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HomeMy WebLinkAbout08-19-11 1505610101 REV-1500 Ex ~°'_1°' '~' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania - DEPARTMENT OF REVENUE County Code Year File Number Bureau of Individual Taxes PO BOX 280601 INHERITANCE TAX RETURN ~ ,~ Harrisburg, PA 1128-o6oi e RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 7 5 4 4 1 5 1 0 0 5 2 5 2 0 1 1 0 5 2 9 1 9 5 2 Decedent's Last Name Suffix Decedent's First Name MI M a j e r `c h i k N i c h© l a °s J (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI M a j e r c h i k L i s a A Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 1 7 3 2. 6 1 2 7 REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 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 T i m H o l m e s 7 1 7 3 4 3 3 2 5 6 First line of address 1 2 2 S 1 6 t h S t r e e t Second line of address REGISTER OF WILLS I>}SE ONLY ~ ~ s ~ __ _ r .~ ~iT ~.~'. ~~.r . ~ ;~..~ _ : --~- te ,.~? ,-. ~ F r -- cn - f~, s~ ~`t .--, , - -- { . 13~jTE FILED"; ; ' r. ~,R City or Post Office State ZIP Code C a m p H i l l P'A 1 7 0 1 1 Correspondent's a-mail address: ~.. 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. SIGNATURE O~'p ~ ~ON RE~~ ONSJBL~E~FOR nl ~ ~G ~E/ U~F2A1.. ~ ~ D;T~ q 168 Carol Street, Ne`fa Cumberland, PA 17070 SIG E OF P ER T P TIVE ~ DAT 12 2 S . 16 t~£rC~e e t , Camp H i 11, PA 17 011 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J REV-1500 EX Decedent's Name: RECAPITULATION 1505610105 ............... 1 1. Real Estate (Schedule A) ............................. . Decedent's Social Security Number 1 7 5 4 4 1 5 1. 0' 0 0 0 0 0 0 2. 2. Stocks and Bonds (Schedule B) ....................................... 0 • O 0 3. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .... ~ 0 O 0 4. 4. Mortgages and Notes Receivable (Schedule D) .................... ~ • • ~ ~ ' ~ 1 3 0 5 3 8 . 7 ~ 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. ' 0 0 0 6. Jointly Owned Property (Schedule F) p Separate Billing Requested ....... 6• 0 0 0 7. Inter-Vivos Transfers & Miscellaneous NO Sepat aterBill ng Requested........ 7. (Schedule G) .. 8. 1 3 0 5 3 8 7 0 ..................... 8. Tota! Gross Assets (total Lines 1 through 7 ... . .... 9. ~ 4 4 0 7 0 7' 9. Funeral Expenses and Administrative Costs (Schedule H) ............... 0 Q 0 10. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ....... 11. 4 4 0 7 0 7' 11. Total Deductions (total Lines 9 and 10) ..................... ~ ~ ~ • ............ 12. 1 2 6 1 3 1' 6 3 12 Net Value of Estate (Line 8 minus Line 11) ................ . . 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ~ ~ Q .................13. an election to tax has not been made (Schedule J) ~ ' 1 2 $ 1 3 1 , 6 3 ........14. .. 14. Net Value Subject to Tax (Line 12 minus Line 13) ... - . TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or 0 • O 0 transfers under Sec. 9116 1 2 6 1 3 1. 6 3 15. (a)(1.2) X .0 - 16. Amount of Line 14 taxable ~ 16. at lineal rate X .0 __ 17. Amount of Line 14 taxable ~ 17. at sibling rate X .12 • 18. Amount of Line 14 taxable • 18. at collateral rate X .15 ~ • ~ ~ 19. TAX DUE .........................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1505610105 Side 2 O 1505610105 J ~),p o.~ . 'Z I - { 1 - i . CAS n File Number ~/~ n REV-1500 EX Paga 3 Z~~l+ ~ ~~ Decedent's Complete Address: DECEDENT'S NAME - -____---_-_ -___-___ - - - --- _ -- - -- Nichola-s_J._ Ma~erc-_i-___- ---- -- -- __ _ - - -- - STREET ADDRESS - - - -- 168 Carol Street - - - - --- --- ---- __ -_ _- _ _ - - - - -- - ,STATE PA ~ Z - ------ -- - 17070 - - --- _ CITY N2W Cumberland 0.00 Tax Payments and Credits: (1) 1. Tax Due (Page 2, Line 19) 2. CreditslPayments 0. 0 0 0. 0 0 A. Prior Payments 0 . 0 0 B. Discount - - - Total Credits (A •~ B) (2) 0.00 3. Interest (3) (4) 0.00 4. If Line 2 is grea F'll in oval on Page 2, Line 20 fo request a refiundthe OVERPAYMENT. (5) -- 0.0 0 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. OLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS PLEASE ANSWER THE F Yes No 1. Did decedent make a transfer and: •,.•.,,,.•.. [] .. a. retain the use or Income of the property transferred ................................ [~ i-l b. retain the riaht to designate who shall use the property transferred or its income :... • ~~ ~] 4~-~ .. c. retain a reversionary interest; or ..................................... ~~ d. receive the promise for life of either payments, benefits or care? .................................................... 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death ~] ..... without receiving adequate consideration? .............................. ~ ~ ~~ 3. Did decedent own an "in trust for" tiremaenbaccouont,dannuity okotheor non probate property, which eath 4. Did decedent own an individual re ........ ................................................................... ..... contains a beneficiary designation . .................................. . ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. IF THE ANSWER TO 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 For dates of death 3 percent [72 P.S. §9116 (a) (1.1) (i)]. of death on or after Jan. 1, 1995, the tax rate imposed on thelvnret spouse from tax,rand the statutory requ cements for disclosure of assets and For dates [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a sure g 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: he tax rate imposed on the net value of transfers from a dece9116 ah1.2)]1 years of age or younger at death to or for the use of a natural paren , an • T adoptive parent or a stepparent of the child is 0 percent [72 P.S § rate im osed 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 • The tax P 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. g p Asiblin is defined, under The tax rate imposed on the net value of transfeorneo arent m comm ntw th the decede bliWhethe by blc od or adopt o9116(a)(1.3)]. 