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HomeMy WebLinkAbout02-20-13~ 1505611101 REV-1500 Ex `°2.11' ~ enns lvania OFFICIAL USE CyLY PA Department of Revenue P Y County Code Year File Number DEPARTMENT OF REVENUE Bureau of Individual Taxes INHERITANCE TAX RETURN '° PO BOX 28o6oi ^ Q ~ ? 0 - ! ? Harrisbur , X128-060 RESIDENT DECEDENT d" ENTE~i D'ECEdENT INFOR TION BELOW ~ ~ _ Social Security Number Date of Death MMDDYYYY Date~of Birth MMDDYYYY i~~ ~.~ GG?S a~ t3~or~, o72S142~ Decedent's Last Name Suffix Decedent's First Name MI ~ ~ ~~u s ~-~ s 8`~ r rr a (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, s- Q 4. Limited Estate ~ 6. Decedent Died Testate ': ° , ,' (AttaGr CoQy of Will) O 9. Litiga#jon Proceeds Received ~: ,~ ~ . , O 2. Supplemental Return O 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust.) O 10. Spousal Poverty Credit (Date of Death Between 12-31-91 and 1-1-95) O 3. Remainder Return (Date of Death Prior to 12-13-82) O 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes O 11. Election to Tax under Sec. 9113(A) (Attach Schedule O) CQRRESPONDEN.~-.THIS,SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name ~ --= ~ - ''" Daytime Telephone Number ZIP Code ..+. c . ~ First Line of Address ~ Z~ S o v `t ~1 ~ S', ~ C o >~ D S T Second Line of Address ~ _. - ~ _ ~ i City or Post Office State C~A-~B E~S'$v ~G ~R R~ISTER O~ILLS~B~NLY ~ ~. ~ I'>R ~ ~ ca cn %~ ~ ~ r~- N ~..t r~„t c,..7 ~-., ~,.,~ -,~ -,~ --a~ ~2 4" r s..+~ ~ ~. .~^'~ 1 l.J ~~ y+~ ~# tw~ D T FIL a u 1 72c 1 35¢9; .. Correspori~lec~t's a-mail address: 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 OF PERSON RESPONSIBLE FOR FILING RETURN DATE ~.o...r...,,~ ~ . ~ : _ ,.... ~ az,~m'? l 20,3 ADDRESS ~'~ ~•~'~+. g GGoJfy - ~ ~1•~•.rn R.S~.,sa~ A, ~T2,ot_3~44 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505611101 1505611101 J 1505611201 REV 1500 EX ... .. ~ _ -• Decedent's Social Security Number _ Decedent's Name: **~~ ~ ~1)c."CtY R 17 w~~,c4 ~~ ___ L ~ '~ 2 2 ~ ' ~ ( v __~~__ RECAPITULATION 1. Reat Estate (Schedule A)....°....... - - .~ .....:...... ~............ ~ ..~.. ~~I~. ~ .. ~ ~ , 2. Stocks and Bonds (Schedule B), .,~...r ... rte:.... ........... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. +- 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. ~ :Z. J 3 S • ~ rt. 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. • 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ~~ 1 ;L ~ ~ ~ ~ ~ ~• 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 9 j ~ (• , L 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............... 10. ~ ~ . ~ ~ . ',~.,~ 11. Total Deductions (total Lines 9 and 10) ................................. 11. ~}' Q S 2 . 1 .G 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. ~ ~ O ~ ~ . ~1 Q 13. Chari fable and Governmental Be~uestslSec 9113 Trusts for which ` "' • s ~' art election to t~;x has not been made (Schedule J) ~ .".13. .t . ~ - ' • • t, 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. $ ~ $ I~..~ ~ TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES _..___.___~ 15. Amount of Line 14 taxable at the spousal tax rate, or ~ • transfers under Sec. 9116 ~ `' ~ `~ ~' ~ ~' ~ ~ • ~" ~ ~• (a)(1.2) X .0_ . 15. 16. Amount of Line 14 taxable at lineal rate X .0 ~ ~ O ~ ~ •~' ~ 16. ^~ 3 ~ 3 • ! 1 17. Amount of Line 14 taxable at sibling rate X .12 s 17. 18. _> Amount of Line t4 ta~cable ' " '~' 3 . x` '' -'~ -~ ~"~ • . . at collateral rate X .15 • 18. « 19. TAX DUE ......................................................... 19. ~=(~~~.~ ~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~ i~. x Side 2 1505611201 1505611201 J REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENTS NAME STREETADDRESS .... ,. ~ ~~_~_~_~~s 1, _ ~! t e s+A o a lSN_ ti ~ 3 S _ _ _ CITY ' Q.?'7 s D u~ ATE ~~ - - ZIP -- - ~?25'~ Tax Payments and .Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments _____ B. Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. .. ~ c1) 3L ~ •7i Total Credits (A + B) (2) (3) (4) (5) '~ 3L3•~1 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 reversionary interest .............................................................................................................................. ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ........................................................................................................................ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving°spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX + (1-9I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER _ c Cry A . ~ ~ ~ e>N S 2~l - 1 ~ Include the pnxeeds 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~-~ '~ 0 R0.S`~ovs N SRN W 308 GARO~~t SYRC.~efi G~~ak~N~ AGGO~~JT ~ G~css e,4S~{.•G ~ Pp . 1'7 2Z.'S No, t 4~. eoo 5So 1 t, ! 8l . 3~. ~q W A~ N v"C ~ s 1TO.rn, 1~~d S4.t~~s,,~s ~,~a,g ~ p~ • ~'t2s7 ReF ~,.~ d o ~ r`La,~>w R~,>~i Fo ~ ~ v per 12 ~ Q 5~' • o0 TOTAL (Also enter on line 5, Recapitulation) I ~ ~ 2 ~ 135.3• (If more space is needed, insert additional sheets of the same size) Qat a 6/ 15/ 12 Pa e 1 Primary Account 142000550 Enclosures Bet t y A Ci vans 129 V~AI nut Sot t om Fid Unit 135 Shippensburg PA 17257-8120 Account Ti t I e 50+ Interest Checki ng Account Number Pr evi ous Bal ance 3 Deposits! Q'edi t s 5 Checks/ Debit s Servi ce Fee I nt er est Pai d GLr r ant Bel ance C H E C K I N G ACCOUNT S Bet t y A Di vans Check Saf ekeepi ng 142000550 St at errant Dates 5/ 16/ 12 t hr u 6/ 17/ 12 8, 904. 46 Days I n The ~ at errant Period 33 2, 583. 75 Aver age Ledger 9, 864. 54 3, 168. 89 Aver age Col I act ed 9, 864. 54 . 00 1 nt er est Ear ned . 26 . 26 Annual Per cent age Y el d Ear ned 0. 03% 8, 319. 58 2012 I nt er est Paid 1.33 Deposits and Additions Det a Description Mount 6/ 01 XXVA BENEF US TREASIRY 310 1, 094. 00 PPD 6/ 01 XXSOC SEC US TREASIiRY 303 1, 071.00 PPD 6101 PENSI CN CHASE 000920L07 418. 75 PPD 6/ 17 Interest Deposit . 26 - - - CHECK SUuMARY - - - Dat a Check No Amount Date Check No Amount 6/ 06 2018 153. 00 6/ 08 2052 26. 40 6/ 04 2019 12. 50 6/ 15 2053 2, 862. 00 6J 06 2051' 114. 99 ' Denotes rri ssi ng check numbers Date 6/ 15/ 12 Prinery Account Enclosures Bet t y A a vans 129 Vliil nut Bottom lid Unit 135 Shi ppensbur g PA 17257- 8120 50+ I nt er est Checki ng 142000550 (Continued) Qai I y Bal ante I of or rrgt i on Date Bal ante Date Bal ante Oat e 5/ 16 8, 904.46 6/ 06 11, 207. 72 6! 17 6/ 01 11, 488. 21 6/ OS 11, 181.32 6/ 04 11, 475. 71 6/ 15 8, 319. 32 I nt er est Rate Sumrer y 5/ 15 0. 010000% 6/ 01 0. 050000°k 6/ 15 0.010000% THANC Y(XJ FCR BANCI WG W TH CRRSTQMI BANG Page 2 142000550 Bal ante 8, 319. 58 Date 6/15/12 Primary Account Enclosures Betty A Diven s 129 Walnut Bottom Rd Unit 135 Shippensburg PA 17257-8120 50+ Interest Checking Daily Balance Information Date Balance Date 5/16 8,904.46 6/06 6/01 11,488.21 6/08 6/04 11,475.71 6/ 15 Interest Rate Summary Page 2 142000550 142000550 (Continued) Balance Date Balance 11,207.72 6/17 8,319.58 11,181.32 8,319.32 5/15 0.010000% 6/01 0.050000% 6/15 0.010000% THANK YOU FOR BANKING WITH ORRSTOWN BANK T/10/12 Betty A Diveas CIF address change Messages Last stmt balance: Current balance: 1=View 6=Print T=Teat Posted Check No S T/C Deposit Internet 8,319.58 9,353.58 Coai Inquiry Account number: Banking Last stmt date: Statement cycle: trol: From Debit C d' 10:32:38 142000550 1 of 1 6/17/12 15 To 6/01/12 C 163 re it 1,094.00 ,saiance 9 998 46 6/01/12 6/01/12 C 163 1,071.00 , . 11,069.46 6/01/12 C 163 151 418.75 11,488.21 6/04/12 2019 P 091 12 50 .05000000 11,488.21 _ _ 6/06/12 2018 P 091 . 153.00 11,475.71 11 322 71 _ 6/06/12 6/08/12 2051 2052 P P 091 091 114.99 , . 11,207.72 _ _ 6/15/12 2053 P 091 26.40 2 862 00 11,181.32 6/15/12 151 , . ' ~ 8,319.32 6/17/12 160 .010000 - ~y • 8,319.32 6/17/12 151 .26 010 8,319.58 _ 6/22/12 2020 P 091 60 00 . 8,319.58 6/29/12 C 163 . 1,094.00 859.58 9,353.58 F4=Redsply F6=Bal Inq F7=Scan Fwd FB=Scan Bkwd Fil=Prior bal F15=EFT F16BSortm F17=Top F18=Bottom F19=EDI F20=IIafold F22=T/C F23=Checks ~ sQ ~-g ~~. ~~ ~~~)~ ~( Elmcroft of Shippensburg 129 Walnut Bottom Roado Shippensburg, PA 17257 717-530.1400 Statement Date 7/20/2012 Resident Acct # 353500202 Statement Number 0376403 Resident Divens, Betty A. 7/20/2012 Ou~tandin~ Balance $2,957.40 Current Activity - August 2012 Resident Care Fees ~ Ancillari 8/1/2012 0376403 AL LEVEL E MONTHLY CARE June -10 95.40 ($954.00) 8i i/2012 10376403 nL LEVEL MONTi-iLY CAr E .it~iy ..3~1 95.0 ($2,°57.nr0) Balance Due: ($954.04) For Billing Questions please call: Bill To: Vickie Hickman 3530 Keahi Place Kihei, HI 96753 (866)575-7813 