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HomeMy WebLinkAbout06-24-11 (2)1505610105 ~---" Rev-15aoEx~oz-~~,~~,- OFFICIAL USE ONLY PA Department of Revenue .____ Pennsylvania oEPAPTMEdT OF REVEhVE County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po Box 2so6os Narrisburq, PA 1'7128-0601 21 11 0498 RESIDENT DECEDENT _ __._ ENTER DECEDENT INFORMATION BELOW Socia! Security Number Date of Death Mti7DDYYYY Date of Birth MMDDYYYY 185-24-5588 04/04/2011 12/11 /1923 Decedent's Last Name Suffiix Decedent's First Name MI WALLICK BETTY W (If Applicable} Enter Surviving Spouse's Infor mation Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number - - - - - THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL !N APPROPRIATE OPALS BELOW ~ 1. C?riginal Return Q 2. Supplemental Return Q 3. Remainder Return (Date of Reath Priar to 12-13-82) O 4. Limited Estate +~ 4a. Future Interest Compromise (date of C) 5. Federal Estate Tax Return Required death after 12-12-$2} Q 6. Decedent Died Testate Q 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Baxes (Attach Copy of Will) (Attach Copy of Trust.} Q 9. Litigation Proceeds Received © 14. Spousal Poverty Credit (Date of Death Q 11. Election to Tax under :>ec. 9113(A) Between 12-31-91 and 1-1-95} (Attach Schedule C-} CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALI. CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIREiCTED T0; Name Daytime Telephone Numbber _ _ _ ._ Donald W. Darr (717) 637-2160 First Line of Address :846 Broadway Second Line of Address City or Post Office ZIP Code REGISTER OF L_S USE ONLY°- - ~.. f,..~ ---- ~~ ~~ ~ "~.. I " ~ .~ ;C'r1 I'~J _~ C.. DA LE~ _ _ _ _ . ~_~ Hanover, ~, PA ':17055 ``~` Correspondent's a-mail address: dorrlaw ~ k.n Under penalties of perjury, !declare that I have examined t ncl i acco ying schedules an tements, and to the best of my I<nowfedge and belief, it is true, correct and complete. D laration of preparer oth an th a repres tative is based on all i ormation of which preparer has any knowledge. IGt~AT . OF P~RSON,RES~POr i FOR FILING R N J DATE t~ ~ - /f ADDRESS Ir" `e.1 c/o 846 Broadway, Hanover, PA 17331 _ SIGN E flF PR ARE OTH R THAN REPRESENTATIVE / DATE: / ~~~.~//~~j~'`~ .~ -~-~"- ,rte - ~_ Z. ~ i 846 Broadway, Hanover, PA 17331 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 J :.1~ r.-: C ~ t ~ ~ f"r~ _:~ _r ~M ~ --r°a ~.f3 -r ~ ~~ 1505610205 REV-1500 EX (FI) Decedent's Social Sec:urii:y Number Decedents Name: Betty W. WalliCk 185-24-5588 RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule B) ....................................... 2.' 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 11,716.48 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Enter-Vivos Transfers R Miscellaneous Nan-Probate Property 36 19 194 (Schedule G) O Separate Billing Requested........ , . 7. 8. Tota{ Gross Assets (total Lines 1 through 7) ............................. 8. 30,910.84 9. Funeral Expenses and Administrative Costs (Schedule H) .......... ......... 9. 4,972.42 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ...... ......... 10. 1,368.46 11. Total Deductions (total Lines 9 and 10) ........................ ......... 11. 6,340.8$ 12. Net Value of Estate (Line 8 minus Line 11) ..................... ......... 12. 24,569.96 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............... ......... 13. 14. Net Value Sufaject to Tax (Line 12 minus Line 13) ........ . ...... ......... 14. 24,569.96 TAX CALCULATION -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 .0_ 15. _ ... _ . 14. Amount of Line 14 taxable _ _ _ _. _:. . .._ _ _ _ __ __ at lineal rate X .t) 45 24, 569.96 .. 16. 1,105.65 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 105.65 ' 1 19. TAX DUE .. , 19, 20. FILL IN THE OVAL !F YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15056],0205 O 15056],0205 REV-1500 SEX (FI) Page 3 File Number Decedent's Complete Address: 21-11-0498 DECEDENTS NAME ___. Betty W. Waltick STREET ADDRESS - -------- - - -------------------- --~- - Bethany Village 5225 Wilson Rd. CITY ------------- -- --- ---- -- ~ STATE - ------I ZIP ---- ---- Mechanicsburg I PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments _________ - B. Discount 3. Interest 55.28 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (3} (4) (5) 1,105.65 55.28 1,o5a.37 Make check payable to: REGISTER QF UUILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN '"X'" IN THE APPROPRIATE, BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred .......................................................................................... ^ b. retain the right to designate who shalt use the property transferred ar its income ............................................ ^ c. retain a reversionary interest .............................................................................................................................. ^ d. receive the promise for {ife of either payments, benefits or care? ...................................................................... ^ Z. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ~ ^ 3. Did decedent own an 'rn trust for" or payable-upon-death bank account or security at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ........................................................................................................................ ^ IF THE ANSWER TO ANY OF THE ABODE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE O AND FILE IT AS PART OF THE RETURN. For dates of death on or after Juiy 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 [72 P.S. §9116 (a} (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a} (1.1 } (ii}]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements #or disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use ~of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a}(1.2}]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in [72 P.S. §9116(a}(1 }], The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. (1) Total Credits (A + B } (2} 5 ~~~i M~i.~i L!'i~~f~~-l.Tl11F\.C ~: ak u:-i ~l lS i~l R~S.T.t~.~''i ~~~~~thr _ _ _ _ y. ~( t +,.~ ;r7elsl^e i"r ~roc~as ~~ iit~~~~io; s gnu ~f ~t.^' U~L~ ~1 i~ ~~LCC~~S 'tF'P~r~ r~c2iv~t~ ~y tt~e esr~t2. iii ~saperty ,~is~tiy otnrnec# vetith right of susviv~sship nae~st be ~3iscfc~ec! oar ~ch~~i~ ~. FG ~i~?i"C S~3r3~i t~ ??f;ti'Lt?'