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12-12-11 (3)
1505610105 REV-1500 Ex(o=_~~,tFr, PA Department of Revenue Bureau of Individual Tax Pennsylvarria gE~~MENTpgqEVEN4F OFFICIAL USE ONLY es PO BOX z8o6oi Harrisbu , PA i iz8_o6o INHERITANCE TAX RETURN County Code Year File Number 1 ENTER DECEDENT INFORMATION BELOW Social S RESIDENT DECEDENT ~~ ~ ~ ~ d~ ~ I ecurity Number Date of Death MMDDWW Date of Birth MMDDWW 159-24-9799 03/13/2011 Decedent's Last Name 11/30/1917 NEDWICK Suffix Decedent's First Name PAULINE Ml Iff APPllcable) Enter Surviving Spouse's Informatfon Below F Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE FILL IN APPROPRIATE OVALS BELOW REGISTER OF WILDS ~ 1. Original Retum O 2. Supplemental Return O 4. Limited Estate O O 3. Remainder Return (Date of Death 4a. Future Interest Co Prior to 12-13-82) O 6. Decedent Died Testate O in romise (date of death after 12-12-82) O 5. Federal Estate Tax Retum Required (Attach Copy of Will) O 9. Litigation Proceeds Received ~~ Decedent Maintained a Living Trust 1 (Attach Copy of Trust.) 8. Total Number of Safe Deposit B oxes O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A) CORRESPONDENT- THIS SECTION MUST BE C Att OMPLET Name ( ach Schedule O) ED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX I PaUI D. Daggs, Esquire NF ORMATION SHOULD BE DIRECTED TO: Daytime Telepho N ne umber (71'7) 884-4963? r•', ;~:: Q u .; -.a.-t REGISTER O - '`: -~ ~ ~-r First Line of Address ~!UjSE ONLY' ~ ;_-~ - 130 W. Church Street -,. r ` -n '~- Second Line of Address ` ~ -, Suite 100 ; -' `7 `- ' - City or Post Office - --~ --- , t-' Dillsburg State ZIP Code DATE FILED t - ~ PA 17019 Correspondent's a-mail address: aUl da Under SIBW.COf1'1 penalties of perjury, I declare that I have examined this return, mcludm it is true, cort~t and complete. Declaration of Preparer other than ttre g ~ompanying schedules and statements, and to the (GNAT F PE pry Personal representative is ba NSIBLE OR LI G URN sed on all inforrrwtion of which mY knowledge and belief, Preparer has any knowledge ADDRES DATE 128 Ewe oad, Mechanicsburg, PA 17055 09/30/2011 SIGNATURE OF ARER OTHER T REPRESENTATIVE ~~ ADDRESS 130 W. Church Street, Suite 1 Dillsburg, PA 17019 DATE 09/30/2011 L Side 1 1505610105 1505610105 1505610205 REV-1500 EX (FI) Decedent's Name: Decedent's Soaal Security Number RECAPITULATION 159-24-9799 1. Real Estate (Schedule A) ................ ............................. 1. 2. Stocks and Bonds (Schedule B) ....... 143,000.00 .......... . ..................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) 3 ..... . 4. Mortgages and Notes Receivable (Schedule D) ...... ...... . .............. 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) 5 ....... . 6. Jointly Owned Property (Schedule F) O Separate Billing Re ue 7 t d 148,477.12 q s e ....... g, . Inter-Vivos Transfers $ Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 thro h 7 u9 ) ....... ...................... 8. 9. Funeral Expenses and Administrative Costs (Schedule H) 291,477.12 ................... g, 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) 28,140.77 ............... 10. 11. Total Deductions (total Lines 9 and 10) ......... 5,161.55 ........................ 11. 12. Net Value of Estate (Line 8 minus Line 11 33,302.32 13. Charitable and Governmental BequestslSec 9113 Trusts for which 12 an election to tax has not b 258,174.80 een made (Schedule J) ....... . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ... . TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 14 2,174.80 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0 _ 16. Amount of Line 14 taxable 15. at lineal rate X .0 _ 17. Amount of Line 14 taxable 16. at sibling rate X .12 18. Amount of Line 14 taxable 17. at collateral rate X .15 7GQ ,„ ,,,. 19. TAX DUE .........................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 38,726.22 38,726.22 O L 1505610205 Side 2 1505610205 J REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Nurmber Pauline F. Nedwick STREET ADDRESS _ -_ _ _ 110 Linden Drive _- _- __ - __ __ -- CITY _ _ - __ _ _ - - _. - - __ - - Camp Hill 1 STATE - _ _~ - - - -__ - 21P _- -- PA 17011 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments (1) 38,726.22 A. Prior Payments B. Discount 3. Interest Total Credits (A i• B) (2) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3) Fill in oval on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 38,726.22 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: a. retain the use or income of the ro Yes No P Percy transferred .................................................................... . b. retain the right to designate who shall use the ro ~~~~~~~~~~"""~" P perry 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 "in trust 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. §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 fi IIII ng a taX9retum a(re sti Illapplicable even if the surv vingtspousef srthe only beneficlPa ~ ~m thx, and the statuh~ry requirements for discbsure of asserce d For dates of death on or after July 1, 2000: ry • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 pen;ent, except as noted in [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (11-08) Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERIfANCF TAX RERIRN REAL ESTATE RESIDENT DECEDENT ESTATE OF PAULINE F. NEDWICK FILE NUMBER All real 2111-0381 ~~~ ~~ ~~ ~ ~ a ~~ 1° 001A^10e roust ~ reported at fair marfcet value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buv or sell- hrdh ~,a„~~„ b~..,..._~~_ ~____ . , REV-i5D8 EX+ (il-1o) Pennsylvania SCHEp1/LE E DEPARTMENT OF REVENUE WHO BANK DEPOSIT'S ~ MISC t . RESIDENT oEQ~oEN~r "~' PERSONAL PROPERTY ESTATE OF: PAULINE F. NEDWICK FILE NUMBER: 2111-0381 Include the proceeds of litigation and the date the proceeds were received ny the estate. All Property jointly owned with right of survivorship must be di l sc osed on Schedule ITEM F. NUMBER DESCRIPTION VALUE AT DATE 1. Metro Bank Account No. 0536308778 OF DEATH 2_ M & T Bank Account No. 631724496 37,764.00 3_ M & T Bank CD No. 031003913824221 1,620.35 4. Sovereign Bank CD No. 1055177461 35,222.96 5. Sovereign Bank CD No. 1055356461 30,293.87 g. Household goods /Personal Property 31,158.45 7, Refund from PPL 6,249.00 g_ Refund from Wells Fargo (Homeowne-'s Insurance) 247.01 g_ State Retirement Board (final check) 115.50 10. Refund from Golden Living LTC 76.24 11. Real estate closing -credit for county taxes 4,254.16 12. Real estate closing -credit for school taxes 246.50 13_ Real estate closing - credit for sewer 1,212.24 16.85 TOTAL (Also enter an Line 5, Recapitulation) ; I 148,477.12 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT oECEDEivr GGT~T! w~ SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS PAULINE F. NEDWICK ITEM NUMBER A• FUNERAL EXPENSES: I' Trefz & Bowser Funeral Home 2- Romberger Memorials FILE NUMBER 2111-0381 Decedent's debts must be reported on Schedule I. e• ADMINISTRATNE COSTS: 1• Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City ------ 2,682.27 1,280.00 0.00 - -- ---------------- State _- ZIP _______ Year(s) Commission Paid: z• Attorney Fees: 5,850.00 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: 331.50 5• Accountant Fees: 6. Tax Return Preparer Fees: ~• Costs of Publication + postage B- Real estate closing -seller's assistance 200.00 9- Real estate closing -broker fees paid estate 5, 720.00 ~ ~- Real estate closing -state tax paid by estate 8,830.00 ~ ~- Real estate closing -fees for tax cert., escrow and notary 1,430.00 ~y- Estate Auction fees -Chuck Bricker Auctione 47.00 , er 1, 770.00 TOTAL (Also enter on Line 9, Recapitulation) ; 28,140.77 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES 8c LIENS w~n~c yr ~ PAULINE F. NEDWICK FILE NUMBER Report debts incurred br the decednnr wry.,. F,. a_,.,..~_. ____, _ 2111-0381 REV-1513 EX+ (O1-10) j ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ~ BENEFICIARIES ESTATE OF: PAULINE F. NEDWICK NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [Indude outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1• Mary Ann Podraza, 128 Ewe Road, Mechanicsburg, PA 17055 2• Ty W. Shatzer, 343 (th Street, New Cumberland, PA 17070 RELATIONSHIP TO DECEDENT Do Not List Trustee(s1 friend friend ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. 6. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1, FILE NUMBER: 2111-0381 AMOUNT OR SHARE OF ESTATE 50% 50% 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. ~ I, Pauline F. Nedwick, of Camp Hill, Cumberland County, Commonwealth of Pennsylvania, do hereby declare -this to be my Last Will and Testament, revoking all other Wills and Codicils heretofore made by me. I am single as both my husband and son have predeceased me. I have no surviving family members. ARTICLE I: BURIAL INSTRUCTIONS It is my preference that I be cremated and that my ashes are placed in my family plot in the Hershey Cemetary. ARTICLE II: PAYMENT OF EXPENSES AND 'T'AXES I direct my Executor to pay the expenses of my last illness, iFuneral and burial not covered by my pre-paid contract (including the cost of a monument or marker over my grave), from my estate as soon as practicable after my death. All federal, state and other death taxes payable on the property forming my gross estate for those purposes, whether or not it passes under this Will, or whether it passes by reason of joint ownership thereof, such as certificates of deposit, savings bonds, etc., shall be paid out of the principal of my probate estate just as if they were my debts, and none of those taxes shall be charged against any beneficiary. Dethlefs - Pylzosh Law Group, LLC Page 1 of 7 2132 Market Street, Camp Hill, PA 1701 1 (717)975-9446 ARTICLE III: TANGIBLE PERSONAL PROPERTY . I give all personal property (including, but not limited to, clothes, jewelry, works of art, pictures, books, any collectiblPS, and anv purely personal effects) owned by me at my death, and all insurance policies on such property, as follows: (1) To those individuals, who survive me by thirty (30) days, who are designated on a list or memorandum signed by me which refers to this Will, or is found with a copy thereof, the items listed beside their names. If no such list; is found within thirty (30) days of my death, it shall be presumed that no such list exists. (2) The balance (including any item under subparagraph (1} above, the bequest of which has lapsed, in as