HomeMy WebLinkAbout01-14-11~ REV-1500 Exl°'-'°'
PA Department of Revenue pennsylvanla
Bureau of Individual Taxes eager aevne~c
PO Box.2lsosol INH
Harrisburg, PA 1712&0601 F
1505610143
OFFICIAL USE ONLY
Cautty Caie Year Fib Number
TAX RETURN 21 10 0537
)ECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
195 16 6876 05 19 2010
Decedent's Last Name
SHIVELY
(If Applicable) Enter Surviving Spouse's Inforrnatlon Below
Date of Birth
04 27 1921
Suffix Decedent's First Name
DAVID
Spouse's Last Name Suffix Spouse's First Name
SHIVELY VIVIAN
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
MI
G
MI
J
1. Origlnel Retum ~ 2. Supplemental Retum ~ 3. Remainder Retum (date of death
Prior to 12-13-a2)
4. Limited Estate ~ qa, Future Interest Canpromiee
(date or death after 72-12-82)
^ 5. Federal Estate Tax Retum R cared
eq
® g. Dacedera Died Testab
(Attach Copy ofvnlq
® 7 Ma' a Living Tout
wa tapy) O
6. Total Number of Safe Daptun Boxes
9. Lltlgation Proceeds Received ~ 10. ~P~,~~~t{aa~otdeem
)) ~ 11.Ekiction to tax under Sec. 8113(A)
(Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
WM D SCHRACR III 717 432 9733
First Iine of address
124 W HARRISBURG STREET
Second line of address
Clty or Post Office
DILLSBURG
Correspondent's e-mail address:
Under penaniea of perfun, l deGare that I
L. Bailey /
knowledge and belief,
any knowledge.
/ - - - - -- ~ ----........ _ DATE
Wm. D. Schl'ack ~'~~~~,
T
124 W. Harrisburg Stgeet, Dtllsburg, PA 17019
Side 1
1505610143 1505610143 J
State ZIP Code
PA 17019
REGISTER OPS USE ONLY ,
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schedules and statements, and to the best
is based txt all informatlon of which txaoan
PA Inheritance Tax Return
Signature of Additional Fiduciaries
ESTATE OF FILE NUMBER
Shively, David G. 21-10-0537
Under penaRies of perjury, 1 deGare 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 #2
Name
Addressl
Address2
City, State, Zip
Date
AAechartlcsburg, PA 77055
ruc nsnrv soee~
REV-1500 EX
oeceasm'sNams: Shit/@I~/, David G.
RECAPITULATION
1. Real Estate (Schedule A) ...........................
2. Stocks and Bonds (Schedule B) .................
1505610243
.................................................... 1.
.................................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3.
4. Mortgages & Notes Receivable (Schedule D) ........................................................ 4.
5. Cash, Bank DeposRs & Miscellaneous Personal Property (Schedule E) ............... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers 8 Miscellaneous 1~(oq Probate Property
(Schedule G) LJ 5eparate Billing Requested............ 7,
B. Total Gross Assets (total Lines 1-7) ..................................................................... g,
Decedent's Social Security Number
195 16 6876
91,350.00
2,521.06
573,833.10
667,704.16
9.
Funeral Expenses ~ Administrative Costs (Schedule H) .......................................
9. - '
2 6 7 62.8 0
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 3 , 7 65.16
11. Total Deductions (total Lines 9 & 10) ................................................................... 71. 3 O , 52 7. 9 6
12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 63 7 , 17 6 . 2 0
13. Charitable and Governmental Bequests/Sec 8113 Trusts for which
an election to tax has not been made (Schedule J) ............................................... 13.
14. Nat Value SubJect to Tax (Line 12 minus Line 13) ............................................... 14. 63 7 , 17 6 . 2 0
TAX COMPUTATION - sEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a>(1.2) x .00 0.0 0
15.
0.0 0
16. Amount of Line 14 taxable 63 7 17 6.2 0
at lineal rate X .045 . 16. 2 8
, 672.93
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. 28 , 672.93
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
0
Side 2
1505610243 1505610243 J
REV-1500 EX Page 3
Decedent's Complete Address:
FIIeNumbsr 21-10-0537
DECEDENT'S NAME
Shively, David G.
STREET ADDRESS
702 Henry Street
CITY
Mechanicsburg STATE
PA ZIP
17055
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) 28,672.93
2. Credits/Payments
A. Prior Payments 28,500.00
B. Discount 1,433.65
Total Credits (A + B) (2) 29,833.65
3. Interest (3)
q, If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (q) 1,260.72
Cheek box on Pags 2 Lina 20 to request a refund
5, If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
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 tronsferred :............................................................................... ^x ^
b. retain the right to designate who shall use the property transferred or its income :.................................. x
c. retain a reversionary interest; or ............................................................................................................... x
d. roceive the promise for life of either payments, benefits or caro? ............................................................ x
2. If death occurred after Deoamber 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideretion? .................................................................................................................... ^
3. Did decedent own an "in trust for° or payable upon death bank account or security at his or her death?....... ^ ^x
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneflcary deaignation? .................................................................................................................. 0 ^
IF THE ANSYVER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving
spouse is 3 percent p2 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jahuary 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. Thq statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disGosure of
assets and filing a tax return aro'still applicable even 'rf the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the met value of transfers from a deceased child 21 ears of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparbnt of the child is 0 percent [72 P.S. §9116 (a) (1.2)].
. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)].
. The tax rate irr~oaed on the met value of transfers to or for the use of tha decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.3) . A
sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blo or adoption.
Rev-1502 E1lt (11-05)
I SCHEDULE A
REAL ESTATE
collYONWEIuTN OFVENNSVWANw
INHERITANCE TAX RETURN
RESIDENT OECEDENf
ESTATE OF
21
NUMBER
All ratl properly owned aoINY w u a tenant in eomnon mwt M reported at itlr merkst vdua. Felr markN value Is delvrod as Ole property
exotvel0ed belaroart a v~5~q boyar arW a wlWrp ssNsr. nssher Wirp compsYW ro buy «~eq, b01h rou0nabls ~ ~ ~~ ttaacdlss ~~ ~
property whleh h )olRdYowrted wNh rlah! or wrvlvorah muN b• dlae ~a~ of tlta rslwere
b on aeMduN f.
Atheh • copy oT 1M teltlemeM sheet Nthe properly hat been sold
Include • copy of the deed ahowina deeadenl'a interest N owned as tenant M common.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
1 Decedent's undivided 1/2 Interest in former primary residence at 873 Hawthorne Avenue, 91,350.00
Mechanicsburg, Upper Allen Township, Cumberland County, Pennsylvania (see line 101 of
HUD-1)
TOTAL (Also enter on Line 1, Recapitulation) I 91.350.00
(h more space is needed, additional pages of the Same Size)
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule A (Rev. 11-08)
Rsv-1Eee p(a )e-96)
SCHEDULE E
CASH, BANK DEPOSITS, ~ MISC.
PERSONAL PROPERTY
cau~aNwfurN of vENNSnvANu
INHERITANCE TA%RETURN
REeAENT DECEDENT
ESTATE OF FILE NUMBER
_ Shively, David G. 21-10-0537
krolude tt»potestI~ a I'' arw the date the arceeeds were nosiwr by the estate.
