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Home My WebLink About11-05-10 1505610148 EX (01-10) REV-1500 OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN 21 10 0 0 3 5 PO BOX 280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 188-20-8796 1],202009 06201927 Decedent's Last Name Suffix Decedent's First Name M I BURKHOLDER TROY A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name M I Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH T'HE - - REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW ® 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Rellurn (date of death prior to 12-13-82) ^ 4. Limited Estate ^ 4a. Future Interest Compromise (date of ^ 5. Federal Estate Tax Return Required death after 12-12-82) 0 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 ^ 1 1. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number CRAIG A• HATCH, ESQUIRE 717-731-9600 ~ First line of address 1013 MUMMA RD, STE 1,00 Second line of address City or Post Office State ZIP Code LEMOYNE PA 17043 Correspondent'se-mall address: C • HATCHaGATESLAWFIRM • COM ~n __._, , . { ~_ - r ,-_ ~`~ t_;> .., .~ 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. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE DIANA D • MILLER, EXECUTRIX ,(~~ / c_.,~-r.. ~( ~.Q cr l ~~ ~ "~ f /v 8 CEDAR ROAD CARLI E, PA 17015 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE t' f "` DATE ,- CRAIG A • HATCH, ESQUIRE „ ---~t~`~ , ~ ~Q~', ~///~, - __ ADDRESS 1013 MUMMA ROAD, SUITE 100 LEMOYNE, PA 17043 PLEASE USE ORIGINAL FORM ONLY 1505610148 ~_ ~ ...~ REGISTER - WIC USE ONV_-~ -•~ --,~ .~' ~ ._ . J..., tom,-,- _ ~`.`r. - `,.~ _.j ~ ~:Y r ~, DATIE FILED '^--~+ Side 1 9M4647 4.000 1505610148 °" J 1505610248 REV-1500 EX Decedent's Social :>ecurity Number 188-20-8796 Decedents Name BURKHOLDER TROY A RECAPITULATION 1. Real Estate (Schedule A) 1, $ 0 • 0 0 2. Stocks and Bonds (Schedule B) . z. $ 2 2 ,16 7.5 6 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) , 3, $ 0 • 0 (] 4. Mortgages and Notes Receivable (Schedule D) 4, $ 0 . 0 0 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) 5. $ 5 8 , 017.5 9 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested g, $ 0 • 0 0 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested 7. $ 2 91, , 5 7 7.0 9 8. Total Gross Assets (total Lines 1 through 7) g. $ 3 71, 7 6 2 •2 4 9. Funeral Expenses and Administrative Costs (Schedule H) , , 9. $ 31, 2 0 5.8 0 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) 10, $ 6 5 3. 4 2 1 1. Total Deductions (total Lines 9 and 10) , 11. $ 31, 8 5 9.2 2 12. Net Value of Estate (Line 8 minus Line 11) 12, $ 3 3 9 , 9 0 3.0 2 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) , • 13, $ 0 . 0 0 14. Net Value Subject to Tax (Line 12 minus Line 13) • 14, $ 3 3 9 , 9 0 3.0 2 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers un~er Sec. 9116 (a)(1.2> x .o _ $ 0.0 0 15. $ 0.0 0 16. Amount of Line 14 t xable 4~ at linealratex.o $339,903.01 16. $15,295.64 17. Amount of Line 14 taxable at sibling rate X .12 $ 0 • 0 0 17, $ 0 ' 0 0 18. Amount of Line 14 taxable at collateral rate X .15 $ 0 • 0 0 18. $ 0 • 0 0 19. TAX DUE 19. 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610248 1505610248 9M4648 4.000 $L5,295.64 a J REV-1500 EX Page 3 File Number --...r.--- - ---- ---- - - DECEDENTS NAME BURKHOLDER TROY A STREET ADDRESS CUM ERLAN CITY STATE ZIP CARLISLE PA 17015- Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments $16 , 0 0 0.0 0 e. Discount $ 7 6 4 •7 8 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in box on Page 2, Line 20 to request a refund. (4) (1) $15, 295.64 $16,764 •?8 (3) $ 0.0 0 $1,469.14 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) $ 0 • 0 0 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 Dec. 12, 1982, did decedent transfer property within one year of death ® ^ without receiving adequate consideration? . " ^ C~ L or payable-upon-death bank account or security at his or her death? 3. Did decedent own an "in trust for 4. Did decedent own an individual retirement account, annuity, or other non-probate property, which ® ^~ L contains a beneficiary designation? 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 uses of the surviving spouse is 3 percent [72 P.S. X9116 (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. X9116 (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. X9116(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. Total Credits (A + g) (2) 9M4671 2.000 REV-1503 EX + (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Tro A. Burkholder 21 10 00:35 All property jointly-owned with right of survivorship must be disclosed on Schedule F. 3was9s ~.ooo (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Trot/ A Burkholder 21100035 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM V/SLUE AT DATE NUMBER DESCRIPTION OF DEATH 1 (First National Bank Certificate of Deposit No. 1730072635 $15,305.54 2 OM Financial Life Insurance Co. refund $450.00 3 Erie Insurance premium refunds $29.00 4 refund - cash $684.00 5 refund - cash $70.00 6 Miscellaneous personal property, including vehicles. (Value is gross proceeds from auction.) $37,915.50 7 Discover Card refund for overpayment $1.49 8 U. S. Treasury decedent's 2009 federal income tax refund $1,155.00 9 PA Department of Revenue decedent's 2009 state income tax refund $290.00 10 Erie Insurance premium refunds $104.00 11 Erie Insurance premium refunds $86.00 12 Snedeker Oil refund $479.85 13 Verizon refund $8.01 14 Prudential Life insurance policy of Mary A. Burkholder paid to Estate of Troy A. Burkholder. $1,439.20 TOTAL (Also enter on line 5, Recapitulation) $ ~ $58 , 017.59 3wa6aD ~.ooo (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 TATS OF FILE NUMBER Troy A. Burkholder 21 10 0035 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 NUMBE DESCRIPTION OF PROPERTY INCLl1DE THE NAME OF TFE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACHA COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION fF APPLICABLE TAXABLE VALUE 1 • ING Annuity Contract No. C045247-OX $5,293.57 100.0000 $0.00 $5,293.57 Owner/Annuitant: Troy A. Burkholder Beneficiaries: daughters, Diana D. Miller and Carol J. Fultz 2 Transfer made by decedent to Diana Miller on March 23, 2009. $32,340.98 100.0000 $0.00 $32,340.98 3 Aviva IRA No. 30EL767265 $87,059.58 100.0000 $0.00 $87,059.58 Owner/Annuitant: Troy A. Burkholder Beneficiaries: daughters, Diana D. Miller and Carol J. Fultz 4 Old Mutual Spectrum Rewards Reserve Acct. No. L9167706 Beneficiaries daughters, Carol J. Fultz and Diana D. Miller $13,144.11 100.0000 $0.00 $13,144.11 5 Old Mutual Spectrum Rewards Reserve Acct. No. L9102165 Beneficiaries: daughters, Carol J. Fultz and Diana D. Miller $8,059.36 100.0000 $0.00' $8,059.36 6 Single-family dwelling located at 330 Old Park Road, Lewistown, Mifflin County, Pennsylvania; being Tax Parcel No. 16,03-0101; $136,318.44 100.0000 $0.00 $136,318.44 Total from continuation sched les $9,362.05 TOTAL (Also enter on line 7, Recapitulation) $ $291,577.09 If more space is needed, use additional sheets of paper of the same size. 9W46AF 2.000 Estate of: Troy A. Burkholder Schedule G (Page 2) Item No. Description DOD Value of Asset $ Interest Exclusion transferred to Troy A. Burkholder, Trustee of the Burkholder Family Trust dated February 9, 2009, by Troy A. Burkolder's Deed dated February 9, 2009, and recorded on February 23, 2009, at Instrument No. 2009-000676 in the Mifflin County Recorder of Deeds Office. Value is gross sale price. 7 Members 1st Federal Credit Union Acct. No. 363535-00 Account made joint with decedent's daughter, Diana D. Miller, on October 3, 2009. 8 Members 1st Federal Credit Union Acct. No. 363535-11 Account made joint with decedent's daughter, Diana D. Miller, on October 3, 2009. $6,787.76 100.0000 $3,000.00 $5,573.29 100.0000 $0.00 21 10 0035 Taxable Value $3,787.76 $5,573.29 Total (Carry forward to main schedule) $9,361.05 REV-1511 EX+ ~,ao9, SCHEDULE H pennsylvania DEPARTMENT OF REVENUE FUNERAL EXPENSES A N D INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Tro A. Burkholder 21 10 0035 Decedent's debts must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~ Diehl's Flowers, Inc. flowers for funeral $243.80 B. 1 Total from continuation schedules I $8,674.30 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2. Attorney Fees: $7 , 250.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address 4. 5. 6. 7. 1 2 City State ZIP Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Return Preparer Fees: Verizon phone service Penelec electric service Total from continuation schedules $157.50 $83.39 $141.10 $14,655.71 TOTAL (Also enter on Line 9, Recapitulation) ~ $ $31 , 205.80 swasac z.ooo If more space is needed, use additional sheets of paper of the same size. Estate of: Troy A. Burkholder 21 10 0035 Schedule H Part 1 (Page 2) Item No. Description Amount 2 Rev. Kari Swigart funeral service $125.00 3 Rev. Sarah Keilhotz funeral service $175.00 4 Guss Funeral Home funeral goods & services $8,249.30 5 Lewistown Monument Company engraving $125.00 Total (Carry forward to main schedule) $8,674.30 Estate of: Troy A. Burkholder Schedule H Part 7 (Page 2) 3 4 5 6 7 8 9 10 11 Miscellaneous expenses incurred during administration of estate, i.e., paper supplies, supplies and fees to clean real estate, fax charges, etc. Barger's Landscaping Plus lawn maintenance/snow removal Raine's Plumbing, Heating & Drain Cleaning house repair to prepare for sale Cumberland Law Journal publication fee Robert Baer real estate appraisal PA Department of Transportation fee for duplicate copy of vehicle title Don Chesney, Auctioneer Auctioneer's fees on sale of real estate and personal property, paid outside of closing. Register of Wills fee for additional short certificates Settlement charges on sale of 330 Old Park Road. (See Schedule G.) 21 10 0035 $181.63 $595.00 $128.65 $75.00 $250.00 $22.50 $11,697.51 $32.00 $1,673.42 Total (Carry forward to main schedule) $14,655.71 REV-1512 EX+(12-08) SCHEDULE pennsylvania DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RFRI~IFNT I~FCFr~FNT ESTATE OF FILE NUMBER m_.... T ~,.rLL.~I i-ler 21 10 0035 Resort debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. 8W46AH 2.000 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: FILE NIUMBER: Tro A. Burkholder 21 10 0035 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).J 1. Diana D. Miller 8 Cedar Road Carlisle, PA 17015 Members 1st Federal Credit Union Acct. No. 363535-00 Inventory Value: $3,787.76 Members 1st Federal Credit Union Acct. No. 363535-11 Inventory Value: $5,573.29 Transfer made by decedent to Diana Miller on March 23, 2009. Inventory Value: $32,340.98 One Half of Residue: ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APP ROPRIATE. ([ NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ $0.00 If more space is needed, use additional sheets of paper of the same size. 9 W 46AI 2.000 Estate of: Troy A. Burkholder Item No. Description 1 $149,100.49 2 Carol J. Fultz 10 Nittany Lion Drive Lewistown, PA 17044 One Half of Residue: $149,100.49 Schedule J Part 1 (Page 2) Relation Daughter Daughter 21 10 0035 Amount $190,802.52 $149,100.49 DEATH CERTIFICATE 1 h1s 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. Linda A. Caniglia State Registrar ~4~~~~ No. d~ H105-143 REV 11!2006 7YPEIPRINTIN PERMANENT BLACK INN .~ ^~ `• 0 w U LL 0 W Z MAR 1 ~; 2010 Date COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS 11483 9 CERTIFICATE OF DEATH (See instructions and examples on reverse) STATE FILE NUMBER 1. Name of Decedent (Frst, middle, last, suffix) ~~ r ~ ~,~ ~ ~~ ~'~ ~ • (~u.~ k 2. Sex IYb,~~ 3. Social Security Number ~ ~~ - ~ - ~~q to 4. Date of Death (Month, day, year) ~Ir~e~n b~ 2U, ~i 5. Age (Last Birthday) Under 1 year Under 1 day 6. Date of Birth (Month, day, year) 7. Birthplace (City and state a foreign country) 8a. Place of Death (Check only one) ' ~~ Yrs. Months Days Hours htinmes ` p //~~ -•y '`+-~ ~+ ~ I"t ~ 1 (`~1; ~ ro Pfd Hospital: ~f ^ Inpatient LTy ER /Outpatient ^ DOA Other. ^ Nursi Home Residence ng ^ ^Other • Specify: - 8b. County of Death 6c. City, Boro, Twp. of Death Bd. Fat7lily Name (If not institution, give street and number) 9. Was Decedent of Hispanic Origin? No ^ Yes 10. Race: Ameocan Indian, Black, While, etc. ~ ~urnb~;c~ u~ct r ~•-(J1,1') J `~ ~~ `1 S \>~ f1 Q~' rn Q~l~ ~ f ~C,.11~~ (If yes, specity Cuban, Mexican, Puerto Rican, etc.) (Specify) `l 1h ~~~~ 11. Decedent's Usual Occu atwn Kind of work done Burin most of waki tile. Do rwt state reload 12. Was Decedent ever in the 13. Decedent's Education (Specify only highest grade completed) 14. Madtal Status: Married, Never Married, 15. Surviving Spouse (If wife, give maiden name) iK+inAd of iW~or`k' W~1 f~~ ~ ~ DKind of Business` / llfnd~u~try p ~lZL..l' ~ ll WI IV, ~v U.S. Armed Forces? ,~,1 L^Jdres ^No Elementary I Secondary (0-12) ~ College (1-4 or 5+) Widowed, Divorced (Specify) ~l} ~ ~W ~~ ~~ 16. Deceden~MaitingA~ess (Sire city t tow ,state, zip code) / ~ ' Decedent's II,,s~ r Did Decedent ~ m- ~d~ s-~ T \ l~ ~V 1(~ we rn a 17c State =C Yes Act al Residence 17a Decedent Li d i ~ l .~ (~ ~, ~ l ~~ ~' ~ , . , wp. u . ve n ~n `` ~~ v1 Township? 17b. County ~rn~x1 tel.-1 t~ 17d. ^ No, Decedent Lived within A ~ ~ ~ s l ctual Limits of City /Boro 16 Father's Name (RrsL middle, lass, suffix) 1b~ ~r u~kh~tc~~r' 19. Mother's Name (First, mkidle, mai en surname} ~fii ~, i~~r~ih -~,vr 20a Informant's Name (Type I Pri ` /t rn t C~nA, - + ~~ ~ `~ 20b. In~ojr~mant's Mrailin~g A~d~dre~ss (yStreet~city(I town, stale, zip c~ode~) y ~ a 1~ `_ l1 Vrl.l~l.t..~ i'„v~~ Lt~C.f ~(~''t,s l ~ ~ to ~J 21a. Mettad of Disposition ^ Cremation ^ Donation 21b. Date of Disposition (Month, day, year) 21c. Place of Disposition (Name of cemetery, crematory or other place) 21d. Location (City I town, state, zip code) • [~. Burial ^ Removal from State :Was Cremation or Donation Authorized A ~I~ / ~ ~~n I ~ ~ ~ ~ (y~ (/~ ,n,~,, ~~q ~ ~ ~j ~V~,~y ~~., i ~j~. `"~~~~ ' 4' m ^ Other - Specity by Medical Examiner 1 Coroner? ^ Yes ^ No r ` li ~ 1 V`,1 `) Q ~/ ~ 1 , ~ \Z.. 1 ~~+K.1 - 1 ;~ `I \ x 1 ~ 22a. Si nature of Funeral S~erv~iice~Lke see (or p n ac~tingya~s s~uc~h) ~ I ~ 22b. lFicen1se(Njumryber 22c. NaNa me anCd Address of Facility .{ y~ ,~y` y.~ +~ 71 r~ ^ ~ ~ ~ lui/ t~l n.J~ `/ 1 ~Jl -lf7l ~ ~ , , g 0 ~7 ~ ~ ~ ~ f ~ I t ' V ~ U f ~t ~ 1 ~,-l U~•~S ~ ~ (/I U J v ~ Complete Items 23a-c only when cenitying 23a. To the best of my knowledge, death occurred at the time, date and place stated. (Signature and title) 23b. License Number 23c. Dale Signed (Month, day, year) physician is not available al time of death to cenify cause of death. Items 2426 must be completed by person 24. Time of Death 25. Dale Pronounced Dead (Month, day, year) 26 Was Case Referred to Medical Examiner /Coroner for a Reason Other than Crematon a Donation? ' who praxwnces death. i ~ ; `S M ~m t ~in n ..• ~ ~ CJI Yes ^ No CAUSE OF DEATH (See instructions and examples) r Approximate interval: Part II Faster other ~ignilicant conditions contributing to death, ?B. Did Tobacco Use Conlnbule to Death? Item 27. Pan C Enter the chain of events -diseases, injuries, or complicatwrm - Thal drectty caused the death. DO NOT enter terminal events such as cardiac arrest, r Onset to Death but nat resulting in the underlying cause given in Part I. ^ Yes ^ Probably respiratory arrest. or ventricular 6hrillation without showing the etiology. List only one cause on each line. r r ^ No ~ Unknown ~ '~ IMMEDIATE CAUSE (Final disease or f-,q y u ! ~,,r, n l q~ ~ ~ ~1~.,(.~ ~ i d th dit lti 1 "T„ `V r j L 29. It Female: ng n ) , con ion resu ea { / r -~ a r ^ Due to (or as a consequence of): r Sequentially list conditions, it any, b ' li l i h B d r Not pregnant witNn past year ^ Pregnant at time of death ng to t e cause sle on ne a. ead Enter the UNDERLYING CAUSE Due to (or as a consequence off: r ^ Not pregnant, but pregnant vrilhin 42 days (disease or injury that irufiated the c r events resulting in death) LAST. r of death Due to (or as a consequence of): r ^ Not pregnant, but pregnant 43 days to 1 year r • d. r befae death ^ Unknown rt pregnant within the past year 30a. Was an Atopsy 30b. Were Autopsy Findings 31. Manner of Death 32a. Date d Injury (Month, day, year) 32b. Describe How Injury Occurred 32c. Place of Injury: Home, Farm, Street, Faday, Pertained? AvaJable Prior to Completion rc~ ~ Natural ^ Homicide Office Building, e~. (Specity) of Cause of Death? ^ Yes ~No ^ Yes ^ No ^ Ar.~dent ^ Pending Investigation 32d. Time of Injury 32e. Injury al Work? 32f. If Transporlalion Injury (Specify) 32g. Location o(tnjury (Street, city r faun, state) ^ Suicide ^ Could Not be Determined ^ Yes ^ No ^ Diner I Operala ^ Passenger ^ PedesMan M. Other • Specity: 33a Ceni6er check on one 33b. S nature and Title d Certifier g • Certifying physkian (Physican cenitying cause d death when another phys~ian has pronounced death and completed Item 23) - y' r - ~.L To he best of my knowledge, death occurred due to the cause(s) am! manner as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ • Pronouncing and certifying physician (Physician both pmnouncirg death and certifying to cause of death) ~ 33c. License Number 33d. Date Signed (Month, day, year) To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner az stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ • Medical Examiner f Coroner ~(~ 1 ~ `1 -~ ~ ~ t ~ ~ ~ '/ L On the basis of examination and 1 or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner az stated_ ^ ~ Name and Address of Person Who Completed Cause of Death (Item 27) Type t Print J Q ' ~ V ! S W ~'- N>7 ~i9 n 35. Registrar s Signature and Dist t Number 36. Date Fled (Month, day, year) Disposition Permit No. o/ ~ ` LAST WILL AND TESTAMENT OF TROY A.BURKHOLDER fIUIII.DIIC JyJICIIIJ I IJ !JV VJIJ iL~viLVVJ v~.