Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
01-05-11
' 150567121 REV-~ 500 EX (f~6-0~} OFFICIAL USE ONLY PA Department of Revenue Coun Cade Year File Numbsr Bureau of Individual Taxes ~' PO BOX 280fit31 lNHER{TANCE TAX RETURN 2 1 1i D 0 3 9 5 Harrisburg, PA 17128.0601 RESIDENT DECEDENT ENTER DECEDENT {NFORMAT{ON BELOW Sociat Security Number Date of Death Date of Birth 2 0 1 1 8 6 5 0 4 0 4 D 6 2 D 1 D D 3 D 8 1 9 2 7 Decedent's Last Name Suffix Decedent's f=irst Name Mt C H R I S T M A S D O R I S L (If Applicable) Enter Surviving Spouse's Enformation Below Spouse's Last Name Suffix Spouse's First Name Mf Spouse's Social Security Number THIS RETURN MUST BE FILED tN DUPLICATE WITH THE REGISTER OF WILLS Fft_L tN APPROPRIATE OVALS BELOW 0 1.Original Return ~ 2. Supplemental Return ~ 3. Remainder Return {date of death prior to 12-13-82) 4. Limited Estate ~ da. Future Interest Compromise {date of ~ 5. Federal Estate Tax Return Required death after 12-12-82) Q 6. Decedent Died Testate [] 7. Decedent Maintained a Living Trust 1 8. Total Number of Safe Deposit Baxes (Attach Copy of Will} (Attach Copy of Trust) Q 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 91 i3{A} between 12-31-91 and 1-1-95} (Attach Sch. O} CORRESPONDENT - TH{S SEC?i0N MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX tNFORNIATION 5HOULD 8E DIRECTED T0: Name Daytime Telephone Number N E E L Y E- M E A L S 7 1 7 ? 6 3 1 3 8 3 ~_.~ Firm Name (ff Applicable} R E A G E R 8 A D L E R P C First line of address 2 3 3 I M A R K E T S T R E E T Second line of address City or Post Office C A M P H I L L State P A ~ REGISTER ©F USE ONLi~-- ,. ~ r '=J ~ t r -~~, T1 `~~... _ ~ - .~7 C..1 ~.~ ~~ ,-... . n.,...„ ~-~~~r °°"°' - . DATA FILED .. ..t ~ Y .....J _.:7 _. __F-~ --~ . , .~-_~ -~, -, ~.~'7 Q "`c7 ZIP Code L 1 7 0 ], 1 Correspondent's e-mail address: J G R O S S~ R E A G E R A D L E R P C• C O M Under penalties of perjury, I declare that I have exam~ed this return, including acwmpanying schedules and statements, and to the best of my knowledge and beliefi, it is true, CaR~ and complete. t7eclaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. d ADDRESS - ~ -" -_ 311 A NDAL WA CAMP HILL PA 17D17, SIGN U 0 E THAN REPRESENTATIVE pAT /j~ / " ((J ADD ESS 2331, KET STREET CAMP HILL PA 17011, PLEASE USE ORIGfNAL FORM ONLY Side 1 1505607121 1505607121, D~a J 150560?221 REV-15430 EX Decedent's Social Security Number Decedent's Name: D O R I S L• CHRISTMAS 2 0 1 1 $ 6 5 0 4 RECAPITULATION 1 5 9 9 0 0 0 0 t. Real esta#e (Schedule A) ........................................ 1. . 2. Stocks and Bonds (Schedule 8) .................................. 2• 3. Closely Held Corporation, Partnership or Soie-Proprietorship (Schedule C) ..... 3. • 4. Mortgages & Notes Receivable (Schedule D) ........................ 4. • 4 9 4 9 $ ' 0 5 5. Cash, Bank Deposits & Miscellaneous PersonaV Property (Schedule E} ....... 5. 6. Jointly Owned Property (Schedule F) #_,_I Separate Billing Requested ....... 6• ~' $ ~ ~ ~' ' ~' ? 7. inter Vivos Transfers 8 Miscellaneous Non•Proba#e Property 6 x 3 9 3 8 (Schedule t3) n Separate Si#6ng Requested ....... 7. . 8. Total Grass Assets (total Lines 1-7) ............. 8. 2 3 4 2 $ 3. 6 0 9. Funeral Expenses & Administrative Costs {Schedule H) .......... .... .. 9. ~ 1 6 ? 8 • 2 ~ 1 5 4 9 4 • ? 3 t 0. Dehts of ©ecedent, Mortgage Liabilities, ~ Liens (Schedule 1) ...... .... .. 1©. 11. Total Deductions (totat tines 9 & 10) ..................... ...... 11. 5 ? 1 7 3. 0 2 12. Net Value of Estate (Line 8 minus Line 11) ................... .... .. 12• 1 ? ? 1 le 0 • 5 8 13. Charitable and Govemmenta# Bequests/Sec 9113 Trusts for which an a#ection to tax has not been made (Schedule J) ............ ... ... 13. ~ ? ? 1 3, Q 5 8 14. Net Value Subject to Tax (Line 12 minus Line 13} .. 14. ' TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 0 0 0 15 0. 0 0 . (x)(1.2) x .0 . 16. Amount of Line 14 taxable Z ? ? 1 1 0 5 $ ? 9 6 9. 9 8 • at lineal rate X .x45 16. 17, Amount of Line 14 taxable 0 ~ 0 17 0 • ~ 0 at sibling rate X .12 . 18. Amount of Line 14 taxable ~ D 0 0 0 D at collateral rate X .15 18. . ? 9 ~ ~ . ~ 8 19. Tax Due ......................................... .... ...19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^X Side 2 150560?221 150560?221 REV-15(30 EX Page 3 Fife Number Decede»t's Complete Address: ~~' ~'° Q3~$ DECEDENT'S NAME DORIS L- CHRISTMAS STREET ADDRESS - --.... _-_ .- _.._.._ _____..-- 19__ tafINDING HILL DRIVE _____._ -....__..._._ _ -----_...-- --...r_.,_ --- _._.. ._..._-----....._.~.-- -.. ._.. -- -.._..---- - CITY ~ STATE ~ ZIP MECHANICSBUR& €PA 17D55 lax Payments and Credits: ~. Tax Due (Page 2 Line 19) {1) 7, 969.98 2. CreditslPayrnents A. Spousal Poverty Credit B. Prior Payments $ , 7 Q 3.18 C. Discount 39 8.5 t7 'Total Credits (A + 9 + C) (2} 9 ,101 • b 8 3. InterestlPenalty if applicable D. interest E. Penalty Total Interest/Penaity (D +E } (3} p . 40 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the dVERPAYtNENT. l=ilt in oval on Page 2, Line 2fl #o reques# a refund. (4} Z ,13 ~, . ~p 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5} D • D D A. Enter the interest on the #ax due. (5A} B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) D - DD 1Vlake Check Payable to: REGISTER OF WILLS, AGFNT ..Y+.•' l t.....we .-r .. ... 1C:.C tLt:Zflw:vif '" ~. ..r.4rh(+i' ~FY .... .':~1.»r.>.ga...C rv.. ~±p. "F'iK• :F.1$r2 `:i f'a,~{ ':f: •4vr:.:.:^K'. ~-•'CY::+:{;H~i~.;.~ .,,sr tx. w....+.«..r:a-^ . ., c; ...~ M,x . ~.., t~.,.~.. it _t:sc; i~-' i~.,7+az ...:~'#s'. :8 ~~+.""~+. ~:r.~" :xis :.m~,.~~ ..-..-FS'" ~-r=~'i'~ ~„ `-f"r .~x..._ r.- ..: .. ..........r-. +:x~'' i:.,,.Z.•«. «i+,,.: K '3:ixt : ,...~Siip : t«~ o.'-~~~ r":Y,'." ~ o T ~ ut:,x.. ~. . ~L..,. x -...- k.. ttt~ ~ ^Y."; . :45R7er' .~ r .,~'~.a e . : "~. » » r :i~'.- :'..}~.. Rt. '~ ttd~ . '•.!. Ca"n~~t.-..ti.~. ,E ~..xr.~sc,', ~.:. .,.'k«~ tfi~r,"k."~ :ak.; 5.~. .:4r.»~w~~~~ ..r~:rt r.. r:.i?L. f_.. .x^~".sY:s... yid, ^~r...~G~' -~,,, ^x~~L~ e„t~x ,~:~",~ ....ns... - .... ~:~t, r~T, T; v:4 .':r.'tfi 'r ~_- ~ - "i`:C... ..!! ...~...r~..~..~ ...e"...t.'.e. ..., ~Sii;.t: ~Y_~ -rr, ...~.........~x..iy4wM;:i,. t::. .-..-...,-.sue.. rw.i~ a..e .r. .vn. ~'irrY.~~:'I'... _. ': ..n.........r~ir..e.w.M1N~ ...(....[..<..1~:.'.~:e.»~..Lrr.i. .. Kart .r a E,.x4-. *..~`a'~h+V.st:..tt.' ''..'cn»>-.tt.... ..._._. ._. .=t'4: C._wa.xw......... x.D.........a...., r'~.`~'."1L'.lC:'~~..,:.:".......__..~:f:...mN... e_.................L'.»^~.~'~' ... E ... '.~ ! ~.s.:'~ .