All ProPertY 1DIRaY~o~Nrtad tlw( i tlu ryht of wrvWafhiP Rluat ba dlacloeedon aehedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Decedent's undivided 1/2 interest in reimbursement to Seller for texas and sewer paid in 172.15
advance of closing on former primary residence at 873 Hawthorne Avenue, Mechanicsburg,
Upper Allen Township, Cumberland County, Pennsylvania (see Iinea 407, 408 and 409 of
HUD-1)
2 I Erie Insurance -refund of unused premium
3 ~ MEDCO -reimbursement for medications
4 ~ Refund - Lowe's
170.50
2,147.38
31.03
TOTAL (Also enter on Line 5, Recapitulation) I 2,521.06
(If more space ie needed, additlalal papas of ttre earns size)
Copyright (c) 2002 form software only The Ladtner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98)
Rav-1610 ON (e-ee)
SCHEDULE G
INTER-VIVOS TRANSFERS ~
MISC. NON-PROBATE PROPERTY
cot,woNwFwt.TN of vENNanvANu
INNERnANCE rAx RETURN
RESIDENT DECEDENT
ESTATE OF
David G.
FILE NUMBER
21-10-0537
This sd,edub must bs eanpbled and flbdd tM answer b eny of questions 1 throu0h 4 on the reverse side d the REV-1500 COVER SHEE7 b ye..
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE NAME OF SFEREE THEIR RELATIONSHIP TO DECEDENT AND
THE DATE OF TRAM FER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH
VALUE OF ASSET % OF DECD'S
INTEREST
EXCLUSION
(IF APPLICABLE)
TAXABLE
VALUE
1 Capital One Direct Banking -Account #1243388052 100,000.00 100,000.00
(see attached)
2 Discover Bank -Account #303-496430-0 (see attached 100,388.52 100,398.52
3 Membere 1st Federal Credit Union -Certificate of 35,040.22 35,040.22
Deposit Account#312776-40 (see attached)
4 Members 1st Federal Credit Union -Certificate of 100,162.74 100,162.74
Deposit Account #312776-41 (see attached)
5 Members 1st Federal Credit Union -Certificate of 26,815.06 26,815.06
Deposit Account#312776-42 (see attached)
B Members 1st Federal Credit Union -Certificate of 45,062.56 45,062.56
Deposit Account #3127763 (see attached)
7 Membere 1st Federel Credit Union -Regular Savings 10.00 10.00
Account #312776-00 (see attached)
8 Selves EE and 1 U3 Savings Bonds (see attached) 166,344.00 166,344.00
TOTAL (Also enter on Line 7, Recapitulation) I 573,833.10
(If mqe space is needed, additlonal papea of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Fonn PA-1500 Schedule G (Rev. 6-88)
REY•1161EX~110-061
SCHEDULE H
coMr~~e~~Awv, FUNERAL EXPENSES 8s
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Shively, pavid G. 21-10-0537
Debts of decedent must be reported on Schedule I.
ITEM
DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
See continuation schedule(s) attached
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commisalons
Name of Personal Raprosentative(s)
Street Address
City State Zio
Yearfs) Commission paid
2. Anomev's Fees Wm. D. Schtack III
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
Clty State Zio _
Relationship of Claimant to Decedent
4. I Probate Fees
5. Accountant's Fees
6. Tax Retum Preparor's Fees
2,686.92
9,500.00
527.50
7. Other Administretive Costa 14,048.38
See contitMUation schedule(s) attached
TOTAL (Also enter on line 8, Recapitulation) 26,782.80
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1li00 Schedule H (Rev. 10-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Shively, David G. 21-10-0537
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Exosnses
1 Auer Cromation Services of Pennsylvania, Inc. 1,980.88
2 Luncheon following burial service
3 Marshall's -Albums for Memorial Service
4 Marshall's -Frames for Memorial Service
5 Marohall's - whiteboard for Memorial Service
6 Mechanicsburg Church of the Brothron -Memorial Service
7 Printing costs for Memorial Service
8 T 8 J Monument -engraving marker
9 Vases of roses for Memorial Service
H-A
Other Administrative Costs
10 873 Hawthorne Avenue, Mechanicsburg, Upper Allen Township, Cumberland County,
Pennsylvania - PPiI<L electric service during period of administration
11 873 Hawthorne Avenue, Mechanicsburg, Upper Allen Township, Cumberland County,
Pennsylvania -United American Water service during period of administration
12 Check fee
13 Clerk of Orphans' Court -Fiduciary Release filing fee
393.97
11.00
10.00
4.99
150.00
9.08
103.00
24.00
2,686.92
42.19
10.25
6.50
20.00
Copyright (e) 2002 form software only The Lackner Group, Inc. Forth PA-1500 Schedule H (Rev. 6-98)
scHeou~e x
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF
G.
FILE NUMBER
21-10-0537
ITEM
NUMBER DESCRIPTION AMOUNT
14 Cumberland County Law Journal -estate advertisement 75.00
15 Decedent's undivided 1!2 interest in Seller assist to Buyer of former primary residence at 873
Hawthorne Avenue, Mechanicsburg, Upper Allen Township, Cumberland County,
Pennsylvania (see IMe 509 of HUD-1)
16 Decedents undivided 112 Interest in settlement charges on sale of former primary residence
at 873 Hawthame Avenue, Mechanicsburg, Upper Allen Township, Cumberland County,
Pennsylvania -Settlement charges to Seller (see Ifne 1400 of HUD-1)
17 Erie Insurance -premium due during period of administration
18 Miscellaneous expenses during period of administration (fax charges, postage fees, printer
cartridge, etc.)
19 Out-of-Pocket expenses - Certlfled Mail to S(33
20 Out-of-Pocket expenses -copies and fax to IRS
21 Patriot News Company -estate advertisement
22 Register of Willa -Inheritance Tax Return filing fee
23 Reserve for future administretive expenses
24 Unitsd States Postal Service -Postage
H-B7
4,410.00
8,096.75
93.00
106.58
3.24
12.79
141.24
15.00
1,000.00
15.84
14,048.38
Copyright (c) 2002 forth software ony The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
Rav-7672 liX+ (12-09)
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, ~ LIENS
coraaowAFUTH of rew+arkvARu
INlERRANCE TAX RETURN
REBIDEM DECEDENT
ESTATE OF FILE NUMBER
Shively, David G. 21-10-0537
Rapat dabq Inaurnd br tM daudaM prlar to daaM thak nmMnad unpNd ak Iha dab of dsalh, IncWdinp unrRNr9wnudmuNCN sXpansp.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Country Meadows at Home - last Illness 85.00
2 Country Meadows -debt of dececent 2,632.08
3 Decedent caro of Camp maintenance - Hainey's Mower 47.85
4 Decedent's sham of Camp maintenance - Lowe's 161.95
5 Decedents share of Camp maintenance - Marohall's 48,gp
6 Decedents share of Camp maintenance - repair to shower 10.00
7 Decedents share of Camp repairs - Walmart 24.81
8 Decedents share of electric at Camp - PP8:L 19.46
9 Dr. Azizkhan -last illness 21 87
10 Hampden Township Ambulance -last illness 34.47
11 Mobile X-ray -last illness 3.85
12 PA Retina Specialist -last illness
23.02
13 V. Eugene Kilmore -last illness 17.65
14 Visiting Angels -last illness 828 7S
TOTAL (Also enter on Llne 10, Recapitulation) I 3,765.16
(If moro apace la needed, additional papas of the same size)
Copyright (c) 2009 form software only The Lackner Group, Ino. Form PA-1500 Schedule I (Rev. 12-08)
REV•1615 EXs (11-0a)
SCHEDULE J
oo-lt~y~~°"iA BENEFICIARIES
ESTATE OF'"7! ,
5hive ,David G.