-ri rvi.~ i .vvc..fvv-r I19 WEST MARKET STREET LEWISTOWN, PA 17044 (717) 246-5.479 ~,,.e~..-,-.~...-, BARRON & ZtMMERMAN COUNSELLORS-AT-LAW 220 BRIDGE STREET MIFFIi!VTOWN, PA 17059 (717) 436-8221 . LAST WILL AND TESTAMENT I, TROY A. BliRKHOLDER, of Derry Township, Mifflin County, Pennsylvania, being of sound mind and body, declare this to be my Last Will E1nd Testament, and do hereby revoke alI Wills and Codicils previously made by me. ITEM 1: I give, devise and bequeath all and every part o:E my entire estate, real, personal and mixed, whatsoever and whereso- ever situate, including property over which I shall have any power o f appointment , to my wife, MARY A . BUR.K~iOLDER, provided that she shall survive me by a period of Ninety (90) days. ITEM 2: Should my wife, MARY A. Bti`R,K.~~OLDER, fail to survive me by a period of Ninety (901 days , I give and bequeath my wife' s large diamond ring to Fny daughter, Carol J. Burkholder; provided that she shall survive me by a period of i~~inety (901 days . Should Amy .J .3..,_._i,~..... /~......-.l T D.,~.-l. i., ..l ,a .. .- ~..~ 1 +-.~ n„r~r~ try ma h~-r n r~er~ n~ n~ ~dti.l Lldll~lll.t:l, l.rGL1V~ J. tJLliL~liVlliCl, LG1.t LL' s7ulV.J'vG ~++4 vJr ~ rc.r..iv+.s v~•- Ninety (901 days a T then give and ben„earh said. large diamond ring to wy daughter, Diana D, Burkholder. ITEM 3 : Should my wife ; NT~RY A . BTTRK~~03,DrR , fail to survive me by a period cf Ninety (9J1 days, I give and bequeath my ~,~Tife's wedding band with diamond chips and rr~y wife's black onyx ring with diamond chip to u>,y daughter, Diana D. Burkholder, provided. that she shall survive me by a period of Ninety (901 days. Should my said daughter, Diana D. Burkholder fail to survive me by a period of Ninety (90) days, I then give and bequeath said wedding band with diamond chips and said. b~_ack onyx ring with diamond chip to my daughter, Carol J. ~ ~!~ ,, n-- l r I UIII . DHC Jy~ LC1115 r I f ! .lU lJ.l I J I LI VC ~ LVVJ VJ •~ I li V 1.! I VVVt vV~ Burkholder. ITEM 4: Should my wife, MARY A. BURK.~IOLDER, fail to ~>urvive me by a period of Pdinety (90) days, I give, devise and bequeath. all the rest, residue and remainder of niy entire estate, real, persona. and mixed, whatsoever and wheresoever situate, including property over which I sha11 have any power of appointment, as follows: (a) Fifty (50%) percent to my daughter, Diana D. Burkholder, provided that she shall survive me by a period of Ninety (90) days . Should my said daughter fail to survive me by a period of 1Vinety (90) days, I Chen give, devise and bequeath her interest in this the residue of my estate to her there living issue, per stirpes. Should my said daughter die without leaving issue to survive me by a period of Ninety (90) days, then her interest in this the residue of my estate shall be disposed of as hereinafter provided by Sub-paragraph (b) . j (b) Fifty (50°10) percent to my daughter, Carol J, Burkholder, provided that she shall survive me by a period of Ninety (90} days, Should my said daughter fail. a survive ~;~e by a ' period of Ninety (90} days, I then give, devise t~ .- L. ~ ,.- ~ ri +- +- ; „ t- l„ e t- h o r p ~ ; ri 4 4 P n _f' ctnd Uet~l.LCc[~h 1LC1. ,illteres L .PLC 4aa.rVV t~aati- .'...".......... i my estate to her then living issue, per stirpes, Should my said daughter die without leaving issue to survive me by a period of Ninety (90} ddy s , ti~r~ her interest in this the re s; d~1e n f_ my estate shall be disposed of as hereinbefore provided by Sub_paragraph (a) . ITEM 5: I appoint The Russell National Bank, Lewistown, Petznsyl- vanes, guardian of any property which passes, either under this Will ' or otherwise to a minor or with respect to which I am authorized to appoint a g„a,-dia~, and have not otherwise specifically do-ne so, pro- vided that this appointment of a guardian shall not supersede the right of any fiduciary in its discretion to distribute such share to another for the u~inor' s benefit , ray said guardian shall have the power to use ~~ 2 ck t"IUIII.DHC JUJICIIiJ ! iJ J~U U~iJ iLivc~LVV~ v...-L ~~v~v ~ •,.,~~~~~~ principal a~ well as income from time to time for the minor's support, welfare and education (including education beyond the high ;school level), without further responsibility, to the minor or to any person taking care of the minor. ITEM 6 : I direct that my ~ ust debts , funeral expenses , including ~y grave marker, estate taxes, inheritance taxes, and all other administration expenses are to be paid out of the residue of my estate as soon as practicable after my decease, as apart of the expense of the administration of ray estate. ITEM 7: I appoint my wife, MARY A. BURKHOLDER, as Executrix of this iuy Last gill. Should my wife, MARY A. }3URKH.OLDER, 'be unwillir_g or unable to so act, I then appoint my daughter, Diana D. Burkholder, as Executrix of this my Last Will. IN ~rJIT~UESS W~~ER.EQF, I have hereunto set my hand this i~~'~ day of i~' 180. '-`" r ur ~ o er ThP preceding instrument, consisting of this and two (2) other typewritten pages, each identified by the signature clf the Testator, was on the day and date thereof signed, published anti declared by TROY A. BURKHQLDER, the Testator therein named, as and for his LAST WILL, in the presence of us, who at his reque~;t, in his presence and ir. the presence of each other have subscribed our names as witnesses hereto. ~- - - - THE BURKHOLDER FAMILY TRUST DATED FEBRUARY 9, 2009 THE BURKHOLDER FAMILY TRUST G' ~~~ THIS TRUST AGREEMENT is executed in triplicate on this ~_ day of Felbruary, 2009, by and between TROY ANDREW BURI~IOLDER, now of 330 Old Park Ro<~d, Lewistown, Mifflin County, Pennsylvania 17044 (hereinafter called "Settlor") and TROY ANDREW BURI~IOLDER, now of 330 Old Park Road, Lewistown, Mifflin County, Pennsylvania 17044 (hereinafter called "Trustee"). ARTICLE I. TRUST ESTATE 1.01. Initial Principal. Settlor, desiring to establish an irrevocable trust, doers hereby irrevocably transfer, assign and deliver to the Trustee and its successors, and assigns the assets listed on Schedule A, attached hereto and made a part hereof. As further evidence of s,:zch assignment, the Settlor has executed or will execute or cause to be executed such other instruments as may be required for the purposes of completing the assignment or transfer of title to such property to the Trustee. The Trustee accepts such transfer and assignment to itself as Trustee, and undertakes to hold, manage, invest and reinvest the assets of this Trust, and to distribute the income and principal of the Trust in accordance with the provisions of this Agreement. 1.02. Additional Principal. The Settlor and any other person or persons, with the consent of the Trustee, shall have the right at any time to make additions to the corpus of this Trust or any share thereof hereby established. All such additions shall be held, governed, and distributed by the Trustee in accordance with the terms and conditions of this Agreement. The Trustee, in its sole discretion, may require, as a prerequisite to accepting property, that the transferring party provide evidence satisfactory to the Trustee that (i) the property is not contaminated by any hazardous or toxic materials or substances; and (ii) the property is not being used and has never been used for any activities directly or indirectly involving the generation, use, treatment, storage, disposal, release or discharge of any hazardous or toxic materials or substances. 1.03 Disclaimer. The Trustee shall have the right to disclaim, in whole or in part, prior to its acceptance by the Trustee, any interests in property for any reason, including but not limited to a concern that such property could cause potential liability under any federal, state, or local environmental law. ARTICLE II. IRREVOCABILITY OF TRUST 2.01. Irrevocability. Settlor has been advised of the consequences of an irrevocable trust and hereby declares that this Trust shall be irrevocable and shall not be altered, amended, revoked, or terminated by Settlor or any other person or persons. ARTICLE III. LIFE INSURANCE POLICIES 3.01. General Provisions. If any insurance policies are transferred into this Trust, the Trustee shall be vested with all right, title, and interest in and to the transferred policies of insurance, and is authorized and empowered to exercise and enjoy, for the purposes of~the Trust herein created and as absolute owner of such policies of insurance, all the options, benefits, rights and privileges under such policies, including the right to borrow upon and to pledge tl-~em for a loan or loans. The Trustee takes all rights, title, and interest in and to the above stated insurance policies subject to any prior split-dollar life insurance agreement and assignments, which may be in effect at the time of transfer. The insurance companies which have issued policies are hereby authorized and directed to recognize the Trustee as absolute owner of such policies of insurance and as fully entitled to all options, rights, privileges, and interests under such policies, and any receipts, releases, and other instruments executed by the Trustee in connection with such policies shall be binding upon all persons interested in this Trust. The Settlor hereby relinquishes all rights, title, interest and powers in such policies of insurance which Settlor may own .and which rights, title, interest and powers are not assignable, and will, at the request of the Trustee, execute all other instruments reasonably required to effectuate this relinquishment. 3.02. Payment of Premiums. The Trustee shall be under no obligation to pay the premiums which may become due and payable under the provisions of any policy of insurance which may be transferred or assigned to this Trust, or to make certain that such premiums are paid by the transferor of such policy, or to notify any persons of the nonpayment of such premiums, and the Trustee shall be under no responsibility or liability of any kind in case such premiums are not paid, except the Trustee shall apply any dividends received on such policies to the payment of premiums thereon. Upon notice at any time during the continuance of'this Trust that the premiums due upon such policies are in default, or that premiums which will become due will not be paid, either by the transferor or by any other person, the Trustee, within its sole discretion, may apply any cash values attributable to such policy to the purchase of paid-up insurance or of extended insurance, or may borrow upon such policy for the payment of premiums due thereon, or may accept the cash values of such policy upon the policy's forfeiture. In the event that the Trustee receives the cash value of such policy upon its forfeiture for nonpayment of premiums, the amount received shall be added to the corpus of this Trust, and shall be administered according to the terms of this Agreement. If the insured under such policies of insurance, becomes totally and permanently disabled within the meaning of any policies and because thereof the payment of premiums, or any of them, shall during the pendency of such disability, be waived, the Trustee, upon receipt of such knowledge, shall prorriptly notify the insurance company which has issued such policies, and shall take any and all steps necessary to make such waiver of premium provision effective. 3.03. Duties of Trustee With Regard to Life Insurance Policies. The Trustee shall be under no obligation or duty whatever except with respect to the safekeeping of such policies of insurance and the duty to receive such sums as may be paid to them, in accordance with the requirements of this Trust, by the companies issuing such policies, and to hold, manage and disburse such proceeds subject to the terms of this Agreement. Upon the death of the insured, the Trustee shall make reasonable efforts to carry out the provisions of this Agreement., including the maintenance or defense of any suit, provided, however, the Trustee shall be under no duty to maintain or enter into any litigation unless its expenses, including counsel fees and costs, have been advanced or guaranteed in an amount and in a manner reasonably satisfactory to the Trustee. The Trustee may repay any advances made by it or reimburse itself for any such fees and costs from any corpus or income of this Trust. ARTICLE IV. TRUST DISTRIBUTIONS 4.01. Trust Principal. The entire corpus of this Trust, including the assets initially transferred to this Trust, subsequent additions to this Trust, and the proceeds of any sale, exchange or investment of such Trust assets, shall be used for the purposes herein conitained. 4.02. Income Distribution. During the Settlor's lifetime, the Trustee shall distribute all of the net income of the trust to, or for the benefit of the Settlor, TROY ANDREW BURI~IOLDER. The Trustee shall make no distributions of principal to TROY ANDREW BUR~IOLDER. L'pon the admission of TROY ANDREW BURKIIOLDER to a long term care facility for a period of time in excess of thirty (30) days, the Trustee shall cease the distribution of income from this Trust to TROY ANDREW BURKHOLDER and such income shall accumulate to the principal of this Trust. 4.03. Principal Distributions. Upon the death of the Settlor, TROY ANDREW BURI~IOLDER, the Trust shall terminate. Upon termination of the Trust, the remaining Trust estate shall be distributed in separate and equal shares to the Settlors' children, DIANA D. MILLER and CAROL J. FULTZ, per stirpes. If either of the Settlor's children predecease the termination of this Trust, the predeceased individual's share shall be distributed, unless otherwise stated, equally to the predeceased individual's issue, per stirpes, provided that if any named individual predeceases the termination of this Trust without leaving issue, then such predeceased individual's share shall be distributed equally to the surviving named individuals, per ;stirpes. 4.04. General Power of Appointment. Settlors' children, DIANA D. MILLER and CAROL J. FULTZ, are hereby granted the general power to appoint some or all of the principal of this Trust to themselves upon written notice issued to the Trustee. The Trustee shall present such written notice to the Settlor who, upon receipt, shall have a period of time not to exceed ten (10) business days to veto the proposed exercise. If and in the event that a veto is not received by the Trustee as described above, then the proposed exercise shall be deemed valid. This power shall not be exercisable under their Wills. ARTICLE V. POWERS OF TRUSTEE 5.01. General Powers. In addition to such other powers and duties as may have been granted elsewhere in this Trust, but subject to any limitations contained elsewhere in this Trust, the Trustee shall have the following powers and duties: A. In the management, care and disposition of this Trust, the Trustee shall havE; the power to do all things and to execute such deeds, instruments, and other documents as may be deemed necessary and proper, including the following powers, all of which may be exercised without order of or report to any court: (1) To sell, exchange, or otherwise dispose of any property, real, personal or mixed, wheresoever located, at any time held or acquired hereunder, at public or private sale, for cash or on terms as may be determined by the Trustee, without advertisement, including the right to lease for any term notwithstanding the period of the Trust, and to grant options, including an option for a period beyond the duration of the Trust. (2) To invest and reinvest all or any part of the Trust Estate in any common or preferred stocks, shares of investment trusts and investment companies, bonds, debentures, mortgages, deeds of trust, mortgage participations, notes, real estate, or other property the Trustee, in the Trustee's discretion, selects; provided that the Trustee may not invest in any stock or securities issued by thE; corporate Trustee or issued by a parent or affiliate company of such Trustee; in the manner that, under the circumstances then prevailing (specifically including, but not limited to, the general economic conditions and the anticipated needs of thc; Trust and its beneficiaries), persons of skill, prudence, and diligence, acting in a similar capacity and familiar with those matters would use in the conduct of an enterprise of similar character and similar aims, to attain the Settlor's goals under this trust agreement. (3) To retain for investment any property deposited with the Trustee hereunder. (4) To vote in person or by proxy any corporate stock or other security and to agree to or take any other action in regard to any reorganization, merger, consolidation, liquidation, bankruptcy or other procedure or proceedings affecting any stock, bond, note or other security held by this Trust. (5) To use lawyers, real estate brokers, accountants and any other agents, if such employment is deemed necessary or desirable, and to pay reasonable compensation for their services. (6) To compromise, settle or adjust any claim or demand by or against: the Trust and to agree to any rescission or modification of any contact or agreement affecting the Trust. (7) To renew any indebtedness, as well as to borrow money, and to secure the same by mortgaging, pledging or conveying any property of the Trust, including the power to borrow from the Trustee (in the Trustee's individual capacity) at a reasonable rate of interest. (8) To retain any business interest transferred to the trustee, as shareholder, security holder, creditor, partner or otherwise, for any period of time whatsoever, even though the interest may constitute all or a large portion of the trust principal; to comply with the provisions of any agreement restricting transfer of the interest; to participate in the conduct of the related business or rely upon others to do so, and to take or delegate to others discretionary power to take ar.