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Home My WebLink About10-14-111 1505610105 REV- i ~oo EX (oz-ii) (FI) OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Year File Number Bureau of Individual Taxes oEO.w1~E o. INHERITANCE TAX RETURN PO BOX z8o6oi ^-~ Harrisburg, PA 1'7128-o6oi RESIDENT DECEDENT ~-~ ~ ~ ~ c~ c~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYW Date of Birth MMDDYYYY 209-12-5368 01 /14/2011 11 /05/1923 Decedent's Last Name Suffix Decedent's First Name MI Navratil Nada M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW CIC 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 Tai: 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 Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Teresa L Shaner First Line of Address 23 Edgewood Drive Second Line of Address City or Post Office Mechanicsburg State ZIP Code PA 17055 Correspondent's a-mail address: REGISTER ~ BLS USE ONLY ~.".. ~ ~. ~ `~ _ ' ~ .,:. ~. ,.._ . ~..rl ..... - ~~ ~~ -. 1. ..._ -~ ~E FILED ~ .~~ unaer penalties of perjury, I declare that 1 have examined this return, inGuding 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 OF PERSON RESPO BLE FOR FILING RETURN UA E ADDRESS 23 Edgewood Drive Mechanicsburg PA 17055 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE HUUKtJJ PLEASE USE ORIGINAL FORM ONLY (717)697-8329 Z7 i ~ t l~ Side 1 ~,~, 1505610105 1505610105 J Previous editions are obsolete A. Settlement Statement B. Tvoe of Loan form HUD-1 (3/86) ref Handbook 4305.2 U.S. Department of Housing and Urban Development OMB ADDroval No_ 2502-0265 1. ^FHA 2. ^FmHA 3. ^Conv. Unins. 6. File Number 4. ^VA 5. ^Conv.lns. 31261PRENEAU - 7. Loan Number 8. Mortgage Insurance Case Number TFis orm is urrns e o give you a sra emt~ of ua se emeTcos~s. rr~f pa~an~ y e se amen agen are s own. C. NOte: Items marked'(p.o.c.)° were paid outside the closing; they are shown here for information purposes and are not included in the totals. WARNING: h is a crime to knowingly make false statements to the United States on this or any other similar form. Penalties upon conviction can include a fine and im dsonment. For details see: Title 18 U. S. Code Section 1001 and Section 1010. TlteEXpreSS Settlement System Pflnted O4/O8/2011 at 10:17 CLT D. NAME OF BORROWER: Paul G. Preneau and Therese Yvonne Preneau ADDRESS: 6324 Chesterfield Lane Mechanicsbur Pa 17050 E. NAME OF SELLER: Estate of Nada Navratil ADDRESS: 837 N. Walnut Street Mechanicsbur PA 17055 F. NAME OF LENDER: ADDRESS: G. PROPERTY ADDRESS: 837 N. Walnut Street, Mechanicsburg, PA 17055 Mechanicsbur Borou h H. SETTLEMENT AGENT: Keystone Land Transfer, LTD PLACE OF SETTLEMENT: 3421 Market Street Cam Hill Pa 17011 I. SETTLEMENT DATE: 04/08!2011 J. SUMMARY OF BORROWER'S TRANSACTION: K. SUMMARY OF SELLER'S TRANSACTION: 100. GROSS AMOUNT DUE FROM BORROWER 400. GROSS AMOUNT DUE TO SELLER 101. Contract sales rice 133 000.00 401. Contract sales rice 133 000.00 102. Personal Pro art _ 402. Personal Pro art 103. Settlement char es to borrower line 1400 2 708.37 403. 104. 404. 105. 405. Ad'usVnents for items aid b seller in advance Ad'ustments for items paid b seller in advance 106. Cit /town taxes 406. Cit /town taxes 107. Count taxes 04/08/11 to12131/11 433.66 407. Count taxes 04/08/11 to12/31/11 433.66 108. School taxes 04/08/11 to06/30/11 285.42 408. School taxes 04/08/11 to06/30/11 285.42 109. 409. 110. 2nd tr assoc dues rtn 04/08111 to 06/30/11 109.45 410. 2nd tr assoc dues rtn 04/08/11 to 06/30/11 109.45 111. 2nd tr sewer/trash rtn04/08/11 to06/30/11 107.91 411. 2nd tr sewer/trash rtn04/08111 to0fi/30/11 107.91 112. 412. 120. GROSS AMOUNT DUE FROM BORROWER 136 644.81 420. GROSS AMOUNT DUE TO SELLER 133 936.44 200. AMOUNTS PAID BY OR ON BEHALF OF BOR ROWER 500. REDUCTIONS IN AMOUNT DUE TO SELLER 201. De osit or earnest mone 1 000.00 501. Excess De sit see instructions 202. Princi al amount of new loans 502. Settlement char es to seller line 140(]_ 10 576.16 203. Existin loan s taken sub'ect to 503. Existin loan s taken sub'ect to 204. 504. Pa off of First Mort a e Loan 205. 505. 206. 506. 207. 507. 208. _ 508. 209. 