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Home My WebLink About10-09-13 (2) , _.. , � 1505610140 REV-1500 EX (02-11)(FI) PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Po BOx 2soso� INHERITANCE TAX RETURN 2 1 1 3 0 0 8 6 Harrisbura,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 0 1 1 0 2 0 1 3 � 1 1 1 8 1 9 4 7 Decedent's Last Name Suffix Decedent's First Name MI B U R K H 0 L D E R D E N N I S A (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1.Original Return � 2.Supplemental Return � 3.Remainder Return(Date of Death Prior to 12-13-82) � 4.Limited Estate � 4a.Future Interest Compromise(date of � 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.) � 9.Litigation Proceeds Received � 10.Spousal Poverty Credit(Date of Death � 11.Election to Ta�nder Sec.�9113(A) Between 12-31-91 and 1-1-95) ttach Schec�O) � CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TA�FIF MATION�ULD I�ECTED T0: Name Daytip�'�e�one�ber� � A S E T H T • M 0 S E B E Y , E S Q . 7 � � �� 3 � � 4 1 c„ . ., C:�tE�6l�S O i11�F�LS LY �t � �� ::�.� � First Line of Address ° W„�� '� �;,, i`� � 1 0 E A S T H I G H S T R E E T �"' � � � Second Line of Address City or Post Office State ZIP Code DATE FILED C A R L I S L E P A 17 0 1 3 Correspondent's e-mail address: SMOSEBEY(a�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,conect and complete.DeGaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIG RE OF ERSON RESPONSIBLE FOR FILING RETURN DATE ��- �o/ J13 ESS 180 MARTEL CIRCLE DILLSBURG PA 17019 SIG RE F PREPARER OTHER T N REPRESENTATIVE DATE ^. �f � ADDRESS 10 EAST HIGH ST T CARLISLE PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 � 1505610140 1505610140 J , , , � 1505610240 REV-1500 EX(FI) Decedent's Social Security Number �ecedent'sName: DENNIS A • BURKHOLDER RECAPITULATION 1. Real Estate(Schedule A) . . . . . . . . .. . . . .. ... ... . . ... .... . ... . .. . . . . . . 1. 5 2 0 0 0 . 0 0 2. Stocks and Bonds(Schedule B) .. . .. . . . .. .. . . . . . .. . . ... . . .. . . . . . . . . . . 2• • 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) . . . .. 3. • 4. Mortgages and Notes Receivable(Schedule D) . ... ... .. ... . . .. . . . . .. . .. . 4. • 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). . .. . . . 5. 4 6 7 3 7 . 3 2 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . .. . . 6. • 7. Inter-Vivos Transfers&Miscellaneous N -Probate Property (Schedule G) � Separate Billing Requested . . . . .. . 7. 1 6 5 0 8 7 . 1 6 8. Total Gross Assets(total Lines 1 through 7) . . .. . .. . . ... . . .. . . . . . .. . . . . s. 2 6 3 8 2 4 . 4 8 9. Funeral Ex enses and Administrative Costs Schedule H 9. 3 7 6 9 4 . 0 0 P � ) .. . . . . . . .. . . . . . . .. 10. Debts of Decedent,Mort a e Liabilities,and Liens Schedule I 10. 4 0 5 5 7 . 6 5 9 9 � ) . . . . . . . ... . . . �1. Total Deductions(total Lines 9 and 10) . .. . . . . .. . ... . . . .. . . . . . . . .. . .. . 11. 7 8 2 5 1 . 6 5 12. Net Value of Estate(Line 8 minus Line 11) . .. . . . . .. . ... . . .. . . . . ... . . . . �2. 1 8 5 5 � 2 . 8 3 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. 1 8 5 5 � 2 . 8 3 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 16. Amount of Line 14 taxable at lineal rate X•045 1 8 4 5 7 2 . 8 3 16. 8 3 0 5 . ? 8 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 1 0 0 0 . 0 0 �8. 1 5 0 . 