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HomeMy WebLinkAbout09-04-121505610101 REV-1500 Ex `°1.1°' ~ OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Year File Number ^EPAPTMENI'OF PEVENUE Bureau of Individual Taxes INHERITANCE TAX RETURN -~ ~H , /~-" PO BOX 28o6oi RESIDENT DECEDENT ~ 'j` Harrisbur , PA 1'7128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 166-26-0923 06/05/2012 08/30/1932 Decedent's Last Name Suffix Decedent's First Name MI Houseman Ella ~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI N/A 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) (~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust U 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 ~ Attach S~haxOunder Sec. 9113(A) between 12-31-91 and 1-1-95) ( ) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number Andrew H. Shaw, Esquire (717) 243-7135 First line of address 200 S. Spring Garden St Second line of address Suite 11 City or Post Office State ZIP Code Carlisle PA 17013 REGISTER O~-MILLS USE ONLY, ~+. ..:7 ~w..- ~ T ..,.. -~ i . ~--,-7 -fi3 ~ ' ~ ~.-%. '" : t7' C'i C ~ _ "~' TE+FILED ,. z" i ~~-~i ~- ... ,~;-: .-;: -r- ~, ::; _~ `~ ~ ;.. -..r~ Correspondent's a-mail address: andreW ashawlaw com 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. SIGN F~ERSQNf~SPONSIBLE FOR FILING RETURN DATE ,~ ~fbDRESS 430 untain Roa 1V wville, PA 17241 SIG RE F HER THAN REPRESENTATIVE j DATE r A6DRESS 200 S. Spring Garden Street, Suite 11, Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J ,1 C ~) J 1505610105 REV-1500 EX Decedent's Social Security Number 166-26-0923 Decedent's Name: RECAPITULATION 1 0.00 1. Real Estate (Schedule A) ........................................... . . 2 1,667.82 2. Stocks and Bonds (Schedule B) ..................................... . .. 3. Closel Held Cor oration, Partnershi or Sole-Pro rietorshi Schedule C Y p P p P( )... 3. .. 0.00 4. Mortgages and Notes Receivable (Schedule D) ......................... .. 4. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 4,360.00 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. 18,304.38 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 00 0 (Schedule G) O Separate Billing Requested...... .. 7. . 8. ( g ) ................ Total Gross Assets total Lines 1 throw h 7 ........... .. 8. 24,332.20 9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. 1,659.40 1 ~a~' ~~ 10. 9 9 ( ) ............ Debts of Decedent, Mort a e Liabilities, and Liens Schedule I 10. .. ~ 11. Total Deductions (total Lines 9 and 10) ............................... .. 11. 3,386.50 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 20,945.70 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 00 0 an election to tax has not been made (Schedule J) ...................... .. 13. . 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. 20,945.70 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 0 0.00 15. 0.00 16. Amount of Line 14 taxable at lineal rate X .0 45 20,945.70 16. 942.56 17. Amount of Line 14 taxable 0.00 17 0.00 at sibling rate X .12 . 18. Amount of Line 14 taxable 0.00 18 0.00 at collateral rate X .15 . 942.56 19. TAX DUE ...................................................... ... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 1505610105 ,~ REV-1500 EX Page 3 rlaradant'c Cmm~lpte Address' 0.00 DECEDENT'S NAME Ella J. Houseman STREET ADDRESS 1128 Fairfield Street CITY Mechanicsburg STATE PA ZIP 17050 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount 3. Interest 47.13 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. File Number Total Credits (A + B) (2) (3) (4) (5) Make check payable to: REGISTER OF WILLS, AGENT. 942.56 47.13 0.00 0.00 895.43 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................... ...... ^ b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ ^ . ~ c. retain a reversionary interest; or .................................................................................................................... ...... ^ ^ x d. receive the promise for life of either payments, benefits or care? ................................................................ ...... If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death 2 . without receiving adequate consideration? ........................................................................................................ ...... ^ x^ 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(1.2) [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the 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. LAST WILL and TESTAMENT I, ELLA J. HOUSEMAN, of 1128 Fairfield Street, Mechanicsburg, Hampden Township, Cumberland County, Commonwealth of Pennsylvania, being of sound and disposing mi~~d, memory and under standi~~g, do hereby make, publish and declare this as and for my Last Will and Testament, hereby revoking any and all other wills and codicils heretofore made by me. FIRST. I direct that all my just debts and funeral expenses be paid from my estate as soon after my death as practically and conveniently may be done. SECOND. I direct that my remains be cremated in accord with my expressed wishes. THIRD. I authorize my personal representative to expend funds from my estate, in such amounts as my personal representative shall consider necessary and desirable for the purchase, erection and inscription of a suitable marker for my grave. FOURTH. In the event my son, ALBERT W. HOUSEMAN, JR., has not repaid the Twenty Thousand Dollars ($20,000.00) previously loaned to him and evidence of payment must be in written form signed by me, I give, devise and bequeath the sum of Twenty Thousand Dollars ($20,000.00) each to my children, KAREN L. NAILOR, VICKI M. CROMER, DEBRA J. COLLINGS and JOSEPH F. HOUSEMAN. If my son ALBERT W. HOUSEMAN JR., has repaid said loan, then he shall receive the same sum of Twenty Thousand Dollars ($20,000.00) as KAREN, VICKI, DEBRA and JOSEPH. FIFTH. I give, devise and bequeath all of my estate of whatever nature, be it real, personal or mixed, and wherever situate unto my children, KAREN L. NAILOR, VICKI M. CROMER, DEBRA J. COLLINGS, JOSEPH F. HOUSEMAN and ALBERT W. HOUSEMAN, JR., in equal shares, per capita. SIXTH. I direct that any and all Inheritance, Estate and Transfer taxes imposed upon my estate passing under my will or otherwise, shall be paid out of the principal of my residuary estate. SEVENTH. I hereby nominate, constitute and appoint my son, JOSEPH F. HOUSEMAN, as executor of this my Last Will and Testament. I hereby relieve my Executor from the necessity of posting security in connection with his duties, as such, in any jurisdiction in which he may be called upon to act insofar as I am able by law to do so. In addition to the powers conferred by law, I authorize my Executor, in his absolute discretion, to retain in the form received and to sell either at public or private sale any real or personal property owned by me at the time of my death. EIGHTH. I have made, or may from time to time make, a written memorandum expressing my desire to give certain items of personal property to specific persons. I urge my Executor and Beneficiaries to respect these wishes. Such a memorandum, if made, shall be stored in conjunction with this Will. IN WITNESS WHEREOF, I have hereunto set my hand and seal,to this, my Last Wi11 and Testament, consisting of two typewritten pages this (~ ~ day of ,2011. a r' fy L .