HomeMy WebLinkAbout08-28-13 (2) _
J 15056101�5
REV-1500 EX(o2-uJ(Fq�
PA Department of Revenue Pennsylvania . OFFICIA�USE ONLY
BureauoflndividualTaxes ^F..,�,�f��°'INHERITANCETAXRETURN CounryCode Year FileNUmber
PO BOX 280601 � I� �/ �
Harnsbur PA i7iz8-o6oi RESIDENT DECEDENT
trv i tR�ECEDENT INFORMATION BELOW
Social Security Number Date of Death MA9DDYYYV
Date of Birth MMDDYVVY
05/30/2013
06/03/1918
DecedenPs Last Name SuRix
� .. DecetlenYS First Name MI
Roccati
Helen �
(If Applicab�e)Enter Surviving Spouse's Information Below
Spouse's Last Neme Su�x
Spouse's First Name M�
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Original Return O 2. Supplemental ReWrn
O 3. Remainder ReWm(Date o/Death
O 4.Limited Estate Priorto 12-13-82)
O 4a. Future In�erest Compromise(data of O 5. Federal Estate Tax Return Required
death eRer12-12-g2)
R� 6. Decedent Dietl Tesfete � 7. Deceden!Main[ained a Livin Trust 0
(Atlach Copy of Will) 9 8. Total Number of Safe Deposit Boxes
(Attach Copy of TrusL)
O 9. Litigation Procceds Received O 10. Spousal Poverty Credit(Dafe of Death O it Elaction to Taz undei Sec,9713(A)
Batwaen 12-31-91 and 1-1-g5) (Attach Schetlule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETEO.AlL CORRESPONDENCE AND CONFIDENTIAL TA%INFORMATION SHQULD BE DIRECTED T0:
Name
Daytime Telephone Number
Jacqueline M. Verney, Esq
(717) 243-9190
REf�yfER OF W��L&4 E ONj�,J
� o m
First Line of Address -T� G>
44 S. Hanvoer St r^ � �% �' `��'
A » e..... n� ,;�i ��';�
SecondLineofAddress r -= c�'�' � _� c:
$s U� - .
�+- , , p c.
� C.> , ..� --�� _r�
� � C: .:.:;� '_1 ..._ "r .
City or Post ORce - -
St2t8 ZIP COde � _ TE PILED-' "�- � �
Carlisle PA 17013 "D � Y
y, cn u; �
ca
CorrespondenPS e•mail address: 'LEff18y�801.00111
Under penalties of perjury,I tleclare that I have e�mined ihis return,including accromvanying schedules entl statements,and to Ihe best of my knowledge and belie/,
it is[rue,cortect antl complete.DeGaration of preparer other then the perwnal representative is based on all informafion of which preparar has any knowladga.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN
DATE
ADDRESS
IGNATURE OF PR ARER OTHER THA�y(2FpRE TATIVE �
� DRE �V� � ^�ZEQ _ I !
44 S_ �.�N'o✓�,z b-� sL� � I�a � � v
PLEASE USE ORIGINAL RM ONLY
Side 1 '
I,�, 1505610105 1505610105 J
��
_
� 1505610205
REV-1500 EX(FI)
DecedenPS Social Securiry Number
DecotlenPS Name:
RECAPITULATION
i. Real Estate(Schedule A). . .. . . .. . .. . .. . .. . .. . . . . . . . . . .. ... .
�' 0.00
2. Stocks and Bonds(Schedule B) . . . .. . ... .. . . . .... . .
. . . . . . .. . . . .. .... . . 2.
0.00
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) . .. .. 3,
0.00
4. Mortgages and Notes Receivable(Schedule D) , , , , , , ,, , , ,, ,
4 0.00
5. Cash, Bank DeposiGs and Miscellaneous Personal Property(Schedule E)... .. . . 5,
16,898.56
6. Jointly Owned Property(SChedule F) O Separete Billing Requested .. . . ... 6.
7. Inter-Vvos Transfers 8 Miscellaneous Non-Probate Property 20,989.00
(Schedule G) O Separate Billing Requested_ .. . ... 7, 341,459.00
8. Total Gross Assets(total Lines 7 through 7). . ...... .. . . .. . .
e 379,346.56
9. Funerel Expenses antl Administretive Costs(SChedule H). . .. . .
s 15,399.18
70. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I).. . .. . .. .. . .. .. 1p.
975.32
11. ToWI Deductions(total Lines 9 and 10)... .. . . .. ... . . . .. . . . . . . . . .. .. ... .
�� 16,374.50
72. Net Value of Estate(Line 8 minus�ine it) .. . ..
_ . .. . . . .. . . �2. 362,972.06
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) . .. . . . . . . . . . . . .. .
13. 0.00
14. Net Value Subject to Tax(Line 12 minus Line 73) ..... . .
�a. 362,972.06
TqX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RqTES
15. Amount of Line 14 taxable
atthe spousaltax rate,or
transfers under Sec. 9116
(a)(72)X.0_
15.
i6. Amount of Line 14 taxable
at lineal rete X.0 45 16,333.74 �g
17. Amount of Line 14 taxable � � � � .
a[sibling rete X.12
17.
18. Amount of Line 14 taxable
at collateral rate X.15
18.
t9. Tnx ouE._ . . . . _ . . .. . . _ . �s. 16,333.74
_ .
20. FILL IN THE OVAL IF YOU ARE REqUESTING A REFUND OF AN OVERPAYMENT
O
L Slde 2
1505610205 15056102�5 J
REV-1500 EX(FI) Page 3
File Number
DecedenYs Complete Address:
DECEDENT'S NAME
Helen L. Roccati
STREETADDRESS � �� �� .
The Bridges at Bent Creek
2100 Bent Creek Road
------ ----
GTY _- .- . . __—_..._ _ .. .
.._—.— _—_.—_.._ .._—__..
__ .._. _____.
�. STATE - ._.__.. .—.__._- ___._�__
Mechanicsburg, zia
PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (
2. CreditslPayments 16,333.74
A. Prior Payments 705.68
B. Discount . . ...... . ...... .816.68
3. Interest � � TotalCredits(A+B) (2) 1,522.36
4. If Line 2 is grealer than Line 1 �Line 3,enter the difference. This is the OVERPAYMENL �3)
Fili in oval on Page 2,Line 20 to request a refund. (4)
5. If Line t+Line 3 is greater than Line 2,enter the difference.This is[he TAX DUE. (5) 14,811.38
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 trensferred.........................................._.............................................. ■ ❑
b. retain the nght to designate who shall use the property transfened or its income .............._..................._....... � �
c. relain a reversionary interest.......................................................................
....................................................... ❑ ❑
d. receive the promise for life of eithe�payments,benefits or care?......................_...........,.................._.._....._... � �
2. If death occurred afler Dec. 12,1982,did decedent transfer property within one year of death �
without receiving adequate wnsideration?........... .
......................_...........................................
, . _........ �
3. Did decedent own an"in trust for"oi payable-upon-death bank account or searity at his or her death?....�......... � �
4. Did decedent own an individual retirement account,annuiry or other non-probate property,which
containsabenefciarydesignation? ..........._.__...........__..............................................................._...................... � ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND fILE li AS PART OF THE RETURN.
For dates of deafh on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for lhe use of the surviving spouse
is 3 percent[/2 P.S.§9116(a)(1.1)(i)j.
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of iransfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)].7he statuie does not exempt a transter to a surviving spouse from tax,and the statutory requirements fior disclosure of assets and
filing a tax retum are still applicable even if the surviving spouse is the oniy beneficiary.
For dates of death on or after July 1,2000:
. The tax rate imposed on the net value of hansfers hom a deceased child 21 years of age or younger at death to or for the use of a nalural parent, an
adopNve parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(12)].
• The tax rate imposed on lhe net value of transfers to or for the use of lhe decedenPs 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 decedenfs siblings is 12 percent[72 P.S. §9116(a)(1.3)j.A sibling is defined,
under Section 9102,as an individual who has at least one pareM in common wilh the decedent,whether by blood or adoption.
REV-a5o8 EX+(o8-ia)
,�i pennsylvania SCNEDULE E
�y� �EPARTMENTOFREVENUE CASH, BANK DEPOSITS & MISC.
tNHERRFNCETAXRFNRN PERSONAL PROPERTY
REStOENT�ECEOENT
ESTATE OF: FILE NUMBER:
Helen L. Roccati 21-13-0664
Indude the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disciased on Schedule F.
IfEM VALUE AT DATE
NUMBER DESCRIPT[ON
OF DEATH
1. US Savings Bonds(See attached listing. 2 bonds were owned solely by executrix. Those values 16,898.56
have been deducted from the value shown on attached listing)
TOTAL (Also enter on Line 5, Recapitulation) $ 16,898.56 �
If more space is needed,use additional shee[s of paper of the same size.
Calculated Value of Your Paper Savings Bond(s) Page 1 of 3
Calculated Value of Your Paper Savings Bond(s)
Caiculator Results for Redemption Date 06/2013
. . . .
$2 512.50 17 009.06 14 496.56 1.40
Bonds: 1-123 of 123
. . . -
NA E ' �25,12/1978 12/2008' $18JS $89.52 • _ $108.27 MA
. . _ _
NA E _ $25 12/1978.__ 12/20081 $18J5 $89.52 _ ;108.27 MA
NA E $25 11/1978 ._ 11/2008 $18J5 $89.23 $107.98 MA
NA E _ $25 11/1978 _ 11/2008 $18J5.__ $89.23 _ _ $107.98 MA
_
NA E ' $25 10/1978 10/2008' $18.75 $88.22 ;306.97, MA
NA E $25 10/1978 _ 10/2008 $18J5' $88.22 #306.97 MA
NA E _:_ $25 09/1978. _ 09/2008 $18J5 $88.22 _ . �106.97 MA
NA E ' $25 09/1978, 09/2008 $18J5' $88.22 _ #306.97, MA.
NA E $25 09/1978; __. 09/2008'_ _ $18J5 $88.22 #106.97 MA
_
NA E $25 08/1978 ; 08/2008 _ $18J5.__. $88.22 #306.97 MA
NA E $25 08/1978 08/2008 $18J5 $88.22 �106.97 MA
NA E $25 07/1978 07/2008 $18J5 $88.22 $106.97 MA
NA E ; $25 07/1978;__ 07/2008 $18J5 $88.22 _ ;106.97 MA
NA E ' $25 06/1978 06/2008 $18J5 $88.19 $106.94 MA
NA E $25 06/1978 06/2008 $18J5' $88.19 #106.94 MA
_ _ _ _ _. __
NA E $25'OS/1978' I05/2008: $18J5' $87.92 ;306.67' MA
_ _
NA E $25;05/1978 O5/2008! $18.75 $87.92. �106.67' MA
NA E $25 04/1978 04/2008 $18J5 _ $89.79 �108.54, MA
__ . _
NA' E $25 04/1978 _ 04/2008 . _ $18J5 $89J9 �108.54 MA
NA E $25 03/1978 _ 03/2008 $18J5 $89J9 _ �108.54 MA
NA E $25 03/1978: _ 03/2008 __.$18J5.,_ $89.79 $108.54 MA
NA E ' $25 03/1978' 03/2008' $18J5', $89J9 $108.54 MA
NA E $25 02/1978 _ 02/2008 $18J5', $109J0 _ $128.45 MA
NA E ' $25!02/1978 02/2008 $18J5' $109J0 $128.45' MA
NA E $25 01/1978, 01/2008 $18J5 $109J0 $128.45 MA
NA E $25 O1/1978 _ 01/2008 _ $18J5 $109J0 ¢128.45 MA
NA E $25 10/1977 10/2007 $18J5 $120.92 $139.67 MA
NA E $25' 12/1977i ' 12/2007 $18.75' $109J0' #128.45i MA
_ _ _ _ _ .
NA E $25'12/1977' 12/2007 $18J5' $109J0', ;128.45' MA
_ _ . _ _
NA E $25 11/1977' 11/2007 $18.75 $109.34' �128.09! MA
NA E $25_il/1977 11/2007 $18.75 $109.34 $128.09 MA
NA E $25 10/1977' 10/2007 $18J5 $120.92I ' $139.67' MA
NA E , $25 09/1977 09/2007 $18J5 _ $120.92 $139.67 MA
NA E $25 09/1977 09/2007' $18J5 $120.92 $139.67' MA
NA E , $25.09/1977 _ 09/2007 $18J5 $120.92 _ $13,9.67 MA '
NA E $25,08/1977 _ 08/2007 _ _ $18J5'; $120.92 $139.67 MA
NA E $25 OS/1977 08/2007 $1SJ5 $120.92 $139.67 MA !
NA E $25 07/1977 07/2007 $18J5 $120.92 $139.67, MA
NA E : _ $25 07/1977. _ 07/2007 $18.75 $120.92 $139.67 MA '
NA E $25 06/1977 06/2007 $18.75 $120.95 $139J0 MA
NA E $25!06/1977 06/2007! $18.75' $120.95 $139J0 MA ;
http://www.treasurydirect.gov/BGSBCPrice 6/12/201.3 '
:alculated Value of Your Paper Savings Bond(s) Page 2 of 3
NA E $25 05/1977 OS/20b7 �18J5' $120.65 $139.40 MA
NA E $25,05/1977 OS/2007 $18J5! $120.65 $139.40 MA
NA E $25 04/1977 04/2007 $18 JS $119.29 $138.04! MA
NA E $25 04/1977 04/2Q07 $18.75' $119.29 $138.04 MA
NA E $25-04/1977 04/�007 $18 JS' $119.29 �138.04 MA
NA E $25 03/1977 03/2007 $18J5' $119.29 �138.04 MA
NA E $25 03/1977. 03/2007 $18 J5 $119.29 $138.04 MA
NA E ' $25 02/1977 02/2007 $18 JS' $119.29 �138.04 MA
NA E $25 02/1977 02/2007 $18J5 $119.29 ;138.04 MA
NA E $25 O1/1977 O1/2007 $18J5 $119,29 $138.04 MA
NA E $25 O1/1977 01/2007 $18J5 $119.29 $138.04 MA
NA E $25 12/1976 12/2006 $18 JS $119.29 $138.04 MA
_ _
NA E ', $25 12/1976_ 12/2006 $18J5' $119.29' $138.04 MA
_ _
NA E $25I11/1976 11/2006 $18J5' $118.90' �137.65 MA
NA E $25 11/1976 11/2006 $18JSI $118.90 $137.65 MA
_ _. _ _
NA E $25 10/1976 10/2006 $18 J5 $117.57 �136.32 MA
NA E $25 10/1976 10/2006 $18.75 $117.57 #136.32 MA
NA E $25 10/1976, 10/2006. $18J5 $117.57 $136.32 MA
NA E $25 09/1976' 09/2006 $18 J5. $117.57 ;136.32 MA
NA E $25 09/1976 09/2006 $18 JS $117.57 #136.32 MA
NA E $25,08/1976 08/2006 $18 JS _ $117.57 $136.32 MA
NA E $25 08/1976 08/2006 $18J5 $117.57 $136.32' MA
NA E $25 07/1976 07/2006 $18 JS _ $117.57 $136.32 MA
__
NA E $25 07/1976 07/2006' $18 J5 $117.57 $136.32 MA
NA E $25 07/1976 07/2006 $18.75 $117.57 $136.32' MA
NA E $25 07/1976 07/2006 $18J5 $117.57 $136.32 MA
_
NA E $25 06/1976' 06/2006 $18J5 $117.59 $136.34 MA
NA E $25 06/1976 06/2006 $18.75 $117.59 $136.34 MA
NA E $25 OS/1976 OS/2006 $18.75 $117.29 $136.04 MA
NA E $25 OS/1976; OS/2006 $18J5 $117.29' ;136.04 MA
NA E ; $25 04/1976 04/2006 $18J5' $116.01 ! $134J6 MA
NA E ' $25 04/1976 04/2006 $18J5 _ $116.01 $134J6 MA
_
NA E $25 04/1976 04/2006 $18.75 $116.01 ! $134J6' MA
_
NA E $25 03/1976 03/2006 $18J5, $116.01 �134.76 MA
NA E $25 03/1976 03/2006 $18J5 $116.01 �134J6 MA
NA E $25 02/1976 02/2006 $18J5 $116.01 $134J6' MA
. _ _ _
NA E $25 02/1976 02/2006 $18.75 $116.01 $134J6 MA
NA E $25 O1/1976 Ol/2006 $18J5 $116.01 $134J6 MA
NA E $25 O1/1976 Ol/2006 $18J5 $116.01 $134J6 MA
NA' E $25 12/1975 12/2005' $18JSI $116.00 $134J5 MA
NA E $25 12/1975 12/2005 $18J5' $116.00' �134J5 MA
_ _ _ _
NA E $25 11/1975 11/2005 $18J5' $115J1 ' ' $134.46 MA
NA E $25 11/1975 11/2005 $18J5', $115J1 $134.46 MA
NA E $25 10/1975, 10/2005 $18 J5, $114.40 $133.15 MA
NA E $25 10/1975 10/2005 $18.75 $114.40, $133.15I MA
NA E $25 10/1975 10/2005 $18.75 $114.40 ¢133.15 MA '
NA E $25 09/1975 09/2005 $18J5', $114.40 $133.15' MA
NA E $25 09/1975' 09/2005 $18 JS $114.40 $133.15 MA
NA E . $25 08/1975��.. 08/2005 $18 JS�. � $114.40'. � $133.15.. MA ..
NA E $25 08/1975 OS/2005 $18J5 $114,40 $133.15 MA
_
NA E $25 07/1975 07/2005 $18JSI $114.40 $133.15 MA
_ __
NA E ' $25 07/1975I 07/2005 $18 J5 $114.40 $133.15 MA '
_ _ _
NA E , $25 06/1975 06/2005' $18.75I $114.40 $133.15 MA '
NA E ' $25 06/1975 06/2005 $18.75 $114.40 $133.15 MA '
NA E ' $25 OS/1975 OS/2005 $18J5 $114.08 $132.83 MA
NA E $25 OS/1975 OS/2005 $18J5 $114.08 $132.83 MA
NA E $25 OS/1975 OS/2005 $18 J5 $114.08 $132.83 MA '
http://www.treasurydirect.gov/BC/SBCPrice 6/12/2013
Calculated Value of Your Paper Savuigs Bond(s) Page 3 of 3
NA E $25 04/1975' 04/2005 $18 JS' $112.82 $131.57 MA
NA E $25 04/1975' 04/2005I $18J5 $112.82 $131.57 MA
NA E , $25 03/1975 03/2005 _ $18J5 $112.82 $131.57, MA
NA E $25 03/1975 03/2005 $18J5 $112.82, #131.57 MA
NA E $25!02/1975 02/2005 $18J5' $112.82 $131.57 MA
NA E $25'02/1975' 02/2005 $18J5' $112.82 ;131.57 MA
NA E $25 O1/1975, O1/2005 $18 J5 $112.82 #131.57 MA
NA E _��25 O1/1975 O1/2005 $18J5 $112.82 $131.57 MA
NA E � $25 O1/1979� O1/2009 $18.75 $89.53 #108.28 MA
NA E �25 O1/1979% O1/2009 $18J5 $89.53 $308.28 MA
NA E $50 12/1979 12/2009 $37.50 $183.74 �221.24 MA
NA E\ $50 11/1979 11/2009 $37.SOI $183.74 �221.24 MA
NA E � $50 OS/1979 OS/2009 $37.50 $181.16 �218.66 MA
NA E $50 04/1979 04/2009 �37.50 $179.06 �216.56 MA
NA E �,' ;; $50 11/1974 11/2004 $37.50 $225.02 �262.52 MA
NA E ,. { $50 10/1974 10/2004, $37.50 $222.54 $260.04„ MA
NA E � $50 09/1974 09/2004 $37.50' $222.54 �260.04 MA
NA E ; $50 08/1974 08/2004 $37.50' $222.54 #260.04 MA
NA E $50.07/1974 07/2004 _ $37.50 $222.54 $260.04 MA
NA EE'j $50 03/1980 03/2010 $25.00 $140.74 $165.74 MA
NA EE� $50 03/1980 03/2010 $25.00 $140.74 $S65J4 MA
NA EE � $50 02/1980 02/2010 $25.00 $140J4 $165J4 MA
NA EE I $50 02/1980 02/2010 $25.00 $140J4 $165J4 MA
NA EE i $50 O1/1980 O1/2010 $25.00 $140.74 #165.74 MA
NA EE J $50 10/1992 10/2013 10/2022 $25.00 $46.18 4.00% $71.18
� Totals for 123 Bonds 2 512.50 14 496.56 17 009.06
� .
NI :Not Issued �f�p6� �x-�������� -
SS.s"a
NE Not eligible for payment �' �SCyyy�f�3S//��(1
PS 'Includes 3 month interest penalty s6'' C'�
MA 'Matured and not earnin interest
- � �l/ , 5U
C�.C�G�CL,(,2CGLF.u'L� /(o, �/� SC�
http://www.treasurydirect.govBGSBCPrice �/»/���� _ '
REV-S5og Ex+(o1•io) -
� '�``s= pennsytvania SCHEDULE �
OEPq%TMENTOFq@VENUE
� IWiERITANCETA%RElUItN ]OINTLY-OWNED PROPERTY
RE5[DESiT DECEDENf �
ESTATE Oft FILE NUMSERt
Helen L. Rocoati 21-13-0664
If an asset became jolntiy owned within ane year of the decedenYs date af death,it must be repoeted on Schedule G.