nearly equal shares as is practical to Mary Ann Podraza and Ty W. Shatzer, to be divided among them as they may agree. ]:n the event that there is disagreement, they shall select one item, in rotation, in ordE~r determined by lot, until such time that all desired items have been selected. Any disputes concerning the allocation of my tangible personal property shall be resolved by my Executor, in my Executor's sole discretion. (3) Atty item not taken by, or distributed to, any individual pursuant to paragraphs (1) and (2) above, shall be sold and become part of my residual estate. ARTICLE IV: REAL ESTATE I hereby give my real estate interests, including the house and property, located at 110 Linden Drive, Camp Hill, Pennsylvania, to Mary Ann Podraza and Ty W. Shatzer, in equal shares. ARTICLE V: DISTRIBUTION OF MY ESTATE I hereby give the rest, residue and remainder of my estate, of any nature whatsoever, to Mary Ann Podraza and Ty W. Shatzer, in equal shares. ARTICLE VI: PROTECTIVE PROVISION To the extent permitted by law, neither the principal nor income of any distribution shall be subject to attachment, levy or seizure by any creditor, spouse, Page 2 of 7 assignee or trustee or receiver in bankruptcy of any beneficiary prior to his or her actual.. receipt of income.or principal distributed. The Executor shall pay the net income and the principal to the beneficiaries specified by me, as their interests may appear, without regard to any attempted anticipation, pledging or assignment, and without regard to any claim or attempted levy, attachment, seizure or other process against the beneficiary. ARTICLE VII: FIDUCIARY FOWERS I .hereby grant to my Executor the continuing, absolute and discretionary power to deal with an ' y property, real or personal, held in my estate, as freely as I might in the handling of my own affairs. My Executor shall have fill authority and power to handle administration, division, management and distribution of my estate in any manner which he or she deems appropriate, necessary, or in the best interests of my estate. Such power shall be exercised independently and without the prior approval of any court or judicial authority. Without in any way limiting the generality of the foregoing, I hereby grant unto my Executor the following specific powers and authority, in addition to, and not in substitution of, powers conferred by law: (a) To retain any or all of the assets of my estate without regard to any principal of diversification, risk or productivity. (b) To invest in all forms of property without restriction to investments authorized for any type of fiduciary. r• (c) To compromise any claim or controversy. (d) To loan money to or to purchase property from my probate estate. fie) To borrow money from any person, including any Executor, and to mortgage or pledge any real or personal property. (f) To sell at public or private sale, to exchange or to lease for any Page 3 of 7 period of time, any real or personal property, and to give options for sales, exchange or leases, all for such prices and upon such terms and conditions as they deem proper. (g) To allocate receipts and expenses to principal or income or partly to each as .they deem proper. (h) To repair, alter or improve any real or personal property. (i) To purchase investments at premiums and to charge premiums to income or principal or partly to each. (j) To subscribe for or to exercise options for stocks, bond; or other investments; to join in any plan or lease, mortgage, meager, consolidation, reorganization, foreclosure or voting trust and to deposit securities thereunder; .and to generally exercise all the rights of security holders or employees of any corporation. (k) To register securities in the name of a nominee or in such manner that . title shall pass by delivery. (1) To exercise all power, authority and discretion by this instrument after termination of any trust created herein until the same is fully distributed. (m) To commingle the assets of any trust estate created by the Will in any one or more common funds for greater convenience and flexibility. (n) To employ attorneys, accountants, engineers and other such persons, professional and otherwise, as may be necessary for the proper administration of this estate and to pay their compensation from such funds. ' (o) To pay off the.balance of any mortgage. (p) ~ To appoint a professional or corporate co-Executor or• professional co- Trustee to provide counsel and assist in fulfilling administrative tasks, and to pay reasonable compensation for their services, and to charge same to (or apportion the same between) income and principal as he may deem proper. r Page 4 of 7 ARTICLE VIII: EXECUTOR I hereby appoint my friend, Mary Ann Podraza, to be the Executrix of my Will. Upon her death, resignation or inability to act or continue to act for any reason, I appoint my fiiend, Ty W. Shatter, as my alternate Executor. ARTICLE IX: MISCELLANEOUS PROVISIONS A. Fiduciary Provisions No Executor named in this Wlll shall be required to give bond or other security in any jurisdiction in which he or his successor shall act yin connection with my estate.. Nor shall any guardian or property or persons be required to give bond for the faithful