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Home My WebLink About07-17-12 (2) 1505610105 OFFICIAL USE ONLY County Code Year File Number "~ REV-1500 ex to2_ll, «, ~ . PA Department of Revenue pennsylvama Bureau of Individual Taxes au - ~ INHERITANCE TAX RETURN Po BOx zso6o> RESIDENT DECEDENT Harrisburg PA 1'712$-0601. ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 206-10-9199 10/23/2011 03/02/1919 Decedent's Last Name Suffix Decedent's First Name MI HILTON PAUL J (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number KATHY A. KOKOSKI, EX. (717) 234-1833 REGISTER OF WILLS USE ONLY n.f First Line of Address ~~'7. ~ ~`. Tt ~~ 6209 WESTOVER DRIVE ~~ ~.,~ r-_ tf Second Line of Address _ ~G,-; 1 ; ~1 ~ ~ -~- City or Post Office State ZIP Code ~1;E;FtLED ~ --~ : MECHANICSBURG PA 17050 . ~ N ~ c.~ ~ ;,,,,, Q Correspondent's a-mail address: CdkCpa120 comcast.net Under penalties of perjury, I deGare that 1 have examined this return, including accompanying schedules and statements, and to the hest of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge . S~IQ ~ ~I~RE$OF FjfRS~l ~t~Ey~PO~N~I~LE,`OR FIt~NG RETI} ~~`=~~~~/~~' ~ v ~~r~ E /~ 6209 VV€~fOVER DRIVE, MECHANICSBURG, PA 17050 SIGNAT KE~RER~ER T REPRESENTA~/E DATE ADDRESS CHARLES D. KOKOSKI, CPA, 120 STATE STREET, HARRISBURG, PA 17101 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 J fl c: REV-1500 EX (FI) Decedent's Name: PAUL J. HILTON Decedent's Social Security Number 206-10-9199 RECAPITULATION 1. Real Estate (Schedule A) ........................................... .. 1. 0.00 2. Stocks and Bonds (Schedule e) .................................... ... 2. 478,404.06 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 0.00 4. 9 9 { ) ........................ Mort a es and Notes Receivable Schedule D 4. ... 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).... ... 5. 898,141.65 6. Jointly Owned Property {Schedule F) O Separate Billing Requested .... ... 6. 198,702.68 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 7 78 500 00 (Schedule G) O Separate Billing Requested..... ... . . , 8. ( 9 ) .......................... Total Gross Assets total Lines 1 throw h 7 8. ... 1,653,748.39 9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. 61,007.82 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............ ... 10. 3,426.87 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. 64,434.69 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. 1,589,313.70 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) ..................... ... 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. 1,589,313.70 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 16. 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. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610205 1505610205 1505610205 0.00 0.00 0.00 238,397.05 238,397.05 O REV-1500 EX (Fi) Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME PAUL J. HILTON STREETADDRESS 5225 WILSON LANE, APT. 4133 CITY MECHANICSBURG STATE ZIP -- PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments (1) 238,397.05 A. Prior Payments 185,000.00 B. Discount 9,736.84 3. Interest Total Credits (A+ g) (2) 194,736.84 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3) Fill in oval on Page 2, Line 24 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (51 43,660.21 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: a. retain the use or income of the property transferred .................................................................................. Yes No b. retain the right to designate whc 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 receiving adequate consideration? .............................................................................................................. ^ ^ 3 Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ........................................................................................................................ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 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. .~ Pennsylvania SCHEDULE A DEPARTMENT Of REVENUE REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: PAUL J. HILTON FILE NUMBER: 21 11-1149 All 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 ex~anged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. it more space is needed, use additional sheets of paper of the same size. REV-7503 E'` ~~ (7-v.) pennsylvania DERARTMF.NT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT S~NEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER PAUL J. HILTON 21 11-1149 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH I' See attached PNC Bank, statement listing HH savings bonds 307,500.00 2 Edward Jones, 4400 Derry St., Harrisburg, PA 17111 (Account 616-19655-1-9) -See attached a. Invesco High Yield Fund (5,792.722 shares) 22,649.54 b. Ladenburg Thalmann Financial Services, Inc. (21 shares) 44.52 c. Franklin Strategic Income Fund (1,960.875 shares) 19,628.36 d. Frog & Switch (25 shares) 9,150.00 e. Miscellaneous 119.82 3 Nationwide Securities, LLC (Account 22-1325052100) -See attached a. Nationwide Fund Class D (8,402.941 shares) 108,061.82 4 Marietta Gravity (30 shares) -See attached 11,250.00 * Includes total proceeds /redemption of bonds including interest. TOTAL (Also enter on Line 2, Recapitulakion) I$ 47$,404.06 If more space is needed, insert additional sheets of the same size For offiaal use onty: PAUL J. HILTON Customer Name Customer No. PD F 1522E SPECIAL FORM OF REQUEST FOR PAYMENT OF OMB No. 1535-0004 Department of the Treasury UNITED STATES SAVINGS AND RETIREMENT Bur~u of the Public Debt SECURITIES WHERE USE OF A DETACHED FOR OFFICIAL USE ONLY (Remised buy 201 f) REQUEST IS AUTHORIZED TRANSFER MONTH s YEAR _!_ Visit us on the Web at FISCAL AGENT CODE www treasurvdired aov 11APORTANT: FoNow instructions in tilling out this form. You should be aware that the making of any false, fttxitious, or fraudulent claim or statement to the United States is a critrw that is punishable by tine andlor knprisonmenL PRMIT IN INK OR TYPE ALL INFORMATION 1. DESCRIPTION OF BONDS I am the owner or_person entitled to payment of the securities described below, which bear the name(s) of PAUL J. HILTON ISSUE DATE SERIAL NUMBER ISSUE DATE SERIAL NUMBER ISSUE DATE SERIAL NUMBER 02100 D5191653HH 02100 V1458984HH 02/00 V1458988HH 0?!00 D5191654HH 02/00 V1458985HH 02100 V1458989HH py00 D5191655HH 02/00 V1458986HH 02!00 V1458990HH 02100 V1458983HH 02100 V7458987HH 02100 V1458991HH _._:_ v......,.~..e..~ .. ................. i (ff)rou nNd R/OI'9 Space, aAaCn saner a r~r r awv. m fna,.. a,.cca v. ~...., ..... ~...~.~~~r~ i 2. REQUEST FOR PAYMENT ^ a check. I request that the described bonds be redeemed and payment be made in the form of ~ direct deposit. ^ To the extent of: (Complete this line onty if partial redemption and reissue of the remainder Is desired or if the signer is entitled only to a portion of the bonds listed. See Item 2 in the Instructions.) f,~~l~q~~ UGC ?~ .Z',~, . .3s-6Q393~~ (Social Security Number of Payee) OR (Employer Identification Number of Payee) 3. DELIVERY INSTRUCTIONS (Read item 3 to the Instructions before canp/ehng this section and complete onty ttem 3A or 3B.) A. Please mail my redemption check to: (Name) (Number and Street, Rural Route, or P.O. Box) (City) (State) (ZIP Code) B. Please deposit my funds directly, as authorized below: THE ESTATE OF PAUL J. HILTON (NarrlelNart~s on the Account) 5004483612 Type of Account: ~ Checking ^ Savings (Depositor's Account No.) Bank Routing No.: 031312738 PNC BANK, N.A. (717) 730-2385 (Finanaal Institution's Name) (Phone ~o•) .