~f :;~c r3w~{?7~C3? S~?t'.(?rS tl~ ~~~E'i' G{ i:i~t Sdriif' Sfi°. ,.~ i...__t~f .. ~~ p~e~~~~~~~~~ hF..Si~~N~ DE~.:~J~i';T ~ a "+ g~P.'Sgl~.a~ ~ ~°~gpi~J{. 1F 4J»~7g j~~ fg.~l, i 7 ~ ~ ~ a:p~~ f~111{°~L^d~ y+~yg _ _. __..._.._.__. ~~ i.P4 S ~ ~~ ~~R~~ i~4J~°95#~~ betty 1~V. V1(alli~k 2~-~~-~~4`38 ,i?IS S~"f~~USt:: ~?'`u5t ~~ CC+; ~~:~?t~'~ 7,Ili~ i~~2{~ it %i'•t?Cf~S!"d?~ f:G ~i?Y ;;F Qta2SCiv^S : s~?~Q;,`f,}~ 4 :1'1 ~ d~2 %i'::'$!? Ct t"e ~rvf-I~iv ;c }'~:a. 7 ` :?'?t~r~ S~<i.~ S r:Fede:~; :~5~ ~~~l~iGi~t~ cl;E?et': Oi JSY#'!' ~` flQ 5a!7?C SiI.f'.. ~ ~~, ~~ ~ ~ p$~~w ~ g{ y~~j ~~pwe ~ gg~ ~$g ~~j~y/ +~4~t 4~~f gy~~ i).~. s'A`a7M~i`:T f_!' t1~'~~~t:.i ~: 2 N M's '~Aw %'!F'F~ l>M6 ~ Rla Ml ~ ~I # ~j ¢~s` °°~' ¢ ~ ~'t'IC~S TH ~tt_ IH~ rtl_i.1hq: ~ ~~~~~~gf ~ i4s 04` # tiES:i'icMi ncrEpri'a; ~ t ~~r~~~ ~~ ~ ~~~~ ~~~~~ ~ Betfiy ~V. ~f~fal4ick 2'1-~Z-Q~~B .._.~..._.._....________~~,_ ~a~ced~a~t`s ~ebt~ ~~ b~ re~a~r~~~ ~n ~ch~d~ie I. i Eft ~ ^~ ~ _ _...~r~:i ~P~i S.i~P~ ~_._....,...._._.~~..__.,._...e,. _ _ ~a~~i,?jii'T!~:i4 ~.._.__ 3 _., ~,t< <; ,~,.~ _.._...,.~t ~:..fi~i' 2 ' . ~ t Auer Grema#ios~ Services. #uneral director dill € ~ ; ~ ~:~. ~3~ 2. j ~ t t i ~ Rest ~-ia~e~ Gemeter~, eernetery k~~i! ~ € ~ I ~ ~ . ~35. rJG 2 i f,:. ; ~ P'3 it liid p~l.J7 ~t'S~ 2td i. ~. ~t~T~. S t ~._... ~ ~1~~~..~. a../t L.Gt~ t_..._i~5. j3I I 2 n„ _ t 2~ } ii.'i ~!C r``~' tai P'E! i'l.!i~i ?\?:~~4?CL'S(i',f,~t ~~3 ~~C1 S ._.__.__.____._____.__._...____..........___..._.,.._____._.______... _.__ 1 F ^ ~. ~ ~ i3 E .~. , ! tti ?'C:Ttly ~;i~i3"i~`ti~t;, • `c ~4?~:~~2"~` ,},.f iS ~ ` `"9r' ~` ?',St'~'~c ,tT ;? v '^~ '`~~ ^ ,J ~ :+.J ^SC.7lEJS ~~;~~, ";~ Jc it~ GS C!Ci~ .L _-, c!'..~C' P,.:I:iG!• VJ:1 i i r~, ~ ~ i 2 2 ~i' ~!. ~ tEtiS ~ ~ ~ ` ~~S __-----_-----~------~~---•-----_--------- = I ~ ~ i ~:~~}.~.':7 Wit: i"~~:~. ~ :}~.~U~ ~(7 t { +~ yy 3 ~' ! Bucher, ~~/ise & Dorn, reimburse Short ~ertsficates ~ 'i2.~~ f ~. ~ F~eaister o~ mills, file ir:h8ritance fax & Inventory ~ 3~. ~;J ~. i Carlisle Ses?tirjel, AdmfiiiStfatfl~ L@gaI Ads ~ '~ ~~.~~ ~o. ~ Cumberland Co. I,a~r ,~QUrr~al, Administrator Lega4 Ads ~ 7~.C~C? ~'€,~T~4L (Al v Fr'E;~r ur; ~.i~?~ ~, P,e::a~;!~uiatic€~ ~ ~ ~.~i2.~2 i~ m~~fi Sr aC~ S h~f~£~~; .~S£ ~~ul~;Cit%ii 5~?~~~.5: Ci a2?~~?!' ~'` ~~?? 5~tt7iC S;Zt?. ~~ -- r, ~-' ~L 1G~! 1~~ tiES:Dctii :~E ~.F~C!':T ~?E~~°~ t~~ ~E~E~E~~'f ~~-~~ - Betty ~~i'. Waliick 2~-11-0498 Report debts incurred b~ the decedent prior t€~ death that rerttained unpaid at t4~e date of death, including c~nreisnbursed medi~s~l expenses. -' '?"IT."E c~~C~ ;5 ^~t:~Gif, i;~5£~r'~~t~i~~0;'r",! Si ~£'.fifi ~3~ :~'t !iiar;2 5i:'t. '. tit::.- _.:, :iE~~Ap7MF~;z~ tJi= R~',.G~tl~ ' ' *~r C ~~~~~$~'+~~~~~"~ i~inr.5'[T~?NL : T,vX RETUnP7 k RES:Gc!`iT JE~:~JcNT ~ _ qFe TT`p {~~e (/~~pww M~1PV~8r 'S6i k Z ~~~ l1 MA'il.Yb ~0. ~~t~y ~N. 1~1€'allicl< ____. ~1-~'~-~49E~ RELATIf?NSI±IF T{} DECE~+E~T A~9c?J?VT OR S~sARE ~iJ~+$EF M `ASE ADD ADDRESS CF FEItSG±~{Sj RECEIVi^iti FROFERT~' d30 !',dOt List T~ustee~s} _~_. _~_ t7F ES?ATE __... ~ _ TA,XA$LE DIRTR:$i.~Tit'}~iS jI~?ciade Q~iL!~!~ill S,t'30L!J"a. CI!S~''!~'U~!Oh5 [7E1~ ~(~~?$fiL!'S Qr~,7r ._.,.._. .. SLe. 9ii6 ~~} (1.2;, ~. Qo~glas ~.'Vlfalls~k, 72~ .4rli~gtor~ Rd., Camg~ Hl{~; PA ~7~~ : sore '12;~~4.