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HomeMy WebLinkAbout05-30-12 (2)1505610105 REV-1500 ~"°Z-""Fn ~ PA Department of Revenue Pennsylvania OFFICIAL USE ONLY Bureau of Individual Taxes oEO"pT"`"' ` Coun Code Year File Number PO BOX z8o6oi ~ INHERITANCE TAX RETURN }~G Harrisburg, PA 17128-o(io1 RESIDENT DECEDENT ~ / ~ ~ I ~ C ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 234-28-9100 11 /17/2011 03/03/1919 Decedent's Last Name Suffix Decedent's First Name MI KIRBY BESSIE M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW C>D 1. Original 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) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) 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 CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number SALLY J. WINDER _. First Line of Address P.O. BOX 341 Second Line of Address City or Post Office NEWVILLE Corcespondent's a-mail address: State ZIP Code PA 17241 REGISTER OLS USE OMpY -'17 ~ 'TI -T:. ~ --G ~" c,, -- O r ~ ~-' ~ > ~- - ~~; , _' J ` = - ~ .. _. --~ .. C1? DATE FILED ("~-_ ~~ -z~;~' r r i C t`- ~ ri Cn ~ _~~ Side 1 1505610105 1505610105 Under 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 true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. 1505610205 REV-1500 EX (FI) Decedent's Social Security Number Decedent's Name: BESSIE M. KIRBY 234-28-9100 RECAPITULATION 1. Real Estate (Schedule A) ........................................... .. 1. 59,000.00 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. 11,487.41 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers ~ Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested...... .. 7. 8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. 70,487.41 9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. 21, 903.43 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............. .. 10. 1,433.65 11. Total Deductions (total Lines 9 and 10) ............................... .. 11. 23,336.43 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 47,150.98 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. 47,150.98 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 45 47,150.98 16. 2,121.79 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ....................................................... ..19. 2,121.79 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME BESSIE M. KIRBY STREET ADDRESS 1141 MEANS HOLLOW ROAD - -. - - ---- CITY SHIPPENSBURG ------ STATE PA ----------- ZIP 17241 Tax Payments and Credits: 2. Tax Due (Page 2, Line 19) CreditslPayments A. Prior Payments B. Discount 2,121.79 2,121.79 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fitl 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) (3) (4) (5) Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred ................................................................................... ....... ^ b. retain the right to designate who shall use the properly transferred or its income ..................................... ....... ^ c. retain a reversionary interest ....................................................................................................................... ....... ^ d. receive the promise for life of either payments, benefits or care? ............................................................... ....... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................................... ....... ^ 3. Did decedent own an "in trust for" 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? .................................................................................................................. ...... ^ 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 [72 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 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. REV-1502 EX+ (O1-10) Pennsylvania SCHEDULE A DEPAKTMENT OF REVENUE REAL ESTATE INN9tITANCE 7Ax RERIRN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: BESSIE M. KIRBY 21-12-0108 Ali real property owned solely or as a tenant in amnion 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 fads. Real properly that is joiMiy-owned with right of survivorship must be disclosed on Shcedule 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 1• 1141 MEANS HOLLOW RD, SHIPPENSBURG, PA. SEE ATTACHED DEED ETC 59,000.00 TOTAL {Also enter on Line 1, Recapitulation.) I # 59,000.00 If more space is needed, use additional sheets of paper of the same size. ~(~~ ~~ ~ '- OMB Approval No. 2502-0265 =' -~r ~~ `= a. Settlement Statement (HUD-1, ~~~~~ b. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number: 1. ` J FHA 2. ~ ~ RHS 3. ~ Cnnv Unfna 4. ~ VA 5. ~ Conv. Ins- C. Nola: This form is furnished m give you a statement of actual settlement costs. Amounts paid to and byihe settlement agent are shown. Items marked °(p.o.c-)' were paid outside the dosing; they are shown here for informational purposes and are rot inducted in the totals. - - - _. D. Name & Address of Borrower. E Name & Address of Seller. E Name & Address of Lender Ray E. Myers Kimberly S. Myers Estate of Bessie M. +Gmy G. Property Location: H. Settlement Agent: L Settlement Date: 1141 Means Hollow Rd. Salty J, Winder Shippensburg, PA P+a~e o+settlemenL MaY S0, 2012 700. Gross Amount Due cram Borrower 40D. Gross Amount Due to Seger 101. Contract sales price 102. Personal property 401. CoMratt sales price 9 ~~.0 402. Personal property 703. Settlement charges to borrower Qinei400) ,103 704. 404. toy. ~~ Adjustment for items paid b saber in advance - t06. Cityltotvn taxes to 12/31/12 162.84 Adjustments for items paid by saber in advance 406. City/town taxes to 107. County taxes to 407. County taxes to 108. Assessments tc 408. Assessmems t tog. '11-'12 03. o 409. - 110. d1Q tit. 471. 112, 412. 120. Gros: Amount Due from Borrower 59,993.18 ,yap. Gross Amount Doe to s~ler i 59,266.18 200. Amounts Paid or in Behalf of Borrower 500. Reductiorn M Amount Due to Seoer 201. Deposit or earnest money 507. Fxcess deposit {see instructions) 202. Prinripal amount of new loan(s) soz Settlement charges io seller Qine 7400) - 3 571 8 203. Existing loan(s) taken subject to . 0 503. Existing loans) taken subject to ~' 504. Payoff of first mortgage loan ~' 505. Payoff of semnd mortgage loan 206_ ~ 207. 507. 208. ~ 209. ~~ Ad' stments for Reins unpaid salter 'ustments for Reins unpaid b seller 270. City/town taxes to a70. Cityltown taxes to 211. County taxes to - Sii.Countytaxes to 272. Assessments to 512 Assessments to - 213. 573. 214. 574. 215. 51 s. 216. 576. 277. 577. 278. SiB. 279. 519_ z2o. Total Pave br/ter Borrower 5,000.00 520. Total Reduction Amount Due Seger 3,571.80 300. Cash at Settlement fromlto Borrower 600. Cash at Settlement to/from Seger 301. Grass amount due from borrower Qine 720) 601. Gross amount due to seller Qine 420) 302. Less amounts paid by{for borrower Qine 220) ~ ( ) 602. Less reductions in amount due seller Qine 520) 303. Cash ~ From aTo Borrower ~ 54,993.18 ~' ~' aTo From Seller 55 694.38 The Public Reporting Burden for this collection of information is estimated at 35 minutes per response for collecting, reviewing, and reporting the data. This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number. No confidentiality is assured; this disclosure is mandatory. This