< . ... _.. _ v PLEASE ANSWER TFlE 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 proper#y transferred : ...................................................................... ^ b. retain the right to designate who shall use the property transferred or its income; ............................... Q c. retain a reversionary interest; or ...................................................................r........................... ^ d. receive the promise for life of either payments, benefi#s or care? ............................................... r ....... QXC] 2. I# death occurred after Oecem~r 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................... r............... ^ 3. Did decedent awn an 'in trust for° or payable upon death bank account or security at his or her oath? ......... ^ Q 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................. ~ ^ IF THE ANSWER TO ANY OF THE AI30VE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE ETAS PART OF THE RETURN. For dates of death an or after Juiy 1, 1994 and before January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three {3} percent [72 P.S. §9116 {a} (1:1} (i}~. Far dates of death an or a#ter January 1,1995, the tax rate imposed on the net value of trans#ers to or for the use of the surviving spouse is zero (O) percent (72 P.S. §9116 (a) (1.1} (ii}J. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disdosure of assets and feting a tax return are still applicable even if the surviving spouse is the only beneficiary. Far dates of death an or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age ar younger at death to or for the use of a natural parent, an adaptive parent, or a stepparent of the child is zero (0) percent (72 P.S. §9116(a)(1.2)J. The tax race imposed on the net value of transfers to or far the use of the decedent's lineat t3enefiaaries is #our and one-half (4.5} percent, except as Hated in 72 P.5. §9116(1.2) (72 P.S. §9116(a}(i}J. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is Twelve (12} percent (72 P.S. §911ti(a}(1.3}J. A sibling is defined, under Section 9102, as an individual who has at least one parent in c~rrfmon with the decedent, whether by good ar adoption. REV-1502 EX + {6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIa REAL ESTATE INHERITANCE TAX RETURN RESIDENT' DECEDENT ESTATE OF FfLE NUMBER DORIS L• CNRSSZMAS ~~ 1D 8395 Afl real property owned solely or as a tenant in common must be reported at falr market value. Fair market value is defined as the price at which property would be exchanged between a willlgg bu5rer and a wlllin4 seller, neither being compelled to buy arse!{, both having reasonabVe knowledge of the relevant #ac~s. (I# more space is needed, insert additional sheets of the same' size) REV-'E5Q8 EX + (6-98} SCHEDULE E COA~+AONWEALTH OF PENNSYLVANIA CASN, BANK DEPOSITS, & MASC. IN RE5 DENT DECEDENT N PERSONAL PROPERTY ESTATE OF ffLE NUMBER DORIS L• CHRISTMAS 21 1Q 0395 InGude the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owrred with right of survivorship must be disclosed ors Sche~fule F. 1rEM vALU~ Ar oATr= NUMBER DESCR{PT{4N 4i= DEATH 1. NEW CUMBERLAND FEDERAL CREDIT UNION - SAVINGS (S1) 193.33 PO 80X 65b, NEW CUMBERLAND, PA 17D7D-Db58 2• NEW CUMBERLAND FEDERAL CREDIT UNION - CD 818.D9 PO BOX 658, NEW CUMBERLAND, PA 17D70-Db58 3• MEMBERS 1ST FEDERAL CREDIT UNION - SAVINGS - 27529D-DD 55.55 5DDD LOUISE DRIVE, MECHANICSBURG, PA 3-7055 4• MEMBERS 1ST FEDERAL CREDIT UNION - CHECKING - 275290-11 4,2D9.6D 5DDD LOUISE DRIVE, MECHANCCSBURG, PA 17D55 5• MEMBERS 1ST FEDERAL CREDIT UNION - INVESTMENT SAVINGS - 27529D-Q§ 4,74b•51 50DD LOUISE DRIVE, MECHANICSBURG, PA 17D55 6• MEMBERS 1ST FEDERAL CREDIT UNION - CD -- 275290-40 2,337.84 5DDD LOUISE DRIVE, MECHANICSBURG, PA 17D55 7• EDWARD BONES - MUTUAL FUNDS ACCOUNT 242-1DD56-1-8 8,894.07 1fl1D WESLEY DRIVE, SUITE ZD4 MECHANICSBURG, PA 17D55 8• 1997 BUICK LESABRE 1,5DD•OD 9• SAFE DEPOSIT BOX ITEMS 35Q•Rt1 10• ,JEWELRY APPRAISAL 2,883.QO 11• MEMBERS 1ST 5000 LOUISE 12• MEMBERS 1ST 50Q0 LOUISE 13- MEMBERS 1ST 5DDD LOUISE FEDERAL CREDIT UNION DRIVE, MECHANICSBURG, FEDERAL CREDIT UNION DRIVE, MECHANICSBURG, FEDERAL CREDIT UNION DRIVE, MECHANICSBURG, SAVINGS -127?D-OD 12.31 PA 17055 INVESTMENT SAVINGS -1277fl-D5 3,895.88 PA 27055 CD - 127711-40 5,b21.48 PA 17D55 14- ITAX AND SEWER PRO RATIONS - SALE OF REAL ESTATE { 1,4&4.43 15. COINS 80•DO 16- PERSONAL PROPERTY ,SDO.QD TOTAL Also enter on line 5, Recapitu{anon) $ 4 9 , 4 9 8.0 5 (lf mare space is needed, insert additional sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Residen# Decedent DOR(S L. CHRISTMAS 2'I 1p 0395 Decedent's Name Page 1 File Number Schedule E -Cash, Bank Deposits, ~ Misc. Persona! Property ITEM VALUE AT DATE NUM$ER DESCRIPTION OF DEATH y7. INSURANCE REFUND- NATIONWIDE 43.66 18• TRASH REFUND - REPl16LIC SERVICES-, INC• y3Q.50 1`i- CONSIGNMENT STORE - PASSITON 20.75 19• OIL REFUND - SHILPLEY OIL y,18q.12 20• CUMBERLAND COUNTY VETERANS AFFAIRS - FUNERAL CONTRIBUTION yQi7.00 2y• MEMBERS 1ST FEDERAL CREDIT UNION - CD - 2775290-44 yi],248.93 Sp00 l.OUISE DRSVE, MECHANICSBURG, PA 17055 SUBTOTAL SCHEDULE E y y, 9 y S• 9 6 GRAND TOTAL SCHEDULE E S 49,498.05 REV-1505 EX + (6-98) SCHEDULE F COMMONtNEALTH OF PENNSYLVANIA JOINTLY-OVUN~D PROPERTY fNHERITANGE TAX RETURN RESIDENT DECEDENT ESTATE OF Ftt.E NttMBER DORIS L• CHRISTMAS 21 10 0395 tf an asset was made Mini within one year of the decedent's date of death, it must be reported on Schedule G. SURVNING JOINT TENANTS} NAME ~ ADDRESS RELATIONSHIP TO DECEDENT A.NATALIE A• WHITE B PETER J- CHRISTMAS C JOINTLY-OWNED PROPERTY: 311 ALLENDALE WAY DAUGHTER CAMP HILL, PA 17D11 231 LINCOLN STREET ISON ENOLA, PA 17D25 ITEM NU#ABER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANKACCOUNT NUMBER OR S#MILAR i1}ENTIFYfNG NUMBER ATTACH [}EED FOR JOINTLY-HEED REAL ESTATE. DATE OF DEATH VALUE O1= ASSET ~ OF DEGD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S ENTERESI 1. A. 2!i?ODb PSECU - SAVINGS (S1) 1D5-D0 50• 52.5D 1 CREDIT UNION PLACE HARRISBURG, PA 1711D ~• A 2/2p06 PSECU - CHECKING tS4) 1,949.54 50• 974.?? I CREDIT UNION PLACE HARRSIB#JRG, PA 1711D 3• A 2/2D06 PSECU - MONEY MARKET ES?) 4,310.63 50• 2,1,55.32 1 CREDIT UNION PLACE HARRISBURG, PA 1711D 4• A 2/2DD6 PSECU - CD (S5D) 1,256.05 SO• b28•D3 b CREDIT UNION PLACE HARRISBURG, PA 17110 5 • A 2/i'D06 PSECU -- CD t S51) 1, 306.79 5D • b53.4D 1 CREDIT UNION PLACE HARRISBURG, PA 1711D b• A 2/20D6 PSECU - CD (S53) 5,608.11 50• 2,804-06 1 CREDIT UNION PLACE HARRISBURG, PA 1711D 7. A 2!2006 PSECU - CD (S56) 1,52?•81 5D• 763.91 1 CREDIT UNION PLACE HARRISBURG, PA 1711D B• A 2/2D06 PSECU - CD (S57) 1,527.82 50• 763.91 1 CREDIT UNION PLACE HARRISBURG, PA 1?11D 9. A 2/20D6 PSECU - CD (S58) 593.09 5Q• 296.55 1 CREDIT UNION PLACE HARRISBURG, PA 1711t] 10• A 2/20D6 PSECU - CD (S59) 594.18 50• 297•Q9 Z CREDIT UNION PLACE HARRISBURG, PA 1711L1 TOTAL (Also enter on line 6, Recapitulation) ~ $ 18 ., 0 4 b -17 (!f more space is needed, insert additional sheets of the same size) Continuation of REV-'1500 Inheritance Tax Return Resident Decedent DORIS L. CHRISTMAS 21 30 0395 Decedent's Name Page 2 File Number Schedule F-2 -Join#ly-Owned Property ITEM NUMtBER LETTER FOR JOlM TENANT GATE MADE JOINT DESCRIPTION Ot: PROPERTY INCLUDE NAME OF FINANGAL INSTITUTION AND BANK ACGOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOENTLY-HELD REAL ESTATE, DATE OF DEATH VALUE OF ASSET % OF DECUS INTEREST DATE OF DEATH VALUE OF DECEDENTS iNTERESI 1I• B 9/2DD7 MEMBERS 1ST FCU - CD - 27529D-42 5,526.68 5R• 2,763.34 SDDD LOUISE DRIVE MECHANICSBURG, PA 17~SS 12• B 3/2DD8 MECIBERS 1ST FCU - CD - 27529D-43 3+1,?$6.57 5t]• 5,893.29 SDOD LOUISE DRIVE MECHANICSBURG, PA 17D55 SUBTOTAL. SCHEDULE F-2 ~ 8, 6 S 6.6 3 Gt2AND 70TAL SCHEDULE F-2 ' $ '! 