0 0 19. TAX DUE . .. . .. . . . . . . . . . . . . . . . . .. .. . ... ... .... . ... . . .. . .. . . . . . . 19. 8 4 5 5 • 7 8 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: 21 13 oos6 DECEDENTS NAME DENNIS A.BURKHOLDER STREET ADDRESS 203 WEST PINE STREET CITY STATE ZIP MT.HOLLY SPRINGS PA 17065 Tax Payments and Credits: �• Tax Due(Page 2,Line 19) (1) 8,455.78 2. Credits/Payments A.Prior Payments 3,238.18 B.Discount Total Credits(A+B) (2) 3,23 8.18 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) 5,217.60 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 ...................................................................... ❑ � h. retain the right to designate who shall use the property transferred or its income ............................... ❑ 0 c. retain a reversionary interest ..................................................................................................... ❑ � d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ 0 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? ......... ❑ � 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation?.................................................................................................. � ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)j. 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 retum are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in(�2 P.s.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].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 INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF: FILE NUMBER: DENNIS A.BURKHOLDER 21 13 0086 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 seiler,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 in So.Middleton Twp.,Cumberland Co.,PA,known as Tax Parcel No. 52,000.00 40-32-2334-069,being described in Deed dated 6/16/1987,and being recorded in Cumberland County Deed Book"S",Vol.32,Page 810,and being conveyed to Dennis A.Burkholder, Decedent herein. Value is actual sale price. See attached Settlement Statement TOTAL(Also enter on Line 1,Recapitulation.) a 52 000.00 If more space is needed,use additional sheets of paper 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: DENNIS A.BURKHOLDER 21 13 0086 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. 2011 Chevrolet Silverado pick-up truck 20,000.00 See attached valuation 2. 2007 Rhino 450 4x4 2,147.00 See attached valuation 3. Toy Hauler camper 3,500.00 4. Carolina Freight Credit Union 1,804.47 See attached valuation S. Woodhouse LLC,no value 0.00 6. Members lst FCU,savings 301913-00 5.00 See attached valuation 7. PNC Bank checking 5004923817 744.05 See attached valuation 8. PNC Bank savings 5112937343 643.84 See attached 9. Colonial Penn Life,refund of premium 252.42 10. UGI,refund 3,748.52 11. Tax proration 295.21 12. Miscellaneous cash deposit 67.30 13. Value of personal property selected by Troy Burkholder pursuant to Paragraph 3(a)of Will. 12,050.00 See attached list 14 Value of personal property removed by Jeanne Beat 1,000.00 15 Humana,refund 42.30 16 Central Pennsylvania Teamsters Pension Fund,January 2013 retirement benefit 384.00 TOTAL(Also enter on Line 5,Recapitulation) a 46 737.32 If more space is needed,use additional sheets of paper of the same size. . . Continuation of REV-1500 Inheritance Tax Return Resident Decedent DENNIS A. BURKHOLDER 21 13 0086 Decedent's Name Page 1 File Number Schedule E-Cash, Bank