509. Ad'ustments for items un aid b seller Ad'ustments for items un aid b seller 210. Cit /town taxes 510. Cit /town taxes 211. Count taxes _ 511. Count taxes 212. School taxes _ 512. School taxes 213. 513. 214. __ 514. 215. 515. Inheritance Tax Escrow 7 481.25 216. 516. ~- 217. 517. 218. 518. 219. _ 519. 220. TOTAL PAID BY/FOR BORROWER 1 000.00 520. TOTAL REDUCTION AMOUNT DUE SELLER 18 057.41 300. CASH AT SETTLEMENT FROM OR TO BORROWER 600. CASH AT SETTLEMENT TO OR FROM SELLER 301. Gross amount due from borrower line 120 136 644.81 601. Gross amount due to seller line 420 133 936.44 302. Less amounts aid b /for borrower line 220 1 000.00 602. Less reduction amount due seller line 520 18 057.41 303. CASH FROM BORROWER 135 644.81 603. CASH TO SELLER 115 879.03 SUBSTITUTE FORM 1099 SELLER STATEMENT: The information contained herein is important tax information and is being furnished to the Internal Revenue Service. If you are required to file a return, a negligence penalty or other sanction will be imposed on you if this item is required to be reponed and the IRS determines that it has not been reported. The Contract Sales Price described on line 401 above constitutes the Gross Proceeds of [his transaction. You are required by law to provide the settlement agent (Fed. Tax ID No: 1 with your correct taxpayer identification number. If you do not provide your correct taxpayer identification number, you may be sublect to civil or cdminal penalties imposed by law. Under penalties of perjury, I certify that the number shown on this statement is my correct taxpayer identification number. TIN: / SELLER(S)SIGNATURE(S): SELLER(S) NEW MAILING ADDRESS: SELLER(S) PHONE NUMBERS: PENNSYLVANIA INHERITANCE T INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES A N D PD Box zeocol TAXPAYER RESPONSE HARRISBURG PA 17128-D601 REV-1543 EX AFP (OB-OB) FILE N0. 21 ACN 11105342 DATE 01-31-2011 TERESA L SHANER 23 EDGEWOOD DR MECHANICSBURG PA 17055 EST. OF NADA M NAVRATIL SSN 209-12-5368 DATE OF DEATH 01-14-2011 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS ® CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call (717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 40676-11 Date 09-08-1984 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance 2 421.95 payment to the Register of Wills. Make check ~ payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 1 ~ 210.98 months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due wall become delinquent Potential Tax Due $` 54.49 nine months after the date of death. PART TAXPAYER RESPONSE FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of 0 N E Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K ~ B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3^ below. PART If indicating a different tax rate, please state OFFICIAL USE ONLY ~ AAF relationship to decedent: PA DEPARTMENT OF REVENUE TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1. Late Established 1 1 2. Account Balance 2 $ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 - 5 6. Amount Taxable 6 $ 6 7. Tax Rate 7 X 7 8. Tax Due 8 $ 8 PART DEBTS AND DEDUCTIONS CLAIMED ^3 DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. HOME C ~ WORK ( ~ TAXPAYER SIGNATURE TELEPHONE NUMBER DATE iuiwL (inter on Line 5 of Tax Computation) 8: PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE NO. 21 Po Box zaocol TAXPAYER RESPONSE ACN 11105343 HARRISBURG PA 17128-0601 DATE 01-31-2011 REV-1543 EX AFP (OB-08) TYPE OF ACCOUNT EST. OF NADA M NAVRATIL ~ SAVINGS SSN 209-12-5368 ~ CHECKING DATE OF DEATH O 1-14 - 2011 ~ TRUST COUNTY CUMBERLAND ~ CERTIF. REMIT PAYMENT AND FORMS T0: TERESA L SHANER REGISTER OF WILLS 23 EDGEWOOD DR 1 COURTHOUSE SQUARE MECHANICSBURG PA 17055 CARLISLE PA 17013 MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a ,ioint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717; 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUICTIONS Account No. 40676-42 Date 09-08-1984 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance 10 045.50 payment to the Register of Wills. Make check ~ payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 