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05-09-12 (2)
• - y 1505610105 REV-1500 EX (eav ) (FI) PA Department of Revenue OFFICIAL USE ONLY Pennsylvania Bureau of Individual Tazes °°°'^'^~°'^'.E^°' Count Cade Year Flie Number Y INHERITANCE TAX RETUR I " -~ PO BOx 26o6ot N( // ~ ~~ Harrisbum, PA t7tz8-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Dale of Death MMDDYYYY Date of Birth MMDDYYYY 04/15/2010 II '02/14/1925 I Decedent's Last Name _ _ __ Suffix Decedent's First Name MI Failor Miriam li C I i I , _ (If Applicable) Enter Surviving Spouse's Information Below Spouse s Last Name Suffix Spouse s First Name MI Spouse's Social Security Number _ ~ THISRETURN MUST BE FILED IN DUPLICATE WITH THE __ __I REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW ~ 1. Odginal Retum O 2. Supplemental Return O 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust H. 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 8E COMPLETED ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD 6 RECTED T0: c Name _ _. _... Daytime Telephone Ntr~r rv James A. Miller (717) 737-6400 ~T ' < C ~ . . . r REGISTER OF W EONLY . - v ~- First Line of Address n C~ --~~ 4 S. 17th Street ~ =`, _. __ _.. .... .... _.. ., y Second Line of Adtlress _ _ h City Or Post Office _.. State 21P Code GATE FILED _ . Camp Hill ~i PA 17011 Correspondent's a-mai l address: james~paatlaw.com Untler penalties of perjury, I declare that I have examined this return, Including accompanying schedules and statements, and to the best of my knowledge and belief it is tr e, correct and com , e. Declaration of preparer other than me personal representative is based on ell information of which preparer has any knowledge. GN T E OF PER S F FILINGpJtI'URN PATE 05/08/2012 347 E STREET Carlisle 1701 SIGNATURE OFSIGNATURE OF PREP~Oy1EpyHAN RR DATE St Camtrflill PA 17011 Side 1 L 1505610105 1505610105 J m `,.~ U> C ~;: C7 r' rt1 _ 7 C, 7 t _,. _._ <~ r~ ~n 1 - Y J REV-1500 EX (FI) Name: Miriam C. Failor RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. Decedent's Social Security Number 120,000.00 '. 2. Stocks and Bonds (Schedule B) ..................................... .. 2. ~! L..___._..__...-_......__.._._ 0.00 '~.. __...__...._.._..__._._..__..___.. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. ICI _ _ _ _ ' _ 0.00 ~' 4. Mortgages and Notes Receivable (Schedule D) ......................... .. 4. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. ~i $,811.$7 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. '~, 0.00 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Pro e ~~_...._...._...._....__._..._.___ ~ _..___..._..._........._._._._.__.__. Schedule G O Se crate Billio Re nested...... l ) P 9 q . . , 7 0.00 B. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. 128,811.$7 II 9. Funeral Expenses antl Administrative Costs (Schedule H) ................. .. 9.. 13,020.42 '~ 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............. .. 10. 311,951.$3 11. Total Deductions (total Lines 9 and 10) ............................... .. 11. ~~~ I 324,972.25 '. 12. Net Value of Estate (Line 8 minus Line 11) ............................ _____________.__...._...._ .. 12. ..____._._._...._____.._-.;. -198,160.3$ 13. Charitable and Governmental Bequesls/Sec 9113 Trusts for which i'~~-"'~-""~~""~-'~-"'-'"'~" "~'~~-~"'~~~~~~'~"'~"~""""""""""- an election to tax has not been made (Schedule J) ...................... .. 13. i____.__....._....._..._ .............__ 0.00 ....____......._....._.._._...._._.._. 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. ~~ •198,1$0.3$ TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 tazable at the spousal tax rate, or transfers under Sec. 9116 "--- - - ---- ~ ---- ...__. __. 15. 16. _.__ A axable ~ i n ___. _. ~r X O t l neal ate ~ ~ ~ ~ 16. i 0.00 17. _.._... _. ._ _ . .._..___ ._. .. ____...... . Amount f Line 14 taxable .___.__...._.._._...._.._.__.... __._......_._....___......_ s at siblin rate X .12 0.00 ~~, L 17. ~ ~~ ~ 18. ______.______._..__....._._..____~..___.__I Amount of Line 14 taxable 15 0.00 at c ll t l t X _____..._.._.___.._.__. _._..__.__.__..__.._ . .. 0 00 o a era ra e . 19 . ~~ 19. TAX DUE ........................................................ . 19. ' 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p 1505610205 Side 2 1505610205 1505610205 REV-1500 EX (FI) Page 3 Decedent's Complete Address: Flle Number DECEDENT'S NAME Miriam C. Failor STREET ADDRESS 460 Stone House Road CITY Carlisle 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 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) Total Credits (A + B) (2) (5) 0.00 0.00 (3) (4) 0.00 0.00 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred .................................................................................... ...... ^ b. retain the right fo designate who shall use the property Uansferced or its income ...................................... ...... ^ c. retain a reversionary interest ........................................................................................................................ ...... ^ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ 2. If death occurced after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate censideration? ........................................................................................................ ...... ^ ~ 3. Did decedent own an "intrust for" orpayable-upon-0eath 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 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 are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [/2 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 benefidades 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 [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. uwavF~ces ' smart J. xoc>~ ATIOPNEY AT UW is S. HANOVER STREET -SUITE 101 CARLISLE, PENNSYLVANIA 17013 (71T)24b-2698 • FOii.