Your cancelled check is your receipt -Keep this portion for your records Retum this portion with your payment BCC SHIPPENSf3UKU OPEKH fIO~SS, PLC PLAZA II OFFICE BUILDING, STE 101 Payment D-ue Uate: 9510 ORMSBY STATION RD Amount Due: LOUISVILLE, KY 40223 Statement Number: Resident: Divens, Betty A. Resident Acct# 353500202 Send Remittance to: BCC SHIPPENSBURG OPERATIONS, LLC PLAZA II OFFICE BUILDING, STE 101 9510 ORMSBY STATION RD LOUISVILLE, KY 40223 Resident Statement $/ii2u i2 ($954.00) 0376403 Make Check Payable to: BCC SHIPPENSBURG OPERATIONS 00000000037640320356003500202107202D1260000-9540010 REV-1511 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHED~ILE N FUNERAL EXPENSES & ADMINISTRATIVE COSTS tSTATE OF . »~v FILE NUMBER _ ~.l-1 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES: Li) Jc~.e'tttv~ltt rti••.'C1..d~ss tkva~1. fZeF*~s~-Meai A1~7'a1t F vrr t ~- l;~ LBY GAwr:TQ, vseRK.S ~1JCs0.wv,N ~, o ~ i .N-L s ie~~ B. ~ ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City _ State Zip __ _______ Year(s) Commission Paid: 2• Attorney Fees t ~o~vv-t !~. h1~f~.p~.~ ~„~,Q ~~ ~w~,L 3•. Family Exemption: (If decedent's address is not the same as claimant's, attac h explanation) Claimant Street Address _ City _ State Zip ________ Relationship of Claimant to Decedent 4. Probate Fees (,rv ~.s1~ o~ ~,v ~wb t 1w.1 ~ r~ d RC C -S41.o ft. • 6 W ~~J S 5. Accountant's Fees s• Tax Return Preparer's Fees ~. 7'1•~~.•- w>'-5 F vxd8 1.~C'11' ,,,t FttGov,~ 1. No. tqz. ooe ~SGo Ghesryc'~ R tLav 1N~ ~ o Rt-STov.>f ~ ~w aK a ~ ~ 10 °t4 • o L„ "('e R+t~1-4 '~ De_~'~s~Tcne,.~L' oR Ye,ie,o~t~s A~4'a~RS ~•!~ ~~~M~~ ~cY ~~~ t e1 ~l.R, R tt.mv wt's' Fell ~.l.R , ~ -s C. ~ 2s12 p!~y *.~,~.~ ~ . E1.~,c Cwwla~c ~ c..,11~ wiL'1~ d~~,,s t`c beck o,,s 1 m, os /Ze~~. ~ J o ~•>i. , s o AMOUNT 300. o0 # ~~ 4,00 '~ 2tq. t8 Jro • eo ~ 213 • So r ~5,«~ TOTAL (Also enter on line 9, Recapitulation) I $ ~ l ~ , (og If ( more space is needed, insert additional sheets of the same size) ORRS 0 0 ORRSTQWNBANK A Tradition of Excellence P.O. Box 250 Shippensburg, PA 1 ?257 Temp-Return Service Requested Date 10/15/12 Primary Account Enclosures I~~~~~I~~~~II~~~I111111~~~111111~~~1~1~~1~~1~11~1~1~1~1~~11~~~11' 001126 0.6500 AV 0.350 TR00005 Betty A Divens 928 S 2nd St Chambersburg PA 17201-3549 M O N ~O N ~--~ O 0 0 N ~--~ ~--~ O O .--1 O 0 N 0 00 O N • C~ N O O (`7 ~~ V'! O ~ N ~~ Page 1 142000550 C H E C K I N G A C C O U N T S Account Title Betty A Divens DID YOU KNOW? All Or rstown Bank debit and ATM cards are protected by FraudWatch PLUS. If suspicious activit y is noticed on your card, Fraud Prevention Services w ill call to notify you. Visit www.orrstown.com/Onli ne-Banking/Securit y-Center/ATM-Debit-Card-Safety-Tips.aspx for more informaion. 50+ Interest Checking Check Safekeeping Account Number 142000550 Statement Dates 9/17/12 thru 10/15/12 Previous Balance 1,094.08 Days In The Statement Period 29 Deposits/Credits .00 Average Ledger 679 11 1 Checks/Debits 1,094.00 Average Collected . 679 11 Service Fee .00 . Interest Paid .00 Current Balance .08 2012 Interest Paid 1.41 Electronic Debits and Wi thdrat+als Date Description 10/05 Chargeback Daily Balance Information Date Balance Date 9/17 1,094.08 10/05 Interest Rate Summary 9/16 10/05 Amount 1,094.00- Balance .08 0.010000 0.000000 To Reconcile Your Checking Account 1. List and Total aff outstanding checks including those still outstanding from previous statements. 2. Enter the "Balance This Statement" found in the last block of the summary line on the front of this statement. 3. List deposits and other credits not shown on this statement. 4. Total items listed in steps 2 and 3. 5. Enter and Subtract the total of the outstanding checks as deternuned in Step 1 above from total in Step 4. 