5, 022.75 months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential TaX Due ~` 226.02 nine months after the date of death. P~T TAXPAYER RESPONSE ~ FAIIURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. ONE B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were vaid. Complete PART ~2 and/or PART 3~ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 $ 3 X 4 $ 5 6 '~ 7 X 8 $ PAD OFFICIAL USE ONLY ~ AAF PA DEPARTMENT OF REVENUE 1 2 3 4 5 6 7 8 PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. H OME C ) WORK C ) TAXPAYER SIGNATURE TELEPHONE NUMBER DATE TOTAL (Enter on Line 5 of Tax Computation) 5 PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND F I L E Po Box 260601 TAXPAYER RESPONSE ACN HARRISBURG PA 17128-0601 DATE REV-1543 E% RFP (R8 -0 B) N0. 21 11105344 01-31-2011 TERESA L SHANER 23 EDGEWOOD DR MECHANICSBURG PA 17055 EST. OF NADA M NAVRATIL SSN 209-12-5368 DATE OF DEATH 01-14-2011 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach. a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 787-8327 with questions. COMPLETE PART I BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 40676-43 Date 09-08-1984 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance 11 payment to the Register of Wills. Make check 2 521 $ . ~ payable to "Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to Tax NOTE: If tax payments are made within three $ 1 260 56 ~ . months of the decedent's date of death, Tax Rate )( .045 deduct a 5 percent discount on the tax due. Potential Tax Due Any Inheritance Tax due will become delinquent $ 56.73 nine months after the date of death. PART TAXPAYER RESPONSE FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. ONE B L 0 C K ~ B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART ~ below. PART If indicating a different tax rate, please state OFFICIAL USE ONLY ~ AAF relationship to decedent: pA DEPARTMENT OF REYENUE TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE 1. Date Established 1 1 2. Account Balance 2 $ 2 3. Percent Taxable 3 X 3 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 - 5 6. Amount Taxable 6 $ 6 7. Tax Rate 7 X 7 8. Tax Due 8 $ g' PART DEBTS AND DEDUCTIONS CLAIMED 3^ DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. HOME C ) WORK TAXPAYER SIGNATURE TELEPHONE NUMBER DATE IUTAL linter on Line 5 of Tax Computation) :> REV-i511 EX+ (10-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Nada M. Navratil 2111-0359 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' ObiturarylExtra Death Certificates & Flowers paid to Myers Funeral Home 665.00 2. Church Rental to hold funeral service & luncheon in -Grantham Brethren in Church 200.00 3. Pastor -The Rev. Daniel R. Mikesell 200.00 4. Organist -Lois Payne 75.00 5. Funeral Luncheon -Dan Asbury, Ida Wenger, Shirley Brubaker 400.00 s. Gingrich Memorials -Engrave Date 160.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City _ ___ __ State ZIP Year(s) Commission Paid: Z• Attorney Fees: 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: 315.50 S• Accountant Fees: 6• Tax Return Preparer Fees: ~• Replace roof on Real Estate -Old Glory Contractors 4,299.19 $. Closing Costs on Real Estate -Settlement 4/8/2011 10,576.16 s. 10. 11 12 TOTAL (Also enter on Line 9, Recapitulation) ai 16,890.85 If more space is needed, use additional sheets of paper of the same size. ~, Olde Glory Contractors, 219 York Street Hanover, PA 17331 717-633-5254 Fax: 717-632-9101 Bill To ',Teresa Navratil-Shaner 1837 N. Walnut Street Mechanicsburg, PA 17055 Invoice Date work began Invoice # 4/4/2011 02233 Terms Claim # Due on receipt Quantity Description Price Each Amount Total Cost of Repairs: 2,255.4'1 2,255.41 Deductible: $500.00 Additional 8 Square of Roofing (other half not covered by 2,043.78 2,043.78 insurance) . 1 ~I lJ II °~ ' Subtotal $4,299.19 Payments/Credits $-2,255.41 Balance Dine $2,043.78 U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT File Number: 31261 PRENEAU PAGE 2 SETTLEMENT STATEMENT TitleEx ress Settlement S stem Printed 04/08/2011 at 10.17 CLT L. SETTLEMENT CHARGES PAID FROM PAID FROM 70C. TOTAL SALES/BROKER'S COMMISSION based on rice $133 000.00 = 7 980.00 BORROWER'S SELLER'S Division of commission line 700 as follows: FUNDS AT FUNDS AT 701. $ 3 990.00 to Re/Max Real Associates SETTLEMENT SETTLEMENT 702. 