Loading...
HomeMy WebLinkAbout09-17-13 (2) 1505610140 REV-1500 Ex (02-11)(FI' OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN 1 2 1 3 0 1 8 1 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MNIDDYYYY Date of Birth MMDDYYYY 1 2 2 5 2 0 1 2 0 5 3 0 1 9 3 3 Decedent's Last Name Suffix Decedent's First Name MI G I B S 0 N J 0 H N R (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ❑X 1.Original Return 2.Supplemental Return 3. Remainder Return(Date of Death Prior to 12-13-82) 4.Limited Estate 4a. Future Interest Compromise(date of El 5. Federal Estate Tax Return Required death after 12-12-82) QX 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 0 8.Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) F1 9. Litigation Proceeds Received 10.Spousal Poverty Credit(Date of Death ❑ 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number S E T H T - N 0 S E B E Y 7 1 2 4w 3-3� 1 c rn C-> Rt9IS7ER OF WILLS USEONL 7 rnv � ,� First Line of Address r— z rn __J ) (! 3 p = 711 7 -n 1 0 E A S T H I G H S T R E E T ° o 'f n -,.1 Second Line of Address O O n I CP � City or Post Office State ZIP Code D DATE FI d C A R L I S L E P A 1 7 0 1 3 Correspondent's e-mail address: SMOSEBEYC&MARTSONLAW.COM Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERMSE PO I FOR FILI RETURN Yr ADDRESS 1000 GOODYEAR ROAD GARDNERS PA 17324 SIGNATUITOF PREPARER OTHER HAN REP SENTATIVE DATE 11 ADDRESS 10 EAST HIGH STREET CARLISLE PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 1505610240 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: J O H N R - G I B S O N RECAPITULATION 1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . .. . . . . . . . . .. .. . . . . . . . . . . . 1. 2 5 0 0 0 . 0 0 2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .. . . 2. 1 0 5 . 6 9 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . . . . . 3. 4. Mortgages and Notes Receivable(Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). . .. . .. 5. 2 9 6 1 3 . 7 9 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. 8 6 4 . 2 2 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested . . . . . . . 7. 0 . 0 0 8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 5 5 5 8 3 . 7 0 9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9. 2 0 0 0 6 . 9 4 10. Debts of Decedent,Mortgage Liabilities, and Liens(Schedule 1) . . . . . . . . . . . . . 10. 2 5 6 3 3 . 2 9 11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . 11. 4 5 6 4 0 . 2 3 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 9 9 4 3 . 4 7 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . .. . . . . . .. . . . .. . . . . . . . 13. 14. Net Value Subject to Tax(Line 12 minus Line 13) . . . .. . . . . . . . . . . . . . . . . . 14. 9 9 4 3 . 4 7 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)x.0 _ 0 . 0 0 15. 0 . 0 0 16. Amount of Line 14 taxable at lineal rate x .045 9 9 4 3 . 4 7 16. 4 4 7 . 4 6 17. Amount of Line 14 taxable at sibling rate X.12 0 . 0 0 17. 0 . 0 0 18. Amount of Line 14 taxable at collateral rate X.15 0 . 0 0 18. 0 . 0 0 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . 19. 4 4 7 . 4 6 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑ Side 2 1505610240 1505610240 J REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: 12 13 0181 DECEDENT'S NAME JOHN R. GIBSON STREETADDRESS 425 CHESTNUT STREET,APT.2 CITY STATE ZIP MT. HOLLY SPRINGS PA 17065 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 447.46 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 0.00 3. Interest (3) 4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 447.46 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred ...................................................................... ❑ X❑ b. retain the right to designate who