HomeMy WebLinkAbout06-18-13 (2) J 1505610105
REV-1500�x�°�-��,«"�
OfFICIAL USE ONLY
PA Department of Revenue pennsytvania
Bureau of Individual Taxes �"^'"`" "`°`"" County Code Year File Number
Po sox z8o6oi INHERITANCE TAX RETURN
Harrisburq PA 19128-0601 RESIDENT DECEDENT �o�1 '. !3 Q�/��p
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
� 04/08/2013 10/17/1929
Decedent's Last Name Suffix DecedenTS Firet Name � MI
Staley Elizabeth G
(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 Relum O 2. Supplemental ReWm O 3. Remainder Re[um(Da[e of Dealh
Priorto 12-13-82)
O 4. Limited Estate O 4a. Fu[ure Interes[Compromise(date of O 5. Federal Estate Tax Retum Required
death after 12-12-82)
� 6. Decedent Died Tes[ate O 7. Decedent Maintained a Living Trust . 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9. Li�iga[ion Proceeds Received O 10. Spousal Poverty Credit(Da[e of Death O 11. Election to Tax under Sec.9113(A)
Belween 1231-91 antl i-1-95) (Attach�chetlule O) �
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPON�ENCE AND CONFIDENTIAL TAX INFORMATION�1�6f1 BE DIREEif6 T� P�r�
Name Daylime Tele r+�NumberC � �
Andrew C. Sheely, Esquire 717-697-7� � �' z t'' �
�n r r., --� �
r z rTi r+r m
REGI� �� LS USE ONC
� � O � 'R
Firsi Line of Address � C ^� �,
127 South Market Street -,� � `� }--
a o cn ca
_. c� '�
Second Line of Address
P.O. Box 95
City or Post OfliCe State ZIP COdO DATE FILED
Mechanicsburg , 17055
correspo�den��s e-maii address:andrewc.sheely@verizon.net
Under penalties of perjury,I declare that I have examinetl this retum,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,wrrect and complete.Declaration of preparer other than the persanal representative is based on all infortnation of which preparer has any knowledge.
S/IG�NATURE/OfF PERSON ESPONSIBLE FOR FILWG RETURN y p )
LrnN✓/ ,!• .f.?�, Co /p/�j
pn—nv c �/
GaryA. Staley, Executor, 1188 Warm Springs Road, Chambersburg, PA 17202
SIGN RE OF PR ER THAN REPRESENTATIVE ATF
o=�� ('.��i� G����/3
Andrew C. Sheely, Esquire 127 South Market Street, P.O. Box 95, Mechanicsburg, PA 17055
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 15056101�5 1505610105 ���
� 1505610205
REV-1500 EX(FI)
DecedenPS Social Security Number
Decedenfs Name: St8I8Y, Elizabeth G. ���-� -� �
RECAPITULATION
1. Real Estate(Schedule A). .. . . . . . . .. . ... . ... . ... . . . . . . . . . . . .... . .. . ... 1. $119,900.0�
2. Stocks and Bonds(Scheduie B) .. . . ... .. . . ... . . . . . . . . . . . .. . . ... . . ... .. 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. $96,1�5.95
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. �. $216,005.95
9. Funeral Expenses and Administrative Costs(Schedule H). . . . .. . . . .. . .. . . . .. 9. 1Q�51.$1
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1).. .. . . ... .. . . . . 10. 17,$95.99
11. Total Deductions (total Lines 9 and 10). .. . . .. . . . .. . . ... . .. . . . .. . . . ... . . 11. $27,447.80
12. Net Value of Estate(Line 8 minus Line 11) . . .. . . .... . .. . . . . . . . .. . . . ... . . 12. $188,558.15
13. Charitable and Governmental BequestslSec 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. $18$,558.15
TAX CALCULATION•SEE INSTRUCTIONS FOR APPLICABLE RATES
'I5. Amount of Line 14 taxable
at the spousal tax rate,or
transfers und=��ea 9116 � -
(a)(1.2)X.0 15.
16. Amount of Line 14�=�able � � � � �
atlinealrate X.o45 $188,558.15 �g $8,485.12
17. Amount of Line 14 taxable � .
at sibling rate X .12 �7.
18. Amount of Line 14 tazabie � �
at collateral rate X .15 �g,
19. TAX DUE . . . . . . . . . . . . .. . . . . . . .. . .. .. . ... . . . . . .. . . .. . . . .. . .. . . . ... . 19. $8,485.12
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Side 2
� 1505610205 15�56102�5 �
REV�'1500 EX(FI) Page 3 File Num6er �/ — �,J _ Q��/
Decedent's Complete Address: �=�
DECEDENT'S NAME
Efizabeth G. Staley
CTRFF7 Af1l1RFSS
63 West Vine Street
r^`�� - � STATE � I ZIP --
Shiremanstown f� ( 17011
Tax Payments and Credits:
1. Tax Due(Pa9e 2,Line 19) (1) $8,485.12
2. Credits/Paymenis
A.Pdor Payments . $8,061.00
B.Discount $42425
7otal Credits(A+g) ip) 8,485.25
3. Inferest
(3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.
