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HomeMy WebLinkAbout01-09-12z 1505607121 ~~~~ ` 500 ~ (06-05) OFFICIAL USE ONLY PA DepaMient of Revenue Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Number Po eox 2eosot: 2 1 1 1 6 0 0 Heniabura, PA 1~12e-0601. RESIDENT DECEDENT ENTER tgECED~NT INFORMATION BELOW. Social Securely Number Date of Death Date of Birth "1.7..7 24 6577 042 42011 122919 32~ Decedent's Last Name Suffix Decedents First Name MI F o l t z M a d e l i n e G (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW Spouse's First Name THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS MI © 1.Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prbrto 42-13.82): 4. LWnited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required death after 12-12-82) 6. DeoadeM Died Testate ~ 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) Q 9. Leligation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sea 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESt~ONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFbENTULL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number Wayne F S ha de Esquire ?17 2-43 0220 Finn Name (H Applicable) .~ ~~ First line of address 5 3 W e s t Second Ilne of address City or Post Office C a r l i s l e P o m f r e t S t r e e t State ZIP Code ...._~._ ~ ~ ~ c ~ r-- ~ '~ . I C.f ~.:' . ~~~ t1R #`~ - e _.... ~? C")C~7~ yp , .. 1 . . i C~ C . ~ -~ ~~ j DATE FILED ~ ~.~m ~~ ~r C'`~ "F~7 P A 1 7 0 1 3 corrospondenYs e-mail address: waynefshade(a~comcast.net Under perlaBes of perjury, I declare that I have exarrmed this return, krdrrding acoompar-yklg schedules and statements, and to the best of my knowledge and. belief, it b tnre, oolrerel and oomplNe. Declaration of preparer other than the personal representative is based on aN Infomlatbn of which preparer has amr knowledge. PE -0N LE FOR FILING RETURN ~r~ Dy /2 OF Dr REPRESENTATNE e 53 West Pomfret Street Carlisle PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505607121 1505607121 1505607221 . REV-1500 EX . Decedents Social Security Number DecedenPa Name: Madeline G.: Foltz 1. 7 7 2 4 6 5 ? ? RECAPITULATION 1. Real estate (Schedule A) , , , , , , , , , , , , , 1. 6 3 3 0 0. 9 3 ........................... 2. Stocks and Bonds (Schedule B) .................................. 2. • 3. Ck~sey Hek1 Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. • 4. Mortgages & Notes Receivable (Schedule D) ........................ 4. • 5. Cash, Bank Deposits 8~ Miscellaneous Personal Property (Schedule E) ....... 5. 7 3 6 5 • ? 9 6. Jointly Owned Property (Schedule f=) 0 Separate Billing Requested .:..... 6. • 7. Inter Vnros Transfers 8~ Miscellaneous N -Probate Property (Schedule G) ~ S Billi R eparate ng equested ....... 7. , • 8. Total Gross Assets (total Lines 1-7) ........................... 8. 7 0 6 6 6. 7 2 9. Funeral Expenses >3< Administrative Costs (Schedule H) ................ 9. 2 8 4 7 6. 7 2 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule q ............ 10. 9 7 4 8 . 9 5 11. T~1 Dsductlons (total Lines 9 810) ........................... 11. 3 8 2 2 5. 6 7 12. Nst Value of Estate (Line 8 minus Line 11) ......................... 12. 3 2 4 4 1. 0 5 13. Charitabb and Governmental BequestaJSec 9113 Trusts for which an ebdion to tax has not been made (Schedule J) .................. 13. 14. NetValus~ubJsct to Tax (Line 12 minus Line 13) .................. 14. 3 2 4 4 ,:1. 0 5 TAX COMPUTATION - 8EE IN8TRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal. tax rate, or transfers under Sec. 9116 (a)(1.2) x 0. 0 0 15. 0. 0 0 16. Amount of line 14 taxable at lineal rate x .oa5 3 2 4 4 1. 0 5 1s. 1 4 5 9. 8 5 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17. 0. 0 0 18. Amount of Line 14 taxable at collateral rate X .15 0. 0 0 18. 0. 0 0 19. Tax Due ................................................ 19. 1 4 5 9. 