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Home My WebLink About01-15-13 (2)--~ REV-1500 EX (01-10) 1505610143 PA De artment of Revenue ~ OFFICIAL USE ONLY p Pennsylvania County Code Year File Number Bureau of Individual Taxes DEPARTMENT OP REVENUE PO 80X.980601 INHERITANCE TAX RETURN 2 1 ` ~ ~ Harrisbur , PA 17128-0601 RESIDENT DECEDENT I ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 12 20 2010 06 12 1936 Decedent's Last Name Suffix Decedent's First Name MI COONS C. JUNE (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW ® 1. Original Return ^ 4. Limited Estate ® g Decedent Died Testate (Attach Copy of Will) ^ 9 Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS ^ 2. Supplemental Return ^ qa Future Interest Compromise (date of death afler 12-122) ^ ~ Decedent Maintained a Living Trusl (Attach Copy of Trust) ^ 10. Spousal Poverty Credit (dale of death between 12-31-91 and 1-1-95) ^ 3. Remainder Return (date of death prior to 12-13-82) ^ 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes ^ 11 Election to tax under Sec. 9113(A) (Attach Sch O) MI CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number TERRENCE J KERWIN 717 ~ 62 37~~5 ~ r %.~ ~ rn First line of address 4245 STATE ROUTE 209 Second line of address City or Post Office State ELIZABETHVILLE pp~ Correspondent'se-mail address: tjk~kerWInlBWflrnl.COn1 ZIP Code 17023 `_ Cry~ REGISTEI~F WILL$~SE ONLY M ~ ~ ~ D ~ t_--' " . .~ t~:f ry°t f~'t 1 ~,, G7 ,ryyf CJ ;~ ;J - t : ~ c ;, K: ~ _ ~... DATE FILE'6 ~ `~ ~ unaer penalises of perjury, I declare that I have examined this return, inGuding 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. SIGNATUR~,,F,~ E FOR FILING RETURN DATE Michael L. Coons f~/U ~~~ 3 1772 North Meadow Drive, Mechanicsburg, PA 17055 SIGNATURE OF PRF'PARER OTHER THAN REPRESENTATIVE DATE Terrence JKerwin ~ ~Q d~3 ADDRESS 4245 State Route 209, Elizabethville, PA 17023 Side 1 1505610143 1505610143 i~~~ J 1505610243 REV-1500 EX Decedent's Social Security Number Decedent's Name: COONS , C. JUNE RE CAPITULATION 1. Real Estate (Schedule A) ........................................................................................ .. 1. 127,098.70 2. Stocks and Bonds (Schedule B) .............................................................................. . 2. 3 Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... . 3. 4. Mortgages & Notes Receivable (Schedule D) ......................................................... . 4. 5. Cash, Bank Deposits 8~ Miscellaneous Personal Property (Schedule E) ............... . 5. 15,750.00 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ............ . 6. 7 9 . 8 5 7 5 1 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 1 6 2 4 9 0 7 7 (Schedule G) ^ Separate Billing Requested ............ . 7. , 8. Total Gross Assets (total Lines 1-7) ...................................................................... . 8. 3 8 5, 1 9 6 9 8 9. Funeral Expenses & Administrative Costs (Schedule H) ...................................... . 9. 26,716.13 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................... . 10. 11. Total Deductions (total Lines 9& 10) ..................................................................... . 11. 2 6, 7 1 6 1 3 12. Net Value of Estate (Line 8 minus Line 11) ............................................................ . 12. 358, 480.85 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. 3 5 8 , 4 8 0 8 5 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 3 5 8, 4 8 0 8 5 at lineal rate X .045 16. 1 6, 1 3 1 6 4 17. Amount of Line 14 taxable at sibling rate X 12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. Tax Due ................................................................................................................... 19. 1 6. 