Loading...
HomeMy WebLinkAbout01-26-11 (3)15056041125 ~' REV-1500 Ex (OS-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Po sox2sosol INHERITANCE TAX RETURN 2 1 1 0 0 0 2 9 4 Harrisburg, PA 1x128-0so1 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 7 2 3 4 5 4 6 1 0 3 2 0 2 0 1 0 0 6 0 6 1 9 4 3 Decedent's Last Name Suffix Decedent's First Name MI DAL T O N J U D I T H A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security durrrber THIS RETURN MUST BE FILED iN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return ~ 2. Supplemental Retum ~ 3. Remainder Return (date of death prior to 12-13-82} 4. Limited Estate ~] 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Retum Required death after 12-12-82) Q 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95} (Attach Sch. O) GUKKtSF'UNUtN 1 - 11115 ,tti 1 IVN MUJ 1 lit t:VMf'Lt 1 tU. ALL GVKKtSYVNUtNIa AMU IrVPIr1UCP11 WL 1 w~ mrvranh i wn vnvvw oG vmcv ~ ~.v ~ v. Name Daytime Telephone Number H A R O L D S I R W I N I I I 7 1 7 2 4c,~ 6 0 .~; 0 Firm Name {If Applicable) I R W I N L A W O F F I C E First line of address 6 4 S O U T H P I T T S T R E E T Second line of address City or Post Office C A R L I S L E State P A _.~: c_~ REGISTER OF v~rtl~~ ONLY ~, ~ ,- -~ rn ~ ;~ , ~ •s^? _. ~. ~:. _, ~,_. ~, „ . t.;_ DATE FILED "-~'3 4--r'~ -_- r- ~ .- ..~ ~`~ `~ ~-r7 ZIP Code ~ 1 7 0 1 3 Correspondent's a-mail address: !rwln/awoHlce~gma/1.com Under pe~tal~es of u , I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, ~, tract and late. Declaration of preparer other than the personal representative is based on all infomlation of which preparer has any knowledge. SIGNATt~ F PERS SPONSIB E FOR (LING RETURN ~ ~ DT~ - L_ t ADDRE 30 ATSON DR CARLISLE PA 17015 SIGNA nF PR ER OTHER THAN R T THE DATE ADDRE S' ~ ~~ 64 SOUTH PITT STREET C RLISLE PA 17013 PLEASE USE ORIGINAL-FORM ONLY 15056041125 Side 1 15056041125 i a 15056042126 °' REV-1500 EX Decedent's Name: JUDITH A . DALTON Decedent's Social Security Number 1 7 2 3 4 5 4 6 1 RECAPITULATION 1 7 7 6 0 0 0 0 1. Real estate (Schedule A) ........................................ 1. 0 0 0 2. Stocks and Bonds (Schedule B) .................................. 2. 3. Closely Held Corporation, Partnership orSole-Proprietorship (Schedule C) ..... 3. 4. Mortgages 8~ Notes Receivable (Schedule D) ................... ... 4. 5 3 9 3 3 2 5 5. Cash, Bank Deposits 8~ Miscellaneous Personal Property (Schedule E) ....... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 0 0 0 7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property Billi R d t t ~] S 7 1 8 3 7 1 1 8 3 ....... ng eques e epara e (Schedule G) , . 8. Total Gross Assets (total Lines 1-7) ........................... 8. 4 1 5 2 4 5 0 8 9. Funeral Expenses ~ Administrative Costs (Schedule H) ................ 9• 10. Debts of Decedent, Mortgage Liabilities, & liens (Schedule l) ............ 10. . 11. Total Deductions (total Lines 9 8-10) ........................... 11. 12. Net Value of Estate (Line 8 minus line 11) ......................... 12. 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) .................. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) .................. 14. 6 1 2 6 2 1 1 7 2 5 6 3 6 7 1 3 3 8~ 2 5 7 8 2 8 1 4 1 9 3 0 0 0 0 2 8 1 .4 1 9 3 0 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 (a)(1.2) X •0 15. 16. Amount of Line 14 taxable 2 8 1 4 1 9 3 0 at lineal rate X .045 1s. 17. Amount of Line 14 taxable 0 0 0 at sibling rate X .12 17. 18. Amount of Line 14 taxable 0 0 0 at collateral rafie X .15 18 19. Tax Due ............ ........................... .. ~..... ..19. 20. F1LL IN THE OVAL 1F YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 0 0 0 1 2 6 6 3 8 7 0 0 0 0 0 0 . 1 2 6 6 3 8 7 D Side 2 , 15056042126 ~ 150.56042126 J 1500 EX Page 3 File Number cedent's Complete Address: 002 CEGENTS NAME - ~D/TH A. DALTON REET ADDRESS ''O EDWARD DRIVE t Y STATE ZIP CHAN/CSBURG ' PA !7050 X Payments and Credits: Tax Due (Page 2 Line 19) (1) 12,6sa.87 Credits/Payments A`. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) InteresUPenalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E ) If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. 0.00 (3) 0.00 (4) 0.00 (5) 12,663.87 (5A) (5B) 12,663.87 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or inceme of the property transferred : ...................................................................... ^ 0 , ~, b. retain the right to designate who sha8 use the property transferred or its income; ............................... ^ • c: retain a reversionary interest; or ................................................................................................ ^ a d. receive the promise for life of either payments, benefits or care? ....................................................... ^ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ......................................................:................................ ^ 3. Did decedent own an "intrust for'" or payable upon death bank account or security at his or her death? ......... ^ ^ 4. Did decedent own an Individual Retirement Arxount, annuity, or other non-probate property which contains a beneficiary designation? ........ ...................................................................................... 0 ^ THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. gates of death on or after July 1,1994 and before January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse ee (3) percent [72 P.S. §9116 (a) (1.1) (i)]. gates of death on or after January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent '.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and a tax return are still applicable even if the surviving spouse is the only beneficiary. gates of death on or after July ~1, 2000: ax rate imposed on the net value of transfers from a deceased childtwenty-one years of age or younger at death to or for the use of a natural parent, an five parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. ax rate imposed on the net value of transfers to or for the use of the decedents lineal beneficiaries is four and one-half•(4.5) percent, except as-noted in S. §9116(1.2) [72 P.S. §9116(a)(1)]. ax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3}]. A sibling is defined, under ~n 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. ' J-1502 EX + (6-98) _ ` COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ~ (If more space is needed, insert addifional sheets of the same size) TATS OF FILE NUMBER , D/TH A, DALTON 00294 ;II real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. V-1503 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN .RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS STATE OF FILE NUMBER JD/TH A. DALTON Opyg./ ITEM ;UMBER 1. NONE A{I property jointly-owned with right of survivorship must be disclosed on Schedule F. DESCRIPTION VALUE AT DATE OF DEATH ~' ti TOTAL (Also enter on line 2, Recapitulation) S 0.00 (If more space is needed, insert additional sheets of the same size) V-15o4 EX + (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT =TATE OF ~D/TH A. DALTON FILE NUMBER 00294 Sdtiedule C-1 or C-2 (inducting all supporting information) must be attached for each dosely-held corporaiton/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted forsole-proprietorships. ITEM VALUE AT DATE _ .'UMBER DESCRIPTION OF DEATH ~, ,; r; TOTAL Also enter on line 3, Recapitulation s (If more space is needed, insert additional sheets of the same size) SCHEDULE C CLOSELY-HELD CORPORATION, _ PARTNERSHIP OR SOLE•PROPRIETORSHIP V-1507 EX + (6-98) "COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT _ STATE OF UD/TH A. DALTON FILE NUMBER 00294 All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM !UMBER DESCRIPTION 7, c ( i VALUE AT DATE _ OF DEATH TOTAL Also enter on line 4, Recapitulation ~ (If more space is needed, insert additional sheets of the same size) SCHEDULE D MORTGAGES & NOTES RECEIVABLE V-1508 EX + (6-98) • SCHEDULE E CASH BANK DEPOSITS & MISG COMMONWEALTH OF PENNSYLVANIA , , . RN IN T PERSONAL PROPERTY RES DENT D EDEN . =TATE OF FILE NUMBER ~D/TH A. DALTON 00294 Indude the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE CUMBER DESCRIPTION OF DEATH 1. MEMBERS 1ST FEDERAL CREDIT UNION 320.55 Check/ng Account No. 1520760011 Value based on statement attached as Exhib/t °C° 2. MEMBERS 1ST FEDERAL CREDIT UN/ON ~ 4~ 1.59 Money Management Account No. 152076 0005 Value based on statement attached as Exhibit °C° 3. MEMBERS 1ST FEDERAL CRED/T UN/ON ~~8~,10 Sav/ngs Account No. 152076 0000 Value based on statement attached as Exh/blt "C" 4. M/SCELLANEO!/S HOUSEHOLD CONTENTS AND PERSONAL PROPERTI/ 6,085.00 Value based on auction proceeds Suctioneer's Account attached as Exhlbft "D° 5. 2007 TOYOTA COROLLA 11,020.00 Value based on Kelly Blue Book KBB appraisal attached as Exh/b/t "E" 6. HERSHEY MEDICAL CENTER 44.70 Refund 7. DUPONT ` 29.00 Ret/cement Savlogs Plan D/strlbut/on 8. REAL ESTATE TAX PRORATION 894.93 See HUQ1 at Exhibit °B° 9 SEWER /TRASH PRORATION 115.76 See HUD-1 at Exhib/t "B° 10. AMERICAN EXPRESS 109.47 Refund ~ 1. STATE FARM INSURANCE 58.15 Refund of Unearned Homeowners Insurance Premium TOTAL (Also enter on line 5, Recapitulation) ~ ~ 53 933.25 (If more space is needed, insert additional sheets of the same size) V-1509 EX + (6-98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOfNTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT TATE OF FILE NUMBER !D/TH A. DALTON _ ~Z~ N an asset was made joint within one year of the decedents date of death, it must be reported on Schedule G. 5URVNING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT _ __ NONE iNTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY 96 OF DATE OF DEATH -', FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF ;BER TENANT JOINT IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST A, NONE 0.00 0.00 tr~ ~. ' TOTAL (Also enter on line 6, Recapitulation} ~ (If more space is needed, insert addiitonal sheets of the same size) 0.00 `V-1510 EX + (6-98) SCHEDt/LE G INTER•VIVOS TRANSFERS & COM NHERITANCE TTAX RETURNAN~ MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT -TATE OF FILE NUM@ER ~DiTH A. DALTON O0Y9;4 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY EM riBER uia.uDE THE w~rE of THE TRaas~EE, THEIR r:aanoHefnP To oECEDEHT ANO THE DATE OFTRnW8FER ATfACHACOPYDFTHEDEEOr~tREALEBTATE. DATE OF DEATH VALUE OF ASSET °~ OF DECD'S EXCLUSION TAXABLE INTEREST nFAPPIICABLE) VALUE _ RELIANCE STANDARD (beneflclary - Steven S Michael Dalton ) 72,026 99 l00. 72,026.99 Annuity Contract No. EL000!l20A Amount based on statement attached as Exh/b/t"F' - - JOHN HANCOCK (beneflclary -Steven 8 Michae/ Dalton) 714,367.44 l00. ~ !4,367.44 Annuity Contract No. 2675909 Amount based on statement attached as Exh/b/t °G" - SUN LIFE FINANCIAL (beneflclary. -.Steven 8 Michae/ Dalton) 50,000.00 l00. 50,000.00 Anna/ty Contract No. KA 13085674-!) Amount based on statement attached as Exh/bl! "H" SYMETRA L/FE (beneflclary -Stereo 8 Michael Dalton) 39,558.56 !O0. 39,558.56 Annuity Contract No. AA07808l3 Amount based on statement attached as Exhlb/t ..L. KRAFT FOOD GLOBAL (beneflclary Steven 8 M/chae/ Dalton) 7,758.84 100. 7,758.84 Salary Retention P/an Amount based on statement attached as Exhib/t "J° 1 TOTAL Also enter on line 7 Recapitulation ~ !83 7!!.83 (If more space is needed, insert additional sheets of the same size) EV-1511 EX + (12-99) ' SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES ~ - INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT -- TATE OF - _ __ FILE NUMBER UDITH A. DALTON 00294 Debts of decedent must be reported on Schedule I. __ ITEM NUMBER DESCRIPTION AMOUNT - _ _ FUNERAL EXPENSES: ---- 1. EW/NG BROTHERS FUNERAL HOME 5,750.50 ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2, Attorney Fees IRW/N LAW OFFICE 21,500.00 3, Family Exemption: (If decedents address is not the same as claimants, attach explanation) Claimant . Street Address c: City State Zip Relationship of Claimant to Decedent 4. Probate Fees REGISTER OF WILLS 443.50 5 AcxountanYs Fees 6. Tax Return Preparer's Fees 7. 