(7L'y.Q46.0828 WILL OF MIRIAM C. FAILOR n ~~ '~? v zi~~ r,:. Cep -- cn ;~ "'J C'~ ~ '~ O -n :_jc= ~~ I, Miriam G Failor, of Carlisle, Cumberland County, _' Pennsylvania, declare this to be my last Will and hereby revoke all prior Wills and Codicils. I direct that all my just debts, funeral expenses, gravemarker and administrative expenses shalt be paid from my residuary estate as soon as practicable after my death. I direct that all inheritance, estate, transfer, succession and death taxes of any kind whatsoever which may be payable by reason of my death shall be paid out of my residuary estate. 3. I direct that my entire estate be distributed as follows: A. I leave everything to David A. Failor, Sr. Should he predecease me, I leave my estate to be distributed in equal shares to my children David A. Failor, Jr., Audrey F. Failor, Vickie F. Frye, Rodney L. Failor, Michael L. Failor and Wesley E. Failor. Should any of my children predecease me, I direct that their share shall lapse and go to the surviving children. 4. I appoint David A. Failor, Jr. as Executor of this my last Will. If he should predecease me or cease to act in such capacity, I appoint Audrey F. Failor as alternate. 5. The Executor of this Will shall have the power to distribute my estate in kind or in cash, or partly in either. I direct that no Executor acting under this Will shall be required to enter bond in any jurisdiction. IN WITNESS WHER OF, I have hereunto set my hand this ~ -' ~ day of r ,' ~t C-~'E' 1 , 2002. LpAW~O~K,~FICE30F(~(~('. 1 n ~'/ (/ Plllil\3. HVVV / ~ ~•. t. L,_ Cl. it \ \. ~~ •(t. ~ `~f I' 1 Miriam C. Failor HANOVER STREET SUITE 101 ,RLISLE. PA 17013 ~~~ ~- :` ~'J i r~ sa ~': t: Tt `~ ~; .~rre+' tom. Cs~ ~n VOFFICESOF ~.vJ, xoc~ DOVER STREET 117E tot ;lE, PA 17013 Miriam C. Failor, as and for her last Will in the presence of us, who at her request, in her presence and in the presence of each other have subscribed our names as witnesses hereto. .~ - WITNESS WITNESS N N ~ ~ m~ ~ V ° o~~~ ~~~ E ~~~ H N (p cjc~~ ~ U7 ~ X f6 T ~ T m~'a ~~ ~ G ~ ~ N ~ ~ ~~ ~ ~ ~N ~ ~ y ~ ~ ~ m d ~ °jt0 ayi v ~ ~Y~ a ~ v°°19Eo ~ End w- ~ ~ ~ N tNC TJ U 'C .. L +. fb ° ~~i9E~ ~' t ; c c v ~ ,,2. ° 0 ~ o c ~a 1.i. n '~~ ~ O O ~ 'O ~~ C '` ~~ V °w oL N~ 4 U <pppp~ U~ ~~ ~~, I t LL co T7r~ c aci a O a: N m Y ..° .T ,~ ~' ti . -c =• ~' ~~ i .~ i 4 G co t ~ ~ ~ E L U 3 y. N U, ° ~ U c o U 3 REV-1502 E%+ (O1-10) pennsylvania SCHEDULE A DEPARTMENT OF REVENUE REAL ESTATE INNERffANCE TA% RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Miriam C. Failor 21 11-0935 All real property owned solely or az a tenant in common must be reported a! fair market value. Fair market value is defined as the price at which property would be exchanged beMeen a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant fads. Real property that Is Joindyowned with right of eurvlvorehip moat ba dlcdoaed on Schedule F. Attach a copy of the settlement sheet If the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE A7 DATE NUMBER DESCRIPTION OF DEATH 1 458,460,464 Stonehouse Road, Carlisle, PA 17015 120,000.00 TOTAL (Also enter on Line 1, Recapitulation.) I ~ 120,000.00 If more space is needed, use additional sheets of paper of the same size. A. Settle.nent Statement B.T eof Loan ' 1. FHA 2. OFmHA 3, OConv. Unins. fi. File Number 4. VA 5. Conv. lns. MT 011.77RCS C. Note: nemem.nea•m.e=Ywve wla ouwa.Ne rmNnyy; navre mown nin lprinram.Abn yurppwe WAgNMO: X Ie s uMne b FnpwlnaY make lase aUlNNenUUSN I)n!W SWee on Nls Orany pbe wmhgtlpn unlndlbe a floe era I aspnmeni. Fa WIWa see: mM 1a U. 9. Lose aectlw 1001 N D. NAME OF BORROWER'. Edward L. Ege and Deborah N. Ege ADDRESS. E. NAME OF SELLER'. Etdale Ot Miflam C. Fdflot ADD ESS: F. NAME OF LENDER: Farmer and Merchants Trull Company ADDRE S: otChamberabur 20 S. Maln Blrast Chamberabun G. PROPERTY ADDRESS: 458,4608064 Storehouse Road, Carllale, PA 17015 Parch 08.10-0525-017 Dickinson Townshl H. SETTLEMENT AGENT: ACCP, Inc. roes nuur tares) nr Nanamdr aaoss U.S.. .rfmant of Houetng antl Urban Development GMB Aolxoval No. 2502-0265 7. Loan Number 8. Mongage Insurance Case Number ana.N nmiwPemek+'nn uwe. TateExpress SetOement System 1 100. GR053 AMOUNT DUE FROM BORROWER 1 400. GR03S AMOUNT DUE TO SELLER 4 101. Contract les nce 120000.00 401. Conirecl salsa 120000.00 102. Pers al Pr n -002. Personal Pro 103. Se0lamenl ch s to bonower Ilne i 3 420.75 403. 109. 404. 05. 05. 207. 507. _ _ - 208. 50 . 209. 50 . Ad uslmeMS for Items un aid b seller Ad uslmerde For items un ald seller 213. 513. 214. 514. 215. 515. 16. 516. 217. 517. 18. 51 . 19. 220. TOTAL PAID BYIFOR BORR R 300. CASH AT SETTLEMENT FROM OR TO BORROWER 301. G oss amount due from bo r 6ne 120 302. L s amouma aid b llor arrower line 220 303. CASH FROM BORROWER 8000.00 125095.89 98 000.00 29 095.69 519. 