1 3 1 6 4 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505610243 1505610243 J REV-1500 EX Page 3 File Number 21 Decedent's Complete Address: DECEDENT`S IJA Coons, C. June STREET ADDRESS 309 Manchester Road _ __ _ clrY --------- -~--- STATE ZIP Camp Hill PA 1701.1 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments 15,000.00 B Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box 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. Total Credits (A + B) (1) 16,131.64 (2) 15,000.00 (3) 43.43 (4) (5) 1,175.07 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 :.................................................................. ....._. ~ [x j b retain the right to designate who shall use the property transferred or its income :....................... _. _.... ~ x ~_ , c. retain a reversionary interest, or ...................................................................................._........._. ........ L_ ] ~XJ d receive the promise for life of either payments, benefits or care? .............................................................. i_-] [x] 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without _ receiving adequate consideration? .............................................................................................. ............ C 1 CXl 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? ...................................................................................................................._ ~~ ~__~ 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 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 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 ears 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) (y.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)1. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, w ether y blood or adoption. i SCHEDULE A COA~AONWEALTH of PENNSYLVANIA ' REAL ESTATE INHERITANCE TAX REI"URN RESIDENT DECEDENT 1_ ._ _ ___-____-__ -__ _ - __.. -_____- - _ _._ I FILE NUMBER ESTATE OF COOf1S, C. June 21 All real property owned solely or as a tenant in common must be re orted at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on schedule F. Attach a copy of the settlement sheet if the property has been sold. Include a copy of the deed showing decedent's interest if owned as tenant in common. ITEM DESCRIPTION VALUE AT DATE OF NUMBER DEATH 1 Residential real property located at 309 Manchester Road, Lower Allen Township, Cumberland 127 098.70 County, Tax Parcel #13230545380. Sold on December 20, 2011, with net proceeds to Estate of $127,098.70. TOTAL (Also enter on Line 1, Recapitulation) I 127,098.70 SCHEDULE E CASH, BANK DEPOSITS, 8~ MISC. COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY INHERffANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER ESTATE OF 00011S, C. June 21 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. - _ _ - - ITEM NUMBER 1 Personal household items 2 2010 Toyota RAV-4 LTD DESCRIPTION VALUE AT DATE OF DEATH 750.00 15, 000.00 TOTAL (Also enter on Line 5, Recapitulation) 15,750.00 SCHEDULE F COMMONWEALTH OF PENNSYLVANIA .JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Coons, C. June 21 If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT Leesa V. Coons 1514 Capitol View Drive Daughter A New Cumberland, PA 17070 JOINTLY OWNED PROPERTY: ITEM NUMBER - DATE ' .FOR JOINT f _ _ --~~ 9CRlPT.IO~C~F PRO~'ERT~Y y ~ _-I Uclude name o Inancial ms u Ion an ban account numbe DATE OF DEATH ~ or similar identi In number. Attach deed for'omtl -held real VALUE OF ASSET ' -- _ __ _ % OF D --- -- DA~AOF OFTH ' TENANT DINT estate INTER ST DECEDENT S INTEREST _ _ _ 1 ~ A 06/04/2008. . PSECU Certificate of Deposit ID-53 - 1x,259.58 i -__ -- 50% - 9,129.79 2 A I' 06/04/2008 PSECU Certificate of Deposit ID-54 5,101.31 ~,` 50% i 2,550.66 3 A 06/04/2008 ' PSECU Certificate of Deposit ID-55 ~ 1a,z9a.7z ~ i 50% ' 7,147.36 4 A 06/04/2008 ! PSECU Certificate of Deposit ID-57 I 43,810.28 I 50% I 21,905.14 5 A 06/04/2008 ', PSECU Certificate of Deposit ID-60 21,964.x9 ', 50% 10,982.45 6 ! A ', 06/04/2008 PSECU Money Market ID-07 13,304.13 ~ 50% : 6,652.07 7 A 06/04/2008 PSECU Checking Account ID-01 7,949.x9 ' 50% 3,974.95 8 A 06/04/2008 ! PA Central FCU Certificate of Deposit j 20,252.x61 50% ' 10,126.23 OA6-Acct. #40353-016 9 A 06/04/2008 PA Central FCU Certificate of Deposit I I 1x,772.71 ~. 