FiU in oval on Page 2,Line 2D to request a refund. ' (4)
S. If Line 1 +Line 3 is greater than Line 2,enler ihe difference.This is ihe TAX DUE. (5) $8,485.12
Make check payable to: REGISTER OF WILLS,AGENT.
.'.. ._.. _ _.� _ . .�_.-., ---..•.�- . . _ ...._ _ _. _ __ ..e _.._. _ _ ..,_.��_�... .
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
t. Did decedent make a transfer and: Yes No
a. retain Ihe use ar income of the property transterred......................................................._................................. ❑ �
b. retain Ihe right to designate who shall use the property transferced or,its income ............................................ ❑ �
c. retain a 2versionary interest .............................................................................................................................. ❑ �
d. receive the promise for life of either payments,benefits or qre?...................................................................... ❑ �
2. If death occurted aHer Dec. 12,1982,did decedent Iransfer property within one year of deaih
without receiving adequate consideration?................................_......................__..........................._...;................. ❑ �
3. Did decedent own an"in trust tor'or payable-upon-death bank aaount or security at his or her death?.............. ❑ � �
4. Did decedent own an individual retiremeM account,annuity or other non-probate property,which
containsa 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.
Foc dates of death on or after Jufy 1,1994,and before Jan.1,1995,�the tax rate imposed on fhe net value of transfers to or for the use of ihe surviving spouse
is s pe�cent(�2 P.s.gst�s(a)(t.�)f)1
For dates of death on or a(ter Jan. 1, 1995, ihe tax rate imposed on the net value of transiers to or tor the use of the surviving spouse is 0 percent
�72 P.S.g9116(a)(1.1 J(ii)].The stalute 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 sGll applicable even if the surviving spouse is fhe only benefidary.
For dates of deafh 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 lhe use of a�atural parent,an
adoptive parent or a slepparent of the child is 0 percent(72 P.S.§9116(a)(1.2)J.
. The tax rate imposed on Ne nei value oi transfers to or tor the use of ihe decedenfs lineal beneficiaries is 4.5 percent,except as noled in[72 P.S.§9116(a)(1)].
. The tax rate imposed on the net value of transters to or tor the use ot the decedent's siblings is 12 percenf[i2 P.S. §9116(a)(5.3)J.A sibfing 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-1502 EX+(11-OB)
� � pennsylvania SCHEDULE A
�EVqqTMFNT OF qEVENUF
INNERITANCE TA%REfVRN REAL ESTATE
RESIDENT OECEDENT
ESTATE OF FILE NUMBER
Elizabeth G. Staley 21-13-0416
All real property owned salely or as a tenant in common must be reported at fair marke[value.Fair market value is defined as[he price at which property
would be exchanged between a willing buyer and a willina seller,neither being compelled to buy or sell,bo[h having reasonable knowledge of the relevant(ac[s.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
Attach a copy of[he settlement sheet if the property has been sold.
ITEM Include a copy of the deed showing decedenPs interest if owned as tenant in mmmon. VALUE AT DATE
NUMBER Of DEATH
DESCRIPTION
i. Decedenfs residence localed at 63 West Vine Street,Shiremanstown,PA 17011. Tax Parcel No. $119,900.00
37-23-0557261. Value oer real estate settlement sheet dated June 4.2013.
TOTAL(Also enter on Line 1, Recapitulation.) $ $119�900.00
If more space is needed,insert additional sheets of the same size.
�� OMB Approval No.2502-0265
s A. Settlement Statement (HUD-1) FINAL
1.Q FHA 2.Q RHS 3.Q Conv.Unins. 6.File Number: 7.Loan Number. S.Mortgage Insurance Case Number:
1J-1344 7377553
4.Q VA 5.Q Conv.Ins.
C.Noh:This(ortn is fumishetl to give ypu a sWtement of actual settlement cosfs.Amounts paitl to antl by the settlement agents are shown Items marked
"(p.o.c)"were paid outs(de the dosing ihey are shrnvn here for infortnational purposes antl are nM inGuded in the tofals.