8.046.3 7 REV-1530 EX + (6-98) COMMONWEALTH QF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT pECEDENT ESTATE OF SCHEDULE G INTER-VIVOS TRANSFERS & MASC. NON-PROBATE PROPERTY FILE NUMBER D4RIS L• CHRISTMAS 21 1D 0395 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTEON OF PROPERTY ir~auor THE NAME of THE Twws~rtEE. Tt~IR RELATIONSHfP To oEC~Hr ANO THE DATE OFTWwSFER ATTACHACOPYOFTHEOEEDFORRf.ALESTATE. DATE OF DEATH VALUE O1=ASSET % OF DECD'S INTEREST EXCLUSION pFAP?UCABL.E) TAXABLE VALUE Z. PSECU IRA (SS2) 6,839.38 SD• 3,419.69 NATALIE WHITE - I?AUGFtTER 2 • PSECE! IRA t S52) 6, 839.38 50 • 3, 419.69 PETER J• CHRISTMAS - SON _ TOTAL Also enter on tine 7 Recapitulation} ~ ~ ~, , 8 3 q . 3 8 (If mole space is needed, insert add'stional sheets of the same size} REV-1 B1 ~ EX + {'10-06) SCHFDUt,E H C0t~lA0NWEALTN OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMlNISTRATfVE COSTS RESIDENT DECEDENT ESTATE OF FILE I!!tlMSER DORIS L• CHRISTMAS 21 10 0395 Debts of decedent must be reported on ScheduEe ><. ITEM NUMBER DESCRIPTION AMOUNT - A. FUNERAL EXPENSES: 1. MALPEZZ7: FUNERAL HOME 8,863.79 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Persona{ Representative (s} N A T A L I E A• WHIT E Street Address 37,1 ALLENDALE WAY City CAMP HILL State P A Zip 17 II 11 Years}Commission Paid: 2 011 2, AttomeyFees REAGER 8 ADLER, PC 3, Farniiy Exemption: of decedent's address is not the same as daimanrs, attach explanation} Claimant Street Address City State Zip Relationship of Claimant ~ Recedent 4. Probate Fees CUMBERLAND COUNTY REGISTER OF WILLS 5 AccountanCs Fees 6. Taz Retum Preparers Fees I:O, Ol3Q • Ofl 6,0DO.00 373.5II 7. LEGAL ADVERTISEMENT - CUMBERLAND LAW JOURNAL 75.0[l 8• LEGAL ADVERTISEMENT - JOURNAL PUBLICATIONS 79•t]II 9. SELLER ASSISTANCE - SALE OF REAL ESTATE 4,797•aII yo• COMMISSION - SALE OF REAL ESTATE 9,71z9•IIII 7:1• TRANSFER TAX -SALE OF REAL ESTATE 1,599.00 12• SEWER & TAX CERTIFICATION - SALE OF REAL ESTATE 12.00 TOTAL (Also enter on Isne 9 Recapitulation} $ , 47-,b78.29 (lf rare space is needed, insert additional sheets of the same size REV-1592 EX ~ (92-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVAN4A DEBTS OF DECEDENT, INttERITANCE TAX RETtlRN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF ~ F1LE NUMBER DORIS E,.- CHRISTMAS 23, 1.D D395 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medicaE expenses. ITEM VALUE AT DATE NUMBER DESCRIPI"ION OF DEATH 1. VISA - MEMBERS 1ST CREDIT UNION ?9•D6 B• PERSONAL SERVICE LOAN - PSECU 9,399.51 3• HOME CARE - ALEXANDRA QUJISTIN ?DD•Di3 4• DUMPSTER/TRASH REMOVAL - NATALIE WHITE 365-QD 5• CLEANING HOUSE - KATHLEEN BURGESS 39D•DO b• JEWELRY CONSULT - MORROW FARRARI 25•D4 ?• COPY 4F DEED FLORIDA LOT - HIGHLANDS COUNTY CLERK OF COUNTY 5•DD COURT 8• SEWER BILL - UPPER ALLEN TOWNSHIP 224.DD 9. MONITOR - AMERICAN MEDICAL ALARMS 49.9^ ZO• JEWERRY APPRAISAL - HENERSON & CO. JEWELERS, INC• 32D•DO 11• TRASH - YORK WASTE 3D5•SD 12• CO-PAY FOR APPOINTMENT - DAVID PULMARY 3CI.48 13• REMOVAL OF PROPERTY FROM HOUSE - JOHN t1• ~iUTZABAUGH 5D0•DD ]:4- 2DI~Dt2D11 SCHOOL REAL ESTATE TAXES - DENNIS ZERBE, TREASURER 1,b42.41 Z5• INSURANCE PAYMENT - NATIONWIDE INSURANCE 111.84 TQTAi. (Also enter on Line 10, Recapitulation) ~ ~ 15 ~ ~ ~ 4 . ? 3 (It more space is needed, insert additional sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent DORIS L. CHRISTMAS 21 10 0395 Decedent's Name Page 3 File Number ScF~edute 1-Debts of Decedent, Mortgage Liabilities, & Liens ITEM NUMBER DESCRIPTION AMOUNT 16• WATER - UNITED WATER 126•?7 17• ELECTRIC - PPL ELECTRIC 7~g.,p Z8• OiL - SHIPLEY 285.0(3 19- WATER MAINTENANCE/REPAIR - ACH H4ME SERVICES 295.76 SUBTOTAL SCHEDULE t 2, 3 4?• t7 3 Gf2Al~tD TQTAL SCHEDULE { ~ 9 5,494.73 REV-1500 Discount, Interest and Penalty Worksheet Discount Calculation Total Amount Paid within three calendar months of the decedent's date of death: 8, 7U3.18 Discount: 3 9 8.5 7 Interest Table Year Days Delinquent this time period Balance Due this year Interest this period Before 1981 1982 1983 1984 1985 1986 1987 1988 throu h 1991 1992 1993 throu h 1994 1995 throu h 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 TOTALS Penalty Calculation If the decedent's date of death was on or before March 31, 1993, insert the applicable amount: Total Balance Due on January 17, 1996: Penalty: ,~~ ~f~ 2~1Q ~P~; ~ 3 P#~ f2: LAST WILL AND TESTAMENT ~ Q r r OF ~'~~~~ r~r DORIS L. CHRISTMAS I, DORIS L. CHRISTMAS, now domiciled in Cumberland County, Pennsylvania, declare this to be my Last Will and Testament. I revoke all .other wills and codicils that I may have previously made. Article I My just debts and expenses of my last illness, funeral, and administration of my estate shall be paid by my Executor from the principal of my residuary estate as soon as practicable after my death. Article II All inheritance, estate, and succession taxes (including interest and penalties thereon, but not including any generation skipping tax) payable by reason of my death shall be paid out of and be charged generally against the principal of my residuary estate without reimbursement from any person. This provision is not a waiver of any right which my Executor has to claim reimbursement for any such taxes which become payable as the result of any property over which I have the power of appointment. Article III I give, devise and bequeath my tangible personal property in accordance with any memorandum I have handwritten or signed, located with my will or with my valuable papers and found within 30 days of the probate of my will. Gifts may only be to persons who survive me or to organizations which exist at my death, and if there is a conflict, the memorandum having the latest date shall govern. To the extent no such memorandum is found, or all of my tangible personal property is not disposed of pursuant thereto, my tangible personal property shall be added to my residuary estate and pass under Article IV hereof. Article IV All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, I give, devise and bequeath IN EQUAL SHARES to my children: PETER J. CHRISTMAS, of Mechanicsburg, Pennsylvania, and NATALIE A. WHITE, of Camp Hill, Pennsylvania. However, if a beneficiary fails to survive me by thirty (30) days, but leaves descendants who survive me by thirty (30) days, those descendants shall receive, Pe~° Stirpes, the share the beneficiary would have received had he or she survived me by thirty (30) days. The share of any deceased child who does not have living issue shall be distributed to my surviving child. Article V I nominate, constitute and appoint my daughter, NATALIE A. WHITE, as Executrix of my Last Will and Testament. In the event of the renunciation, death, or inability to act, for any reason whatsoever of my Executrix, I nominate, constitute and appoint my son-in-law, JOHN F. 2 WHITE, as successor Executor of my Last .Will and Testament. I direct that my Executrix or successor Executor be permitted to serve without bond. In addition to those powers granted by law, I grant them power to distribute in cash or in kind, in like or in unlike