shall use the property transferred or its income ............................... ❑ I] c. retain a reversionary interest ..................................................................................................... ❑ (] d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ N 2. If death occurred after December 12,1982,did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ❑ 0 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ......... ❑ ❑X 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation?.................................................................................................. ❑ 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent or a stepparent of the child is 0 percent 172 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedents 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)].A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REV-1502 EX-(12.12) pennsylvania SCHEDULE A DEPARTMENT OF REVENUE REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: JOHN R.GIBSON 12 13 0181 All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a Copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. Real estate located at 327 North Baltimore Avenue,Mt.Holly Springs Borough, 25,000.00 Mt. Holly Springs,Cumberland County, PA,known as Tax Parcel No.23-32-2336-056,being described in Deed dated March 12, 1976 and recorded in Cumberland County, PA, Deedbook C27,Page 321,being conveyed to John R. Gibson and Shirley M.Gibson,husband and wife. Shirley M. Gibson died on November 1,2008 leaving title solely vested in John R.Gibson. See attached Settlement Statement. TOTAL(Also enter on Line 1,Recapitulation.) $ 25 000.00 If more space is needed,use additional sheets of paper of the same size. REV-1503 EX+(e-12) pennsylvania SCHEDULE B DEPARTMENT OF REVENUE INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER JOHN R.GIBSON 12 13 0181 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 1.822233 shares,Carlisle Companies,Inc., CUSIP 142339100 105.69 See attached. TOTAL(Also enter on Line 2,Recapitulation) $ 105.69 If more space is needed,insert additional sheets of the same size REV-1508 EX+(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: JOHN R. GIBSON 12 13 0181 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 1994 Skyline mobile home 12,000.00 See attached Settlement Sheet. 2. 2002 Chevrolet sedan 1,500.00 3. Comcast-refund 157.04 4. Highmark-refund 241.40 5. FirstEnergy-refund 217.97 6. Express Scripts-refund 10.00 7. U.S. Treasury-2012 income tax refund 207.00 S. Pennsylvania Treasury -2012 income tax refund 11.00 9. County tax proration -property located at 327 N.Baltimore Avenue 222.33 10. School tax proration-property located at 327 N.Baltimore Avenue 767.06 IL Lot rent proration -property located at 11 Northview Drive 27.39 12. Tax proration-property located at 11 Northview Drive 88.42 13. Westem&Southern Life, Annuity Contract No. W0020879221;Beneficiary: Shirley Gibson, 14,164.18 deceased. Payable to Estate 14. Bankers Life and Casualty Company;Beneficiary: Shirley Gibson, deceased 0.00 Payable to Estate($5,196.72) TOTAL(Also enter on Line 5,Recapitulation) $ 29 613.79 If more space is needed, use additional sheets of paper of the same size. REV-1509 EX+(01-10) pennsylvania SCHEDULE F DEPARTMENT OF REVENUE ,JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: JOHN R. GIBSON 12 13 0181 If an asset was made jointly owned within one year of the decedent's date of death,it must be reported on Schedule G. SURVIVING JOINT TENANTS)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. STEVEN A. GIBSON 75 BONNYBROOK ROAD,LOT 16 SON CARLISLE,PA 17013 s. DAVID L. GIBSON 5316 OXFORD CIRCLE,APT. 14 SON MECHANICSBURG,PA 17055 C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FORJOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENTS VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'SINTEREST 1. A.M. 8/31/94 M&T Bank,checking account no. 1195522 2,592.67 33.3333 864.22 See attached. TOTAL(Also enter on Line 6,Recapitulation) $ 864.22 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX-(10-09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER JOHN R.GIBSON 12 13 0181 Decedent's debts must be reported on Schedule t. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERALEXPENSES: 1. Ewing Brothers Funeral Home,Inc. 8,204.82 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Cathy J. Murtorff 2,745.00 Street Address 1000 Goodyear Road City Gardners State PA ZIP 17324 Years)Commission Paid: 2014 2. Attorney Fees: Martson Law Offices 3,516.00 3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: Register of Wills,Cumberland County 198.50 6 Accountant Fees: 6. Tax Return Preparer Fees: 7. The Sentinel-legal advertising 200.16 8, Cumberland Law Journal- legal advertising 75.00 9. Stock evaluation report 1.55 10. Comcast-final bill 130.87 11. North View Manor Management,LLC-lot rent for February(11 Northview Drive) 383.50 12. Heller's Gas,Inc. -property located at 11 Northview Drive 332.49 13. Met-Ed-property located at 425 Chestnut Street 140.31 14. PPL-property located at 11 Northview Drive 64.87 15. Real estate commission-property located at 11 Northview Drive 3,000.00 16. Water and sewer- final bill for property located at 11 Northview Drive 101.11 17. 2013 County taxes-property located at 11 Northview Drive 57.88 18. Water inspection-property located at 11 Northview Drive 125.00 TOTAL(Also enter on Line 9,Recapitulation) $ 20 006.94 If more space is needed,use additional sheets of paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent JOHN R. GIBSON 12 13 0181 Decedent's Name Page 1 File Number Schedule H - Funeral Expenses &Administrative Costs-67. ITEM NUMBER DESCRIPTION AMOUNT 19. Transfer taxes-property located at 327 N.Baltimore Avenue 250.00 20. Barbara Boise,2013 county taxes-property located at 327 N.Baltimore Avenue 409.88 21. Postage 25.00 22. Register of Wills-additional probate 45.00 SUBTOTAL SCHEDULE H-137 729.88 REV-1512 EX,(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER JOHN R.GIBSON 12 13 0189 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. M&T Bank, installment loan account no. 12044446888934998 22,858.72 See attached. 2. GE Capital Retail Bank Lowe's Consumer, account no. ************2001 -account payable 2,366.73 3. PPL-account payable for property at 11 Northview Drive 43.56 4. Met-Ed-account payable for property at 425 Chestnut Street 251.21 5. William J.Phelan,M.D. -account payable 20.00 6. Walnut Bottom Radiology-account payable 10.00 7. North Middleton Authority-account payable for property at 11 Northview Drive 83.07 TOTAL(Also enter on Line 10,Recapitulation) $ 25 633.29 If more space is needed,insert additional sheets of the same size. REV-1513 EX.(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: JOHN R. GIBSON 12 13 0181 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE 1 TAXABLE DISTRIBUTIONS [Include ou�tr�'qghtspousaldistributions and transfers under Sec.91i6(a)(1.2).1 1. Richard E. Gibson Lineal 1,643.00 75 Bonnybrook Road,Lot 33 115 of residue Carlisle,PA 17013 2. Harry L. Gibson Lineal 1,643.00 75 Bonnybrook Road,Lot 33 115 of residue Carlisle,PA 17013 3. David L. Gibson Lineal 864.22 5316 Oxford Circle,Apt. 14 1/3 of Sch.F,Item 1 Mechanicsburg, PA 17055 4. David L.Gibson Lineal 1,643.01 5316 Oxford Circle,Apt. 14 115 of residue Mechanicsburg,PA 17055 5. Steven A. Gibson Lineal 864.22 75 Bonnybrook Road,Lot 16 1/3 of Sch. F,Item 1 Carlisle,PA 17013 6. Steven