~y action with respect to its management and affairs which an individual could take as outright owner of the business or the business interest, including the voting of stock (by separate trust or otherwise regardless of whether that separate trust v~~ill extend for a term within or beyond the term of the trust) and the determination. of all questions of policy; to execute and amend partnership agreements; to participate in any incorporation, reorganization, merger, consolidation, sale of assets, recapitalization, liquidation or dissolution of the business, or any change in its nature, or in any buy-sell, stock restriction, or stock redemption agreements,; to invest in additional stock or securities of, or make secured, unsecured, or subordinated loans to, the business with trust funds; to take all appropriate actions to prevent, identify, or respond to actual or threatened violations of any environmental law or regulation thereunder; to elect or employ with compensation, as directors, officers, employees, or agents of the business, any persons, including a trustee of any trust held under this instrument, or any director, officer, employee, or agent of a corporate trustee of any trust held under this instrument, without adversely affecting the compensation to which that trustee would otherwise be entitled; to rely upon reports of certitieci public accountants as to the operations and financial condition of the business, without independent investigation; to deal with and act for the business in any capacity (including in the case of a corporate trustee any banking or trust capacity and the loaning of money out of the trustee's own funds) and to be compensated therefor; and to ;yell or liquidate the business or any interest in the business. (9) To register any stock, bond or other security in the name of a nominee, without the addition of words indicating that such security is held in a fiduciary capacity, but accurate records shall be maintained showing that the stock, bond or other security is a trust asset and the Trustee shall be responsible for the acts of the nominee. (10) To set aside as a separate trust, to be held and administered upon the same terms as those governing the remaining trust property, any interests in property, for any reason, including but not limited to a concern that such property could cause potential liability under any federal, state, or local environmental law. B. Whenever the Trustee is directed to distribute any trust principal in fee simple to a person who is then under twenty-one (21) years of age, the Trustee shall be authorized t:o hold such property in trust for such person until he becomes twenty-one (21) years of age, and in the meantime shall use such part of the income and the principal of the trust as the Trustee may deem necessary to provide for the proper support and education of such person in the standard of living to which he has become accustomed. If such person should die before becoming twenty-one (21) years of age, the property then remaining in trust shall be distributed to the personal representative of such person's estate. C. In making distributions from the Trust to or for the benefit of any minor or c-ther person under a legal disability, the Trustee need not require the appointment of a guardian, but shall be authorized to pay or deliver the distribution to the custodian of such person, to pay or deliver the distribution to such person without the intervention of a guardian, to pay or deliver the distribution to the legal guardian of such person if a guardian has already been appointE;d, or to use the distribution for the benefit of such person. D. In the distribution of the Trust and any division into separate trusts and shares, the Trustee shall be authorized to make the distribution and division in money or in kind oar in both, regardless of the basis for income tax purposes of any property distributed or divided ire kind, and the distribution and division made and the values established by the Trustee shall be binding and conclusive on all persons taking hereunder. The Trustee may in making such distribution or division allot undivided interests in the same property to several trusts or shares. E. If at any time after Settlor's death the total fair market value of the assets of any trust established or to be established hereunder is so small that the corporate Trustee's annual fee for administering the trust would be equal to or less that the minimum annual fee set forth in the Trustee's regularly published fee schedule, then the Trustee in its discretion shall be authorized to terminate such trust or to decide not to establish such trust, and in such event the propE;rty then held in or to be distributed to such trust shall be distributed to the persons who are there or would be entitled to the income of such trust. If the amount of income to be received by such persons is to be determined in the discretion of the Trustee, then the Trustee shall distribute the property among such of the persons to whom the Trustee is authorized to distribute income, and in such proportions, as the Trustee in its discretion shall determine. F. The Trustee shall be authorized to lend or borrow, including the right to lend to or borrow from the Settlor's estate, at an adequate rate of interest and with adequate security and upon such terms and conditions as the Trustee shall deem fair and equitable. G. The Trustee shall be authorized to sell or purchase, at the fair market value as determined by the Trustee, any property to or from Settlor's estate, the estate of Settlor's spouse, or any trust created by Settlor or Settlor's spouse during life or by will, even though the same person or corporation. may be acting as executor of Settlor's estate or the estate of Settlor's spouse or as trustee of any other such trusts and as the Trustee of this Trust. H. The Trustee shall have discretion to determine whether items should be charged or credited to income or principal or allocated between income and principal as the Trustee may deem equitable and fair under all the circumstances, including the power to amortize or fail to amortize any part or all of any premium or discount, to treat any part or all of the profit resulting from the maturity or sale of any asset, whether purchased at a premium or at a discount, as income or principal or apportion the same between income and principal, to apportion the sales price of any asset between income and principal, to treat any dividend or other distribution on any investment as income or principal or to apportion the same between income or principal, to charge any expense against income or principal or apportion the same, and to provide or fail to provide a reasonable reserve against depreciation or obsolescence on any asset subject to depreciation or obsolescence, all as the Trustee may reasonably deem equitable and just. under all of the circumstances. 5.02. Actions and Voting by Trustee. When the authority and power under this Trust is vested in two (2) or more Trustees or Co-Trustees, the authority and powers are to b~e jointly or individually held by the Trustees or Co-Trustees. 5.03. Trustees Power to Deal with Environmental Hazards. The Trustee shall have the power to use and expend the trust income and principal to (i) conduct environmental assessments, audits, and site monitoring to determine compliance with any environmental law or regulation thereunder; (ii) take all appropriate remedial action to contain, clean up or remove any environmental hazard including a spill, release, discharge or contamination, either on fits own accord or in response to an actual or threatened violation of any environmental law or regulation thereunder; (iii) institute legal proceedings concerning environmental hazards or contest or settle legal proceedings brought by any local, state, or federal agency concerned with environmental compliance, or by a private litigant; (iv) comply with any local, state or federal agency order or court order directing an assessment, abatement or cleanup of any environmental hazards; and (v) employ agents, consultants and legal counsel to assist or perform the above undertakings or actions. Any expenses incurred by the trustee under this paragraph may be charged against income or principal as the trustee shall determine. ARTICLE VI. SPENDTHRIFT PROVISION 6.01. General Provision. No beneficiary shall have the power to anticipate, encumber or transfer his interest in the Trust Estate in any manner other than by the valid exerci;>e of a Power of Appointment. No part of the Trust Estate shall be liable for or charged with any debts, contracts, liabilities or torts of a beneficiary or subject to seizure or other process by any creditor of a beneficiary. ARTICLE VII. CONSTRUCTION OF TRUST 7.01. Choice of Law. This Trust shall be administered and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. 7.02. Code. Unless otherwise stated, all references in this Trust to section and chapter numbers are to those of the Internal Revenue Code of 1986, as amended, or corresponding provisions of any subsequent federal tax laws applicable to this Trust. 7.03. Other Terms. Unless the context otherwise requires, the use of one or more genders in the text includes all other genders, and the use of either the singular or the f-lural in the text includes both the singular and the plural. 7.04. Captions. The captions set forth in this Agreement at the beginning of'the various divisions hereof are for convenience of reference only and shall not be deemed to define or limit the provisions hereof or to affect in any way their construction and application. 7.05. Sites of Trust. The Trust shall have .its legal sites in Mifflin County, Pennsylvania. ARTICLE VIII. COMPENSATION OF TRUSTEE AND APPOINTMENT OF SUCCESSOR TRUSTEE 8.01. Compensation. The Trustee shall receive as its compensation for the services performed hereunder that sum of money, based on an hourly charge or percentage rate, which the Trustee normally and customarily charges for performing similar services during the time which it performs these services. 8.02. Removal of Trustee. Settlor may remove the Trustee, at any time or times, with or without cause, upon thirty (30} days written notice given to the current Trustee. Upon the death of the Settlor, a majority of the current beneficiaries may remove the Trustee, at any time or times, with or without cause, upon thirty (30) days written notice given to the Trustee. Upon the removal of the Trustee, a successor Trustee shall be appointed in accordance with the terms set forth in Paragraph 8.03. 8.03. Appointment of Successor Trustee. The Trustee may resign at any time upon thirty (30) days written notice given to the Settlor if Settlor is living, or in the event of~ Settlor's death, upon thirty (30) days written notice given to the current beneficiary or beneficiaries (including a beneficiary's natural or legal guardian or legal representative), hereunder. Upon the death, resignation, removal or incapacity of the Trustee, a successor trustee may be appointed by the Settlor during Settlor's lifetime, or, after Settlor's death, by a majority of the current income beneficiaries. Any successor trustee thus appointed, or, if the Trustee shall merge with or be consolidated with another corporate fiduciary, then such corporate fiduciary, shall succeed to all the duties and to all the powers, including discretionary powers, herein granted to the Trustee. Unless otherwise designated by the Settlor during his lifetime, the successor Trustees shall be the Settlor's daughters, DIANA D. MILLER and CAROL J. FULTZ. ARTICLE IX. PERPETUITIES CLAUSE [THIS ARTICLE IS INTENTIONALLY LEFT BLANK.] ARTICLE X. ACQUISITION OF UNITED STATES TREASURY BONDS ELIGIBLE FOR TAX PAYMENT; PAYMENT OF TAXES, FUNERAL EXPENSES, AND EXPENSES OF ADMINISTRATION 10.01. Acquisition of Bonds. The Trustee may, at any time, without the prior approval or direction of the Settlor and whether or not the Settlor is able to manage Settlor's owri affairs, acquire United States Treasury Bonds selling at a discount, which bonds are redeemable at their par value plus accrued interest thereon for the purposes of applying the proceeds to the payment of the United States estate tax on the Settlor's estate; and the Trustee may borrow from any lender, including itself, with or without security, to so acquire these bonds. 10.02. Payment of United States Estate Taz by Bond Redemption. The Settlor directs that any United States Treasury Bonds which may be redeemed at their par value plus accrued interest thereon for the purpose of applying the proceeds to the payment of the United States estate tax imposed on the Settlor's estate, and which are held by the Trustee, shall, to the extent of the amount determined to be required for payment of the estate tax, be distributed to the legal representative of the Settlor's estate to be used by the legal representative ahead of any other assets and to the fullest extent possible to pay the estate tax. 10.03. Payment of Death Tazes and Other Estate Settlement Costs. After 1:he Trustee has complied with paragraph 10.02, above, and ascertained from the legal representative that all such bonds have been redeemed in payment of the United States estate tax, the Trustee. shall also ascertain from the legal representative whether the legal representative has sufficient assets to pay the remaining Legacy, succession, inheritance, transfer, estate and other death taxes or duties (except the additional estate tax imposed by Section 2032(c), or corresponding provisions of the Internal Revenue Code of 1986 applicable to the Settlor's estate and imposing the tax) levied or assessed against the Settlor's estate (including all interest and penalties thereon), all of which taxes, interest and penalties are hereafter referred to as the death taxes, interest and penalties. If the legal representative advises the Trustee that insufficient funds exist to pay all the death taxes, interest and penalties, the Trustee shall then pay to the legal representative from the trust property, an amount equal to all the death taxes, interest and penalties in excess of the funds available to the legal representative for this purposes, which payments are to be made ~~vithout apportionment. In making the payments, the Trustee shall use only those assets or their proceeds which are includable in the Settlor's gross estate for purposes of the United States estal:e tax and shall not impair the marital portion without first exhausting the entire non-marital portion. If the Executor of the Settlor's estate, in such Executor's sole discretion, shall determine that appropriate assets of Settlor's estate are not available in sufficient amount to pay (1) the Settlor's funeral expenses, and (2) expenses of administering the Settlor's estate, the Trustee shall, upon the request of the Executor of the Settlor's estate, contribute from the principal of the trust estate the amount of such deficiency; and in connection with any such action the 'Trustee shall rely upon the written statement of the Executor of the Settlor's estate as to the validity and correctness of the amounts of any such expenses, and shall furnish funds to such Executor so as to enable such Executor to discharge the same, or to discharge any part of all thereof itself by making payment directly to the person entitled or claiming to be entitled to receive payment thereof. No consideration need be required by the Trustee from the Executor of Settlor's estate for any disbursement made by the Trustee pursuant hereto, nor shall there be any obligation upon such Executor to repay to the Trustee any of the funds disbursed by it hereunder, and all amounts disbursed by the Trustee pursuant to the authority hereby conferred upon it shall be disbursed without any right in or duty upon the Trustee to seek or obtain contribution or reimbursement from any person or property on account of such payment. The Trustee shall not be responsible for the application of any funds delivered by it to the Executor of the Settlor's estate pursuant to the authority herein granted, nor shall the Trustee be subject to liability to any beneficiary hereunder on account of any payment made by it pursuant to the provisions hereof. IN WITNESS WHEREOF, the Settlor and Trustee have hereunto set their hands and seals as of the day and year first above written. ~~ ~'~ -. ~ -(SEAL) T ANDREW BURI~IOLI)ER, SETTLOR COMMONWEALTI~ OF PENNSYLVAivIA G~!