1/ERIZON -Telephone BIIIs 409.17 8. HAMPDEN TOWNSHIP -Sewer and Trash Bl/ls 465.76 9. PENNSI~LVAN/A- AMERICAN WATER COMPANY - Water Bllls 143.22 10. PPBL - Electric BIIIs 1,445.60 11. COMCAST -Cable Bpls 212.93 12. ROWE'S AUCTION SERVICE -Persona/ Property Auct/on Expenses 2,179.75 - 13. R.T. CARET/ TRUCKING LLC -Hauling 833.62 14. SELLER ASSIST -Real Estate Sett/enient ~ 7,000.00 ~ :... 15. REAL ES'~ATE COMMISSION 10,656.00- 16. TRANSFER TAX -Rea/ Estate Settlement 1,776.00 17. IRW/N LAW OFFICE -Real Estate Attorney Fee 350,00 18. HSA -Hoene Warranty Cost on Rea/ Estate Settlement 419.00 c' TOTAL (Also enter on line 9, Recapitulation) S 61262.11 (If more space is needed, insert additional sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent 1~IT'Fi A. DALTON 21 10 00294 =cedent's Name Page 1 ~ File Number hedule H -Funeral Expenses & Administrative Costs - B7. ITEM DUMBER DESCRIPTION AMOUNT 19. BARRISTERS LAND ABSTRACT COMPANY -Real Estate Sett/enrent Costs 43.00 20. MICHAEL LANGAN - 2010 County / Township Real Estate Taxes 373 08 21. MICHAEL LANGAN - 2010/2011 School Real Estate Taxes . ' 1,200.66 2Z. UGI - SereIce and Gas Bills 247.49 23. STANLEII'S PAVING -Home Repairs Prior to Real Estate Settlement 1,350.00 24. ACBH SERVICES -Gas Line installation Prior to Real Estate Settlement 375.00 25. fUGI -Gas Hook-up Fee 25.00 26. LOWE'S - Prue-.settlement Repairs to Real Estate 4,032.83 27. REGISTER `OF WILLS - Flle Inventory and Appralsement 30.00 SUBTOTAL SCHEDULE H-B7 7,677.06 -,V-1512 EX + F12-03) SCHEDULE COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, - JNHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS ___ RESIDENT DECEDENT _ _ _ ~ _ __ ~TATE OF FILE NUMBER -EDITH A. DALTON OOZg~4 Report debts incun~ed by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. "'ITEM VALUE AT DATE - - NUMBER DESCRIPTION OF DEATH 1. ANDREWS b PATEL 26.88 Medcca/ BJII 2. CV PA/N MANAGEMENT 12.68 Med/ca/ B//I 3. WEST SHORE EMS 281.54 Medcca/ B/II 4. TR/STAN ASSOC/AYES Zg4.93 Medcca/ BI/Is 5. SPEC/AL EVENT EMERGENCI~ MED SERVICES ~ Z01.79 6. 7. tr. 8. 9. 10. 11. 12. 13. 14. 1~ Med/cal B/II MSHMC PH~'SIC/ANS GROUP Medcca/ B/ll GE MONEY BANK Outstand/ng Balance KOHL'S PAI~MENT CENTER Revoly/ng Charge Account AMERICAN EXPRESS Credit Account MEMBERS 1ST FEDERAL CREDIT UNION Home Equity LOC Accent No. 152076-0002 MEMBERS 1ST FEDERAL CRED/T UNION Visa Account MEMBERS 1ST FEDERAL CREDIT UNION Second Morgage Account No. 1 SZ076 0003 DARR1rL, /G GU/ST/TE, D.O., INC Medcca/ B/ll PINNACLE HEALTH MEDICAL SERVICES Medical BJlls x CONTINUING CARE RX Med/ca/ BI// 44.70 3,104.74 167.11 109.47 9,290.38 4,313.14 " 3,824.48 142.16 97.64 ZZ.0~4 TOTAL (Also enter on line 10, Recapitulation) S - -- (If more space is needed, insert additional sheets of the same size) 66 Continuation of REV-1500 Inheritance Tax Return Resident Decedent DITH A. DALTON 21 10 00294 dent's Name Page 2 File Number hedule I -Debts of Decedent, Mortgage Liabilities, & Liens ITEM 1MBE R DESCRIPTION AMOUNT 16. QUANTUM IMAGING AND THERAPETIC ASSOCIATES 3L02 Medical BIIi 17. CHURCH OF, GOD HOME, INC 1,205.00 Nursing Horse Expenses 18. MEMBES 1ST FEDERAL CREDIT UNION ~ 49,165.51 a Payoff o! First Mortgage , 19. HOLY SPIRIT HOSPITAL 52.77 Medcca/ Biil 20, PINNACLE NEATEN EMERGENCY 33.76 Medical BIN 21, CUMBERLAND VALLEY PAIN MANAGEMENT 141.93 Medica/ BI/I SUBTOTAL SCHEDULE I 50,629.99 GRAND TOTAL SCHEDULE I 3 ~ 72,563.67 ~-1513 EX + (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J ____ BENEFICIARIES , F A. DALTON NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [indude outri~ ~ spousal distributions, and transfers under Sec. 9116 a 1.2 GARY L, DALTON 343 Oak Drive New Cumberland, PA 17070 , M/CHAFE D, DALTON 1365 Harbor Lake DHve Largo, FL 33770 STEVEN T. DALTON 30 Watson Drive Carlisle, PA 17015 FILE NUMBER 00294 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE ineai 113 Residue foes/ 1/3 Residue -neai 1/3 Residue ~ _ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET - - _ __ 1. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. NONE 0.00 1 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. NONE ' 0.00 - __ ~, ~; ~, G E j~,. _ TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET a - 0,00 (If more space is needed, insert additional sheets of the same size) EXHIBIT "A" LAST WILL AND Ti~STAMEHT I, JUDITH A. DALTON, of fi040 Edward Drive, Mechanicsburg, Cumber{and County, Pennsylvania 17050, do hereby make, publish and declare this to be my fast will- and testament, hereby revoking all wills heretofore made by me. - 1. I direct my personal representative to pay all of my debts, funeral and administrative expenses as soon as convenient after my decease. I direct that all inheritance taxes imposed or payable by reason of my death and interest and penalties thereon with respect to all property, whether or not such property passes under this Will, shall be paid by my personal representative out of my estate. 2. l authorize and empower my personal representative to sel! any realty andfor personalty owned by me at my death and not specifically devised or bequeathed herein, at public or private safe or sales and to give goad and sufficient deeds andfor bills of sale therefore, in fae simple, as {could da if living. My representative is authorized and empowered to engage in any business in which i may be engaged at my death, for such period of time after my death as seems expedient to said representative. 3. I give, devise and bequeath all of my estate of whatever nature and wherever situate to my children share and share alike, the child or children of any deceased beneficiary taking the share their parent would have taken if living. 4. f nominate -and appoint my sons, Michael D. Dalton and Steven T. Dalton, to be the co- personal representatives of my estate, to serve without bond 5. 