A.Gibson Lineal 1,643.01 75 Bonnybrook Road,Lot 16 115 of residue Carlisle,PA 17013 7. Cathy J.Murtorff Lineal 1,643.01 1000 Goodyear Road 115 of residue Gardners,PA 17324 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE, II. NON-TAXABLE DISTRIBUTIONS: A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART Il-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size. FFILMS ATAFILEMLM10161,hwill LAST WILL AND TESTAMENT OF JOHN R GIBSON I,JOHN R. GIBSON, a legal resident of the Borough of Mount Holly Springs, Cumberland County, Pennsylvania, being of sound and disposing mind, memory, and understanding, do hereby make, publish, and declare this as and for my Last Will and Testament, hereby revoking all other wills and codicils heretofore made by me. FIRST: I direct that all my just debts and funeral expenses, including my grave marker, shall be paid from the assets of my estate as soon as practicable after my decease. SECOND: I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my estate. THIRD: I devise and bequeath the residue of my estate, of every nature and wherever situate, to my wife, SHIRLEY M. GIBSON,provided she shall survive me by thirty (30) days. Should my wife, SHIRLEY M. GIBSON, predecease me or die on or before the thirtieth day following my death, I devise and bequeath the residue of my estate, of every nature and wherever situate,to my children, equally, provided that the share of any child who predeceases me or dies on or before the thirtieth day following my death shall be added to the share or shares for my other children and shall not be devised per stirpes. FOURTH: I nominate, constitute and appoint my wife, SHIRLEY M. GIBSON, Executrix, of this, my Last Will and Testament. In the event of the renunciation, death, resignation, or inability to act for any reason whatsoever of the said SHIRLEY M. GIBSON, I nominate, constitute, and appoint my daughter, CATHY J. GIBSON, Executrix, of this, my Last Will and Testament. I hereby relieve my Executrix or her successor from the necessity of posting security in connection with their duties as such in any jurisdiction in which they may be called upon to act, insofar as I am able by law so to do. IN WITNESS WHEREOF, I have hereunto set my hand rrd seal to this, my Last Will and Testament, consisting of one typewritten page, this_4Z day of aT oBEl� 2000. nn ee (SEAL) John R. Gibson, Testator Signed, sealed, published, and declared by the above-named Testator, John R. Gibson, as and for his Last Will and Testament, in the presence of us,who, at his request, in his sight and presence, and in the sight and presence of each other, have hereunto subscribed our names as witnesses. ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA ) SS. COUNTY OF CUMBERLAND ) I, John R. Gibson, Testator,whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn or affirmed to and acknowledged before me by John R. Gibson, the Testator, this l 7 k' day of 2000. ''- Te tator, John R. Gibson Notary Public NOTARIAL SEAL CORRINE L.MYERS, Notary Public Carlisle Boro.Cumberland Counry My Commission Ex wes May 27,2b03 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ) SS. COUNTY OF CUMBERLAND ) We, Edward L. Schorpp and �YY�a r Ci a 7 .r+. the witnesses whose names are signed to the attached or foregoing instrument, be >g duly qualified according to law, do depose and say that we were present and saw Testator sign and execute the instrument as his Last Will; that John R. Gibson signed willingly and that he executed it as his free and voluntary act for the purpose therein expressed; that each of us in the hearing and sight of the Testator signed the Will as witnesses; and that to the best of our knowledge the Testator was at that time eighteen or more years of age, of sound mind, and under no constraint or undue influence. n Sworn or affirmed and subscribed to before me by Edward L. Schorpp and�1'1Arai l 4044 v witnesses, this I`I'I^ day of 0�?A-1�.h� 2000. (SEAL) Witness, Edward L. Schorpp C � (SEAL) Witn ss (SEAL) Notary Public NOTARIAL SEAL YER C arjjs a MC umS, I I Publ c arlise Boro,Cumberland�ounty�5 !en Expires Ma 27,2 003 OPrint This Page OMB Approval No.2502-0285 M111 ; A. Settlement Statement (HUD-1) 1.U FRA 2,O RHS 1©Conv.Unlns. B. FOO Number. 