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Home My WebLink About02-16-12s 1505610105 REV-1500 ac°2_i1,tFn OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN "" ( PO BOX 28o6oi RESIDENT DECEDENT ( Harrisburg. PA 17128-0601 __ ~~ ~° ENTER DECEDENT INFORMATION BELOW ' Social Security Number Date. of Death MMDDYYYY Date of Birth MMDDYYYY ~... . ::178-26-3952 07/15/2011 05/20/1933 Decedent's Last Name Suffix Decedent's First Name ~~ MI Metrger Jack , G _.... ~ ....._i (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name _,.,_,..._~..~ __ __~_ MI _._..... ~ G ~ Metrger :Emma ~_ . _~_._.~r~. d__ Spouses Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Retum O 3. Remainder Retum (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required death after 12-12-82) O 6. Decadent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O} CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTUIL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Linda R. Metzger ~ Fircf I ina of Address 816 W. Foxcroft Drive Rarnnd 1_ine efAddress REGISTER S USE '"+'T '~i ~~~ W DATE FILED .~'- ~~ -r K 2 ~' ~ City or Post Office State ZIP Code ' Camp Hiil PA 17011 t ................ __..... __.~~~...~~~__ __.. __.....M~...._.-. Correspondent's e-mail address: Under penalties of perjury,) declare that I have examined this return, including acxompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNA RE RSON RESP BLE F RETURN DATE ~0 SIGNATURE OF PREPARER OTHER THAN REPRESENTA DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY 1505610105 Side 1 1505610105 -~ra- 1505610205 REV 1500 EX (FI) Decedent's Social Security Number ~aeors Nerve: Jack G. Metzger ~ 178-26-3952 ................. ............................................................................................... _...................................... _.........., RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule B} ............... . ....................... 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. ~ 6,300.00 '' 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ...... 6 97,259 28 _.._._..,...w..,~~~ .._..~__..__..,~ :_..._. 7. Inter-Vivos Transfers ~ Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Asaets (total Lines 1 through 7) ............................. 8. i 103,558.28 9. Funeral Expenses and AdminisVative Costs (Schedule H) ......... . ...... . .. 9, 7,930.39 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............. . . 10. 90.18 11. Total Deductions (total Lines 9 and 10) ................................. 11. ': 8,020.57 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 95,538.71 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which "~ an election to tax has not been made (Schedule J) ........................ 13. ~- 14. Net Value SubJect to Tax (Line 12 minus Line 13) ........................ 14. 85,538.71 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or ~..~~. ~ ~._.__ ~ .~... ~.,~..__w_~.~~~.._. ...~.,- __.._.~._... transfers under Sec. 9116 93,334.71 (a)(1.2) X .OQQ 15.: 0.00. 1s. Amount of Line 1a taxable ~ ~~~~ 99.18 at lineal rate X .0 4~t`. 2,204 00 ' 18. ._.~ 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 ~ 18. __~-~ 99.18 19. TAX DUE .........................................................19. : . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~ Side 2 1505610205 1505610205 J REV A500 EX (FI) Page 3 Decedent's Complete Address: File Number DECED NTS NAME Jack G. Metzger, Sr. ' STREET ADDRESS 2737 Lisburn Road CITY Camp Hill STATE PA ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior. Payments B. Discount 3. Interest 257.11 4. If Line 2 is greater than Une 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. (1) 99.18 Total Credits (A + B) (2) 257.11 (3) (4) 157.93 (5) Make c~yMh~eck 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 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 receNing adequate consideration? ................................................................................................ 3. Did decedent own an "in trust for" or payable-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? ............................. Yes No ......... o ^ ..... ^ 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 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return an; 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. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal benefiaaries is 4.5 percent, 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 p2 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 INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER Estate of Jack G. Metrger, Sr 21-11-0839 Ali 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 exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is f ointty-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Indude a copy of the deed showing decedents interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION i. '2737 Lisburn Road, Camp Hill, PA 17011 (See Schedule F) ..., ~ TOTAL (Also enter on Line 1, Recapitulation.) $ 0.00 If more space is needed, insert additional sheets of the same size. Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCNED~ILE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Jack G. Metzger, Sr 21-11-0839 Indude the proceeds of Iitigatlon and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disdosed on Schedule F. TOTAL (Also enter on Line 5, Recapitulation) ~ 6,300.00 If more space is needed, use additional sheets of paper of the same size. REV-s5og EX+ (oi-so) Pennsylvania DEPARTMENT Of REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEp11LE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: Jadc G. Metzger 21-11-0839 It an asset became jolntiy owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A, Linda R. Metzger 816 W. Foxcroft Drive, Camp Hill, PA 17011 Daughter B', Emma Metzger :2737 Lisburn Road, Camp Hill, PA 17011 Wife __ _ ~ ~_ C. _... n, . .. ~_ _ .... _ _ _ . JOINTLY OWNED PROPERTY: ItTIER DATE DESCRIPTION OF PROPERTY % OF oaTE OF DEATH rIEM FOR )p1Nr WIDE INCLUDE NAME OF FINIWCIAL INSTITUTION AND BANK ACOOUNi NUMBER OR SIMILAR DATE OF DEATH DECWENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSET [NTERESr DECEDENTS INTEREST 1. A ~,....., ,..~.~ _. 12/06195 2737 Lisbum Road, Camp Hill, PA 188,700.00 50 94,350.00 .... 2 __._ AB ' ;11130/10 Savings Accounts - Alit No. 5003659436 3,212.00 50 1, 059.96 3; :Ala ;11130110 Checking Acxount -Acct No. 5140042942 5,604.00 50 1,849.32 TOTAL (Also enter on Line 6, Recapitulation) $ 97,259.28 If more space is needed, use additional sheets of paper of the same stze. 1/16/12 2737 Lisburn Rd, Camp Hill, PA 17011 -Zillow Homes Pennsylvania Lower Allen Township real estate Neighbofiood „2737 Lisburn Rd~._.__.,,~, ~^N/ ~~ N _ ~ ,~ ~, . ;' ZestimateA~. $188,700 Rent $1,352/mo Zestimate: /f' j Est. Mortgage: $694/mo ~ rf~ i See current rates on Zillow ~~~ 62 View Your 2012 GYedit Scores Now ,Free! ' ~'~ ~ .,~~~. Beds: - Baths: - Sgft: ,690 Lot: 0,037 sq ft / 0.46 acres Type: Ingle Family Year built: 1964 Parking: - Cooling: - Heating: - Firepiace: - -y:-~ ~u ~~~, _._ -_ .~~` ~ ~~ I ~.~ v a _ '~~ ~`. i ®201.2 MlaowR Corporadon ®2010 NAVfEQ ®AND _„„ 1 .;~~. „ , _,. _ This is a 2690 square foot, single family home. It is located at 2737 Lisburn Rd Camp Hill, Pennsylvania. The nearest schools are Lower Allen Elementary School, Allen Middle ~ School and Camp Hill High School. More facts Post for sale/rent Save E-mail Edit Share Map Print Charts and Data Value Range 30-day change $/sgft Zestimate $188,700 $142K - $225K +$600 $70 Rent Zestimate $1,352/mo $1.iK - $1.9K/mo -$3 $0.50 Owner Comment Post a comment Loading chart... See Your 3 Q'edR Scores From A6 3 Bureaus Online! zillow.comlhomedetails/2737-Lisburn-Rd-Camp-Hill-PA-17011/9259444_zpid/ 1/2 JAN-25-2012 08:54 From: ~ PN~BANIC January 25, 2l)12 '1'o Whom It May Cancf3rn 7177360254 To:+17175911756 P.1~1 JACK CT ME'1LGER was a joint owner an a Mr~nCy Market account with F MMA G M~T7CC1?It and LINDA R MIiST7.CRR an the date of lus death, Jul. 15th, 2011. His dc~lth was rcc;orded and prcx:cu,sad on Aug. 8tlt, 2011 at wlue:h time; his name was removed fram the ac:c:eaunl. Please contact me with any cluestianc or eaneCrrls, thank Yau~ S1riCCrCly, Rl(:hitIYl W3Y1~ Financial S~lcs Consultant rrrc BA1vit Cular C1iiPf Brdncb T 717-761-3291 F 717-?30-0254 richard.wan8,@Pno.cpm !'NC' Bank - Leading the way A member of !ha PNC Fifldf1Ci31 ScxvicCS GrUUD PNC i38nk -Camp Hill, PA www.pnd>ank.~m - ~._..R- PENNSYLVANIA INHERITANCE T INFORMATION NOTICE • BUREAU OF INDIVIDUAL TAXES AND PO BOX 280601 n ~ HARRISBURG PA 17128-0601 PEe-AR ME ~.~' AXPAYER RESPONSE REV-lets E - S '~** FILE N0. 21 11-0839 ACN 11159250 DATE 09-01-2011 2~8t7 Jd~l. ~~ PM ~~ ~0 E~A~~T CO.. q4 ** EMMA G METZGER 2737 LISBURN RD CAMP HILL PA 17011-8009 EST. OF JACK G METZGER SSN 178-26-9352 DATE OF DEATH 07-15-2011 COUNTY CUMBERLAND. REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS ® CHECKING TRUST CERTIF. P NC BANK NA provided the department with the information below, which was used in calculating the inheritance tax due. Records indicate that at the death of the above-naaed decedent, you were a joint owner/beneficiary of this account. If you are the spouse Of the deceased and any aax-unt other than zero is reflected below on the Potential Tax Due line, note no tax a~ay De due, but You oust nottfy the department of your relationship to the deceased by checking Box C in PART 1 below and Writing "spouse" in PART 2. If ,yYou believe he information is incorrect. please obtain written correction frog the financial institution, attach a copy to this form and return _~._ _ir to the above addeess. -.-Please call .71Zr..7.87-8327. with_QUestions_, _ _- __ __ ::. ......... .-.- -. - - - -. --- COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 5140042942 Date 11-30-2010 To ensure proper credit to the account, two Established copies of this notiu wust accompslal Account Balance 5,604.00 punt to tho Register of Wills. Make ehedc payable to ''Register of Wills, Agent". Percent Taxable X 50.000 Amount Subject to TaX $ 2,802.00 NOTE: If tax payments are made within thrao months of the decedent's data of death. Tax Rate X .00 deduct a 5 percent discount on the tax due. Aro inheritance tax due will become delineuent Potential Tax Due ~ .00 nine months after the dat• of death. P~T TAXPAYER RESPONSE 1 A. The above infonation and tax due is correct. Remit payment to th• Ragistar of Wills with two copies of this notice to obtain CHECK a discount or avoid intorest, or return this notice to the Ragistar of Wills and C 0 N E ~ an official assessment will be issued by the PA Department of Revanua. BLOCK B. The above asset has bean or will be reported and tax paid with the Pennsylvania inhoritanea tax return ONLY filed by the 'state representative. C. ~ The above informs ion fs incorr a and/or debts and deductions ware paid. Complete PART ~2 and/or PART ~ below. PART If lnaicatsng a oirrerent rolstionship to decadent: TAX RETURN - CALCULATION LINE 1. Dato Established __. ._ . _ 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rat• 8. Tax Due 3 ~ 4 ~ 5 6 ~ 7 X 8 $ DATE PAID PAYEE DESCRIPTION AMOUNT PAID PART DEBTS AND DEDUCTIONS CLAIMED a Under ponaitios of perjury, I declare that the facts I reported above aro true., correct and complete to the bo t of my knowledge and belief. HOME C'7/7 ) 7~ ~ ~~ ~a .