1 suggest that my personal representative retain the services of Harold S. Irwin, Ill, Carlisle, Pennsylvania in the settlement of my estate - tN WITNESS WHERE©F, I have hereunto set my hand and seal this 22"d day of April, 2009. EAR) J DITH A. DALTON Signed, sealed, published and declared by the above-named person as and for a fast will and testament, in our presence, who at said person's request, in said person's presence and in the presence of each other have hereunto set our names as subscribing witnesses. ____ ACKNaWLEDGMENT AND AFFiD/~ViT WE, JUDITH A. DALTON, SARAH A. HARDESTY and KATHRYN M. MULLEN, the testatrix and witnesses respectively, whose names are signed to the foregoing instrument, being first duly swom, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her last will and that she had signed willingly, and that she executed it. as her free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the .presence and hearing of the testatrix, signed the wiN as a witness and that to the best of their knowledge the testatrix was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. JXJ ITH A. DALTON ~. '~ ~~ i ~ SAR ARDE "~~~ ~~ KATH YN .MULLEN COMMONWEALTH OF PENNSYLVANIA :ss: COUNTY Oi= CUMBERLAND : Subscribed, swom to and acknowledged before me by JUDITH A. DALTON, the testator herein, and subscribed and swom to before me by SARAH A. HARDESTY and KATHRYN M. MULLEN, witnesses, this 'Z"z--day of April, 2009. /i Notary Public .::ui~W ~AL'CH QF PENNSYL~iANL NOTARIAL SEAL Harold S: Irwin Iii: E~sq, Notary Public ~.; Carlisle, Cumberland County "~v rM,r~~~cign cx~res February 06, 2011 EXHIBIT "B" I,F, , `~,Ii'<~ . ~ett~ement statement (HUD-'~ ~ 1. XD FHA 2, ~ RHS 3 ~ Conv. Unins 6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number: . . 10-01-2-15805CAP 201095443 446-0441949-703 4. ^ VA 5. Q Conv. Ins. C. Note: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agents are shown. Items marked "(p.o.c)" were paid outside the closing; they are shown here for informational purposes and are not included in the totals. D. Name & Address of Borrower: E. Name & Address of Seiler: F. Name & Address of Lender: Bebawy G. Esttanous, Samira H. Bahoor, Saly B. Gad Estate of Judith A. Dalton also known as Judith E. Dalton Howard Hanna Mortgage Services 107 November Dr., Apt 1, Camp Hill, PA 17011 6040 Edward Drive, Mechanicsburg, PA 17050 119 Gamma Drive, Pittsburgh, PA 15238 G. Property Location: H. Settlement Agent: I. Settlement Date: 10/22/2010 6040 Edward Drive Banisters Land Abstract Company Disbursement Date: 10/22!2010 Mechanicsburg, PA 17050 Telephone: 717-761-6190 Fax: 717-761-4072 Hampden Townshi p Place of Settlement: TitleExpress 3310 Market Street, Camp Hill, PA 17011 Printed 10/21/2010 at 10:52 am by J E 100. Gross Amount Due from Borrower 101. Contract sales price 177,600.00 102. Personal ro rt 103. Settlement charges to borrower (line 1400) 10,251.88 104. 105. Ad'ustments for items aid b seller in advance 106. City/town taxes to 107. County taxes 10/22/2010 to 12/31/2010 65.98 108. School Taxes 10!22/2010 to 06/30/2011 828.95 109. Sewer & Trash 10/22/2010 to 12131/2010 115.76 110. 111. 112. 120. Gross Amount Due from Borrower ~ 188,862.57 200. Amounts Paid by or in Behalf of Borrower 201. Deposit or earnest money 3,000.00 202. Principal amount of new loan(s) ~ 175,200.00 203. Existin IoaMsl taken sub'ect to ~ 204. 205. 206. 207. Seller Assist 7,000.00 208. Good Faith Deposit 375.00 209. Ad'ustments for items unpaid b seller 210. City/town taxes to 211. County taxes to 212. School Taxes to 213. 214. 215. 216. 217. 218. 219. 220• Total Paid by/for Borrower 185,575.00 300. Cash at Settlement fromRo Borrower 301. Gross amount due from borrower (line 120) 188,862.57 302. Less amounts paid by/for borrower (line 220) 185,575.00 303. u is Cash CX J From ~ To Borrower epo uig u en or is m ec ron o m orma lon is a ima e a mmu es r 3,287.57 r 400. Gross Amount Due to Seller 401. Contract sales puce 177,600.00 402. Personal ro rt 403. 404. 405. Ad'ustments for items aid b seller in advance 406. City/town taxes to 407. County taxes 10/22!2010 to 12/31!2010 65.98 408. School Taxes 10/2212010 to 06/30!2011 828.95 409. Sewer & Trash 10/22/2010 to 12!3112010 115.76 410. 411. ~ , 1412. 420• Gross Amount Due to Seller f 178,610.69 500. Reductions In Amount Due to Seller 501. Excess deposit (see instructions) I j 502. Settlement charges to seller (line 1400) 35,133.50 503. Existin loan(s) taken subject to 504. Payoff of first mortgage loan to Members 1st Federal Credit Union 49,165.51 505. Pa off of second mort a e loan 506. 507, Seller Assist 7,000.00 508. 509. Ad'ustments for items un aid b seller 510. City/town taxes to 511. County taxes to 512. School Taxes to 513. 514. 515. 516. 517. 518. 519. 520. Total Reduction Amount Due Seller 91,299.01 600. Cash at Settlement to/from Seller 601. Gross amount due to seller (line 420) 178,610.69 602. Less reductions in amount due seller (line 520) 91,299.01 603. Cash QX To ~ From Seller 87,311.68 pe espouse or ec trip, reviewing, aria repo lnq e a a. rs agency may no co is In a rt a you are no regwre o t Mb lortn, unless it tlisplays a currently valid OMB conlml number. No con(itlenlialNy is assured; this tlisclosure is msndatory, This is despnetl la provide the panics to a RESPA wveretl Innsadion wNh inlormHba during the settlement process. f Previous editions are obsolete r ge 1 i:it11:7fi~:1cIM~1t~'ti~ =~- ~.a,.r 700. Total Reat Estate Broker Fees $ 10,881.00 Paid F;'OrTi P'atd FI"Gi't'1 Di,~ision or c ;mmi~sion line 700 as follows: i3orr'ower`5 ~ Seller's ~ 701. $5,328.00 to Cavalry Realty LLC 5 ~ Funds at ~ Funds at ~ rug. $5,553.uu to r+uwAKU HArvrvA ~ztAi_ ~srArE Settlement Settlernert i 703. Commission paid at settlement 25.00 10,656.00 800. Items Pavabte in Connection with Loan 801. Our origination rharge (Includes Origination Point °fo or $0.00) $615.00 (from GFE #1) 802. Your credit or charge (points) for the specific interest rate chosen $438.00 (from GFE #2) 803. Your adusted origination charges (from GFE A) 1,053.00 804. Appraisal fee to A sisals b E.J. K.o enhaver (from GFE #3) 350.00 805. Credit report to GBC Innovis, Inc (from GFE #3) 108.16 806. Tax service to from GFE #3 807. Flood certification to FDSI (from GFE #3) 13.00 808. to 900. Items Required b Lender to be Paid in Advance 901. Daily interest charges from from 10/22/2010 io 11/01/2010 @ $22.20001day (from GFE #10) 222.00 902. Mortgage Ins. Premium for months to De t of HUD (from GFE #3) 3,856.14 903. Homeowner's insurance for 12 months to