~ SS: COUNTY OF ~~L On this, the ~ day of February, 2009, before me, a Notary Public, the undersigned officer, personaiiy appeared TROY ANDREW BI7RI~OLDER, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within Trust Agreement, and acknowledged that he executed the same for the purposes therein contained. IN WITNESS WHEREOF, I have set my hand and official Seal. ~~~z CQMfV10NWEALTF~ OF Pc!':i~lSYL1/AN(A Ot Public Notarial Scat Commission Expires: Teri k_.'r~,fatker, Notary Public Lemoyna 1:3c~n:,, ~;~.rr;i-,e~an~ aunty My Commission Expires Jan. 20, 2011 Member, Pennsylvania Association of Notaries The foregoing Trust Agreement was delivered, and is hereby accepted, at Lewistown, Pennsylvania, on February ~, 2009. 9 ~/Z ~ (SEAL) T ANDREW BURKHOLDER, T STEE WITNESS: SCHEDULE "A" SCHEDULE REFERRED TO IN THE ANNEXED TRUST AGREEMENT DATED: FEBRUARY ~, 2009 FROM TROY ANDREW BURKHOLDER, SETTLOR TO TROY ANDREW BURI~IOLDER, TRUSTEE PROPERTY DESCRIPTION: SAFE DEPOSIT BOX INVENTORY (NO VALUE TO CONTENTS) REV-485 EX + (3-04) ~. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 SAFE DEPOSIT BOX INVENTORY Please Print or Type MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS COUNTY CODE FILE NUMBER SOCIAL SECURITY IRequiredl OR DEATH CERTIFICATE NUMBER (only if SSN is unknown- 2010-00035 188-20-8796 DECEDENT'S NAME (LAST, FIRST, MIDDLE) DATE OF DEATH BURKHOLDER TROY A 11/20/2009 ADDRESS OF DECEDENT (STREET) (CITY) _ (STATE=) (ZIP CODE) 8 CEDAR ROAD CARLISLE PA 17015 NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX (NAME) DIANA D MILLER (STREET NAME) (CITY) __ (STATE-) (ZIP CODE) 8 CEDAR ROAD CARLISLE PA 17015 NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING a. (NAME) (RELATIONSHIP) DIANA D MILLER DAUGHTER (STREET NAME) (CITY) _ (STATE) (ZIP CODE) 8 CEDAR ROAD CARLISLE PA 17015 b. (NAME) (RELATIONSHIP) _ CAROL JEAN FULTZ DAUGHTER (STREET NAME) (CITY) (STATE=) (ZIP CODE) 10 NITTANY LION DR LEWISTOWN PA 17044 c. (NAME) (RELATIONSHIP) _ (STREET NAME) (CITY) (STATE) (LIP CODE) • NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED (NAME) FIRST NATIONAL BANK (STREET NAME) (CITY) (STATE) (ZIP CODE} 32 E MARKET STREET LEWISTOWN PA 17044 1 NAME OF PERSON MAKING LAST ENTRY DATE AND TIME OF LAST ENTRY DIANA D MILLER 12/1/09 12:15 pm DATE OF CONTRACT TO RENT BOX NUMBER OF BOX _ ~ TITLE UNDER WHICH BOX IS REQUESTED 02/17/1978 273 TROY A OR MARY A BURKHOLDE.R NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX a. (NAME) b. (NAME) TROY A BURKHOLDER (STREET ADDRESS) (STREET ADDRESS) 8 CEDAR ROAD (CITY) (STATE) (ZIP CODE) (CITY) (STP,TE) (ZIP CODE) CARLISLE PA 17015 NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY ELLEN SHEETZ BRANCH MANAGER WAS A WILL IN THE BOX? ~ YES ^ NO If yes, a. Date of will: 03/24/1980 b. Name and address of personal representative, if named in the will (NAME) DIANA D MILLER (STREET NAME) (CITY) (STATE) (ZIP CODE) 8 CEDAR ROAD CARLISLE PA 17015 c. Name and address of attorney, if any __ (NAME) CRAIG HACH (STREET NAME) (CITY) (STATE) (ZIP CODE) 1013 MUMMA RD SUITE 100 LEMOYNE PA 17043 as ist m etas . (2) Stocks: List in detail every common or preferred certificate, warrent or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) Obligations of U. S. Government: Number of items, date of issue, face value, names in which registered and type of ownership. i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. _ tem tem escription 8 on final safe de box contra - 8 A.AA envelope with 2 Columbus Mutual Life Ins Co brochures dated 6/5/72 CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I SAFE DEPOSIT BOX INVENTORY: lgp~ ~ M ~~... f /~ gnatu ~ ~n . - ~. tel. ri a rmt ame an c ec appropriate ox e~low. pmt TitTeELLEN SHF.FTZ ecDappr~opripateMox LER _ _ ~ Executor(trix) ~ Administrator(trix) BRANCH MANAGER Estate Representative ~]J_oint owner of safe deposit box ttac a > >ona s eet s i necessary or use up ~cates o t ~s page o "form.. - PA REV-1500 SCHEDULE B STOCKS and BONDS 1VC3 TROY A. BURKHOLDER & MARY A. BURKHOLDER JT TEN 330 OLD PARK RD LEWISTOWN PA 17044 ~unia~a va~~ inanci Corp. If you have any questions regarding your account, please contact Investor Relations at 1-800-368-5948 or a~t infoC~rtco.com. ACCESS YOUR ACCOUNT ONLINE! You can access and manage your account online through the Registrar and Transfer Company website~. To login, simply go to Www.rtco.com and click on "Online Services" to request a User ID and password. Issue# Account# Stock Symbol 5881 0002580004 JUVF.O OPTIONAL CASH INVESTMENTS MUST BE RECEIVED FOR NEXT Dividend Reinvestment Information INVESTMENT DATE BETWEEN 01/22/2010 AND G2/22/2010 Rcar_nrrl 1')atP- -t -t / i ~ / n o Pavahle Date'- i ~ I n i / n 4 Reinvestment Ootinn: T~TTT.T. AR TTJ~TG_C'i`Ml+'1JT RECORD DATE SHARES ENROLLED IN REINVESTMENT Amotxtt VVithheki From Gross Net Amount Security/ __ Certificate and Boric Shares Plan Shares Total Reinvestment Sha Rate($) Gross Amount($) Tax($) Fee($) Reinvested($) Gommon Stock 668.0000 315.9290 983.9290 0.20000 $196.79 $196.79 Plan Account Activity Date Description Fees and/or Commissions $ Net Dollar Amount $ Price per Sha $ Transaction Shares Total Shares in Plan ~~~ Forward 2 84.4 0 4 5 03/02 SHARES PURCHASED / DIV. $180.96 17.440600 10.3758 294.7803 06/01 SHARES PURCHASED / DIV. $182.93 17.750000 10.3059 305.0862 0901 _SHARE~__ PURCHASED _/.. DIV.-_ ._ -----.---.___ .-- __ _._$194 _.62 _ .1,7._949300. _ 10-.,..8428_--_-_ _ ~-- .__ 3.15_•._929.0... _ 12/O1 SHARES PURCHASED % DIV. $196.79 17.900040 10.9939 326.9229 Year-To-Date Investment Summary Total Dividertds($) Tax Withheld($) OptionaWoluntary Investments($) Fees and/or Gommissions Paid by You($) Tax ReQortaWe GarT>party Paid Fees and/or Commissions($) Total $755.30 $755.30 Total Holdings and-lwarket Value (Value of-all shares aYe based on -cast purchase price) Security Certificate Shares Book Shares Plan Shares Total Shares Price per Share($) ~Market Value($) COMMON STOCK 668 .0000 326.9229 994 .9229 17.900000 f $17, 809.11 ~1 f- ~ ; . t '1 .~ ' Transaction Form ' ,~, A hold tnriU be placed on a~ transactions if an address ~ -~; Juni Va t ll ` TROY A . BURKHOLDER & has oocurred,rritliinthb last 15 days- ' P i l Wi hd l _ a a ~~e - nn n ~ MARY A BURKHOLDER JT TEN art a t rava Continue Plan arti tion p `"~' . l/V . 3 3 0 OLD PARK RD Issue a certificate for this number of took and Issue#: Account#: LEWISTOWN PA 17044 plan shares 5881 0002580004 (Please indude s~aoo feet Signature(s) for issuance or sale and/or change of address. " Medallion Signature Guarantee required for sale request of 510,000 ar higher. All joint owners must sign. Names must be signed exactly as O tional Investment p Full Withdrawal Terminate Plan participation shown on this statement. {Partner/Officerlrrustee must sign as Partner/OfficerlTrustee.) Make check payable to: Registrar and Transfer Company Issue a certificate for all full book and plan _ Amount enclosed in U.S_ Dollars: ^ shares and a check for fractional shares Your Optional Investment can (Please incdide S1o.00 feet be a minimum of $500.00 per investment and a Address change air share transfer maximum of $3,000.00 per year Mark box and complete ttie appropriate portion on the reverse side ^ PA REV-1500 SCHEDULE E CASH, BANK DEPOSITS & MISCELLANEOUS PERSONAL PROPERTY ~, ~ ~ ~~ Gates, Halbruner, Hatch & Guise, P.C. 1013 Mumma Road, Suite 100 Lemoyne, PA 17043 Dear Sir or Madam, www.fnb-online.com Info-Line 1-800-817-8787 Customer Service I-800-~~55-5455 RE: ESTATE OF TROY A. BURKHOLDEF: SSN: 188-20-8796 DOD: 11/20/09 As per your request, the following information is provided as of Date of Death: CD # 173 007263 5 Opened 2/14/08 Titled Troy A. Burkholder, Sr Balance $15,300.51 Accrued Interest $5.03 Safe Deposit Box # 210002739 Opened 9/ 1 /89 Titled Troy A. Burkholder, Sr. Mary A. Burkholder Location: Lewsitown Branch (717) 248-4951 Account Closed 1/25/10 Box Closed 1/25/10 If you should have any further questions, please do not hesitate to contact me at 724-983-6068. Very truly yours FIRST NATIONAL BANK ~~ ~ ~~ Deborah L. Bartosh .~ 1 ~,~' ~~'" v ~r ~~~( ~ ~~ .-. ~~. ~ . ~. IVO. 5007407 ASA1 DATE ACCT. NO. DESCRIPTION DR. CR. 01/11/2010 01/11/2010 218002 513614 FEDERAL TAX W/HOLDI2JL9167573 EIA FP PP.RT SURR. RNWL9167573 500.00 50.00 Please retain this portion for your records OM Financial Life insurance Company PO Box 81497 Lincoln, NE 68501 ,. .,~ ._ ~ ,_ .., - {~L~ - 'f ~ - 3. - ..- -~ ~ t~•sf~h ~~ 4'sJ~• ~ ~:~ `~Qy.i~ ,,.`!,. •,t7~j~4 tar 4. ~~ ,ssF ~ s~'',~. :.Si" h O€~'! FlNAhdCtAL LIFE !~SlJRA,hlCE C4~lPAMY JPMorgan Chase Bank, N.A. ~~~; ~.~ r, e; ~ i~~ P.t7. Box 81497 Lincoln, NE 68501-1497 Columbus, OH ~~~ ~ ~~~ -ly 56-1544_ .Void if Not Cashed Within 60 Days 441 Date: January 1I, X010 ~~~Oo00 /~~~, Four Hundred Fifty and 001i00 --------------------------------------.._.._._..----------------------------------------------.._...--•------- ~Saf~R,•s ;7~ ~/~• DIANA D MILLER O~~~l.r O~ 8 CEDAR RD CARLISLE, PA 17015 "'""°"~° `~`"~ ~, End {nsurance ~~,. Group 100 Erie fns. PI. Erie. PA 16530 NOT{CE OF PREMIUM REFUND DATE MO. DAY YR 12 21 09 DPt64G t/0 REFUND AMOUNT $29.00 POLICY NUMBER Q06 040881 I H AGENT NO. AA7665 AGENT'S NAME APPLE INSURANCE AGENCY REASON 3 REF. No. 2536350 c~tECK No. 26536350 TROY A BURRHOLDER C/0 DIANNA MILLER 8 CEDAR RD CARLISLE PA 17015-9752 AA7665 NON-NEC~OTIABL-E ~~,~ ~~ ,~.s'~ ~~ ~N 6'~`` FINAL SETTLEMENT SELLER NAME ~~~~~~ ~ ~ ~~ t~S DATE OF SALE ~3- S '~" ~-ro- L [1 4DDRESS _OCATION OF SALE PHONE ZIP AUCTIONEER PHONE SELLE~t` ~Xf'E~~ - Cf _~ PROFESSIONAL FEES AUCTIONEERa2~~ $ ~ ~ Z ~ -~ ~" CASH $ ~-~~Y1eQr'" .~,~-- $ I ~ ~~ . 0 o CHECKS $ v~~lc~~ CASHIER $ OTHER RECEIPTS OTHER EXPENSES ~ t~~ #~11-t- ~ ~ $ °~ ~ ~ 1 S•S~ ~t r--~ _ $ ~. ~ (~ _~~ ~~ r ~ ~ ~ ~ Fad--~3~ _ $ ~ ~ ~~ . ~fl $ E ~~..fJ"t -- $ $ -- $ $ $ - $ $ TOTAL RECEIPTS $~~'-t---J r~~ .~ $ LESS TOTAL EXPENSES $ ~ ~ ~~ • ~- TOTAL EXPEt~ISES :- .s - _ NET PROCEEDS PA1fABt~ TC} SEttElt $ ~' y ~.p.~~ ~.~ ~~ ((or we), the seller, accept this settlement and acknowledge recei t of the above specified net proceeds firom the auction of my goods and property sold on the above date. Paccept al} responsibility for providing merchantable title to all goods, and property sold, and for delivery of title to the purchaser. - ~=-= Date uctioneer or Cashiefr's 'nature (Seller`s Signature t~~ ~ ~.. ,~ F~ ` ~~ ' oar 2310 35956631 TINT TEXAS NS C~TAX RE~U~p pUS tCA . ~~ 2$ .~ 0 30 QBUR~ r ~ ~~~ ~~tt~ pt`~ti~ 0~~' ~trAt~ 31 200~p900 I30 ,1 2310 35g56b 12/09 ~~~.IN,~~111.~~~~;i1~1 C 31 R~*~~1155*oQ pay to IAA MILLER~~~~R p~Cp the order ~~ B DY p BURK`H $~ E p AR RDA 1 015 - 97 5 2 .~~_~_~:,~,_sfl --„tt :- =t1~~=tt-t.=-'1-,`_-i~--,~i~~== i C ~ 4~ ~ E-. 1 Yf ~3. i . t''' ~ ~'~"~ 1='=1- '"-`t~ lit-t ` 'i!t_ ' "~ S ~. E" r y :mil -~ ~ ~t' 1~~~ ~~1,.-~.. ~~,~:_ ~-~~~t_~~.,~~~;t ~~~ y ~ - t1'-~ ,~`-i i~ ~ ttt,~_t,- t, fc~~" ~~~'"'' ~'~"t't, a'i!1~ ,yc~ ;~1=~--- =i~;_~~_t~N~~ ~ ~t; ,~~~~ i~};,~~ ~iYt„_r.~;1"-~itt= -;~.;; t 1_.i _- it: - _ ~- i:" Cl 4 D~ L 0 35g5~,~,3 ~,'~ ~V ~ r ~~ v~ ~~~ I~'6L9ti28L8ii' ~:03L30Lti22~: L2L9 538ti7~i' .. , . DO NOT ACCEPT WITHOUT HOLDING TO LIGHT TO VERIFY WATERMARKS. ~u ~~~~ ~ (~~~~ ~~~ ~,i~ ,~ C~ ~~ ~~ ~~u~Q~ ~<.J~i r-. V. wn i v~o ~ni~, r r ~ v~.,v ... .._.».r ~_._....__-- --- - '~~~ Exchanae Member Erie insurance Group CANCELLATION NOTICE 100 Erie Ins. PI. Erie, PA 16530 MAlL DATE O4/ 14/ 10 CANCELLATIOfV EFFECTIVE BAL: $104.00 CR POLICY NUMBER Q06 0408811 H 04/13/10 12.01 AM POLICY EFFECTIVE DATE 06/04/09 PIONEER FAt~iILY AUTO POLICY STANDARD TIME NAMED INSURED TROY A BURKHOLDER C/0 DIANNA MILLER AA7665 8 CEDAR RD CARLISLE PA 17015 WE ARE NOTIFYING YOU THAT THE ABOVE POLICY IS CANCELLED AS OF THE CANCELLATION EFFECTIVE HOUR AND DATE SHOWN ABOVE. IF WE HAVE BEEN ASKED TO PROTECT OTHER INTERESTS, WE ARE REQUIRED TO ADVISE THEM OF THIS CANCELLATION. THE REASON FOR THIS ACTION REQUEST OF NAMED ENSURED -SOLD PREVIOUS BALANCE UNUSED PREMIUM PRESENT BALANCE 00113 -~ ~~~_~ $ . 00 ~ < $104.00 CR $ CR REFUND CHECK ENCLOSED AA7665 APPL APPLE INSURANCE AGENCY ,, p C 9 I ./ ; p~ /~~ ~ I /~/1 ~I _ l~l~ 932EXC 6/00 ~ Old ~5u rci~ ~~C 100 Erie Ins. PI. Erie. PA 16530 AA7665 REFUND AMOUNT ~ ~ 04 • '~0 POLICY NUMBER Q06 04'08811 H AGENT No. AA7665 AGENT'S NAME APPLE INSURANCE AGENCY REASON 1 REF. NO. 2767241 CHECK NO. 267672'41 TROY A BURKHOLDER C/0 DIANNA MILLER 8 CEDAR RD CA.Rt ISLE pa 27015 ~~~~ ~~iSt,~s~C~ ~~fl~~ 100 Erie Ins. PI. Erie, PA 16530 PAY TROY A BURKHOLDER Tfl C~ G DIAAII`dA IIiLLER THE 8 CEDAR RD flRflER CARLISLE PA 170I5 OF coop REASON FqR Ci-IECK Premium Refund Due 10 Code 1 • Pdicy C2ncelied Code 2 • Policy ExpirerJ Code 3 • Premium Reduction Code 4 • Orerpayrnent VOID 180 DAYS AFTER DATE POSITIVE PAY PROTECTED POUCY NUMBER AGENT REF. NO. QOfi 0408811 H AA7665 2767241 DATE MO. DAY YR. 04 13 10 NON-NEGC>TIA~L-E oBnittliafv~i-u:a~iiSfu3iGtft,u~ri~ti:ii~l ~iy-i~io Sarsk of America, NA 6 t 1 Ailama, Canty, Georgia DATE C~:CR NO= 267b7241 M©_ DAY YR 04 13 10 $104 , AGO Securih inturca i~tluelcQ t)etxili oc btcl~ EXACTLY ~'~*~~j~ 104 D(}LLARS AND 00 CENTS ~~~~. AUTHORt~=D SIGTIATURE 11'267672~4~1f' ~:061Li2788~: 3'9 999 651411' THE ATTACHED CHECK IS AN OVERPAYMENT REFUND ON YOUR DISCOVER CARD ACCOUNT NUMBER THANK YOU FOR SHOPPING WITH DISCOVER CARD. ~ ~~ r~rllrlr~~ilrrirrir.rirrirrrr.i...r.jrir„iliiili•iirlri~irrlril c • ~~~ i 1 ESTATE TROY A BURKHOLDER 1 8 CEDAR Rn ~1 1~ CARLISLE PA 17015-9752 oars cf~cru~ t~~ceosatwr ~rxr~ 02/O1/IO 9275196 $1.49 02b40249876 DISCOVER BANK NEW CASTLE, DELAWARE 62-64/311 _- -- - --z ------ ----- --- -- ---- ----------- - -- . ____ __ __-x- __ _- ~A~ ~ ,_ __.... --- -- - - ` _ _ ~ ~ - ---- ~~c ~ ~ ~ ~ tom. ; oou.A~ ~c~n~ rl,6~iTi-1~ DAY YEAR ~ ` ___ ___ _ _ _ _ ~_ _k _ __ _ $ -._~_.g__~ 02 ~ 41 f ~. 0 ~ _ 9275198 ~ ^ 0264024987b PAY ~' ~~_`__~._ 1 4 ~~ ~rartlE ESTATE TROY A BURKHOLDER ~ ~0~"°~S°"°"~ ORDER $ CEDAR RD uF CARLISLE PA 17015-9752 J~1 -~' 9 2 ? 5 ]~ 98~~' ~:0 3 ~ 100 6 4 9~: ~, 40000(]08 9~~' Form 712 (Rev. May 2000) Life Insurance Statement OMB No. 1545-0022 Department of the Treasury Internal Revenue Service DeCedellt-It1SUCed (To be filed by the executor with Form 706, United States Estate (and Generation-Skipping Transfer) Tax Return, or Form 706-NA, United States Estate (and Generation-Skipping Transfer) Tax Return, Estate of nonresident not a citizen of the United States.) 1 Decedent's first name and middle initial 2 Decedent's last name 3 Decedent's social security number 4 Date of death Mary A Burkholder (if known) 191-32-9734 05/18/2007 5 Name and address of insurance company The Prudential Insurance Com an of America PO Box 13902 Philadel hia, PA 19176 6 Type of policy 7 Policy number Family Policy 22244756 8 Owner's name. If decedent is not owner, 9 Date issued 10 Assignor's name. Attach copy of '11 Date assigned attach copy of application. assignment. 11/01/1961 12 Value of the policy at the 13 Amount of premium (see instructions) 14 Name of beneficiaries time of assignment Tana D Miller Executo r Of The Estate Of $0.00 roy Burkholder 15 Face amount of policy 15 ~> 1, 4 8 8.0 0 16 Indemnity benefits 16 9; 17 Additional insurance 17 9' 18 Other benefits . 18 9~ 19 Principal of any indebtedness to the company that is deductible in determining net proceeds 19 9i 20 Interest on indebtedness (line 19) accrued to date of death . 20 y; 21 Amount of accumulated dividends 21 ~' 22 Amount of post-mortem dividends 22 9> 4 3 .9 0 23 Amount of returned premium 23 9i 24 Amount of proceeds if payable in one sum 24 9> 1, 4 3 9.2 0 25 Value of proceeds as of date of death (if not payable in one sum) 25 ~6 26 Policy provisions concerning deferred payments or installments. Note: If other than lump-sum settlement is authorized for a surviving spouse, attach a copy of the insurance policy. Cash dividend paid but not earned: $92.70 27 Amount of installments 27 :6 28 Date of birth, sex, and name of any person the duration of whose life may measure the number of payments. ~~~! 29 Amount applied by the insurance company as a single premium representing the purchase of // installment benefits 29 30 Basis (mortality table and rate of interest) used by insurer in valuing installment benefits. 31 Were there any transfers of the policy within the three years prior to the death of the decedent? ^ Yes ^ No 32 Date of assignment or transfer: Month Day Year 33 Was the insured the annuitant or beneficiary of any annuity contract issued by the company? ^ Yes ^ No 34 Did the decedent have any incidents of ownership on any policies on his/her life, but not owned by him/her at the date of death? ^ Yes ^ No 35 Names of companies with which decedent carried other policies and amount of such policies if this information is disclosed by your records. The undersigned officer of the above-named insurance company (or appropriate Federal agency or retirement system official) hereby certifies that this statement sets forth true and correct information. --('"~~ / j„~ 1 _ ~~ ~ f Vice President, Signature - a YY~ (ft1~ Title - Customer Service Office Date of Certification - 0 5 / 17 / 10 Cat. No. 10170V Form 7~2 (Rev. 5-2000) f PA REV-1500 SCHEDULE G INTER-VIVOS TRANSFERS and MISCELLANEOUS NON-PROBATE PROPERTY ING ~v March 19, 2010 Law Offices of Gates, Halbruner, Hatch & Guise, P.C. Attn: Traci L. Sepkovic 1013 Mumma Road, Suite 100 Lemoyne, PA 17043 RE: Troy A. Burkholder C045247-OX Dear Ms. Sepkovic: Below is the information that was requested on March 19, 2010. Contract Number: C045247-OX Type of Contract: Individual Annuity Date of Death Value as of 11/20/2009: $5,293.57 Owner: Troy A. Burkholder Should you have any additional questions or concerns please contact our Customf;r Service Center at 1-800-366-0666 and a representative will be happy to assist you. Sincerely, ~laria~,ile ArZniiity Cer~i~ec JH Annuities are issued by ING USA Annuity and Life Insurance Company and distributed by Directed Services LLC, member NASD. Both companies are members of the ING family of companies. 