~-. ~k . ' Gl. y ~ , ~-~- Pflf1~ f = - PD F 3500E ~ - Refresh ~ ~ ry B ~ ~~ ~ (Revi d J CONTINUATION SHEET FOR LISTING SECU se anuary 2007) RITIES PRINT IN INK OR TYPE ALL INFORMATION The bonds described on this form are included in the attached PD F 1522 E ISSUE DATE FACE AMOUNT BOND NUMBER UVSCRIPTION (Provide complete Soa l S a ecurity Number [for example, 123-45.6789) . names. indudi middle names or initials, and addresses on the bonds 02/00 5,000 V1458992HH 206-10-9199 02/00 5.000 V1458993HH PAUL J. HILTON 02/00 5,000 V1458994HH 4916 LANCASTER STREET 02/00 5,000 V7458995HH ~ HARRISBURG, PA 17111 02/00 5,000 V1458996HH BEING DEPOSITED TO: 02/00 5,000 V1458997HH 356939307 02/00 5,000 V1746214HH ESTATE OF PAUL J. HILTON 07/03 5,000 V7746215HH 6209 WESTOVER DRIVE 07/03 5,000 V1746216HH MECHANICSBURG, PA 17050 07/03 5,000 V7746217HH 07/03 5,000 V1746210HH - 07/03 5,000 V1746211HH 07/03 5,000 V1746212HH 07/03 5,000 V1746213HH 07/03 5,000 V 1746218HH 07/03 5,000 V1746219HH 06/01 1,000 M7924621HH 06/01 1,000 M7924624HH 06/01 1,000 M7924625HH 07/01 1,000 M8020111HH 02/00 1,000 M7397822HH ~ ~~1~s~ .s•G,. .d. ~ ~ . Ignature) PD F 3500 E Department of the Treasrxy Bureau of the Public Debt (Revised Jarwary 2007) Refiresh CONTINUATION SHEET FOR LISTING SECURITIES PRINT iN INK OR TYPE ALL INFORMATION The bonds described on this form are included in the attached PD F 1522 E ISSUE DATE FACE AMOUNT BOND NUMBER INSCRIPTION (Provide complete Social Security Number [for example, 123-45-6789], names, indudi middle names or initials, and addresses on the bonds OZ/00 1,000 M7397823HH 206-10-9199 02/00 1,000 M7397824HH PAUL J. HILTON 02!00 1,000 M7397825HH 4916 LANCASTER STREET 02/00 1,000 M7397826HH HARRISBURG, PA 17111 0?J00 1,000 M7397827HH BEING DEPOSITED TO: 02/00 1,000 M7397828HH 356939307 06/01 1,000 M7924622HH ESTATE OF PAUL J. HILTON 06/01 1,000 M7924623HH 6209 WESTOVER DRIVE 06!01 1,000 M7924594HH MECHANICSBURG, PA 17050 06/01 1,000 M7924595HH 06/01 1,000 M7924596HH 06/01 1,000 M7924597HH 06/01 1,000 M7924598HH 06/01 1,000 M7924599HH 06101 1,000 M7924600HH 06J01 1,000 M7924601HH 06/01 1,000 M7924602HH 06/01 1,000 M7924603HH 06/01 1,000 M7924604HH 06/01 1,000 M7924605HH 06101 1,000 M7924606HH (S(gnature) Ptint~ ;;P>i~int , Refresh PDF3500E ~. Bureauu ofnthe Public Debtry CONTINUATION SHEET FOR LISTING SECURITIES (Revised Jarwary 2007) PRINT IN INK OR TYPE ALL INFORMATION The bonds described on this form are included in the attached PD F 1522 E ISSUE DATE FACE AMOUNT BOND NUMBER INSCRIPTION (Provide complete Social Security Number [for example, 1235-6789), names, includ' middle names or initials, and addresses on the bonds 06/01 1,000 M7924607HH 206-10-9199 06101 1,000 M7924608HH PAUL J. HILTON 06/01 1,000 M7924609HH 4916 LANCASTER STREET 06/01 1,000 M7924610HH HARRISBURG, PA 17111 06101 1,000 M7924611HH BEING DEPOSITED TO: 06/01 1,000 M7924612HH 356939307 06/01 1,000 M7924613HH ESTATE OF PAUL J. HILTON 06/01 1,000 M7924614HH 6209 WESTOVER DRIVE 06/01 1,000 M7924615HH MECHANICSBURG, PA 17050 06/01 1,000 M7924616HH 06/01 1,000 M7924617HH 06101 1,000 M7924618HH 06/01 1,000 M7924619HH 06/01 1,000 M7924620HH 07101 1,000 M8020112HH 07/01 1,000 M8020113HH 07/01 1,000 M8020114HH 07/01 1,000 M8020115HH 07/01 1,000 M8020116HH 07/01 1,000 M8020117HH 07/01 1,000 M8020118HH a ~ (Signature) .Print Refresh PD F 3500 E Department of the Treasury Bureau of the Public Debt CONTINUATION SHEET FOR LISTING SECURITIES (Revised January 2007] PRINT IN INK OR TYPE ALL INFORMATION The bonds described on this form are included in the attached PD F 1522 E ISSUE DATE FACE AMOUNT BOND NUMBER INSCRIPTION (Provide complete Social Security Number [for example, 123-45-6789], names, indudi middle names or initials, and addresses on the bonds 07/01 1,000 M8020119HH 206-10A199 07!01 1,000 M8020120HH PAUL J. HILTON l 07/01 1,000 M8020121 HH 4916 LANCASTER STREET 07/01 1,000 M8020122HH HARRISBURG, PA 17111 07/01 1,000 M8020123HH BEING DEPOSITED TO: 07/01 1,000 M8020124HH 356939307 07/01 1,000 M8020125HH ESTATE OF PAUL J. HILTON 07/01 1,000 M8020126HH 6209 WESTOVER DRIVE OT/01 1,000 M8020127HH MECHANICSBURG, PA 17050 07/01 1,000 M8020128HH 07/01 1,000 M8020129HH 07/01 1,000 M8020130HH 07/01 1,000 M8020131HH 07/01 1,000 M8020132HH 07/01 1,000 M8020133HH 07101 1,000 M8020134HH 07/01 1,000 M8020135HH 07/01 1,000 M8020143HH 07/01 1,000 M8020144HH 07/01 1,000 M8020145HH 07/01 1,000 M8020146HH ~~G- -d- r-- , ~-- cs~~re] ..'....Print Refresh PD F 3500 E . otuUie P w~ Die tbtb ry CONTINUATION SHEET FOR LISTING SECURITIES (Revised January 2007) PRINT IN INK OR TYPE ALL INFORMATION The bonds described on this form are included in the attached PD F 1522 E ISSUE DATE FACE AMOUNT BOND NUMBER INSCRIPTION (provide complete Social Security Number [for example, 123-45-6789], names. lndud' middle names oa initials, and addresses on the bonds 07/01 1,000 M8020152HH 206-10-9199 07/01 1,000 M8020153HH PAUL J. HILTON 07101 1,000 M8020147HH 4916 LANCASTER STREET 07/01 1,000 M8020148HH HARRISBURG, PA 17111 07/01 1,000 M8020149HH BEING DEPOSITED TO: 07/01 1,000 M8020150HH 356939307 07/01 1,000 M8020151HH ESTATE OF PAUL J. HILTON 07101 1,000 M8020160HH 6209 WESTOVER DRIVE 07/01 1,000 M8020161HH MECHANICSBURG, PA 17050 O7/01 1,000 M8020162HH 07/01 1,000 M8020137HH 07/01 1,000 M8020138HH 07/01 1,000 M8020139HH 07/01 1,000 M8020140HH 07/01 1,000 M8020141HH 07/01 1,000 M8020142HH 07/01 1,000 M8020136HH 07/01 1,000 M8020154HH 07/01 1,000 M8020159HH 07/01 1,000 M8020158HH 07/01 1,000 M8020157HH ~ A - ~ ~k Vn.. ignature) ~ ~_ .. ... _.~ ;:.,.:.Print.. Refresh PD F 3500 E Bu~reau~the pt~~1'~TC Die cb ry CONTINUATION SHEET FOR LISTING SECURITIES (Revised January 2007) PRINT IN INK OR TYPE ALL INFORMATION The bonds described on this form are included in the attached PD F ~~~ E ISSUE DATE FACE AMOUNT BOND NUMBER INSCRIPTION (provide complete Social Security Number [for example, 123-45-6789], names, includi middle names or initials, and addresses on the bonds ' 07103 1,000 M8020156HH 206-10-0199 07/03 1,000 M8020155HH PAUL J. HILTON 07/03 1,000 M9045257HH 4916 LANCASTER STREET 07/03 1,000 M9045258HH HARRISBURG, PA 17111 07/03 1,000 M9045259HH BEING DEPOSITED TO: 07103 1,000 M9045260HH 356939307 07/03 1,000 M9045261HH ESTATE OF PAUL J. HILTON 07/03 1,000 M9045262HH 6209 WESTOVER DRIVE 07/03 1,000 M9045263HH MECHANICSBURG, PA 17050 07/03 1,000 M9045264HH 07!03 1,000 M9045265HH 07103 1,D00 M9045266HH 07/03 1,000 M9045267HH 07/03 1,000 M9045268HH 07/03 1,000 M9045269HH 07/03 1,000 M9045270HH 07/03 1,000 M9045271 HH 07/03 1,000 M9045272HH 07/03 1,000 M9045273HH 07/03 1,000 M9045274HH 07/03 1,000 M9045275HH • ~' (S ns) Print Refresh PD F 3500E ..... Bu eau menthe PuW~c Debtry CONTINUATION SHEET FOR LISTING SECURITIES (Revised January 2007) PRINT IN INK OR TYPE ALL INFORMATION The bonds described on this form are included in the attached PD F 1522 E ISSUE DATE FACE AMOUNT BOND NUMBER 1NSCRtpnoN (probe ~p~ Social Security Number [for example, 123-45-6789], names, indudi middle names or initials, and addresses on the bonds 07/03 1,000 M9045276HH 206-10-0199 07/03 1,000 M9045278HH PAUL J. HILTON 07103 1,000 M9045279HH 4916 LANCASTER STREET 07/03 1,000 M9045280HH HARRISBURG, PA 17111 07/03 1,000 M9045281HH BEING DEPOSITED TO: 07/03 1,000 M9045282HH 356939307 07/03 1,000 M9045283HH ESTATE OF PAUL J. HILTON O7/03 1,000 M9045284HH 6209 WESTOVER DRIVE 07/03 1,000 M9045285HH MECHANICSBURG, PA 17050 07!03 1,000 M8045286HH 07/03 1,000 M9045287HH 07/03 1,000 M9045288HH 07/03 1,000 M9045289HH 07103 1,000 M9045290HH 07103 1,000 M9045291HH 07/03 1,000 M9045292HH 07/03 1,000 M9045293HH 07/03 1,000 M9045294HH 07/03 1,000 M9045295HH 07/03 1,000 M9045296HH 07/03 1,000 M9045297HH • ~ ~. (SignaturQ) Print Refresh PD F 3500E _ ,... _.. . a~~u ~~tie ~c D~ebcry CONTINUATION SHEET FOR LISTING