NUMBER PERSON Sl RECEIVING PROPERTY
I TAXABLE DISTRIBUTIONS [incude outright spa
distributions, and tra
under Sec. 9118 a
Rebecca L. Bailey
702 Henry Street
Mechanicsburg, PA 17055
Christina M. Poulin
3 Ashburg Drive
Mechanicsburg, PA 17050
Vivian J. Shively
c/o Rebecca Bailey
702 Henry Street
Mechanicsburg, PA 17055
FILE NUMBER
ATIONSHIP TO I SHARE OF ESTATE
DECEDENT
w~~.r ...r,., (Words)
f OF ESTATE
(sas>
Child
Child
Spouse I Interest derived
from Trust
I Total
Enter dollar amo nts for distributions shown above on lines 15 throw h 18 on Rev 1500 cover sheet as a ro i
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN
CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
318,588.10
378,588.10
637,176.20
~ v ~ n~ yr rI1R 1 ~~ - G 1 CR i v i h~ nun- i nxnt3LE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE
Copyright (e) 2009 form software only The Lackner Group, Inc. Fonn PA-1500 Schedule J (Rev. 11-OS)
CLIENTS4SHIVELY, David~David -Will
~ ~u ~~~
OF
DAVID G. SHIVELY
BE IT REMEMBERED, that I, DAVID G. SHIVELY, of 873 Hawthorn Avenue,
Mechanicsburg, Upper Allen Township, Cumberland County, Pennsylvania, being of sound
ii?in~++: memory:. and understanding, do make, publish, and declare .his as and for my Last Will
and Testament, hereby revoking and making null and void any and all Wills and T estaments and
writings in the nature thereof by me at any time heretofore made.
ITEM 1: I direct that my hereinafter named Executors pay all my just debts, my
funeral expenses, and the expenses of the administration of my estate. With this direction, I
authorize and empower my Executors to expend for my funeral expenses and interment such
amounts as may be considered necessary and proper, without regard to any limit that may be
prescribed by a court of law.
ITEM 2: I direct my Executors to pay all inheritance, estate, succession, and legacy
taxes of whatsoever nature and kind, to which my estate or the transfer of any property passing
hereunder or otherwise passing by reason of my demise, may be subject and to charge such taxes
against my residuary estate, it being my intention that none of the aforesaid taxes, either federal
or state, on any property required to be included in my gross estate, under the provisions of any
state or federal law now in force or hereafter enacted, shall be prorated among the persons
interested in my estate to whom such property is or may be transferred or to whom any benefit
accrues.
ITEM 3: In the event my spouse survives me, I give and bequeath unto my
daughter, REBECCA L. BAILEY, INTRUST, NEVERTHELESS, all of my undivided interest in
our marital premises known and municipally numbered as 873 Hawthorn Avenue,
t~3F~:iiaYi2CStrii%~, YCrl.ri5}r~VdIlia, including hE ~unter'r:^ }~rieree". 1.rF-~ '-~'rustee sl^ial,l rrx=~i.f:xc.s?~. t~.;
premises for the use of my spouse until such time as my spouse moves from the family residence,
and expresses an intent to not return.
Upon my spouse's relinquishment of the right to occupy our marital home, I direct that
my Trustee arrange for the appropriate marketing of the premises, with the proceeds generated
.jl
thereby to be added to the corpus of my existing Funded Revocable Trust.
ITEM 4: All the rest, residue, and remainder of my estate, of whatsoever nature and
wheresoever situate, whether it be real, personal or mixed, including property over which I have
a power of appointment, I give, devise, and bequeath unto my daughters, REBECCA L. BAILEY
and CHRISTINA M. POULIN, in equal shazes, per stirpes.
ITEM 5: I appoint my daughter, REBECCA L. BAILEY, and her husband,
JEFFREY L. BAILEY, as Executors of this my Last Will and Testament, directing that they shall
Page -2-
not be required to give bond for the faithful performance of duties in this or any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this, ~~ day of
rte/ X~"-~--.-' ..~.... , 2~~8.
DAVID G. SHIVELY ~
The preceding ir!SL~ iiliteilt, ~~rt515LI1i~, vi it"ti;i uT'ist 't'~T4 (.t~ ~ryt~"i~:Y. ?'~~~°Sn~riCCeri 1}dgP_,?; +%~%:;P
on the day and date thereof signed, sealed, published, and declared by the Testator herein
named, as and for his Last Will and Testament, in the presence of us, who, at his request, in his
presence and in the presence of each other, have subscribed our names as witnesses hereto.
,.-
f ' ' ~ ~,
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-...._...-°~,I~r~.7~k.:,~- 1.~_~~x.'''.~u..:rn^t~ OF ,~~A.....~ C.\~~~~~::Wi~ti.~u 5'x.1.
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Page -3-
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF YORK /
,_~
We, DAVID G. SHTVELY, and
~-x d ~„
the Testator a1x~ the witnesses,
whose names are signed to the attached or foregoing instrument, being first duly
sworn, do hereby declare to the undersigned authority that the Testator signed and executed the
instrument as his Last Will and Testament, and that he signed willingly, and that he executed
~Lds:'~cl=rFFaSki{viulunL'stryai:~iv"t:~,llci~uiNQS~s 112rF?.it~U'.~r~SSed,anG~t`!~',~:~r'.ntcL}:± r,ri.Tit.PgB~:
in the presence and hearing of the Testator signed the Will as witnesses, and that to the best of
their knowledge, the Testator was at the time eighteen (18) years of age or older, of sound mind,
and under no constraint or undue influence.
;,..
DAVI G. iVELY
., f:
,•~=.
(`.
_...._ 'f
SWORN TO AND SUBSCRIBED
ME THIS ~J ~ DAY
2008.
Ngtar(ai Seal
Janet S. Gore, Notary PubNc
1~11sbtug ®oiU, York County
MY Cammissbn E~ires Oct. 25, 2010
CLIENI'S44HNHLY, David\Trust Agreement
FUNDED REVOCABLE TRUST AGREEMENT
OF TRUST is executed this ~/t/u- day of
2005, between DA G. SHIVELY, presently of 873
Hawthorn Avenu ,1 echanicsburg, Upper Allen Township, Cumberland County, Pennsylvania,
(hereinafter called "Settlor") and DAVID G. SHI'VELY, presently of 873 Hawthorn Avenue,
Mechanicsburg, Upper Allen Township; Cumberland County, Pennsylvania, (hereinafter called
"Trustee").