Howard Hanna Insurance Services (from GFE #11) 540.00 904. months to from GFE #11 1000. Reserves De osited with Lender 1001. Initial deposit for your escrow account (from GFE #9) 519.95 1002. Homeowner's insurance 5 months $ 45.00/month $225.00 1003. Mortgage Insurance months (a1$ 77.97/month $0.00 1004. City Property Tax months $ 0.00/month $0.00 1005. County Property Tax 11 months $ 28.26/month $310.86 1006. School Taxes 6 months $ 100.06/month $600.36 1007. Aggregate Adjustment $-616.27 1100. Titte Char es 1101. Title services and lender's title insurance (from GFE #4) 1,444.63 1102. Settlement or closing fee to $ 1103. Owner's title insurance -Stewart Title Guaranty Company (from GFE #5) 9.00 1104. Lender's title insurance -Stewart Title Guaranty Company $1,339.88 1105. Lender's title policy limit $175,200.00 Lender's Policy 1106. O'wner's title policy limit $177,600.00 Owner's Polley ! j a 1107. Agent's portion of the total title insurance premium $1,0"280 ~ 1108. Und~-rrrnt?r's portion cf the total title insurance premium $266.08 1 ! 1109. to $ 1 1200. Government Recording and Transfer Charges 1201. Government recording charges (from GFE #7) 135.001 1~(l? noon Qa~ ~n ne~.+„~„a ~~~ ~n o.,ia~~o en nn 1203. Transfer taxes (from GFE #8) 1,776.00( 1204. CitylCounty tax/stamps Deed $1,776.00 Mort a e $0.00 1205. State Taxlstamps Deed $1,776.00 Mort a e $0.00 1,776.00 1206. Deed $0.00 Mort a e $0.00 1207. ' 1300. Additional Settlement Char es ) 1301. Required services that you can shop for (from GFE #6) t 1302. Attorney Fees to Harold Irwin, Es 356.00 1303. Home & Pest Inspection to fns ect a Home $315.00 P.O.C. B' 1304. Home Warranty to HSA 419.00 { 1305. Overnight Fee (payoff) to Banisters Land Abstract Posta e - H 13.00 1306. Reimburse Tax Certification to Barristers Land Abstract General - H 5.00 ~ 1307. Escrow Fee to Barristers Land Abstract General - H 1308. Escrow for inheritance taxes to Barristers Land Abstract Escrow - H 25.00 20,000.00 1309. 2010 County/Twp Taxes to Michael Lan an, Treasurer 373.08 ;, 1310. 2010/2011 School Taxes to Michael Lan an 200.66 1 ~; 1311. SewerlTrash - 3rd & 4th Qtrs. to Hampden Township , 315.76 ''' - - ~ ~ + + '10.251.88 35,'t 33.50 #Paid outside of closing by (B)orrower, (S)eller, (L)ender, (I)nvestor, Bro(K}er. ',. ious editions are HUD-i Comparison of 7ood Faith Estimate (GFEI and HUD-1 Char es i Char es That Cannot increase HUD-i Line Numoer Our origination charge # 801 Your credit or charge (points) for .he specific interest rate chosen # 802 Your ad}usted origination charges # 803 Transfer taxes # 1203 - Char es That in Total Cannot increase More Than 10°10 - Government recording charges # 1201 Appraisal fee # 804 Credit report # 805 Flood certification # 807 Mortgage Ins. Premium # 902. Title services and lender's title insurance # 1101 Owner's title insurance # 1103 ~. • ~• ~ ~ ~- Char es That Can Chan e Initial deposit for your escrow account # _1001 Daily interest charges from #901. $22.2000/da Homeowner's insurance # 903 - i oooa rartn Gsumate % tiUS,- k 615.00 515.00 ! 438.00 433.00 1,053.00 1; J53,00 1,;,'6.00 1,776.00 Good Faith Estimate NUD•1 , 210.00 135.00 375.00 350.00 i 50.00 108.16 13.00 13.00 3,856.14 3,856.14 1,570.75 1,444.63 15.00 ~~. CO 1 I 6,089.89 .5,915.93 ~ $ -173.96 nr -2.8565°(, Good Faith Estimate HUD-1 1,596.00 .519.95 88.80 222.00 450.00 540.00 Loan Terms Your initial loan amount is $175,200.00 Your loan term is 30, years Your initial interest rate is 4.6250°!° Your initial monthly amount owed for principal, interest, and any mortgage $978.74 includes insurance is ^X Principal ^X Interest I L^J Mortgage Insurance ``.=Can YOUr 1nlefe5i rate rise? ~ ~ No. ^ Yes, It Cali fiSe tC~ a maxlrrlUm Ot %.Tiii? rir~t . ;"iang° ~~~ ~ will be on ! 1 and can change again evens years atter w=ry chancy i date, ;cur interest rate can increase or decrease by °/ , n•,~~ hP ~r:e ,~t the loan, your ~i interest rate is guaranteed to never be lower than °r ~ hianPr th ,~ `=o. I I Even if you matte payments on time, can your loan balance rise? I X^ No. ^ Yes, it can rise tc a maximum of $ Even if you make payments on time, can your monthly amount owed for XD No. ^ Yes, the first increase can be on / / and the monthly principal, interest, and mortgage insurance rise? amount owed can rise to $ iIi The maximum it can ever rise to is $ (Does your loan have a prepayment penalty? ^X No. ^ Yes, your maximum prepayment penalty is $ Does your loan have a balloon payment? ^X No, ^ Yes, you have a balloon payment of $ due in years on / / Total monthly amount owed including escrow account payments ^ You do not have a monthly escrow payment for items, such as property taxes and homeowner's insurance. You must pay these items directly yourself. 0 You have an additional monthly escrow payment of $173.32 ' that results in a total initial monthly amount owed of $1,152.06. This includes principal, interest, ar mortgage insurance and any items checked below: ^X Property taxes 0 Homeowner's insurance I ^ Flood insurance ^ ^ ^ 'Vote: If you have any questions about the Settlement Charges and Loan Terms listed on this form, please contact your lender. Previous editions are obsolete Page 3 of 4 HUp_ ~T1~:TC~-~ ~,.,..r HUD CERTIFICATION OF BUYER AND SELLER 4 have care `r,lly r,viewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, it is a true and accurate statement of all receipts and disbursements ri ade on my account or by me in this transaction. 4 further certify that I have received a copy of the HUD-1 Settlement Statement. Bebaway G~. ~~stfar ous "`~ t Samira H. Bahoor ., .' '7 .. t ; Saiy B. Gac4 ^...._ Estate of Judith A. Calton also known as Judith E. Dalton ~,~ '^ ? ~; i o _,, r. The HUD-1 Settlement Statement which l have prepared is a true and accurate account of this transaction. I have caused or will cause the funds to be disbursed in ~~ccorciance with this statement. ,.. ,~ .. ~ _ ,~~- - ._ 1 DATE SETTLEMENT AGEi~1T ?NARNING: lT 1;. A Ch21ME TO KNOWINGLY MAKE FALSE STATEMENTS TO 7HE UNITED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON CONVICTION CAN IPJCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 18: U.S. CODE SECTION 1001 AND SEC ~ ION 1010. previous edii:ions are obsolete Page 4 of 4 HUD-i EXHIBIT "C" 56~~ In~7Uiic~S to_ ~Via~ra ;~uv~#cW~boarci: (800)'3 )-'x'328 5ppp ~.ouise ~rsu~~ y s,all: Box 40 ~ % i 7) 69 ~-4372 or (8U0) 283 437-' PD ~'~C3: '717j f~97-5312 or (800) 283-2328 ext X312 Mechanicsburg, ~'/~ "W~flw~ `~e~e~ranc~: (8U0) 237 r 2813 www. memrJers~W st.nrc~ X62 -i. 4i:1 ±=~4,.:..