~£~ 2. Qavicl V~. allie#~,'~~ SQetem Hollow Rd., Newville; ~'A ~724~ son ~ '~ ~:~~4.~~ EP~'!ER DOLLAR A~YSDUNTS E4R DISTRI$~TICi~S SNuNI~V ABiI4E 0!~ LIfYES IS T'rERt`7ii3H act OF RE`Y'iS~iL' C~J'ER SHEET. AS AF'FRiiFR'.[ATE. ~~ I~ ?V0~-TA?:A$!.E DiSTRI$uTifli~S A, SFDisSAL ~?iSTRI$UTit~\S ~~lDER. SECTIti1 9.1':3 F+JR ~'dHIC~ AN ELECTtt7ti TD TA:~ IS N{JT TAKES>: B. CI~I~RITA€~LE ADD Gi?ti~RS~I~fEP~TAL I)I~ T RI$~l T ICSS: I. ~`QTA~. ~~ PART II - E~iTER i0 TRL ivGN TAXA$LE DISTRI$4'TI~fdS Qtv LIILE 13 ~E €tE'~!-15~~ Ca~'rlER SHEET. ~ ~ _..___ ii il'!O~E S~aC~ !S 7Q@tI~{~; USE c~~tlt~!Gf1~j S!?2f-.k5 Q` ~3Fe~ ?f tf?Q SBRiE SIZP.. ACNB BANK Apri129, 2011 The Law Office of Don Dorr Attn: Donald W Dorr 846 Broadway Hanover PA 173 31 RE: Estate of Betty W Wallick Dear Mr. Dorr: . The following information is being provided as per your request: Acct. Type Account No. Balance at Accrued Ownership Date D.O.D. Interest to Opened/Joint D.O.D. Classic 136] 767 $7,388.74 $0.08 Individual 6/1/84 Money Market Inquiries concerning ACNB Corporation stock information should be directed to the Registrar a.ncl Transfer Company at 1-800-368-5948. If you need any additional information, please contact me at (717)339-512'.. Sincerely, .-~ -.. . -; ` - ~-~-_ ,~, . -_ ~..A ~ ~ _1 _ _. Barbara J Warner ACNB Bank Deposit Services Representative II PO Box 3 ] 29, GET~ssuRC, PA 17325 I rHOrre 7 i 7.334.3161 I TOLL FREE 1.888.334.2262 I acnb.com I acnbbusiness.co~m t t~ER ARE ~ ~ ~ ~ ~~ ~IATIOI~ >~FR~ IFS ~F ~ E'~~>~~I,'~AIA ~N'~~ • _ 4100•Jonestown Road, Harrisburg, PA 17109 1-800-720-8221 Fax 1-717-541-9943 Shawn E. Carper-Supervisor Charges are only for items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items you have not selected, we will explain the reasons in writing below. If you have selected services that may require embalming, you may have to pay for embalming. You do not have to pay for embalming that you did not approve. Embalming is not required for direct cremation or immediate burial. Embalming is not required by law, except in certain special cases. if you are charged for embalming, we will explain why below. STATEMENT OF GOODS AND SERVICES SELECTED Deceased: Charge to: Name A. SPECIAL SERVICES: Direct Cremation ................................. Nationwide Guarantee Program ................ Worldwide Travel Protection ................... TOTAL SPECIAL CHARGES ....................... Address City State Zip Code ~ Phone Number D. AUTOMOTIVE EQUIPMENT: Removal Venicle ..................................... Lead Car and/or/Clergy Car........ ................. Family Car (Sedan or Limo) ..................... Service Vehicle .................................... TOTAL OF AUTOMOTIVE EQUIPIIRE~NT.,...... B. FROFESSIONAL SERVICES: Services of Funeral Director and Staff......... Dressing and/or Cosmetizing .................. Facilities and Staff for Memorial Service...... Crematory Charge ............................. Staff and Equipment for Memorial Service.. Private ID Viewing ............................... Witnessing the Cremation ..................... Packaging and Forwarding Cremated Remains by Registered Mail .................. Personal Delivery of Cremated Remains..... Scattering of Remains over Land or Sea...... TOTAL OF PROFESSIONAL SERVICES....... C. MERCHANDISE: Register Book ................................... Memorial Folders/Prayer Cards ................. Thank You Cards ............................... . Rememberance Package ...................... . Urn(s) ..................... ........................ . (Description) Urn Burial Vault Container .................... (Description) E. CASH ADVANCE ITEMS: Grave Opening ......................................_ Cemetery Equipment ............................ Newspaper_.:. _ ....... Newspaper _~_ _ Newspaper _ ...., Clergy .................................. ............. Church/Sexton/Organist/Soloist ................. . Flowers... ................. . ............................ County Coroner Fee ................................ Certified Copies of the Death Certificate....... Veteran Flag Case......... Grave Marker/Monument Date of Death Date of Arrangements, TOTAL MERCHANDISE .............................. TOTAL OF CASH ADVANCES ....................... SUMMARY OF CHARGES: A. Special Charges ................................. B. Professional Services .......................... C. Merchandise ....................................... - D. Automotive Equipment............................. _ E. Cash Advanced Items ........................... SUBTOTAL .................................................. CREDITS ............................................ ._ , TOTAL DUE .................................................. PAID ........................................... ,............... BALANCE DUE ............................................. If any legal, cemetery, or crematory requirement has required the purchase of any- of the items listed above. we will explain the requirement below. I agree that I have examined the items of goods and services selected above and found them to be correct and according to the arrangements I have requested. I acknowledge receipt of a copy of this Statement of Goods and Services Selected. I represent that I have sufficient funds available for payment of the cash price for the goods and services selected. 1 also agree to make payment of $ within days. I agree to be jointly and severally liable with anyone else who signs below. A late charge of per month amounting to per year will be applied to the unpaid balance beginning -~_ days from the date of this agreement:- I wilt also pay to the Funeral Director all reasonable costs paid by the Funeral Director to collect amounts l owe under this agreement. Those costs may include attorneys' fees, court costs and other costs. Any additional services or merchandise ordered or requested after the date of this agreement will be considered part of this agreement and the cost thereof will be reflected-on_ the final bill or statement. (Seal) (Purchaser) (.Date) (Seal) _ _ (Licensed Funeral Director) (Date) Interment Order and Authorization No interment shall take place until a written authority, signed by the proper relative or.legal representative of the deceased, has been. given to the Cemetery performing the interment. The undersigned hereby request and authorize: in accordance with and subject to its rules and regul Name of Decedent (First) Birthdate (mo/day/year) _ ,' .. _ ,: ~, Property Owner (First) Interment Space (describe) ~' ,. ,.