520. TOTAL REDUCTION MOUNT DUE SELLER 890. CASH AT SETTLEMENT TO OR FROM SELLE 601. Grose amount due M seller line 420 602. Lela nfductbn um ue seller line 520 803. CASH TO SELLER R 121874.94 121 671.94 121 874.94 0.00 SUnBpBATpleTUTEFORM tON SELLER STATEAENT: TNe blam.tlm ponWma Mnln N MpwlNl Na InlmnFlbn erq NENny MnNM1etl b Ne bNmN Wuww. BUNG. N rvu an nqulnG to IIN a rNym, NN AUt po`.e~el[miluLeWGPU Pm[wasd Tb wn glen~~NngWMPobnP.rNa Fnaau Wa GWmInU NNpM1nnW O.m owned lNa CanInN 8NS. PM1w lfcepM On PoEm ER MBTRUGTEWB~. NNN nN NUU wp Nur Mn bN neNMnw flN Fqml R11S, SW or ExMww M Rindpel geNEmO.,kt wY9en.'MNpur M[ollN IM slum: Motlpr InnreNmF. pNn Ne FpNlulN pUb M Form <TW, FUN a38]] ~a dbr BMMuN tl fFarm IU.U). YumemfNppumMalevbwPNae Ne MMUnw1ePM1(FN. TatNNO:~)wI1F cpnadWxpeyFrymMketlM numGS. Mywl ap not prPNEF pur wnMNy NrIEUrYINellw eY ergem to cMlwcrwlwl wnWGf lnrpMt6 py Nw. er111b pUlNyea MperMrY.7'renny NN m. numeerFnmm un NNeN.IMNmle mr caned NxoeyerNMnflpelWnmmAer. TIN: 1 BFLLERIS)$IGIUTUREIB): __1 6ELLERtS1 NEW MAILING AUOPE38'. Imm HUD-t rd8e~rel H.naboa ATOSz _.._____.._. __....,.~ cM l.:...d.,.-`Ir9M1.TT PAGE2 ~?~~~~ WARNING: IT ISACRBAE TO KNOWMGLYMNtE FALSE STATEAE:MSTO TIE TM HU6t &eONUMNd e1M mx111tl:INae pnpNeabe WearWe2uraW .cm+ma W+Vena0alon. UNRE08TATE8ON THI9OR ANY BINt1Uft FORM.PENKTIES OFONCDNVICTgN IBeveauetl n'AM Ceu Nna+ro De tlbbw+aa Ha:cwasn0s MNlBls eblemeM. CAN IIIGLUDE AFME ANpIk1Ffl13ONN¢NI. FOP DEfAR39EETITIE te'. U 8. CODE &ECigN 1W1 AND 9EGTIWI tOtO. ~ ~~ 1ttiD GERTIFIGTION OF BUYEP AND BELLEfl I aew tWWlly mWevM Na HUpl3ptlbT0103IMM:gN 0MMN0 bM101 mykIWMOaga aM6ellef,M4a e~/Me[cwele eMlemMl al ellfeCelpb al:a als0usemanb mMem mya[munlabyme in Nb/I+nNOdon.I luMenndMy NNI mpya Ne NU619edbnani 8101snm1. ~~16t-GYC ~ - - --- ~~ \\ .~ REV-v5o8 EX+ (nno) ~ Pennsylvania DEPRPTMENT OF REVENUE INHERRANCE Tq% RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Miriam C. Failor 21 11-0935 If more space is needed, use additional sheetr of paper of the same size. ~ M&T Banlc Understanding what's importantm «~.a~ 04344 sxp+ ESTATE OF MIRIAM C FAILOR DAVID A FAILOR JR, EXEC 460 STONEHOUSE RD CARLISLE PA 17013-9448 M&T's QuickLine: Buffalo (7I6J 616-1900 Outside Of The Buffalo Area (800J 714-2440 AMOUNT OF CHECK(S) RETURNED $ 6,716.17 NUMBER OF ITEM5 # 2 AMOUNT OF FEES $ 30.00 IJATF. U9-08-II Dear Customer Your account, number 9856120135, hes been charged for the total value of the following items which were deposited and subsequently returned for the reasons indicated below. As a result of these transactions, your account may now be overdrawn. Please note that any service charges incurred aze listed above for your reference. The unpaid items have been forwarded to your office at which you opened your account. If you have any questions, please call your Branch Office or QuiclcI,ine at the phone number listed above. DETAILED LISTING OF RETURNED DEPOSITED ITEMS 090211 I $1,88L94I MI33ING MENT 0038000890 ~ 05500025 160000046908 090211 $4,834.23 ENDORSEMENT I 0038000885 05500025 60000046908 1 I M[SSING 1130098 PAOE 1/1 VR96EN02 ~rsa~x ^~prhly r~arden 1-800-724.2440 Account History '*"0135 M & T Totally Free Checking stmt Posting t5>~CtIptlOtr WlttidraWaM q9 flts BaPahce Indicator Date Po 09/27/2011 DELUXE CHECK CHECKIACC. 0 911 6 /2 01 1 DEPOSIT 0911212011 REVERSE RETURNED DEPOSITED ITEM FEE 09/0812011 RETURNED DEPOSITED ITEM FEE 09/0812011 DEPOSITED ITEM RETURNED 09/07J2011 DEPOSIT $13.50 $8,715 17 $30.00 $39.00 $8,718.17 $8,811.87 .. . i,>r~W'`: r ~,._e.c/~ .~ I .: :" „~a' ~i,§YIPAhV d ' ~.ra~ $8,798.37 $8.811.87 $95.70 $05]0 $9~i.70 55.811.8'/ L~~ This is not an official statement I 09!28/7.011 10:40 AM 1 I REV-1511 EX+ (10-09) pennsylvania ~T DEPARTMENT OF REVENUE INHERITANCE TA% RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Miriam C. Failor 21 11-0935 Decedont's debts mart be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Ewing Brothers Funeral Home 4,618.40 Viewing/Service - $4250; Mass $85; Death Cert copies $18; Flowers $132.50; Obit Advert $132.90 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name{sJ of Personal Representative(s) David A. Failor Jr street Address 464 Stonehouse Roed qty Carlisle state ?A zIP 17015 Year(s) Commission Paid: 2012 z. AttomeyFees: Mi11er Lipsitt LLC 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address a. 5. 6. 7. a b qry State Relationship of Claimant to Decedent Probate Fees: CumberlarldCounty Register Accountant Fees: Tax Retum Preparer Fees: Legal Advertising Cumbedand Law Journal Sentinnel 6,390.60 1,500.00 257.50 0.00 0.00 75.00 178.92 TOTAL !Also enter on Line 9. Recaoitulationl ~ S 13,020.42 ZIP if more space is needed, use additional sheets of paper of the same size. Ewing Brothers Funeral Home, Tnc. 630 South Hanover Street Carlisle, PA 17013- (717)243-2421 August 3, 2010 David A. Failor Jr. 464 Stone House Rd. Carlisle, PA 17015 The Funeral Service for Miriam C. Failor We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING 1S AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES Traditional service with Viewing/One Day $4250.00 FUNERAL HOME SERVICE CHARGES $42$0.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE TNAT YOU HAVE SELECTED $4250.00 Cash Advances Clergy%Mass Offering $85.00 Certified Copies of the Death Certificate , $18.00 Flowers, _ - .