Deposits,&Misc. Personai Property ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 17 HMA Physician Management,refund 25.00 18 Members 1 st FCU 28.21 SUBTOTAL SCHEDULE E 53.21 GRAND TOTAL SCHEDULE E � 46,737.32 � , REV-1510 EX+(08-09) pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER DENNIS A.BURKHOLDER 21 13 0086 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST ��F n�ucae� VALUE 1. Wells Fargo IRA,Beneficiary:Troy M.Burkholder,son, 100% 165,087.16 100.00 165,087.16 See attached valuation TOTAL Also enter on Line 7,Recapitulation � 165 087.16 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 INHERITANCETAXRETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER DENNIS A.BURKHOLDER 21 13 0086 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Hollinger Funeral Home,Mt.Holly Springs,PA 4,016.14 2. Troy Burkholder,reimbursement for funeral reception expenses 800.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Troy M.Burkholder 10,500.00 Street Address 180 Martel Circle �i�y Dillsburg State PA Zip 17019 Year(s)Commission Paid: 2014 2, �ttomey Fees: Martson Law Offices(estimated) 13,500.00 3, Family Exemption:(If decedenYs address is not the same as claimanYs,attach expianation.) Claimant SVeet Address -- City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: Cumberland Register of Wills 233.50 5 Acxountant Fees: 6. Tax Retum Preparer Fees: 7, Short Certificates 10.00 8. Cumberland Law Journal,advertising Letters Testamentary 75.00 10. The Sentinel,advertising Letters Testamentary 200.16 11. 1%Realty Transfer Ta�c 520.00 12. Diversified Appraisal Services,appraisal fee 337.50 13. Allstate,homeowner's insurance pending sale of real estate 157.30 14. Wolfe&Company,real estate commission 2,000.00 15. Exit Platinum Plus,real estate commission 2,000.00 16 Notary fees 5.00 17. Robert C.Cairns,County/Twp.real estate taxes pending sale of real estate 339.72 18. Mt.Holly Springs Authority,final water bill 52.30 1 g. Robert C.Cairns,Tax Certfication 10.00 TOTAL(Also enter on Line 9,Recapitulation) a 37 694.00 If more space is needed,use addi�onal sheets of paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent DENNIS A. BURKHOLDER 21 13 0086 Decedent's Name Page 3 File Number Schedule H-Funeral Expenses�Administrative Costs-B7. ITEM NUMBER DESCRIPTION AMOUNT 20. SMTMA,fmal sewer bill 62•22 21. Members 1 st FCU,balance of home equity line paid from real estate proceeds 364.28 22. Trash removal fee pending sale of real estate 600.00 23. CV Welding,home repair pending sale of real estate 530.61 24. First Energy,electric service,pending sale of real estate 266.96 25. SMTMA,sewer,pending sale of real estate 177.07 26. Colonial Penn Insurance,premiums pending sale of real estate 280.47 27. 21st Century,auto insurance,camper,truck,auto insurance 149.30 28. First Energy,fmal payment 81.47 29. Additional Probate 125.00 30. Reserve for miscellaneous filing fees and additional costs 300.00 SUBTOTAL SCHEDULE H-B7 2,937.38 , . REV-1512 EX+(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT� INHERITANCETAXRETURN MORTGAGE LIABILITIES&LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER DENNIS A.BURKHOLDER 21 13 0086 Report debts incuITed by the decedent prior to death that remained unpaid at the date of death,including un�eimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Members lst,home equity loan#301913-03 