6. This Figure should be your checkbook balance. If it does not agree, review the above steps, note the following instructions and if necessary review your checkbook entries. O OUTSTANDING CHECKS NUMBER AMOUNT TOTAL RECONCILEMENT 0 IN CASE OF ERRORS OR QUESTIONSABOUT YOUR ELECTRONIC TRANSFERS Telephone: 1-8$8-677-7869 • Address: P.O. Box 250, Shippensburg, PA 17257 If you think your statement or receipt iswro ng or if you need mo re information about a tra nsfer o n the statement or receipt, please contract us as soon as possible using the above telephone numberoraddress. We musthearfromyounolaterthan60daysafterwesentyoutheFlRSTstatementonwhichtheerrororproblemappeared. (1)Tell usyourname andaccount number(ifany). (2) Describethe errororthe transferyouare unsure aboutand explain asclearly asyou can why you believe there is an errororwhy you need more information. (3) Tell usthe dol lar amount of the suspected error. If youtell usorally, we may requirethatyou send usyour complaint or question in writing within 10 business days. Wye will determine whether an error occurred within 10 business days (20 business days if the transfer involved a new account) afterwe hear from you and will correct any error promptly. If we need more time, however, we may take up to 45 days (90 days if the transfer involved a new account, apoint-of--sale transaction, or a foreign-initiated transfer) to investigate your complaint or question. Ifwe decide to do this, we will credit your account whin 10 business days (20 business days ifthe transferinvolvedanewaccount) for theamountyouthinkis in error, sothatyouwillhavetheuseofthemoneyduringthetimeittakesustocompleteourirwestigation.If we ask you to put your compla int or questio n in writing an d we do not receive it within 10 business days, we may not credit your account. Your account is oo rtsidered a new account forthe first 30 d ays afterthe first deposit is made, unlesseach of you alrea dy has an established account with us before #his account is open ed. We will tell you the resultswfthinthree business days aftercompleting our investigation. If we decide thatthere was no error, we will send you a written explanation . You may ask forcopies o fthe docume ntsthat we u sect in our inv estigation. LINE OF CREDIT ACCOUNT INFORMATION Important Information AboutYour Account Charges: Wp compute the FINANCE CHARGE on youraccount by applying the periodic rate to the "average daily balance" ofyour account (including currenttransactions). To get the "average daily balance," we take the beginning balance ofyour account each day, add any new loans, and subtract any payments, credits, unpaid finance charges, and unpaid insurance premiums. This gives usthe daily balance. Then, we add up all the daily balances forthe billing cycle and divide thetotal by the number of days in the billing cycle. Th is gives us the "average da ily baia nce." If a "finance charge adjustme~lc rate which applied inrthe billirtgcecyGe fordwhich hel adjustment was made and t»r the number'o9daysforwlh~~ich the adjustment was adjustment applies by the pe made. Billing Rights Summary In Case of Errorsor ©uestions About Yo ur Statement If you think your statement is wrong or if you need more information about a transaction on your statement, write us on a separate sheet at the address shown on your statement as soon as possible. We must hear from you no later than 60 days afterwe sent you the first statement on which the error or problem appeared. You can telephone us, butdoing so will not preserve your rights. In your letter, give usthe following information: (1) Your na me and accou nt number. 2 The dollar amo unt of the suspected error. (3) Describe the a rror and explain, ifyou can, why you believe there is an erro r. Ifyou need more information, describe the item you are unsure about. You do not have to pay any amount in question while we are investigating, but you are still obligated to pay the amounts on your statement that are not in question. While we i nvestig ate yo ur que stion, we ca nnot report yo u as de linque nt or to ke any action to col lest the amount in q uestio n. ORRS 0 ~RRST4WNBANK A Tradition of Excellence P.O. Box 250 Shippensburg, PA 17257 Temp-Return Service Requested Date 8/15/12 Page 1 Primary Account 142000550 Enclosures 001131 0.4500 AV 0.350 TR00005 Betty A Divens 428 S 2nd St Chambersburg PA 17201-3549 0 M .--i .--~ O 0 m 0 N .--1 O O O r-1 O 0 M o ao O N . 01 '--1 o ch ~~ N O C H E C K I N G A C C O U N T S Account Title Betty A Divens 50+ Interest Checking Check Safekeeping Account Number 142000550 Statement Dates 7/16/12 thru 8/15/12 Previous Balance 1,094.06 Days In The Statement Period 31 Deposits/Credits .00 Average Ledger 1,094.06 Checks/Debits .00 Average Collected 1,094.06 Service Fee .00 Interest Earned .01 Interest Paid .01 Annual Percentage Yield Earned 0.01$ Current Balance 1,094.07 2012 Interest Paid 1.40 Deposits and Additions Date Description Amount 8/15 Interest Deposit .01 Daily Balance Information Date Balance Date Balance 7/16 1,094.06 8/15 1,094.07 Interest Rate Summary 7/15 0.010000$ THANK YOU FOR BANKING WITH ORRSTOWN BANK To Reconcile Your Checking Account 1. List and Total all outstanding checks including those still outstanding from previous statements. 2. Enter the "Balance This Statement" found in the last bock of the summary tine on the front of this statement. 3. List deposits and other credits not shown on this statement. 4. Total items listed in steps 2 and 3. 5. Enter and Subbact the total of the outstanding checks as detemuned in Step 1 above from total in Step 4. 6. This figure should be your checkbook balance. If it does not agree, review the above steps, note the folkriring instructions and if necessary review your checkbook entries. ® OUTSTANDING CHECKS NUMBER AMOUNT TOTAL RECONCILEMENT IN CASE OF ERRORS OR QUESTIONS ABOUT YOUR ELECTRONIC TRANSFERS Telephone: 1-888-677-7869 • Address: P.O. Box 250, Shippensburg, PA 17257 If youthinkyourstatementorveceipt iswrong or if you need more information about a transferonthe statement or receipt, please contact us as soon as possible using the above telephone number or address. We musthearfromyounolaterthan60daysafterwesentyoutheFlRSTstatementonwhichtheerrororproblemappeared. (1)Tell usyourname andaccount number(ifany). (2) Describethe error orthe tra nsfer you are unsu re about and explain asclearly asyou can why you believe there is an error orwhy you need more information. (3) Tell usthe dollar amount of the su spected error. If youtell usoralty, we may requirethatyou send usyour complaintorquestion in writing within 10 businessdays. Wle will determine whether an error occurred within 10 business days (20 business days if the transfer involved a new account) afterwe hear from you and will correct any error promptly. If we need more time, however, we may take up to 45 days (90 days if the transfer involved a new account, apoint-of--sale transaction, or a foreign-initiated transfer) to investigate your complaint or question. Ifwe decide to do this, we will credit your account whin 10 business days (20 business days ifthe transfer involved a new account) for the amount you thi nk is in error, so that you will have the use ofthe money during the time it takes us to complete our i nvestigation. If we ask you to put your compla int or questio n in writing and we do not receive itwith in 10 business days, we may not cxedit your account. Your account is ce nsidered a new account fo rthe first 30 d ays after the first deposit is made, unlesseach of you alrea dy has an established account with us before #his account is open ed. 1Me will tell you the resultswithin three business days afte r completing our investigation. If we decide that there was no error, we will send you a written expla nation . You may askforcopies ofthe documentsthatwe used in our investigation. LINE OF CREDIT ACCOUNT INFORMATION Important Information About Your Accou nt Ch arges: We computetheFINANCE CHARGE on youraccount by applying the periodic rate to the "average dairy balance" ofyour account (including currenttransactions). To get the "average daily balance," we take the beginning balance of your account each day, add any new loans, and subtract any payments, credits, unpaid finance charges, and unpaid insurance premiums. This gives usthe daily balance. Then, we add up all the daily balances forthe billing cycle and divide thetotal by the number of days inthe billing cycle. Th isgives usthe "average da iry balance." If a "finance charge adjustment" is shown on this statement, we computed this portion of the FINANCE CHARGE by multiplying the principal amount to which the adjustment applies by the periodic rate which applied inthe billing cyGe forwhich the adjustment was made and by the number of days forwhich the adjustment was made. Billing Rights Summary In Case of Errorsor Questions About Your Statement 1f you think your statement is wrong or if yo u need more information about a transaction on yo ur statement, write us on a sepa rate sheet at the address shown on your statement as soon as possible. We must hear from you no later than 60 days after we sent you the first statement on which the error or problem appeared. You can telephone us, butdoing so will not preserve yourrights. Inyourletter,give usthe following information: (1) Your na me and account number. (2) The dollaramo unt of the suspected error. (3) Describethe a rror and explain, ifyou can, why you believe there is an erro r. Ifyou need more information, describe the item you are unsure about. You do not have to pay a ny amount in question wh ile we are investigating, but you are still obligated to pay the amounts on your statement that are not in questio n. While we investig ate yo ur que scion, we cannot report yo u as de linque nt orta ke any action to collect the amount in q uestio n. ORBS 0 QRRSTQWNBANK A Tradition of Excellence P.O. Box 250 Shippensburg, PA 17257 Temp-Return Service Requested Date 11/15/12 Page 1 Primary Account 142000550 Enclosures 1~~~~~1~~~~11~~~~1111111~~~111111~~~1~1~~1~~1~11~1~1~1~1~~11~~~11' 001135 0.4500 AV 0.350 TR00005 Betty A Divens 428 S 2nd St Chambersburg PA 17201-3549 M O N -n ch r, 0 0 ,-, N O O O O O M ~--i '--~ O OD O N 01 ~--~ O O M ~~ (n O C H E C K I N G A C C O U N T S Account Title 50+ Interest Checking Account Number Previous Balance Deposits/Credits Checks/Debits Service Fee Interest Paid Current Balance Betty A Divens 142000550 .08 .00 .00 .oe .00 .08 Check Safekeeping Statement Dates 10/16/12 thru 11/15/12 Days In The Statement Period 31 Average Ledger .08 Average Collected .08 2012 Interest Paid 1.41 Daily Balance Information Date Balance 10/16 .08 THANK YOU FOR BANKING WITH ORRSTOWN BANK N r\ .--I To Reconcile Your Checking Account 1. List and Total all outstanding checks including those still outstanding from previous statements. 2. Enter the "Balance This Statement" found in the last block of the summary fine on the front of this statement. 3. List deposits and other credits not shown on this statement. 4. Total items listed in steps 2 and 3. 5. Enter and Subtractthe total of the outstanding checks as determined in Step 1 above from total in Step 4. 6. This Figure should be your checkbook balance. If i[ does not agree, review the above steps, note the folknving instructions and if necessary review your checkbook entries. m OUTSTANDING CHECKS NUMBER AMOUNT TOTAL 0 RECONCILEMENT IN CASE OF ERRORS OR QUESTIONSABOUT YOUR ELECTRONIC TRANSFERS Telephone: 1-888-677-7869 • Address: P.O. Box 25Q, Shippensburg, PA 17257 If yo u think your statement or receipt is wro ng or if you need mo re information a bout a tra nsfer o n the statement or receipt, please contact us as soon as possible using the above telephone number or address. We musthearfromyounolaterthan60daysafterwesentyoutheFlRSTstatementonwhichtheerrororproblemappeared. (1) Tell usyour na me and account number (ifany). (2) Describe the error orthe tra nsfer you are unsu re about and explain as clearly as you can why you believe there is an error orwhy you need more information. (3) Te!! us+he do!!ar amount of the su spected er, or. Ifyou tell usorally, we may requirethatyou send usyour complaint or question in writing within 10 business days. Wle will determine whether an error occurred within 10 business days (20 business days if the transfer involved a new account) after we hear from you and will correct any error promptly. If we need more time, however, we may take up to 45 days (90 days if the transfer involved a new account, apoint-of-sale transaction, or a foreign-initiated transfer) to investigate your complaint or question. Ifwe decide to do this, we will credit your account wthin 10 business days (20 business days ifthe transfer involved a new account) for the amount you thi nk is in error, so that you will have the use of the money during the time it takes us to complete our i nvestigation. If we ask you to put your compla int or question in writing and we do not receive lt with in 10 business days, we may not cxedit youraccount. Your account is co nsidered a new account forthe first 30 days afterthe first deposit is made, unlesseach of you already has an established accountwith us be#ore#his account is opened. 111~e will tell you the resultswithinthree business days aftercompleting our investigation. If we decide thatthere was no error, we will send you a written expla nation. You may askforcopies ofthe documentsthatwe used in our investigation. LINE OF CREDIT ACCOUNT INFORMATION Important Information About Your Account Charges: We compute the FINANCE CHARGE on youraccount by applying the periodic rate to the "average daily balance" ofyour account (including currenttransactions). To get the "average daily balance," we take the beginning balance ofyour acxount each day, add any new loans, and subtract any payments, credits, unpaid finance charges, and unpaid insurance premiums. This gives usthe daily balance. Then, we add up all the daily ba lances forthe billing cycle and divide the total by the number ofdays inthe billing cycle. TFtisgives usthe "average da ily balance." If a "finance charge adjustment" is shown on this statement, we computed this portion of the FINANCE CHARGE by multiplying the principal amount to which the adjustment applies by the periodic rate which applied inthe billing cycle forwhich the adjustment was made and by the numberofdays forwhich the adjustment was made. Billing Rights Sunxnary In Case of Errors or Questions About Yo ur Statement 1f you think your statement is wrong or if you need more information about a transaction on yo ur statement, write us on a sepa rate sheet at the address shown on your statement as soon as possible. We must hear from you no later than 60 days after we sent you the first statement on which the error or problem appeared. You can telephone us, butdoing so will not preserve yourrights. In yourletter, give usthe following information: (1) Your na me and account number. (2) The dollar amo unt of the suspected error. (3) Describe the a rror and explain, Ifyou can, why you believe there is an erro r. Ifyou need more information, describe the item yo u are u nsure about. You do not have to pay a ny amount in question wh Ile we are investigating, but you are still obligated to pay the amounts on your statement that are not in question. 1l1At Ile we i nvestigate yo ur question, we ca n not report yo u as de linque nt or to ke any action to col lectthe amount in q uestio n. REV-1512 EX+ (12-03) scwEUU~E ~ COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT i ESTATE OF FILE NUMBER ~~~ t VGN j ,~ R rt d b ~ epo e ts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses ITEM . NUMBER DESCRIPTION TE VA OF DEATH ~~.} ~ e~ Sk~~f~?..~tL~.,u~ o p•R-~-i ~o-us tRcc >I.s 35~50o L•-Z .~" R.r°[' ~ 2gG~.. os ~~ kNo~~vtius, 8~,~.,~t a~seew~,.,, ~- G~-lae. Ft~S'IC ~1-wA~c~ tv ~S ~ <G~-ys M~~~~~~ ~o• ao ~ "~ ~ oe i' F Si,~t KL ~ ~.t.3Cai. ~Ge ~ ~"~s ~ i ~ L ~ Atp~ ~ ~~~w,s.s"C~c ~ ~ ~ 30. o0 . . l~~ S o v~ti,. >t1A,q V N A-1 N V ~, V N~. ~ S ~ ab ~,~ F 11R.t G1~•~"~~,~sl~vw~ K.c~,~tAS. ~ C q~ C. ~~j 'D, ~4cs ~e„ ~ 1 z. so . ~, CAS CoPR~ o>N Eq~-P~-c L pal 4 24.44 TOTAL (Also enter on line 10, Recapitulation) $ I ;3 ~ 3 ~- ~ ,~..~ (If more space is needed, insert additional sheets of the same size) REY•1513 EX + (1-9n COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~ ~+ NUMBER I. X21 ~3) ~~~ L~ II. SCHEDULE J BENEFICIARIES FILE NUMBER 21 - 1 'x„ RELATIONSHIP TO DECEDENT AMOUNT OR S NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Ust Trustee(s) OF ESTATEARE TAXABLE DISTRIBUTIONS (include outright spousal distributions) ~6SRaSAR~ K• '~1~e.NS S ~ ~~fa sY• Sp ~ /~v G~,~ N-.~ e. l~Sl~ ~ ~ , ~a , i "t 2.~s , ~ i ~l„~~l ~ • ~~.,~.~s ~I 5 g ~ ~~ A~.T~.,>~ ~.~.R~>r, ~>wa s o ~ ~aQ-e.N CRS,~t, PAS t'12Z-$' r ~t4~ ts"0. S ~ SR.~ps.L +h. ~ tvt.*1 ~ ,e>Ls~ ~ ~~~~~>>~ ~.~a ,~~. O ~ ~. V~ ~ ~.91A.. b hvg~ ta33Z.. ~ ,~'i„ ~ ~~e.,~ ~o>w~ " ~ au~~,~'zR .. 115 '~ A . 1'1 LZ.S G RGe ,c C w S'~L.c, . r ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE , ON REV 1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET ~ S (If more space is needed, insert additional sheets of the same size) REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA r ~ CERTIFICATE OF GRANT OF LETTERS No . 2012- 00704 PA No . 