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HomeMy WebLinkAbout11-15-111505611188 EX(02-1111F1) ~ ~ REV-1500 OFFICIAL USE ONLY pennsy!>uania PA Departmentaf Revenue - "°- County Coda Year File Number Bureau oflndividualTaxes INHERITANCE TAX RETURN Po Box2eoool 2 1 1 1 D 4 6 D Harrisburg, PA 17128-0801 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 184 12 2321 03 15 2011 10 04 1922 Suffix Decedent's Frst Name MI Decedent's Last Name Sara ~ Arnold (If Applicable) Enter Surviving Spouse's Information Below MI Spouse's Last Name Suffix Spouse's Frst Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return I~ 2. Supplemental Return O 3. Remainder Return (Date of Death Prior to 12-13-82) Q 4. Limited Estate D 4a. Future Interest Compromise (date of f~ 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) Q 9. Litigation Proceeds Received l~ 10' Betweenl2-3 Y g reania(D ~e95~ eath 0 11' Alttach Schedule O)r Sec. 9713(A) CORRESPONDENT -This section must be completed. All Correspondence and Confidential Tax Information Should be Directed to: Daytime Telephone Number Name John E• Slike, Esquire 717 612 5800 First Line of Address Saidis, Sullivan & Rogers Second Line of Address 635 North 12th Street, Suite 400 City or Post Office State ZIP Code Lemoyne PA 17043 REGISTER Q'P)WILLS USE O LY?, f' - ~ l , _ _ r'] . •, ~ ~ ~' ~ --, ,. ... ,. - - C_s ~- __ - ... :_. ~ { r., TEFILED •• ' •~ i Correspondent s e-mail address: jSlike ssr-attorneys corn it ins trueecorrlectand oompletecDeclahati n of the prreparer o'threrthan perso1nalaepresentat ve fs based on aldl nformation of wh ch preparer has any knodwledge belief, DATE SIGNATURE 0~F PERSON RESPOt~iFiJBLE F~ FILING RETURN N _ ~ ~ ^ M " DDRESS// 312 East 5taaonsl Mecha!/nicsbur , PA 17055 (GNAT R'OFPREPAREROTHERTH~ ~DDRES 35 North 12th t I e.,-r A 17ntl:i '/( PLEASE USE ORIGINAL FORM ONLY i- 1505611188 Side 1 1505611188 J 1505611288 Rev-1500 EX (FI) Decedent's Social Security Number 184 12 2321 Decedent's Name: $ d r cl 0 A r n o l d RECAPITULATION 14O,DOO.OD 1. Real Estate (Schedule A) ......................................... 1' 158,785.94 2. Stocks and Bonds (Schedule B) ••••••••••••••••••••••••~••""""' 2 o•Do 3. Gosely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) • • • • • • 3• O•DO 4. Mortgages and Notes Receivable (Schedule D) • • • • • • • • • • • • • • • • • • • • • • • • • 4 101,041.56 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) • • 5 0.00 6. Jointly Owned Property (Schedule F) L~ Separate Billing Requested • • ~ • • • 6• 7 Inter-Vivos Transfers & Miscellaneous Non-Probate Property D , D D . (Schedule G) 0 Separate Billing Requested • • • • • • 7, 399,827.5D 8. Total GrossAssets(totalLineslthrough7).•••••••••••••••••••••••• a 42,347.41 9. Funeral Expenses and Administrative Costs (Schedule H) • • • • • • • • • • • • • • • • • • 9• 18,376.34 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) . • • • • • • • • • • • • 10. 60, 723.75 11. Total Deductions (totalUnes9and10) .••••••••••••••••••••••••••••• 11 339,103.75 12. Net Value of Estate(LineBminusLinell).•••••••••••••••••••••••••••• 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which D • D D an election to tax has not been made (Schedule J) • • • • • • • • • • • • • • • • • • • • • • • 13. 339,103.75 14. Net Value Subject to Tax (Line l2 minus Line l3) •••••••••••••••••••••• 14. TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 ^ • D D 15• D • D D (a)(1.2) X .00 16. Amount of Line 14 taxable D • D D 1 g D . D D at lineal rate X .045 • 17. Amount of Line 14 taxable 8 4 ~ 7 7 5. 9 4 1 ~ 10 ,17 3 •11 at sibling rate X .12 , 18. Amount of Line 14 taxable 2 5 4 , 3 2 7 •81 1 g 3 8 ,14 9 • 17 at collateral rate X .15 . 48,322.28 19. TAX DUE .................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~ 15D5611288 Side 2 15D5611288 File Number Rev-1500 EX (FI) Page 3 21 11 0460 Decedent's Complete Address: Sara O. Arnold STREET ADDRESS CITY I STATE Mechanicsburg PA Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments 46,000.00 A. Prior Payments B. Discount 2'420.98 Total Credits (A + B) 3. Interest 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. P 17055 (1) 48,322.28 (2) 48,420.98 (g) 0.00 (4) 98.70 (5) 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 • • • • • • • • • • • • • • • • ^ c. retain a reversionary interest ................................................... ^ 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 "intrust for' orpayable-upon-death bank account or security at his or her death? • • ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, ................... which contains a beneficiary designation? • • • • • • • • • • • • • • • • • ' • ' ' ' ~ ' ' ' ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART 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 is 3 percent [72 P.S. Sect. 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. Sect. 9116(a)(1.1)(ii)]. The statue 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. Sect. 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. Sect. 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. Sect. 9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+(01-10) Pennsylvania OE.PARTMf NT OF Rt VFNUf INHERITANCE TAX RETURN RESIDENTDECEDENT SCHEDULE A REAL ESTATE FILE NUMBER: ESTATE OF: 21 11 ~46~ Sara O. Arnold 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 .. .