30,047.86 See atta.ched 2. PNC credit card 4311963130443315,account payable 7,995.91 3. Outstanding checks on date of death on PNC checking 50-0492-3817 400.00 4. Colonial Penn,premium payable 93.49 5. Comcast,account payable 600.23 6. Interstate Waste,account payable 40.47 7. IRS,2012 personal income taa�due 243.00 8. Verizon Wireless,account payable 77•84 9. UGI,account payable 222•23 10. Nephrology Associates,account payable 25.00 11. Quantum Imaging,account payable 46.09 12. VNA Community Care,account payable 342.87 13. Celtic Health,account payable 98.68 14. Pinnacle Health,account payable 73.00 15. Apex,account payable 5.00 TOTAL(Also enter on Line 10,Recapitulation) S 40 557.65 If more space is needed,insert additional sheets of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent DENNIS A. BURKHOLDER 21 13 0086 Decedent's Name Page 4 File Number Schedule 1-Debts of Decedent, Mortgage Liabilities,&Liens ITEM NUMBER DESCRIPTION AMOUNT 16. 21 st Century Insurance,account payable 85.02 17. AllState Insurance,account payable 79.21 18. Advanced Disposal,account payable 81.75 SUBTOTAL SCHEDULE I 245.98 GRAND TOTAL SCHEDUIE I a 40,557.65 . . REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: DENNIS A.BURKHOLDER 21 13 0086 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS [Inciude out n'q ht spousai distributions and transfers under Sec.91�6(a)(1.2).] 1. Troy M.Bwkholder Lineal 184,572.83 180 Martel Circle Dillsburg,PA 17019 2. ** Jeanne Beat Collateral 1,000.00 c/o Andrew Shaw,Esq. 200 S. Spring Garden St., Suite 11, Carlisle,PA **The specific bequests to Jeanne Beat under Paragraph 3 (b)of the Will abate pursuant to 20 P.S. Section 3541 to satisfy the outstanding administrative expensive expenses and debts of the Decedent 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 II-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. ' • �F:�FILES\C�\!3991 Burl�holda�13971.1.wiilZOiT � OR1GlNAL RETAINEO 8Y: .. • � , MAR'TS�'=v DEA�tDO�F'WTLY.IAMS -- , 07'TO CzII.80Y,&FSIZER , � � � EAST GH��T�RA.E�T LAST WILL AND TESTAMENT ��y��pA 17oi3 � (717)243-3341 I,DENNIS A.BURKHOLDER,of Mt.Holly Springs,Cumberland County,Pennsylvania, being of sound and disposing mind and memory,do hereby make,publish and declare this to be my Last Will and Testament,hereby revoking any and all former Wills or Codicils made by me. 1. I direct that all my legally enforceable debts, funeral expenses, testamentary expenses and a11 dea.th taxes(whether such taxes may be payable by my estate or by any recipient of any property) , shall be paid from my residuary esta.te as soon as practicable after my decease and as part of the administration of my estate. My Executor sha11 have no duty or obligation to obtain reimbursement for any such tax so paid,even though on proceeds of insurance or other property not passing under this Will. 2. I give such items of personalty as are itemized in a certain list attached hereto(if any)to the persons named thereon, which list is signed and dated by me at the end thereof. . 3. I make the following specific bequests: a. Unto my son,TROY M. BURKHOLDER, the following items: (1) any and all guns that I may own at the time of my death; . (2) any interest that I may have in Woodhouse, LLC; and (3) such of my personality as he shall choose. b. Unto my friend, JEANNE BEAT,th�fall��.�ing.