50% ' 7,386.36 OC6-Acct. #40353-016 ~I 10 A ' 06/04/2008',. PA Central FCU Savings Acct. 5.00 ' 50% 2.50 j TOTAL (Also enter on line 6, Recapitulation) t 79,857.51 ~' ~ COMMNHER TANCEOTAX RETURNANIA SCHEDULE G INTER-VIVOS TRANSFERS ~ RESIDENT DECEDENT _ ~ MISC. NON-PROBATE PROPERTY ESTATE OF Coons, C. June ~ FILE NUMBER ~ 21 _ .. .. _. _. _.. -- -------'--- -- ----------- --1----- - -...... This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes. __ r _ _ _.__ __ _ - ---- - -_ -- _.._. T ---- -- . _ __ _ - _ - ITEM DESCRIPTION OF PROPERTY include the name of the transferee, their relationshi to decedent NUMBER !! DATE OF DEATH VALUE OF ASSET ~~ OF ! EXCLUSION DECD'S TAXABLE VALUE ! (IF APPLICABLE) and the date of transfer. Attach a copy of the deed for real estate. INTEREST 1 U.S. Savings Bonds Series I ~ z,za3.ao 100% 2,243.40 ' Payable on death to: Michael L. Coons, son 2 '' U.S. Savings Bonds Series I 2,za3.ao ' 100% 2,243.40 !Payable on death to: Leese V. Coons, daughter j ~ ', 3 '' U.S. Savings Bonds Series I ~ 2,2as.ao ! 100% ! 2,243.40 Payable on death to: Kimberly A. Rineer, daughter ' it 4 ! PSECU IRA Acct. #9341866342 ~2s,sas.oo ' 100% ', 125,643.00 I Beneficiaries: Michael L. Coons, Leese V. Coons, Kimberly A. Rineer, children of decedent i~ ', 5 Erie Annuity#547-753 30,~~~.5~ 100% 30,117.57 Beneficiaries: Michael L. Coons, Leese V. Coons, Kimberly A. Rineer, children of decedent TOTAL (Also enter on line 7, Recapitulation) 162,490.77 SCF~DULE H o r~~ COMMONVYEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT E '" A11w~rC~TL]ATA/C /1/'1CTC /'~L~I~~~w~7 ~ Iv7 ~ ~rG \/~/~7 ~ ~ D CEDENT ESTATE OF Coons, C. June FILE NUMBER _. _ 21 Debts of decedent must be reported on Schedule I. _ __ ITEM NUMBER FUNERAL EXPENSES: DESCRIPTION ', AMOUNT A. 1 Parthemore Funeral Home 10,855.00 2 ~, Rolling Green Cemetery 4,418.00 3 , Gingrich Memorial 1,850.00 B. ADMINISTRATIVE COSTS: 1. ' Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zip Year(s) Commission paid 2. Attorney's Fees Kerwin & Kerwin, LLP -- Terrence J. Kerwin 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. I Other Administrative Costs 1 I Cumberland Law Journal -Estate Notice TOTAL (Also enter on line 9, Recapitulation) 3,000.00 327.50 75.00 26,716.13 Sd~ule H Funeral Expe~es & COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ~~ RESIDENT DECEDENT ESTATE OF Coons, C. June ~ FILE NUMBER --... _ - _ ___ __ - _ - -------- - - ----- -- -- - 121 1 2 'The Sentinel -Estate Notice - --- -- ~ - _ _ -- - - -- -- __ 145.06 3 Register of Wills -Releases 15.00 4 PPL 456.61 5 Verizon 112.11 6 .Lower Allen Township -sewer ! 322.25 7 Comcast I 63.00 8 PA Water 244.13 9 'Visa - PSECU 412.36 10 'Bonnie Miller, Treasurer 9.80 11 Bonnie Miller, Treasurer -real estate taxes 578.40 12 'Sherwin Williams -paint '~ 269.18 13 Refund of State Employees Retirement Fund for overpayment ' 3,004.12 14 ;Erie Insurance -premium 409.00 15 UGI -gas bills I 134.61 16 Closing costs, e.g. copies, postage 15.00 Page 2 of Schedule H REV-1513 EX+ (11.081 SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Coons, C. June 21 ---- -- --- - ---_ --_ r - - --- - _ _ RELATIONSHIP TO ~ SHARE OF ESTATE AMOUNT OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$) RECEIVING PROPERTY i _ Do Not ~ISt Trustee(s) I, TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1 ;Michael L. Coons Son ' 1/3 1772 North Meadow Drive Mechanicsburg, PA 17055 2 Kimberly A. Rineer 203 North Timber Court Harrisburg, PA 17110 3 Leesa V. Coons 1514 Capitol View Drive I Daughter 1/3 ~' Daughter 1/3 New Cumberland, PA 17070 ~ Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet, as appropriate. II. NON-TAXABLE DISTRIBUTIONS: IA. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN I B CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 - - _ .. __ I ___ _--_ A. SETTLEMENT STATEMENT (HIJD-1) ~~3 ~`r n .~ I. U FHA 2. 4. ^ vA 5. 6. FILE NUMBER: 11-00249-ALT 8 MORTGAGE INS i . l.nac rvv.: ~. rov r t: ~ ms romt is furnished to give you a statement of actual settlement e~sts. Amounts paid ro and by the settlement agent are shown. Items marked "(p.o.e.)" were paid outside the closing• they are shown here for informational purposes and are not included in the totals D. NAME & ADDRESS Anae F. Ruggabw OF BORROWER: 2828 Russel Rd. Cam Hilt PA 17011 E. NAME & ADDRESS The Estate of C. June Coons OF SELLER: 309 Manchester Ro Cam Hill PA 17011 F. NAME di: ADDRESS Cesh OF LENDER: G. PROPERTY LOCATION: 309 Manchestw Road, Camp Hill PA 17011 H. SETTLEMENT AGENT: Asstued Land Transfers, Inc. 301 Market Street, Lemoyne, PA 17043 (717) 761-4720 PLACE OF SETTLEMENT• Lawvws Realty LLC 307 Market Street, Lemoyne, PA, 17043 (717) 761-4720 I. SETTLEMENT DATE. 12120!2011 " _"------" "- -"""'° ' 100. Grose Amount Due From Borroww: n. Summa of Seller's Transaction 400. Gross Amount Dae To Seller: I Ol. Conttatx sales ria 135 000.00 401. Contract sales rice 102. Perswral 402. Personal r 135 000.00 103. Settlement ch ro borrower. (line 1400 2 564.70 403. 1D4. 404. 105. 405. Ad'uatmenb For Items Paid B Seller In Advan ce: Ad ustmenb For Items Paid B Seller In Adv ance: 106. Ci /town taxes ro 406. Ci /town taxes ro 107. Coun taxes 1220/1 1 ro !2/31/1 l 17.77 407. Coun taxes 12/20/11 ro 12/31/11 108. Assessments to 17.77 408. Assessments to 109. School Taxes 1220201 I rob/30/2012 609.7 409, School Taxes 12/10/2011 ro b/30/2012 110. Sewer/Refuse Oct-Dec 12202011 ro 12/312011 12.53 410. Seww/Refuse Orx-Dec 12202011 ro 12/312011 609.76 l i 1. 411. 12.53 112. 412. 113. 413. 114' 414, I 1 S. 415. I t 6. 416. 120. Gross Amount Due From Borrower: 138 204.7 6 420 Gross Amount D T S ll , . ue o e er: 135,640.06 201. De osit or earnest mon 202 P i i l 1000.0 0 501. Excess de it (see instructions . r nc a amount of new Ioan(s 502. Settlement ch ro seller line 1400 203. Existin loans taken sub'ed to 503. Existin loans taken sub'ect ro 20 037.86 204. Credit To B r 653.50 504. Payoff 1st Mt Ln 2D5. . 505. P ff 2nd M . Ln 206. . 506. Credit To Bu r 207. 507 653.50 208. 508. 209. 5~. Adjustments For Items Unpaid By Seller: Adjustments For Items Unpaid By Seller: 210. Ci Rown taxes to S l0. Ci /town taxes to 21 I. Coun taxes ro 511. Coun taxes to 212. Assessments to 512. Assessments to 213. 513. 214. 514. 215' S 15. 216. 516. 217' 517. 218. 518. 219. 519. 220. Total Pald By/For Borrower: 1,653.50 520. Tohl Reductions In Amount Due Seller: 20,691.36 301. Gross amount due from borrower ine 120 138 04.7 601. Gross amount due ro seller ine 420 302. Lass amount aid /for borrower (line 220 1 653.50 602. Less reductions in amount due ll i 520 135 640.06 se er ne 20 691,36 303. Cash (®FROM) i~I'O) Borrower: 136 551.26 603 C h X~ ' O , . as ( I O) ( FROM) Seller: ] 14,948.70 Previous Edition is rlhcnlete Form No. 1581 ..._ ~i _~---- SB~4-3538-000-I 3/86 // i ~' // ''1 ^..~.- RESPHUD-1 (3-86) X i 4. Lu c.>• ` .~ 'i d 6~G / Page 1 of 3 A, H0 4305.2 y L. X X ~__.~__, ~. - - Q' OMB No. 2502-026 7F LOAN FHMA 3. ^ CONV. UNINS. CONV. INS. 7. LOAN NUMBER 1'• SETTLEMENT CHARGES Escmw~ il_nn2w_Ar'r ~~.. ~~~ oa~c~ni uRC~ s ~,omm~ss~on: used On Price S °~ - Paid From Borrower's Paid From S ll ' ~ I Funds e er s Fund At s At I Settlement Settlement ' i n ai 704. 