~T~ft. `" /'l ~ WORK C ) 9 ~ ''I/ TAXPAYER SIGNATURE ~f ' TELEPHONE NUMBER DATE PENNSYLVANIA INHERITANCE BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG PA 17120-0601 '`` INFORMATION NOTICE AND en ~~ir TAXPAYER RESPONSE 4 .-'i•.V etv-~s~a oc ~cr css-tu T FILE N0. 21"-,I~~~:1~ ACN 11002918 DATE 08-30-2011 JAN 25 PM 2:20 ~~~~ ~N~" """ ' •~ 1.+51,. LINDA R METZGER 816 W FOXCROFT DR CAMP HILL PA 17011-1845 EST. OF JACK G METZGER SSN 666-01-1086 DATE OF DEATH 07-15-2011 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT ® SAVINGS CHECKING TRUST CERTIF. PNC BANK NA provided the department with the information below. which was used in calculating the inheritance tax due. Records tndleate that et the death of the above-named decedent. you were a point owner/beneficiary of this account. It you are the spouse of the deceased and any amount other than zero is reflected below on the Potential Tax Due line. note no tax may be due.' but you awst notify the department,ot your relatlonshlp to the deceased by checking Box C in PART 1 below and writing "spouse" in PART 2. If-yyou believe the information is incorrect. please obtain written correction from the financial institution, attach a copy to this form arM return it to the above address. Please call 717-787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE-BIDE- FOR FILING AND-PAYMENT INSTRUCTIONS -- - ---- Account No. 5003659436- Date 11-30-2010 To ensure proper credit to the account, two Established copies of this notice must aceompara~ payment to the Register of Wills. Make chock Account Balance 3 ~ 212.00 psyabl• to "ReOister of Wills, Agent". Percent Taxable X 100.00 NOTE, If tax payments era wade within three Amount Subject to Tax ~ 3 ~ 212.00 months of the deeedont's data of death, Tax Rate X .045 deduct a 5 Parcant discount on the tax dw. Aw inheritance tax due will becoeie delingwnt Potential Tax Due $ 144.54 nine months after the date of death. PARr TAXPAYER RESPONSE 1^ - ~. A. ~ Tha above information and tax duo is correct. Resit payment to the Re03ster of Wills with two eopias of this notice to obtain a discount or avoid interest, or return this notico to the Re03ster of Wills and CHECK an official assessment will be issued by the PA De partment of Revenue. C ONE ~ BLOCK B. ~ Tha above asset has been or will be raportod and tax p aid with the Pennsylvania inheritance tax return ONLY filed by the estato representative. C. ~ Tha above info a ion is ineorr et and/or debts and deductions ware paid. Complete PART ~ and/or PART 3~ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Dat• Established 1 2. Account Balance 2 ~ 3. Parcant Taxable 3 X 4. Amount Subject to Tax 4 ~ 5. Debts and Deductions 5 6. Amount Taxable 6 $ 7. Tsx Rat• 7 X 8. Tax Du• 8 ~ PART a DEBTS AND DEDUCTIONS CLAINED Under penalties of perjury, I declare that the facts I raportod above aro true corm t/a~n`d complete to ha -best of ny knowl and belief. HOME t 7 ) ~ ~~ / ~U WORK ~ rAYaev _ ern G TELEPHONE N MBER D T DATE PAID PAYEE DESCRIPTION AMOUNT PAID REV-1511 EX+ (10-09} Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INNERITANCETAxRETURN ADMiNiSTRATIVE COSTS ESTATE OF FILE NUMBER Jack G. Metzger, Sr. 21-11-0839 Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES 1' `,Neill Funeral Homes, Inc 2,645.42 .. 2. Funeral Luncheon 1,101.18 3 Rolling Green Memorial Gardens 3,437.50 Royers Flowers 94.34 B. ADMINISTRATIVE COSTS: 1. Personal Representatlve Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 200.00 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address 4. 5. 6. 7. City State _ Relationship of Claimant to Decedent Probate fees: Accountant Fees: Tax Return PreDarer Fees: 451.95 TOTAL (Also enter on Line 9, Recapitulation) $` 7,930.39 ZIP If more space is needed, use additional sheets of paper of the same size. - " `----'riessage Center -luncheon after funeral for father Page 1 of 1 ----~-,~ GULLIFTY'S RESTAURANT GULLIFTY'S UNE-ERGROL'NO 1104 CARLISIE~ ROAD CAMP HILL., PA. 17011 717-161-6692 15 Joann C --- _ _-. fik 4171; _ __ __. Monday, Jul 18 at 8:28 PM ARTY Gst 3 Ju123'11 11:13AM r" <guUiftyike(l~aol.com> . -.. _ 35 PEPSI .net 1 f <<E ICE 1'EA ~ 87.50 rai for father - ~~RTY 2.00 ~ "''~~ F~i;io E SEEING YOU AND MARIE TODAY. THESE E NENS 770.00 1 F;i fAli_ OR YOU AND YOUR FAMILY, MAY GOD'S U 9~ 3G . r)! , DRAT U;CHIX CORN AND DUMPLING 1~i'.1' ~ DIINICHES ON ASSORTED BREADS., YUKON ' D ,~ ~~~~vict : ~ ~ `> i ~ , N SALAD W/ 3 DRESSINGS, CONDIMENT . ~~>~mt i~~4~ ' . ~ i ~1~"i ~ MATO, ONION, MAYO,.DELI MUSTARD AND . ~~, ~~'~ '~'~' +'uu HAVE ~NJgYEa Yuu-~ ~;r•~, ~ PERSON. YOU'LL. HAVE BEVERAGE, TAX, 18% ~~ ~aE. a1 GU!l;IFTY'S & ~~t : tf ~ ~'S +~-ro~ .OO LINEN CHARGE. THERE WILL BE A CASH ~t k'ilPF (Ei'`,EE, ~K ~i ~%u+ o., iHF wkn ~ FORGOTTEN ANYTHING OR YOU HAVE ANY ci ECE E GET BACK TO ME. BEAT FAIT' POGR Jqq QUALITY TEAT FAIR POgR 'hftn•//mail ~~pri~nn ~nm/wPl-mail/rn~l~lir./mint is»9wiri=vim wi~loPt Mailf)rwn ~Ritvrn-instil l J17/7(11'I. Jt~1-20-2012 0104 January 20, 2012 ROLLING GREEN CEMETERY Rolling Green Cemetery 7177614826 P.01r01 Attn: Ashley Attorney Peter Russo's Office Re: Jack G. Metzger As per your request the arrangements for Jack G. Metzger's burial were a total of $3437.50. Please let me know if you require any additional information. Rne~rrle Manager ~~~. 