3 990.00 to Era-Nrt Inc. LLC 703. Commission aid at Settlement 7 980.00 704. Broker Fee to Era-Nrt Inc. LLC 195.00 800. ITEMS PAYABLE IN CONNECTION WITH LOAN 801. Loan Ori ination Fee 802. Loan Discount 803. A raisal Fee 804. Credit Re ort 805. Lender's Ins ection Fee 806. Mort e A lication Fee 807. Assum lion Fee 808. 809. 810. 811. 900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 901. Interest From to ~ /da 902. Mort a e Insurance Premium for to 903. Hazard Insurance Premium for to 904. 905. 1000. RESERVES DEPOSITED WITH LENDER FOR 1001. Hazard Insurance mo. @ Imo 1002. Mort a e Insurance mo. ~ $ /mo 1003. Cit Pro ert Tax mo. ~ /mo 1004. Coun Pro ert Tax mo. (~ $ 49.40 /mo 1005. School taxes mo. ~ $ 104.60 /mo 1009. A re ate Anal sis Ad'ustment 0.00 0.00 1100. TITLE CHARGES 1101. Settlement or closin fee 1102. Abstract or title search 1103. Escrow Fee -Inheritance Tax to Stone Lafaver &Shekletski 125.00 . 1104. Title insurance binder I 1105. Document Pre aration to Stone Lafaver &Shekletski 150.00 1106. Nola Fees to Cash 10.00 1107. Attomev's fees includes above items No: I 1108. Title Insurance to Ke stone Land Transfer LTD 921.37 includes above items No: 1109. Lender's Poli 1110. Owner's Polic 133 000.00 - 921.37 1111. 1112. 1113. 1200. GOVERNMENT RECORDING AND TRANSFER CHARGES 1201. Recordin Fees Deed $ 62.00 • Mort a e $ • Release $ 62.00 1202. Cit /Count tax/stam s Deed 1 330.00 • Mort a e $ 1 330.00 1203. State Tax/stam s Deed 1 330.00 • Mort a e $ 1330.00 1204. 1205. 1300. ADDITIONAL SETTLEMENT CHARGES 1301. Surve 1302. Pest Ins action 1303. Broker Fee to Re/Max Real Associates 395.00 1304. 2nd tr assoc dues to W nnewood Park Townhouse Owners Assoc P.O.C. 120.00 Seller 1305. 2011 Coun Tax to Bar L. Heckard* 592.84 1306. 2010 School Tax to Ba L. Heckard* P.O.C. 1 255.18 Seller 1307. 2nd tr sewer/trash to Mechanicsbur Borou h 118.32 1308. Re-Sale Cert to W nnewood Park Townhome Owners Assoc 75.00 1400. TOTAL SETTLEMENT CHARGES enter on lines 103 Section J and 502 Section K 2 708.37 10 576.16 HUD CERTIFICATION OF BUYER AND: I have carefully reviewed the HUD-7 Settlement Statement and to the st of my knowledge and belief, h i or by me in this transaction. I further certify that I have receive a p f ih HUD1 Settlement Statemen au reneau r'. r Estate of Nada Navratil /~ y: eresa aver, xecu rix WARNING: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON CONVICTION CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 78: U.S. CODE SECTION 7001 AND SECTION 1010. The HUD-t Settlement Statement which I have preparetl is a true and accurate account of this transaction. I have caused or wilJl /ca/u~seyy/th//e,~funJds/%tofb/e~disburs/tee/dpi/a/c~coJrdance with this statement. SETTLEMENT AGENT: l L '° '•~~~i'Z~ ~JC/ DATE: REV-1512 EX+ (12-OS) ~ Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE 7AX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Nada M. Navratil 2111-035!3 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1• Golden Living Centers -Rehab 1102-1106 portion not covered by Insurance 707.50 2. Physicians of Rehabilitation, Industrial & Spine Medicine -portion not covered by Insurance 6.32 3. Physicians of Rehabilitation, Industrial & Spine Medicine -portion not covered by Insurance 97.84 4. Water Bills for Real Estate paid after death up to sale of home 418/11 42.81 5. Electric Bills for Real Estate paid after death up to sale of home 418/11 (total electric town home) 588.35 6. Sewer and Trash Bill paid to Mechanicsburg Borough 118.32 7. Homeowner Assocation Bill for 1st & 2nd Qtr 2011 -Paid to Wynnwood Assoc. 