$132.50 The Sentinel Obit with Pboto $132.96 TOTAL CASH ADVANCES AND SPECIAL CHARGES . $365.40 Total Total Cost , _ $4618.40 SUH-TOTAL $4618.40 IDIITIAL PAYMENT /DISCOUNT /CREDITS 4618.40 TOTAL AMOUNT DUE $0.00 The unpaid balance over 30 days is subjected toe 1.50 % service charge per month - 18.0000 % per annum. O °~~ ~~ ~ ~ ~. ~- D D ~~ RECEIPT FOR PAYMENT GLENDA FARMER STRASBAUGH Receipt Date: 9 02/2011 Cumberland County - Register Of Wills Receipt Time: 0:06:25 One Court$ouse Square Receipt No.: 1066859 Carlisle, PA 17013 FAILOR MIRIAM C Estate File No.: 2011-00935 Paid By Remarks: DAVID A FAILOR JR HMW ------------------------ Receipt Distrib ution ----•~- ------- -------- --- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 210.00 CUMBERLAND COUNTY GENERAL FUN WILL 15.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 4.00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN - Cash --------------- $257.50 Total Received......... $257.50 CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717) 249-3188 Fax: (717) 249-2888 November 25, 2011 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: James A. Miller, Esquire RE: Miriam Failor Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on the following dates: November 11, November 18, and November 25, 2011, Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 0 .00 Total Amount Due $ 75.00 Payment received by Receipt Page The Sentinel 487 E North Street Carlisle PA 17913 1-717-243-2917 Date: 02!22/72 Time:14:48 CREDIT CARD SALE Card Data: ••"7021 K Tran Amount: 178.92 Approval Code: 09372G Clerk ID: SENWCLFC Invoice #: 404554 -Legal - Feilor Card Balance: 9.D0 vrvnv.cumberlink.mm Customer Copy Page 1 of 2 https://leeapp-vwarpl,app.leeent.netlcgi-bin/auth.cgi 2!22/2012 The Sentinel www.combe~link.com 1 G UaLA[ y+arr+~ sauec PEac+cau+rv MILLER LIPSITT LLC 4 SOUTH 17TH STREET CAMP HILL, PA 17011 T77-7378400 AD NUMBER PAGE NO. 404114 1 of 1 BILL DATE SALESPERSON 77/23/17 wolfs START DATE STOP DATE 11/09/11 11/23/11 10 PUBLIC Publlcatlon Ineertlona Rate Net Amount Gross Amount 3 THE SENTINEL- LEGAL 3 LGL $169.92 TOTAL AD CHARGE $169'92 3 MOBILE SITE M082 52'00 3 PROOF OF PUBLICATION 01PRF $7.00 Purchase Qder Est. M. Failor PAY THIS AMOUNT $178.92 $214.70• `AFTER 12178/11 Thank you for advertising with The Sentinel! Deadline for in-column legal ads is 4:00 p.m. two business days prior to date of insertion. For questions, call (717) 240-7130. RWan ma pordon ash yourpsymenr THE SENTINEL ^ Check # ^ Credit Card c%LEE NEWSPAPERS ~ ® ~ ®~ ® ~ PO BOX 540 m WATERLOO IA 50704-0540 '~#~ . E>tp. Dale: m m Name on uedlt cartl Sipmidlre Please make ch THE SENTINEL do LEE NEWSPAPERS PO BOX 540 WATERLOO IA 50704-0540 Ad Number Billing Date ~ 11@3!11 ~ Amount Due ~ $ 178.92 ~ ~t aooxas THE SENTINEL i~ MILLER LIPSITT LLC c/o LEE NEWSPAPERS 4 SOUTH 17TH STREET PO BOX 742548 CAMP HILL, PA 17011 CINCINNATI OH 452742848 1~1~~1~1~1~~~1~11,~~i~l~~l,~1~1~1~1~~1~~11~~1„I~~II,~I~I,~~II 21540200000004041140000DD0000000002147000000178920 REV-1512 EX+ (12-OB) Pennsylvania SCHEDULE I DEPARTMENT OE REVENUE DEBTS OF DECEDENT, INHERRANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Miriam C. Failor 22 11-0935 Report debb Incurred by the decedent prior to death that remained unpaid at the date of death, Including unrelmbursed medial ezpensea. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 • : 2008 Real Estate Taxes 2,651.36 2. 2009 Real Estate Taxes 2,780.47 3. Pennsylvania Department of Public Welfare, CIS # 940165706 297,075.63 4. David AFailor, Jr. - 2011 Homeowner insurance $405.70; home heating fuel $1224.61 1,630.31 5 Closing costs pursuant to sale of real estate -see attache HUD 1 settlement statement 7,814.06 a. Seller Attorney Fee - $375.00 b. 1 °k transfer tax payable by seller $1200.00 c. 2011 county real estate taxes $535.13 d. 2011-12 school real estate taxes $2940.20 e. 2010 ~untylschool real estate taxes $2763.73 TOTAL (Also enter on Line S0, Recapitulation) ; 311,951.83 If more space is needed, Insert additional sheets of the same size. DENNIS MARION GARYEfu..~BERGER ~ CHIEF OPERATIONS OFFICER T, .. CHAIRMAN RICHARD ROVEGNO EDWARD SCHORPP VICE CHAIRMAN + SOLICITOR BARBARAB.CROSS TAX CLAIM BUREAU OF CUMBERLAND COUNTY STEPHEN D.TILEY SECRETARY One Courthouse Square, Room 106, Carlisle, PA 17013-3389 ASSISTANT SOLICITOR. (717)240-6366 Printed: 6f 14/10 C Receipt No.: 75518 13:16:40 Receipt Date: 6/14/2010 Control Number: 8-000306 **** RECEIPT **** Page: 1 Property Description: FAILOR DAVID A 460 STGNEHOUSE ROAD LAND APPROX 5 ACRES CARLISLE PA 17015 Residential W/ Comm Funct Situs Information: 460 STONEHOUSE ROAD Map No: 08-10-0626-017 Tax Year Description DICKINSON TOWNSHIP Penalty & Face Interest Costa Total 2008 CTY-DICKINSON TWP 2008 CLB-DICKINSON TWP 2008 MUN-DICKINSON TWP 2008 SCH-CARLISLE AREA 2008 BUREAU COSTS 2009 BUREAU COSTS 319.17 72.55 25.14 5.74 1792.92 407.94 15.00 8.00 Received For Year OE 2008 .64 Received For Year Of 2009 391.72 30.88 4.90 2200.86 8'""0 0 $2651.36 .64 $.64 Tendered > CASH Received By > MM Paid By > FAILOR, DAVID A Remarks > Total Received $2652:00 * Continued ;t . . DENNIS MARION GARY EICHF'.9ERGER CHIEF OPERATIONS OFFICER CHAIRMAN RICHARD ROVEGNO EDWARD SCHORPP VKECHAIRMAN SOLICITOR 4 BARBARA 6. CROSS TAX CLAiM BUREAU OF CUMBERLAND COUNTY STEPHEN D.TILEY SECRETARY One Courthou se Square, Room 106, Carlisle, PA 17013-3389 ASSISTANT SOLICITOR Printed: 5/13/11 C (717)240.6366 Receipt No.: 81.615 14:13:54 Receipt Date: 5/12/2011 Control Number: 8-000306 **** RECEIPT **** Page: 1 Property Description: FAILOR DAVID A 460 STbNEHOUSE ROAD LAND APPROX 5 ACRES CARLISLE PA 17015 Residential W Comm Funct Situe Informs ion: 460 STONEHOUSE ROAD Map No: OB-10-0626-017 DICKINSON TOWNSHIP Tax Xear Description Penalt & ~,~ Face Intere~t Coats Total 2009 CTY-DICKINSON TWP 335.09 73.67 408.76 2004 CLB-DICKINSON TWP 25.14 5.55 30.69 2009 FIRE-DICKINSON TWP 2009 SCH-CARLISLE AREA 30.73 6.75 37.46 1870.14 411.49 14.36 2281.63 2009 BUREAU COSTS 7.55 7.SS Received For Year Of 2009 $2780.,47 Total Received $2780.47 Tendered > CASH Received By > MM Paid By > FAILOR, VIOLET Remarks > Balance Due Aa Of 5/12/2011 Claim Year: 2010 2657.79 Claim Balance: 2657.79 Receipt Number: 81615 Total Received: $2780.47 Oct.18. 