181 ] ('.arlisle Road • ('.amp IIill, PA 17gt1 • 717-7G1-0USS • fax 717-761.4824 www,r<>ltin~reenccmetery.c.~m • 1)ignltyM~morial.c~m TOTRL P.01 Seller. NeUI Fumud Home, Inc. 3401 Madmt garnet 3501 Decry Street Camp FIdl, PA 17(1114428 Hartisbarg, PA 17111 (717)737-8726 717-564-2b33 Kevin J. SIu7labeer, Supervisor Stephar J. WUsbach, Supervisor Contract g- 741101000270 Case. A -278242385 Part One of Three Pun Statement of Funeral Goods and Services Selected/Purchase A~eeem o7rtisrloll DsteofDeath 07/15!1011 Name of Deeaud Jack (381st Mt#zaer I)ste of Birth 05/20/1933 Deceaud'a Last Addraaa 2737 Lisburn ltd City Camp Hill Saab Zip Code 17011-8009 Pwchaaara Name Emma Metz¢tx Phaee Nvonber (717) 737-6552 Pwehaser's Homer Addrou 2737 Lisbtttn Rd City Camp Hill Saa PA Zip Code 17011-8009 Co-Ihrrchaser's Neme Phone Number Co-Perchasd'a Hme Addroa Ciry Saa Zip Code In this Agreement wade you and you to the Purchaser and tlk Co-Prtrcheser, if any. argaiog tlris Agroemerrt. T~ words we, ua and our to the Fwretal Provider a Seiler whore nma and address appaer shove. Fa good and valuable ansidaatiwr, which e~h parry acknowledges receiving, you egaa to buy the gouda and sarvioa described below. Yon sum us b proparo and are to the body of the decedent named in this Agreement and to conduct the funeral erM aervias and ineau the charges listed in said Agreunerrt We have the right to collect the coal amouna due wrier this Agreement fi+om any person who signs this Agrammt as Purclaaer a Co-Pacheaer. (N/A pxHaatsa Charzat are navy fbr Were Oat yen eekead or that are required. Itwe arc required by brw or by a aoeary or erematory to me ay lama, we will erphie the reaseas b wrRlag hdarr. oyes a • haervrl Ou nay rugnira eobalmieg, such u a fhaeral wkh vfewhq, you my have ro paytor mbamrieg. Yon do not have a pay far eobalskag you did eat approve uyo. adected arraagemeaa sack as a direct t~atioa or imedlate berial. Ifwe surged for mbatming, we wUl e:plahr why 6elew. , SEC NI- ND AN MERCHANDISE FUNERAL DIRECTOR AND STAFF 8ERVICEB CaslxtaAlsermtiveConainer• Bernie Professioad Service Fee f Inci PACKAGE OFFERNIOS 2 035 00 Dnect Cremation s , bnmediue Baia! s nla Forwudiag Remain s Na Receiving Remains S Na S der S n/a CARE AND PREPARATION OF REMAINS Embalming S Na Othu Proparatton (specify) ~iy, s Intl S der S Na S der S der USE OF FACILITIE8 AND RELATED SERVICES Vitiation s der Pursuer! Ceromony S rJa Memorid Serviee S Na Graveside service s °% Other (apecrfy). ; n/a S Na S Na TRANSPORTATION Tmnafaring Remain to Fuaaral Home S Inc! Fmenl Vahida/Heuae S de Other ( Trumkr ao a Form Cruoetav S Intl Service Vetiide S hrJ S Na S ~ S ~ S Na _ S Na OTHER 000D8 AND SERNCES Memerisl Basset S Na s N8 f Ns S Na S ~ S der S Na s Na Marruftrctrtrer/$upplic Model Name/Number Malarial Species of Wood Type of Metd WengM/Ciar!~e• mania l.rdabr Corr S Na Outs Burial Conainer: Mmufacmra/3upplier Mudd Name/Number Mataid S °/a Um: Mmufachrrer/Supplier Mudd NamdNwober Materiar S der S Na S der t ds TOTAL SECTION 1 ' ~-""•` 8ECTION U -CHARGES TO BE INCURRED BY US ON YOUR BEHALF (Ce-tafn cAaryes maybe ssrYmsrYd = e"means astbnatted,- ova surge yon Or our aervka m obainiog there items marked wkh aa'X' ~~ der Ccernetorv S Ns Clerav / Reliaaus Facility S 75.00 Musicaoa a Singers ,der Certified Copies _ 30.00 Newspaper Notices rah NewsoaperNotice 65.42 der de der s Permit 25.00 der der der der der S d~ S ~ S der rah der TOTAL SECTION II S 196.42 TOTAL SECTKN4 I CHAROE8 s 2'450'00 TOTAL SECTION U CHARGES S 195.42 TOTAL SECTION I AND SECTION 11 CHAROCQ S $645.42 ..~ r vNj 7 1!/// S' ~ 2/ /I Ih1RgtA38R9 QRnALa ATE DATg S' IXITIALa AND DATE Part'!tw of Three Part Name of Deccesed Jade Galen Metrger Contrmt. / - 741101600270 Statement of Funeral Goods and Services Selected/Parchase Agreement ' TOTAL SECTION 1 AND SECTION II CHARGES S 2,645.42 SECTt^" m _ u ~ rou~arrese s t2as.oo) ToTALALLOwANCEs SECTION N -TAXES Tnteblelldm3ecti~I+or-SectlonIIl S nh ~ S der TOTAL TAXES 0 % 8 0.00 TOTAL CHARGES: 8sefbo p) + (~ + or - (Itl) + (Np S 2,400.42 Les Cash ltceetvd s °ta ~~ s Na Ut-pMd btWna toss by: 07I25I2011 S .2,400.42 PAYMENT TERMS: Yau ttndastod ttiat m etmertion of alit by aabject a federal a site caedit diecloatre, bstllmart sales, or oche oomtaoe edit ataAUm, is centooptted by this AgteamaR. You have ro r~ht a dde paymeut of say ansasst doer ~r Wis Agroemeot You agroe thst }~ src paaarlly lisbk for payuwu of tfie appliabb 6ahmce due dawn ou qre Stetemmt o[Fuaual floods ad Sevicea Sdecd by the due dst idioued ~ tla Sttemem. Such payment will be made to us at the address ~ forth io this Agroanmt. Where the OrO amomK due will not be paid prior b the performing of the aervkm called for by this Agteanart, you autlarize m b inquire irrb your ecdlt hif0ory. IDI]fT1FICATIONAHD DE8CRIP71ON OF MANDATORY ITEMS AND EXPLANATION OF EMBALMING CHARGE: We haw; idmgtied and described blow eny legrd, opoetary arcramkay regtriromeot tlau camps! the purdine of say items !lard in Pert One and we have exptbd why we c-rrged fa embalming. You edmowhxlge