is designed to provide the parties to a RESPA covered transaction with information during the settlement process. revious editions are obsolete Paae 7 of 3 HUD-t 700. Total Real Estate Broker Fees Divison of commission Qina 700) as follows lot. $ 2,950._.._ ~a RF.JMAX Premier Executives 702. $ to __ .. ___ 703. Commission paid at =_ettlemeni - - - -- " Paid Frem Paid From Borrower's Seller's - - ~ Funds at Funds at Settlement Settlement 2,950.00 800_ hems Payable in Connection with Loan ---- 801. Our origination charge S 802. Your credit gr charge (coints) {or the specific interest rate chosen $ iam GFE Ht) (from GFEs2) 803. Your adjusted originatiar, charges - - - _ --- 804. Appraisal fee to (from GFE A) _ __ (from GFE~3) BOS. Credit report to (from GF[ k3) _ _ 806. Tax sendce to ' (from GFE a=') 607. Flood certification _ (from „FE i:3) 808. 900. hems Required by lender to Be Paid in Advance 401. Daily interesf charges from to ~ $ fday (from GFE tr5p} 902. Mortgage insurnce premium for months to ifrom GFE?±) 903. Homeowner's insurance f.r years to ;I om GFE ~': t) 404. '1800. Reserves Deposited wilt Larder 1001. Initial deposit for your escrow account (from GFE k~} 1002 Hcmeo~+mier's insurance morths ©$ per month $ 1003. Mortgage insurance months ~ S per month $ 1004. Property taxes months ~ $ per month $ 1005. mgnthsC~?$ _ __ per month $ _. 7006. morrhs ~ 5 per month $ 1007. AcgregateAdjustment -$ _ _ _ 1100. rule Charges 1101. Title services and lender's-,file insurance (tram GFEs4) 1102. Settlement or closing fee s _ _ _ 75.00 _ 1103. Owr:er's title insurance __ __ (fmm 9FE 65) 1104. Lender's title insurance $ 5105. Lender's title policy lima $ - - ~ ' 1105. Ctwner's title policy limit $ ____ 1107. Arent"s portion of the total Ltle rnsurancc premium $ - 1108. Undervri[er's portion e{the total title insurance pr<mium $ 1208. GaverruneM Recordtrrg and Traasfa Charges 5201. 6evernmenrrecording charges {fiomGFE!t7) 1202. Deed $ 62.00 Mortgage $ Releases $ 62 00 _ i 3. Trans er taxes _ _ _ ___ _ ifrom t;FE 58j 1204, City/Countytaxf=tamps Deed $ Mortgage $ S90.~0 1205. State tax/stamps Deed $ , fortgage $ ij~,00 1205. 1300. Add'rtiorra- Setdemerrt Charges 1301- Required services that you ran, shop for (tram GFE k5) 1302. CFJMA, sewer bill for May _ $ 31.80 i303. g , _ _ _ _ ',1304. 1305. _ 11400. TotalSettlemerrt Charges (enter on lines 103, Section J and 502,_Section KJ. irl ; ~ G;~~,~~~G~i _, ~ Previous edition bsotete Page 2 of 3 ~~_ f HUD-1 TAX PARCEL N0.39-40-2585-014 THIS DEED, MADE this ~~day-af May, 2012, BETWEEN Doris F. Kibler and Kathy G. Chamberlin, as Co- Executors of the Estate of Bessie M. Kirby, late of Southampton Township, Cumberland County, Pennsylvania - - - - - - - - - - - - - ----------------------------------------------GRANTOR AND Ray E. Myers and Kimberly S. Myers, husband and wife, of 240 Old Sawmill Drive, Newburg, Pennsylvania, as tenants by the entireties _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ----------- GF:ANTEES WHEREAS, Bessie M. Kirby died November 17, 2011, testate, a domiciliary of Southampton Township, Cumberland County, Pennsylvania, seized of the real estate hereinafter described, and WHEREAS, decedent's last will and testament, dated July 15, 2004, was duly probated by the Register of Wills for Cumberland County, Pennsylvania, and is recorded at the Office of the Register of Wills for Cumberland County, Pennsylvania, as Estate No. 21-12-0108, wherein decedent appointed Doris F. Kibler and Kathy G. Chamberlin as Co-Executors of her estate, and WHEREAS, Doris F. Kibler and Kathy G. Chamberlin duly qualified as Co-Executors of