SECURITIES (Revised January 2007) PRINT IN INK OR TYPE ALL INFORMATION The bonds described on this form are included in the attached PD F 1522 E ISSUE DATE FACE AMOUNT BOND NUMBER INSCRIPTION (Provide complete Social Securely Number [for example, 123-45-6789], names, induct' middle names or initials, and addresses on the bonds 07/03 1,000 M9045298HH 206-10-9199 07/03 1,000 M9045299HH PAUL J. HILTON 07/03 1,000 M9045300HH 4916 LANCASTER STREET 07/03 1,000 M9045301 HH HARRISBURG, PA 17111 07/03 1,000 M9045302HH BEING DEPOSITED TO: 07103 1,000 M9045303HH 356939307 07103 1,000 M9045304HH ESTATE OF PAUL J. HILTON 07/03 1,000 M9045305HH 6209 WESTOVER DRIVE 07103 1,000 M9045306HH MECHANICSBURG, PA 17050 07/03 1,000 M9045307HH 07/03 1,000 M9045308HH 07/03 1,000 M9045309HH 07/03 1,000 M9045310HH 07/03 1,000 M9045311HH 07103 1,000 M9045312HH 07!03 1,000 M9045313HH 07/03 1,000 M9045314HH 07/03 1,000 M9045315HH 07103 1,000 M9045316HH 07/03 1,000 M9045317HH 07103 1,000 M9045318HH (St nature) Print : '. .. -Refresh PD F 3500 E &Deproaart ~of~~n~ ry CONTINUATION SHEET FOR LISTING SECURITIES (Revised January 2007) PRINT IN INK OR TYPE ALL INFORMATION The bonds described on this form are induded in the attached PD F 1522 E ISSUE DATE FACE AMOUNT BOND NUMBER INSCRIPTION (Provide complete Social Security Number [for example, 123-45-6789], names, ir~cludin middle names or initials, and addresses on the bonds 07/03 1,000 M9045319HH 206-10-9199 07103 1,000 M9045320HH PAUL J. HILTON 07/03 1,000 M9045321HH 4916 LANCASTER STREET 07103 1,000 M9045322HH HARRISBURG, PA 17111 07103 1,000 M9045323HH BEING DEPOSITED TO: 07103 1,000 M9045324HH 356939307 07/03 1,000 M9045325HH ESTATE OF PAUL J. HILTON 07/03 1,000 M9045326HH 6209 WESTOVER DRIVE 07/03 1,000 M9045327HH MECHANICSBURG, PA 17050 07103 1,000 M9045328HH 07/03 1,000 M9045329HH 07/03 1,000 M9045330HN - 07/03 1,000 M9045331HH 07103 1,000 M9045332HH 07/03 1,000 M9045333HH 07/03 1,000 M9045334HH 07/03 1,000 M9045335HH 07/03 1,000 M9045336HH 07!03 1,000 M9045337HH 07103 1,000 M9045338HH 07/03 1,000 M9045339HH i (Signature) Print `.Refresh -. ; PD F 3500E ,:; e~~,r~a,~~~i~ try CONTINUATION SHEET FOR LISTING SECURITIES (Revised January 2007) PRINT IN INK OR TYPE ALL INFORMATION The bonds described on this form are included in the attached PD F 1522 E ISSUE DATE FACE AMOUNT BOND NUMBER INSCRIPTION (Provide complete Social Security Number [for example, 123-45-6789], names, indudi middle names or initials, and addresses on the bonds 07/03 1,000 M9045340HH 206-10-9199 07/03 1,000 M9045341HH PAUL J. HILTON 07103 1,000 M9045342HH 4916 LANCASTER STREET 07103 1,000 M9045343HH HARRISBURG, PA 17111 BEING DEPOSITED TO: 356939307 ESTATE OF PAUL J. HILTON 6209 WESTOVER DRIVE MECHANICSBURG, PA 17050 r~ ~ (si9 ~) 1'NC Ba.r}Jr.~ ° G iFor the period 11 /01/2011 fto 11/22/2011 000953 EST OF PAUL J HILTON DECD CHARLES D KOKOSKI CO-EXTR KATHY A KOKOSKI CO-EXTR 6209 WESTOVER DR MECHANICSBURG PA 17050-2341 PNCBANI Primary account number: 50-0448-3612 Page 1 of 3 Number of enclosures: 0 For 24hour banking, and transaction or interest rate information, sign on to PNC Bank Online Banking at pnc.com. 'a Forcustomerservioecall 1-888-PNC-BANK Monday - Friday: 7 AM - 10 PM ET Saturday & Sunday: a AM - 5 PM ET Para servicio en espafiol, 1-866-HOLA-PNC fiNovipt Please contact us at 1-888-PNC-BANK ® Write to: Customer Service PO Box 609 Pittsburgh PA 15230-9738 Visit us at pnc.com ® TDDterminal:l-800-531-1648 For hearing impaired clients only Performance Select Est Of Paut J Hilton Decd Interest Cheddn Account S11mms Charles D Kokoski Co-Extr 9 ~ Kathy A Kokoski Co-Extr Account number: 50-0448-3612 Overdraft Protection has not been established for this account. Please contact us if you would like to set up this service. Your account is currently Opted-0ut of Overdraft Coverage. To learn more, visR us online at pnc.com/overdraftsolutions Balance Summary Beginning Deposits and Checks and other Ending balance otheradditfons deductions balance .00 1,319,75 7.61 47.02 1,319,710.59 Average monthly Charges balance and fees 775,449.17 47.02 Interest Summary As of 11122, a total of $4.46 in interest was Annual Percentage Number of days Average collected Intenast Paid Paid this year. Yieid Famed (APYE~ i^ Erteres! period halo..^.ce fo: APYE this period 0.01% 22 741,136.]7 4.46 Aatilrity Detail Deposits and Other Additions Date Amount Description 11/02 264,288.30 Deposit Reference No. 520798903 11/08 746,311.01` /Deposit Reference No. 522767893 11/18 1,653.84 ) Deposit Reference No. 522548510 11/22 807,500.00 Direct Deposit - H/Hli Redmt Bur Of Pub Debt XX~s`XXXX1298 11/22 4.46 Interest Payment There were 5 Deposits and Other Additions totaling $1,578,757.81. --__ _ _ . ~ Account Number 616-19655-1-y Account Type Estate Flnandal Advisor Jeff Zavoda, 717-561-2480 4400 Derry St, Harrisburg, PA 17111 Statement Date Oct 29 -Nov 25, 2011 00005682 01 AV 0.340 01 TR 00030 EJADD011 000000 sm ESTATE OF PAUL) HILTON ~ CHARLES D KOKOSKI & ~ KATHY A KOKOSKI EXEC 6209 WESTOVER DRIVE MECHANICSBURG PA 17050-2341 ~I~Ill~lnll~lnll~rlllllllllr~~~ny~ll,,,lllllnull,~,l„11 The Three P's of Planning for Retirement ~w b° 2q4 Page 1 of 4 Although preparing for retirement may seem like just another task on your growing to-do list, you can prepare for that period of your life now. By working with your financial advisor today, you can address the three aspects of a retirement strategy: planning for the expected, preparing for the unexpected and positioning your portfolio for both. It's never too early or too late to start planning for the future, so contact your financial advisor today. This Period Thls Year 592.24 Beginning value $51 _ $0.00 $0_00 , Assets added to account 51,867.98 51,867.98 Income 1 Month Ago $0.00 Assets withdrawn from account 0.00 ~ -119.82 0.00 -119.82 1 Year Ago $0.00 Change in value Ending Value _155.92 S51,592.24 -155:92 Ending Cash & Money Market _ _ Balance Cash 5119.82 Amount Amount Invested Withdrawn Stocks Price _Q_ua_ntlty I_n_ ce Inception S Since Inception ^ _ _ _Value Frog Switch & Manufacturing Co _ 366.00 _ _25 _` _ _ _ __- V ., _ __ ^- ' ___ 9,150.00 LadenburgThalmann Finl Svcs 2.12 21 - - 44.52 Amount Amount Invested Withdrawn Mutual Funds Price Quantity Since Inception Since Ince_ptlon _ Value Franklin Strategic Income Fd A 10.01 1,960.875 - __- _19,628.36 Invesco High Yield Fund CIA 3.91 5,792.722 - - 22,649.54 Total Acxount Value 551,592.24' ,;u i. iJ~ LULL !, iUrn v: croon _ .__...,. - - - -,.r Nationwide Funds° i~r~e~trnent Update OT/01l2011- T2/30/a0i1 TOTAL VALUE OFYOUR ACCOUNI'(5) .... 3110 r ty~r~on ~ , ~1kfd0 Ytdue SQDf Chfaye6aYeW --- ._..__~ EWyYafir 500 I1V• iiUU ~ L iNVESTtxt PAUL J HtITON ESTATE ~ CHARLt:3 D KOtOD5K1 & KATHY A tC01aJ5K1 ~(EC ~ YdESTONffi DR MtCFUWIC58UFmG PA 1)050-341 ' ~ ' ' • ACCOUNT REPRESENTATIVE M+ICONESUMMRRYYfAR,T8pI1TE _:: :- _. ... DEFAULT . :~ T.aDekxal Tfrobe >:UNDOIFECTACCQIJNT-Ui+ISULICiTEO gyp' Sa00 seaa PG t30X 10x2205 TetmffTpol~Mt : COLUMBUS OH 43218-2205 L~eq•1~ni _. _........_.~ _._..._---._ ~_..._..~ d~tiBer ~ SOHO 50.00 ACCOUfNT StliN-AARY.TfAR TO DATE Fund•kwua ih4teud Yalueu~f Slat Itrwlcr ih~~gei. k~dAuawA~rrR M~j,p~ 0f~1/2Pl1 17I30pD11 Ptin ! dSYars Yt+uc~ MaTIOY~EFQMDt1A9s0 ! ~ 4BA0 ; 4000 ; 513A1 ; 0bf0 SODO - t~ 0n 9ntAraf K Jtca a f td dA:bry OaltovtolaI@:ell. YSlritorp(wd5miar; LLC~US~Mgtos~gaslfxnrrrlnwMryMt/or.Ilk~aarid~Fu~k.Nattrolrlfytyomxaant mrrt6er.,aFou-oeratme~athri6+bw+fOeEnadsHm netcfi~o9ed.ffivnevet>TrnE:tiriae!)rusedanTx tttauKfacsl,rouac~doimrra,Rt, tfYa+tsreftCffes+at~We~l'ft!~Op(a uifefwert famss.lro+rlttxyu0dedtl~oulhilas4FaCO ng6oo'fod~h[ta~ neivihrO +odt~svetd. wcwuuldabfGkyauba9txer(arelkttroY.etdndep rrdRci~ingywr.om..