�±eins, � � � - : (1) my Chevrolet Silverado Pickup Truck; (2) my Toy Hauler Enclosed Trailer; (3) my ATV Rhino; and ' • � (4) the sum of Fifty Thousand Dollars ($50,000.00). 4. , I give, devise and bequeath all the rest, residue and remainder of my estate, both real and personal property,unto my son, TROY M. BURI�HOLDER, absolutely. ^� [InitialsJ Page 1 of 3 r � • �� • r r� � 5. I nominate, constitute and appoint my son,TROY M. BURKHOLDER, as Executor of my estate. In the event my said son sha11 be unable or unwilling to serve in such capacity,then I appoint my brother,RONALD E. BURKHOLDER,to act in such capacity. 6. I direct that all fiduciaries acting under this Will,whether or not named herein,shall not be required to give bond for the faithful performance of their duties in any jurisdiction. 7. I authorize and empower my Executor,or his successor,in their sole and absolute discretion, to purchase or otherwise acquire and retain any investments of which I die seized or any real or personal property of any nature;to sell, lease,pledge,mortgage, transfer, exchange, dispose of or grant options in regard to any or a11 property of any kind forming a part of my estate for such terms and such prices as they may deem advisable;to borrow money for any purposes connected with the protection and preservation of my estate;to mortgage or pledge any real or personal property forming a part of my estate or to join in or secure the partition of same; to compromise any claims or demands of my estate against others or of others against my esta.te;to make distribution in kind and to c�use any share to be composed of cash, property or undivided fractional shares in property different in kind from any other share; to employ agents, attorneys and proxies and to delegate to them such power as my Executor, or his successor, considers desirable and to pay reasonable , ,. compensation for such services as may be rendered by such agents, attorneys and proxies; and to execute and deliver such instruments as may be necessary to carry out any of these powers. In . ... addition,I direct that my Executor,or his successor, shall have the power to conduct an inventory of any safe deposit box necessary to the administration of my estate. IN WITNESS WHEREOF I have hereunto set my hand and seal this ��day of �� ,2011. . , �� CSEAL) Dennis A. B�rkholder SIGNED,SEALED,PUBLISHED AND DECLARED by the above-named Testator,as and for his Last Will and Testament,in the presence of us,who at his request,have hereunto subscribed our names as witnesses thereto, in the presence of the said Testator and of each other. J� � � � Page 2 of 3 . . - - - -- - . _ , � . .• . . , � COMMONWEALTH OF PENNSYLVANIA ) . SS. COUNTY OF CUMBERLAND ) We,Der�nis A. Burkholder, Seth T. Mosebey and /�. � the Testator and the witnesses,respectively,whose names are signed to the foregoing instrument,being first duly sworn,do hereby declare to the undersigned authority that the Testator signed and executed the instrument as her last Will and that the Testator has signed willingly, and that the Testator executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as a witness and that to the best of his/her knowledge the Testator was at that time eighteen years of age or older,of sound mind and under no constraint or undue influence. <�� /L� Dennis A. Burkholder,Testator J+ itness . � e Wi e ' ' Subscnbed,sworn to and acknowledged before me by Dennis A.Burkholder,Testator,and — subscribed and s orn to before me by ,� /, as and �a�. the witnesses,-this /S�'d ' �y��Gt.