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10-31-12 (2)
15[]561D143 REV-1500 Ex (01-101 ~ OFFICIAL USE ONLY PA Department of Revenue Pennsylvania coumy code year File NumSer Bureau of Individual Taxes °E°°"'"EXiO°"~"H1° Po Box zaosol INHERITANCE TAX RETURN 21 12 0034 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth O1 02 2012 08 27 1921 Decedent's Last Name Suffix Decedent's First Name MI METCALF ESTELLA R (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 ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-e2) 4. Limited Estate ~ qa. Future Interest Compromise ~ 5. Federal Esfate Tax Return Required (date M death a fter 12-1282) I~ g Decedent Died Teslale ~ 1 7. (geja tlh RLopy o/~i seta Living Trust O 8. Total Number of Safe Depoait Boxes LJ (Attach Gopy or Will) 9. Liti anon Proceeds Received 9 ~ 19. Spousal Povenv CredR{date of death ~ 11.Eleclion to tax untler Sec. 9113(A) (wean 12-31 91 antl -1-95) (Attach Sch. (tom r•s ~..2 ~ -~ CORRESPONDENT -THIS SECTION MU5T BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMA OULD B~11REC~ ^ Name Da time Telep y er~tlpmber i y ~ r~" GEORGE F DOUGLAS III "-I ESQ 7:17 24~~J733 W , c _; .' . Cn- r , aJ ~ REGISTER OF11lICCS USE~ILY ~ ";``~ - Q:. r1 - .p '` .'t First line of address ~; ~ tV 354 ALEXANDER SPRING RO c' Second line of address DATE FILED City or Post Office State ZIP Code CARLISLE PA 17015 Correspondent's a-mail address: gdOUglaB@Sa12tr1annhUghes.COm Under penalties of perjury, I declare that I have examined this return, including accompanying 5chetlules and statement=-" and to the best of my knowledge and belie(, it i5 true, dgmect antl complete. Declaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge. Lauren D. Metcalf, Jr. / O ^ dtlo SIGNAT RE OF PREPARER OTHER THAN REPRE ENTATIVE ~~ TE ~~~ G ~ George F Douglas, III Esq. I 0 ~ L$ ~~ Z 354 Alexander Spring Road, Suite 1, Carlisle, PA Side 1 150561[]143 1.'S17561U143 J PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF I FILE NUMBER Metcalf, Estella R. 21-12-0034 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. Signature #2 Name Address1 Address2 City, State, Zip Date Signature #3 Name Addressl Address2 City, State, Zip Date 26 Spend-A-Buck Drive Dillsbura//PA 17019 /G C1~2 Mount Holly Springs PA 17065 ~ 2~ 1 ~- Glenn E. Metcalf 228 Pine Road ,J REV-1500 EX Decedent's Social Security Number oeceaeor: Name Metcalf, Estella R. RECAPITULATION 1. Real Estate(ScheduleA) ...................................................................................... . 1. 169,000.00 2. Stocks and Bonds (Schedule B) ............................................................................ . 2. 112 , 87 6.94 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)........ . 3. 4. Mortgages 8 Notes Receivable (Schedule D) ....................................................... . 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .............. . 5. 23 , 03 6.44 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 62 , $ 02.80 7. Inter-Vivos Transfers & Miscellaneous h{oq-Probate Property (Schedule G) a Separate Billing Requested............ 7, 8. Total Gross Assets (total Lines 1-7) ................................................................... .. 8. 3 67 , 716.18 9. P ( )........._._ ................. Funeral Ex enses & Administrative Costs Schedule H 9. ........ 48 , 270.69 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ...................... ........ 10. 3 , 2 97 - 92 11. Total Deductions (total Lines 9 & 10) .......................................................... ......... 11 _ $1 , 5 68.61 12. Net Value of Estate (Line 8 minus Line 11) .................................................. ........ 12. 316 , 147.57 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ....................................... ........ 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................................... ......... 14. 316 , 147.57 TAX COMPUTATION • 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 .00 15. 16. Amount of Line 14 taxable 316 , 14 7 . 5 7 16. at lineal rate X .045 17. Amount of Line 14 taxable 0 0 0 17 at sibling rate X .12 . . 18. Amount of Line 14 taxable 0 0 0 18 at collateral rate X .15 . . 19. Tax Due ................................................. ................................................................ . 19. 150561243 0.00 14,226.64 0.00 0.00 14,226.64 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 1505610243 Side 2 1505610243 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-12-0034 DECEDENT'S NAME Metcalf, Estella R. __ STREET ADDRES:i 945 Forge Rd. CITY Carlisle ~ STATE: PA ZIP 17015 Tax Payments and Credits: 1. Taz Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 14,000.00 711.33 (1) 14,226.64 14,711.33 484.89 Total Credits (A + 6) (2) 3. Interest (3) 4, If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2 line 20 to request a refund 5. If Line 1 + Line :I is greater than Line 2, enter the difference. This is the TAX DUE. (5) Make Check Payable to: REGISTER OF WILLS. AGENT. PLEASE ANSWER THE' FOLLOWING QUESTIONS BY PLACING AN °X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :............................................................................... ^ b. retain the right to designate who shall use the property transferred or its income :.................................. ^ c. retain a revetlsionary interest; oc..........._ ........................._................._................................................... ^ d. receive the pfomise for life of either payments, benefits or care? .................................................._........ ^ [x] 2 fter December 12, 1982, did decedent transfer property within one year of death without o rr uatei .. 9 q consideration? .................................................................................................................... reoervm ade ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....... ^ ^x 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ^ ^x IF THE ANSWER TO ANY OF THE FjBOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 1 .~ u~ :.--~ 4 ... .s',~«.~~x.aa~a"~+.Fd-„*ix+:';. " =s'.~d`d'.;:~'~''w ~~.a.:;`~`Nra .~"!x~'e~fE;S'~ .. ~ ,3,,^: "=i+(, -.. ~ ;~.t r:;Y.-~f~, ...?s: 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 i[72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 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 statyrte does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and fling a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death oin 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 ofthe 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)]. A sibling is def red under Section 9102, as an individual who has at leas( one parent in common with the decedent, whether by blood or adoption. Rev-150E EX~111-08) SCHEDULE A REAL ESTATE COMMCNWF\LTH OF PENNSYLVANIA INHERIT4NCE TA% RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Metcalf, Estella R. 21-12-0034 All real property owned solely or as a tenant In common must be reported at fair market value. Fair merkel value is definetl as the price at which preparty would be exrhangetl between a willing buyer antl a willing seller, neither being compelled to buy or sell, both having reasonable knoaAedge of the relevant /ads. Real property which is jointlyowned with right of survivorship must be disclosed on schedule F. Attach a copy of the settlement sheet i(the property hac been sold Include a copy of the dead showing decetlenl's Intamst If owned ac tenant In common. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Real Estate locateq at 945 Forge Road, Carlisle, -South Middleton Township, (:umberland 169,000.00 Co., PA -See Settl¢ment Statement (HUD-1) attached TOTAL (Also enter on Line 1, Recapitulation) ( 169,000.00 (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule A (Rev. 11-OS) Rev-1503 EX~ (6-98) SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TA%RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Metcalf. Estella R. 21-12-0034 All propeM lolntlyowned with right of survivorship must he tliscloaetl on Schedule F. ITEM NUMBER C:USIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH MorganStanley Smith Barney 1 1,117.346 shares of American Balanced Fund A 18.21 20,346.87 2 15.7594 shares of Calamos Global Dynamic Income Fund 7.30 715.12 3 1,700 shares of CalamosStrategic Total Return Fd 8.35 14,195.00 4 185.418 shares of Capital World Growth & Income Fund A 32.12 5,955.63 5 300 shares of Dentsply Intl. Inc. 34.99 10,497.00 6 580.!161 shares of Growth Fund of America A 28.73 16,668.03 7 100 shares of Hershey Co. 61.78 6,178.00 8 112 shares of Motorola Mobility Holdings 38.8 4,345.60 9 128 shares of Motorola Solutions Inc. 46.29 5,925.12 10 250 shares of PPL Corp. 29.42 7,355.00 11 250 shares of Proctor & Gamble 66.71 16,677.50 Other Individual Securities 12 265.62331 shares of Corning Incorporated 13.085 3,475.68 13 36 shares of MetLlfe, Inc. 31.733125 1,142.39 TOTAL (Also enter on Line 2, Recapitulation) 112,876.94 (If more space is needed, adtlitional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev4609 EX~ (6-961 COMMON W EAITH OF PENNSY W ANIP INHERITANCE TA% RETNHN RE610ENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF (FILE NUMBER Metcalf, Estella R. 21-12-0034 Indutle the proceetls oflitigation and the date the proceetls were receivetl by the estate. PII property fointly-owned with the right o/ aurvivorahip must be diacloaed on schatlule F ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH MorganStanley SrrtithBarney 1 MorganStanley SrtlithBarney, Money Market Account No. 724-07735 4,173.03 2 Western Asset Mohey Market Class A 805.62 3 Met Life -Annuitypaymentonl/2/2012 198.16 4 2001 Buick Sedan • VIN 2G4WS52J211308442 4,000.00 5 Household furnishings - at net proceeds of sale 1,162.35 6 Household furnishings -taken in kind 1,500.00 7 Century Link -refund 5.41 8 Comcast -refund 11.02 9 Connect America.com LLC -refund 179.70 10 Sentinel-refund 35.55 11 The Hartford -refund unused premium 31.52 12 U.S. Treasury -refund 225.03 13 Metropolitan Life Insurance Company -Annuity Contract No. 000846205RB -beneficiary is 10,709.03 decedent's estate TOTAL (Also enter on Line 5, Recapitulation) I 23,036.44 (If more space is needed, atltlitional pages of the same siee) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rav-1509 E%~I6-e6) COMMON WEALTH OF PENNSVLVNNIA INHERITRNCE TR%RETURN ecmncuT!1Gf FnENT SCHEDULEF JOINTLY-OWNED PROPERTY ESTATE OF nt wllhin one year of the tlecetlent'a date of death, it mun[ be reported on ADDRESS 28 Spend-A-Buck Dr. Dillsburg, PA 17019 1914 Mary Lane Carlisle, PA 17013 SURVIVING JOINT TENANT(S) NAME A. Carol M. Turner g, Lauren D. Metcalf, Jr. C. NUMBER RELATIONSHIP TO DECEDENT Daughter Son JOINTLY UWntU rr ca~rcnt n. PROPERTY OF DATE OF DEATH ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF 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 ASSE % DECD'S INTEREST VALUE OF DECEDENT'S INTEREST 1 A&B 8131201A Members 1st Federal Credit Union, Certificate of Deposit No. 15978-00043 41,958.78 100.000% 41,958.78 2 ASB 81612011 Members 1st Federal Credit Union, Certificate of Deposit No. 15978-00044 12,293.69 100.000% 12,293.69 3 A 8/22/20{1 Members 1st Federal Credit Union, Certificate of Deposit No. 15978-00045 3,118.83 100.000% 3,118.83 4 AS,B 1112/19$3 Members 1st Federal Credit Union, Checking Account No. 15978-0011 508.66 33.334% 169.56 5 AFrB 912 711 9 8 5 Members 1st Federal Credit Union, Money Market Account No. 15978.0005 13.500.74 33.334% 4,500.34 6 AFrB 7112/191!9 Members 1st Federal Credit Union, Regular Savings Account No. 15978-0000 2,284.75 33.334% 761.60 TOTAL (Also enter on Line 6, Recapitulation) I OL,O VL.tfY (If more space is needed additional pages of the same size) Copyright (c) 2002 form software olnly The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98) REV~1161 EXi 110-06EE1WWgqIEEITT qq~~cc EERRNNEE gg~~JJ COMMN RESILIENTEDE~GEUENTRN ANIA ESTATE OF FILE NUMBER Metcalf. Estella R. 21-72-0034 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT N M R A, FUNERAL EXPENSES: See continuation schedule(s) attached B. I ADMINISTRATIVE ¢OSTS: 1. Personal Representakive's Commissions Narne of Personal Representative(s) 11,304.33 Street Address City State Zio Year(sl Commissiqn Paid Waived 2, Attorney's Fees Salzmann Hughes, P.C. 15,100.00 3. Family Exemption: (Ilf decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zio Relationshio of claimant to Decedent 4. Probate Fees 427.50 5. Accountant's Fees 6. Tax Return Preparer'S Fees 7. Other Administrative Costs 21,438.86 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 48,270.69 SCHEDULE H FUNERAL EXPENSES & \DMINISTRATIVE COSTS Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA•1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Metcalf, Estella R. 21-12-0034 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Carlisle Memorial $ervice, Inc. -lettering added to monument 273.00 2 Hoffman-Roth Funleral Home -funeral services 10,649.45 3 Nell"s -funeral reception 231.88 4 Rev. Gebilius - funjeral services 150.00 H-A 11,304.33 5 Other Administrative Costs Carol M. Turner - geimbursement for home improvement expenses paid to sell real estate in 430.53 order to administek the estate 6 Century Link - pholne service 1.95 7 Copenhaver Roofing - recaulking chimney Flashing to sell real estate in order to administer 75.00 the estate 6 Cumberland Chimney Sweeps -repairs to the chimney needed to sell real estate in order to 849.45 administer the estate 9 Cumberland Chim}~ey Sweeps -repairs to the chimney needed to sell real estate in order to 849.45 administer the estate 10 David L. 8 Jody M Kirk -seller assistance paid to sell real estate in order to administer the 5,000.00 estate 11 Glenn E. Metcalf -reimbursement for home improvement expenses paid to sell real estate in 198.73 order to administeY the estate Copyright (c) 2002 Form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-96) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Metcalf, Estella R. 21-12-0034 ITEM NUMBER DESCRIPTION AMOUNT 12 Help U Sell Detwil@r Realty -commission paid to sell real estate in order to administer the 4,000.00 estate 13 Lauren D. Metcalf, Jr. -reimbursement for replacement of car battery and inspection needed 126.03 to sell the automobile in order to administer the estate 14 Lauren D. MetcalfJr. -reimbursement for home improvement expenses paid to sell real 184.73 estate in order to Administer the estate 15 Met Ed -electric service 411.64 16 Met Ed - electric service 54.12 17 Met Ed -electric service 14.11 18 Met Ed -electric service 33.35 19 Met Ed -electric service 11.88 20 Met Ed -electric service 34.58 21 Met Ed -electric service 24.56 22 Met Ed -electric service 56.16 23 Prudential Homeslale Services Group -commission paid to sell real estate in order to 4,920.00 administer the esfr'ate 24 PSC Hazardous V1laste -refuse 20.00 25 Recorder of Deed9 - 1% realty transfer tax paid to sell real estate in order to administer the 1,690.00 estate 26 Register of Wills -.filing fees 30.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-96) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Metcalf, Estella R. 21-12-0034 ITEM NUMBER DESCRIPTION AMOUNT 27 Salzmann Hughes; P.C. -reimbursement for probate expenses reimbursement for payment 75.00 to Cumberland LaW Journal for legal advertising 28 Salzmann Hughes, P.C. -reimbursement for payment to The Sentinel for legal advertising 221.40 29 Salzmann Hughes{ P.C. -reimbursement for payment two short certificate's 8.00 30 Salzmann Hughes] P.C. -closing costs and final fees for income tax preparation, postage 1,000.00 and miscellaneou$ contingencies in order to administer the estate 31 South Middleton Township Authority -final water and sewer service 84.87 32 South Middleton Township Authority -water and sewer service 112.32 33 Sou[h Middleton Township Authority -water and sewer service 112.32 34 The Law office of Andrew H. Shaw -title services and lender's title insurance fee paid to sell 15.00 real estate in orded to administer the estate 35 The Virtus Group -radon mitigation system installed to sell real estate in order to administer 725.00 the estate 36 UGI -gas service 153.64 37 UGI -gas service 106.99 38 UGI -gas service 69.18 39 UGI -gas service 23.33 40 UGI -gas service 20.36 41 UGI -gas service 17.40 Copyright (c) 20021orm software only The Lackner Group, Inc. Forth PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Metcalf, Estella R. 21-12-0034 ITEM NUMBER DESCRIPTION AMOUNT 42 UGI ~• gas service 18.40 43 UGI -gas service 16.42 44 UGI -gas service 5.96 H-67 21,438.86 Copyright (c) 2002 form sokware only The Lackner Group, Inc. Form PA-1600 Schedule H (Rev. 6-96) Rev-1513 E%+It1-0a) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEOITH OF PENNSVLVNNIP INHERIT/1NCF TT% RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Metcalf, Estella R. 21-12-0034 Re~pon tlebts incurted by the decadent prior to tleath that remelned unpaid al the tlata of death, induding unreimbursed medical a%pensea. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Bonion -credit card payment 223.44 2 Cenkury Link -phone service 30.76 3 Christian Companion Caregivers -balance due on account 200.00 4 Comicast - balanceidue for T.V. cable serive 20.02 5 Hartford Insurance -automobile insurance 59.64 6 Lauren D. Metcalf, llr. -reimbursement for 2011, 1040 income tax paid 196.80 7 Lauren D. Metcalf, Jr. -reimbursement for 2011, PA40 income tax paid 109.00 8 Masland Associates -balance due for medical services 50.00 9 Masland Associat$s -balance due for medical services 25.00 10 Met Ed -electric service 136.34 11 South Middleton Township Authority -water and sewer service 110.80 12 UGI -gas service 166.46 13 VISl1-credit card pSayment 1,460.59 14 VIS/\ -credit card payment 509.07 TOTAL (Also enter on Line 10, Recapitulation) I 3,297.92 (If more space is needetl, additional pages of the same size) Copyright (c) 2009 form software only, The Lackner Group, Inc. Form PA•7500 Schedule I (Rev. 12-OB) SCHEDULE J COM IN~~W~;~.A~N~iE~F-?EOf~{N~$YRN ANNA 'b `~ ~ ~'t BENEFICIARIES ESTATE OF FILE NUMBER Metcalf, Estella R. 21-12-0034 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSONISI RECEIVING PROPERTY DECEDENT (Words) ($$$) I TMSABLE DISTRIBUTIONS [include outright spousal • dlstributlons, and transfers under Sec. 9116 a 1.2 1 Lauren D. Metcalf, Jr. Son 1/4th Residue 79,036.89 1914 Mary Lane Carlisle, PA 17013 2 Carol M. Turner Daughter 114th Residue 79,036.89 28 Spend-A-Buck Drive Dillsburg, PA 171019 3 GI'enn E. Metcalf Son 114th Residue 79,036.69 228 Pine Road Mount Holly Springs, PA 17065 4 Patrick L. Metcalf Grandson 1/24 th Residue 13,172.82 900 Mud Level load Shippensburg, pA 17257 5 Nathan J. Metcalf Grandson 1/24th Residue 13,172.82 216 Pine Rd. Mount Holly Springs, PA 17065 See continuation schedule attached Continuation 52,691.26 Total 316,147.57 Enter dollar amount for distributions shown above on lines 15 throw h 18 on Rev 15 00 cover sheet as a r o riate. NON-TAXABLE DIS RIBUTIONS: II. A. ;SPOUSAL DIST IBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) SCHEDULE J BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: Estella R. Metcalf 01/02120'12 179-14-7536 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) 6 Melanie A. Munson Granddaughter 1/24th Residue 13,172.82 3903 Dennison Ave. Drexel Hill, PA 19026 7 Lauren K.F. Metcalf Granddaughter 1/24th Residue 13,172.82 1914 Mary Lane Carlisle, PA 17013 8 William B. Turner III Grandson 1/24th Residue 13,172.81 28 Spend-A-Buck Dive Dillsburg, PA 1701 9 Eric Alan Turner Grandson 1/24th Residue 13,172.81 28 Spend-A-Buck Drtive Dillsburg, PA 17019 Total 52.691.26 1 LAST WILL AND TESTAMENT I, Estella R. Metcalf, of South Middleton Township, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do publish and declare this as and for my last will and testament, hereby revoking any and all wills by me at any time heretofore made. Item I. I devise and bequeath all my property, real and personal, in four equal shares, to my children: Lauren D. Metcalf, Jr., Carol Metcalf Turner, and Glenn E. I~/[etcalf, and one share to my six grandchildren to be divided equally among them. Item II. If any of my children should predecease me, that child's share will go to'~ its issue, per stirpes. If any of my children die without issue, that child's share wu'll go to my surviving children. Item III. It any of my grandchildren shall be deceased, his or her share will go to his or her issue per stirpes. If any grandchild should die without issue, his or htar share will go to my remaining living grandchildren in equal shares. Item III. I nominate constitute and appoint my son, Lauren D. Metcalf, Jr., artd my daughter, Carol Metcalf Turner, and my son, Glenn E. Metcalf, as my )executors. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 2002. day of _- x.., y ti .~G - Estella R. Metcalf Signed, sealed,:. published and declared by the above-named testatrix, as and for her last will an'd testament, who at her request, in her presence, in our presence, and. in the presence of each other, have hereunto subscribed our names as attesting witnesses: ~ ^ `-LJ) i ~~ ~)l~ -~ \ G r'} L U r ~ !l ~ C' 1~ ~ ~~.'i~ .. -:T~ C', COMMONWEALTH OF PENNSYLVANIA ) ss. COiJNTY OF CUMBERLAND _ t ~A n~ ~ , and Yl C ~~ ~' -~-, the witnesses whosle 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 testatrix sin and execute the instrument as her last will, and that she signed willingly and t at she executed it as her free and voluntary act for the purposes therein contained, that each of us in the hearing and sight of the testatrix signed the will as witnesses; and that to the best of our knowledge, the testatrix was at that time 18 ov more years of age, of sound mind and under no constraint or undue influence. ~, ~~ ~~/~~ Sworn to and subscribed before me n T H , 2002. this ~ day of 1 ^ - - ~~- SIB^~ A- y ~'sry U Notarial Seal Qepge F. Douglas, III, Notary Public Carlisle i3oro, Cumberland Crn~nry MY Commiasi~in Expires June 2f. 20C3 COMMONWEALTH OF PENNSYLVANIA ) ss. COUNTY OF CUMBERLAND ) I, Estella R. Metcalf, 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 thereim expressed. Estella R. MetcJa~lf ~ Sworn to and suxbscribed before me this ~T l- dray of , 2002. No ry Notarlat seal oeerq. f. Douo~~. m, Notary PuWie Comm ~~ Wires June 28, 2003 `,~Ilf~~;" ~.`~ct~fc~tlCft~.i~aa~euten-~nvwt/ •<: 1. Q FHA 2. ^ RHS 3. ^Conv. Unins. 8. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number: 12A5 6000032506 446-1356246703 4. ^ VA 5. ^Conv. Ins. C. Note: Tnis form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agents are mown. Iteme~ marked "(p.o.c)" were paid outside the closing; they are shown here for informational purposes and are not included in the totals. D. Name & Address of Borrower E. Name 8 Address of Seller F. Name 8 Address of Lender: David L Kirk, Jody M. Klrk The Estate of Estella R. Metcalf CBC National Bank 637 S. College Street, Carlisle, PA 77013 3010 Royal Blvd. South„ Suite 230, Alpharetta, GA 30022 G. Property Location: H. Settlement Agent: I. Settlement Date: 09/07/2012 945 Forge Road The Law Offce of Andrew H. Shaw, PC Disbursement Date: 09/07/2012 Carlisle, PA 17015 200 5. Spring Garden Slreel, Suite 11, Carlisle, PA 17013 South Middleton Township Telephone:777-243-7135 Place of Settlement: TitleExpress 200 S. Spring Garden Street, Suite 11, Carlisle, PA 17013 Printed 09/07/2012 at 10:57 am by SDC 100. Gross Amount Due from Borrower 400. Groas Amount Due to Seller 101. Contract sales price 1fi9,000.00 401. Cont2d sales price 169,000.00 102. Personal ro art 402 Personal ro art 103. Settlement charges to lrorrower (line 1400) 9,094.65 403. 104. 404. 105. 405. Ad'ustments for items aid b seller in advance Ad ustmenta for items aid b seller In advance 106. City/town taxes to 40fi. City/(own loxes to 107. County taxes 09/07/2012 to 12Y31I2012 139.66 407. County taxes 09/07Y20121012/31/2012 139.66 708. Scholl Taxes 09/07/2012 to 06/3012013 1,37fi.06 408. School Taxes 09/O7Y101210 06130/2013 1,376.06 109. ags. ng. a1o. 111. 4n. 11z. 41z. 120. Gross Amount DUe from Borrower 179,610.57 420. Grose Amount Due to Seller 170,515.71 200. Amounts Paid b or In Bahalf of Borrower 500. Reductlona In Amount Due to Seller 201. Deposit or earnest money 2,000.00 501, Excess deposit (see instructions) 202. Principal amount of new lo:an(s) 161,324.00 502. Settlement charges to seller (line 1400) 12,40099 203. Existin loo s taken subecl to 503. Existin loo s taken sub'ect to 204. 504. Pa od of first mon a e loan 205. 505. Payoff of second mortgage loan 206. Sellers Assist 5,000.00 506. Sellers Assist 5,000.00 207. 507. 206. 508. 209. 509. Ad ustments for hems un aid b seller Ad'ustmenta for Items un aid b seller 210. City/town taxes to 510. Cityttown (axes to 211. County taxes to 511. County taxes to 212, School Taxes to 572. School Taxes to 213. 513. 214. 514, 215. 515. 216. 51fi. 217. 517. 218. 518. 219. 519. 220. Total Paid b Ifor Borrower 168,324.00 520. Total Reduction Amount Due Seller 17,400.99 300. Cash at Settlement fromlto Borrower 600. Cash at SetOemenl tolFrom Seller 301. Gross amount due from borrower (line 120) 179,610,57 6g1. Gross amount due to seller (line 420) 170,515.72 302. Less amounts paid byflor borrower (line 220) 168,324.00 602. Less reductions in amount due seller (line 520) 77,400.99 303. Cash ^X From ^ Ta Borrower 11,286.57 fi01. Cash ^X To ^ From Seller ^B p~M may no .o e~ a,n o.ma.en,• wine no ~wuv 153,71d.73 ecemeee Previous editions are obsoleDe Page 1 of 4 HUD-1 700. Total Real Estate Broker fees 58°20.00 Paid From Paid From Division of commission Tine 700 as follows: Borrowers Seller's 701. $4,000.00 to Help USell Detwiler Realty Funds at Funds at 702. 84,920.00 to Prudential HOmesale Services Group Settlement Setlaement 703. Commission paid at settlement 8,920.00 704. Broker Fee to Prudential Homesale Services Group 295.00 800. Items Pa able in Connection vdlh Loan 801. Our origination charge Qnrludes Origination Pcinl %or $0.00( $5,589.46 (from GFE#1) 802. Your credit or charge(polnlsl for the specific interest rata chosen $-4,344.46 (from GFE#2) 803. Your adjusted origination charges (from GFE A) 1,245.00 804. Appraisal fee to Diversified A asses Servic $490.00 P.O.C. B' (from GFE #3) 805. Credit report to Foote Ca stet for Cretlit Plu: $21 B2 P.O.C. B' (from GFE #3) 57.27 806. lax service to from GFE #3 807. Flood certification to from GFE #3 808. fo 900. Items Re aired b Lender to be Paid in Advance 901. Daily interest charges from from 09N7/20121o 1010112012@$15.4694Iday (from GFE #10) 371.27 902. I4ongage insurance premium for months to Dept. of HUD (from GFE #3) 2,774.63 903. Homeowners insurance for years to Ede Ins. Exchange 856200 P.O.G(89Qrom GFE #11) 904. months to - (from GFE #11) 1000. Reserves De osiled with Lender 1001. Initial deposit for yourescrcrw account (from GFE#9) 886.68 1002. Homeowner's insurance 5 months 46.83Imonth 8234.15 1003. Mortgage insurance rtwnths $ 157.161month $ 1004. Property taxes nronths 8 O.OOlmonlh $ 1005. County saxes 9 months 36.721month $330.48 1006. School Taxes 5 months $ 138.111monfh $fi90.55 1007. Aggregate Adjustment $-368.50 1100. Title Char es 1107. Title services antl lender's lisle insurance to The law Office of Andrewh from GFE #4 1,443.50 15.00 1102. Settlement or closing fee to $ 1703. Ownefs lisle insurance from GFE #5 191,50 1104. Lender's title insurance $1,053.50 1105. Lender's title policy Ilmi18151,324.00 Lenders Policy 1106. Owners title policy limit $169,000.00 Owners Policy 7107. Agent's portion of the total title insurance premium $99600 1108. Underwnler's portion of the total title insurance premium $249.00 1109, Deetl Prep. Fee (POC) to Salzrman Hu hes $ 1100. Government Recordin and Transfer Char es 1201. Government recording charges $ (from GFE #7) 140,00 1202. peed $62.00 Mon a e $78.00 Release $ 1203. Transfer faxes $ (from GFE#B) 1,690.00 1204. City/County faxlstamps Deed $1,690.00 Mod a e$ 1205. Slate Taxlsfamps Deed $1,690.00 Mon a e $ 1,680.00 1206. UPI Fee Deed $ Mod a e $ 1207. $ 1300. Additional 8etllement Char es 1301. Required services that you can shop for (from GFE #6) 1302. Survey tp $ 1303. la 1304. 