7. Loan Number. 8. Mortgage Insurance Case Number: 20134 4,Q VA S.C3 raw-Ins, C.Nate: This torte is furnished to give you a statement of KWai settlement costs.Amounts paid to and by the settlement agent am shown.Items marked'(p.o.cJ•Mm paid outside the dosing(hey are shown hem for Informational purposes and are not Included In the totals. D.Name d Address of Sonaver: E.Name 8 Address of Seller. F. Name 8 Address of Lender. Christian 0,Kurtz Estate of John R.Gibson NIA Deanna C.Jotmmn-Shughart Cathy J.Murtatf 255 Old State Road 327 N.Baltimore Avenue Gardners,PA 17324 MI Holy Springs,Pa 17065 G,Property Locat H-Settlement Agent: 1. Settlement Date: 327 N.Baltimore Avenue Jarquelm M.Varney.Esquke 8x17113 MI.Holly Springs,PA 17DSS Plana of Settlement: 44 South Hanover Street Carlisle,Pa 17013 100.Groan Amount Due from Bonowar 400.Greta_Amount Due re Seller - 101.Contract sets$price 25000.00 401.Contract seise price 25000.00 102.Personal ro A 402.Personal property 103.Settlement charges to bnnmver 7a 1400 793.00 403. 104, 404. 105, 405. Adjustment for Rams paid by astier In advance Adjustments for hems paid by seller In advance 108.Chylloval texas to tm 406,Cityrfaven taxes to 107.Countyburet, 8+17113 to 12131113 409AW, 222.33 407.Counrytexes 8117113h,12131113 409,11W 222.33 108.Assessmente to 408.Assessments to 109. 409. 110. 410. M. 411, 112.2012113 SUaci tue 1 534,13 split 787.08 412.2012173 school tare 1 534.13 787.08 120.Groan Amours Due from Borrower '} " 28 782.39 420.Groan Amount DUO to Senor 1 25 989.39 200,Amounts Paid by or In Behalf of Bortowsr-- 800.ReducBpns in Amount Due to Setter 201.Deposit W oamast money 2500.00 SOH.Excess deposit fees instructions 2,503.00 202.Principal amount of new bans 502.Settlement chances to saber Olne U00 984.88 203.Existbna loanial taken suciect to 503.EAStin bens taken Subject to 204. 504.Payoff of first morgage banMBT Bank 22 108.81 205. 505.Payoff of Second mortgage ban 208: 508. 207.Payments made to seller Sales Agreement 3 887.13 507.PaynneraS made to sager Sales Agreement 3,887.13 208. $08. 209. 509. Ad uetmante for Items unpaid Salter Ad ustment$fW Roma unpaid by seller M.CI Arum taxes 10 lyr, $to.Ci /t wn taxes to lyr 211,County taxes to 511.Cou ntv nixes to 212 Assessments (0 512.Assessments l0 tw 213. 513. 2U, 514. M. 515. 210, 519. 217. 517. 218. 518. 219. Sig. r 220.Total Paid b RW eonowar 6387.13 520.Total Reduction Amount Due Seller i 29 178.82 300.Cash at Settlement fromh,Bonovnr 800.Cash at Settlement Whom Setter 30L Gross amount due tram borrower One 120 . 29.782.39 801.Gross emm,m due to seller 9o, 25989.39 302.Less artaunts Ran bwrewer We 220 8 387.13 802.Less reductions in amount due eager Me 5201 29 178.82 303,Cash ®From To Bomswaf 20,385.29 603.Cash ®From 0 To Seller 3,189,43 The Public Reporting Burden for this collection of information is estimated at$5 minutes per response for collecting, revWM g,and reporting the data.This agency may not collect this information,and you are not required to complete this form,unless it displays a currently valid OMB control number.No confidentially is assured;this disclosure is mandatory.This is designed to provide the parties to a RESPA covered transaction with information during the Settlement process. Eck A "ZAem 3� POT Registered To:Jacques"M.Verray,Esquire FDT b Copyrighl 02004.2010 w A&FonnSopni Previous editions am obsolete Page 1 of 3 HUD-1 ®Print This Page L.Settlement Charges 100.Total Real Estate Broker Fen PeW From. PeW Frorti DMSIOn of commission nne 700 as fonows: Borrwrefa S@We 701.5 to Fund e et a 'A Funds at 702.9 to Satnamenls Sedkmerd, 703.Commission paid at aeelee ent 0. 