~`~..2W ~~, ~'7 W.'~~1.Y+'n~"', _ -. ~~ ~o '1-ransaction Description Additions __ ~W~biractions-- --- __._ -----~ea~: s -: ~,.....e.... ~ .~_~. ;;, ,,,~...~, '" Mar U9 Deposit ACH SYMETRA ~I ,200.00 ID: 9910742133 DATA: 93 C ANABA CO: SYMETRA ~'S "~ Mar 10 Deposit ACH SOC SEC i , 061.00 ~-----~ ID : 3031036030 CO : SOC SEC ~=~~~" '~~`~- ""'""""""' "8°~~ ~ ~ ~"~~ Mar 16 Withdrawal Transfer To Loan 0002 ~~ Mar 19 Deposit ACH AETNA ASC 100.00 `~' 93'a TYPE: DIR DEP ID: 8066033492 CO: AETNA. ASC , u44 ~Q ~~ ~' Mar 19 Withdrawal ;37. ~~_ . ' Mar 20 Deposit by Check 32 , 000. {)0 34 , 84~ 10 Mar 24 Withdrawal Transfer To Share 0011 11 ,201.8- z3°ra4`.-8 Mar 24 Withdrawal ~~, '13,14- `I9,v29.'14 Mar 24 Withdrawal 9,304.46- 10,024.a.~ Mar 24 Withdrawal ,~,326.`~5` 5,19e3.~8 Mar 24 Ending Balance 6 ' 198 ' S8 0005 -MONEY MANAGEMENT Date Transaction Description Additions Subtractions i3aiance Feb 25 Balance Forward ~' 11 ' S3 Feb 28 Deposit Dividend Tiered Rate 0 ~ 03 4 11.55 Annual Percentage Yie/d Earned 0, t00'~ from 02/0 l/2010 through 02/28/20 ?0 Mar 24 Ending Ba/ante '~ ' ` ' S~ LUAN ACCUUNT~ ooo~ - H4~ME EGZU9T" Date Transaction Description Amount: 9nteres~; =c'e:= ---_--P°'incio~al _ Balance zJ Feb ,?5 Balance Forward - - _--- -- z` - ~, ~' ^" ~~,~ Mar 01 ~ r ~_ ~ ~`~ ,~ . ~:~~ ~ ~~?~ . ~ci - ~~%8~+ 3'i Payments ~ ranste ~ om Snare OOOU ;'S'i . 0(~i `G5 , v~ Mar 24 Endinq 8a/ance ~~~ ' -~''~ ~ " l Annual Percentage Raie 8.990% Dail! Fcate t~19150°i° 0002 -HOME Ei3UITY Date Transaction Description Amount Interest Fees Principal Balance Feb 25 Balance Forward 9 ,445.20 Mar 16 Payments Transfer From Share 0000 204.74 49.92 0.00 154.82- 9,290.38 Mar 24 Payments 9,304.41 14.03 0.00 9,290.38- D.00 HOME EQUITY Closed - '' * *This is the final statement presenting information on this product" "` '' * " P/ease retain this Tina/ statement for tax reporting purposes "' " 0003 ~ HE~OC ' 2~:C MO!?TG~-GE trr~dit ~:r:zit 0.00 ~red:~ A;;a~la~l~2 rv.00 Date Transaction Description Amount Interest Fees Principal Balance Feb 25 Balance Forward 3 ,900.86 Mar 19 Payments 87.24 7.37 3.49 76.38- 3 , 824.48 Mar 24 Payments 3,826.05 1.57 0.00 3,824.48- 0.00 Mar 24 Ending Balance 0.00 Annual Percentage Rate 3.000% Daily Rate .008219% ** Periodic Rate May Vary On This Loan ** YTD SUMMARlE~ TOTAL DlV1DENDS PAID TOTAL LOAN INTEREST PAID 0000 REGULAR SAVINGS 0.70 0001 HOME EQUITY 866.19 0005 MONEY MANAGEMENT 0.08 0002 HOME EQUITY 177.10 0011 CHECKING 0.00 0003 HELOC - 2ND MORTGAGE 27.52 Total Year Ta Date Dividends Paid 0.78 NOTE: Total includes closed shares Total Year To Date Interest Paid 1 , 070.8'1 NOTE : Total includes closed loans EXHIBIT "D" 25Q5 Ritner ~igl~way Carlisle, F'A y7(T~5 F~a.ve ~,c~we (.ABU 22g5L} dill ,awe (AU 1538L) 243_I,g78 637-47J4 243-2677 Auction Is Action Fail `rRC)`N~" for ,~atisfa:cticrn SE~..I..ERS 1'~AlVI~ ,~'.~'~ A~I3R,ESS ~I-i~l~T 1~~T~ i'I~h~ I~.~.'I'~/I~JCArT'T~3N CLERK ~c ._, ~]E~CRI~~It~hT OF M~;RC~A.T~D-~S1iE I Commission the Auctioneers to sell the merchandise to the highest bidder by I'u.blic Auction. 1Vierchandise to be sold as is & grouped as necessary to obtain bids. I certify .that I am the owner or authorized represen- tative of the merchandise, goads and or property and have good title and. the right to sell and that they are free fram all incumbrances. I agree to accept all responsibility for providing merchantable title and for delivery of title to the purchaser. I agree to hold harmless the Auctioneers against any claims of the nature referred to in this agreement. _ AUC'I'I~N SIGNA~'I3R,E ~`otal Sales (Clerking 'T`ickets Attached) ~ _ Less Sale Expense: °,1o Commission Auctioneer c%, Comn-~ission Clerks ~~'I'~IER SE~I:.ERS SIf~NA~'I..1RE 'I`~~'~.I.. S~~~E E~.~EI~~SE Ia~Ir~~~T~"T'EIv~ SE IJI~E 1'-,S 1~~'I~ EXHIBIT "E" ___ ___ __ -- --- - - __ ........ ~ ....~..~ ~ ~~...iii~, i~~.yv.cr. - i~C.RiG~ .C?J.U~ d'SO~JIti Excdttttett ~11,67f7 ' • Looks MW. M In ezcelknt mechanlGl coatlkion and needs no rawndhionlnq. • tJevu had any paint or body work and k free of rust. • Ue+n thk histery and wlp pass A smog and safety Inspection. • Engint compartment Is ck+n, wtth no flukl kaKa rnd is Erse of any wrar er vlsibk a dei•tts. • Complete and verlf+sbk xrvlce records. Less than 59i~ of atf used vehkks fall into this category. GOOfj ir11,O2O ' • Wee oY anY major detects. • Gaan tick hstory, the paints, kiddy. end Mterbr have only minor fp any) blemishes, and there are no major mechanical prebkma. • IJttla or no rust on this vehick. ' • Tires match end nave wbehnWl trod wear left. • A "good" venkk will need some raeonditbnNq to ba sold at retail. Most conwmer owned vehitles kill Into this category. ' FBti • Soma mechancai or cosmetic detects and needs servkinq but is still In reasonabk running conditon. f Clean thk history, the paint, body andior k+terMr need work perfdrmetl by a profmaanal. • Tires maY need to De rsplattd. • 'Thera may be wme repartabla rust damage. ' Poor • Severe mechancal end/or tosmstk delacb and is M poor rdnning cond!tkn. ~, • May nave probNms that cannot be rudiVy fired such as a damaged frame or a ' rusted-through body. • Branded tick (ealvags, food, etc.) or unwbstsntiated mileage. Kelley Blue Book dean not attempt to report a value on a "poor" vehicle bepuse the vaWe of -. these vahfttes varies greatW. A vehkls in poor condition may ragoirs an independent appraisal to determine Ks value. ' • Penntylvania 4J3J2o10 accurate Condition ApPtii••i ChanAe Condition AccureteiY appraising the condition of a vehkk K an important aspect in dehrmininq Ka Blue Book value. Taking our 15 quactron wndttlon quiz wiU anwre You know the correct condtion rotlnq, ~~~ ~ ~ ~ ` 6EARCH LUC/t t. LI57'ING5 .r ![1:U Ke/laY &ua Ifouk Ca„ Irrc. AM rrdhts resolved. 