2072113 School saxes to Robert Caims i,fi91.12 1305. Final Walerl5ewerAa#Oi!i046 to SMTMA 84,87 •rr ~ ~ r ~ t 9,094.85 12,400.99 'Paid outside of closing by (B)orrower, (S(eller, (L)ender, Q)nvesfor, Bro1K)er, '"Credit by lender shown on page 1. "'Credit by seller shown on page 1. Previous edi[ions are obsolete Page 2 of 4 HUD-1 Cha ea That Cannot Increase HUO-1 Line Number Our origination charge M 801 5,569.46 5,589,46 Vour credit ar charge(po7ntsJ for the specific Interest rate chosen p 802 -4,344.48 -0,344.46 Your adjusted origination charges k 603 1,245.00 1,245.00 Transfer taxes k 1203 1,69000 1,690.00 Char es That in Total Cannot Increase More Than 70% Good Faith Estimate HUDI Govemmenl recording charges p 1201 150.00 140.00 Appraisal fee q 804 540.00 490.00 Credit report p 805 60.00 79,09 Modgage insurance premium g 902 2,774.63 2,774.63 p a 3,524.63 3,463.72 $ -00.91 or -1.1607% Char es That Can Chan a Gaod Faith Estimate HUP1 Initial deposit for your escrow account # 1001 2,391.75 886.68 Daily interest charges from p 901 §75.4694/da 464.OB 371.27 Homeowner's insurance p 903 507.00 5fi2.00 Title services and lenders title insurance p 1101 1,477.00 1,443.50 Owner's litre insurance q 1703 100.00 191.50 p Loan Terms Your initial loan amount is $161,324.00 Your loan term is 30. years Your initial interest rare is 3.5000% Your initial monthly amount owed for principal, interest, andany mortgage $881.58 includes insurance is Q principal X^ Interest 0 Mortgage Insurance Can your interest rate rise? 0 No, ^ Yes, it can rise to a maximum of %. The first change will be on I / and can change again every years after / I .Every change date, your interest rate can increase or decease by %. Over the life of the loan, your interest rate is guaranteed to never be lower than %or higher than %. Even if you make payments on lime; can your loan balance rise? Q No. ^ Yes, it can rise to a maximum of $ Even if you make payments on timay ran your monthly amoont owed for ^X No. ^ Yes, the firslincrease wn be on / / and the monthly principal, interest and mortgage insurance rise? amoum owed can rise to$ The maximum it can ever rise to is $ Does your loan have a prepayment penalty? ^X No. ^ Yes, your maximum prepayment penalty is $ Dces your loan have a balloon payment? ^X No. ^ Yes, you have a balloon payment of $ due in years on / I Total monthly amount owed including escrow account payments ^ You do not have a monthly escrow payment far items, such as property taxes and homeowners insurance. You must pay these items directly yourself. X^ You have an additional monthly escrow payment of 8221.66 that results in a total initial monthly amount awed of $1,103.24. This inGUtles principal, interest ar mortgage insurance and any items checked below. Q Property taxes ^X Homeowner's insurance ^ Flood insurance ^X School Taxes ^ ^ Nate: If you have any questions about the Settlement Charges and Loan Terms listed on this form, please contact your lender. Previous editions are obsolete Page 3 of 4 HUD-1 HUD CERTIFICATION OF BUYER ANU St LLtR I have carefully reviewetl the HUD-1 Settlement Statement and to the best of my knowletlge and belief, it is a true and accurate statement of all rea;ipls and disbursements matle on my account or by me in this transaction. I further certify that I have received a copy of the HUDt Settlement Statement. n Z~/ I~ David L Kirk ~ ~ ~ 1C4~1 Jotly M. Kirk The Es a of Estella R. Metcalf disbursetl in accortlance with this is a true antl accurate account or will cause the funds to be ~~' / - i~% DATE WARNING: IT ISA CRIME TO IMOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANV SIMILAR FORM. PENALTIES UPON CONVICTION CAN INCLUDE F. FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 18: U.S. CODE SECTION 1001 AND SECTION 1010. Previous editions are obsolete Page 4 of 4 HUD-i Name of Borrower, David L Nirk Jody M. Kirk Name of Se!ler: The Estate of Estella R. Metcalf File Number: 12-85 Prepared 09N7I2012 at 10:57 am Note: This page displays am itemization of the charges shown on line 1101 of the HUD-1 Settlement Statement This page accompanies but is not a part of the HUD-1 Settlement Statement. If a discrepancy exists, the information on the HUD-1 Settlement Statement applies. 1100. Title Charges Borrower Seller 1107. Title services and lender's title insurance to The Law Office of Andrew H. Shaw, PC 1,443.50 15 00 Notary Fee to Sarah D. Dieckman $ 25.00 Borrower Overnight Fee to The Law Othce of Antlrew H. Sh~$ 40,00 Bonower Document Prep. Fee to The Law Office of Andrew H. Shr$ 100.00 Bortower Tax Cert. Fee to Law Office of Andrew H. Shaw T $ 5 00 Seller _~ Notary Fee tc Sarah D. Dieckman $ 10.00 Seller 100 No Vio11100 to Law Office of A. H. Shaw/STGC($ 50.W Bonower 300 Surveyl300 to Law Offce of A. H. ShawISTGC($ 50.00 Borrower 900 EPL-Res18.1 to Law Once of A. H. ShawISTGC($ 50.00 Borrower ClosingSvcLtdCL to Law Office of A. H. ShawISTGC($ 75.00 BOnower Subtotal E 405.00 1102. Settlement or dosing fee to $ 0.00 1104. Lender's title insurance to Law-0Hice of A. H. Shaw/STGC($ 1 ,053,50 N09. Deed Prep. Fee (POC) SellerlLender credits shown on oaoel to Salaman Hu hes $ POC=Paid Outside Closing 0.00 Previous edi[ion5 are obsolete Page 1 of i HUD-1 _ _ Corning Inc., GLWr Historical Quote - (tiYSE) GLW, Corning Inc. Stock Price - BigCha.r... Page 1 of 1 ii Chsrts' a ......= alNwwMe ECIpr 3ym Cmsn Y.eywcr~e SEARCH . 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F(sHex Invesnlexn~ Yw.rswwunrrale~~J~:_met ._... .. _. trleN.'in~1.UZka Home Oumee N•vn Inautltln MewN• Hlnpdcal °upbe 919Repons TDis Hi51DeuI.GuMes IDDI aMwi you iD bOk up D secnrAy3 exatl tlosinp pri4. 61mDly tyce In Ne symMl enC a rrislonul tlele ID Wew a 9uol¢ enU mini Rren ror slat secuMy. ~': Enter symbol. met ~ Enter°ate 1/07/12 Mel Lite Inc. -- Trre aan na. 2orz < _.- ]2.66 ~r<r 72.67 73.5175 - ]1.99 ---~ 9,66],771 No S tits P $ponsoree Llnka Brain Tumor Symptoms Leatling me Quest in Diagnosis of Brain Cancer Tumor Symptoms Geea~swaleee Inheritance Taz Find Inheritance Tax Near Vou. See Actual Customer Reviews! Loralalm Is He Cheating On You? 1) Enter His Email Address 2) See Hidtlen Pics 8 Social Profiles Now! srokm[nmrFine.cnealers Constipahon Symptoms Feeling Constipated? Leam Alwut How To Treat Constipation Symptpms Now sannrnrmccom „/ Looking iar ~ Mwllrlllie a broker?a broker? TreD¢ Tree for BO Ceys . G¢I uD to fa00 wily TO Amemntle S e • ! Compare Brokers M~F•wI•M 8rtr Gerpr GcDllr•CV. i> TrNes, F•sl FyeculiDn9 tl°„w I AMN I ~sl¢ CepYrgDl X11] MscB•M14ske, In[. AM npM• re•erveE BY UaInH m'n arte, Yau •9m to geT~n rUa!•nD Pm•c Pdw upEeleO IOn VID11) Inbee•y pe10 D~DVM•E by 61%T•blun ene •u>p[I to lema W rL Halo n=et one [anent enD~eldBy 061a pr0nele ey $I%Tekkvrs. Inlr•eay eMB DllByee per a.[~•npe lepuvem•nh p[w Jan•s Inee.ea (SM(Mm pew Jon•B 8 Company, In[ All Huoles ale rn local e.cnenH¢ nme Feel lime last sale O%0 peovkee by NASpRO Mete Inlarm•Ipn on NASpAO b•eee avrMNS enO me==un•nl lin•nci•I MMU• mwtlry aa. aal•r•a+s mmw.! ror N.•e•s. •ne sD mnm![ ror omer!!=n.nse! oow Joeee mal.!•sM nom pow JoneB s ewnp•nr. m= ssXe mve.y em le proorDee ev six r.ux,ln •ne r• n I•.n eumlBm•. albym. al pum!• •a m m[e e.=n•se bml. http://bigrharts.marke$watch.com/historical/default.asp?symb=met&closeDate=1 %2F3%2... 3/28/2012 _:t ~. ~. _..-_ t~t ~ 11',1. I'.1 ',_. ~!!:. ~. :n .... ~ .. ..,1! '. _.. ., _. ,anaar,, 27, 2012 M org a nSt a n ley Salzmann Hnghes, P.C. S m it h B a r n ey Attorneys a[ Law Atm: Cleorge F. Douglas, II I 354 Alexander Spring Road, Suite I Carlisle, PA 17015 Re: Estate of Estella R. Metcalf, Deceased an Ol/OZ/2012 Account #'s: 724-07735 Mc Douglas: Per your request, please end the date of death values for the above referenced accounts Accoant # 724-07735 Svmbcil Cusi Description uan[ity ~_ Price L00 Total 62 805 SBCX 714992955 Western Asset Money Market 805.62 . CI A BDP 123992711 Bank Deposit Program 4,173.03 1.00 4,173 03 (Money Market) XRAV~ 249030107 Den[sply Intl Inc. 300 34.99 10,497.00 HSY 427866108 Hershey Co. 100 61.78 6,178.00 MSI 620076307 Motorola Solutions Inc 128 46.29 5,925.12 MMI 620097105 Motorola Mobility Floldings 112 38.80 4,345.60 PPL 69351 T106 PPL Corp 250 29.42 7,355.00 PG 742718109 Procter & Gamble 250 66.71 16,677.50 C}{W 12811 LI07 Calamos Global Dynamic 15.7(194 7.30 115.11 Income Fund CSQ 128125101 Calamos Strategic Total 1700 8.35 14,195.00 Return FD SH BEN INT ABALX 024071102 American Balanced Fund A 1117.346 18.21 20,346.86 CWG!IX 140543109 Capital WOrld Growth& 185.418 32.12 5,955.63 Income Fund A AGTHX 399874106 Growth Fund of America A 580.161 28.73 16,668.02 $113,237.49 TOTAL If you have any question s, please feel Gee to call me at (717) 730- 1816. 'Thank. you, ~ n r + t~~ ~ r 1 ~ ~ /~ t ~ i ~ { ^1 f ,.. r • ~~ ;_~ ~ , ! L ~. ~ ., (,J ~ . ----- IiFF11~ ~ , fA r,~. ... 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CI .S._-_.f c:'v r1' 5. ....T 4V ~rv W. :l=t t t : . ± oeL~,~r...r: ~,1_ EST ~:_..=1__A ..ETC:-II_r- -- c_a_.,_; ='gig==: U~•;I~,1,: ~-l2ryo _. -, C:=iF;CL TU':NEt Via, .~r~Lr-J:'l' ri Alfa": ii F: ~ 1 ~~ i ~' i_4I_ i'J r'!= i -i'~ ~ 1 J :_ ~. _ I}Bill ry85CT"A~~:1Oil °f 1C:B >!~'y' TG'c.I L40 ~{ 'C+. -- ~_ 11'1>}T ._ ~ ll_~Y-. .. `i. 'mi'l J~.IIbS r,_,,`IyiJ'~ 1 ~. k0 r Inrr 1 .S ll. 4T ll -- ur~vEFt cLOTf DES 1 i m. elm -- hOLL CLOTHES 1 5. k;l DCl . C_L O-''LIFE= 4. ~0 , 1 •g. w~J _ aHT.~ -- DRESS J'~ I,LOVE I I CT 1 ~+. n7 LraDiES '='~UIT 1 i.a~1l ht:~r.E uP ,. Il ~` i '/ Ln Il~:l 1 .I?L~ J. _. i '~ iL Il - r~.~r~ LII?Ic v_ i i. k'. •i - URESU - 1=.2i - ^JRESS ~ 3. Q~+l Df~ES~..; 1 1r.0'ti - L w u- Fi v 1 '. _ -l;~gcE 1 _. Ill ERGS;; 3. y?Il - UrtES~ 1 ~0 1~.4 r ;~ " r. r. .7 r'G i:. .. 1 'rl , kh ~r -- UREi~S ! 3.4T'l -- Dr:ES~ '7, tLll - h1ILITGR`f 1 "I`~' - PRESSES 1.k~ ufi ter". "_ i _. Iia - DRESS 1. ~' ... ~^ u. rtG°''"=. .. i °. 4%.~ , zT _. ...,~. Dit~=_ r.. a._ 1„I-l1`i~'~.1 EC~ - 11-~• !''-1 ~~ul_L. ~~r~ l- _ _;.. ':~I N. `1dA1"n. CUm i-ii~r.~^' _ ~.{I-11 ~~ i[7 `~ Settienent =1-',2 E'~T E'-TEL.I_G h!=TCcaLi- 3ellcr. 7~t?!~~ ...'C f~AF.UL TURN-+. - nnr m r{~ ~r is r.~ ~:i} .Jr ~:. r'v i1 F ~~~_:} vet J; LL ~13L'Rv P:-1 1 ; 019 It-ell i:B3C'Y'1F~tliiil '-' Llr'rr~iJ TOTE _ G f i 4i i 5 5: O n 2+. t ..~ 4_l . v''. ~ l ?1 ~ =r 3_ -32~t6 F'ric_e ~6Y 1 l l 1 Items: ~+9 amount: 9E-,..?0 _e>s _.d;il~.stolants. Total _~ . 0 z J. ~L L~ 3. 041 321.00 2~4. ?13 S~ MEMBERS 15` FEDERAL CREDIT U VION REGULAR SAVINGS ACCOUNT: Account Plumber/Suffz 15978-00 Date Account Established 04/09/1974 Principal Balance at Date Of Death $2,284.73 Accrued Interest to Date of Death $ 02 Total Principal and Accrued Interest $2,284.75 Name of Join[ Owner Carol Turner 07/12/1979 Date Joint Ownership Established Lauren Metcalf Name of Joint Owner Date Joint Ownership Established 07/12/1979 CHECKING ACCOUNT: 15978-11 Account (Number/Suffix 11/03/1977 Date Account Established. 