D.Name&Address of Borrower. E.Name&Address of Sellec E Name 8 Address of Lender:
Kate Reigle Gary A Staley,Exea�twof�he Estate of Elizaheth G. Suspuehanna Bank
1128 Columbus Avenue,Apt 4,�emoyne,PA 17043 Staley 3501 ConwrE Road Yak,PA 17402
63 Wesi Vne Street,Shiremanstam,PA 17071
G.Property locatiort H.SetUemerrt Agent: I.SetUement Date:O6/0M2013
63 West Vne Street HersheyAbstracl,LLC Disbursement Date:06�04@013
Shiremanstown,PA 17011 p:717.566d600 F:777-56G-08�0,2t8 East Main Slree�,
Hummels�avn,PA 1703G ,
717-S6Gd600
Place of Setllement: TitleExpress
3 Lemoyne�nve,Lertroyne,PA P�nted 08f042013 at 9:43 am
by BG
�700:"Gross�AmounCDuefrom-Borrov.er""'� - � 400: GrossAmouMDueSaSNler-.-
t0t. Cont2dsalespnce �� 1t9.90D.DD Wt. conGaqsalesprice � 119,900.00
102. Pnsonal 402. Personal ro �
103. Setllemenichargestobortw�erQmei§00) 7,369.57 A03.
104. 4pq.
105. 405.
Ad'usfinentsforitems aidh sellerinadvance Ad'usdnenisforilems ai0 sellerinaMance
lW- Gtyftownlazes 0610412013SOM121372013 363.52 406. City%owniaces O61D4R013to11/3V2013 363.52
107. Counry taxes to 4�7. Counry t�es to
708. AsseSSments O6(042013toW130120M13 52191 A08. pssessmeMS C6�MR013to06i3D12013 121.91
109. June HOA Fee O6fOQ2013 ta 06/30Yt013 7875 409. June HOA Fee OSrD4l2013 ta O6/30I2013 7875
110. S�wer6l4tl31(3Qfl3 1633 410. Sewer614I53bPJJ)t3 i6$3
111. 411.
112. 412.
��� GmssAmountDcefromBorrower 117,850.02 420. GrossAmountDUetoSelkr 720,460.51
100:�-NnouMSPaid �nrinBehiAtoEBOrtovier'-' - •- - WD.^''�Reductim�sMWnouMDUefoSe➢er �- -
201. DeposRoreamesimoney �7,000.00 501. Eccessdeposit�sceinstnclions)
202. PrindpalamountMnewloan(s) �is,3oa.00 502. SeNemen�char9estosPJler(Gne14�U) e,sti2.as
203. Existin Iw s takensub'ectto 503. Erislin loa s takensu 'ectio
204. 5p4. Pa oHoffirstmat loan
205. Appraisal POC dF0 00 505. Payoff M second morigage loan
206. CreditRepon(pa) 28.00 506. Retainetltorsetllemeniservices t,OW.00
207. SellerASSis� 7,194.00 507. SeflxAStist 7,19400
208. 5p8.
209. 509.
AO'ustmenls for kems un aid b seller Ad'ustmenis for Nems un aid b selix
250. Citylirnmtaces Io 510. Ciry/to.vntazes to
217. Counry t�es to 511. Counry t�es to
212. Assessmenis to 512. Assessments ro
213. 513.
214. 514.
275. 515.
216. 516-
Y17. 517.
218. 578.
219. 519.
120. Total Pad h Itor 8otrow¢r 170.985.00 SM. Total Reducfian Amount Due Selltt 16,806.86
300:�:CashatSetllemeirthomRoBorrow¢r�':-�= � �- - 600.:"CashatSettlementm/homSeller " � - -
301. Gross amount due(rom 6wrrnve�(line 72f1) �@7.850.02 601. Gross artrourR due M sdler(ilne d20) 120,480.57
302. �essamountspaidbyttw0orroxerpine220) 12q,985.00 fipP, Less�etluaionsinamounidueseiler(Iine520J 76,606.86
3U3. Cash Q From �7oBortower 2,865.02 6D3. Cash Q To � FmmSNler 103,6T3.65
M' S1amaNaHIXWqa�MMMnMCNBemeoiwrb�.NemnfMilolhbun�'¢OFJOnvehm�iMk<✓1�xCbPwYiiMw%��iFESP�mm1uMMMMmnu�w�MtMUnianem
Previous edi[ions are obsolete Page 1 of 4 HUD-7
700. ToWI Real EsUte Broker Fees - - $6,987.36�� �� � Paid From . Paid�From
Divisionofcommission Iine700 asfollows: � - � - - �Borrower'S - Seller's
���� $3,606.18 to Howard HannaReaf Estate FundS-dt� - -Fund5 at
702. $3,381.18 �o RSRRealtors Settlement Settlement
' 703. Commission paid at se�tlement 5,987.36
704. Eamest Money Deposit �o HowaN Hanna Real Eslate $1,000.00 P.O.C.B'