performance of their duties in any jurisdiction. B. Specific Items of Property - Gifts of specific items of property mentioned in this wil]. or any separate writing that is binding upon my Executor shall fail to the extent that I, or any duly authorized agent of mine, dispose of such property prior to my death. My Executor shall~not substitute cash ox any other assets for any such property. C. Matters of Interpretation For simplicity; I may have expressed pronouns and otr~er terms in one number and gender, but where appropriate to the context, these terms shall be deemed to include the other number or gender. D. Paragraph Constriction Paragraph headings in this Will are for reference only and shall not affect the meaning, construction or"effect of this Will. Page S of 7 IN WITNESS WHEREOF, I have hereunto set my hand and seal this 22na day of November, 2010. ~~ ~, ~ ~~~~. ~. ~~~~~ .J~ (SEAL) . Pauline F. Nedwick SIGNED, sealed, published and declared by Fauline F. l~tedwick, the above Testatrix, as and for her Last Will and Testament, in the presence of us, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as witnesses. . Residence: k.~l P/~ 170 ~ ~ ~ ~- ~ ~ ~ ,~ Witness i /~ ~ ~;Cfti~ ~~ /~_. . `- - '~' ~~~ lLResidence: Witness Page 6 of 7 COMMONWEALTH OF PENNSYLVANIA ss COUNTY OF CUMBERLAND We, the undersigned, whose names are signed to the attached or foregoing instrument, being first duly sworn and qualified according to law, do hereby declare to undersigned authority that we were present and saw the Testatrix sign and execute the instrument. as her will, and that she had signed willingly (or willingly directed another to sign for 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 that to the best of their knowledge the Testatrix was at that time eighteen ea age or older, of sound mind and under no constraint or undue infle;~ I, the said Testatrix, do hereby acknowledge that I signed and a ecuted the instrument as my last will, that I signed it willingly, and that I signed as my free and voluntary act for the purposes therein expresse a~ Pauline F. Nedwick ,~ l 1 Su./„,~~r 0~. 'I ~~ Residence: ~' til f%H ~ f ~9 ~ 1 ~» -~ Witness ~ , ~[. ~ Residence: n' :~ ~l ; ~ ~ S %• i it errs Subscribed, sworn to and acknowledged before me by the above-named ;1 witnesses, this 22nd day of November,' 2010. ,~ NOTARIAL SEAL ~ ----. ... • DARREIL C DETHIEFS j ` Notary Public CAMP Hlll BORO, CUMBERLAND COUNTY +` ~.,,,r,(j/~, fs,J~, My Commisslon Expires Aug 5, 2012 Otary Public Page 7 of 7 C16?!~_?tral No. 2502-0265 IIIU~I A• S~St `~l .- L [ j F"~2. Q RHS 3. Q Conv. Unins. 6' er. 7. _ tuber: . Afortgage Insurance: Case Number: 1t-ti12CAP 680U4'~I186 10.10-&~pt322fip3, 4. [~Ylt ~: ~ Cons. ~.- C. Note: This form is fumis to gave you a statement of actual settlement costs. Amounts paid to and by the settlement agents are shown Items marked . "(p.o.c)" were paid oul.~ide the Dosing; they are shown here for informational purposes and are not included in the totals. D. Name & Address of Borcovver: E. Name & Address of Seller: F. Name & Address of Lender: Nicholas L. Evans Estate of Pauline F. Nedwick Members i st Federal Credit Union 10 F Street, Carlisle,PA 17013 110 Unden Drive, Camp Hill, PA 17011 5000 Louise Drive, Mechanicsburg, PA 17055 G. Property Location: H. Settlement Agent: I. Settlement Date: 08/3'V2011 110 Linden Drive Camp Hill PA 17011 ' Barristers Land AbsUact Company Disbursement Date: 08/3'U2011 , 3310 Market Street, Camp Hill, PA 17011 Lower Allen Township Telephone:717-761-6190 Fax: 717.761-4072 I Place of Settlement: 3310 Market Street, Camp Hill, PA 17011 TitleExpress Printed OtV30l2011 at :i:59 pm by LM :. , 100. Gross Amount Due from Borrower 400. Gross Amount Due to Seller 101. ConUacl sales price 143,U00.00 401. Contract sales price 143 000 00 102. Personal 0 402. Personal rt , . 103. Settlement charges to lxxrower (line 1400) 7,700.97 403. 104. 404. 105. 405. Ad'ustments for items aid b seller in advance Ad ustments for Items aid b seller in advance 106. Cityflown taxes to 406. Cityftown taxes to 107. County taxes 08/31/2011 to 12!3112011 246.50 407. County taxes 08/3112011 to 12/31/2011 246 50 108. School Taxes 08/31/2011 to 06/30/2012 1,212.24 408. School Taxes 08!3112011 to 06/30/2012 . 1 212 24 1~• Sewer 08/3t/2011to 09/30/2011 11m 16.85 409. Sewer 08/31/2011to09/3012011 , . 16.85- _ ....~..~,~.~..,...,. . 410. ..__.___ .. 111. 411. . k,~ . , ... . . -°- .,__ 412. from were 952,175.56 , 420.. GroaaAmoyntDuetoSeller.. -' ,.a Beha9f of Borrower 500. Reductions in Amount Due to Seller y 1,000.00 501. Excess deposit (see instructions) 202. Prinppal amount of new loan(s) 146,074.00 502. SetOement charges to sever (line 1400) 6 203. Existin s taken sub' to 6,307.00 204. Credit for Amount Paid 503. Existin to s taken su 'ed to 400.00 504. Payoff of first mortgage ban 205. 206. 505. Pa off of second mat loan 207. ~. 208. 507. ~. 209. 509. Ad ustments for hems un aid b seller 210 Cityflawn taxes Ad ustmenta for Items un aid b seller . to 211. County taxes to 510. Cityltown taxes to 212. School Taxes to 511. County taxes to 213. -512. School Taxes to 513 214. Seller Assist 5,720.00 . St4. Seller Assist 215. Reimburse Pest lnsptn-VA Loan 5,720.00 75.00 515. Reimburse Pest Insptn-VA Loan 216. 