and agreethat ambelmhrg aodrar prepatagotr of the renthtmay beperformed atthe fecOiry of Oaabove-referaioed fuoad home or at another fadlity that is duly licaued sad equippd to provide such services Funeral Home Rewkea 'exertion Attar Z4 Hours Whm Bmbelmioa Ice Not Authorized You conform that you have examhrd tla service and metcheodis iteraa used t Fart f)oe and farad drem a be totted end aceording t the arrangement ader:tad sod tltt prior to signing thin Sttxomt, you roviewed and approvd a tampbtd copy of Orin Stsmreot. You elan ooofnm the you hm bear informed ofyour right b select arty such s[vitxt and macheodise m you desire, ed tlau you haw the laWl right to arrange Oa tiaaral xrvicea for the dxeased named stover Acknowledgement of Disclosures/Disclaimer Thor Federal Trade Cormoission Trader Reguluion Rub on •Fuoxrl laduetrY Pncdces• raquiras satin diaclasurea and prole'bib miarapraeottbm. The folbwiog is a checklist we ask t6me we nerve t tad and sign to verify Ott the limed amngernaot coofaeoce was caduetdm compliance with the Rule. You. who made tla amogaorent fethe flrrrxal ad tied dbposigon of qa abovo-oemd deced®t, do lareby attar t tla following: 1. You wem given a Oareral 1Mce List effective on 11!08/1010 prim a disawing limas! artaoganart or tla sdedbn of any funeral goods or services. 2. You was drown a Caket Prke List etlbRive on I lA)8I2010 prig t dieawbg eadcat. 3 . You was mown ro Outr BurW Conthre Frice Lirt effective oo 11A18f2010 prig a diaarsiog ouoer burial corasinors. 4. You wero advised the the law does sot raprce mdrdmiog except S. You was not adviead that eroDalabg is regdted for direct ormugon. immdiat burls! or a clled teaks flmxal wahout viewing or visitOon if rettigaeOoa is aveilablq where ate err bad law doer not roquke amMlmbg b ouch cesea. 6. You were sot sdvlaed that mY law raryiraa a casks for direct eemagon a tlmt a ca+ket. other then m altanegve tontine. is required for dues cremation. 7. You was advisd tltt art Iaw does mt require the purchse of en Dote burid centioe a arty of the flrrreral garde or services you sdedd, except as set forth oo your Smtenrant of Ftmanl Goods sad Savica Sekctd. 8. No cte®a wem mods to you a a the merchaodiaa a servba (embalming, cadre. Dote burial ) t the effect that embahniag a the use of eaY mxthendise avaikbb Brom us would defy the deoompaigoo of the reamios for a tong tem a iodefaite e®e, or tlmt soy such nremhaodiee would the bey from gravasite subetrrces. No reprmmtadam awartaatie vrae made b you about der prMective fadtna of casket or Dote bail camsinas other tlta tlwae meda by Os menufachcer. 9. You was advised qtr the tlaerd flrm'a coat ~ tla isxm listdm Part One, 3eaion>L may be diffaan based err volume a cash discount or orbs profens;orrslhmde cuaama where permittd by stets a lord law. NOTICES TO PURCNASERICO-PURCHASER SEE PART THREE FOR TERMS AND CONDITIONS THAT ARE PART OF TFtlB AGREEMENT. DO NOT S83N THIS AGREEMENT BEFORE YOU READ R OR IF IT CONTAIN ANY BLANK SPACES. YOU ACKNOWLEDGE RECEIPT OF AN EXACT COPY OF THIS AGREEMENT. BY 8K>yttllifi THIS AGREEMENT, YOU ARE AGREEING THAT ANY CWM YOU MAY HAVE AGAINST THE 8ELLER SHALL BE RESOLVED BY ARBITRATION AND YOU ARE OIVIINi UP YOUR RIfiHT TO A COURT OR JURY TRIAL AS WELL AS YOUR RIGHT OF APPEAL 6rterartd ~ 21 day of July ,2011 Purdtse~'aName SmmaMdzge PurchasersSigoauue '~ tax rYKb ~' ' Sodel Seaairy A - - gy. Xevia J ShiOebee ~ ~_~~ D / Z7.3 g L Co-Parchaxts Naos ~0°N'x0 I'1C00s0 Co-Purchaerssigtatme Co-1!urchasers Social Secrulty O - - 1 a(Mat tritrt I hrtw eompletWhetrhxred tltb documwrt o requbed by the Company's SOXKsy Control Checkllat: Pdt-t Nate: Slpnsttro: Title: Date: Part 1Treo of'171ree Para ' - TERMS AND CONDITIONS ASSIGNMENT TO US OF MONIES DUE: You agree that any monies assigned to us in conjunction with this sale shall be paid to us within 60 days of the date of this Agreanent Upon our giving you at least five (S) days prior written notice that any monies due under any such assignment(s) have not bees paid to us u promised, we can require that any such unpaid amount(s) previously credited to your acwunt be paid by you.at once. WAIVER OF RIGHTS: We have no; by the exeartion of this Agreement with you, waived any rights we have to file a claim in the estate of the decadent named in this Agreement Any amounts collected by us from the estate of the decedent or from any other source, shall be credited against any amount owed by you under this Agreement SELLER AGREES: We agree to furnish all services and merchandise as indicated on the Statement of Fungal Goods and Services 3da~/Purehase Agroanent AUTHORIZATIONS: You aclmowledge that if selected, cremation services will not be performed pursuant to this Agreement until all appropriate authorizations, inthe complete discuGion of the Seller, have been received. ANNOUNCEMENT: You authorize us to publish an obituary or manorial announcement in a newspaper, online or in any other appropriate medium. This does not authorize us to incarr or impose any additional charges unless set forth on this Agreement. WARRANTIES WE DISCLAIM: BY SIGNING THIS AGREEMENT YOU UNDERSTAND THAT WE, NOT BEING THE MANUFACTURER OF ANY OF THE GOODS BEING PURCHASED, EXPRESSLY DISCLAIM, TO THE EXTENT ALLOWED BY APPLICABLE LAW, ALL WARRANTIItS, EXPRESSED OR IMPLIED, OF MERCHANTABH.ITY OR FITNESS FOR A PARTICULAR PURPOSE OR OTHERWL4E. THE ENTIRE RISK AS TO THE QUALITY AND PERFORMANCE OF THE GOODS REMABYS