~iu~dbne:~foon.tioaereamia~res~sy sar+a s(Foent.ad ~~a~t~oha.(~f~ +MMtelAtfxTwttsttvi~oreceaexarweian. wu~onM1Qrsoet~tarl~ry etetftera4asffifa:taryxtlbtitty. Fadtea:tiiret~asa futIDOea+adbkdortontcOfayoOheym~nr9e0ulgradaRmoa.l~vaGkaaeear6w 1PNir7dmuyFidltdiaEolwtDett Torpitlt~ptirolia+evidtaomtau4uTudrarQHltx74pfulFiud':natrdray~darttnr~sus~r'/KyArmr+C aaAo:xi•I00•W10tA ACCt)tltYT AETNtTY1tEAit TO gATk t:oNTACT ! nl~txtlnAnonl sharaholderSerNces 1-800-~48-0924 9'00 am fo thR00 prn ET Autottwbad Line :1-800-818-0920 Internet auww.naGanwide(undscam NEWS A111D 1!!IFORhtAT10N Ctopltal Geina Mfarmetlow Nor AvWeblo YourZ011 capltztgalns dlstributlons for Watieshwlda Mueuai Funda arc available at hntr.//wwYlr nbdotturidQ. tom/rnutuaEhtr+ds-dis:ributlons.Is c. I(you Aav~ questiarrs, ptaste car+tacr your flnandal and taz adv):ors ar tail Shareholder SetYttes at 1-800-848.0920. F.ed4moLLfl.me WtW-Aawat pwt+tfx: RedYdMf>' ~ IirNo~ds/SSort• lawg•kra Marta ~.- ~ Trtmlf ifla b WNw _ MATIOM1fDtiYNOpASSOlMYi1~ 50.00 Si00,0o1#t 50.06 S9~0O TdslOolxYtdu ~ SO.00 St01.0d1.12 f0.10 50.00 .. TRAYISACTION DETA11 _ . NAT E D CLAS6 ti IMU IFfU . , ACCT PAUL) CHARLES D KOK03lI1 d'e - KATHY A KO1C06H! E)tFC 6209 WE3T04ER t3R AIECHAMCSf1IJRG PA 17050-7341 .. , O.t~' :: Dgotpyw DrMtlAim~t' ' ,`JwRW.loe'. StimslbkTprdaalba'; TxtlRam O1HVdll (tliltfi Stt,Of 5138: ! OA00 ' .1'V2~~: .,137305I1OD 5111f $Q,00 ', 8,4a24f1 Leu.'x) . unlnln : sit~lEo'~i -. __._....... . ._ itor~iai- stief- e~ri~-~ ebeo F.a~9htrlwoe llii4-miT'J ~ SOAO s13At.. ... .... .. ._..... a0to , ~Iationwid~- Funds' On iota 5We' 1.UtaeyeNtlhiee:TtKaggrPpoeataltF~ttcactbr~s(purctuses.redetaptiots.ezctriagPS,dfvtdetds}andsMa~es4mx>tet P~riorwvidei:uedsdlsteibutedby vaOedtfTtg fhts pedoti. Nat)ortwido Fund DEslAbptots 2.7ialho~pas:'In; peeoen00eoffOUriDtal Inldtrps teprrsented by Ctls fttndot aaou:tt, LLC (1~Dy A4etliber FINRA.1000 3.Red[ct?otptTheaggdeg3teotallademptbns,wNtRle3wals,eatAanges eraeTotherttd:tdloe=to!heaccountduringth)s Cantkuanta~~lvQ,SuItQ400,K1ng ~~• ......... _. _____.. _ of Prussia, Pa 19406.. 7 -- ~oaw..•aoao'.o~oi2t,aa.a~aeaoeaxlmwyrtt....rwr....._xrxv.......ouoosssrf _ ~~~~ MARIETTA GRAVITY WATER COMPANY is anon-public corporation operating as a public utility company. As of January 4, 2012, the company is in the process of being sold, proceeds of which are estimated to be between $312.50 and $400 per share. See attached "DISTRIBUTIONS TO SHAREHOLDERS AFTER THE SALE" statement issued by this non-publicly traded company. Valuation here has been estimated at $375 per share. ~ ~ ~0~~~/~~ ~/j i /Jffd~/VP ~ to ~~+'/Yr"f' DISTRIBUTIONS TO SHAREHOLDERS AFTER THE SALE The Company will continue to exist after consummation of the sale to Columbia Water Company and will continue to be managed by the Company's Board of Directors elected by shareholders. After consummation of the Sale Agreement, the Company will be required to pay federal and state taxes on the sale of assets at an estimated combined tax rate of 44% and to pay income tax on its other income for 2011 and any subsequent years. The Company currently anticipates that it will have between $1,000,000 and $1,280,000 available for an initial distn'bntion to shareholders, which world equate to an initial distribution of between $31250 and 5400 per share., The amount of the initial distribution will be determined after consummation of the sale and making provisions for payment of taxes and other current liabilities, and the establishment of reserves for any unpaid liabilities and future costs and expenses_ It is anticipated that this initial distribution will be able to be made within a relatively short period of time after consummation of the sale. Each shareholder (other that those perfecting dissenters rights) will receive a pro rata portion of any distribution based on the number of shares of Company common stock owned. Following the initial distribution to shareholders, the Board of Directors will gradually wind down the Company. After collection of outstanding receivables, receipt of payment in full of the purchase price promissory note by Columbia Water Company at the end of two years after the consummation of the sale, the sale of any non-cash assets not sold pursuant to the Sale Agreement, and payment or provision for any remaining liabilities, the Company will liquidate and dissolve and make a final distribution to shareholders. Because of indemnification obligations under the Sale Agreement, it is currently anticipated that the Company will not complete this process until two or more years after consummation of the Sale Agreement. The Company cannot estimate at this time the amount of funds that will ultimately be available for liquidating distributions to shareholders or when any such distributions will be made. -7- COMMONWEALTH OP PENNSYLVANIA INHERffANCE TAX RETURN RESIDENT DECEDENT SCNEpt~LE C CLOSELY HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF PAUL J HILTON aU su information) must be attached for each claseN~d co-P°ra>>onlPa~U~erslup irderest of the decedent, other man a Schedule C-t or C•2 (including PP~!~9 _ _- _-- L_.~_ _.....,..~;,,,. ;,,~,..,,~,,, r~, he aibrttitted for sole-oroDrietashiPs• tILG DIU~DC1l 21 11-1149 RE~':1507 EXt (6.98) SCNEDVLE D COMMONWEALTH of PENNSYLVANIA MORTGAGES $ POOTES INHERRANCE TAX RETURN RECENABLE RESIDENT DECEDENT ESTATE OF PAUL J. HILTON FILE NUMIBER 21 11-1149 hu P~PBRY 1clm~yowne0 Wltll right Of survivershie ~nuef !fs Iliawln~a./ ... e-~~..~_ i~~ ~~K„~ ~w ~~ nawCa, mser[ aaaroonai sheets of the same size) Pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: PAUL J. HILTON 21 11-1149 Include the proceeds of litigation and the date the proceeds were received by the estate. All properly jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Centric Bank, 6480 Carlisle Pike, Mechanicsburg, PA 17050 (MM --Account 3022300) 108,355.61 2 First National Bank of PA, 4140 East State St., Hermitage, PA 16148-3389 (CD --Account 100256437) 100,548.60 3 Graystone Tower Bank, 100 Granite Run Dr., Lancaster, PA 17601 (CD --Account 3000127030) 101,107.11 4 Integrity Bank, 3345 Market St., Camp Hill, PA 17011 (MM -- Account 201045253) 100,664.87 5 Members 1st Federal Credit Union, 3512 Market St., Camp Hill, PA 17011 (2 CD's -- Account 256687) 100,276.18 6 Orrstown Bank, PO Box 250, Shippensburg, PA 17257 (CD --Account 4000031764) 108,604.49 7 US Treasury, San Francisco, CA (CSA Annuity) 768 82 g Kraft Foods Global, Inc. (KF Qual Plan) 32 22 g Cash -- on Hand 370.00 10 Sale of personal items -- remainder left at Bethany Village or donated to Salvation Army 1,050.00 11 Veterans Administration -- Burial Check 100.00 12 US Treasury -- CSF Lump Sum 545.75 13 Deposit Refund -- Bethany Village 271,200.00 14 IRS Refund - 2011 3,671.00 15 PA Department of Revenue Refund -- 2011 347.00 16 Grandfather clock and miscellaneous wall decorations 500.00 TOTAL (Also enter on Line 5, Recapitulation) $ 898,141.65 If more space is needed, use additional sheets of paper of the same size. REV->5og rX+ (oI-1o) pennsylvania SCHEDULE F DEPARTMENT DF REVENUE INHERITANCE TAX RETURN ]OINTLY-OWNED PROPERTY RESIDENT DECEDENT ESTATE OF: PAUL J. HILTON FILE NUMBER: If an asset became jointly 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• KATHY A. KOKOSKI 6209 WESTOVER DRIVE MECHANICSBURG, PA 17050 FRIEND B. C. JOINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE ]DINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOI ATE OF DEATH %a OF DE ' DATE OF DEATH 1~ A' 08/19/10 NTLY HELD REAL ESTATE. CENTRIC BANK -- (CD --Account 3037959) VALUE OF ASSET CEDENT S INTEREST VALUE OF DECEDENT'S INTEREST 127,641.35 50% 63 820 68 2 A. 07114/10 PNC BANK - (CHECKING -- Account 5112029871) , . 