7500 516 217. . 517 218. . 219. 518. 220. Total paid b /for Borrower 1 519. - - 53,269.00 520. Total Reduction Amount Due Seller 300. Cash at Settlement fromRo Borrower 72,10Y,gg 301, Gross amount due Iran borrower (line 120) 600. Cash at Settlement tolfrom Seller 302. Less amounts paid by/fa borrower (tine 220J 152,176.56 601. Gross amount due to seller (line 420) 144,475.59 153,289.00 602. Less reductions in amount due seller (line 520) 303. Cash ~ From QX T B 72102 00 o orrower 1,092.44 603. Cash QX To ~ F ~h,~,...s.,,~.,,._....~.....•.......____ ~ __ rom Seller 72,373.59 Previous editions are obsolete Page 1 of 3 HUD-1 h~~-, al Estate Broker Fees $ 9,055.00 Division of commission (line 700) ars follows: Paid From Paid From Borrower's Seller's 701. $4,540.00 to Keller Williams of Central PA Funds at Funds at 702. $4,515.00 to HOWARD HANNA REAL ESTATE Settlement Settlement 703. Commission paid at settlement 225.00 8,830.00 800. Items Pa able m Connection with Loan 601. Our origination charge (Includes Origination Point 0.000°k or $0.00) $305.00 (ftom 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) 305 00 804. Appraisal fee to Members 1st Federal Credit Union (from GFE #3) . 400 805. Credit report to Members 1st Federal Credit Union (from GFE #3) , 20,00 806. Tax service to from GFE #3 807. Flood certification to Members 1st Federal Credit Union (from GFE #3) 12 50 808. Reinspection Fee to (ftom GFE #3) . 809. VA Funding Fee (Financed) to Members 1st Federal Credit Union (from GFE #3) 074 3 00 810. Va Funding Fee (cash) to Members 1st Federal Credit Union (from GFE #3) , . p 50 , 900. Items Re aired b Lender to be Paid in Advance 901. Daily interest charges from from 112011 to 09/01/2011 @ $17.24481day 902. Mortgage Ins. Premium for months fo (from GFE #10) (from GFE #3) 17,24 903. Homeowner's insurance for months to Westfield Insurance $517.00 P.O.C. B 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) ~q gg 1002. Homeowner's insurance 3 months $ 43.081month $129.24 , 1003. Mortgage Insurance months $ 0.00/month $ 1004. City Property Tax months $ 0.00lmonth $ 1005. County Property Tax 7 months $ 59.741monlh $418.18 1006. School Taxes 3 months $ 118.80/month $356.40 1007. Aggregate Adjustment $-238.94 1100. Title Cha es 1101. Title services and lender's title insurance 1102. Settlement or dosing tee to $ from GFE #4 1,318.75 t 103. Owner's title insurance -Stewart 7itie Guaranty Com an p y 1104. Lender's title insurance -Stewart Tite Guarani Com n Y a from GFE #5 P Y $1,318.75 1105. Lender's title policy limit $146 074.00 Lender's Polic , y 1106. Owners title policy limit $143,000.00 Owners Polic y «_. -3107,=Agent's portion of the totaliitle insurance premitim $1,057.19 1108: Underwriter's portion of the total title insurance remium $261.56 .. .- 1200. Govemment Recordin and Transfer Cha es - 1201. Govemment recording charges $ 1202• Deed $64.00 Mort a $102.00 Release $ (from GFE #7) 218,50 1203. Transfer taxes $ 1204. CitylCounty tax/stamps Deed $1,430.00 M $ (from GFE #8) 1,430.00 1205. State Tax/stamps Deed $1,430.00 Mort e $ 1206. Deed $ Mort e $ 1,430.00 1207. Record Assignment of Mortgage $~ ~ 1300. Additional Settlement Char es 1301. Required services that you can shop for 1302. Deed Preparation to Dethlefs-P kosh t.aw - POC Seller (from GFE #6) 1303. Pest Inspection to Ins ion Center $ 1304. Trash - 9/5-9/30/11 $75•~ P.O.C. B• 1305. Reimbursement for Tax Cert to Lower Allen Townshi Authorit 1660 to Barristers Land Abstract General - H 1306. Inhedtance Tax Escrow 10 to Barristers Land Abstract Escrow - H 1307. Escrow Fee . 56 000 00 to Barristers Land Abstract General - H 1308. Notary Fee , . to Linda McBeth 25. ~cu~i~w. rrra'ii.TTi [Iii !•~~ ~ ~. 12. 'Paid outside of closin b B ~ ~ ~ 7,700.97 66,307.00 9 Y ( )orrower, (S)eller, (L)ender, (I)nvestor, Bro(IQer. "Credit by lender shown on page 1."'Credit by seller shown on page 1. previous editions are obsolete Page 2 of 3 HUD-1 ~s~~ :Faith Estima6t - -""" 1Chages ~_ C~raes That Cvarriot Increase HUD-1 " ~.=her J'Gao~. stimat~ ., , I1r~Y Our wigiriation charge' _:,. #. ~ 305.00 305.00 Your credit or-charge (points)"foilhe specific inleresf ra,e chosen # '802: 0.00 0.00 Your=adjusted odginatiori:charges, # 8(b~~ 305.00 305.00 Transfer taxes # 1203 1,430.00 1,430.00 Char es Thatin Total:Cannotiricrease More~ihan 10°k .' , GovernmenCrecording charges ~ :: #.1201 .Appraisal fee '#'804 ~ CreditrepoR '#'805 Flood cenification # 807 ., Reinspection_Fee r #, 808 • VA Funding Fee (Fin9nced) ' q 809 Va Funding Fee (cash) • . ? q 810 `Owner's htle insurance , , # 1103 _ T i Cfta es'Thaf Can Chan e Initial deposit for your escrow account ,-,# ,1001 , , Daily interest charges from _ ~ #, 901 $17.2448/da Homeowners insurance # 903 Title services and lender's title insurance #.:1101 ,. Pestlnspection # 1303 #. # Loan Terms Good;Faith'Estimate 1iUD-1 238.00 216.50 400.00 400.00 20.00 20.00 12.50 12.50 100.00 0.00 3,074.00 3,074.00 0.50 0.50 0.00 0.00 3,845.00 3,723.50 -121.50 or -3.1599°~ '.1'r'_Good:Falth EetE/nate: HUD-] i = ; 483.34 664.88 275.92 17.24 ~•~ 517.00 1,573.75 1,316.75 50.00 75.00 Your initialloan;amountis'~ ~': $146,074.00 Your loan term is ;' 30. years