shares, and to file any qualified disclaimer I could have filed if living. My Executrix or successor Executor shall receive reasonable compensation for services rendered to my estate. Article VI In addition to the powers conferred by law, I authorize my Executrix or successor Executor, in his/her absolute discretion: (a) to retain in the form received and to sell either at public or private sale, any real estate or personal property except that which I specifically bequeath herein, (b) to manage real estate, _ (c) to invest and reinvest in all forms of property without being confined to legal investments, and without regard to the principal of diversification, (d) to exercise any option or right arising from the ownership of investments, (e) to compromise claims without court approval and without consent of any beneficiary, (f) to file any federal income tax return for any year for which I have not filed such return prior to my death, (g} to make distributions in cash or in kind, or in both, and to determine the value of any such property, (h) to employ any attorney, investment advisor, or other agent deemed necessary by my Executrix or successor Executor; and to pay from my estate reasonable compensation for all their services, 3 (i) to conduct alone or with others, any business in which I am engaged in, or have an interest in at time of my death, and (j) to receive reasonable compensation in accordance with their standard schedule of fees in effect while their services are performed. IN WITNESS WHEREOF, I, DORIS L. CHRISTMAS, hereby set my hand to this my Last Will and Testament, on , ~ r r l ~-~- , 2006, at Harrisburg, Pennsylvania. n / f~n .~ 1 s ~ i DORIS L. CHRISTMAS In our presence, the above-named DORIS L. CHRISTMAS signed this and declared this to be her Last Will and Testament and now at her request, in her presence, and in the presence of each other, we sign as witnesses. Name Address J ~ ~ '~ ` 2000 Lin lestown Rd. Suite 202 Harrisbur PA 1 ~ g, 7110 ~ ~ ~ ~`t 2000 Lin~lestown Rd., Suite 202, Harrisburg, PA 171.10 ~~ ~. 4 I, DORIS L. CHRISTMAS, Testatrix, who signed the foregoing instrument, having been duly qualified according to law, acknowledge that I signed and executed this instrument as my Will, and that I signed it willingly as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and Acknowledged before me by DORIS~. CHRISTMAS, the Testatrix on ot~rv Public 2006. i~ ~~ j' ~ ~ DORIS L. CHRISTMAS COMMONVdirALTH OF PE~dIVSYLVkNIA Notarial Seal Kim M. Smith, Notary Public uehartna Twp., Dauphin County ~ mission Expires Nov. 2, 2005 We, the undersigned witnesses who signed the foregoing instrument, being duly qualified according to law, depose and say that we were present and saw the Testatrix sign and execute this instrument as her Will; that she signed and executed it willingly as her free and voluntary act for the purposes therein expressed; that each of us in her sight and hearing signed the Will as witnesses, and that to the best of our knowledge, that she was at that time eighteen (18) years or more of age, of sound mind, and under no constraint or undue influence. Swom to or affirmed and Subscribed_ to before me and ~ ~ .~ r. _ ~~ ' , witnesses, on ,~ ~ L ~( , 2006. ~ ~ ... Not Public ./ ' ~ ~ 1 r! Wi ess 4, \y, Pv'~ Witne ~;OIViMfJ;~tw~H.f.','F~ l?r Yell+iS~'~,,'lAidi~ Notaria! Sea! l~im M, Smith, Notary !'ublic SusQuehanna Twp., Dauphin Oounty My Camrrris~siara Expires Nor. 2, 2008 A A SE7lLEM1cNT STATEMFJJ'r (HUD-1) ~r~`"`~`°`~ Select Platinum Settlement Services, LLP * ~~~ * ~`~ 3912 Market Street S `'~.~•~ Camp Hill, PA 17011 (717) 737-0884 FINAL B. TYPE OF LOAN 1. FHA 2. RH5 3. CONY. UNINS. 4. ^ VA 5. ^ CONV. INS. 6. ESCROW FILE NUMBER 7. LOAN NUMBER: 00102127-001 MAW 7117877717 8. MORTGAGE INSURANCE CASE NUMBER: 446-0369998-703 c. NOTE: This tbmt is famished to give you a statement of acluaJ settlement costs. Amounts paid to and by >rie settlement agent are shown. !Isms marlaed "YP.Q G)' ware paid outside the closing; ~,ey are shown here for inlF~rrrlatronat purposes and are not included in the totals. o. NAME of soRROwER: Cletus L. Taylor and Oonna M. Livening ADDRESS of BoRROwER: 705 Old Cabin Hollow Road DjllsburQ, PA 17019 E. NAME OF SELLER: Estate Of DariS L. Christmas ADDRESS OF SELLER: 311 Allendale Way Camp Hill. PA 17011 F. NAME OF LENOER: PHH Home Loans, LLC d/b/a ERA Home Loans ADDRESS OF LENDER: 1 Mortgage Way Mount Laurel, NJ 08054 G. PltopERTY LOCATION: 19 Winding Hill Drive Mechanicsburg, PA 17055 Cumberland County 42-27-1888-017 Parcel #42-27-1888-017 H. sETTLEMENTACENT: Select Platinum Settlement Services, LLP (717} 737-0884 PLACE of sETTLEMENr: 3912 Market Street, Camp Hiil, PA 17011 I. sE1'n.EMENC DATE: 9/16/2010 PRORATION DATE: 9!162010 DISBURSEMENT DATE: 9/16201 O J. UMMARY OF B OWER'S TRANSACTION K SUNMAARY OF SELLER'S TRANSACTION :. i. ;'.;,>,;.:..:.; -:•::: ;`•-;..',.;: ; ~:>: , -......, , .x400: •.; GROSS `AMOUNT:DUE TO'SELLER.:.. a , • , , 101. Contrad Sales Prix 159,900.00 401. Contract Sales Prioe 159,900.00 102. Personal Property 402. personal Property 103. Settlement charges to Borrower (line 1400) 12,635.07 403. 104. 404. 105. 405. ADJUSTMENTS FOR REMS PAID BY SELLER W ADVANCE: ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE: 106. 1Town Taxes 406. C /Town Taxes 107. Cou Taxes 09!16!10 to 12/31/10 149.46 407. Cou Taxes 09/16/10 to 12/31/10 149.46 108. Assessments 408. Assessments 109. School tare 09!16/10 to 06!30/11 1,317.79 409. School taxe 09/16/10 to 06/30/11 1,317.79 110. Sewer 08H6/10 to 09!30!10 17.18 410. Sewer 08/16/10 to 09/30/10 17.18 111. 411. 112. 412. 113. 413. 114. 414. f 115. 415. 120. GROSS AMOUNT OUE FROM 130RROtlVER: 174,019.50 420. GROSS AMOUNT DUE TO SF11ER: 161,384.43 200::iAWOIXVTSPADBY.~t~iNBEHALfOFBORROWER ::°::~.: , : .: :.. ;::; :500'•REDUCI'IONS~1NA1w0UNT•.DCE~TOSELLER; 201. Deposit or earnest money 1,000.00 501. F_xcess deposit (see instructions) 202. Principal amount of new k>an(s) 157,774.00 502. Settlement cha es to Seller line 1400) 12,518.25 203. F..~osting ban(s) taken subject to 503. F~cistin loan(s) taken su 'ed to 204. 504. Payoff of first mo age loan 205. 505. Payoff of second mortgage loan 206. Seger Assist 4,797.00 506. Setter Assist 4,797.00 207. Se1lerTransferTax 1,599.00 507. Seller7ransferTax 1,599.00 208. 508. 209. 509. ADJUSTMENTS FOR ITEMS UNPAID BY SELLER: ADJUSTMENTS FOR ITEMS UNPAID BY SELLER: 210. Cityrl'own Taxes 510. C' !Town Taxes 211. County Taxes 511. Coun Taxes 212. Assessments 512. Assessmertits 213. 513. 214. 514. 215. 515. 216. 516. 217. 517. 218. 518. 219. 519. 