SURVNWG JOIM TENANT(S)NpME(Sj ADDRESS REUT(ONSHIP TO OECEDENT
A�Marie T. Heggiin 1647 Harrisburg Pike Cariisle,PA 17013-1616 daughter
0,
C.
JOINTLY OWNED PROPBRTY: .
tERfA Dn7E DESCRIPTSON OF PROPER'IY ip Of DATE OF oFATH
t7frt r'qi]OIhT kat1E lN4i%SE NAME 4F ftNANCiAt tNStFittit�e AND flNiK ACCIXAVT NU1�R 9N S:NStAR 6ATE OF OEAtH DELTDEN('S YAUIE Oi
NUMBER TEtUMi' RSINf IDEN�IMNG NUMBER.ARA[ii 6EE6 FOR 70INfiX H£t9 REAL ESTA7E. VMUE 6F AS5E( SNiEREST OKSOFNt'S IXSEREST
1. A, 02/16/05 PNCcheckingaccoun15501286708 41,878.00 50 20,989.00
TOTAL(Also enter on Line 6, Recapitulation) $ 20,969.pD
[f more spate is needed,use addit+onal sheets of paRer of the same size.
�� euREnu oF �NO�vZO�A� T�ES� � � Pennsylvania lnheritance Tax j �y-� .PennSYLVc'�Ci18
PO BOX 280601
HARf(ISBfIRG PA 17126-0601 Information NoUce � DEPARTMENTOFREVENUE .
eEV-�5�a[x oo�[xsc<os-�xI
And Taxpayer Response FILE NO.2713-0664
ACN 13136399
DATE 07-01-2013
Type of Accouni
Estate of HELEN L ROCCATI Savings
SSN 214-03-8713 Checking
Date of Death 05-30-20i3 Trust
MARIE T HE6GLIN CountyCUMBERLAND Cert'rficate
1007 HARRISBURG PIKE
CARLISLE PA 17013-1616
�PNC BANK NA provided the department with the information below indicating that at the death of the
above-named decedent you were a joint owner or beneficiary of the account identified.
Account No.5507286708 Remit Payment and Forms to:
Date Establlshed 02-162005 REGISTER OF WILLS
Account Balance $47,978.00 7 COURTHOUSE S(iUARE
Percent Taxable X 5p CARLISLE PA 17013
Amount Subject to Tax $20,989.00
Tax Rate X 0.150 NOTE`: If tax payments are made witfiin three months of the
Potential Tau Due $3,148.35 decedenYs date of death,dedud a 5 perceM discouM on the tax
With Sqo Discount (Tax x 0•95) $(see NOTE') due. Any inheritance tax due will become delinquent nine months
after the date of death.
PART Step 1 : Please check the appropNate boxes below.
1
A �No tax is due_ 1 am the spouse of the deceased nr I am the pareni of a decedent who was
21 years old or younger at date of death.
Praceed to Step 2 on reverse. Do not check any other boxes and disregard the arnount
shown above as Potenfia!Tax Due.
__ . _— _ ___. _ , _ _ ---_ _ _
g �The information is The above information is correct,no deductiorts are being taken,and payment will be sent
correct. with my response.
Proceed to Step 2 on reverse. Do nof chedc any other twxes.
p �(The tax rate is incorrect. � 4.5'Yo I am a lineal beneficiary(paren child, randchild,etc.)of the deceased.
�"(Select correct tax rate at
right, and cromplete Part � �p�, I am a sibling of the deceased.
3 on reverse.)
� 15°/a All other relatlonships(including none).
p �Changes or deductions The information above is incorrect and/or debts and deductions were paid.
listed. Complete PaR 2 and part 3 as appropriate on the back of this form.
E �Asset will be reported on The above-identfied asset has been or will be reported and tax paid with the PA Inheritance Tau
inheritance tax form Retum filed by the estate representative.
REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes.
Please sign and date the back of the form when finished.
PART Debts and Deductions
2
Allowable debts and deductions must meet both of the fotlowing criteria:
A. The decedent was legally responsible Por payment,and the estate is insufficient to pay the deductible items.
B, You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department.
{If addi6onal spaca Is required,you may attach 81/2"x 71"sheets of paper.)
Date Paid Payee Desc�iption Amount Paid
G,aGl''� G
Total Enter on Line 5 of 1"ax Caiculation $
PART Tax Calculation
3 If you are making a correction ta the establishment date{Line 1}accopnt balance(Line 2},or percen#t�abte{Line 3},
p[ease obtain a written correctfon from the financial institution and attach it to this form.
1. Enter the date the account was estabiished or titled as it existed at the date of death.
2. Enter the totaE balance of the accourrt inciuding any interest accrued at the date nf dea2h.
3. Enter the percentage of the account that is taxable to you.
a. First,determine the percentage owned by the decedent.
i. Aceounts that are held"in trust for"another or others were t Op°/,owned by the decedent.
ii. For joint accounts estabiished more than one year prior to the date of death,the percentage t�able is 100°h divided
by the tota!number of owners including the decedent. (For example:2 owners=50%,3 owners=33.33%,4 owners
=25%,etc.}
b. Next,divlde the decedent's percentage awned by the number of surviving owners or beneficiaries.
4. The amount subject to tax is determined by multipiying the account balance by the perceni taxable.
5. Enter the totai of any debts and deductions alaimed from Part 2_
6. The amaunt taxable is determined by subtracting the debts and deductions from the amount subject to tax.
7. Enfer the appropriate tax rate from Step t based on your rslet"sonship to fhet3ecedent.
!f indicaiing a different tax rate,please state f �,,
your relatipnship to the decedent: .. I'��' - '�u'�-�!�-`
�, �r.
1_ Date Estabiished t �,/1�l : �'��
2. Account Balance 2 $ '�/�,��. af'
3. Percent Taxable 3 X �
4. Amount Subject to Tax 4 $ .�-t" L y.�
5. Debts and Deductions 5 �_
6. Amount Taxable 6 $ ,/� SrL3 7, „� �'�
7. Tax Rafe 7 X�`` "� �°�'
8. Tax Que $ $ f�of r�^04.
9. With 5% Discount(Tax x.95) 9 x �;5, �j
�'Jt8(� 2: Sign and date belpw. Retum TWO completed and signed copies to the Register of Wilis listed on the front of this form,
aiong with a chsck tor any payrnent you are making. Cbecks rraust be made payabie to"Register of Wills,Agerrt." Do npt send
payment directly to the Department of Revenue.
Under penalty af perjury, I declare that the facts I have reported above are true,correct and complete to the bast of my knowledge and
6elief.
Wock
�_ Home �� � � - � � ��"�i���
� ;,:
Taxpayer Signa#ute Telephane Number Date�
IF YOU NEED FURTHER ASSISTANCE, CON7ACT PENNSYLVANIA DEPARTMENT OF REVENUE
DI51"RtCT OFFICE, 4R TNE INHERITANCE TAX DIVESION AT 717-787-8327. SERVIGES FflR
TAXPAYER� WITH SPEGIAL HEARING ANDlOR SPEAKING NEEDS dNLY: 1-800-447-3020
P.EV-15ID EX+(OB-09)
; � .w pennsylvania SCHEDULE G
���� DEPNRTMENTOFPEVENUE INTER-VIVOS TRANSFERS AND
INHFRRFNCETA%RENRN MISC. NON-PROBATE PROPERTY
RES[DEffr DECE�EM
ESTATE OF FILE NUMBER
Helen L. Roccati 21-13-0664
This schedule must be mmpleted and filed if the answer to any oF questions 1 through 4 on page three of the REV-1500 is yes.
DESCAIPTION OF PROPERTY
REM ixauce�w�am�mn�srEaff,TMnanu.cnwsrmroo�od+rano DATEOFDEATH WoOFDECO'S EXCLUSION TAXABLE
NUMBER n�onr�aF�wwsFm.nnaanmarornceo�raancucsrah. VALUEOFASSET INTEREST prarouva.e VALUE
t. Helen Roccati Revocable Living Trust 341,459.00 100 0.00 341,459.00
� TOTAL(Also enter on Line 7, Recapitulation) $ 341,459.00
If more space is needed,use additional sheets of paper of[he same size. .
Ascaunt values as of OS/30/2tl13 are listed below.
Account Inforrnation-Basic Brokerage
Account Num6er Qwnership
OtXt71072199�133 Trust:$341,459.8Q
Acef Ne+sKAmeripriM Brokxag9 Aceout� i!E t#�.EN Rl7CCAT1 REV i.tV TR UG1�223 99 #�.EN R�GCJ�I �S7'EE
AcCt NO�OOliDT2i99133 A�ctTypp:Nm-i��itWd
JlpitMl�l► i1C1� �i0 �lN�R G1fqp� PIICIIq 1�1t�)
i�E�ii�i�lt�'a�I88@II� � E�j���87i� 4.24Q,@Q 2l�Q ?S,BQODO
CASFt CABH E41IlYfU.B1I8 2�195.50 t.04 22.1l590
EiOQ�NiqBIIGORP iQ�N LMt#ECAP�T!?CK iO�tOD 429� i�i.CQ
�H�R��l�N�'E08.�'� �uk��fEWdH%�if 1,OdO.�G 100.b3 1,0095�
�t�3reu��s�Ct�a �a[.va a+�c� s,�o.no ���e ,a.a�s�
C07��Yiti'�Y�9�'tYA 3SG'Ri5 CltBNEt�liYf418tTS 2T.QGG.GQ 505.14 7�.141A!
9fRA��iM'11170Mf�llA �� FG�DM� �t�EB l�75f.2Y 4.31 37,TU1A/
QFPENfEI1�tR�91�R L1HWY1( HIpF1-YIBDI�cEb OPP�R 3,$34.�2 T.6i 70,785�8
tI�IOftAI.lI�NIChALGiA p4Ct'�IE �txib6
48�ONdiitA�.lt�CJiifON81NC V2 LAtiQECAPBTOGK 1.89Q.60 �11:� �8,�41!!0
AatnratTC�. Si�1,t59�
r1r1s'.(.�i�n1� 1� r���
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- l6�x+{'4#srl�.W
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L0lZ0 3�JCd NI`1�3N Atl2131 0L99CtrZiSt 0£�£I EL@LI9Z189
R@V-ASLi EX+ (OS-13j
� pennsytvania SCHEDULE H
DEPAP7MENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCETA%REiURN ADMINISTRATIVE COSTS
' RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Helen L. Roccati 21-13-0664
DecedenPs debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
n. FUNERAL EXPENSES:
i' Neill Funeral Home Camp Hill, PA 17011 602.00
z. Wake(in Pennsylvania) 4,481.80
3. Perfect Memorials-cremation urn 179.95
a. Overstock.com-charm for cremation urn 15.99
5. Fram Monument•memorial marker 2,053.50
s. The Garden Gallery-wedding photo restored(for Wake) 159.00
�. Woodmont Grill-meal after burial(in Maryland) 770.66
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: �
Name(s)of Personal kepresentative(s) _ _
5[reet Address _.._. ..._.
City _..__ __._State ___ZIP ....
Year(s)Commission Paid: .......
5,000.00
2. Attomey Fees:
3. Family Exemption: ([f decedenYs address is not the same as claimant's,attach explanation.)
Claimant _
Street Address ..._ ._... ....._ ......
Ciry ....... __._ .. State .._.. ZIP ___..
Relationship of Claimant[o Decedent ,,,,_ _ ._.. _.
i
4. Probate Fees: 500.00
5. Accountant Fees:
6. Tax Return Preparer Fees: 250.00
7. Sentinel-advertise letters 147.02
a. mail expenses 23.41
s. Liquidation charges of Ameriprise Financial Trust Account 843.15
TOTAL(Also enter on Line 9, Recapitulation) $ 15,399.18
if more space is needed,use additional sheets of Daper of the same size. .
SCHEDULE H-CONTINUATION
A. Funeral Expenses
8. Karns Foods- flowers $ 22.70
9. Officiate-Richard Guest (in Maryland) $350.00
�v�/GG Fvw��`� �°rn�
c�x�°�yL ��af��
NameofD� �mLguonG CoatractM-741L01000417 . .
Statement of Funeral Goods and Services Selected/Parchase Agrcement
TOTAL SECTIWI I AND 8ECTON il CXAROES S 3,657.00
SECTION IY-ALtOWANCES
r,■cnuowbo� a c2ossoo�
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da
Lqs Dedu�'btes_ � S N
TOTALTAXES Q � % S
TOTAL CHARGE3: Seefbn(I)t(q1+or-1101�IM� S � �
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4y Order HisWry Infarivation-Perfect Mamoria?s 'tthrs:iiwww,perfecd�rsass.comtaccos�_n�swry_unv.puv:ti�u�,_....
.s
Perfect Memariais - Order Infarmation
Questians or concems?Cantac#us at i-$00-979-8767 ar through e-maiL
Order#302022 {Received) �°`�'r"�;',
Delivery Address: Order Date:
marie hegglin Sunday 3une 23,2013
1007 harcisbwg p9ke
Cazlisle,Pennsylvayaia 17013-1616
LFnited States
ShiFPing Met6ad:
Free Standard Delivery(5 ta 7 busiuess days firom date of shipmentj
Prodacts:
I x Butterfly Blisa Cloisonne Crematian Urn-Wood Base $179.95 ;
-EtarnaT F.'m6race FIem7:No Pendant
Billing Tnformation:
_ _ _ _ . _ __ __ _ _ _ __
: BiIIing Address:
m�aris hegglin
100'7 barri5burg p�7ce
catTiste,PennsyIvania 17013
United States Sub-Total:$17995 .
Free Standard Delivery(5 to 7 business $4�
Payment Method; daqs from date of shipmeat):
Seeure Credit Card Total:$179.95
_ . . _.. _ . _
Order History
_ . _ .
Ob12312013 Received
_. _ _. .
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( af2 dJ23120i310:49AP
Overstockcom,save�ap to 80°/o every day! https:/lwww.overstockcom/myaccowit?myaccke}r—order_details&inv_..
Order Details
OrtlerDate:JUtl29/2013 Shlppl�pAOtlress: BIIIInpAGOnss: PaymantMathoO:
Order NumEer:125724399 Marb HeyB�� Mane HegBbn Cretlil CeM
1007 HertiaOUrg Pike 1007 HertisWrg Pike
Cahlab,PA 17013 Catlinb,PA 17013
Item Deacrlpdon aty Tofal PACS ShtuaRnckinp
Y Le Preciose SINer Puryla Enatrel entl CZ Ro�ery�ial 1 315.99 SNppetl 07-29•2019
Telephone C�arm US Postnl Servke
,M� � Writaareriew 9400110200882845531047
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co.mc .. RQCKVILLE:
INiv Fishbein 822=D Rockville Pike"
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9RLT1 MOflE POCkVILIE I�'�.3���114�-���1
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MRS MABIfi HEGCiLIN Phoae: H-717-385-0433
1047 HA1tRIS8URG PIRE RSF.# 16364
CARLISLE, HA 27013 Cemetary ST MARY'S CHURCH
Location ROCKVILLE, MD
Rabbi
EDt3AR ROCCATI � 01-13-2491
FZELE�d LOLTIS� 12�CCATX OS-34-241.3
FRONT—BACK=82DE3—�POP
MONUMENT POLISHED * * *
SIZE: 2-0 X 0-8 X 1-4
MATERIAL: IMPERII�L GI2EY SMOOTH
TtJP SHAPE:MATCIiING SLANT
CC7I7E: P3 RqUGH *
3ID&�4P=i`,.n°,�I
BASE POLISHEA *
SI2E: 2-6 X 1-2 X 0-6
MATERIAL: IMPERIAL GREY 3MOOTF2
MARGIN: PT,
ROIIGH *
SSDES-=TOP—MARGIN
FOOTSTONE POLISH$D
SSZE:
MATERIAL: SMOOTH '
MARGIN:
TC}P SHAPE: , ROUGIi
BRONZE: IN$CRIPTION
QS'T TAX TOTAIr�---
F(3tINi}A'PZON 210 .00 21Q.00 PROCSE' ATTACHED
PERMIT 15 . Oq 15 . 00 AND APPRQVED LE'TTERING,
MCINUMENT 1725 . 00 103 . 50 1828 . 50 TRY TO MAT'CH DESTGN TO SXZS1'ZNG
MARKER MARKER F'OR TERfiSA r C}SWALI)
VASE {S}
CEM.LTRTNG
EX.LTRING
ADTNL WQRK
TOTALS 395Q. d0 103 .5d 2053 .50 � .
DEPbSIT 2053 . 5q
BAI�1iNCE LlUE 4, 0 0
ABO'C7E TOTAI, INCLUDES (X) FOtJNDATIQN & PERMIT.
PURC SER: FRAM MflNUMENT COMPANY, INC.
DAT : 06-1 13 By: �f'"'��� "'
BALANCE DIIIs PitIpIi TQ 22dSTALLATION ON CEME�
NOV9 ACCEPTINC3 MASTSRCARD ANll V23A
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l0 N. Hanover Street
� Carlisle,PA 17013-3413 D� "`, ` _
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IBER.PR7
WOODMONT GRILL
(301)656-9755
5erver: aI�� � #1459 08/03/2013
Table Sl/1 4:24 PM
�uests: 14 10026
keprint #: 5
CIIICAGO SPINACIi DIP 13.00
SMOKED SALMON � 13.00
PEEL & EAT SHRIMP 16.00
PEEL & EAT SHRIMP 16.00
BREAD PLATE 4.00
BREAD PLATC 4.00
HAWAIIAN RIB-EYE 32.00
KEY LIME PIE B.00
�OG POINT 11.00
HAWAIIAN RIB-EYE 32.DO
IIOT TEA 3.SO
RI6 SAND PLATiER 25.00
SIDE CAESAR
VEGGIE BURGER 17.00
COFFEE 3.50
CoCA-COLA � 3.50
iCE6ERG WEDGE SALA� 15.00
BARBENE RIBS � 27.00
COCA-COLA 3.50
ESPRES50 Z.00
DIET COKE 3.50
FRENCH DIP 19.00
DIET COKE 3.50
PINEAPPLE JUICE 4.00
CHEESEBURGER . 17.00
PINEAPPL[ JUICE 4.00
GINGER ALE 3.50
JACK UANIEL5 10.00
ROCKFISFI 25.00
6INGER AlE 3.50
ICE CREAM SUNDAE 8.00
CoCa-co�a 3.50
FLYING TUNA PLATTER 23.00
TANQUERAY 10.00
�ANQUERAY 10.00 �
fILCT MIGNON 34.00
5]:DF CAF5AR
HFNDRY HRW 11.00
cor-Fe� 3.50
GLEN�IVET � 13.00
GLENLIVET � 13.00
FLYING TUNA PLATTER 23.00
ALMA ROSA 10.00
RIB 5/1N0 PLATTER Z5.00
SID6 CAESAR
GLENLIVET 13.00
RIQ SAND PLAI?ER 25.00
SIUE GAESAR
COFFEE 3.50
GIENIIVET 13.00
ROCI<FISH 25.00
1LMA ROSA 10.00 �
Page 1
Fm:WO�'.' n� Grill To:receipt from 08/�3i13 (171724l5010) 15:5G 08/05/13 EST Pg 2-2
IBER.PRT
Subtotal 618.50
rax 40.83
Total 659.33
Gratuitv 111.33
Total 770.66
v7:5a #XXxxXXXXXXXX8363 770.66
auth:411512
AMBER HARTMAN
GENERAL MANAGER
--- Check Closed ---
�age 2
1 fle �7GIIWae1 MARIE HEGGLIN AD NUMBER PAGE N0.
-�� www.cumb�rlink.com 1007HARR186URGPII� .,�� 4Y1277 � . tOf1
G CARLISLE,PA 17D1S I�� BILL DATE SALESPERSON
�/�O�Y� 717-243-1788 ry`
���a ��� g' � 07MONS wolfc
START DATE � STOP DATE
osnsr�s o�nor�s
no Nur.e� no oESCRirrar+ cv,ss uNEs
422277 EXECUTRIX NOTICE LETTERS TESTAMENT 70 PUBLIC NOTICE3 26 • 2 eols
Pubiieation ImeRlo� Rate NM Amount Gross Amount
3 THE SENTINEL-LEGAL 3 LGL 5138.06
TOTAL AD CHARGE S13&O6
3 PROOF OP PUBLICATION 01PRF $7.OP
3 MOBILE SITE MOB2 $2.00
PREVIOUSLY PAID ($747.08)
Purd�naord�r Est.H.L.Roccati � $0.00 . � $0.00
THE SENTINEL
Thank you for advertising with The Sentinell Deadiine for do LEE NEWSPAPERS
incolumn legal ads is 4:00 p.m.two business days prior to PO BOX 5�0
date of insertion.Fw questions,call(717)240-7130. WATERl00 IA �7040540
- — — ___. _
___ — ---- __. — _ _ _
_ — - x.mmudsna��r�wr� Legal
THE SENTINEL ❑ Check# ❑Credtt Card Ad Numb� �»
c/o LEE NEW3PAPERS ❑ � ❑ � ❑ � ❑ - Bllling Date 07N0/1S
PO BOX 5�W
WATERLOO Ul 50704-0540 '�� AmouM Due $ .00
. . rny.��m m k Fv�YFU"�`. . .
Nemawaetlitcartl �� . $
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�,.,y� aoo+za TME SENTINEL� � .