0 in ee 1 'n ce re ' r t 1 i r r 1 i to 1 ' e e ti 4 'tle ' u i 1 cu 1107. Attorney's fees to (includes above item Numbers: ) 1108. Title insurance to Assured Lend Transfers, Inc. (Basic) (includes above item Numbers: 1101, 1102, 1103, 1104 ) 1 033.75 v v I 1 ]4 I 2 5. 1 w ~ - yy 13 e r 5 1 ]2 150. 4 13 ~ 1 hi it" h t r 'ne - a 2 cti 2 2 .7.86 -- -- , ~.. < vi ~ SB-4-3538-000-i X X sr „ SELLER'S AND/OR BORROWER'S STATEMENT Escrow: I1-00249-ALT I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief, it is a true and accttratc statement of all receipts and disbursements made on my account or by me in this transaction. I further certify that I have received a copy of the HUD-I Settlement Statement. Borrowers/Purchasers Anne F. Ruggaber Sellers The Estate of C. Lune Dons ,~- --~ The HUD-1 Settlement Sffitement which I have prepared is a true and accurate account of this transaction. I have caused or will cause the funds to be disbursed in accordance with this stat~em~ent, / Settlement Agent: i l; 4' ~~~'" Date: /1~~~ Title Officer, Assured Land Transfers, Inc. WARNING: It is a crime to knowingly make false statements to the United Sffites on this or any other similar form Penalties upon conviction can include a fine or imprisonment. For details see: Title 18 U.S. Code Section 1001 and Section 1010. Page 3 of 3 ATTACHMENT TO HUD 1 Escrow No.: 11-00249-ALT Settlement Date: 12/20/2011 Title No.: 11-00249-ALT Pace: t EXHIBIT A: IJiIJD Section 1300) Additional Settlement Charges: Deed Preparation to Johnson, Duffle, Stewart & Weidner Home Owner's Warranty to AHS Home Warranty Services, Inc. Total: 13uver Amount Seller~unt 150.00 435.00 585.00 P.O. Box 61013 {111) 234-8484 {Harrisburg) Harrisburg, PA 11105-1013 (B00) 2311328 (Natiomvide) website - http://www.psecu.com 066805 2360175 IMPORTANT TAX RETURN DOCUMENT ENCLOSED JOINT OWNER LEESA V GOONS JUNE COONS ~ 0186XXXXXX I 120110123110 PAGE 5 .: ~:.... :.:.:. ...........:. a..,..Ti ~y.: ,;.: 4•o-:::;..<a: •;;,•:.v .. : ::• •~ FWANCE ...f... ::' ~ • ~ :::.:.~.;•:: ,;::;.;.;•::::.::•.::::.... y. • .: :..:::.....:... :.:.::,ate'-.,~. ,x .. . . . . ":' ~~ ~ ~ :~::y::;::; 1 ......:.:,. ----.. . : . ~: .::. ::. :~ :::<>uwi : •.4i::i: 'i 'R ..:Flf!rlf!ll.~~~ 12/01 RENEWED AT 0.900% TO MATURE 12/01/11 12/31 PAYMENT: DIVIDEND 0.900% ANNUAL PERCENTAGE YIELD EARNED 0.90% FROM :.,....>.~>,....:::::: ~ ;.:: :;:::::;;:;;:.;;.:..,.;::::.:,,;:.:::. :.:. :.::.. 13.95 18259.58 12 .:::.....: 1/1.O...THROUGH 12/31/10 --------------------------------- _______________ _____ 1201 ID 54 12 MONTH CERTIFICATE BEGINNING BALANCE 5094.86 12/31 PAYMENT: DIVIDEND 1.490% _.. :.. ... -_ .. ~'~%t at-11.l:A:YR':;`lYii+ii-~M•JrsY+.~:..w ti~.:.::~>~+:_ ~^•'.~ `_: ~ ; _ .. :..::. ~......:.. ~ . ~,. ,.. ..... _ 6 .4 5 51 O 1 .31 DIVIDEND YTD: YEAR TO DATE ~;:.:.:,:.:.;»:<::::~>::::<:<::>:::~:<:<>:.>::::»:>_>>::>::<:>::%::>: 69.05 ----------- ------------------------------ ------------------------------------------- ----------------------- -------- 2/0.1. ID 55 12 MONTH CERTT~rear~ ver_*~~*~.. ,,.....,._ 12 MONTH CERTIFICATE HILL MATURE ON _05/10/11.::,.~.::.,:::.,:.,::.:>:::~:;;:.»:<.>:.;:.>;:.~::»;»»::<>::;~;;:::::;:~:>s::~:~~:a:~:::~<::~>~ DIVIDEND YTD: YEAR TO DATE 114.10 .::< :..::.......... . .... . ................:.:...:::::::::::.:~»>:P+: iiii:.:.......::.....: -.: ;..:!:::.mot: ti?iij,:~i'v ~{Si'ti:fi}}?};~i'~i ~5i?`Ilii::i?!ij.:;5}:::}:({:::ti{:;::: is}:ii:S? ni:5:~ ~%'i>.'•yy':;:.:i 12/31 PAYMENT: DIVIDEND 1.240% ::....:.:.:,.:: .:....::...:.:...:.... .............:..:.::...::.::::::.:>:;;:r:.:.;::<.;:.:;;:.>:.:>;:>:.;::r::;::>:«~>::.::»::~: ANNUAL PERCENTAGE YIELD EARNED 1.25% FROM 12/01/10 THROUGH 12/31/103810.28 12/31,._.... ENDING BALANCE ....:....:.......... :: ...........:...:.........;.;;<,.:::::::::;,>::::;«:<~<:;;:;:;::>~:>:.:>;.;:.::;::.::..,:;:;;:.::,::.;;:.::.::::::.:::.~::::::.:...................... 