing in CUMBERLAND County, Commonwealth of Pennsylvania, being in good health and of sound and disposing memory do hereby make, declare and publish this as my Last Will and Testament, hereby revoking all former Wills and Codicils heretofore made by me. FIRST: I direct that all of my debts not barred by the statute of limitations, expenses of my last illness, funeral expenses, costs of administration and claims allowed in the administration of my estate shall be paid by my Executor hereinafter named, from my estate as soon after my decease as shall be found convenient. SECOND: I make the following gifts: a.) I give and bequeath my household and personal effects and other tangible personal property (not including cash or securities), together with any existing insurance thereon, to my daughter CAROLYN A. BRUAW; and b.) I give and bequeath, in memory of Helen E. Fager Mong and my grandfather, C.A. Miller: 1.) The sum of Fifteen Thousand ($15,000.00) Dollars to the Building Fund of the Salvation Army of York, Pennsylvania; and 2.) The sum of Ten Thousand ($10,000.00) Dollars to the Fire Company serving Yoe, Pennsylvania. THIRD: I give, devise and bequeath the rest, residue and remainder of my estate, whether real, personal or mixed, and of any nature whatsoever and wherever situate, to my daughter CAROLYN A. BRUAW. FOURTH: I hereby nominate, constitute, and appoint CAROLYN BRUAW and LORI PHILLIPS, as Co-Executor of this, my Last Will and Testament. My Executors shall not be required to post bond regardless of state of residence. All references to the Executor herein shall be applicable to any substitute Executor. ~~ ~" ?~ FIFTH: My Executor shall have, in addition to the powers and authority conferred upon my Executor by law, the following additional powers and authority: To sell at public or private sale, exchange, transfer, partition, give options upon, repair, lease, mortgage, pledge or otherwise dispose of any property, real or personal, at any time constituting a portion of my estate, and upon such terms and conditions as the Executor shall deem wise. 2. To invest and reinvest any money at any time in such bonds, stocks, notes, real estate, mortgages, life insurance, annuities or other securities, or such property, real or personal, as the Executor shall deem wise, without being limited by any statutes or rule of law regarding investments by the Executor. 3. To retain, without incurring any liability, as investments, any property owned by me at the time of my death, as long as my Executor may deem it wise, and even though such property is not the kind of property an Executor would purchase as an investment; and even though to retain such property might violate sound diversification principles. 4. To cause any security or other property which may constitute a portion of my estate to be issued, held or registered in the Executor's own name, or in the name of a nominee, or in such form that title will pass by delivery. 5. To consent to the reorganization, consolidation, readjustment of the financial structure, or sale of the assets of any corporation or other organization, the securities of which constitute a portion of my estate, and to take any action with reference to such securities which, in the opinion of the Executor is necessary to obtain the benefit of any such reorganization, consolidation, readjustment or sale; to exercise any conversion privilege or subscription right given to my Executor as owner of any securities constituting a portion of my estate resulting from any reorganization, consolidation, readjustment, sale, conversion or subscription. 6. To pay all costs, taxes, charges and expenses in connection with the .administration of my estate, including such compensation to the Executor which shall be in accordance with established fees throughout the period of administration of my estate. 7. To determine what is "income" and what is "principal" hereunder, and my Executor's decision thereon shall be final; and to purchase securities at a premium or discount, ,~~~~ 2 and to apply or charge said premium or discount against income or principal as the Executor may determine. 8. The Executor may make payments to or on behalf of any person who is the beneficiary hereunder but in no event, however, shall payments be made to any creditor or other such person because of anticipation of payment by the beneficiary, and any such claim made by way of anticipation by the beneficiary shall be of no validity or legal effect. 9. To borrow money from any person, firm or corporation, including any corporation acting as an Executor hereunder, for the purpose of protecting and preserving or improving my estate hereunder; to execute promissory notes or other obligations for amounts so borrowed. 10. To employ legal counsel, accountants, brokers, investment advisors, custodians, managers and other agents and employees and to pay reasonable compensation out of my estate or any funds held hereunder to which said compensation is attributable. 11. To carry on any business owned or controlled by me at my death for whatever period of time my Executor shall think proper, and my Executor shall have the power to do any and all things my Executor deems necessary or appropriate, including the power to close out, liquidate or sell the business at such time and upon such terms as my Executor shall deem best. 12. To make any division, distribution or partition of the estate or trust property in cash or in kind, pro rata or non-pro rata 13. To compromise controversies. 14. To do all other acts in my Executor's judgment necessary or desirable for the proper and advantageous management, investment and distribution of my estate. SIXTH: I direct that all transfer and inheritance taxes, state or federal, assessed because of my death, whether the funds, property or insurance proceeds to which such taxes are attributable pass under this Will or not, shall be paid out of my residuary estate; that my Executor pay, or provide for payment of all such taxes at such time, or times, and in such manner as my Executor deems best. 1 IN WITNESS WHEREOF, I, HELEN E. MONG, the Testator to this, my Last Will and Testament, typewritten on four sheets of paper which I have identified at the bottom of each page by my initials, hereunto set my hand and seal the ~ day of ~-v~ 2008. HELEN E. MONG The preceding instrument consisting of this and three other typewritten pages, each identified by the initials of the Testator, HELEN E. MONG, this day and date thereof signed, published and declared by HELEN E. MONG, the Testator therein named, as and for her Last Will, in the presence of us who, at her request, in her presence, and in the presence of each other have subscribed our names as witnesses. i ~,, f!~~ COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS I, HELEN E. MONG, Testator, 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; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. HELEN E. MONG Sworn or affirmed t//o'' and acknowledged before me by HELEN E. MONG, Testator, the ~'~ day of .r~/-',L/11.1~/ , 2008. (SEAL) ®®® NOTARIAL SEAL DAVID H RADCLIFF Notary Public LEMOYNE BOROUGH, CUMBERLAND COUNTY My Commission Expires Jun 29, 2008 ~~_ Notary Public COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF~CUMBERLAND J ~ r 7~ S'~r`r" and ~~~, `i ~ ~ ~ ~E< ~~.~ `1 ~ the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testator sign and execute the instrument as her Last Will; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testator signed the Will as witnesses; and that to the best of our knowledge the Testator was at that time eighteen oi~ more years of age, of sound m' an under no constr ' t or undue influence. .~ ~ `- :a,; Sworn or affirmed to and subscribed to before me by ~~ nni K~- L--• ~Per;~ and ~, ~~~E ~~ C ~. 1 ~_~_~`t_ `~ ~ witnesses, this ~ ~``t day oil c'~~Lf/d.~% , 2008. (SEAL) NOTARIAL SEAL ~' ~a-! '~ l~ DAVID H RADCLIFF otary Public Notary Public LEMOYNE BOROUGH, CUMBERLAND COUNTY My Commission Expires Jun 29, 2008 ~1 ~'~i