~_ .p _ _ _ n' ~} S i Funeral Home Funeral Home Address Place of Funeral Service Type _ofi;Cemetery S2rvicrs , ~. , .. , Outer Barial Container Description ~. Memorial Description Memorial Base Description Casket/Wrn Description REMARKS Interment Fee Overtime Charged °~~ ,.., ` °~ ations to inter the remains of: (M.l.) (Last) Age ~ . ~' Sex Date of Death (mo/day/year) Veteran ' ~ ~ ` s. ^ Yes ~No (M•i•J -, (Last] -~ Telephone Number _ _, ..• Purchased,- _ ~ - , ~' _ ~ ~ Preneed ^ At-need Director ' City Day Day ,~.. . _ Manu#acturer, , Manufacturer f: Manufacturer ~~ Manufacturer ~.. L' _ . Telephone Number ~I <~,. State Zip. .~ '.>'' / .` (mo/day/year) Time of Service '""~ ^ AM ^ PM (mo/day/year) Time of ~lervice ~_ ° ~-,~ `~ C`AM PM w _ ^ - ~. sided By _"" ~' ~ ~~-~ r 'Ided By ~ - ~_ ~ , - , ., ~ ,.. ° - '. Ided By r, rded By ~ ~ "_' - _ n ~ry Other Charges ~ .~` ~ _ ,, Total ,....._--.,~.~.~ry ~ , ~.q Family Verification ~- _ -~~" ~ ~ ~~''_ ~ "Date3~ ' ~ a ~'.:u... Swx C. The undersigned hereby certify that they are the next-of-kin of the above named Deceased, or otherwise have the full I~gal authonty to direct the interment, entombment or inurement of the remains of the Deceased, and hereby authorize the above-named cemetery to make disposition of the remains of the Deceased as indicated above. The undersigned hereby further certify and represent that they are. the owner(s) or authorized representative(s) of thl~ Awner(s)_of the above-described Interment .Rights and hereby authorize use of the said Interment Rights for the interment, entombment or inumment of the remains dP the Deceased. Cemetery is hereby authorized to install any outer burial container purchased in connection with this interment in the interment space described herein. The undersigned hereby agree to indemnify and hold harmless the cemetery, its affiliates, and their respective agents, shareholders, officers, directors and employees from any and all losses, costs, or liability, including reasonable attorney's fees, it or any of .them may sustain in connection with any misrepresentations, misstatements, negtigenc~e;.ntentional actS,~or misconduct by the undersigned as it relates to the interment, entombment or inumment authorized hereunder. The undersigned agree that, ~it,its ouufl°exp~ri5e;-tkfe cemetery has the right to correct any error in the interment, entombment, or inurement. Tfiis forr» rr~ust be signed by (1) the property owneKAND (2) the closest next-of-kin. , ,M , / °. w .y Authorized Represents Signature S ~ `' ='~- ~ ~~° ~"'° '` Date '; Print Name ,, , ,,, Relationship ., ,.. • ~~ ..__ .,, ~ t t ~~ .State ' ... ~ ZI ,° ~ ... ~ d Address City _~ „_ _ p Telephone Number Authorized Representative Signature Date Print Name Relationship Address City "`~ ~ ~ - State Zip Telephone Number L.~ ,BANK _, **''*"*"*'''`*'""'*AUTO*'`3-DIGIT 170 3339 0.9920 AT 0.365 14 1 14 I~~~III~~~lll~~~~~~ll~~~li~~~ll~ll~~ll~~~~~ll~~~l~lll~~~l~~l~l BETTY W WALLICK C/O DOUGLAS C WALLIC 720 ARLINGTON RD CAMP HILL PA 17011-1603 602 pow rates on home equity lines and loans for a limi use it for any needs you may have -pay, off high build your .dream kitchen or pay for tuition. Thes r much longer -stop by one of our fic or call 1.877.883.2262 toda . Equal Housing fender. Equal opportunity nder. CLASSIC MONEY MARKET ACCOUNT ----- -- Begin mg Balance ~ Previous Statement Balance 03/31/11 $6 301 74 + Deposits and Other Credits 1 , . -Checks Paid or Other Debits 1 -Service Charges + Interest Paid Ending Balance Days in Statement Period 30 Account Detail Date Activity Description Deposits/Credits BEGINNING BALANCE 04-01 US TREASURY 303 XXSOC EC 1 087.00 BETTY W WALLIC , 04-20 INTEREST PAYMENT 04-20 CLOSING TRANSACTION . 57 04-30 ENDING BALANCE Interest Summary From 04/01/11 Through 04/30/11 Days in Statement Period Interest Earned Annual Percentage Yield Earned Interest Paid This Year Interest Withheld This Year ~~ ~;/ ;~~ ~ .~~ c~ ~~~ r ~~~ i j Statement Date: 04/30/11 i Account #: 1361767 V i' Page l i ~` _. ~~-Jf~ ~,} ~- t `,.- ~.,, c~ ~ -. me only! t bills, l ~ ~`'~" on't last ~ ,~ ~~'~~~ FDIC . ~`', `-' ~~, 1 ' ~_ ~~~G~ti~ Account # 1361767 Activity Ending Balance ,087.00 ,389.31.- .00- .57 $.00 ,389.31 Balance 6,301.74 7,388.74 7,389.31 .00 .00 30 $.57 .15% $10.89 $.00 acnb.com • acnbbusiness.com • P.O. Box 3129, Gettysburg, PA 17325 • Phone 717 334 ~ ~ 61 • Toll Free 1.88'~8.334.ACNB (2262) L.~ ~_ ACP~TB BANK ~MP> ~^ ~~ `~G~ '""'`'`*"`'`*"""'`"'*AUTO*"3-DIGIT 170 3340 0.8320 AT 0.365 14 1 15 i~~~rll~~~iii~~,~~~ii,~~l~~~il~~~~~~1!liui~l~~~r~~~~l~~~lii~i~ DOUGLAS C WALLICK OR DAVID W WALLICK 720 ARLINGTON RD CAMP HILL PA 17011-1603 612 ;~n, pow rates on home equity lines and loans for a limi ed k;me only! use it for any needs you may have -pay off high i Ater ''t bills, build your dream kitchen or pay for tuition. These r~tesj~'on't list much longer -stop by one of our offic 's ~,~~C~I or call 1.877.883.2262 today. i'j Equal Housing Fender. Equal opportunity Lender. emb ~ FDZC. Page 1 CLASSIC MONEY MARKET ACCOUNT ~I ~ I Account Summa ~;' ~ Account # j 1681575 ~ _ __ Previous Statement Balance Beginning Balance Activity Ending Balance 03/31/11 +Deposits and Other Credits $22,194.72 - ; --- - - - -- -Checks Paid or Other Debits .00 -Service Charges .00- +Interest Paid .00- Ending Balance ,I ! 2.74 Days in Statement Period 30 ; ! ~,j~~ $22 ,197.46 Account Detail ~~! ~i Date Activity Description Deposits/Credits ,;. he f s/Debits - Balance BEGINNING BALANCE I,~: 04-30 INTEREST PAYMENT ~ !'; ;?2 ,194.72 04-30 ENDING BALANCE 2 ' 74 ~ '~' ~ 22 ,197.46 il, I ~ 22,197.46 Interest Summa From 04/01/11 Throu h 04/30/11 '; j ,~ Days in Statement Period ;; - Interest Earned 30 Annual Percents a Yield Ear 9 ned ~,'j,l $2.74 ' Interest Paid This Year ~ ~~ ' .15% Interest Withheld This Year $3.10 j j~ $.00 Overdraft Char es /Refunds Summa !~'l Description ~ ~i - j T .~ is ;isle yTD Total returned item fees ~ h ~ 0 .00 Statement Date: 04/30/11 jII~ Accounts#: 1681575 acnb.com • acnbbusiness.com • P.O. Box 3129, Gettysburg, PA 17325 • Phone 717 334 I ~ 61 • Toll iFree 1.88l3.334.ACNB (2262)