Your iriitial interest rate is - 4.2500% Your initial monthly;amount owedTor principal, inleresf, and any: mortgage $718.60 includes insuranceis X^ Principal X^ Interest ^ Mortgage Insurance Can your ihtetest rate rise? ^X No. ^ Yes, it can rise to a maximum of %. The first change ' will be on / / and can change again every years after / / . Eivery 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 °h or higher Ihan %. Even if you make payments on time, sari your loan balance rise? ^X No. ^ Yes, it can rise to a maximum of $ , Even`if you make payments.on time can yourmonthly,amountcwed fors ^X No. ^ Yes, the first increase can be on / / and the monthly princpal, interest, and mortgage insurance rise? ° ; amount owed can rise to $ _ The maximum it can ever rise to is $ Doesyourban have a prepayment perialtj~ ~, X^ No. ^ Yes, your maximum prepayment penalty is $ Does your loan fiave a balloon payment? X^ No. ^ Yes you have a baloon payment of $ d i , ue n years on / / Total monthly amount owed including esaovi-account payments ^ You do not have a monthly escrow payment for items, such as property taxes and homeowner's insurance. You must pay these items directly yourself. ^X You have an addifional monthly esaow payment of $221.62 ' that results in a total Initial monthly amount owed of $940.22. This indudes principal interest, any • mortgage insurance and any items checked below: Q Property taxes ^X Homeowner's insurance ^ Flood insurance ^ "'^t ' If ^ ^ - e. you have any questions about the Settlement Charges and Loan Terms listed on this form, please contact your lender. - -, . 4,....~.. 5 ~e;a'~sEi'itx.'i. .•r+~ _. Previous editions are obsolete Page 3 0 3 HUD-1 HUD CERTIFICATION OF BUYER AND SELLER 1 h:3ve carefully reviewed the HUl}1 Settlement Statement and to the hest of my knowledge and Melief, it is a true and accurate statement of all receipts and disoursements made on my :rccount or by me in this transaction I further certify that I have received a copy of the HU0.1 Settlement Statement r~G~y~ -/ Nicholas L. Evans Est t of auli . Nedwick .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 ~~ ~ETTLEM AGEN DATE ,K..,,r.~r„ ., F ,,~,,~.:, ~~,.r~~1.-ate t;-+'„ e~~ ~ '- _ NARNING IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM PENAILTIES UPON :ONViCTiON CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 18: U.S. CODE SECTION 1001 AND SECTION 1010. 1~vious editions are obsolete Page 4 of 4 1~ HUD-1 ~ • ~ ~ ~~ ds Name of Borrower. Nicholas L Ettans + a Name of Seller: Estate of Pauline F. Nedwic0. File Number 11-Ot-6-19612 TkleExpress Prepared 08!302011 at 12:03 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. " $ ~~~( ~`~ ~ ~ 1~ a ; ~, a ent ~ ~ ~ ~ mil PU ~S't3t~~e'., 11011: TitleCtiaig~s _ ~. ~} ~ k ~ ~~:t3 ,~` d ,r`, F~~ ~ w < >,~~e~e '~"~~~ ~ ' `'h ;lire t) "3~v ~ ~ ~'i .~ ,'ti- ~ '"- :, . ` l :. . ~~ m 1101. Title services and lender's title insurance 1,318.75 a. b. c. d. $ 1102. Settlement or dosi fee 1103. Owners title insurance 1104. LendersGUeinsurance ( icy 1,093.75 $ 1,318.75 a. Endorsement900 EPL-Residential 50.00 b. Endorsement 300 Survey 50.00 c. Closin Service Letter 75,00 d. End 100 50.00 (Total 1103 + 1104) 1105. Lenders UUe pot flrtlit 5146;074:00 ' 1106. 'Owner's title pot` pmtt $143,000600 1107. A Ys pofGon of~the:total UUe insurartCe premium $ 1,057.19 11(18.. Underwritels portion of the total UUe'in§utance prem.. 26f.56 (Total 1107 + 1108). 1109. Basic Rate 1110. 1111. 1112. ~.. . . . . r 1100'T,ttIe.C ' 'eswi Ra ee: ' p °'~ ~ ,,,,; "~~_ ,; ~ , ~~, '~°~es~. PQC 'rzl;i Pik ~~ ne. d~'Y -~.'~: P~~dr 1101. Title services and lender's title insurance $ 1104. Lender's UUe insurance to Banisters Land Absirad Company 1,318.75 1,318.75 r .:. Date 8/26/ i ; Nic as L. s c ~, E~~ BANK 888.937.0004 myme#rf~bank.com Balance intonnation reflects transactions through 6~0 PM on that business day. Some deposits may rwt be available for immediate withdrawal Checks and other items received for deposit subject to the provisions of the Uniform Commercial Code or arq~ applicable collection agreement. 72 13:24 3/2812011 08~D1 #****8775 T1rDDWd $ 37,764.24 SIMPSUN FERRY STORE108 s-t s 3MM t0/t01Mf ETRo ~+~ ~ ~ myme#robank.com eelanoe irNonna>ian re9ects transacliorrs orough eAO P-rl om mat wseress day. sane deposes may ma be avaiiettle for immediate wilfrdrawai. checks artd other rew~ived for aepoed 9ubjea b the provisions of me Urtiiorm commeraal code a any appticable oaleaia, agreement. 75 13:28 3/28/2011 0801 4*ik***3126 TItDDDep $ 37,764.24 SIMPSDN FERRY STORE408 t ~-,e 3MM 10/t01NT - _. __..- __--- ~ _ ... -- __ - _ -i vez S. Fs et-- m :~_ _ - - F sia=~ g~= iFSFfr~ €aat Fans =FsP=-rates- - _ i - i; ~ ate-` E s : c! is cnr• -z .._ - _.___. w i ~. t i i ~ .= i , _ , -- ~ j C+JS70 ~R N+inAE {PRi"•,^ j _ 1 -- I I - I DESCRlP~p~+t~ _~ r i ~- ~ I 1 r r ~ ~ - _- - - -~ ~_ _ _ i '-- ,~_ I - - . Ora;ra; - Prccessir+g'vilwt _ _ _ __.- i Copy - Branch ' ~ - - r:.. _ -- _ r'USTS"}tv1EE? SIGNATURE -' ,' ,-' G/L NO. _ POSTING COST CTR. JULf J C~~ COSG GEAR SEQ. NO, fiP 7 ._ - t'DSTn~a'7SdG ~ ! _ i EPdFtAYEE tvUMBtR ~ i, sus P~ T ACCa1r:Tn - _ - LDESCRIPTIO'd ______~ ~! .'i t ~- 8_~ ~ Criginat -Processing 1Nork may -Branch + fi A `; - _ I L~YI~ ~[~ ~~~A~ i ~V~ {, is GF-26918/07) AUTHORiZATiON ~.:naft Pr -_~ 1 t , - - ~-, f ! 