9 Section 9102, as an individual who has at least p REV-1502 EX+ (11-08) ~ pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILI.NUMBER Nicholas Jon Ma j erchik ~~ ~~ _. 2 ~ _ << _~;~.-7 `~' ~j~r _Q~~~S,-~ All real property owned solely or as a tenant in common must be reported at fair market value. Fair market valu~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 is jointly-owned with right of survivorship must be disclosed on Schedule F, If more space is needed, insert additional sheets of the same size, REV-1503 EX+ (6-98) SCFIEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Nicholas Jon Majerchik ~~.- Zc- ll --oG~"-~7 20 t (--- c~~~~s'-7 All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1504 EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER ~ rfo. 'z - (~ - c~6Srj Nicholas Jon Ma j erchik '~~?~ ~ ~ - ~ 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 supporting information to be submitted for sole-grogrietorshios. tir more space is needed, insert additional sheets of the same size) REV-1507 EX+ (1-97) `~~~:' SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER D ~~. `Z(-<<- X57 Nicholas Jor~a_ ~Ma j erchik 2~~ (_~~'r7 All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1508 EX * (1-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ M~~7C. INHRESIDENT DECEDENT RN PERSONAL PROPERTY ESTATE OF FILE NUMBER ~ 1~0- ?(-l~-aG'SrZ Nicholas Jon Majerchik Zoll_ ~~~-,7 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ING Direct - Savings Account Account Number 40830744 Address: ING 909 Locust Street Des Moines, IA 50309-2899 2. Toyota Highlander-2004 3. I Lexus RX-2003 4. ~ Jaguar XK Series-1997 5. PPG Payroll check payable to Estate of Nicholas J. Majerchik ($ 12,211.22) Payment of$ 1999.25 from Executrix to PPG for overpayment $12,211.22 - $1,999.25 = $ 10,211.97 $ 79,351.73 $ 16,300.00 $ 14,565.00 $ 10,110.00 $ 10, 211.97 TOTAL (Also enter on line 5, Recapitulation) I $ 130, 538.70 (If more space is needed, insert additional sheets of the same size) >, ~, ~f O U U c~ v a~ ~. .~ Q G--i O U U c~ U U ~, N U ~_ A O O Q a U Q .s~ c~ O Z ~_ N a w H Z U U a 2 W a ~T~ ~ W a ~••~ a. `~ r ~' ~? C ~ r tp C Y I ~ ~ ~ ~i c i a~ ~ ~ 0 L ~I 3 ~i ~~ _ 0i ~ ~ ! of C ~ ~ LLI e Z a I ~i v ~ N ~ ~.. c F- rn ~ ~-' m m R d! m O O N w ~ C ~ ~ C 7 Q ~M ~' I m i C_ C m L! ', LL ~ L. ~ ~ I L i ~ ~ m ~ ~ .. ;~ C' I, ~ ~ _ a c m an ~ ~I A a ~ ~ ~ U ' `Q ~ ~; O , + O Q + Q' ~ ', ~ ': „~ "' ~ R ~ Q I ~ ~~ ~ ~ t- C r ~ y~ ii , x w J ~, U ~ ~I ~ ~ U ~ ~ ~ ~I ~ ~ V NI ' C C ~ U ~i ' ~ ~ v (O ~ U ~• ~ ~ ~+ UI ~ ~ ~ C _ C. . Z, , ~ !YI c0 c4 O ~ ~ a ~ i m ~ ~ ~ a~ c a v i - t~ U coo N as ~ y cfl O ~ O = '~ ~ ~ O '~ /~~ ~ 3 '~c 3 3 °~. ~ ~ V a L 3~a °~ ~ ~ ~. ~ ti ~ c7 O C d `~ cD ~ ~ o0 90 O ~ ~p •~ ~ I` s~ ~ Q b"~ ti ~p t"'! ~ v ~. ~ (O c~ v' 00 ao ~Q ~ ~ ~ r m 4k ~+ ~ O ~ O .. tC C O N O Q °v ~i Q~ C .; R C tQ C ~L v m ~ ~ U U Q Q ~ ~ n ~ U m Z J rn v~ c c .~ .~ f/~ {n ~ c m ~ as a a C 0 v d O O C Y a.. U m ~ . L ~ V~ ~ =a C O~ O v ~ 'L a V m d o ~ C ~ L C ~ o w ~ O Y ~ ~f ~ N ~ w ~ C C1 ca C L Y U m 3 N v N m .~ Y m n ~ ~\~' /~ O N N O C O F-- W a O M N C O .N N I ~, •/ _. ~ _: W ~w ~~ ~. ~~ zW ~ L`1 1J ~ Cd G a Y 0 L m t H .'d C3 W m F- 3 0 O m L v m m m c 0 v a 0 N m r. 0 2004 Toyota Highlander Limited Sport Utility 4D Trade In Values, Reviews -Kelley Blu... Page 1 of 4 ti Kelley Blue Boalc YNE MusrED RE4t)URCE FlnCj Car 'd3ii_JeS Or `eaf3..JreS h~~me ~ car values ~ cars for sate ~ car reviews ~ kbb top picks ~ research tools Popular at KBB.com ,.!) 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I ,\\ 4 ~~ I ll,~.llJll iI jll'I~'I I~I~JJ!{11~I~1~ I~(III 111111 II~~I I ~ II.I~, ~p lI~ I ,, ~ \\1 \\ \ ;\j\I,1\,,`~ 1\ k JJ I I I 1 1~ I I I I I ~ \ I I I V II I I I ~~ I f I 4 ,1 1 I 1 I I I'I 1 11 ~ \ 1 , 4 II III I 1 1 ! Illil II~ , 1 11\1\ I I I II I I II~IIIII ~I lII' i Illlll~lilr gI!!II uIIIP , ' 1! IIlildl III I I I I I I'! ~~u 1 r \\ \ \h\~ q t\~P16Q', \ ~i`~1 ,1' .~„oo:. ~..~..,,.„~,~...,o~~.,,. ,. , >~I•,..,o,.,..o,~.~. ~~ ..von i %i+~ ~gy~~ o~~y~:~ :. o. ~ J~ _ ~y i cx e g • ~! ~.` t x~o r; ~ - ~+r ~'+.~ v0~r xnvo~rt.u ~.ex.]c. [ - xool rex ;nr> Erg ~N p x~PO~~enr • VEHICLE 3DENTIFICATION NUMBER I I till!! ~~R. .,111 0 9 ~;,,°I I h iM f~ O~ 1Y~FfI~T4E' I T7TL~ M1fUMF3~F ~\ ~~ ~, h n ~ ,.r~a~, E ii i ~~u: J~6 Ii~6Vil.4 ~G..41r 4d6 m~_i1u 4 r D~.i,oa4 u11a! y~. - ~ ~:~, ~,f '~ ~, ~~~ . "- BODY TYPE .~ DUP. ~.~~ ...SEAT CAP~~ ~ ,'~I'~AteO TITLEIk"F`AT~ 1.114 (yI"Jf,~JC~ PFtCa~C1, ~~~~ ~~~~~~~ ODOM. MILES .~ .aDOM:~STATlJ~ .; i I i1i 1~ 1 11 I I 1 ~I i I I' r1i1 i ~ixwi+ a urtrl e t Jwa X11 ~ ~ d~~s I . ~ ~ ......,... E ,. ~..~~ ~..oo..E. , ~ o ~ oo...o,. , ..~o .... ~...,. ~...o ~~, F .~ ..~..~~ t . ~ ..... . DATE PA TITLED DATE OF ISSUE. ~ ~UNLADEN WEIGHT -GVWR GCWR Tfl'LE BRANDS ~ Il I I I ~III~ IJII ~R ~'A ~S ;~ ' 1 1'11111 ~iIpIIII~I'II d~ r III' N I'~ ~~ T II 111 i • ~ II !f i' i 11~ 71~IA y ~~~~I~~~~i ;FII ~,!I IIi~ ~ ~~ ~ II , M , >J'I?S I ~E MECHq,hJ~~ 1'1111 ~ ~ { Ill~i,l"~~ 1~' '~~~J Llf~t~~ , 'll~~~l~~il J~~ ~ ~I ~ ui ; J~III - . ~„~ ~_ III~~' yI Ir, , II,~~ II N~I dI I I ~ ,~, ~I ~ M~YIEAO'~ ~ ~ li, i~ a (llll ,~s'~4 ""r I ~'IiI ~I~iI ~; d,~ = Nd~ I ! . I~~ ~ ! ~IL Ml}~EAGE-0i1;,C,YJ,7~T~'P~I ~~yy '~ 4 =EXEMPT ~AOM ODOMETER DISCLOSURE • _ ~ ~c~~~_ ~,~~'~~ ~r R~{",~,ISTERED OWN i li il! IIIIIJ ~Ilrl ~I ht~~ ~ i ~- ~•Y- 7ITt.E BRANDS \ \ ~. 