WITNESSETH:
I M 1. Settlor grants, assigns and sets over to Trustee, and its successors, all of the
i~HRACK R,
~"""`C~
property described in Schedule "A", annexed hereto, and said property, together with all other
property, real or personal, that may be added to the Trust (such property in addition being
hereinafter called "Principal"), shall beheld by Trustee, IN TRUST, upon the following terms.
I F~VI 2• During Setrlor's lifetime, to pay to him the net income therefrom and so
much of the Principal as shall be requested by Settlor, or as Trustee, in its discretion from time
to time, deems advisable for Settlor's support to maintain him in the standard of living to which
Settlor was accustomed at the time of creation of the Trust. If Settlor is, in the opinion of
Rebecca L. Bailey, disabled by reason of age, illness or any other cause, Trustee shall apply for
Settlor's benefit as much of the net income and Principal of this Trust as Trustee may from time
to time think advisable for Settlor's support, to maintain Settlor in the standard of living to
which Settlor was accustomed at the time of the creation of the Trust. G~~_
sr ~
TTE~V13. Following Settlor's death, the successor Trustee shall set aside the sum of
FIFTY THOUSAND DOLLARS ($50,000.00) to be maintained as a separate account, the income
from which separate account should be distributed to my spouse VMAN J. SHTVELY, to
supplement her income. It is directed that all liability for income taxes generated by those
earnings shall be assumed by her. , Uuon the death of my spouse, the Fifty Thousand Dollars
_($50,000.00) shall be divided equally between my daughtersu REBECCA L. BAILEY and
CHRISTINA M. POULIN.
ITEM 4. Followine Settlor's death, the successor Trustee shall accomplish the
following distributions of the corpus of this Trust:
A. The sum of FIFTEIN THOUSAND DOLLARS ($15,000.00) to be utilized
by the Trustee,to maintain the family "Camp", which is established upon real
estate owned by J. F. & Sons, Inc., an existing non-profit corporation, utilization
of which funds are to be at the sole discretion of the Trustee or Successor Trustee
hereinafter designated. After the disbursements herein are enumerated, the sum
of FIFTEEN THOUSAND DOLLARS ($15,000.00) is to remain in the Trust as
otherwise outlined, subject only to the decision of the Successor Trustee as to
when the Trust shall finally be terminated and the Camp sold. All funds derived
from the ultimate sale of the Camp shall be divided equally among my heirs as set
forth in Ite}:f"3. F! hereof.
. _.__.%
Page -2-
If in the opinion of my Successor Trustee there shall accumulate, as a result of a
return on investments, an amount that is greater than necessary to maintain the
Camp, the Trustee may distribute the excess to my two dau h~,.,ters. REBECCA L.
BAILEY and CHRISTINA M. POULIN, at my Trustee's discretion.
B. To pay outn;,ght to the stevson of Settlor, HARRY B. MINSCH, lesser of
the sum of FORTY-FIVE THOUSAND DOLLARS, ($45,000.00), or an amount
egtual to Twenty Per-Cent (2096) of the net value of the corpus of this Trust at
the time of my death.
C. After taking into account distributions set forth in Item 3. A. and B.
hereof, I direct that a sum equal to Fifty Per-Cent (50%) of the remainder of the
corpus of my Trust be distributed to my daughter REBECCA L. BAILEY. The
dividends therefrom may accrue; however, no other Principal sum shall be added
to that account.
In the event that my beloved daughter, Rebecca, predeceases me, I direct that her
share of the residue of my Trust be distributed as follows:
(1) Fifty Per Cent (509'0) unto my son-in-law, JEFFREY L. BAILEY;
(2) Twenty-Five Per Cent (2596) unto my granddaughter, ONDREA
L. KOSER; and
(3) Twenty-Five Per Cent (2596) unto my grandson, BRANDON J.
BAILEY.
l~
Page -3-
D. All the remainder of the corpus of my Trust, subject to the distribution set
forth in Item 3. A., B., and C. shall be placed into a Vanguard Monex Market
Tre~sury,Mutual Fund in the name of my daughter CHRISTINA M. POULIN.
The dividends therefrom may accrue; however, no other principal sum shall be
added to that account.
E. In the event that any beneficiary of this Trust shall be less than twenty-
five (25) years of age at the time of my death, I give the share of such child unto
Successor Trustee, REBECCA L. BAILEY, INTRUSTNEVERTHELESS, for the
following uses and purposes.
(1) My Trustee shall hold and administer said Trust property, collect
the income therefrom, and expend or apply the net income as hereinafter
directed. During the administration of my estate, the income earned by
the property included in this trust shall be considered income of this Trust
and subject to distribution as hereinafter provided for other income of this
Trust.
(2) My Trustee shall pay and/or use for the benefit of said minor
beneficiaries or their lineal descendants so much of the net income as
deemed necessary for their support, maintenance, and education, and any
income not so used shall be accumulated and added to the corpus of this
Trust.
Page -4-
(3) My Trustee shall have the power in her discretion to encroach
upon the corpus of the Trust estate in such amounts and at such times as
she may deem necessary in order to provide for the support, maintenance,
care, and education of said minor beneficiaries.
(4) All of the net income may be paid to or for the benefit of the
beneficiaries at least semi-annually.
(5) Upon attaining the age of twenty-five (25) years, the subject
beneficiary shall have the right to withdraw his/her share of Principal
from the Trust.
ITEM 5. It is my expressed intent that any distribution made under the provisions
of this Trust, be it a distribution in settlement, or a loan, can be made in the form of cash, or
appreciated securities, with the value thereof being established as of the date of my death.
TTEM 6. I appoint DAVID G. SHIVELY, presently of 873 Hawthorn Avenue,
Mechanicsburg, Pennsylvania, as Trustee of the Trust hereinbefore created, giving unto him the
powers, and charging him with the duties hereinafter enumerated. In the event of the death,
disability, or incapacity of said Trustee, I appoint,RFRFC'C'A T B iI FY ac Succeacor Trustee
under the terms and conditions hereinafter set forth. In the event of the death, disability, or
incapacity of my daughter, Rebecca L. Bailey, I appoint my son-in-law, JEFFREY L. BAILEY,
as a successor Trustee under the terms and conditions hereinafter set forth. In the event of the
death, disability, or inability of my son-in-law, Jeffrey L. Bailey, I appoint my grandson,
Page -5-
BRANDON J. BAILEY, as Successor Trustee under the terms and conditions hereinafter set
forth.
ITEM 7. The Principal and income of this Trust shall be free from anticipation,
assignment, pledge or obligation of Settlor, or of any beneficiary hereunder, and shall not be
subject to any execution or attachment or to voluntary or involuntary alienation.
ITEM 8. The Trustee shall have the power, but not duty, to make such expenditures
out of the Trust as my Trustee, in his or her unfettered discretion, may consider appropriate in
order to facilitate the settlement of Settlor's estate. In exercising such power, Trustee may pay,
in whole or in part, any or all of the following items:
A. The expenses of Settlor's last illness and burial, including cost of grave
marker; his debts, his income taxes, the death taxes on any and all property
included in his gross estate for tax purposes; and all other items in connection
with the settlement of his estate.