HG� MARIE HEGGLIN do LEE NEWSPAPERS
1007 HARRISBURG PIKE PO BOX 7425�8 '
CARLISIE, PA 17013 qNCINNA710H 45274-2518
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d 21540200UU00�422277DO�OOODOOO�OOODOGODUOO�OODD0002
PROOF OF PUBLICATION
State of Pennsylvania,County of Cumberland
tackie Cox,Director of Sales,of The Sentinel,of the County and State aforesaid,being
duly sworn,deposes and says tltat THE SENTINEL,a newspaper of general circulation
in the Borough of Carlisle,County and State aforesaid,was established December 13�,
1881,since which date T'HE SENfINEL has been regularly issued in said County,and
that the prumted notice or publication attached hereto is exactly the same as was printed
and published in the regular ediiions and issues of
Tf�SENTINEL on the following day(s): .
Tune 26,Tuly 3.10,2013
COPY OF NOTICE OF PUBLICATION
� � �. �� " ' ,� � Affiant further deposes tbat he/she is not
• • : PYC��1T�NlN0�14E' .. `..
inberested in the subject matter of the
iM4e{a;�Fesqm#MaryanihsFaMteWNELENLROCCATt,lYl�ofWa , �
rownmta orsnwrs��,cu�u�caMnp,e«+�ynw.�m,�a�a, aforesaid notice or advertisement,and that
n�;ne«�a*��a+�+m�en�e ; �� all allegations�the foregoing statement as
- A11p�waomknpwinytMmeeNes"ftl'baWde6tedtoeeiREqstewlpmake
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Merie NpyGn.Exscutnx� �e� •
. 1007 N�d�irb�PIKe..
Gedpls.PA 70f9`
Sworn to and subscribed before me this
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Otliar � �19453 �
VAL�EY FORGE �lnss �
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2QIIVaI'kd(e ;,�owr"i�et
Aill'kltt� F°�: 3 O.J, ,n � �ea � $3.10
Total Fee: � u.�; Lnbel #s 70122210000230605467
C2Sh: $ 0.75 .�.....
i0t21 P81d: ,�: �.'3 Issue� PYI: . � -�-�� -----�.. � . $6:1f. .: `^
(hdllk yati ! FARGq Np 56103 Zone-6 $0.46
H rst-C1nss �e#ter
0.30 oz.
Expected Dellvery: Thu 07/11/13
Return Rcpt iGreen terd} $Z.55
�(e tertified 33.10
Labet #: 7012221DOtI023fl60547�
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Zssus PVTc �`$6.21
NE4Q Y4RK NV SQ4fi9 $Q.46
Lone-2 First-Class
Letter
0.30 oz.
Expected Delivery: Ned Q7/10/13
Rsturn Rcpt (Green Eard} §2,55
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labsl #: 7A12221D�Q0230505481
4v�iWYf�
Issua PYI: $6.11
Total: >rx' '_.> r. $i8J4 -
Pnid bY:
Debit Card $18«79
Rccaunt #: riXxXXXXRXXXX8363
Approvnl JJ: 98377C
Fransaatior� �{: 368
23 903110Q13
Aeceipt#: Q�2581
@@ for tracking or inquirles yo to
USPS.com or catt 1-800-222-1811.
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BkTGHTEN SOMEONE'5 MAILBOX. Greeting cards
avaitabla far purchase at seiect Post
Offiwas.
.,. Jr.J.nriueAYrFrtA�4i*fekMFiikFAMprtA*W kNFiM
Mrs. Hegglin,
A11 of the costs are Ifsted on the statements but you actually haVe Co calcn{att#t yotat'self scr
there's no reason tp do that when f have 2 6etter optio�s for yau.
1. The selis were all placed on 7/2a&7/30. For each transaction, you should have
receSved a ttade confi[rmation in#he maii.This canfirmatfo�wi?i have the informatian
you're loakiag for.
2. To make things even easier, below is a list of what you're looking fior:
-�or ehe seil of 677:the commission was$225.00,the hendling fee was$6.04&the transactian
fee was$.40.
-for the seif of XC?M: khe commiss€on was$115.i�C},fhe handfing fee was$6A0&ihe tra�saction
fee wa$$.17.
-fo�the 5ell of VZ: the commission was$4SS.pp,the handling fee was$6.�q &the#ransaction
fee was$1.58.
-Far the sell of the 22 FESSC Bank CD's the handiing fee was$6.�7.
-For the seli of the First Tru&t Balanced Income UIT:the hendling fee was$6.00.
-for Yhe sell af the Oppenheimer Rochester National Munlcipal€uttd:the handling fee was$6.OQ
-Far the sei!af the 4gpenheimer Global Strategit�neame Fund:the handling fee was$6,00.
Ameraprlse charges a$6.QQ handling fee on all types of orders&you'll see that above.The
transaction fee was charged on the 3 stock sells.7his f�e is a fes charged by the SEC on stock
sells. It is based upon a percentage of the principal amount. As ynu can see, iYs a very smali
percentage&goes directly to the SEC.4 of the orders had only khe handling fee charged as
ihere were no commissions&no transaetion fees chargEd.
I hope this answers your questions. Please (et m� know if you need anything etse.
Thank you.
�0/L9 3�tld NIl�J�3H /�2R131 0L05TUZLLL 0£�EL ETOL/9ZI90
ftEV-T512 EX+(12�i2) �
� pennsyivania ��HEDULE I
DEPARTMENT9FPEVENl1E DEBTS OF DECEDENT,
i""FRR""c�T^X RETUR" MORTGAGE LEABILITIES &LIEPIS
t�sioEnr oECEOH+r
ESTATE OF PICE NUM6ER
Helen L. Roccati 21-13-0664
Report debta incurred bp the decedent priar to Ecath tfiat remained unpnid at the date of death,inciuding unreimbursed medlcai pcpenses.
ITEM VALUE AT OATE
NUMBER CIESCRIDTiON OF OBATH
1• Susquehanna intem�Mediane Gamp Hiil,PA 13.97
2. Rehabcare Group East,Inc St. Louis,MO 384.8p
3. R4BC limited Partnership-guest mea15117113 98.40
4. Montgomery Medical Equipment Ca-wheel chair$23.42+$pZ7.00=$250,42 250.42
5. Pa dept af RevenUe Personal Income taY 8.81
6. Alert Pharmacy-medicetions 127.94
7. ATT medical insurance premium 171.38
Tp7AL(plso enter on tine 16, Recapitulation) $ 975.32
if mpre space is neetled,insert atltlitional sheets of the same size.
Remit payment to: P�fienf ReCeipt
Susquehanna interna! Medicine Wednesday,�une 26,2ais
890 Poplar Church Road Suite 5Q8 �
Camp Hilt, PA 17011 �����
(717} 761-3875
Marie Negglin
�"_'-
1007 Harrisburg Pike
Cariisle, PA 17413 Empioyer ID 2516S64d0
Provider ED 1730749
Helan L RoecaG(208A4yEric J Binder MD/490828 �
Coronary atheroscierasis of unspecified type tlf vessei,native ar graft(414.q0)
Ulcer of heai and midfqot pp�.14)
031222Q13 Office Call Levei 111(99213 GV,GW) $9p.D0 1.p $90.00 $0.00
04/19/2013 Medicare paymervt from Medi�are(PAj 369250309 �A��
50.00
0411 9120 1 3 Transfarfroml�surance 3692gp3pg $0.00 $O,QO
05/08/2013 Medicare adjustmentAdjustmentfrqm Medicare(PA) -$20.t5 $0.00
0510$t2013 Medicare Payment from Medicare{PA} _$5�,gg , ��p
05/17/20i3 Insurance Payment from UnRed HeatthCare(GA)CC $0.00 $0.00
05/57/2413 Trartsferfinm Insurance _g�3.g7 $�g,g�
As part�ipati�physicians,we have agreed ta accept assignment for ya�r re�zM
services,provided a0 COWSUR4NCE amowts are paid by you within 6�days frtam
the date of Mis oofice. This statement reflects your COtNSURANCE liatrility.
08/26/2613 Patient Payment from Roccati,Helen L � $0.00 -gi3.97
Balanca: 50.04 $OAQ
So.� Sa.oa �o.00 �o.00 �a.� �o.oa SOAO . 50.00 50.00
Susquehanna Internai Medicine*890 Poplar Church Road Suite 5Q8`Camp Hill, PA 17011-2200*(717}761-3875
LESS pCCOUNT ENCOUNTER
�.�i'", .` Of�41FT►i9N C�a�s� ��s aa�a�E �
VISIT SUMMARY FOR�MELEN ON 72l27/12-12131/12 311.58-
1986488
12/27l72 OT EVAL 116.87
12127112 THEBAPUTIC EXEH 15 MIN OT 40.50
72/27/12 SELF CARE 15 MINTS OT 40.50
12/31/12 THERAPUTIC EXEH 15 MIN OT 4Q.5C
12/31/72 SELF CARE 16 MINTS OT 40.50 �
12131/72 NEUROMUSCULAIi REED �5 MIN 40.50 �
12/37/12 THENAPUTIC ACT 15 MINT OT 40.50
12/31I72 � CONTRACTUAL ADJUSTMENT/OT 95.53-
� 7l11/73� � PA MEDICAHE•CLAIM FILED 5359.67
1/28/73 MEDICARE B PAYMENT . 193.20- � � _
1/28l13 CONTNACTUAL 22.85- �
VISIT�SUMMARY FOR HELEN ON 12/27/12-72/31/12 . 306.T6- �
1986496
72/27I72 PT EVAL � 108.88 � �
12/27/12 MANUAL THERAPYPT 15 MIN 40.50 �
12/27/12 THERAPUTIC ACT 15 MINT PT , �� 1� 40.50 �
12/37/72 MANUAL THEHAPY PT 16 MIN �'�� _`Y/� 40.50 - . � �
72/31/72 THERAPUTIC ACT 16 MINT PT ,� �� �`'� � 40.50 � . � �
72I37H 2 THENAPUTiC EXEN i6 MIN PT ���, � � 40.50 -
.. a2139�112-_--°NEWROMUSCULAR-REED-IS-NFIN..- _ '� -.: ..�''._._,_ . ,.-:_._4Q�-5g.- �__,�..__.__.- ..._...__.__� .....,_...__«_ .�.
12/31/12 CONTRACTUAL AWU$TMENTIPT � 101.67-
7/77113 PA MEDICARE�-CLAIM FILED $361.88 �Z�� - �
1/28/13 � MEOICAHE B PAYMENT y���� � 160.45- �
7/28l'13 CONTHACTUAL '✓ . 24�.64- � �
VISIT SUMMARY FOR HELEN ON Ot/02/13-01129/13 - 1�427.36- ��
2017184
CURRENT 30 DAYS 60 DANS 90 DAYS 720 DAYS TOTALDUE
151.66 .00 .00 233.14 .00 384.80
REHABCARE GROUP EAST INC
THE BALANCE ON YOUR ACCOUNT IS NOW 90 DAYS OLD. PO BOX 5044B9
PLEASE REMIT IN FULL ST LOUIS, MO 63150-4469
PLEASE CONTACT OUR OFFICE AT 1-888-808-8029.
8B8-808-8029
32491-358X"TT510H4MY000383
.. . .. ._ ...�...,. ......�...o �...nn.r� �
4U.50
1l74/73 NEUHOMUSCULAp REED 76 MIN 40.50
'1/16l13 MANUAL THERAPY PT 75 MIN 40.50 �
1M6l73 THERAPUTIC ACT 16 MINT PT 40.50
. 1./1@/13 . THERAPUTIC EXER 15 MIN PT Bl.00
1/16l73 NEUpOMUSCUTAR REED 75 MM � 40.50 � - �� � �� �
1/16M3 MANUAL�THEpAPY PT 15 MIN 40.50 �
7l18/13 THERAPUTIC ACT i6 MINT PT - 40.50 �
7/16/13 THERAPUTIC EXEp.ib MIN PT � 40.50
1/23(73 MANUAL THERAPY PT 15 MIN d0.50
'1/23/13 THERAPUTIC ACT 15 MIN7 PT 40.50 �
CURRENT 30 DAYS 60 DAYS 90 DAYS 120 DAYS TOTALDUE
151.66 .00 .00 233.14 .00 384.80
THE BALANCE ON YOUR ACCOUNT IS NOW 90 DAYS OL0. REHABCARE GROUP EAST INC
PLEASE REMIT IN FULL. PO BOX 504469
PLEA$E CONTACT OUR OFFICE AT 1-888-808-8029. ST LOUIS, MO 63150-4469
888-808-8029
� 32491-35BX•TTS10H4MY000383 �
RC3BC Limi�ed Parfnership s:ate�,�r�t
202 Black Matt Road
DouglassvilSe, PA 19518 Account: horobc-6'f 77-horache2
Date: 06l18/13
Helen Roccati Payment:
c/o Marie Negglin
1007 Harrisburg Pike
Carliste, PA 17U13
[}a#e Deseription Charges Payments Balance
Balance Forward 0.00
O5/T7113 Guest Meal- 5/12 Brunch 18,06 78.00
��C c-.�� �� b,;c�,c�,+� c��- �r�"C�"�,�K Cv�a
/� ;� � ��'�
-� ,� � .
Current 3�J D2ys 80�ays 90 Days Amc�unt Dirs
o.00 �s.no o.00 o.on �a.00
ORDER NO C[JSTOMER NPI SHIP DAT& TERM9
23119b5 3989 1134303962 04j03J2013 3983
DATES OP 3EFtVICE ITEM D&SCRIPTION ¢TY BRICE EXT8NDE0
1 09jflSji3 - 04f03j13 TR3X5RC 151 WHBELCHAIR - RECLZNER {X-9) 1250.06 75a.40
S28NTAL
2 04/03/13 - 09/03/13 LELR Elevating Legrest, For 6fiee2 S 28.00 25.00
R&A'TAi.
�
��� ��.�� �� l�J
� � �
�
cot�irt�s sax.a aetovirr i�s.00
� SA2.88 TAX 0.04
NON ALLOIPSL7 55.97
AUJUSTiS8NT8 0.00
PAYl�NTS 43.70
DVL FROM CUSTOMER 23.42
Raymeots by check wiEi be canverfed into electronic fuad#raasfers. To tregin receiririg your stat�ts ekctra��ty,ptaase
Funds may be debited from your account as soon as the same day naWgate Ro www.patieMnotebook.eom to ragister. You wi�i
paYrtfent is receiVed. �f your St#emem tD(5�6829294}to compkte the
regfstratWn. Thank you.
HELEN ROCCATI PATIENT BAI.ANCE
Montgomery Medicai Equipment Company
$23.42
1 �E���������� 5�t-spo .2azs4�s
.. .
antgomery ice quipment Company To pay your 6ill online visit:www.mvzaav.eomiMontaomervMedtcab
122 Mfii Road Suite A13D �
Phoenixviile, PA 19456
��,"" �f<,,��
F2ETURN SERVICE REQUE$TED ''�'�� �ry�u
Phone#: (4$4) 9d�.0174 �""���`�" "`�'�"y ��`�L �
PBtient: 08/17/13 �$227 00 z°�3983
" . ctiaxs��s.IU�!c+t�flns�t,€c�t&�L�s SHOW�AiIESUNT@ �
- � nar�wn;ts�ega�.nN�,TF�nSN�Ti,?: PAID-HEfiE:".. �P .
sem�iox:3easzeser
i�lf��ll�1��61�11i���1Ei���l��i,ii�«�;�t,��,���tiE������«�li1�t �
HEI.EN R4CCATT
� � 10p7 HARRSSBURG PIKE Montgomery Medical fquipment Campany
CARtISLE PA 17p13-1616 PO 80X 371863
PITTSSURGN PA 15254-7863
I���IIJ,1��Jd�lJd1��J���I1�rL�1L��dI,dL���ILJ��iI
OC]003B4526397Q��OD65825O�OOt]227OC10004
RE:Pasc Due Acoount
There az8 ttialances on}rout account that have now become p&st due.Below are the datxs of the services and produck yau
have received from TMantgomery Medical.We I�ave sent you sn initial inwice shArtly after you have receeved aur prodnct
and we have not yet ra:eived paycnent from you.We may or may not ha�alreadp billed your ins+�rence com�np First;in
any case;the reivaining balance is your responsibility.
If}�au irave uiade payment within 5 business days of the date an this sta#ement;the papmenk will be reflected on the nezt
past dua statement(Uniess the fu22 amount sliown was pud,xn which ease na past due statement wslt be issued and we
apologizefortheincanvenience). '
We c��ant 10 help you fulfill yca�r c�mmitrt�nt withor�t uudue�ardship. If yon aze uoab3e to send paymesrt todaY>P�
contact our office to establish irrimediate payment amaignments,either t6rqugh pSans or credit card by pbone!
"Cfiank You
$1�lIIg�Cp'iZhllCIlf . � � - . � .
� Uate Iavaiae D�sarigtion . � R�3ni�
-113/2613 3341285 Cushion GelFoat2 16 X 18 11.91
1/3/2013 3391284 AntiTipper Adjustable wWhee :8.79
ZJ3/2013 3391289 Y7IiEELCHAIR RECLINER K4 , 27.91
_ _�f�,t?Q33 _.�.. 3'2$l?RQ. _� � ' R^ YM� t ^l Ftyj], [},Q, $.Q_
2J3J2013 3342248 � WHEELGHAIR RECLIYdER X4 27.81
3/3/2013 335201p WHEELCHAIR RECLINER K4 20.86 �
� 5/3/2013 3375365 V7HEELCHAIR RECLINER K4 Z0.52 �
�o begin feClWitq your itatmMnts aleMronically,pieasE navigat8 to www.paderNnoteqoak.00m to register. Vou will�need ynur StatemeM.ID�
884628347�to compl�e the rcgPstration. Tliank you. . .
rayments by eheek wiil be canvet#+u!irrta elnctronk iumi transiers.F�s rt�ay�tiehited�frart poGU'.acenuM as.soon��tht same dey payment is ncelved
N�utlH16WlWI��IYMMNY9NIIIC�b � . .
BUREAUOFINOFVIDUALTARES pennsylvania �.
POBOX280a31 PERSONA� �INCOME TAX DEPARTMENTOFREVENUE
BABRISSE7RG PA 17128-8431 � �
BfIIING NOTICE �"'•"°�``_"`°'„'
DLN: 1212Qd562533
pATE OF NOTICE: JUN 24 2013
S6CIAL SEC. NUM: 2i4-03-8723
TAX YEAR: 2012
PREASSESSMENT AM6UhiT 5�5.81
HECEN L ROCCATI BAi�ANCE{S) DUE FOR YOUR ACCOUtiT AS OF JUl Od 2D13•
1007 HARRISBURG PIKE -�+ BALANCE INCLUDES ESTIMATED TAX UNOERPAYMENT PERALTY �-
CARLISLE PA 17013-161b OWE� PAID eALANCE
LTEIUNDER .6p .00 .60
EST PNLTY 8.81 .00 8.81
LEGAI .00 .00 .00
SNTEREST .60 .QO .00
USE TAX .00 .00 .00
PIT TAXlRPD 497.Q0 447.Q0 _._.!lil.
2p12 BALANCE DUE � 8 �l
- PWS OTHER TAR YEAR(S) LIABILTTIES (SEE REVERSE
TpTAL. DUE NOW*- (PLEASE PAY 7HI5 AMOUNtaOTICE) .OQ
. USiNG THE ENCLOSED COUPpN) 8.81
THE KIGURES 5NOM'N 8EL�W REpRESENT dM0UNT5 AS ORI6INA�lY ftE40RTEb
ON YOUR 2012 TA% RETURN OR AS AOJUSTED BY THE DEPARTMENT.
ORIGINAL 4R
AGJuSTEQ AHOUNT'a
lA. GRO55-COMPENSATION.......................... 0
IB. SCHE6UtE UE f%P£kSEY....................... fl
7L. COMPENSATtON................................ 0
2. INTEREST (SCHEDULE A)....................... 6,308
3. QIVIDENDS {SCHE6UlE 8}...................... 4.845
4. NE7 INCOME OR tOSS.......................... b
5. TAXABLE SALE - GAIN OR LOSS................. 21
SA. CAPI7Ai. C,AIN EXCLUSi6H...................... 0
6. RENTS, ft0YA4TIES, PATENTS, COPYRIGHTS....... 0
7. ESTATES AND TRUSTS (SCHEOULE d)............. 0
8. fiAMBLIN6 AND LOTTERY WSNNINGS............... p
9. GROSS TAXABLE INC9ME (AOD LINES 1C.2-5,6-81. I6,174 �
10. O7HER OEDUCTIQNSCMEDICAL. HEALTH, TllITSON}.N 0
S1. NET PA TAXABLF INCOME(ISNE 9 HSNUS LIHE i07. Sb,l7�
12. TAX LIABIL77Y (MUITIPI.Y LINE 11 8Y .b3070).. 497 �?�('l s�.� .�J
13. TAX IdSTHHELD CFR4M Y2'S).................... 0 . • � _ �,,
ld, CREDIT FRON AREVI005 TA% YEAR......:........ p * t�
15&16 ESTIMATED TAX & E%TENSION pAYMEN7S.......... 0 'j „ i ",�
il. TAX MITHHELO Ai REP08TE0 4N NHK-i........... 6 " 9�
I8. TOTAL CREDIT$ (ADp LINES 14-11)............. Q � f G�
198. NUMBER Of DEPENDEN75........................ 0 �� f
21. TAX f6R�IYENESS CRF6IT...................... �
22. RESIUEN7 CREDIT iSLMEDULE G)................ 0 "'.?
23. CREDITS (SCHEDULE OC)......... ^
2Il. T07AL CREAITS {ADD LINES 13.18,21-23)....,. p
. ...
......... ...
0
26. TA% DUE (LINES 12 PLUS 25 MTNUS 24).,....... 497
27. PENALTIES AN9 ?KTEREST......................
29. OYERPAYMENT.................................
3p. RffUM�EO....._......