909 Locust Street Des Moines. IA 50309-?899 lNG USA .4iunrrti~ and L(/E~ Ii7stn-arxc~ C~nmj~nrti~ JH / DIANA D MILLER EQ(1001117405F SquiTrust Life Insurance Campany 5400 University Avenue West Des Moines, Iowa 50266-5997 1-866-598-3692 PHILLIP J MILES 2854 N 2ND ST HARRISBURG, PA 17110 23 March 2009 RE: POLICY NO. EQ0001117405F OQVNER: DIANA D MILLER DELIVERY INSTRUCTIONS PLEASE DELIVER THE ENCLOSED DELIVERY NOTICE TO THE OWNER AND H,aVE IT SIGNED AND RETURA: IT TO THE HO?.~E OFFICE. PLEASE DELIVER THE FOLLOWING ENCLOSED DOCUMENTS TO THE OWNER: PRIVACY NOTICE CONTRACT SLnviMARY BUYER' S GUIDE Application Checklist ~ J 7 0 °~ Client Name: , ~ ~ ~_ ~ I (,( -'~(~1 Date Subm: Company: Product: _['~~ ~ -~- }(~ l.~ Prepaid / Transfer Q / ~ Amount: $ ~~~ Transfer from: ~f~~P ~.~ ~ ~f'rm rTrn ~ t ~t Y'~~C~~P~ I't nr1~ )- ~"a ~_ ~I I~ D Date: Poticy #: ~O I ~ t`1 ~ ~ ~ Issue Date: c..~ C°~~? Agent #: ] ~~ ~ ~~- N~TES: ~ ~ `.. ~. ' o ' ~y ~a - ~ ~ l ~ ~~r~ ~~~-- d yes ~~ a-~- U~.~- -~ o -~~ l l ~.~ed ~h t P ova- ~ ~-~-~b~ 1 ~ -~x-m . Q~n:~ ~~ t -~ ~, ~t ~Q ~ ~~,~ ~ ~ v' ~ ~3- PGA.' t ~~ ` ~'e. /~ -~-~- ~~~mo~~ ~ v-~- ~ ~Sv 1=~b P ~ n p ~1~ ~ _ ~.~ ~ ~ 3~ ~~ rtCF~~/P~ CDn~rm~-~' ~~ ab~~ ~~~ ~ _ ~ ~~ ~a 1 I Pol.Rec. Date: ~ DeI. A t. Date: PP ~, Notes: ~~ ~~~ E 1.1 l~~' Ll S t 1 Financial Services ANNUITY APPLiCATI~N Product ~~Ott~,G} Ian ~~p~~S Lr~c4C.x EquTruat Lice Insur>tnce Company 5400 Ur~rersity Ave Attn: Box 14500 West Des Il~faines !A 50266 Contract #t , (Hortlo OfFice Usa Ony) t~rirn Lef1~Y Pnoduver Name Fun Offlc~ Itddress olllce Phone ~ Pr~oduoer ~ X '~ l~c~a All references to "the Cornp~tny` sRafi mean EqulTrost Life ice Company of West Des Moines. Iowa, 602. 1~. C~ompleta Name (`Rrat~niddls-last} f 2 Canpb/e Name (firs!-rrliddleaest) 2. Sex 3. Age 4. Date l 13. Sex 14. Age 15. t3irM Date 5. Residential Address 16. Resideertial Address 8. City 7_ State 8. ZIP 1 T. City 18. Slate 19. ZIP 9. Soc6il #~ 10. Daytime Phone # r w ~ .- 23. Complete Name (first-+rlid~s-fast) 20. Sodas SewrRy # 21. Dayt6na Phone # 33. Con+pbte Name ~ddo~st) 24. Sex 25. Age 26. B6th DaM 34. Sex 35. Age 38.66th Date 27. Residential Address 37. Residential Address 28. City 29. State 30. ZIP 38. Cry 39. State 40. ZIP v ~ . v.,um .mew nr~ ~ ~ ~~ R I JL unyarr~e rrlorre ~ I gi . Jocl~l l@QYI[y/ i Ih iF 14.1. Ua~T11B rnorte $ Benclklary proceeds will be split equally if no perr~ntages:n provkted. Kl~M ownership is elected, "surviving spouse° must be lisbd as prsrlary berretkiety. PRIMARY: Fu.~ t+ia~ (i~~ooi~a.Aa~ aa~ttrw ~-rot~ ro awn ~ecerrr ~c>J8~ lcy0'/• rte.. ...._..~., .~.._.._ _ coNnI~I~ENT: ~ tt~ (w~esr-iroo~-~s1~ sa~lts~ ia~u-nowe~ ro o err ^ Pleeso check here if you are attaching adddbnal Bwxllcbry iniorrhatbn. ^ !RA Transfer ^ IRA Rolbver ^ IRA Corrtribt~fion -Tax Year ^ SEP !RA ^ Simple iRA ^ Roth IRA ^ Roth Conversion !RA ~ Nonqualifisd ^ athsr Pieria aocep~6ed but NoT adminisRered by EgwTrust Life insurance Company: ^ Keogh/Corporate Pension ^ Sec. 457 Def. Comp. ^ Other 436-121(03-06) Page 10(3 - lnoompbtie without aN pages a. Does either the Owner or Prpposed Inatmed have any other life ir~seranoa pufid~es or annuity oontrads'T (~ Yea ^ tJo K "Yes" and rsgtsired by your state, complete the ReplacemerK Natlce b. Is the t:orttrod applied br replacing or likely to nepmce any existing like insurance o- annuity oont ~ 'Yes K 'Yes'. complete your state-apecitfe Notice ,~-t-~' For applk~trrta in C or : It is unlawful to Iv~onMngiy provide false, incomplete, or misleading fads or' infom~ation to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading fads or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the poiicytx~kier or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Qivtsion of insurance within the Department of Regulatory Agendas. For applicants in the District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penafties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially reNaied to a claim was provided by the: applicant For appllcartts in F orida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an applk~tion containing any false, incomplete or misleading information is guilty of a febny of the third degree. For applicants in C: Any person who knowingly and with intent to defraud any insurance comF-any or other person tiles an application for insurance containing any materially false information or conceals, for the purpose; of misleading, information conoerrting any fact material thereto commits a fraudulent insurance ad, which ig a crime. For applic~n~s In Ne~v,Jersev: Any person who includes any faire or misleading information on an apF~ication for an insurance pdicy is subject to criminal and civil penalties. For applicants in Qj, ji g: Any pen;on who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or flies a claim containing a false or deceptive statement is guilty of insurance fraud. For applicants in V nia: It is a crime to knowingly provide false, incomplete or misleading informatia~ to an insurance company for the purpose of defrauding the company. Penalties irx~~de imprisonment, fines and denial of insurance benefits. For applicants in Nebrgska. Orevort, and Vermont Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties. For applicants In Washtrunt~on: Any person who knowingly presents a false or fraudulent claim for payment of a Ion or knowingly makes a false statement in an application for insurance may be gui~y of a criminal offense undesr state law. For applicants in AlL OTHER STATES: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information conoeming any fad material thereto commits a fraudulent insurance act, which is a crime and sut~jeds such person to criminal and civil penalties. 436-121(03-06) Page 2 of 3 - Incampleb without au pages e~ a. Pr~ernium Surfed with Appkation i b. Ar~tfdpated Value of 1036 F~ochanpell'ransler/Rollor-er i CERTIFICATION . Under perraRfes of perjury, 1 taertFy drat 1. The numbs; shown Der this faeen is error Domed taxpayst idenit~k~ltion +number (a 1 am waiti~ Ior a rnerrrber b be i:swd b me), :nil 2. 1 am not subject b backup wilhho~drp because: (a) I am exempt Iran bada~p vritlrholding, or (b) I haw rwt been nofried by 1M Internal Rewrwe Service (3RS) that I am subied b backup wilhlnoldirp ss a resieR of a faiure b report a!f iraerest or dividends, of (c) tM IRS has noticed me 1Mt ! sm no krrgar subject b tradaip wWeoldiep, and 3. I am s U_S. psrwer (i~dudinp a U.S. residernt alien). You must cross out Item 2:bow if you haw been not7ied by firs IRS that you are wrrertily subject fo backup vrrifhhoktirg because you have t'aiisd b spat all IrMaerrrt and dividends on yaw tact reEureL For vast estate trsr~lloens, !Darn 2 duos not apply. For morlQaQe ierterest paki, aogerisMbn a abaerdoerrtNett d secvre+ed properly, anoaratbn d debt; ooeetrrbr#iorrs b an indnridual roti-eenent artaeperrwnt (IRII), and Hera other ttran irrlseest and dividends are eat b tlee CsrM7ra but must ovide caned TIN. UvVb dsdare that s! statements in this AppRca#bn an bw to the best of mylour lo~owledge and bNief. and agree that this AppNcatbn shaf tie a pz~ of the Annuity Carrtrail issued by the Company. Acceptance of any Annuity Contrail issued on this Application shag oorr$titut~ ratitlcation of any corrections, additbns, or changes made by the Compsrry and recorded 4t the space "Special Requests, Remarks end Con~edbns ar Endorsements' eiooept that no change shaft be made as to amount, claseillcatbn, plan ar benet~a, unkes agreed ib h writing. ~ is understood that ra pr+oduar ar other unsutlwrized parson aocoept an Exe~a+tive Goer or an Assistant Secretary of the Company fi suthortoed to waive brfeitunts, b make or alter corrhsds, or to waive arty of the Company's tights or roquirementa. The !Nernst Revenue Service does not roqulre your constM to any provision of this docun+ent otfier ttnan the cert#fications required to avid tlsckap wlthhoidlrg. K the contract applied for conffiins a Market Value Ad~usbnent provision, payments and ~altses af~e subjec# ~ a ilAarkat Value Ad}ustment which may result In upward or downward ad/ustrnents in amounts wltlxsrawn or surrendered whin a Surrender Charge is deducted. Slyned / /~ and ~ r f Date ajl~~o9 ~>e ~ ~ "~ ~~es ~ t~ if 'Yes", please explain: ~~x1~.~ ~P~ - Q l ~ ~ ~rt~nn ~~ iC' for any repiaceirnent, indic:srts the type of coverage proposed m be nptsced: ^ 'Term Lice ^ Whole Life ^ Variable Lifie 'Fixed Annuity ^ Variable Annuity ^ Other - be specific 2. Advertising materials: • I a~Y that 1 used only insurer~pproved salsa mafiarial with this Application and that an original or a Dopy of all salsa mathriat eras left with the Pnaposed Owner. • 1 oerfify chat a printed copy of any electronically presenbd vales material was/w~l be preser>bed m the Proposed Owner no labr than the date the Contract is delivered. 3. i certify th Application is in aooordsnca with the Company's written statement of the Company's po with ro tri the acoe bility of rspla nfia. ~~ la~o9 ~gnaturo doter pab 436-121(1)3-06) Page 3 of 3 - incotnplate wittwu! ah payee i . WIM tt,is plan replace any existing life ir>st~ranoe or amuity? (Using the de16n'rtion of Replacement adoptrid by your state.) AV l VA Aviva USA 611 Fifth Ave. Des Moines 1A 50309 Tel 800 343 5660 vvww.avivausa.com March 22, 2010 Gates, Halbruner, Hatch & Guise, P.C. Attn: Traci L. Sepkovic 1013 Mumma Rd, Ste 100 Lemoyne, PA 17043 Re: Troy A. Burkholder Policy #30EL767265 Dear Ms. Sepkovic: Thank you for your recent request for information regarding the policy referenced above. This policy was an IRA issued on August 24, 2007. Troy A. Burkholder was the sole annuitant and owner of this policy. The beneficiary designation is Diana D. Miller and Carol J. Fultz, daughters. The date of death value is noted below. Date of Death: November 20, 2010 Account Value: $ 87,059.58 if you should have any questions, or need additional assistance, p{ease do not hesitate to contact our Customer Service Department toll-free at 1-800-343-5660. Cordially yours, ~~ Jen Bradfield Claims Administration Specialist VJ American Investors Life Insurance Company, Inc. Aviva Investors North America, Inc. Aviva Life and Annuity Company Aviva Life and Annuity Company of New York Aviva USA Corporation ~~ o~D MuTUa~ rset i;~ifj"s:~zi ~s:'saneiat t~eik=.~€rr% 777 Research Drive Lincoln, Nebraska 68521 PH 1.866.702.2194 FX 402.479.0198 OM FlNANC1AL LfFE INSUPANCE COMPAN'f Otth FINANGfAL LIFE INSURANCE COMPANY OF tvE~V YORK. :March 22, 2010 Gates, Halbruner, Hatch & Guise, P.C. Attn: Traci L. Sepkovic, Paralegal 1013 Mumma Road Suite 100 Lemoyne, PA 17043 Policy: L9102165 & L9167706 Owner: Troy Burkholder Annuitant: Troy Burkholder Dear Ms. Sepkovic: I am writing in follow up to your letter dated 03/16/2010 on the policy referenced above. The information reduested is listed below. L9102165 Title of Account: Spectrum Rewards Reserve Joint Owner(s): None Issue Date: 10/31 /2005 Beneficiary: Carol J. Fultz & Diana D. Miller Date of Death Value: $8;059.36 Interest from 1/1/10 to Date of Payment: $9.88 Credit/Loan Balance: None L9167706 Title of Account: Spectrum Rewards Reserve Joint Owner(s): None Issue Date: 01/18/2008 Beneficiary: Carol J. Fultz & Diana D. Miller Date of Death Value: $13,144.11 Interest from 1/1/10 to Date of Payment: $51.37 Credit/Loan Balance: None w w w o m f n c o m Old Mutual Financial Network is the marketing name for OM Financial Life Insurance Company (Home Office, Baltimore, MD); and OM Financial Life Insurance Company of New York (Home Office, Purchase, NY). ~, ,~ ~ ~ ~ j.,'~ ~ rM FINANC;iAL t_IFE INSURANCE CUPJIPA.NY k~~~.••JJJ"' t ~ rJp~ F;h„~ANCIAI LIFE IP~Sl11~ANCE COfJI~'AP~!'f OF Nc~N YC)iil4 If you should have any questions, please do not hesitate to contact us at 1-866-702-2.194, extension 3322. Sincerely, Ashley Young Life Claims Examiner OM Financial Life Insurance Company Old Mutual Financial Network is the marketing name for OM Financial Life Insurance Company (Home Office, Baltimore, MD); and OM Financial Life Insurance Company of New York (Home Office, Purchase, NY). Barbara .A. Stringer MIFFLIN COUNTY RECORDER OF DEEDS REGISTER OF WILLS CLERK OF ORPHANS' COURT Courthouse 20 North Wayne Street, Lewistown, PA 17044 Phone: (717) 242-1449 RECEIPT FOR PAYMENT Instrument Number: 2009-000676 Instrument Type Indexed Party: DEED BURKHOLDER TROY A SR AKA Receipt Distribution Fee/Tax Description Payment Amount DEED 14.00 DEED - WRIT .50 DEED - RTT STATE .00 MIFFLIN COUNTY SD .00 DERRY TOWNSHIP .00 DEED - A/H 11.50 J.C.S. / A.T.J. 10.00 CO IMPROVEMENT FND 2.00 REC. IMPRVMT FUND 3.00 Check# 1~?044 $41.00 Total Received......... $41.00 Record Date: Record Time Receipt No. Recording Page Count: 6 N O O O 0 C7 2/23/2009 01:46:27 215634 Paid By Remarks : REC' D MAIL/GATES HALBRUNER CH T BURKHOLDER/BURR:HOLDER TRUST I t~reby R"'IF'Y t tI><is d~c~t ~~ r~rdcd In tit Recorder's ~#~ce cif IV[Iftliin County, Pennsyhr~ni~ '~ ~~~s .'~ S :7 S. Certification Page DO NOT DETACH This page is now part of this legal document. Saebara A. Stringer" Re~grder of peeds NOTE: Some information subject to change during the verification process and may not be reflected on this page. PREPARED B~' AND RETURN TO: CRAIG A. HATCH, ESQ. GATES, HALBRUNER & HATCH, PC 1013 MUMMA ROAD, SUITE 1100 LEMOYNE. PA 17043 TAX PARCEL NUMBERS: 16.03-0101 & 16.03-010? DERRY TOWNSHIP DEED THIS INDENTURE Made the 9`'' day of February, in the year two thousand nine (2009). BETWEEN TROY A. BURKHOLDER, SR., a/Wa TROY A. BURKHOLDER, widower, now of 330 Old Park Road, Lewistown, Mifflin County, Pennsylvania, 17044, party of the first part, GRANTOR, AND TROY ANDREW BURKHOLDER, Trustee of THE BURKHOLDER FAMILY TRUST, dated February 9, 2009, now of 330 Old Park Road, Lewistown, Mifflin County, Pe1111SyIVallla, l 7044, pal"ty of the second part, GRANTEE. WITNESSETH, that said party of the first part, for and in consideration of the sum of One ($1.00) Dollar, lawful money of the United States of America, well and trilly paid by the said party of the secolid part to the said pa--ty of the first part, at or before the sealing and delivery of these presents, the receiipt whereof is hereby acknowledged, has hereby granted, bargained, sold, aliened, enfeoffed, released, conveyed and confirmed, and by these presents does grant, bargain, sell, alien, enfeoff, release, convey and confi--lrl unto tiie said party of the second part, his heirs, successors and assigns, PARCEL NO. 1 ALL THAT CERTAIN piece, parcel or tract of land situate in the '1~ownship of Uerly, County of M iffl in and State of Pennsylvania, bounded and described as follows, to wit: IiEGIltiTillivG nt n pviiit iii tlic Gciitcr iiilc of tilt piibliC rond leading tO Tvcwtoii alGiig iilie of ti~ic yard ciiGc; thence along the line of said fence in a northerly direction 120 feet to a post and the end of a stone retaining wall; thence along other lands now or furlrierly of C. Lintrler Ada~ils et ux., in a general westerly direction 1 13 feet to a point; thence along said other lands now or formerly of C. Limner Adams et u~., in a general southerly direction 220 feet to a point in the center line of the aforesaid public road; thence along the center line of the said public road in a general easterly direction 276 feet to a point in the center of the aforesaid public road, the place of BEGINNING. BEING bounded on the South by the aforesaid public road, and on the East, North and West by other lands now or fonrlcrly of C. Limner Adams ct ux., and having thereon erected a farm dwelling h~~iise, chicken house and other ili~provements. TOGETHER with the right in the grantee, his heirs and assigns, to the use in conu»on with C. Limner Adams et ux., their heirs and assigns, of a right-ot=way and driveway 30 feet in width extending along the eastern side of the premises herein above conveyed from the aforesaid public road to other lands now or formerly of C. Limner Adams et u~., with the fi-ee right of ingress, egress and regress in, to and over the same. TOGETHER also with the free right and privilege in the grantee, his heirs and assigns, ofthe use of water from the spring upon other lands now or formerly of C. Limner Adams et ux., said spring lying to the west of the premises herein conveyed with the right and privilege at the expense of the grantee, his heirs and assigns of laying, maintaining, replacing and repaic•ing a pipe line or pipe lines from the said spring to the premises herein conveyed with the free right of ingress, egress and regress in, on, over and to the lands now or formerly of C. Limner Adams et ux., for the purpose of laying, maintaining, replacing and repairing said pipe line. BEING Tax Map Reference No. 16 ,03-0101. BEING the same premises which Troy A. Burkholder, Sr. and Mary A. Burkholder, his wife, b}~ their Deed dated July 23, 1971 and recorded in the Recorder of Deeds Ofifice in and for Mifflin County, Pennsvlvania, in Deed Book 194, Page 320, granted and conveyed unto Troy A. Burkholder, Sr. and lVlaiy A,. Burkholder, husband and wife. Mary A. Burkholder departed this life, thereby vesting complete title under operation of law to Troy A. Burkholder, Sr., Grantor herein. PARCEL NO. ALL THAT CERTAIN vacant parcel of land located in Derry Township, Mifflin Count}~, Pennsylvania, bounded and described as follows: BEGINNING at a set iron pin along a 33-foot right-of--way I:nown as Old Park Road; thence along residue lands now or formerly of Fred A. and Beverly K. Adams North 29° 56' 23" West 257.55 feet to a set iron pin; thence along same North 58° 31' 16" East 463.20 feet to a set iron pin; thence along same South 33° 56' 15" East 150.00 feet to a set iron pin at the nor±l~ern edge ofOld Park Road; thel~ce a!o~~g O!d Park Road, South ~b° 03' 45" West 135.J % feet t0 a point; thence ali~ng Saille SOlltll ~~~`~ ~=~-' 4.; '' Vest ~~.