8 5 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYM ENT Side 2 15056`0?221 1505607221 REV-1500 EX Page 3 . Decedent's Complete Address: File Number 21 11 600 DECEDENTS NAME Madeline G. Foltz STREET ADDRESS 1910 Sterretts Ga Avenue CITE Carlisle STATE PA ZIP 17013 Tax Payments and Credits: t• Tax Due (Page 2 Line 19) (1) 1,459.85 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments 1,500.00 C. Discount 72.99 Total Credits (A +B +C) (2) 1,572.99 3. InteresUPenalty if applicable D. Interest E. Penalty Total InteresUPenalty (D + E) (3) 0.00 4. If Line 2 is greater than Line 1 + lane 3, enter the difference. This is the OVERPAYMENT. FIII In oval on Page 2, Llne 20 to request a refund. (4) 113.14 5. ff Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 0.00 Make Check Payable fo: 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; or ............................................................................................ .... ^ d. receive the promise for life of either payments, benefits or care? ................................................... .... ^ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ................................................................................... .... ^ 0 3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? ..... .... ^ 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .............................................................................................. .... ^ 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. A... ~~_ c ~ _ .. - ~1~.'.i.~Y-~K~- .tom,.. For dates of death on or after July 1,1994 and before January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent p2 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) peroent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exemat 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 beneficary. For dates of death on or after July 1,2000: The tax rate imposed on the net value of transfers from a deceased child twenty-0ne 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 zero (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 four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) ]72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the deodent's siblings is twelve (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 + (6-99) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT Madeline G. Foltz 21 11 600 All real property owned =okly or as a tenant in common must be reported at fair market value. Fair market value is defined as Ure price at whidr property would be exchanged between a wiNing buyer and a willing seller, neitl~er being oompetied to buy or seN, both having reasonable knowledge of the relevant facts. Real nrooerty which le leirrtlv~owned wish rkrht of sunivorehio must be discbsed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH et as 1910 Sterretts Gap Avenue,Cazlisle, County, PA TOTAL (Also enter on line 1 (If more space is needed, insert additional sheets of the same size) ~ A. Settlement Statement (HUD-1) OMB Approval No. 2502-0265 B. n 1.^ FHA 2.D RHS 3.D Conv. Unins 4.D VA 5.D Conv. Ins 6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number: , C. Note: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked " .o.c. 'were aid outside the closin ;the are shown here for informational u ses and are not included in the totals. D. Name & Address of Borrower: Robert L. Foltz, Jr. 1900 Douglas Drive Carlisle, PA 17013 E. Name & Address of Seller: Estate of Madeline G. Foltz c/o Wayne F. Shade, Esquire 53 West Pomfret Street Carlisle, PA 17013 F. Name & Address of Lender: G. Property Location: 1910 Sterretts Gap Avenue North Middleton Township Carlisle, PA 17013 H. Settlement Agent: Wayne F. Shade, Esquire 53 West Pomfret Street Carlisle, PA 17013 TIN: Phone: (717) 243-0220 Lot : 6-7 -8 Block: Place of Settlement: 53 West Pomfret Street Carlisle, PA 17013 I. Settlement Date: 8 / 30 / 2 011 Funding Date: 6/30/2011 J. of T n K. Summa Seller's Transaction 1 F Borrower 400. Gr Amount ue To Sel r 101. n 62 500.00 401. Contrail sales rice 62 500.00 102. P rso I 402. Personal 103. Settleme t cha s to borrower line 1400 1 037.00 403. 104. 404. 105. 405. Ad d seller in advance Ad'us eats r Items id seller in a nce 106. C• !town taxes: 408. C• /town taxes: to to 107.COUn taxes:8/30/2011-12/31/2011 139.87 407.Coun taxes:8/30/2011-12/31/2011 134.87 t0 Robin K. Sollenber er to Robin K. Sollenber er 108. Assessments: 408. Assessments: to to 1 ~• 409. 110. School Tax 8/30/2011-6/29/2012 1 387.10 410. School Tax 8/30/2011-6 29/2012 1 387.10 111. 411. 112. 412. 1 . G rom r 65 058.97 4 .Gross Am Due T Ilex 64 021.97 r n 201. 6 250.00 501. ins 202. Pri I new n s 502. Se nt cha to Iler line 1400 721.04 203. tak n su Veil to 50 . Exi i n s taken u ' to 2~• 504. Pa off of first mo loan 205. 505. Pa off of serrond mort a e loan 2~• 506. De osit or earnest mone 6 250.00 207. 507. 208. 508. 209. 509. n i sel r Ad n n i Iler 210. C' /town taxes: 510. C' /town taxes: to to 211. Cou taxes: 511. Coun taxes: to to 212. Assessments: 512. Assessments: to to 213. 513. 214. 514. 215. 515. 218. 518. 217. 517. 218. 518. 219. 519. r 6, 250.00 520. otal R do Amount ue Iler 6 971.04 .C h T 1 301. G d from over line 120 65 058.97 601. Gross amount due to seller litre 420 64 021.97 302• id /For borrower line 220 6 250.00 602. Less r uilions in amount d Iler line 52 6 971.09 o r 58, 808.97 803. h ®To ^ From let 57 050.93 ~ ne rwq-c Reporting Burden for this CoileCtion of information is estimated at 35 minutes per response for Collecting, reviewing, and reportirp the data. TMs agency may not co0ect this infonnatiorr, and you are not required b~ complete this form. unless it displays a Currently vaNd OMB Control. number. No Confidentiality ie assured; this disdosuro >a plattdatcary_ This is ~;~,Q$~,jp ,spA aovered_traritadion with iMormation durinn the settlsnlent DroCesa. ~ i 1 sy Soft. revious editions are obsolete. Page 1 of 3 HtJ0.1 L. Bafflement Cha File Number: Loan Number: X00. ToEal Real F_state Broker Fees Paid From Paid From f ommtssion line 700 a follows: Borrower's Seller's 701. S1 875.00 t0 Mark K. Keller POC Funds at Funds at 702. to Settlement Settlement 703. Commission id at settlement 704. ble In Connection With Loan 801 ~ Our ination cha e S from GFE ~1 802. Y it r cha a ints for the s c interest rate chosen S from GFE ~2 803. Your ad'usted o ' ination cha es from GFE A 804. last fee to from GFE AKi 805. Credit ort to from GFE sKi 808. Tax Service to from GFE t13 807. Flood certification from GFE d3 808. 809. 810. 811. .Item I Le To Be Paid In Advance 901. Dai interest cha e8 from to @ $ /da from GFE #10 902. MO a insurance ium for 0 months to from GFE i3 903. Homeowner's insurance for 0 ears to from GFEl11 904. 905. 1 With Lender 1001. I r unt frtlm GFE #9 1002. Homeowner's insurance months @ er mo $ 1003. Mo insurance months @ er mo S 1004. Pr taxes months @ er mo S 1005. months @ er mo S 1008. months @ er mo 1007.. Ad' stment 0.00 1101. Titb sen+ir~ss and lender's title insurance from GFE e4 110 : Sedbfnent ondosi fee 1103.Owlter's title insurance from GFE tl`5 1104. lelxier's title Insurance 1105. Lender's ' limft S 1106.Owner's tide limit S 1107. nt's of the total insurance remium S 1108. Underwriter's rtion of the total insurance remium S 1109. 1110. 1111. 1200 and Transfer Cha 1201. C3ovemment rekord' cha from GFE a 62.00 1202. Deed 62.00 Mort a Release 1203. Transfer taxes from GFE #8 625.00 1204. C' /Cou tax/stam s: Deed S e S 1205. State tax/stam :Deed 625.00 Mo e S 625.00 1206. $ 1207. C 1301. uired services that can sh for from GFE t16 350.00 1302.Advertisin to Mark K. Keller $420.76 POC 1303.Attorne fee to Wa ne F. Shade 350.00 1304. Water and sewer to North Middleton Authorit 96.09 1305. 1306. 1307. 1308. 1400. Toot Cha enter on lines 103 Section J and 502 Section K 1, 037.00 721.09 r nave rsvrewad vre HUD-t SeWemBm Statement and t0 the pest of my Knowletlge and belief, ft is a true and accurate statement of all receipts and diebursemenffi made on my in trap rUiel' certify that 1 have received a copy of the HUD-1 Settlement Stat~nent. Ro L Fol z, Buyer/Borrower Est t f Madel' ne oltz Seller Buyer/Borrower Seller This Settlement Statement which IYe prepared is a true and accurate account of this transaction. l e u or will use nds to be disbursed in accordance with this statement. 8/30/2011 Wayne F. Shade, Esquire Settlement Agent Date ~31+JING: N is aetirsae to knorvfnaly make false e~loments to ttre United States on ttNs or am otheo simflertorm Penaltles upon conviction can include a ihreort. Q 2009.2014 Easy Soft. PreviOUS editions are obsolete. Page 2 of 3 , : , HUD-1 . _ ' ` Faith f.stimada GFE) and F1tH?-1 Cha :;barges That Cannot Increase HUD-1 Line Number Our o ' ination cha a #801 Your credit or cha ints) for the s cific rate chosen #802 Your a 'usted o ' ination cha es #803 Transfer taxes #1203 ' Total Inarease~batwaen fa`FE and FiuD-1 cnargos Initial for our escrow account #1001 Dai interest cha es #901 Homeowner's insurance #903 Lean Tenors Good F2ith F~tl ate ff 0.00 0.00 0.00 0.00 0.00 0.00 0.00 625.00 f3oc~li Faith EaUmat! 1tUA~4 0.00 62.00 0.00 62.00 62.00 c3oo4f P>31it1'- t'dstirr ~ 0.00 0.00 0.00 0.00 0.00 0.00 Your initial loan amount is $ Your loan term is Years Your initial interest rate is °~ Your initial monthly amount owed for principal, interest, and $ includes any mortgage insurance is ^ Principal ^ Interest ^ Mortgage Insurance Can your interest rate rise? ®No. ^ Yes, it can rise to a maximum of %. The first change will be on and can change again every after . Every change date, your interest rate can increase or decrease by %. Over the life of the loan, your interest rate is guaranteed to never be lower than % or higher than °~. Even if you make payments on time, can your loan balance rise? ®No. ^ Yes, it can rise to a maximum of $ . Even ff you make payments on time, can your monthly ®No. ^ Yes, the first increase can be on and the monthly amount amount owed for principal, interest, and mortgage insurance rise? owed can rise to $ . The maximum it can ever rise to is $ . Does your loan have a prepayment penalty? ®No. ^ Yes, your maximum prepayment penalty is $ . Does your loan have a balloon payment? ®No. ^ Yes, you have a balloon payment of $ due in years on Total monthly amount owed including escrow 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 directy 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. O 2009-2011 Easy Soft. Previous edfions are obsolete. Page 3 of 3 HUD-1 REV-1508 EX + (8-98) COMMONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN RESIDENT DECEDENT ESTATE•OF Madeline G. Foltz SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21 11 600 Induda the proceeds of H6gation and the date the proceeds were received by fhe estate. All properly jointly-owned with right of survivorship must be discbsed on &heduk F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~. , c ec ng account 2. Commonwealth of Pennsylvania, property tax rebate 975.00 3. United States Treasury, social security benefit for Mazch 1,166.00 4. Cazlisle Regional Medical Center, overpayment of invoice 3.35 5. Cazlisle Regional Medical Center, overpayment of invoice 795.00 6. Cazlisle Regional Medical Center, overpayment of invoice 79.91 7. State Farm Fire and Casualty Company, premium refund 261.86 8. Proceeds of sale of 1979 Dodge Dynasty 750.00 9. Proceeds of sale of household contents 400.00 1 TOTAL (Also enter on line 5, Recapitulation) i 7.365.79 (If more space ~ needed, insert additional sheets of the same size • J.1/i~OLi ~~~wa 499 Mitchell Road, Millsboro, DE 19966 Adjustment Services Phone 888-502j1349 F az (302) 934-2955 May 26, 2011 Wayne F Shade.. 53 West Pomfret Street Carlisle, PA 17013 Re: Estate of Madeline Foltz Social Security: 177-24-6577 Date of Death: Apri124, 2011 Dear Sir or Madam: Per your inquiry on May 20 2011, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type of Account Account Number Ownership (Names o, fl Opening Date Balance on Date of Death Accrued Interest Total Checking Account 3740560408 Madeline G Foltz 1098 $2,934.67 $ .00 -- --------------------------------------------------- $2,934.67 For any additional intormatlon on the above accounts, incinding ownership and any changes, dosures and/or reimbursement of funds, please call the High Street Carlisle Once at #717-240-4536. We were unable to locate any safe deposit box for the above-mentioned decedent. This letter does not include any aooouMs in which the deceased may bare been hoed as Power of Attorney, (,~Slodian of Uniform Tran.4fers, xepreeenmtire Payee, ~ Tntsbee under a Writtet Agreement Sincerely, Tammy Spencer Adjustment Services REV-A 511 EX+(10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES F~ INHERRANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Madeline G. Foltz 21 11 600 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUN RAL EXPENSES: 1, Ho an-Roth Funeral Home & Crematory, Inc. 9,558.59 2. Cumberland Valley Memorial Gazdens, grave mazker 2,895.00 3. Osiris Holding of Pennsylvania, Inc., interment fees 1,720.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Robert L. Foltz, Jr. 4,000.00 Street Address 1900 Douglas Drive Cary Carlisle state PA Z;p 17013 Year(s) Commission paid: 2012 2; Attorney Fees Wayne F. Shade, Esquire 4,000.00 3, Family lacemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decadent 4, prp~~ F~ Register of Wills of Cumberland County 265.50 5 Aocountanl's Fees 6. Tax Return Preparers Fees ~, Cumberland Law Journal, advertise Letters Testamentary 75.00 8. PPL, electric service 51.06 9. State Farm Fire and Casualty Company, homeowner's insurance 334.00 10. Diversified Appraisal Services, real estate appraisal 350.00 11. North Middleton Authority, water service 86.42 12. CenturyLink, telep~IOne service 9.06 13. PPL, electric service 95.23 14. State Farm, autompbile insurance 183.63 15. The Sentinel, advertise Letters Testamentary 200.16 16. North Middleton Authority, water service 82.30 17. York Waste. Disposal, trash removal 4$.54 18. Mazk K. Keller, commission to sell real estate 1,875.00 TOTAL (Also enter on line 9, Recapitulation) ; 2$,476.72 (If more space is needed, insert additional sheets of ttre same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent Madeline G. Foltz 21 11 600 Decedent's Name Page 1 File Number Schedule H -Funeral Expenses 8~ Administrative Costs - 67. ITEM NUMBER DESCRIPTION AMOUNT 19. Mazk K. Keller, advertising real estate 420.76 20. North Middleton Authority, water service 96.04 21. Robin K. Sollenberger, Tax Collector, 2011 school real estate taxes 1,665.43 22. Register of Wills, filing Pennsylvania inheritance tax return 15.00 23. - Register of Wills, filing Account, etc. 450.00 SUBTOTAL SCHEDULE H-67 ~ 2,647.23 REV-1512 EX + (12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES ~ LIENS RESIDENT DECEDENT ~ ESTATE OF FILE NUMBER Madeline G. Foltz 21 11 600 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Sarah A. Todd Memorial Home, nursing home fees 5,678.89 2. ~ Genoptix Medical Laboratory, unreimbursed medical expense 3. Kinetic Imaging, unreimbursed medical expense 4. American HomePatient, unreimbursed medical expense 5. ~Mateya Law Firm PC, attorney fee 6. DBMS Performance and Repair, automobile inspection 7. ~ Cumberland Goodwill Fire Rescue EMS, ambulance service 8. Cumberland Goodwill Fire Rescue EMS, ambulance service 9. Cumberland Goodwill Fire Rescue EMS, ambulance service 10. Moffitt Heart & Vasculaz Group, unreimbursed medical expense 11. Three Springs Family Practice, unreimbursed medical expense 12. Millennium Pharmacy Systems, Inc., unreimbursed medical expense 13. Cazlisle Regional Medical Center, unreimbursed medical expense 14. Cazlisle Regional Medical Center, unreimbursed medical expense 15. ~Cazlisle Regional Medical Center, unreimbursed medical expense TOTAL (Also enter on line 10, Recapitulation) ~ S 412.10 95.58 5.75 1,025.00 49.28 75.00 84.03 150.00 13.36 85.81 31.53 5.77 18.94 79.91 9,748.95 (If more space is needed, insert addffanal sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent Madeline G. Foltz Decedent's Name Page 2 21 11 600 File Number Schedule 1 • Debts of Decedent, Mortgage Liabilities, ~ Liens ITEM NUMBER DESCRIPTION AMOUNT ar is a egio a is enter, unreirri arse me is expense 17. Robin K. Sollenberger, Tax Collector, per capita tax for 2011 11.00 18. Carlisle Regional Medical Center, unreimbursed medical expense 1,132.00 SUBTOTAL SCHEDULE I 1,938.00 GRAND TOTAL SCHEDULE I S 9,748.95 REV-1473 EX + (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Madeline G. Foltz 21 11 600 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE 1 TAXABLE DISTRIBUTIONS [ndude ht ssppoousal distributions, and transfers under Sec. 9116 (a (1.2)j 1. Robert L. Foltz, Jr. Lineal 1,150.00 1900 Douglas Drive Cazlisle, PA 17013 2. Mazcy J. Foltz Lineal 31,291.05 1900 Douglas Drive Cazlisle, PA 17013 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: ' 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET ; (If more space is needed, insert additional sheets of the same size) REV-1500 Discount, Interest and Penalty Worksheet Discount Calculation Total Amoun# Paid within three calendar months of the decedent's date of death: 1,500.00 Discount: 72.99 Interest Table Year Days Delinquent this time period Balance Due this year Interest this period Before 1981 1982 1983 1984 1985 1986 1987 1988 throw h 1991 1992 1893 throw h 1994 1985 throw h 1998 1999 2000 2001 2002 2003 2004' 2005 2006 2007 2008 2009 TOTALS Penalty Calculation If the decedent's date of death was on or before March 31, 1993, insert the applicable amount: Total Balance Due on January 17, 1996: Penalty: • ,: .~ LAST WILL AND TESTAMENT OF MADELINE G. FOLTZ I, Madeline G. Foltz, of 1910 Sterrets Gap Road, Carlisle, Cumberland County, Pennsylvania, being of sound mind, make this my will. I revoke any other wills or codicils to wills made by me. ARTICLE I. DISTRIBUTION OF MY ESTATE A. I give my tangible personal property to my son, Robert Foltz. Tangible personal property includes stamp or coin collections but does not include other money or stock certificates or other evidences of intangible rights. or interests. Tangible personal property does not include any property that is held primarily for investment purposes or used in connection with any business in which I may be engaged or in which I may have any interest at the time of my death. B. I give the residue of my estate to my granddaughter, Mazcy J. Foltz, a minor. It is my intention that my granddaughter Marcy J. Foltz inherit the entire residue of my estate, including my residence. ARTICLE II. PAYMENT OF EXPENSES AND OTHER CHARGES I desire a modest Christian burial. I direct my Executor to pay for my burial expenses (including the cost of a monument or marker). The estate, inheritance and similar taxes assessable on my death (including only taxes on assets passing under this will) shall also be paid as a cost of administering my estate and my Executor shall not request any beneficiary to pay any such tax. ARTICLE III. MISCELLANEOUS PROVISIONS Matters of Interpretation. For simplicity, I have expressed pronouns and other terms in one number and gender, but where appropriate to the context these terms shall be deemed to include the other number and genders. The bold headings are for convenience and shall not affect interpretation. ARTICLE V. APPOINTMENT OF FIDUCIARIES AND POWERS A. I name my son, Robert Foltz, to be my Executor. It is my desire for the Executor to be remunerated according to local custom. ]:n the event that xhe said Robert Foltz is unable or unwilling to serve, I name Mark A. Mateya, presently of Cazlisle, PA, to serve as Executor. If Page 1 of 4 M.G.F.. administration of my estate or any trust springing here from should be necessary in any jurisdiction where my Executor or my Trustee is unable to qualify, or if my Executor or my Trustee deems it necessary for any other reason, I give to my Executor and my Trustee the power to designate any individual or corporation with trust powers to serve with my Executor or my Trustee or in my Executor's or my Trustee's stead. I request that no security be required of any Executor or Trustee, including an Executor or Trustee named pursuant to the preceding sentence. References in my will to my "Executor" and my "Trustee" aze to the one or ones acting at the time, except where otherwise specifically provided. B. Any individual who serves as Executor or Trustee shall be entitled to receive reasonable compensation for his or her services and, whether or not such individual receives compensation, shall be entitled to be reimbursed for expenses incurred for such services. C. I grant my Executor and my Trustee the powers set forth in 20 PaC.S. §§ 3311-3332 and 20 Pa.C.S. §§ 7771-7780 respectively. In addition, my Trustee may merge any trust under this will with any trust having the same trustee and substantially the same dispositive provisions. If at any time after my death the size of any trust under this will is so small that, in the opinion of my Trustee, the trust is uneconomical to administer, my Trustee may terminate the trust and distribute the assets to the person or persons authorized to receive the trust income in such shares as my Trustee may deem appropriate. No Trustee who is also an income beneficiary of the trust at issue shall exercise any discretion granted in the preceding sentence. My.Executrix and my Trustee may distribute tangible personal properly passing to a minor to any adult person with whom the minor resides, and that person's receipt shall be a suflicient voucher in the accounts of my Executrix and my Trustee. D. It is my desire that my Executrix or alternate Executrix, herein above named, consult with Mateya Law Firm in the handling of my estate, they being familiaz with my affairs. ARTICLE VI. DEFII~tITIONS The following definitions shall be applicable to all of the provisions of my Will except where otherwise specifically stated: 1. The use of the masculine shall include the feminine or neuter and the use of the singulaz shall include the plural, and vice versa. 2. The term "estate," where appropriate, shall include any trust hereunder. Page 2 of 4 M.G.F.. .~ 3. The term "minor" shall mean an individual who has not attained the age oftwenty- one years. Executed this 1 ~'~ day of ~'Y1 C , 2011. Signed, sealed, published, and declazed for and as his Last Will and Testament by the testator in our presence, we all being present at the same time; and we, in his presence and at his request and in the presence of each other, have subscribed our names as witnesses whereof, all on the date last above written. OF ~~? ~a , ~1©1~ Page 3 of 4 M.G.F.. COMMONWEALTH OF PENNSYLVANIA CUMBERLAND COUNTY : to wit: Before me, the undersigned authority, on this date personally appeared Madeline G. Foltz, and `'~1 ~},~ ~ ~ • ~ 1E ,and ~~~ ~ ~~~ ~ F~. known to me to be the testator and witne ses, respectively, whose names are signed to the foregoing instrument and, all of these persons being by me first duly sworn, Madeline G. Foltz, the testatrix, declared to me and to the witnesses in my presence that said instrument is her Last Will and Testament and that she had willingly signed and executed it in the presence of said witnesses as her free and voluntary act for the purposes therein expressed, that said witnesses stated before me that the foregoing Will was executed and acknowledged by the testator as his Last Will and Testament in the presence of said witnesses who in her presence and at her request and in the presence of each other did subscribe their names thereto as attesting witnesses on the day of the date of said Will and that the testatrix, at the time of the execution of said Will, was over the age of eighteen years and of sound and disposing mind and memory. Sworn and acknowledged before me by MADELINE G. FOLTZ, the testatrix, y~~ A~fj~ ,witness, and m A R Y )al F,C~ ~~ , witness, this -f-_ day of ~ ~~ , 2011. E G. FOLTZ Witness Witness // Notary Public COMMONWEALTH OF PENNSYLVANG My commission expires: Notarial Seal Frances A, Aumlller, Notary Pub~C SOUttr Mlddlebon Twp., Gmrberland ODUMy My Comm~sion Expires Marcfi 16, 2014 Member, Pentrsvivania Assodatbn of Notaries .~ Page 4 of 4 M.G.F..