66 $508 Principal Balance at Date bf Death . Accrued Interest to Date df Death $.00 Total Principal and Accrued Interest $508.66 Name of Joint Owner Carol Turner 11/02/1983 Date Joint Ownership Established Lauren Metcalf Name of Joint Owner Date Joint Ownership Established Og/03/2011 MONEY MANAGEMENTjACCOUNT: Account NumberlSuffx 15978-OS 08/27/1985 Date Account Established 500.63 13 Principal Balance at Date'~of Death , $ Accrued Interest to Date of Death 11 Total Principal and Accrued Interest $13,500.74 Name of Joint Owner Carol Turner 09/2 711 8 8 5 Date Joint Ownership Estiablished Lauren Metcalf Name of Joint Owner Date Joint Ownership Estlablished Og/03/2011 CERTIFICATE OF DEPG'~SIT: ' Account Number/Suffix 15978-43 Date Account Established) 08/03/2011 Principal Balance at Data of Death $81,957.52 Accrued Interest to Date pf Death $1 26 Total Principal and Accruied Interest $41,958.78 Name of Joint Owner Carol Turner Date Jolnt Ownership Established 08/03/2011 Name of Joint Owner Lauren Metcalf Date Joint Ownership Established Og/03/2011 15978-04 " 15978-05"' OSID6I2011 08122/2011 $12,293.32 $3.118.74 $.37 $.09 $12,293.69 $3,118.83 Carol Turner Carol Turner 08106/2011 08/22/2011 Lauren Metcalf 08(0612011 'Roll Over from Certificate on Deposit 15978-40, Originally Established 12(30(2010. "Roll Over from Cenificate df Deposit 15976-41, Originally Eslablishetl 01/06/2011, Certi(cate of Deposit 15978.41 was a roll over from Cenificate of Deposit 15976-441, Originally Established 02/06/2006. •^ROII Over from Certificate pr Deposit 75978-42, Originally Eslablisned 0 312 412 0 0 5. VISA: VISA Account Number VISA Balance Date VISA Opened Joint O~Nner Estate of: Estella R. Metcalf Date o1'' Death: 01/02/2012 Social Security Number: 179-14-7536 4672090000264192 $509.07 02/05/1992 N/A MEMBERS ts' FEDERAL CREDIT UNION / /J r Leigh-Ahne Stallings J Lending Insurance Support Specialist January 24,2012 -... ... 5000 Louise Drive P.(7. Cios d0 ~lechnnicsbuxg, Pennsknnia 17055 (800) 283-23'_'8 ua-wmembeTSlst.ocg -~ ~ ~ INFORMATION NUllla FILE N0. 21 12-0034 BUREAU OF IND]'.VIDUAL TAXES AN D PU BDX 290601 Pennsylvania AcN 12106944 HARRISBURG PA lnz9-oeol oaenaTncrvr oe eevfnuc TAXPAYER RESPONSE DATE 01-30-2012 PEY-154] Er I.IP 105-Ill CAROL TURNER 28 SPEND A BUCK DR DILLSBURG PA 17019-9377 EST. OF ESTELLA R METCALF SSN 174-14-7536 DATE OF DEATH 01-02-2012 COUNTY CUMBERLAND REMIT PAYMENT AND frO RMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provi detl the department w:[h the information below, which was used in calculating the inheritance tax due. Recp rtls indicate that at the death of the above named decedent, You were a joint owner/beneficiary of this account. If y0U are the SDDUSe of the deceased and amy amount other than zero is reflected below on the Potential Tax Due tine, note no tax may be due. but you must notify the daps rtment of your' relationship to the deceased by checking Box C in PART 1 Deiow and writing "spouse" 1n PART 2. If you believe ,.he information is incorrect, please obtain written correction from the financial institution, attach a coDY to this form and return it to the above address. Please Call 717-787-8327 with Dues ti ons. COMPLETE PART 1 BELOW at SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account ho. 15978-43 Date i->t--Bit~Ytt'L'tl- To ensure oro Der credit ko th¢ account, two Account Balance Percent Taxable A mo unY Subject to Tax Taz Rate Potential Tax Due Established E-3-~0\~ $ 41,958.78 X ~ .045 S 'i'ti Y. u T ~-=r~- copies of this notice must accompany paYmeni to the Resist er of Wills. Make check payable to "Resister of Wills, Agent". NOTE: If Sax pat me nis are made within three months of the dace dent's tla to of death. deduct a 5 percent tli scount on the fax due. AnY inherit ante Sax due will become delinmuent nine months after the date of tla ath. E A. ^ The above information and taz due is correct. Remit Davment to the Register of Wills with two copies of This notice to obtain a discount or avoid interest, or return this notice to the Resister of Wills one C H E C K an mffici al assessment will be i ssued by the PA Department of Revenue. ONE BLOC K B. ~ The above asset has been or will be reported and tax Daid with ihrr Pennsylvania inheritance tax return D NL Y 'filed by the est eta representative. C. ~ The afro ve info rma ion is incorrect and/ar debts and tla tlu ctions were paid. Fompl ate PART ~2 end/or PART 5^ below. ..,,yy~~ PART If indicating a tl!i ffer¢nt tax rate, please state f+ 32,y: rs FF ~ 1Y 'OS' ~~ ~'". ^ relationshlp to decedent: ~~h~` ~ ~'~ ~ `~itl ' 2 s~~"ri'~~~A?'OEPA7k ~ l~11 TAX RETURN - CALCULAh•ION OF TAX ON JOINT/TRUST ACCOUNTS P,AI~h `" LINE 1. Dale Establlshetl 1 ~~~~M~t* e ~ ~~ h a, 4~ 2. Account Balance 2 +S ~re~ '~''~Ri~$+R, .n .,. ~~ S. Percent Taxable 3 X ,,,, 3u~~~ +~rs;x, `' 4. Amount Subject to Tax 4 $ ~~~ ~~~~~~'9~*`§~.~`s~I~k 5. De bf:; and Deductions 5 - T'~~ ~}T~~~~'~~n~~ ~r `li#= t~ gyar v mf,i'"~.a~~~s'~iuxv.g~r ~..T~e ,n Xs 6. Amount Taxable 6 '~ ,, 1' ~ i , 7. T a x R a t e 7 X ~ N.p .~~~' a a'~.4~' +a' ``'`:~Y~?-.'~~'h~ t*'~e ~ 4~` V' s Y' ih y S ~S 5:F *fi. w4 fi 8. tax Ilu¢ B $ r',, ,B' s„'~ 6it"a rS.fxn~tz~'"+.8 ~" 's"+ V",'x PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE - DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare toot the facts I reported above are true, correct and complete t~t,.he^be_st of my\kn~ow l~e~d,9~r~a nd belief. HOME C ) }~^ ~'` ~C!7-<~ L/~9" "1-z-~ WORK ( '~ 1Z ) ~V /i - (C~-51 ~ :~ ~ ~''~u / 2 BUREAU OF INDIVIDUAL TA%ES PO Box 280601 HARRISBURG PA 17128-0601 A. ^ INFURMAIlUN NUI1Ct AND TAXPAYER RESPONSE FILE N0. 21 12-0034 ACN 12106945 DATE 01-30-2012 LAUREN METCALF 1914 MARY LN CARLISLE PA 17013-1043 EST. OF ESTELLA R METCALF SSN 179-14-7536 DATE OF DEATH Di-o2-2012 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS TD: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA ].7013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the tlepa rtment with the information below, which ways used in calculating the inheritance tax tlue. Petards indicate that at the death of the above named decetlent, yeu were a joint owner/Denefi cia ry oT this account. If you are the spouse Of the deceased and any amount other; than zero 1s reflected below on the Potential Tax Due line, note no tax may be due, but you must notify the department of youd relationship to the deceased by checking Box Lin PART 1 below and writing "spouse" in PART 2. If you believe the information is incorrect. please obtain written correction from the financial fnstitu :i on. attach a copy to this form and return it to the aDOVe address. Please Call 717-787-8327 with eves ti ans. COMPLETE PART 1 B1:LDW x SEE REVERSE SIDE FOR FILING, AND PAYMENT INSTRUCTIONS _. Atcounf No. 15978-43 Date - - To ensure proper credit to the account, two Established ~- ~-- 201 t Account Balance Percent Taxable Amount Subject to Tax Tax Rate Potential Tax Due CHECK ONE [ BLOCK ONLY {.~~ Pennsylvania VE PAXinEN' nF pEV ENVf 4EV~I543 Er I.FP [OS-I11 $ 41,958.76 X Su.o~ x-~-~t $ „l0 r) '19..3''1 '6 ~ 99SZ7- X ~ .045 conies of this notice must accgnpanv p avme nt to the Register of Wills. Make check payable to "Register of Wills, Agent". NOTEI If tax payments are Wade within three months of the tlec etlent's date of tleath. deduct a 5 percent discount on the tax tlue. Any inheritance kaz due will become tlelinquent nine no nths after the date of tleath. above information and tax tlue is correct. Remit payment to the Register of Wills with two Copies of Phis notice to obtain a discount or avoid interest, or return this notice to the ReNister of Wills and an official assessm enY will be issued by the PA Department of Revenue. B. (x/I The above essel has been ar will be reported and tax oeid with the Pennsv lva nia inheritance tax return filed by th¢ estate representative. C. ~ The above inf orr~~m~~g~~attl Son is incorrect antl/or debts antl tle tluctions were paitl. Complete PART u antl/ar PART ~ below. PART If indicating a different tax rate r¢la tionship to decedent: TAX RETURN - CALCULATION DF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Established 1 2. Account Balance 2 3. Percent Taxable 3 X 4. Amount Subject LoTax 4 $ 5. Deb is and Deductipns 5 6. Amount Taxable 6 7. Tax Fta to 7 X e. Tax Dua 8 $ Under penalties of perjury, I declare that the facts I reported above are true, correct and complete to the b~Je s~t~o f~m~y knowl¢dge and belief. HOME ~ ) 1~`'_"' ~ d ~ ~ WORK C-It-( ) „ty 9 ~(~'~3?~ ~~~'~2Q12 ease state l l2 }7 .4Y;w - ~i-L~ L~ FTIt~ PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID BUREAU OF INDIVIDUAL TAXES PD Bax zaobBl HARRISBURG PA 17128-0601 Pennsylvania 'J EGPPTM ENC OF PEVE NIIF P[V~I5f3 Er PfP <45-111 1NtUKMAl1UN nullt,e AND TAXPAYER RESPONSE FILE N0. 