B. Any such items may be paid directly by Trustee or the funds for their
payment may be transferred by Trustee to Settlor's executor or administrator; and
neither such executor or administrator or any beneficiary of Settlor's estate shall
be required to reimburse Trustee for any funds so paid or transferred. All such
death taxes on present or future interests shall be paid at such time or times as
Trustee may think proper, regazdless of whether such taxes are then due,
K&
L ' ~ ,~
Page -6-
provided that any postponed taxes on future interests shall be chazged against a
particular share with respect to which the taxes aze imposed.
TEEM 9. Trustee shall have all of the following powers in addition to those vested
in it by law and by other provisions of this Trust, applicable to all property, whether principal
or income, including property held for minors, exercisable without court approval, and effective
until actual distribution of all property:
A. To retain any or all of the assets of this Trust, real or personal,
without regard to any principal of diversification of risk;
B. To invest in all forms of property, including stock, common trust
funds and mortgage investment funds, without restriction to
investments authorized for Pennsylvania fiduciaries, as it deems
proper, without regard to any principal of diversification of risk.
C. To sell at public or private sale, to exchange, or to lease for any
period of time, any real or personal property and to give options
for sales, exchanges or leases, for such prices and upon such terms
or conditions as it deems property.
D. To allocate receipts and expenses to Principal or income or partly
to each as it from time to time thinks proper in its sole discretion.
E. To lend to, or purchase from, Settlor's executor, even though
1 RA(`iC o_
.rte
Trustee is also such executor.
Page -7-
F. To hold property in the name of Settlor, or in its name without
designation of any fiduciary capacity, or in the name of a nominee
or unregistered trustee.
ITEM 10. Subject to the approval of Trustee, anyone may add property, both real or
personal, to the principal of this Trust, by deed, will, or otherwise.
ITEM 11. Settlor reserves the right by any instrument in writing intended to take
effect during Settlor's lifetime, signed by Settlor, and delivered to Trustee, to revoke or amend
this Agreement of Trust in whole or in part, provided that the duties, powers and liabilities of
Trustee shall not be substantially changed without its written consent.
ITEM 12. Trustee may at any time after the death of Settlor and Settlor's wife merge
any separate trust held hereunder with any other separate trust held by Trustee under
agreement of Settlor's wife, if the terms of the trusts are then substantially similar and held for
the primary benefit of the same person.
I M 13. Trustee may receive compensation for the performance of its function
hereunder based upon a~~ Pnna~.1 rn~rh*?e~ er cent (39~0~ of the market value of the fund
administered, r~b~„p~,d from that fund simultaneousl3~ with distribu 'ons made hereunder.
ITEM 14. The situs of this Trust for administrative and accounting purposes shall be
RL
in the County of Cumberland and Commonwealth of Pennsylvania, and all questions pertaining
to construction or validity of the provisions of this instrument shall be governed by the laws of
the Commonwealth of Pennsylvania.
Page -8-
IN WITNESS WHEREOF, the Settlor has hereunto set his hand the day and year above
first written. Trustee has also set his hand the day and year above first written.
~ [/,J~ ,
~y,Ti9~/ U~(..rGG
/J DAVID G. SHNELY - Settlor
DAVID G. SHIVELY - Trustee
n r /
Trustee hereby acknowledges receipt of the property described in Schedule "A".
DAVID G. SHIVELY -
Page -9-
ACKNOWLEDGMENT
TH
COUNTY OF
V
On this /~ day of
,VANLA
undersigned, personally appeared DAVID G
. SS
2005, before me, the
as "Settlor" and as "Trustee", known to
me (or satisfactorily proven) to be the person whose. name is subscribed to the within Funded
Revocable Trust Agreement, and acknowledged that he executed the same for the purposes
therein contained.
IN WITNESS WHEREOF, I have hereunto s~my han?l and
3. (~a~e, Nomry Publ~
~ Baq Yak Carey
N!y Conr~eion Exprec occ 25, 2006
1Asntrer. AaeodeUon O(No~eties
1 t~~
r~frs•ry'yP OMB Approval No. 2502-0285
3.~~~
_~ ~fy'~~ A. Settlement Statement (HUD-1)
~yM o W 6"
al Tu..n ...~.....
1
®FHA 2
~ RHS 3
C
U
i 8. File Number: 7. Loan Number: 8. Mortgage Insurance Cese Number.
.
.
. Q
Onv.
n
ne. 08-191.001 0300535481
4. ~ VA 3. Q Conv. Ins.
C. NoN: Thla form l8 lumlahed ro give you a ~atetement of actual sepbmenf costa. Amounts paid ro end by th settlement agent are shown
.
hems merketl /p,o.c.)' were paid cutalde the doMng; ploy ere shown here sx lnrormeponel
r
o
d
pu
p
ses an
ere not lnquded ro Ms rotela.
D. Neme end Address of Borrower: E. Neme and Address of Seller. F. Name and Adtlrees of Lender:
Gregory P. Leonard and Vivian J. Shively WELLS FARGO BANK, NA
Edca T. Leonard Eebte of David G. Shively 8155 RodcsWe Road, Sulb 116
873 HavNwme Avenue Indel»ndence, OH 44131-2207
Meehanipburp, PA 171166
G. Progeny Lotxtlon: H. Satllement ApenL• 8&0610988 I
Setdemsnt Dab:
873 Hewthomp Avenue Community Land Transfer, LLC .
Megrenlceburp, PA 17066 2331 Market Street
Cumlxanand County, Pennaylvenie
Came HIII, PA 17011
Ph. (717)909.8949 June 28, 201 0
PNCe of SeltlemenY.
2331 Markq Street
Cam HIO, PA 17011
J. summa of Borrawr'e tnneaetlon K. sum of ae1NPs tranpctlon
100. Grose Amount Due hortr Borrower: 400. Gross Amount Due b Seller.
101. Contreq salsa rice 182 700.00 401. Contract sales 182 700
00
102. PersgtN 402. Pefsonel .
103. SatllerneM C b BorrowM Llne 1 12 471.21 403.
104. 4~.
105. 406.
wlrrrarrb for a«ns ki b Se1Nr In adva ustmenb for Items b 8 INr In advance
105. /Town Taxes b ~ 408. CI /Town Texea to
107. Coun Taxes 08/28/10 t0 01/01/11 324,08 407. Coun Taxes 08/28/10 b 01/01/11 324
08
108. School Taxes 08/28!10 b 0!01/10 18.54 408. Sdrool Texee 06128!10 b 07!01/10 .
18
54
109. Sevrer 2nd Otr. 06/28/10 to 07!01!10 3.89 409. Sewer 2nd Otr. OB/28H0 to 07!01/10 .
3.89
110. 410.
111. 411.
112. 412.
120. Grose Amount Dw from Borrower 195,515.50 420. Grose Amount Dw to SeINr 183,044.29
200. Amounts Paid or In Bella of Borrower 500. Retludibne M Amount Dw ae1Nr:
201. D t or eamaat mon 1000.00 601. Excess see Instructlons
202. Prktd I amount of new bens 180 71.00 602. Settlement se ~ Seger Llna 1400 18 193
50
203. ExlsBn loan a taken w to 603. Exlatln bans bken wb ed to .
2~• 504. Pa Flret M e e
206. 605. Pa a Sewn e e
208. ~.