704.UstIng Aigeel Eemesf Money Retention 705. BOO.Items Payable In Connection with Loan 801.Our origination charge from GFE s1 802.Your credit or Charge is for the speciflc Interest rate chosen horn GFE 02 803.Your adjusted orlaination charges from GFE A 804.Appraisal fee to from GFE Ill 805.Cwt report to from GFE B3 808.Tax service to from GFE 03 607.Fioed ceri0cetion horn GFE e3 808. 809. 812-. 812. 813. 900.Items Required b Lender to Be Paid in Advance .�- .r .n.•" . 901AWlyinteresichorgesfrare l0 9 I hen GFq#1 902.Mort me insumace ium for months to from GF 903.homeowners insurance for Years to from GF 904. 905. 1000.Reserves De sited with Lender - 1001.Inmlel deposft for your escrow account from GFE 0 9 1002.Homed es Imurerce months®9 /mo. 1003.Mcwtqa,e Insurance months a It /roc. 10D4,Propeft taxes mordhs a 9 /coo. 7005. months®It /Mo. 1006. months S /coo. 1007. morons®9 /coo. 1008.Aggregate Adjuster m 1100.Ti0e Charges 1101.TB1e swAws and lenders etle Insurance - horn GFE 04 471. 1102.Settlement or dosieg fee to Jacqueline M.Verny,Esquire 400.00 1103.Owner's tide Insuranoe Penn Anon OBTI from GFE 05 1104.Lenders title Insurance Penn Aftornys OBTI 1105.LerKler'slittepoicylimit 90.00 1106.OVmere role poky Ilmh $0.00 1107.Agerd'aportloeof the total idle Insurance Pearalure to • 1108.Undeivaitera of iM total title Insurence mmlum to Perm Attormys T Ins. 1109.Coon 8 Company T81e Search 71.00 1110.Vakeft F.Gsee Notary foe 1111. 1112.CPL to Penn Ahorne s OB Me Insumnc9 1113. 1114. 1200.Govemmenl Recording and Transfer Charges - 1201.Govemmem moorcift rim es - - from GFE a 72. 1202.Deed 72.00 Mortgage Releases 1203.Trersder taxes from GFE a8 250.00 250. 1204.C1 /Count tax/Marep Deed Mortgage 1205.Some tayMareps Deed MWgage 1206. 1207. 1208. 130O.AdditionlSoMoreentCharge, - - - 1301.Required services that you car,shop for from GFE N6 1302. 1303. 1304. 1305. 1306.ON mall for payoff to Jacquellee M.Verwy, EsquIre 25.00 1307.SarbamBoiwkftHoDyTmCoHeaor2Ol3CorrwpTues 408.88 1400.Total Settlement Charges(enter on lines 103,Sectlon J and 502,Section K) 793. 684.88 FDT Registered To:Jacqueline M.Vemey,Esquire FDT Is Copyright O 2004-2010 w AbFanns.com Previous editions are obsolete Page 2 of 3 HUD-1 OPnnt This Page ADDENDUM TO HUD-1 SETTLEMENT STATEMENT CERTIFICATION OF BUYER AND SELLER I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief,it Is a true and accurate statement of all receipts and disbursements made on my account or by me In this transaction. I further certify that I have received a completed copy of pages 1,2,and 3 of this HUD-1 Settlement Statement� Christian D.Kunz ,/ ,� BuyerfBorrower Cathy J.Munoril, eaulz,Esl John Gibson, Seller Deanna C.Johnson-Shughert V BuyedBOrraer Seger euyertsorrower Seger BuyerrBOnower Seger WARNING:It is a crime to knowingly make false statements to the United States on this or any other similar forth. Penalties upon conviction can include a fine and Imprisonment. For details see:Title 18 U.S.Code Section 1001 and Section 1010 The HUD-1 Settlement Statement which I have prepared is a true and accurate account of this transaction. I have caused or will cause the funds to be disbursed In accordance'w in this statement, rl • Y�—.