�-�, 2011. � c►-��- a Notary Public ao��a�ws��.�oF�va�► NO�TARIAL s�' . Victosi�L. �CountY Carhsle.Boro, M commission e ' Decembat 20 2014 Page 3 of 3 ....��.........�... �. ..��...�......�..a....��.�.��....�._. ...�..�...rv..��.��...�.. 1l1V�.L ._-_.. ' ' SETTL•EMENT STATEMENT ri ess sec�ement s tem L. SETTLEMENT CHARGES PAID FROM PAID FROM 700.'TOTAL SALESBROKER'S COMMISSION based on rice S5 000.00=4 000.00 BORROWER'S SELLER'S Division of commission lir�e 700 as fdloMrs: FUNDS AT FUNDS AT 701. 2 000.00 to WON9 S CW11 RNItOfs SE7TlEMENT SETTLEMENT 702. 2 000.00 to Ex�Platinum Plus 703. Commission ' at Settlement 4 000.00 800.REMS PAYABLE IN CONNECTION WITH LOAN 801, Loan ' �abon Fee 96 802. t.oan Discount 96 803. aisal Fee 804..Credit . 805. 806. 807. 808. ' 809. 810. 811. 900.ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 901. Intere�From to Ida 902. Insuranoe Premium for to 903. Haz�d Insurance Premium for to 904. 905. 1000.RESERVES DEPOSITED WITH LENDER FOR 1001.Hazard insurance mo. /mo 1002.Mort Insuranoe mo. /rra 1003.C Tax mo. Imo 1004.Coun Tax mo. Imo 1005.Schod Tax mo. Imo 1009.A sis Ad strr�ent 0.00 0.00 1100.TITLE CHARGES 1101.Settler►�ent or C ' Fee 1102.AbsVatx or Tide Search 1103.Tide Examinallon 1104.Title Insuranoe Binder 1105.Document apon 1106.N Fe.es 5.00 5.00 1107.Attar�e s fees indudes above items No: 1108.Tide Insurance to BariC SCherer LLC 636.pQ indudes above items Wo: 1109.Lenders Pd' 1110.Ormers Pol' S2 000.00 -636.00 . ._1111. 1112. 1113. 1200.GOVERNMENT RECORDING AND TRANSFER CHARGES 1201.Recordi Fees Deed 67.00 •Release g7.pp 1202.C' /Coun taxl Deed Z0.00 �Mort 520.00 1203.State Taxl Deed 20.00 •Mort �p.pp 1204. 1205. 1300.ADDITIONAL SETTLEMENT CHARGES 1301.Z013 Coun /Townshi Tax Bil to Robsrt Cain�Tax Coilectot 339,M 1302.F��Water 8ip to II�.H01 5Z.30 1303.Inheritance Tax Pre-Pa t to isbr of Wilb 3 .18 1304.Tax Certific�ion to Robert Caims Tmc Colloctor �p.pp 1305.Final Sewer B�I to South Middleton TowrKhi Munid Auttari g� 1400.TOTAL SETTLEMENT CHARGES enter on lines 103 Section J and 502 Section 1 Z28.00 227.42 HUD CERTIFICATION OF BUYER AND SELLER I lieve canhdy reviewsd Me MUO-1 SettkmxN Statanarri and to Cie bes[o(my Nrpwlsdp�and beliaf,d is a true and accur d atl ritMrwnaMs ma0�on aocoixM b�w ar Ey ms in .1 hr�r i hava of the HUO-1 Settlament SfaiwnerN ames . y . �� ' WARNING:IT IS A CRqrE TO KNONANGLY MAKE F/LLSE STATEMENTS TO TME The HUD-7 SWtbmxrt Stalemant wlrch I haw prepred is a trus and aoaraM axrourN d M�is UNITED STATES ON THIS OR ANY SMAILAR FORM.PENALTIES UPON CONVICTION trantaction.I haw pwsd or wiq tlr(unclt to b�ditbursed in acoord�na wilh tlp p�t«n�nf. CAN INCLUOE A Fit�AND IMPFISONMENT.FOR OETAll3 SEE TfTIE 18: � U.S.CODE SECTION 1001 AND SECTqN 1010. ��`�� SETTLEMENT AGENT: pATE: ��C��t e � Settleinent Statement u.s,DepaM�ent of Housing and Urban Development T �of La�n OMB roval No.2502-0265 ❑FHA 2. ❑FmHA 3. pConv.Unins. 6.Rle Number 7.Loan Number 8.Mortgage Insurance Case Nurtiber VA 5. Conv.lns. 2013-20MEFF No�s: n.ms mar�.d�.aa�w..p.id o�a�a.n.do.�an.now�n«.ror rxar„�aiw,a,rpo..s arw ar.r,w nckww:,a,.ca.�.. TideExpress Setdement System 4VARNNG:N is a aim ro Ivawiqly m�w faw to tlw UniMd 8t�Ms on tl�is or 1�dfrr tlmilr tam.Pen�NMs upon c«wialon c.n:�ckw.bn.ana F«aMaail..