21 12-0034 ACN 12106946 DATE 01-30-2012 CAROL TURNER 28 SPEND A BUCK DR DILLSBURG PA 17019-9377 EST. OF ESTELLA R METCALF SSN 179-14-7536 DATE OF DEATH 01-02-2012 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS TD: REGISTER OF WIt.LS 1 COURTHOUSE SgUARE CARLISLE PA 7.7013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provitletl the tleDa rtment with the infarma Lion below, which was used in calculating the inheritance tax due. Records indicate that at the deatA of the above-named decedent, You were a joint owner/beneficiary of this account. If you are the Spouse of the deceased and any amount othed than zero is reflected below on the Potential Tax Due line, note no tax may be due, but you must notify the department of your relationship to the deceased Dy checking Boz C to PART 1 below and wrt ti ng "spouse" 1n PART 2. If you Del ieve oe information is incorrect, Dl ease obtain written correction from the financial institu lion, attach a copy to this form and return it to the above .address. Please Call 717-787-8327 wi to cuesti on s. C OMPLET'E PART 1 BIE LOW ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 15978 Account Balance Pe rcenY Taxable Amount Slubject to Tax Taz Rata P ot¢ntial Tax Due Date i~v~-91f"'i B'B'G Established ~'~~'~\i g 12,293.69 X jc.0'~ M-t4'67 S ic~Y6 [iS 2~-048-99 X .045 To ensure proper cre tlit to the account, two copies of this notice must accompany payment to the Register of Wills. Make check paw able to "Register of Wills. Agent". NOTE: IP tax paw menu are ma tle within three months of th• decedent's date of death, tledu<k a 5 percent tli scount on the tax due. Anv inhe riian~e tax due will become tlel in AU ent nine months after the tlate of death. A. ~ The above information and tax due is correct. Remit naymenf to the Register of Wills with Ywo copies of this notice fo obtain a discount or av oitl interest, or return this notice to the Register of Wills and C H E C K an official asse ssme ni will be issued by the PA Department of Revenue. ONE BLOC K = B. ~t-~ ~ The above asset has been or will be reported antl tax nail with the Pennsylvania inheritance tex return D NL Y filed by the estate representative. C. ~ The above inf orma ion is incorrect antl/or debts and de tluctions were paid. Complete PART ~ and/or PART ~ below. PART If indicating a different tax rata, please state s Itr a?''x `* DF ~~~ a ~$ "~ ~~ ~ 2 relationship to decedent: ~" ~y;~ `3'e ,„ <~ ~ e,.:/w'~.~'"8X tiCP MIl Cf>~iiili TAX RETURhI - CALCULATION LINE 1. DaSa Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and De tlu ct Sans 6. Amc unt Taxable 7. Tax Rate 8. Tax Due PART DATE PAID PAYEE OF TAX ON JOINT/TRUST ACCOUNTS 2 S a X c $ 5 - 6 $ ~ X DEBTS AND DEDUCTIONS CLAIMED DESCRIPTION AMOUNT PAID Untler penalties of perjury, I oecla re that the facts I reportetl above are true, correct ono complete to the best of my know le tlge and belief. [J HOME ( ) 7~ 4 y'l rsli ~ +~e~~~ WORK ( -"11l 1 ,3Yy-~ SS_3 ~~ ~ ZA Z TAXPAYER ~S IGNATUR ~;~ y _ i=~,- _ , ht~ E=(ci~ TELEPHONE NUMBER DATE BUREAU OF INDIVIDUAL TAXES PD Bax zegsol HARRISBURG PA 17128-0601 11'1r lJ KI'iNllun f\urtl..~ AND TAXPAYER RESPONSE __ ~m~ Pennsylvania DE eARTMCN' OF PEVENOE FILE N0. 21 12-0034 ACN 12106947 DATE 01-30-2012 LAUREN METCALF 1914 MARY LN CARLISLE PA 17013-1043 EST. OF ESTELLA R METCALF SSN 179-14-7536 DATE OF DEATH 01-02-2012 COUNTY CUMBERLAND REMIT PAYMENT AND FDRMS T0: REGISTER OF WILLS 1 COURTHOUSE S4UARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST F CU Drovided the deoartment with the 5nf ormation oel ow, which was usetl in calculating the inheritance tax due. 0.e rords indicate that d[ the death of the above-named decedent, you were a joint owne N ben eficiary of this account. If y0U are the spOUSe Of Lhe deceased and arty amount other than zero is reflected below on the Potential Tax Due line, note no tax may be due, but you must notify the deD-irtment of your relationship to the deceased by checking Box C in PART 1 below and writing "spouse" in PART 2. If you believe the inf orma tf on is incorrect. Dl ease obtain written correction from the financial institut.i on, attach a copy to this form and return it to [he aoove address. Please cell 717-7878327 with ouesti on s. COMPLETIE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account IVO. 1597$-44 Date A-e-a~==-wo To ensure orooer credit to the account, two Establishatl ~ -~''.l ll ~~ conies of this notice must accon pane f W'll M k h k Account Balance Percent 'taxable Amount Subject to Tax Tax Rate Potential Tax Due PART ^~ CHECK ONE [ BLOCK ONLY ER RESPONSE A. ^ the above inf ormaiion and tex tlue is correct. Ren it payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. B. I,a The above asset has been or will be reported antl tax paid with the Pennsylvania inheritance tax return S`i filed by the estate representative. C. ~ The above inforwation is incorrect and/qr debts and deductions were paitl. Complete PART 2^ and/or PART ~ below. PART If indicating a different tax rake, please relationship to decedent: TAX RETURN - CALCULATION LINE 1. Date Established 2. Account Balance 3. Pe rc e~.nt Taxable 4. Amou rit Subject to Taz 5. Debts and Deductlmns 6. Amount Taxable 7. Tax Flate e. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS i 2 $ X 5 - ~ s.ms..~ '' 'i $ v v s ":Y.. #vu '" 6 1,,, ~ . 7 X ~ ~~7r DEBTS AND DEDUCTIONS CLAIMED DESCRIPTION AMOUNT PAID Untler penalties of perjury, I de Clara that the facts I reported above are true complete to the C st of my knowletlge alief ~ HOME C ) F K~ WORK ( .~IZ ) . payment to the Reea ster o s s. a e c ec 12, 293.69 pav able to "Register of Wills, Agent". NOTE: It tax pav vents are nade within three $48~-9-9 months of the decedent's date of death. . 0 4 5 tletluct a 5 percent discount on the Yez due. Any inheritance tax tlue will become delinquent -~-2-rv-8- nine months after the date of tleath. correct and -~33s ZI~'~Zctz- DATE PAnRT u DATE PAID PAYEE _. _ L~ InrUKnfttaun Hulas. ra (FILE N0. 21 12-0834 BUREAU DF IND wlouat Taxes AND ~ACN 12106948 PD BDX 290601 pennsylvania HARRISBURG PA 17129-0601 pCeggTMENTOF9EVEnuE TARP AY E R R E S P D N S E DATE D 1- 3 0- 2 0 1 2 PEV-1540 FY 1iP fY5 111 CAR CIL TURNER 28 S.P END A BUCK DR DILL.SBURG PA 17019-9377 EST. OF ESTELLA R METC ALF SSN 179-14-7536 DATE OF DEATH 01-02-2012 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA I7013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF.' MEMBERS IST FCU Drovl ded the department with the information oelow, which was used in calculating the inheritance Sax due. Records fndicate that at the death of the dbove~named tle cedent. you were a dint owner/beneficiary of this account. If y0U are the sp0ese Of the deceased and amy amount other than zero is reflected below on the Potential Tax Due line, note no tax may be due, but you must notify the del~a rtment of your relationship to the deceased by checking Box C 1n PART 1 below and writing "spouse" in PART 2. it toutnela~ ve add re ss rmaP~easesca11o717~78]o832]e wobnaQ Ue sti on sn correction from the financial institution, attach a copy to this Torm and return C OMPLEI'E PART 1 B'~EL O!!'--C~SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 15978-45 Date -24~YtT97 93 To ensure orooer credit to the accounf, two ~++ ' ~ L -,~1{ copies of this notice must accompany Estahlished V pavme nt to the Resister of Wills. Make check AccOUnt Balance $ 3 r 118 • 83 pav able io ''Register of Wills. Agent". Percent Taxable X /UC'~ C ='~ NOTE: If tax payments are wade within three Amount !iubject to Tax f ; ~~6,~5"~ rr~~r-r- -1T»x•":~ months of the decedent's date of death. X . 0 4 5 tleduct a 5 percent di scounf on the kax due. Taz Rate Anv inheritance tax tlue will become delinmu ent Po to ntial Tax Du¢ S` lyU.3 ,S ~" nine months after the date of death. PARr TAXPAYER RESPONSt 0 FAI~ Rl;?~Tt~t jtCESPONij~~13~i~~,RESULT~f~N,"AN'OFFIZIAL,TAXv~15$ESSMEN7a A. ^ The above information and tax due is correct. Renit payment to She Register of Wills with two copies of this notice to pbt ain a tliscouni or avoitl infe re st, or return this notice to the Register of Wills and C H E C K an official assessment will be issued by the PA Departure of of Revenue. ONE -~ B L OC K B. ~ The above asset has been or will be reported and tax paitl with tlue Penn sv lvania inherit once tax return 0 NL Y filed by the estate representative. C. ~ The above inf orma ion is incorrect and/or debts antl tle tluctio ns were paid. Complete PART ~ and/or PART ~ below. pggT If !indicating a different tax rate, Please state +^ t td`s ~"~ ~i-~ 2 relationship to deced¢nt: Cv ,~rk'~pA'~c.TIFPART~IF~ a. ~,~,ay TAX RETURIJ - CALCULATION LINE 1. Dates Established 2. Account Balance 3. Percent Tazable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amou of Taxable 7. Tax Rate 9. Tax Due PART OF TAX ON JOINT/TRUST ACCOUNTS 2 $ s X c ~` 5 6 T X DEBTS AND DEDUCTIONS CLAIMED Untler penalties of perjury, I tleclare that the facts I reportetl abov¢ are true, correct and l ief. a n d b e l e d 9a complete to the b t of my know NOME C ) / Q ~ ~ ~ ~ / ~ ~`~ /""C1r ~'Y~"lam WORK C ~1~ ),~`IY -~.33~ c~ ~' LU Z XPAYER SIGNATU E nil&~ _{rU:_,"}~.i` L~F,, j-L TELEPHONE NUMBER DATE OATS PAID PAYEE DESCRIPTION AMOUNT PAID BUREAU OF INDIVIDUAL TAXES PD Bax 280607. HARRISBURG PA 17128-0601 f.'~l Pennsylvania JE PAflimEN' nF NEVENUE aE~.:5~3 E, .:r :ea ~: r: CAROL TURNER 28 !iPEND A BUCK ^R DILI_SBURG PA 17019-9377 INFORMATION NOTICE AND TAXPAYER RESPONSE FILE ND. 21 12-0034 ACN 12106940 DATE 01-30-2012 EST. OF ESTELLA R METCALF SSN 179-14-7536 DATE OF DEATH 01-02-2012 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SgUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS © CHECKINf TRUST CERTIF. MEMBERS 1ST FLU provided [he tlepa rtment with the information below, which was used in calculating the inheritance tax due. Records indicate. that at the tleath of the abpve~named tle cedent, you were a joint owner/beneficiary oT this account. If you are the spouse of the deceasetl and lny amount of hen than zero is reflected below on the Potential Tax Due line. note no tax may be due, but you must notify the deiia rtment of your relati onshlp to the deceased by checking Box C in PART 1 below and writing "spouse" in PART 2. If you believe he information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. Please call 717-]B7~B327 with aue5ti ons. COMPLEIfE PART 1 BELOW =-SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 15978-11 Date 1-1--83-'-39-y-9 To ensure proper cretlit ko the account, two Established ~\ ' +~' rrf E+S conies of this notice rust accompany payment to the ReBist ar of Wills. Make check Account Balance $ 508.66 oav able to "Register of Wills, Agent". Percent Taxable X 16.667 NOTE: If tax oav me nts are made within three Amount ^>Ubdett to Tax $ 64.78 months of the decetle nt's date of de of h. Tax Raba X .045 tletlu<t a 5 percent tlisc wnt on the tax due. Any inheritance tax due will become delinquent PotenYi~al Tax Due g 3.82 nine months after the tlate of death. PART TAXPAYER RESPONSE A. ^ The above information antl tax tlue is correct. Remit payment to the Register pf Wills with two copies of this notice to obtain a discount or avoitl interest, or return this notice to the Resister of Wills and CH E C K _ an official assessment will be issued by the PA Department of Revenue. 