decedent's estate and Letters Testamentary were granted on January 25, 2012, and WHEREAS, all federal and state inheritance and estate taxes have been or will be paid and will not be permitted to become liens upon the real estate herein conveyed; neither shall Grantor permit any lien to exist or remain upon the real estate herein conveyed as a result of the Pennsylvania Department of Welfare Estate Recovery Program, and WHEREAS, the real estate herein conveyed was not specifically devised by said will. NOW, THEREFORE, WITNESSETH, that for and in consideration of Fifty-Nine Thousand and No Hundredths ($59,000.00) Dollars, in hand paid, the receipt whereof is hereby acknowledged, the said Grantors, as Co-Executors as aforesaid, do hereby grant and convey in fee simple unto said Grantees: ALL that certain tract of land situate in Southampton Township, Cumberland County, Pennsylvania, bounded and described as follows: BEGINNING at a post at the edge of a road leading from Shippensburg, Pennsylvania to the South Mountain along Mains Run, and at the southern corner of land owned now or formerly o Bruce and Wilbur Mooney; thence North 68 %2 degrees East along said Mooney land and land of Bruce Mooney to a stone fence, approximately 696 feet; thence in a Southeasterly direction along stone fence and land owned now or formerly by Beaston to a post, approximately 163 feet to a post; thence South 68 %i degrees West approximately 696 feet, along lands now or formerly of Hancock and James Wyrick to a post on the easterly side of said road; thence along said road North 36 degrees West approximately 163 feet to the place of BEGINNING. CONTAINING 2.6 acres, more or less. BEING the same property which Aaron S. Lesher and Elizabeth M. Lesher, husband and wife, by deed dated October 25, 1965, and recorded in the Cumberland County Recorder of Deeds Office, Deed Book B, Volume 22, Page 887, granted and conveyed to Alvin J. Kirby and Bessie M. Kirby, his wife. Alvin J. Kirby died August 3, 2009, survived by his wife, Bessie M. Kirby thus vesting fee simple title in her. TOGETHER WITH all and singular the rights, liberties, privileges, hereditaments and appurtenances whatsoever thereunto belonging or in any wise appertaining, and the reversions, remainders, rents, issues and profits thereof, and all of the estate, right, title, interest, property claim and demand whatsoever of the said decedent at and immediately before the time of her decease, in law or equity, of, in, to or out of the same. TO HAVE AND TO HOLD the said granted premises by the said Grantees, their heirs and assigns, forever. AND the said Doris F. Kibler and Kathy G. Chamberlin, as Co-Executors as aforesaid, for themselves, their heirs, executors, and administrators, do covenant, promise and agree to and with the said Grantees, their heirs and assigns, by these presents that they, the said Co-Executors -2- as aforesaid, have not heretofore done or committed any act, matter or thing whatsoever whereby the premises hereby granted, or any part thereof, is, are, or shall or may be impeached, charged or encumbered in title, chazge, estate or otherwise howsoever. Grantees by accepting and recording this deed waive any claims or any liability that might be made against the Grantor as a result of any environmental actions. IN WITNESS WHEREOF, the Grantors have caused this instrument to be duly executed the day and year above written. Witness: ~~ ~l ~ (SEAL) Doris F. Kibler, as Co-Executor of the Estate of Bessie M. Kirby (SEAL) G. Chamberlin, as Co-Executor of the Estate of Bessie M. Kirby -3- STATE OF PENNSYLVANIA SS COUNTY OF CUMBERLAND , On this ~ day of 2012, before me,-the undersigned officer, personally appeazed Doris F. Kibler -and Kathy G. Chamberlin, known to me to be the persons whose names is subscribed to the within instrument and acknowledged that they executed the same in the capacity therein stated and for the purposes therein contained. In witness whereof, I hereunto set my hand and official seal. Notary is COMMONWEALTH OF PENNSYLVI1NfA i NOTARIAL SEAL #~ SALLY J. WINDER, NOTARY PUBLIC NEWVILLE, CUMBERLAND COUNTY MY COMMISSION EXPIRES MARCH 14, 2018 CERTIFICATE OFRESIDENCE I hereby certify that the precise residence of the within Grantees is: zip Old ~ ~ ~-, ~-~ , ~ ~t~--1 ~ a-~F- v ~~ Witness my hand on this ~~ day of , 2012. J -4- REV-1$OS EX+ (1i-10) ~ Pennsylvania ^AC SCNEpt1LE E DEVARTMENT OF REVENUE CASHr BANK DEPOSITS & MISC. INHERrrANCE TAX RETURN PERSONAL PROPERTY RESroENr oECEOENr ESTATE OF: FILE NUMBER: BESSIE M. KIRBY 21-12"0108 Include the proceeds of litigation and the date the proceeds were received by the estate. All property joiTTtly owned with right of survivorship must be d"tsdosed on Schedule F. ITEM VALUE AT DATE nr Hato 1. ORRSTOWN BANK, CHECKING ACCT 534234 101.23 2. ORRSTOWN BANK, SAVINGS ACCT 16202 257.22 3. ORRSTOWN BANK, INTEREST CHECKING ACCT 102002649 145.79 4. HOSTETTER'S SALVAGE, SCRAP METAL 130.00 5. PROCEEDS FROM PUBLIC SALE OF PERSONAL PROPERTY, 4123112 3,189.56 6. ORRSTOWN 4000042904, 30047636, FUNERAL FUND 7,663.61 TOTAL (A1so enter on Line 5, Recapitulation) ; I 11,487.41 If more space is needed, use additional sheets of paper of the same size. iviay co i ~ urst3p Kathy 7175324393 p,4 5;25/12 Alvin J Kirby Deposit Inquiry 08:35:33 Closed Messages Col lection Account n Msg umber: 534234 Last stmt balance: .00 Last stmt Gate: 1 of 1 2/26/12 - Currer~t alar_ce: _00 Statement cycle: 25 1=View E=?rint T=Tset Control: From To Posted Check No 10/11/11 S T/C Debit Credit Balance 10,~14I11 F C 142 183 10 7 77 100.00 273.04 _ 11/09/11 P 053' . 27 56 165.27 11/10/11 F 142 . 109.00 ~ ~ 1 100.00 209.00 _ 1206/11 101 P 090 0 00 1 12,12/11 F 142 . 100.00 11.23 111 23 12;16/11 C 183 107.77 . 3 46 _ 1/05/12 1/26/12 P 020 2.00 . 5.46 1/26/12 C C 183 178 =07.7? ?5 00 102.31- 1/27/12 N 136 . 107.77 137.31- 29 54- 1; 30/12 2, 01112 $ 334 35.00 . ~~-~-~~- ~ _ P 050 5.4E ~nn F4=Redsply F6=Ba1 Inq F7=Scan Fwd F8=Scan Bkwd F11=Prior bal F15=EFT F16BSortm F17=iop F18=Bottom F19=EDI F20=Unfolc: F22=T/C F23=Checks Urrstown 3ank.L-tncoln Way Fast AEA; 031315036 branch ~4~=i0 NI M CO N 248----~' b'a~lt 179 MAY 2 5 111 May 15 i Z 02:38p Kathy 7175324393 p.3 5125/12 Bessie P9 K? rb2r Deposit Inquiry 08:3?.52 Closed Messages Account n umber: 16202 Last stmt balance: .3G Last stmt date: 1 of 1 4/01/12 - Current balance: .OG Statement cycle: 32 1=View; 6=Print T=Tset control: ~rcl't To Posted Check 11/15/1' No S T/C Debit Cxadit Balance 12/02/11 C 151 163 .1500000C$ 257.22 _ 12!06/11 P 025 998.OC 253.79 1,255.22 1 509 01 _ 12/06/11 12/12/11 P 025 90.00 , . 1,599.01 12!15/11 F 144 151 100.00 1,499.01 12%27/11 P 058 432 00 .15000000 1,499.01 _ 12!30/11 m 053 . 998.00 1,067.01 69 01 12!31/11 160 1.7C . 71 70 1/13/12 360 3.00 . 67 71 1/13/12 361 3.00 . 67 71 1/16/12 2!01 /12 151 .15000000 . 67.71 _ 2/01/12 P P 160 050 67.72 -O1 ~~~, F4=Redsply F6=Ba1 Ind F7=Scan Fwd F8=Scan Bkwd F11 =Prior bal Bottom F15=E FT F16=Sort F17=Tcp F18=Bottom F19=EDI F20=f1nfold F22=T/C F23=Checks Orrstown Bank-Lincoln Way East ABA: 03 7 3 7 5 036 Branci~ #9910 'J MMCON 248---~~~.._ Vault 179 ~_ MAY z .may co ~ c ucstsp Kethy 7175324393 p.2 5!25/12 Bessie M K.irb y Deposit Inquiry 08:3b:32 _ C3osed Messages ~iccount number: 102002649 Last stmt balance: Current balance: .00 bast stmt date: i of 1 2/20/12 _ 1~View 6=Print T=Tset .00 Statement Control: From cycle: 20 Posted Check No 11/02/11 S T/C Debit Credit To Balance _ 11/02/11 P 02G 151 1,682.b4 1,736.28 11/07/11 X312 C 183 193 47 _0100000~3g 1,736.28 _ 11/07/11 X310 P 090 . 