240.00 S. Visa Bill Dec. charges Patriot News, Home Service Water & Sewer renewals & Lifeline- paid Feb 2011 259.38 TOTAL (Also enter on Line 10, Recapitulation) I ~ 2,060.52 If more space is needed, insert additional sheets of the same size. IIIII III I IIIII IIIIIIIII IIIII I!II! IIIII IIIII IIIII I II IIII 1666843493 golden living centers WEST SHORE STATEMENT QUESTIONS ABOUT YOUR BILL? (866) 325-5606 STATEMENT BATE PATIENT NAME ACCOUNT NUMBER 02/01/2011 NADA NAVRATIL 00285434930001 PREVIOUS BALANCE NEW CHARGES PAYMENTS ADJUSTMENTS NEW BALANCE 0.00 707.50 0.00 0.00- 707.50 DATE/PERIOD COVERED ACCOUNT ACTIVITY OTY/DAYS CHARGES PAYMENTS ADJUSTMENTS 01/02/11 01/06/11 CO-INSURANCE 5 707.50 ~~~ / ,JJ ;,l ~~,+.., . n ~,~' ~~~ "} ~ r ~`' n ~ ~ . ~ ~ ~ ~ ~~~ i~ ~( Z. ~ ~ ~~ ~ ~ ~ ~ \ ~ ~~`l . ~l To ensure maximum utilization of your healthcare benefits, please remember to tell us about any ne~v insurance plans you may have, including Medicare and Medicare Advantage, by completing and mailing the reverse side of the coupon. Thank you for choosing Golden L/vingCenters. MAIL YOUR PAYMENT USING THE COUPON BELOW PAYMENT DUE DATE 02/15/2011 -OR- PAY YOUR BILL ONLINE AT www.goldenliving.com ` '' AMOUNT DUE • $ 707.50 DET P IIIII !1111 IIUI I I I III IIIII IIIII IIIII II III III II IIII 1714543493 golden living centers WEST SHORE STATEMENT QUE~iTIONS ABOUT YOUR BILL? (866) 325-5606 STATEMENT DATE PATIENT NAME ACCOUNT NUMBER 03/01/2011 NADA NAVRATIL 00285434930001 PREVIOUS BALANCE NEW CHARGES PAYMENTS ADJUSTMENTS NEW BALANCE 707.50 0.00 -707.50 0.00 0.00 DATE/PERIOD COVERED ACCOUNT ACTIVITY QTY/DAYS CHARGES PAYMENTS ADJUSTMENTS 02/11/11 PAYMENT -707.50 To ensure maximum utilization of your healthcare benefits, please remember to tell us about any nfsw insurance plans you may have, including Medicare and Medicare Advantage, by completing and mailing the reverse side of the coupon. Thank you for choosing Golden LivingCenters. PAYMENT MAIL YOUR PAYMENT USING THE COUPON BELOW DUE DATE 03/15/2011 -OR- PAY YOUR BILL ONLINE AT www.goldenliving.com ~ ~' AMOUNT DUE ' • $ 0.00 DETACH HERE AND RETURN BOTTOM PORTION WITH YOUR PAYMENT FOR TIMELY PROCESSING GOLDEN LIVINGCENTER -WEST SHORE C/O NORTHEAST BILLING OFFICE 1500 ARDMORE DRIVE, SUITE 101 PITTSBURGH PA 15221-4466 ^ Check box if address below is incorrect or insurance information has changed. Indicate changes on reverse side. TERESA SHANER 22 EDGEWOOD DRIVE MECHANICSBURG PA 17055-2781 00285434930001 NADA NAVRATIL .~ ~ .~ . ~ • 03%01/11 03/15/11 0.00 Check here to pay by credit card and enter credit card information below. ^ VISA ^ MASTERCARD ^ DISCOVER CARD NUMBER CVV CODE' ZIP CODE CARDHOLDER NAME EXP. DATE SIGNATURE AMOUNT I he (;VV cotle is athree-digit number usually found on the back of your credit card. Please Make Check or Money Order Payable To: GOLDEN LIVINGCENTER -WEST SHORE P.O. BOX 644407 PITTSBURGH P'A 15264-4407 PHYSICIANS OF REHABILITATION, INDUSTRIAL & SPINE MEDICINE, P.C. STATEMENT 1 "r, ~ aster Boulevard 4310 Londonderry Road Michael F. Lupinacci, M.U. STATEMENT DATE PAGE P.C). Box 2028 Bloom Bldg. Suite 106 William A. Rolle, Jr., M.D. --- - P/lechanirsburg, PA 17055 Han~isburg. PA 17109 (717) 691-3755 (717) 561-4242 www.prismdrs.com I~~'~'~°'~~~ ~• ~• ~=~~' Lisa A. Eaton, PsyD ACCOUNT Billing Dept: (I17) 591 4405 Tax I.D #25-1 65 1 500 Please retain this portion of statement for your records. NUMBER ~ ~`,T j ~IZI NSACTION DATF IPJV_NO 1 POST PRTIEIJT CDR ~ PROCEDURE _ DESCRIPTION OF SERVICES DIAGNOSIS AMOUNT tI~'1. x:11. ~!~::1/1.:1 1`•lA:UA h1F _ 4•~ fi~lEi) I CAPE-_" L~ I:~AI__I_QW hlAiiia II I}1F _ 1 r11 ~'~IYI~IF.h.!`i"_.h11~.'I7I Cf-~FiE: h!t-il~i~ ~ MF E~~~l AI~'f-'!_ I F.~I? 'TO T?E:I:~iJC'T I HI__r " 't`'C1IJ N - U E h11' C~~UF'C"!' I ~lha f=~L_E A~F= CA 1_ ~'~ 1. --.y.~~ 1. B T Wf-_"frha ~ : ~:;rZr AM faN~ ~+ a ~~~ 'i}1. ~ ~. ~~~-~ ~r. ti~ CURRENT OVER 30 DAYS-_ ~ OVER 60 DAYS OVER 90 DAYS OVER 120 DAYS ACCOUNT AGE ANALYSIS TOTAL AMOLINT DUE --- PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE ACCOUNT NO. C.,?. 4C- E5. ~~~- ~Hu, ~,4~ C./• JL~ • ~~ . ~ PLEASE MAKE: YOUR CHECK PAYABLE TO PRISM. PHYSICIANS OF REHABILIl"ATION,lNDUSTRIAL & SPINE MEDICINE P.C. 5 ".T 17 an~ster Boulevard 431 o Londonderry Road , Michael F. Lupinacci M D STATEMENT P.O. Box 2028 Mechanicsburg PA 17055 C31oom Bldg. Suite 106 , . . William A. Rolle, Jr., M.D. _ STATEMENT DATE PAGE , Harrisburg, PA 17109 (i17) 691-3755 (717) 561-4242 www.prismdrs.com Billing Dept: (717) 591-4405 Tax LU. #25-1651500 Lisa A. Eaton, PsyD r - ----- -- ~ V~AC'TION DATE INV. NO POS. - "-- -- ~ __ _ Please retain this ortion of statement for your records. P PP,iIENT T DR. PROCEDURE ---- ~ ~ ACCOUNT I NUMBER ,.