�—�E, 6 -17-13 Ja uellne M.Vemey,Esquim Settlement Agent Date WARNING:It is a crime to knowingly make false statements to the United States on this or any other similar form. Penalties upon conviction can Include a fine or imprisonment. For deails see:Title 18 U.S.Code Section 1001 and Section 1010 FDT Registered To:Jacqueline M.Verney,Esquire FDT is Copyright 0 20042010 wvnv.AO.Fonns.ocm Previous editions are obsolete zzzzxcma HUD-1 Estate Valuation Date of Death: 12/25/2012 Estate of: John R. Gibson Valuation Date: 12/25/2012 Account: Carlisle Companies, Inc. Processing Date: 04/25/2013 Report Type: Date of Death Number of Securities: 1 File ID: 10161.1.gibson Shares Security Mean and/or Div and Int Security or Par Description Nigh/Ask Low/Bid Adjustments Accruals Value 1) 1.822233 CARLISLE COS INC (142339100) COM New York Stock Exchange 12/24/2012 58.56000 57.10000 H/L 12/26/2012 58.48000 57.85250 H/L 57.998125 105.69 Total Value: $105.69 Total Accrual: $0.00 Total: $105.69 Page 1 This report was produced with Estateval, a product of Estate Valuations S Pricing Systems, Inc. If you have questions, please contact EVP Systems at (818) 313-6300 or www.evpsys.com. (Revision 7.3.1) eo' SETTLEMENTSTATEMENT late SELLERS:&-r,47 E._cFL0n✓ ListU �11.scN=CArH�//JHATCPFE• .C.L' BUYERS:,a.,,,, L--TACKER— ..__._ ---._—.— loMf /JP5 SE t LRS TRANSACfION SALE PRICE: S—a p2a-'eio LESS Payoff LESS Commission -_, Coo•AO _ . LESS F/AU AIATGA f4!C A LESS 2or3 c/r rAZ LESS wA reA rrny LESS LESS LESS _ (-) � 3 a93•s9 PLUS Proration of lAt Rent _ Z73g__ PLUS Proration of Taxes BA.yg_ (4) _/!5•Rl Lfn DUE TO/FROM SELLERS S_ " � a _o.:j1 —02 ........................................................................................... BUYERS TRANSACTION SALE PRICK: S 147600.00 Title Transfer Fe: ' a a•5o Insurance__Years ?U•C• Closing Peas Proration of[All Rent Proration of Tuxes School/7YUfy'9 Coumy30n •YZ5!Y Other Other Other__ SUBTOTAL ;d�'8.3 LESS Deposit Received -c• LESS Amount Financed 0-04 TOTAL CREDITS Fpo•E30 DUE TO/FROM BUYERS $—L4`"-"J ........................................................................................... DISBURSEMENTS �_—T,,,e���.<•_To_G�[A1+raa�y�31��easa�t/� 3,oc>o.m �•���� Fr.,G T-KnMOW44.f_TN+�SZdGKTS L�ro. .3.TO.GCS JAa y/..u�SEY'^'•T A✓q.•.. M1ao.aPSVNl�urseoWj� !o/.1! 6-7.a2 �xosccn!_To_Esa7�o . �A?_(.�r:4SnR? _�8.3/•82 11)AZIA ..nip>ip�l-SA�_ C--/��G/LFil /a.5�•GL^� FymiF. cr ivwR / n✓ B .fl/ Ll /7• d////Lr�/,t J e . Annuity Operations Western & Southern Life Po Box 2916 Cincinnati,OH 45201-2916 A member of Western&Southern Financial Group toll free 600.926.1702 fax 513.629.1799 Date: 0514612013 MARTSON LAW OFFICES ATTN MELISSA SCHOLLY 10 EAST HIGH ST CARLISLE PA 17013 Re: Contract Number W0020879221 Dear Ms. Scholly: Please accept our condolences on the death of John Gibson. We are here to serve you during this difficult time. As a designated beneficiary, Shirley Gibson is entitled to receive payment on the Western-Southern Life annuity referenced above. Payment of benefits under the contract is the obligation of, and is guaranteed by,Western-Southern Life Assurance Company, Cincinnati, Ohio. The following settlement options are available to you: • Lump sum. You can receive your settlement in one installment. Any earnings on this contract may be subject to tax. Westem-Southem Life encourages you to seek tax or legal advice before selecting this option. i If you choose this option, Western-Southern Life will automatically establish a Premier Account in your name. This interest-bearing account provides you immediate, convenient access to your proceeds. See the enclosed brochure for full details. Please sign the enclosed Account Authorization form and return it with the claim form. • Lump sum. You can receive your settlement in one installment. Any earnings on this contract may be subject to tax. Westem-Southem