~. _ I, ~ ,. . ~~` .,, ELLA J. HOUSEMAN Signed, sealed, published and declared by the above named Testatrix ELLA J. HOUSEMAN as and for her Last Will and Testament, in the presence of us, who, at her request, in her sight and presence and in the sight and presence of each other, have hereunto subscribed our names as witnesses. COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS. I, ELLA J. HOUSEMAN, Testatrix whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn or affirmed to and Acknowledged before me, by r° ELLA J. HOUSEMAN this 1l -= day /~• ~/ V, N ary ublic `~ NOTARIAL SEAL LINDA J PiPP Notary Public _ CARLISLE 80ROUGH, CUMBERlANl7 CNTII' My Commissipa Ex~-ints Jun 18, 2013 ELLA J. I-~OUSEMAN ~. - ~~ of, 2011. ~~ COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS. We, ~ ~- ~~. ~~~ ~ ~ I~~. ~r ~~~ ~ ~~- and ~~~ ~~ ~~ r-~~ ~, /d;~~.Lr- ~~ ~. the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw ELLA 3. HOUSEMAN sign and execute the instrument as her Last Will; that she signed willingly and that she executed as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the will as witnesses; and that to the best our knowledge, the Testatrix was at that time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. Sworn or affirmed to and Subscribed before me by ~-~ ~ ~ ~~~. ~ - ~ h ~- ~-,, ~`~ ~` ~' And ~~ ~ ~ ~- ~ ~~ • ~~ ,` ~ ~ ~t.,1C ~~ ' ,witnesses, t 2011 This C I --- day of G~,.~~.:.~' ~~-. ~l s ~~ ~. No ry ublic N©?ARIAL SEAL 11NDA J PIPP ~ Public CARLi$LE BDRtt, GUMBERLAND~~CN~ ~~ My Gommis~ion E~fir~s Jun 18, 2013 REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Ella J. Houseman 21-12-0645 All aroperty jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) Page f of 2 i. Prudential ~omputershare Computershare Trust Company, N.A. PO Box 43033 Providence, RI 02940-3033 Within USA, US territories & Canada 800 305 9404 Outside USA, US territories & Canada 732 512 3782 www.computershare. com/investor 00],992 ~IIIIIIIIIIIIIIIIII~I~~l~l~llllllll~lll~l~lllll~~ll~lll~llll~llll JOSEPH F HOUSEMAN EX EST ELLA J HOUSEMAN 430 MOUNTAIN ROAD NEWVILLE PA 17241 ~ IIFID III VIIIVIIIII IVIIIVIIIVIIIVIII lulVIIII II Pruden#ial Financial, lnc. -Sales Advice :~~: Trade Date: 16 Aug 2012 14:03 (Time) Settlement Date: 21 Aug 2012 Cost Basis Method: FIFO Shares/Units Sold Price per SharelUnit (USD) Gross Amount of Sale (USD) Trading Fees (USD) BankinglWire Fees (USD) Taxes Withheld (USD) Other Fees (USD) Net Amount of Sale (USD) 31.000000 54.235530 Covered Transaction Total: 0.000000 1,681.30 13.48 0.00 0.00 0.00 Noncovered Transaction Total: 31.000000 1,667.82 Covered ShareslUnits Sold Covered Cost Basis (USD) Covered Short Term GainlLoss (USD) Covered Long Term Gain/Loss (USD) Overall Covered GainlLoss (USD) 0.000000 NIA NlA NIA N/A PLEASE SEE REVERSE SIDE FOR IMPORTANT DISCLOSURES AND DEFINITIONS 1 L T R P R U "'~ OO1 ~;D700o3 ~ us.l tr.csal. il_ 395 2/00 1 992/00 1 992/i REV-1508 EX+ (6-98) r, ~ . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Ella J. Houseman 21-12-0645 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) l ,v~v \~ ° ~„ ;r ~")~I~~~y,~,111tl ~ ~`~TIF~~RT~~r I' ~" 'TIT"L~ FOi~ ~, '~f=~Ht`,~LE ~ ~ .r, ,~, ~~\~\jrl1~ h ~ II'y'~,~ f 1 rr~~ r ., ~ _ _ ~ .. 1 4 im i t~ w:.. i kt' ~ ~l r flglIryr~\4 all%'1!111' I ~ ~ '. 1l tf 1 i~ rr /. .ev~ .~,rnn '~ r..nain 1 .en Y 11 .. l nl ' 1 ' i 1~. i .an .nnoa `ri tt ~\~. `Lii~ 11 N\ t \lt 'i~~ i/~ ~~~"..wo~.r.•,n°°vuuai..new n•.xn°i..,nnn~nanna.r non "n..,.i.~„°°..,....~ ~~.d........,~ ................. 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I~\~~'~~n .~'MQ .L7Al` ~ VFa.~i 49yVKi~f ~ OG ~ 1 ` .,, 1 ~ ~ ` Cly~ r. ~7 p ~ . ~ ~ .-~ l p +~`~Illl~~t11~*A,rRk"' t U'~41a~ ~, t ,1 ~~ ~fWl$8, ~11~f ~~ ~~~ ~'~ ~~;Ma1'f Pl~ul°~\ I,, I,„, 1'4'111 b~~s'St~2d a5'"ICenants 1 t bmn~h~;~~n ~t~~~~101 one~~~i4vkhc~~,'fnfetesi:r~f%,~/~ ~ .i ,~o' „~1 1,~ ,, 1,,, 1 Ir r~e~° ~ ~ ur~l1'n ~ ~ ~1~Geas,>;tl pwnergne~ to his/~er';h IF OK estate}.. ~`~1''~ ~, ~.rrhlldrl, /~, \ 1 I i Mill }PERSON ADMINISTERING DAT+i ~ I ~'e.~,~ ~: ~ 1 iySP h1~N bATE:. , ,~~; -~ IF 110 uElv11 ~HEGK y ~~ ~~ ~ ,> t ~~ I ll" ,/ i~ I I l r ;~, /'~/r~ ~ 1111 :',~ ' 15~' ~~E~HOLDER~ t~ _ , ~, i~~j ~j/~~ t n~ /°\,'I Ili I 111 ~ 1 1 . , f r ~ o OITY , 4~! 