~ •- ~ ~ ~ 1 J~~ 1 ! -- ' I - ------ - - --- DESCRIPTION OF SERVICES DIAGNOSIS AMOUNT . /~:.1 / 1 1 f ~C:f/ 7. 1 I NADA ~ !'~IFI~. NADF ~ ~ i~`fFI ~ 81Z+ r~F'F'I_IED TO DEDUCTI DLE ~ I~'~,l i i ' • NAD~ I~ ` ~ ~ 44?I t*iEUIGARE DISAL_Lt:]W r,:3. ,.:;k~ `l4!~`~f i 1 i t I It t " ~ 1 ~ f~~AYI~'IENT-t~IED I CARE C7. 48-- •>I~I~!11 j hlr:,Dt,~ Coif- I~ i'dADA i"* I= . 1~ f='A't'I~YENT-~PLUE ~HIELI) ~~..:,~ ~'`'..._ E /I;~t~l j• 1• i I 1 NADA I l~iEL i -4 --f `r'OL)R ~:hlD Ii'JS DOES h~lD"I~ COV -R • ~~-- '/~~'~! 1 1 i~lt"1D(-? 1'~il" I r f'~IED ]:CARE f--''ART B DED, THIS I S I f ~h'~/ 1 1 1 NI=1D~~ t~~~~'L. ~ --4 1 y. YOUR BALANCE F= AY ° ME.NI -BLUE SHIELD i I I i ~. ~. 91 _ I l YOU HF VE (~rlt{ OOEST I {~p~W:,~~ ~~LE_ASE GA L 5 =~ 1-rt4 WEEhJ ::~~ Ali IAND f+: ~~~~I hi, iB I ,~~1 ~~- i ~ ~ ~z5 ~ ____ _ ~_ T_-----_ . ~~+ ---- --- ~ ACCOUNT TOTAL JRRENT OVER 30 DAYS I OVER 60 DAYS OVER 90 DAYS OVER 120 DAYS AGE AMOUNI' ANALYSIS DUE --- PLEASE DETACH AND RE1 UHN I NIJ rvr-r ~ i~rv vvi ~ n ~ vvi ~ ~,"......,..__ ACCOUNT NO.___ J S~. ~~+ ~ ~~ • 5 PLEASE MAKE YOUR CHECK PAYABLE TO PRISM. REV-1513 EX+ (Oi-10) ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: ~ Pennsylvania SCHEDULE ~ INHERITANCE TAX RETURN RESIDENT DECEDENT BENEFICIARIES ESTATE OF: FILE NUMBER: Nada M. Navratil 2111-0359 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• Teresa L. Shaner, 23 Edgewood Dr. Mechanicsburg PA 17055 Daughter 1/3 2. John B. Navratil, 1354 Kiner Blvd. Carlisle PA 17015 Son 1/3 3. Robert Navratil Jr., 303 S. Baltimore St. Dillsburg PA 17019 Son 1 /3 II 1 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. `$ If more space is needed, use additional sheets of paper of the same size. REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA CERTIFICATE OF GRANT OF LETTERS No . 2011- 00359 PA No . 21- 11- 0359 Estate Of : NADA M NA VRA TlL (First, Middle, Last) Late Of : MECHANICSBURG BOROUGH CUMBERLAND COUNTY Deceased Social Security No : 209-12-5368 WHEREAS, on the 18th day of March 2011 an instrument dat=ed August 18th 2004 was admitted to probate as the last will of NADA M NA VRA TlL /First, Middle, Lastl late of MECHAN/CSBURG BOROUGH, CUMBERLAND County, who died on the 14th day of January 2011 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA EARNER STRASBAUGH Register of- Wills- in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: TERESA L SHA NER who has duly qualified as EXECUTOR(R/X) and has agreed to administer the estate according to law, all. of which fully appears of record in my office a t CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 18th day of March 2011. ` Regts~er of Wills (T i X ~ Ili ,~ ~~ ~~~(~~.t~l `s~~ 1 Deputy * *NOTE* * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST,) 1 y ~ ~ _ ' ~~'9 ~ + ~ . e j. ~ ~ ~°~' ' n ' ~ n ~ r't r'- , LAST WILL AND TESTAMENT OF - _ NADA M. NAVRATIL - I, NADA M. NAVRATIL, of Mechanicsburg, Cumberland County, Pennsylvania, do hereby make this my Last Will and Testament, revoking any former Wills and Codicils made by me. FIRST: I was married to ROBERT NAVRATIL, SR., and am now widowed. l: have three (3) children: TERESA L. SHANER (born 10/5/54); JOHN B. NAVRATIL (born 8/15/50); and ROBERT NAVRATIL, JR. (born 5/14/46). These persons and any children born to or adopted by them are described in this Will as "my issue." Provided, however, no adopted person shall benefit hereunder unless the order or decree of adoption is entered before such adopted person attains the age of twenty-one (21) years. SECOND: I give my tangible personal property and all casualty insurance that I am carrying on said tangible personal property to such of my children who are living at my death to be divided equitably among or between them as they may determine, or, if they are unable to agree, as my Executor shall determine, after considering the wishes of such children. I