2011 8'.§1AM Third Party L'iabil'ity pennsylvania BEPABTMENT OF PpaLIC WELFARE October 18, 2011 MILLER LIPSI7T COURTNEY A BUR BANK 4 SOUTH 17TH STREET CAMP HILL PA 17011-2314 Re: Miriam Failor CIS #: 940165706 $$N: ###-##-4195 Oate of Death: 04/15/2010 Dear Courtney A. Burbank: No. 1903 P. 2 Please be advised that the Department of Public Welfare maintains a claim In the amount of 5297,076.63 against the above-mentioned estate. This claim Is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Departmenk according to Act 49, 62 P.S, 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed Is the Department's Itemized statement of claim. A portion of this medical expense, namely X26.745.83, was incurred during the last six months of the decedent's IIFe; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely d27L330.00, is to be entered as a priority Class 5,1 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim Is admitted and when payment may be expected. If the estate accounting {a complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available.. Please complete the enclosed Decedent's Assets Itemization Form and return to the Department. Please Include proof of funeral bill, proof of burial account, proof of personal care account, copies of orlglnsl Ilfe Insurance policy forms naming beneficiaries, proof of any and aU stocks and bonds, date of death bank statements and copies of orlglnsl signature cards or proof from banking institution showing ownership of any and all bank accounts. Please forward these documents to the address above no later than October 27. 2011. Sincerely, ~iz,,.,,..J Karin L. Tyler QQ Claims Investigation Agent 717-772-6614 Bureau of program 1n1E9r1ty I OivlSiCn ar7bltYl PdKy Uablllty I AECAVEr`( SLG11On PO Box Bg86 i Harrlsbur0, PennsylvanW 17105-8486 Oct. 16. 2011 6.S1AM Third Party Liability LGMMONWEAL711 OF PENNSVLVANU OEPAR7MEN70F pUOUG WELFARE BUREAU OF FINWC4IL OPERATIONS 7PL 860710N • CASUALTY IINR 4000X8186 W,RR16BURG PA /T10.Sb/BE October 14, 2011 STATEMENT OF CLAIM SUMMARY No. 1963 P. 4 NAME Fstele of FAILOA, MIRIAM 1O 940188 788 MEOICAI ~ CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIENT ~.% 48,440.32 88,500.26 LONG TERM CARE 28,879.21 206,065.18 230,794.36 DRUG 8.48 77,834.63 1Y,841.01 REIMBURSEMENT TO DPW 26,746.63 277,330.OD T47,076.63 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN -• 236003113 a -~ • ~. 0 0 0 0 H = h Get a reloadadl.e 4lestern Union Prepaid MasterCard. ~ Add Honey a~ggaain and again. Mo. credit check: or bank aoaxmt ~ required. Vet orre at westernunion.conlnynoneywise Z ~ENTS~ ~'~" 000095 D'f 01011 S2?b.40 7riIRlDRED26DOtLAfiS AMD n - F v .~ Z r ns ° ti n.i u eur~BU~..up.~xve n..ananl ti e * 1 420385'1 51 3 * o gO m b M WeJSq ~5 .o. n PF ,~ N S ~~{ ' ~ ~ ~ p,r ~_ a N~ ~ ~ ~ ~ a~ CO ~~ nt - ~w r~ ~ T ' ~''~ F-+ ~ <b~ ^ m i om a y ~ ~ , ~ r~- S y ea DETACH HEFlE o w /-+ ~~ Brethren Mutual Insurance Company Hagerstown, NID 21740 POLICY NUMBER: HPP 0181906 02 EFFECTIVE DATE: 01 /19/2011 EXPIRATION DATE: Ot j19/2012 INSURANCE TYPE: HOMEOWNERS AGENCY:8090000 VALLEY AGENCY COMPANY PHONE: 717-264-4311 MIRIAN FAILOR ESTATE CJO DAVID FAILOR JR 464 STONEHOUSE RD CARLISLE, PA 17015 PREMIUM NOTICE -The second payment of your insurance premium Is now due. You may pay in full, or with a $6.00 service charge make the scheduled payment on or before the payment due date. Thank you far your business. ** f :f1\/Fn0/:F WII I !:FARE IF Nf1T GF(`FIUFI~ RV OLVAnFNT fli 1F TATG ** Premiums findorsemente/Fees cash applied Amount Due Bill Due If you have any questions, please contact your agent or our policyholder service department at 1-800.6214264 AMOUNT PAID: $~ DATE PAID: ~- /Q - I/ CHECK NO.:~~ PLEASE READ IMPORTANT INFORMATION ON REVERSE SIDE. ~, Brethren Mutual Insurance Company POLICY NUMBER: HPP 0151906 02 Hagerstown, MD 21740 EFFECTIVE DATE: 01 /19/2011 ~ EXPIRATION DATE: 01/19/2012 INSURANCE TYPE: HOMEOWNERS INSURANCE BILLIN.Ca N©TICE' AGENCY:8090000 VALLEY AGENCY COMPANY PHONE:717-264-4311 MIRIAN FAILOR ESTATE C/O DAVID FAILOR JR 464 STONEHOUSE RD CARLISLE, PA 17015 PREMIUM NOTICE -You may pay in full, or with a $6.00 service charge per payment, make payment under any of the multi-pay plans listed below on the specified due dates. Thank you for your business. ** COVERAGE WILI. CEASE IF NOT RECEIVED BY PAYMENT DUE DATE ** PAY PLAN (11 PAY PLAN (2) PAY PLAN (3) 951.tia ,' O1/19I1"1 2ti1""SO O1,/1§%11 ~..