WI'T'H THE MANUFACTURER AND NOT US. SHOULD THE GOODS PROVE DEFECTIVE FOLLOWING THEIR PURCHASE, EITHER THE MANUFACTURER OR YOU, AND NOT US, WILL ASSUME THE ENTIRE COST OF ALL NECESSARY SERVICING OR REPAIIt3.WE ARE SELLING THE GOODS ON 'AS IS' OR WITH ALL FAULTS BASIS.YOU AGREE THAT YOU ARE NOT ENTERING INTO THIS AGREEMENT BASED ON ANY STATEMENT OF FACT OR PROMISE MADE BY US TO YOU WHICH RELATES TO THE GOODS BEING PURCHASED, ON ANY DESCRIPTION BY US OF THE GOODS, OR ON THE EXHIBITION OF ANY SAMPLE OR MODEL OF THE GOODS. YOU ALSO AGREE THAT THE FAII.URE OF THE GOODS TO CONFORM TO ANY SUCH STATEMENT OF FACT, PROMISE, DESCRIPTION, SAMPLE OR MODEL SHALL NOT GIVE YOU ANY RIGHTS AGAINST US. NOTICES TO YOU (THE PURCHASER): Notices to you shall be sufficient if mailed to your last known address. DELAY IN ENFORCEMENT: We erm delay enforcing any of our rights under this Agreanent without losing than end rro such delay forbearance or other action or inaction on our pert will create any new Agreement or understanding with respect to the payment or other tams herein unless there is a writing signed by both parties with respect to any such new agreerrrent or understanding. PARTIAL PAYMENTS: We can aaxpt partial payments, even though marked to indicate payment in full or full satisfaction of deb; without losing any of our rights under this Agreement. No aaxptance by us of a check for such partial payment shall be deemed a modifierrtion of this Agreement COLLECTION COSTS AND ATTORNEYS' FEES: This Agreement may be referred to an attorney who is not our salaried employee for collection or enforcement In such even; you agree to pay all reasonable costs of oollection to the extent permitted by law, including court costs, disbursements, and other Iawfirl charges incurred in the collodion of your indebtedness; provided, however, that each party shall pay its own attorneys' fees inermed in connection with any collection effort or any other dispute of any nature relating to this Agreanent and the trensacfioa ewntanplated herby. RESPONSBiIIdTY FOR PAYMENT: This Agreement shall not constitute a release of liability imposed by law upon the decedents estate, but all persons signing this Agreement will be responsible individually and together, for paying all amounts due under this Agreement We can take action against you to collect amounts due under this Agreement, ever if we do not take such action against any other person(s) signing this Agreement LIMTfATION OF ACTION: You agree that to the extent allowed by law, any action against us for breach of this Agreement must be commenced by you or your represartative(s) within one year after such cause of action has accrued. INVALID PROVISIONS: If any part of this Agreement is unenforceable, the rest of the Agreanent will stay in effect TITLES AND CAPTIONS: The titles and captions appearing at the beginning of the various sections of this Agramart have been inserted for convenience of reference only. They will not in any way affect the construction, interpretation or meaning of the text of said sections themselves. ARBITRATION: YOU AGREE THAT ANY CLAIM YOU MAY HAVE RELATING TO THE TRANSACTION CONTEMPLATED BY TffiS AGREEMENT (II~iCLUDING ANY CLAIM OR CONTROVERSY REGARDING THE IIVTERPRETATION OF THIS ARBIITRATION CLAUSE) SHALL BE SUBMITTED TO AND FINALLY RESOLVED BY MANDATORY AND BINDIQdG ARBITRATION W ACCORDANCE WITH THE APPLICABLE RULES OF THE AMERICAN ARBITRATION ASSOCIATION ("AAA");PROVIDED, HOWEVER, THAT THE FOREGOING REFERENCE TO THE AAA RULES SHALL NOT BE DEEMED TO REQUIRE ANY FILING WITH THAT ORGANIZATION, NOR ANY DIRECT INVOLVEMENT OF THAT ORGANIfZATION. THE ARBIITRATOR SHALL BE SELECTED BY MUTUAL AGREEMENT OF THE PARTIES. IF THE PARTIES FAII. TO OR ARE UNABLE TO AGREE ON THE SELECTION OF AN APPROPRiAT$ ARBITRATOR, THE AAA SHALL SELECT THE ARBITRATOR PURSUANT TO ITS RULES AND PROCEDURES UPON THE APPLICATION OF ONE OR BOTH PARTIES. THIS AGREEMENT TO ARBITRATE ALSO APPLIES TO ANY CLAIM OR DISPUTE BETWEEN OR AMONG THE SELLER, YOU AS THE PURCHASER, ANY PERSON WHO CLAIMS TO BE A THIRD PARTY BENEFICIARY OF THiS AGREEMENT, ANY OF THE SELLER'S EMPLOYEES OR AGENTS, ANY OF T$E SELLER'S PARENT, SUBSIDIARY, OR AFFILIATE CORPORATIONS, AND ANY OF THE EMPLOYEES OR AGENTS OF THOSE PARENT, SUBSIDIARY OR AFFILIATE CORPORATIONS. EXCEPT AS MAY BE REQUIRED BY LAW, NEITHER PARTY NOR AN ARBITRATOR MAY DLSCLOSE THE EXISTENCE, CONTENT, OR RESULTS OF ANY ARBITRATION HEREUNDER WITHOUT THE PRIOR WRI1"PEN CONSENT OF BOTH PARTIES. ENTIRE AGREEMENT: This Agreement contains all terms which have bear agreed upon by us and you relating to the goods and services listed on the Statement of Funeral Goods and Services Selaxed/Purchase Agrcement This Agreement replaces ell other discussions and agreemerrb, whether oral or written, relating to those goods and services. No subsequent discussion or agreernent can change the terms of this Agrear-ent unless it is written and is signed by both us and you. JURi$DICTION: This Agreement gall be governed by the kwal law of the state in which the funeral service is being performed and you agree that the jurisdiction of any suit involving this witl lie in the courts in that jurisdiction. QUESTIONS REGARDING SERVICE: Ia the event you wish to question any area of our service, you may contact us at your convenience at the address shown on Pert One. SERVICE8 AGREEMENT TERMS AND CONDITIOFIS Thk SenAcas Agreernerk (tla •ApreemsnY') k made between