111 I~ I III II II ~I, 'ill~Ill,Il IIISII~ lIl if I v ~<: y. A ANT10l1E VEHICLE o 1. ' I 1 I i I ~I1 IIJJII I~~11 JI'I,t gill I +IIIIIJ 11 I111I ~~ ~ ~ f?a~ _ C ~ CLASSIC VEHICLE , ' Ill I NI,~! I lJ~~: ~I trtr t ` car Ir r,st~r tutu,{~ ' ' D = CQLLEGTIF3LE VEf11CtLE 1 I,t ' y~ I J ~ s ~ ~ i i ~,,,~~ i III 'I , ll~~ II~~II l ItIlI i !i~ -- - ~ ',F x 1JL!T OF CQLiNT1~Y IIL ~ ~ II,I'!~J IJI~IIj,II I IrIpI~111II1~1 I ~ ~ i• G .~ OAiGINALLY MF(~b F'fSR N(~^L9 S. „~ ~. . ~~I~ 4 k'I III'I p 1,1~,~111 Illli IIII ~I,~,II11ill,'~I~f~c ~ ~ LIISTAIBU"i1pN ~. ~~'.R +GlI~~Rt~I£11I~1!4~'~u~i ~~~~~ ~_ ~: L =LOGGNGVEHICLEHICLE \\' TTY' i'~ P = ISNVAS A POUCE VEHICLE II 1~1 11 l II '1~ I ~' III~II~I' I R = RECONSTRUCTED , ~~ lI II ~ `1 ~ IuIII 1 III Ili,! I 1~II d !~,I,I lli 111iIV I I, IP, u I S =STREET ROD , :_ • 1 I ail IV I ~ III I, I ~ I ~ q ~•I' 1~I'~IIII~ I I I, T = RECOVERED THEFT L'cHIGLE l11 1 ~ 111 IF~ Ili I~' ll 1111 ,i l l V ~VEHICLECOAITAthB P,EISSUEG VIN j l h, ill 1, 1 ~ I~ I ,`+I'll ~ II,II~ h ,i o I ~y ~ II ~ ~I ' 1 n1 111 ~ I1 h U II W =FLOOD VEI~ICLE I I, 111 I 1 I l 1~I I i'i II i FIRST LIEN FAVOAUF: i 1i:'111'i~~ III ~ I~ II I I ~ I'll ~, X = ISt3tJASATAXI II ull I SEGOtrI 1 ~ I I I ~ LIE~i ~~ ~~~I~j' ; I i1 'i I I il,, ~1~~~,1 ~ it P 1 - - ~ ~` _.. ~ Il 111'11 { _ ~„I I "i~ Ii~I',~f~ll~ 1 n Ill I I. i ~ • ~ I, III; I I~I I~l~l ~jlJll !I I ~'I i i i I it ~i 'I '. , ~ ~ ,i III IpI;, '~~~ f III~1111' V III ~ ~II '~I II I I ~ ~ ~I~~'1 tf a second lienholder is fisted II dp fisfact,~~I ~ t~ ~II 1~ the fii ;II~~ I If ,, , ~ lienholder must forward this Tjtle I gllllth I Bu~rea~lll"~ IMo~II bhl~ti~ ~Ith kt ' 111~~i~!Ir~~ ' ~., t ~I;, I,,~I~ I Il~ ,I11~JII I . : 1 - ~ FIF3$~'~,t)rN AELEASELY appropriate torte ar}d fee. Ilt l,,i~~, 11111 !' II~~II~~I Ip~ Ilu n ~I I~ ~; 111111 11~~~11~1 III ~ I i i DATE ~ II iy, II j17Ih I I " ' r BY SECONDcLIEN RELEASED AUTHORIZED REPRESENTATIVE `' DATE • .MAILING ADDRESS F3Y • }~ 7 AUTHORIZED REPRESENTATIVE f~~~~~~~~ ~ ,; ~~~~~~~3~ ~~~ ~~~~~~ S i • .1 • • h • t certify as of the date of issue, the official records' ofi the Pennsylvania Department. _ ~ ~ ~ ~ ~ ~ ~ ~ ~ L _ _ ~ of`Transportation reflect that the person(s) or eompany,'named herein is the lawful owner - I• • of the said vehicle. - Secretary of Transportation • . . . . SUBSCRIBED AND SwOR If a bt)-purchaser other than your spouse is listed and. you want .the tifle to ~ .. g E ^., death of one ' ~ ~ I .t ~ g l ~~ yorshi ~O ~ .~ ~ , 1~1 I~ ~R k ~ ,' TTIII i ~ ~„~ 0li ilr ~ Ili ! I inn F ~ , 4 ~ Fo ~IIE i ' ''I'+I urn Av bwnet;~tltles oesnto survlvtn 'dwneYl GHECFC N G" erwl sy tkf$ ~tt6 -ell ~,~~ II"I' I"' ~ I ;' 'IJi~I, ~ill~I~,1~11,~4(IlIIIIII~I ~ Ill be~ssued as "l'Enants In Common ((3rr death of orrH,~iwner I1'tf~ra8tv~4t . ~:.~r~~ ~I 11 1' I~Ij~QI I, 61I~ ;I` II ~' ~`~ - asedowner goes to his/her heirsor estate).: I I~1 ' 1 II I' I yMt q , i 1 lit ~ ( I ~~„ OATH ~'••~~• i .11 ~ I ~yI ~ ST LlEfy DATE: --~ ,~iF NO Lt+_~N, CHECK ~ ,.'~~ .I ~ I ! ~ II ~, ~ A!illn ~~~ ~~~~~~M~ r- l l II 111 1 II ~F" I llUyu ~ ~ ~ ~1 r~ f ~ ~ N~}~~~~~~~~~~ ~ 1ST LIENHCLDER ~ ~ ~ ZAN~f~ Nt I~€p~~~R; .Notary Public ' I u R ~i3FR~T }~t~ 8tfi~i3`' tt~ilbBf~ ~,~ i I~I11II STl1'~'ll lul'Ii111~~~11,~I1~Idliill nt I ~Q j{jl ,~: :~r Y~ ~1 .GNU ~ ~, ii 1I1i111~~~1 IiCI l Ill II~I111~1 i illlll,l STATE ~ ~:.~[P ~"~ .... ". _~ Y ~ ssr~1~ ~ Iras Au . u~t 2~1 ~ ~~13 I T'>~ ,III l;l',Il III u~~ll~ IIIil,1 '~~1; II~I'1~11<Ilf" -- i III IIYd II li1l 111 411 II It11~ I iq 11 r 'i,.P,:, 1 FIN~~I~~AL FM~I~~~~~I~,I^GN NUMBER ~, 2NDLIEN DATE: 1 ~ JF NO LIEN CHECK 3Ae tuil#eisgned di6reby 3nekes epplketton for Genrticala of Ttle to Ne vehicle described ~ I~. I I. ~ I I ~pbdve sutg~ti to 9i~GUtrlb7ar1G8s amt idher:Jegat dg[rtuse2 forth here. 1 III IfI,Iil,l iIII III II, ,1111 I~ ~~ 2ND LtENHOLDEF r~~hil L; 111111`1 II" I 1 ~ ~~~ ~ ~ ~ u'I I u I~l~~~l~,~ !11011(I~I~lllp ~ 1~ I r STREET '1 ~I 1l11'11fll~~l1111, ~1 IIII~d' ~~~~~~~~~ I, ~ ~ ,II , II,II~~I 11111~iGII~ ~I'I ! I ~4 I ~~~~ I i I UIIIII II rulGllll~ll h ' A GN CfTY 11~11IIllj1 STATIefIIIlli!'11 ~~Z1P N O SIGNATURE OF.CO•APPUCANr/rITLE OF AUTHORIZED SIGNER FINANCIAL INSTITUTION NUMBER 2003 Lexus RX 300 Sport Utility 4D Trade In Values, Reviews -Kelley Blue Book Page 1 of 4 ~ Kelley Blue Book i1tE TRL1S1Ed RFSOU.cr Fl rid rat' 'vdllJeS Cyr h~ablt~ home ~ car values ~ ears for sale ~ car reviews ~ kbb top picks ( research tools x. Popular at KBB.COrTI iG C;ot)iest Cars finder t,?,(li)ii advertisemert '^'i'1' °'~~' Hums > .~~a. Vai~~.ie, ~ vf~~.us > Rk: > 2C03 a Style > Options :> RX 3Ci0 sport Utility ~}D 2003 L2XU5 ~ RX - go ~~~~--~ ~ ~ 2003 nexus RX .;t ~ RX 300 Sport Utility 4D Mifeaye:60,621 Change edit options Change style tike this car ~:~ ~' ~_.ar Z Tell u~ style / O~iti,:>ns 3 See Blue Book Value values specs new car finder used cars for sale write a review consumer reviews Trade-I n / Sel I Va I ues see Used Car Prices l`~rat~~-Iri Private Party Excel lent Good Fair $15,365 ,~ $13,315 Change condition Get a CARF/UC Record Check tenter VIN (n~tinnal) go ~~ 'vu vIN' Pcci Problem' Get your New Car Price price your next car advertisement L~ price your next car ,Nn~ ids, view view view Seller's Resources Now much can I afford? ~ USr Our IYIOII.hi'y };d y;rvi+?s'd CalLUId2Cit 1Nhat if my credit's not perfect? - Ap!