1 l 5 I I d „I , I ~-~AT ' ' , ~~~ // / ~/"~ ~ TU_,, I I i. i I C I Ily rifRl II 7j ~ ~3NANC°~~L INSTITUTION NUMBER ~I,lll I I ~ ~ - II I I , ~'I ~' 1 ~ - I ,~~ 1'~.. Or 2ND LIEN DATA; II -+~ IF ~1~ #.IEN, ~l>•~OK _,. I `3~-'-~' 1 ~ ~~ ' ~I 1. anetl fierflby makes appllcalion is Gertflcal& of Title }o the vahkNa iJescrlbed ` ' ' <<I ;,. Ljr .i to tha encumbrances ano ocher legalclaims Set forth here, ~~ ~ ' p - ~ " ~ ~./ + 2ND. Lt~NHOLp~R, ~ ~ i II I I "~ ~,>s ~ . > STREET`, I ~I h l ~~ i~ /~ ~/'~yy ~` ~G ;SIGNATURE OF APPLICANT OR AUTHORIZED 51~,NEk} -. I i ~ 1 d..1r„J ~ l I I t 1 I 1 I ~ I i~'~1TY liil , I ~;I ll l i .1 „lld 8~"A~`E~ ~ 1~j~, II ' I';II .II I ,; II r~~~ ' FIN4NG,C~L 1NST17UT10N CUMBER ~,,,,_ t ~a ~~y/' - 41~ ~ TLIRE OF EO APPLICANT/TITLE OF' P;UTHORIZEQ SJ.GCILf3 - y v, , s, -~"V : HI ff~ll utu~iaanmlNl{IwmaminnuuuK.,r l 1.~'_.~..,.5!e,. , 1 ,~.r, I t11.q~trpn, ,~nt l'.Ir~:r csa~.nsu4lhw,w,~t~~,~',-,~v..,;';,~.,;u~~'urtiu~u„uL:.i~.tyW(~1„N:L,~,:eu~7~t.,,~~u;.,:~, ~>~9r(ie~uu:,,~:,r..~,.,.:~a(;<'._.~ .. -.,I,wu>&4to,. .°.nw~, ., .ea!m(4;uutf•° Kelley Blue Book i .~f ~~~~ Kelley Blue ~~Qk T`t~~ r,,A>tt ~~ ~, ,~~t; ~~. http://www.kbb.com/hyundai/sonata/2000-hyundai-sonata/sedan-4d/?... ~~ ~ -,-~ Y©u +can't fake fast.' ~~ ~ ~,~ • ~_~ vc= >~c total ~er~c~r.ii,~ei uv~~e:gc ror.---~ tl ~7T; yr€th~ n F y~ t ~ ~~ -rctcx-t~~t~d sror s,t ~cnsion ar~o 20,f Ibv,;t .~s of tc~rq~i~. s, \\ .ate\o\~~~ pvsAutin. advert'sement _ why ads? Your Blue Book® Value - ..~.. =- - ~ ~- ~ ~- ~ 2000 Hyundai Sonata "'-'~'"P~ Style: Sedan 4D "yl ~ . Mileage: 75000 Private Party Value Vehicle Highlights Excellent MPG: City 18/Hwy 26 $4,085 Doors: 4 Very Good $3,860 Drivetrain: FWD Good EPA Class: Midsize Cars $3,760 Country of Origin: Korea Fair $3,235 Your Configured Options Our pre-selected options, based on typical equipment for this car. J Options that you added while configuring this car. Engine Comfort and Convenience 4-Cyl, 2.4 Liter Air Conditioning Transmission Power Windows Automatic Power Door Locks Drivetrain Cruise Control FWD Steering Power Steering Tilt Wheel Entertainment and Instrumentation AM/FM Stereo Cassette New Cars You Might Like ~.:~~.. ~,r \ 2013 Hyundai Sonata `~.'~^~^ ~~~ ~~~ 2013 Mazda MAZDA6 ..~~:~ "~"~"' ~ 2013 Nissan Altima ..,~~a Max Seating: 5 Engine: 4-Cyl, 2.4 Liter Transmission: Automatic Body Style: Sedan Country of Assembly: Korea Safety and Security Dual Air Bags Side Air Bags Wheels and Tires Alloy Wheels 1 of 2 8/31 /2012 11:45 AM Kelley Blue Book http://www.kbb.com/hyundai/sonata/2000-hyundai-sonata/sedan-4d/?... Glossary of Terms Kelley Blue Bookp Trade-in Value -This is the amount you can expect to receive when you trade in your car to a dealer. This value is determined based on the style, condition, mileage and options indicated. Kelley Blue Bookp Private Party Value -This is the starting point for negotiation of a used-car sale between a private buyer and seller. This is an "as is" value that does not include any warranties. The final price depends on the car's actual condition and local market factors. Excellent Condition: 3% of all cars we value meet this criteria. This car looks new and is in excellent mechanical condition. It has never had paint or bodywork and has an interior and body free of wear and visible defects. The car is rust-free and does not need reconditioning. Its clean engine compartment is free of fluid leaks. It also has a clean title history, has complete and verifiable service records and will pass safety and smog inspection. Very Good Condition: 23% of all cars we value meet this criteria. This car has minor wear or visible defects on the body and interior but is in excellent mechanical condition, requiring only minimal reconditioning. It has little to no paint and bodywork and is free of rust. Its clean engine compartment is free of Fluid leaks. The tires match and have 75% or more of tread. It also has a clean title history, with most service records available, and will pass safety and smog inspection. Good Condition: 54% of all cars we value meet this criteria. This car is free of major mechanical problems but