__ __ _ ...:~~:_.. ~.,„e. ~...r ~ ..,~w~n -Sauer. neither 6eino compelled to buy orsell, both having reasonable knowledge of the relevant facts. If more space is needed, insert additional sheets of the same size. REV -1503 E X+ (8-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Sara O. Arnold 21 11 0460 (tf more space is needed, insert additional sheets of the same size) REV -1508 EX+(11-10) Pennsylvania SCHEDULE E ~ °t`,"H1ME"' aF REV~N~f CASH, BANK DEPOSITS, & MISC. INHERITANCETAXRETURN PERSONAL PROPERTY RESIDENTDECEDENT ESTATE OF: FILE NUMBER: Sara O. Arnold 21 11 0460 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Balance due from Glenn Arnold Trust 29,772.45 $3,900 plus $25,872.45 2 PNC Bank Checking Account 51-4000-1745 35,019.89 Per 05/11/11 letter Interest on above item accrued as of decedent's death 0.12 3 Sovereign Bank Money Market Account 1051079357 15,678.42 Per statement 4 Misc. Household Items 2,610.00 5 2000 Buick Century 3,000.00 Sales price 6 Heritage Medical Group Refund 402.00 7 Misc. Refunds 21.00 8 Comcast Financial Agency Corporation Refund 52.77 9 AT&T Refund 40.62 10 Genworth Refund Rcd 6/1/11 697.67 11 Erie Refund rcd 6/10/11 274.00 12 IRS, 2010 Form 1040 refund 1,236.68 (includes $14.68 interest) 13 Genworth Refund rcd 08/31/11 269.63 14 Erie Homeowner's Insurance Refund 269.00 15 Patriot News Refund 242.35 16 Tru-Green Refund 32.88 17 PSERS Annuity Payment 334.68 18 Genworth Financial Check 02/01/11 to 3/15/11 4,427.40 Total from continuation Schedule(s) 6,660.00 TOTAL (Also enter on line 5, Recapitulation) 101 ,041.56 If more space is needed, insert additional sheets of the same size Page 2 Estate of: Sara O. Arnold 21 11 0460 Schedule E -Cash, Bank Deposits, and Misc. Personal Property Item Value at Date Number Description of Death 19 Genworth Financial -Long Term Care Insurance Payment 6,660.00 TOTAL. (Carry forward to main schedule) ...... 6,660.00 REV-1511 EX+(10-09) ~`il Pennsylvania SCHEDULE H ~ DEI'APTMFN7 OF R(VENUf FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENTDECEDENT ESTATE OF FILE NUMBER Sara O. Arnold 21 11 0460 Decedent's debts must be reported on Schedule I. ITEM AMOUNT NUMBER DESCRIPTION A. FUNERAL EXPENSES: 1 Funeral dinner/Pastor 2,100.00 2 Camp Hill Trinity Evangelical Lutheran Church 600.00 3 Myers - Harner Funeral Home, Inc. 784.00 g. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s~ameS I. Enterllne Street Address 312 East Siddonsburg Road Mechanicsbur State PA Z;p 17055-6011 city g Year(s) Commission Paid: 2011 2. 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: 5. Accountant Fees: 6. Tax Return Preparer Fees: See schedule attached 14,927.71 10,000.00 427.50 13, 508.20 TOTAL (Also enter on Line 9, Recapitulation) 42,347.41 If more space is needed, use additional sheets of paper of the same size. Estate of: Sara O. Arnold Schedule H, Part B -Administrative Costs Miscellaneous Expenses Page 2 21 11 0460 Item Description Amount Number 7 AT&T Services 80.23 8 AT&T 16.32 9 PPL 101.75 10 Silver Spring Township, sewer services 106.00 11 Saidis, Sullivan & Rogers, out of pocket expenses ($75.00 Cumberland Law 82.49 Journal, legal advertising/$7.49 postage) 12 AT&T 80.05 13 United Water 22.00 14 Smith Lawns 41.34 15 Smith Lawns 133.56 16 United Water 10.82 17 Lowes, plants for flower beds 48.55 18 Gerald Gillging, plumbing repairs 200.00 19 Penn Waste, July -Sept 2011 44.35 20 United Water 200.44 21 Saidis, Sullivan & Rogers, out of pocket expenses 166.30 22 Erie Insurance, homeowners insurance June 2011 to June 2012 332.00 23 PPL 73.76 24 Smith Lawn Care, mowing 84.80 25 PPL 7.42 26 Silver Spring Township Authority 295.00 27 United Water 16.27 28 PPL 28.68 TOTAL. (Carry forward to main schedule) ...... 2,172.13 Estate of: Sara O. Arnold Schedule H, Part B -Administrative Costs Miscellaneous Expenses Page 3 21 11 0460 Item Number Description Amount 29 Saidis, Sullivan & Rogers, out of pocket expenses 6.47 30 Smith Lawns 63.60 31 United Water 16.27 32 Auction pick-up 125.00 33 Saidis, Sullivan & Rogers, out of pocket expenses 4.00 34 PPL 51.15 35 Costs of sale of 35 Westfields Drive, Mechanicsburg, PA 17050 10,002.45 Commission $6,400.00 Notary fee $ 10.00 Deed $1,400.00 Sewer $ 108.14 (4/1/ to 8/30) School tax $1,196.87 (2011/2012) Total $11,125.01 Adjustments for items paid by seller in advance $ 141.91 County taxes 8/30/11-12/31/11 $ 980.65 School taxes 8/30/11-6/30/12 $1,122.56 Total 36 Haars Auction, commission for sale of household items 149.10 37 Smith Lawns 63.60 38 Vickie Enterline, reimbursement for cards, quilts, stamp postage 172.00 39 PPL 31.92 40 Saidis, Sullivan & Rogers, out of pocket expenses 4.00 41 United Water 10.51 42 Pottieger's Construction, roof repair 500.00 43 Cumberland County Register of Wills, filing fees 30.00 44 Smith Lawns 106.00 TOTAL. (Carry forward to main schedule) ...... 