~ly with c ~pecl..,ast ^otv I want Oo ~ my car for sale ~ '~' Top lOs & News • 10 Coolest:ars u~uier tB.JOC) ~G'Otl • 201.2 BMbU GSQi C)nvertiblP: A urai:;hu: Prrner Share Print My Recently Viewed My Saved Cars save My Kf3P ZIP Code: l IQ70 iGn In http://www.kbb.comilexus/rx/2003-lexus-rx/rx-300-sport-utility-4d/?vehic leid=2474&inte... 8/ 14/2011 2003 I,exus RX 300 Sport Utility 4D Trade in Values, Reviews -Kelley Blue Book Page 2 of 4 Search Used Cars for Sale near New Cumberland LExt15 ~ V'p tc 75 Miles away from ZIP ~~~ search Sell It Yourself -FAST place your adf l.f~?y."; ii t;i3~ r,iStOr'Y i~ fc~_~ rt~tr _?uy advertitiement get your t:oolkit - BankofAmerica -d3j Know your credit score Apply for an auto loan before you buy - starting at 3 54~/~ - Find Your New Car Explore new-car reviews, ratings, and more, then get the Fair Purchase Price. Popular Topics Car Reviews & News Acrto Shows Latest News `op 10 Family Car, for 201: Featured Article Great Car i~ea~s K.EE Expert Reviews w~hY ads? price your next car lbp 10 I=ami'~~y are: of :?t~11 • Five C;reat Car Deal°, Read More Nevis See This Car's Awards • 2011 (3e~t Resale Value A~w~rrds More Awards Help Company Industry Relations FAQ 4tK7ut Us Advertising S e Map Contact U<_. Media Center Find a fVew Car Careers Linking ~ohcy Share Print My Recently Viet^red My Saved Cars save P-~y xE3~ Z1P Code: l:?07i~ zign In http://www.kbb.com/lexus/rx/2003-lexus-rx/rx-300-sport utility-4d/?vehic:teid=2674&inte... 8/14/2011 _. _ _. _ - _ _ _. _ '..~ ,~ _. _ - __ ~e1 ._ t 5 ~ ti ~~t'ti .:jA:' ' t ' ~ ,` ~. - ~ I~ ~ I ~~ ~i~ i~~iq,t 'f%~~i ""C~~ fs; .. ~ 'f~ ~ `; ~~,• `~' ' " , ~ i ., ~~~ . CO ti : ." i'ift~ r ' , ~ y ~ F .:.u- ^m se's" t~~~,: ..~ - , ~'ICATE OF T~TLEFOR ~ V~'i!~[G~.E ~~ ~ f~~,R~II I _. ~ -W.... ...-._._- ..... r I~ - 1 '~.1JBU 11 i ~ ~ ~ ~ L ~~ Ea 3 ~ ~ Q~~ ~`~~~~~ ~ "`~~ ~# ' ~ ~' 'r~U~. ~ ~ ~ ~ 6~946~t?ZDD~ (~A . i~• ~,~y. MAKE OF VE VEHIC II HIC_E ~ ' ~~~ ~ LE IDEM'1FICATION"NUMBER ~ ~ ~~ TITLE NUMBER :w i ~ s _.. ,;~ BODY TYPE . :'. ~ ,~...~~ ~ _ IOR TITLE STATE ~ ODOM. PROCD. DATE DUP. I SEAT CAP: IIPR ODOM MILES ODOM STATUS ~ GVWR I I ~~ ~ ~ ~ ~~~~ GCWR ~ TITLE BRANDS ""' • ~ , UNLADEN WEIGHT DATE OF ISSUE DATE PA TITLED t . I- ' "' ~ ~, '~ f :. ^ ;. g9r? ~ ~"' ~~ ~~ ~ ~ ~ 6,' fit, + ~ _. • R~r.~ISTER~D OWN~1q,~~) i~ ~ ~ 7 ~ ~# e f. `- u "~ i'I~ilil~ Illl~uill ~ll~~l~111+ lil ~. ~ f..~ ~~ i~r~~ L~I~Ii~ Illl li~'~ ~I~ W 4. lll~~\~~1fI~F^ ~~ Yfi ~~?1'TF ~t.t f,..~t '4.~ ' ~ I ~ lill~fl'~rr III.I.~I j~llli. ~. _ .~ ~~~a ~I~~,I~ ~,Illll"~i113'I ~II~~ ,_ .. ° i I{~.II III i l~~)NI~ I~i~l !I~i IEN FAVOR OF' FIRST LIEN FAVOR OF: SECOND L '~? •~ ~ if a second lienhold~r is listed u cn satisfaction of the first lien, the iirsl p - lienholder must forward this Title to the '8u~eau of Motor Vehicles wrth the +7 appropriate form and tee. ~I' ~ FIRSLL(EN RELEASED ~ • DATE s `: . - BY SECOND LIEN RELEASED _ AUTHORIZED REPRESENTATIVE DATE - MAILING ADDRESS BY • • ~ G ~ ~ ~ r G 7 3 AUTHORIZED REPRESENTATIVE ~ (~ f1 I RCH - NI CH~LA~ J ~~JE ° ~ 168 ~AR~L _ST _. ___ NEW CU~IE3El~L.Nh PA 1?~7D ~ -•• ALLEN D BIEHLER f i certify as of the date of issue, the official records of the .Pennsylvania Department ~ of Transportation reflect that the person(s) or company named herein is the lawful owner ~ :: •'- • • of the said Ile. Secretary of Transportation , :. ,.. ~ , .. I 1 i ' I 1 1 _ ~ <~ -'= :- lf a co-purchaser other than your spouse i5iisted and you want the title to SUBSCRIBED ANDS o be listed as "Joint Tenants With Right of Survivorship" (On death of one ' ~;,~,~ TQ t9EF E tdE: a pA En owner, title, goes to surviving owner.) GHECK.NERE ^. Otherwise, the title - . .. ~~ ,, ~, will lie issued_as'Tenants in Common" (On death of one owner,;fiteresf of ' s ~ Lz'.i\~ std ~ ~•~ ~ ~ deceased owner goes to his/her heirs or esta#e). - -Ni~i~ • !,i GN DMNIST I D ~ IF NO LIEN, CHECK 1STLIEN'DATE; ~ _ io • :. ~ ~~ ' ' 1ST LI HOLDER ~ ~~~~~~~~ ~~~~.: a ~' si= D1=DER;=~, ~lotaty Public NE M i STREET V . ~~~~ CdifT1E32f)2f~d~r{'irC)'17T)ty Ht1I BOrO ~ CITY.. STATE ZIP ~ {j3lT1Q ~Q~3 t~st~0 A e W , ug s My Gammissian Expir f IFTH~fN ELT, CHECKHERE n FINANCIAL J INSTITUTION NO L W . i NOTE: FIN REQUIRED v) T d IF NO LIEN, CHEC , 2ND LIEN DATE:, ' -~ K r W Ttie urd9rsigied hers0y makes appLCa[ion for Cerirfieafe of Title to the vehicle describe above, subject to theencumbrances and otheriegal claims set corm herp_ ' 2ND LIENHOLDER i ~( i STREET ~ ~. GNER ,li.~ ~ CITY °'" STATE ZIP IF THI ^ FINANCIAL ECK HERE S SIGNATURE OF CO-APPLICANT/TITLEOF AUiHOAIZED SIGNER INSTITUTION NO tiAUAM Nµ ...,r..iwwa,~,._.M;ww ~~, FIN REQUIRED NOTE f 1t ,~ ~1 ~' 1997 Jaguar XK Series XK8 Convertible 2D Trade In Values, Reviews -Kelley Blue Book H. y ~ ~ ~ Kelley Blue VWn THE TRUSTED RESOURCE ® Flfld Caf YdIUeS Of f~h11~25 home ~ car values ~ cars for sale ~ car reviews { kbb top picks ~ research tools .rr~~ _ ._.~_._____...._~_.._. ________.._.~.___~_._____ ~____..___.___________.___,.__________..._ popular at KBB.com .r - ,,~ ~~ ~rzr~. i !1 G U !~ !2 ~-{ K ~ 10 Coolest Cars Under _r. ,._ .~-a =•~ ~~~ ,,_E. _ $18,000 '~~!k.=a . ~ ~ why ads advertlsemerK Home > Car Values > Jac}uar > Xk: Series > 1997 > Style > Options > 1997 la9Uaf XK SerleS XK8 Convertible 2D 1997 Jaguar XK Series XK8 Convertible 2D Mileage: 17,639 change edit options change style Like tftiscar 1 Select four C,ar 2 Tell Us Style /Options 3 See Blue Book Value 4 ~y~Mprice your-next car ~~ __...____.M_.______.___v_._._._. ~...~! values specs new car finder used cars for sale write a review consumer reviews go 1 of 4 8/14/11 11:03 Ali 1997 Jaguar XK Series XK8 Convertible 2D Trade In Values, Reviews -Kelley Blue Book Trade-In/Sell Values see use ~r Trade-in Private Party Excellent r'~ Fair $10,560 ~ 10,110 $9.~s Change condition Get a CARFAX Get your Record Check New Car Price .Enter VIN (optional)_,. - go i ~__._.__._.__.__._._ _.___ __.i P price your next car ~X~ 130 'dIPJ? No Problem! KBB Expert Suggestions :~+" '~. . a;~ 2012 Jaguar XK Series 2012 Chevrolet Corvette 2012 Aston Martin Virage viev~~ view view Search Used Cars for Sale near xershey '~ iE'v actual phot=os, c=ompare prices, and buy your ne;~t car. Jaguar XK Series up to i ~75 Miles -_-~~_ ~y from z~-17033T-. search Sell It Yourself -FAST List it can Ai_ztotraderearn Use our free S?lier's Toolkit and reach t~ver to upload your 14 million shoppers. listing to social sites. place your ad get your toolkit ~AGUAR(~-~CK .'