32. CREDITED TD NE%i YEAR$ ESTIMATEp TAX........ 0
32-]6.TOTAL DDNATIONS (lINES 32-86)............ � 0
THE REASONtS) FOR THIS NOTICE ARE AS FQLLOWS:
AN UNOERPAYMENT 6F E5TSMATE6 TA% PENAL7Y HAS $EEN AD6E6 TQ Y06R ACC4UNT. PENNSYI.VANIA tA4t BEflUIBES
THAT ALL TAXPAYERS WHO EXPECI' 70 RECEIVE AT LEAST 58,000 OF PA TAXABLE INCOME, WHICH IS NOT SU6dECT
TO fMPC�YER N'ITHNQI"vING, PiLE A OECLARATIOH UF PENNSYL4ANSA ESTSMA7f0 TA% ANO MAKE INSTALLMENT
PAYMENTS DURIN6 THE TAX YEAR. TNiS INF�RMATION I$ LISTE6 IN THE TA% I#STRUCTION B�OKlE7, qHICH
ALLOMPANIE$ TNE TA% FORMS EACH YEAR. AN UNDERPAYMENT OF ESTIMATED TAX IS DETERMINED WHEN THE AMOUNT
OP TA% PBEPAID I5 LESS THAN 90 PEftCENT QP THE�ACTUAL TAX SNOWN ON THE ANNUAI RETURH. SF THE
PREPAYMENT WAS NOT 90 PERCENT OF THE TAX SHOWN 6N T8E RETURN, YpU MUST AAY INTEREST FOR UNOERPAYMENT
pf E5TIMATED 7A8E5. INTHREST IS FIGURED SEPARATE4Y FOR EACH INSTALLMENT DUE DATE. IF YOU FEEL THAT
THIS PfNA4?Y WAS A6DfP IN ERRpR, PI.EASE COMP(,ETE AN4 SUBMfT Att REY-2630. THE REV-i534 IS AYAIIABLE
ON REVENUE'S WEB SITE AT WWW.REVENllE.S7AiE.PA.OS OR Y6U CAN OR�ER THE FORM PAOM THE DEPARTNENT'S
24-HOUR AllTOMATEU FORMS ORDERING MESSAGE SERVICE BY LALLING 1-800-362-2050.
ANY UNPAID BALANCES WILL REDUCE OR ELIMINATE ANY FUTURE REFUN6.
iF YOU Dd NOT REPIY tCITHIR 30 6AYS FR6X THE DATE Of THIS NO7ICE OR PAY THE ANOUNT OU£, Y4ll it24.L 6E
ASSE5SED. YOU WILL THEN HAYE THE RIGHT TO APPEAL TO THE OEPARTMENT.
fF YOUR CASE NAS BEEK PLACE4 VITH A COtCECTION A6ENCY, YOU MAY BE SUBJECF 74 AD6IFIQNAt FEES. t!P TO
39 PERCENT OF THE AMOUNT DUE MAY BE IMPtlSED ON ANY LIABIL17Y N07 PAItl PRFOR TO REFERRAL TO A
C�LLECTSON AGENCY pR CAN7RACT COUNSEI.
*The `TOtal Due How° may nat reflect payments remitted to the department withnn 15 days priar to the �
r� date of this notiCe. Please compare the date of this notice with YouY banking records before
�' contacting the department.
t SEE REVERSE SIDE FDR MORE INFORMATION
J
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REV-1513 EX+;Oi-SO)
'.� m'pennsytvania SCHEDULE �
mr��urance rax rteruara BENEFYCIARIE5
a�smear oec�rn
E5TATE OFi FILE NUMBER;
Helen L. Roccati 21-13-0664
RElATIONSHIP R}DECEDENT AMOUNT QR SHARE
MUMBER NAME AND AODRESS OF FER50N(S}RECE7VtNG PROP£RTV �o Not List Trustae(5} OF ESCATE
I TN(ABLE DISTRIBUTIONS[Include ouhight spousal distributions and krensfers untler
Sec.9116(a)(11).]
i. Sfiiday rortuna 43379 Cerys Brook Ct Ashhum,VA 201d7 daughter 24°l0
2. Marie Hegglin 10Q7 Harrisburg Pike,Carlisle,PA 1�013 daughter 74%
3. Ann Marie Fortuna 3068 34th Sf.S, Fargo,ND 58103 granddaughter 4°l0
4. Aaror�Hegglin 1007 Harrisburg Pike,Carlisle,PA 17d13 grandsan 4°l0
5. Roger A.Fartuna,III,200Riverside Blvd,Apt 10W New York,NY 10069 grandsan 4°/a
6. PAoira Hegglin 32 Parker Road,West long 8ranch,Nd 07764 great granddaughter 4°k
7. Gavin Hegglin,32 Parker Road,West Long Branah,NJ 077A4 great grandson 4°/a
ENTER DOIIAR AFI0UNT5 ROR DSSLRI&UTIONS SHOWN A$OVE ON tSNES 15 TNAOUGH 18 OF REV-5500 COVER SHEET,RS APPROPRIRTE,
II NON-TAXABLE DISTRIBUTIONS
A, SPOUSAL DISTRIBUTIpNS UNDER SEC7ION 9113 FqR WHICH AN ELECTION Tp TAX IS NOT TAKEN:
1,
B, CHARITABLB AND GOVERNMENTAL DISTRIBUIlONS; �
1.
TOTAL OF PART II- ENTER TOTAL NON-TAXABCE DISTRIBUTIONS ON UNE 13 OF REV-1500 COVER SHEEL $
[f more space is needed,use adtlitional sheets of paper of khe same size.
T AfiT WI'.LL AND TESTAMENT
OF
HELEi�I L. ROCCATI
T, HELEN L. 120CCATI,curcenfly residing at Tlre Bridges at Bent Creek, 2100 Bent
Greek Ttoad,Iviecl�anicsbarg, Cumberland County,PennsyIvania,being af saund anti dis�sing
mind,memory and understanding,do hereby make,publish and fleclare tlzis as and for my Last
Will and Testament, hereby revoking and making void anq and all former�lls,Codicils, or
writings in the nature thereof,by me at any time heretafore made.
FIRST: I hereby direct my Perscmal Representative to pay all my j�tst debts, funeral and
administrative expenses aut of my esfate,as soon as practicabte after my death.
SECOND: I direct that all taxes wluch may be assessed in conseqnence af my death, of
whatever natr,ue and by whatever jurisdiction imposed, shall be paid out af my estate as a part
af the administratioa of my estate.
THI12D: I herehy direc�t that my human remains be cremated.
FOURTTi: I hereby give,davise and bequea#h my entire estate,real,personal ar mixed, af
whatever naiwe aad description,however acquired and wheresaever situate which I may awn
or have the right to dispose af at the time of my death„ as follows:
A. Unta MARTE T.HEGGLIN,per stirpes and not per ca�rita,absolu#ely,
seventy-four percent(74%)of my estate.
B. Unto SHIRLEY FORTUNA,per stirpas and nat per capita, absolutely, tweniy-
four percent{24%}of my estate.
C. Unto ANN 141ARIE FORTUNA,ROGER A.FORTUNA,III,t1ARON L.
HEGGLIN, GAVIN FIEGGLIN AND MOIRA I3EGGLIN,or the smvivors
of thezn,two percent(2°Jo}of my esta#e,per stirpes and nat per capita,
absolntely.
I hereby specifically direct that anyone who contest this Will sha11 lose thei�portian of
tiie estate, ifthat Will contest is defeated. That person's share sh�Il go back iato item Fourth,
Sect'ran A.
FTkTH: I hereby nominate, canstitute and appc>int my daughter, MAB]E T. HEGGLITV,as
Executrix of this my Last Will and Tastament. Tn the event she is deceased,unable or
unwilling to serve in said capacity,then I nominate,canstitute and apperint TERRY L.
HEGGLIN, as Executor. In the event he is deceased,unable or unwilling to serve in said
capaeity,then I nominate,canstitute and appoint JOSEPH SPIEL$AUER,as Executor. T
clirect that my personal regresentative{s}shail not be reqaired to give t�nd ar security for the
perfarmance of their duties ur any juriscliction.
\
SIXT�T: In the event that GAVIN HEGGLIN and/or MOTRA HEGGLIN shall be undex the
age of Ewenty-ane{21)peazs,iheir shares of said property shall be held in two se�arate
TRLTSTS and adnunistered and distributed in accordance with the following provisians:
A. All of the income of each Trust shatl be accumuiated and reinvested
in such a manner as to increase the size of tha trust res; and
B.As much of the principat and accumulated income of each Trnst as
TRUSTEE may fram time ta time think advisable for the support and
eciucatian{including college education,l�th graduate aad undergracluate}
of said children,or during iIlness or emergency, or for general welfare and
maintenance shall either be paid to them or else applied directly for their
benefit by the TRUSTEE after taking into cansideration their other reaciily
available assets anfl sources of income.
C. Ta pay the accumuiated income and grincipaI then existin�;in the Tnastee's hands
when Gavin Hegglin attains the age aftwenty-one(21),to pay the accixmulated
income and principal then e7tisting in the Tnysstee's hands when Moira Hegglin
aitaius the age af twenty-ane{21},at whieh time the Trust sha11 eease.
SEVElYTH: I nominats,constitute and appoint'!'T20Y T3EGGLIN as TRCJSTEB ttnder this
my Last Wil l and Tes#arnent. In the evcni he is unable or unwilli.ng to serve in such capacity, I
then appoint ET2IN HEGGLIN as TRUSTEE under this rny Last WiII anfl Testament.
� EIGIiTH: [n addition to the powers canferred bq case law,by stahne and by other provisions
of this Last Will and Testament,my personat representative,and any successors in that capacity
shali have the foliowing discretionary powers applicable to all zeal estate and gersonai pmperry
held by Ehem,which powers shall be effective without Qrder of any Court and which shall exist
and cantinue until the tirne of actual distribution:
A_ To retain any pmperty of any natvre received by them for whatever perial it shall
be deemed advisable;
B. Ta invest and reinvest atl or any part of the assets of my EsEate without regazd ta
statutes lixniting the property which a fiduciary may purchase;
C. Ta sell,h�ansfer, exchange ar atherwise dispose of,any part of the assets of my
Estate,far cash or an terms,publiciy or privately,ar to iease,withoe�t liability on the
puzchasers to see to the appiication of the proceeds,and to give options for these
prurchases without the obligation to repudiate them in favor of a higher offer;
D. To execute and deIiver any deeds, teases, assignments or other ins��unents as may
be necessazy to cany out the provisions ofthis Will;
E. To borrow money,if necessary to faciiitate the adminisfration and closing of my
Bstate,including the right to boaow money from any bank, and to mortgage or
piedge any asset of the estate as security;
P. To loan to,aad to purchase assets&om, my Estate>even if also a.cting as Bxecntor
tt�ereof;
G. Ta assume continuance of the status af any beneficiary with regard to death,
marriage,divorce,illness,ineapacity and similar incidents ar matters in the absence
of infornaa#ion deemed reliable witlxout liability for disbursements made on such
assumption;
H. To make any distrihution hereunder ei#her im kind or in money, or partiallq in kind
or partially in monep, considering af course the reasonable wishes of the
beneficsary. I}i�tribt�tion in kind shall be matie at the appraiseti value af ihe
praperty disiributecl, as it is set forth 3n the Inheritance T�Retum filed in my
Bstate;
T. To exercise any subscription right in cannection with any securiry held hereunder,
ta consent ta or parlicipate in any recapitalization,reorganization,consolidation or
merger of azty corparation,campany or association,the securifies of which may be
held hereunder;and to delegate authority with respect thereto,ta deposit
investments under agreements,to pay assessments,and generally to exercise all
rights af investors;
7. Ta continue in any parhiership,joint ven#ure,joint ownership ar other business
entergrise af which I am a part at the time of my death;
1{_ To compmmise claiYns;
L. To continue for whatever period of time my personal representative shall deem
necessary any awnership as a tenant iu common or as a partner,in reat estate or
atber propert)and to act as I would have done had I been living;
M. Ta do ail other acts in ffieir judgment necessary or desirable for the proper
management,investment and distribation of the assets af my Bs#ate;
,
N. I direct thaf my personat representafive may be compensated for the secvtces they
r�nder as Execuwr under this my L,ast Will and Testament;
Q. Shoutd anq changes occur in the Infernal Revenue Code or Pannsylvania statutes
after the date of the execution of this Will which affect the taar liability af my estafe,
then to the extent gassible and as may be permitted by law,my�rsonal
representative sha11 have the power and discretion to interpret this Will and to
administer my Estate in a manner which results in the lowest tax liability possible;
IN WITNESS WHEREOF,I hereunta set my hand and seal this !� day of
2�tt4
- , �' ^ �'Ji
� �- �, u �� i-�''v.-t_i�`-:�.L
� �
HEI..EN L.ROCCATI
SICrNET3, SEALED,PT.I�LZSi-3ED and
DECLARED in the presence of:
--��--
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��A{ONGt'FALTH OF PFNNSYL VANCA
Karou A Truearc,N�1ic
�lva Sgr�gs 7oa�P,{,�6Ql�d Cwmty
Aty cammissiou ex ires December 19 2013
ACKNUWLEDGEMENT
I,i1ELER L.12QCCA'I`I,the Testairix wfiose name is signed ta the attached or
foregoing insMrrument,having been dulq qualified according to the law, da herebq acknowledge
that I signed and executed the.instrument as my Last Will and Testament; that I signed it
willingly,and that I signed it as my free and voluntary act for the purpases therein e�pressed.
��� >f/ C� i �'..��r
FIELEN L. 12{}CCATI
Swo� jn or affirm d d aclrnowledged before me by HELEN L. ItOCCA"TI,the Testatrix,t�is
_�bic. day of���,��w2,� 242�.
—~ ���s����---��'
o Public �
. �I.7HOFP&NNSY'LVANIA
NOTARIAC SFAL,
Kmrn A Tnro�,Notazy PubGc
S�lvm SpriugeToamhip,CLmbalandCamty
IIA !'XI�IIfilOH4 iresDecem6ea19,1013
FIRST AMENDMENT
TO
REVOCABLE DEED OF TRUST
OF
HELEN L. ROCCATI
THIS FIRST AMENDMENT TO REVOCABLE DEED OF TRUST is executed on this
'' ''"`�• day of��-Ct� ='���.— , 2007, by HELEN L. ROCCATI, of Baltimore County,
Maryland, as settlor, and MARIE T. HEGGLIN, a successor trustee. Any reference in this trust
agreement to the "trustee" sha11 apply to any trustee or trustees then serving.
SECTION 1. FIItST AMENDMENT TO REVOCABLE DEED OF TRUST. By
agreement dated February 23, 1999, the settlor entered into a T'rust Agreement. Under
����"T`�{2IV'`iDF���`��"�T3��I-lyI�'H,A�L`t�JWS,ATv1ENC)N!E;i�Tj of tha±agreement,the
settlor reserved the right to amend or revoke the trust agreement at any time, subject only to the
trustee's consent with respect to any modification in the trustee's duties,powers, liabilities and
compensation. The settlor now wishes to amend the Trust Agreement. The revocable deed of
trust is now amended as follows:
SECTION 2. AMENDMENT OF TRUST AGREEMENT.
DISTRIBUTION OF TRUST is hereby Amended to read as follows: Upon the cieath of
the Grantor,the Trustee shall retain in trust, or distribute, the residual of the Grantor's estate as
hereinafter specified.
The Trustee shall distribute those parts of the estate as lollows:
l. Unto MARIE T. HEGGLIN, Seventy-four(74%)percent of my estate,
per stirpes and not per capita, absolutely.
2. Unto SHIRLEY L. FORTUNA, Twenty-four(24%)percent of my estate,
per stirpes and not per capita, absolutely.
3. Two (2%)percent of my estate to be divided among ANN MARIE
FORTUNA, ROGER A. FORTUNA,III,AARON L. HEGGLIN,
GAVIN HEGGLIN and MOIRA HEGGLIN, or the survivor of them.
4. I hereby specifically direct that anyone who contests this Will shall ]ose
their portion of the estate if that Will contest is defeated. That share sha?I
go to item SECOND, section A.
SECTION 3. RATIFICATION OF AGREEMENT. As amended above, all
provisions ofthe HELEN L. ROCCATI REVOCABLE DEED OF TRUST dated February 23,
I
1999, and any arnendments thereto,remain in fult force and effect.
�J
EXECTJTED ON �" �' 1��`" f� "� 2�07.
WTINESS:
,
� �.� , �
�"..l f .�...� __..__. �l .� �•
��_- _ •'�lt'�� ��'`; u__r___�r�� (SEA1G}
_ HE�L. ROCCATI,�e;ttlor
i � � '
����` ;':
ATTEST: R�'AKIE T.1�IE / , Suocessor Trustee
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,-�'.. '. / _ � By: '>r� �, .�.; _ :� ;.;—
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Title: �� ' ;:�
1 �';
{Cf}RPORATE SEAL}
STATE OF MARYLANI� ,,� ;
�-£��'fCf}IJNTY OF r:_�,� =.,:� :: !�-
I HER.EBY CBRTIFY that on -f' c`a��U ,2007, before me,a natary
pablic of the State of Maryland,personal3y I�LEN L.ROCCATI,the settlor named in this
first amendment to revocable deed of�r t and acknowledged it to be her act and deed.
����u ��i�i;���
�KR`����,DM M. B�i��f . '.
.
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a ' taor °.�?^'- =-� , ��
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'"+'✓�9�`-.. .. .:a ,,.` My cammission expires `�� "i .1 t..� '
+re''Jf F i i�t�``�r' .
STATE OF MATiYLANb ��
�"�tC4t3NTY QF l '�t 1, -!�'"'-i-°
I HEREBY CEI2TIFY that on ���" f`i%�`"�. _' '�- 2007,before me,a notary
puhlic of the State of Maryland,persanally MARIE T. HEGGLIIV,the successor trustee nazned
2
THE
ESTATE PLANNING PORTFOL20
I�ND
REVOCABLE LIVING TRUST
OF
HELEN L. ROCCATI
Prepared by
THE LAW OFFICES OF
W. LEE KING JR. , P.A.
900 East Ocean Boulevard, Suite 142
Stuart, Florida 34994
(561) 223-2100
and
10884 S. Federal Highway
Port St. Lucie, Florida 34952
(407) 337-3595
1(800) 741-0885
Please contact The Law Offices of W. LEE KING
Jr. , at the above address for any further
assistance regarding this estate planning
document and the settlement of the estate at
the appropriate time in the future .
ABSTRACT OF TRUST
�,.
The undersigned hereby certifies that on l:lG � � , 1999,
they created a Revocable Living Trust . This Trust is known as :
the HELEN L. ROCCATI Revocable Living Trust, dated _i � ,
1999, HELEN L. ROCCATI, Grantor and/or Trustee.
This Trust Agreement is entered into by and between HELEN L.
ROCCATI, of the County of St . Lucie, State of Florida,
hereinafter called "Grantor" , and HELEN L. ROCCATI, whose
resi_dence and post office address is 2321 S . W. Monterrey Lane,
Port St . Lucie, FL 34953 , hereinafter referred to as "Trustee . "
Reference in this Trust to the "Trustee" shall be deemed a
reference to whomever is serving as Trustee or Co-Trustees,
whether original, alternate, or successor.
This Trust shall be known as :
i- , "The HELEN L. ROCCATI Revocable Living Trust, dated
Y.G � � � , 1999, HELEN L. ROCCATI, Grantor and/or Trustee. "
The initi�l primary beneficiary of this Trust shall be HELEN
L. ROCCATI .
r The effective date of this Trust Agreement shall be
F„C�' .� � , 1999 .
WITNESS
POWER OF TRUSTEE TO ACT INDEPENDENTLY
Notwithstanding any other provision to the contrary, the
Grantor specifically authorizes the original Trustee, during her
life and while serving as Trustee, to have the authority to
perform all powers and acts as granted under this Declaration of
Trust, and the powers provided in Chapters 737 and 738 of L-he
Florida Statutes, as amended, which are incorporated herein, and
shall include the right to contract for and in behalf of the
Trust and to execute, negotiate, and compromise such instruments
as may be necessary to carry out the purposes and intents of this
Trust .
ORIGINAL TRUSTEE
The original Trustee under this Declaration of Trust shall
be HELEN L. ROCCATI, to serve with all of the obligations, powers
and authority contained within this Trust Agreement .
SUCCESSOR TRUSTEE
In the event of the death of the original Trustee, or if for
any reason whatsoever he ceases to serve as Trustee hereunder,
the Grantor nominates and appoints MARIE T. AEGGLIN to serve as
Trustee hereunder without the approval of the court . In the
event that MARIE T. HEGGLIN is unable or unwilling to serve, or
to continue to serve, at any time for any reason whatsoever, then
in that event the Grantor nominates and appoints TERRY L HEGGLIN,
i
i
2 _ ttir�tmate D� r;bu.tion. If the Grantor, Grantor ' s
spouse, all issue of the Grantors, and all ather beneficiarie� of
this Trust shal.i die �r�or to the time set for final distri�ution
of the Trust, the remaining assets, including accumulated incame
shall be distributed in accordanr_e with the Statute of Descer.t
and Distribution of Florida in effect at the time af the death of
the Gran�or.
(a) The wards "children"' and °ia�ue'" used in this Trust
shall include legally adopted children.