1 0 N E BLOC K J B. t~ The above asset has been or will be reported antl tax paid with the Pennsylvania inheritance Sax return - ONL Y t~J filed by the estate representative. C. .The above informa ton is incorrect antl/or debts and tle tluct ions were paitl. Complete PART 2~ antl/or PART ~ below. PART Sf Sntlicating a different tax rate, please state °~rh~ L~~~rl~~~~~~ ~" ~'~ td ` '^" ''' y „k~ "" a ^ relationship 2 to decedent: ' R r1"~traf,~ PJ4Y`DEP R HE~ - RN - CALC ULATION OF TAX ON JOINT/TRUST ACCOU NTS , , f~A"p'i~ 1'~7~°~`~'"~*# 6?. TAX RETU '~` ~ VR'?s,' 71V i ~~ ~~ LINE 1. De to Establis hed 1 ~ ~ ~'Amw.~: ,~ tea, ~ ,x 2. Account Balance 2 S 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 5. Debts and Detluctions 5 6. Amount Taxable 6 $ 7. lax Rate 7 X 8. Tax Due 8 PART DEBTS AND DEDUCTIDNS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I tlecla re that the facts I reported above are true, cc rrect and complete to the best f my knowledge and belSef. HOME ~ ) ~~ ~ WORK ( .,I1) ay 5~_.h~~ ri tL'(Z TAXPAYER SIGNATURE /~ +.~. ~ _ Ft~f- _ j.1, TELEPHDNE NUMBER DATE BUREAU OF INDIVIDUAL TAXES PO BOX 280601 HARRISBURG P11 L]128-06D1 pennsytvania JE PAPTM CN' p6 FEVENUE eEV 1541 Er 1rr 10511) INFDRMATION NOTICE AND TAXPAYER RESPONSE LAUREN METCALF 1914 MARY LN CARLISLE PA 17013-1043 FILE NO. 21 12-0034 ACN 12106941 DATE 01-30-2012 EST. OF ESTELLA R METCALF SSN 179-14-7536 DATE OF DEATH 01-D2-2012 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS ® CHECKIN TRUST CERTIF. MEMBERS 1ST F CU provided the tlepariment with the information Delow, which was used Sn calculating the inheritance tax due. Records intli ca to that at the death of the aDove-n amed decetlent. you were a ,]pin[ owner/beneficiary of this account. If you are the gp0uge Of the deceased and any amount other than zero is reflected below on the Potential lax Oue line, noteno tax may be due. but you must notify the deI>a rtment of youn relationship to the deceased by checking eox C in PART 1 below and writing "spouse" in PART 2. ]T you believe '.he information is incorrect. please obtain wrf tten correctf on from the financial institution, attach a coDY to this farm antl return i[ to the above address. Please call ]ll-787-8327 with Dues t.pns. C OMPLE'fE PART 1 BELOW ^.SEE REVERSE SIDE FOR F7LING AND PAYMENT INSTRUCTIONS Account No. 15978-11 Date '/- To ensure groper cretlit to the account, two Established 61- a-~~(~'y cog ies of this notice must accomoany pavnent to the Register of Wills. Make check Account Balance S 506.66 oav able fo "Register of Wills, Agent". Percent Taxable 'X 16. 667 NOTE: If tax oavme nts are made within three Amount :>u bject to TaX yv 84. 78 months of the decedent's date of death, Tax Rate X . 0 4 5 tletluct a 5 percent tli sc ognt on the tax due. Any inheritance tax due will become delinouent P otent i:al Tax Ou¢ g 3. 82 nine months after the date of death. C. ~ The above informs ion is incorrect and/or debts and deductions were Paid. Comolete PART 2~ and/or PART 3~ below. ppg7 If i.n tli sating a tlifferent tax rate, please stake relationship to decedent: TAX RETURN - CALCULATION LINE 1. Date Es tabl is hetl 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 6. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 +S x X 5 6 $ ] X 8 PART DEBTS AND DEDUCTIDNS CLAIMED 0 DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I tlecla re that the farts I reported above are Y.rue, correct and co mp let¢ the b-e~s tp~of~ my k owledge and f elief. / HOME C ) -4, ~ •~; \Q.d-.c~ WORK C -)Il ):~44'~~.'3~S ~l~ Z.G'~Z. iifi~~ ~ f f'~`~- E,~}-1;,(t TELEPHONE NUMBER DATE - ti;_' A. ^ The above information antl tex due is correct. Remit oavme nt to the Register of Wills with two conies of this notice to obtain r C NEC K _ a tliscaunt or avoitl interest, or return this notice to the Register of Wills and I 0 NE -1 r-~ an official assessment will ba issued by the PA Department of Revenue. L B L OC K 11 B. A/~ The above asset has been or will be re oortetl and tax paid with the Pennsylvania inheritance tax return ONLY 4+ filed by the estate representative. TOTAL CEnter on Line 5 of Taz ComputatlonJ 6 BUREAU OF INDIVIDUAL TA%ES Pd Bax zaosol HARRISBURG PA 17128-0601 ~. Pennsylvania UE VANTMCNI DL REVENVF YEY~1543 ER PFp t05 ~11) INFORMAI tuN nu i tl,t AND TAXPAYER RESPONSE FILE N0. 21 12-0034 ACN 12106942 DATE 01-30-2012 CAROL TURNER 28 SPEND A BUCK DR DILLSBURG PA 17819-9377 EST. OF ESTELLA R METCALF SSN 179-14-7536 DATE OF DEATH 01-02-2012 COUNTY CUMBERLAND REMIT PAYMENT AND DORMS T0: REGISTER OF WILLS 1 COURTHOUSE SOUARE CARLISLE PA 1.7013 lrrt ur Accuuni ® SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the Department with the information bet ow, which was used in calculating the inheritance tax tlue. Records intli cafe that at the tleata of the above-named decedent. you were a joint owner/beneficiary of to is account. If you are the SDOUSe of the deceased and any amount of her than zero is reflected Delow on the Potential Tax Due line, note no tax may be due, but you must notify the department of youm relationship to the deceased by checking Box C in PART 1 below and writing "spouse" in PART 2. If you believe be information is incorrect. please obtain written correction Trom the financial in5ti tutl on, attach a copy to this form and return it to the above atltlress. Please tall 717-7878327 wi [h pues ti ons. C OMPLE T'E PART 1 BiELOW e- x E REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 15978--05 DaY¢ 09-27-1985 To ensure preoer credit to the account, two Established conies of this notice must accompany payment to the Register of Nills. Maka check Account Balance $ 13,500.74 paw able 1:0 "Register of Wills. Agent". Percent Taxable X 16.667 NOTE: if tax pavne nts are made within three Amount Slubject to Tax $ 2r25O.17 months of the de cetlent's date of death, Tax RatFi X . 0 4 5 de tluci a 5 pe rce ni tli sc ou nt an the tax due. Anv inheritance tax tlue will become delinquent Potential Tax Due s` 101 26 nine months after the tlate of tleath. PART TAXPAYER RESPONSE FAIL RE PTO RESP,~QNR~WIiL~RESU~T3N~T1}I~j-SFFICIAE,TAX,A$SESSf1EN7 -. ~. m.. . u , . A. ^Tha above inf orn ation and tax due is corrv ct. Remit payment to the Register of Wills with two conies of this notice to obtain a discount or avoid interest, or return this notice to the Register of Wills and r C H EC K = an official assessment will be issued by the PA Department of Revenue. L ONE Rd--11 BLOC K B. n/~ The above asset has been or will be reported and tax paid with the Pennzvlvania inheritance tax return 0 NL Y ''//FY'' tiletl by the estate representative. [. ~ The above inf or~Im,a Iaon is incorrect and/or debts and tleducfions were paid. Complete PART u and/or PART ~ below. PART If i.n dicating a different Yax rate, please state awr £'~ .~, O~G~AL ~~J$~, `!1N ja '~d relationship to decedent: 1 2@ ~ ~~A TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS ~i'7£.~+~~ '''~~~~~~ I~ PAa~. ~w~~~,`4,~~~~'~ ~~ : I LINE 1. Date Establishetl 1 sli ~#,. w~, i~,. _ ~N1 +:,~,.:~ afe'~3t}s~i rNiMwg 2. Account Balance 2 X ~T~i~~'ya~.+,,~~~ 3. P¢rc ent Taxable 3 _ r~~;7m~j ~„t~$~~,~i~~~ 4. Amount Subject to Tax 4 ~ .'I`' 5. Debts and Deductions 5 ~~ ~ ~~~~~~~~ ~~~~~ ~. l+''t'v'~tl -x Sip. %~ tlx ubp'Z.$ n~ 6. Amo u.nt Taxable b `- ~~ x ~,e 7. Taz Rat¢ T X a ~~ 8. Tax Due B $ 'k?. $'' PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID TOTAL (Enter on Line 5 of Tax Computation) a Un tler PenaltSes of perjury, I declare that the facts I r¢portetl abov¢ are true, correct antl complete Yo t e best of my knowletl9e and belief. HOME ~ ) ~.-21Xy`~~-`~~~~. ~j WORK C ll 'Z > .~~j c1 - ~'~3~ .LI 8~2.u12. TAXPAYER SI NATURE ~.{-t~.j~,--ri~~. r;; i-~tY TELEPHONE NUMBER DATE PD BDX 288601 eons lvama NARRISBDR GIPA IylD128-06815 pE VnainE nE~aEVErvuE PEY-1545 Ex 9FV [05-11) LAUF;EN METCALF 19101 MARY LN CARL.I SLE PA 17013-1043 INFORMATION NO11CE AND TAXPAYER RESPONSE FILE N0. 21 12-0034 ACN 12106943 DATE 01-30-2012 EST. OF ESTELLA R METCALF SSN 179-14-7536 DATE OF DEATH 01-02-2012 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA :17013 TYPE DF ACCOUNT ® SAVINGS CHECKINf TRUST CERTIF. MEMBERS 1ST FCU provided the department wi to the information below. which was used in calculating [he inheritance tax tlue. Aec prd5 intli Cate that at the death pf the above-named decedent, you were a joint owner/beneficiary Of this aCCOUnt. If yoD dre the spouse Of the deceased and any amount other than zero is reflected below on the Potential Tax Due tine, note no tax may be due, but you must notify the department of your relationship to the deceased by checking Box C in PART 1 below and wri tf ng "spouse" in PART 2. If you believe the information is incorrect. please obtasn written correction from the financial institution. attach a copy [o Lois form and return it to the above address. Please tall 717-787-8327 with questions. C OMPLEi'E PART 1 8'E LOW ^ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 15978 -05 Data 09-27-1985 To ensure Droner credit to the account, two Established copies of this notice nusf accompany pavwent to the Re Buster of Wills. Make check Account Balance S 13,500.74 Day able tq "Resister of Wills. Agent". Percent Taxable X 16.667 NOTE: if Sax Payne nts are ma da within three Amount s-subject to Ta% $ 2r250.17 nonths of the tle cedent 's data of de eth. Tax Ra tee. X . 