3 9,559.00 50% 4,779.50 . A. 01/25/10 PNC BANK -- (MM -Account 5112501304) 101,357.00 50% 50 678 50 4. A. 01/06/10 PNC BANK -- (MM --Account 5112709228) , . 158,848.00 50% 79,424.00 TOTAL (Also enter on Line 6, Recapitulation) I $ 198 702 68 If more space is needed use additional sheets of paper of the same size. RE6' X510 ~X+ (08-09) Pennsylvania SCHEDULE G DEDARTMENTOFREVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER PAUL J. HILTON 21 11-1149 rnis schedule must be completed and filed if the answer to any of questions 1 through a on page three ~ the REV-1500 is yes. DESCRIPTION OF PROPERTY IhM DVa,UDE THE MANE DF THE TRAI6FERFE, THEIR A9/fROK5Ti1P TO DECEDENT AND DATE OF DEATH 96 OF Dt:CD'S IXCLUSION TAXABLE NUMBER THE DATE OF TRANSR3t. ATTACH A COPY OF THE DEED RXt REAL STATE. VALUE OF ASSET INTEREST (1F APPL[CAaLE) VAWE 1. DOROTHY E. GOFFUS -FRIEND 11/6/2010 10,000.00 3,000.00 7,000.00 1/3/2011 13.000.00 13,000.00 2 ANDREW W. GOFFUS -FRIEND 11/6/2010 3,750.00 3,000.00 750.00 1!3/2011 13,000.00 13,000.00 3 SHERRY A. GOFFUS -FRIEND 11/6/2010 3 75000 3,000.00 750.00 1l3J2011 13,000.00 13,0.00 4 KATHY A. KOKOSKI -FRIEND 11/6/2010 5 ~ ~ 3,000.00 2,500.00 1/3/2011 13,000.00 13,000.00 5 CHARLES D. KOKOSKI -FRIEND 11/2010 5,500.00 3,000.00 2,500.00 1/3!2011 13,000.00 13,000.00 TOTAL (Also enter on Line 7, Recapitulation) # ~ 78,500.00 If more space is needed, use additional sheets of paper of the same size. REV-~Sll EX+ ~~,-Oa; pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF PAUL J. HILTON Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION A• FUNERAL EXPENSES: I' NEILL FUNERAL HOME, 3501 DERRY ST., HARRISBURG, PA 17111 (INCLUDES ALL EXPENSES ASSOCIATED WITH FUNERAL /BURIAL) FILE NUMBER 21 11-1149 AMOUNT 4,681.82 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 39,000.00 Name(s) of Personal Representative(s) CHARLES D. & KATHY A. KOKOSKI _ Street Address 6209 WESTOVER DRIVE City MECHANICSBURG State PA zIP 17050 _ Year{s) Commission Paid: 2012 2• Attorney Fees: 5,800.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant N/A Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 1,326.00 5• Accountant Fees: 8,750.00 6• Tax Return Preparer Fees; 1,450.00 ~. TOTAL {Also enter on Line 9, Recapitulation) ~ $ 61,007.82 If mare space is needed, use additional sheets of paper of the same size. !Jeill Funeral Home, Inc. 3501 Derry Street Harrisburg, PA 171111817 (717)564-2633 Supervisor :Stephen J. Wilsbach The fdlowing LS a detailed bill for the professional services and/or merchandise arranged for Paul J. Hilton Date of Service :October 27, 2011 Kathy Kokoski Statement Date October 27, 2011 6209 Westover Dr Contrail Number 741200200934 Mechanicsburg, PA 17050-2341 Arranger Name Daniel C Huff Jr. Initial Selet~ion Flnal Selection Difference Package Offerings Immediate Burial $2,795.00 $2,795.00 - Basic Professional Service Fee Intl Intl -- Total Package Offerings $2,795.00 $2,795.00 - Merchandise 147982 Revere Silver Metal Steel 18 Cauge Crepe $1,695.00 ~ $1,695.00 -- Total Merchandise $1,695.00 $1,695.00 - Cash Advance Certified Copies of the Death Certificate $90.00 $90.00 -- Newspaper Notice -- $101.82 $101.82 Total Cash Advanoa $90.00 $191.82 $101.82 Total Services, Merchandise and Cash Advance $4,580.00 $4,681.82 $101.82 Total Charges (total Services +/- AAovrarrces + Taxes) 64,580.00 $4,681.82 5101.82 Less Cash Received $0.00 \\ ~`~ l D $4 681 82 `\ • ` ance ue Unpaid Ba . , ~ ~ ~, .-~- ~ .. cam- £ ~ REV-' 512 <=X+ ! 12-OS) ~ a Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DE6T5 OF DECEDENT, MORTGAGE LIABILITIES & LIENS FILE NUMBER ESTATE OF PAUL J. HILTON 21 11-1149 .. .. , _ __ ____ ._ ~__w .~.,..e...,a...a ~~~ticd at the date of death. indudin9 unreimbursed medical expenses. If more space is neeaeo, mser< aamuvna~ m~ccu ~~ u~= ~~~~~ ~~~-• i ~ Account Number Due Date Amount Due 717 691-1666 !743 17Y Upon Receipt $13.53 v~r VBf"~20n 1'16YLtS _ Don't Move Without Verizon! Call 1-888-416-9691 before you move. We'll help set up your Internet, TV & Phone for your new address. You can be up & running in no time! DON'T WAIT! And be sure to ask ft FiOS is available in your area. Service availability vanes. We Want You to Stay With Us You are a valued customer & we want to deliver the very best service & value to you. Call uc at 1-888-675-8090 to find out about the new ways Verizon can save you money. We appreciate being your provider, and we would like to keep you with us longer by improving your Verizon•experierrce. Call About Our New Bundles! Call 1-888-678-8090 to team about our great, new special burxile offers for Verizon customers. We'll assess your needs and make swe you have the best combination of Internet, TV & Phone services at The best value. Oon't wait. Call today! Account Information Staternent Dace: 11/14/11 MR PAUL J H~TON Phone: 717-691-1666 Account Summary Previous Balance $47.2$ Payment Received Oct 13 - --__ _ -$27.85 __ Balance Forward 579.43 New Charges _ _ Current Activity... -$3.80 Taxes, Fees and Other Charges - -- -$2.10 _ Total New Charges Amount Due -Please Pay Now 513.53 ` ~ ~ ~~ ~o( Z- Watrt Automatic Payment? Questions about your bill or service? Enroll below or at Venzon.com to authorize your financial View your bills in detail at verizon.com or call 1-800-VERIZON (1-800-837-4966). institution to deduct the amount of your monthty bill from Enter your ten digit number 717-691-1666. Use 743 if asked for the three digits the account associated with your enclosed check and following your accourrt number. send payment directy to Verizon. To discontinue Customers wfth disabilities can reach us by TTY at 1-800-974-6006. Automatic Payment, call Venzon. Please keep a copy of this authorization. ~ Please return remit slip wfth payment. ~~ T Bethany Village 325 Wesley Drive Mechanicsburg, PA 17055 Paul J Hilton 5225 Wilson Lane Apt. 4133 Mechanicsburg, PA 17055 STATEMENT Page: 1 of 1 - ~1Cyvorce ~T" ~ `" ~y~ date 239573 23899 11 /04/2011 k Due L7afe _: •~ cif Due` ':AmounfPaid - 11/11/2011 $3,076.08 ~ ,~Gy ~~'a<~i tSta~ne Hilton, Paul J PLEASE DETACH AND RETURN UPPER PORTION WITH YOUR REMITTANCE Hilton, Paul J Bethany Village -The Oaks 11 /04/2011 t ption f ' nits ' ' ~ r; n ~.~~ fi -; r ~. ~. a nce . FresriF~ ~:= Tftr .. „ ~~ xw-'.~. -~ 5 ~~~°, ~:.;-~ <.-. ~ ~ ., ~~~ r SID N RESPON IBIL ITY 9/30/2011 Balance Forward 20.00 Payment Received (10/24/2011) -20.0 $0.00 10/21/2011 10/22/2011 Room and Board 2.00 Day 347.0 694.0 $694.00 10/05/2011 10/20/2011 MedicareA/MC HMO Coinsurance 16.00 Day 141.5 2,264.0 $2,958.00 10/21/2011 10/21/2011 Nutritional Supplements 1.00 Each 1.0 1.0 $2,959.08 10/21/2011 10/21/2011 Incontinence Care- Mod/Heavy 1.00 Day 11.5 11.5 $2,970.58 10/21/2011 10/21/2011 Complex Wound Care 1.00 Day 12.0 12.0 $2,982.58 10/21/2011 10/21/2011 Mobility Alarms 1.00 Each 4.0 4.0 $2,986.58 10/21/2011 10/21/2011 Specialty Mattresses 1.00 Each 11.5 11.5 $2,998.08 10/22/2011 10/22/2011 Incontinence Care- Mod/Heavy 1.00 Day 11.5 11.5 $3,009.58 10/22/2011 10/22/2011 Complex Wound Care 1.00 Day 12.0 12.0 $3,021.58 10/22/2011 10/22/2011 Mobility Alarms 1.00 Each 4.0 4.0 $3,025.58 10/22/2011 10/22/2011 Specialty Mattresses 1.00 Each 11.5 11.5 $3,037.08 10/23/2011 10/23/2011 Incontinence Care- Mod/Heavy 1.00 Day 11.5 11.5 $3,048.58 10/23/2011 10/23/2011 Complex Wound Care 1.00 Day 12.0 12.0 $3,060.58 10/23/2011 10/23/2011 Mobility Alarms 1.00 Each 4.0 4.0 $3,064.58 10/23/2011 10/23/2011 Specialty Mattresses 1,00 Each 11.5 11.5 $3,076.08 TOTAL TOTAL RESIDENT RESPONSIBILITY $s,o7s.os ~Z-13-1~ ~~Ot~ 'lie nt~nel ww mbtrlink.com ~--- C1JC75{E 9~PEG PE4RV CC~l1N'Y JOHN ALEXANDER ROE 2520 DOEHNE ROAD HARRISBURG, PA 17110-0622 717~871~9870 AD NUMBER . PAGE NO. 404157 1 of 1 BILL DATE SALESPERSON 11/25/11 wolfs START DATE STOP DATE 11H0/11 11/24/11 ~ 404157 ~ ESTATE NOTICE NOTICE IS HEREBY GN ~ 10 PUBLIC NOTICES ~ 46 * 2 cols ~ Publication Insertions Rate Net Amount Gross Amount 3 THE SENTINEL -LEGAL 3 LGL $244.26 TOTAL AD CHARGE $24426 3 PROOF OF PUBLICATION 01PRF $7.00 3 MOBILE SITE MOB2 $2.00 ,` y ~~ . 