«:raU te u.s.cod.s.ctlon'i0o1 ana s.aion to1o. NAME OF BORROWER: Jama L.NeA and Cafhy J.Ni�ff ADDRESS: 519 ChKtnut Mt Hol �i s PA 1T065 NAME OF SELLER: Estab d Dennis Burkholdar ; ADDRESS: clo T M.Burkholder 180 Martel Circle Dilisbu PA 17019 NAME OF LENDER: ADDRESS: PROPERTY ADDRESS: Z03 West Pins�Mount Holly Springs,PA 1T065 South Middlata�Townshi � SETTLEMENT AGENT: Bsric Schu�LLC�Tdephone:717-249-6873 Fanc:717-249-5755 PIACE OF SETTLEMENT: 19 Wat Sadh Carlisl� PA 1T013 3ETTLEMENT DATE: Og131/T013 ' I : I0.GR08S AMOtJNT DUE EROM 80RROWER �00.GR038 AMOUNT DUE TO SELLER 11. Contraet sales 52 000.00 401. Contrac�sales ' S 000.00 l2. Pe�sonal 402. Person� l3. set�r�enc cn ro borrowe�6ne�aoo 12ZS.00 aos. M. 404. �i. 405. Ad'ustrrisnts tor itarna id aeHer in advance 'usbtients for imrrm id seNer in advanos l6. C' IGown ta�ces 406. Ci Itorm taxes )7. Coun taocea OS131N3ro12131H3 200.10 407. Cau taxes 05131M3to1?J31M3 200.10 �8, sc�oo�rax 05131M3ro0613QV13 95.11 408. Sc�oo�Tax 05131H3ro06130h3 95.11 �9. 409. 10. 410. 11. 411. 12. 412. Z0.aR08S AMOUMT DUE FROM BORROWER S3 523.21 4T0.GR088 AMOUNT DUE TO SELLER .21 ,00.AMOUNTS PAID BY OR ON!BEHALF OF BORROWER 500.REDl1CTI0N8 IN AMOUNT DUE TO 8ELLER 01. or eamest 5 000.00 501. Exc�ss see insUtx�fons 02. Prir�ci artaunt of new loans 502. Sedlement ch to seNer line 1400 8 .�12 03. Fxisti s taken su ' to 503, Exi�i s taken to :04. 504. Pa d Fi�st Loan 30 412.14 Nlsmb�ts 1rt FCU :05. 505. P af second mat loan :06. 506. '07. 507. '.08. 508. '-09. 509. Ad us�nents for itams un seller Ad u�nsnb for it�un seli� ?10. C' Rorm taxes 510. C' /town taxes �11. Coun taxe.g 511. Coun taxes ?12. Sctad Tax 512. School Tax �13. 513. 214. 514. 215. 515, 216. 516. 217. 517. 218. 518. 219. 519. 2Z0.TOTAL PAID BYIFOR BORROYYER 5 000.00 520.TOTAL REDIJCTION AMaJNT DUE SELLER 6�.56 300.CASH AT SETT�EMENT FROM OR TO BORROWER 600.CASFI AT SETTLEMEMT TO OR FROM SELLER 301. Grose amount due fram borroMrer Ine 1 ZQ 53 523.21 601. Gross amouM due to seAer line 420 .21 . 302. Less amounts ' /for borrawer Yne 220 9 000.00 602. l.ess reduction amount due selier line 520 38 839.56 303.CASH FROM BORROWER 48 523.21 603.CASH TO SELLER 13 655.6� -- - - - __ __ � . . . _ _ r� �� C.� . C�LET To whom it may concern: This 2011 Chevrolet Silverado Extended Cab 1Lt 4x4 with 13458 miles is in overall excellent Condition. Vin# 1GCRKSE306Z123618 Lawrence Chevrolet would pay $20000 for this truck today. This value wouid be valid for 30 days from today. SALES MANAGER � CHAD BAKER LAWRENCE CHEVROLET �,,�,--� ��// � � l.awrenceChevy.com ( 6445 CARLISLE PIKE MECHANICSBURG,PA 17050 ( 717-766-0284 800-427-4505 Lots to�at Lawrence. �� . ��-�-- . � . _ ll�L�� rJ�i v.• / _ - -�.. �,�e c��.� ��,v ,,,` — �° � � � ro � v, � � � a �. � hc� � � � K r' N• a �`�' x' � � � �` a� z ° C an � �. � � � � n � .. � ,,� „ � .. , X � H �n � N � � � � � o � � � , � Z H t�-► O� � �"'� f-�.i x C'7 � �' �'' � k '� �' � � n � v tfl � v � � Q 1 H 0 9C N � � . � p � r y � c � � �-' � � � O . � � ,� _ tn •� `� O ' � t!� .. � � N � - F � � y .. r- . � o � (D H . � N b - •• a Cn rr � !p .. .. . � � � � � -- O = (3'� - \ t-+ W 4 2 - - Cm? - - � � C - - � � --_ m - _ � � _ �J`t - C.p - � tG3 --- d �,�� _- _ . •�-c�.,.Q._ _ _ � - _ "' �U13 11;11AM pN� — _ — Ba�k - . No, p 15� p 1/2 A '�• � • � � "+R�L-C� 1.9e 2(/,� � �YCtOI�g L,Q�.O �la�°n La'��c , ��S� �s Carlisle,PA ��p73 , �L; �� . s�N:20 _��kbo�d�. . �p�_�l� 3��9�79 1��201; . — � ��'Ms. ptt�: . rn respo�e to yo� � . reco��ovv�e foi��t for Date o f�y�$ �,�� . �g: �C�OL7� ba�anCeS f - A��g Acc,�unf °r��ustorn�.no = t�n�#Sp049�3gZ 7 t�abo�'e� o�r -- ��bala,nce: . _-_ $ 774.05 non�� E�S.A B � - _ S�`'��Ac �t��ng ��LDE.