(b) Personal Pr�n�±-hy D� �„.ybyti.ga. The Grantor requests
the Trustee to abide by any memorandum by the Grantor directing
the disposition of personal and household effects of every kind
including, but not limited to furniture, appliances, furnishangs,
pictures, chine, silverware, gla�s, boaks, jewelry, wearing
apparel , and all policies of fire, burglary, property damage, and
other insurance on or in connection with the use af this
property. 4therwise, the personal and household effects of the
Grantor ehall be distributed with the remaining assets af the
Truet Estate .
POT7R:�V.EA WILL
Personal Representative: MARIE T. HEGGLTN
3uccessor Persona2
Representative: TERRY L, HEGGLIN
D�98LE PbWER OE_�7.'TQ$�y�'OR PROPF$�y,�J$�A��'�x
Attarneys-in-Fact: MARIE T. HEGGLIN
Sucoessor-in-Fact TERRY L. HEGGLIN
D�ART,�OWER O� AmmORNFV FQ�gE,�kTACBRE�
Attorney-in-fact: MARZE T. HEGGLZN
Successor Attorney- TERRY L. HEGGLIN
in-£act:
I�IOMINATIQPT_.S�?.__GS1gB22ZAN O�_TIiE.��RS.OSi:
_ __
Appointee: MARIE T. HEGGLIN
Successor: TERRY L. HEGGLIN
�P�II�TTSEN�QF_PI3YSSCI&L�I3__S�D�xF hti�-T�**�'.y__�4MPETEN�Y:
Physician 1:
Physician 2 :
FINAL INSTRUCTIONS:
Grantor wishes to be buried and has left instructions with her
personal representative regarding disposition of her body.
BENEFICIARIES OF THE LIVING TRUST:
During the life of the Grantor:
HELEN L. ROCCATI
_ __
to serve as Successor Trustee, without the approval o€ any court .
When two or more persons are named to act simultaneously
with another designated Trustee, the Ca-Trustees serving must act
in concert . This provision does not apply to the Grantor (s? .
Should any one ar more of those named fail to qualify or cease to
act as Trustee, then the Trustee shall be the next one in order
to qualify.
Should all of the abave named persons be unable or unwilling
to act as trustee, current income beneficiaries, {or their
guardians) holding a majority Trust interest shall salect a
Successor Trustee.
PQWERS pF TRUSTEE
The Trustee shall have the following powers, duties and
discretions in additian ta thase otherwise granted herein or by
law, and except as elsewhere herein specifically restricted.
GENERA.L PROPERTY POWER
The Trustee shall have all such powers and is authorized to
do all such acts, take all such proceedings anfl exercise all such
rights and privileges in the rnanagernent of the Trust Estate as if
the absolute owner thereof, including, without limiting the
generality of the terms, the right to manage, control, develop,
improve, sell, convey, exchange, partition, mortgage, assign,
divide, subdivide, repair, to change the character of any Trust
property; Co grant options and Co sell upon deferred payments; to
dedicate ta pubiic use, abandon and otherwise dispose of any
Trust praperty, when, in the judgment of the Trustee, it is in
the interests af the beneficiaries to do so; to enter into any
lease as lessor or lessee for a term within or extending beyond
the duratian of. the Trust; to grant or take an option to purchase
ar lease; to borrow funds, with or wiChout Trixst propPr.ty as "
securi.ty, for such purposes as tYie Trustee sh�ll deem advisable;
to invest and reinvest principal and income in every kind or
property, real and personal; to place Trust assets i.n the hands !
of agents selected by the Trustee, in order to facilita�e
transacY.ions and record keeping in connection with those assets
and for safekeeping; ta create restrictions, easements, and other
servitudes; ta compramise, arbitrate or otherwise adjust claims
in favor of ar against the Trust, to institute, compromise and
defend actions and proceadings aY., the expense of the Trust
Estate; and to carry such insurance as the Trustee may deem '
advisable . '
FOWER REGAR7JING SECURITIES
The Trustee shall have, regarding securities, all the
*.
rights, powers and privileges of an owner, including the right to
vote stock, give proxies, pay assessments and other sums deemed
by the Trustee to be necessary for the protection of the Trust
Estate; to participate in voting trusts, pooling agreements,
foreclosures, reorganizations, consolidations, mergers and
liquidations, and in connection therewith, to deposit securities
with and transfer title to any protective or other committee
under such terms as the Trustee may deem advisable; to exercise
or sell stock subscription or conversion rights; to open an
account with a brokerage firm of the Trustee ' s choosing, in the
Trustee ' s name, in the Trustee ' s own behalf for the purpose of
the purchasing and selling of all kinds of securities and
authorizing such brokerage firm to act upon any orders, including
margin orders, options, both covered and uncovered, instructions
with respect to such accounts and/or the delivery of securities
or money therefrom and received from said Trustee; and to retain
as an investment any securities or other property received
through the exercise of any of the foregoing powers. The Trustee
is further authorized to sign, deliver and/or receive any
documents necessary to carry out the powers contained within this
paragraph.
LIFE INSURANCE AND ANNIIITIES
The Trustee is authorized in the Trustee ' s discretion to
maintain and/or purchase policies of life insurance and/or
annuities on the life or for the benefit of any Trust
Beneficiaries and to hold and pay upon successive occasions, the
premiums to be charged against income or principal, as the •
Trustee shall determine.
The owner of any life insurance policies payable to the
Trustee shall have all rights under any such policies, including
the right to change the beneficiary, to receive any dividends or
other earnings of such policies without accountability therefore
to the Trustee of any beneficiary hereunder, and may assign any
policies to any lender, including the Trustee, as security for
any loan to either Grantor or any other person; and the Trustee
shall have no responsibility with respect to any policies, for
the payment of premium or otherwise, except to hold any policies
received by the Trustee in safekeeping and to deliver them upon
owner' s written request and upon the payment to the Trustee of
reasonable compensation for services . The rights of any assignee '
of any policy shall be superior to the rights of the Trustee.
This is to witness that I , HELEN L. ROCCATI have read the
provisions of the HELEN L. ROCCATI Revocable Living Trust
Agreement and understand the provisions therein.
IN WITNESS WHEREOF, the provisions of the Declaration of '
Trust shall bind HELEN L. ROCCATI as Grantor, and HELEN L. `
ROCCATI as Trustee; Successor Trustees assuming the role of
.'
,'
.
;
rights, powers and privileges of an owner, including the right to
vote stock, give proxies, pay assessments anc3 other suma deamed
by the Trustee to be necessary for the protection of the Truet
Estate; ta participaCe in voting trusts, paoling agreemants,
foreclasures, reorganizations, consolictatians, mergers and
liquidations, and in connection therewith, to deposit securities
with and transfer title to any protective or other committee
under such terms as the Trustee may cleem advisable; to exercise
or sell stock subscription or Conversion rights; to open an
account with a brokerage firm of the Tzustee ' s choosing, in the
Trustee� s name, in the Trustee � s own behalf for the purpase of
the purchasing and selling of a11 kinds of securities and
authorizing such brokerage firm to act upon any orders, including
margin orders, options, both coverect and uncovered, instructions
with respect to such accounts and/or the delivery of securities
or money therefrom and received from said Trustee; and to retain
as an investment any securities or ather property received
thraugh the exercise of any of the foregoing powers . The Trustee
is further authorized to sign, deliver and/ar receive any
documents necessary ta carry out the pawers contained within this
paragraph.
LIFE INSLTRANCE AND ANNUITIES
The Trustee is authorized in the Trustee's discretian to
maintain and/or purchase policies of life insurance and/or
annuities on the life or for the benefit of any Trust
Beneficiaries and to hold and pay upan successive occasions, the
premiums to be charged against income ar principal, as the
Truetee shall cletermine .
The owner esf any life insurance palicies payable ta the
Trustee shall have all rights under any such policies, including
the righC to change the beneficiary, to receive any dividends or
ather earnings of such policies withaut aecountability therefore
to the Trustee of any beneficiary hereunder, and may assign any
policies to any lender, includiny the 'Prustee, as security for
any loan to either Grantor or any ather person; and the Trustee
sha11 have no responsibility with respect ta any policies, for �
the payment of premium or otherwise, except to hold any policies
received by the Trustee in safekeeping and to de2iver them upan �
owner' s written request and upon the payment to the Trustee af
reasonable compensation for services . The rights oP any assignee
of any golicy shall be superior ta the rights af the Truatee.
This is to witnass that I, HELEN L. ROCCATI have read th�
provasion, of the HELEN L. ROCCATI Revoaable Living TrusC
Agreement and understand the ,provision� therein.
IN WITNESS WHEREOF, the provisione of the Dec7.araCion of
Trust shall bind HELEN L. ROCCATI as Grantor, and IiELEN L.
ROCCATI as Trustee; Successor Trustees assuming the role of
_. _ ___ . r—„-..... .. .. . _ _. __. _ __. _ _ .
Trustee hereunder, and the Beneficiaries of the Trust, as well as
their successors and assigns .
This Living Trust dated at �i����„�, Florida.
This , � 3 day of �,,�% :-- , 1999 .
�( .N..%' C,.i'y� � ' �� �) �'C�'�(/ L l.
Witness Si nature Grantor '
�c� �i N G
Printed Witness Name
Gl Y�0�
Witness Signature
S y�v��r ��tT��lA
Printed Witness Name
, ,
.- r �. IC�.��� � �J\ ��'c��.��� .
Witness Sig ature Trustee
/c� �:�v��
Printed Witness Name
✓� ���--�
Witne s Signatur
�N L✓�,q �,fl'SY�
Printed Witness Name
STATE OF FLORIDA
COUNTY OF MARTIN�
On this� day of ��, 1gg9, before me
personally appeared HELEN L. ROCC TI, as Gra r, ersonally
known to me or who has presented ' ���iU�
as identification, the person desckibed in and � executed the
foregoing instrument, and acknowledged t e�Grantor ex uted the
same as Grantor ' s free act and deed. �
�
�
; �, �. /j�
���"'"y�,. 9'°"` ? ' U'.�1�
_. . �,n co�rassro��a�aee EzaINEe
- �� aqusi3L2oao Signa ure , f No ary Public
^OxcEOrXNUTA'^r!AUMfiA�MCP �xf�.
Printed Notary Name
My Commission Expires :
Commission Number:
�
i
�
— _ _
STATE OF FLORIDA
COUNTY OF MART N
On this � day of � , 1999, before me
personally appeared HELEN L. ROCCAT as Truste�, p rsonally
known to me or who has presented , ���(p � �Y ( ����_
as identification, the person descri ed in an w� executed the
foregoing instrument, and acknowledged t Trustee e cuted the
same as Trustee ' s free act and deed. , 7
, �l, (fii�
,,,�,,.,, Signatur otary/ Public
r�rh�;; Mpda Grnt !q ("-� /
?r. r MY COMMISSION Y CC5744�IXPIRES � .A.l.� l. �Ij,l��
�•,�,�'a' apuns�,x000 Printed No Name
'?qFro�0.'•''� �onoeorwwrn�rvax/ixsuaauee.irx.
My Commission Expires :
Commission Number:
,
�
COMPETENCY CLAUSE ADDENDUM
IAPPOINTMENT OF PHYSICIANS TO DETERMINE COMPETENCY
%
IfiI, HELEN L. ROCCATI, becomes incompetent, I shall cease
to serve as Trustee, Co-Trustee, Surviving Trustee, or Successor
Trustee, of The HELEN L. ROCCATI Revocable Living Trust, for the
duration of my incompetency, and shall be removed or replaced as
follows . Those persons designated to serve as Co-Trustee or
Successor Trustee (Living Trust) , Guardian of the Person
(Nomination of Guardian of the Person) , and Attorney or Agent
(Durable Power of Attorney for Property Management and Health
Care) under the attached documents in this Estate Plan would be
authorized, appointed, and duly empowered to serve as specified
in each of those documents, respectively, with or without the
approval of any court of competent jurisdiction, for the duration
of my incompetency.
DEFINITION OF INCOMPETENCY
I will be deemed incompetent only when:
1 . The appointed physicians listed below have specified in
writing in the Statement of Expert Evaluation or a
successor document, that I am unable to competently
serve as Trustee under this Trust because of inental
impairment, using the definition of inental incompetency
or incapacity in accordance with Chapter 744 of the
Florida Statutes, which defines as incompetent any
person who is so mentally impaired as a result of
phyaical or mental illness or disability, or
retardation, or as a result of chronic substance abuse,
that such person is incapable of taking proper care of
himself or herself or his or her property or fails to
provide for his or her family or other persons for whom
that person is charged by law to provide, or any person
confined to a penal institution within this State; or
2 . If a court of competent jurisdiction determines that I
am unable to manage the affairs of the Trust .
APPOINTMENT OF PHYSICIANS
I , the undersigned Trustor, hereby appoint the following as
physicians to determine competency or incompetency to care for
myself and to serve as Trustee under this addendum to the Trust,
should the need arise . By the term "physicians, " I am referring
to licensed physicians, licensed psychologists , or licensed
social workers .
_ _ _
2 . Agn� � ca +on o m t„�;nare rnc°mget�nc�c _ Application to
terminate incompetency may be made to a court of
competent jurisdiction, within the jurisdiction of the
situs of the Trust at the time .
SIGNATURE
I hereby sign this document indicating that I have read and
understood its provisions, on this �_ day of February, 1999 .
� � '�� \;;%^ i�l ,�� �
� .r'�,��n�i. �-�, 1;�'� (�`-�G(!�
HELEN L. ROCCATI
� << � � - ����- �
Witness Witne s
STATE OF FLORIDA
COUNTY OF MARTIN
On , 1999, before me, the undersigned, a
Notary Public i a d for said County and State, personally
appeared EN L. RQCCA"I, personally known to me or who has
presented ^ �/ as identification, and whose
name is subscribed o the within instrument and acknowledged that
she did sign the foregoing instrument and that the same is her
free and voluntary act and deed. I further attest that HELEN L.
ROCCATI appears to be of sound mind and not under or subject to
duress, fraud, or undue influence.
IN TESTIMONY W EREO , I have hereunto set my l�and and
of i ial seal at `�- , Florida e (l� da of
° l� , 1999 . ' �
J/
�f ,
,
Signature q �ot Pu lic
Mp�N IIIMR � �
:�`'M� Mr ca,xMSSar��a�ee�exri�s /1
'%'.��: aqus�st�aoo (�, �( �
"'�"��g' °0N0EDT""�n""PN"�,�� printe No� y Name
My Commission Expires :
My Commission Number:
SUMMARY OF ESTATE PLAN
In these documents, different terms are used to define
different capacities, with varying powers, in which you or
designated family members may act . Some of the terms used are :
GRANTOR: The Creator or Maker of the Trust
TRUSTEE: The Administrator or Manager of the Trust
BENEFICIARIES: The People Who Benefit From the Trust :
1) Usually, you will be the beneficiary
during your lifetime.
2) Upon your death, the beneficiaries are
those named in your Trust (i . e. ,
children or siblings) .
PERSONAL
REPRESENTATIVE: The person named as administrator oP your
estate in your Pour-Over Will; used only
if/when assets are omitted from transfer into
the Trust .
TRUST NAME: The HELEN L. ROCCATI Revocable Living Trust dated
, 1999, HELEN L. ROCCATI, Grantor
and Trustee
ORIGINAL GRANTOR: HELEN L. ROCCATI
ORIGINAL TRUSTEE: HELEN L. ROCCATI
SUCCESSOR TRUSTEES UPON YOUR DEATH: '
1) MARIE T. HEGGLIN SS# 158 36 3850
2) TERRY L. HEGGLIN SS# 345 36 7510
BENEFICIARIES OF THE LIVING TRUST: '
During the life of the Grantor: HELEN L. ROCCATI i
Upon the death of Grantor: MARIE T. HEGGLIN
SHIRLEY L. FORTUNA �
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in this first aznendment to revocable deed of hust, and being authorizefl ta do so, acknowledged
tiris instnunant to be the acY and deed o��sch�cr��oratiori.
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Resignation of Trustee
I, Helen L. Roccati, Trustee of the Helen L. Roccati Revocable Deed of Trust, do hereby resign
as Trustee and appoint my successor trustee, Marie T. Hegglin as Trustee for the Helen L.
Roccati Revocable Deed of Trust.
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Helen L. Roccati
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My Commission expires �- i '.^�� �''�,9 J�o��r�,�'`
Acceotance of Annointment
I, Mazie T. Hegglin, successor trustee, do hereby accept appointment as Trustee of the Recovable
Deed of Trust of Helen L. Roccati.
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PERSONAL AND FAMILY DATA
CLIENT DATA: FOR HELEN L. ROCCATI
Name Preferred for Trust : HELEN L. ROCCATI Revocable
Living Trust
Address : 2321 S. W. Monterrey Lane,
Port St . Lucie FL 34953
County: St . Lucie County
Social Security Number: 214 03 8713
Date of Birth: 6/3/18
Place of Birth: Washington, D. C.
PARENTS' DATA:
�Dl E��e_S�Ia[ne Pl a�P �f Ri rth
John W. Crown Maryland
Harriet Crown Maryland
CHILDREN' S DATA:
j33jp� B� rYhdav S.ex
MARIE T. HEGGLIN 7/16/47 F
SHIRLEY L. FORTUNA 4/14/45 F
ALLOCATION OF TRUST ASSETS
Upon the death of the Grantor, and after the debts and other
obligations and provisions of the Trust Estate have been
satisfied and any special distributions and retentions have been
made, the Trustee shall allocate the assets of the Trust as
provided below.
DIVISION INTO SHARES
The Trustee shall first make any special distributions as
set forth below in that subsection entitled Special Distributions
_ _ _ _ _ . _
DECLARATION
OF
RET/OCABLE LIVIN� TRUST
OF
IiSLSN L. ROCCATI
i'his agreement is rnade this 'C -�° day of �-�_,:' � ' , 1999,
'r�=*ween HELEN L. ROCCATI, hereinafter referred to as the
:"��a:�*orfSettlor, and HELEN L. R4CCATI, hereinafter referred to as
'!'rur,*_ee. I, HELEN L. ROCCATI, af St . Lucie County, Florida, as
:�7-�ntor, have conveyed and assignec3 ta myself, as Trustee, the
pr:,�p�.rty described in Schedule "A" attached hereto, and I hereby
de^..Ja:re that I and my successors as Trustee shall hold and
a�.m:'+,r.ister al2 sueh property anc3 all other property at any time
or time thereafter transferred {including, among other things,
any property transferrefl by reason of my death} to the Trustee,
a°�� the proceeds af all such progerty and all investments and
z-.<_-znvestments thereof (sometime hereinafter called the °Trust
�'�.�.ate") , in trust, as follows :
a�umvrr.x�
$'TB7'�TMF,N�' n�'SI'�'T�EN'SHIP APi[� RES�I2EPIC]t
� I hereby cieclare that I am a citizen of the Uniteci States of
'�me�ic�, with my permanent resit3ence and Iegal domicile in the
�i��,j af Port St . Lucie, St. Lucie County, F2orida. My social
�,ec'�ri*�� number is as Eollows: HELEN L. ROCCATI - 214 03 8713 .
Al2.TIC7�E_IZ
_ TSF.CTC:N,'ATTQ�_Q.L .'j'j3Tj.,�^'J,'
Ti�is DeclaraCion and the Trust Estate hereby ereated, as at
any time amended prior to my cleath, sha11 be ]cnown as the HELEN
L. RUCCATI REVOCAHLE LIVING TRIIST dated .�s"��,_' , 1999, and
it sha?' be sufficisnt that it be referred �o as such in any
instr.umEnt af transfer, deed, assignment, bequesC, or device ,
B�TS..CLE _TTT
J3,8MES_BNLZ. AD�G4T.".R
Ia adcYition to tnyself, the following persons are namecl and
referred to in some capacity in this Truet;
1 . MARSE T. HEGQLIN' whose present address is 100?
rIa.r°�isburg Pike, Carlyle, Fa. 17013 .
2 . TERRY L. HEGC3LIN whose present address is 1007
i?a�:�isburg Pike, Carlyle, Pa. 17023 .
3 . SIiIRLTY L. Fp12TUNA whose present address is 840 South
Atlantic, Virginia Beach, Va. 23951 .
�'PTP!T.R ..=y
T7?CT4T pRO�!}y$,",('�'
The Grantar herehy trangfers and flelivers to the Trustee the
property listed in Schedule A annexed hereta, to have and to hold
the same in any cash, securities, other real ancl gersonal
property whieh tha Trustee may pursnant to any of the provisians
hereof at any time therea£ter hold or acquire, all of such
praperty being hereinafter re£erred to as the Trust Estate for
the uses and purposes and upan the terms and conditions herein
set forth.
The Grantor has paid over, assigned, granted, conveyed,
transferred and delivered, and by this Agreement does hereby pay
over, asaign, grant, convey, transfer and deliver unto the
Trustee the property described in Schedule A, annexed hereto and
macie a part hereof, and has caused ar will cause the Trustee to
be designated as beneficiary of thase life insurance policies
describecl in Schedule D, annexed hereto and made a part hereof.
These insurance policies, and any ather insurance policies that
may be delivered to the Trustee hereunder or under which the
Trustee may be designated as beneficiary, the proceeds of al2
sueh po3icies baing payable to the Trustee, and any other
property that may be received or which has been received by the
Trustee hereunder, as invested and reinvested (hereinafter
referred to as the "Trust Estate") , shall be held, administered
and distributed by the Trustee as hereinafter set forth.
Separate property {defined as praperty owned by ane spouse}
of the Grantor transferred to the Trustee, as invested and
reinvested, together with the rents, issues and profits therefrom
(hereinafter referre@ Co as "the separate estate°} shall retain
its character as separate prapsrty of the Grantor who transferred
such property to the Trustee, subject, hawever, ta the provisions
of this Agreement .
The owner of any life insurance policies payable to the
Trustee shall have all rights under any such policies, including
the righC to change the beneficiary, to receive any dividands or
other earnings of such policies without accountability therefor
to the Trustee or any beneficiary hereunder, and may assign any
policies to any lender, including the Trustee, as security far
any loan to the Grantor or any other person; and the Trustee
shall have azo responsibility with respect to any policies, for
the payment af premiums or otherwise, except to hold any palicie� -
received by tha Trustee in safekeeping and to deliver them upon
awner' s written request and upon the payment to �he Trustee af
rfu:�onable compensation for services. The righta of any assignee
of any golicy shall be superior to the rights of the Trustee. If
any policy is surrenflered or if the beneficiary oE any policy is
changed, this trust shall be ravQked with respect to such policy.
Hawsver, no revocation of the trust with respect to any policy,
whether pursuant to the provisions af the preceding �entence or
otherwise, shall be effective unless the surrender or change in
bene£iciary of the policy is accepted by the insurance company.
Upon the death of the insured under any pol9.cy held by or known
to, and payable to, the Trustee, or upan the occurrence af some
event prior to the death of the insured that matures any such
policy, the Trustee, in its discretion, either may collect the
net proceeds and hald them as part of the principal of the Trust
Estate, or may exercise any optional method of settlement
available to it, and the Trustee sha11 deliver any policies on
the Grantor' s life held by it and pa�able to any other
beneficiaries as those beneficiaries may direct . Payment to, and
the receipt of, the Trustee shall be a full discharge of the
liability of any insuranee company, whieh need not take notice of
this agreement or see to the application of any payment. The
Trustee need not engage in litigation to enforce payment of any
policy without indemnification aatisfaetory ta it for any
resulting expenses.
Nothing in this Article shall be construed as limiting the
right of the Grantor ta dispase of by will of her interest in any
life insurance policy on any other person' s life that is payable
to the Trustee hereunder.
ART.T�T?_v
n.nSlL?t}Na ma mRC7ST._EfiTATE
As long as this Agreement remains unrevoked, either the
Grantar or any other person, with the consent of the Trustee, may
add oCher property to the Trust hereby created, by �ransferring
surh property to the TrusCee hereunder by deed, assignment, or
ather instruments of transfer, bequests or devise, and if so
added, such property shall be covered by the provisions hereof,
the same as i£ originally included hereunder.
813TICLF vI
R8V'OCATSC}N OF fi$IIST
6. 01. The Grantor shall have and possess, and hereby
reserve Che following rights and powers to be exercised at any
tirne, and �rom time to time in writing and effective on delivery
to the Trustee hereunder:
a} to revoke this Agraement and any trust establisheci
hereunder in whole or in part, whereupon the Trust Estate or part
thereof affected thereby shall be dis�ributefl as the Grantor
sha11 direct in writing.
b} to change the identity or number, or both, of the
Truetee hereunder;
c} to alter or amend this Agreement in any and every
particular manner germitted by law; and
d) ta withdraw any and all trust property from the
operation of this Agreement .
e) a ganeral power to appoint by will, all or any portion
of this Trust, including principal, undistributed income,
insurance proceeds or szmilar cantracts or benefits, if any,
which may be payable to this Trust or to Trustee by reason of my
death, to such person or persone, including the personal
representative of my estate, outright or in further trust. This
power is limited in that no power is reserved to appaint any part
of this Trust which would not be includable in my gross estate or
would be exempt for federal astate tax purpases_ Ta exercise
this power, my will shall make specific reference to this
subparagraph of this document . If no will exercising this
general powar is made known to my Trustee within 34 days
following my death, my fiduciary shall be fully protected in
relying an the presumption that no such document exists.
'+pn�en�t}�F Tr»g�pg�,p_]�.monr3mant
6 .02 . The Trust may not be altered, madified, revoked,
ar amended to change the abligations, duties, ar rights of the
Trustee without the consent of the Trustee to snch amertdment.
Tr,�s e _Dut;es on�;P •o a +on
6 . 03 . If the entire trust is revoked by the Grantor, the
Trustee shall transfer to the Grantor all of the Trust Sstate and
sha11 execuCe and deliver to the Grantor all instruments
which are necessary or appropriate to release all interest of the
Trustee in the trust .
S*'.��_croc�±.l�y an _D.eath ta£_C�a.^t.flr
5 . 04 . From and a£ter. the cleath of Grantar, the Trust
created hereby shall become irrevocable and shall not kre altered,
amended, revokecl, or terminated.
�Lemp s a
6. 05 . The use and occupancy of any real property hald in
this Trust for the lifetime of the Grantor shall qualify for the
Homesteacl Exemption provided by Florida Statute. In the event
that the Trust Estate property includes the primary residence of
the Grantor, the Grantor shall have the exclueive right to the
use and occupancy of said residencp. Sa long as tha Grantor
oecupies such residence, she shal3 be entitled to the homestead
exemption an such property and the Trustee shall have no
responsibility or liability to maintain such residence, to pay
taxes therean, to pay insuranee thereon, or in any manner be
responsible for the maintenance, preservatian and repair of such
residence . If such residential property is no longez used by the
Grantor for her personal residence, the Trustee may, in its sole
discretion, dispose af the interest in the residence then owned
by the Trust and add the praceeds thereof to the principal of the
Trust ,
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7. 01 . During the lifa of the Grantor, the Trustee shall
pay ta or apply for the benefit of the Grantor in quarterly ar
other convenient installments all of the income from the Trust
Estate unlees otherwise directed by the Grantor.
=nV8810n Qf�'r�ine_�ina� for �z�an .ar .
7 . 02 . The Trustee may pay to ar apply for the benefit af
the Grantor, in addition to the income from the Trust Estate,
such amounts from the prineipal of the Trust Estate, up to the
whale thereof, as the Trustee in its sole and absolute discretian
may from time to time deem neceesary or advisable as the Grantor
may from time to time request or as the Grantor otherwise
clirecCs. Zn Che absence of a �demand by the Grantor, the Truetee
in it� absolute discretion may pay to or apply for Che benefit of
Grantor such amounts from the principai of the Trust Estate up to
the whole as the Trustee cleems necessary or advisable to provide
for the health, maintenance, support and general welfare of the
Grantor.
��nt Dur3.ng� A Per+or� o Tr�f+r_m_itX
7 . 03 . At any time while the Grantor is physically or
mentally unab3e to manac3e the affairs as determined hereunder,
the Succesaor Trustee may use such part of the income and
principal of this Trust a� he �eeme necessary to provide far the
support and mainCenance af the Grantor, including any medical
expenses ar other expenses incurred, and to make gifts out of
trust assets not reasonably required, in the judgment af the
Successor Trustee, for the cantinued support and maintenance of
the Grantor anfl her descendants in connection with estate, gift,
income or other tax planning, accumulati.ng any income not used
current2y ae prineipa]. . The Suecessor Trustee may pay any auch
expenses oE the Grantor directly or make payments to the Grantor
without the intervention crf a guardian. During the period of
such disabi2ity, the Successor Trustee may make purchases or
sales of real and personal. pxoperty without securing the
Grantar' s direction or consent pravided that said purchases and
sales will be usecl solely and comp2etely to provide continued
,
�
support and maintenance for the Grantor during her period af
infirmity. In the evant that the proceeds are not used to
provicle for the Grantar ' s sale anc3 complete continued support and
rnaintenance, then, in that event, the Successor Trustee may not
act without the Grantor's direction or consent . In the event
that treatment and care is needed and necessary, the Successor
Trustee shall utilize the Truet Estate, partially antijor wholly,
to meet the cantinued support and maintenance of the Grantor
during her period of in£irmity. Any purchaser, seller, transfer
agent, or other person dealing with the Successor Trustee may act
on the sole signature and direction of the Successar Trustee and
may conclusively presume that the Successor Trustee ha� the
Grantor' s directian far or consent to a purchase
or sale or that the Grantor' s direction or consent is not thert
necessary.
Provieians for rnnapac;�tv; �.j2@f�,II,'�.t1S1X1A_ Cert fic�tio21
Proaedure.� ??eleaae..D�. Med+ca'i Tnf�±-ma�+on;��n,x3,nued
�hax.itahl��3.via$
7. 04 . If Grantor during any period of time becomes
incapacitated (as that term is fully defined below in this
paragraph) the Successor Trustee of this Trust may, pursuant to
the qualificaCion and terms as set forth in Article 7 . 03, apply
all or any part of the net income or principal af thie trust far
the benefit of Grantor, in such amaunts and in such rnanner as
said Trustee may determine without regarci to other means of
support or financial assistance for the following purposes:
1 . For the support, health, and maintenance of the
previausly accu�tomed manner of living of Grantor.
2 . For the discharge of any obligatinn that, in such
Trustee ' s opinion, is legally enforceable against Grantar, and
3 . For any other purpose or puxposes that the Trustee
believes to be directly beneficial to Grantor.
"Incapacity" is c3efined for purposes of this Trust AgrAement
as existing whenever any Trustee of the Trust comes into
possession af any of the fallowing;
1 . A Court Order, which is judicially praper and
sti11 currently applicable, holding a person to be legally
incapacitated to act in his or her own behalf, or
2 . Duly executed, witnessed and acknowledged written
cer�ificates of two (2} licensed physicians (each of whom
represents that he or she is certified by a recognized medical
board} each certifying that such physician has examined the
Grantor and has concluded Chat, by reason of accident, physical
or mental illness, progressive or intermittent physical or mental
deterioration, or other similar cause, such person had, at the
date thereaf, become incapacitated to act rationally and
prudently in his or her own personal and financial best interest,
ar
3 . Evidenee, whiah eueh Trustee deems to be
creditable and still cuxrently applicable, that Grantor has
disappeared, ie unaccountably absent, or is being detained un8er
fluress where he ar she is unaDle effectively and prudently ta
look after his or her own personal and financial best interest;
Then and in thaC event and under those circumstances:
l . Such person shall be deemed to have thereupon
became "incapacitated" as that term is used in and for all of the
purposes of this instrument, and
2 . Such incapacity shall be deemed to cantinue until
such Court Order, certifiaates, and/or circumstances have beaome
inapplicable ar have been revoked.
Any physician's aforesaid certificate may be revoked by a
similar certificate to the eEfeot that the pereon is na longer
thus incapacitated, executed either (S} by the originally
certifying physician or (ii) by two (2) ather licensed, board
certi�ied physicians .
No Trustee shall he under any duty ta institute any inquiry
into a persan's possible incapacity.
Each pereon who signs this instrument ar an acceptance of
trusteeship hereunder @oes, by so signing, waive all gravisipns
of law relating to disclosure of confidential medical information
insofar as that disclosure would be pertinent to any inquzry made
under this Article and does thereby specifically authorize her
personal attending physician to release all medical records and
information pertaining to the state of her health for and sa2ely
limited to the purposes set forth and described above in thie
paragraph_
Pa�_vment .�,., Cgge �].�.InCag3cit�[
? . 05. In case the income or principal gayment under any
trust created hereunder or any share thereaf sha11 become payable
to a pertion under the age of twenty-one (21) , or ta a person
under legal disability, or to a person not adjudicated
incompetent, but who, by reason ot illness or merttal or physical
disability, is, in the opinion of the Trustee unable properly to
admin3ster such amounts, Chen such amounts shall be paicl out by
the Trustee in such of the following ways as the Trustee deems
best : (1) directly to the beneficiary; (2} to the legally
appointer3 guardian af the beneficiary; {3} to some relative or
friend for the care, support and eflucation of the beneficiar}r;
(4) by the Trustae using such amounts directly far the
beneficiary� s care, support and education.
�,gmTrr.F_V2TS
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x7�12F,.�.SRG o.��MIlY_T.�rB.aTS4AT
8 . 01 . The Last Wi11 of Grantor contains definite
instructions for payment of e�tate and succession taxes including
instructions for the payment of such taxes by the retiemptian of
certain United 6tates Government Bonds, commonly known and
referred to as fiower bonds, for that purpase, and the
instructions as contained in Grantor' s said Last Will are
incorporated in this instrument by reference. Written statements
by the personal representative of the sums ta be paicl hereunder
shall be sufficient evidence of their amount and propriety, and
the Truatee shall be under no duty to see ta the application of
any such payments, ar to question their amount, or their
necessity.
After Grantor' s death, the Trustee sha21 pay from trust
principal, either directly or through the Persona2
Representative, such amounts as the Personal Representative of
the Grantar' s estate shall certify in writing are required ta pay
debts, taxes, and expenses of administration of the Grantor' s
estate . The determination of the Personal Representative of the
Grantor's estate as ta the amount of any payment requis-ecl
hereunder shall be conclueive and binding upan all persons
interested in the trust and the Grantor`s estate and in no event
shall any asset not includable in the Grantor's gross estate be
used to make such payment .
8 . p2 . I direct that the bequests and devises in this
document shall be construed under the rules of construction
relating to devises under a will as found in Florida Statutas,
Part VI of Chapter ?32 and the provisions of Sections ?33 . 805,
733 . 807, 732 . 507, 732 . 801, 731 .201, ?33 . 809, 733 . 812, and
738 . 05 (2} , as amended.
8 . p3 „ I€ an interest described in this Trust terminetes
anfl, after application of the rules of canstruction described
above , no continuing or succeeding interest in that asset. is
provided, it is directed that inCerest shall vest in those
persons who then would be my heirs at law under Part I, Laws af
Intestate Succession of Chapter �31 af the Florida Statutes.
8 . 44 . To the extent thaC an}r estate taxes are payable
from this Trust, all such taxes shall be apportioned amang the
respective interests in this Trust under the provisions of
Floricia Statutes Section 733 . 817 in the same manner as if such
respective inCerests wera devises under a will. To the extent o£
any tax imposed by Chaptar 7.3 of the Internal Revenue Code, that
tax shall be paid ar apportioned among the respective interests
as provided in Section 2603 (b) af the Code.
AR__ '!� ,'T'S.'T:�=,X
DIST�T.3Y!'S"�ON OF TRUST ramAmr ,�mON�.'lE�Ti�
�B.&�TS9S
Upon the death of the Grantar, the Trustee shall divide the
Trust Estate as follows :
1 . g�,�„r;�., a„d ngar_±-��,,,r�,on af T +�+ : Upan the deaCh
of the Grantor, and after the debte anti ather obligations and
provisions of the Trust Estate have been satisfied and any
special distributions and retentions have been made, the }aalance
of the Trust Estate shall be held, managed and distributed as
follows :
a) Sg.ec.tal_.�iatrib�,tis�na: The Trustee shall first
make �the following Special Distributions : ,�:
,�,�-1 tJ C�/' !��
That,, certain note, secured by the Mortgage Deed which is ����;, ��(}
�
held by tkie,, trusC, from TERRY L. AEGGLI�7 and MAItIE T. HEGGLIN, my
san-in-law aisd daughter, shall be forgiven, dischargeci and
satisfied in f�,ll upon the demise of the Grantor.
�.
The Trustee sY�a11 give to my daughter, MATtIE T. NEGGLII�I, the
fallowing parcels a� real property free of any liens, debt�, ��,�yLµ�
martgages, judgements .and creditor claims : r
�
The property l�cated at 2321 S.W. Monterrey Lane, Part
St Lucie, Fl 34953 , legall;y described as: Lot 35, Block 1136,
Port St Lucie, Sectian 9, aecording ta the Plat thereof, recarded
in Plat Book 12 , Pages 39A tArough 39I af the Public Records of
St Lucie County, rl .
The property located a�. Monterrey Lane, Port St Lucie,
Fl 34953 , legally desccibed as : Lot 7, Biock 2136, Port St Z,ucie, +;
Section 9, accarding to the Plat theraof, recarded in Plat Book
12 , Pages 39A thsough 39I of the Public Recards of St Lucie / �
County, Fl . DG�` �"I� '�'"��erJ^{
' t�' .��'"�,�
The Trustee shall give the sum a£ cne`. thousand do3lars � �
t$1 , 000) and fifty (50) of the aha.res of AM�HT3CH stock cahich are
held by the Trustee at the time of death of t'ke Grantor ta each .
of my following grancichildren: ANN MARIL EZANO;",,RC}�ER ANTIi4NY
FORTUNA, AAR023 HEGGLIN, and TROY HEGGLIN. .
,,.
4
b} i2a.Yis9,c�n,_i.zktg._u°har.ea: The Trustee s 11 allocate
the balance af the Trust Estat� inL-a separate shares�s�`otias to
provide ane (1) share fcrr each pars�3n named as a primary��
baneficiary of the Grantor. Each share shall be allocated as
£ollows:
p�±mar�, n n d ;ary_ Sh^�.�e P9:�CErit
MARIE T. HEGGLIN 1 54�
SF3IRLEY L. FdRTUNA 7. 5��
c) IZis.tri,�ssta.�_o_�T.�zs�: Upon the death of the
Grantor, the Trustee shall retain ir� T��ust, or distribute #:he
residual of the Grantor' s estate as hereinaftex specified.
The Trustee shail distribu�e those parts of the estate
allocated ta MARIE T. FILGGS�Z2d and SIiIRI,SY L. F4RTL7NA, outright,
per stirpes, as spon as is reasonable and practicable .
2 . Dis�z.a.blitian to TsS.ltast£.1?�is�ar�Benp�,ciariss. C7pan
the death of a primary beneficiary of. this Trust prior to a
complete distribution hereunfler, the Following inat�°tzctzon� shall
be followeci:
(a) When the oldest living child of the primary
beneficiary reaches the age of twenty-one {21) years, the Trustee
shall divide the Trust assets, for ar_counting purposes, intc as
many equal shares as are equal to r_he number of the children of
the primary beneficiary then living. The Trustee neecl not
physically divide the Trust assets into shares, but c�ay regard
all shares as a single funci for. inve3tment pu-rposes, if it
desires . Hawever, all distrik>utJ.cns cf incame and principal
thereafter shall be made to ene 3�eneficiaries of each share f'rom
his or her respective share .
(}�} As each child of primary beneficiary reaches
thzrty-five {35) years of aqe, or at any time thereafter, the
Trustee shall pay anfl distribute in cash or in kind t.o auch chil3
all remaining undistributed income and di.�tr�bute in cash ar in
kind Go such child al� of the assets of ]�is or her share
remai.zing at the time sucn cYtilc� rea.^hes aye thirty-fi�=e (35l ,
upon aritten re�vest by said child.
f,c? 3� the event tYxa�� a,�. heir (issv.e of a d�ceaser�
primary beneficiary) attends a pcet-sacondary ecucational
institutian, sucYi as a cola.ege, t.znive.r.s.i.ty, or zroc�rional-
technical school, on a full-timc- basi:� !as defined by tkiat
institution) , then that heir shail have ar.cess to part of his ar
her sha.re ta assist with educacianzl and ra�ated 2iving expenses,
such payr�ents to be made rsn a r�gular. basis (at lE=.ast twice r�er
yearj , the amount to be d2ter.mir.ed so2ely in the discretian t��
the Successor Trustee. After. paymenta haJe r_e�sed di�e �ither to
clegree or program completion or lacic af ful].- time enroll�r,ent,
then any portian af tne balance remai�xi.r�cr of said 'neir' s share
sha1l be distributed tc. hin7 or n=r upon �.he attainment of thirty-
tive (35) years of age, a�s set L'crtk, �bove.
(d) Except as �et forth above for issue of deceased
primary beneficiaries, if a share is created for the issue of any
deceased child of the Grantor or deceased primary beneficiary, or
if any child of the Grantor dies before receiving all of the
assete af his or her share leaving issue surviving, such share
shall be dzstributed to such issue, per stirpe�; provided,
however, if assets are distributable to a person who is less than
thirty-five {35) years of age, they shall be retained in TrusC
for the benefit of that person until he ar she attains the age af
thirty-five (35) years, on the following terms:
The Trustee may pay to that minor child such amaunts of
the net income and principal of Chat minar' s trust as the Trustee
may deem necessary for his or her health, support, maintenanee
and educatian, after taking into consideration his or her income
and means of support from other eources . When the minor child
reaches age thirty-five (35) years, the Trustee shall distribute
the Truet to him or her. If he or she dies before reaching
thirty-five {35) years, the Trustee �hall distribute such Trust
ta his ar her estate.
(e) If any child of a primary beneficiary dies befare
receiving all of the assets of his or her share without 3eaving
issue surviving him or her, or if all of his or her issue shall
die befare final distribution of such share, that child' s share
shall be added equally ta the shares o£ the primary beneficiary' s
other children (coixnting as one share the share held Eor the
issue of anather deceased child of the primary beneficiary} , to
be held in Truat if such shares have not been disCributed, or to
be distributed outright if such shares have already been
distributed; or if the primary beneficiary' s other children have
already received final distribution of their shares and are no
langer living or if there be no then living children of a primary
beneficiary, then to the then living issue of the Grantor, per
stirpes .
(f) With xespect to any distribution made hereunder,
the Trustee need nat require the exhaustion of personal resources
as a condition for making disbursements under the authority of
this Article. The judgment of the Trustee as to the propriety
and amount of all such payments shall be conclusive.
However, the Truatee, may, in his or her 8iscretion,
require as a conditian precedent to the distribution of any Trust
asseY_s for support ox advancement, that the beneficiary furnish
eviflence of his ar her financial condition, income, earning
capacity and assets, in form and content saCisfactary ta the
Trustee . The Trustee shall be antitled to rely upon tha written
certification of such beneficiary or the guardian of such
beneficiary as to the nature and extent of such beneficiary' s
need for sixpport, and the inadequacy af sueh beneficiary's
i
resaurces apart from the Trust. The Trustee shall not be
required to make further inquiry as ta the authenticity of the
facts so certified.
(g) Grantor hereby directs that if, at the time of the
distribution af her trust estate, ar any part thereof, there
sha11 be due to Grantor' s estate from any of the beneficiaries
deseribed herein, abligations of any kind, or evidence of debt of
any kind, then such obligation or obligations shall be treated ae
an advancement and shall be dedueted from his or her legacy or
legacies specified hereunder before the payment �hereof shall be
mada b� GranCor' s said personal representativeJtrustee .
{h} ��t�mat� �i,stsibuti�n . Zf the Grantor, all issue
of the Grantar, anfl all other beneficiaries of this Trust shall
die priar to the time aet for final distrzbution of the Trust,
the remaining assete, including accumulated income shall be
distributed in accordance with the Statute of Descent and
Distribution of Flarida in effecC at the time of the death of the
Grantor.
(I) The words °chzldren" and °issue'" used in this
Trust ahall include legally adop�ed children.
(j } aP;,gnr�l Fronertv D�s -r�h � -+on. The Graritor
requests Che Trustee to abide by any memoran@um by the Grantar
directing the disposition of personal and household effects of
every kind including, but not limited ta furniture, appliances,
furnishings, pictures, china, silverwara, glass, books, jewelry,
wearing apgarel, and a11 policies of fire, burglary, property
damage, and other insurance on or in connection with the use of
this property. Otherwise, the personal and household effects of
the Grantor shall be distributed wiCh the remaining assats of the
Trust Estate.
BRmrrr.F�{
Ap�QYNTMENT Q� T12LTaTEE ANTf_$17��R�OR '�`T2i7S.mxx
The nriginal Trustee of Yhis T.rust iN th� Grantar. Grantor
may change the identity or number, or both, or the Trustee during
her lifatime. The pravisiona for the appointment of a Successor
Trustee to serve in place of the Grantar as Trustee are set forth
hereafter in this Article. In the event of my death,
resignation, refusal or inability to serve and act as Trustee,
for whatever reason hereunder, I nominate anci appoint MARIfi T.
FIPsGGL2b1, as Successor Trustee. In the event of the death,
resignation or refusal or inability for whatever reason of NtAl2SE
T. HEG6LIN to act as a Trustee hereunder, I nominate and appoint
TERRY L. HEGGLIN, as Sucesspr Trustee .
Each Trustee serving hereunder shall nat account ta the
Successor and upon aceeptance of the accaunt by the new Trustee
sha11 be relieved of all duties and responsibilities relative ta
his or her perfarmance as Trustee.
nom__ Tnr.�yr_y=
T TFtE P�WFRG A�7'1�_,�',�TF.�
NoCwithstanding any other provisions to the contrary, the
Grantor specifically authorizes the original Trustee, during her
life and while serving as Trustee, ta have the authority to
perform all powers anfl acts as granted under this Declaratian of
Trust, and shall include the right ta contract for and in hehalf
of the Trust, and to execute, negotiate, and compromise such
instruments as may be necessary to carry out the purposes and
intents of this Trust .
Trustee and the Successors shall be gaverned by the
provieipns of Section 737 and Section 738, Florida Statutes, as
amended, not in conflict with this instrument, and sha11 have all
additional powers and responaibilities granted and imposed by
statute to Trustees at the time af application that are not in
conElict with this instrument . In addition, without Iimiting any
common law or statutory authority and without the need to apply
to any court, Trustees shall have the following powers and
responsibilities :
a. To acquire, retain, improve, manage, pratect, invest,
reinvest, exchange, lease, sell or option to sel1, borraw,
mortgage, pledge, tranafer, and convey trust property, real
property, tangible personal property, and intangible personal
property (including without limitation stocks, bonds,
obligations, mortgages, and other securities, and interests in
them) , without regard to any law, court ruling, or ru7.e or
regulation governing fiduciaries in that manner, and on any terms
that Trustees deem advisable, even for terms beyond the expec�ed
term pf any Trust provided for in this instrument; to apen,
maintain, and operate a brokerage account tlncluding a margin
account arid the trading in listed and covared optians) in the
name of the Trust; and to invest, reinvest, hold, and uote as an
asset of the Trust property the capital stock of any eorporate
Trustee of any Trust created by this instrument, and ta invest
and reinvest of any Trust created by this instrument, and to
invest and reinvest that propezty in the common funcis of said
carporate Trustee .
b. To employ counsel, accountants, or ather agents ta
handle Trust business and to pay reasonable amount for those
services .
c. To invasC and reinvest in stocks, band, options, trade
on margin, any real, personal ar mixed prcrperty whethar or not
ineame-producing, deemed by the Txustee to be for the best
interest of the Trust arttl the beneficiaries hereuncler, without
being limited to Trust inveetments provided by law, and
notwithstanding that the same may constitute leaseholds, royalty
interests, patents, interests in minea, oil and gas wells, or
timber lands, or other wasting assets, or may consist in whole or
in part of unregistered or unlieted sacurities, or may cansist af
life insurance policies, with or without a cash surrender value.
d. To accept from anyone a contribution ta the principal
of any Trust provided for in this instrument .
e. To pay the expenses that in ite judgment is reasonable
for the delivery af all gifts and distributians_
f. Ta charge or credit to principal any premiums and
discounts on interest-bearing securities purchased at more or
less than par.
g. To disclaim a power that it considers to be burdensome,
unnecessary, or unwise.
h. To make distribution of principal distributahle to a
donee who is a minor at the time of distribution to the custadian
for that minor under the Florida Uniform Transfers to Minar Act;
and if there be na custodian, to appaint a custodian (who may he
one of the Trustees) .
I . The distributions of the Trust Estate need not be
satisfied by distribution of undivided shares in assets, provided
that each of those distributions sha11 be of equal vaiue.
Tnstead, the value of a share to be distributed and any pecuniary
gifts may be partially or wholly satisfied in cash or in kind ar
by both, and diatributions in kind may be entire praperty ar
undivided shares of property.
j . With regard to all policies of life insurance that are
payable to Trustees :
(1) to execute and deliver receipts and other
instruments and take such actian as may be apprapriate to obtain
poseession and control of the policies; and
(2) to execute and file proofs of claim required to
collect the proceeds of insurance policies. The receipt of
Trustee shall consti�uCe full acquittance to insurance campanies
for all proceeds so paid. Trustee shall, however, be under no
obligation to institute legal proceedings for the calleetion or
proceeds of any poliay until it has been indemnified ta its
satisfaction for al1 costs and expenses, ineluding attorneys '
feea .
k. To purchase assets from ar sell assets ta the Persanal
Representatives of Grantor�s private estate, or the Personal
Representatives of the probate estate of Grantor or any member pf
Grantor' s family, but prices paid or recaived shall be the
approximate fair market value at the time af the transaction anfl
the assets purchased sha11 be proper investments for the Trust
Estate.
i
l . When any act or caurse of conduct is subject to a
contingency under the terms of this instrument, Trustee may act
or continue a caurse of conduct as if the contingency has not
occurred until it receiveg actual notice af the event contro3ling
the contingency. This provision shall not ralieve a person
receiving an otherwise improper distribution from liability for
return af the distribution nor affect the duty of Trustee to
recover the distribution, if in its judgment it shau2d do so.
m. To be disoharged and released of alI ftzrther Iiability
for all truet properties following distribution to beneficiaries
pursuant to express authority provided for elsewhere in this
instrument.
n. Ta set aside and keep on hand whatever reserves Trustee
fleems wise for anticipated expenses, including reasonable
compensation for the services of professionals and amount held in
reserve to pravide for fluctuatiane in gross amount .
o. To hold unproductive assets that are part of the trust
property when Grantor dies and ta pay fram incame the costs of
holding that property, excep� as may be atherwise pravided far in
this instrument .
p. To purchase and to maintain Chrough the payment af
premiums life insurance insuring any member of Grantor's family.
Tha� insurance may be of any kind and any amaunt determined
appropriated by Trustee, after considering the trixst funds
available and objectives of each Trust and o£ each beneficiary.
q. To elect and use all applicable provisions of the Cade
for federal estate, gift, and income tax gurposas to effect the
lowest tax liability to the Trust Estate and its Yseneficieries,
to extend the time for payment of those taxes, and ta make or
join with any other �axpayer in effecting Che eleetions permitted
by Code .
r. Notwithstanding any ather provisions af this instrument
to the contrary, if any part of �he Trust E�tate consists of
bands redeemable at par and accrued interest to date af payment
for the purpose of payment of federal estate taxes, then up to
the amount of those taxes and to the extent of the par value of
the bond, Trustes shall pay those taxes with those bonds.
s . If at any time in the judgment of trustee the value of
the principal held in any Trust created undar this instrument
does not warrant the continuance af the Trust under the economic
circumstances then existing, Trustea is authorized and empowered
to terminate that Trus� and to distribute its assets to the
beneficiary or benaficiaries trs wham income may he diatributed
immediately beEore termination; and the assets sha11 be
distributed in the proportions in which the beneficiaries are
eligible to receive distribution of income if made.
t . To convert unproductive or nonproductive assets into
productive or liquid assets when deemed absalutely necessary to
meet and fulfill the intent to adequately maintain the welfare of
beneficiaries.
u. To lease any real estate held hereunder for any term
notwithstanding the duration af thie Trust .
v. To enforce any bonds, martgages, or other obligatians
ar liens held in the Trus�; to enCer upon such contracts and
agreements and to make such compramise or settlement of debts,
claims or controversies arieing therefrom, including the
compromise of any claim asserted by or against the Government of
the United States or any state or any political subdivision
thereof for or on accaunt o£ any tax, as in its so2e discretion
deems necessary or advisable.
w. To consent to the organization, consalidation, mergers,
liquidation, readjuatment of, or other change in any corporation,
company, or association, or to the sale or lease of the property
thereof or of any part thereof, any of the securities or oCher
property of which may at the time be held in the Trust, and to do
any act nr exercise any pawer with referenae thereto that may be
].egally exercised by any person owning similar property in his
own right, including the exercise of options, deposit or exehange
of securities, entrance into voting Trusts, and entering into
agreements or subscriptions which it may deem necessary or
advisable in connectian therewith.
x. To vote in persan or by praxy any shares of stoek hald
in the Trust .
y. To enter into installmant sale agreemente or annuity
contracts or deferred compensation agreements for eecurities or
other property as may be deemed appropriate for the trust fund,
and to issue installment notes or other appropriate items on
behalf of the Trust in payment of said agreement . Annuities
hereunder shall include private annuities w3th individuals and
Trustees af other Trusts .
z. To compromise, adjust, settle, or submit to arbitratian
any claims in favor of or against the Trust .
aa. To use nominee registration of Trust assets, wherever
appropriate .
bb. To allocate any shares of stock qualifying for
favorable tax treatment in a redemption under Section 303 of the
Internal Revenue Code to beneficia'ries of shares of this Trust
bearing the burden of qualifying 'taxes and costs.
cc. Ta continue the operation af any busaness until sueh
time as the Trustee deems the time for sale of same ta be masY
advantageaus to trust estate.
dd. Ta lend funds to the Grantor' s generai estate upon such
terms and conditions as to interest rates, maturities, and
security as the Grantox' s personal representative and the Trustee
shall agree, the fact that they may be the same in no way
affecting the validity of thie provision.
ee. Ta combine assets of two or more trusts if the
provisions and terme of each trust are substanCielly identical,
and to administer them as a single trust, if the Trustee
reasonably determines that the administration as a szngle trust
is consistent with Che Grantor' s intent, and facilitates the
trust ' s administration without defeating or impairing the
interests of the beneficiaries.
ff. Tn divide any trust into separate share or separate
trusts or ta create separate trusts if the Trustee reasonably
deems it appropriate and the division or creation is consis�ent
with the Grantor ' s intent, and facilitates the trust ' s
administration without defeating or impairing the interests of
the beneficiaries.
gg, To divide property in any trust being helfl hereunder
with an inclueion ratio, as defined in section 2642 {a) (1) of the
Internal Revenue Code of 1986, as from time to time amended or
nnder similar future legislatian, of neither one nor zero into
two separat� trusts representing two fractional shares of the
property being divided, one to have an inclusion ratio of one and
the other ta have an inclusion ratio of zero, ta create trusts ta
receive property with an inclusian ratio o£ either one or zero
and if this cannot be done ta refuse ta accept praperty which
daes not have a matching inclusion ratio ta the recaiving trust ' s
ratio, all as the Trustee in iCs sale discretion deems best .
hh. If the Trustee shall act as the Personal Reprasentative
of the Grantor' s estate, to elect to allocate any partion or all
oE the Grantor' s generation-skipping transfer exemption provided
far in Code Section 263i, or under similar future legislation in
eEfect at the time of the Grantor`s death, to any pqrtian or any
other trusts or bequests in the Grantor' s Wi11 or any other
transfer which the Grantar is the transferor for purposes of the
generation skipping tax. Cenerally, the Grantor anticipates that
the Grantar' s Persanal Representative wi1l elect Ca allocate this
exemption first to direct skip� as defined in Code Section 2612,
and to make the special election under Section 2652 (a} t3} of the
Cade Co the extent the Grantar' s Persanal Representative deems in
the best interesC af the Grantor's estate.
ii . To hold any securities or other property in its own
name as Trustee, in its awn name, in the name of a nominee (with
or without disclosure af any fiduciary relationship} or in bearer
form.
jj . To subdivide, develop, or dedicate real property to
public use or to make or obtain the vacation of plats and adjust
boundaries, to adjust differences in valuation an exchange or
partition by giving or receiving consideratian, and to deflicate
I
easementa to public use without cansideration.
kk. To inaure the assets of the Trust Estate against damage
or lass and the Trustee against liability with respect to third
persons.
11 , To borrow money and to encumber, mortgage or pledge any
asset of the Trust Estate for a term within or extending beyanfl
the term of the trust, in connection with the exercise of any
gower vested in the Trustee .
mm. To purchase property, real or personal, £rom the
Grantor' s general estate upon such terms and conditions as ta
price and terms of payment as the Grantor' s personal
representative and the Trustee sha11 agree, to hold Che praperty
so purchased as a par� of the Trust Estate although z.t may not
qualify as an authorized trust investment except far this
prcavision, and to dispoee of such property as and when the
Trustee shall deem advisable. The fact that the Grantar' s
gersonal representative and the Trustee ara the same shall in no
way affect the validity of this provision.
nn. To make any decisions which the agent may, in his or
her own discretion, determine are appropriate to qualify the
principal far Medicaic?, including a power to divest the principa3
of aseets, to convert assets from non-exempt to exempt assets,
anc3 to change the damicile of the princigal to another state
where the Medicaid eligibility rules are mare £avarable.
oo. To authorize the agent, when acting as agent of this
Trust, to make gifts to the principal, and to those persons named
in the principal 's will, and to arrange for �ransfers of jointiy
held property to the attorney-in-fact, and ta the name of those
persons menCipned in the principal ' s will, and when ea aeting, ta
authorize such "self-dealing" with assets, give my full approval
and do not prohibit any self-dealing.
pp. Ta authorize the Trustee, ahauld he ar she serve as
Trustee, to use this Trust to transfer my family hame to his or
her sole ownership . To further authorize him or her, should he
or she eerve as Trustee, to usa separate assets, othar than the
home itself, to provide cash to pay down the martgage to an
extent nece�sary, in his or her sole judgment, ta ma}ce the
monthly payment on the mortgage manageable for his or her income
alone . To further authorize this self-dealing and, effectively,
the authority to make a gift from the respective grantar ta the
agent , so that he or she can preserve the family home in the
event grantor is severely 8isabled.
qq. To act on my behalf in dealing with my pensian and
retirement plans, including the power ta maka 3RA contributions,
SRA roil avers, voluntary contributiona, borrow from any
retirement plan, e2ect or select pay aut options, and take any
other steps which might be taken on my own behalf with regard ta
I�I�� �
my retirement and/or IRAJpension plans, including changing the
ownership or beneficiary designations on such accounts, plans
andfor annuities and waiving non-employee spousal rights .
rr. To convert joint assets into sole ownership of the
other joint tenanC, and alsa to liquidate any jointly held assets
and to direct the investment holder to make the check to
liquidate the distribution to the benefit of only ane of the
joint owners.
ss . To appoint a epecial agent for the purpose of carrying
out transactions which would otherwiae, with regard to the named
agent, be self-dealing or result in a transfer for the benefit of
the agent, the agent ' e creditors, or the agent ' s estate, with
limited authority as follows: to transfer any home in which
grantor has an interest to the attorney-in-fact and to such of my
children (the agent or to such of those persons named in my will}
as the special agent may select in his or her sole discretion,
and to make gifts of my property to the attorney-in-fact ar my
children as the special agent rnay aelect .
tt . To appoint a special agent, for the purpose of carrying
out transfers which might benefit the agent, the agent ' s
creditors or Che agent ' s estate; I specifically authorize such
transfers by a special agent . I authorize transfers of my home
anrl other property by the special agent Co meml�ars of the
following claes o£ beneficiaries : the banefzciaries named in my
will andjor Revocable Trust .
nsrmrnT.R XTT
j}T[�'R4T j7T(!p,mT(}bI
The Grantor has canfidence in the investments in which she
has been ar will be depositing hereunder and no change need be
made by the Trustee in these investments solely for the purpose
of creating a diversity in investments , The Trustee sha11 be
authorized to sell or atherwise dispasa af sueh investments, if
and to the extent tha Trustee deems such sale ar dispasition to
be in the best interest of the Tru�t Estate, without being
constrained to do so.
namr •C�'�.XT_?I.
mn�74T�'S R�,?�NA'�?bN
A. Any Trustee may resign hy written notice setting foxth
the effective date hereof, delivered persanally, ar sent by
registerecl or certified mail, return receipt requestec3, at least
twenty (20} days priar ta such effective clate, to the living
benef3.ciaries to or far wham ineome may currently be paid or
��1 I
used, or their duly appointed guardians, addressed to the last
known aclriress of each such person as disclosed by the Trustee ' s
records.
B. Any sole Trustee, within twenty {20} days after the
effective date of resignation, shall deliver personally or by
registered or certified mail, return receipt requested, to the
Successor Trustee and to each such beneficiary, a statement from
the date of the last accounCing of the Trustee to the effective
date of resignation together with an inventory of Che assets
belonging to each Trust at the effective data or resignation.
Any Trustee resigning shall in timely manner maka any transfers,
assignments, ar conveyances necessary to vest title in and ta the
assets of the Tru�t Estate in the Succeseor TrusCee.
C. When the Successor Trustee shall deliver a receipt for
the assets of each af the Trusts to the Trustee so resigning, the
latter shall stand and be discharged of all its duties and
abligations hereunder.
D. The Successar Trustee shall be vested with all powers
of the original Trustee.
au�rrr+r, r.�gry
'1,'$jjRTF.F.�R AOND�'_ �FS'Pi'�N'4T�j.�$'�j'S.f�'$,
A. No Truatee or Successor Trustee eerving hereunder shall
be required to give any bond or securiCy for the faithful
performance of duties as such Trustee.
B. Na Trustee shall be liable for any errar of judgment or
for any lass resulting from the exercise of any discretionary
power herein conferred in connection with administering the Trust
Estate, and any Trustee shall be fuily proteeted in any action or
inaction hereunder taken in good faith, including without
limitation action or inaction an the advice of counsel {including
any firm af which any Trustee may be a member or employee} .
C. In any contract or ather obligation macte by the Trustee
on behalf of any Trust created hereunder, such Trustee may, and
is hereby authorized to, stipulaCe and provide against personal
liability on such contract or obligatian, and the rights created
under and by virtue of such contract shall belong ta the Trust
for which it is made and the obligation under any by virtue of
such contract shall be the obligation of sueh Trust .
i7. The Trustee may freely act under all ar any of the
powers by this agreement given to a.t in all matters cancerning
the Trust hereby established, after forming its jadgment laasecl
upon all the circumstances of any partieular situation as to the
wisest anci best aourse to pursue without the necessity af
obtaining the consent or permissian af any persan interested
therein, or the consent ar approval of any caurt, and notwith-
. 1
standing that iC may also be acting as Trustee o£ ather Trusts,
or as agent for other peraons, entities, or corporations
interested in the same matters, or may be interested in
connection with the same matters as stockholder, director,
officer, partner, joint venturer, or otherwise; and the gifts
made in this Trust have been eo made in contemplation of such
freedom af judgment and action.
E. In the event that any party serving as Truetee
hereunder is diequalified by the laws of any state frorn holding
title to ar dealing in any manner with any aeset (whether real,
personal ar mixed) of the Trust Estate, then the other party
serving as Trustee shall have the power to hold title to said
asset, as Trustee, without the disqualified Trustee, and deal in
any manner with said assets, as TrusCee, without the concurrence
of the disqualified Trustee. Subject to the express terms
contained in the trust, if the Trustee so disqualified is the
sole Trustee, the Trustee shall have the power ta designaCe any
party as Successor Trustee for the purpose of holding title ta
said asset, as Trustee, without the disqualified Trustee and
flealing in any manner with said assets, as Trustee without the
cancurrence o£ the disqualified Trustee. The term, "dealing in
any manner" or "deal in any manner" encompass using any power
conferred upon tha Trustee hereunder {subject to any 2imitations
on such powers} with respect ta assets of the Trust Estata.