21- 12- 0704 Estate Of : BETTYA DIVENS (First, Middle, Last) a/k/a : BETTY AMELIA DIVENS Late Of : SHIPPENSBURG BOROUGH CUMBERLAND COUNTY Deceased Social Security No : 162-22-6675 WHEREAS, on the 25th day of June 2012 an instrument dated March 2nd 1988 was admitted to probate as the last will of BETTYA DIVENS /First, Middle, Lastl a/k/a BETTYAMELIA DIVENS 1 a to of SHIPPENSBURG BOROUGH, CUMBERLAND County, who died on the 13th day of June 2 012 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsyl vani a, hereby certify that I have this day granted Letters TESTAMENTARY to: VICKIE K HICKMAN and BERNARD H DI VENS who have duly qualified as EXECUTOR(R/X) and have agreed to administer the estate according to law, all of which fully appears of record in my office a t CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 25th day of June 2072. _ egister o lls eputy * *NOTE* * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) ~ ~ ' ALL OF BETTY A. DIVENS I, BETTY A. DIVENS, of Antrim Township, Franklin County, Pennsylvania, being of sound and disposing mind, memory and understanding, revoke any prior wills and codicils and declare this to be my will. My husband Harold L. Divens has predeceased me. As of the time of execution of this will my lineal issue consist of my five children, eight grandchildren and one great-grandchild. My son Bernard H. Divens has two children, Shelly and Chad, and one grandchild, Kendra. My son John M. Divens has three children, Krista, Cory and Jennifer. My daughter Vickie K. Hickman has no children. My son Samuel M. Divens has two children, Heather and Samuel, Jr. My daughter Dolly J. Buckley has one child, Alisha. ITEM I. E%PENSES AND TA%ES. I direct that as soon as may be con- venient after my decease there be paid from my estate all of my just debts, expenses incident to my illness, my funeral expenses and, from the principal of the residue of my estate, al 1 of my state and federal inheritance and estate taxes. ITEM II. RESIDUARY GIFTS. I direct that my entire residuary estate be converted into cash and that my residuary estate be divided into equal shares with one share going to each child of mine who survives me, and one sh~-e divided equally among the children who survive me of any child of mine who predeceases me. /Betty A. Divens -.., ~., ~p ~ ate ~ ~} ; ~-, ~ --~ ~- !'t't c Cf? - y CJt t _ _3 i ~-r ~ C~G` ~ ~ ~, ; `.,,T Q ~ ~ --~ - -?-~ D ~~-~ ~ ;~~ C> ;..~ r-, cn ~~ C3 a-t -~ w ` ITEM III. FINANCIAL GUABDIAH. In the event that any person who is a beneficiary under this will or who is a beneficiary of insurance proceeds or who is a beneficiary of other property with respect to which I have power to appoint a guardian is under a legal disability due to minority at the time of distribution, I appoint my herein named Financial Guardian as guardian of the estate of said minor beneficiary and I authorize my said guardian to use such amount or amounts of income or principal as shall be necessary, in the sole discretion of my said guardian, for the maintenance, support, medical expenses and education of said minor during the period of his legal disability due to minority. ITEM IV. APPOINTMENT OF FIDUCIARIES. I appoint as Financial Guardian of any financial guardianship hereunder the surviving parent of the minor beneficiary, provided that surviving parent was married to a child of mine at the time of the death of my child, and provided that no such surviving parent shal'1 serve or continue to serve as a financial guardian for a minor grand- child of mine if the minor's surviving parent has remarried after his or her marriage to my child. I appoint First National Bank of Greencastle, Penna., as Alternate or Successor Financial Guardian to serve in all financial guardian situations not above provided for. I appoint Bernard H. Divens and Vickie K. Hickman or the survivor of them as Co-Personal Representatives of my estate. If both of them pail to qualify or cease to act, then I appoint as my Alternate or Successor Personal Repre- sentative the oldest child of mine willing and able to act as such. If all of r etty A. Divens - 2 - .~ ~` ~ ' my children fail to qualify or cease to act, then I appoint First National Bank of Greencastle, Penna., as my Personal Representative. ITEM V. NO BOND. I direct that no fiduciary appointed hereunder shall be required to post bond in this or any other jurisdiction. IN WITNESS WHEREOF, I, BETTY A. DIVENS, the Testatrix, hereby execute on /~/-'~i,l ~ 1988, this my will, typewritten upon three (3) sheets of paper. ~'i ~ ? . ~ ~-.~ (SEAL ) tty A. Divens In our presence BETTY A. DIVENS signed this and declared it to be her will and now at her request, in her presence and in the presence of each other, we sign as witnesses. l~7 ~ ~..~,z..~.., ' ~ - 3 -