. ~1 ,.. F ",.»~-. tr.•.~ti'a _. .. ..~..~ ~.-.FF 4~~h .. ?"as,, .,. :-•E 4. s- r ~: :~> why ads? Seller's Resources How much can I afford? Use our monthly payment calculator What if my credit's not perfect? Apply with a specialist now I want to list my car for sale Get: your free Selle~ s Toolkit ''~'` Top 10s & News + 10 Coolest Cars under X18,000 - 2011 + 2012 BMVJ 6501 Convertible: A Graphic Primer • Top 10 Family Cars of 2011 • Five Great: Car Deals Read More Plews Sharc Print iVl}~ Recend}' Vicw~b~1` Sa~~ed Cars save ti1y K}31~IPCodel:7033 Sign In 2 of 4 8/14/11. l 1:03 AM 1997 Jaguar XK Series XK8 Convertible 2D Trade In Values, Reviews -Kelley Blue Book C Check a car's history before yor; br,y. jaguar XK Series BapkofAmerica Know your credit score Apply for an auto loan before you buy = starting at 3.54% ___ ;!~". ~rv~~~ Find Your New Car Explore new-car reviews, ratings, and more, then get the Fair Purchase Price. Request a Quote Get a E~rochure Find a Dealer Test Drive rAC.UAR KK why ads' t ~ your next car ~_ _.___._.__----._._._______._____._.~_r Popular Topics Car Reviews >!< News Help Company L~dusfry Relations Auto Shows Latest News FAQ About US Advertising Top 10 Farroy Cars for 2011 Feahtred Article Sibe Map Contact Us Media Center 5 Great Car Beals K136 ~t Reviews Ford a New Car Caress Linlting Policy 2011 Best Resale Value Awards Car Videos What's My Car Worth Business Sdutions New Cars KiiBs" Mobile Follow KBB RSS Twitter Facebook YwTube Mobile Apps iPhone® Android"' Wirrdows® D 1995-2011 Kelley Blue Book Co.®, Inc. AU rights reserved. Copyright & T~adernarks ~ Terrns of Service ~ Privacy Policy Have comments about our Blue Book Values? Give us your feedback. © 2011 Kelley Blue Book Co., Inc. All nghts reserved. 8/12/2011-8/18/2011 Edition. The specific ir-farmation requirr~d to determine the vakre for this parbarlar vehkie was supplied by the person generating this report. Vehicle valuations are opinions and may vary from vehicle to vehicle. Actual valuations wiN vary based upon market oonditia-s, specifications, vehicle wr-ditron or oMer particular dreumstances pertinent to this parbev/ar vehicle ~ the transaction or the partiPS to the trartsacLion. This report is intended for the ~drvidual use of the person generating this report onty and shall not be sold or transmitted to another party. KeNey Bkre Book assumes ra responsibility fix errors or omissions. (v.11082) Sparc Print M~ Rccentl}~ Vicw~ Savcd C'ar~~ save M~ KRF3~IPCodel:7O33 Sig=n In 3 of 4 8/14/1 ] 11:03 AM ERTIFICATE OF 1 fLE FOR A VENICE .....,..., ._.,._.. ....... _ ._..... _ E ,...,.~. v i M _-. r r r r. .~ / ' R~ i , ' t i ,...,o~, r..~,,.~, ,,.,.,, ~. VEHICLE IDENTIFICATION NUMBER YEAR .MAKE OF VEHICLE TITLE NUMBER Ka ~ „6.oo.or~.oo,.. ~o ss33 .r,.oo,,,...~, ~., ~r,oo, ..oo~,,,,o t«oar ..wo`o n:~od:E„oo,,oy,.E~~oa ~ F or E„oo a ~~~~„~, r~. ~~o,.r.; '.oo,rE..o aE .,a °" ~oo,.,,r~oo~~r. o~., ,oo~a., or,~.~~a,.,,.oo~.E..oo~.,,.oo..,. ~..~„oor.E,«.~,.~« .E,~:o~,:r„~o~.E,~ „~~..o,~a~.M1O~.. o .~, ~... ~::=r~ ~~„oo.~,.o~..E..~o,.E.,oa,.,~ o,~o.., , , oE,,;. 'o, ;~ ,o~ ~.:~~„~;A o,:l.~ or,,,,o,..r.. ;.,~.,o;.~,'.o;~°<.~o,~,~~,;ooa°<., E,;;.,,r~~.«~o„ .'.o;;~~'.,o; ~„ o,.r.~o,"; ~.~ ,oa,K oo~~«„o.,E,~,o„I~: .~'~~,' oa"I~,~ . ,... ~ a~t.~> _ ,~ ~w. ,.„ ~..o~, ~ o ~.::: .,,,~o,., , a oo.~,. .o,rr,~ ~o,,:~., ,,.,o,,.,w~-.~.,'o.,t°,~oo.or,~:a.,.,;o„~x E .,oo,.r,~ oa,.E,.o r~,oo,., -o,r~e,o~ ..,„o ~ ,o,,,..~..oo„r. .. ~, ~ r..~ ,,~ =:S -.,, BODY TYPE ~~ ~ pUP SEAT CAP F ~ PRIOR TITLE STATE~~ ODOM. PROCD DATE ODOM -MILES rr~ ODOM. STATUS ..• ,,:__ :.• ' ~ oeeDv+ooinos~n~~e' rini:.oai ii: anr~~oorrmoov ' .v. d o -~~ wvoo+ri ioor r ,.r.wo:. ~~~, , r,n,oo„EP~~aa~ ~~ o ..,..„r., ;v .~, . . ,,.r. oo .~ ,oa,.,., oa„. ,~ .o .~.~~~ a, E..oo r, ,..,~~ ,.,.. a , ~o K„oo ~. r,,.. , , a..,..oo ~.. , .,~ .,.. ,. =• ~~ DATE PA TITLED DATEtOF ISSUE UNLADEN WEIGHT ~ •~~ ~~ ~~~ L ~GVWR F ~ ~eFYLi'GCWR TITLE BRANDS `•~~:.7 ` . ~ - - - ODOMETER STATUS ' 0 =ACTUAL MILEAGE " _ 1 =MILEAGE EXCEEDS THE MECHANICAL _ • - - __. . ' - _ _- -. -. -.-- _- -= LIMITS --- _-= ~ - - =_ _ - - = - --- - 2-=IJDT-THEACTUALMILEAGE -- ~ - - - - 3 _ TOMPERING VERIFIED AGE-ODDMETER -_ ~ ~-t~Gl I~LaI ~- rr ~~ ` - ~-= EXEMPT FROM ODOMETER DISGLbSUAE-_-- F1~~',.1$T~RED OWNER(S) ~~ M ~ TITLE BRANDS 3 c1. ` ~r 'i r - # {~~i ~•jv~' ~~~ A = ANTIQUE VEHICLE ~L~~~~~ ~~~ ~~..~F'~~~j~I~/~;r,t:t,r/ _,:.~rte.i..r. 4:' C= GLASSICVEHICLE f '~ ~ D =COLLECTIBLE VEHICLE f ~ ~~ - G = DRIGINALLYMFGD. FOR NON-US .. ~{ ~,i~fy DISTRIBUTION ' ~'f~ 3i.. V ~ ~ ~ ~~'~i i ~ iJ ~ ~ ~ ~ ~ ~ ~ H AG~ifGULTURAF VEHICLE ' L - LOGGfti1G VEHICLE ~~ P = I~lwA$A POLICE VEHICLE ,. R = RECO,fJSTRUCTED • ~ ~ ^ VEM LE CONTAINS REISSUED VIN LOOD VEHICLE X = 13M/AS A TAXI .FIRST LIEN FAVOR OF: SECOND LIEN FAVOR OF: y. nkl 'ii!IP .et. . ~ ~. If a'second liehholder is listed upon satisfaction of the first lien, the first, ~/~ J~ 2 Iienholder:must forward this Title to the Bureau of Motor Vehicles with the FIRST LIEN RELEASED ~ appropriate form and fee. DA/TE . . ~ ~W /UC~ ~/( BY SECOND. LIEN RELEASED y AUTHORIZED REPRESENT T E ' DATE ~,i MAILING ADDRESS :ill ~ ~ 7 BY AUTHORIZED REPRESENTATIVE -~~1 I ~ ~ 3 t7 t~ ~ J - -_ - __ _- - 1 , }'1 f, ¢~ ,M. $ - x ' d . 3 !certify as of the date of issue- the official records of the Pennsylvania Departrnenl ~ 3 ot!',Transportation reflect that the person(s) or company named herein is the lawful ownot >-• " ' ~; -,-.< '' { ~. of >he said vehicle. ~~ Secretarp of Transportation ~ ~ l', I I! 11'~ ~' _ ~ .. r r?'4"~'~°~ .