800. Hems Pa abk in Connection with Loan� � � � � --� � � � - �� - - � � '
801. Ouroriginationcharge QncludesOnginationPoint %or$0.00) $895.00 (fromGPE�1)
8�2. Your aedit or charge(points)fw thz specific intewst rate chosen $ (irom GFE#2)
803. Youratljustedonginationcharges (fromGFEA) 895.00
804. Apprtisaltee toA raisafl 's0c5ofutionLLC (komGFE#3) 466.00
805. Credit repon to CoreL ic Credco (trom GFE II3) 28.00
80fi. Tax service to Picst American Rea1 Estate Tax Service (from GFE#3) 93.�0
BOZ Floodcetlifica�ion toCoreLO icFlaodServices (fromGFE713) 12.50
808, b
900. Ilems Re uired Lender to be Paid in Advance - � � � � � -- � � - -� � - �
901. Oailyinteresichaigesirom fromO6l04R0131o07101i2013@$15.7111iday (fromGFE#10) 35620
902. MoRgage insurance premium for monihs to (fmm GFE#3)
903. Haneaxrzfsinsurance ta earstoEnelnsurance (SromGFEft1f) 653.W
904. months to from GFE#11
1000. Reserv s De osfted with Lender- - � � � � � �
1001. Initialdeposittoryourescrowaccoun� (fromGFE#9) 2,OZ0.81
1002.Homeowners insu2nce 3 monihs $ 54.4?/month 816326
1003.Mortgage insurance mon�hs $ O.00lmon�h $
1004.Property taxes 5 manths $ 52.40/monih $262.00
1005.School Tazes 13 months $ 14723/monih 81.913.98
7006.Assessmenls monlhs $ 0.00lmoMh 8
10W.A9gregate Adjusiment $-316.44
1700.7RIeCha- es � -� � - " � � � ` � � �-
1101. Tdleservicesandlender'stitleinsurance tcomGFEp4 ����
1102. Setllementorclosingfee �oHershe Abstract LLC $����
1103. Ownefs li�le insurance-Fideliry National Title Insurance Company trom GFE#5 11�OA0
1104. Lenders�illeinsurance-FidelityNa�ionalTi�le�nsuranceCOmpany $275.00
1105. Lendefs tille policy limit$716,303.00 Lendefs Policy
7106.Owners fi0e policy limit$119,900.00 Ownefs Policy
7107.AgenCs portion of the totat title insurance premium $1,165.00
to Hershe Abstract LLC
11�8. Unde�writefs portion�f the total tltle insurance premium $270.00
to Fidelil National Ti�le Insurance Co an
1109. .
1200:GovemmenfRecardin andTans(erChar es� � � - � - -
1201.Govemmenl recuding charges $ (from GFE#7) 141.00
1202. Deetl$40.50 Mon a e$80.50 Release$
12SI3.Transie�tanes $ (fromGFE#8) 1,199.00
1204. City/Countytadslamps Deed$1,199.00 Mort a e$
12�5.StateTadstamps Deed$1,199.00 Mort a e$ 1,199.00
1206. Deed$ Moh a e$
5207.AssessmeniFee $20.00
7300. AdditionalSeNlementChar es�� - - � - � � - - � . �� � - -
1301.Required services ihat you can shop f0� (irom GFE p6)�
1302. SurveY to $
1303. to
530A.Home Warrenty �o HSA 419.00
1305. ResaleCertification �opM� 150.00
5306.JuneHOAFee IoPMI 87.50
13W. Tax Cedification to Robet M.GuA 5.00
1308.£leqricalrepair toRenovationsComan Inc. 76500
'�� ' � � 7,369.51 S,fi12.86
'Paid outside ot closing by(B)orrower,(S�eller,(L�ender,(1�nvesta,Bro(K)er.°Credit by lender shown on page 1."'Credit by seller shmm on page 1.
REV-i5�8 EX+(u-io)
� = pennsylvania SCHEDt1LE E
OEFARTMENTOFFEVENUE CASH, BANK DEPOSITS & MISC.
�NHERITANCETAXRENRN PERSONAL PROPERTY
RESIDEM DECEDEM
ESTATE OF: FILE NUMBER:
Elizabeth G. Staley 21-13-0416
� Indude the proceeds of IitlgaUOn and the date the proceeds were received by the estate.
Atl property 7oinHy owned with right of survivorship must be disclosed on Schedule F.
�M VAIUE AT DATE
NUMBER DESCRIPTION OF DEATH .