~b t;et t0 a polllt; thence alo~~g same South 38° 1 3' 00" W~Yst 30.52 f~Yet to a point at tl~e corner of land no~v or f{~~.i~~~rly of Troy aiirj Mary Riirl<holdc~r; thence along land now nr foi-ii~erly of RiirkhnlriPr North 26° 29' 34" WE~~t 1O8.O6 feet to an existing post; thence along same South 69° O l' 20" West 109.99 feet to an existing post; thence along same South 14° 32'.38" East 193.48 feet to a point along Old Park Road; thence along Old Part: Road South 45° 08' 26" West 96.61 feet to a set iron pin, the place of BEGINNING, CONTAINING 1.62 acres and being Proposed Lot Addition on a Survey by Tuscarora Land Surveying for Fred ,A. and Beverly K. Adams, dated September 4, 2002, and recorded in Book ,Page ___. PART OF Tax Nlap Reference No. 16 ,03-0102 to be added to 16 ,03-0101. GRANTORS certify that no hazardous waste, within the meaning of the Solid Waste Management Act of 1980, is presently being disposed of or has ever been disposed of by the Grantors or to the Grantors' actual knowledge in or ~~pon the premises above described. BEING the same premises which Fred A. Adams and Beverly K. Adams, husband and wife., and Fred A. Adams, as Executor of the Estate of Agnes A. Adams, deceased, by Their Deed dated October 24, 2002 and recorded in the Recorder of Deeds Office in and for Miffin County, Pennsylvania, in Deed Book 5 l0, Page 2465, granted and conveyed unto Troy A. Burkholder and Mary A. Burktir~lder, husband and wifie, as tenants by the entireties. Maly A. Burkholder departed this life, thereby vesting complete title under operation of law to Trov A. Burkholder. Grantor I~erein Grantor herein. THIS IS A TRANSFER FOR NOMINAL CONSIDERATION TO A TRUSTEE OF A LIVING TRLJST~ A.ND IS THEREFORE EXEMPT FROM THE PAYMENT OF REALTY TRANSFER TAX. THIS TRANSFER IS ALSO EXEMPT AS A TRANSFER TO AN ORDINARY TRUST IN THAT ALL BENEFICIARIES OF TI~iE TRUST ARE THE SETTLOR OR THE SETTLOR' S ISSUE. TOGETHER with all and singular the buildings and improvements, ways, streets, alleys, driveways, passages, waters, watercourses, rights, liberties, privileges, here-ditaments and appurtenances, ~arl~atsoever unto the hereby granted premises belonging, or in any wise appertaining, and the reversions and remainders, rents, issues, and profits thereof; and all the estate, right, title, interest, property, claim, and demand whatsoever of the said Grantor, as well at raw as in equity, of, in, and to the same. TO HAVE AND TO BOLD, the said lot or piece of ground above-described, with all and singular the buildings and improvements thereon erected, hereditaments and premises hereby granted, or mentioned and intended so to be, with the appurtenances, unto the said Grantee, his heirs and assigns, to and for the only proper use and behoof of the said Grantee, his heirs and assigns forever. AND the said Grantor, for himself, his heirs, executors and administrators, does covenant, promise and agree, to and with the said Grantee, his heirs and assigns, by these presents, that he the said Grantor, and his heirs, all and singular the hereditaments and premises hereby granted or mentioned and intended so to be, with tl~e appurtenances, unto the said Grantee, his heirs and assigns, against them, the said Grantor and his heirs, and against all and every person and persons whomsoever lawfully claiming or to claim the same or any part thereof, hy, frrnn or under him, her, them or any of them, shall and will, subject as aforesaid, SPECIALLY WARRANT AND FOREVER DEFEND. IN WITNESS WHEREOF, the said party of the first part has hereunto set his hand and seal, the day and year first above-written. SIGNED, SEALED AND DELIVERED IN THE PRESENCE-@F OMMUNWEAL~I~H OF PENNSYLVANIA ~~ ) I 9 TR~'(Y URHOLDER, SR. ~. IRO' A. BURHOLDER ~`'` SS: COUNTY OF MIFFLIN On this. the 9`h day of February, 2009, before me, a Notary Public for the Commonwealth of Pennsylvania, the undersigned officer, personally appeared TROY A. BURKHOLDER, SR. known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purpose therein contained. IN WITNESS WHEREOF, I hereunto set my ban and officia seal. C~GP~~i~9Qt~VVF~L.T~? Oi~= ~,=`,;i~!SYf_VP~a(A i~ctaraSea! ~ ~ Not Public E ~refl ~.. 111icd~kF ; ~ i~1o~21'y ~6.'tJ~IC ~ \ ~errnyne E ,ro, ~ismr,erlGinJ ;aunty t~1y C~rrirnis;-;:of.i expires ~1an. 20, ~0~ ~ Member. "~~~r;nwivcni~ ksscc~~tion o` PS^t~ ., ::'ie~ CERTIFICATE OF RESIDENCE 1 hereby cer-ti~~ that the present residence of the Grantee herein is as follo~~1s: The Burkholder Family 'T'rust Troy A. Burkholder, Trustee 330 Old Park Road Lewistown, PA 17044 FINAL SETTLEMENT LLER NAME ~~-~~ h ~ l ~ ~~~~~ - DATE OF SALE: -~}) ~ ~ ~v )DRESS PHONE ZIP CATION OF SALE ~~ ~ ~ ~ ~'~ ~ ~ ~~ JCTIONEER ~~ ~~~ _ PHONE 'Ltd S `~~1~7 fop f - ,. S~iRiS E3!`~~S ;; .~ IBS` ~ ~w I ~ ~, c~~0~ PROFESSIONAL FEES r =--{ AUCTIONEER $ Z ~ ~ ~ ~'~ CASH $ ;>> ~~.:, ~~~~=~ CHECKS $ CLERK $ ~a`j a `?~ OTHER RECEIPTS ~ ~~R ~ $ ~, OTHER EXPENSES - $ $ ,~{~ _ $ $ - $ $ _ $ $ - $ $ ,~ - $ $ ~ d 1 ~ _ $ $ >~ `~\ TOTAL RECEIPTS $ $ LESS TOTAL EXPENSES $ _- a I (or we), the seller, accept this settlement and acknowledge recei t of the above specified net proceeds from the auction of my goods and property sold on the above date. Paccept all responstbility for providing merchantable ti t. all goods, and property sold, and for delivery of title to the purchaser. Date i Auctioneer or Cashi 's-Signature (Se~r's Signatur~jt ~__ ~ /~ ~~` - g~~~l~~ .~`~~~ A. Settlement Statement (HUD-1) i 6~I~11 ~~.;~~~ rJMB Approval No. 2502-0265 B. Type of Loan _ 6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number: 1. ~ FHA 2. ~ RHS 3. ^Conv. Unins:. HACF~NBERG-JOSEPH P i08I5228-3948 4. ~ VA 5• ®Conv. Ins. C. Note: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are 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 8 Address of Borrower: E. Name & Address of Seller: F. Name & Address of Lender: Joseph P Hackenberg The Burkholder Family Trust, KishacoquiDas Valley National Bank, 162 Orchard Grove Avenue 330 Old Park Road 30 Carriage House Lane Lewistown, PA 17044 Lewistown, PA 17044 Reedsvilie~, PA 17084 Shannon M Hackenberg 162 Orchard Grove Avenue Lewistown , PA 17044 G. Property Location: H. Settlement Agent: 1. Settlement uate: 330 Old Park Road Houck B Gingrich, Richard L Gingrich 04/15/2010 Lewistown, PA 17044 Phone Number: 717-248-6751 23 N Wayne Street Mifflin County Lewistown, PA 17044 Place of Settlement: 23 North Wayne Street, Lewistown, PA Disbursement Date:04/15/2010 J. Summary of Borrower's Transaction K. Summary of Seller's Transactwn ____ ,.__..... r,..., c_,.... c,...,...,e, d00_ Gross Amount Due To Seller 101. Contract sales price 5136, 000.00 401. Contract sales price $136, ODG. 00 102. Personal property 402. Personal property 103. Settlement charges to borrower (line 1400) 56, 722.65 403. 104. Hope Treaster 2010 Cty/Twp S1, 089.52 404. 105. 405. Adjustments for items paid by seller in advance Adjustments for items paid by seller in advance 106. City/town taxes to 406. City/town taxes to 107. County faxes 04/15i~2010 to 06,`3C/2C10 $318.44 407. Court; taxes 04/15/2010 to 06/30,/2010 S3I8. 44 108. Assessments to 408. Assessments to 109. 409. 110. 410. 111. 411. 112 412. 120. Gross Amount Due From Borrower SI44, 130. 61 420. Gross Amount Due To Seller 5136, 318.44 ...... . __ _ ___._ __ .. n_ ~_ o_a...u ns o,.-.......,. snn RwrlucTinns In amnunr uue i o aeuer 201 Deposit or earnest money 515, 000.00 501. Excess deposit (see instruction;>) S15, 000.00 202. Principal amount of new loan(s) 5129, 200.00 502. Settlement charges to seller (fine 1400) 203. Existing loan(s) taken subject to 503. Existing loans} taken subject to 204. 504. Payoff of first mortgage loan 205. 505. Payoff of second mortgage loan 206. 506. 207. Transfer Tax from Seller SI, 360. 00 507. Transfer Tax from Seller $1, 360.00 208, 508. Gates, Halbrtmer & Hatch Escrow for Pa Inh Tax 59, 088.54 209. 509. Adjustments for items unpaid by seller Adjustments for items unpaid by :teller 210. Cityltown taxes O1/OI/2010 to 04/I5/2010 S313. 42 510. City/town taxes 01/01/2010 to 04/15/2010 $313.42 211. County taxes t0 511. County taxes to 212. Assessments to 512. Assessments to 213. 513. 214. 514. 215. 515. 216. 516. 217. 517. 218. 518. 219. 519. 220. Total Paid By1For Seller 5145, 873.42 520. Total Reduction Amount Due Seller 525, 761.96 301. Gross amount due from borrower (line 120) 5144, I3o. 61 601. Gross amount due to seller (lirn~ 420) _SI36, 318.44 302. Less amount paid by/for borrower (line 220) ( 5145, 873.42) 602. Less reductions in amt. due seller (line 520) ( 525, 761.96 ) 303. Cash ~ From ~ Tn Borrower SI, 742. SI t:93. Cat;h ~ Tn n From Selle! ~ $IIO, 556.48 The public Reporting Burden for this collection of information is estimated at 35 minutes per response for collecting, reviewing, and reporting the data. This agency may not collect this information, and you are not required to complete this form, unless, it displays a currently valid OMB control number. No Confidentiality is assured; this disclosure is mandatory. This is designed to provide the parties to a RESPA covered transaction with information during the settlement process. L. Settlement Charges 700. Total Real Estate Broker Fees Paid From Paid From Division of Commission (line 700) as follows: Borrowers Seller's 701 $ to Funds at Funds at Settlement Settlement 702. $ to 703. Commission paid at Settlement 704. ( P.O.C. by ) ~._~_ n_....~~.. ~., n........,.a:.... ~nrrti r .,~., 801. Our origination charge Kiahacoquiiias valley National Bank $ 631.95 (from GFE #1) 802. Your credit or charge (points) for the specific interest rate chosen $ (from GFE #2) 803. Your adjusted origination charges (from GFE A) 5631.95 804. Appraisal fee to J. A. Appraisal ( P.O.C. by ) (from GFE #3) 5395.00 805. Credit report to Credit Plus sol ( P.O.C. by ) (from GFE #3) S25. 08 806. Tax service to wells Fargo Baru ( P.O.C. by ) (from GFE #3) 5100.00 807. Flood certification First Amer Fld Dzrt ( P.O.C. by ) (from GFE #3) S14.5o 808. 809. 810. 811. 812. 900. Items Required By Lender To Be Paid In Advance 901. Daily interest charges from 04/25/2010 t0 05/02/2010 @$ I8. 8419 /day (from GFE #10) $301.47 902. Mortgage Insurance Premium for months. Monthly premium: (from GFE #3) to 903. Homeowner's insurance for 1.40 years. Annual premium: (from GFE #11) to Mut Ben Sns Co. $699 POC Borrower 904. years. Annual premium: to 905. ~nnn ao~e.,.e~ ne.,.,~~ro~ wltti r o.,rlo~ 1001. Initial deposit for your account (from GFE #9) $934.65 1002. Homeowner's insurance 3.00 months @$ 58.25 per month $ 174.75 1003. Mortgage insurance months @$ per month $ _ 1004. Property taxes 3.00 months @$ 90. 79 per month $ 272.37 1005. school Tax 10.00 months @$ 123.28 per month $ 1, 232.80 1006. months @$ per month $ 1007. Aggregate Adjustment -$ 745.27 ~ •r nn rrro rtti~~.,o~ 1101. Title services and lender's title insurance (from GFE #4) Sl, 460.50 1102. Settlement or closing fee 1103. Owner's title insurance rTrc (from GFE #5) $16.50 1104. Lender's title insurance STIC 5685.00 1105. Lenders title policy limit S129, 200.00 1106. Owner's title policy limit S136, 000.00 1107. Agents portion of the total title insurance premium BSS-CR S42I. 05 1108. Underwriter's portion of the total tit-e insurance premium ITIC $255.45 1109. 1110. iiii. 1112. 1113. 1114. 1115. 1200_ Government Rer_ordina and Transfer Charoes 1201. Govemment recording charges (from GFE #7) 5123.00 1202. Deed $ 53.50 ;Mortgage $ 69.50 ;Releases $ 1203. Transfer taxes (from GFE #8) S2, 720.00 1204. City/County taxlstamps: Deed $ 1, 360.00 ;Mortgage $ 1205. State tax/stamps: Deed $ 1, 360.00 ;Mortgage $ 1206. 1207. 1208. 1209. 1300_ Additional Settlement Charges 1301. Required services that you can shop for (from GFE #6) 1302. $ 1303. $ 1304. 1305. 1306. 1307. 1308. 1309. 1400. Total Settlement Charges (enter on lines 103, Section J and 502, Section K) S6, 722.65 PfP.V In11C Pditinnc arr: nhcnlate Pana 7 of '~ HUO-1 Certification (continued from HUD-1) 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 and disbursements made on my account or by me in this transaction. I further certify that I have received a copy of the HUD-1 Settlement Statement. Borrower: '' ,; _ Date: -~-/.S 1d Jose P acke%~~ 162 Orchard Grove AvE~nue Lewistown, PA 17044 Borrower: ~ _ Date: ~ /S /p a non M Hackenberg Seller or Agent: ~li~, ,, ~ Date: 1 d e Burkholder ' i y Trust 330 Old Park Road Lewistown, PA 17044 Seller or Agent: . Date: 162 Orchard Grove Avenue Lewistown , PA 17044 The HUD-1 Settlement which I have prepared is a true and accurate account of this transaction. I have caused or will cause the funds to be disbursed in accordance with this statement. Date: Settlement Agent: i Date: if J/.~- Richar in c WARNING: It is a crime to knowingly make false statements to the United States on this or any other similar form. Penalties upon conviction can include a fine and imprisonrnent. For details see: Title 18 U.S. Code Section 1001 and Section 1010. S~ MEMBERS 1St FEDERAL CREDIT UNION REGULAR SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established CHECKING ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner Date Joint Ownership Established Estate of: Troy A. Burkholder Date of Death: November 20, 2009 Social Security Number: 188-20-8796 363535-00 08/01 /2009 $6, 787.24 $.52 $o, 787.7 5 Diana D. Miller 10/03/2009 363535-11 08/01 /2009 $5, 573.00 $.29 $5, 573.29 Diana D. Miller 10/03/2009 MEMBERS 1ST FEDERAL CREDIT UNION ~~ Leigh- nne Stallings Lending Insurance Support Specialist March 18, 2010 5O~)O Louise llrive P.O. B<» 40 ~lechanicsbLir~, Penns~~l~-ani~ 17(:)55 (80O) 283-2328 «-~~-w.membersl st.or~ PA REV-1500 SCHEDULE H FUNERAL EXPENSES and ADMINISTRATIVE COSTS Lewistown Monument Company 730 Valley Street Lewistown, PA 17044 BILL TO Diane Miller 8 Cedar Rd. Carlisle, PA 17015 iIiVVItrC DATE ~ INVOICE # 5/7/2010 S 10035 T-- P_O_ NO. TERMS PROJECT NET 1 S DAYS QUANTITY DESCRIPTION RATE AMOUNT 1 9 Digit Death Date 12:5.00 125.00 NOV. 20, 2009 FOR TROY A. BURKHOLDER IN UNION CEMETERY, MIFFLINTOwN, PA j~d ~~ ~G~~' o0 ~i~ S/a°~~~ COMPLE`T`ED OIV INVOICE DATE Tota! $1ZS.oo ,~ Guss Funeral Home 20 South Third Street Miff l intown, PA 1709 Karl E. Guss, Funeral Director Barbara Guss Partner, Funeral Director (717) 436-2149 Services for Troy A. Burkholder Date of Death: November 20, 2009 Professional Services, Use of Facilities and Equipment 20 Gauge Landen Bronze Metal Casket _ Monticello Wilbert Vault Cash Advance Items: Lewistown Sentinel Obituary 10 Certified Death Certificates Cemetery Charges: Grave opening Total Funeral Expenses Amount due Guss Funeral Home $4,200.00 1,990.+DO 1,330.00 169.3 0 60.00 500.10 $8,249.30 $ 8,249.3 0 Fuli payment is appreciated by December 23, 2009. 1.~~/o interest per month will be charged on any unpaid balance. The friendship and good will you have accorded us is worthy of our most sincere thanks. We, therefore, express our appreciation of your confidence and we sincerely hope that our service has been in every way satisfactory and comforting to you. Most Respectfully, e ~ ~, .. ~ ~~~~~ Barbara Guss Partner f~~ ~#jy3 ~aI~~8J49.3a RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 BURKHOLDER TROY A Estate File No.: 2010-00035 Paid By Remarks: DIANA MILLER WZ ------------------- Fee/Tax Description PETITION LTRS TEST WILL SHORT CERTIFICATE JCS FEE AUTOMATION FEE Check# 147 Total Received......... Receipt Date: 1/13/2010 Receipt Time: 08:53:33 Receipt No.: 1059621 Receipt Distribution ----- -------- ------- ---- Payment Amount Payee Name 90.00 CUMBERLAND COUNTY GENERAL FUN 15.00 CUMBERLAND COUNTY GENERAL FUN 24.00 CUMBERLAND COUNTY GENERAL FUN 23.50 BUREAU OF RECEIPTS & CNTR M.D 5.00 ----- CUMBERLAND COUNTY GENERAL FUN ----------- 157.50 ~ 157.50 , ~' iv ~ i i~ ~ ~~ r VE'~`-~Ot1 My Account at verizon.com/bi!lview 717-248-2105 717 248-2105519j08Y 3/28/2010 Venzon News Entertained and Under Budget Call 1-888-558-0306 th save big on home ~~ entertainment. Get High Speed Intemet 3M, DlRECTV® service & phone for just $99.99/mo. for 1 yr w/term agmts. Plus, get $100 back via a Visa prepaid card from Venzon. Don't wait. Sign up by 6119, Subj to taxes 8~ fees. Terms b restrictions apply. Fast Intemet far Under $20! Call 1-866-232-2830 for Venzon High Speed Intemet with speeds up to 1M for $19.99/mo. w/ 2 yr. agmt. Save time b money with Venzon. Sign up by 8/21. 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Direct Payment Enrollment i Online Billing b Payment :Questions about your bill? __ _- ___-__ ~ _ _.__-- _ - _ -._ _--- -- ~ _ _. _ -----r_____ .__ _ __ _-- venzon.com/billpay venzan.com/btllview _~~verizon com or 1-800 VERIZON,(1 800-837-4966)_ __ Please rerian this remit slip with payment ., New Charges Due Apr 26, 2010 V!$1'/,1~~ Account Number 717 248-2105 519 08Y Total Amoutrt Due: $17.64 0 3 2 8 2 0 Yes! 1 want to be a Literacy Champion. hrake ct-edc Payable to Venzon Q Sign me up fir a $1 monthly donation to Verimn Reads_ 00076173 01 AT 0.357 VPC09011 0243 XX TROY A BURKHOLDER 8 CEDAR ROAD CARL{SLE PA 17015-9752 ~~li~~u~ll~~il~~ii~~~,~~i~llii~~~.Ij~~~,~l~i~~ll~~lll~ii~i~~~iil 0~ ~~ VERIZON PO BOX 28000 LEHIGH VALLEY PA 18002-8000 I~~~III~~I~II~~~I1~~~~~1~1l~~I~II~~~II~~~I1~~~~~~111 10971702482105519502801319000D060QOOOOOOOODOODD00176400000D f Y Quick Bill Summary for TROY A BURKNOLDER Previous Balance $17.64 - __ _ __ Payments Received Mar 23 -$17.644 Balance Forward $.0[I New Charges Voice Services (See pg 3) $8.5:3 _ _. - Taxes, Fees 8 Other Venzon Charges $9.11 Total New Charges Due by April 26, 2010 $17.