~V'^ _'., F t ': ~ ~ sF~vm~.•eo-e~n i • • . ..~ •+., S ~? SUBSCRIBED AND RN /~'~ `~ `~ If a co-purchaser other than yqur spouse Is listed and you want the title to ~~ `. TO EFORE ME: (J ` ( be listed as "Joint Tenants Wifh Right of Survivors~hipp" (On death of one t : owner,- title goes to surviving owner.) CHECK HERE LJ. "Otherwise, the title_ •~s~• -' - ;_ well b_sassued as 'Tenants in Common" {On death of one owner lnteres - S:.. - - ~~'~' = -_ ~ deceased owner goes io his/hey heirs d[ estate). 3~1;~ - ' RsoN I sT w TST=LIEN DATE: -~ IF NO LIEN, CHECT< __ ~~ i',1M01dWEALTH OF= PENNSYLVANIA - ~, = - -1ST LIENHOLDER - _ .:.,~~__.' - NOTARIAL SEAL - w SUZAN.NE M.,DEDEAER, Notary Pu41iG sTREET cn Camp Hi11 Boro, Cii nberland:C-ounty My COmrr115SIQf1 E!(pl(ES A17gUSt'~Q z~~3 CITY STATE ZIP M FINANCIAL INSTITUTION NUMBER 2ND LIEN DATE: M ~ IF NO LIEN, CHECK N The ,undersigned hereby makes. application for Oertiflceta of Ttle {o the vehicle described T above; subject to the encumbrencos and olher legal clams set forth here. 2ND LIENHOLDER _ v , - I STREET - _ - = _ CITY STATE 21P O ~ _- FINANCIALINSTITUTION NUMBER -- - SIGNATURE QF CO-APPllCANTlTITLE.OF AUTHORIZED SIGNER - - _ - - ~ - Estate ofi NICHOLAS J MAJERCNIK PPG lD: 10310:•. Soc Sec No: 166 CAROL STREET Check No. 306.267015 NEVI! CUMBERLAND PA 17070 ANowanr;e Withholding Status Federal: 0 Single State (PA) : 0 Not Used Earnings ~HQurs ~ Current '~ Y-T-D peductions Current Y 'AYMENT AT DEATH 14149.62 141.49.62 PAYMENT TO ESTATE 12211.22 12211.22 ti c i Current Y•T~D .. .,. DesCrlpt~on :> Currant ' Y~T-D' S on. r p Des 00 U Q Oash urns 12211.22 12211.22 Federal Taxably Gross 0.00 0. p~!M Pre-Tax Deduction 0.00 0.00 State Taxable Cross 0.00 0.00 A M Tax Deductions 0.00 0.00 00 0 FICA Taxable Gzoss 0.00 0.00 Y A Other Deductions 0.00 . R • NET PAY 1221.1.22 1221.1.22. Y -- Detach end retain this statement of earnings and deductions !: PAYROLL CHECK PPG INDUSTRIES PAY Twelve Thousand Two Hundred Eleven Dollars And 22' Cents*,f*,-~~~*~~***~*~•w*~•~•~~r*~t*~*~r.~•~*•>f~*~tf~***~a~*.**•~~ TO THE Estate of NICHOLAS J MAJERCNIK oROER oF: 1 Sg .CAROL STREET .~.-.,,, r.r ~~~oco~ nnin oe 17f17(1 ++~~n~,aafi.?nL~++• ~:D53LOL56L~~ ~0?9900~i~93i8++• A ~ . 531 CHECK Noy 30622670't 5 r rv t~ ~uu~~>< ~C~ July 11, 2011 Ms. Lisa A. Majerchik 168 Carol Street New Cumberland, PA 17070 Dear Ms. Majerchik: You recently processed a total distribution of the PPG Employee Savings Ptan as the beneficiary of recently deceased plan participant Mr. Nicholas Majerchik's Savings Pian account balance. Please accept my condolences on his death. We discovered after the monies had been transferred into your account and subsequently paid out to you that his account had not been adjusted for the May Savings Plan deductions and matching company contributions that were deducted on his original May paycheck but then refunded back to him after his May 25 passing. !f you look at his May 2421 month-end check yvu will not see any Savings Plan deductions. The May deductions and company matching contributions overpaid to you total $1,999.25. The $1,999.25 overpayment includes $1,634.00 in before-tax contributions and $365.25 in company matching contributions (see the attached for the posting of these contributions to his account). Please send a check made payable to PPG Industries in the amount of $1,999.25 to my attention at PPG Industries, Inc., One PPG Place -- 4t" Eloor, PGH, PA 15272 to clear up this overpayment. We apologize for this error and any confusion the contents of this letter may cause. If you have any questions or need a further explanation, please call me at (412) 434.3926. Sincerely, L7 . oseph G. Zyra, Manager PPG Employee Savings Pian Attachment ----~,,;>h. ~,;~ ~ d~ ~ ~ yk ~:'~ ~ ,~ _c~aC+~.T ;'Y ~ ..-~ ~f ~ b- ~'C'./ jl? ~" a,a dux .: ..c,.. '~°'.. a`,3~L.aa{pth F ~ ryq~,, ~.~~+~.~?~!wyR:{i~6+.-^'YiE+~ R v+ ,~ ,' . Nicholas J. Ma~erchik Estate _., . . , so-eos9~zs,s 1001 Lisa Q. Majerchik, Executrix 168 Carol St. New Cumberland, PA 17070 -~~ +? 1 DgsE pQr.~. 7~/'~ r ORDER OF E '''r~f ~ ~ J 'R"' ~ 1 i V .~-'t 1 ; , J V 'T C' v i ~ ~ ~ ' i~ ~~~~~a; o u°~~ ~ ~ ~~~ f ~ . ARS ! e.a BELCO COMMUN/iY CAEDi7 UNION Baewt~ur6rGW~ ~: 2 3 ~ 38099 ?~: 00089 29 3 58~~' 4.-,.~ L00 ~, - r ~~ ~~~c~ . Lisa Ann Majerch~k ~t - M14. G~4 c~'C' (,1 ~ ~j ~ - y C'~G~~1;~-~~l j~rt a -~Z:l~ ~ r . ~~4 2 v (~ -~.~ ~1~ ~,h~- ~z..J~ - ~ ~ ~~~ (en c h t tt -,'Y1 t.~ ~~-~ ~ fn us b~ C.1nec~i~ ~e n c (a ~~' -- ~'1011`. -c:.. ~v V (J'~,b~. ~~w r,,~, _, REV-1509 EX + (1-97) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Nicholas Jon Ma i erchik ~~ Ko 2f-«'OG~~ /2,~c(- bc~~n __._ V If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT B C. JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name of financial institution and bank account number or similar identifying number. Attach deed for jointly-held real estate. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. None TOTAL (Also enter on line 6, Recapitulation) $ 0.00 (If more space is needed, insert additional sheets of the same size) REV-1510 Ex + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE G INTER-VIVOS TRANSFERS ~ MISC. NON-PROBATE PROPERTY Nicholas Jon Majerchik FILE NUMBER ' t'/J '~- Zc-I~-~Y~Sr-1 / ~~ - ob~aS'~ This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE . DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION IF APPLICABLE TAXABLE VALUE 1. None TOTAL (Also enter on line 7, Recapitulation) I $ 0.00 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) SCHEDULE M COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Nicholas Jon Majerchik (~ ~_ 2 t-<c -~ `Z~,r -~,~-~ Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Parthemore Funeral Home and Creation Services, Inc. Partehmore fee = $ 4,268.57 Less $100.00 'dotal = $4,168.57 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Lisa A. MajerC~llk Street Address 168Carol__ Street ___ ~ ~. __ ___ _T ____ ~; :_ ___ New Cumberland PA 17070 City State Zip ____.