2 ~i Purchase Order ESt.PaulHilton PAY THIS AMOUNT $253.26 ~ $303.91* *AFTER 12/20N 1 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. THE SENTINEL c/o LEE NEWSPAPERS PO BOX 540 WATERLOO IA 50704-0540 rc~um uns porwn wrui yrxrr pay-nen~ ^ Check # ^ Credit Card ^®^®o®^® Acct #. Exp. Date: ^ ^ Name on credit card Sigr~ure ki:"c JOHN ALEXANDER ROE ~~ 2520 DOEHNE ROAD HARRISBURG, PA 17110-~22 Please mafw check payable to THE SENTINEL THE SENTINEL c/o LEE NEWSPAPERS PO BOX 540 WATERLOO IA 50704-0540 Legal THE SENTINEL c/o LEE NEWSPAPERS PO BOX 742548 CINCINNATI OH 45274-2548 I.I..I~I~1~~~1~11~~~1~1~~1~~1~1~1~1~~1~~11~~1~~1~~11~~1~1~~~11 2154020000D004041570000000000000003039100000253265~ 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. December 2, 2011 TO: RE: CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (71 ~ 249-3166 Fax: (71 ~ 249-2663 John A. Roe, Esquire Paul J. Hilton 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 18, November 25, and December 2, 2011, Advertising Cost $ 75.00 l~ Proof of Publication $ 0.00 ~2 ~~ ~ loo Second Proof Request $ 0.00 Payment received $ 0 .00 -~, Total Amount Due $__ 75_00 Payment received by ccurity rn hunted dorum en t. Scc 6-ack for deta 80-12T3/di3 QPNCBANK "°- coos ^ 1 117 Pxc s.~. x.a oao DATE 1~~1C ~ ( ~ Z.~ ~ ` Cmxal PA PAY TO THE \ I -}- ~ ~ ~ , ~ (~ ORDER OF ` ~ A~ ~~ ~ J ~ __ V~~ M Q a ~~~ DOLLARS 8 ESTATE OF EST OF PAUL J HILTON CHARLES D KOKOSKI,CO•EXTR KATHY A KOKOSKI,CO-EXTR e2oo wESTOVER oR FOR -~~ _ _r.. - ~- - -~7-""~F ADMINISTRATOR I M' PERSONAL ._._._ .. __.. ------ REPRESENTATNE ---_. _ _.___._!~ TRUSTEE ~i'00 i006n' ~:03 L31 2738: 50044836 L 2u' .~-~ RED 1513 EXt (O1-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE BENEFICIARIES ~~~ ESTATE OF PAULJ NUMBER I 1. 2. I 3. 4. 5. 6. 7. II 1. i. HILTON NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY TAXABLE DISTRIBUTIONS [Indude outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] DOROTHY E. GOFFUS, 4909 FRANKLIN ST., HARRISBURG, PA 17111 EVELYN V. LATHROP, 4911 FRANKLIN ST., HARRISBURG, PA 17111 MARIE REAMS, 205 TREZIYULNY ST., OSCEOLA MILLS, PA 16666 ANDREW W. i~ SHERRY A. GOFFUS, 943 MANOR DR. STEELTON, PA 17113 CHARLES D. ~ KATHY A. KOKOSKI, 6209 WESTOVER DR. MECHANICSBURG, PA 17050 ANDREW W. GOFFUS (1/2 OF REMAINDER OF ESTATE) KATHY A. KOKOSKI (1l2 OF REMAINDER OF ESTATE) RELATIONSHIP TO Do Not List Tn FRIEND FRIEND FRIEND FRIENDS FRIENDS FILE NUMBER: 21 11-1149 AMOUNT OR SHARE OF ESTATE 500000.00 25000.00 25000.00 150000.00 150000.00 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: N/A B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: wA TOTAL OF PART II -ENTER TOTAL NON TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I S If more space is needed, use additional sheets of paper of the same size. ~v-,5,4,x+ ~°.~~ SCNEp111.E K ~ pennsylvatme LIFE ESTATE, ANNUITY GEPARTlIENr OR REVENUE eue~,arrndwra~,atTa>oes &T'ERM CERTAIN ~rt~~gPn 17s~o6oi (CHECK BOX 4 ON Rtv-s5oo COYER SHEEn (ESTATE rDF fib NUMBER PAl rl .1 HILTON 21 11-1149 This schedule should be used for all single-life, joint or suooessNe life estate and berm-certain ~atiorrs. For dates of death prior to 5-1-89, actuarial fa~orS for Single-kfe c~ulations qn be obtained from the Departrrrerit of Reu~erx~e. Achiarial factors Carl be found and in A 1457for dates of death from~5.1 ther+~fter. ~ from 5-1-89 to 4-30.99, Indicate below ttte type of instrument that crested the future interest and attadt a Dopy of it to the tax return. [7 Will ~ Irrtervhros Deed efi Trust ~ Other NAME OF LIFE TENANT • DATE OF BIRTH • ~~ ABE AT DvATE Off DEATH Ti9tM OF YEARS LIlE ESTATE I5 PAYABLE N/A ^ Life or D Term of Years ^ life or ^ Term of Years ^ Life or p Term of Years ^ Life or ^ Tenn of Years O life or p Term of Years i. Value of fund (ran which life estate is payable .........................................g 2. Actuarial factor per appropriate table ............................................... . Interest table rate - O 3.596 O 6% D 10% ^ Variable Rate % 3. V7Nu d Bfe estate (L6~e 1 nwklpiled by Lune 2) ....................................$ NAME OF LIFE ANNUITANT • DATE OF BIRTH • i ASE AT DATE OF DEATH TlRM OF YEARS AI~BWATY IS PAYABLE ^ Life or ^ Tenn of Years ^ Life or ~ Term of Years ^ Life or ^ Tenn of Years ^ Life or ^ Term of Years 1. Value of fund from whidt annuity is payable ...........................................5 2. Check appropriate block below and enter corresponding number ................ . Frequency of payout - ^ VVeeidy (52) D Bi-weelchr (~ ^ y (12) ^ Quarterly (4) ^semi-annually (2) O Annually (1) D Other ( ) 3. Amount of paY~ P~ period ........................................................$ 4. Aggregate arxwal payment, Line 2 multiplied by Line 3 .................................. . 5. Annuity Fatxor (see irrstrvcaons) Interest table rate - D 3.596 ^ 696 ^ 1A% p Variable Rate % 6. Adlusttnent r-actor (See ir~strucxions.> ......... . . . . . . . . . ........... . . . . .... . .. . . . . . . . 7. Vahre of amruity - If using 3.5, 6, or 10%, or if variable rate and period payout is at end of period, cala~ation is Line 4 x Line 5 x Line 6 ...........................$ If using variable rate and period payout is at beginning of period, calculation is (Line 4 x Lie 5 x Lhre 6} + Une 3 ...............................................$ NOTE: The vakies of the funds that create the above future intrE+rpsts must be reported as part of the estate assets on Sdredules A through G of the tax return. The r+esutdng life or annuity interest should be reported at the appropriate tax rate on Urns 13 and 15 through 18 of the return. If rows space is needed, use additional sheets of the same size. REV-1644 EX+ (01-10) j~, pEf11'15~/ll/af1'la i.1J DEWWTf1ENT Of REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT INHERITANCE TAX SCHEDULE L REMAINDER PREPAYMENT OR INVASION OF TRUST CORPUS I. ESTATE OF PAUL J. HILTON II. FILE NUMBER 21 11-1149 This schedule is appropriate only for estates of decedents dying on or before Dec. 12, 1982. ~ ~ R This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust corpus (principal). REMAINDER PREPAYMENT: A. Election to Prepay Fled with the Register of Wills on (Date) B. Name(s) of Life Tenant(s) Date of Birth Age on Date Tenn of Years Income or Annuitant(s) of Election or Annuity is Payable C. Assets: Complete Schedule L-1 1. Real Estate ...........................$ 2. Stocks and Bonds ......................$ 3. Closely Held Stock/Partnership .............$ 4. Mortgages and Notes ....................$ 5. Cash/Misc. Personal Property ..............$ 6. Total from Schedule L-1 ..............................................$ D. Credits: Complete Schedule L-2 i. Unpaid Liabilities .......................$ 2. Unpaid Bequests .......................$ 3. Value of Non Includable Assets .............$ 4. Total from Schedule L-2 ..............................................$ E. Total Value of Trust Assets (Line C-6 minus Line D-4) ...........................$ F. Remainder Factor ................................................... . G. Taxable Remainder Value (Multiply Line E by Une F) ............................$ (Also enter on Line 7, Recapitulation) III. INVASION OF CORPUS: A. Invasion of Corpus (Month, Day, Year) 8. Name(s~ of Life Tenant(s) Date of Birth Age on Date Term of Years Income or Annuitant(s) Corpus or Annuity is Payable Consumed C. Corpus Consumed ....................................................