381 12/01 ID 60 12 MONTH CERTIFICATE BEGINNING BALANCE 12/01 PAYMENT: TRANSFER FROM SHARE Ol ,,_.,:._..........._ AUTOMATIC SHARE TR~NSFGa 21696.25 250.00 21946.25 12 MONTH CERTIFICATE WILL NATURE ON 10/14/11 ....~:k.~!~?~?~i.x:3~!..:~ DIVIDEND YTD: YEAR TO DATE 47.02 ----__ :: ~: ....UJ:.i..i.:M.~Y1a-~.-..... ...-~~-~~_.~:~ ii .......: :.. .:::.. .:.: ~. ......... .. -- --- l.UP1111VUtD UN FOLLO~T - _ .............:.......,:.:::::::..:..::,.:;:;.;:.;:;;:..;::::<«>::;<::«:<:::>::>;:: r ~ ~ ~%- ,; ~~% ,, ,, ~,~t, Pennsylvania State Employees Credit Union P.O. Box 61013 (11 T) 234-8484 (Harrisburg Harrisburg, PA 11106-T Ol 3 (800) 2311328 (Nafionwide) i r W@bSrile ~ ~1 ~p:~~M/W W.pSecv.C011'1 015181 204840 TRANSFER HIGH-INTEREST RATE BALANCES TO YOUR PSECU UISA® TO SAVE. GET A LOW RATE AND PAY NO PSECU BALANCE TRANSFER FEE. GO TO PSECUaHOME®, ''MOUE HONEY." JOINT OWNER LEESA V COONS JUNE COONS FMIANCE CHAliGiE 1 / ID 1 REGULAR SHARES BEGINNING BALANCE 8188.85 O1/O1 WITHDRAWAL TRANSFER TO SHARE 53 250.00- 7938.85 AUTOMATIC SHARE TRANSFER 0186XXXXXX 1010111013111 PAGE 3 ABOUT LOANS MARKED WITH AN ~ v~~~"~ STATEMENT OF ACCOUNT WRITE TO: PENNSYLVANIA CENTRAL FCU 959 EAST PARK DRIVE HARRISBURG PA 17111-2810 RETURN SERVICE REQUESTED _ PA Central ~ Toll Free 800-356875 FEDERAL CREDIT UNION Fax 717-564-1503 www.pacentralfcu.com ~~ >00439 6737067 001 092119 T C JUNE COONS &/OR LEESA V COONS 309 MANCHESTER RD CAMP HILL PA 17011-6123 v C c a a 'ELECTRONIC FUNDS TRANSFERS" WRITE TO THE ADDRESS AT LEFT OR CALL: 717/564-4661 r.U. rsox 6iU I3 (/ I ~) 234-tlgtlq (tiornsburg) Harrisburg, PA 11106-1013 {800) 237-1328 {Notionwide) ~, ~w~bs€te ~ h>ffi~://tti~v;r~~.E~~~cE~.~c?«t '• ~ ~ ~ ~ ~ 00000106 1 AV 0.335 I~~~I11~~~111~~~~~~11~~~11~11~~~~~11~~1~1~~11~11~~~1~1~~1~1~~1 JUNE COONS 309 MANCHESTER RD CAMP HILL PA 17011-6123 ANNUAL IRA-SUMMARY FOR CALENDAR YEAR 2010 PAGE O1 KA ITPE: TRADITIONAL IRA BENEFICIARIES: MICHAEL L COONS - 33.000% LEESA V COONS - 34.000% KIMBERLY A RINEER - 33.000% ~,,:;~'~`' 0186 XXXXXX THE FAIR MARKET VALUE, (FMV) OF YOUR IRA WILL BE REPORTED TO THE INTERNAL REVENUE SERVICE ~APYE = ANNUAL PERCENTAGE YIELD EARNED 1/O1 S50 BEGINNING BALANCE 1/31 01/31 S50 DIVIDEND 4.410% APYE~ 4.50% FROM O1/O1/10 THROUGH 01/31/10 02/28 02/28 S50 DIVIDEND 4.410% APYE* 4.50% FROM 02/01/10 THROUGH 02/28/10 3/31 03/31 S50 DIVIDEND 4.410% APYE* 4.50% FROM 03/01/10 THROUGH 03/31/10 4/30 04/30 S50 DIVIDEND 4.410X APYE* 4.50% FROM 04/01/10 THROUGH 04/30/10 5/31 05/31 S50 DIVIDEND 4.410% APYE~ 4.50% FROM 05/01/10 THROUGH 05/31/10 6/30 06/3rn S50 DIVIDEND 4.410% APYE* 4.50% FROM 06/01/10 THROUGH 06/30/10 7/31 47/31 S50 DIVIDEND 4.410X APYE~r 4.50% FROM 07/01/10 THROUGH 07/3I/10 8/31 08/31 S50 DIVIDEND 4.410% APYE* 4.50% FROM 08/01/10 THROUGH 08/31/10 9/30 09/30 S50 DIVIDEND 4.410% APYE* 4.50% FROM 09/01/10 THROUGH 09/30/10 1D/31 10/31 S50 DIVIDEND 4.410% APYE* 4.50% FROM 10/O1/10 THROUGH 10/31/10 I1/30 11/30 S50 DIVIDEND 4.410% APYE~ 4.50% FROM 11/Ol/10 THROUGH 11/30/10 12/01 12/01 S50 NITHDRAWAL NORMAL DISTRIBUTION %% FEDERAL WITHHOLDING 1,048.03 12/31 12/31 S50 DIVIDEND 4.410% APYE~ 4.50% FROM 12/01/10 THROUGH 12/31/10 12131 S50 ENDING BALANCE 124,716.24 467.12 0.00 125,183.36 423.50 0.00 125,606.86 470.46 0.00 126,077.32 456.99 0.00 126,534.31 473.93 0.00 127,008.24 460.36 0.00 127,468.60 477.43 0.00 127,946.03 479.22 0.00 128,425.25 465.50 0.00 128,890.75 482.76 0.00 129,373.51 468.93 0.00 129,842.44 5,240.18- 1,048.03 124,602.26 466.70 0.00 125,068.96 125,068.96 TRADITIONAL SUMMARY PREVIOUS YEAR CONTRIBUTIONS CURRENT YEAR CONTRIBUTIONS 0201 000 000 1 0.00 0.00 5001948 Erie Famil Life y ~.