___ Year(s) Commission Paid: ------- ~ .-0~-------- -------- - ----- 2 • Attorney Fees $ 0 . ~~ 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees $ 238.50 5. Accountant's Fees $ 0.00 6. Tax Return Preparer's Fees $ 0.00 7 $4,168.57 $ 238.50 TOTAL (Also enter on line 9, Recapitulation) I $ 4, 407.07 (If more space is needed, insert additional sheets of the same size) \~~~~~// ~~ ~ A Family Tradition Of Caring' PARTHEMORE Funeral Home & Cremation Services, Inc. 1303 Bridge Street P.O. Box 431 New Cumberland, 'PA 17070 (717j 774-7721 (Fax) 774-546 vcwvw.parthemore.com Gilbert W. Parthemore, Founder Gilbert J. Parthemore, Supervisor Stephen K. Parthemore, CFSP Bruce R. Parthemore, Pre-Need Coordinator, CPC Professional Memberships: NFDA • PFDA DCFDA • CCFDA t,~.,~„~ o~,aa ~~,,~ G ~~ E~ LE The Rule 2'ou Knox, The People ~°ou Trust - -;~ ~ ~ ~; __: m n Mrs. Lisa A. Majerchik 168 Carol Street New Cumberland, PA 17070 6/3/2011 We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. The following is an itemized statement of the services, facilities, automotive equipment and merchandise that you selected when making the funeral arrangements. Terms Due Date Account # Net 30 7/3/2011 2011035.1 Description Amount SERVICES & MERCHANDISE Visitation/Viewing 435.00 1vlemorial Service 575.00 Reflections Stationery Set 135.00 Direct Cremation 2,250.00 Memory Chest Urn, Cherry 188.00 Total Services and Merchandise 3,583.00 CASH ADVANCE ITEMS Death Notice, Harrisburg Patriot 215.57 20 Certified Copies of Death Certificate 120.00 Clergy Honorarium 200.00 Organist Honorarium 125:00 Cumberland County Coroner Fee, Cremation Authorization 25:00 Total Cash Advances 685.57 ~t ~_p~, , ~~ F- ~ ~W nts-~ ~1~~ ~ ~ ~~ ~(,~-i ~ G~.~ k~ o~ ~%~.~ w-e, can Vin. ~ tom, ~.e. ~oG ~ ~ ~-~ ~~ ~ ~ ~Q ~ `~ Cr t Total $4,26s.s7 Payments/Credits $o.oo Balance Due $4,268.57 J try ~, Zo l I ~. ~. ~. - - -- y A Family Tradition Of Caring Funeral Home & Cremation Services, Inc. - - ~ ~. Majerchik 6/3/2011 treet erland, PA 17070 ,y appreciate the confidence you have placed in us and will .continue to assist you in every way ase feel free to contact us if you have any questions in regard to this statement. The following :d statement of the services, facilities, automotive equipment and merchandise that you selected g the funeral arrangements. - - - ~ Terms -` .. ._ ._. -~ . ~.- - Net 30 ._._.._~_~..,~j.;~',,='~'~.-%,:r_~ ~k.- ~ MERCHANDISE ,~ . _... -- i ~~ Super<~isor Stephen K. Parthemore, CFSP Bruce R. Parthemore, Pre-Need Coordinator, CPC Professional Memberships NFDA • PFDA DCFDA • CCFDA In7ernabone{ Oder of the G ~~ EN LE The Rule You Know. The People You Trusr °~g vice :ationery Set :ion t Urn, Cherry Total Services and 1Vlerchandise -CASH ADVANCE ITEIVIS Death Notice, Harrisburg Patriot 20 Certified Copies of Death Certificate Clergy Honorarium Organist Honorarium Cumberland County Coroner Fee, Cremation Authorization Total Cash Advances 435.00 575.00 135.00 2,250.00 188.00 3,583.00 215.57 120.00 200.00 125.00 25:00 685.57 ~l?{ C-~I So~.~ ~~.aa.~ kin out ~a.-~ w-e. cQn ~-1n ~0 10~. ~o~ ~o~ ~ I~a.~ ~ ~~n ors ~ ~a - `s~n~aU ~- - ~~~_ ~i . ~-- n Due Date ~ Account # 7/3/2011 2011035.1 Description Amount Total $4,26s.s7 Payments/Credits $o.oo Balance Due $4,268.57 J~`I ~a 2f~ll ~i,d ~~. ~ t~~ • 5~I RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date: 6/08/2011 Cumberland County - Register Of Wills Receipt Time: 13:56:23 One Courthouse Square Receipt No.: 1065880 Carlisle, PA 17613 MAJERCHIK NICHOLAS JON Estate File No.: 2011-00657 Paid By Remarks: LISA MAJERCHIK CJ ------------------------ Receipt Distribution ----- -------- ------- ---- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 135.00 CUMBERLAND COUNTY GENERAL FUN WILL SHORT CERTIFICATE 15.00 60.00 CUMBERLAND CUMBERLAND COUNTY COUNTY GENERAL GENERAL FUN FUN JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M D AUTOMATION FEE 5.00 - CUMBERLAND COUNTY GENERAL . FUN Check# 3543 --------------- $238.50 Total Received......... $238.50 / Track Your ~xpensas ^ AutoJt'rwvel d Eduoatiort Q Medlcaf/Dentat ^ Business d Entertainment ^ Savings ,~° ~ D Charities ^ Food D Taxes ` ~ ~ ~ t ~-~ ~ O Clothing p Home ^ Utilities ~ '-•" ^ Dependent Care ^ Insurance ^ Other ~~' FOR'p ITfM AMOUNT m , 1 ~ ~ 1 f.,'~J~~J r ~ i._.Jr ~i `; ~.. 1. t~ f !'' ~, i ; j (. r.~. ~ ~~ { ~ 1. i~' r ~.~ t ^~ ~ (~, :i ~~ ...~.._BALAN~%,~ DEAO$IT For enhanced security your account number has been blocked out on this copy ____ ,~. Foa•o TAX DEDUCTIBLE ITEM ^+ °~~"! ~,~ r _ D ''~ yy _._. s t 5 1 i ' NEGOTIABLE . _..~ ._ _...,....._..r~._ .. .~., .. REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCI~IEDIJLE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NU BER Nicholas Jon Majerchik /~ Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. (It more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) SCI~IEDIJLE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER / Nicholas Jon Majerchik `~/~ ~, -z(_~~ _o~s7 /~.