Making Everlaadnp Memorbs, LLC., a Delaware, United Sibs based Nmitd Ilabillly oomparry, and you. the tlagomsr iderrtltled on the remorse side hereof. SERVICES, PRODUCT8 AND CHARGES: The Life 3bry products and servicas caarently offered by us are Iktd on the reverse side (the 'Life Story'). BY entarkq hb tl» Agnarrarrt you roe b order are Ltfe Story products and aervicas hdkxtd an the ravens dde with reaped to the person(s) klerditled (the 'Subject'. and b pay the dwrgee hdlceted furs •Charges'~. Unbss otlrerwise indicated. s1 Charges are non-nefimdable. We reserve the rlpM to chenpe the (oars avaNabAtly oral prtdnp of 1M praduds and servk:es offered by us, hduding products and aervloea rolatlrp b updatlng and suppbmentlrq previously posted materials oonosnrirrp the SubjscL RKiHT TO USE; CONTENT'S: You represent that you own. or have recaNed wrtltn psmdeaion b use atl materials (the `Matedak~ submttled for hdualon, prosenMbn or dkpky in the Subject's LNe Sbry h aooordanee wtlh tlrk Agreement. and you gnats b us a perpetual. royally-flee tlcame b dhplsy the Matriak in the Subjects LlOe Story on our web ails. an arty appAcWle servica provMer's web sib, and other dkpby and dllsUiYibrrtlon metlrods, iF applicable. VJe reserve the right, h our bob dkrsetlorr, b reject or reArae b prablish, present or othenvke dkpky any and all Matdak submtlbd by you whldr we detrmhe b be happrcprtab or rsrsraitbb. INDEMMFICATIOtI: You agree b asersrre flap and oompbte reaponsibilfty for the form. aubstanca and cantard of aU Materkls. You spree b IndemNfy and hold us, and each of our shales, and tlaak respsdiw olAoers, enrpkryees, and repreaenttivea trarmleea from and agahst arty and aN dehu, bases, obtlgatlons, pablitlss, damages, detidencfa, )trdpmenls, teak card eaOenees er(dnp out of or rektlrrg b arty and atl Metrisls submfltd by you and the use thereof as canWnpktd by tlrk AgresrnerM, hdudkp, wNhait Wnitatlon, ddrns regaMkq vkAetlons of tlrlM party copyrights, contldentletlly or seaecy rights or otlrer proprbtary hterost, even H tl k eetblktted tlret we were paAbtly negNpent or otlbrwise at trdL The provkions of ihk paragraph ahatl survive tertnhadon of drk Agresrrrxrt TERMINATION: V11e may terrnkfale itrk Agreement at any thre h the evert oF. W a dkagreenreM between you card us cancemhg any MateAek requested b be inchrlad wtlldrr the Subjects LUs Sbry; (~ yorr failure b pay arty Charges when due: or (i~ at airy time. in our sob dkcretlon, upon wrtlbn notlca b you. You may terrrrkraM thts Agreement at arty tlms, brit tlris wits not afbct arty of yarn prior obggatbrre. LNETED WARRANTY: LBBTATION OF LIABILITY: TO THE EXTENT PERMITTED BY APPLICABLE LAW, WE DISCWM ALL RESPONSIBILITY FOR THE CONTENT QF Tits 81M.IECT'8 UFE 8T'ORY. WE DO NOT WARRANT AGAINST SERNCE EiTERRUPTIWrB OR ANY ERRORS IN THE DISPLAY OR PRESENTATION OF TIM SUBMITTED MATERIALS. FUTHERMORE, WE ONE NO WARRANTIES REGARDING YOUR INTERNET ACCESS, COMPUTER EQtNPMBIT ChlATIBElIY OR SOFTWARE CONFN3URATIONS. TIp8 WARRANTY ONES YOU $PECIflC LEGAL RIGHTS, AND YOU MAY ALSO HAVE OTHER RKiHTS WHN:H VARY FROM STATE TO STATE. IN NO EVENT WILL WE BE LWBLE TO YOU, ANY AUTTIORI~D PERSON OR ANY OTHER PERSON FOR ANY INDIRECT, INCIDENTAL, SPECIAL OR t~INiEQIMNTIAL. DAMAfM:6 OF ANY CHARACTER EVEN IF ONE OF OUR REPRESENTATNE8 HAS BEEN ADVISED OF THE POSSIBILITY OF SUFI DAMAGES. IN NO EVENT SHALL THE AGGREGATE DAMAGES AGAINST US OR OUR LIABILITY EXCEED THE CHARGES PAID BY YOU HEREUNDER. SOME STATES DO NOT ALLOW THE IXCLU810N OR LBBTATION OF INCIDENTAL OR CONSEQUENTW. DAMAGES, SO THE ABOVE LBETATION OR OCCLUSION MAY NOT APPLY TO YOU. AlISIGNMENT: Wb may assign thk Agreement at any time wftfrout your prbr wnsent. Tfds Agreement shell be badhp upon fhe successore, penNtbd assigns, heirs and exeartore of the partles hereto. GOVERNING LAW: Thts AgroemeM arW the performance hereunder shell be governed by and conshrred h aceordanca with the taws of the state in which thk AgreenreM has been eoncubd. witlrout reference b such state's drake of law provkiora. ARBRRATION: You ease that any dkput, rmrBOVarey or dekn adsinp out of or rNatlrrg b tlrk /lgrewrrart shall be submitbd b and tlnaly resolved by mandatory and birrdirrp arbibatlon h socadance witlr odes of the American Arbitratlon Aeacdatlon. The arbibatlon shell be caWuded by one arbtlrabr aebcted by mutual a8 of the partles and abets Dodo in the cNy or ooaky h whch tlak /~reenrerN was exeatd. The prevailnp party h any each arbttralbn shaA be entered b recover it roswnabb cosh and attorneys fees as part of arty award ordered tlrereirr. and judgment may be entered upon arty arbitratlon award h any court having ENTIRE AGREEMENT: Thk Agreement, topetlrer wNh all extr6it and order fomrs atlacired herMo and incarparatd herein. coMahs aN terms whbh have been agreed upon by you and us regarding the aerobe described hereh. TMs Agreement replaces aN other discussions and agreement, whether orel or wriltn. Ho subaequeM dkctrabn or agreement can drenge the trtns of tart Agreement unless tl k h wrtlkg and signed by both parties. ~ ~~ --~~~m=-+~ r _ D ~ O O ~ ~ ' ~ ~ ~ s c a ~ ~ ,,~ ~ .-~. x. ~c cn cn n c -r c sv z u' ~ ~ -c to cr+ •~`~{- "" Q• W „~ ~ ~ ~ , O %'G- LL c n O Y '-h r! ra O-- ~ ~ ~ ' H ~ rn - x '~c ~~ 1 .. ~~.-r- ~' ° c~ ~- o a :c x -~r+G]O07Os < C ~ ~. x ~ ~CL Sys-y-mp ~ O CDO j ~ C ~ '~ C N W O - ~ ~ J O 3 p :O ~ O ~ ~ y G7 r r e - X ago ~ t r ~y h v ~ m r m -< x _..~ ...