3 .. ~ C~QMER NAN?E (PP.ICJTj ---DATE _ 4-__~! _` i, w ' i f 1 ~ .. ~- ,t ~ ~ )) _ r_ ~~~.. ~ ~ _ _ ,. .... ~~~tl..'-, ~-~E 3.r .. ~...- .-...___. ~ - , .'~ CUSTOMER £IC,NATURE Gtt NO. ' 2 POSTING COST CTR. 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Sovereign[ I ~® Checking, Savings, loans 1.877.SOV.BANK srnrereignbank.com CU51'OMER RECEIPT TD ikt~ Date 03/28/11 14:50 Tlr 010 T AN 145517 Seq 0200 0168 Ant ~31„158~ ~ >7 880008 7/70 Swedgn BaNc is a AAenbcr FDIC l~&T ~.~~ ACCOUNT N0 ACCOUNT TYPE 63172496 M8T SELECT WITH INTEREST 00 0 04306M NM 017 10896 PAULINE F NEDWICK C/0 MARY ANN PODRAZA 128 EWE RD MECHANICSBURG PA 17055 INTEREST EARNED FOR STATEMENT PERIOD 0.01 INTEREST PAID YEAR TO DATE 0.07 i+nn11\IT [•11NYA~V CAPITAL-HARRISBURG BEGINNING BALANCE DEPO$ TS 8 OT HER_ADDITIONS n v v v v .. • .. ..... CHECKS PAID .. ... . OTHER` SUBTRACTrONS CURRENT INTEREST PD ENDING BALANCE N0. AMOUNT N0. AMOUNT N0. AMOUNT 1,590.49 1 29.85 0 0.00 1 1,620.35 0.01 0.00 • n I~ n 1 1\ I T A r T T\/ T T V AV V V V .~ • n v • . - DEPOSITS,INTERES C:H~CKS 8 O'THER DAILY. POSTING ;DATE TRANSACTION DESCRIRTION 8 OTHER ADDI'fiONS SUBTRACTIONS BALANCE 51,590.49 03-01-11 BEGINNING BALANCE 03-01-11 SUN SUN 29.85 1,620.34 03-28-11 INTEREST PAYMENT 0.01 03-28-11 CLOSEOUT 1,620.35 0.00 ENDING BALANCE 50.00 ANNUAL PERCENTAGE YIELD EARNED = 0.00 WARM UP WITH SPECIAL SAVINGS THIS SPRING AT POPULAR RETAILERS WHEN YOU USE YOUR M8T CHECK CARD OR M8T VISA CREDIT CARD IN STORES, ON THE WEB AND OVER THE PHONE. PICK UP A COUPON BOOK AT YOUR LOCAL M8T BRANCH, OR VISIT MTB.COM/SHOPPING FOR GREAT DEALS ON SPRING SAVINGS. IF YOU PAY WITH YOUR M8T CHECK CARD, BE SURE TO SELECT (OR ASK TO USE YOUR CARD AS) "CREDIT". LOOBA (8107) a, . : c +. r "F r, t'~~3+ ~`~ - •, t STATEMENT PERIOD PAGE MAR.O1-MAR.29,2011 1 OF 1 _ _ __ s m~ y ~~ S ~_~~ r a o ~ y~~ °~ r m~ ~~ '0 0 Sa i ~ R ~ v ~~ ~ ~ ~ ~ ~ ~ ~ "'1 t ~----`~ ~ ~~ ms`s ~ .'~"°' r '° ~ .+ <<t o ~~ v vm ~ ~~ fA7CnRISn O~ O ~ I 1 I I $~ ~ ~ ~ -~ ~ ~. c~ ~ ~ ~ cs1 c ~ •'4 ~~ ~a r ~~ _ ,~ ___ _ - ! :fir .s a .. '•t' j. ~ ~ -~ ~ - ~ . - . Chuck Bricker, Auctioneer.- . .Buy & Seii on Commission - Complete Sate Service .. .. . -~ S3 Texaco I~t~., •~echanicsburg, PA '17055 7f6-,5185 ;~ ,~ / - porsorWal P~rope~tli of l `~v~-l ti~ /" ~~ ~i Gx Ad~lesrrs - . IoW ~ Pob~ ~aie ~ ~ ~~~- ~ ~ ~ I l ~'~ Out~dandit~ ~.--~I12Li5~ Totat Safe ~ (~ U ~ iJ ~ t ~ r`'f ~ ~- Tbtat l~seics ~ p ~ '~ U`z-.~ - Total Cush ~ '~ ~ d OLD - ~ P:gout . s:mss.: ,` . . . - ~ wswt~ior~.es ~ tlioeics q' b U IW-r Vf/~~ s7 O f O~ • ~~ ~~ oI` H~ ~ (~~ _./ ' . Tofu ~~sas ~ - `~ U old ~17~7a~D° ~~ ~~~•~U~f ~~ e~ C+ . i~~~ ~2~+~ _.. _. T ~~ P ~~: c~~~~ r - w `, O ~~. o r~ r W n.i r .. r ru r ui W r a ire Z & .Bowser funeral Come, Inc. .f 114 West Main Street:. Hummelstown, P'A 17036 717-566-0451 Stephen R Hall, Funeral Director-Super~risor Patricia Hill Krow, Funeral Director Statement of Services and Merchandise Services for: Pauline F. Nedwick Date of Death: March 13, 2011 Professional Services Services of Funeral Director and Staff Preparation of Un-Embalmed Body Automotive Transfer of remains to Funeral Home Hearse to Crematory Car to and From Crematory for Cremains Special Charges Cremation Total of Direct Cremation Package Cemetery Expenses Cemetery Opening/Closing Charges Transportation by Funeral Directors Private Inurnment by Funeral Directors Merchandise Alternative Container Cash Advances Newspaper Notice - Harrisburg Patriot Certified Copies of Death Certificate- 15 copies Coroner's Authorization $ Included $ Included $ Included $ Included $ Included $ Included $ 1,665.00 $ 475.00 $ 130.00 $ 100.00 $ 100.00 $ 97.27 $ 90.00 $ 25.00 Total of Merchandise and Cash Advances $ 1,017.27 TOTAL DUE $ 2,682.27 ~l~- //o QQ ~A (~ Q eA 1 (C rc~x ~rr-~>J ua~ v~~L~ 1~~~~~~~~~ ~~1~1~^1~ALJ .................:.................................. Date Bought::....... ........... ....... GRANITE -MARBLE - BR~pNZE . No ............................................. E.ls........ ......... .................. Memorials Since 1929 esign no ........................................... Found .......:..........:............................ PLANT AND DISPLAY -2395 STATE STREET. code Mont ...................:..................... Terms...... .....:......Down payment' Balance within 30 days after completion. HARRISBURG, PENBROOK, PA 17103 PHONE 232-1147 ode Mkr.. ~, 1% per month charge wiu be made on all r fir- ~„~ past due accounts. .`°" ~7 tr' ~, ,~--,~~fr,,! 800-340~i744 ect. IVo.;,.,%~..... .~....~ ... ............ TO.~c-~.i.:..~'~`:~....~.:!~~~°I~.~c!".:'.C:`...t~'':fa:g.f:~:4"*:y...'~«~? •Y~;+~"~:~`•r'~/~:'%'~f.$f#!'~:. L1~T'E...{~.f..~"~'},...h~-.~~`.tj........ ADDRESS ....... ....... .... .......... .ORDER NO. 'DESIGN NO. MATERIALS `'... ''.'f ~'4'~.... TERMS ...................:............. DIE ................................ ' ....................... PRICE OF MONUMENT ............ ........ .......... .......:. ............................... PRICE OF MARKER ..... ..~~~%.~,1... ~ ~^ ~.~ ... BASE ...................... ........................... ......... .,,1...... , ... e MKR S.~. ~'', a~'`e~ J~° 1'.,~`'".,e~i,.... ..~.+~`.