1. Members 1st Savings Acct.#21481•0�,principal at date of death$50.17,accrued interest of$0.00 $50.17
2. Members tst Investment Savings Acet.#21481-05,prinapal at date of deatl�$78,274.50 accrued interest of $78,278.01
$3.51
3. PNC chedcing acct.#51-4006-1211 -date of death balance $14,925.74
4. Couniry Meadows Refund $2,852.03
TOTAL (Also enter on Line 5, Recapitulation) $ 96,105.95
If more s0ace is needed, use addiUonal sheets of paper of the same size.
Y ��
�
� >y
c-a �
MEMBERS 151
FIDF1w.CItIDII'OMON
REGULAR SAVINGS ACCOUNT•
Account Number/SUKx 21d87-00
DateAccountEstablished . p�����1979
Principal Balance at Date of Death 550.17
Accrued Interest to Date of Death $.00
Total Principal and Accrued Interesl 550.17
Name of Joint Owner None
INVESTMENT SAVINGS ACCOUNT•
AccountNumbedSuKx , 21481-OS
Date Account Established 10/OSl1992
Principal Balance at Date of Death 578,274.50
Accruetl Interest to Date of Death $3.51
Total Principal and Accrued Interest $78,278.01
Name of Joint Owner None
VISA ACCOUNT:
Account NumberlSuffix 4672090000233379
Date Account Established O6I05/2007
Principal Balance at Date of Death $.00
Name of Joint Owner Cardholder None
EM ERS i�FEDERAL CREDIT U I
. — — .. ... . . .. � �V�--� �"�' ,
Danielle A. Kline - - ' � ' --" - ' -
Lending Insurance Support Specialist
April 19,2013
Estate of:ELIZABETH G.STALEY
Date of Death:04I08I20'13
Social Security Number: 182-22-6659
5000 Louise Drivc • P.O.Box 40 • Mechanicsburg,Pennsylvania 17055 • (800) 283-2328 • wanvmembecslstorg
Performance Checking Account Statement �PNCBANK
PNC Bank
Primary account number:57-4006-727 7
Page i of 4
For qro p�rlod 03/07/5t073 to 04lOSl2A7S Num6erof enclosures:D
001130 For 24hour banking,and transaction or
� ELIZABETH G STALEY �interestrateinformation,signonto
2102 BEpCON CIR PNC BankOnline Banking at pnc.com.
MECHANICSBUR� PA 17055-6170 'g Forcustomerservicaca{I t-888-PNGBANK
Monday-Friday: 7 AM•10 PM ET
Saturclay&Su�day: 8 AM-5 PM ET
Para servicio an espaRol,1-866-HOLA-PNC
Morinpi Please contaot us at 7-888-PNC-BANK
�Writeto:CUStomerService
- -..___.._ _ __.-- - . � POBox609 .
Pitlsburgh PA 75230-9738
�V isit us at pnc.com �
� TDDterminal:l-800-531-1648
For heazirig impa'ved clirnts only
Performance Checldng Elizabeth G Staley
Interest Checlung Account Summary
AccouM number: 51-4006�1211
OrerdnN Protecdon has not been established for this account.
Please corrtad us if you would like to set up this service.
Overdraft Corenge-Your account is currentlyOpbd-Out.
You oryour joint owner may revoke youropain or optvu[choice at any time.
To learn more about PNC Overdrak Solutions visit us online at pnc.comb�erdraitsolu[iona.
Call ib77-5663605,visit any branch,or Sign on to PNC Online Benking,end select the'Werdrak
Solutions•link uiMertheAccouM Servicessectionto manage bothyour Werdrak Coveragaand OverdraR
Protection settinga.
BBL3OC6 SU1A�tW�
Be9innln9 Deposits anE Checks and ot�er Entling
balance MheraAditions tleEUdions balance
12,910.10 2,98427 468.68 14,925.74
Avera9e morRhly Charges
balance and tees
18,066.90 .00
Transaction Summary
Checkspai7! GheckCaMPOS CM1eckCard!l9a�kcaM -
withdrawals slgnetl t2nsactions POS PIN transactfons
7 0 0
Total ATM PNC 0ank Other Bank
trenuctions ATM t2nsactions ATM transaMions
0 0 0
Inle�es! Spmmary As of 04/04,a total of$.32(n interest was
Annual Perce'Rage Number ot tlays Average colleMed IMerest Paid Paid thi5 yeaf.
Yieltl Eametl(APYE) in iMerest period balance tor APYE thls petfod
0.01% 29 18,066.80 .11
�4 `
STATEMENT
Country Meadows West Shore 4
4837 East Trindle Road Statement Date: OS/Ol/2013
Mechanicsburg, PA 17050
Telephone (717)975-3434
Amount Enclosed $
Amount Due: $ -2,852.03
Account#: 94134
RE: Elizabeth Staley
Henry Killick
2102 Beacon Circle
Mechaniaburg, PA 17055
Please detach and retum top portion with payment.