207. 507. D sit diet. ae s
208. 508.
209. Seller Assisi 8 680.00 50p. Seller Aulst 8 850.00
aalrrbnb fM Items un Id b aelNr ustmeMe ter keme un Id b SeINf
210. C /TOVm Texee b 510. CI /Town Taxes N
211. Coun Taxes to b11. Coun Taxes ro
212. School Texee b 512. Sdwq Texee to
213. 513.
214• 514.
215• 616.
218. 516.
217• 5 Estate of David G. Shivel
218. 516. 1!2 Interest InhsrNence faxes to x er, 8,188.00
219.
220. Total Pald b Borrower 190,121.00 520. Total Retlue0on Amount Dw Sellw 104,043.94
300. Cash at SetaerrreM fraMo Borrower a00. Cuh at wttlerrrent to/hom 9sINr
301. Grose amount dw hqn Borrower Erb 120 195.516.50 801. Grwa amount due to Sa0er 9ne 420 183 044.29
302. Lets amount kl b r Bortower Ilse 220 190,121.00 802. Lees reductlone due Seller One 620 ( 104,043.94
303. Cash ~X From ~ To Borr 6,394.50 609. Cash ~X To n From SNbr 79,000.35
,~
j~ExyidtiT ~~~
/ r r
C. i:. ~` -
1%
n ~ r ~ i/
~SYC~'h'ED(./Lt~s ~~/7 ~~ aE ~• ~ ~ ~ ~ittt
ill Ri01e Rperaq ew~n b aW aoeslbn MYiarnaear Y waralr0 M 76 rrinulr Pe tiPda.for mrrcexl, rs.IMie. mtl rapgitie M Ma 1xY pnry-.y ndadNd ai Ybrmeeon, wl ym w-not wpYnE b
mrgM. riY bm, uNr aawr. • ~'rrr001A) male nuner. w mrMl6mtlNNY arwrd: ai d.olwur Y mwW Wry. inY Y ENIpiwE b Prorbr M Wrr~ b e REBPA mwiW bbirCron v.M MlMrratlm
dAq Mraananl paLS.
Pepe 1 of 3 HUD-1
(LEONARD.GREGORY.PFDPoB-1 p1.001f/)
L. SetGement Cha es
700. Total Raal Estate Broker Faas S 8
792
50 Pre P
,
.
8/011 0/comml8abn Ilrre 700 BY /OIbWS: mn Pre Fmm
7 792. to THE NOMESTFAD OUP IN eonox~h tiYrfr
702. 1 FuMra
asuraiwx Pam a1
b
03. e n am.nisr,t
704. 8 792.
705. Buyer Commbsbn to The Homestead Grou
I
p,
nc. 295 00
900. dame Pa 61s In COnnsctlon wdh Lan
801.Our Inatbn the Indudee O inalbn Poim % or S 945.88 from GFE IMi
802. Your creditor eharge (polnb) for the spedOC interest refs chosen S (from GFE A12)
80 . our uated o ne on the from GFE 6A gg5
g8
804. reisal fee to RES Diroct from GFE 1Ki - ,
gg3
00
805. Crodk Re rt to REL3 from GFE tIC1 .
14
84
BOB. ax ae rb to ( FE ACi .
807, food certi0cedon to
808. from FE ttq
9' from G E
pct.
911. (from GFE tp
900. Mms R aired lender to Bs Pab In Advanu ram
901. DsI Inbroet cha a from 08/28!10 to 07/01N 0 3 E25.310000ldey (from GFE Ik10) 75
93
902. Mo a insurance remium for onfhe to De t. of HUD from GFE sK1 .
3 ggg 88 ,
. Homeowne a aurence r aro to fete arm Ins. rpn 59
~' from GFE M11
!~5' (from OFE 011)
1 D00. Rsasrvea Itsd wdh Lar1Mr
1001. Inkbl depoek for your escrow eocount (from GFE M9)
omaowns a nsunna mon r mon 2,241.95
1 o nsurence months r month S
1004. Property texas S
samenb mon c ~ 5 r monfA
un Taxes months r month
1005.
S
1008. Counry/yownship 8.000 months ~ 5 50.57 per month j 303,gp
1007. Sehool Taxes 14.000 monMa ~ S 184.34 per month E 2,300.78
1008. Aggregate Ad)usMent S -526.99 -r
1009.
S
1100. Tide CM se
1101. Tkb aervlae end tinders tltb Insurence from
1102. Seklement or ebein tee
S 1,538.75 5.00
i iD3. er's lkb msurenee b MMUNITY IAN FER INSURANCE AC T. from GFE •6 45
00
1104. Lenders tlUe insurance to UNI A S 1,228.76 .
1105. Lsndera tkb of Ibnk S 180 271.00
1108. Owners uue I Ilmn s 1 B2 7oD.DD
1107, ante Non of the total tkb insuance romlum to Commun Lend Trenster LLC S 1 120.
1108. Undsrwdters ortbn of tM total tllb Inaurence remium to COMMUNITY LAND TRANSFER INSUR 152.85
1108. Deed Pre . Commun Land Trensfer, LLC
1110.
11
1112.
1113.
1200.Oovernmant Rewrding and Trerofar CMrass -
1201. Gowfmment rocordi eha es to Recorder of Deeds Office from GFE i7 138
00
1202• Dead S 62.00 Mo e S 74.00 Rebaeea S Other S .
1209. Trenster taxes to Recorder of Deals OfBCe from GFE A18 1,827.00 - " ~,
1204. C ICouMy tax/atampe S 1,827.00 S ,rr
1205. State taxRtam s 5 S }
1208. POA to Recoder of Deeds Omce 1 827.00
1207 27.00
.
1300. Addillorwl 9attlsmsnt CM
1301. R ulrod services that u can sho for from OFE r18 36g
Op '
~.° k: .
1302. Home !Peal Ins Ion to A ha Home Ins bit S 350.00 ,
,
1303. Food Life of Loan to WF Flood Ins. inc. S ig,OO
1304. 2nd Qtr. Sewer to U r Albn Townshi
1305. See addirl dbb. ezhibfl l0 112.00
1400. Total Settlement CM amsr on IIrtN 109 Sactlon J and 602 Section K 570.20 5,430.00
aV tluilp NOrlMM~rW,rwl NU YU~„Y..~f....~.w~,..w.,.n..~.•.. ~..~____. ~,.._._ -- 12 471.21 18 193.50
Community n afar, LL , Se ant AgsM
Certified to be a true copy.
Page 2 of 3 HU0.1
(LEONARD.GREGORY. PFDADB•191.001?)