Life encourages you to seek tax or legal advice before selecting this option. If you choose this option, a check for the entire amount, including any interest, will be mailed directly to you. • Income payments. • income payments. You can receive a stream of guaranteed income payments. if you choose this option, a variety of options are available. Some guarantee you an income for as long as you live, others spread your distribution out over the number of years that you choose. You must select this option within 1 year of the annuitant's death. Payments from qualified annuity contracts will be taxable when you begin receiving payments. If you select this option, please complete the enclosed Election of Annuity Income Form in addition to the claim form to specify the terms of your payments. • Continue the required minimum distribution.You can continue to receive the IRS-mandated annual distribution that was already being paid from this contract. The contract value will continue to grow tax-deferre(((d while distributions are stretched out Westem-Southem Life Assurance Company /_ y, ` -T--ptn -1 ( 1 -0 �4) as long as the distribution method allows. Additional information will be provided if you select this option. + Continue the contract. if you are the spouse of the deceased, you can change the contract ownership and keep it in force. The contract will continue to grow tax- deferred at a guaranteed interest rate. Withdrawals do not stop the tax deferral growth. Date of-death value !"j4, The enclosed claim form is for your use in selecting a settlement option. Please return your completed form, along with an original certified death certificate, using the postage-paid envelope provided. Our goal is to serve your needs and we will implement your selection as quickly as possible. We understand that decision-making may be difficult right now, if you have questions or wish to discuss your options, a representative is ready to help you. Call toll-free at(800) 926-1702 Monday through Thursday, 8:00 a.m. to 6:00 p.m. Eastern time and Friday, 8:00 a.m. to 5:00 p.m. Eastern time. Sincerely, jua-jj1WdX__ Teresa Fleisch Annuity Administrator Annuity Operations Department F021/FI-02-M"909 © M&T sank 499 Mitchell Road,Millsboro,DE 19966 Adjustment services Phone 888-502-4349 Fm (302)934-2955 March 12,2013 Martson Deardorff Williams Otto Gilroy & Faller 10 East High Street Carlisle, PA 17013 Re: Estate of John R.Gibon Social Security: 203-24-8079 Date of Death: December 25,2012 Dear Sir or Madam: Per your inquiry on March 7,2013, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: L Type of Account Checking Account Account Number 1195522 Ownership(Names on Steven A. Gibson David L. Gibson John R Gibson Opening Date 08,13111994 Balance on Date of Death $2,591.66 Accruedlnterest $ .01 Total $2,592.67 ) , 2. Type of Account Installment Loan Account Number 11044446888934998 Ownership(Names oJ) John R Gibson(borrower) ShirleyM Gibson(co-borrower) Opening Date 1212812005 t Balance on Date of Death $22858.72"Ais amount is not to be IJGh. t m 1 used for payoff purposes. Fora payoff balance,please call 1-800-724-1440 Current Balance $ 12451.83 ••This balance is not a payoffbalance Sck' F, _LV m C I 3) For any additional information on the above accounts,including ownership and any changes,closures and/or reimbursement of funds, please call the Mount Holly Springs at 717-486-3038. We were unable to locate any safe deposit box for the above-mentioned decedent. This letter does not include any accounts in which the deceased may have been listed as Power of Attorney,Custodian of Uniform Transfers, Representative Payee,or Trustee under a Written Agreement Sincerely, Valarie Mercer Adjustment Services ,'yrG1_i v L,