, . - ._
Da's •
� .�DaM� . � ' � . - . � � Descri�tion. . . .. uant . Rate �.� � .Cha es. .. .-. Pa ments �
Balance B/F 3,921.50
04/O8/13 MEMBERS 15T 114.50
04/08/13 MEMBERS 15T 3,807.00
OS/14/13 ALEY,E 33.00
03/27/13 /set 1 16.50 16.50
04/O1/13-04/30/13 N Shared Studio 30 -3,807.00
04/Ol/13-04/07/13CN Shared Stvdio 7 876.13
04/OS/13 CN Shared Studio 1 78$q
04/03/13 /set 1 16.50 16.50
����t 31-60 Days 61-90 Days Over 90 Days Amount Due ,
-2,852.03 .00 .00 .00 -2,852.03
Thank you for choosing Country Meadows of West Shore 4! .
Please Indude the top portion of this bill with your payment by the -
i5th using the endosed envelope.Make your diedc payable to Country Statement Date: OS/01/2013
Meadows Assodates.
Elizabeth Staley-Account #: 94134
Country Meadows West Shore 4
4837 East Trindle Road
Mechaniaburg, PA 17050
Telephone(717) 975-3434
REV•1511 EX+(10-09)
�]pennsylvania SCHEDULE H
OEPANTMENTOFREVENUE FUNERAL EXPENSES AND
'""ER'T^"c�T"'�"E""'" ADMINISTRATIVE COSTS
RESI�ENT DECEDENT
ESTATE OF FILE NUMBER
Elizabeth G. Staley 21-13-0416
Decedent's debts must be reported on ScM1edule I.
[TEM
NUMBER DESCRIPTION AMOUPlT
a. FUNERAL EXPENSES:
1' Richardson Funeral Nome $6,128.31
2 Brachendorf Memorials, Inc. $710.00
e, ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: � $0.00
Name(s)of Personal ReDresentative(s)Gary A. Staley
street aedress 1188 Warm Spring Road
�;ty Chambersburg _state PA Z�p 17202
vear(s)Commission Paid: .
$2,205.00
z. nttorney Fees: A/�(re GcJ C- s h�e�y� L S�U i Y�
� 3. family Exempiion: (If decedenYs address is not the same as claimant'S,attach explanation.)
Claimant
Street Address_
City_ _State ZIP
. Relationship ot Claimant to Decedent_
$408.50
4. Probate FeeS: '
5. Accountant Fees:
6. Tax Return Preqarer Fees:
7. Reserves to conclude Estate administration,final accountings $600.00
TOTAL(Also enter on Line 9, Recapitulation� $ 10,051.81
If more space is needed,use additional sheets of paper of the same size.
RECEIPT FOR PAYMBNT
GLENDA FARNER STRASBAUGH Receipt Date : 4/12/2013
Cumberland County - Register Of *Aills Receipt Time : 10 :31 : 18
One Courthouse Square Receipt No. : . 1073795
Carlisle, PA 17Q13
STALEY ELIZABETH G
Estate File No. : 2013-00416 - --
Paid By Remarks : GARY A STALEY
CJ
---'---'- --------------- Receipt Distribution -------- - - _ _____________
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 60 . 00 CUMBERLAND COUNTY GENERAL FUN
WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 25 . 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN ,
INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN
INVENTORY ___ ____ 15 . 00 CUMBERLAND COUNTY GENERAL FUN
Check# 2995 $ --
Total Received. . . . . . . . . $158 . 50
REV�1512 EK+(12-OB)
� � ;pennsylvania SCHEDULE I
�EPqflTMENTOf qEVENUE DEBTS OF DECEDENT,
INHERITAIYCETA%RENRR MORTGAGE LIABILITIES & LIENS
11ESIOEfJT DECEDENT
ESTATE OF FILE NUMBER
Elizabeth G. Staley 21-13-0416
Report debts incurred by the decedent prior to death tha[remained unpaid at the date of death,including unreim6ursed medical expenses.