have complete confidence that my children or my Executor will honor any written instructions that I may leave with regard to said tangible personal property. Any such property not so distributed shall be sold, and the proceeds added to my residuary estate to pass as hereafter described. THIRD: I give, devise and bequeath all the rest, residue and remainder of my property of every kind and description (including lapsed legacies and devises) wherever situate and whether /~/~ . ~ r: S ~, :I', acquired before or after the execution of this Will, absolutely in fee simple to my three children in equal shares to be distributed as follows: (1) The shares for TERESA L. SHANER AND JOHN B. NAVRATIL will be distributed to them, or if they do not survive me to their issue, pet• stirpes; (2) The one-third (1/3) share going to ROBERT NAVRATIL., JR. shall be held in an irrevocable trust, the trustee being TERESA L. SHANI?R, or if she fails or refuses to act, to JOHN B. NAVRATIL. The funds shall beheld in a money market account or similar account with a monthly payment to ROBERT NAVRATIL, JR. in the amount of $400, until all funds are paid. 'The funds held in trust shall not be subject to levy and the payments shall not be permitted to be anticipated. It shall be held as an irrevocable, spend thrift trust four the sole benefit of ROBERT NAVRATIL,, JR. At the time of his death, if any funds are remaining in the trust, they will be distributed to the issue of ROBERT NAVRATIL, JR., namely ROBERT L. NAVRATIL and AMY J.:~"AVRATIL, in equal monthly shares of $200 per month, until all principal and interest has been distributed. FOURTH: If all the beneficiaries described in Article Third above are deceased and no other disposition of the residue of my estate is directed by this Will, then and in that event only, I give, devise and bequeath the rest, residue and remainder of my estate, real and personal, to those persons living at the date of my death who would be my heirs, their identities and respective shares to be determined in accordance with the law in effect in the Commonwealth of Pennsylvania at my death, as if I had died intestate. z ~ /~_ ,~ ;; .. 3 FIFTH: If any person under the age of twenty-one (21) years shall become entitled to any share hereunder, then such share shall immediately vest in such beneficiary, but notwithstanding the provisions herein, my Executor may distribute such beneficiary's share to any adult person standing in loco parentis, or to a legal guardian of such beneficiary, or to a custodian (to be selected by my Executor) under the applicable Uniform Transfers to Minors Act, without requiring bond of such adult person, guardian or custodian. The receipt of such adult person, guardian or custodian shall constitute a full release of my Executor for any property so distributed. SIXTH: No person shall benefit hereunder unless such beneficiary shall survive me by thirty (30) days. SEVENTH: (1) I name my daughter, TERESA L. SHAKER, as my Executor. If she is unable or unwilling to serve, I name my son, JOHN B. NAVRATIL, as my Executor. I direct that my daughter, herein referred to as my Executor regardless of number or gender, serve without bond in any jurisdiction in which called upon to act. (2) Except as otherwise provided herein, if all of the above persons should fail to qualify as my Executor hereunder, or for any reason should cease to act in such capacity, the successor or substitute Executor shall be some attorney or bank or trust company wiith trust powers, which successor or substitute Executor shall be designated in a written instrument filed with the court having jurisdiction over the probate of my estate and signed by my daughter, TERESA L. SHAKER, or if she fails to act, signed by or on behalf of my son, JOHN B. NAVRATIL, or if he fails to act, by the court having jurisdiction over the probate of'my estate. (3) My Executor shall receive reasonable compensation for services rendered. EIGHTH: (1) I give to any Executor named in this Will or any Codicil IZereto or to any successor or substitute Executor all of the powers enumerated in this