&4 Total Amour>rt Due by Apri126, 2010 $17.6 UfE:f'/'1 Manage Your Account Phane Number Account Number Billing Date iV1y Account at verizan.com/biiiview 7i7-248-2105 717 248.-2105~519jt~Y 2!28!2010 ~_._ ---- verizon News Enterkained and Under Budget Call 1-877-903-8111 to save big on home entertainment. 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Payments Received Feb 23 -$14.49 Bala~e Forward $,00 New Charges Voice Services Taxes, Fees 8 Other Verizon Charges Total New Charges Due by March 25, 2010 See pg 3) $8.53 $9.11 $17.64 Total Amourrt Due by March 25, 2010 P~31~ ~,~ ~~~~~ Direct Payment Enrollment :Online Billing $ Payment ~ Questions about your bill? verizon corrilb~llpaty _ j _venzon.com/billview E venzan.com ar 1-800-VERiZON (1-800-837-4966).. _. _.. _ - __ . Manage Your Account Phone Number Account Number Bitting Date ~~~. My Aoootmt at .caNbi~view 717-248-2106 717 24B-2705519fD8Y lf28/2U10 .. , Venzon News yet More, Save More ;ail 1-877-896-5534 ~ make sure you're Setting the best Verizon services at the best slue -from phone and Internet, fi TV ~ Honey-saving bun~es. 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Quick Bill Summary for TROY a tn~s Prrwaus Balance $17.25 -- Payments Received ,lan 25 _ -$17.25 -- __ Baflance Fnrrrard #,Op Herr Voice Services (See pg 3) $5.38 - - --- _ - Taaoes, Fees b other Verizon Charges - X9.11 Toibt Ilea i~atges il)ee ~ 24, 2U10 ~1 Total An~oud Due blI Febnwry 24~ 201Q X14.49 f .~ ~~f a .~ ~s.~ Direct Payment Enrollment Online Billing & Payment ~ Questions about your bill? verizon.com/billpay verizon.com/biilview ~ verizon.com or 1-800-VERIZON {1-800-837-4966) ~?rT l Y`" Manage Your Account Phone Number Account Number -~"'~7~ _ ~ My Account at verizon.com/bittview 717-248-2105 717 248-2105~51908Y Verizon News _ - _ -_ Quick Bill Summary for TROY A BURKNO[DtR Bitting Date 12/28/2009 Rdd Verizon Tireless & Save Call 1-888-553-7502 by 1J76/14 SAVE B1G! Combine Verizon Wireless w/ DIREC3V® , Internet & dome Phone for $108.98/mo for mos.1-6; $124.99/mo for mos. 7-12; with term agreements. Subject to availability, terms, and other charges. 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Valid thru 12/31109.- __ -- _ - -- Quick Bill Summary for TROY A BURKHOLDER Previous Balance X37.91 Payments Received Nov 24 __-__-__ _ _-_ ~ ~ -_$37.91 8alarne Forward ~•~ New Charges Voice Services ~ (See pg 3) $7.39 Taxes, Fees & Other Verizon Charges Total New Charges Due by December 24, 2009 ~ata1 Amorrttt Dt~e b~ December 2~ 2009 ~l~L ~~ ~ ~ tZ~u ~~~ $8.98 ~~ ~~ s.3a ~~____ IJirect Payment Enrollment ~ Online Billing & Payment ~ Questions about your bill? _ ___ ------------- ------z-- - -__-____ - --- - , _____ ~_ _ _ __ ---------- - __._- ------ - -- ---- - -- verizon.cam/bilipay __. __ __ __ _ venzon.cam/biilview ___. ': verizon.com or 1-800-VERIZON (1-80p-837-4966'1 April 15, 2010 A F"rstE»ergy Co--~pany Billing Period: Apr 03 to Apr 14, 2010 for 12 days Bill Based On: Estimated Meter Reading Final Bill Prorated Bill Account Number: 10 00 13 0962 3 3 Bill for: TROY A BURKHOLDER 330 OLD PARK RD t_EWISTOWN PA 17044 Standard Residen4al ^ *** PLEASE SEE CREDIT REFERENCE MESSAGE ON PAGE 3. ~** - enera n orma ion Bill~issued by: Customer Serrrice 1-800-545-7741 Automated Outage Reporti 1-888-5444877 PO Box 16001 "` Cdlections Readng PA 19612-6001 ~ 1-800-962-4848 visit us on-tin www.firstenergycorp.com Pace tQ Cotn M+~ssa ~ .. Your current PRICE TO COMPARE for generation and transmission from ec is listed below. For you to ;ave, a suppliers price must be Power. Standard Residential -0001248476 5.7i cents per k1Nh Customer reserves the right to shop for an electric supplier. ~i ~-~ ~ . ~~ . , eta o _ . ec:._a ~s or a, .._.. , o a ~, ortn~-t~or~.: , e eft one._num ;,_ ~s . _;~ _-` Page 1 of 4 P64 ~~I ~~Ir~ A FmstEnergy company Billing Period: Mar 05 to Apr 02, 2010 for 29 days Next Reading Date: On or about May 05, 2010 Bit! Based On: Actual Meter Reading Prorated Bill Bill for: TROY A BURKHOLDER 330 OLD PARK RD LEWISTOWN PA 17044 Standard Residential I _ _ - ~ n . Q~ , ion _ -- Bi{{ issued by: Customer Service 1545.7741 PO Bo 16Q01 "~ ~lectiotn~s 0 Rn9 1-888-544.4877 Rea~ng PA 19612-6001 1-800-962--4848 visit us on-line ~ wwar.firstenergycorp.com _ f `, I~'ri~e :~+~ .ors , ICa.lUlee_ ... _ : _ Your current PRICE TO COMPARE for generation and transmission from Penelec is listed below. For you to save, a supplier's price must be lower. Standard Residential -0001248476 5.70 cents per kWh Customer reserves the right to shop for an electric supplier. 1 t ~~ t~ `~~ i~ ~~~~ ~~~ e~ o: er pages or a _ r forts, .tn arrlna ron ,an ~ e ,, _one hum . ers Prep '~ e~ A FustEnergy Company Return this part with a check or money order Payable to Penelec Account Number: 1000130ft6233 Amount Paid• ~ fl{I~.I.II{t,~l,,,I{!..l~.,~~{111.~„~I~!!!~{{,~,li~{{{~~{{~,{{,! **********~**AUTO**3-DIGIT 170 P{ease Pay ;18.03 00020660 O1 AT 0.354 Due By April 26, 2010 TROY A BURKHOIDER 8 CEDAR RD PENELEC CARLISLE PA PO BOX 3687 17015-9752 AKRON OH 44309-3687 {~I~~I~I~~I~~Il~ll~~~i~l~~~~ll~~ll~~l~~i~l~~~ll~~i~i~~~l~~~lli 03~1D0013096233000D000[70000000000000000180300000180132 March 05, 2010 Account Number. 10 00 13 0962 3 3 P~ene~ec ,a~srE.,~sr~«~~y Bill for: TROY A BURKHOLDER 330 OLD PARK RD LEWISTOWN PA 17044 Billing Period: Feb 06 to Mar 04, 2010 for 27 days Next Reading Date: On or about Apr 06, 2010 Bill Based On: Actual Meter Reading Prorated Bili Standard Residential Page 1 of 4 P64 cco .: . Your previous biN was ~ 32.20 j Total payments/ac~ustments _32.20 Balance at billing on March 05, 2010 0.00 0.00 Current Basic Charges Penelec -Consumption 21.62 otal-.Duey ar 2 , - .ease pay rs amour _ "..~~' ., .. __ _ , To avoid a 1.50% t_ate paVmP_nt CEtaK1P_ hP~nA arlrlarl fn vnu~ hill nln~~n nw 1•v ~hn d..n .1.~4n enera n orlma fan Bill issued by: Customer Service 1-800-545~.77g1 Penelec ~ Automated Outage Reporting 1-88g-X44.4877 PO Box 16001 ~s~~.~ Cdlections Rea~ng PA 19612001 1-800-!~62-4848 visit us on-line at www.firstenergycorp.com Price tt~ Coal : Mersa e Your current PRICE TO COMPARE far generation and transmission from Penelec is listed below. For you to save, a supplier's price must be lower. Standard Residential -0001248476 5.70 cents per kWh Customer reserves the right to shop for an electric supplier. rGY IClG'V A F~siEr~er9Y ~P~Y Billing Period: Jan 06 to Feb 05, 2010 for 31 days Next Reading Date: On or about Mar 05, 2010 Bill Based On: Actual Meter Reading Bill for: TROY A BURKHOLDER 330 OLD PARK RD LEWISTOWN PA 17044 Standard Residential . . ~ _; - -`;. , , ri~e_to C~ri~ are .C~~_ !~ v _. __ Your cement PRICE TO COMPARE for generation and transmission from Penelec is listed below. For you to sawe, a supplier's price must be lower. Standard Residential -0001248476 5.T0 cents per kWh Customer reserves the right to shop for an electric supplier. ~~ ~ ~~' 3 2'1~ '~.~ ~3,a. ee o , er pages . or, a , ~,. iona rtt orma. fon fin:. tie, ep, . cant num ors ,~1'1e~C a F~r~eryy corrzP~Y ill~~lii~l~il~ll~.,llllll'lllt~lllll~lllllll~lll.,i.lrl~llii~~y ***~~********AUTO**3-DIGIT 170 00023436 O1 AT 0.354 TROY A BURKHOLDER 8 CEDAR RD PENELEC CARLISLE PA PO BOX 3687 17015-9752 AKRON OH 44309-3687 0110001309623300000000000000000000000032200000032208 Return this part with a check or money order Payable to Penelec Account Number: 10001309Ei233 Amount Paid ~ Please Pay X32.20 Due By March 01, 2010 a~ s ` f, 1~1~ '~~ ~ 2t1i0 Acaoutd Nt~nbet: 10 00 13 0962 3 3 A~~ Bill for: TROY A Bt1RKti0LDER 330 OLD PARK RD LEIMSTOWN PA 17044 Billing Period: Dec OB ~ ,~ 05, 2010 for 29 days Next Reading Dale: On cx abot4 Feb 04, 2010 Bali Baued Qn: Acta~al Meter Keating Pratated ~ Standard Residential Page 1 of 4 Pfi~ r To avoid a 1.50~lL Late Paynu~ (~w+ge treNtg added iu ~ 1~, tom/ b~!- ffie due dale; G~~~ ~ fa~~~~ -~/So ~ 33.3 .- - ~ . ,:.: _ ~ ._ _. !° _A~9es or a., ._- _onat ~n orzn~bo~ e _ one~tu~ rs, . - •'~ .~ v ~ 2009 Acootmt Number: 100013 3 3 C A ~ Bill far: TROY A BURKHOLDER 330 OLD PARK RD LEWISTOWN PA 17044 Billing Period: Nov 05 to Dec 07, 2009 for 33 days Next Reading Date: On or about Jan 06, 2010 Bill Based On: Achim Meter Readttg Standard Residential Page 1 of 4 P64 Pil~ sued by: Customer Service 1-800-545-7741 PO Box 16001 ~~ Automated Outage Reporting 1.g8g..544-4877 Cdlections 1-800-962-4848 Reading PA 19612-6001 visit us on-line at www.firstener co com 9y ~- .: w .... f w: :. ,.~,1.,t. ~~ _ ~' ......... .. --a~.~.. xa. ~ir:~. a .~:3:'~s.~._;3~.;.c';. 'Si~~: c.:wtii,.~:S.."3~-.. ~ - _ ... Your current PRICE TO G4MPARE for generation and transmission from Peneiec is listed bdow_ For you to save, a supplier`s price must be loM+er. Standard Residential -0001248476 5.38 cents per kWh Customer reserves the right to strop for a~n electric supplier. Pal ,a~a~~ti ~ 1 ~(5 ~ 2g.s~f _~ ~ w ._ .~ 6. ,~~~ ~. ~ a ~. ii "~ j 1 f ~~ I~~ ~:~` ~~~ ~~ ~ ~. 'TAI~G~T ~?tPECT MGRE. PAY LE5S GAf2LISLE - 717-243-3387 01/11/20:!0 '!1:42 AM EXPIRES 04/1]./10 STATIONERY-OFFICF 031030415 '?IN BINDER T $; .49 031050062 50CT SHEET T $;t.69 031050536 tPJUE1( DIVIDE T $?_ . 94 2 9 $0.97 ea 031051095 13PKT FILE T $; .29 SUBTO"f AL $2U.41 T = PA TAX 6.0000°6 can $2U . 41 $] . 22 I U T AL $27..6^s 3312 DISCOVkf2 NETWORK GHAf2GE $2]..63 Target Phar-nacy We're herf~ to hel~~E gam - 7pm M-F yam - 7pm Sat 11am - 3ptn Sun I~EC~2-0011-209'x"•0076-~i165-0 VCD#751-~'.59-14U t -CJ=s` ~' i -ccJr~is~ 9~, ~, ~~„ (c1 ~~ ~ ~~~ . ~~ ~ ~ `~~~ ~' t ~P` ~ ~' ~~ ~ ~ ~ ~~ ~ ~ ~~ ~ ~ ~~~~ ~ .- C ~~ r c.~ ~-~ ~ ~ ~ ~~ ~S~~i~ ,~ ~~;. -, "1 :, ~~ BAR~'~R'S ~SC~t~~G ~'L.t1S 435 OLD PARK ROAD LEWlSTOWN, PA.~7044 PHONE#(717)242-5328 #20-2352817 BILL FOR: SNOW REMOVAL AND ICE MELT BILL TO: .TROY BURKHOLDER 330 OLD PARK ROAD LEWISTOWN, PA. 17044 r -_.___ QTY SNOW REMOVAL \~~~~~ 7 SPECIAL NOTE: ~ PLEASE CALL US WITH ANY OF YOUR LANDSCAPING NEEDS, THANK YOUt!! PRICE AMOUNT $135.00{ ~,` 0.00 0.00 PLEASE MAKE PAYMENTS TO: BARGERS LANDSCAPING PLUS THANK YOU FOR YOUR WE ARE FULLY INSURED AND WE BUSINESS!!lYOU CAN EXPECT OFFER FREE ESTIMATES. PROFESSIONAL QUALITYIII THANK YOUII But0006 "QUALITY YOU DESERVE" PA022519 ~ o.oo ~- -- ------ - o_oa BILL DUE ~_;135.00 ~~~~~~ //7Ei4%!~ /" ~ / PLEASE KEEP THIS FOR YOUR RECORDS, THANK YOU!! ~. ~ ~~;~ ~ r -~ ~ C~ l~~ B~u~ BtLL DATE: 2/22/10 ESTIMATE NUMBER # 6 JOB NAME BURKHOLDER "THANK YOU FOR THINKING OF US" ~ BARGERS LANDSCAPING DESCRIPTION SNOW REMOVAL ON 2/3, 2/fi, 2/11 ~'~# OLD Pi~JROC d40AD L~p~~I~TO, PA.17Q4~ ~-~~1~1E`t'97~2~2-328 ~~poL~:A~"~ ~~' SIV01~l1 REMOVAL AND ICE MELT i i - _._.,~ e TROY BURKHOIDER 330 OLD PARK ROAD LE~IISTOWN, PA '! 7044 CpTY SNOW REMOVAL BILL #2 ~~~~ DATE: 1131/10 ESTIMATE NUIIflBER # 6 JOB IVAIYEE BURKNC>LDER "T~NO{ Y®U E®~3 THINKING of US,y BARGERS LAIdDSCAI~~~~"~ DESCRIPTION PRICE A~AOUPI'P $35.OOI 0.40 SNOW REMOVAL ON 1/8 l ~, .^~ `' `.,` ~~ SPECIAL NOTE: ,- _~t; n ~; ._ •~ _ r !f t U „`tip ~ r 'y- PLEASE CALL US WITH ANY OF YOUR LANDSCAPIdVG NEEDS, THAldK YOU!!! PLEASE MAKE PAYMENTS TO: ~~~~~: ~.._.~~ ~ ~ ,~. «~ ~S~ ~Pt~~ PLUS THANK YOU FOR YOUR ~~E t~RE FULLY INSURED AND WE BUSlNESSt!lYOU CAN EXPECT OFFER FREE ESTi~IIATES. PROFESSIONAL 6~UALITYlf t /~ THANK YOUt! BU10006 661~~ ~~~~~ ~ ~ ~~U ~"~ ..T ':1 C': ~~"''7 PA022519 -- -- - ----0.00 -- -- - - a.ao~ o._oo ~ ___ -_...--~~Y®® BILL DUE ; __ $3aa0® _. ~~ ,G : ~ - . .__ ==' ~~, ~ - - ~~ /' ~~~~ t ~ :: GL' ~~a` 7 l RAlNE'S PLUMBING, HEATING & J®B lNVOIGE DFdAiN CLEANING 6 Harlon Lana_ fLCWl~IUWF 1, 1"'f'1 F (V~i''F (717) 248-6101 CUSTOMERS ORDER NO DfytE ORD&RED ; A,l _ __ ;.} i ORDER TAKEN BY DATE PROMISED ^ A.M. ^ P.M. BILL TO P40FtE ADDRESS MECHANIC CITY HELPER JOH NAME-ANO.LOCATION' ~" '' , { [] DAY WORK DESCRIPTION OF NJORk ^ CGNTFIACT ~ExTaA QUANT. DESCRIPTION OF MATERIAL USED PRICE AMOUNT ~` 1 E .~ r ~ v ~~ v~ /t C~~ -? -- - E __- ~ - HOURS LABOR AMOUNT MECHANICS ~ TOTAL MATERIALS HELPERS ~ TOTAL LABOR - , I hereby acknowledge the satisfactory completion of the above described work. TOTAL. LABOR TAx SIGNATURE DATE GOMPLETEp ~ ~~~. ~.~ 0 CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717) 249166 Fax: (717) 249-2663 February 26, 2010 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Craig A. Hatch, Esquire Troy A Burkholder Estate RE: Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: February 12, February 19, and February 26, 2010 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, beers regularly issued weekly in the said County, and that the printed notice or publication attached rlereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, vlz: February 12, February 19, and February 26, 2010 ___ Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in ithe subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. ,- L~ a Marie Coyne, Ed~ or SWORN TO AND SUBSCRIBED befc-re me this 26 day of February, 2010 Burkholder, Troy A., deed. Late of Middlesex Township. Executrix: Diana D. Miller c/o Craig A. Hatch, Esquire, Gates, Halbruner, Hatch & Guise, P.C., 1013 Mumma Road, Suite 100, Lemoyne, PA 17043. Attorneys: Craig A. Hatch, Es- quire, Gates, Halbruner, Hatch & Guise, P.C., 1013 Mumma Road, Suite 100, Lemoyne, PA 17043. ~.__ a ~ °' Cr Notary ~ f h '~ ''t'_~ ~C ~o-l CC°r~ ~ r 1'` - , ~.re.... ~;~; 28, ~,-;~I G .... ~:F: :.Tr... .a :£.Y..AG ~_ i pie ray, sue;.-~vew5 ~v. 812 Market St. Harrisburg, PA 17101 {nquiries - 717-255-8213 GATES, HALBRUNER & HATCH, P.C. ATTN: ACCTS PAYABLE 1013 MUMMA ROAD SUITE 100 i_EMOYNE PA 17043 c~~e patriot-Dews NOw you know THE PATRIOT NEWS THE SUNDAY PATRIOT NEWS Proof of Publication Under Act No. 587, Approved May 16, 1929 Commonwealth of Pennsylvania, County of Dauphin} ss Marianne Miller, being duly sworn according to law, deposes and says: That she is a Staff Accountant of The Patriot News Co., a corporation organized and existing under the laws of the ~'~ ~r~~mon~,n~eaith of Pennsylvania. with its principal office and place of business at 812 to 818 Market Street, in the City of Harrisburg, County of Dauphin, State of Pennsylvania, owner and publisher of The Patriot-News and The Sunday Patriot-News nevvspapers of general circulation, printed and published at 812 to 818 Market Street, in the City, County :and State aforesaid; that The Patriot-News and The Sunday Patriot-News were established March 4th, 1854, and September 18th, 1949, respectively, and ali have been continuously published ever since; That the printed notice or publication which is securely attached hereto is exactly as printed and ~>ublished in their regular Ciail and~or JUl lda i ivietr0 editions which a" "eai"ed on the date'S+ indicated bei~w. That neither shie iior said Cony dri~ IS Y Y ~I' l-) p~ Y r~icrested ~~ ~ the subject matter of said printed notice or advertising, and that all of the allegations of this statement as to the time, r~t~ ce an;~i cl~laracter of publication are true; and Trial she has personal knowledge of the facts aforesaid and is duly authorized and empowered to verify this statement on :~ci Waif or . ric Natnot-News Co aforesaid by virtue and pursuant to a resolution unanimously passed and adopted severally by the ~;ocKl~olders and board of directors of the said Company and subsequently duly recorded in the office for the Recording of Deeds ire and for said County of Dauphin in Miscellaneous Book "M", Volume 14, Page 317. PUBLICATION COPY This ad # 0002042840 ran on the dates shown below: February 05, 2010 LETTERS TESTAMENTARY for the February 12, 2010 Estate of Troy A. Burkholder, deceased, `~/ C_ ' ~ -- February 19 2010 late of Middlesex Township, Cumber- ~~ - ~ lanii County, Pennsylvania, having been / ,.!1 granted o the undersigned.on January ,~ ~ ',/~~// i ~' .~--' 13, 2010"all persons indeti#e~to the Es- ~ ~ L tote are requestei! to ma~c'e immediate ~ ~ ' paymenfiand those;hgving ciaims' ~ j a9ainst~the Estate are'tequested tb pies- - ~,~ enfthem for settlement without delcy ~` ', to. Sworn to and subscribed before me this ~6,d'ay of e,.bruary, 2010 A.D. Diana-D. Ayliller,~Executrix I , c/o Craig A: Hatch> Esquire ~ __ __ /, ~" GATES, HALBRUNER, + ~ ' HATCH & GUISE P.C. ~~ ,k /~~~ ~~ ~.~~' L ~' (~ rf ~ ~/ 1013 Mumma Road, Suite 100 G ~~ ~ ~- C` ~--~-_ ~_,~~`` Lemoyne, PA 17043 __ --- Notary Public CGMh1Qw`wt~L~~~ ~'~ p~NNSYLVANIA Notar?s~f S~a~ ~t~en~~e ~. ~3ner, Notary Pubfic Qity (~ ~alr~Gi~~, U~u~hin County My Gomm~s~a~n ~,;r~ tdov. 26, 2011 iVlember, Penn zt,~~tania association of Notaries BURI~HOLDER March 5 & 6 Friday Sale $9893.00 Saturday Sale 14222.50 Saturday Vehicles & Tractor 13800.00 Total Sale $37915.0 Vehicle & Tractor Sale Total 13 800.00 Auctioneer Fee 10% Personal Property Sale Total 24115.50 Auctioneer Fee 25% Advertising Total Budding Rental Total Expenses Payable to Auctioneer Net Proceeds Payable to Seller Seller's Signature Seller's Signature Auctioneer S ignatu 13 80.00 6028.88 ~go.33 ~r ,a i ~a 250.00 ~ ~~ I ~~ 8439.21 ~ `~ 1 ~~'~ , '~ ~ 29476.29 j ~ CV ~ Q Date 3 0 /c~ Date ~ D C~ Date 3 1 U ~(a r~ ~~ ,~ -~~ ~~ , . ; ~~ ~ ~ ~~, r r ~~~~~~ ~~ RECEIPT FOR PAYMENT GLENDA FARMER STRASBAUGH Receipt Date: 3/08/2010 Cumberland County - Register Of Wills Receipt Time: 10:16:11 One Courthouse Square Receipt No.: 1060236 Carlisle, PA 17613 BURKHOLDER TROY A Estate File No.: 2010-00035 Paid By Remarks: DIANA MILLER CJ ------------------------ Receipt Distribution ------------------------- Fee/Tax Description Payment Amount Payee Name SHORT CERTIFICATE 32.00 CUMBERLAND COUNTY GENERAL FUN Check# 163 $32.00 Total Received......... $32.00 ..