4i2:YU 10~4i7L2d1J F.d/tinr.. fha sl+e.:hir MNrmaNnn /eduhMl ru rklermina nw value ror thl6 purtkulAr vuha:lr was wprdMd bK me perwn ounerntM!p dlAti reenrl, VMlcfu va/uatans are ookuons aml mrv vary irwn vMJCk to vuhicM. AtYUaI vsllartkrns NMl vary Nswl rxron marker rvndMrons. spetlhCalaN/s, YBhIrM! tt/adNnn or other panki/NrrCirtumsf+n tMr /Y rtMenf lu rhrs tnxul.rr vehkle nr did nanv+abn nr rtro partM!a' m the nanwWOn. yhw rawrr h !mender/ !br the lddwMluAl usr of thn poison Wnerntmp rhrs Imam-only etttl shall not be sold nr tnnsnrMleU m anorha/ party. r.Mlev due Flunk a!sunws nn rosplmaiWNry ror m!vs or omasrnns, , v: 100J1; a1 K•B.can /in!'/k' Nl+v (;All lYw1 Gn'r. I/cxwmtfi F kxD!or< rivwv li fkwlewti thMk:rx h Iirvenurv t]aasite`tls I.wrr.4 h Ir/,wurmuvl KU13rr(irebi KHFi~Mnhii° ff n.rr'yllec. Feprnnp hrte/ ytKk Auto 5nim' Itew Con For Sek trued Cars fur SaM hew Car Pncac 5 Greet Cur Deals l'ar lu!wern Grr Ykleus Auto Slwws { ll•sut K•B Atwut. Us urntntt Iht Unfer!: FAi! MrrUla Advutltit>S) Unk;nq pr5vacy Site Map CopMOM h traMarwrks 7dno of Servkr i O 1995-2010 KMIeN Blue Bpolt Ca., Int. Itrv+msx uWuirfer Page 2 of 2 http://wv~~7.kbh.corns:bb/~sed~ars/Fricing~eportl20~7_~'©y©t~_~;oral~a,~~2~ ~'_P'rivate~i~~... 4/3120 ~ ~i EXHIBIT "F" 1'~~~ ~ ?ODD >R~R~~~icet Streer, Suire: R 5{)G) t~hii~tielpl7ia, f'A 1~~{)'--7~)a ....Life Insurance Cvmpln~~ ~ ,, OS/t0/2Q10 {r~c~a7 ~~-~~oa S'CEVEN T. DAL'fUI`~1 30 WATSON DR1VE_ C'AIZLISLE PA I7015 Cuntrart `i~Tumber.' ELC04'1 120A Dear Claimant: 17lease .allow us tQ .express our sincere sympathy;and concern fir-your Loss. The Company is aware that financial hardships so often occur during these times. We have therefore developed the RSL Peace of Nliind .Account as a safe place to maintain your Benefits ~vl~ile allowing ,you immediate access to the funds_ As Dart c~I` tl~e~ settlement process, t[~e annuit~r proceeds nave be°n nhaced iii your aeeoun~ . li` indicated beinv~~, ~. pot~eioa~ o~ youz- benefit is ta;:abi; in~eres~. Description oC Pa~~ment amount: Z~1 Di/ATH BEI~IEFIT `$35;955.97 TAXABLE 1'ORTIfJN $ 3,455.97 rEDERAL TAXES W[THHELD $ -0.00 STATE TAXES WITHH'EI;D $ d.00 Tt~TAL -$35,955:97 Your account is an interest=bearing-account and wil] earn interest at ~ competitive rate. You will be receiving; a personalized checkbook within a few days to access your account at any time. You may m~iintain this account for as long as you wish, o~•,you may close it by simply writing a check :for. the ful an~ount. If you'have any questions about your account ,please call your Insurance Service f~epresentative, at: I -877-849-QQ3Q. l~~you have any questions regarding your claim or the benefit amount paid, please direct them to the Iannuiry;Department at: l -8C}Q~HELP=RSL It is our_sincere desire that the.added t~exibility the RSL Peace af'Ntind Account. c,t~'ers, will assist you .during this period. Sincerely, ~. ,~1r'r~' C4~t~~3~:1"~~r Annuity Department =~:0~' r Te ~ 4~+^ r !~'C. `'`I.ISP"ti?"`®Om FA?~ N0. !~!©v. ~ S 2010 03: 29PM E'3 ()S/!t)/2010 11A 1 c'' ~-t n 1~ !_ I;~, taA t_1'ON ~;~tli5 1-1A1~.t~C_)t~ I_~1K~ f3f~lVlr ~~:aant,n•:r~~t i`antl~rcr; 6;1.,t'i(101 12i)A !'t~;;+~~~ nllo~4~ ~~~ to ex~resS our ~;inrcrt: syrnpa.thy and concern Ic,r your icr~c. The Company is aware the ~ t r~i9~:++~~':i.ll I~:~ret:ai~ipc ~ at`rett occut~ cEt.{ri{t~ the:sc timer.. UJc: ha~c oihe~t~Fore eleveigped the R~~.. ~cacc c~ I~,rii+~~:~ ~~.e:ccst,++tt t~s ~ sal`e p6tac:E~ tc~ ~t~aintftitt Ni)uc° Etenci~{t:~. wiiil;: ~ICc-wi{r~ ~-ittr imnroa~eviiut~ ncc~q~ ro tits i' ,w~~ds~ - ~~,~.:; ~~+ura~ oi` the ~ettte»it:{e~ ~nroc~c~~ titc~ anrtuit~P p~{°~:et:d:~ its.~~~~.~ i~t~eo~ 1~Itst:G~& io°~ ~!rtur• ac~;t~{.{n~ . ! ~ io~d~iaaet~,~:: ~:,;~ic~~pf, ~a ~,c-awi~ttt ~tG` yot{€° hene;6'it i ~ tta~ab`e: intc~{•eyt.. Acycri~rtitin of Pa}~ment Amaunt Paid t`~h ~"l'1-1 li l;Nl~l~!'1' ~3G,071.t12 '1'~~~~1_t t'C~It~f'IUN ~ :x,5'71.02" i~~:;taF?1tAt_. TADS ~11'1'1-Il-I~I.,n .~ 0.00 5'1',x'1' ~ '1' A \ !"~ S W 17'1-11.1 ~ t„ t~ S U.Off ~'~-++r .+cco+ntt i:a etn inlerc.~t-la~ttrinb a~;c:caunt ttnd will c7nt i{tterCSt at ;e c:dmpetitive r~~e;• '~'~~tu ~t~iil tic reGeivin~; ;a }~er:~r~ns-lyzetl a:heckhook. ~rithin a fcrv d7ys to tsctress your accfluni a6 any time . 't'c~-+.{ Wray maintt-iet this account !'or a~ fang as yr.-t.{ wick, sir yuU +1tay c~io;;e it ley simply ~vritin~; u Clte~,~ fir {k~u t'ull amount. 1 t~ yr-~r t~{~+vc: any qu4~tiun:: ahuut your accuttint, , rlc:gSe ca11 ytx{r inwt{zwancc ~,ervi~e f~epre~se;nta~ivc~, aa: 1 ~t~'7~-R4~-OU3U. I E' ~r~-t+ F+uvc a{~y questions re~g~rdi+t~, yout• erEaim nr tltie f~a;nt;tit amretinr paid, plehcc clircet then: tc~ the /e+~ni+ity l:~ep~{'{mnne ~{t: 1-RC10-W1r1.1'•~)tSE., Ea e;; nu{• si»e;a;re~ ciesir~ {ha{. ehe ndJert lle~ibility {h~ kSl.. !'CaC.e u!'IviincE ~~:a:nunt nfi'cr~, will ussist ~r.u l t~.;++~t+i1y ~t;pfl~{11t~{t~ EXHIBIT "G" r Jaktn Hancock-Life lnsufance Company (U,S.~) Aniuiity Service C)ffice P.Q. Box 9505 _Portsmouth, NH 03802-9505. MNA•~0022i STEVEN T. DALTO~N - - 30 WATSON DRIVE CAR L!S LE PA 17015 - r .. ..Gross Amount. 57,183.72 Surrender Charges X0.00 ,Administration -ee Sp,pp `~~`~ r~ ~_t~~IMt!tE~. .:'itlEViR ~t~C~~F.A°~' ~'. - Rider fee SU.OG~ F `Fecierad Witithoiding SOACi ti Juditi<a A. ~aitor~ State Withholding gp.pQ . NA Vf~, kmaun# Sip.pG State ~rerniun~ ~`a~ Sp.O~ <D~iTE : ;:: ;. .~.Aii)AA.Ut~'~..... _ ;~~~H~~~?~NiJMi3~f~; . ` i3onus Enhancement keversal SO.pC 04/26/2010 . $7,183.'F2 010i858fi96 .Check Atrtiount $7,183.72 Sep~arabe-canfirnw st~tsm~rrt aril! ~ married. If lrotr ina~ .ahyr ,r,~upk~tlo~ta p4aa~ ~caiF Qur Service Eiep~irtr~t+~n~t ;a~ 87T-~1-HE-F~RIu1 X81'7-~43.38~'fi~ an+y busln~et~ day` ba+twarwt 8 AIi~ tQ S FN~t ES"!". ~~ ~ ~i .Judith A, Dalton 2675909 FRD1~ o The ~itu~~`eCI. !~uShroom FAQ IND. 1~ .IOIM1 MM100Ck Ufr4111sursnOb SSgmp~A~r rU.S.A~ AtMluliy 9ervlc+e OKlcs P.O. boot 9600 1~rtstaotth~ atl o9~OQ~0606 ~w..a~ ~AICNARL D. DALTON 1~ MAR80R LAKE DR. i.AROO, F!. 33770 -- :--- -;:: ':oaiiiil~ ~ ~~~!1.l1A~''~ .hutllt6a ~, aolror~ 1 ~,'. .. ~O :~.