Will and al]'~ of the powers applicable by law to fiduciaries in the Commonwealth of Pennsylvania and in particular through the Pennsylvania Probate, Estates and Fiduciaries Code, as effective and as in efi:ect on the date of my death, during the administration and until the completion of the distribution. of my estate. I direct that all such powers shall be construed in the broadest possible manner anti shall be exercisable without court authorization (2) My Executor is authorized and empowered to acquire and to retain, either permanently or for such period of time as my Executor may determine, any assets, including the capital stock of any closely held corporation, whether such assets are or are not of the character approved or authorized by law for investment by fiduciaries and whether such assets do or do not represent an over concentration in one investment. (3) My Executor is authorized and empowered to disclaim any interest, in whole or in part, of which I, or my Executor, may be the beneficiary, devisee, or legatee;, by executing an appropriate instrument (in accordance with section 2518 of the Internal Revenue Code of 1986, as amended, or such similar section as may then be in effect). (4) My Executor is authorized and empowered to sell at public or private sale, or exchange, and to encumber or lease, for any period of time, any real or personal property and to give options to buy or lease any such property. Additionally, my Executor is authorized and empowered to compromise claims, to borrow from anyone (including a fiduciary hereunder) and to pledge property as security therefor, to make loans to and to buy property from anyone (including a fiduciary or beneficiary hereunder); provided that any such loans shall be adequately Y: secured and at a fair interest rate. (5) My Executor is authorized and empowered to allocate property, charges on property, receipts and income among and between principal or income, or partly to each, without regard to any law defining principal and income. NINTH: All estate, inheritance, succession and other death taxes imposed or payable by reason of my death and interest and penalties thereon with respect to all property comprising my gross estate for death tax purposes, whether or not such property passes under this Will, shall be paid out of the residue of my estate, as if such taxes were expenses of administration, without apportionment or right of reimbursement. I authorize my Executor to pay all such taxes at such time or times as deemed advisable. IN WITNESS WHEREOF, I have set my hand and seal on this my Last Will and Testament this ~~j~day of 2004. ~1~~R~~~(SEAL) N~'iDA M. NAV TIL, Testatrix SIGNED, SEALED, PUBLISHED, and DECLARED by NADA M. NAVRATIL, as and for her Last Will and Testament, on the day and year last above written, in the presence of us, who, at her request, in her presence, and in the presence of each other, all being present at the same time, have hereunto subscribed our names as witnesses: ~~ ~ ~- /C~r ( ^ ~, _~ SELF-PROVING AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA . SS. COUNTY OF ,_.-~z,,,,~-~- ~'~, :~4,( WE, '-!~ /{ and l}~ i ~1, ` (..~ 9..~. ~ ~..n lit ~~ f and NADA M. NAVRATIL, the Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instn~ment, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and that she had signed willingly (willingly directed another to sign for him/her), and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as witness and to the best of his or her knowledge the Testatrix was at that time eighteen (18) years of age or older, of sound mind, anal under no constraint or undue influence. NADA M. NA RATIL, Testatrix Wi ess ~/ f ~ r /~~-L~ Witne s fitness ~ Subscribed, sworn to, and acknowledged before me by NADA M. NAVRATIL, the Testatrix, and subscribed and sworn to before me by ~,~~~~~ ~~ 9 i ~ ,and 17~: M ~ ~. ~\ ~- U; r,1~- witnesses, this _~ ~'1`•'+-day of , 2004. ~"M- s,__ Nota • Public -- COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL .CYNTHIA J. RULE, Notary Public Crimp Hill Boro., Cumberland County 6 M Commission Expires February 3, 2008