~ ................. CEMETERY FOUNDATION .. ...., ..... ..r ............. ...... ...POSTS..... ...................................... ......... ........ ........ ......... ' ~~,~ LEAVE SPACE FOR~.~ ..MORE INSCRIPTIONS TOTAL COS'C ................. ......... ALL FUTURE LETTERING TO BE EXTRA c''~`~ ~ • 1 ~' , ~ ~` ice- ~~~ „~"'+~+~~~ ~ i ~~ ected in~-~'~~ ....: ~'"' C~~~f'...., .......................during To be er ..... ....................... ............ ............C .... the month o~"T.K..~'..........~~...~,.......,unless tilnavoidably delayed by labor troubles and other contingencies beyond our „ c~ntr~il arld then as soon as prat~ticable therea~ber:, Yes No D ~ optional vuidalism protection T 20 year 10 year f '} j~~y undersigned (h reinafter known as the urchaser) agrees to R mberger Memorials .,..: ..:...l..ieraM.;~:! .....~"..'....... ..............................Dollars m e o .....~~.'~-'n~~.....:...~e.~'{.i~ ............:~{...~£~~.~........ ...... .... .... ...... .......&o dat of acceptance fthisorder. it is further understood that upon acceptance of this grder the contract so .made cannot be cancelled, altered~or modified by the ptirchaser or by an agent of RombergerMemorials or in any manner except by agreement in writing betw~n the pttrehaser and Rotnberger memorials, and the above monument and appurte- nances are to remain the property of Romberger memorials, until fully paid for with right of removal. I" ~.- ~` .....: ....... .... Date. ... .. •.,~+-''~..,........................... .. .... ..... Acceptec~at ............ ~~ ......... ...... ... t. ~ ~ ~~ ~, `~ ,..~.. ; ,s ~ Purchaser ~!/ .~~..~~f ...~?~ . ~- I i .. -. .. 48500041046 REV-485 EX (05-04) SAFE DEPOSIT BOX INVENTORY PLEASE I>JSE pR~Q~NAL pp~ ONLY PA Depatrnent of Revenue $Ogel SecUrt7Y OI' D~th Certificate Number Date Of Death County Code Year File Number 159-249799 03/13/2011 peoedenYs Last Name Suttix First Name NEDVUICK PAULINE ADDRESS OF DECEDENT STREET CnY: ©~ ~ n I inrien Drive Camp Hill MI F STATE: ZIP CODE: PA 17011 NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSR BOX NAME Ma Ann Podraza Executrix STRE~'f ADDRESS: CITY: STATE ZIP CODE: 128 Ewe Road Mechanicsbur PA 17055 ueue ennliFiRB sNn RELATIONSHIP (IF ANY) TO DECEDENT: OF PERSON(S) PRESENT AT THE BOX OPENING - -- RELATIONS . a. NAME Attorney ._ Paul D Daggs CRY. STATE: ZIP CODE: S~~"DD~SS~ Dillsburg PA 17019 130 W Church Street, Suite 100 RELATIONSHIP. b. NAME: STREET ADDRESS: a NAME: S7REErADDRESS: CRY: STATE: ZIP CODE: RELATIONSHIP: CITY: STATE: ZIP CODE: NAME AND ADDRESS OF FINANCUU. INSTITUTION WHERE THE SAFE DEPOSR BOX IS LOCATED NAME: Metro Bank STATE: ZIP CODE: STREETADDRESS: CnY: 5032 Sim son F® Road Mechanicsbu PA 17050 NAME OF PERSON MAIaNG LAST ENTRY LAST ENTRY Ma Ann Podraza, Executrix DATE OF CONTRACT t0 RENT BOX NUMBER OF BOX usuF ewn anDRESS OF PER80N(81 HAVING ACCESS TO BOX DATE AND TIME OF 6130/11 0:00 am TI'R.E UNDER WHICH BOX IS REQUESTED a NAME: Pauline Nedwick deceased STREET ADDRESS: 110 Linden Drive CnY: STATE: ZIP CODE: tea..,., ual PA 17011 b. NAME: STREET ADDRESS: CITY: STATE: ZIP CODE NAME AND Tm~ OF EMPLOYEE TAIQNG THE INVENTORY WAS A WILL IN THE BOX? ^ YES ®NO ff Yes, a Date of will: b. ~~ and address ~ personal ropra:eedadve, ff named In the wilt NAME Ma Ann Podraza Cam' STATE: ZIP CODE: STREET ADDRESS: Mechanicsburg PA 17050 128 Ewe Road G Name and addre~ of attorney, ff any NAME: Paul D. Da s CITY: STATE: ZIP CODE: STREET ADDRESS: 130 W. Church Street, Suite 100 Dillsburg PA 1701.9 48500041046 48500041046 ~+ A CC n~nncrr CZnY IAIVFNTC~RY Page ~ of REV~i85 FJC V /1 ^ r.. v r.. ^ v ..... ... - - - - - - - - - INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certlficate, name in which stock is registered, and number of shares and loss of stock. (3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last dljte appearing in book, name of bank and branch, and balance. (8) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) Ail other contents. (9) Retum completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DMSION DEPT. 280601 HARRISBURG, PA 17128-0601 ITEM NO. ITEM DESCRIPTION 1 Deed to 110 Linden Drive, Camp Hill, PA 17011 2 marriage license 3 birth certificate 4 atizenship paperwork I CERI7FY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD iS CORRECT AND COMPLETE TO THE BEST OF MY 1040xILEDGE AND BELIEF. PERSON RECEMNG COPY OF SAFE DEPOSR BOX INVENTORY: SIGNATU / SIGNATURE PRINT NAME Paul D. Da s PRINT NAME AND TE BOX BELOW: Ma Ann Pod PRINT TITLE Attorney DATE 11/26/2011 CHECK APPROPRIATE BOX: ~ ~`~~ ~ Adnrr~aartubc) ^ Eat^m Rep,eaenl^li~ne ~ JdM owner or safe deposit boot NOTE: Attach additional 8'/~" x 11" sheet(s) if necessary or use duplicates of this page of form. The Departrrlent is alAllamad by lax, 42 U.S.C. §405 (oK2KC)[7, b require disdosure of Social Security rrurrlbers in car^ledon whh adrrrristering state tax laws. The DeparUrlerlt uses tale Soda) sea.+ty r^mlber to iderltly the decedent and persarlad repreaerllebves of ttla estate. The CornraonwealUl may also use the irlforrrtetlon in exchange of tax irdomration agreements xdtll Federal and bral aulFwrlGes. Ttre state taw the Corrurlorlwealtll's from disciosirl corlfiderdiBl tax'vlfortnation for ofiidal