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Home My WebLink About08-10-111505610143 REV-1500 Ex (a1-1o) ~ OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Year File Number Bureau of Individual Taxes DEFNRTMENT OE REVENUE Po eox.2sosol INHERITANCE TAX RETURN 21 10 1182 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 483 62 9955 11 17 2010 04 18 1949 Decedent's Last Name Suffix Decedent's First Name MI KAYSER JEAN (If Applicable) Enter Surviving Spouse's Information 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 IN APPROPRIATE OVALS BELOW a 1. Original Return ^ 2. Supplemental Return ^ 4. Limited Estate ^ 4a. Future Interest Compromise !date of death after 19-17-A71 ,n 8 Decedent Died Testate ^ T~ (AttacheCo a of Trusd a Living Trust ~ n i (Attach Copy of Wilq Py ) State ZIP Code PA 9. Litigation Proceeds Received 10. Spousal PovertyY Credit (date of death 11, Election to tax under Sec. 9113(A) ^ ^ between 12-31-91 and 1-1 -95) - (Attach SCh. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number GEORGE F DOUGLAS III ESQ 717 249 6333 First line of address 354 ALEXANDER SPRING RO Second line of address City or Post Office CARLISLE Correspondent's a-mail address: gdouglas@Salzmannhughes.COm 3. Remainder Return (date of death prior to 12-13-82) ~1 5. Federal Estate Tax Return Required __1 __ 8. Total Number of Safe Deposit Boxes REGISTER OF WILLS USE ONLY ~. -. C7 ' `-._ ~ ~~ i ~ ' _;.. _-_... J ti-i ''-. `_ -' -. -~ __ _ DA`l`E~ FILED T~ ' r: _,.? ~_ . ' ,~ i. /. ~' --; Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. eclaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAT E F PERS N R~SP SIBLE FOR FILING RETURN DATE ,~ Peter Ka ser - ~ ~ ~ ADDRESS 1301 110th Street Bode IA 50519 SIG TURE OF PREPARER OTHER THAN R RESENTATIVE ~v~ .. ~ George F Douglas, III Esq. ~% ~~ I T~ ~ AD RESS 354 Alexander Spring Road, Suite 1, Carlisle, PA Side 1 1505610143 1505610143 1505610243 REV-1500 EX Decedent's Social Security Number DecedenrsName. Kay$er, Jean 483 62 9955 RECAPITULATION 1. Real Estate (Schedule A) ....................................................................................... 1. 12 9 , 500.00 2. Stocks and Bonds (Schedule B) ............................................................................ . 2. 71.18 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3. 0 • 0 0 4. Mortgages ~ Notes Receivable (Schedule D) ....................................................... . 4. 4 5 x 0 0 0. 0 0 5 Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 225 , 967.80 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous -Probate Property (Schedule G) ~j Separate Billing Requested............ 7. 273,339.85 g. Total Gross Assets (total Lines 1-7) .................................................................... . 8. 673 , 878.83 -- 9. ---- Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 75 , 651.05 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 144 , 082.97 11. Total Deductions (total Lines 9 & 10) .................................................................. . 11 219 , 734.02 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 454 , 144.81 13. Charitable and Governmental Bequests/Sec 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. 454 , 144.81 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 15 0 . 0 0 (a)(1.2) X .00 . 16. Amount of Line 14 taxable 2 7 3, 3 3 9. 8 5 16. 12 , 3 0 0 . 2 9 at lineal rate X .045 17. Amount of Line 14 taxable 482.98 108 17. 13 , 017.96 , at sibling rate X .12 18. Amount of Line 14 taxable 321.98 72 18. 10 , 848.30 , at collateral rate X 15 19. Tax Due ................................................................................................................. . 19. 3 6 , 16 6. 5 5 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505610243 1505610243 REV-1500 EX Page 3 File Number 21-10-1182 Decedent's Complete Address: DECEDENT'S NAME Kayser, Jean ___ _ __ - _.__ STREET ADDRESS 3536 Countryside Lane _ ____ CITY STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) _ 36,166.55 2. Credits/Payments A. Prior Payments 30,000.00 B. Discount 1,578.95 Total Credits (A + g) (2) 31,578.95 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box 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. Make Check Payable to: REGISTER OF WILLS, AGENT. (3) (4) (5) 4,587.60 • ~ . •r~ ~i'~' 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 :.............................................................................. ^ ^x b. retain the right to designate who shall use the property transferred or its income :.................................. r~ ^x c. retain a reversionary interest; or ...................................................................................................... ...... 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? ...................................................................................................._............. ~_~ ^x 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 rr ~~ contains a beneficiary designation? ................................................................................................................. u ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. __ --- - - - - --- ~r,~r' 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 [72 P.S. §9116 (a) (1.1) (i)]. For dates 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 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 for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: . The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0 percent [72 P.S. §9116 (a) (1.2)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1 )]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-1502 EX+ (11-06 ) SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Kayser, Jean 21-10-1182 All 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. Real property which is jointly-owned with right of survivorship must be disclosed on schedule F. (If 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) Rev-1503 EX+ (6-98) SCHEDULE B STOCKS 8~ BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Kavser. Jean 21-10-1182 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 $25 U.S. Treasury Series EE Bond - No. L438028320EE, 25.00 dated 12/1989 -principal Accrued interest on Item 1 through date of death 46.18 TOTAL (Also enter on Line 2, Recapitulation) 71.18 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1503 EX+(6-98) SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR COMMONWEALTH OF PENNSYLVANIA SOLE-PROPRIETORSHIP INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Kayser, Jean _ 21-10-1182 Schedule C-1 or C-2 (Including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supponing Information to be submitted for sole-proprietorships. (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule C (Rev. 6-98) Rev? 507 EX+ (6-98j ~.. COMMON W EALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES 8~ NOTES RECEIVABLE ESTATE OF (FILE NUMBER _ Kayser, Jean _ _ _ 21-10-1182 All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule D (Rev. 6-98) Rev1508 EX• (6-98) ,~ . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF (FILE NUMBER Kayser, Jean 21-10-1182 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with the right oT survivorship must be disclosed on schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Aldersgate Methodist Church, Boy Scouts of America -Troop #160 -Freckled Moose 413.00 Fundraising -1 211 61201 0 2 Bald Eagle Area Music -Freckled Moose Fundraising - 12!1412010 511.00 3 Big Spring School District -Freckled Moose Fundraising - 12/06/2010 2,310.00 4 Boiling Springs Aquatic Boosters -Freckled Moose Fundraising - 12/23/2010 1,414.00 5 Brandywine Heights Area School District -Freckled Moose Fundraising - 11/18/2010 750.00 6 Brian K. Heckman -Freckled Moose Fundraising -12/15/2010 280.00 7 C.L.A.S.S. -Freckled Moose Fundraising - 12!10!2010 700.00 8 Calvin G. Johnson -Freckled Moose Fundraising - 12110!2010 91.00 9 Camp Hill School District -Freckled Moose Fundraising -11111/2010 119.00 10 Camp Hill School District -Freckled Moose Fundraising -1110812010 567.00 11 Cash on hand 115.11 12 Catherine L. Gannon, Eagle FC Force -Freckled Moose Fundraising -12/1512010 1,001.00 13 Central High Activities Fund -Freckled Moose Fundraising -12!1612010 2,044.00 14 Centre Hall Parent Teacher Group -Freckled Moose Fundraising -10/27/2010 3,017.00 15 Chambersburg Area Senior High School -Freckled Moose Fundraising - 12!07/2010 1,372.00 16 CHS Girls Softball Boosters -Freckled Moose Fundraising -11122/2010 2,485.00 Total of Continuation Schedules See attached a es TOTAL (Also enter on Line 5, Recapitulation) 225,967.80 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1506 EX+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, 8~ MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN continued RESIDENT DECEDENT ESTATE OF FILE NUMBER Kayser, Jean 21-10-1182 ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 17 Commonwealth of Pennsylvania -payment of unclaimed property 30.00 18 Conestoga Crew Club -Freckled Moose Fundraising -12!19!2010 917.00 19 Conrad Weiser Area School District -Freckled Moose Fundraising -12/23/2010 2,423.00 20 Corl Street PTO -Freckled Moose Fundraising -11116/2010 1,177.00 21 Cumberland County Magic -Freckled Moose Fundraising - 11/1512010 1,505.00 22 Cumberland County Magic -Freckled Moose Fundraising - 11/22/2010 63.00 23 Cumberland Valley Band Boosters -Freckled Moose Fundraising - 12115/2010 1,162.00 24 Cumberland Valley School District -Freckled Moose Fundraising - 12/16/2010 2,072.00 25 Diakon Lutheran Social Ministries -Freckled Moose Fundraising - 12109/2010 2,198.00 26 Diocese of Harrisburg St. Patricks Church -Freckled Moose Fundraising -11/3012010 455.00 27 Elizabethtown School District-Freckled Moose Fundraising -01/0512011 1,281.00 28 Encore! Home School Productions -Freckled Moose Fundraising -12/13!2010 924.00 29 Faith Fellowship Church -Freckled Moose Fundraising -11112/2010 1,771.00 30 Ferguson Township Elementary PTO -Freckled Moose Fundraising - 12/11!2010 959.00 31 FTC v/ QVC, Inc. -final check representing a settled lawsuit against QVC, Inc. 87.95 32 Gettysburg Area School District High School Activity Funds -Freckled Moose Fundraising - 847.00 1 211 412 01 0 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1508 EX+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, 8~ MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCETAX RETURN continued RESIDENT DECEDENT ESTATE OF FILE NUMBER Kayser, Jean 21-10-1182 ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 33 Grandview PTO -Freckled Moose Fundraising - 11/18/2010 4,641.00 34 Hams Jr. High Cheerleaders -Freckled Moose Fundraising -12/1312010 364.00 35 Happy Hearts Preschool -Freckled Moose Fundraising -12116/2010 588.00 36 Horse Savvy 4H Club -Freckled Moose Fundraising - 12/10/2010 651.00 37 Iowa State Bank Trust Department -decedents beneficiary share of Bernard Thilges Trust 425.00 38 Iowa State Bank Trust Department -decedents beneficiary share of Alfred Thilges Trust 350.00 39 Iowa State Bank Trust Department -decedents final beneficiary share of Bernard Thilges 18,361.21 Trust 40 Iowa State Bank Trust Department -decedents final beneficiary share of Alfred Thilges Trust 41 James D. Gregory -Freckled Moose Fundraising - 12/13/2010 42 Jean S. Fronk -Freckled Moose Fundraising -11!26/2010 43 John A. Kurtz -Freckled Moose Fundraising -11/17/2010 44 John A. Kurtz -Freckled Moose Fundraising -12!1112010 45 Juniata Valley School District -Freckled Moose Fundraising - 12103/2010 46 Junior League of Williamsport -Freckled Moose Fundraising - 11/18/2010 47 KAPPA Chapter of Alpha Delta Kappa -Freckled Moose Fundraising - 11/16/2010 48 Kernsville Elementary PTO -Freckled Moose Fundraising - 1 2/1 51201 0 7,895.32 350.00 72.00 371.00 266.00 1,722.00 511.00 609.00 1, 561.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1508 EX+ (6-96) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, 8~ MISC. PERSONAL PROPERTY continued ESTATE OF FILE NUMBER Kayser, Jean 21-10-1182 ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 49 Kernsville Elementary PTO -Freckled Moose Fundraising - 01/0912011 42.00 50 Kimberly A. Weaver -Freckled Moose Fundraising - 12/07/2010 1,036.00 51 L.D. CCC -Timothy Gingrich, President -Freckled Moose Fundraising -12/06/2010 545.00 52 LAHS Choral Boosters -Freckled Moose Fundraising - 12113!2010 805.00 53 LDHS Swim Team Booster Club -Freckled Moose Fundraising - 12/14/2010 819.00 54 Lewisberry Community Fire Co. -Freckled Moose Fundraising - 11/23/2010 189.00 55 Linda J. Swift -Freckled Moose Fundraising -12/0712010 14.00 56 Manheim Central School District -Freckled Moose Fundraising - 0110712011 2,107.00 57 Monique P. Varner -Freckled Moose Fundraising - 12/22/2010 14.00 58 Muncy School District -Freckled Moose Fundraising -1211312010 469.00 59 Northwestern Indoor Twirling Boosters -Freckled Moose Fundraising -11/1512010 700.00 60 Old Bellaire Chapter No. 375 Order of Eastern Star -Freckled Moose Fundraising -11/2212010 721.00 61 PAHS Cheer Boosters Inc. -Freckled Moose Fundraising - 11/1912010 1,512.00 62 Print Co. Graphics -Freckled Moose Fundraising - 08/20/2010 430.00 63 Red Land High School Music Boosters -Freckled Moose Fundraising -11/1112010 623.00 64 Ryan A. Kerr -Freckled Moose Fundraising - 12/07/2010 875.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1508 EX+ (6-98) ,~. COMMONWEALTH OF RENNSYLVAN~A INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, 8 MISC. PERSONAL PROPERTY continued ESTATE OF FILE NUMBER Kavser, Jean 21-10-1182 ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 65 SCMS Cheerleading -Freckled Moose Fundraising -12/13/2010 595.00 66 Sea Lions Swim Team -Freckled Moose Fundraising -11/22/2010 1,176.00 67 Sea Lions Swim Team -Freckled Moose Fundraising - 11/30/2010 35.00 68 Shippensburg Area Senior High Central Treasury -Freckled Moose Fundraising -11123!2010 1,316.00 69 So Hunt Co School Dist. -Freckled Moose Fundraising -1210912010 1,470.00 70 South Middleton School District -Freckled Moose Fundraising -12/17/2010 1,134.00 71 Spring Grove High School Activity Fund -Freckled Moose Fundraising -11/1712010 785.00 72 State College Area School District -Freckled Moose Fundraising - 01106/2011 2,065.00 73 Steven D. Loerts -check on hand 10.00 74 Susquehanna Twp. Music Boosters -Freckled Moose Fundraising -12/08/2010 847.00 75 Tamaqua Elementary PTO -Freckled Moose Fundraising - 11/16/2010 2,149.00 76 The Crayon Box Day Care Center LLC -Freckled Moose Fundraising - 12/15/2010 385.00 77 The Dance Academy Competition Team -Freckled Moose Fundraising - 12/15/2010 546.00 78 The Hallelujah Gang -Freckled Moose Fundraising - 11118/2010 161.00 79 Timothy Lutz -Freckled Moose Fundraising - 12/11/2010 42.00 80 UZELAC Gymnastic Booster Club -Freckled Moose Fundraising - 12107!2010 672.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1508 EX+16-98) ,~ COMMONWEALTH OF PENNSYL VANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, 8~ MISC. PERSONAL PROPERTY continued ESTATE OF FILE NUMBER Kavser, Jean 21-10-1182 ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 81 Veronica M. Schrack -Freckled Moose Fundraising -11117/2010 351.00 82 Williams Valley School Dist. -Freckled Moose Fundraising -1111512010 1,512.00 83 Williams Valley School Dist. -Freckled Moose Fundraising -1111912010 50.00 84 Wilson College Gov't Assn. -Freckled Moose Fundraising -12115!2010 560.00 85 Citizens Bank, Business Partners Checking Account No. 6201608307 -Freckled Moose 77,631.67 Fundraising 86 Citizens Bank, Circle Checking Account No. 6100662756 4,285.19 87 Citizens Bank, Circle Checking Account No. 6100766985 4,867.58 88 Citizens Bank, Green Checking Account No. 6100662748 1,364.04 89 Citizens Bank, Premium Business Money Market Account No. 6213767294 -Freckled Moose 661.11 Fundraising 90 PNC Health Savings Account Services Account No. 1084227810010 462.37 Accrued income on Item 90 through date of death 1.87 91 2001 Dodge Caravan -VIN 1 B4GP453118242528 500.00 92 2006 Dodge Caravan -VIN 2D4G44L66R883612 6,500.00 93 Household Goods 2,700.00 94 Chrysler Service Contract -refund 212.52 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1508 EX+(6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY continued ESTATE OF FILE NUMBER Kayser, Jean 21-10-1182 ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 95 Comcast -refund 83.45 96 Hampden Township Sewer Authority -refund of sewer service 14.99 97 Ohio Casualty -refund unused premium 256.00 98 State Farm Fire and Casualty Company -refund due to cancellation of homeowners 214.97 insurance 99 State Farm Fire and Casualty Company -refund due to cancellation of automobile insurance 302.53 100 Time Inc. Shared Services -refund 18.00 101 Wachovia Bank -IRA 25-703-027-1404417, decedents estate is the beneficiary 25,330.92 TOTAL (Also enter on Line 5, Recapitulation) I 225,967.80 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1510 EX+ (6-98) SCHEDULE G - ~ INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Kavser. Jean 21-10-1182 This schetlule must be completed and filed if the answer to any oT questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY THE DATE OF TROANSFERSATRACFi A COPY OF TORE DEIED ~OR REAEES TATDE DATE OF DEATH VALUE OF ASSET ~ OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 Citizens Investment Services -IRA L7C190349, 5,204.36 100.000% 5,204.36 beneficiary is Martha Kayser, Mother 2 Vanguard -Cargill Partnership Plan 401(k) -Martha C. 268,135.49 100.000% 268,135.49 Kayser, Mother -beneficiary TOTAL (Also enter on Line 7, Recapitulation) I 273,339.85 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) REV-1151 EX~ )10-06) ,~, , COMMNHERITANCE~ AX RETURNANIA RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES 8~ ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Kayser, Jean _ 21-10-1182 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A, FUNERAL EXPENSES: See continuation schedule(s) attached 11,868.10 B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Peter Kayser Street Address 1301 110th street City Bode state IA zio 50519 Year(s) Commission paid 15,015.00 2, Attorney's Fees Salzmann Hughes, P.C. 18,500.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zia Relationship of Claimant to Decedent 4. Probate Fees 534.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 29,733.95 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 75,651.05 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ~ I _. ESTATE OF FILE NUMBER ,_ Ka ser, Jean 21-10-1182 ITEM AMOUNT NUMBER DESCRIPTION Funeral Ex e~nses 1 Becky Kayser -reimbursement for funeral travel 612.58 2 Ewing Brothers Funeral Home Inc. -funeral services 4,105.87 3 Lentz Funeral Homes -funeral services 1,957.05 4 Peter Kayser -reimbursement for funeral food and funeral travel 1,728.66 5 Peter Kayser -reimbursement for head stone 2,011.28 6 William Kayser -reimbursement for funeral travel 1,452.66 H-A 11,868.10 Other Administrative Costs 7 Citizens Bank -monthly maintenance fee Account No. 6100662748 4.99 8 Citizens Bank -service charge Account No. 6100662748 3.00 9 Citizens Bank -monthly maintenance fee Account No. 6100662748 4.99 10 Citizens Bank -service charge Account No. 6100662748 3.00 11 Cornerstone Land Transfer, Inc. -additional funds due on the sale of real estate in order to 49.77 administer the estate 12 Cornerstone Land Transfer Agent for FNTIC -courier fees paid to sell real estate in order to 30.00 administer the estate 13 Dick Kayser -reimbursement for refuse disposal, cleaning out the house,mileage and gas 932.20 paid in order to administer the estate Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Kayser, Jean 21-10-1182 ITEM NUMBER DESCRIPTION AMOUNT . 14 Donald Hagerich -Freckled Moose -Butterbraid service 274 hours and 874 new accounts 7,724.00 15 Donald Hagerich -Freckled Moose -Butterbraid service 265 hours 7,621.00 16 Michael Langan -tax certificate paid to sell real estate in order to administer the estate 5.00 17 Patricia A. Rosendale, CPA -preparation of 1099- Misc for the Executor 20.00 18 Pennsylvania American Water -balance due on account 17.43 19 PPL Electric Utilities -final electric service 391.06 20 Prudential Thompson Wood -commission paid to sell real estate in order to administer the 4,532.50 estate 21 Re/Max 1st Advantage -commission paid to sell real estate in order to administer the estate 4,782.50 22 Recorder of Deeds - 1% realty transfer tax paid to sell real estate in order to administer the 1,295.00 estate 23 Recorder of Deeds -Mortgage satisfaction paid to sell real estate in order to administer the 50.50 estate 24 Register of Wills -four short certificates 16.00 25 Register of Wills -four short certificates 16.00 26 Register of Wills -fee for exemplified copies of probate documents 40.00 27 Register of Wills -filing fees and final expenses 130.00 28 Register of Wills -two short certificates 8.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE- COSTS continued ESTATE OF FILE NUMBER Kayser, Jean 21-10-1182 ITEM NUMBER DESCRIPTION AMOUNT 29 Salzmann Hughes, P.C. -reimbursement for three FedEx mailings 46.50 30 Salzmann Hughes, P.C. -reimbursement for FedEx mailing 15.50 31 Salzmann Hughes, P.C. -reimbursement for 2 FedEx mailings to pay off American Express 41.00 and Bank of America credit card balances 32 Salzmann Hughes, P.C. -reimbursement for FedEx mailing 20.50 33 Salzmann Hughes, P.C. -closing costs and final fees for income tax preparation, postage 1,000.00 and miscellaneous contingencies in order to administer the estate 34 State Farm -automobile insurance for 2006 Dodge Caravan 323.12 35 State Farm -balance due for automobile insurance for 2006 Dodge Caravan 70.38 36 The Sentinel-Legal -Legal advertising 191.16 37 Valerie S. Stacknick -notary fees 10.00 38 Wenger Meats & Ice Co. -December storage unit for Freckled Moose Butterbraid supplies 338.85 H-B7 29,733.95 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 E7(+ (t2-081 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8~ LIENS ESTATE OF FILE NUMBER Kayser, Jean 21-10-1182 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 American Express -balance due on credit card account 12,000.00 2 Assoc. Otolaryngologists of PA, Inc. -balance due on account 70.00 3 Bank of America -balance due on credit card account 6,200.00 4 Christine E. Gloss -Freckled Moose -Butterbraid commission 324.00 5 Citizens Bank -Payoff Loan No. 6007221087 75.50 6 Citizens Bank -Payoff Loan No. 6050588699 40,869.78 7 Citizens Bank -loan payment for Account No. 605088699 664.26 . 8 Citizens Bank -commercial loan payment for Account No. 111910 06082215290101 225.98 9 Citizens Bank -commercial loan payment for Account No. 111910 06082215290101 224.44 10 Citizens Bank -payoff commercial loan account No. 060-0001-8221529-0101 6,809.22 11 Country Maid, Inc. -balance due on account for Freckled Moose Fundraising 54,903.61 12 DCM Services LLC -balance due on Kohl's credit card 2,491.63 13 Dean Dunn -preparation of final life period income tax returns for 2010 500.00 14 DMC Services for Kohl's -balance due on credit card account 2,491.63 15 Donald Hagerich -reimbursement for supplies, shipping, miscellaneous items for Freckled 969.85 Moose -Butterbraid service 16 Fulton Bank -payoff loan account no. 1057-2251112937 3,680.61 17 Goodwill -donation of household goods 1,700.00 Total of Continuation Schedules See attached pages TOTAL (Also enter on Line 10, Recapitulation) 144,082.97 (If more space is needed, additional pages o` the same size) ~~opyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-C8) Rev-1512 EX+ (6-98) ~. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS continued ESTATE OF FILE NUMBER Kayser. Jean 21-10-1182 ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 18 Hampden Township Sewer Authority -final sewer service 165.02 19 Michael Langan, Tresurer - 2010 County real estate tax 387.69 20 Michael Langan, Tresurer - 2010-11 School real estate tax 1,519.09 21 Nancy Campbell -Freckled Moose - Butterbraid service 54.75 hours 739.13 22 Pennsylvania American Water -final water service 79.76 23 PPL Electric Utilities -electric service 364.29 24 St. Joseph Medical Center -Balance at date of death balance due on account #030243240 723.47 25 The John Hopkins Hospital -balance due on account no. 208074070 2,275.40 26 The John Hopkins Hospital -balance due on account no. 908945652 35.00 27 The John Hopkins University -balance due on account no. 30-4713600 429.60 28 The Johns Hopkins Hospital -balance due on account 260.36 . 29 The Salvation Army -donation of household goods 1,000.00 30 TruGreen -lawn service 95.40 31 Verizon -balance due on account 389.58 32 Verizon Wireless -balance due on account 267.51 33 Wenger Meats 8~ Ice Co. -October and November storage unit for Freckled Moose 1,061.50 Butterbraid supplies 34 West Shore Tax Bureau -balance due for self employment tax 89.66 i;opyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) SCHEDULE J COM IN~ ERITANCE~ ~ RETURtJANIA DE EDENT BENEFICIARIES RESIDENT ESTATE OF FILE NUMBER Ka ser, Jean 21-10-1182 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT o Not ist Tru to s (Words) ($$$) I TAXABLE DISTRIBUTIONS [include outright spousal ~ distributions, and transfers under Sec. 9116 a 1.2 See attached schedule Tota I 454,144.81 Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 15 00 cover sheet, as a r o riate. NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 1.3.0E REV-1500 COVER SF1EE_I I_ - Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-081 SCHEDULE J BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: Jean Kayser 11/17/2010 483-62-9955 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) 1 Peter Kayser 1301 110th Street Bode,lA 50519 2 William Kayser 26991 Southeastern Ave. Sioux Falls, SD 57108 3 Jerome Kayser 2501 Elm Ave. Gilmore City, IA 50541 4 Howard Kayser 305 2nd Ave., NW West Bend,lA 50597 5 Richard Kayser 106 1st Ave., NE West Bend, IA 50597 6 Jennifer Schiele 2092 Delta Ave. West Branch, IA 52358 7 Jacklin Knorr 690 South Jones Blvd North Liberty, IA 52317 8 Jacob Kayser 1301 110th Ave. Bode,lA 50519 9 Nicholas Kayser 1301 110th Ave. Bode, IA 50519 Brother 12% Residue as per [~,bau.u~; Item Fifth of the Will Brother 12% Residue as per 21,696.60 Item Fifth of the Will Brother 12% Residue as per 21,696.60 Item Fifth of the Will Brother 12% Residue as per 21,696.59 Item Fifth of the Will - Brother 12% Residue as per 21,696.59 Item Fifth of the Will Niece 6.67% Residue as per 12,053.67 Item Fifth of the Will Niece 6.67% Residue as per 12,053 rs? Item Fifth of the Will Nephew 6.67% Residue as per 12,053.6 Item Fifth of the Will Nephew 6.67% Residue as per 12,053.66 Item Fifth of the Will 1 SCHEDULE J BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: Jean Kayser 11/1712010 483-62-9955 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) 10 Casey Kayser Nephew 6.66% Residue as per 12,053.66 2501 Elm Ave. Item Fifth of the Will Gilmore City, IA 50541 11 Kelly Kayser Niece 6.66% Residue as per 12,053.6c", 2501 Elm Ave. Item Fifth of the Will Gilmore City, IA 50541 12 Martha Kayser Mother All Schedule G Items 273,339.85 13 Russell Steele Friend Per Third Item of the 432 Frederick Rd. Will Roaring Spring, PA 16673 Total 454.144.,x? 2 LAST WILL AND TESTAMENT OF JEAN KAYSER n r~ o ~ T, l "' ~ ~ ~ C7 =T, f ~T1 --_ ~ n , - ..1 ~\ -~ ~ - ~, - ::. --;, N I, JEAN KAYSER, of Camp Hill, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void any and all former Wills, Codicils, or writings in the nature thereof, by me at any time heretofore made. FIRST: I direct that my remains be cremated and that the expense of my cremation be paid from my estate as soon after my death as conveniently may be done. SECOND: I hereby order and direct my Executrix or Executor, hereinafter named, to pay all my just debts, funeral and crematory expenses, testamentary expenses and all Inheritance, Estate, Transfer and Succession Taxes, as soon as may be conveniently done after my death, out of my residuary estate. Further, to the extent that sufficient assets exist in my estate, any and all inheritance or other estate taxes, whether to non-charitable or charitable beneficiaries, shall be paid by my Executor or Executrix from the residuary of my estate prior to distribution and no part of the taxes paid shall be prorated or apportioned among the persons or beneficiaries receiving the taxable property regardless of tax rate applicable by law to each such persons or beneficiaries. THIRD: I give devise and bequeath my interest in a business known as Nutri-Innovations, located in Minnesota to RUSSELL STEELE, per stirpes, who lives in Martinsburg, Pennsylvania. FOURTH: I give, devise and bequeath my interest in our family farm, located in Iowa, to four of my brothers, PETER KAYSER, WILLIAM KAYSER, JEROME KAYSER, and HOWARD KAYSER, in equal shares, per stirpes, all of who are co-owners of the said farm. FIFTH: I give, devise and bequeath sixty (60%) percent of the remainder of my estate, both real and personal, which includes my interest in a business known as Freckled Moose Fundraising to all five of my brothers, PETER KAYSER, W!LLIAM, !~.AYSER, JERO^!!E KAYSER, HOWARD K,4YSER, and RICHARD K.AYSER, in equal shares, per stirpes. The remaining forty (40%) to be divided between my nieces and nephews, JENNIFER SCHIELE, JACQUELINE KNORR, JACOB KAYSER, NICHOLAS KAYSER, CASEY KAYSER and KELLY KAYSER, in equal shares, per stirpes. SIXTH: In the event any of my above-named nieces or nephews shall not have attained the age of eighteen (18) years at the time of my death, I hereby give, devise and bequeath his or her share, be it real, personal or mixed, of whatsoever kind and wheresoevver situate to their parents, IN TRUST NEVERTHELESS, for the use and benefit of my said nieces and nephews. The Trustees, authorized to act jointly or separately as the case may be, shall invest the funds in good and safe securities, legal for Trust funds in the Commonwealth of Pennsylvania and may use the income derived therefrom for the support, maintenance, health, education and general welfare of my said nieces and nephews. In addition, I hereby authorize and empower the Trustees to use as much of the principal as they in their sole discretion shall deem necessary and proper for the support, maintenance, health, education and general welfare of my said nieces and nephews, and to distribute absolutely to them the principal and accumulated income, if any, upon his or her attainment of the age of eighteen (18) years. LASTLY: I nominate, constitute and appoint my brother, PETER KAYSER, to be the Executor of this my Last Will and Testament. In the event that PETER KAYSER shall be unable to serve as Executor for any reason, I appoint my brother, L^JILLIAI~!! KAYSER, as Executor. No Executor er Executrix sha!! be required to flle bond in this or any otherjurisdiction. IN WITNESS WHEREOF, (have hereunto set my hand and seal this ;~/ A .Z !day of ~`o ~--z~ , 2010. ~ ,, i ~~ ~' ~-~ JEAN KAYSER SIGNED, SEALED, PUBLISHED and DECLARED in the presence of: ~ r ,~ ~ , ~ COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss I, JEAN KAYSER, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Swo~ntor affirmed to and acknowledged before me, by JEAN KAYSER, the Testatrix, this ~. ~ day of ~~,~~.,,,~-2., , 2010. JEAN _YSER, Testatri NOTARIAL SEAL. GEORQEF DOUQLA3, HI, NOTAAYPU8LIC -~ CARLJSLE BORO, CUMDERL{WD COiJNTY ~r ' '"~1~/` ~ - ~ ~~ 'ail'COMMISSIONEXPIRESJUNE28,201t1 Notary Public 4 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss We, George F. Douglas, III and -~ , , _ ~~ ~ - ;~ ,~~ ,the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her Last Will; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Swor or affirmed to and subscribed to before me by George F. Douglas, III and _ :~_~.-.-~~'~, this 2~'=' day of 1~,~,~~~. _ , 2010. ~' n ~' ~'__._ George F. Dougla ,III, Witness ~c~~~ ~ ~ ~~ .y~ Witness NOTARIAL SEAL ~ _ ' r~ i IGEORQE F. DOUOlA3, IU, NOTARY PUBLIC I CARllSLE BORO, CUMBERLAND COUNTY Notary Public MY COMMISSION EXPIRES JUNE 26, 2011 SETTLEMENT STATEMENT - - - -- - -- -- ------ - _ _ _x-~-n ~ _ - - - r ~L. SETTLEMENT CHARGES - - - -~ ~ ral~Frtorn ~ ~A~~FROrs _700. TOTAL SAL=S/B~~ rCEP,'S ~C r~ ~~ss'Ot: based on price 5129,500.00 = 9 315.00 _ _ 16oRF•0?r~rER'S ~ T~ _LEIR'S -- -- ~L ~ "~S'~Or n"'1',5 IG [ '~:iWS. ~, 'Uti'DS AT ~ ~UVrJS AT ~ 701_5_.__. __._ 4.782.5 tc RCIh~aX 15t AdVantaCJ0 - ____---___-. - - - i .S ET`L~M=fJ-i ; S~TTLEM~NT __ Oc 4 532 50 t Prudential Thompson Wood - - - - ---- -- : ! - - _ - , i ~3 Cc, nmiss 0 ' -ac ~ ~ I~Te ~ __ , _ _ __ - -- i 9,315.00 - -- _ _ ~ 7~4 a ker+ee _ t~ Prudential Thom son Wood - - -----~ ~ - I I 200.00' - _ 1 800. ITEh1S PAYAE3_LE IN CONNECTION WITH LOAN - -- _ ____ __ __ _ _ ~ 801 Loar_0 al I ,n gee -- --- - --- ----- r-- -- - - -~ ---- __ --- - ----- I 802 ~ ~oa^ D s.,,u o •-------- ---- - ---- ----- 6C3 oo~raisal, rep, I I J - -- - 1106 _ -- --i 800. _ - -- _._ V _-_-. ._-____ -_ - ------- - - -- ---- --- - -- ___ ___ ~ ~____~__ 4 ~ _ - _et _ - -__ --__ I _ - --1_-__ ~t1 I ~ 900._ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE _ 961 !merest Frem •o r ~ !dav 902, rAOrtnage Irsurance_Prerriam fcr__D_mont !o ?03 Hzzard !nsurae~e Premium for 0 mont to 904. ------- -- ~ -V - ----- - --- ------ ' 1000. RESERVES DEPOSITED WITH LENDER FOR tia-ard I. -m? I-_1002 t:1~~e losurar.ce _ _- mom 5 !ma -- -I ~ - ~ 1QC3 Ci~Pro ep rtyTax _ rno a~S Imo - _ _ ___ 1C~'C Counr, pro„o,•v r .t mo rl $ 'mo _ ~_~~:_ ~ l~ - tOCE School taxes mo_n S !mo ------------ ---- _ - -- i -- _1.~9_Aggr~ate_An~lysish~ustmenl _ --- j 0.00 ~ 0.00 1 100. TITLE CHARGES __ _ - 1 __ _ _rt Setlleme~lor I•s~~ngFee ~ ~ ~ ___ _ ?~2 A6 ract er I I Sezrch_ to Cornerstone Land Transfer Agent for FNTIC ~ --~- i 125.00' ` i t S. Tltt EX I nl ICn -__ ____ _. -- ~- - -_-__ _ ~ t? S. DocJm m p: L'e I 1 1106 Notary Fees _ ,o Valerie S. Stacknick ' ~' 5.00 i 10.00 I i 1r)7_Atlol^..e'a s `ees _ ___ to Robert Qu~ley _ __ 370.37 _ _1ncl~des 3JOao items l0 1101,1103 ~ ~ -' t i a ~ It e Irs ____ ro Cornerstone Land Transfer Agent for FNTIC - ~ --- -- - 435.00 Inc.lodes abora items f;o----- --- - - -1 _ _11 o Lender's Fo cy_ _ _ -- -- - ---- ~ _ - --- - - i _?_t_ ~ Ow r is aJ iw__ _ 129 500.00 • 435.00 _'~_t '_ax Cer,i+,catior __ to Michael Lan an - '„ ? 7 -- - -- - ---- - ~ ' ~ 5.00 - '1''.3 - - _ _ _ 1200. GOVERNMENT RECORDING AND TRANSFER CHARGES - _ ~~1 Re ordir~ Fees Deed S 62.00 hlor'aaae $ Release 5 ~ 82,00 C~2 (,i~_ocn y axl~_a~s- _re a 51195.00 p,lor.oaae S _ 1 295.00 ~ - 1~03- S1a,e Tax,I=_!am;s ___ Deed 51 295.00 IJor.oaae S -------- -- - 4 1 295.00 t[u4 G,1sraaoe~ -----=CE'd _ - 1J5. ".lortsaae sa s'action Deed S ^.1cr,;aae S _ Release X0.50 i F 50 50 _ _ 1300 ADDITIONAL SET_T_LEME__NT CHARGES - -- 1:101 4th Otr Sewer/Reruse to Hampden Township Sewer Authorit ~ -~ y __ ' ' 165.02 ~ ~:' 2 2C10_Cty Two ex_ c fdlchael Langan~Treasurer I Lr 3 2C~0 11 S ~~u Tax _ hllchael Langan Treasurer ~- 387.69 , _ t i0c Coen r rces _ _ c Cornerstone Land Transfer Agent for FNTIC i _ 1 519.09 _ ~3;.~ cscrow;r n o' _s!a e T_axes_. _to Cornerstone Land Transfer Agent f or FNTIC ~ _ - ~ 30.00 _ __ __ I `:~0 ^ Ater Pennsylvania Arnerican Water ~ 8 741.25 _ I I ;37 rc,v_ n_ ~o _ Co nerstone Land Transfer Agent for FNTIC 79.76_ _ _ - I 67 774.25 ' r __ _j400. TOTAL SETTLEMENT_CHARGES -~erteron',i s ^C3 Se 'or„and 5C2 Sec;icn ~~ -- ---- _- --- - - ____ 2 492.37 , 89 372 56_ ~~.UD :.ERTIFIC A'ION OF BUYER AND SEL~_ER . I I'nV ! '~y .v the rJ0 I '. o •he ~¢ yY y~ C bel p~, i5 a I'U¢ ar.p 'oC ~ 7~ t( Ihul ~e uc( v~ n coFV ois'ne nU.. 1 Se . em¢ ~ $I~I¢menl a P S -,.e,T E't; 0~ al ~B ~ anC C Sn~rse'n¢nis II IrJn - I/ l~u^ `\f Y a mdtl2 en rt~ C'CU'ni r \ t -- ~ ~ I- sr re ~-n~¢ --- ~ - _ 1h l+~NIN IT 5 A CI' '1 Knr J('Ly Mt K Et. '- - Er -h ''O TNr- Tne h1UD 1 Sei;l¢me~' S:a'e^/~enl wn,-n 1 na ~e p, ec s a •r ie antl accu•ar¢ a~co~n• o~ •n s llVlr SiSlE50~T~.S Rn`v Srfl 2H ~DR1 IA„' SD DK ^r N'J~C"Oh e~5p r.~[I~i~/!~e al,. tls_ etlsbursetl !.n^. IrJrL UC~A~ EFr ~.s ~a1S rN K ~.p ~_, q~..,S S~E ~.LE '.6 ~ ~ wln ms sale nI U S I,ODr. SECTq h t.,J r•.:; ~. ~ .,\ ~ ~ cor..axe /~e //D a O ~ ~ N O ~ ~ ~ C > Q r- o ~ ~~ 0 0~ N N N r- ~ ~ ~ _ ~ '~ O ~ Y ~ Qpyl' ~ ~ C C_ C •` W .` a ~ ~ ~ ~ LL d I~'; y~ ~i a; c ~ - --- p Ci ~ p! Z m~ i~ !~ ~~ d 7 ~ ~ N ~ d C 'O O iN ~~69 V a 0 H O W p C ~Im 0 m (0 d a N o ~ ~ c ~ C O.O ~ N ~' ~ 'O ~N j~ O T.~ ~ ~ a ooZ's Z ~ ~ X ~n~c~ L ~ U ~ O = O C C w ~ O O N L y "O i ~ a N O Z C O O ~ N~«-w _ 2 a ~ 0 2 ~ N ... ~ ~ ~,~,0 o ~'~ a°- m~~~m mac X~ C O O X f0 .t_N ~ ~ ~ U ~ M O 'O X •~~~ ~ W ~nWN~'~ co .- -p Q a w ~~ c 3 oZ•~ c`a~ ~ ~ ~ o ai ~ ~rn.~ ~ w ~~^,~~ > • ~°' ~~ ~ ~, 7 C ~ O C W ~ f6 .O m -O?~-'= W .L ~ ~ = W N (0 (0 C O c9 ` c0 L(") U in o O 0 b~9 ~ ~ c c"- ~ 3"'~~ ~ O -~•~~ ~ ~ m y m W O C N `~ X c U ~ 3 3W ca • OWLLI `o ~ O W W ~ ~ O O ~ ~ N N d.N O f0 Y ~~~U <n Q fn (n N N ~mm3 ~' O ~ ~~~~ O ::. (0 Q~ ~ a u, . .~ Sent: Friday, February 04, 2011 10:08 AM To: George Douglas Cc: James Hughes; Tammy Siegrist Subject: RE: Kayser Estate and Nutri innovations George: I just faxed to you documentation on the equity ownership issues that you requested. There are only two current membership interests in Nutri-Innovations 1. 13 Below Inc. [ 5%] 2. James F. Beck [95%] There are no other equity interests. None was offered to Jean. Jim Beck Nutri-Innovations LLC Subject: Kayser Estate and Nutri innovations Date: Thu, 3 Feb 2011 17:29:14 -0500 From: GDouglas@salzmannhughes.com To: foragefan@hotmail.com CC: ]Hughes@salzmannhughes.com; TSiegrist@salzmannhughes.com I am working on the inheritance tax filing for the Commonwealth of Pennsylvania and I am required to show whether or not Jane was a member of Nutri-Innovations, LLC. I have reviewed the Certificate of Organization and the By Laws but they don't give a listing of the members. Please forward me something that would show who the members are and their ownership interest. This is why I requested the stock register and certificates because they should help us answer the question I need to answer in the very near future. Thanks, George 2/4/2011 PRaNnssoR~x NaTE A,MOtJNT QF NOTE: $_25,000,00 DATE: 5/1/I O_ FOR VALLTI; RECEIVER, the undersigned, NUTRI-INNQVATIQNS, a MN ~ONiPANY, having its principal place of business at 2241 Kallie Court, Stillwater, MN. 55082 (Obligor),promises to pay to JEAN' K,AYSEII; (Obligee),residing at 3536 Countryside Lane, Camp Hill, PA 17011., yr such other place as he or she may designate, the sum of _Twenty-five Thousand Dollars * ~` * * *(~ 25,000.00 }* * * * *DOI.L.AIZ5, together with interest at EIGHT (8 %) Percent Per Annum, DUE AND PAYABLE _JAN l., ZOII. (1) NUTRI-INNQVATI4NS shall have the right, without premium or penalty, to prepay all or any part of the unpaid balance and, in the event that such prepayment shall not satisfy the balance in full, Obligor will continue to pay interest at EIGHT {8 %) PERCENT per annum on the tmpaid balance. (2) Isi the event of default by NUTRI-INNQVATIQNS, the principal sum shall bear interest at the rate of EIGHT (8%) PERCENT per annum unXil tloe entire principal balance has been paid and. satisfied in fitll. (3) The holder of this Pxomissory Note, in any elTart action or proceeding to enforce the covenants set fox the therein, ox in any action for collection shall be entitled to reasonable attorneys' fees calculated any an }aourly basis. far actual time expended in all respects in enforcing rights conferred by dais $or-d of Note, including (without limitation thereto) client consultations, research, draftsmanship, travel and appearance time, in addition to all casts, disbursements and allowances otherwise provided by law. The undersigned waives presentment}notice of dishonor and protest. STILLWATER, MINNESOTA NCJTRI->LNNNdVATIONS BY: -- - - ~.' STATE OF N1I?VNESOTA On the 1('~day of,u~~ 2010 befoze ime, the undersigned, personally appeared JAMES F. SEC:K, perso~~ally known to me or proved to me on the basis of satisfactory evidence to be the individual whose namo is subscribed to the ruitl~.in instrument and acknowledged to xne that he executed tine same in: his capacity, and that by lvs signatwe o.n the instrument, the individual, or the person - uponbehalf ofwhich the individual acted, executed the instrument. r~ /~ / ` ~,---- ~ _ ^iY,; 4.MY J P~IFER _ ~;. Notary Public ~-- ~.. Minnesota 1'JOlary ll 7C ` ` Commission Ex ices Jan. 31, 2012 PRQI•T1SSC)R~i' NOTE ,A,_MULINT OF NOTF_.:'!;_20,000.00 T~A,TF: 11/1/ltl FOR. VALUE RECEIVET?, tlio undersigned, NLiTRi-~1tiNQVATI4NS, a Mitt C'OMPANX, having its principal place of business at 2?41 Kallie Count, Sti.llwatez, MN. X5082 (obligor},promises to pay tv .TF,AN KAYSER (Ubl%gee),residixtg at 3536 Countryside Lane, Camp Hill, PA 17011. ur such other place as he oz st-e znay designate, the stun of_Tweaity Thousand D411ars ~'~***($ ZO,QQQ.QQ }*'~***pQLL,LiRS, together with interest at EIGHT (8 %) Percent Per Annum., pIjF ANA PAYABLE 1~ 3L1N , ZQ11. (1) `NCrTRL-INNOVATIONS shall have the night, w~itliout preniiuin or pcnal.ty, to prepay all or any part. of t}te utrpaid balance and, in the event that such prepay-iment shall not Satisfy the balance i.z~ fia11, Obligor will continue to pay interest at EIGH'T' ($ %} PERCENT per annum on the ulapaid balance. (2) 1n the event of default by NUI'liI-INNOVA.T.1C)NS, the pri_i~.cipal sum shall be~-u- interest at. the rate of FIGI~'1<' (8%) I*I;irCENT per annum until the entire principal balance has been. paid anal satisfied in fiill. () The kioldez of this Promissory Note, in anv e~art action oz pzoceediu1g to ~rtforce tl~e covenants set for the therein, or in. any action for collection shall be entitled to reasonable attorneys' fees calculated on an hourly b4sis for refuel time expended in all respects in enforcing rights conferred by this Bond of Nate, i_ncludir~g (w'~tbout Limitation thereto') client consultations, research., dz'sftsnlanship, travel and appearance time, in a.dditi~n to all costs, disbursements and allowances otherwise provided by law. The tuidersig~~ed waives presentment, notice cif dishoztur artd protest- STTL L,~'ATER. MTNNpSOTA NUTRI- . VATICINS BY: STATE Ok' MINNESOTA Ot~ tl~e~,tQ~ciay of ~\1a 2010 before rne, the iuldersi~ed, personally appeared .TA.lY~S F. BECK, personally kmow-n to me or proved tq ~e on the basis of satisfactory evidezzce to be the individual whose t~r3e is subscribed to the within instnuiient anal aclc1zowledged t.o me that l~.e e~,ecutecl the same in his cap:~city, and d.~at by his si~ature on the ixtstrun~ent, the individual, or the pezson tips ~n behalf of wbhick~ the individual acted, executed the instrument. _-_~ -. -~ - AMY J PElF~ER ,,~„ FJotary PuC!~c J~ ~,~~""'" ~ ~1 t~ainnasota ,otz3L~, Publi h1v Commissior Ez iresJan 31, 2012 ~~ Citizens Bank- December 24, 2010 Salzmann Hughes, P.C. Attorneys At Law Attn: George F Douglas III, Esq 354 Alexander Spring Road Suite 1 Carlisle PA 17015 Estate of Jean M Kayser Date of Death: Nov 17, 2010 SSN: 483-62-9955 Dear Sir/Madam: One Citizens Drive ROP112 Riverside, RI 02915 In accordance with your request, the attached information sheet has been provided in the above decedent's naive as of his/her date of death. For Installment Loans or Line of Credit accounts, contact our Loan Department at 1-800-708-6680. For all other inquiries, please call 1-877-579-2667 Sincerely, ~~~ ~ ~~~ I~~UC~ Kelli-Jean Pa' a Decedent Account Processing REF#: 474855 ~~ Citizens Bank Account Number 6100662748 Account Title Jean M Kayser Date Opened 11/19/2001 Account Type Checkin Principal Balance as of DOD $1364.04 Interest from Last Posting to DOD $ .00 Account Balance as of DOD $1364.04 YTD Interest to DOD $ .00 ~~ Citiaens Bank Account Number 6100662756 Account Title Jean M Kayser Date Opened 11/19/2001 Account Type Checking Principal Balance as of DOD $4285.19 Interest from Last Posting to DOD $ .00 Account Balance as of DOD $4285.19 YTD Interest to DOD $ .00 ~~ Citizens Bank Account Number 6100766985 Account Title Jean M Kayser Date Opened 7/1/1988 Account Type Checkin Principal Balance as of DOD $4867.58 Interest from Last Posting to DOD $ .00 Account Balance as of DOD $4867.58 YTD Interest to DOD $ .00 ~~ Citizens Bank l Account Number 6201608307 Account Title Jean M Kayser DBA Freckled Moose Fundraisin Date Opened 6/2/2005 Account Type Checking Principal Balance as of DOD $77631.67 _ Interest from Last Postin tg o DOD $ .00 Account Balance as of DOD $77631.67 YTD Interest to DOD $ .00 ~~ Citizens Bank Account Number 6213767294 Account Title Freckled Moose Fundraisin Date Opened 5/4/2009 Account T e Checkin Principal Balance as of DOD $661.11 Interest from Last Posting to DOD $ .00 Account Balance as of DOD $661.11 YTD Interest to DOD $83.15 ~:~~- ~" ~~1Tr~IC'HOVIA Wachovia Bank Balance Confirmarion Services P O Box 40028 Roanoke, VA 24022 December 24, 20 ] 0 SALZMANN HUGHES PC ** Reference lD: 323991 S SUBJECT: Verification / Confirmation of Account and Balance Information prrn7ded for: Customer: JEAN M KAYSER (SSN# XXX-XX-9955) Date of Death: November 17, 2010 Deposit Account Information Account Aooourrt Date of Death Tye Number Balance Average Balance Date Maturity Operxd Date Interest Accnied Rate Irien~t YTD Date Irfereat Paid Cloaod C11EC`KING XX?C2~'7{XXJ+4381 50.00 10/2?J2010 50.00 50.00 LEGAL. TITLE: JEAN KAYSER IRA 7{h'?{X7~7{k"}Dt7tiX4417 S25,330.92 10/22/2010 51.87 50.00 LEGAL TITLE: JEAN KAYSER Far Beneficiary Claim Form information, please call 1(866)786-4890. SAVINGS X3c"k?Oc~"a7c?s0242 S0.00 10/22J2010 50.00 $0.00 IF,GALTITLE: JEAN KAYSER Page 1 of 2 --. ., ~~~ ~, Reference ID: 323991 S ~~~r~'HOYI A. Ia'o Safe Depaait Box found fa custerrer. » Date of death tialance does not include scented interest. ~ if date of dcmth occum3 cut a weekend a a holiday, date of death balance does rot rrielude any transactiorn [hat were made dunng that tune period ~y r. ,~s.~.c~ Amy C'rraybill Servicenter Associate Phone:(~40)~63-7323 a8~ aB By accepting this information, the recipient theseoC represents and warrants b Wells Fargo Bank, N.A ("Wells Fago'~, that the recipient is authorized by the customer to receive lawfully this information The recipient agrees that it will rot disclose this information b arty third party, unless compelled b do so by ]eppl process, and that it will lawfully use this information The recipient acknowledges that Wells Fargo does not rep esen[ and warrant that the information is complete and accurate. The recipient further sclunwladgca that the inforation may not dixbse the entire relationship between antomer and Wells Fargo. The informaton is subject to change without rotice to the recipient The recipient agrees b indermnffy, deliend, and hold Wells Fargo harmless from and against arty claim resulting fran the disclosure and use of the inforrm~ion by the recipient a from the breach by the recipient of arty agreement, representation, or warranty contained herein Wachavia Bank and Wachovia Bank of Delaware aze divisions of Wells Fargo Bank, N.A Page 2 of 2 y~ Citiz~~ :. ti ~ ~ ~ ~~,,,, 711 Investme `:_ January 19. 201 I Salzman Hughes. P.C. Attn: Geargc F. Douglas III 354 Alexander Spring Rd, Suite J Carlisle, PA 1701 RE: Account Number L7C 1)03-19 Reeistration: Jean Kayser Dear Mr. Hughes: I am writing with regard to your recent request for the ^bo~~c refere nced account. Please extend our condolences to the family of N1rs. Kayser. In your letter you requested a x~aluc for the date of Mrs. Kayser's p assing, No~~em bcr 17, 2010. Please find that information in the follo~~~ing table: Fund;'L-quity position Number of Shares Shar e Price Value of Account Oppenheimer (.apita- 36.744 541.05 51,097.84 Appreciation ~~ (OPTFS) Oppenheimer Capital 33?93 S36.30 5845.53 Appreciation B (OTGB\) Oppenheimer Global Stratehic 473.896 54.30 53,037.7 Income A (OPSIX) Oppenheimer Global Strategic 283.816 54.31 51,223?4 Income B (OPSGX) lccumulated Value as of tio~ ember 17, 2010 55,'_04.36 This account eras opened on April 17, 3002 us a u~aditional IR:~ account. Martha Kayser, her mother, was named the beneficiary at that time. Our records hay c no reference [o her hu~ing any other accounts ~~ ith our firm. Please direct all correspondence to: CCOISC Alailstop :11CN210 PO Box 42021 Pro~~idence, RI 02940 Securities. Insurance ~~ ;! MS1310, Boston, MA (l~ ~ '~~ Pennsylvania. ~€ RBS , _, ~ '; State Street, .. , car; t: of se.. - ----~ .~ ,,s y~ Citizens 71~ Investment Services 725 Canton Street Norwood, MA 02062 I understand that it can be difficult to settle financial matters ~~-hen you experience a loss. We are here to help you. If you have any questions, please call us toll-free at 800-9-12-83 0, Option 4, Monday through Friday from 8:30 a. m. to 5:00 p.m., ET. ~'~'e ~~ ill be happy to assist you. ~ / "_" .~,, Tim Jacks Beneficiary Account Services Specialist Securities, Insurance and Investment Advisory Services offerer, t~~ ~ I, c` hu vc i•i~t ~ ~r, t ilizentil N a. aWRAitiz es Bank ofe Street, MS1310, Boston, MA 02109. (800) 942-8300. CCO Inveat~*~erit i ~~• ~~• r: .~., ~i i •_+ tiii. . Pennsylvania. ~ RBS _ _ __ _ _ __ _ -- --- ~ SCCL'r~t'eS and Ing~iranCB Prndurts are I d~JT ~: I Ir..i`~l ~kFl JVn' Sf ", i ~ ,-"~L ~1rJT(=~~% • P~1AY Ln ~E VAl Uf= --~ _ niter n nconciT . t,lrl INCI !~.1 I '.'r ~...~ r =1 ~ ~. ' l -•~r,ln is ,J1 q(,EN(;V ~~ ~T a~ Vdl'1P~U~!"Cl~ March 28, 2011 SALZMANN HUGHES, P.C. ATTN: GEORGE DOUGLAS 354 ALEXANDER SPRING ROAD CARLISLE, PA 17015 RE: Cargill Partnership Plan - 401(k) Plan Number: 091080 Dear Mr. Douglas: P0. Box 2900 Valley Forge, PA 19482-2900 www.vanguard.com Thank you for contacting Vanguard on March 24, 2011, regarding Jean Kayser's retirement account. As you requested, this letter is to confirm that as of the close of business on November 17, 2010, the date of her passing, the account balance was $268,135.49. The beneficiary listed on the account is Martha Kayser. If you have addi":ional questions, please call me at the Vanguard's Life Events Team telephone number 877-496-9472, extension 48067. I will be available Monday through Friday from 9:30 a.m. to 6 p.m., Eastern time and will be pleased to assist you. Sincerely, Jill Marie Kingsland Life Events Team Participant Services