~ 0111 ~~ 261.50 07/18/11 171.30 04/1 ss~.on" 171.3d o7j1 -~6 MONTHLY REVOLVING PAYMENT PLAN (EFT/Credit Card): $49.97, tsn the -:19t:h; of -eaeYi mdnth. '~ (includes $4.00 service charge) * The minimum payment due is the amount of the let installment of the pay plan you If you have any questions, please contact your agent or our policyholder service department at 1-500-fi21-4264 AMOUNT PAID: $ DATE PAID: CHECK NO.: PLEASE READ IMPORTANT INFORMATION ON REVERSE SIDE. `~ Brethren Mutual Insurance Company Hagerstown, IvID 21740 POLICY NUMBER: HPP 0181906 01 EFFECTIVE DATE: 01 /19/2010 EXPIRATION DATE: 01/19/2011 INSURANCE TYPE: HOMEOWNERS AGENCY:8090000 VALLEY AGENCY COMPANY PHONE: 717-264.4311 MIRIAN FAILOR ESTATE CJO DAVID FPJLOR JR 464 STONEHOUSE RD CARLISLE, PA 17015 If you have any questions, please contact your agent or our policyholder service department at 1-800-621-4264 AMOUNT PAID: $ DATE PAID: CHECK NO.: PLEASE READ IMPORTANT INFORMATION ON REVERSE S1DE. vvyPO~BOX 683n"~ HUMMELSTOWN~ PA 17036 7I?-243-5858 ~+~~ RECEIPT ~*~ DAVID FAILOk 8k ESTATE 460 STONEHOUSE RD GAkLISLE, PA iZ013 DATE REF # DESGP,IPTION IJ05J11 21343 Beginning Balance CASH Ending Balance F'YMT 'JN ACCT CASH OS-,Tan-1i 03:18 PM JG ~'. Account # 65153 AMOUNT 311.23 -100.00 211.23 DA`JID FAILOR Sk E5 Acc~~unt # 65153 Date 1/05;11 REF # AMOUNT 21343 311.23 -100.00 211.23 ~I. 0 ~!' f` G SUBURBAN F'RDFANE ' PD BDX 683 HUMMELSTDWN, PA !7036 717-243-5858 ~'** RECEIPT ~** DAVID FAVOR 5R ESTATE 4b0 5TDIVEHDL'SE RD CARLI5LEP PA 17013 DATE ftEF # DESCkIPTIDN 1/2C%%11 21549 Beginning Balance CASH Ending Balance CA5H PAYMENT 1/26/2411 26-Jan-li 62:41 PM 5R Account # 6523 AMDUNT 214.44 -214.40 6.60 DAVID FAILDR SR ES Account # 65153 Data 1/26/il REF # AMOUtVT 21`09 214.40 -214.46 0.00 r PO BOX 683 HUMMELSTOWN, F'A 1703b 717-2k3-5858 *~*~ FECEIF'T *~# DAb'ID FAILOk 5k ESTATE Accaunt # b5i53 DAVID FAILOF Sk ES k60 STONEHOUSE kD CAFLTSLE, FA 17013 Accaunt # 65153 Date 2f©9/11 DRTE REF # DESCFIPTION AMOUNT FEF # AMOUNT 2104/11 21711 Beginning Balance 343.19 21711 393,14 CASH -365,00 -3b5.00 Ending Balance 28.19 28,19 CASH PAYMENT 2!412011 99-Fet}-il 02:20 PM SP, p0 r~a:r 6~3 HiJMMELTiI~N, "r'N 1?:736 ~i~--24w-sass x~~+r F'EvETp? ~~~ CC;V?4 FASLOF tik ESTATE' ACC3unt '+F b5153 ;,~~ s;aras~a±+se er r?:~TE =tEF # DESCRT_fiTIOPi AMOU~tT 1G"Jbr;ai 21t~°3 Begtnnir,„~ Bala.nce 545.21 G=1WH -145.21 E~diny Ealancc U.f!4 PYMT OC*! AC^r v~;~H ~AUSu Fnt4_~k Sk z. Ac_z~!nt ~ 651`x'7 Dace1.2/G'6; i~ FEI= ~: AMOUNT 2198 24H.22 -:4~.2i 4. G4 Suburban PO BOX 683 Propane® HUMMELSTOWN, PA 17036 Page 1 of 2 Account Number: 2028-065153 Customer Name: pAVID FAILOR SR ESTATE Statement Date: 11/0912010 Due Date: Upon Receipt PREVIOUS ACCOUNT BALANCE / $341.66 Current Activity $-96.45 TOTAL ACCOUNT BALANCE: ` $245.21 _ tt~ Please disregard if already paid ~ ~ °~ ~ PREVIOUS ACCOUNT BALANCE $341.66 ( Date Reference No. Oly Descrlptlon Amount Due Delivery 1: DAVID FAILOR SRl460 STONEHOUSE RD/.ICARLISLE PA 17013 ) S 1q-25-10 20710 CASH $-100.00 ~ 11.09.10 LATE CHARGE $3.55 ~ TOTAL CURRENT ACTIVfTY $-96.45 ~ ~ • a Amount SubJect to Late Payment Charge On Unpaid Balance Monthly Rate Annual Rate '~.. $236.61 1.50% 18.00% ~• ~ Payments made by personal check may be elecbonically deposited. '. LP gas volume ae delivered, has been adjusted for the volume at 80 degrees Fahrenhek (18 degrees Celsius) where required by law. '. To pay your bill online, please visit us at our website wwwsuburbanpropane.wm. For billing and other InqulHea please call 1.600.PROPANE (1.800.776.7263) or 7 17.2435858 Please detach and return below portion with your payment Account Number: 2028-065153 Suburban Due Date: Upon Receipt Amount Due: Propane® $84Ers'4 ly5~ 2~ HUMMELSTOWN, PA 17036 Amount Paid: $ Address Service Requested Please wdta your acwunt number on your check '. ^ Check here for change of address (see reverse for details) oaoo. uaa. as ~nr~~~nr~~~rnn~~u~~n J~un~~u~n~nrl~r~n~ur~~u~rlr~ DAVID FAILOR SR ESTATE 460 STONEHOUSE RD SUBURBAN PROPANE CARLISLE, PA 17015-9448 PO BOX 663 HUMMELSTOWN, PA 17036 ~m~~~r u~~~nun~~r~r~r~r~ur~r r~r~n~~u~u~~r r~~uu~r~r~ 2028001109109000024521g0002452100000065153 . _ _. _ __ SUBt1RBAN PRQ°ANE FJ BOX bpi Hi]PSMELSTO4,N. FA i?03b ^l"-243-5p5p *~* FrECE:IFT #-~ 9A'IG FAILOR SR eSTATE Account # 5513 DAVID FAILOR SR ES 4ti~ STONEHOUSE RG CARLISLE, FA i7!?23 Account # b~1~3 GATE REF = DEECR:P7IQN AhtO11N7 REF # A!~QUNT tl/2c/iC~ ?U?3O Begirtr~ing Balance 2a5.c1 209~9p 245,22 CF.5N -Ui0.0U -10C.~7U Ending Balance 145.21 145,21 F"e'iNi ON ACCT CASH 22-t~tav-iG .:12x35 F'M JC auDUnarn. rnurni~c PD BOX 683 kUMMELSTDWN, PA !7036 717-243-SB58 *+"* RECEIPT ##e DP.i~ID FAILDR SR ESTATE 460 5TDNEkDU5E RD CARLISLE, PP. 17013 DATE REF # DESCRIPTION 10/2S/ZO 20^14 Beginning Balance CASk Ending Balance CASk PAYMENT 10/2S!2410 25-Dct-10 12:58 PM SR Account # 65153 AMOUNT 341.66 -100.00 241.66 DAVID FAILOR 5R ES Atcvunt # 65153 DatelU/25/10 REF # AMOUNT 20710 341.66 -104.00 241.66 ,~ iN ,., . ~ ~ ~ 9 f ~ ~' a ~, c m ._ I ~ 1 - . ~ F~ ~.. ; r. R ~ ~ °~ ~ ~ ~' D Z y y D ~ , : ~ ~ :F . ..... ..... ..... ...... ..... ..... ..... ..... ... . . ..... ...... ..... ..... ..... ...... ..... ..... ..... ..... ..... ..... ..... `~ : W` n ~ ~ ~ $ ~ ~ _.. ~ y Q, !'7 J~i ~ f' ~ i -~ n ~~ N ~ - m ~c n ~ !~ W ~' N ~ > z m 1, m " ~ '. ~ ~ ~ C y,. (u N REV-1513 EX+ (O1-10) pennsytvania SCHEDULE J '~ INRERRANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Miriam C. Failor 21 11-0935 NUMBER NAME AND ADDRESS OF PERSON(S) RECENING PROPERTY RELATIONSHIP TO DECEDENT Do Not Llst Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [tndude outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. David A. Failor, Jr., 464 Stonehouse Road, Cadisle, PA 17015 Son 1 /6 2. Michael L. Failor, 458 Stonehouse Road, Carlisle, PA 17015 Son 1 /6 3. Westley E. Failor, RD 2, Box 48-B1, Loysville, PA 17047 Son 1 /6 4. Vickie L. Frye, 2701 Aubum Riche Lieu Rd., Aubum, KY 42206 Daughter 1/6 5. Rodney L. Failor, 181 Creek Road, Newville, fPA 17241 Son 1/6 6. Audrey J. Adams, 5810 US Hwy 92 W, Lt 133, Plant City, FL 33566 Daughter 1 /6 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON-TAXABLE DISTRIBUTONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARRABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I f If more space Is needed, use additional sheets of paper of the same size. James A Miller, Esquire MILLER LIPSITT LLC Attorneys for Deceased INRE; ESTATE OF Miriam C Failor, DECEASED IN THE COURT OF COMMON PLEAS Cumberland COUNTY Orphans' Court Division NO. zotl-00935 PANo ESTATE SETTLEMENT AGREEMENT AND RELEASE THIS AGREF117IIVT, executed this day of ~ . 2oi2, by and between David A Failor Jr, individually and as Executor of the to of Miriam C Fa>Zor, Deceased, and Audrey F Fa~1or, Vickie F Frye, Rodney L Failor, Michael L Fa~7or, and Wesley E Fa~1or, individually and collectively being all the (testamentary) heirs of Miriam C Failor. W I T N E S S E T H WHEREAS, Miriam C Failor, died April t,5, zolo and Letters Testamentary were granted on September z, 2oii to David A Failor Jr, Executor; and WHEREAS, the Executor has proceeded with the administration of said estate and has prepared his accounting in the nature of a statement of receipts and disbursements. A true and correct copy thereof is attached hereto and made a part hereof, marked "Exhibit A' ;and WHEREAS, the pasties hereto desire that the ~oeaitor shaIl not be required to file an accounting with the Orphans' Court of Cumberland County and the net proceeds of the estate shall be distnbuted without the necessiEy of'filing a formal aorount NOW, THEREFORE, the parties hereto, intending to be legally bound hereby, Page ~ of 4 - Failor Estate Settlement AgreemenURelease mutually agree as follows: i. The parties hereto, and each of them, agree and acknowledge that they have fully and carefully examined the statement of receipts and disbursements and schedule of distribution relating thereto and the Executor fee of g% of the gross Estate value, and find the receipts, disbursements and schedule to be true and correct, and acceptable to the parties hereto and each of them, and further, that each has received a copy of this Agreement. 2. The parties do release, remise, and forever discharge the Estate of Miriam C Failor, Deceased, and David A Failor Jr, Executor, of and from all manner of acts suits, claims/ accounts, accountings, debts, dues and demands whatsoever which they or their legal representatives or assigns may at any time hereafter have, against the Executor, the said estate or the assets thereof, from, for, touching or concerning any of the assets and property of the said estate andJor any claim or interest thereto or herein, and the administration, management, collection, sales or distribution of any of the said assets and for or on account of any money, interest, income, assets or proceeds out of the same, from the time of the death of said decedent to and including the date of this Agreement and release. 3. This instrument is a full and final Estate Settlement Agreement by and among the parties hereto, both fiduciaries and individuals, all of the same having arrived at, concluded and executed after a full and complete disclosure of the assets of the said estate and the rights of the parties herein, and all of the partieshe.~o and eachofthem ag-eeto abidebythe teanshereof. 4. The parties agree that they will and at all times in the future and whenever necessary, appropriate or convenient make, execute, and deliver to the said Executor andfor other parties or persons, any and aIl instnunents, documents, conveyances, deeds, releases or other Page 2 of a - Failor Estate Settlement Agreement/Release inshuments at anytime necessary or convenient to carry out the intention of this Agreement and/or to permit, assist and enable the Executor to fiilIIl his duties with reference to said estate and aIl of the assets thereof. 5. This Agreementconstitutestheentireundetstandingamongthepatties andeachofthem aclmowledges that no representations or statements of any kind, written or oral, have been made to them or any of them prior hereto by the Executor or by arty other person or party upon theirbehalf. 6. The parties further specifically agree that nothing in this Agreement shall be construed as an acceptance by them of any asset not accounted for in the Schedule of Distribution or any asset discovered after the date hereof, said assets to be divided equally among all beneficiaries. The parties further agree to reimburse the Estate an equal pro-rata .share of any valid claims, bills or other assessments received and payable after the date hereof ~. ThisAgreetnent shall inureto the beneFrt of and shallbebinding upon the patties hereto, and each of them, their heirs, executors, adminishatots and assigns. 8. This Agreemenrt maybe executed in counterparts. Page 3 of a - Failor Estate Settlement AgreemenbRelease IN WITNESS WHEREOF, the parties have hereunto set their respective hands and sealsthe dayandyearfust above mentioned. P)avid A Failor r, individually David A Failor Jr, Executor of ° ie Estat of Miriam C Fa~1or, Deceased AudreyF Fa~1or Vickie F Frye RoclneyLFailor Michael LFattor WesleyE Fa~1or Page a of a - Failor Estate Settlement AgreemenURelease ~ r after the date heieoE ~. lhis Agreement shall inure to the benefit of and shall be binding upon the parties hereto, and each of them, their heirs, executors, adminishators and assigns. 8. 'IhisAgreementmaybee.~utedinocamteiparts. IN WTiNE.SS WHEREOF, the parties have hereunto set their respective hands and seals the day and year first above mentioned David A Failor Jr, individually David A Failor Jr, Executor of the Estate of Miriam C Fa~1or, Dew AudreyFFat~A~ams Vc1deFFrye Rodney L Fa~1or Michael L Fa~1or Wesley E Fa$or Y .. after the date hae~ 7• 'T'his Agreement shall inure to the benefit of and shall be binding upon the parties hereto, and each of them, their heirs, executors, adminishators and assigns. 8. 'I'tvsAgc+eemeirtmaybeeacecutedincanurte!parts. IN WITNESS WIiEREOF, the parties have hereunto set their respective hands andsealsthe dayandyearfiist abovementioned. David A Failor Jr, individually David A Failor Jr, Executor of the Estate of Miriam C Failor, Deceased AudreyF Favor Viclae F Frye 12odneyLFa~lor Michael L Fa~1or Wesley E Failor k hereto, and each of them, their heirs, executors, administrators and assigns. 8. ThisAgreementmaybeexecutedincounterparts. IN WITNESS WHEREOF, the parties have hereunto set their respective hands and seals the day and year first above mentioned. David A Failor Jr, individually David A Failor Jr, Executor of the Estate of Miriam C Fa~1or, Deceased Audrey F Fa~1or Vickie F FYye G l .,C r~ Rodney L Fa~1or Michael LFailor WesleyE Failor after the date heieaf ~. This Agreement shall inure to the benefit of and shall be binding upon the parties hereto, and each of them, their heirs, exeartors, administrators and assigns. 8. ThisAgreementmaybeexecutedinowmterparts. IN WT11vESS WHEREOF, the parties have hereunto set their respective hands and seals the dayandyearfirstabovementicned. David A Failor Jr, individually David A Failor Jr, Executor of the Estate of Miriam C Failor, Deceased AudreyFFa~lor Vickie F Frye Rodney L Fa~7or /~~ '~ ~~ MichaelLFailor WesleyEFailor ..,* . after the date hen~£ ~. This Agreement shall inure to the benefit of and shall be binding upon the parties hereto, and each of them, their hens, executors, adminishators and assigns. 8. 'T'his Agreemenrt maybe executed in counterparts. IN WITATF.SS WHEREOF, the parties have hereunto set their respective hands and seals the day and year fast above mentioned David A Failor Jr, individually David A Failor Jr, Executor of the Estate of Miriam C Fa>7or, Deceased Audrey F Fa~7or Vickie F Frye RodneyLFailor Michael LFailor esley E F ' r • ,s - EXHIBIT A STATEMENT OF ACCOUNT ESTATE OF MIRIAM C FAILOR DATE OF DEATH: April 15 2010 LETTERS GRANTED: September 2 2011 ASSETS: VALUEIAMOUNT A. Real Estate: 458, 460, 464 Stonehouse Road, Carlisle PA 17015 $ 120,000.00 - Real Estate taxes prorated reimbursements (HUD 407/408) $ 1,674.94 B. Personal Property: M&T Bank Account Number 9856120135 $ 6,811.87 C. Monumental Life Insurance payment to Ewing Bros funeral home $ 1,000.00 TOTAL ASSETS $ 129,486.81 11 DEBTS-DISBURSEMENTS: 1 Funeral Home -Ewing Brothers, Carlisle PA $ (4,618.40) 2 Register of Wills, Cumberland County -Probate Fees $ (257.50) 3 Attorney Fees -Miller Lipsitt LLC" $ (1,500.00) a Legal Advertising -Cumberland Law Journal $ (75.00) b Legal Advertising -The Sentinel $ (178.92) 4 Executor Fee - David A Failor, Jr $ (6,390.60) 5 Taxes - 2008 real estate taxes $ (2,651.36) 6 Taxes - 2009 real estate taxes $ (2,780.47) 7 Homeowner's Insurance - 2011 $ (405.70) 8 Home heating fuel $ (1,224.61) 9 Closing costs for sale of home, IA above $ (7,814.06) 10 Department of Public Welfare -compromised settlement on S2e~s~6.6a - cls eao~6s7os $ (101,589.55) - Department Of PUbIIC Welfare - compromised settlement on $297975.64 -CIS 940185706 $ (0.64) TOTAL DEBTSIDISBURSEMENTS $ (129,488.81) III SUMMARY: A TOTAL ASSETS: $ 129,486.81 B Less TOTAL DEBTS/DISBURSEMENTS $ (129,486.81) N BENEFICIARY DISTRIBUTION: 1 Michael L Failor 458 Stone House Road Carlisle PA 17015 $ - 2 Westley E Failor RD2, Box 48-81, Loysville PA 17047 $ - 3 Rodney L Failor 181 Creek Road, Newville, PA 17241 $ - 4 Vickie L Frye 2701 Auburn Richelieu Road, Auburn KY 42206 $ - 5 Audrey J Adams 5810 US Highway 92 West, Plant City, Florida 33566 $ - 6 David A Failor, Jr 347 E Street Carlisle PA 17013 $ - -~ Nav.l6. 2411 4:28AM Third Party Liability pennsy[vania DEPAPTMbNT Ui PUlLIC NbLAANa ~~ November 15, 2011 MILLER LIPSITT COURTNEY A 8UR BANK 4 SOUTH 17TH STREET CAMP HILL PA 17011-2314 Re: Miriam Fallor CIS #:940165706 55N: ###-##-4195 Date of DeadT: 04/15/2010 Dear lames Millar, Esquire: Na, 3881 P, 2/2 Thts IeUer Is to advise you that arxording to the Information you provided to our office regarding the assets of the above-referenced estate, the Department of Public Weifare will accept the balance, namely apy,Qya58g.ss remaining In khe estate far payment of our flxlsting claim. Please have the check made payable to the Departrnent of Pubiic Welfare and forwarded to my attention et khe address hated below. Your cooperation In resolving this matter Is appreciated. Sincerely, i:~r Karin L. ryler Clalrns Investlgatlon Agent 717-772-6614 717-772-6553 FAX faxed same date 11;23 and maNed eureeu of Program mtegnty I otwsnn o(Thtrd Parry ~sMlar• I Peecvery Sac0on PO eax 8486 I Nalribbwp, PamsyNanla 17105.8486