~ .a. ~ ' CQ ` p ~ 'T P C; ~ ~ N Ot Gj ~ ~ ~ .. „"- Q% X X N L.C co ~ h ~ ~' ~ '~ 3> . G ti - RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARMER STRASBAUGH Receipt Date: 8/02/2011 Cumberland County - Register Of Wills Receipt Time: 10:18:36 One Courthouse Square Receipt No.: 1066526 Carlisle, PA 173 METZGER JACK G SR Estate File No.: 2011-00839 Paid By Remarks: CJNDA R METZGER ------------------------ Receipt Distribution ------ ------- -------- --- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 260.00 CUMBERLAND COUNTY GENERAL FUN WILL 15.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 32.00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN Check# 6731 ---------------- $335.50 Total Received......... $335.50 The Patriot-News Co. 2020 Techno~,~-~y Pkwy Suite 300 Mechanicsburg, PA 17050 Inquiries - 717-255-8213 METZGER 816 W FOXCROFT DR CAMP HILL PA 17011 ~e~latriot News Now you know THE PATRIOT NEWS THE SUNDAY PATRIOT NEWS Proof of Publication Under Act No. 587, Approved May 16, 1929 Commonwealth of Pennsylvania, County of Dauphin} ss Holly Blain, being duly sworn according to law, deposes and says: That she is a Staff Accountant of The Patriot News Co., a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, with its principal office and place of business at 2020 Technology Pkwy, Suite 300, in the Township of Hampden, County of Cumberland, State of Pennsylvania, owner and publisher of The Patriot-News and The Sunday Patriot-News newspapers of general circulation, printed and published at 1900 Patriot Drive, in the City, County and State aforesaid; that The Patriot-News and The Sunday Patriot-News were established March 4th, 1854, and September 18th, 1949, respectively, and all have been continuously published ever since; That the printed notice or publication which is securely attached hereto is exactly as printed and published in their regular daily and/or Sunday/ Community Weekly editions which appeared on the date(s) indicated below. That neither she nor said Company is interested in the subject matter of said printed notice or advertising, and that all of the allegations of this statement as to the time, place and character of publication are true; and That she has personal knowledge of the facts aforesaid and is duly authorized and empowered to verify this statement on behalf of The Patriot-News Co. aforesaid by virtue and pursuant to a resolution unanimously passed and adopted severally by the stockholders and board of directors of the said Company and subsequently duly recorded in the office for the Recording of Deeds in and for said County of Dauphin in Miscellaneous Book "M", Volume 14, Page 317. PUBLICATION COPY :°:;<~~~ ~ ,~r~. ., .Y. LETTERS O~ ES~~~TARY for the Eptaft osl' ti SR. deceased lats,3~~or~r',~ , 'Fowristhlp GumtierlandCbut-fy°'~Npnlo;hcw , In0 brim ~raul[tiRd~ ~ on ,~ Auoiist Z 20111,,a~ to the, titaftare F,_ ~ make Imme- dlaf payment a1d hovlgp claims , ~' aftc, thi;Estcte ari ~~utsted fo Pres ., eptm for ieNlemenl wiftqut dalay._`t to , , ~-~. _ , ~ ~ ~ •- ' Llrida R. AAetzc~r, l=xeaifrlx s . ':816 W. FoXaoff Drive. :^, - 'Camp HIt1,.PA' 17011 ~ This ad # 0002169143 ran on the dates shown below: September 23, 2011 September 30, 2011 October 07, 2011 before me is 11 y tober, 2011 A.D. Swom to ~~_ ~ y~ Notary Public COMMONWE,gLTM OF PENNSYIVANiq Sherrie L Lower paxt~ ~P., Dauphin County pi ber ~~ ~~ ~. 26, 2011 svlvanla Association of Notaries The Patriot-News Co. ., 2020 Technc*!ggy,Pkwy Suite 300 L Mechanicsburg, PA 17050 Inquiries - 717-255-8213 METZGER 816 W FOXCROFT DR CAMP HILL ~lle~latriot News Now you know PA 17011 INVOICE ACCT # NAME ALL CHARGES ARE NET AD ORDER # DATE IED TION ADDTL INFO. TYPE OF CHARGE AMOUNT 215485 METZGER 215485 METZGER 215485 METZGER 0002169143 09/23/11 METRO WEST 0002169143 09/30/11 METRO WEST 0002169143 10/07/11 METRO WEST BASIC AD CHARGE BASIC AD CHARGE BASIC AD CHARGE AFFIDAVIT CHARGE $37.15 $37.15 $37.15 $5.00 $116.45 TOTAL: REMITTANCE ADDRESS The Patriot-News Co. 23794 Network PL Chicago, IL 60673-1237 Please include the Account # or Ad Order # (above) with your remittance--Thank You NOTE: This Invoice replaces the Order Confirmation which we previously sent with Proofs of Publication ~~ REV-1512 EX+ (12-08) SCHEDULE I pennsylvania ~ DEPARTMENTOFREVENUE DEBTS OF DECEDENT, ~ INNERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS ~ RESIDENT DECEDENT ESTATE OF FILE NUMBER Jack G. Metrger, Sr. 21-11-0839 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. ,. RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date: 8/02 2011 Cumberland County - Register Of Wills Receipt Time: 10. 3:42. One Courthouse Sqquuare Receipt No.: 1066528 Carlisle, PA 1713 METZGER JACK G SR Estate File No.: 2011-00839 Paid By Remarks: CJNDA METGER ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PHOTOCOPIES 1.50 CUMBERLAND COUNTY GENERAL FUN ---------------- Cash $1.50 Total Received......... $1.50 '" ~; .. ~, `~ • " CUMBERLAND COUNTY RECORDER OF DEEDS" RECEIPT Inv Number: 93529 Invoice Dater 09/20/2011 9:47:11 AM RECEIPT Reg/Drvv ID: 0301 Customer: Last Change: Receipt By: COUNTER By: KW COPY C_hg # Charge /Payment /Fee Description Amount Inst # / Inst Date Municipality 1 COPIES $3.00 Fee Detail: COPY FEE $3.00 TOTAL CHARGES $3.00 PAYMENTS CASH $5.00 TOTAL PAYMENTS $5.00 AMOUNT DUE $3.00 PAYMENT ON INVOICE ($3.00) BALANCE DUE $0.00 REFUND DUE $2•~ CASH REFUND ($2.00) Date: Sep 20, 2011 9:47:26 AM Page 1