ITEM_
NUMBER DESCRIPTION VALUE AT DATE
6f DEATH
i. Real estate settlement costs,per settlement sheet dated June 4,2013 $16,806.86
2. Diamond Pharmacy•final bill $338.07
3. PennsylvaniaAmeriranWater-finalbill �8�.00
4. PpL Electric Utilities-final bill $108.96
5. UGI UtiliSes,Inc.-final bill $30.10
6. Country Meadows•final bill $33.00
TOTAL(Also enter on Line 10,Recapitulation) g ��.395.99
]f more space is needed,insert additional sheets of the same size. �
REV-1513 EX+(01-10)
�pennsylvania SCHEDULE 7
DEGAqTMENTOfHEVENUE
INNERRANCE TA1(RENRN BENEFICIARIES
RESIDEfiT DKEDENT
ESTATE OF:
FILE NUMBER:
Elizabeth G. Staley 21-13-0416
NUMBER NAME AND ADDRESS OF PERSON{5)RECENWG PROPERTY �tpol NM��5�Tryn���N I AMUOf IESTATE Rrct
I TAXABIE DISTRiBUTI0N5[Include outright spousal distributions and t2nsfers under
Sec.9116(a)(1.2).]
1, GaryA.Staley, 1188 Wartn Spring Road, Chambersburg,PA 17202 Son 100% Rest, Residue&
Rc!mainrlPr
EMER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 Z}IROUGH 18 OF RF/-1509 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPoUSAL D15TRIBUTlONS UNDER SECTfON 9113 FOR WHICH AN ElECT70N TO TAX IS NOT TAKEN;
1.
8. CHARITABLE AND GOVERNMEfVrAL DISTRIBUTIONS: � -
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTR[BUT[ONS ON LINE 13 OF REV-I500 COVER SHEET. $
If more space is needed,use additional sheeLS of paper of the same size. .
L� ST �IILL � ND `f� ST � l�I � 1VT'
� �'
� LIZ � � � °f� �e ST� L � 1'
I, ELTLABETH G. STALEY, of Shiremanstown, C�mberland County, Pennsylvania,
being of sound and disposing mind, memory, and understanding, do hereby make, publish, and
declare this to be my Last Will and Testament and hereby revoke all other Wills and Codicils
that I have made, including the Will dated December 18, 1974.
FIRST: I give, devise, and bequeath all of my Estate, of whatever nature and
wherever situate, to my son, GARY A. STALEY, of Chambersburg, Pennsylvania, so long as
C� he shal] survive me by thirty (30) days.
\
SECOND: Should my son fail to survive me by thirry (30) days or should he for any
� reason fail to take under this, my Last Will and Testament, then I give, devise, and bequeath
1 ,��, all of my Estate, oi wnatever naiure and wherever situate, to my brother, HENRY G.
� HILLICK, of Mechanicsburg, Pennsy]vania, so long as he shall survive me b
y thirry (30) days.
TH�: All interests of any beneficiary in the income or principal of this Estate,
while undistributed and in the possession of my Executor, even though vested and
distributabie, shall not be subject to attachment, execution or sequestration for any debt,
contract, obligation or liability of any beneficiary and, furthermore, shall not be subject to
pledge, assignment, conveyance, or anricipation.
FOURTH: All inheritance, estate, and succession taxes (including interest and any
penalties thereon) payable by reason of my death shall be paid out of and be charged generally
against the principal of my residuary estate, without apportionment or right of reimbursemenf
from any person. In the event that a substantial portion, as determined in the sole and absolute
jud�ment and discretion of my Executor, of the non-probate assets such as an annuity or
mutual funds are directed to be paid to a beneficiary or beneficiaries, so that the taxes referred
to herein would be paid out ofthe probate residue passing to the beneficiary or beneficiaries of
this will (whether or not the same as the beneficiary or beneficiazies under the non-probate
asseu), my Executor, in the Executor's sole and absolute judgment and discretion, shall have
the right to allocate the full or partial payment of the taxes to the beneficiary or beneficiaries of
the non-probate assets.
.��
FIFTH: In addition to all righu and powers conferred by law, I authorize and
� empower my Executor and his successors, in his absolute discrerion and without necessity of
�\' obta�� court approval:
�v' A. To buy investments at a premium or discount.
L�
� B. To hold property unregistered or in the name of a nominee.
,� C. To give proxies, both ministerial and discretionary.
� D. To wmpromise clauns.
E. To join any merger, consolidarion, reorganizarion, voting uvst
plan, or any other concerted acdon of securiry holders and to delegate discretionary duties with
respect thereto. �
F. To lend to, and buy from, my estate.
G. To borrow and to pledge real and personal property as securiry therefor.
H. To sell at public or private sale for cash or credit or partly for each, to
exchange, or to lease for any period of time, any real or personal property, and to give oprions
for sales, exchanges, or leases.