\ Insurances Member Erie Insurance Group Home Office 100 Erie Insurance Place Erie, Pennsylvania 16530 814.870.2000 Toll free 1.800.458.0811 Fax 814.870.2437 www.erieinsurance.com April 5, 2011 Michael L Coons 1772 N Meadow Dr Mechanicsburg, PA 17055 Dear Mr. Coons: Mailed via Certificates of Mailing Re: Annuity ## 547-753 Annuitant: C. June Coons Please accept our sincere condolences to you and your family. Enclosed is our check in the amount of $9,722.07 which represents your share of the net death benefit. The calculation of this amount is: $10,039.19 - Gross Death Benefit $317.12 - Less Federal Income Tax Withholding $9,722.07 - Net Death Benefit Federal law requires us to report this transaction to the Internal Revenue Service on Form 1099-R. A copy of this form will be mailed to you by January 31, 2012. Please notify us of any address change before that time. If you have any questions, please call me at 1-800-458-0811, extension 2243, or Melody Bokshan at extension 2922. Sincerely, ~~ Sally Austin Life Claims Specialist Life Policy Administration SLA:SLA Enclosures: Check (s) cc: Brian K. Huffman, AA7940 *AN05477530* Disclaimer: The information contained in this letter is intended to give you a general understanding of the manner in which certain Internal Revenue Code provisions apply to particular transactions involving Erie Fatuity Lice products. This information should not be construed as tax or legal advice but, instead, as informational only. The tax treatment of any particular transaction may vary depending upon your individual circumstances and you an; encouraged to consult with your tax advisor or attorney if you have any questions concerning the tax treatment of this or any other transaction invobing an Erie Family Liie product. The ERIE Is Above All In Service`. Erie Family Life ANNUAL STATEMENT OF P OLICY VALUES ~.~ I nsurance® STATEMENT PERIOD: JANUARY 01 2010 -DECEMBER 31, 2010 I^.ONTttACT ~1iF•ORM,AT~1 OWNER: C J COONS ANNUITANT: C J COONS POLICY NUMBER 547753 PRODUCT NAME FLEX PREMIUM DEFERRED ANNUITY TAX QUALIFICATION NON-QUALIFIED ANNUITY DATE OF ISSUE JUNE 08, 2002 THANK YOU FOR CHOOSING ERIE FAMILY LIFE AS A PARTNER IN BUILDING YOUR SECURE FINANCIAL FUTURE. IF YOU HAVE ANY ADDITIONAL INSURANCE NEEDS, PLEASE CONTACT YOUR AGENT OR OUR OFFICE AT THE NUMBER LISTED AT THE BOTTOM OF THE PAGE. If applicable, IRS forms 1099 and 5498 wilt show account number EE547753 for this contract. C0:111TRI4CT ACTIVITY ACCOUNT VALUE AS OF JANUARY 01, 2010 $28,662 44 PREMIUM RECEIVED DURING CURRENT PERIOD $0.00 ROLLOVER/TRANSFER/1035/RECHAR/CONVERSION $0.00 INTEREST CREDITED FOR CURRENT PERIOD $1,146.50 GROSS DISBURSEMENTS (INCLUDING SURRENDER CHARGES FEES AND WITHHOLDING , ) $0.00 ACCOUNT VALUE AS OF END OF DECEMBER 31, 2010 $29,808.94 *SURRENDER VALUE AS OF DECEMBER 31, 2010 $29,808 94 c:vl~lyT srTI=RIE+ST RATE As of 01/12/2011, the rate credited to new deposits is 4.000. The rate credited at the time of deposit is guaranteed for one year. Interest rates are determined by current and historical financial market conditions and are adjusted by Erie Family Life as necessary. Agent name: BRIAN K. HUFFMAN 4345 LINGLESTOWN ROAD HARRISBURG, PA 17112-9531 (717) 652-2249 /F N/E CAN BE OF ANY ASSISTANCE, PLEASE CALL YOUR AGENT OR CALL US AT 1-800.458-0819 OPTION 3. Member Erie Insurance Group • Service Center • P.O. Box 83026, Lincoln, NE 68501 • Toll free 1-80058-08] 1 • Fax 866.567.1219 • www erieinsurance com ~tt~t ~i11 ~ctt~ (~1ESfttmPrct OF NNE COONS I, NNE COONS, of the County of Cumberland, State of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish, and declare this to be my Last Will and Testament, hereby revoking and making void all Wills and Codicils at any time heretofore made. +~ ARTICLE I: I order and direct my Executor to pay any expenses of my last illness and funeral, as soon after my decease as may be convenient. ARTICLE II: I give devise and bequeath my entire estate, real, personal, tangible and intangible, including any automobiles, household and personal effects and other property of like nature owned by me at the time of my death, together with the