....^,r,.~n...~r, o. vew Term tsamap t(iFE) and HU0.1 Charges Good Fakh Estlmab HU0.1
Cha That Cannot Increase HUD-1 Llns Number
Our odpinetion charge # 801
Your credk or the e ( oint for the s IrNerost rate chosen # 802 945 88 945 6B
Your ad usted o Inatbn Cha s # B03
Transfer fazes 945 88 945 88
#1203 1,827.00 1,827.00
~
Cha
That in Total Gnnot Increase Moro than 10X
Good Faith Estlmab HU0.1
GowmmeM rocordinp charges #1201
AP reisel fee # 804 144 00 13800
Credk R 450.00 446.00
# 805 46
00
Mo a Insurance Premium #902 . 14.84
3,988.87 3,g6g,86
Total 4,605.87 4,582.70
Increase between GFE end HU0.1 Chergea S -43.17 or -p.g4
---_.,-- .._. __.. _.._..r Good Faith Gstimste HUD-1
InlNsl deposit for your escrow amount #1001
3,020.79 2,241.96
Daily Interest drarges #901 E 25.310000/day 329.03 75.93
Homeowners Inauronce # 903
Tkh servkes arM lenders tkb insuance #1101 450.00 859.00
Owners Ntk Insurance to COMMUNITY LAND TRANSFER vent k r..nv 2,00025 1,538.75
Food LHe of I
Loan Terms
Your InlUat loan amount la S 180,271.00
Your loan term b 30 years
Your IniWl Inbrost rob N 5.1250 Yo
Your Inltlal monthly amourd owed for principal, irderoet end E 981.55 incudea
any mortpaps Insuranu Is
Pdncpal
O Interest
Mortgage Insurence
Can your Inbrest rate rbs7 QX No ~ Ves, k een Asa to a maximum of 9b. The Brst
charge will be on and un change apsin every _ months after
. Emory change date, your Interest tale can Ineroaee or decroass
by %. Over the IHe or the ban, your Interest rate k puaranleed
to never be rower Then % or higher than y5,
Even N you make payments on tlme, can your loan balance rba7 ~ No ~ Yea, it ran des to a maximum of S
Even Hyou make payment on tlme, un your monmy
a
t
d f QX No ~ Yes, lhs flre1 increase Can be on and the monMty
moun
owe
or pdnelpal, Inbrost, and mortgage Imurence rise? amount owed can dse to E
The maximum It can ever rise to is S
Does your loan have a prepayment psnally7 ~X Na ~ Yes, your maximum prepayment penaNy is $
Does your loan have a balloon paymsnCy ® No ~ Yea, you have a lwlbon payment of S
tlue In _ years on
Total monthly amount owed including escrow account payment ~ You do not have a monthty escrow payment for Hema, such ae property
taxes and homeowner's insurance. You must pay these ttema directy
yoursaH.
~X You haw an eddklonal monthty escrow payment of 5289.83 that rosuNe
In a total initial monthly amount owed of 51,251.38. Thla incudes
principal, interest, arty moripege insurance and any Hema checked below:
® Property taxes QX Homeowners Insurance
Flood insuance
rare: n you new any qussrana about ma settlement Charyea and Loen Tsrma listed on this form, please mntq your kndar.
Page 3 of 3 HU0.1
(LEONARD.GREOORY. PFD/0&191.OOtl7)
HUD-1 Addendum
Borrower(s): Gregory P. Leonard and Erica T. Leonard Seller(s): Vivian J. Shively
873 Hewthome Avenue
Mechanicsburg, PA 17055
Estate of David G. Shively
Lender: WELLS FARGO BANK, N.A.
setdementAyent:Community Land Transfer, LLC
(717)9098949
Plate of settlement: 2331 Market Street
Camp Hill, PA 17011
settlement Dab: June 28, 2010
Property Location: 873 Hawthorne Avenue
Mechanicsburg, PA 17055
Cumberland County, Pennsylvania
Additional Adjustment For Items Paid By Seller In Advance (Borrower Debit)
DeseNptfon Amount FromlThrouph Prorated Amount
Sewer (2nd Qtr.) 112.00 04/01/10 through 08130/10 3.89
Total Llne 109!408 3.89
Additional Disbursement
PayeelDescHptlon NotelRef No. Borrower Salter
Pinkas Building 8 Roofing
_ Roof Replacement #2942 5,430.00
Wells Fargo Home Mortgage 570
20
Principal Reduction .
Total Additional Disbursements shown on Line 1306 S 670.20 S 6,430.00
Adjusted Origination Charge Details
Origination Charge
to WELLS FARGO BANK, N.A.
945.88
Total S 945.68
Origination CredlUChargs (point) for the specific Interest rate chosen
Totl E
Adjustd Origination Charges S 945.88
Reserves Deposited with Lender
Homeowner's Insurance
3.000 at 54.92 per month 164 76
Countylfownship
8.000 et 50.57 per month 303.42
School Taxes
14.000 at184.34 per month 2,300.78
Aggregate Adjustment
at per month -528.99
Total 2,241.95
WARNING: tt b a erkne to knowingly meks~ fak+s statement to tM United stet» on tlde or any eknller form. Peneltlee upon convk:tlon tin
IneluM a floe and knprieonmerrt For dstlb we: TttN 18 U.s. Code 8ectlon 1001 end Seetlon 1010.
(LEONARD.GREGORY.PFD/OB-191.001!/)
HUD-1 Addendum . Continued
Title Services and Lender's Title Insurance Details BORROWER SELLER
Closing Service Letter
Community Land Transfer, LLC
Electronic Doc. Preparation
Community Land Transfer, LLC
Wire Fee
Community Land Transfer, LLC
Notary Fee
Community Land Transfer, LLC
Overnight Fees
Community Land Transfer, LLC
End. 100 300 8.1
Community Land Transfer, LLC
75.00
50.00
10.00
10.00
15.00
150.00
5.00
Total ; 310.00 ; 8.00
Owner's Title insurance BORROWER SELLER
Owner's Policy Premium
to COMMUNITY LAND TRANSFER INSURANCE ACCT.
Total
1,273.75
; 46.00 E
Lender's Title Insurance BORROWER SELLER
Lender's Policy Premium
to COMMUNITY LAND TRANSFER INSURANCE ACCT.
Total
1,228.75
1,228.75 ;
WARNING: h 4 a crime to knowin8y make tales statements to the Unhed 8fetae on Mb or alryr similar Coml. Penekhe upon eonvletlon can
include ^ ilne and knpdeonmenL For dstglle tse: Title 18 U.B. Code Ssctbn 1001 and Ssctlon 1010.
(LEONARD.GREGORY.PFlN08-191.00117)
DAVID G SHIVELY REV TR
DAVID G SHIVELY, TTEE
873 HAWTHORN AVE 363
MECHANICSBURG PA 17055
Re: Account ending in 8052
Dear David G Shively Rev Tr,
Direct Banking
June 18, 2010
Depository Institution: Capital One, N.A.
Here is your new Capital One Direct Banking Certificate of Deposit (CD). Please review the information for
accuracy.
Thank you for choosing Capital One Direct Banking, the smart choice for savings.
Sincerely,
Mark Elliot
Executive Vice President
Capital One Direct Banking
David G Shively Revocable Trust
David G Shively
Certificate of Deposit
CUSTOMER INFORMATION:
The account holder(s) listed above have established a Certificate of Deposit as follows:
Account Number: 1243388052 Date Issued: 07/11/2008 Amount Deposited: $100,346.26
ACCOUNT INFORMATION:
Term: 24 Months Ma#urity Date: 07/11/2010
Annual Percentage Yield: 4.15% Interest Rate: 4.07°r6
Interest Compounded: Daily
Interest to be paid: Monthly by Add to Balance
Depository Institution: Capital One, N.A.
Non-negotiable Member FDIC
Remember that you can check rates, access your current balance and obtain additional account information by visiting us online at
vuww.capitalonedirect.com. or by rolling 1-888-810-4013. Representatives are available to assist you Monday through Friday,
8 a.m. to 8 p.m., and Saturday, 8 a.m. to 2 p.m., Eastern Time.
Member FDIC, 02070 Capkal One
Capital One is a federally registered service mark. All rights reserved.
""" ` BAN K t N G THAT D E L I V~ R S
_. _.._.e.~nr~ / , , ., o .. ~ N.,-iii ~ ,. L u~ y
DISCOVER'
July 20, 2010
The Law Office of Wm D Schrack III -
Wm DSchrack III
124 West Harrisburg Street
Dilisburg PA 17019-0310
RE: David G Shively
Dear Sir/Madam:
Thank you for your recent inquiry. The following is the information you requested concerning the above
referenced estate:
Account Number ending in:
Account Type:
Account Status:
Account Title:
Balance as of Date of Death:
Current Balance:
Current Rate:
Maturity Date:
Safe Deposit Box:
4300
Certificate of Deposit
Open
Dayid_G ShvJey_Rev Living,T~ust datedl0/2008 -Owner
David G Shiveey -Trustee
$100,398.52
$101,117.49
4.27%
12/01/2010
No
• Note: Interest is accrued daily and paid monthly. Due to interest being paid monthly, interest
reporting for income tax purposes Is based on interest paid.
If you would like to obtain additional information or have questions concerning your account, you may contact us
by calling 1-800-347-7000 (TDD 1-800-347-7454). Our automated voice response system is available 24 hours
a day 7 days a week or you may visit our Web site at www.discoverbank.com. Account Managers are also
available to personally assist you 24 hours a day, seven days a week.
Sincerely,
Deposit Products
Customer Service
V
Death Balance Letter
~~ PO Box 30416, Salt Lake City UT 84130-0416
St
MEMBERS 1#
NBDBBALCRffi11T UNION
Account Title: David G. Shively Funded Revocable Trust
Trustee: David G, Shively
Successor Trustee: Rebecca L. Batley
REGULAR SAVINGS ACCOUNT•
Account Number/Suffix 312776-00
Date Account Established 08/28/2007
Principal Balance at Date of Death $10,00
Accrued Interest to Date of Death $0.00
Total Principal and Accrued Interest $10.00
CERTIFICATES OF DEPOSIT:
Account Number/Suffix 312776-40
Date Account Established 08/28/2007
Principal Balance at Date of Death $35,000.00
Accrued Interest to Date of Death $40.22
Total Principal and Accrued Interest $35,040.22
CERTIFICATES OF DEPOSIT:
Account Number/Suffix 3127761
Date Account Established 01/12/2009
Principal Balance at Date of Death $100,000.00
Accrued Interest to Date of Death $162.74
Total Principal and Accrued Interest $100,162.74
CERTIFICATES OF DEPOSIT:
Account Number/Suffix 3127762
Date Account Established 02/02/2009
Principal Balance at Date of Death $26,770.17
Accrued Interest to Date of Death $44,66
Total Principal and Accrued Interest $28,815.06
CERTIFICATES OF DEPOSIT:
Account Number/Suffix 312776-43
Date Account Established 04/Og~~a
Principal Balance at Date of Death $45
000
00
Accrued Interest to Date of Death ,
.
$62.56
Total Principal and Accrued Interest $45,062.56
MEMBERS 1sT FEDERAL CIf,RJE`DnIT UNION
Leigh- nne Stallings
Lending Insurance Support Specialist
December 15, 2010
Estate of: David G. Shively
Date of Death: May 19, 2010
Social Security Number: 195-16-8876
5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 www.memberslst.org
Calculated Value of Your Paper Savings Bond(s)
Calculated Value of Your Paper Savings Bond(s)
Calculator Results for Redemption Date 05/2010
'4~ c-~ Price ~'otaf ~/alue
Totalln4:erest YTIA Interest
Bonds: i-12 of 12
Yage 1 0l 1
"~,r-i:, - Series Denorva Issue Next i`in~+I gs§ue Ps•iee Trrtere3t Interest Bdalue
Oate Accrual P4atesr lty date
2401547 EE $10,000 12/1992 06/2010 12/2022 $5,000.00 $7,392.00 4.00% ;12,392.00
0014244461 I $10,000 02/2002 06/2010 02/2032 $10,000.00 $4,596.00 5.09% $14,596.00
0014244451 I $10,000 02/2002 06!2010 02/2032 $10,000.00 $4,596.00 5.09% $14,596.00
-0014244441 I $10,000 02/2002 06/2010 02/2032 $10,000.00 $4,596.00 5.09% $14,596.00
,0011892251 I $10,000 10/2001 06/2010 10/2031 $10,000.00 $6,068.00 6.11% $16,068.00
0011892241 I $10,000 10/2001 06/2010 10/2031 $10,000.00 $6,068.00 6.11% $16,068.00
',0011892231 I $10,000 10/2001 06/2010 10/2031 $10,000.00 $6,068.00 6.11% $16,068.00
2401546 EE $10,000 12/1992 06/2010 12/2022 $5,000.00 $7,392.00 4.00% $12,392.00
2401545 EE $10,000 12/1992 06/2010 12/2022 $5,000.00 $7,392.00 4.00% $12,392.00
2395545 EE $10,000 02/1993 08/2010 02/2023 $5,000.00 $7,392.00 4.00% ¢12,392.00
2395543 EE $10,000 02/1993 08/2010 02/2023 $5,000.00 $7,392.00 4.00% #12,392.00
2395544 EE $10,000 02/1993 08/2010 02/2023 $5,000.00 $7,392.00 4.00% X12,392.00
Notes
NI Not Issued
NE Not eligible for payment
P5 Includes 3 month interest penalty
MA Matured and not earnin interest
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LAW OFFICE OF
WM. D. SCHRACK III
124 WEST HARRISBURG STREET
DILISBURG, PA 17019
Telephone 717-432-9733 email
Telefax 717-432-1053 Schracklaw@comcast.net
January 13, 2011
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Register of Wills of Cumberland County
Cumberland County Court House
One Courthouse Square
Cazlisle, PA 17013-3387
Re: Estate of David G. Shively
D/D: May 19, 2010
File #: 21-10-00537
i
To Whom It May Concern:
-._.
C.,)
4~
You will find enclosed herewith two copies of aREV-1500 that have been executed by the Co-
Executors and me, and aze submitted for filing with the Depaztment of Revenue. In addition, I
enclose one copy of the face page which bears a red copy stamp that I ask you time stamp and return
to me in the envelope provided.
Attached to the bottom of this letter is my Trust Account check for the sum of $15.00, which
covers the filing fee.
WDS/jsg
enc.
Sincerely,
. SCHRACK III