~«_~Y,c~-~, RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)) 1. Lisa A. Majerchik Wife 100% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. None B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 ~ None TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ Q , 00 (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMENT OF NICHOLAS JON MAJERCHIK I, NICHOLAS JON MAJERCHIK of New Cumberland, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament, and revoke any and all previous Wills and Codicils I have made. ITEM I: I direct that all of my just debts and funeral expenses, including all expenses of my last illness, shall be paid from my residuary estate as soon as practicable after my death, as a part of the expense of the administration of my estate. ITEM II: All federal, state, and other death taxes payable because of my death with respect to the property forming my gross estate for tax purposes, whether or not passing under this Will, including any interest or penalty imposed in connection with such tax, shall be considered a part of the expense of the administration of my estate and shall be paid out of the residue of my estate, without apportionment or right of reimbursement. ITEM III: I give, devise, and bequeath all the rest, residue and remainder of my estate, wheresoever situate, to my wife, Lisa Ann Majerchik on the condition that she survives me by a period of thirty days. ITEM IV: If my wife, Lisa Ann Majerchik, does not survive me a period of thirty days, I then give, devise, and bequeath all the rest, residue, and remainder of ~-~, t:.. ~~ ~ ~ ~-- my estate as follows ~' ~-~ T t _` , r' r--. -- ~ ~ . ~_ .i ~~~ ~ ~ r` ,` _..1.~ .. , i -,-= D ` j O 1) My nephew, Mark Wentz, should receive my Admiral pocket watch with gold moose chain. This was my grandfather's watch. 2} My nephew, Mark Wentz, should also receive the Valley Forge grandfather clock. 3) My niece, Lisa Scott, should receive the Nichols and Stone rocker. 4) My niece, Lisa Scott, should also receive a bench and small table. Both of these items are made of wood and are black in color. They were gifts from my mother. 5) My niece, Lisa Scott, should also receive my wife's quilt collection. 6) My great-niece, Allison Scott (daughter of Lisa Scott) should receive the Jewell Tea China Collection and all of the jewelry except the Admiral pocket watch previously devised to Mark Wentz. 7) Daniel Smith, should receive all of my tools albeit mechanical, woodworking, gardening, etc. 8} The remaining assets of my estate should be made part of the residual estate. The residual estate should be distributed as follows. A) Eighty percent (80%) of the residual estate should be given to my mother Julia Maj erchik. If my mother should predecease me, eighty percent (80%) of the residual estate should be given to my sister Georgiann Wentz. If both my mother (Julia Majerchik) and 2 sister (Georgiann Wentz) should predecease me, forty percent (40%) of the residual estate should be given to my nephew, Mark Wentz, and forty percent (40%) of the residual estate should be given to my niece, Lisa Scott. B) Ten percent (10%) of the residual estate should be given to the Penn State University, Beaver Campus, College of Mechanical Engineering for a scholarship fund. C) Ten percent (10%) of the residual estate should be given to The Pymatuning Yacht Club to be used only for the installation of new windows in the main clubhouse. D) If Mark Wentz, Lisa Scott, Penn State University, Beaver Campus or The Pymatuning Yacht Club are in any way unable or unwilling to accept the portions of the residual estate specifically devised to them, the percentages of the residual estate that I have allocated to the persons} or entity(ies) unwilling or unable to accept their share(s) should be made part of the general residual estate and equally distributed to the remaining aforementioned persons or entities willing and able to receive their shares. ITEM V: I hereby appoint my wife, Lisa Ann Majerchik as Executrix of this my Last Will and Testament. If my wife, Lisa Ann Majerchik should predecease me, 3 or otherwise fail to qualify as Executrix, I then appoint Daniel Smith as Executor. Mr. Smith resided at 3 88 W. County Line Road, Jamestown, PA 1 b 134 at the time this Will was created. ITEM VI: I direct that no Executrix or Executor serving hereunder be required to post bond or enter security in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal this a ~ day of ~--~--~ , 200. ~~ "'~~ ~ ~ ~4~ (SEAL) NICHOLAS JON JERCHIK The preceding instrument, consisting of this and three other typewritten pages, was, on the date thereof signed, published, and declared by, the named Testator, NICHOLAS JON MAJERCHIK as his Last Will, in the presence of us, who at his request, in his presence and in the presence of each other, have subscribed our names as witnesses hereto. ~ residing at ~: ~~s: ~ r~ , ~w ~~.,.. ~~~ ~,~ ~ .~ ~ '~`~-~- ,vim residing at ~,2~ ~ - ,~,~-,~.~,~ , r ~G,,. ~~~ ~ , 4 COMMONWEALTH OF PENNSYLVANL~ COUNTY OF CUMBERLAND ss: WE, NICHOLAS JON MAJERCHIK, ~'c~~ +~ ,~ ~ ~ ~re.~r-~ ~{ ,and ~-r'1-ems. dL ~ ~ v `' ~~ the Testator and the v~~itnesses, res ectivel , p Y whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his Last Will and Testament, and that he had signed willingly and that he executed it as his free and voluntary .act for the purpose therein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as witnesses and that to the best of their knowledge the Testator was at that time eighteen years of age or older, of sound mind, and under no constraint or undue influence. ^'~~T_ NICHOLAS JO MAJERCHLK Witrie`ss t.,e.~ ~~~ Witness Subscribed, sworn to, and acknowledged before me by NICHOLAS JON MAJERCHIK, the Testator, and subscribed and sworn to before me by ~vf~r~ (~ ~ o~~e~ ~~ and ~~,~~~., ~-- ~~ o~ e.~s ,witnesses, this r~~-f' day of `~~-- , 200. ~, COMrufUt',WtALi h UI• PEIVNS'r'LvN,ivit~ I~ Public NOTARIAL SEAL BARBARA STUMP, Notary Public Camp Hitl Boro, Cumberland County - e My Commissior+ Expires Nov. 12, 2010 ~ ~ - - - ~ ~ ~~~ ~ ~~~~,~~~ ~~~- - My Commission Expires: ~ ~ ~~ ~ ~ G5 ~ 5