F. The fact that individuals are serving as trustees
hereunder shall not prevent any af them from purchasing all or
any portion of the assets af the Trust Estate, which shall at any
time constitute any part of this Truet . The aforesaid Trustee
shall in no way be prohibited, individually ar jointly, ar in any
other capacity, fram, direatly or indirectly, purchasing any
assets that sha11 at any time be a part of the Trust Estate. The
preceding provisions of this paragraph e�ress the Grantor' s
wishes and shall not be contxoverted or corttravanact hy any
�tatute or rule or law ta the contrary.
G. No person dealing with the Trustee shali be obligated
ta see to the application af any monies, securitias or other
property paid or delivered to him or to inquire into the
expediency or propriety of any transaction or the authority or
the Trustee to enter into and consvmmata the same upon auch terms
as it may deem advisable.
ARTICLE XV
,�M7NTfiTRAT=pj,.7 �j7D '�NQTRjTG"�',T_�'
15 . 01 . The use of heading and of gendsr references in
this Trust instrument is merely for convenience and sha11 have no
legal effect . Whenever the context sa requires, the plural shall
�..__
Tntent of Gr�n�o.r_8�3g3s3'luu� - �T�_stXi,b1� -�o�tlf.?±BS.ets I
15. 16 . The Grantor, HELEN L. ROCCATI, declares she has
carefully considered the distributions that have been directed in
this Trust Agreement and acknowledge that she has taken into
consideration all individuals, including both relaCives and non-
relatives, that have been named as beneficiaries of this Trust
Agreement.
The Grantor further declares that it is her desire and
intent that the provisions of this Trust Agreement are to remain
confidential as ta all parties . The GranCor directs that only the
information cancerning the benefits paid to any particular
beneficiary shall be revealed to such individual and that no
individual shall have the right to informatian concerning the
benefits paid to any other beneficiary.
In the event that any named beneficiary or other inctividual
who is not specifically named shall contest any aspect af tizis
Trust or attempt to set aside, nullify, ar voict the Trust or the
distribution thereof in any way, then notwithstanding any other
indication in this Trust to the contrary, Che Grantor directs
that such rights of such person shall be ascertained as it would
have been determined had that person predeceased the execution af
this instrument without living issue. In the event that any
court of law determines that any individual who is either a
beneficiary or who is not named as beneficiary shali have the
right to any intereet in the Trust Estate, other than as
apecified in this Trust Agreement, the Grantar directs that such
individual shall be given a nominal amaunt only, not to exceed
one and no/lOp dollars ($1 . 00} .
�Ys1t1SSPman}a
15 . 17 . The Trustee has the right to reduce a
beneficiary' s share by any gifts or loans ae known in "3ahedule
B. " The Tru�tee ahall make any gift or Zoan to a beneficiary or
potential beneficiary as directed by the Grantor{s) and the
Trustee shall , upon the direction of the Grantor (s} , reduce such
beneficiary' s share by the amount of any gift or un-repaid loan
as shown in "Sctisdule 8. "
Tni-.an}in�_ to Avpy.{j_gx,g��,g
15 . 18 . St i.s the intentican of the Grantor to avoid
probate thraugh the use of thie Trust Agreement . If, however the
Trustee (s) of this Trust and the Personal Representativets} of
the estate of the Gran�or shall mutually determina that it �hall
be in the best interests of the beneficiarias of the Trust, and
the beneficial interests of tha beneficiaries shall not hereby be
altered, the Trustee(s) may subject any asset ta probate to
accamplish a result unavailable without probate {ex. : to bar
include the singular and vice versa.
A. If any pravision or conditian af this TrusC agreement
shall be determined ta be invalid or void £or any reason, such
determinatian shall not af£ect the validity af any other
provision of condition.
B. The Trustee may construe this instrument, and any
action taken in reliance upon such construction shall fully
protect the Trustee even though it may be subsequently determined
that such canstruction is erroneous.
?3,i�+-if+nt±ons to �iALOr.g_3nd Others �n��,1,ea�al D� a�t'� � v
15 . 02 . In making distributions from tt�e Trust to or for
the benefit of any rninor or other persan under a legal
disability, the Successor Trustee need not require tha
appointment of a guardian, but shall be authorized to pay or
cleliver tkte same to the custodian of such. person, including a
custodian far such persora under the Flarida Uniform Transfers ta
Minor Act, with the power to select any persan or entity to act
as such custodian twho may be the Personal Representative of Che
Grantor' s estate or the Successor Trustee} , to pay or fleliver tha
same to such person with4ut the intervenCion of a guardian, to
pay or deliver the same to a legal guardian of sueh persan if ane
has already been appointed, or to the same for the benefit of
such person.
8nnointinn_ $and and '{y�,�$��yEntH,_t,p-_$R,Zif9fir�ar_w
15 . 03 . The Trustee andJor Succes�or Trustee shall nt�t be
required to file an inventory, accaunting or other returns or
reports to any court or to give bond irt any jurisdiction in which
such requirements may be waived by the terms af this Agreement,
but shall fixrnish a formal statement of receipts and
disbursements and accounting at least annually to each persan
then entiCled to incoma from any Truet .
Divisioa_�^d D#strabut;an in�Lind
15 . 04 . In the distribution of the Trust and the division
inta separate Trust.s and shares, the Sucressar Trustee shall be
authorized to make the distribution ant3 division in money ar in
kind or both, regardless af the basis for income tax purposes of
any property distributed or divided in kind, and the distribution
or division made and the values es�ablished by the Successor
Trustee shall be binding and conclusive on a11 persons taking
h�reunder. In making snch distribution or divisian, the
Successor Trustee may allocate undividecl interast in the same
property to several Trusts or �hares.
ASlocatian ���cp�. a++d EYnenses
15 . 05 . Except as otherwise providad herein, all receipts
af money or property paid or delivered to the Trustee and/or
Succeasor Trustee and a31 expenses shall be allacated ta
principal or income in accorclance with the laws of the State of
n��i
Florida; pravicied, however, that with regard to any iCem not
governer3 by such laws, the Trustee andfor Successor Trustee shall
have discretion to determine whether items ehould be charget3 or
credited to income or principal or allocated between inecame and
principal as the Trustee andJor Successor Trustee may deem
equitable and just under a11 tha circumstances.
Notwithstanding anything ta the contrary eontained herei.n,
any benefits received by ar payable ta the TrusCee andfor
Successor Trustee hereunder from pension, prafit sharing,
re�irement, or ather full benefit plan of which the Grantor is a
member shall not be paid, used ar applied to any indebtedness of
the Grantor at the time of her rieath ar otherwise expendefl for
the flirect or indirect benefit af the Grantor' s probate estate or
the creditors. SpeciPically, and without limitation, such
benefits shall be used for the payment of expenses af
aclministratian af the Grantor's estate, federal andJor estate and
inheritance taxes.
$nendthri�t Provisian
15. 06. The interest of any beneficiary in any Trust
created herein shall not be transferred, assigned or canveyed and
shall not be subjec� to the claims of any creditars af such
beneficiary, and the Successor Trustee shall conCinue
dzstributing 1'rust property directly ta or for the benefit of
such beneficiary as pravided for herein natwithstanding any
transfer, assignmenC or conveyance, or actian be creditors. If
the Successor Trustee is prevented by any transfer, aseignment or
conveyance, or by any praceeding braught by any creditor, ar by
any bankruptcy, receivership or other groceer3ing, fram
distributing property directly to or far the benefit of any
beneficiary, the Suceessor Trustee shall hold and accumulate the
property which would have been distributed until the Successor
Trustee is able to distribute such property directly to or far
the benefit o£ such beneficiazy ar until the death of such
beneficiary, whichever first accurs; ancl an the deatY� of such
beneficiary any such property so held and accumulated sha11
become part of the principal af Che Truat anc3 shall be disposed
of as provided for the princigal .
T.ax�:lea.t.i�oas
lS . d7 . t3nle�s otherwise expressly directed hereunder, the
Trustee and/or Successor Trustee shall be authorized ta make any
election or allocation permitted by any tax Iaw, if in the
opininn of the Trustee andfor Successor Trustee such election or
allacation is for the combined best interest of the estate and
the berzeficiaries thereaf, and shall be authorized to maice, or
fail to make, such atijustment between the parties or the several
devises or accaunts as the Truatee andfar Successar Trustee may
deem equitable and just uncler all tha circumstances.
,�,�D��'7f^� -i86
15 . 08 . Anything herein to the contrary noCwithetanding,
the Trust created herein shall terminate not later than twenty-
one {21) years after the death of the Grantor, and all
beneficiaries hereunder living at the date this Trust Agreement
is �igned, and if any Trust created herein has not sooner
terminated, the Trustee at said time shall pay over, convey and
dela.ver �he remaining Trust assets then in its possessian in
equal shares to the persons then entitled ta receive the income
therefrom.
TSX..."�' ea mpn�__of lzeve�cabls._."_�raxita���s�
15 . 09. For income tax purposea, the Trust shall be
treated as a revocable °Grantor Trust" pursuant tq IRC Sectian
676 . All items of income anci expense relatec2 to the assets af
this Declaratian of Trust or ite operation shall be reported by
the Grantor as if owned by her individually on the Grantor' s
conventianal 1040 tax return.
�ge O'�__'�'I'7l9't. TdE'�y�,'��_?S� �On Ni?mhPr
15 . Z0 . As long as the Gzantor is living, this etxtire
Trust is revocable. The Grantor shall use her Social Security
number as the Trust Identi£ication Number(s) ; HELEN L, ROCCATI -
224 03 8713 .
tTpon the death af Grantor, the entire Trust becomes
irrevocable by its terms and as�ets retainecl in Trust should be
identified by using the IRS Employer ldentificatian Number
When part, or a11, of the Trust become irrevocable, a Form
1041 tax return, or appropriate alternative form, as specified by
IRS ragulations, shall he filed annually for income ancl expen�es
relating to assets retained in the irrevocable part of Lhe Trust .
All ather income and expenses will be reported on the Grantor' s
Form 1440 tax return.
Char .er' (y_f__ PrQnerty_tt_,i1s'.1'a_a_��CI
25 . 11. During the life �f the Grantor, any property
transferrad to this Trust �hall retain its ariginal character
and, in the event of revocation, the Trustee shall distribute
such property to the Grantar based on the same property right�
she had prior to transfer to the Trust . Any and all gifts made
by the Trustee (:�) of Trust assete shall constitute a surrender by
the Grantar as to such property.
gri�,na7 _mr,ist��
15 . 12 . The original Trustee under this DecZaration of
Trust sha11 be HELEN L. ROCCAT2, to serve with all the
obligatiozz, powers and authority contained within this Trust
Agreement .
],)yggp�pi a+-ann_Q o£ dYantor
_._—. �
15 . 13 . In the event that the Grantor shauld disappear,
the Grantor nominates and appaints the persan(s) named as
Successor Trustee (s) to sarve as Trustee hereunder during her
abgence, managing this Trust until Che Grantor reappears and is
competent to resume management of this Trust. During her
� absence, the Successor Trustee is to ensure the wel€are of any
minor or handicapped child-beneficiary as part of the rnanagement
of �his TrusC . If Grantor is still miesing after two years, even
if the missing Grantor' s body is noC faund, then a11 tha assets
in the Trust are to be distributed as provided in Allocatian aad
Distribution af Trust Assets.
Rpe�?„rinn af Canf7.;,r . an „yjt;n�,.�,ar,�„g�
15. 14 . Any controversy between the TrusCee or Trustees
anci any other Trustee or Trustees, or between any other parties
to this Trust, including beneficiaries, involving the
construction or applicaCion oE any of the terms, provisions, or
conclitions of this Trust sha11, on the written request of either
or any disagreeing party served on the other or athers, be
submittecl to arbitration. The parties to such arbi�ratian shall
each appoint ane pezson to hear and determine the dispute and, if
they are unable �o agree, then the Cwo persons so chosen shall
select a third impartial arbitrator whose decision shall be final
anfl canclusive upan both parties. The cost of arbitration ehall
be born by the lasing party or in sueh praportion as the
arbitrator{s} shall decide . Such arbitrations shall comply with
the commercial Arbitration Rules of the American Arbitration
Association, 146 West 51st Street, New York, New York 10200.
Furthermore, the Grantor clesires that this 2rust, the Trust
Estate anfl the TrusC adcninistrators and beneficiaries shall not
be involved in time-consuming and costly litigatian concerning
the function af this Trust and disbursement of the assets.
Additionally, the Grantor has taken great care to designate,
thraugh the provisions af this 'Trust, haw she wants the Trust
Estate distributed. Therefare, i£ a benefir.iary, or a
representative of a beneficiary, or one claiming a beneficial
interest in the Trust Estate, shauld legally challenge this
TrusC, its provisions or asset distributions, then all assets to
aaid challenging beneficiary shall be retained in Trust and
distributed to the remaining bensficiaries herein named, as if
said challenging beneficiary and his ar her issue h.as predeceased
the distribution of the Trust Estate.
The defense of such litigation, including costs incurred by
representatives of the Grantor} s estate, the Trustee af this
Trust and their agenCs, attarneys, accountants and represantative
shall be paid Eor by the Trust.
�t�IliD nryr_Qf C.ranto�
15 . 15 . The Gzantor hereby declares Chat she may, by
separate addendums to this Agreement, designate or appoinC two
(Z) of the following persans, from one ar more categories listefl
below, who shall be authorized and empawered to examine, evaluate
and determine the campetency of the appointing Grantor or Trustee
of this Agreement :
�} Licensed Qhysician;
�} Licensed Psychologist;
�} Licensed Social Worker;
d) Mental Retardation Team.
Thase appointed from the abave categoriea, hereinafter
referred collectively as "physicians, "' shall be authorized and
empowered to conEirm in writing, in the Statement af Expert
Evaluation or a successor document, the competency or
incampateney af the appointing Grantor or Trustee as defined by
Fiorida Chapter 744 et al ar a successar cade. Their jaint
decision shall be binding upon the Grantor, Trustee and
Beneficiaries of this Trust.
If a Grantor hae not named two physicians of her choice by
separate addendum, or if one ar both of the physicians namad are
unable ar unwilling to serve, the Grantar hereby authorizes his
or her "Agent" appointed under her Durable Pawer of Attarney for
Healthcare, to name one or both physicians, ae appropriate, to
determine her competency in accardance with the faregoing
provisions.
If a Grantor or Trustee who has been declared incompetenC
because of inental impairment (caused by physical ar mental
illness or disability, mental retardation, ar chronie subsCance
abuse) , by two (2) physicians, shauld recover and feel capable of
taking proper care af himself or herself and the Tru�t estate,
that Grantar or Trustee may have his or her competency restared
by one of the following procedures :
l . �onf; rma_�inn �f �omn�t�n�� - Competency may be
canfirmed in writing by the two (2) physicians
listed in the Competenoy Clause Addendvm, or by
any twa physiciane appointed at the sole
discretian of the other Go-Trustee or Suecessoz
Trustee or in the alternative by two (2)
physicians appointed by the Grantar�s °Agent° in
said Grantor' s Durable Power of Attorney for
Healthcare; or
2 . $giliC�rion to T�rmina p Tn�mm�P �n � -
Application to terminate incampetency may be made
ta a court of competent jurisdiction, within the
jurisdiction af the situs of the Truet at that
time .
i
I
future creditor claims) .
Convevance o�,�p,�zt,�+J Contr�rt of Grantor
15 . 19. In consideration of the provisions made within
this Trust Agreement for each Grantbr by the other, the Grantor
agrees and binde herself, her personal representatives, heirs and
assigns as follaws:
1 . ThaC by the executian of this Trust document, the
Grantor hereby conveys to herself, as Trustee, all
that unregistered personal property of every type
owned by her.
2 . That any additional personal property, whether
received by purchase, gift, inheritance or
otherwise, shall pass without further action on
the part of either Grantor or Trustea into the
Truet and shall be held by Trustee, ar Trustee ' s
succeasor, in the Trustee ' s capaoity as Trustee.
3 . Ta receive, as a Trustee for this Trust, any af
the Grantor' s jointly owned property or insurance
proceeds (excluding any installment annuity-type
benefits or any tax deferred payments which are
"rolled over" or tax deferred lump sum payments
which are "rolled over"} ,
$253'� Praviaions
15. 20 . Additionally, i� any stock transferred ta this
Trust quali£ies as S-Corporation Stock pursuant to Internal
Revenue Code 5ection 1361, said stack shall be allacated into a
separate share, known as the QSST share, and shall be managed
according tcr the following provision:
1 . During the life of the transferor of said stock,
the sole beneficiary of. the QSST share sha11 be
the transferor of said stock.
2 . Any income or corpus of the QSST share shall be
distributed only ta the transferor.
3 . The transferor' s right ta receive ancome from the
4SST share shall termiraate upon the earlier of the
transferor's deaCh or the �ermination af this
Trust .
4 . Zf the Trust terminates during the life o€ the
transferor, the QSST share shall distribute all of
its assets ta the transferor.
I
5 . Upon the death of the transferor, the QSST share
shall merge with the residue of this Trust .
3t is the Grantor' s intention that the provisions of this
Trust in general, and thie section in particular, establish a
contract between the Grantor, to convey to the Trustee, (and
successor trustee? , all of the Grantor' s property, whether now
owneci or later acquired.
'bRTTf'T.E XV2
]'.TARTT,TT�.�i'QR p�(!T$' bF R •DE •''-'� tJR T$u '�TEES"
No Successor Truetee qualifying hereunder shall be obligated
to explain the accounting books and records af any prior Trustes;
nor shall any Successar Trustee be liable for any act of
misfeasance, malfeasance or nonfeasance of a preflecessor Trustee.
It is fixrther specifically agreed that any such Successar Trustee
snall be respansible solely anfl only for trust assets coming inta
the possession (actual or constructive) af such Trustee and far
its fiduciary actions only from and after the time sueh Succesaor
Trustee qualifies to aerve as such and actual3y commences
administration of the Trust Estate.
88TI.CLE_.}�SZZI
DEF'[ 2�_TION$
Whenever used in this Agreement, unless the context requires
o�herwise:
a) The term "pereonal representative" includes executor,
executrix, exacutrices, executare and administrator,
administratxix, administrators and administratrices, with or
without the Will annex as well as their eubstitute and
successars .
b) The t�rrn "Trustae" m�ans the szngular or multip7.e
Trustees appointed herein, as well ae their substituta and
successars.
c) The terrn "net income" shall include net income after
the payment of a11 trust administration expenses, trustees ' fees
and taxes other than beneficiary income taxes .
d) The term "issue" sha11 be limiCed to lawful issue and
shall include both descendants and person� cancaived hut nat yet
barn, including adopted chiidren or persons.
e} The term "medical care" as usec3 herein shall include
institutional care, special treatment or training, nursing
assistance and medication.
f) The term "support" shall inclncie {but not be limited
to) the expenses of the last illness, funeral and burial of a
FINAL INSTRUCTIONS
To: NEW AND SVCCESSOR TRUSTEES
The death or serious incapacity af a Trustar is a traumatic
event. Dealing with the event, your awn feelings, and those af
your family can result in overlaoked detail� and additianal
confusion.
If you are alone, telephone a friend who can spend the next
few haurs with you. Shock and trauma can take unaxpected forms.
Familiarize yourself with Che pracedures on the following
pages. The Living Trust Estate Plan has been designed to
minimize and avoid the trauma of probate. Nonetheless, following
a death or incapacity, there are significant decisions that need
to be made. Accordingly, this section is designed to assist in
making thase decisions, and to help you get through the details
as easily as possible.
The sugge�tions are general, and shou3d be adapted ta yaur
particular situation through con£erences with your family and
legal anfl financial advisors. See the following pages title
"What To Da Upon Incompeteney of Trustor° or "What Ta Do Upan
Death of Trustar" far the information that has been placed there.
Also, in the event of the Trustor' s death, see the pagee which
the Trustor has campleted stating personal wishes for the funeral
or memorial service, etc.
If the Trustor is incapacitated, be aware af the
significance af the DURABLE PO�PER OF ATTORNEY FOR HEALTH CARE and
LIVING WSLL so that the wishes for the Trustor are followed, and
timely health care C72C131pXk3 can he macle.
I,ocate the Trustor� s important papers and refer ta the
information filed under the various tabs far the listing of
papers, records and advisors.
The Memorandum of Desired Distribution of Personal Property
can be of immeasurable value in precluding family disharmony.
Many children, with the best of intentions, and even though in
sorrow following tha death of a parenC, squabble aver personal
effects and who should receive them.
C,flMMONWEAITM OF PENNSYiVANiA 4EV_1162 EX(11.96)
pEPARTMENT OF FEVENUE
BUAEAU OF INOIVi6UAtTAXES
4HT.280fi01
HARflISBURG,PA 17128�Ofi01
PENh18YlVANlH
RECEiVED FROM: tNHER1TANGE AND ESTATE TAX
OFFICIAI. RECEIPT
�a. co o� 7��s
HEGGLIN MAR1E T
1007 NARRISBURG P{KR
CAR�ISLE, PA 17013
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
.."_"__ mm "_"'"_" "'__'..
13136398 1 $7p5.68
ES7ATE INFORMATION: ssN: zia-os-s�i3 f
FILE NUMBER: 2113-(7664 �
DECEpENT NAME: ROCCATf HELEN L �
DATE O� PAYMENT: 4?8/C?5/2013 �
POSTMARK DATE: 08/05/2013 (
couNrv: CUMBERLAND �
DATE OF DEATtf: 05f 3Q/2C?7 3 �
�
TOTAL AMOUNT PAtD: $705.8$
REMARKS:
CHECK# 7129
iNITIALS: CJ
sEa� RECEIVED BY; GLENDA FlaRNEfi STRASBAUGH
REGISTER OF WILLS
TAXPAVER