� Estab�shed; - �`��S�°unt . , r 1-24-200� _- _- �Zz9�7343 � _ ��balauce: �64 D , - ��rest p�d p J_�I.3.84+p.Op��eE�V7�`A BURKH E = 20I3 �01_1.��2�mteresrt �LD�,� �bli�hed,p1-3�- 1'3�O.OQ � 20Y2 _ = ��ase no�� -- ��'oF s,� �e�lo not�m provides da�of - -- _ these i��s P cess ao��n��°��ances for d = 4f,fice. 'ple�e call 1-888- ��oos or �!°osrt��o�� , _ - pNC B�IVI{ 76 provide s��e �� C.Us� Chec�• -- (�-8�g_ Z z265)or s� n1�, ,�'�,ou� ��ng and _ Su��3'� P b��o�, �ed�� - __ ]ocal p.NC��c�e�� _- _ Na�o , �'�nch = p�,��Fina,uci�l,�e�,ice� _ M�� ,N1q, Cen�er -- �� - � �ag� � �� -- � � � _ � - ��:�-� � . - - - - C � �,� - - - �-� �� m - Items o f _ P�rsonal pr - _ 195� �pe�'Sele�te - - JO�D lymOUth d by TrOy P J��Deer e A �rs�a�t tO S�c KubOta tra� $ $ I,SOp,p tl�n 3�a�of t Jon boat� tor � g p O 0 be �'i11; 0 p Enclos�d d trail�r � 6�0 .lp� utl jl � ,'000•�Q I��r�la�tY trailer � 1�lis��ll��o ty�mower $ 2SO O T°tal: us Personal � 3 p�� — 0 prope� $ 6�0.oo — $ 1,Opp�� _ �12�OSp,�� - � - - � _ �� - _ - - __ _ � �� - - __ ''�c �,� - St - ��MB�S 1st� ��ZT UNION q� �R AVINGS qCC unt Number/S��X �UNT: �-ate q�Unt � P��n��Pa�Balan Estabiished A�rued Intere�at Date of peath 301913_00 7ota1 p�� st to Date of peath 03��2007 Nam� pa�and qccrued Interest $5•00 of Joint p�,yner $.00 ��AN ACCOUNT; $5•00 - A�count N� None Date p mbeNSu�X Princi pened Loan Type a�ance 301913_03* Collateral Secured 09/p4�2010 Interest Rate $30,047,86 Name of�o_Bo�OWer 2p Wespu�tY/Contractua►p 4 69/ t Pine Street,ly�t Noea9e of Shares VISq AC #Loan does not None y Springs,pq 17p65 _ COUNT; have Iife insurance. Account Nu►nb�r/S��x Date q��unt Established Principal Balan - - Narne of J . �at Date of Death 467209000 o►nt Ovyner Cardholqef �4/13/200g0056184* - �.00 - "'Cont None - ractual Pled9e of Shares, ME B S�Sr FEDERAL _ CREDI UNIO - � Dan�elle q,Kline � Lending Insuranc�Su February g,2013 pPort Specialist �te°f'�ENNIS - _�f Death:01h0/2p13RKHp��ER = - �a�Security Nur�ber:200-36-93 =-- - 79 - �e Drive . p� Bo� • _ _ � Me�anicsbur p - _ _ �� ennsplva�ua 17p55 . 8 - - — _ �� /� ,. � 00)283-232R . �_ ��f ��t.LC �a�,��.C4p$dd�$ ' �30�7� wcr ��QI.,.��$ C r�Frs�� ''1 • �0 ro rv r� � a N N � t0 Q� N ry �I Q � tA' �4Q t^I � a�i C Q � `'� '� - M A �� g � � � -- � �, � � � — = r" � � r � *� ,� -_ C ,� -- - � � � � —- ° ,o � � � ai � ' __ � � � ,� � � � -__- � � �' .� � -- n� � — = .� � � � - � - � ° o � C Q ` h 3 —-__-= +� � � � �4t � -- - � � tt't � �-�y O ' � � �� ''U� � N 'r'r� *-� _ Zy � ~ � � � - � � � a � � _- � � X a � N — � � Lri o .�, •�► � � � � =- •"► C � y� `A ++ � � _ Qt � � Q � � � 'Q � u -- 4 a �a '� � � � � � � _ �i � � -- � � i�%i � iti N, � `�' _ - � � � � .� o � � �,,, � ... _ - � � `� � � � � � _- �, � � ,` w .� � ,� - v' � � 2 a � ,�t ,� � -_- i? � ,- � � � « -_ 4 � � ' � � - -— �. � ��,, � � y -_ - � � � � - �. o � p a� �O � � .� c, - — � � N �� Q � N � _ CY � '�+ q�j '� � �� - �er FtNRq1slPC � � ` _--_ Q p -- _ �� 'd �� c� - .` �$�'�:�'�go,�. - ��M��j^(� . . , - Y Y V��Y�Q�Y��V��ry� ' M I t •. - - � _ - - -'�'C!'.i• . !!i �y��:6 — — - `�—"� � ,�-� ��c�� [ - - r �/� G �� -