220. TOTAL PAS BYIFOR BORROWER: 165,170.00 $20. TOTAL REDUCTIONS IN AMOUNT DUE SELLER: 18,914.25 300:CASH f1T,SEITLEYENT:FR0IWT0 BORRWYER: :, r:. ~.'t: , 800:.CASH ATSETTLEMENT~TOVFROM~SEU.ER ,, 301. Gross amount due from Borrower (tins 120) 174,019.50 601. Gross amount due to Seller (line 420) 161,384.43 302 Less amount paid byltor Borrower (line 220) 165,170.00 602. Less reduction in amount due Seller t6ne 520) 18,914.25 303. CASH (®FROM) ( ^ TO) BORROWER: 8,849.50 603. CASH (^ FROM) (®TO) SELLER: 142,470.18 The Public Reporting Burden for this cdlection of information is estimated at 35 minutes per response for coflecting, reviewing, anq reporting the data. This agenyr may not C0118Ct this inbrmatiort, arxi you are not required to complete this form, unless it displays a currently valid OMB control number. No oonfdentiatity is assured; this d>$dosure is mandatory. This is designed to provide the parties to a RESPA covered transaction with information during the settlement process. Previous edisons are obsolete Pace 1 of 4 HUD•1 L SETTLEMENT CHARGES ESCROW FILE NUMBER: 00102127-001 MAW 700 .TOTAL•REAL ESTATE BROKERfEES ,• , . DMSION OF CObgJMSS10N (L1NE 700) AS FOLLOWS: 701. 54,872.00 tD RdNtax 1st Advantage Inc. PAID FROM BORROWERS FUNDS AT SETTLEMENT PAID FROM SELLER'S FUNDSAT 702. 54,797.00 to ERA NRT LLC ~~~~ 703. Corrnnission Pala at satttQrr+ant 9.769.00 704. Additional Brkr Fee t0 ERA NRT LLC 195.00 705. .... ,. ::800._ ITEMS PAYAB[.E• W CONNECTION WITH LOAN: ;' P.0 C ... 5460.00 (rrom GFE e1) 801. Our origination ~9e 802. Your cradlt or charge (points) for the specific interest rate ctwsen 52,255.48 (from GFE N2) 803. Your adjus0ed ongmatror- et~arges tp PHH Hone Loans, LLC dfila ERA Home Loans (iron GFE A) 2,715.48 804. Appraisal fee b STARS (~ GFE *s) 415.00 805. Credit report to CBC Irxwvis, Inc. (~ GFE ~) 6.18 806. Tax service PfO"' ~E'M> 807. FIOOd oertificadon (from GFE e3) 808. Scoring Fee m FPIMA 15.95 809. 810. P.O C :::.900.:'I?EMS REQI~RED 6Y LENDER TO` BE PA(D IN ADVANCE: ~ . 901. Daly intenxt charges (srom GFE sE1o) 275.55 trom9/16/201ototonr2olo ®s18.3700lday x (lsdays) 902. Mortgage insurarme premium for 0 month(s) to Dept Of HUD (from GFE rf3) 3,471.82 903. Horneownefs insurar-Ce for 1 year(s) b State Farm (kom GFE x11) (317.00}6 904. 905. <~DDa . t~ostrm wnn~l uianER: ,. 1001. Initial deposit for your escrow aooount (from GFE *s) 626.84 1002. Hortreowrlers insurance 3 mOnlhs ~ S 26.42 par month 579.26 1003. ~rt9a9e insurance moms ®5 70.18 per month 1004. City property taxes rtwntits ®S per month 1005• aunty proPe+b taxes 8 montlrs ®5 42.89 per month 5343.12 1006. Annual atctessrnems months ®S per month 1007• Scholl Taws 3 nlontlts Q S 139.66 per month 5418.98 1008• momhs Q 5 per month 1009• Aggregate Acct. Adj. morttlrs ®5 per month -52'14.52 ,.11DQ_''ZiT1'E`CJ~IARGES:a,; . ;.:_ .... .:.. ... '` 1101. Title senigea and tinders title insurance (from GFE sa) 1,493.75 1102. Settlement or dosing tee 1103. Ow~lers tide. insrxarrce to Select Platinum Settlement Services, LLP (from GFE s5) 10.00 1104. Lenders title insurance • to Sebct Platinum Settement Servirxs, LLP 51,148.75 1105. Lenders tide policy Rmk $157,774.00 1106. Owners file policy Nfnh 5159,900.00 1107. Ager-Cs POD Ot the total tale klslxarxr Premium 51,112.44 ro Saba Platinum Settlement Services, ttP 1108. Underwriters potion of the total title msurarxre prerriium 5271.31 to Otd Repubtic Plaationai Title ins. Co. 1109. End. 700.300, 8.1 • to Sdect Platinum Settlement Services, LLP S150.00 1110. tnaured Gkuing Lettar • to Old Republic National Title Ins. Co• 575.00 1111. Notary Fees • t0 Settlement OtTioer 540.00 1112. °See atFached for brcekdown 580.00 10.00 120Q.'. GOVERNMENT RECORD11~1G ~AI+tD TRANSFER CHARGES.... :: _ ,': ' . .:!;, ,';;: ' .:;.P.O C .:: ;. 1201. ~ record~g ~~ prom CaFE ~ 192.00 1202, Deed 582.00 Mortgage 5110.00 Release 10.00 1203, Transfer taxes (from GFE tr61 3,198.00 1204, CitylCounty taxlslamps Deed 51,599.00 Mortgage 50.00 t205. State tax/stamps Deed 51,599.00 Mor~age 50.00 1206. 1207. _..,.pOC >..1300: ~ADDITIONAL~SET1'I:EIYENTCFIARCES. •: = 1301. Requirod services thst you isfri shop ~ t~i+ CFE tsl 19.50 1302. Pest Inspection to Mdse SheeN (40.00)8 1303. Home Inspection to NTilce Sheet' (240.00) 1304. Sewer 6!1!10-8/30/10 ib Upper Allen Sewer Authority 112.00 1305. RePaks m CMH Builders 1,031.50 1306. "sae attactlad for breakdown 519.50 1.595.75 1400. TOTAL SETTLEMENT CHARGES (Enter on iliac 103,Secdion ,! -and -line 502. Section IQ 12,635.0? 12,518.25 1 have piefuly reviewed the HUD-1 Settlement Statementand to the best of my Kncarledge and b¢liet, N isa true and accurate statement of etl receipts adld distwrsements made On my aCdount or by me in tltis lransacGOn. I further aertiy drat (have teaeived a eo .oLttre..tlyD-1 Settlement Statement ~~. ~~~ ~ ~ ~ ~~ Cktu L. Taylor f rate of Doris L Christm l ., onna M. Livening - - - ~~ Bort+owers Seders The IiUD-1 Settlement Statement 1Nrch I ,true Ocutate aeoaxrt of thistcsnaaction. 1 have caused Or wit Muse the funds to be disbursed 'n accordance with this s ,p•! j~ ~`~ "' / ~' SettkmentAgent ~ /~ ~ /' `-' Date Select PI b~num Settlemerrt Services, LLP WARNING h is a crime tQ laiorringiy moire take statements b the United Stites on this or any smiar form. Penatlies upon ca-viction ran include afire and inprisonmerri. For detail sce: Title 16 U.S. Code Section 1001 and Section 1010. previous editions are obsolete Pace 2 Of 4 HUD-1 Escrow Number: 00102127-001 MAW Gompattison'of Good`Fa[t!1 E§timate jGFE):and;HUD='1.Charges :': .; .. ;::` Charges That Cannot Increase HUD-1 Line Number Our origination charge #801 Your credit or charge (points) for the spedfic interest rate chosen #802 Your adjusted origination charges #803 Transfier taxes #1203 Cha That in;Totaf :Carinot`Intrease'Mort~`Than 1 O•ti : = ~. ~: ,,' Government recording fees #1201 Appraisal fee #804 Credd report #805 Scoring Fee #808 Mortgage insurance #902 Flood Cent Fee #1309 Total Increase between GFE and HUD-1 Charges _. :Ct~arges.Tfiat:Ca6Ctiange' ~ ~ ''. Initial deposit for your escrow account ft'1001 Daily interest charges #901 $18.37001 day Homeowner's insurance #903 Tide services and tender's title insurance #1101 Owners title insurance #1103 Loan Terms Good`F'a'rth'Estimate ; ;., HUD=1 460.00 460.00 2,255.48 2,255.48 2,715.48 2,715.48 3,210.00 3,198.00 :Good'Faifh Estimate,':°.: HUD-1 . 2n.ao 192.00 415.00 415.00 6.18 6.18 15.95 15.95 3,471.82 3,471.82 19.50 19.50 4,205.45 4,120.45 $ -85.00 or -2.0212°k ;:GoodF>tirtti Estimate:'; > . '' ,:HUI>~1 . 716.06 626.84 293.92 275.55 317.00 317.00 465.00 1,493.75 1,208.75 10.00 Your in~al Ioan amount a $157,774.00 Your loan term is 30 years Your initial irrter~t rate is 4.2500% Your initial monthy amount awed for principal, interest, and any $846.34 includes mortgage insurance is X~ Principal nx Interest X~ Mortgage Insurance Can your interest rate rise? X~ No. ~ Yes, it can rise to a maximum of 0.0000%. The first change will be on and can change again every after .Every chamge da0e, your irudrest rate can increase ordecrease by 0.0000%. Over the Gfe of the loan, your inbrest rate is guaranteed to never be tower than 0.0000% or higher than 0.0000%. Even if you make your payments on time, can your loan balanrx rise? ^X No. ~ Yes, it can rise to a maximum of $ 0.00. Even if you make your paymerris on time, can your monthly amount [x No. ~ Yes, the first irxxease can be on and the monthly amount owed can owed for principal, interest, and mortgage insurance rise? rise to S 0.00. The maxmnum it can ever rise to is $ 0.00. Does your loan have a prepayment penalty? ~ No. ~ Yes, your maximum pn'paymerrt penalty is $ 0.00. Does your ban have a balloon payment? Q No. ^ Yes, you have a balloon payment of $ 0.00 due in 0 years on . Total monthly amount owed inchxiing escrow account payments [~ You do not have a monthly escrow paymentfor items, such as property taxes and homeowners insurance. You must pay these items direCdy yourself. 