I. To exercise any option permitted by law which he believes to be
advantageous from the viewpoint of overall tax reductions, including, without lunitation of the
foregoing, power and authoriry to claim administration or other expenses either as income tax
deductions ot inheritance or estate tax deductions, without regard to whether they were paid
from principal or income and without requiring adjustments between principal and income for
any resuliing effect on income or esrdte taxes, and a deduction of such expenses for income tax
purposes shall be given effect in computing the respective shares of all persons interested in
�my estate set forth herein, even though the effect is to increase the share of one beneficiary or
� class of beneficiaries hereunder at the expense of another; and to make such adjustments, if
� any, between beneficiaries with respect thereto as he shall deem appropnate in view of the
�J nature of the transaction and the amounts involved.
.�`� J. To distribute in cash or in kind or partiy in each.
,3
' � The powers �anted hereunder shall be exercisable with respect to all real and persona]
�� properry, including, but not limited to, income and principal held for aunors or disabled �
beneficiaries at any tune, until the actual distriburion of all properry. All powers, authoriries
and discrerion granted here shall be in addition to those granted by law and shall be exercisable
without leave of court. However, nothing herein shall be interpreted or construed to
encourage, authorize, empower, or permit the Executor to act or cause anyone to act in a
manner con�ary to or inconsistent with accepted standards of portfolio diversificarion and risk
management.
SIXTH: I nominate, constitute, and appoint my son, GARY A. STALEY, as
Executor of this, my Last Will and Testament. In the event of the renunciarion, death,
resignation, or inability of my son to act for whatever reason in this capacity, then I nominate,
constitute, and appoint my brother, HENRY G. IQL,LICK, as Executor of this, my Last Wili
and Testament.
I direct that no representative named above shall be required to post security for the
faithful performance of his duties in any jurisdiction insofar as I am able by law to relieve him
of such obligation. Any of my representarives shall be enrifled to reasonable compensarion for
the performance of the duries set forth here.
IN WITNFSS WHEREOF, I have hereunto set my hand and seal this S4y day of
�t1►}�«.bc/ > 2006, on this, the fourth of four typewritten pages. I have also signed the
left-hand margin of the first three of these pages for purposes of idenafication only.
;�. .. � ;:,
ELIZ� �:I[T-I G. STALE '
SIGNED, PUBLISHED, and DECLARED by the Testatrix, ELIZABETH G.
STALEY, as her Iast VJilI and Testament, in the presence of us, who at her request, in her
presence, and in the presence of each other, have hereunto subscribed our names as wimesses.
�_o�L..�. i,Jnu.� Y�� R�,.,,n�...� Da..�r
iM.-�—�.�� ��nS,f
o�� �JfSi �A�� ��/E
—�,o% � !�/� / 7QZS-
ACKNOWLEDGMENT
Commonwealth of Pennsylvania
County of C�mberland
I, ELIZABETH G. STALEY, Tesratrix, whose name is signed to the attached
insu�ument, having been duly qualified according to ]aw, db hereby acl�owledge that I signed
and executed the inshvment as my Last VJilI and Testament; that I signed it willingly; and that
I signed it as my free and voluntary act for the purposes therein e�cpressed.
EL . BETH G. S AT. �
Swom or affirmed to and subscribed before me by ELIZABETH G. STALEY, the .
Testatrix, this ��1�' day of �p.�,�m�o Y- , 2006.
�l J �- �(�2�./�
Notary Pub�c
COMMONWEALTH OF PENNSYLVANIA
tJotaiial Seal (
�'tarY M��per.Nomry Put�x
(�ry�Ff�Boro.Cumbstand County
My�mrt�sion E�yires Oct 27.2007
MemDer,Pennsylvan?x 455ociolion Of Noteries
AFFIDAVIT
Commonwealth of Pennsylvania
County of Cumberland
We, Debra K. Wallet and ��n�e �.e �M��G�e witnesses whose names
are signed to the attached instrument, being duly qualified according to law, depose and say
that we were present and saw the Testatrix, ELIZABETH G. STALEY, sign and execute the
instrument as her Last Will and Testament; that she executed it as her free and voluntary act
for the purposes therein expressed; that each of us in the hearing and sight of the Testa�ix
signed the Will as wimesses; and that, to the best of our knowledge, the Testatrix was at that
time 18 years of age or older, of sound mind, and under no constraint or undue influence.
1.Qaf.�,. � . �Js�,r
� °"=��_�
�/
Swom or affirmed to and subscribed before me by ��p j� �,�h�� � �. �d
�i�n � o` >mric_, witnesses, this (d� �y of�AOk� �r. , 2006.
�'1(���,, � o�o-�� '
Notary Pub�ic �
COMMON W EA�TH O'r?EhiNSYLVANIA
Nota�el Sea'a �
. Mary M.Loper.No�ary Public
. Camp F�Boro.Cianberland Counry
MY Camm'ssion E�yires Oct 27,2f107
, Member.Pennsylv?ni;.qsso'Jatior O;Notaries