--- ~ ° ~ ~Jy~ :~a- ~ ~ ' ^ ~ / ,~7 ~~, C~~ fl.C- ~f ` ~a ~~~~~ ~, ~~t1C_~~~ ~ ~'~ ~~ ~~ y~ r "' OMB Approval No. 2502-065 ~f ~~ `1 ~ ~ * ' ~ . ~~ A. Stettlement Statement HUD-1 ~~ {~ - :. ,.. B. Type of Loan 6. File Number: 7. Loan Number: B. Mortgage Insurance Case Number: 1. ~ FHA 2. ~ RHS 3. ~ Conv. Unin:,. HACKENBERG-JOSEPH P Z08Z5228-3948 4. ~ VA 5. ®Conv. Ins. C. Note: This form is furnished to give you a st+3tement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked "(p.o.c)" were paid outside the closing; they are shown here for informational purposes and are not included in l:he totals. D. Name 8 Address of Borrower: E. Name 8 Atldress of Seller: F. Name 8 Address of Lender: Joseph P Hackenberg 162 O d G h A The Burkholder Family Trust, KishacoquiPlas Valley National Bank, rc ar rove venue 330 Old Park Road 30 Carriagge House Lane Lewistown, PA 17044 Lewistown, PA 17044 Reedsvil(~, PA 17084 Shannon M Hackenberg 162 Orchard Grove Avenue Lewistown , PA 17044 G. Property Lccation: H. Settlement Agent: I. Settlement Date: 330 Old Park Road Houck 8 Gingrich, Richard L Gingrich 04/15/2010 Lewistown, PA 17044 Phone Number: 717-248-6751 23 N Wayne Slreei Mifflin County Lewistown, PA 17044 Place of Settlement: 23 North Wayne Street, Lewistown, PA Disbursement Date:04/15/2010 J. Summary of Borrower's Transaction K. Summary of Seller's Transaction 100. Gross Amount Due From Borrower ann_ [;rocs mm~iinr n~~p r~ ~ouar 1C',. Contract Malec price e1 ~F, non. nn 4M Cnntrart sates price SI36, DOG. 00 102. Personal property 402. Personal property 103. Settlement charges to borrower (tine 1400) $6, 722, 65 403. 104. Hope Treaster 2010 Cty/Twp $I,OB9.52 404. 105. 405. Adjustments for items paid by seller in advance Adjustments for items paid by seller in advance 106. Cityltown taxes to 406. City/town taxes to 107. County faxes 04/I5/20Z0 to 06;.:,0;2010 ~glg, 14 407. County taxes 04/15/2010 to 06/30,/2010 $3IB. 44 108. Assessments to 406. Assessments to 109. 409. 110. 410. 111. 411. 112. 412. 120. Gross Amount Due From Borrower S144, I30. 61 420. Gross Amount Due To Seller $136, 31B. 44 ~uu. Hmounrs raga tsy yr m Dena[[ ur norrovver 5uo. Fteuucuons in amount ouw Tn .SPuwr 201. Deposit or earnest money 515, 000.00 501. Excess deposit (see instructions) 515, 000.00 202. Principal amount of new loan(s) 5229, 200.00 502. Settlement charges to seller (tine 1400) 203. Existing ioan(s} taken subject io 503. Existing loer.(s) taken subject tO 204. 504. Payoff of first mortgage loan 205. 505. Payoff of second mortgage loan 206. 506. 207. Transfer Tax from Seller 51,360.00 507. Transfer Tax from Se1.Ier $1,360.00 208. 508. Gates, Halbruner & Hatch Escrow for Pa Inh Tax S9, 088.54 209. 509. Adjustments for items unpaid by seller Adjustments for items unpaid by seller 210. City/town taxes OI/02/2010 to 04/I5/2010 $313. 42 510. Cityltown taxes 01/02/2010 to 04/15/2010 5313.42 21 i. County taxes to 511. County taxes to 212. Assessments to _ 512. Assessments to 213. 513. 214. 514. 215. 515. 216. 516. 217. 517. 218. 518. 219. 519. 220. Total Paid By/For Seller _ 5145, B73. 42 520. Total Reduction Amount Due Seller 525, 761.96 301. Gross amount due from borrower (line 120) SI44, 230. 61 601. Gross amount due to seller (line 420} 5136, 318.44 302. Less amount paid by/for borrower (line 220) ( 5145, 873.42) 602. Less reductions in amt. due seller (line 520} 525, 761.96 } 303. Cash r 1 Frcm ~ Tn gnrrower ._ $I, 792. 8I 603. CaFh ~ Tn n FCPC!? 'Setter _- $IIO, 556.48 The public Reporting Burden for this collection of information is estimated at 35 minutes per response for collecting, reviewing, and reporting the data. This agency may not collect this information, and you are not required to complete this form, unless, it displays a currently valid OM8 control number. No Confidentiality is assured; this disclosure is mandatory. This is designed to provide the parties to a RESPA covered transaction with inform~ition during the settlement process. L. Sett-ement Charges _.- 700. Total Real Estate Broker Fees Peid From Paid From Division of Commission (line 700) as follows: Borrowers Seller's Funds at Funds at 701.:6 to Settlement Settlement 702.:6 to 703. Commission paid at Settlement ( P.O.C. by ) 704. _ ~_ ~,.....,.,..:..~ w:«ti r „~., auu. rwms rayau~n n~ ~,v~~~~~ .............~ ~...... 801. Our origination charge ICishacoquillas Valley National Bank $ 631.95 (from GFE #1) 802. Your credit or charge (points) for the specific interest rate chosen $ (from GFE #2) 603. Your adjusted origination charges _ (from GFE A) 5631.95 804. Appraisal fee to J. A. Appraisal ( P.O.C. by ) (from GFE #3) S395. 00 805. G'redit report to Credit Pius sot ( r.o_c. by ) (from GFE #3) S25. 08 806. Tax service to Wells Fargo Bank ( P.O.C. by ) (from GFE #3) $100.00 807. Flood certification First Amer Fld Wert ( P.O.C. by ) (from GFE #3) 514.50 808. -- 809. -- 810. _ 811. 812. ,_ 900. Items Required By Lender To Be Paid In Advance 901. Daily interest charges from 09/15/2010 to 05/OI/2010 (~$ 18.8919 /day (from GFE #10) $301.47 902. Mortgage Insurance Premium for _ months. Monthly premium: (from GFE #3) -- to 903. Homeowner's insurance for 1.00 years. Annual premium: (from GFE #11) to illtlt Ben Ina Co. $699 POC Borrower _ 904. years. Annual premium: - to eserve p 1001. Initial deposit for your account (from GFE #9) -- 5934.65 1002. Homeowner's insurance 3. 00 months @$ 58.25 per month $ 179.75 1003. Mortgage Insurance months @$ per moniil $ __ 1004. Property taxes 3.00 months ~?$ 90.79 per month $ 272.37 1005. school Tax 10.00 months @$ 123.28 per month $ 1, 232.80 1006. months @$ per month $ 1007. Aggregate Adjustment -$ _ 745' 27 .7V:J. 1000 R s De osited With Lender . ,................. y.... 1101. Title services and lender's title insurance (from GFE #4) 51, 460.50 1102. Settlement or closing fee - 1103. Owner's title insurance rTic (from GFE #5) - $16.50 1104. Lender's title insurance ITIC 5685.00 1 105 Lender's title policy limit 5129,200.00 1106. Owner's title policy limit 5136, 000.00 1107. Agents portion of the total title insurance F~remium Bss-CR $421.05 1108. Underwriter's portion of the total title insurance premium ITIC $255. 45 - 1109. 111G. -- 1111. 1112. 1113. 1114. 1115. 12nn Government Recording and Transfer Charges 1201. Government recording charges (from GFE #7) -- S123. 00 1202. Deed $ 53.50 ;Mortgage $ 69.50 ;Releases $ 1203. Transfer taxes (from GFE #8) 52, 720.00 1204. City/County tax/stamps: Deed $ 1.360.00 ;Mortgage $ 1205. State tax/stamps: Deed $ 1, 360.00 ;Mortgage $ 1206. 1207. - 1208. - 1209. 1300. Additional Settlement Ch 1301. Required services that you can shop for (from GFE #6) 1302. $ 1303. _ $ 1304. 1305. 1306. 1307. 1308. _ 1309. 1400. Total Settlement Charges (enter on lines 103, Section J and 502, Section K) S6, 722.65 Previnnc aditinnc ara nhcnlPta Panes 7 of '~ Hl1D-1 Certification (wniinued frond hiUD-1) 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 a!! receipts and disbursements made on my account or b;~ me in this transaction. I further certify that I have received a copy of the HUD-1 Settlement Statement. ~1 .~J ~7- ~ ? Seller or ~ r ' / Etorrower:C_/i~~,, ~,. /~; ~~ Date: -~-/S ~C1 Agent: J/~,v:~;c „Cate: ~ ;f ~Q ~ Jose P acke e Burkholder ,~rrrst / ' ~~ y 162 Orchard Grove AvE:nue 330 Old Park Road Lewistown, PA 17041 Lewistown, PA, 17044 /~, ~-; ~~ E3orrower. ' ~.`-~_~~.~ Date: ~ /S /c. ti.- -a - non M Hackenberg Seller or .~ t Agent: ~ Date: C 162 Orchard Grove AvE~nue Lewistown , PA 17044 The HUD-1 Settlement which I have prepared is a true and accurate account of this transaction. I have caused or will cause the funds to be disbursed in accordance with this statement. _ Date: Settlement Agent: ~ , ` Date: If f/.~' Rirl-iar ,in r~ .~../ M/ARNING: It is a crime to knowingly make false statements to the United States on this or any other similar form. Penalties upon conviction can include a fine and imprisonment. For details see: Title 18 U.S. Code Section 1001 and Section 1010. PA REV-1500 SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES and LIENS ~. Vel'i~r~ .~~ Manage Your Acxount Phone Number Account Number Billing Date My Account at verizon.comlbiliview 717-248-2105 717 248-2105 519 08Y 10/28/2009 Venzon News 3 Months Free of Internet Order now and get 3 months FREE of Verizon Nigh Speed Internet (up to 1 M) for just $19.99/mo. w/1-yr agn~ement Do what you i love: a-mail, shop, share photos, download games, and more! Call 1-877-331--2375 for details. Terms & restrictions apply. Valid 8/16 thm 12/19/09. Install by i/31/10. '~ FREE HIGH SPEED INTERNET '~ Get 3 mos. FREE HSI when you order TV, Phone & HSI. Get it at{ for $75.00/mo for the 1st 3 months & $99.99/mo for months 4--12. Plus FREE Verizon Wt-F! Don't wait! Call 1-888-456-0032 today! Speeds up to 3M. verizon.conv'witi. Sc;bj, tQ term agreements: availability & restrictions. Valid 9/20-12/19. Simplify With ONE-BILLC~ Too many buts? Roii 4 into 1. Get your Verizon ~I local, long distance, High Speed Intemet & Verizon Wireless charges on a single bill, it time is r~ney, start saving today. Cali 1-888-456-4472 to sign up. Restrictions & terms apply.- Quick Bilf Summary far TROY A BURKHO[.DER Previous Balance Payments Received Oct 22 Balat~ Forward New Charges Voice SerVICeS ----_ ^ ($ee Taxes, Fees & Other Verizon Charges Tots! New Changes Due by t~vembet 24, 2009 $38.05 --$38Afi ;.OIJ p9 3) ~---------- -- -$26.43 - _-_--_------- $11.K8 ------ ----_ --- ------- $37.91 Total Amou ue by Noveim 24, 2009 $37.91 '~ ~ ~ ~s2Q !i~%v~ a~ t ~' ~ ~~ ~~ ,~ xis ~A~ "(f! ~~)~x~ ~a (3~~~~aIS ~~°'t~ Direct Payment Enrollment Online Billing & Payment questions about your biH'~ verizon.com/billpay verizon.camlbiliview verizon.com or y-800-VERiZON (1-8110-837-4966) ~~ ~. /~~ / E ~ /' \. 1(x../.1 ~-~ T~ ` 1 l t i~ 1 F~t'1@~C November 05, 2009 Account Number. 10 00 13 0962 3 Bill for: TROY A BURKHOLDER 330 OLD PARK RD LEWISTOWN PA 17044 Billing Period: Oct 06 to Nov 04, 2009 for 30 days Next Reading Date: On or about Dec 07, 2009 Bill Based On: Actual Meter Reading Standard Residential Page 1 of 4 P64 - Price.:#q -~CompaXe Message Your current PRICE TO COMPARE for generation and transmission from Per>elec is listed below. For you to save, a supplier's price must be lower. Standard Residential -0001248476 5.38 cents per kWh Customer reserves the right to shop for an electric supplier. ~~~~ f ~ Iz~l c~ ~.~ ~ 3S ee o . ,er pa es , oti a t,_EQna ~n_.ormat~on an , +~ ±~p .ratite, nur~ r.el'~....,.: POWER EQUIPMENT INC. ;:`,spa a 225 York Road Carlisle, ~A ~?Q13 71 ?-249-5338 Fax ? i ?-249-0?3? ~, www.petermanpower.eom Tl~e Oitfc~ov~~ Power E~~r~i~~ltrc~rtf ~~~ec'irzlist Sl~~cc ZJ~~~' SNIP TO: SOLD TO: .?CCT. hC1 '.J titJ. Milt' -- _._ _ , DATE ~ INVOICE NO. SALESMAN `: STORE P/O NUtv1BER B/O 'LINE ! PART NUMBER ~ DESCRIPTIOf~1 SPECIAL INf=ORPAATION LIS f i~~lEl Ah%?OJPtT ~~ V~, I~~ 1G ~l~~v ~~o IMPORTANT NOTICE it is agreed as pad of the consideration for This sale that the price shown hereon for the goods shalt be paid on or belore the t 0th day of the month following the month of purchase. Any portion at the sale. prise not paid ;vi;h in said time period shall thereafter bear interest at the HIGHEST PREVAILING RATE. AU claims and returned goods h4UST be accompanied by this in~~oice. There e~ill he no refund or exchange cn eaec(ric31 par;. The factory warranty constitutes all of the warranties with respect to The sale of this item/items. The seller hereby expressly disclaims all warranties, either expressed or implied, including any implied ~•:arranty ei rner- ~hantabilily cr litness for a particular purpose and the seller nedher assumes nor authorized any other person to assume for it any liability in connection r:ith the sale of this itemlilems. <--~ ../~ ~, ~~ ~:~ ~ C~ . ~ ._ I ~~ C~ ~~ ARGIER'S LAND~CAP{[~fG P~U~ ~ OLD ~i4R~C RO~® ~~~~"J~Tt~tA/~+1, ~~. 77~ BILL t~OR: + WEEKLY MOWING ~tLL ~'Oe i ;TROY 8URKHOLDER 330 ®LD PARK ROAD LEWIST©WN, PA. 17044 ~2TY INVOICE # 1112 BILt~ DAVE: 8!30!09 ES7'It~RATE N1IMBER; # '131 ~®B I11AME~ BURKHOt_DER i "Tlt.)iA~t~+I!Kp~YO/Sl~1~EpCl1~~R TNtNKING ~i'6- Jae 99 i BARGER'S LANDSCAPING DESCRIPTION WEEKLY MOWING WEEKLY MOWING, TRIMMING ON 8J6, 8!13, PRICE 1~-IttlOtll'~`~ $32Ct.t30; Q.4il :8119, 8/27 n i ' ~~ ~~ F ~ ~~ :~ ~ ~ ~ ~ ~r ,J t t '".. ' ~~ A r' ~ 1 --- _, ee SPECIAL NOTE:: WE ®® SNOW REM01/AL ~lPlD SO M11 'H 1~ ~ ~~ ~ ~'' '~ ~ ~ PLEASE ASIt 115, T6~IANK YOUlt , } ~ ----- ---- -- - --- ------ 0.0© PLEASE I~iAKE PAY#tPITS T®: 4~~ OLD DARK RD. LEWtSTOW;~, PA.15'~~i SULLY i~ISl1RE[~ FREE ESTIMATES PAa~~s1 ~ ~U~ oaos BttJ-~F~SATURE. DA~~ O~ AccEP~rANC~: TN~-WK Y®11 FOR Y011R Bt1SINESSI!!Y®~! CAN EXPECT PR®EESSIONAL OUALITYt1t ---------- 0.00 0.00 , ~ ~ ~~~ I~ I~~ ~~ 1700 S LINCOLN AVE LEBANON PA 17042-7597 *039406 - 1114os o~ao6 TROY A BURKHOLDER 8 CEDAR RD CARLISLE PA 17015-9752 V~ . STATEMENT OF MEDICAL CARE COST RECOVERY ACCOUNT ACTIVITY NAME OF FACILITY LEBANON VA MEDICAL CENTER (595) FOR QUESTIONS ABOUT YOUR ACCOUNT, PLEASE PHONE THE BELOW NO. ~-g66-4o8-2657 For written inquiries concerning your account please send them '= to the MCCR or Revenue Office at the facility address above. Payments received after 11 / 10/2009 will be on your next statement. ~_ Billing questions please call 1-866-408-2657 +ce.,+ ni~..,e• TRaY O BURKHOLDER ----- -- - - .. ...:...... ............n.... -..- ...-. - ::l -- - _ __ _ _ _ _ - -- - ._ti-.~::::-.- ......:: :. .E~ Lt}~:~ ~F 10/20/2009 COPAY RX:2928363 FD: 10/19/2009 8.00 595-KOOOLZH DRUG:LORAZEPAM 0.5MG TAB DAY5:30 QTY:90 PHY:WEBER,JANE A CHG:38.00 10/30/2009 PAYMENT 9.00- 595-K9091W4 ~~~~ ~~ ~1 f! ~, ~ ~ . 4 ~~ ~~~ SUMMARY OF P~~I~_~~-hA~: :~?~.... x:~ >:.1= ~:------------- ---------- -- -- ---------------------::::::::._::::::::::. :.::~::::.._:.~::::::::::::::.::::::.::: -: MONTHLY C 9.00 9.00- 8. s.oo ..._,_-.._.,P_1_~~F___S--1cTnr.H.,,T.N~t&. ~r1!iv ~- ~E~ rnnt-nth...BF.IJ.iAA~..~~v~TN.,.~E~X~?.ERtr nr] _ny1~ .!8~.t1~F ~~.-!~L .G~~cpf~~~~~F...~~tLr~~~xen~!i______.~.-- -- -- Account No: 595-0000000-132439-BURKH Stmt Qate: 11 / 14/2009 _ _ _ .: _ ~ _ - ~r ~>~ ` PATIENT NAME PATIENT ACCOUNT NQ. DATE OF SERlltCE TYPE OF SERVICE ~ Tray A Durkholder 9450937 11/20/2009 EMERGENCY ROOM DATE DESCtitPTtON PAYMEtVTJADJUSTMENTS I 3 E € 12!28/09 ADJUSTMENT 90.Q1- 12/18/09 IN5URANCE PAYMENT 86.31- ( ;.~ ~1,~ j•a ~. ;~~ i ° 1 t y~I t'~ ~ I ~ ~/ PAYMENTS AND CHARGES RECEiVEQ AFTER THE STATEMENT QATE WILE BE REFLECTED ON THE NEXT STATEMENT. ' f ; ~ ~ i $ 5 0 , 0 0 :~ MESSAGES FOR BILLING QUESTIONS PLEASE C~ / ~ The amount shown on this statement is outstanding at , _,,,,, this time. Your prompt payment will be greatly (717) 960-1680 ! appreciated. l t Bills can be paid online at our hospital Internet web site www.carlislermc.com ~' ~, '~ 1 UPON RECEIPT V Cumberland-Goodwill Fi~eRescue PO BOX 12910 PHILA, PA 19176-0910 Phone #: (800 367-0512 Federail Tax ID: 23-2298422 ~° ~ tt=~~ ;,r'~=jt`f~~== TROY BURKHOLDER If~S~.FRt~E~IG CG0904606 TROY BURKHOLDER 8 CEDAR RD CARLISLE, PA 17015 BALL !~ttSMB~P: i tt?~tC O~ C~~~: ~- t~Eyt..E..r':.~: i-E-Cv!~rl: -~ ~:.t: ~~Y~r~~!(S} c~~ ~F~Y~1's~6~€~~y~~' 1 ~~i 14611 CG0904606 11 /2012009 06:24 PM IBAL NONE 8 CEDAR RD CARLISLE REGIONAL MEDICAL CTR CARDIAC ARREST ~ ~ S~;yft~7~i 4~ F+~f fit, Tt~+p~ ?.f~.3t,..~t!- 1 F4JrV~. ~6- 1r~P-Y~a i7G ~ x ~ .i ~ ~.I~; i Y f i [F;f-r s_x~ Fr _" ~.: f~[F i i Sl.,} ~ t+` ry' ;g~ .~...~.,. .._.~~ ~ ~ • ~~i ` __~.. STYLET A0422 .._, 1.0 ~ ~ 6.29 fi.29 MtLEAGE CHARGE A0425 c 11.0 11.50 126.50 ~ f ? i i ~ ~ i ~ i -~ 1782.94 _~ ~~~s~~t~~flra o~ ~~Y~~~ ~ ~~c~~~r ~ ~ PA~~~`r~T ~~z~ ~ ~~,~L~O~~ ~ - Medicare Assignment Adjustment 01/25/2010 ~ 1317.85 Insurance Payment - GEISINGER GOLD HEALT t { f 1764988 I 01/25J2010 # 415.09 2~4 a_ P~.E.~~:E SAY T;€w AMOL,~~t~~' ~-d~_;~ $50.00 Y~ PHILA, PA 19'f76-0910 Phone #: (800j 367-0512 Federal Tax ID: 23-2298422 °r``~~y'^~'~ ~ E`"F~~'''_=~ TROY BURKHOLDER lil~E_EE~i'='a~3CE: CG0904606 TROY BURKHOLDER 8 CEDAR RD CARLISLE, PA 17015 CALL NUMBED: DA i E C€= CALL: TIME OE CALL: CALLEf ~: ~~,~~~~: :~L . RE,~ ~~~{s} FCC ~~~ 14611 IBAL CG0904606 NONE 11 /20/2009 06:24 PM 8 CEDAR RD CARLISLE REGIONAL MEDICAL CTR CARDIAC ARREST ~..~. ~~,.,v is ~l~f-T1rS~; ~J S"' v -~5=,},"c r.'.`.~' ) n ~ f ~ k I ~e{\i1~5 i'~:".i~~ ~ ._ ~ :^t:e:;{~+~'~ ?1+~ t ~_ i MICU EMERGENCY LEVEL 1 A0427 !(~ i.0 1337.94 1337.94 ~ ATROPINE 1 MG A0394 3.0 5.00 15.00 BAG VALVE MASK A0422 1.0 34.86 34.86 f COMBINATION DEFIB/PACER PADS A0392 1.0 59.85 59-~ ' EKG ELECTRODES (4pk) A0398 1.0 4.54 4•~- ENDOTROL ET TUBE A0422 1.0 41.83 41.83 EPI 1 MG 1:10000 A0394 1.0 5.13 5.13 ET TUBE HOLDER A0422 1.0 1924 19-24 ETC02 (ADULT) FILTERLINE SET A0422 1.0 25.80 25.80 GLOVES A0398 2.0 3.65 7-30 OXYGEN A0422 1.0 6i .91 6i .91 j PERIPHERAIIV A0394 ( 1.0 36.75 36'75 ~ ! ~ ' ' ~SCRIPTIC~N i3F P~ll'z'~.4l=t~iT ~ SECE#I~S e~AvI~E?~IT ~..' 4TE ~5 i~t(JUttl"~ _ f ~' ~ ~ I r ~ ~ ~ ~ { ~; t i iI { ~~ ~~P ~x`~~ ~1YI~~~~~~ s~~-sits' ~~ ~a'S . Continued on Next Page ~ DETACH ALCNC, QEBFC3r'~MATION AND RET~J~iN STUB WITH t'AY41IiE(VS AnrauNT Dul= _ 50.00 PATIENT NArr~ : BURKHOLDER, TROY A CaLL Nulv~~c~ CG0904606 AIvIQUN ` s ~~~'~ ~~ PAS TENT NUMBER: 14611 BILLING ©ATE: 01/26/2010 ENCLOSED _r_ ~ _ This is the amount due after your Insurance Carrier's payment. ~~ ~ ~~sA -----f AIVD .S i ER ~ ~.~s, ~J~~ C(1` ~ ~~i;CEI~T ELF 1 ~~ *** END OF ATTACHMENTS ***