63 00 1 592.81 , _ 11/07/11 X311 P 091 . 19 36 1 529.81 11/08/11 X308 C 183 . 48 00 1,510.51 _ 11/08/11 X314 P 090 . 811 47 2,462.51 _ 11/09/11 X313 P 090 . 75 OG 651.04 _ 11,10/11 X309 P 090 . 174 25 576.04 Il/10/11 11!14/11 ~31E P 151 091 . .000OOOOOQ 401.79 401.79 _ _ 11/22/11 X317 P 091 256.00 111 26 145.79 1/05/12 P 020 . 34.53 ~ _ _ 2/0_/12 P 050 84.06 49.53 ` . 0! 0-~" F4=Redspl~~ F6=Bal Inq F7=ScGn Fwd FB=Scan Bkwd F11=?rior bal F15=EFT F16BSort~ F17=Top F18=Bottom F19=EDI F20=Unfold F22=T/C F23=Checks Ckrstown Bank-Lincoln Way East ABA: 0313 ] S 036 Branch #9910 MMCON 248---_-1~ Vault 779 MAY 2 5 2Di1 ~,~ ~ lti~ -v-- ~~~~ REV-1511 EX+ (10-Q9) Pennsylvania DEPAATMENT OF REVENUE INHERrfANCE TAX RETURN RESroeNr DEtEDENr SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER BESSIE M. KIRBY 21-12-0108 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' FOGELSANGER BRICKER FUNERAL HOME 10,436.16 WILSON MONUMENT COMPANY, LETTERING 106.00 e. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) DORIS K16LER/ KATHY CHAMBERLIN Street Addrnss 205 HARVEST LANE/ 33 INDEPENDEDNCE DR. rty CHAMBERSBURG/ SHIPPENSBURG State PA ZIP Year(s) Commission Paid: 2012 2. Attorney Fees: 3. Fatuity Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Gaimant Street Address Gty State Relationship of Claimant to Decedent 4. 5. 6. 7. 8. 9. ~o_ 11. ZIP Probate Fees: Accountant Fees: Tax Return Preparer Fees: CUMBERLAND LAW JOURNAL, ADVERTISE LETTERS VALLEY TIMES STAR, ADVERTISE LETTERS RE/MAX PREMIER EXECUTNES, REAL ESTATE COMMISSION VIVIAN COY, 2012 CTY REAL ESTATE TAXES 3,524.38 4, 024.38 197.50 250.00 85.00 55.25 2,950.00 274.76 TOTAL (Also enter on Une 9, Recapitulation) I $ 21,903.43 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) SCHEDULE I ~ pennsylvania DEPARTMENT OF REVENUE DEBTS OP DECEDENT, ~ TAB ~~ MORTGAGE LIABILITIES I~ LIENS aESUx-Nr oEC®ENr ESTATE OF FILE NUMBER BESSIE . KIRBY 21-12-0108 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1• ADAMS ELECTRIC, NOV. THRU APRIL BILLING 439.53 2. NEW VIEW LANDSCAPING, SNOW REMOVAL 45.00 3. FALLING SPRINGS NURSING HOME, BALANCE OF ACCT 7.50 4. ULTRA SOUND SERVICES, ACCT BALANCE 7.45 5. SUMMIT CANCER AND HEMATOLOGY SERVICES, ACCT BALANCE 253.72 6. DIRECT TV, ACCT BALANCE 74.55 7. WSEMS CHAMBERSBURG, AMBULANCE ACCT 156.80 8. CFJMA SEWER ACCT 201.10 9. CAC, SOUTH MOUNTAIN FIRE DEPT, BALANCE DUE 112.00 10. PENNCONNECT, HOMEOWNER'S INSURANCE 136.00 TOTAL (Also enter on line 10, Recapitulation} I ~ 1,433.65 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ] BENEFICIARIES ESTATE OF: FILE NUMBER: BESSIE M. KIRBY 21-12-0108 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1• SUSIE MACKEY 19 LANTERN LAN, SHIPPENSBURG, PA DAUGHTER 1/7 2. PATRICIA MOWERY, 3526 KNOBS RD, UNION, WV DAUGHTER 1/7 3. DARLENE STEE P.O. BOX 3059, FORT PIERCE, FL DAUGHTER 1/7 4. VICKIE MINER, 1020 COUNTY RD 181, NEW ALBANY, MS DAUGHTER 1/7 5. KATHY CHAMBERLIN, 33 INDEPENDENCE DR., SHIPPENSBURG, PA DAUGHTER 1/7 6. KYLE KIRBY, 351 STROHM RD, SHIPPENSBURG, PA SON 1/7 7. DORIS KIBLER, 203 HARVEST LN, CHAMBERSBURG, PA DAUGHTER 1/7 II ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TATAI AC DADT T7 - C~ITCfI T(1T111 ~InAI TAV~~I C f\TCT<17O1 ITTl1~IC r1~1 I TIC 17 !1C AC\/ 1 C/\/\ rn\/CA CLJCGT Id If more space is needed, use additional sheets of paper of the same size.