0 You have an additional mortihly escrow payment of $208.97 that results in a total initial monthly amount owetd of S 1,055.31. This includes prinapal, ;Merest, any mortgage insurance and any ;tams checked below. 0 Property taxes Q Homeowners insurance ^ Flood insurance o a Note: H you have any questions about the Settlement Charges and Loan Terms listed on this form, please contact your lender. Previous ed'rtioru are obsolete Pace 3 of 4 HUO-1 ' Escrow Number. 00102127-001 MAW HUD 1112 DETAILED BREAKDOWN OF ADDITIONAL TITLE CHARGES Detail Seller Description Amq~t Amount 1113. ~Doc/Wire Fee • to Select Platinum Settlement Services, LLP $50.00 .1114. Overnight Fees • tQ Select Platinum Settlement Services, LLP $30.00 1115. Tax Cert Reimbursement to Select Platinum Settlement Services, LLP 10.00 Total as shown on HUD page 2 line #1112 10.00 HUD 1200 DETAILED BREAKDOWN OF GOVERNMENT RECORDING AND TRANSF ER FEES Buyer Seller Amount Amount City & County Tax/Stamps City Tax/Stamps: Deed $1,599.00 Total as shown on HUD page 2 Une #1204 1,599.00 . Buyer Seller Amount Anaunt State TaxlStamps State Tax/Stamps: Deed $1,599.00 Total as shown on HUD page 2 Line #9205 1,599.00 HUD 1306 DETAILED BREAKDOWN OF ADDITIONAL SETTLEMENT CHARGES Debit Seller Description Amoutt Amount 1307. Electrical Repairs to Timothy R. Be'~tzel 1,305.75 1308. Repairs to CMH Builders 290.00 1309. Flood Cert Fee • to STARS '$19.50 Total as shown on HUD page 2 tine #130fi 1,595.75 Previous editlor+s are obsolete pace 4 of 4 MUD-1 REV-485 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 SAFE DEPOSIT BOX INVENTORY Please Print or Type MUST 8E COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS COUNTY CODE FILE NUMBER SOCIAL SECURITY OR DEATH CERTIFICATE NUMBER 201-186504 DECEDENT'S NAME (LAST, FIRST, MIDDLE) DATE OF DEATH Christmas, Doris L. 4-6-2010 ADDRESS OF DECEDENT (STREET) (CITY) (STATE) (ZIP CODE) NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT SOX (NAME) Natalie A. White (STREET NAME) (CITY) (STATE) (ZIP CODE) 1816 Chatham Drive Camp Hill PA 17011 NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING a. (NAME) (RELATIONSHIP) Natalie A. White baughter (STREET NAME) (CITY) (STATE) (ZIP CODE) 1816 Chatham Drive Camp Hill PA 17011 b. (NAME) (RELATIONSHIP) (STREET NAME) (CITY) (STATE) (ZIP CODE) c. (NAME) (RELATIONSHIP} (STREET NAME} (CITY) (STATE) (ZIP CODE) NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED (NAME) Members 1st Federal Credit Union (STREET NAME) (CITY} (STATE) (ZIP CODE) 5000 Louise Drive Mechanicsburg PA 17055 1 NAME OF PERSON MAKING LAST ENTRY DATE AND TIME OF LAST ENTRY Doris L. Christmas March 2, 2006 DATE OF CONTRACT TO RENT BOX NUMBER OF BOX ~ TITLE UNDER WHICH BOX IS REQUESTED 1-19-2006 118 Doris Christmas NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX a. (NAME) b. (NAME) Doris L. Christmas (STREET ADDRESS) (STREET ADDRESS) 19 Winding Hill Drive (CITY) (STATE) (ZIP CODE) (CITY) (STATE) (ZIP CODE) Mechanicsburg, PA 17055 NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY Jennifer M. Walker WAS A WILL IN THE BOX? ^ YES ®NO If yes, a. Date of will: b. Name and address of personal representative, if named in the will (NAME} (STREET NAME) (CITY) (STATE) (ZIP CODE) Q ~ ~ Y` ~( c. Name and address of attorney, if any (NAME) .. ~ ' ~: r , (STREET NAME) (CITY) (STATE) (ZIP CODE) SAFE .DEPOSIT BOX INVENTORY Page Of INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) 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. ITEM NO. ITEM DESCRIPTION i CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS CORRECT ND COM LETE O THE EST Y KNOWLEDGE AND BELIEF. PERSON RECEIVING COPY OF SAFE DEPOS T BOX INVENTORY: SIGNATU I SIiGNAT~URE ( /1 n PRINT NAME y ~A~ ~ [~ • 1~ l~.T ' ~3 PRINT NAME AND CHECK`APPROPRIAT BOX B(ELO)W: ~'v\ ~ t~ 1.1 ~ ~ V-~~~. PRINT TITLE ~~~~~ \IATI"•_ ~t -1_ DATE ~~~rp / j O CHECK APPROPRIATE BOX: Executor(trix) ^ Administrator(trix) ^ Estate Representative ^ Joint owner of safe deposit box ~.~ ~ ~. r.«a~~~ aaaiiwna~ a~is x ~~-~ sneet~sJ It necessary or use duplicates of this page of form. SAFE DEPOSIT BOX INVENTORY Amount item Year. Peter Christmas Birth Certificate 49 Two Dollar Bilis 28 50 cent pieces 27 25 cent pieces (bicentennial) 1776-1976 1 one dollar coin 1971 6 5 cent pieces 11 1 cent pieces '"wheat pennies" 1 Canadian 25 cent piece 1949 1 $2 bill 1976 1 $1 bill 1957 4 $2 bills 1995 3 25 cent pieces 14 Sacqu wea Coin - Goid 2000 1 roll pennies (.50) 1971 9 one cent pieces 1890-1908 1 Canada 10 cent piece 1975 4 U.S. quarter dollar piece 1894-1911 1 Canadian 25 cent piece 1969 1 German Deutsmark 1937 2 25 cent pieces 1943, 1963 14 50 cent pieces approx. 70-90 28 25 cent. pieces State quarters 9 25 cent pieces 1977 + 1 5 cent piece 1959 $100 Series EE C61279197EE Brandon 78 50 cent pieces 8 Buffalo 5 cent pieces 1921-1934 7 $2 bills 2 Libe ten cent piece 1920, 1937 1 $1 bill 1957 1 Mor an half-dollar 1900 61 1 cent pieces 11 5 cent pieces 1890-1926 1 one dollar bill 1957 1 one pound -Bank of En land DR 49 309900 1 500 Yen VG398694F 2 One Dollar 1921 2 Wooden Nickel 1 10 Yen P591021 K 3 Canadian $1 bills 31 50 cent pieces (bicentennial) 1968-1991 8 25 cent pieces 1 wheat penny 1958 3 Canadian 25 cent pieces 2 Canadian 5 cent pieces 8 5 cent pieces 5 1 cent pieces 3 Canadian 5 cent pieces 8 $1 dollar coins 1971-1972 20 half dollars 1 one cent piece 1912 46 one cent pieces 1 German 10 cent 1949 3 one cent pieces 1923, 1924 2 5 cent pieces 1943 4 Canadian 10 cent pieces 1 10 cent feces 1916 3 L100 Italian coins 6 1 cent pieces 1909-1944 2 L50 Italian coins 144 1 cent pieces 3 25 cent pieces 1 50 cent iece 1954 5 Canadian 10 cent pieces 1 Canadian 1 cent piece 7 5 cent piece 9 Canadian 5 cent pieces 1 Susan B. Anthony 1 Pence 1971 1 Canadian 25 cent piece 1961 1 Bahama Islands . 05 1969 1 Liberte Eqalite 10 F 1991 1 Half dollar 1903 1 wheat penny 1925 1 half dollar 1964 1 American Revolution Bicentennial medal Tax Assessment Appeal papers Nationwide Life Ins. Papers Navy/Cumberland Cit Trust Led er Red) zero balance 2nd mort a e papaers mort a e satisfied Pra er from Father Lou Letters & Obituaries from Aunt Ma 2 Canadian $1 bill 2 Wooden Dollar (Paint) 1 $1 dollar, piece 1771 20 50 cent pieces 19 $1 dollar pieces 1882-1972 47 1 cent. pieces 19 5 cent pieces 3 Canadian 5 cent pieces 3 10 cent pieces 4 Canadian 10 cent pieces 4 Bicentennia{ quarters 1 quarter BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 REV-1543 EX AFP C08-OB) INFORMATION NOTICE AND TAXPAYER RESPONSE FILE ND. 21 ACN 10123424 DATE 04-26-2010 NATALIE A WHITE 1816 CHATHAM DR CAMP HILL PA 17011 EST. OF DORIS L CHRISTMAS SSN 201-18-6504 DATE OF DEATH 04-06-2010 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. P S E CU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account If you feel the information is incorrect, Please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. HOME C WORK C ~ TAXPlIVFR CTf~N~TIIRF rr~ rn~,'.