$ D. Remainder Factor ................................................... . E. Taxable Value of Corpus Consumed (Multiply Line C by Line D) ....................$ (Also enter on Line 7, Recapitulation) REV-1647 EX+ (02-10) ~. p~nnsylvania DERIIRTNENT Of REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF PAUL J. HILTON SCHEDULE M FUTURE INTEREST COMPROMISE (ClllCk E;oot 4a on REV-1500) FILE NUMBER z~ ~~-~Tas Thk sdroduk is appropriate only for estaas of decedents vvho died afar Dac. 12,1982. This schedule is to be used for ail future interests where the rate of tax that will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of Instrument that a Bated the future interest and attach a copy to the tax return. ^ Wiil ^ Trost Other I. Benefidaries II. III. IV. NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. N/A 2. 3. a. 5. For decedents who died on or after July 1, 1994, if a surviving spouse exercised or Intends to exendse a right of withdrawal within nine months of the decedent's death, check the appropriate box bebw and attach a copy of the document in which the surviving spouse exerases such withdrawal right. ^ Unlimited right of withdrawal ^ Umited right of withdrawal Explanation of Compromise Offer: Summary of Compromise Ober: 1. Amount of future interest ....................................................... $ 2. Value of Line i exempt from tax as amount passing to charities, etc. (Also indude as part of total shown on Line 13 of REV-1500.) ........ $ 3. Value of line 1 passing to spouse at appropriate tax rate Check one. O 6%, O 3%, O 0% (Also indude as part of total shown on Line 15 of REV-1500.) ,.... $ 4. Value of Line i taxable at lineal rate Check one. O 6%, O 4.5% $ (Also indude as part of total shown on Line 16 of REV-1500.) 5. Value of Line 1 taxable at sibling rate (12%) (Also indude as part of total shown on Line 17 of REV-1500.) ........ $ 6. Value of Line 1 taxable at collateral rate (15%} (Also indude as part of total shown on Line 18 of REV-1500.) ........ $ Total value of future interest (sum of Lines 2 thru 6 must equal Line 1) ....................... $. If more space is needed, use additional sheets of paper of the same size. H105.905 FtEV.(8/111 ' This is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance wtt the Vital Statistics Law of 1953, as amended. WARNING: It is illegal to duplicate this copy by photostat or photograph. 67467c3 No. Hto5-143 REV 1111006 TYPE 1 PRINT W PERMANENT BLACK INK Marina O'Reilly Matthew State Registrar APR~14 2012. Date COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH 101060 (See instructions and examples on reverse) STATE FILE NUMBER 2, Sez 3. Satial Sazany Number 4. Date of Deatl~ (Month, day, year) ~` o ~ 20G -10 -914q 10 -Z~ 6. Date of BiM (MoNh, day, year) 7. Binh ace ~ and stale or coon Ba. Place of Death Check on one " l.Z- Yrs. .. ~. Counry of DeaN &. Gry, Twp. f Deeds 8d. Fad6ry Nanre (If rat inst6ution, give shcet and number) i_r 1. Name of nt (Flrsl middle, teal suKa) aa` ~ • ~ 5. Age (Last Birtiday) Under 1 r Under 1 d Momhs pays Fours Mmaes ~v... 11. Decedents Usual lion ~nd of wale done du' most of Ida. Do not stele retl 12 Was Decedent ever M dre 3. Decedents Education Kind of Work of Bubmessl lndusVy U.S. Nnad Forces? FJemerdary 1 Secondary I Q 1 / `L Yes ^ No 1 1 16. Decedent's Ma6mg Address (Street, cfiy I town, slate, zip code) Decedents SZ ~ ~ W I' ~~ ~ ~ _L ~' ~~ AcWal Residence t7a Btate Ipr 17b. County V ~" ~Inalntc 5 19 18. Fathers Name (Frsl, mitlWe, last, sunal~I ~ L I~O ,^ ^ Hospital: Other ^ Inpatient ^ ER 1 Ou¢retienl ^ DOA Nursing Hone ^ Residence ^ ONer ~ Speey: 9. Was DecedaN of Hisparac Origin? No ^ Yes 10. Race: Anrencan Inds, Blade, Whhe, etc. (If yes, sped(y Chan, (SPA 1 , I Medan, Puedo Rican, etc.) W ~ \ only hi~est grade canpletedl 14. MaritM Status: Martied, Never Marred, 15. Survrvirg Spouse pf wrte, give maiden name) Cokege (1 d a 5+) Wkkwrea, Divorced Ispeadyl W~ awed Did Decedent LNe in a 17c. Yes, Decedent LNed M Twp. Townshry? 17d. ~ No, Decedent lived within Adunt LirntS ~ City IBoro Name (First, midde maiden surname) n v^r. 1~ . ~IOt_.US ~ ? _ /mt?DG~I•tJQ~~aVer ~J~~ I~ RyP~ I Prkil) ~ r , t . . w N a ~'~ ~' k 21a. McOad of ' ~ ~ ^ Crematbn ^ Doption i 21h. Date of Disposition (Month, day, year) or otiier ce 21c. Place of Disposition (Name ry pM )• ~ V 4 ~ ~ 21d. Location (Cnyltown, state, nP 1 N J ~`, Q ~ ~~ Burial ^ Removal Irom State i Was Cremation or Donation Aulhodzed ~ r hl' Ykdled Examiner) Coroner? ^ ~ ^ Yes Na ~ ~ ~ ~ ,~ f I ( 1 byl l~ll~ {~ . IQHp. • V~ . ^ r - S 22a. S' a of F ~ rat Serve Li`nssee pe acting such) 22b. Ucm~se Number _ 22c. Nairn and Address d FadMy ~ 1 ~ (` 1 ~ oV- 3 r ~e zu . ~ K ' 'ems23aeadywhencertityirg stated. Si hue and titia 23a.ToNe of ,deatho¢urtedattlietine,dateandplace (~ ) ~ r 23b. License Number 2 ~„4 ~,`' ~\Z~`~^ ~ (Month, day, year) 3c. Date S ~Q\~ Z~ \\ pMysidan H not avarkMa at time of death to N C ~~-l~'` ~ 1~` . cergty pure of dea - 24. Tme of Death 25. Date Danced Dead (Month, day, ypd 26. Was Case Referred ro Medx~l Examiner I Canner fa a Reason Other than Cremation a Duration? ~ ^ Items 24-26 must be completed by person raauxes deaN who ~\S r~ M. `~ 1 Q~~~\-~ ^ \\ ` c~7 Yes No D N? . p r Approdmate interval: CAUSE OF DEATH (See instructions and examples) i Onset ro Death DO NOT enter krtnmal events such as prdiac artesl d tie death d ' Pan II: Enter odcer sjgntfoant conditions contra to deatlu but not rasa m Use unde pose given in Pan I. ~ ~ dYu9 ea 26. Did Tobacco Use Contribu@ to ^ Yes ^ Probe . ry pore ue that d Hem 27. Pad I: Enter the dam' f~~- diseases, otjuries, w prtp~atiors' ogy. Usl only one cause on each line. ng ge etiol ho wi nwitlwiA s o ory arrest, a ventrkzrlar fihdlla0 respira r i ^ No Unlmovm t 1 } ~ ~ / ~ ~ ~ ~ ' C/~(,, -~ ~ (~ ~{7 /}~ Q ~+ `r 1 L~ `~ ~ mss/ 1 'V ^• ~ ~~~]~ ri N ~ I 1 `1 ~ V ~ ~ ~ 1 ewmrgsm dBa~ ~ arMidE"Aa~i r J n past rear l ot {regnant r N a to (a ~ a canserpecee o : Mn _ ~ O ~Jl r l ~/~ ~ ~ ' ~ ' i ~ ~ ~ ~ ~ ~ ~ V ^ Pregnant at time d death ~ Nol pregpnl, Mn pregiant wiNin 42 days S ~ pndtiom, d ~Y, h. I j~ i i iTa N ro pose fisted m tine a Due to (a as a cereequenc• on: Ercer UNDERLYING CAUSE r ~ r i ~ (~' , ~ ( ( of death ^ Not pregpnt, out pregnant 43 days to 1 year (disease a kipiry tltal initialed the c events resulfing m death) LAST. Due b (or as a pnsequerme oQ: r ~ r before dpth ^ Unknovm if pregnam wtihin the past year d ~ 30a. Was an Autopsy . 30h. Were Autopsy Fmdings 31. Manner of Death 32a. Date of Iquy (Montle, day, year) 32b. Descdhe How Injury Occurred 32c. Place of Injury: Home, Farm, Sueel Factory, Office Building, etc. (Speedy) Perlom~ed? Ava6able Prior to Completion idde l ^ H of Cause of Death? om NaNra Tme al Iryury 32d 32e. Injury at Wok? 321. If Transpodafan Iryury (Speedy) 32g. Laxtnn of iryury (Sheet, city 1 Mwn, sate) ^ Yes ~ ~ ^ Yes ^ ~ ^ Acddent ^ Pending Invesligatim ^ Suicide ^ CduM Not be Detemdned . M. ^ Yes ^ No ^ Dmerl Operator ^ Passenger ^ Pedestrian ^ Oti~er -Specify 33a. Certifier (check any one) sican certiymg pose of death when another physidan has pronaaeed dead and completed Item 23) ' (Ph 33b. Sig re Idle of Certif r ~ ,~, ~ [] ~ ~ ~ l~S~r Y 1 ~ ~~ ~ y . Candying phys¢en To the best of my knowledge, death ocwrted dueto the ceuse(s)and manner es stated-----------------------------"-- 33a license Nu r 33d. Date Sg (Month, da ear) • Pronouncing and cerUlying phyafaan (Physician both pronour~aig death and certirymg to pose d deaN) t~ /4 ~ ~ ~ ~ 33 ~ 0 ~~~ \` W To the beatotmyknowledge,deathaccumdetthetime,doh,andplace,andduetothepuse(s)arrdmennerasaMted__________________^ 'Y1 o