11,336.07 REV -1512 EX+(12-08) ~ Pennsylvania SCHEDULE I bPPNftTMFN? of NFVENUF DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Sara O. Arnold 21 11 0460 Report debts incurred by decedent prior to death that remained unpaid at the date of death, including unrelmbursed medical expenses. VALUE AT DATE ITEM DESCRIPTION OF DEATH NUMBER 1 Home Instead 10,949.26 2 United Water 21.91 3 AT&T 37.41 4 PPL 186.65 5 Home Instead 4,810.60 6 Debra Basehore Wiest, real estate taxes 409.37 7 Fia Card Services 139.42 8 Pinnacle Health Hospice 1,000.00 9 Wagner Associates, Inc, preparation of 2010 income tax returns 350.00 10 John Clemmer, maintenance 35.00 11 Annie Heimback, nursing service 180.00 12 FIA Services (Visa/Medication) 70.07 13 Holy Spirit Hospital 14 Community Life Team EMS 15 Hospital Telephone TOTAL (Also enter on Line ~0, Recapitulation) If more space is needed, insert additional sheets of the same size. 54.65 112.00 20.00 18, 376.34 REV -1513 EX+(01-10) j sl Pennsylvania SCHEDULE J DF.VARIMENT Of REVENUE INHERITANCETAX RETURN BENEFICIARIES RESIDENTDECEDENT ESTATE OF: Sara O. Arnold NuMBE NAME AND ADDRESS OF PERSONS RECEIVING PROPERT z TAXABLE DISTRIBUTIONS [Include outright spousal distributions, and transfers under Sec. s7 ~ s(a)(i .2).] See schedule attached FILE NUMBER: 21 11 0460 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LIN ES 15 THROUGH 1B OF REV-1500 COVER SH E ET, AS APPROPRIATE. zi NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9173 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEEP. If more space is needed, use additional sheets of paper of the same size. Page 2 Estate of: Sara O. Arnold 21 11 0460 Schedule J, Part I -Taxable Distributions Amount or Share Num. Name and Address of Person(s) Receiving Property Relationship to Decedent of Estate Audrey E. Miller Sister 84,775.94 20 West Laurel Street Tremont, PA 17981-1702 James I. Enterline Nephew 148,357.89 312 East Siddonsburg Road Mechanicsburg, PA 17055 Jane K. Fleming Niece 15,138.56 5920 Newton Avenue Philadelphia, PA 19120 Dianne Trostel Niece 15,138.56 515 Park Drive Mt. Zion, IL 62549 Susan K. Green Niece 15,138.56 517 10th Avenue, Third Florr Prospect Park, PA 19076 Deborah J. Khan Niece 15,138.56 117 Lombard Street Philadelphia, PA 19147 Suzanne M. Christensen Niece 15,138.56 712 Lan Street Fort Morgan, CO 80701 Karen E. Miller Niece 15,138.56 20 West Laurel Street Tremont, PA 17981-1702 Joan C. Enterline Niece 15,138.56 9503 Veris Drive - 3 Rockville, MD 20850-6403 LAST WILL AND TESTAMENT OF SARA O. ARNOLD I, SARA O. ARNOLD of Borough of Lemoyne, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament, riereby revoking any will previously made by me. I. I direct the payment of all my just debts and funeral expenses out of my estate as soon as may be practical after my death. II. I bequeath certain items of my tangible personal property, not including cash and securities, in accordance with a written list made by me during my lifetime. In absence of such a list or designation on the list, the remainder of my tangible personal property shall be distributed or sold, as my executor shall decide, including distribution to himself should he so choose, and anything that he does distribute shall be sold and the proceeds added to the residue of my estate. I direct there shall be no public sale of my tangible personal property from my residence. III. I direct that all the rest, residue and remainder of my estate be liquidated with the proceeds thereof to be distributed as follows: r Page 1 .~,% C/CL A. Twenty percent of said residue shall be paid to my sister, Auarey Miller. Should she be deceased, this request shall lapse. B. Twenty percent of said residue shall be paid to my brother, Charles Otto. Should he be deceased, this bequest shall lapse. C. Thirty-five percent of said residue shall be paid to my nephew, James I. Enterline. Should he be deceased, this bequest shall lapse. D. .The remaining twenty-five percent of said residue shall be divided among my nieces who are living at the time of my death. IV. I appoint my nephew, James Z. Enterline, as Executor. If he is deceased or unable to serve as such, then I appoint my niece, Joan Enterline, to act in t his capacity. I request that my executors engage the services of John E. Slike, Esquire or a member of his firm, Saidis, Shuff, Flower & Lindsay, to assist them in the settlement of my estate. Neither of my personal representatives shall be required to post bond in this or any jurisdiction. It is my express desire that my executors shall be compensated in the customary manner for their services. IN WITNESS WHEREOF, I have hereunto set my hand and seal on this, the ~ day of ~ ~~ ~~~,, ( SEAL ) ~,~~ Ham; ~~ SARA O. ARNOLD Signed, sealed, published and declared by SARA 0. ARNOLD, Testatrix therein named, on this and two (2) other sheets of Page 2 paper as and for her Last Will and Testament, in our presence, who, in her presence, at her request, and in the presence of each h have hereunto subscribed our names as attesting witnesses. of er, ~~ ;, ~~ ~, Name { Name COMMONWEALTH OF PENNSYLVANIA } COUNTY OF CUMBERLAND } Address ~~ Address WE, the undersigned, the Testatrix and the witnesses, respectively, whose names are signed to tine foregoing instrunleiit, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as her Last Will and Testament and that she signed willingly (or willingly directed another to sign for him), and that she executed it as her free will 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 witnesses and that to the best of their knowledge the Testatrix was at that time eighteen years of age or older, of sound mind, and under no constraint or undue influence. Sara O. Arnold, Testatrix _. ., j Witness Witnes. Subscribed, sworn to and acknowledged before me by the Testatrix, and s „scribed and ~ n to,,.-before me by both witnesses, this I4__~ day of ~~~l~G/wl/ , 2005. of COMMONWEALTH OF PENNSYLVANIA Notarial Seal Sara J. Ensinger, Notary Public Camp Hill Boro, Cumberland County Page 3 My Commission Expires Oci. ] 7, 2005 Member, Pennsylvania AssociaGor. of Notaries COMMDNWEHLTH OF PENNSYLV ANIG, DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PH 1 7 1 28-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT ENTERLINE JAMES I 312 EAST SIDDONSBURG ROAD MECHANICSBURG, PA 17055 loll ESTATE INFORMATION: s5rv: X84-12-232 FILE NUMBER: 211 1-0460 DECEDENT NAME: ARNOLD SARA 0 DATE OF PAYMENT: 06/ 1 5/201 1 POSTMARK DATE: 06/ 1 4/201 1 COUNTY: CUMBERLAND DATE OF DEATH: 03/15/2011 REMARKS: RECEIPT TO ATTY SEAL CHECK# 1010 ACN ASSESSMENT CONTROL NUMBER REV-1162 EX(11-961 N0. CD 014580 AMOUNT 101 ~ $46,000.00 TOTAL n,n~nLI~1T PAIp: 546,000.00 INITIALS: HMW RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER /-,- ~ OMB Approval No. 2502-0265 i`_ ~ )IhII)~''~ A. Settlement Statement (HUD-1) (IIoiU „T, ... .. ^X Conv. Unins. ^ RHS 3 ^ FHA 2 1 6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number: . . . 11238 0247314818 4. ^ VA 5. ^Conv. Ins. C. Note: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agents are shown. Items marked "(p.o.c)" were paid outside the closing; they are shown here for informational purposes and are not included in the totals. D. Name & Address of Borrower: E. Name & Address of Seller: F. Name & Address of Lender: Kaye A. Ream Estate of Sara 0. Arnold Members 1st Federal Credit Union 163 Easterly Drive, Mechanicsburg, PA 1705D 35 Westfields Drive, Mechanicsburg, PA 17050 5000 Louise Drive, Mechanicsburg, P a 17055 G. Property Location: H. Settlement Agent: I. Settlement Date: 08/30/2011 35 Westfields Drive 151 Advantage Settlement Services Inc. Disbursement Date: 08!30/2011 Mechanicsburg, PA 17050 6375 Mercury Drive, Suite 102, Mechanicsburg, PA 17050 Silver Spring Township Telephone: 717-591-7755 Fax: 717-591-7756 Place of Settlement: TitleExpress 6375 Mercury Drive, Suite 102, Mechanicsburg, PA 17050 Printed 08/29/2011 at 2:09 pm by VW a :a 100. Gross Amount Due from Borrower 400. Gross Amount Due to Seller 101. Contract sales price 140,000.00 401. Contract sales price 140,000.00 102. Personal ro ert 402. Personal ro ert 103. Settlement charges to borrower (line 1400) 4,338.42 403. 104 404. 105. 405. Adjustments for items aid b seller in advance Adjustments for Items aid b seller in advance 106. Cityltown taxes to 406. Cityltown taxes to 107. County taxes 08130/2011 tc 12/3112011 141.91 407. County taxes 08!3012011 to 12131!2011 141.91 108. SchooiTaxes 08l3012011to O6I3012012 980.65 408. School Taxes 08I30l2011to 06/30/2012 980.65 tOg 409. 110. 410. 111. 411. 112. 412. 120. Gross Amount Due from Borrower 145,460.98 420. Gross Amount Due to Seller 141,122.56 200. Amounts Paid b or in Behalf of Borrower 500. Reductions In Amount Due to Seller 201. Deposit or earnest money 1,000.00 501. Excess deposit (see instructions) 202. Principal amount of new loan(s) 48,000.00 502. Settlement charges to seller (line 1400) 11,125.01 203. Existin loo s taken sub'ect to 503. Existin loo s taken sub'ect to 204. 504. Pa ofi of first mort a e loan 205. Lender Paid Credit 375.00 505. Payoff of second mortgage loan 206. 506. 207. `~7 208. 508. 209. 509. Adjustments for items unpaid b seller Adjustments for Items unpaid b seller 210. Cityltown taxes to 510. Cilyltown taxes to 211. County taxes to 511. County taxes to 212. School Taxes to 512. School Taxes to 213. 513. 214 514. . 215. 515. 216. 516. 217. 517. 218. 518. 219. 519. 220. Total Paid b Ifor Borrower 49,375.00 520. Total Reduction Amount Due Seller 11,125.01 300. Cash at Settlement fromlto Borrower 60D. Cash at Settlement tolfrom Seller 301. Gross amount due from borrower (line 120) 145,460.98 601, Gross amount due to seller (line 420) 141,122.56 302. Less amounts paid bylfor borrower (line 220) 49,375.D0 602. Less reductions in amount due seller (line 520) 11,125.01 303. _ _ Cash ^X From ^ To Borrower _ ___ .__ __ _. ....., ........ _ .......... .........m, . . _ _ m,n,, .. „ 98,085.98 e,.eannnaa nr co a ,im. rcvmvnna an 603. Cash ^X To ^ from Seller rcw ,rw ,e a e. s aoerrcv mar no co a is m orma on on rou em no reamre o cnm e e 129,997.55 this/o,rn Unless it disdeYZaturtenllY Velid OMB COnIr01 nvm0er. NO wnuoen„mny ,a ezsurcv: mn unuuw,e,s u„uue,~,y. ..,~.,..~.>'w~=~,~r~,..=••~.v-•-•-•--~~__. ., __. _.__.. _..___. _._.._.. _ - aeuiamenl nmcess. Previous editions are obsolete Page 1 of 4 HUD-1 700. Total Real Estate Broker fees $ 8,400.00 Paid From Paid From Division of commission line 700 as follows: Borrower's Seller's 701. $4,200.00 to Re1MaxlstAdvantage Funds at Funds at 702 $4,200.00 to RSR Realtors, LLC Settlement Settlement 703 Commission paid at settlement 8,400.00 704. Commission to RelMax 1st Advantage 550.00 800. Items Pa able in Connection with Loan 801. Our origination charge (Includes Origination Point 0.000% or $0.00) $830.00 (from GFE #1) 802. Your credit or charge (points) for the specific interest rate chosen $ (from GFE #2) 803. Your adjusted origination charges (from GFE A) 830.00 804. Appraisal fee to (from GFE #3) 805. Credit report to (from GFE #3) 806. Tax service to from GFE #3 807. Flood certification to from GFE #3 808. to 900. Items Re wired b Lender to be Paid in Advance 901. Daily interest charges from from 08!3012011 to 09101!2011 @ $5.8333lday (from GFE #10) 11.67 902. Mortgage Ins. Premium for months to (from GFE #3) 903. Homeowner's insurance for months to (from GFE #11) 904. months to from GFE #11 1000. Reserves De osited with Lender 1001. Initial deposit for your escrow account (from GFE #9) 1002. Homeowner's insurance months $ O.OOlmonth $ 1003. Mortgage Insurance months $ O.OOlmonth $ 1004. City Property Tax months $ O.OOfmonlh $ 1005. County Property Tax months $ 34.811month $ 1006. School Taxes months $ 97.741month $ 1007. Aggregate Adjustment $ 1100. Title Char es 1101. Title services and lender's title insurance from GFE #4 876.75 1102. Settlement or closing tee to $ 1103. Owners title insurance from GFE #5 512.00 1104. Lender's title insurance $696.75 1105. Lender's title policy limit $48,000.00 Lender's Policy 1106. Owners title policy limit $140,000.00 Owner's Policy 1107. Agent's portion of the total title insurance premium $1,027.44 1108. Undenxriter's portion of the total title insurance premium $181.31 1109. 1110. Notary to Vickie Welker 10.00 1111. Tax Certification Fee to 1 st Advanta a Settlement S 10.00 1200. Government Recordin and Transfer Char es 1201. Government recording charges $ (from GFE #7) 158.00 1202. Deed $62.00 Mort a e $96.00 Release $ 1203. Transfer taxes $ (from GFE #8) 1,400.00 1204. City/County tax/stamps Deed $1,400.00 Mart a e $ 1205. State Taxlstamps Deed $1,400.00 Mort a e $ 1,400.00 1206. Deed $ Mort a e $ 1207. $ 1300. Additional Settlement Char es 1301. Required services that you can shop for (from GFE #6) 1302. Survey to $ 1303. to 1304. Sewer (411 l0 8130) Acct #266-266 to Silver S do Townshi Authorit 108.14 1305. 2011112 School Tax to Debra Basehore Wiest, Tax Collector 1,196.87 r, r r 4,338.42 11,125,01 'Paid outside of closing by (B)orrower, (S)eller, (L)ender, {I)nvestor, Bro(K)er. "Credit by lender shown on page 1. "'Credit by seller shown on page 1. Previous editions are obsolete Page 2 of 4 HUD-1 Com orison of Good Faith Estimate GFE and HUD•1 Char es Char es That Cannot Increase HUD•1 Line Number Our origination charge # 801 Your credit or charge (points) for the specific interest rate chosen # 802 Your adjusted origination charges # 803 Transferlaxes # 1203 Good faith Estimate HUD•1 829.00 830.00 0.00 0.00 829.00 830.00 1,400.00 1,400.00 Char es That in Total Cannot Increase More Than 10% Good faith Estimate HUD•1 Government recording charges # 1201 238.00 158.00 Appraisaliee # 804 0.00 0.00 Credit report # 805 0.00 0.00 # 238.00 158.00 ~ $ -80.00 or -33.6134% Char es That Can Chan a Good Faith Estimate HUD•1 Initial deposit for your escrow account # 1001 0.00 0.00 Daily interest charges from # 901 $5.83331day 93.33 11.67 Homeowners insurance # 903 400.00 0.00 Title services and lenders title insurance # 1101 1,558.75 876.75 Owner's title insurance # 1103 512.00 512.00 Your initial loan amount is $48,000.00 Your loan term is 30. years Your initial interest rate is 4.3750% Your initial monthly amount owed for principal, interest, and any mortgage $239.66 includes insurance is X^ Principal Q Interest ^ Mortgage Insurance Can your interest rate dse? ^X No. ^ Yes, it can dse to a maximum of %. The first change will be on / 1 and can change again every years after 1 ! .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 lower than % or higher than %. Even if you make payments on lime, can your loan balance rise? ^X No. ^ Yes, it can dse to a maximum of $ Even if you make payments on time, can your monthly amount awed for ^X No. ^ Yes, the first increase can be on ! I and the monthly principal, interest, and mortgage insurance rise? amount owed can rise to $ The maximum it can ever rise to is $ Does your loan have a prepayment penalty? ^X No. ^ Yes, your maximum prepayment penalty is $ Does your loan have a balloon payment? Q No. ^ Yes, you have a balloon payment of $ due in years on I I Total monthly amount owed including escrow account payments 0 You do not have a monthly escrow payment for items, such as property taxes and homeowner's insurance. You must pay Ihese items directly yourself. ^ You have an additional monthly escrow payment of $ that results in a total initial monthly amount owed of $ .This includes principal, interest, any mortgage insurance and any items checked below: ^ Property taxes ^ Homeowner's insurance Flood insurance ^ ^ ^ Note: If you have any questions about the Settlement Charges and Loan Terms listed on this form, please contact your lender. Previous editions are obsolete Page 3 of 4 HUD-1 1 ,1' HUD CERTIFICATION OF BUYER AND SELLER I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, it is a true and accurate statement of all receipts and disbursements made on my account or by me in this transaction. I further certify that I have received a copy of the HUD-1 Settlement Statement. ~i Kaye A. Rea ale of Sara 0. Arnold 1 ~xECs.~-o2 The HUD-1 Settlement Statement which I have prepared is a true and accurate account of this transaction. I have caused or will cause the funds to be disbursed in accordance with this statement. SETTLEMENT AGE V ~ 7 V ~ ~j DATE 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 18: U.S. CODE SECTION 1001 AND SECTION 1010. Previous editions are obsolete Page 4 of 4 HUD-1 • 1 1 • 1~ • l N b Name of Borrower: Kaye A. Ream Name of Seller: Estate of Sara O. Arnold er um Fi e 11238 TdleExpress Prepared 0812912011 at 12:01 pm Note: This page is furnished to give you an itemization of the amounts shown on Lines 1101, 1103 and 1104 of the Settlement Statement (HUD-1 ). This page accompanies but is not a part of the settlement statement. If a discrepancy exists, the information shown on the Settlement Statement (HUD-1) applies. Paid From Borrower's Funds at Settlement Paid From Seller's Funds at Settlement Amounts Included 1100. Title Charges in Line 1101 1101. Title services and lender's title insurance 876.75 a. Wire In Fee $ 10.00 b. Email\Doc Copy Fee 35.00 c. Overnight Delivery Fee-Package 25.00 d. Notary Fee 35.00 e. Closing Service Letter 75.00 $ 160.00 1102. Settlement or Dosing fee 1103. Owner's title insurance (policy) $ 512.00 512.00 1104. Lender's title insurance (policy) 546.75 $ 696.75 a. Endorsement 900 EPL-Residential 50.00 b. Endorsement 100 (No Violation) 50,00 c. Endorsement 300 Survey 50.00 (Total 1103 + 1104) 1105. Lender's title policy limit $48,000.0D 5012742.18769 1106. Owner's title policy limit $140,000.00 5011442-19080 1107. Agent's portion of the total title insurance premium $ 1,027.44 1108. Underwriter's portion of the total title insurance prem. 181.31 (Tota11107+1108) S 1.2p$,Ib 1109. 1110. 1111. ,,,~ . . . 1 ~ .• . Total Borrower Borrower Seller 1100. Title Char es with Pa ee Char a POC or Credit Line 1101 Paid 1101. Title services and lenders title insurance $ a. Wire In Fee to 1 st Advantage Settlement Services Inc. 10.00 10.00 b. Email\Doc Copy Fee to 1 sl Advantage Settlement Services Inc. 35.00 35.00 c. Ovemighl Delivery Fee-Package 101 st Advantage Settlement Services Inc. 25.00 25.00 d. Notary Fee to Vickie Welker 35.00 35.00 e. Closing Service Leiter to First American Title Insurance Company 75.00 75.00 1104. Lender's title insurance 696.75 696.75 $ 876.75 876.75 ESTATE OF SARA O. ARNOLD gy ~ Date 8/30111 Date 8/30111 Kaye A. Re m Eac.~c~n+2 Sara O. Arnold 35 Westfields Dr Mechanicsburg, PA 17050-7931 Name PA LT Tax-Exempt Admiral PA LT Tax-Exempt,Investor Page > 1 of 1 ~'{y~~ ~ `] .~ ~, 'fit ~ .S°`j4.~~Nf t1M~ . 3.ki~. -j Voyager Services: 800-284-7245 Total report value: $95,530.47 (Total report value includes any accrued dividends.) Fund &Account Date Price Per ~m . ~ .. _ ..__.~..__ Accrued Number Opened Shares Share Value* Dividends 0577-09847079237 12/07/2010 8,871.379 $10.75 $95,367.32 $163.15 0077-09847079237 09/29/1987 0.000'. $10.75 $0.00 $0.00 Totals $95,367.32 $163.15 0822212847 04/27/2011 11:24:28 May 9, 2011 Saidis, Sullivan & Rogers Attention: John E. Slike, Esquire 635 North 12th Street, Suite 400 Lemoyne, PA 17043 ~PCS'FUS Re: Sara O. Arnold Dreyfus Municipal Bond Fund Account Ending Iti: 19120 Reference Number: 20110509133450 Dear Mr. Sli;:e: We are sorry to learn of the passing of Sara O. Arnold, and would like to take this opportunity to extend our condolences to the family. The date of death balance information that you requested is as follows: Fund Name: Account Ending In: Valuation Date: Market Value: Share Balance: Price per share: Accrued Dividends: Account Established Dreyfus Municipal Bond Fund 19120 March 15, 2011 $63,255.47 5,851.570 $10.81 $114.53 (included in market value) April 12, 1993 We appreciate the opportunity to assist you. If you need any additional information, please feel free to call a Dreyfus representative at our toll free number, 1 800 645 6561. We are available Monday through Friday, from 8:00 a.m. to 6:00 p.m., Eastern time. Sin el~y,' ~ ~~ `„_' Saman a erone Correspondent *The information above is based on sources we believe to be accurate, However, it is not to be considered ns nn officio! statement of the account(s) referenced above with MBSC Securities Corporation. BNY MELLON ASSET MANAGEMENT Dreyfus Retail Services is a division of MBSC Securities Corporation, a registered broker-dealer, FINP,A member and awholly-owned subsidiary of The Bank of New York Mellon Cvrporation. BNl' Mellon Asset Management is the umbrella organization for The Bank of Nevv Yorf: IJiellon Corporation's affiliated investment management firms and global distribution companies. Investments offered through PJfBSC Securities Corporation. Are not FDIC insured • Are not bank guaranteed • May lose value Dreyfus P,etall Services 144 Glenn Curtiss Blvd, Univndaie, NY 11555 © M8T Investment Group Trust Operations One M & T Plaza - 8th Floor Buffalo NY 14203 6/3/11 112 ESTATE OF SARA ARNOLD ARNOLD,GW T/A 1153085111 OFFICER 0236 JOSEPH A. MACRI ESTATE OF SARA ARNOLD 50 INCOME TO D/O/D No. 228237159 6/3/11 ^X INCOME ^ PRINCIPAL $3,900.00 TRSCHK:TRCHKI DETACH & RETAIN FOR YOUR RECORDS ~ - - - _ r ; `-.. , HOLD DOCUMENT UP TO THE LIGHT TO UIE'1N TRUE WATERMARK HOLD DOCUMENT UP TO THE LIGHT TO VIEW TRUE WATERMARK ., ;,_,~ •~ ~• ...,.. ~ "..~ ~, u 11 ~ No. 228237159 1o-a 220 ©MBrT Investment Group ~ Date 6/3/11 1153085111 ~I PAY THREE THOUSAND NINE HUNDRED AND NO/100 TO THE ESTATE OF SARA ARNOLD ORDER OF secun«. Features t p9,gp, on sate. U.S. DOLLARS $ 3,900.00 TWO SIGNATURES REQUIRED FOR AMOUNTS OF $10,000 AND OVER TH IZED NATURES MANUFACTURERS AND TRADERS TRUST COMPANY 11' 2 28 2 3 7 1 5911' ~:0 2 2000046: L 700 508 79 2008611' © M8~` Inveestment Group Trust Operations One M 8 T Plaza - 8th Floor Buffalo NY 14203 6/3/11 113 ESTATE OF SARA ARNOLD No. 228237161 6/3/11 ARNOLD,GW T/A 1153085111 OFFICER 0236 JOSEPH A. MACRI ESTATE OF SARA ARNOLD 50 INCOME TO D/O/D ^X INCOME ^ PRINCIPAL $25,872.45 TRSCHK:TRCHKI DETACH & RETAIN FOR YOUR RECORDS ©M&T Investment Group 1153085111 ~~ PAY TWENTY-FIVE THOUSAND EIGHT HUNDRED SEVENTY-TWO AND ~'j 45/ 100 ~., TO THE ESTATE OF SARA ARNOLD ORDER ~ OF se~u~ir Feature= t patai~ on eaor. ~, ~., HOLD DOCUMENT UP TO THE LIGHT TO:VI£W-TRUE.WATERMARK ~ No. 228237161 10-4 220 Date 6/3/11 U.S. DOLLARS $ 25,872.45 TWO SIGNATURES REQUIRED FOR AMOUNTS OF $10,000 AND OVE TH IZED NATURES MANUFACTURERS AND TRADERS TRUST COMPANY II' 2 28 2 3 7 16 X11' ~:0 2 20000 4 6~: ~ 700 508 7 9 2008 611' L ~~ ~iHG ~~E ~t,~v May 11, 2011 John E Slike, Esquire Ssaidis, Sullivan & Rogers 635 N 12th St, Ste 400 Lemoyne, PA 17043 RE: Sara O Arnold SSN: 184-12-2321 DOD: 03/15/2011 Deaz Mr. Slike: ~ -N- ~~ i ~ I In response to your request for Date of Death (DOD) balances for the customer noted above, our records show the following: Checlang Account Account # 5140001745 Established: 01/01/1978 SARA 0 ARNOLD DOD balance: $ 35,019.89 + 0.12 accrued interest Please note that this office provides date of death balances for deposit accounts (IRAs, CDs, Checking and Savings). We do oot pxocess aay fiinapcial tra~asactions or provide statements. If you need assistaaace with any of these items, please call 1-888-PNC-BANK (1-888-762-2265) or stop by your local FNC Bank branch office. Sincerely, National Financial Services Center PNC Bank, N.A. Member FDIC This message is intended for the use of the individual yr entity to which it as addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient or the employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distrihution or copying of this communications is strictly prohibited. !f you have received this communication in error, please notify me immediately by reply or by telephone at 800-762-1775 and immediately destroy this faxed document. SARA O ARNOLD Balances Account # 9059079357 Beginhing Balance $15,678:42 CurrehtBatance '$11 847;21 DeposilslCredits + $2.79 Average Daily Balance $13,600.49 1Nithdrawals/Debits !$3;83400 Interest Paid this Period'" ,$ 2.79 Annual Percentage:Yield Earnetl 0.25% - Earned this Period $ 2.79 Paid Last Year $161.41 Paid'Year-To-Dfite $ 29.34 - 'The interest earned and the interest paid may differ depending on when interest is credited to your account. Checks Posted Check # Date Paid Amount Reference Check # Date Paid Amount Reference 501 03/21 $2,10Qs00 61f562720 `503_ 04/04 $350.00 970862895 502 04/04 $600.00 991377915 504 04/06 $784.00 622832910 4 Check(s) Posted = $3,834.00 An asterisk (') indicates a skip in sequential check numbers. Account Activity Date Description 03-14 Beginning Balance 03-21 CASH GHK 501 An (E) indicates check was converted to an electronic item. Additions Subtractions Balance $15:678.42 "$2:1'00:00 578.4?_ 04-04 CHECK 502 $600.00 $12.978.42 ^04-04 CHECK 503.. $350:00- $12;628':A2 04-06 CHECK 504 $784.00 $11,844.42 04-12 INTEREST CREDIT $2.79...: _.... $11,847;21: 04-12 Ending Balance $11,847.21 IN CASE OF ERRORS OR QUESTIONS ABOUT YOUR ELECTRONIC TRANSFERS (.'AL,L. POUR CUS"fOMER SERVICE CENTER AT'fFIE NUMI3ER SHOWN ON'1'HP TOP UP YOUR S'fA"I'EMENT UR WRITE TU "fl ll. 1;ANK FOR DL:Bff CARD 1SSUE5: Sovereign Bank Attn: Card Dispules'feam MA1 MB3 02 OS I'.O. Box 831002 Boston MA 02283-1002 FOR ALL O'l IIER ISSUES: Soverei~.:n Bank Attn: Client Relations 10-42:-CR I P.O. BOS ) 2616 RL-AL)ING, P.1 19612-2646 Please contact us if you think your statement or receipt is wrong or if you need additional information about a transfer on the statement or receipt. W'c must hear from you no later than 60 days after we sent you the PI)tS'f statement on which the error appeared. • "fell us your name and account number. • Describe the error or the transfer [hat you are unsure about and explain as clearly as you • "I ell us the dollar amount of the suspected error. can why you believe there is an error or why you need Further information. IFyou tell us orally. we may require you to scud your complaint or question in writing within 10 business days. W'e will promptly investigate the mailer and call or write to you with an answer within 10 business days (10 calendar days in Massachusens). If we need more time.. we may take up to 45 days to investigate your complaint or question. H'we do, we will credit vour account within this 10-dav period for the amount you think is in error. so you wtB have the use of the mono} dunng the time it lakes us to complete our investigation. If we asl; you to put your complaint or question in writing and we do not receive it within 10 business days, we may choose not to credit your account. For errors involving new accounts, point of sale purchases or loreign Iransaclions. we may lake up to 90 days to investigate your complaint or question. For new accounts, we may take up to 20 business days to credit your account for the amount you think is in error. We will tell you the results of our investigation within 3 business days after completing our investigation. If we decide there was no error, we will send you a written explanation. Y'ou may ask for copies of the documents Ne used in our investigatiou. important information about your Sovereign Uebit Card The networks through which some of your Sovereign Debit Card purchases are processed have begun allowing merchants to process your purchases without either a signature or a PIN. li you arc not required to enter your PIN when you make a purchase. your purchase may be processed e~iher through the Visa network or through the STAR or NYCE nehvorks. lfyour purchase is processed through STAR or NYCE. different terms apply and you will not he eligible for the rights and protections available through Visa. Please see your Personal Deposit Account Agreemcm for more information. huge 2 of 3 /11510793-57 s rn o- a a :. ... 0 a O ~, rn J .. ru N ru .-a ~' c.0 D L I W +?~• _,,~;y~ ~• °° .o ~.~.~ ti z ~ N ~ M ~ LL N Z r W f X ~e ~ ~ ~ 00> Q (fl i ~'; F- K] ti r- ' ~ ~. N00 Z c-.t d Y ' ~. O ~ ^ U ~ ~ Q ~ ~ \ .Q~ ~- O ~ ~ C] . O~ ~ N N'J ti ~ hi .H ~. ~ U ~ ~ Z d - O Q ~ O ,~ ~ o, r. ~ :~ - r-. 1n o z a .Llp Q ~ -- ~d ~n ~ ~ fV ~ C]a oo - o cn c~ ~o ~ . ~o~ 00 1` ~ O J ~ N - ZWm O+ - ~ r-1 t/1 r r = ~u-v O=OcnZ N - W ct r- ~ ~ ¢32 ~ ~ V ~ ~ - 4ulW C7 M = tnM~ ... 0 o ~ >. ~ -~ m o w u L,, ~ ,: ...~ a a W Z 0 to H- a 0 0 3 r W C W w w .i i~ S '~ OE~SLO .~ a l ._ C2~ CQ s ~- ti ^- a O ._. A _~ u-i O 0 ~' r_ .-~ ~~.. <.. Ld'I,• ~ ~; Erie' insurance Exchange AdamCar ~ Erle Insurance Oroup 100 Eria Ins. PI. ~ Erle, PA 18570 ER1E INSURANCE EXCHANGE P.O. BOX 1699 ERIE, PA 16530 CANCELLATION NOTICE NAMED INSURED COPY MAIL DATE 0901/11 CANCELLATIpN EFFECTIVE BAL. $259.00 CR POLICY NUMBER Q54 2306509 H 08/31/1.1 12.01 AM POLICY EFFECTIVE DATE 06/23/11 HOMEPROTECTOR POLICY STANDARD TIME NAMED INSURED ESTATE OF SARA 0 ARNOLD Cf0 JIM ENTERLINE AA7373 312 SIDDONSBURG RD MECHANICSBURG PA 17055 WE ARE NOTIFYING YOU THAT THE ABOVE POLICY IS CANCELLED AS OF THE CANCELLATION EFFECTIVE HOUR AND DATE SHOWN ABOVE. IF WE HAVE .BEEN ASKED TO PROTECT OTHER INTERESTS, WE ARE REQUIRED TO ADVISE THEM OF THIS CANCELLATION. THE REASON FOR THIS ACTION REQUEST OF NAMED INSURED - SOLD PREVIOUS BALANCE UNUSED PREMIUM PRESENT BALANCE oo5oa WOLF AA7373 J P WOLFE INSUR INC $.00 $269.00 CR $269.00 CR REFUND CHECR ENCLOSED 32EXC 6/00 THE PATRIOT-NEWS 2020 Technology Parkway, Ste. 300 Mechanicsburg, PA 17050 Vendor Number: 9999999999 Check No. 0900D58836 Check Date: 10!10/201 l voice Number Invoice Date Voucher tD Gross Amount Discount Taken Paid Amount 10/182011 00145437 242.35 0.00 242.35 1229263 ,2011-10-18 Newspaper Subscriber Refund SUBSCRIBER REFUND Questions regarding this check coniacl the AP Deg! 717/255-8260 Check Number Date D90005883b ,10/20/2011 Total Total Total Grass Amount Discounts Paid Amount $242.35 $0,00 $242.35 ,~^nonnn~AA1Cn^ ~~n~i~nq~79t: 6C]L879L58u• i`'~ ~~ Genworth Financial ;,~ GENWORTH LIFE INS CO LONG TEi2M CARE INSURANCE DIVISIDN ?.O.Box 40007 LYNCHBURG VA 24506-8939 •••,y 000 0002372 000001000 001 002 0' 13194 INS: ~ 0 { ~n~~'~u~~~~uui~l~u~~~~~~u~l~u~'~u~~~~u11~u~~~~n~~u~1 ESTATE OF SARA ARNOLD 312 E SIDDONSBURG RD MECHANICSBURG PA 17055 - ~ -w ~ea~~a - ~ - r"i~imant• SARA O ARNOLD Page 1 of 3 ~~ Claims: (800} 876-4582 - Payment for Fab 1 2011 through Mar 15 2011: $4,427.44 Section A - Policy D®tails Daily Max: $90.00 Elimination Period: 100 Days Elimination Period Met: Lifetime..Max: _ $E5,700.00 Benefits Paid to Date: $4,410.00 Remaining Balance as of Jun 10 2011: $61,290.00 D ':11 VGID AFTER 180 DAYS ~ ~"`°"" CHECKAMOUNT ~~$4,427.40 u'202~35985011' I;Q..1L9004451: 00000530,911' l Genworth Financial ;,{r GENWORTH LIFE IN5 CO LONG TERM CARE INSURANCE DIVISION P.O.Box 40007 LYNCHBURG VA 24506-9939 W 000 0001 B9B 00000000 001 006 008551N8: 0 0 '~N"'~a~ff)fi~~~~'~~~~~~'~"u~"nl~'n t~fln~~~n1~~u~'~~1~' ESTATE OF SARA ARNOLD 312 E SIDDONSBURG RD MECHANICSBURG PA 17055 Page 1 of 8 __ ce~oa r1 nRl~lfli n - ----------------- -- 800 876-4582 ' - Claims, ~ ) Payment for Jul 25 2010 through Jan 15 2011: $6,660.00 Section A - Policy Details Daily Max: $90.00 Elimination Period: 100 Days Elimination Period Met: Nov 2 2010 Lifetime Max: $65,700.00 Benefits Paid to Date: $11,070.00 Section B - Summary Total Amount Billed: $69,592.27 - Total Exclusions and Plan Limits: $62,932.27* = Total Paid: $6,660.00 * See Explanation of Benefits Paid section for details ..1. .. L ~~.~~.o.~,~ riease ae>•aau uoiu,c „~~~ ....~ ....,,,., ,. ~ ,.~ . CHECK't~0. 51-d ,' C~enworxh Financ+al ,;I~ 2pz1s9sa2z -i""'*,1~ GENwoRTti uFt: INS GD DATE QF-CHECK LON© TERM CA=1NSURANCE DIV1SIbN ' OB>'24l'f ~ :,: P..O:Box 40D07 .. `LYNCFiBURG VA"'24&06-9939 HUNDRED SIXTY'DOLLARS AND NO CENTS **'*" SIX'THOUSAND SIX . PAY EXACTLY VO{D AFTER 180 DAYS 8 ~~"°"' PAY TO THE ORDER OF ESTATE OF SARA ARNOLD 312 E SIDDPNSBURG RD CHECKAMOUNT avLECHANiCSBURG RA 1705'a •: $6$60:00. .> ~„ , !/~.' O ~i~ J7~ll ' % ' " ~ ~ ~ ir,~ lli 3 ~ ,~ ~. i~ lF ~ n~ P~ . 1 UCG0985842 A2467 ,,. u thp~zetl.,8i8t-atu~e 'EPnk of Amerk,y, N:A, a ,. NgRTFORD, CvNNECTtGUT. ~. ~ •-~ - +"t` .:a~ u'202L3956221P e:^~L90044St: D0000 5 304 9u'