-,r •n.unr-.+ .~.._._ IUTAL ctnter on Lane 5 of Tax Computation) ~ BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 REV-1543 EX AFP (OB-OB) INFORMATION NOTICE AND FILE N0. 21 TAXPAYER RESPONSE ACN 10123423 DATE 04-26-2010 NATALIE A WHITE,.... 1816 CHATHAM DR CAMP HILL PA 17011 EST. OF DORIS L CHRISTMAS SSN 201-18-6504 DATE OF DEATH 04-06-2010 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS TD: REGISTER OF WILLS.. 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. PS ECU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, You were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0201186504 Date 01-09-2006 To ensure vroper credit to the account, two Established copies of this notice must accompany. 77 Payment to the Register of Wills. Make check Account Balance 1 305 " . ~ payable to Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 652 89 . months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will becoatie delinquent Potential Tax Due $ 29 • 38 nine months after the date of death. ~~ P~T ___. TAXPAYER RESPONSE ~ A, ,..:. , . . A ...:...:....:. .~~v ~ + ?• ~ ~. A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of 0 N E Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above information is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state "~?~ relationship to decedent: x TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS ~# ~.r.. ~~ ~r .. ..... y .. .. __ ` . LINT= 1. Date Established 1 ~ .:: ;.,: ~s ,ass 2. Account Balance 2 $ s< 3. Percent Taxable 3 X • 4. Amount Subject to Tax 4 $ ~ . '•.>.~, `" t, 5. Debts and Deductions 5 - ~., ~;.; :~~? 6. Amount Taxable 6 $ ;~: 7. Tax Rate 7 X ~ h~9 `~..tr 8. Tax Due 8 $ ,,>s PART DEBTS AND DEDUCTIONS CLAIMED a DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. H 0 M E C ) WORK C ) TAXPAYER ~Tf-;N4TIIRF T~1 ~PUnNF NiiMR~Q. nnT~ TOTAL CEnter on Line 5 of Tax Computation) ~ BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 REV-1543 IX AFP (OH-OB) NATALIE A WHITE 1816 CHATHAM DR CAMP HILL PA 17011 INFORMATION NOTICE AND FILE N0. 21 TAXPAYER RESPONSE ACN l 0123422 DATE 04-26-2010 EST. OF DORIS L CHRISTMAS SSN 201-18-6504 DATE OF DEATH 04-06-2010 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. PS ECU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint ownerlbeneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call (717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0201186504 Date 01-09-2009 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 1 , 255.22 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 627.61 nonths of the decedent's date of death, Tax Rate ~( ~ 0 4 5 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due $ 28.24 nine months after the date of death. .___~ .PART - _ _ _ ^ TAXPAYER RESPONSE . ,.....,..v. ; . ! ......:..:..... . .: j:... . . .. ,. . . A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or check box "A" and return this notice to the Register of 0 N E Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PA RT ~ and/or PART ~ below. PART If indicating a different tax rate, please state relationship to decedent: '` •~ti< TAX RE TURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS ~ . ..:f; LINE 1. Date Established 1 ___ ,. ~,: kx„ s:t.. 2. Account Balance 2 +~ .. .: . .:~ .y..:.~: ~, ,. „~F,~~; ~ .. :.: 3. Percent Taxable 3 X ~ ~'y ~' .,.':~: 4. Amount Subject to Tax 4 $ ,,~r` 5. Debts and Deductions 5 - "<j 6. Amount Taxable 6 ~:>;< ~~`~..~`% 7. Tax Rate 7 X y~~' 8. Tax Due 8 $ Wis. ;£~; ~ PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. H 0 M E C ~ WORK C ~ TAXPAYER STC;NATIIRF TCI coun-~c u~iunrn ...~.- roTAL (Enter on Line 5 of Tax Computation) S BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 REV-1543 EX AFP C08-OB) INFORMATION NOTICE AND FILE No. 21 TAXPAYER RESPONSE ACN 10123420 DATE 04-26-2D10 NATALIE A WHITE 1816 CHATHAM DR CAMP HILL PA 17011 EST. OF DORIS L CHRISTMAS SSN 201-18-6504 DATE OF DEATH 04-06-2010 COUNTY. CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE. OF ACCOUNT ® SAVINGS CHECKING TRUST CERTIF. PS E CU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717~ 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. HOME C WORK C ~ TAYPAVGR CT[_AIATIID~ TGI GP41f1h1G IJIIMRI=A T1ATG TDTAL CEnter on Line 5 of Tax Computations $ BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 REV-1543 EX AFP C88-08) INFORMATION NOTICE AND TAXPAYER RESPONSE FILE N0. 21 ACN 10123426 DATE 04-26-2010 NATALIE A WHITE 1816 CHATHAM DR CAMP HILL PA 17011 EST. OF DORIS L CHRISTMAS SSN 201-18-6504 DATE OF DEATH 04-06-2010 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT ® SAVINGS CHECKING TRUST CERTIF. P S E CU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call X717).787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0201186504 Date 02-25-2005 To ensure prover credit to the account, two Established copies of this notice must accompany Account $alance 4, 310.14 payment to the Register of Wills. Make check +~ payable to Register of Wills, Agent . Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 2, 155.07 months of the decedent's date of death, Tax Rate X ~ 0(45 deduct a 5 percent discount on the tax due. Anv Inheritance Tax due will become delinquent Potential Tax Due $ 96.98 nine months after the date of death. PART TAXPAYER RESPONSE ...... .. .. .... ~~~ •~S~,z A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or check box "A" and return this notice to the Register of 0 N E Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. " C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PA RT 2~ and/or PART ~ below. PART f ndicating a different tax rate, please state :.......... , .,,..:.... ...y,:;;~; ,.G relationship to decedent: •~~•~ TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS •:' F> LINE 1. Date Established 1 ~;; 2. Account Balance 2 $ .'F • 4 ,,~;: ~~ 3. Percent Taxable 3 .. ~ .. .. .... X ... .. .; y...:.• '~ 4. Amount Subject to Tax 4 $ . ,. :v :` 5. Debts and Deductions 5 . - ~ . ... ~. ue ~: ~~ 6 . Amou t n Taxable 6 $ ~ '`` f~,a.,•,;,~:: 7. Tax Rate 7 X ` 'y:': ;, :, „~~ ., 8. Tax Due 8 $ ,<~' v .. .. :..... PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE P AID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. H 0 M E C ~ WORK t ~ T~YPAVFR CT(~AIAT1117G -rr~ rn~~n-,r ~,~~u~r-n ...•.-.- TOTAL CEnter on Line 5 of Tax Computations 8 BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17128-0601 REY-1543 EX AFP (OB-OBl NATALIE A WHITE 1816 CHATHAM DR CAMP HILL PA 17011 INFORMATION NOTICE AND TAXPAYER RESPONSE FILE N0. 21 ACN 10123421 DATE 04-26-2010 EST. OF DORIS L CHRISTMAS SSN 201-18-6504 DATE OF DEATH 04-06-2010 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS ® CHECKING TRUST CERTIF. P S ECU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction fron the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 767-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0201186504 Date 06 - O1 -1999 To ensure proper credit to the account, two Established copies of this notice must accompany 51 payment to the Register of Wills. Make check Account Balance 1 949 . ~ payable to Register of Wills, Agent . Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 974 76 . months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due $ 43.86 nine months after the date of death. PART TAXPAYER RESPONSE 0 s:.:....:..... ~ ....,,:.....,, ........:...:.:.. .~ :>: •. :Y ' .: ~ . A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or check box "A" and return this notice to the Register of 0 N E Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART ~2 and/or PART ~ below. PART If indicating a different tax rate, please state '3` ~x : 2 relationship to decedent: . ~: ~ . xf f. ~ TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS . ,. . ;!.'y,< ..~~?%y . LINE 1. Date Established 1 . :~xi .,, 2. Account Balance 2 $ ~.::w ,<:.< .,,;:: 3. Percent Taxable 3 X ..vhf` . ~. t <f,,:,. 4. Amount Subject to Tax 4 {Y,: 5. Debts and Deductions 5 ,,.J:.::: 6. Amount Taxable 6 $ f ;:t .,. 7. Tax Rate X 7 $ 8. Tax Due 8 fF? . ~; ~~ ~ ~;; .. ... ... PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. H 0 ME C ) WORK C ) TaXPlIVFR CT(,NATIIRF TCI t=oun-,r u,~unrn ...~-~ TOTAL CEnter on Line 5 of Tax Computation) S BUREAU OF INDIVIDUAL TAXES PO BOX 2806D1 HARRISBURG PA 17128-0601 REV-1543 EX DIFP t08-OB) INFORMATION NOTICE AND TAXPAYER RESPONSE NATALIE A WHITE 1816 CHATHAM DR CAMP HILL PA 17011 FILE N0. 21 ACN 10123425 DATE 04-26-2010 EST. OF DORIS L CHRISTMAS SSN 201-18-6504 DATE OF DEATH 04-06-2010 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT ^ savzNGs ^ CHECKING ^ TRUST CERTIF. PS ECU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, Please obtain written correction fron the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. CDMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 0201186504 Date 03-07-2009 To ensure proper credit to the account, two Established copies of this notice must accompany payment to the Register of Wills. Make check Account Balance $ 5, 607 • 19 payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax Payments are made within three Amount Subject to Tax $ 2 r 803 • 60 months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due ~` 126 • 16 nine months after the date of death. PART TAXPAYER RESPONSE ..:.......... .. .. .... .. .. .... .. ,.. ~~x~~ s~li A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. ONE B L 0 C K B. ^ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ^ The above intorma ion is incorrect and/or debts and deductions were paid. Complete PART 2^t and/or PART 3^ below. PART If indicating a different ;.~ tax rate, Please state ~ .. ;' ._ ~,:. relationship to decedent: :~f ~xF TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS .~~~., ~ . ,,r,.,~ LINE 1. Date Established 1 ,,, .. ..... , }5"' 2. Account Balance 2 $ ~ `~~~~ ~ ~ W>:~;;.: 3. Percent Taxable 3 X y + 4. Amount Sub3ect to Tax 4 $ ~.: , / $. 5. Debts and Deductions 5 - 'r a }`~~ 6. Amount Taxable 6 . ~ .,:;. 7. Tax Rate 7 X ;', ~~'~"` 8. Tax Due 8 ~ "'~"' PART DEBTS AND DEDUCTIONS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. H 0 M E C ) WORK C ) T/1XPIIVFR CTf~NATIiR~ rr, rr~„r+ur u.,..n.-r. ---- TDTAL CEnter on Line 5 of Tax computations s GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance Tax becomes delinquent nine months after the decedent's date of death. 3. A joint account is taxable even when the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) the decedent put in joint names within one year prior to death are fully taxable. 5. Accounts established jointly between husband and wife more than one Year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are fully taxable. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE 1. BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in Block A of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with a check for the amount of tax to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. 2. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the estate's representative, place an "X" in Block B of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the register of wills of the county indicated. 3. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check Block C and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with Your check for the amount of tax payable to the register of wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the register of wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent who died after 12/12/82, accounts the decedent put in joint names within one year of death are fully taxable. However, there is an exclusion not to exceed 53,000 per transferee, regardless of the value of the account or the number of accounts held. If a double asterisk C*~) appears before your first name in the address portion of this notice, the 53,000 exclusion was deducted .from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percentage of the account that is taxable to each survivor is determined as follows: A. The percentage taxable of joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF MULTIPLIED BY 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A joint asset registered in the name of the decedent and two other persons: 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7 percent (TAXABLE TO EACH SURVIVOR) B. The percentage taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT MULTIPLIED 8Y lOD = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one veer of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50 percent (TAXABLE FOR EACH SURVIVOR) 4. The amount subject to tax (Line 4) is determined by multiplying the account balance (Line 2) by the percent taxable Cline 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The amount taxable (Line 6) is determined by subtracting the debts and deductions (Line 5) from the amount subject to tax (Line 4). 7. Enter the appropriate tax rate (Line 7) as determined below. Date of Death Spouse Lineal Sibling Collateral 07/01!94 to 12/31/94 3 percent 6 percent 15 percent 15 percent 01/01/95 to 06/30/00 0 percent 6 percent 15 percent 15 percent 07/01/00 to present aTL... ~.... ...4_ _____~J __ t~_ 0 percent --i ___~__ - 4.5 percent * . 12 percent 15 percent --•••= w •~-_ _...~..~~.. ~~~ "~~ ,~C~ ~oiue ur aransrers rrom a aeceasea Cn11o Z1 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. The lineal class of heirs includes grandparents, parents, children. and other lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendants" includes all children of the natural parents and their descendents, whether or not they have been adopted by others; adopted descendents and their descendants; and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The Collateral class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You are legally responsible for payment, or the estate subject to administration by a personal representative is insufficient ~ to pay the deductible items. B. You actually paid the debts after the death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use 8 1/2" x 11" sheet of paper. Proof of payment may be requested by the PA Department of Revenue.