~~,~ 001 Nov. ~~ ?010 03:30PM PS S~urrerrdw~ ,~tMrMni~tr~iorr i~ R ~tl~ ~eeie~a~ VMp-it+o9ttr~ ~tA~ Mf6tM~loi~irr0 Ni1N~i /rr+o~nK Mare I~mktr~r Ts>t 0ont,~ Enha~loernei~t Rtwarsai fr~',18~.T~ 50.00 50.0Q 30.08 St1.0a 10.00 50.00 10.00 50.00 ~~~ ~~ ~' ~ ~ i~ ywl ~..~ quNtions p~sMS wM our s.n~. cwporps~nc a e~t~+w~w Derr-s~-~~~ ~r . ~ botwr.~- e ~ of ~ r-s~t ~T, EXHIBIT "H•• -• ~., fife ~Fir~~neial ~' ~e,n t,ife Assuc~anEe ~oenp~ny vfi ~anads (U.~) ~HEGK Nt}. ~~ ~~~~~ April 22, 2010 Steven T Dalton. 30 Watson Drive Carlisle, PA 17415 'k~~ : L~o~.icy Number: KA13085674-1 Claim ..Number.: DC-39470 - Deceased: Judith A Dalton Dear Mr. Steven T Dalton: En.clased is a check in theamaunt of $25,004.Q0, which represents the claim settlement of this contract. The following information is ..,for .your records: DeatY~ r3enef it : - $25, QOU , 00 Yau will receive an I.R.Q.' tax form fturn us i:n February of next year... Thus. form will .show any taxable portion of this distribution, :along -w~.th the tax kJithheld, as :shown above. ~G~.: shC7L:.Ld ~"ic~Irn.... a~n~' ~u°'~~..~.a~'..~~ ~~PIC°I'"l7.~ ~ ~'4..:t ~C'ta~.~'~i `o.~~.°'~.5~' ~~~ 1. free tc~ ce~ntact our offices at ~~OC.); ~~ f-~'~~~ . ~incerel~j, ....~ a z. sr Ac~m ~ ~~ '~ `~ Pr~::~~'. ~ -r ~,~. ~0 4u~`~~c '"~us~room FAQ F~0„ P ••~•. t~ Sure .t I.iFe P~nan~ia~~` Sun ii~e ~ssurence ~ornpany of ~ana~ia ~t~.~.~ l~.i C~'t~ee~. ~ ~ta2 ~ott~ x.365 ~i~slb®s fake give ~s~o, ~'L 33770 ~H~~11~ NCB. ~i:~Q9Q~~~ RT : Policy Numbes : FCA~.30e56~~ -1 Cla~.m i~umbes : D~-Z X9070 ~ea.l"" Ms . Mi ^hael D32 toh ~rio~.oser~ is a ehecJc ~.n th® amount of ~~5 , d0®. QO , which s®~se~enta the olaim settlement of thin contsac~t. The Following inf©~ma~ti©rr i s f os ~r©us secosc~® ~~:at~t Benefit : ~~~ , p0~ µ ~ ~~ rY4 L ~ ~ yw C~I~r/~.il !s ~"r. ~i ~ .a~ b ~ k w• F- ~1iw:~ ~ ~ y i. iyi,y. ~,~ ~ ~ ~~' ~L alr.•+«~ ~R ~1 • i~IY~ 1~r.. ~ea~ ~ T1~.~. ~ f osra ~i ~. ~, saoo~~, and a~~. a Po~t~. are cf ~~. ~ ~~. s ~~; ~.~u ~~. park ,~ 1f ~®~ s~,at~~.d wave and c~uee~~~.ons conce~ing this matter p~.e~-~e ~ec~l L~see to con~ct ous o~'fices at X800' 367-363 , S~.nceseZy, ~laim® ~~.nistsati®r~ Depa=tmer~t EXHIBIT "1•• - SYMETRA LIFE INSURANCE .COMPANY ~ r r eHECK Nv 003175938-. •••'~• 'P.O. BOX 34694 >CRECK .DATE 05/11j1o ': sEATTLE~ wA 9$124-1fi90 oooas~--tia~-er ~r,P ec DALTON,STEVEN T 30 WATSON DR CARLISLE PA 170.15 ~,I,i~~i,~ih~i,~i„i1,11~~,,1J~i 111 ~„il i~l ,1if ~ 1 i ,,, , , ,, , , , ANNUI'D'"ANT e. DAL,T©A!, ]UDITF& k. w ON~"RA~ - ~' ~ AAE~78t~8~.3: .DUE DATE ~~4,~'rl.f~.~? ~':` DUE TIr.L pQST~t~. REGUC.ATI®11! ~ CHECE:~ ARG hiC~ ~.OfJvEF FQJRINARDLL~. E'LE~.SE t:EE'P ll~~ ZNFORMEC~ Q~F "YOUR CURRENT MAILING ADDRESS. FOR YOUR CONVENIENCE, CUNSIDER U5ING DIRECT DEPOSIT. QUESTIONS? 'PLEASE-CALL l15. PHONE #: 1-Bad-SYMETRA ADDRESS: -SYMETRA LIFE IN5 CO C800-796-3872) option #3 INCOME ANNUITIES.- AI FAX # : 1-866-8T7--8780 Po.BOX 34fi90 rr/rrY#: 1-SOd-.833-6388: sEArrLE, wA 98~2~-1590 OFFICE HOURS : 7:40 - 4:30 PT GROSS-CHECK AMT $19,779.28 PLAN-CODE: AI FIT/STT WHLD AMT $d.Od SCHEDULE OOQ3 ------------'-- MAIL CODE: 40 AMT OF-THIS CHECK: $19,779.28 DISB TYPE: OU DETACH AT 'ERPORATION w-7B5t~BR trtiroe) r~Q!'` :' i hA ~'tu~ ~eCa ~1uShrpcam ~=~~: I`~f~, ~~~F~ .~ ~~1~ @3:29PI~ ~'~ i SvME'IYt/- 4LIFE INSURANCE ©dMPANY i~.0. 6Gx 34690 SEA'f~PLE ~ NMt 96124-1690 ear~aAe~-ds T~- ~ au.TON, ~tc:~L o ~ H~aeoR LAKE oR LARGp ~L ~77Q ~rrr~~Irrr~`~rrrur~~r~rlrOrrrOr~rr6rr~~rr~rr~rrlEr~~rrrr~r`r~ /M1~Y~I7M 6' a ~ M iVi~Y~ ®PV. 6Jf,~t~l7'R.~..~` a~" AAO~'808I.~' ®UE 6~~'E O~,x""~~~'"~.~' ~~ DuE TO POSTAL aEGULATIONS~ GH~Cits ARE NO LONf-ER F'ORWAttDED. PLEASE KEEP US INFOttMED OF YOl1R CURRENT MAILING ADORE55. FOR YOUR CONVENIFNCE~ CONSZOER. USING DIRECT DEPOSIT. QUES'PIONS? PLEASE CALL US. PHONE A~: 1-800-SYNETRA ADDttESS: S1-ME'1'AA 4.IFE INS ~ 0800-798-3870 opt~ior~ +Q3 INCOME ANNUrriES - AI FAx +~ 1-866.817-8760 PO eox 34690 'o'r/'t'IY~: I-600-833-6388 SEATrtE ~ wa 98?~.-4-1690 OFFitE HOURS :7:00 - 4:30 P'~ GkOSS-CNEdt A1+{T S29 ~ 779.28 P4./W 6,00E : AI ~T~s~r wNLa a-~ : sO.Ob St~ouLE :oArt~.~~ AA.. A.Y-~. A.....~-~..~ MbxL CODE. W AM'E' of THas CHEC16: S19 ~ 7?g .2$ DISK 1`YPE : 00 OETAGI@ AY PEIl1~lATtdl~ arEdc wo tf03I.75936 awry OS011f 1d i e ^ w•763N8i~ EXHIBIT "J" _ . ,1~ } F 9 * ~ t l ~a,,~~~k ^~rf~ 1. 4 Kf F~ii~~~.J'.S'N+ -. dwu .+ ~a ''x D~Mx .~ f Thai you aan now~wsw,~, ,~,. _Ya ~~.~ ~~ a=dlrei~°"claposlt '~~ ~ymeni ii-slory; a QORO arrangem;~~s~?r suit±iv!~-g akernaie payees ~r~d r { ,,,N t~"t'`"~~" F' ~~~~ ~, ~~I •'' jTl y' ~[:~~ m' wi.... - N ~' ~ ~k ~ ~~ ~ r Y+ r ~ ~, -;-r ~ a ~ r'~~~ ~~~ '~ra~' i. ., ~ ~ ,t, ;k" ,~ ~ i ~ ~ ~~ , x ~S" a+' r ~ q e ..r r4~M~: Y ,~, ~FCtID, CREASE ANU YEAH +1ERE TU RE,{,+SpyE .GtiECtt . --_ -.~ ....r~rr. ~~ WN l~l y y t1~.~ , ~ n/~ ~y Y P i-: ~ ;` ~frkr t1 ~ Wd ~ , a r c ~ ~r, ~ ' r Y+~ ~_' k~~ y 1 y~~ .~ ~~ il'K~ c. ~Yr f j ' '~. ~` i ~~, u ~~~ y~ ~~ ~ N ~ r P ~ ~ 1^,Y$ s + ~ ~ ~ ~ tl.y~^v Y ~~" 1 PM ^tl' ~. ~ f ~,I' ~' n. ~ ~IMl ~ ~'~ ~~:rr .Mt q 2 + N n i „l eft . ; Yt ~ ~ , ~. ~ li i~ az:c , ~~{ ~ 1 ~j J~ 1i~~~yN~,4~~~C~, ~t~ ~ S tit ben h ~~ tYl ~ ~de~ty carn'1o w~Yo~r~e-~n ~ ,,~ ~ riot.avaalat~e to ~""'~`" ~' re IQw~ec!'by haw. Tht9 service }s htw[dti~~ wt~e ~ , i ~e v ' ^~ ~ a and lienetiaaries re~~ #~Y~ grits ~~ f ~ ,~~ ' ,~'~i1 ~h~, ~~,o~ ~'/ ~p w y ' * t .,. u `~' ~: ~i. . ~ _. ,., r.~ ,~ ~. ~. , '. ~~ T :~1. ~~< L~ ... I 1~. C ~1 T4r ,.... ` ^ L1` l,N...... 1.~ .., ~ ~ H ~I i ~ 4~,~ .,. 1 ~ ~ ~~ ~. ~ 1` A ` _ 7~ ~ ~ ' ~~ , ` ~ f ~ ~ ~ ~, ~ ,~ N ~l a 3a v; a ~ ~ ry ~.. 'S1._ dNi N (L ~~l i ~ X~ '1"i ~ 7 ~r ~ q , 'r ~ ~ 7~ .in.R.~ Aw Nom • 25 2010 ~:'' ~'~ ~, The 5tu~~ed ~ughrtvvm ~ F FAX NO III ~ 1 ~~11Y ~Pb'y~ llww~ 3.103 ~ ' 'Ri4~HY ~...... I DAM o! Chick as ~~~ ~R ~ 7a ~~ ~untNurrNrbW ,wn 1~. ~d ' ~/Tats~r o.~wd- 1 q~n ~1; ~CN1 bti P~-~`ZOM p~~ l369~p~Fy0~R33i' 770 d~~ 1rA1t0 ~~.-.---- . .. oQ5 ~q~g 2a' ~ ~ ~~8r , `:0 ~ i COQ 38pe. MO ~ ~?~ ..~~ ~~ t I ~~f l f+Y ~ ~I~ • fffd' ~r/ ~/f/,/,s" ~r " ~'a ~( • ( '/ ~ ~ ~ ~ Y.. 1 ~•J !~ 1 ; ! J r` ,` / A/ ~ Ijy ~~,~i / R,~'//~ } / ,~, c~. '~ /' ~ I i f,. ,. ~~ ,~ `,.~f: /• ~~; r.; ~r ~ ~T,~r ~T • ~ j~~Pf t~+f max` rY. ! 1 i ,r/ '~ ~ .1 tf ~ , i~l~ •'~,' • ~~ ~j fir. ~ f,hJ /: ' fj ~: r f,.~~ . .. :~ ~~-~~a ~, ~ 1 4 lR r y 1 :. m