insurance thereon, unto my beloved children, MICHAEL COONS, LEESA SPOGLI and KIMBERLY COONS sharing equally. Should any of my children predecease me or otherwise be unable to accept their share, their share shall go to their children or, in the event that they have no children, their share shall go to my surviving children. ARTICLE III: All the rest, residue and remainder of my estate, real, personal and mixed, of whatever nature and wheresoever the same may be situate, i give, devise and bequeath to my beloved children, MICHAEL COONS, LEESA SPOGLI and KIMBERLY COONS sharing equally. Should any of my children predecease me or otherwise be unable to accept their share, their share shall go to their children or, in the event that they have no children, their share shall go to my surviving children. ARTICLE IV: I direct that all estate, inheritance and other taxes, due by reason of my death, including property which does not pass under my Will, be paid by Executor from my residuary estate. ARTICLE V: I direct that no Executor or Fiduciary named, nominated or appointed in this, my Last Will and Testament, shall be required to post any bond or give any security of any type for any purpose whatsoever, any law or rule of court of the Commonwealth of Pennsylvania or any other jurisdiction to the contrary notwithstanding. ARTICLE VI: I name, constitute, and appoint MICHAEL COONS ` as Executor of this my Last Will and Testament. In the event that said MICHAEL COONS predeceases me or dies before my estate is settled, or if for any reason he is unable to serve as Executor of this my Last Will and Testament, I then name, constitute, and appoint KIMBERLY COONS, as the Executrix of this My Last Will and Testament. ARTICLE VII: I hereby order and direct that Sanford A. Krevsky, Esquire, of Harrisburg, Pennsylvania be employed as the attorney for settlement of this estate. IN WITNESS WHEREOF, I, NNE COONS, the Testatrix, have hereunto set my hand and seal this ~3 day of 1j~~ ~ One Thousand Nine Hundred Ninety-Seven. ' 1 ,- ; COONS THIS INSTRUMENT, consisting of four (2) typewritten pages, was by the above-named Testatrix, on the date hereof, signed, sealed, published and declared to be her Last Will and Testament, in the presence of the undersigned, who, at his request, in her presence and in the presence of each other, have hereunto subscribed their names as witnesses. Jo4larou~ ~. Kf~~:V91C~( residing at `?~cX: ~^ f=~~r.1' ~l' ~_ A`v,2.~,v;F ~~ (~ sew residin at ~ Ke I1 ~ ~ (~ ~ P(`~ residing at ~~/~~ ~ I fl (c~~r) ~ ) ]~ ~'('-f lac]( I~;~;~ I IP (%i~ I-1O ~ 3 AFFIDAVIT COMMONWEALTH OF SS. CO[7NTY OF We, Sanford A. Rrevsky, Lawrence J. Rosen and Relly D. Reed, 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 the Testatrix sign and execute the instrument as his Last Will; that he signed willingly and that he executed it as his 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 of our knowledge, the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed to before me by Sanford A. R~evsky, Lawrenc J. Rosen and Relly D. Reed„ witnesses, this .J.>r`t da of _ , 1997. J' ~~ - '~'- . r'~ .~ ; ~~ti Notary Public NO'URIAI SEILL DAWN L 1AN015. Notary Publk -loiri~bwro, DeupMn Ceangr, PA My Conwwwlee EapMw Marsh 19, 2007 -,~ , COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE REV-1162 EX~11-96) BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT N0. CD 016885 COONS MICHAEL L 1772 N MEADOW DRIVE MECHANICSBURG, PA 17055 ACN ASSESSMENT AMOUNT CONTROL NUMBER falA ESTATE INFORMATION: ssrv: i 86-28-68s~ FILE NUMBER: 211 1-01 13 DECEDENT NAME: COONS C JUNE DATE OF PAYMENT: 12/06/2012 POSTMARK DATE: 12/05/2012 COUNTY: CUMBERLAND DATE OF DEATH: 12/20/2010 REMARKS: RECEIPT TO ATTY CHECK#167 SEAL 101 ~ S 15,000.00 TOTAL AMOUNT PAID: INITIALS: HEA RECEIVED BY: $15,000.00 GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER