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HomeMy WebLinkAbout08-22-11 (2)J 1505610140 REV-1500 EX (°'-'°' PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes Po Box 2sosol INHERITANCE TAX RETURN County Code Year File Number Harrisburg PA 17128-0601 RESIDENT DECEDENT 2 1 1 1 0 3 6 9 ENTER DECEDENT INFORMATI ON BELOW Social Security Number Date of Deat h MMDDYYYY Date of Birth MMDDYYYY 1 8 1 3 2 4 4 3 4 0 3 1 6 2 0 1 1 0 2 0 6 1 9 4 0 Decedent's Last Name Suffix Decedent's First Name MI B R I C K E R D O R O T H Y D (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 INAPPROPRIATE OVALS BELOW O 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death 4. Limited Estate ~ 4a. Future Interest Compromise (date of prior to 12-13-82) ~ 5. Federal Estate Tax Return Required QX 6. Decedent Died Testate (Attach Copy of Will) ~ death after 12-12-82) 7. Decedent Maintained a Living Trust A 0 8. Total Number of Safe Deposit Boxes 9 Liti ation Proceed R i ( ttach Copy of Trust) . g s ece ved ~ 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) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO Name : Daytime Telephone Number G E R A L D J S H E K L E T S K I E 7 1 7 7 7 4 7 4 3 5 REGIS~R OF WILLS tJS~ ONLY .-- ~: C~'~ - • -... First line of address ~~ ~ ~ ; 1 4 1 4 B R I D G E S T ,~ `~~ ~ { Second line of address ~ ~~ - ' j - P 0 B O X E ' ~ ~' ~ ~ f ~, City or Post Office State ZIP Code _ __ DtATE FILED ~ - "'t' N E W C U M B E R L A N D P A 1 7 0 7 0 `' Correspondent's a-mail address: g s h e k l e t s k i a s t o n e l a w• n e t 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. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIG TURE OF P~RSC~trl RESFjONSIBLE FOR FILING RETURN _ - __ BARRY J: HOCKL~Y 1B GLENVIEW CIRCLE DILLSBUR SIGNATU E~ C THAN Rr?PRE T ~~ PA 1701 _... DATE GERALD J• SHEKLETSKI, ESQ• 414 BRIDGEST•, NEW CUMBERLAND PA 17070 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 J Continuation of REV-1500 Inheritance Tax Return Resident Decedent DOROTHY D. BRICKER 21 11 0369 Decedent's Name Page 2 File Number Correspondents Name First line of address Second line of address City or Post Office Correspondent's a-mail address State ZIP Code Daytime Telephone Number 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, co ct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAT OF PERSON RESPONSIBL FO FI NG RETURN DATE ADDRESS DIANE M• HOCKLEY, 18 GLENVIEW CIRCLE DILLSBURG PA 17019 J 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: DOROTHY D• BRICKER 1 8 1 3 2 4 4 3 4 RECAPITULATION 1. Real Estate (Schedule A) ....................................... .... 1. 1 2 9 5 0 0. 0 0 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. 2 1 3 ? 4 , 1 1 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .... ... 6. 7. Inter-Vivos Transfers 8 Miscellaneous N n-Probate Property (Schedule G) ~ Separate Billing Requested .... ... 7. 3 2 3 9 5 , 6 8 8. Total Gross Assets (total Lines 1 through 7) ........................ ... 8. 1 8 3 2 6 9 , 7 9 9. Funeral Expenses and Administrative Costs (Schedule H) ............... ... 9. 3 3 1 6 2 . 0 1 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .......... ... 10. 6 3 3 8 . 6 0 11. Total Deductions (total Lines 9 and 10) ............................ ... 11. 3 9 5 0 0 . 6 1 12. Net Value of Estate (Line 8 minus Line 11) ......................... ... 12. 1 4 3 7 6 9 , 1 8 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. 1 4 3 7 6 9 . 1 8 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.o 0. 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .045 1 4 3 7 6 9. 1 8 1s. 6 4 6 9. 6 1 17. Amount of Line 14 taxable at sibling rate X .12 0 0 0 17. ~, 0 ~ 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 18. ~. ~ ~ 19. TAX DUE .... .............................................. .. 19. 6 4 6 9. 6 1 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT a Side 2 1505610240 1505610240 J REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME DOROTHY D• BRICKER - -- ___ STREET ADDRESS 2109 WENTWORTH DRIVE File Number 21 11 0369 CITY _ __ _ - __ ,_ __ _ ZIP CAMP HILL PATE i _ 17011 Tax Payments and Credits: 1 Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments ._ B. Discount 3. Interest Total Credits (A + g) (2) 0 • 0 0 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) 0.00 (5) 6,469.61 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 income of the property transferred : ............................ b. retain the right to designate who shall use the property transferred or its income; ......................... ...... ^ Q c. retain a reversionary interest; or .......................................................................................... ...... ^ 0 d. receive the promise for life of either payments, benefits or care? .................................................. ..... ^ Q 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receivin ade uate consideration . 9 4 ~ ................................................................... . 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .... ..... ^ X^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ............................................................................................. ..... 0 ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FI LE IT AS PA RT OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse 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 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)]. Asibling is defined, unde Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. (1) 6, 469.61 REV-1502 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: DOROTHY D• BRICKER 21 11 0369 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 that isjointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. NUMBER DESCRIPTION 1• ALL THAT CERTAIN PIECE OR PARCEL OF LAND SITUATE IN LOWER ALLEN TOWNSHIP, CUMBERLAND COUNTY, PENNSYLVANIA KNOWN AS 2109 WENTWORTH DRIVE, CAMP HILL, PENNSYLVANIA 17011• BEING THE SAME PREMISES WHICH MICHAEL E• KELLY, HUSBAND AND WIFE, BY DEED DATED AUGUST 24, 1995, AND RECORDED AUGUST 29, 1995, IN THE OFFICE OF THE RECORDED OF DEEDS OF CUMBERLAND COUNTY IN DEED BOOK ],27, PAGE 385, GRANTED AND CONVEYED UNTO LEE C• BRICKER AND DOROTHY D• BRICKER, HUSBAND AND WIFE. LEE C• BRICKER DIED JUNE 10, 2002, THUS BY OPERATION OF LAW VESTING TITLE IN DOROTHY D• BRICKER, DECEASED. THE PROPERTY WAS SOLD TO TERESA BRAVO AND VIDAL 0• BRAVO, HUSBAND AND WIFE, ON JUNE 2011• COPIES OF THE DEED AND SETTLEMENT STATEMENT ARE ATTACHED. TOTAL (Also enter on Line 1, Recaoitulation.l If more space is needed, use additional sheets of paper of the same size. SCHEDULE A REAL ESTATE VALUE AT DATE OF DEATH 129,500.00 29,500.00 REV-1508 EX + (6-98) SCHLD!/LE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & M~$C. INR SIDE TDECEDEN'fRN PERSONAL PROPERTY ESTATE OF FILE NUMBER DOROTHY D• BRICKER 21 11 0369 Include 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 NUMBER VALUE AT DATE DESCRIPTION OF DEATH ~. METRO BANK SAVINGS ACCOUNT NUMBER 616267432 5,953.1x_ 2• METRO BANK CHECKING ACCOUNT NUMBER 512089640 2,925.9- 3• 2004 SUBARU AUTOMOBILE, TITLE NUMBER 59305849001 BR, 12,495.00 VIN JF1SG63684H710347• KELLEY BLUE BOOK VALUE $12,495.OD TOTAL (Also enter on line 5 Recapitulation) I S 21 3 7 4 11 (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (UB-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER DOROTHY D• BRICKER 21 11 0369 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM DESCRIPTION OF PROPERTY --- NUMBER INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE THE DATE OF TRANSFER.ATTACHACOPYOFTHEDEEDFORREALESTATE. VALUE OF ASSET INTEREST (IFAPPLICABLE) VALUE 1. BANKERS LIFE AND CASUALTY COMPANY 32,395.68 100.00 32,395.68 ANNUITY CONTRACT NUMBER 7837893 TRANSFEREE-BRIAN A• HOCKLEY - SON TOTAL (Also enter on Line 7 Recapitulation) I$ 3 2, 3 9 5 6 8 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS - - __ ESTATE OF FILE NUMBER DOROTHY D• BRICKER 21 11 0369 Decedent's debts must be reported on Schedule 1. ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES: ~. AUER CREMATION SERVICES OF PENNSYLVANIA, INC• B ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Paid: State ZIP AMOUNT 1„821•r 2. AttomeyFees: STONE LAFAVER & SHEKLETSKI 12, 000.0 3. Family Exemption: (If decedents address is not the same as claimants, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: LETTERS TESTAMENTARY 323.5 5 Accountant Fees: 6. Tax Return Preparer Fees: ~. LEGAL ADVERTISING - CARLISLE SENTINEL 198.1 8• LEGAL ADVERTISING - CUMBERLAND LAW JOURNAL 75.0= 9• SHORT CERTIFICATES 20.01 10• CUMBERLAND FAMILY PRACTICE 1D•3' 11• LOWER ALLEN TOWNSHIP - SEWER AND TRASH 103.9_ 12• DIVERSIFIED APPRAISAL - HOUSE APPRAISAL 325.01 13• UGI UTILITIES 72.01 14• PENNSYLVANIA AMERICAN WATER COMPANY 122.4` 15• PPL ELECTRIC 214.1' 16• SEARS CREDIT CARD 300.01 1?• SEARS CREDIT CARD 100•DI 18• PAINTING REPAIR AND SUPPLIES 987.9 TOTAL (Also enter on Line 9, Recapitulation) 15 3 3 ,16 2 0 If more space is needed, use additional sheets of paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent DOROTHY D. BRICKER 21 11 0369 Decedent's Name Page 1 File Number Schedule H -Funeral Expenses & Administrative Costs - B7. ITEM NUMBER DESCRIPTION AMOUNT 19- ACE HARDWARE 20• EDWARD CAUDILL - ELECTRIC REPAIR 143.05 150.00 21• UGI UTILITIES 22• PENNSYLVANIA AMERICAN WATER 72.90 23• PPL ELECTRIC 32.07 24• NEW CUMBERLAND FD AMBULANCE 112.55 25• COMCAST 150.00 26• SUSQUEHANNA BANK - CHECK PRINTING FEE 119.12 22.58 27• ACE HARDWARE 28• MISCELLANEOUS HOUSE RELATED EXPENSES 14.36 181.32 29• B & R LOCKSMITH 30• SETTLEMENT CHARGES - SALE OF 2109 WENTWORTH DRIVE, 8D•00 12,759.73 CAMP HILL, PA $21,090.74• (LINE 520) LESS $243.16 (LINE 406) LESS $1,013.28 (LINE 4D9) LESS $ $35.87 (LINE 411) LESS $38.70 (LINE 412) LESS $ 7,000.00 (LINE 509) _ $ 12,759.73 31• SHEAFFER'S CARPET CLEANING 32• PPL ELECTRIC 159.00 33• PENNSYLVANIA AMERICAN WATER 1D•00 34- DIXON FAMILY HOME SERVICES - HOUSE REPAIRS 38.65 744.00 35• LIGHT FIXTURE REPAIR 36• UGI GAS BILL 133.76 37• KREAMER BROS. - WINDOW REPAIR 71.99 38• PPL ELECTRIC 374.65 39• DONEGAL INSURANCE - HOMEOWNER'S COVERAGE 122.55 198.50 40• LOWE'S - HOME REPAIR 41• LOWER ALLEN TOWNSHIP - SEWER AND TRASH 251.99 103.95 42• UGI GAS BILL 43• PENNSYLVANIA AMERICAN WATER 131.99 44• FILING FEE - INVENTORY AND INHERITANCE TAX RETURN 29.69 30.00 45• RESERVE FOR CLOSING EXPENSES 250.00 SUBTOTAL SCHEDULE H•B7 ~ 16 , 4 8 8. 4 0 REV-1512 EX+ (~2-OS) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ~ tStA~t OF FILE NUMBER DOROTHY D• BRICKER 21 11 0369 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH ~. JC PENNEY CREDIT CARD ACCOUNT NUMBER 34721914141 486.60 2• BOSCOV'S CREDIT CARD ACCOUNT NUMBER 0000-0001-1445-1010 1,467.60 3• CITIBANK SEARS CREDIT CARD CREDIT CARD ACCOUNT NUMBER 350.00 XXXXXXXXXXXX6252 4• SEARS GOLD MASTERCARD ACCOUNT NUMBER *******~*~*0263 4,034.40 TOTAL (Also enter on Line 10, Recapitulation) I$ 6 3 3 8 6 0 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (Ot-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: DOROTHY D• BRICKER NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).) 1. BRIAN A• HOCKLEY 18 GLENVIEW CIRCLE DILLSBURG, PA 17019 FILE NUMBER: 21 11 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Lineal 0369 AMOUNT OR SHARE OF ESTATE 1,43,769.18 CENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV 1500 COVER SHEET AS APPROPRIATE II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART li -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I S If more space Is needed, use additional sheets of paper of the same size. ' I F~'~("~-.'4'~>:f''.,'r~L•q',gP.fCN.EF,UOF.~7CHY 2 :'Cll.wpd _ _. c LAST WILL AND TESTAMENT OF DOROTHY D. BRICKER I, DOROTHY D. BRICKER, of Lower Allen Township, Cumberland County, Pennsylvania, declare this to be my last will and revoke any will previously made by me. ITEM I: I direct that my Executrix hereinafter named shall pay all my just debts and funeral expenses as soon as conveniently may be done after my decease from the residue of my estate. ITEM II: I devise and bequeath the residue of my estate, of every nature and wherever situate, to the Trustees hereinafter named, IN TRUST, for my son, BRIAN A. HOCKLEY, to hold, manage, invest and reinvest the share so received, and the accumulation of income thereon. The Trustees shall distribute so much of the income and the principal. of the trust as the Trustees shall in the their sole and absolute discretion deem advisable for the support of my son, BRIAN A. HOCKLEY, after taking into account all other available resources and sources of income including entitlement to government benefits such as Supplemental Security Income, Medical Assistance, General Assistance, AFDC, Food Stamps, Mental~Health/Mental Retardation Services,' Children and Youth Services, Vocational Rehabilitation Services, Attendant Care, or any other type of government benefit or services. It is my intent that this Page 1 of 5 trust shall supplement and not supplant otherwise available government benefits. Upon the death of my son, BRIAN A. HOCKLEY, or in the event that my son, BRIAN A. HOCKLEY, predeceases me, the then remaining principal and accumulated income held in Trust, or all of my estate of every nature and wherever situate, shall be distributed to my son, BARRY J. HOCKLEY, and his wife, DIANE M. HOCKLEY, or the survivor of them. ITEM III: I appoint my son, BARRY J. HOCKLEY, and his wife, DIANE M. HOCKLEY, Trustees of any trust created under this my Last Will and Testament. Should both BARRY J. HOCKLEY and DIANE M. HOCKLEY fail to qualify or cease to act at Trustee, I appoint my son, GARRY LYNN HOCKLEY, successor Trustee. My Trustees shall be entitled to receive reasonable compensation for the performance of their functions hereunder. ITEM IV: Should the principal of the Trust created herein provided for be or become too small in Trustees discretion so as to make, establishment, or continuance of the Trust inadvisable, my Trustee or my personal representative may make immediate distribution of the then remaining principal and any accumulated or undistributed income outright to the person or persons and in the proportion they are then entitled to income. Upon such termination, the rights of all persons who might otherwise have an interest as succeeding income beneficiary or in remainder shall cease. Page 2 of 5 ITEM V: The interests of the beneficiaries hereunder shall not be subject to anticipation or to voluntary or involuntary alienation. ITEM VI: I nominate, constitute and appoint my son, BARRY J. HOCKLEY, and his wife, DIANE M. HOCKLEY, Guardians of the person of my son, BRIAN A. HOCKLEY. Should BARRY J. HOCKLEY and DIANE M. HOCKLEY fail to qualify or cease to act as Guardian, I nominate, constitute and appoint my son, GARRY LYNN HOCKLEY, successor guardian. ITEM VII: I appoint my son, BARRY J. HOCKLEY, and his wife, DIANE M. HOCKLEY, Co-Executors of this my last will. Should my son, BARRY J. HOCKLEY, and his wife, DIANE M. HOCKLEY, fail to qualify or cease to act as Executor, I appoint my son, GARRY LYNN HOCKLEY, successor Executor. ITEM VIII: I direct that my Executrix, Guardian, Trustee or their successors shall not be required to give bond for the faithful performance of their duties in any jurisdiction. ITEM IX. I have made no provision in this my Last Will for my other children as I do not, wish them to receive any share of my estate. IN WITNESS WHEREOF, I, DOROTHY D. BRICKER, have hereunto set my hand and seal this ~ day of 2011, _ f/ J DOROTHY D. ICKER Page 3 of 5 SIGNED, SEALED, PUBLISHED and DECLARED by DOROTHY D. BRICKER, the Testatrix above named, as and for her Last Will and Testament, and in the presence of us, who at her request, in her presence and in the presence of each other, have subscribed our names as witnesses. 414 Bridge St New Cumberland PA Witness Address 414 Brid a St. New Cumberland PA Wi ess Address COMMONWEALTH OF PENNSYLVANIA: SS: COUNTY OF CUMBERLAND I, DOROTHY D. BRICKER, the 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 this 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 contained. DOROTHY D. BRICKER Sworn to or affirmed to alln\\d acknowled ed before me by DOROTHY D. BRICKER, the Testatrix, this v~- day of 2011. Notary Pu lic COMMONWEALTH OF PENNSYLVANIA NOT S CAROL L. TROXELL, Notary PubiiCC Page 4 of 5 New Cumberland Boro. Cumbe~tand Co. MKCorr~i~~i4. __ COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ~ SS: and ~ ,~ the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, depose and say that we were present and saw Testatrix sign and execute the instrument as her last will; that Testatrix 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; that to the best of our knowledge, the Testatrix was at that time eighteen or more years of age, of sound mind and under no constraint or undue influence. /~'~Sworn to or (a"~ffir/med to//and nowledged before me by ~-"~Cc ~ h/ `./`CGI~L~/L / and ~ witnesses, this ~~, .1~ _ day ofv~S~,. 2011. ~~ ZH pF PENNSYLVANIA COMMONW~~ ~ Nary Pty ~ Notary Publ i c ~ ~~~p~~Z013 Pa e ~ ~misslon g 5 o f 5 Z:~RE~DED1Bricker.Uorothy - 2109 Wentworth Drive.wpd Tax Parcel #: 13-23-0549-183 Address: 2109 Wentworth Drive Camp Hill, PA 17011 DEED THIS INDENTURE made the a~ day of Jul,, , in the year 2011, between BARRY J. HOCKLEY and DIANE M. HOCKLEY, Co-Executors of the Last Will and Testament of DOROTHY D. BRICKER, late of Lower Allen Township, County of Cumberland, and Commonwealth of Pennsylvania, of the first part, hereinafter called the Grantor, -AND- TERESA BRAVO and VIDAL O. BRAVO, daughter and father, joint tenants with rights of survivorship, hereinafter called the Grantees; WHEREAS, the said DOROTHY D. BRICKER became in her lifetime seised, as of fee, of and in a certain tract of land, together with the improvements thereon erected, situate in Lower Allen Township, County of Cumberland, and Commonwealth of Pennsylvania, and more particularly described hereinafter; and being so thereof seised, died on March 16, 2011, having first made her Last Will and Testament in writing dated February 10, 2011, duly probated and registered in the Office of the Register of Wills of Cumberland County on March 22, 2011, wherein and whereby she appointed as Co-Executors, the said BARRY J. HOCKLEY and DIANE M. HOCKLEY, to whom Letters Testamentary were duly issued by said Register of Wills on March 22, 2011, wherein and whereby said premises hereinafter described were not specifically devised, all as in and by said Will and the records of said Register of Wills, recourse thereunto being had, appears: NOW THIS INDENTURE WITNESSETH, that the said Grantor, for and in consideration of the sum of ONE HUNDRED TWENTY-NINE THOUSAND FIVE HUNDRED and NO/100--------------- ($129,500.00)------------- Dollars, which has been paid to them by the said Grantees at or before the sealing and delivery hereof, receipt whereof is hereby acknowledged, has granted, bargained, sold, aliened, released and confirmed, and by these presents does grant, bargain, sell, alien, release and confirm unto the said Grantees, ALL THAT CERTAIN piece or parcel of land situate in Lower Allen Township, Cumberland County, Pennsylvania, bounded and described in accordance with a survey and plan thereof, prepared by D. P. Raffensperger, Registered Surveyor, Camp Hill, Pennsylvania, dated May 15, 1962, as follows: BEGINNING at a point on the southern line of Wentworth Drive, said point being five hundred sixty (560) feet in a westerly direction from the western property line of Lisburn Road (Route 21023) produced on the western line of Lot No.9 on the hereinafter mentioned Plan of Lots; thence South sixteen (16) degrees thirty (30) minutes East, one hundred sixty (160) feet to a point on the line of lands now or late of Joseph Fagan; thence along said lands, South seventy-three (73) degrees thirty (30) minutes West, sixty (60) feet to a point on the eastern line of Lot No. 11; thence along the eastern line of Lot No. 11, North sixteen (16) degrees thirty (30) minutes West, one hundred sixty (160) feet to a point on the southern line of Wentworth Drive; thence along the southern line of Wentworth Drive, North seventy-three (73) degrees thirty (30) minutes East, sixty (60) feet to a point, the Place of BEGINNING. -1- BEING Lot No. 10 of Addition No. 2 of "Highland Estates", recorded in Plan Book 5, Page 51. HAVING THEREON ERECTED a one story frame dwelling known as 2109 Wentworth Drive, Camp Hill, Pennsylvania. BEING the same premises which Michael E. Kelly and Mary Lou Kelly, husband and wife, by Deed dated August 24, 1995, and recorded August 29, 1995, in the Office of the Recorder of Deeds of Cumberland County in Deed Book 127, Page 385, granted and conveyed unto LEE C. BRICKER and DOROTHY D. BRICKER, husband and wife. Lee C. Bricker died on June 10, 2002, thus by operation of law vesting title in Dorothy D. Bricker, deceased. TOGETHER with all and singulaz the buildings, improvements wa ys, streets, alleys, passages, waters, water-courses, rights, liberties, privileges, hereditaments and appurtenances whatsoever, thereunto belonging or in any wise appertaining and the reversions and remainders, rents, issues and profits thereof, and all the estate, right, title, interest, property, claim and demand whatsoever of her, the said DOROTHY D. BRICKER, at and immediately before the time of her decease, in law, equity, or otherwise howsoever, of, in, to or out of the same. TO HAVE AND TO HOLD the said lot or piece of ground above described, with the buildings and improvements thereon erected, hereditaments and premises hereby granted or mentioned, and intended so to be, with the appurtenances unto the said Grantees, to and for the only proper use and behoof of the said Grantees, forever. AND the said Grantor, for herself and her respective heirs, executors and administrators, does covenant, promise and agree to and with the said Grantees, their heirs and assigns, that they, the said Grantor, has not heretofore done or committed any act, matter or thing whatsoever whereby the premises hereby granted, or any part thereof, is, are, shall or may be impeached, chazged, or encumbered in title, charge, estate or otherwise howsoever. -2- IN WITNESS WHEREOF, the said Grantor has hereunto set her hand and seal the day and year first ah~ve written Witness Witness >jAl~flt~ J. HOCi~y, Co-Executor of the Last Will. anrl.Testsiment Of nnRnTHY n. RRTC'KRR '~~ ~ . /"~0 (SEAL DIANE M. HOCKLEY, Co-Exe for of the Last ) Will and Testament of DOROTHY D. BRICKER COMMONWEALTH OF PENNSYLVANIA COUNTY OF ~~~t'IG,~ ~ SS: kh On this, the a~ day of ~~~_ , 2011, before me a Notary Public, the undersigned officer, personally appeared BARRY J. HOCI{LEy and DIAL M HOCKLEY, Co-Executors of the Last Will and Testament of DOROTHY D. BRICKER, known to me or satisfactorily proven to be the persons whose names are subscribed to the within instrument, and acknowledged that they executed the same for the purposes therein contained IN WTl'NESS WHEREOF, I have hereto set my hand and notarial seal. COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL JENNIFER A. MEARKLE, Notary Public Notary Public New Cumberland Boro. Cumberland Co. My Commission Expires Ju 1, 2012 I hereby certify that the precise address of the Grantees is DATE: Attorney for -3- * -IIIiIII W~'`o OMII Approval PJo. 2502-0265 I~~II~~I a, A. Settlement Statement (HUD-1) Fq~ ~,. I .~ FHA 2.^RHS 3. ^Conv. Unins 6 File Number . 4 ~VA 5 ^C . BR 7. Loan Number 8. Mortgage Insurance Case Number . . onv. Ins. AVO HE1106000000016 446-0821833 C. NOTE: This forth is famished to give you a statement of actual settlement costs. Amounts paid to and b th ttl I " " y e se tems marked ement agent are shown. (p.o.e.) were paid outside the closing; they are shown here for informational purposes and are not included in the totals . D. NAME OF BORROWER: Teresa Bravo and Vidal O. Bravo ADDRESS OF BORROWER: 4541 Sequoia Drive, Apt. A254, Harrisburg, PA 17109-6413 E. NAME OF SELLER: Estate of Dorothy D. Bricker ADDRESS OF SELLER: c/o Stone LaFaver & Shekletski, PO Box E, New Cumberland PA 17070-0180 , F. NAME OF LENDER: Mortgage America, Inc. ADDRESS OF LENDER: 20 Linden Road, Hershey, PA 17033 G. PROPERTY 2109 Wentworth Drive LOCATION: Camp Hill, PA 1 701 1-7450 H. SETTLEMENT AGENT: NICHOLAS LAW OFFICES P.C , . PH# (717) 540-7746 2215 FOREST HILLS DRIVE, SUITE 37, HARRISBURG PA 17112-]099 , PLACE OF SETTLEMENT: 2215 FOREST HILLS DRIVE, SUITE 37, HARRISBURG, PA 17112-]099 ,~.,t,, ...., 0 ~- : - ,_. - 1 r I 1 . 0 1 I I _-~2 0. 0 1 I m a rr r I' e 4 4 1 4 Ad ustments for items aid b seller in advance Ad'ustments for items aid b seller in advance 1 6 / t / 24 .1 4 / 4 4 108. e m n s o 10 . chool Tax /26/2011 0 /3 /2012 1 013 28 408. As ssmen to 4 h 1 . 7/ / 11 t / /2 1 l 01 28 4 . 1 w r //] / 1 7 4 / t / 112. Trash 7/26/2011 to 9/30/2 11 38.70 412. Trash 7/26/2011 to 9/30/2011 8 38.70 120.Gross Amount Due from Borrower 137,626.27 420.Gross Amount Due To Seller ;ZOO.Aitiountll old`b":ot~`~a''$e~lf`o7~o`°>ircr'~t•~': `' r. r=~~-~ r ~•;:,' ,' , •~ ~.~. OO.Relluctlo i inA t 1 "Ile 130,831.01 . 201. a st m ne 0 N, o . paoaa ' ?uato . a 1 x e o' a in i ~: ~ ` ` '"~~~ 20 E 'tin Ian en ub'ect to 204. 0 Exi tin I en sub'ect t 4 Pa ff r t m a e o n 205. 5 ff fs o d rt a e oan 206 . 506 07. . 0 208. 209 : 5 7 . 50 209a . 50 209b 'Adjutttme tsf Ier ~^ :Q 5 b _ 2] i / wn es t ~ to d.'~ys q • ' ;;t.' o i / wn to es t 211 o n tax s tO 212 As essm n s to 11. Co n taxes to ~1 51 a ments t 214 . to 215, 514. to 216. 5 21 16. 17 21 219. to 518. to 519 220.Total Amounts Paid . to b or in Behalf of Borrower 134,499.00 520. Total Reductions in 300 G'ab ot.Se~em#euT~lb bower.`... ,: ~:„: y Amount Due Seller TI lf~ern~ ~i"]f inS l r ~:~ ~ 21,090.74 301 Gross amount due from borrower line 120 137 626.27 a ro le -.:.~! 601.Gross amount due to seller line 420 J ~ '` 302.Less amounts std b /for b orrower line 220 134 499.00 602.Less reductions m amo t d l 130 831.01 un ue se ler line 520 21 090.74 303.Cash X~From ^To Borrower 3,127.27 603.Cash X~To From S ll e er 109,740.27 Previous editions are obsolete Page 1 of 3 02009 Dis la S stems, Inc. R63 763-5555 - p Y Y t ) l.aserGenerated HUD-I U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT PAGE 2 7 . ' + id Fro Division of Commica;nn r1i e 700) c fnllnwc• ~3 a m ~r. r ~ 3 ~id Erom . ' ~ orrower'ct~ nd ~ '' ~` ,,,,, ller a ` ' 702. t mi n i lmn u -~ s At c;; .< ' ands At ' ~ 704. Broker's Service Fee -~3 to Keller Williams of Central PA East 285.00 68 .":. terns, ' ab e' n' onnect on W tIC .- ao .. - h ;~ *~ .,, ._: , .. ,, a :,.: .-.. ~;,.... ,, , 1 r in e S (from GFE # 1) 8 2. Your credit or char a oints for the s ecific interest rate chosrn $ from GFE #2 (from GFE #A) t from GFE #3 t (from GFE #3) t (from GFE #3) --_~4 (from GFE #3) from GFE #3 ~$ - Re-Ins ection Fee if needed t from GFE #3 O:Items, aired ~ `Lender To:.; a elttrAdVaace ,,, ~ ,.,.. ., , ., a ;,,;,; .r..yr -, .;;~;. Dail interest ch es from to from GFE # ] 0) a r mi m r from E 3 m wn r' I nc for (fromGFE#Il) 4 4 - .:Reserves ;;De s ted rWith ten er . , ; ., .; -u . ,.. - , _,.,; • -,... :~ .- ,~* -:.., 4 , _ :r+, . ~ --.,ti ,, . . 1 1. t l r Cr w CC n (from GFE #9) ' om n n g a ce - 1005. Annual as a sments 3 7 - 1008. S - 1009. -S 171.42 1 . 7Ytle'rCba es _ , v., .:., ~ ,~~a. t:' .~ i =`,.t-r , tY,;;;R~ ";,?;. ;.„r -, Title services and lender's title insurance from GFE #4 x~ rn 2 s (from GFE #5) ll 4 0 d e li ' it 1 A ent's rtion of the total title insurance remium S - 1108. Underwriter's rtion of the total title insurance remium S -- 1109. to 1110. Closin Svc Letter to Stewart Title Guarart Com an 75 00 . 1111. to 18 00 . 1112. to 1113. to `:1200.`Governm~nt Recbrdin ti1'hcT~Fanster'9Ch6` es -. ~. • ~* - ; a' maw ~ t~h:' 1201. Government recordin char es from GFE #7 1202. _ _ 1203. Transfer taxes (from GFE #8) 1204 1 . _ _ 1205. _ _ - 1206. 1207, to 'I300;-rldditional ~Settletb '"U'~ba ' '°` _ 1301. GFE #6) ~~ (from 1302. S 1303. ~ 1304. 1305. tp le.oc sazs.ooa~rn> 1306. 1307. t [P.o.c. ssst.~7 s~nnl 1308. ---~' 1309. 6,795.26 6,7)0.74 I have carefully reviewed the HUD - 1 Settlement Statement and to the besRt of y knlow edge and belief, it is a true and accurate statement of all ~eceipt~ and disbursements made on my account or by me in this transaction. I further certify that 1 have received a copy of the HUD - 1 Settlement Statement. Estate of Doroth r Teresa~ravo _ Borrower By- ~`-~~~~~~~~9--R Se~r v~dal O. Bravo V V Diane M. Hockley, Executor -- Seller The HUD-I Settlement Statemen hich ]have prepazed is a true and accurate account of this transaction. 1 have caused the funds to be disbursed in accord- ance with this statement. / ^ NICHOLAS LAW OFFICES, P. C. --~_~~' settlement Agent 7/26/201 l WARNING: It is a crime to knowingly make false statements to [he United Slates on this or any other similar form. Penalties upon conviction can i Dlude a fine and imprisonment. For details see: Title 18 U. S. Code Section 1001 and Section 1010. Page 2 of 3 13RA~'O Ctim `artson of Goon F it6 Estltftate. GFE) agil HUb=1C31ta es °w> . , GoodFeit6 stimate ' ` ~~ ~ Charges That Cannot Increase HUD-1 Line Number O i i i h _ : - : ur or g nat on c arge #801 - Your creditor charge (points) for the specific interest rate chosen #802 444.00 444.00 - Your adjusted origination charges #803 - Transfer taxes #1203 444.00 444.00 1 295.00 l 295.00 ?~..nA est ~•ILAttn'; otel:Gentiot lrlel'Cii'e31'IO°,•~ ap"i~~°.f. ~.~ ~, +r.,'~ev~~ ti a u =xi40 Alth T, ~.:; j( `~ . Government recording charges #1201 e ] y, A sisal Fee #804 180_00 136.00 Credit re rt #805 425.00 375.00 Flood certification # 07 58.00 89.00 Mortgage Insurance Premium for #902 18.00 18.00 _ 1.249 50 1249.50 1 930 50 1 867 50 $ (63.001 °r _4 7F'ta °/ ~ ` EST 'v~, A l~ ~ :, r:; +r •-a+",`~ +,~ ~ it ~~_. Initial deposit for your escrow account # 1001 Daily interest charges #901 $ 2 07762 320.84 14.6944 /day 73 47 Homeowner's insurance #903 88.17 600.00 401.00 Title services and lender's title insurance # 1101 1 353.00 1 276.75 Owner's title insurance # 1103 20.00 Laan Terms Your Initial loan amount is $ 126 199.00 Your Loan trnn is 30.00 Years Your initial interest rate is 4.25 Your initial monthly amount owed for principal, interest, and $ i l any mortgage insurance is nc udes 739.65 ®Principal ® Interest ® Mortgage Insurance Can your interest rate rise? ®No. ^ Yes it can rise to a maximu f , m o %. The first change will be on and can change again every after . Every change date, your interest rate can increase or decrease by %. Over the life of the loan, your interest rate is guaranteed to never be Even if you make payments on time, can your loan balance rise? lower than % or higher than %. ®No. ^ Yes, it can rise to a maximum of $ Even if you make payments on time, can your monthly ®No. ^ Yes the first increase can be on amount owed for principal, interest, and mortgage insurance rise? , and the monthly amount owed can rise to $ The maximum it can ever rise to is $ Dces your loan have a prepayment penalty? ®No - ^Yes, your maximum pre ayment penalty is $ Dces your loan have a balloon payment? ®No. ^ Yes you have a balloon a ment f $ , p y o due in years on Total monthly amount owed including escrow account payments - ^ You do not have a monthl escro f y w payment or items, such as property taxes and homeowner's insurance. You must pay these items directly yourself. ~1 You have an additional monthly escrow payment of $ 160.42 that results in a total initial monthly amount owed of $ 900.07 .This includes principal, interest, any mortgage insurance and any items checked below: ®Property taxes ®Homeowner's insurance ^Flood insurance ®City Property Tax ®School Tax ^ NOteaf you have anv nurctinnc °t,.,,,r rt.e ce»~,~.._. n - - ------ --••-•e-~ ~•~~ ~~a„ .~~~~~, n,rcu on tms rorm, please contact your lender. Previous editions are obsolete File: BRAVO Page 3 of 3 02009 Display Systems, Inc (663) 763-3335 -Laser Generated HUD- I 'METRO BANK 3801 Paxton Street Harrisburg • PA • 17111 mymetrobank.com 888.937.0004 March 24, 2011 Stone LaFaver 8~ Skekletski 414 Bridge Street Post Office Box E New Cumberland, PA 17070 RE: Estate of: Dorothy D Bricker Tax Identification Number: 181-32-4434 Date of Death: March 16, 2011 To Whom It May Concern: This letter is in reference to decedent account information you requested for the individual listed above.We are able to provide the following: Account Type: Savings Account Number: 616267432 Date Opened: 08/28/2001 Primary Owner: Dorothy Bricker Date of Death Balance: $5953.18 Account Type: Checking Account Number: 512089640 Date Opened: 10/19/1995 Primary Owner: Dorothy Bricker Date of Death Balance: $2925.93 Please feel free to contact me at (717) 412-6126 if I may be of further assistance. erely, ~----- ~ , t 1 ~. 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CITY 9TATE ZR! FINANaAI INSrryVTiON NUMBER ~'*' indi"~'b ""'h' '"M woxaus~ k. c,.rew. a ne. n or ,y„p~ y~,~ 2ND UEN DATE: . a 10~^~+. ~4W b pr eM,uannc...ne aM Mpr w.m w~ Mn ~ •' IF NQ UEt~ CHECK 2N0 UENNOLDER staun:rre ov wwuc~„r on Au*noarzeo siar~ea STREET CITY - STATE yp s~NAnme ~ c4AVnUCANr~rr~~ ~ wT"~ FINANCIAL IN -----~ .. ~0 R 8'RTUTIQfy NUMBER (TYPE OR PRINT) Certificate of Title must be submitted within 20 days, unless the purchaser is a registered dealer holding the vehicle for resa WARNING -FEDERAL AND STATE LAWS REQUIRE THAT YOU STATE THE MILEAGE (ODOMETER READING) IN CONNECTION WITH THE TRANSFER OF OWNERSHIP. FAILURE TO COMPLETE OR PROVIDING A FALSE STATEMENT MAY RESULT IN FINES AND/OR IMPRISONMENT. IMPOR~'ANT NOTICE Please be advised that in lieu of notarization on this form, verification of a person's signature by an issuing agent who is licensed as a vehicle dealer by the Pennsylvania State Board of Vehicle Manufacturers,:Dealers and Salespersons, or its employee is acceptable. The signature and printed~name of the issuing agent or the issuing agent's employee, date of verification, the issuing agenUllcensed dealership's dealer identifi- cation number (DIN) and business name, must be listed in the space provided for notarization. Vehicle seller and purchaser must sign only in the presence of an officer empowered to administer oaths or an authorized agent as identified above. tnv. o.,dy, to a+a link a ny~ar wtoaaapa nrt Iha odomeMt raaAty r• .. f LAST FIRST MI.I. , ~+I .~ ...•-• -. = ~.., -=~~ X mlraId IaMaa Ns aeeatl trliYpa a nr "1M-' 8U81NE93 NAtllf , 3 wdwa ofM~ d Iha bllawNp L+a>,aa k Gf1aCNMt O ~ ~ 4PUl1GfA8ER Hsasw I}la amarA W nWaW, . {''~~ ~~ NOT 7N ac~hrl may f~t .lit ~viceas d n- ~t11pI hNy,.' Q.~. WMNINO; Od7mMAr diG~p~py . rnv. rurotr wnuy Itgt tha vanda ~ Ma a ary anasnbrarca and r+r aMantdp ~ n«w~r traMMrtad b a,. parsoMa) a tM cYaW 4w. arv ' STATE DP Iut~~ueQ PRIC! . OR DW SUBSCRIBED AND SWORN ' r TQ BEFORE ME Dx y - 1 ~ ~, ~' b ~ ,j PURCHASER AN CO~PURCHABER M119T l w d i t/1 1 1 , - S ~ HAA OPAI NERF ' z, ~ ~ ~ ~ , ~UW! . t¢ t11a bMC d 1vpWyaOa Msl tM adtxt~r y • ~ '. TEMMt.d ~p ~ . ~ _ .. ..UST Fl RST Iµ,; -~+„h,,~a"'~. zy„~;;,_.. ~ ~~' ~Q m+Nr .na nb.cu u,..au.t euN.o. a a~. ,~. a m. aatiy etm. r awcuia ~ aiiR~ea «t Pu.r. ~ ~ : - sts+HESa NAME - Rrll~l* Ihs emoux b6 rtrYwpE ~ d NOT ilia Kiel mf~ . In satoMt d Its msd>•IJca1 , NW WARNMI(t OdornaNr d~crept~. VYW altlola kf~rh l' ~'dM ~ CC7-VIIR .- ~ y ~ o rIWtMArlo/and tlNf tlw ow~Mtlp li .jy tl ia paraojY(a)'alrlfM aaaWin n~MS ,. Ap ;. .. ,. SUBSCRIBED AND SWORN. ~ - rnr TO BEFORE ME `+ _ _ Y~ ;~ Y $fATR LP : ORP4~ lPRIC$ k; ~', ~' 3 y ~. ~ ' PURCHASER C6PURCHASE }t f/I H p ~F,_ - - V r - - i A AAffFF HAN~TNAMB HERB. t t u.f ~ usa a ~ptl aDaap~ MM tM adoNaW rar~rp lai - -- ~ CAST FIRST - M.l; -,~,,,•.~ .., . ..-; -; ~ niYa rib Ialbeb MftY acf W milaapa q Qr~WY ~ . ; .. . unsay' ORd d tIM bMow4q Eblt~a 1• ctlaeMart -: ~ &38 NA[ ~ R.Md. at. emaar a oaw - w.,n..r d ns "'wad ~ w Nm tna awr mw a nntllMlpal lYMa WARIpNft.00unNMt STRE[T V1W luNNf tartlltr tlIH iha vNatb k fraa d any anambrrtca and Uisl tlla vrwRnaOlO tM Datann(a) ar a» away IaMd 0° ~ AOOHE>~ SUB3CgIBEO AND SWORN p . ~ TO BEFORE ME: x DAY. y STATE". ~p PURCNAB! PRIDE OR DIN... _ '~ ~. ~~. a ~ PU 9 ,Jr _ _ PURCHASER ANOK)R I - I ~ SELLER MUST -- - - - - HANDPRINT NAME HERE CHECK HERE iF APPLICATION FOR DEALER TITLE'AND COMPLETE SECTION D. TITLING FEES S ~* DANKERS LIFE ANp CASUALTY COMPANY I ~~ 11825 N. PENNSYLVANIA Si., CARNEL, IN 4603? CHECK NO. 0064673922 1H£ BANK OF HEK YORK HELLOH PKILADELPHIA, PA ~]~.}„_ 311 ;PAY THIRTY-TWO THOUSAND, THf~FE HUNDRED NINETY-Fl!!E AND 68/100 -----••---------•--------••-•--...... DATE CHECK ALIpUNT FIOCKLEY BRIAN A 05/16/203.1 ******32, 395.68 THE 18 OLENVIE41 CIRCLE ORDER DILLSBUR4, PA 1718 o:»uow-aN:r..N:>sxxiw++::a:er<w:.er p:a .ww.x:>.>,;x:nyxr:x::a~w.wr DF Y ~ <-+>N>.:iN>.< x«.•r1~d ~oro°o'><a,~ew+ JM. ~ cox '<e exnro'N .. ,n<.. .J: ,xlx:wrxwl:o»ap v aik~. > c Q d % R" ..w i .WVY/FVn^,:C.4'.ixOi:N:f.N»xK>NINt>Oi:M.tOW'>D. %>tNV~x .. ,.._ ...... .__ .. {. N : N 'N WNY» < N'At {itil N11 'tiNaYfY>CW +~NN .. CN V.N •. .. . ..r %~ « vyv•,y1' vO:v{WSI.:a _ _.... _... _....... .. _ _ ._..-- - p4:::::ll>:<vNl61+ro'N, w:::::::r1xYn:hi .:IM>x lx:Jl>lNY.I`wX9pwxlNCCri:w:Y:x Vd10 ARER 100 DAYC AUTHORIZED SIGNAri1NE 1~'Q081.67392r'i~' ~:~3L10D0471. 211969 558ii' Date:OG/06/20].1 DC (D=1, L=0):1. Account:?.969558 Amount:$32,395.G0 Sequence:40©1763270 Check Number:84673922 TranCode;O