may need some reconditioning. Its paint and bodywork may require minor touch-ups, with repairable cosmetic defects, and its engine compartment may have minor leaks. There are minor body scratches or dings and minor interior blemishes, but no rust. The tires match and have 50% or more of tread. It also has a clean title history, with some service records available, and will pass safety and smog inspection. Fair Condition: 18% of all cars we value meet this criteria. This car has some mechanical or cosmetic defects and needs servicing, but is still in safe running condition and has a clean title history. The paint, body and/or interior may need professional servicing. The tires may need replacing and there may be some repairable rust damage. © 1995-2012 Kelley Blue Book Co.", Inc. All rights reserved. © 2012 Kelley Blue Book Co., Inc. All rights reserved. 8/31/2012-9/6/2012 Edition for Pennsylvania 17202. The specific information required to determine the value for this particular vehicle was supplied by the person generating this report. Vehicle valuations are opinions and may vary from vehicle to vehicle. Actual valuations will vary based upon market conditions, specifications, vehicle condition or other particular circumstances pertinent to this particular vehicle or the transaction or the parties to the transaction. This report is intended for the individual use of the person generating this report only and shall not be sold or transmitted to another party. Kelley Blue Book assumes no responsibility for errors or omissions. (v.12090) 2 of 2 8/31/2012 11:45 AM Account Transaction Detail Report ~"~' , Page 1 of 3 ~" Ascending ~ Descending Account Transactio n Detail Re port ~--~ ~~~' ~.~:~ Account Number: 5070081312 Sea rch Criteria: Post Date Effect Date Amount Balance DCN Pin Seq/Ref# Description 03/30/2012 03/30/2012 $150.00 $7,091.66 D N 6665 CHECK PYMTF IA CARDSERVICES0001208900564498 2 04/02/2012 04/02/2012 $58.80 $7,032.86 D N 6666 CHECK PYMTW ELLCARE0001209300910642 7 04/03/2012 04/03/2012 $1,261.00 $8,293.86 C N 202207384D SSA XXSOC SEC U S TREASURY 3030001208900431101 6 04/04/2012 04/04/2012 $150.00 $8,143.86 D N 522294846 CHECK 6667 522294846 04/04/2012 04/04/2012 $24.75 $8,119.11 D N 7898568 715655180A D&D 80086071820001209400645118 1 04/05/2012 04/05/2012 $38.00 $8,081.11 D N 0221157941 PREMIUM U NITEDHEALTHCARE0001209500825181 1 04/05/2012 04/05/2012 $2.00 $8,079.11 D N 2786021 8002512311P RIORITY 50 PL00001209600218299 8 04/06/2012 04/06/2012 $658.00 $8,737.11 C N 166260923 IRS TAX REF U S TREASURY 3120001209500755938 7 04/11/2012 04/11/2012 $400.00 $8,337.11 D N 086519626 CHECK 6669 086519626 04/11/2012 04/11/2012 $200.00 $8,137.11 D Y ATM WITHDRAWAL PNCPK2625 N0411 30386416 CARLISLE PK MECHANICSBUR PA 04/20/2012 04/20/2012 $100.00 $8,037.11 D N 6672 CHECK PYMTF IA CARDSERVICES0001211000852049 7 04/23/2012 04/23/2012 $367.00 $7,670.11 D N 085292198 CHECK 6671 085292198 04/23/2012 04/23/2012 $50.00 $7,620.11 D N 086072768 CHECK 6670 086072768 https ://www. cct.pncb ank. com/eaimsg/sb/EaiMessageS ervlet? S OURCE-CHANNEL=UNK... 6/8/2012 Accoulit Transaction Detail Report Page 2 of 3 Post Date Effect Date Amount Balance DCN Pin Seq/Ref# Description O~L/23/2012 04/23/2012 $0.07 $7,620.18 C N INTEREST PAYMENT O~E/24/2012 04/24/2012 $50.00 $7,570.18 D N 083155292 CHECK 6673 083155292 04i/26/2012 04/26/2012 $200.00 $7,370.18 D N EL 040 004 WITHDRAWAL TEL 04000 48604 OOOSTEL 040 0048604 0005 04/30/2012 04/30/2012 $1,200.00 $6,170.18 D N 524588597 CHECK 6676 524588597 04/30/2012 04/30/2012 $150.00 $6,020.18 D N 086422055 CHECK 6668 086422055 04/30/2012 04/30/2012 $49.00 $5,971.18 D N 085927713 CHECK 6674 085927713 05/02/2012 05/02/2012 $15.00 $5,956.18 D N 6675 AARP A ARP0001212200719679 6 05,/03/2012 05/03/2012 $1,261.00 $7,217.18 C N 202207384D SSA XXSOC SEC U S TREASURY 3030001212200556814 4 05,/03/2012 05/03/2012 $36.00 $7,181.18 D N 084906539 CHECK 6678 084906539 05,04/2012 05/04/2012 $58.80 $7,122.38 D N 6677 CHECK PYMTW ELLCARE0001212400540970 7 05/07/2012 05/07/2012 $400.00 $6,722.38 D N 083282338 CHECK 6680 083282338 05'07/2012 05/07/2012 $38.00 $6,684.38 D N 0221157941 PREMIUM U NITEDHEALTHCARE0001212500688071 4 05/'07/2012 05/07/2012 $2.00 $6,682.38 D N 5228257 8002512311P RIORITY 50 PL00001212800901066 8 05/'08/2012 05/08/2012 $150.00 $6,532.38 D N 522625056 CHECK 6679 522625056 05/09/2012 05/09/2012 $2,000.00 $4,532.38 D N EL 040 004 WITHDRAWAL TEL 04000 48603 0018TEL 040 0048603 0018 https : //v~~ww. cct.pncbank. com/eaimsg/sb/EaiMessageS ervlet?SOURCE-CHANNEL=UNK... 6/8/2012 Accoulit Transaction Detail Report Page 3 of 3 Post Date Effect Date Amount Balance DCN Pin Seq/Ref# Description 05/14/2012 05/14/2012 $9,468.80 $14,001.18 C N 0045494521 BROKERAGE P NCIIBP SETT0001213500816607 6 05/21/2012 05/21/2012 $500.00 $13,501.18 D Y ATM WITHDRAWAL PNCPK2624 N0519 30386416 CARLISLE PK MECHANICSBUR PA 05/21/2012 05/21/2012 $183.72 $13,317.46 D N 083471535 CHECK 6682 083471535 05/21/2012 05/21/2012 $37.00 $13,280.46 D N 6681 CHECK PYMTF IA CARDSERVICES0001214200321820 0 05/22/2012 05/22/2012 $0.07 $13,280.53 C N INTEREST PAYMENT 05/30/2012 05/30/2012 $50.00 $13,230.53 D N 084671128 CHECK 6660 084671128 06/01/2012 06/01/2012 $1,261.00 $14,491.53 C N 202207384D SSA XXSOC SEC U S TREASURY 3030001215100639349 9 06/05/2012 06/05/2012 $38.00 $14,453.53 D N 0221157941 PREMIUM U NITEDHEALTHCARE0001215600791951 1 06/05/2012 06/05/2012 $2.00 $14,451.53 D N 0631513 8002512311P RIORITY 50 PL00001215700061624 6 https://www.cct.pncbank.com/eaimsg/sb/EaiMessageServlet?SOURCE-CHANNEL=UNK... 6/8/2012 Rr::v-isle ~-x+ {IO-t~~) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Ella J. Houseman 21-12-0645 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: i' Hoffman-Roth Funeral Home & Crematory, Inc. 224.90 B. 1 ADMINISTRATIVE COSTS: Personal Representative Commissions: Names} of Personal Representative(s) Street Address City Year(s) Commission Paid: State ZIP 0.00 2• Attorney Fees: 1,300.00 3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation,) 0.00 Claimant Street Address City State Relationship of Claimant to Decedent 4, 5, 6, ~. Probate Fees; Accountant Fees: Tax Return Preparer Fees: ZIP 134.50 0.00 0.00 TOTAL (Also enter on Line 9, Recapitulation) I $ 1,659.40 If more space is needed, use additional sheets of paper of the same size. '~ ~ 1' ~ 7~ .4 icF~S . ,~:n e~,n,_: , s a.:e t~ ;_r~/ ~ v a_ae 3eCa e s L) i ._f ~ +~, ~ - Ai ~ ~: lip i_.A.~..~_; A ::- e9 , ~, , ;., ~ `~ t t, ~ ., ~ ° ~ ., , ~ ~. _gg _ l ~~Jut".T]~ i'~7'tt..if~3i:~~i1.z"t)~~.i 1llflf;~5 tit i~1 Y..;(. ~i.I.i Vicki M. Kohls June 19, 2012 1128 Fairfield Street Mechanicsburg, PA 17050 Statement of Funeral Expenses for: Ella Jane Houseman Date of Death: June 5, 2012 Account Id` 16568-133 PACKAGE.: Immediate Cremation OPTION 5 -Cremation $ 1, 990.00 Sub Total: $ 1,990.00 TOTAL FUNERAL HOME CHARGES: CASH ADVANCES: . $ 1,990.00 ~ 5 Certified Death Certificates at $ 6 00 each . Newspaper Notice -Sentinel $ 90.00 $ 10 Coroner's Fee 9.90 $ 25.00 Sub Total: $ 224.90 To#al Funeral Expense: $ 2,214.90 ~+~~tr~~1t~ 1Vlade• Total Payments Made: $ 2,214.90 Jc~ -~~lc Houseman Check 6685 S~~a~k Houseman Check Jun 11 201 ~ fifi84 Jun 11 2012 11S'00 109 PreNeed Discount Discount SecurChoice , PrN vs Cont Jun 19, 2t~'~Z .90 9fi,53 Check fi59fifi Jun 19, 2012 7,893.47 Balance: $ 0 00 Please return this portion with your Remittance. ~ Amount Enclosed Ella Jane Houseman Service ID#: 1fi568-933 ~. .. } ~_ ,. ~ tt «r -~ ~z ~ ~ i~ _ . - .. ~ - }.~ inn 3 , . - _.. _ _. - ...a ,r ^4: ~1rt ~ J i t i S .. - - - -~..-. -.- s 1 a, ~ ~ 4 } ~'r` Aye ~. ~ > P _ - . ~. ~!1 RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 HOUSEMAN ELLA J Receipt Date: 6/08/2012 Receipt Time: 12:38:51 Receipt No. 1070193 Estate File No.: 2012-00645 Paid By Remarks: JOSEPH HOUSEMANN HMW ------------------------ Receipt Distribution ----- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 20.00 CUMBERLAND COUNTY GENERAL FUN WILL 15.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 16.00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23.50 BUREAU OF . RECEIPTS . & CNTR M D AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL . FUN ---- Check# 6686 ------------ $79.50 Total Received......... $79.50 ~,~! ~R7GOp W~S3vR ar Q1.r~M aws wr ri..+v,r swsrwv s. ,. v., e..+...v.. is lnc.~rr~ct end cnmpf~te #arm on beck. rrrlllrrr~~lrsrrlrlrl~rrrrrrlllrlrrllrrilrlrrrrlrllrrlrlrrlr ~,-~****,-~*,-***~*;*3-~DiCI`t' 170 009037 ELLA J HOUSEMAN 1128 FAIRFlE~.D 57 ME~HA~1lCSBURG PA 170a0~1909 Plnnacie Heal#h Medical ~rOUp, Inc P{~ Sox 4243 ~.ancas#er, PA 17604--4243 oa$~~e~~aaaa~~~~~~oaoaa~~,~~o ~ PLEASE 4f~7"ACH AND RETUFtM TQP PC3RTfC?N W#TH YOUR PAYMENT nit '~ i3` 5.~. i:3$~i ~j 8~7t'S ti1$ [~;(';:. ELLA J HOUSEMAN ID# 38f24~./i(FNNETH R HARM JR MR 05/24/2OJ.2 QFFICE /OUTPATIENT VISIT ESTABLISHED PATIENT EXP PROBLEM FOCUSER 123.00 123.00 06/04/20:LZ HMG ~ SYSTEM CONTRACTUAL ADJUSTf~IENT FROM MEDxCARE -55.30 Ofi/0/2012 PAYMENT FROM MEDICARE 06/20/20],2 PAYMENT FROM AMERICAN PROGRESSIVE 46/24/201.2 PATIENT RESPONSIBILITY -YOUR MEf)ICARE PART B f)EDUCTIBLE IS NOT -67.70 67.70 COVERED UNDER YOUR SECONpARY INSURANCE CARRIER. BALANCE I~UE IS YOUR RESPONSIBILITY. BALANCE TICKET #PGHFPOOaS49 0.00 67.70 Fk,~~~~b`~i~~+s:~~~~ A"*~.d#a~8~~~c.~~i a#.~$ra~~~~~, A~~~~~ ~2~~'e~.d`~.~~~i ~ ~~~~'~''~ °~~~~~~~~€:~~ 67.7'0 ,, ~~~4~~.~~y~~~~e~~, ~~~~~~~~~~ o, 00 .~~~~~~~~,~~~~; ~~~~'~~ 67.70 ~~~~~~~:~~~~~ ~~~:~~ Pi~~aCle Health li~edi~al t~~~up, lr~c ` ~~~~~ ~717~ ~s2~a~7~ PL~AS~ pt~ l~AT SAND CASH THR~JUCH T~~ MA1L. F'(3PQ39 _ _ _ _ _ _ _ _esrr. ~___r~c ti nnoaaa~ __ or unoertnsureo wno a pay ~r~a yu~r~ry. rug i~turC .~~~~ !~ Mfr F ~ ~ ~ ~'Ai~~lB~D BT ~`or Account Information, ~~~h~A~Ii~SBUI~+~ i~A 17C~~t~-1909 ~1@ase Celt {"!''~7') 23A~371'~ or 7 -80Q-Oa3-~S~}~A~ for +C3u~ of Aria G~l~s. See details on the back of this staferrrent if payment has peen seat, p~iease disregard. day flniin+~ at: ~~ff~sifh-ll~~ay.pinnaleh~:aifh.o~'g ~. - „ .... y Patent IYi~~e. l~°i(}u5+enlt~~ ,~lla 1 oi~.s~ ~/h~. ~~i~. 'P.I.~~ ~~~. ~1~ Statement safe: 071'i3I92 Paymerr~s/Ac3just~ments: ~~~r.1~~.82- Ser~rice Date{s3: 8512#319 2~t~filgl/1 ~ Account Balance: s t. , I, 56 . p o A .c+~oaont ll~aab+~rr. 12 9 ~6a~ T8 f'a#ier~ Balance: ~ ~. , ~, 56 . p p .~ f.~ ^ +~I Aia~ M~~~no~~s ~VRAt~i. y ~ ~L.~J ~~~~ ~~X ^ ~~~ ~}IM#~w ~~'~~~wT~p i ~ . Ins, 1: i111l~DlGAi~B A ,t?p For questions, calf our Billing Help line at: ins. 2: DC?lUlllllBl~CiAL. (~T _00 X97--23D-3797 for focal calls or Ins, 3: 9-8t~Q-ti03-~3t364 for t)ut of Ar~:a. Ins. ~: Custot~ter Bcrwice hours: l~ton-Voted-Fd ~:tIU Al~ll to ~:{lD ~'~ ~ 'l`ues~-Thin ~':UO AM to ~:OU P11A nrfaxe ~;neck~ Payable Tea: P~nnaclehealth hospitals ! 1~~1~ 11~1~ il~ll ~~~~ l~~I ~ll~ ~il~ ~~~1 l~~~l ~!1 ~I ~~ac~~~~ea:~ ~~os~~ta~s o~ ~ ~~a~~~t~~ ~A ~. 7 ~ B~ Chack hpx it yaar Addra~ ar insnranrA inMrrnatiAn has chnngsd. Plaasn make chAng+an an baek. AnQ02~4~ QC11 ~.~3 ELITA hC~USBIUTAId 9128 FAiRFIBt~D ST iVIBChAlV1CSBtJi~~ l~'A 17t35Q~-9 ~D~ ~~ww~~~~~~~taa~~~~*#it~R~~t~~~~~ FINNAD~,B MF.ALwTh i-iC.~SI~ITALS P.t~. BtSaC 2353 hAfR~tISBURG, PA 171 p5~-353 h1- yaur rtiyaatm [Il~fipQ~-~Q~~S~'~~4tIB~11~Q~~5bt~tlQ~3ClDD~IDfJf~ l~Iease Ncr~o: Yt~t~' ~~tysf+r<ia~ will bf!/ sep;tely i~r pnc~s~iv~a s+~nr~ces REV-15o9 EX+ (o1-io) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Ella J. Houseman 21-12-0645 SCHEDULE F ]OINTLY-OWNED PROPERTY 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• Joseph F. Houseman 430 Mountain Road Newville, PA 17241 Son B. C. ]OINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR ]DINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. 10/19/10 PNC Bank Savings Account, No. 5006131725 22,157.21 50 11,078.61 2. A. 01101/79 PNC Bank Checking Account, No. 5070081312 14,451.53 50 7,225.77 TOTAL (Also enter on Line 6, Recapitulation) I $ 18,304.38 If more space is needed, use additional sheets of paper of the same size. Account Transaction Detail Report y " Page 1 of 1 .~. ,,e ~. ..,~~ ~; . a :,...,r ..~ ~' Ascending ~` Descending Account Transaction Detail Report ~ ~~~'`: Account Number: 5006131725 Post Date Effect Date Amount Balance DCN Pin Seq/Ref# Description 04/19/2012 04/19/2012 $2.40 $22,155.11 C N INTEREST PAYMENT 05/18/2012 05/18/2012 $2.10 $22,157.21 C N INTEREST PAYMENT https://www.cct.pncbank.com/eaimsg/sb/EaiMessageServlet?SQURCE-CHANNEL=UNK... 6/8/2012 1 1~1 V V111111G 1~Ciilll111~ Account Activity rit~,C t ul i Friday, August 31, 2012 ..; x,° Available Balance: $22,164.04 _~ ,F .~.._. .. _ . Pending 'Transactions These transactions have been submitted to us since the last business day and are not yet posted to your account. When they have posted, they will be reflected in your Posted Transactions. Pending items may affect your Available Balance and are not a statement of your account. ~~t~ €~e~r~rr~tic~r~ ~~`it~e~, aa~~als ~~~~s~.s This account has nv Pending Transacfians Posted Transactions Bare ~~esc~F~Yit~~ t~:~`if~~rat~Y~al~ ~e~aasif.6 ~a~artce 08/20!2012 INTEREST PAYMENT $2.25 $22,164.04 07/20/2012 INTEREST PAYMENT $2.18 $22,161.79 06/20/2012 INTEREST PAYMENT $2.4b $22,159.61 ® Copyright 2010. The PNC f=inancial Services Group, Inc. Al! Rights Reserved. Need Help? Celt us at 1-888-PNC-BANK (762-2265) https:f/vvw~.or~linebanki~~.pnc.com/alservlet/DepositActivityServlet?account=//////////4//~... 8/31 /2012 PO Box 725 New Cumberland, PA '! 7070-0726 _ .._.v._... _ _ .._.._. _- _ __.. __.__ _._-..........._..,.~..~._..__ ___. . ~....- ,_.._ .. .._ _.__.___.._.__~._.... -_...___ .___.._. _...__ . ___. ____._.___._..._.~---._____.___-- C~IflE'.~,r"I{']~1~ii~~'6 ,~~~3d~t!`C" Ti9~:~ t~~fi.l~~ Phoru~: tIY~ :t.:9.~ Cat'1~.Ci 1::sl~nr~~l: rCo~Ciw:t.~-/I~.1~.~ i~=ax. /':i~ ~~.~~C~C~;~~ 1=1T1rsii. ir~~il~i~~rxap~aBi~aiy~;taA~~Y~64~eCr~9`I'ic:~.c:urn t3ate of Service: 611!2012 15:02 plea c vic>it: arar we~bsi~e to providc~ insur~ncc: ~r m~akr p~ymer~i:, ~7nd Patient Name: HOUSEMAN, E~LA f<~r additional f~~ayment o}~~inns and frec.~~renLly nskE:d que:;tians: From: Harrisburg Hospital (Pinnacle) ~t~~~.~r~~~~~~~c~~:~i~~~e~s~~u`'~'i~~:.~~ To: RESIDENCE s • ~ .. a • r. We billed this claim to your insurance; however, they have denied the claim, This balance is now your responsibility. You may contact your insurance carrier regarding the denial. 1'tease remit payment for the balance Thank you. ;,. ,,. ~~~ 6/0'1112 SLS Non-Emergency Transpol A0428 1.0 429.15 429.15 6/01/12 Mileage A0425 9.9 7.50 74.25 T4ta1 503.40 0.00 0.00 ,. ~. t~E:'i'E1Ci-I El1Vr7 RL'fi URN E301~1'UM POR~rIQIV WITH YUUR PAYM~N'1". Ci~c~iit ~~r~l; ,~ j t :l MAS"f C:RC~1ttl) Cf VCt;A ~_] ~Mt:[txc~N I~XPRt SS I._I C)ISCtaVE:R E y s.{ ,~ ~.t li ~ a '' ii S ~rTltaUt'lt f~airl: Please make a~~y cor7"ection<, to address below. ~~f'C1Lf'f,11i'9~f: (:C11~4:r( M~~:c14~r.~ir~n ~ ELLA I'iOUSEMAN Please sand a vUlck~d nc~ck UR p~r~vide blformatinn ixrlaw. ~~,.~.~.-~ 1'!28 FAIRFIELD ST MECHANICSBURG, PA 17050 REV-1513 EX+ (01-10) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ] BENEFICIARIES ESTATE OF: FILE NUMBER: Ella J. Houseman 21-12-0645 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY REDoT otSList TOrustee(D jNT AMOOF ESOTATE ARE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1• Joseph F. Houseman, 430 Mountain Road, Newville, PA 17241 son 17,820.43 2. Albert J. Houseman, Jr., P.O. Box 544 Carlisle, PA 17013 son 339.75 3. Karen Nailor, 23 Cumberland Estate Drive, Mechanicsburg, PA 17055 daughter 339.75 4. Vicki Kohls, 1128 Fairfield Street, Mechanicsburg, PA 17050 daughter 339.75 5. Debra Collings, 28 Emlyn Lane, Mechanicsburg, PA 17055 daughter 339.76 1. 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: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. 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