0 45 deduct a 5 percent discount on the tax tlue. Anv inh e:-it ance tax due will become delinquent Potential Tax Due $ 101.26 nine months after the date of death. FAIiu ETO ResPO~nn~~lI~~'~RES11L'~;~`~#i"AN DFFICt~t,,T,nxxJtSSiEws~~EN A. ^ The above info rn ation and tax tlue is correct. Remit pavnent to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or return this notice to the Re6isfer of Wills and r an official assessment will be issued by She PA Department of Revenue. I ONE BLOC K B. The above asset has been or will be reported and Sax paid with the Pennsylvania inheritance tax return O NL Y filed by fhe estate representative. C. ~ The above info rma ton is incorrect and/or tle bts and de tluctions were paid. Complete PART ~2 and/or PART ~ below. g c ppgT If indicating a different tax rate, please state ~ kpl ~%, ~ ~F ~ $ °+ ^ relationship to decedent: i'1 ~~ Ps?.s ~~' 2 ~~ SexDE 8i~+iIEW,T'' U TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS `p ~k°,~ *y'^~~~~~'" ^~~_ LINE L. Data Established 1 ~ F:: °wi ~i ~' 2. Account Balance 2 $ ,w ~%~ ' ~~' 3. Percent Taxabla 3 X ~ _p ~' 4. Amou of Subject to Tax 4 $ ,.~; ~ .~y"~.p~m'~~'~~x{gy~. ,a ~~ 5. Debts and Oetluctions 5 ~• ' $ a. ui .~~',$tv&a'v+s?"1z..'aaTx ~ t;~.`5~.'ix4~gi?~,"5-„.. 6. Amount Taxable b s ' 7. Taz 12a to 7 X vlut a~ ~,~ y ?'t"~s',r sar "~.y+xj~8[a `-T?~z"sm 8. Tax Due 8 $ `d' $^ ^ PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, L declare that the facts I reported above are true, correct and complete t the best of m owletlg and belie HOME C ) ~~j.G_~~ woRK c ~7~ ) ~yv - (c~ 33J z~8 Z-t, Z TAXPAYER SIGNATURE ~ TELEPHONE NUMBER DATE fit. ~ . Fa- - tf)` tS 4'i1?~. BUREAU OF INDIVIDUAL TA%ES PO BOX 280601 NARRISBURG Pl1 17128-0601 Pennsylvania 'JE PAPTMEN' nF PFVENUE FEV-1543 EY eFP IOS~III INFORMATION NOTICE AND TAXPAYER RESPONSE FILE NO. 21 12-0034 ACN 12106938 DATE 01-30-2012 CAROL TURNER 28 SPEND A BUCK DR DI LI_SBURG PA 17019-9377 EST. OF ESTELLA R METCALF SSN 179-14-7536 DATE OF DEATH 01-02-2012 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS TD: REGISTER OF WILLS 1 COURTHOUSE S9UARE CARLISLE PA 17013 TYPE OF ACCOUNT ® SAYINGS LHE CKIR TRUST CERTIF. MEMBERS 1ST FCU DrOVided the department ui th the information below, which was used in calculating the inhe ri Lance tan due. Records intlicate [hat at the tlea9h of the dbove-named tlecede nt. you were a joint Owner/be nefiCiary of this dcCOUnt. If y0U are the BpOUSe OT the deceased antl .f ny amount otheir than zero is reflected below on the Potential Tax Due line, note no tax may be due, but you must notify the del)a rtment of your relationship to the deceased by checking Box C in PART 1 below and writing "spouse" in PART 2. If you believe '.he information is incorrect, please obtain written come cti an from the financial instt tcti on, attach a cODY to this form and return i[ to [he above address. Please 'tall 717-7B]-832] with Oves ti on s. COMPL E'fE PART 1 QELOW ~ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS - Account No. 1597$-DD Dat¢ 0~e--vr='a~'i'=r To ensure Draper cretlit to the account, two EStablished ~ -12_1`('1 ~~ copies of this notice must accompany Account Balance Percent Taxable Amount Subject to Tax Tax Rate Potential Tax Dua g 2.284.75 X 16.667 g 3BO.sD X .045 1/.14 pavnent Yo the Re Bi star of Wills. Make check oav able to "Register of Wills, Apent". NOTE: If tax oav menu are made within three non khs of the decedent's date pf tleath. tletluct a 5 percent tliscount on the tax due. Any inheritance tax due will become tlelingu ant nine months after the date of tleath. PART TAXPAYER RESPONSE FAIL RETO~RESP,ONDfi,WiLU~RESU1x,~xI(i AH,=OFFICIAL~TAX~'ASSESS,M,EN7:' A. ^Jhe above information and tax tlue is correct. Remit paymenk to the Repister of Wills with two copies of this notice to obt win C H E C K a tliscount or avoid interest, or return this notice ko the Repister of Wills and an official assessment will be issued by She PA Oepartme nt of Revenue. ONE BLOC K B. The above asset has been or will be reported and tax paitl with the Pennsylvania inhe Htanc¢ tax return 0 N L Y - tiled by the estate representative. C. ~ The above inf orr~m~~a~japn is incorrect and/or debts antl tle tlu coons were paid. COnplete PART d antl/or PART ~ below. It i.ndicatin a different tax rate, Please state "f^" .f i£trr ~ e ! lh u' P~T g pia" ;1;,.,r s,~'QF~„~iJ1~i~7q~"~"~0}~~'il~ X11 r elFitionship to tlecedent: -A.'.,~A r~~]T~R$~xl"*.0 TAX RETURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS p~ fµ. &A ~ ~i.W4T.2<i1.h`6P`fi9 *Re. I LINE I. Date Established 1 a. _, ,,,,,. - ,_ __,. . 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts ono D¢tluctions 6. Amount Taxable 7. Tax Rate e. Tax Due PART I~ 2 +S a X c 5 6 'S ~_ DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Untler penalties of perjury, I declare that the facts I reported abov¢ are 1: rue, correct antl complete to the hest of my knowletlge and belief. HOME ~ ) -~ WORK C 1l Z ) ,~~ 4'~=-~j-~ ~ LO Z- TAXPAYER SIGNA URE ~y +:.~_~~~---}-'a ,~~-_~~~~111 ~.~V; TELEPHONE NUMBER DATE BUREAU OF INDIVIDUAL TAXES PD Box 7eabol HARRISBURG PA 1]128-g6gl ~~ Pennsylvania OE PAfliMCN' nF flEVENUE PEV-154) [x nfP t05~111 1NhUKi'IAI luN NV I1Vc AND TAXPAYER RESPONSE (FILE N0. 21 12-0034 ACN 121D6939 DATE 01-30-2012 LAUFIEN METCALF 1914 MARY LN CARLISLE PA 17013-1043 EST. OF ESTELLA R METCALF SSN 17r.7-14-7536 DATE OF DEATH o1-02-2012 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS TD: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCDUNT ® SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FLU Drovitletl [he tlepartment wi to the information below, which was used in calculating the inheritance tax due. 0.e cords indicate that at the death of the auove~named decedent, you were a joint owner/beneficiary of this account. If you are the sDOUSe Oi the deceased and any amount other than zero is reflected below on the Potential Tax Uue 11ne, note no tax may be due. but you must notify the deDa rtment of your relationship to the deceased by checking eox C in PART 1 below and writing "sDOUSe" in PART 2. 1f you believe the information is incorrect. please obtain written cor rectf on from the financial institution, attach a copy to this form and return it to the aDOVe address. Please call 717-787-fi12] wilh questions. COMPLETE PART 1 B'~.ELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 15978--0p Date - - To ensure proper credit to the account, two r ~ 1-12 7~ copies of this notice must accomoa ny Established - 1 pavment to the Register of Wills. Make check Account Balanc¢ $ 2,284.75 pay able to "Register of Wills. A9en t". Percent Taxable X 16.667 NOTE: If Sax pav ments are made within three Amount <lu bdecY to Tax s` 360.80 nonths of the decedent's date of death. ~' 0 4 5 deduct a 5 pe r<ent discount on the tax due. Tax Rato Any inheritance tax tlue will become delinquent Potential Tax Due $ 17 14 nine months after the date of death. ESUL7~„S.N At1 30t.RESpORD ~t~i~L~ ~R ~: FA3LU E ;OFF~C3At>TAXlASSE'SS1iE117'~I y ~,,, , , ~ A. ^ The above information and tax tlue is corre<i. Remit Daum eni to the Register of Wills with twg copies of this notice to obtain a tliscounk or av oitl intere sf, or re h rn this notice to the Resister of Wills antl r C H EC K - an official assessment will be issued by the PA Department of Revenue. I ON E L BLOC K 8. The above as se< has been or will be re oo rted antl tax paid with She Pennsylvania inheritance tax return 0 N L Y - tiled by the estate representative. C. ~ The above inf a rm ation is incorrect and/or debts antl tletluctions were paid. Complete PART 2^ and/or PART ~ below. ppR7 If indicating a different tax rate, please state y~ur:~,`Ltr>*fT~FFz~;L`~A~~"v~ j }°t ~`5y^ C.~ec~, x,ta l 2 re let lOnshlp LO daCedent: Al .~w..r~~'baa.nl:3ntl~wk 3' n av TAX RETUR hI - CALCULATION LINE 1. Date Established 2. Account Balance 3. Percent Taxablm 4. Amount Subject to Tax 5. Debts and Detluctions b. Amount Taxable 7. Tax Rate e. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 2 $ x X c S 5 6 `S 7 X _ ___ Under penalties of Per]ury, I d¢cla re Shat the facts I report¢tl above ar¢ true, corr¢ct and complete to t bes t e no w ¢d g e a n d be li of m y k l /- HOME ( ) . , -~E'---~ / ' ~ I ' Q ~ ~ A r ,/ ~ ' "wit - / C./~ "`-mil !t-1~t7. WORK ( ~ I ~- i) < ~ Q~- !-r i ~ ~ p zd l Z ~ TAXPAYER SI N-G' ATURE - c;~ TELEPHONE NUMBER D PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Metropolitan Life Insurance Company P.O. Box 10342 Des Moines IA 50306-0342 MetLife February 10, 2012 SALZMANN HUGHES P.C. 354 ALIEiCANDER SPRING RD STE 1 CARLI:iLE PA 17015 RE: METROPOLITAN LIFE INSURANCE COMPANY CONTRACT 00084820588 DECEASED'ESTELLA R METCALF To Whom It May Concern: Thank you for your recent inquiry regarding the contract referenced above. Our records indicate that the date of death and the account value on that date are: Date of Death: 01 /0 21201 2 Date of Death Value: 11,958.20 (replacement value) Actual Date of Death Value: 10,709.03 Cost Basis: 7,615.99 All proceeds over the cost basis are considered taxable in the year received. If you Ihave any questions, please contact your representative or call our Customer Service Center at 1-800-638-7732 (Client Line) Monday through Friday between 9:00 a.m. and 6:00 p.m., ET. Sincerely, Daniell Huisman Sr. Annuity Representative -Post Issue Processing MetLife Annuity Operations and Services