Medic~lExamMerlCoroner w On the hasis of ezaminetbn and I or investigatio y opinion, death oceurted et the time, dare, and place, and due to the cause(s) end manner es stated_ 34. Nance Address of Peron WM tad Cause of Dee Item ZT) Type I Pnnt ~ 35. Registrars SI Wre ~ ~ ~ F - ) ,; 7 ~ f !i 1 h~,~ ~ ~],(') z Disposition Permit Na. ~~ ~ J V n :,~ c7 '~7 _: ~-T LAST WILL AND 'TESTAMENT ~ ~~ ^ ; ~' ~~; , PAUL J. HILTON ~~ "=-' '~ - ~ -- ti ~' ^~ I, PAUL J. HILTON, of Swatara Township, Dauphin County, Pennsylvania, being of sound and disposing mind, memory, and understanding, do make, utter, and publish this, my Last Will and Testament, hereby revoking all former Wills by me heretofore made. 1. I order and direct that my Executor, hereinafter named, shall pay in full as soon as may be conveniently possible after my decease my just debts and funeral expenses, including all inheritance, estate, succession and legacy taxes of whatsoever nature and kind, both State and Federal, to which my estate or the transfer of any property passing hereunder or otherwise passing by reason of my death, may be subject, and to charge such taxes against the residue of my estate, it being my intention that none of the aforesaid taxes or any of the property required to be included in the gross estate under the provisions of any State or Federal Law now in force and effect or hereafter enacted, shall be pro-rated among the persons interested in my estate and to whom such property is or may be transferred or to whom any benefit accrues. 2. I give and bequeath my furniture, furnishings, books, silverware, jewelry, pictures, objects of art and all other domestic and household effects and personal goods and chattels of every nature and wheresoever situate, in accordance with a Memorandum which I shall leave with this, my Last Will and Testament. Any of the above property not disposed of by my Memorandum shall be added to the residue of my Estate. 3. I give and bequeath Five Hundred Thousand ($500,000.00) Dollars to DOROTHY GOFFUS, of 4909 Franklin Street, Harrisburg, PA 17111. In the event that Dorothy Goffus should predecease me, then this share should be added to the residue of my Estate. 4. I give and bequeath Twenty-five Thousand ($25,000.00) Dollars to JOHN C. LATHROP and EVELYN LATHROP, his wife, or the survivor of them, of 4913 Franklin Street, Harrisburg, PA 17111. In the event that John and Evelyn Lathrop should both predecease me, then this share should be added to the residue of my Estate. 5. I give and bequeath Twenty-five Thousand ($25,000.00) Dollars to MARIE REAMS of 205 Treziyulny Street, Osceola Mills, PA 16666. In the event that Marie Reams should predecease me, then this share should be added to the residue of my Estate. 6. I give and bequeath One Hundred Fifty Thousand ($150,000.00) Dollars to CHARLES D. KOKOSKI and KATHY A. KOKOSKI, his wife, or the survivor of them, of 6209 Westover Drive, Mechanicsburg, PA 17055. In the event that Charles and Kathy Kokoski should both predecease me, then this share should be added to the residue of my Estate. 7. I give and bequeath One Hundred Fifty Thousand ($150,000.00) Dollars to ANDREW W . GOFFUS and SHERRY A. GOFFUS, his wife, or the survivor of them, of 943 Manor Drive, Steelton, PA 17113. In the event that Andrew and Sherry Goffus should both predecease me, then this share should be added to the residue of my Estate. 9. I give, devise and bequeath all the rest, residue and remainder of my Estate, to KATHY A. KOKOSKI and ANDREW W. GOFFUS in equal shares as follows: A. One share to KATHY A. KOKOSKI. In the event that Kathy A. Kokoski should predecease me, I direct that her share shall pass to her husband, Charles D. Kokoski and her issue, in equal shares. B. One share to ANDREW W. GOFFUS. In the event that Andrew W. Goffus should predecease me, I direct that his share shall pass to his wife, SHERRY A. GOFFUS, and his issue, including his son August Checci, in equal shares. 10. I nominate, constitute and appoint CHARLES D. KOKOSKI and/or KATHY A. KOKOSKI, of Mechanicsburg, Pennsylvania, or the survivor of them, to serve as Executors of this, my Last Will and Testament, to serve without bond of any type whatsoever. 11. In the event that both Charles D. Kokoski and Kathy A. Kokoski predecease me or are unable to serve for any reason whatsoever, I nominate, constitute and appoint ANDREW W. GOFFUS of Steelton, Pennsylvania to serve as Executor of this, my Last Will and Testament, to serve without bond of any type whatsoever. IN WITNESS WHEREOF, I have to this, my Last Will and Testament, set my hand and seal at the end hereof, this n day of March , 2002. 1 s-=- PAUL J. HILTON The preceding instrument, consisting of this and two (2) pages, was on the date thereof signed, published, and declared by PAUL J. HILTON, the Testator therein named, as and for his 3 Last Will and Testament, in the presence of us, who at his request, in his presence, and in the presence of each other, have subscribed our names as witnesses hereto. 1 _. ,, _ ;~ ~~ 7!/ G~~ `--°--`''~WITNESS ~~ ~ LC.:~.. WITNESS ACKNOWLEDGMENT AND AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ) ss COUNTY OF DAUPHIN ) On this 26`~ day of Marc , 2002, PAUL J. HILTON, John A. Roe and Ann M. Robinson, the Testator and the witnesses, respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his Last Will and Testament, and that he signed willingly, and that he executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as witnesses and that to the best of his/her knowledge, the Testator was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. WITNESSES: ' L ~ --.^= -, - r ~- (Seal) :L., ~u-v- (Seal) ~- ~ - ~ P J. HILTON ~` ~ i ~i - ' ~'t ;'t a ~:- ,;4-~ ~ (Seal) 4 Subscribed, sworn to, and acknowledged before me by PAUL J. HILTON, Testator, John A. Roe and Ann M. Robinson, witnesses, this 2~h day of ar , 2002. (.. ~ ~ - --~ Notary Public (SEAL) C~~r<''*.Cy~.d ~.:. wi'=i~T:" s..: ~'~':i3:'7 7w''tr'igC'. Y C..:,1+`+?ist~f :~~i!".~~":.i~`,~ s~:%r, irS-li.`1 ~:ii.:f~~+~!!~!1 IW~~r ~i) ~f~ ~'~L'~~1IJ~~,~(~~iC. lh"4:+~VIGY~v~ V~ 1'iG4~Yr~C'.A 5 MEMORANDUM To The Last Will and Testament of PAUL J. HILTON 1 • A picture of a Dutch boy and girl to Evelyn Lathrop of 4913 Franklin Street, Harrisburg, Pennsylvania. 2. Sligh Grandfather's Clock to Dorothy Goffus, 4909 Franklin Street, Harrisburg, Pennsylvania. 3 • An oil painting of Sheik to Charles D. Kokoski, 6209 Westover Drive, Mechanicsburg, Pennsylvania. 4. The marble top table to Kathy A. Kokoski, 6209 Westover Drive, Mechanicsburg, Pennsylvania. Date: PAUL J. HILTON 6 BEFORE THE REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF PAUL J. HILTON, DECEASED NO 21-11-1149 DECREE OF THE REGISTER OF WII.,LS AND NOW, this 31st day of October, 2011, upon consideration of the Petition for Grant of Letters filed by Charles D. Kokoski and Kathy A. Kokoski, for the above decedent and the instrument offered for probate as the Last Will and Testament, which is dated March 26, 2002, IT IS DECREED that pages 1-5 of the instrument be admitted to probate as The Last Will and Testament of Paul J. Hilton. Page 6 titled "MEMORANDUM" is not admitted to probate as it appears after the testator's signature and is not signed by the testator. IT IS FURTHER DECREED that Letters Testamentary are hereby issued to Charles D. Kokoski and Kathy A. Kokoski this date. They shall have all the rights and duties of a fiduciary under the laws of Pennsylvania and shall proceed with the administration of this estate according to law. /~~Gr~t 1.,~~2~,rQ~ Glenda Farner Strasbaugh, Registe Wills n .. . ~. o =- --.x~ -~ .T_ n .__.; -• m <., i +'J ~ ~... _ `_~ ~ -~ ..,~ ~ '...a, T' ~ _ =y l.~i ~) f _ a~ I- __ 'T.. l.~ ~: