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Home My WebLink About12-19-13 (2) M• � , s � 1505610105 . REV-1500°`��-'1,��,� PA Department of Revenue P�nsylvania OFFICIAL USE ONLY Bureau of Individual Taxes "'""TM`"`°`""`"�` County Code Year File Number Po BOX z8o6oi INHERITANCE TAX RETURN �� 1 ,�"�j 7�; �- � �-' Ha�isburc3,PA i�i28-o60� RESIDENT DECEDENT 'r/� � � � �� ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth . MMDDYYYY —� ! � � 03/20/2013 ; 08/25/1923 ; DecedenYs Last Name Suffix Decedent's First Name MI Famer � �- f � Melvin I� � ; � (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI r--------j ' � ' � I � � Spouse's Social Security Number � THIS RETURN MUST BE FILED IN DUPLICATE WITH THE � REGISTER OF WILLS FILL IN APPROPRIATE OVAI.S BELOW � 1.Original Retum O 2.Supplemental Retum p 3. Remainder Retum(Date of Death Prior to 12-13-82) O 4.Limited Estate p 4a.Future Interest Compromise(date of p 5. Federal Estate Tax Retum Required death after 12-12-82) C� 6.Deoedent Died Testate O 7.Decc�dent Maintained a Living Trust 1 8.Total Number of Safe Deposit Boxes (A�ad,copy of vwu� (Attach Copy of�rust.) . O 9.Libgation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax unde�Sec.9113(A) • Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT—THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFlDENTIAL TAX INFORMATION SHOULD BE�RECTEO T0: Name Dayti , elephone N � �David S. Reinhart, CPA �(717} 3�5154 �, � � . F�I�R�WI USE L�RJ � .� i�' � � � Frst Line of Address � � � +� � Smoker,Smith&Assoc —� � � ° � .��.�,- "'�'� Seoond Line of Address ----- � � ►--� t"'" f� �� G'7 339 W Governor Rd "�„�, � s'� � -.n City or Post OffK:e State ZIP Code DATE FIL� Hershey �� 17033 � Correspondent's e-mail addreas:dreinhart@smokersmith.com Under penetbes of perjury.I dedare that 1 have examined thls�tum,induding ac:oompanying schedules and statem�ts,and to tl�e best of my knowledge and belief, it is Uue,oortec;t and complete.Dedaration of preparer other than the personal representative is based on all I�fonnation of which preparer has any knowledge. SIG RE OF SIBLE ILING RETURN � DA / 1� � ADDRESS 3Ayl� ,�+��r�CQ�►sf" �Q � lC,f d �—+�s�ti� c�e 1�4-.v � ��O7 d . . . SIGNATURE PREPARER OTHER THAN REPRESENTATIVE DATE � ADDRE Smoker,Smith&Assoc,339 W Governor Rd, Hershey, PA 17033 PLEASE USE ORIGINAL FORM ONLY Side 1 � 1505610105 15�561�105 J �� a s � 1505610205 REV 1500 EX(FI) DecedenYs Social Security Number �ae�rs Na�: Melvin W. Famer i RECAPITULATION ' i 1. Real Estate(Schedule A). ............................................ 1. � .220,256.00 j � 2. Stocks and Bonds(Schedule B) ....................................... 2. � 510,825.05 � � _.�-? 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. I � � 4. Mortgages and Notes Receivabie(Schedule D)........... ............. 4. i I 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 7,464.21 6. Jointiy Owned Property(Schedule F) O Separate Billing Requested ....... 6. � 64�762•06 7. inter-V'nr�Transfers 8 Miscellaneous Non-Probate Property { (Schedule G) O Separate Billing Requested........ 7. + 139,808.00 8. Total Gross Assets(total Lines 1 through 7)............................. 8. 943,115.32 i 9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. I 45,548.31 � i 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............... 10. � 5,732.45 11. Total Deductions(total Lines 9 and 10)..............................,.. 11. 51,280.76 12. Net Value of Estate(Line 8 minus Line 11).............................. 12. 891,834.56 13. Charitable and Govemmentai 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) ............ . ......... �a. ( 891,834.56 TAX CALCULA110N-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxabte at the spousal tax rate,or Vansfers unde�Sec.9116 (ax1.2)X.0_ � 15. � 16. Amount of Line 14 taxable at Iineai rate X.0 45 � 891,834.56 �g, 40,132.56 17. Amount of Line 14 taxable at sibling rate X.12 � 17. ' 18. Amount of Line 14 taxable � at coliateral rate X.15 � 18. 19. TAX DUE......................................................... 19.� 40,132.56 � � 20. FlLL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O � Side 2 � 1505610205 ],5056102�5 � , , REV 1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENTS NAME Meivin W.Famer s�rAOO�ss 216 Reeser Rd CITY STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due(Page 2,line 19) (1) 40,132.56 2. Credits/Payments A Prior Payments 30,000.00 B.Discount 1,578.90 Total Credits(A+B j (2) 31,578.90 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) 5. If Line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 8,553.66 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�oome of the property transfemed.......................................................................................... ❑ � b. retain the rght to designate wha�shall use the ProPertY transfeRed or its income............................................ ❑ � . c. retain a r�versionary ir�terest.............................................................................................................................. ❑ � d. nec:eive the promise for life of either payments,benefits or ca�e?...................................................................... ❑ � 2. If death oocumed after Dec.12,1982,did deoedeM transfer prope�ty within one year of death witl�out receiving adequate consideration?.............................................................................................................. ❑ � 3. Did deoedent own an'in trust for or payable-upon-death bank account or security at his or her death?.............. ❑ � 4. Did deoedent o�wn an individual retirement aa�u�,annuity�other non-probate property,which ca�tains a benefiaary de.signation? ........................................................................................................................ � ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AHD 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 surv'nring spouse is 0 percent [72 P.S.§9116(a)(1.1}�(ii)J.The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements fo�disdosure of assets and filing a tan r�etum 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 tl�e decedenYs lineal benefiaaries is 4.5 percent,except as noted in[72 P.S.§9116(aK1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedenYs siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined, under Secction 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. . REV-150'�EX+�,z_,z, SCHEDULE A pennsylvania DEPARTIJEM OF REVENUE WfRITANCE TAX RETURN REAL ESTATE �� ESTATE OF: FILE NUMBER: Melvin W Farner 21-13-0347 Ail real property owned sotely or as a tena�rt in common must be repo�ted at fair market value.Fair market value ia defined as the price at which properfy would be exchanged between a willing buyer and a willing seller,neither being compeiled to buy or sell,both having reasonabie knowledge of the r+elevant facts. Real properly 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 sdd. ITEM Include a copy of the deed showing decedenYs interest if awned as tenant in common. VALUE AT DATE NI�ABER DESCRIPTION OF DEATH 1. House, Cumberland County 10-20-1846-100 242,000.00 216 Reeser Rd, Camp Hill, PA 17070 Less Settlement Costs -21,744.00 TOTAL (Also enter on Line 1,Recapitulation.) S 220,25 6.00 3W4695 1.000 If more space is needed,use additional sheets of paper of the same size. � REV-150Ci EX+(&12) pennsyivania SCHEDULE B °��n�n�M°F�NUE STOCKS & BONDS INHERITANCE TAX RETURN RES�ENT DECEDENT ESTATE OF FILE NUMBER Melvin W Farner 21-13-0347 All property jointly owned with right of survivorship must be discloeed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTiON OF DEATH 1. Citigroup Global V1, 906161 Bond 9, 960.00 2 7906 shares A T & T Common Stock 286, 118.14 3 330 shares Alcatel-Lucent ADR 485.10 4 1637 shares CNB Financial Common Stock 28, 156.40 5 149 shares CenturyLink, Inc Common Stock 5, 152.42 6 1317 shares Comcast Corp Common Stock 33,346.44 7 35 shares Fairpoint Communications Common Stock 259.70 8 448 shares Frontier Communication Common Stock 1,760.64 9 320 shares General Electric Common Stock � 7,507.20 10 100 shares LSI Logic Corp Common Stock 684.00 � 11 81 shares NCR Common Stock - 2,218.59 12 149 shares Quest Corp Common Stock 3, 985.75 13 162 shares Teradata Common Stock 9,331.20 14 1868 shares Verizon Communications Common Stock 90,784.80 15 1111 shares Vodaphone Common Stock � 31,074.67 TOTAL (Also enter on Line 2,Rec�itulation) S 510,8 2 5.0 5 swaess�.000 If more space is needed,insert additional sheets of the same size , REV-1508 EX•(08-12) . pennsylvania SCHEDULE E DEPARTA�NTOF REVENUE CASH, BANK DEPOSITS & MISC. ��"�" PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Melvin W Farner 21-13-0347 include the proceeds of litiga�ion and the date the prooeeds were reoeiv�ed by U�e estate. All ro e oint owned with ht of survivorsh must be discbsed on Scheduie F. �M VALUE AT DATE NUMBER DESCRIPTION pF p�qTM 1 �. Sovereign Bank Certificate of Deposit 1,203.60 2 2002 Honda Odyssey Van 4,000.00 3 Cash on Hand and Household Items 1,000.00 4 State Farm Insurance (Auto Insurance Refund) 263.58 5 Bankers Life Insurance (Insurance Refund) 241.41 6 Central Penn Auto Club (Refund) 46.08 7 IRS (2012 Federal Tax Refund) 566.00 8 PA-American Water (Refund) 42.92 9 Comcast (Cable Refund) 100.62 TOTAL(Also enter on line 5,Recapitulation) s 7,4 6 4.21 3W46AD 1.000 If more space is needed,use additional sheets ofi paper of the same size. ' REV-15109 EX+(01-10) pennsylvania SCHEDULE F ��oF� IN-EF�TNJCETAXRETURN JOINTLY-OWNED PROPERTY RESIDEIJT DECEDEIJT ESTATE OF: FILE NUMBER: Melvin W Farner 21-13-0347 If an asset became Jointly owned within one year of the decedent's date of death,it must be reported on Schedule G. SURVMNG JOINT TENANT(S)NAME(S) ADDRESS RELAl10NSHIP TO DECEDENT q. Nancy L. Stockley 5 Wooded Run Rd, Dillsburg,PA 17019 Daughter g. Bradley A. Farner 304A Hillcrest Dr, New Cumberland, PA l�o�o Son C. Karen L Mateer 991 Mead Rd, Bellbrook, OH 45305 Daughter JOINTLY OWNED PROPERTY: tFnst DATE DESCRIPTION OF PROPERTY 96 OF DATE OF DEATH ITEM �,� MADE INCIUDE NAAAE OF FlN4NpAL INSTITUfIONMD BANCACCOWf I�ABER pR SIMILAR DATE OF DEATH pECEDENT'S VALUE OF NUMBER TEwwr JOINT IOB�111FlfIbG I�L��t A7TACH DEED FOR.JOIMLY F£LD REAL ESTATE. VALUE OF ASSET INIEREST DECEDENTS INTEREST 1. A. 04/29I2010 Belco Credit Union Checking Account 2,416.20 50.00 1,208.'10 2 A 04/29/2010 Belco credit vnion �ertificate of Deposit 10, 903.21 50.00 5,451.E1 3 A 04/29/2010 Belco Credit Union Savings Account 19,093.45 50.00 � 9,546.73 4 A 04/29/2010 Belco Credit Union Certificate of Deposit 65,353.74 50.00 32, 676.87 5 A/B/c Cabin, Huntingdon County 63,515.00 25.00 15,878.75 HCR Rt 475, Orbisonia PA 17243 8560.00 assessment x common level ratio X 7.42 = 63515 TOTAL(Also enter on Line 6,Rec�apitulation) S 6 4,7 6 2.0 6 3W46AE 1.000 If more space is needed,use additional sheets of paper of the sarne size. � REV 1510 EX+(08-09) pennsylvania SCHEDULE G DEPARTMENTOF REYENUE INTER-VlVOS TRANSFERS AND INHERITANCE TAX RETURN MISC.NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Melvin W Farner 21-13-0347 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 y�es. DESCRIPTION OF PROPERIY ITEM r�ct.uoen�ww�oFnfTwu�a�,n�ar�unors�aTO oec�rnw DATE OF DEATH %OF DECD'S DCCLUSION TAXABLE , NUMBE ?hE MiE OF iWV�BFBt ATT/�CIIACOPY OF ThE DEED FOR REAL ESTATE VALUE OF ASSET INTEREST a�u VALUE �. IRA, Belco Community Credit onion 11,542.56 100 11,542.56 2 Annuity, Allianz 67, 930.08 100 67, 930.08 Annuity Allianz 52,803.78 100 52,803.76 3 Annuity, Sun Life Financial 7,531.58 100 7,531.58 #KA00434723-1 TOTA�(Also ente�on line 7,Recapitulation)$ 13 9,8 0 8.0 0 If more space is needed,use additional sheets of paper ai the same size. 3W46AF 1.000 REV-1511 EX+(OB-13) ' • pennsylvania SCHEDULE H DEPAR'TNEIJTOF REVENUE FUNERAL EXPENSES AND NJI-ERITANCETAXRETURN ADMINISTRATIVE COSTS �sioENr oEC��Nr ESTATE OF FILE NUMBER Melvin W Farner 21-13-0347 Decedent's debts must be reporbed on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Myers Harner Funeral Home 13,021.00 1903 Market St, Camp Hill, PA 2 Rolling Green Cemetary, Interment 2,005.00 3 Funeral Luncheon 606.10 B. ADMINISTRATNE COSTS: 1. Personal Representati�re Commissims: 10,0 0 0.0 0 Name(s)of Personal Representativ�e(s�ra dl e y Fa rn e r Street A�dr�e.ss 304A Hillcrest Dr Ciiy New Cumberland State PA ZIP 17070 Year(s)Commission Paid: 2 013 ' 2. Attomey Fee.s: 3. Family Ezemption:(If decedent's address is not the s�ne as claimant's,attach e�lanation.) � Claimamt , Street Address C�Y State ZIP Relationship of Claimant to Decedent 4. Probate Fees: � � 4 3 3.5 0 5. Acxountant Fees: 4,0 0 0.0 0 6. Tax Retum Prepar�Fees: 9 0.0 0 7. Advertising � 223.53 Filing Fees 10.00 Recordings 47.00 � Misc Administrative Expenses 119.23 Storage, Moving, & Dumping Fees 600.51 Real Estate Taxes Less Reimb at Settlement 954.62 Verizon 7.30 PP&L 353.02 PA American Water 162.75 Hampden Twp Sewer less Reimb at Settlement 344.50 Service Oil 1,161.25 Lawn Care 946.00 TOTAL(Also enter on Line 9,R ' ation �ontinued to 2 sw��2.00o If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(pg..�3) ' • pennsylvania SCHEDULE H DEPARTi�MOF REVENUE FUNERAL EJCPENSES AND N�A�ERITANCETAXRETURN ADMINISTRATIVE COSTS �sioEnrr oEC�oErvr ESTATE OF FILE NUMBER Melvin W Farner 21-13-0347 DecedenYs debts must be reported on Schedule 1. ITEM NUMBER DESCRIP110N AMOUNT A. FUNERAL DCPENSES: 1. B. ADMINISTRATNE COSTS: 1. Personal RepresentaUve Commissions: Name(s)of Personal Representativ�e(s) Street Address C�tY State ZIP Year(s)Commission Paid: ' 2. Attomey Fees: 3. Family E�aemption:(If decedent's address is not the s�ne as claimanYs,attach e,�lanation.) � Claimant Street Address C�h State ZIP Relationship of Claimant to De�ent 4. . Probate Fees: . 5. Accountant Fees: 6. Tax Retum Preparer Fees: • . 7. Continued from pg 1 � 35,085.31 Maintenance to maintain estate's real property holdings 4,313.00 Real Estate Repairs 2, 992.00 Radon � 725.00 Cabin Maintenance 2,433.00 TOTAL(Also enter on Line 9,R 'ulation $ 4 5,5 4 8.31 swasH�2.00o If more space is needed,use additional sheets of paper of the same size. ' REV-1512 EX�(12-12) pennsylvania SCHEDULE I DEPARTIuENf OF REVENUE DEBTS OF DECEDENT, NrfRITANCE TAX RETURN MORTGAGE LIABILITIES�LIENS RES�EM DECEDENT ESTATE OF FILE NUMBER Melvin W Farner 21-13-0347 Report debts incurred by the decedent prior to death that remalned unpaid at the date of death,including unreimburasd medkal expensea. ��M VALUE AT DATE NUMBER pESCR�pTION p�p�q.� 1. Belco Community Cr Union Visa Credit Card 724.59 2 Wells Fargo Mortgage - Cabin 25$ owner 4,250. 90 3 Huntingdon County Real Estate Taxes (25�) 221.75 4 Verizon phone bill 8.58 5 PP&L utility bill 101.59 6 Pa American Water utility bill � 65.35 7 Comcast cable bill 97.66 8 Dr. Howard Cohen medical bill 57.03 9 PA Income Tax Balance Due 205.00 TOTAL(Also enter on Line 10,Recapitulation) s 5,7 3 2.4 5 3W46AH 1.000 If more space is needed,insert additional sheets of the same size. ' REV-1�13EX+(01-10) SCHEDULE J pennsylvania DEPARTIYEtJTOF REVENUE BENEFICiARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Melvin W Farner 21-13-0347 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEMNG PROPERTY Do Not List Trustae(s) OF ESTATE I TAXABLE DISTRIBUTIONS[Indude outright spousal disUibutions and transfers under Sec.9116(a)(1.2).] � Nancy L. Stockley Daughter 33.33 5 Wooded Run Rd, Dillsburg, PA 17019 Bradley A. Farner Son 33.33 304A Hillcrest Dr, New Cumberland, PA 17070 Karen L. Mateer Daughter 33.33 991 Mead Rd, Bellbrook, OH 45305 ENTER DOLLAR AMOUNT'S FOR DISTRIBUTIONS SHOWN ABOVE ON UNES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. �I NON-TAXABI.E 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-TN(�BLE DISTRIBUTIONS ON LINE 13 4F REV 1500 COVER SHEET. s 3W46AI 1.000 If more space is needed,use additional sheets of paper of the same size. LAST WILL AND TESTAMENT of MELVIN W. FARNER I, MELVIN W. FARNER, of Hampden Township, Cumberland County, Pennsylvania, being of sound mind, memory and understanding, do make, publish and declaze this t� be my Last Will and Testament, hereby revoking and making void a11 former wills, codicils and other testamentary dispositions by me at any time heretofore made. l. I cl�rect my Executor/Executrix, hereinafter named,to pay as soan as pra.cticable after my decease a1I my legally enforceable debts and the expenses of my last illness and burial. 2. I give,devise and bequeath alI of my esta.te whatsoever and wheresoever situate,unto my . �children,Karen Louise Mateer, Bra.dley Allen Farner and Nancy Louise Stockley, equally, share and share alike, provided they sha11 survive me by sixty (60) days. Should any of my children predecease me or die on or before the sixtieth (60�') da.y following rny dea.th, then and in tha.t event, I give, devise and bequeath the share of my estate to which he or she would have been entitled had he or she survived me by sixty(60}days unto his or her issue per stirpes. 3. I hereby nominate, constitute and appoint my son, Bradley A11en Farner, as Executor of this my�ast Will. If Bra.dley Allen Farner fails to qualify or ceases to act as Executor,then and in his stead, I appoint my daughter, Nancy Louise Stockley, as Executrix. If Nancy Louise Stockley fails to qualify or ceases to act as Executrix, then and in her stead I appoint my � . daughter,Karen Louise Mateer, as Executrix. � � . 1 4. I hereby direct that my personal representative and his successors sha11 not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I, MELVIN W. FARNER, the Testator, have hereunto set my hand and seal to this my Last Will and Testament on this day of ,2011. (SEAL) Melvin W. Farner Signed, sealed,published and declared by the above named Melvin W. Farner,Testator, as and for his Last Wi�l and Testament in the presence of us, who, at his request and in his presence and in the presence of each other, have hereunto subscribed our names as witnesses thereto. Witness . � Witness � 2 COMMONWEALTH OF PENNSYLVANIA : : ss. COUNTY OF CUMBERLAND : I, Melvin W. Farner, Testator, whose name is signed to the attached or foregoing instrument, havi.ng 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 to and acknowledged before �ne by Melvin W. Farner, the Testator, this day of ,2011. . � (SEAL) Notary Public COMMONWEALTH OF PENNSYLVANIA : : ss. COUNTY OF CUMBERLAND : We, and, � , the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law; do � � depose and say tha.t we were present and saw the Testator, Melvin W. Farner, sign and execute the uistrument as his Last Will, that he signed wiilingly and that he executed it as his free and voluntaiy act for the purposes 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 18 or more years of age,of sound mind and under no constraint or undue influence. Swom to and subscribed before me by and , witnesses, � this day of ,2011. Witness Witness � Notary Publ�c � 3 . � REV-485EX SAFE DEPOSIT BOX 1NVENTORY Page . . of INSTRUCT�ONS (1) Cash:Repon t�ta!oniy. (2) Stocks:List in detail every common or prefeRed certificate,warrant or other rights found in box.Stocks are to be designated by name of company,certificate number,date of certificate,name in which stock is registered,and numberof shares and dass of stock. (3) Obiigations of U.S.Govemment:Number of items,date of issue,face value,names in which registered and type of ownership, i.e.,join�y held„payable on death,etc. (4) Bonds:Designate by name,amount,serial number,or other designation.(Bearer Bonds) (5) Bank and Savi�gs and Loan Passbooks:State name of depositor,number of book,last date appearing in book,name of bank and branch,and balance. (6) Jewelry,Coins�Stamps�Manuscripts,etc:Ust and describe as fully as possibie. , (T) Deeds�Mortga�es,Curcent Insurance Policies or other evidences of indebtedness:List and describe as fully as possible. (8) All other conte�ts. , (9) Retum completed fonn to: OEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT.280601 . ' HARRISBURG,PA 17128-0601 REM N0. ITEM DESCRIPTION . --...___ ___�__.____ ,.___.___._ --- ---- �� ----•-------_._.�__._._______..._..---._____._..._.._.,__....___..__.__ ._.._._ . ......_ . ._�.. . CtrC��?i�'�?_3�r`8'm/dlvlZG.-2.a o(yYvX.�zu-r�C,t__�G ---------._.__._---..______. --� ��l��.�..e.�..,f?�,Q� � __---.------------. -- --�__ _� ' �� ` �o —"--_______._ , ____._._ ___...___...__. , ��7Q�-51�_.____ _. � ; � , -.------____.._._.._. � - � � ----_._ ._ ----- --- � '� - / �� ..�� ida .! � �' , ��,��1__.. . ... . --�-!-- - - _�c/?�,� � t G ----____.____...__._....__ __._.___. _____L. � � ' ' - � . � _�_._�.---- . . � ._ _ .____________ !-�-- � � Q _ ��.�_--- - .._____.. __ ._ . _. - !�- ` - � - � � � _ _ ��,,.�:,�C-- . _.�_.�-�.�,... _. t � �, �_ __d.��.' " . _. . .. . _ . ____....__ __.. �� ..._._..._____.__...._.. __.. _. ._. ��"� - �, --- ,-��1,►--5�=�o��-��- ��..�h��.�Y.�- Z —2_ , . � �3 - " ' 3 � _j?� � � ,� ' � — _ -, � . � . ----.__._.__._ ,/ 9 7 J'��d � �� y��/�C. . � .`...-'-r.-•._ !1�1 � PLC - ' " �.zz- � �ti 1 CERTIFY UFiOER NALTY PERJ RY THAT THE ove� oRfl rs PERSON RE EIVING COPY OF CORRECT AND COMPLET€TO�iHE ST OF MY KNOYVLEDGE AND BELIEF. SAFE DEPOSlT BO 1 ENTORY: � � SIGNATUR t � �� ; , � PRINT NAME AN APPR IATE BOX BEIOW: •— - .�'�_� ti...^-�-'- ... .--� _ 1�:-- ;.�__Z_--- ----------_-_-- ��_,��._��e�r_�-..____.__---._._. ---�--.- -. . .. �� OATE CHECK APPROPRIATE BOX: �3�- B�.� �lan� er' ��c�x, ❑,�s��c�, — . �� .L,�.-�� .+3�- ❑Eslate RepresentaUve �Joint ownar of safe deposit box NOTE:Att h�dditional �'1:"x 11"sheet(s)if necessary or use duplicates of thls page of form. The D�trnent is�by law,42 U.S.C.§405(cX2)(CK��to recNire d'�sdosure of Soaal Security numbers�oonnedion with admi�stering state tax laws.The Depa�trneM uses the Soc�Seaxily numbet to id�fj►fhef decedent and pe�sonat representatives of Ihe estate.The Corrwnonwealth may aiso use the infamation in exd�ange o#tax infamation agre�nents w�h Federal ard local ' autl�o�.The state law ibits Ihe Carxnornvealth's rsonnei from disciosi con6dendat tax mformation for off� REV-485EX : SAFE DEPOSIT BOX INVENTORY Page of fNSTRUCTIONS (1� Cash:Report totai only. (2) Stocks:List in detail every common or prefeRed certificate,waRant or other rights found in box.Stocks are to be designated by name of com�ny,ce�te number,date of certificate,name in which stodc is registered,and number of shares and dass of stock. (3) Obligations of!U.S.Govemment:Number of items,date of issue,face value,names in which registered and type of ownership� i.e.,jantly held,payabie on death,etc. (4) Bonds:Designate by name,amount,serial numbe�,or other designation.(Bearer Bonds) (5) Bank and Savings and Loan Passbooks:State name of depositor,number of book,last date appearing in book,name of bank and branch,and balance. (6) Jewelry,Coins,Stamps,Manuscripts,etc:List and describe as fully as possibie. (7) Deeds,MoKgages,Cunent Insurance Policies or other evidences of Indebtedness:List and describe as fully as possible. (8) All other cont�nts. (9) Return completed foRn to: DEPARTMENT OF REVENUE INHERRANCE TAX DNISION DEPT.280601 : HARRISBURG,PA 17128-0601 �M 1TEM DESCRIPTION NO. ��u C. ��a��.�� ' � • � � c/�J , �� — ..c ' R � / / � `f A, �10� i �ici7 - / � . �� t � � 1 � � � � ; ..� - ,� � � - . , _ $� �_�� Q 00 ' i _�_ �. - � � - 5 7 -z�-� :� � i37 ' - � - t CERTIFY UNDER PENALTY O,F PERJURY THAT THE ABOVE RECORD IS PERSON RECEIVING COPY OF CORRECT AND COIIAPLETE TO THE BEST OF MY KN0INLEDGE AND BEUEF. SAFE DEPOSIT BOX 1 NTORY: �(iNA ' SIGNATURE X �E NAME AND PR�RIATE BOX 8El W: �.�1'h � • L''�-Z. � -- e�Ri PRINT TITLE DATE CHECK APPROP TE BOX �Executor(Mx) ❑Administrabt(trbc) � - � �Estats Reprssentative ❑,�c o,��a�o��x NOTf:Attach additional 8'/:"x 11" heet(s)if nec ssary or use duplicates of this page of form. The D�artrnent is atAt►orized by law�42 U.S.C.§405(cK21tC�,to requine d�ure�Soaal Se.cuiity numbe�s in�on wrth adrrinistering state tax laws.The Depautrr�ent u5es ihe Sodal Sean'�y ntsribe��idenGfy tlie deoedent and personal rep�nta8ves of 1he eshate.The C�ortvnornweaith may atso t�se the infortr�ation it exc��ange of tax infortr�tion agree�r�ents w�h fede�al m�d laai ' aulhorities.The sta�e law ihe Comrnonwealth's nel from� confidential tax infortna�on fot offiaai OMB/pproval No.2502-0265 A. SETTIEMENT STATEMENT(HUD-1) B- TYPE OF LOAN • � �tYE�� Colonial Valle AbStf2Ct C0. �- FHA 2. RHS 3. CONV.UNINS. �* *�$ 216 E.Market St. a. ❑vA 5.G(I CONV.INS. 6.ESCROW FIIE NUMBER: 7.LOAN NUMBER: '�� 4� 01329532-001 MAH 1351355568 '"+��E�°'� York,PA 17403 (7�7)848_2g71 8.MORTGAGE INSURANCE CASE NUMBER: FINAL C.NOTE: This fam is fumished to give you a statement of adual setNement cosfs. Amounts paid b and by the setUement agent are shoHm. Items marked"(P.O.C.)'wiere paid outside the dosng;they a�e showr►i►ere for in/onr�afiona/puiposes and are raf inckKied ntt the totals o.wu�nE oF soRROwER: Robert Wie�bowski nooRess oF aoRROwER: 131 Lee Ann Court Enola,PA 17025 E. wanE oF sE��ER: Estate of Melvin W.Farner and Bradley A.Famer Executor n�oRESS oF sE��ER: 304A Hillcrest Dr. New Cumberland,PA 17070 F. NAME OF LENDER: Uflltefl WF10I@SaI@ MO(t9898,ISAOA nooRess oF�NOER: 1414 East Maple Rd. Troy,MI 48083 G.PROPERTY IOCATION: 216 Reeser Rd. • Camp Hill,PA 17011 Cumbe�land County 10-20-1846-100 _ 216 Reeser Road,Camp Hill,PA 17011 ►+.sErn�ENrncE�: Colonial Valley Abstract Co. (717)848-2871. PIACE OF SETTLEMENT: Z�G E.MB�I(@t St.,York,PA 17403 I. SErn�nnEwr DArE:10/21/2013 � PROw►noN a►�: 10/21/2013 DISBURS�Ewr oA7E: 10/21/2013 �• S RY OF BORROWER'S TRANSACTION K. SUMiMRY OF S0.LER'S TRANSACTION _. ....,, :�. ..,,..,, ,. ,_.. ;:^_ , � _ . �, �' � :$�' BZ, �� 'r� _ � `l;� :s�'= '� ��:�,ts.�,'��,„"�,�� _9e ',�, �. „.._ .. _. _ . . _ <,. .. , .. ... . . �- 101. Corrtract Sales Price 242,000.00 401. Contrad Sales Price 242,000.00 102. Personal Property 402. Personal Property 103. Settlement cha►ges to BoROwer(line 1400) 7,317.93 403. 104. 404. 105. 405. ADJUSTMENTS FOR REMS PAID BY SELLER IN ADVANCE: ADJUSTMENTS FOR lTEMS PAID BY SELLER IN ADVANCE: 106. C' lTown Taxes 10/21/13 to 12/31/13 12.14 406. C' lTown Taxes 10/21/13 to 12/31/13 12.14 107. Coun Taxes 10/21/13 to 12/31/13 86.53 407. Coun Taxes 10/21/13 to 12/31/13 86.53 108. Assessments 408. Assessments 109. School taxe 10/21/13 to 06/30/14 1,216.95 409. School taxe 10/21/13 to O6/30/14 1 216.95 110. Sewer 10/21/13 to 12/31/13 88.90 410. Sewer 10121/13 to 12/31N3 88.90 111. Refuse 10/21/13 to 12/31/13 31.75 411. Refuse 1021/13 to 12/31/13 31.75 112. . 412. • 113. 413. 114. 414. 115. 415. 120. GROSS AMOUNT DUE FROM BORROIIYER: . 250,754.20 420. GROSS AMOUNT DUE TO SELLER: 243,436.27 .,... _ .... ,.. . � ;� f;�� `��,�°� 201. Deposit or eamest money 2,000.00 501. Excess de � see instrudb�s) 202. Principal amount of new loan(s) 229,900.00 502 Settlement charges to Seller(line 1400) 14,699.05 203. Existing loan(s)taken subjed to 503. Existi loan(s)taken� ' to 2U4• 504. Payotf of first m ban 205. • 505. Payoff of second mo age ban • 206. Seller Paid Closing Costs 7,200.00 506. Seller Paid Cbsing Costs 7,200•00 207. 507. 208. 508. 209. 509. ADJUSTMENTS FOR(TEMS UNPAID BY SEILER: ADJUSTMENTS FOR ffEMS UNPAID BY SELLER: 210. CityfTown Taxes 510. C' lTawn Taxes " 211. County Taxes 511. Coun Taxes � 212. Assessments 512. Assessments 213. 513. 214. 514. � 215. 515. 216. 516. 217. � 517. 218. 518. 219. 519. 220_ TOTAL PAID BYIFOR BORROWER: 239,100.00 52Q TOTAI REDUCTIONS IN AMOUNT DUE 3ELLER: 21,899.05 _ ., .�_, , . _, ... .,- ,�:: 301. Gross amount due ftom Borrower(line 120) 250,754.20 601. Gross amount due to Selle�(line 4201 243,436.27 302. Less amount paid by/for Borrower(line 220) 239,100.00 602. Less redudion in amount due Seller(line 5201 21,899.05 303. CASH(�FROM� ( ❑ TO)BORROYVER: 11,654.20 603. CASH(❑ FROM) (� TO�SELLER: 221,537.22 T►�e Pubic RepoRing Burden for this colle�on of information is estimated at 35 minutes per response fof aolleding,reviewing,and repoRing the data. This age�y may not collect this information,and y�ou are not required to complete this form,unless it displays a curre�rtly vafid OMB control number. No c�onfider�tiality is assured;this discbsure is mandatory.This is designed to provide the part'�es to a RESPA aovered transaction with information during the settlement process. • L SETTLEMENT CHARGES ESCROW FILE NUMBER: 01329532-001 MAH ,�7A0��T� � E��11 �'8�yd1�E FEfS ,. �,�;�.�x � y�x�,� ��,� ,�� :Y-.�tt��, - - _ �:a 3, .-.>-�1r��._., z� ,5�:..'.. �._+.::.. ,.e..--. ��.' ..'�-'>-. . .,'3,.. ,±,:�'�?#. �.$,.x�3 .rv','°'N.,s`�r ,c'e-::r, ,"'„'Se°',y' ..6z,h,.. ... :�:�: �, .'?r'F£`�-"`.,;-:kz X : � , DMSION OF COMMISSION(LINE 700)AS FOLLOWS: PAID FROM PAIO FROM BORROWERS FUNDS SELLER'S 701. 55,870_00 fo Keiler Williams oi Centrai PA AT SETTLEMENT FUNDS AT 702. 55,870.00 to Keller Williams of Central PA SETTLEMENT 7p3. Commission paid at settlement 11,740.00 704. Transac�ion Fee to Ke11er Williams 295.00 705. �ransac6o�Fee to Ke11er WiNiams CeMral PA 250.00 �.,..: _. . r .. , � ,-. � � ,�.. �` ,;-�.� S�,+T";5:"; `�y k��Mt��41�:. a��P. �."` T i�y ti z. . 3>v, �:� �-�.��.<z , �� 's�� ^"�,�-t x-�a �� 801. ��9inedon chatge Y 53,393.00 (hom GFE s1) �£� gp2_ Your cred'd or charge(pants)for the speci6c interest rate drosen (52,710.52j(irom GFE e2) 803. Your adjusted origination charges (trom GFE A) sg2 48 804. Appraisal tee to Class Appraisal �rrom GFE�p) (475.00lB SO5- Ctedit repOR to Cfedit Plus (hom GFEl3) 20.00 806. Tax service (trom GFE 1Ci) 807. Flood ceAification to Corelog�Flood Services (��) 12.00 808. 809. 810. ,.. _ . ,. _ ., � , , ��.t�. :, x,��`�� ;• < ,.��.�� ;:::. _��a t _ �'��-�"; � �� `� ��'" "�a �. ...,. <'.:� i�. , .., Y � ..' . '..��.. . . �:. .. . .....:'.. ., ..�� .. 7 .: 901. Da�y interest c�►arges (from c�e�rt� 311.78 irom 10/21/2013 M 11/1/2013�528.3438!day 4.5000%(11 days) 902_ �rt9a9e insurance premium tor 0 monih{s) (rrom GFE a3) . 903. Hmneovmers insurance for 1 year(s)to Mstate (fran GfE�111) 473.06 904. 905. �: . . , � _.. ��.'" ricc. .> " ." ,� S 4�;�t�'`��'w t ,. ^ �t�r ''� fi s�1,&"�i�,�� r .� ��' �::��, '� t��:� . ,.'. y«.�q�. `�,c.�. �;'h`3�°4 _.�.,. .. _. .�:., . �00�. �n1f32� . .. . . , . „�:- ..._ , , .: deposit tor your esaow axount �tram c�Fe*s) 697.25 1002. �rs insura�ce 3 months�S 39.42 per month 5118.26 1003. �9e insuranCe monthg�S 128.38 per morrth l 00d• �i1Y ProPertY taxes 9 months�t 5.31 per month i47.79 1005• County property taxes 9 montl�s�S 37.82 per month i340.38 1006. Annual assessments months�i per monih 1007• School texes 5 months�i 149.88 per montti 5749.40 1008• montha�i per month 1009. A99�9ate ACd.Rdj. months�i per momh -i558.58 - � _. .;., -• � .,. ',:.��;.�,.: ��, -;�"'�"��"��,`s" , z � . s� L�.�'�' � � �i«� �,°�r�r�, ��.� .. •, ,� ,;, � re. � i.:. � .�h'e � 3., 1101. Title servbes and knder's dtle insurance�o Cobnial Valtey Abstrad Co. (trom GFE�t) 2,056.00 •1102. Settlement or closing fee • 1103. Owners tltle insurance to Coloniai Valley Abstract Co. �trcm�,rs� �.pp 1104. lenders tltie insurance•to Colonial valiey Abstract co. s1,55o.00 1105. ��s Ude policy limit 5229,900.00 Otd RepubBc Natior►al Title 1106. �er's tlde policy limit 5242.000.00 Oid Repudic Nadonal Title 1107. �s portion of the toRal tide insuPance premium 51.632.85 to Colonial Vapay Abstrac�Co. � 1108. Undervvrite�'s portion of the botal tltle insura�e Premlum 5288.15 �p Old Republic National Title . 1109. Ends.100,300,8.1,1030•to Colonisl Valiey Abstract Co. 5311.00 . 1110. Inaurod Cbsing Let�r•to Old Republic Natlonal TiUe 575.00 1111. Nofary Fees•to MaRha A.Hom i50.00 24.00 1112 "See aUached ia breakdovim 570.00 110.00 , � _:... _.. . .._ .. ., . 'e � �:a ��y d f�� 4��"=d 3 , .- .._ �,.. .�`,c.ti�,:f; `��,..��s c-„x:.:.. . . ... ,_. .. . :a ..-..._ ,..�- . . <. �. . ° . .��.. .... �.a ;:; . .... 1201. Govemmer�t recordinp charges prom G�s7� 156.00 1202. ��7.� �9a9e 589.00 Release 50.00 1203. Tranffer tazes (trom��e) 2,420.00 1204. CNy/Counry taxlstamps Deed i2.420.00 Mor�age to.00 1205- State taxlstamps Deed 52.420.0o Nbrtpage to.00 2,420.00 1206. ' 1207. - »--<�< � „��.,._ �u �� . - �3k. .:..:15Rj ..k 'Y"'ix4. .A?;'�14 A�x:C lxF�'�.�. ��T 1301. Raquited aenrices thnt you can sFaP� (trom GFE�s� 128.36 1302. 4th Qtr.Sewer to Hampden ToYVnship UUNtles 155.05 1303. Nbrtgage Insurance Premium•to Radian i128.38 1304. 1305. 1306. . � 1400. TOTAL SEITLEMENT CHARGES(Enter on line 103;SecBon J-and-line 502,Section Iq 7,317.93 14,699.05 I have carei�ly rovieMred th�H�,ID-1 Setf�merrt Stat nt and b the best of my knowledge and belief,it is a true arni axurata stalement d aA reoeipls and disbursements made on my acaount or by me in this�ran�adion. I.�ir�er t�have received a copy of the HUa1 Set9em�t Statement. � � � -, ��'',.'�' � ..�.. ��, �r�:-'°�� f.:. �-'"'��-�v `..��-`��I` RolSeR Wierbowsk�" � Estate of MeMn W.Famer ��. ��^-�_'°'�. �.��- �"X��v�--- eorrowers Bradley A.�`amer Executor SeNers The HUD- Set ment State nt wh ich I have prepa d is a true and accurate accour�t of this transadion. I have caused or w�cause the fund s b be disbursed in axadancewfth this stateme - �! �� ! /' ,� V�T� SettlementAgeM / ,� Date Coloniai Valle Abst�act Co. WARNING K is a crimeto krwwingiy malae false statements b Q�e United States on riis orany sim'iarform.Penal6es upon oonvictioncan include a fine and imprisonment Fordetads � see:Trtle 18 U.S.Code Section 1001 and Sed'an 1010. Escrow Number. 01329532-001 MAH ' , �=s��ai�s9��of.�o4d �'� �atiinaf,�K(�E�1 aKct�l�[3..��'` `a�,,�''��r�,-��'�`��,� ° �:� cf�:��th' tin�i�� *��s�C1D 1 � . v�,.;. ,..� �_ ��: �;:, , , ,� � , _., Charges That Cannot Increase HUD-1 Line Number Our origination charge #801 3,393.00 3,393.00 Your credit or charge(points)for the specfic interest rate chosen #802 -2,710.52 -2,71U.52 Your adjusted origination charges #803 682.48 682.48 Tra�sfer taxes #1203 2,420.00 2,420.00 ��;, i ��I118��OLa��Vi�T1 � ��,1�.�V�Y�,.`.'i.a, ,��.�`�A`Ys.�` � 'FSU11�.a�w� � '"'� ��-�4..:.�P� 'i . z�*ix �3 s Govemment recording fees #1201 218,� ��.pp Appraisal fee #804 475.00 475.00 Credit report #805 20.00 20.00 Fbod certifiption #807 12.00 12.00 Tdle services and lenders title insurance #1101 2,080.00 2,056.00 Owners title insurance #1103 24g,pp �.pp � # � Total 3,053.00 2,785.00 Incr�ease beiween GFE and HUD-1 Charges $ -268.00 or -8.7783°� �-;��. . � �, ��f��..,•,. �, � t��l��: �� r�,��,�`��;�, ..� �: _ ">.��s �.pa��;�j�� ` ` �;';��,,,�: In�ial deposit for your escrow account #1001 1,406.74 697.25 Daly interest charges #901 S 28.3438/day 311.7g 311.7g Homeennmer's insurance �t903 0.00 473.06 Mortgage Insurance Premium �1303 0.00 128.36 # # Loan Terms . Your initial loan amount is y�g,gpp.pp . Your loan tertn is 3p years Your initial interest rate is 4.5000°i6 Your initial monthy amount owed for principal,interest,and any �1,293.23 indudes mortgage insuranoe is �X Prinapal xQ Interest � x❑Mo�tgage Insurance Ca�your interest rate rise? x❑No.� Yes,�can rise to a maximum of O.Q000%.The first change wiq be on and can change again every afEer.Every cha�ge date,your irrterest rab can inaease or dep�eage by 0.0000%.Over the li�e of the loan,your irrte�t rate is guaraMeed to never be lawer than 0:0000%or higher than 0.0000%. Even if you make your payments on time,can your loan balance rise? X�No.� Yes,�pn riae to a maximum of s 0.00. Even if you make your payments on trne,can your monthly amour�t x❑No.� Yes,the fi�st increase can be on and the monthly amount owed owed for principal,interest,and mortgage insu�ance rise? - can rise to S 0.00. The maximum R can ever�ise to is s 0.00. Does your loan have a prepayment penalty? xQ No.� Yes,your ma�amum prepaymerrt penalty is$0.00. Does your loan have a balloon payment? xQ No.❑ Yes,you hav�e a balioon payment of$0.00 due in 0 years on. Total monthly amourrt owed'mduding escrow account payments �You do not have a montMy escrow paymeM fa items,such as property . taxes and homeovvner's nsuranae.You must pay these items directy yourself. X[]You have an additional mo�dhly e�row payrnent of$23�2.43 that resuns in a total initial moMhy amount owed of S 1,525.66.This includes principal, - irrterest,any mortgage insuranae and any�ems checlaed below: [�X Property taxes ❑X Homeowners insurance ❑Flood insurance []x School taxes ❑ ❑ Note:If y�ou have any questions about the Settlement Charges and Loan Temis listed on this form,please contad your lender. .,�..�_..__��..-------�--.... _. Escrow Number. 01329532-001 MAH . HUD 1112 DETAILED BREAKDOWN OF ADDITIONAL TITLE CHARGES • Detai Seiler Description Amourrt Amount � 1113.Wire/EDD•to Colonial Valley Abstract Co. �50.00 1114.Ovemights•to Colonial Valley Abstract Co. $20.00 1115.Deed Prep to Coloniai Valley Abstract Co. 100.00 1116.Tax Cert.Fee to Colonial Valley Abstract Co_ 10.00 Total as shown on HUD page 2 Line#1112 110.00 HUD 1200 DETAILED BREAKDOWN OF GOVERNMENT RECORDING AND TRANSFER FEES �� Buyer Seller Amount Amount City 8�County TaxlStamps City TaidStamps: Deed $2,420.00 Total as shown on HUD page 2 Line#1204 2 420.00 . Buy�er Seller Amount Amount State Ta�dStamps State Tax/Stamps: Deed $2,420.00 Total as shown on HUD page 2 Line#1205 � 2 420.00 � .,�...�.......,a:.�____--_�__...._ ..---•--• ...._ . • f ESTATE OF MELVIN W.FARNER DATE OF DEATH VALUES-MARCH 20,2013 Per share #of Date of Date of shares Death Value Death Value � A T&T 7,906.00 36.19 286,118.14 Alcatel-Lucent ADR 330.00 1.47 485.10 CNB Financial 1,637.00 17.20 28,156.40 CenturyLink, inc 149.00 34.58 5,152.42 Comcast Corp 1,317.00 25.32 33,346.44 Fairpoint Comm 35.00 7.42 259.70 Frontier Communication 448.00 3.93 1,760.64 General E{ectric 320.00 23.46 7,507.20 LSI Logic Corp 100.00 6.84 684.00 NCR 81.00 27.39 2,218.59 Quest Corp 149.00 26.75 3,985.75 Teradata 162.00 57.60 9,331.20 Verizon Communications 1,868.00 48.60 90,784.80 Vodaphone 1,111.00 27.97 31,074.67 TOTAL � � 500,865.05 . a.,.�.--.� ?�w� !-ti+Q.c1�.. . �� t�5-O��S Allianz Life Insurance Company ,� of North America �1��nz �l� PO Box 59060 Minneapolis, MN 55459-0060 � 800.950.1962 , April 1, 2013 NANCY STOCKLEY C/O 216 REESER RD CAMP HILL PA 17011-1923 Re:Annuity Contract Number(s):70488320 and 70510505 Dear Nancy Stockley: We sent you this letter because you are the named beneficiary of Melvin Famer. Please accept our sincere sympathy on your loss. Listed below is information needed to file a claim for benefits on the fi3ced annuity contract number(s). � Payment Options Choose one of the options on the claim form. � . • IMPORTANT NOTICE: In accordance with the Intemal Revenue Code and�ontract provisions, if annuifization is selected,the first annuity payment must be received within one year from the date of death for non-qualified funds and by December 31�following the year of death for qualified fiunds.After these dates,this option is no longer available. . �✓ , . �� y ? � z�-�; . � Contract tnformation � Su►cY�mden vAU�t�t, • Contract Number Annuitiza#ion Minimum Payout Cash Tax Status Value Period Value 70488320 �28,830.49 5 years $22,643.36 Non-Tax-Qualified 70510505 $22 5 years $17,fi01.26 � Non-Tax-Qualified / �3 Y �2'-�� Contract va/ues ar+e affected by withdrawals,partial surrenders, loans, and market value adjustments;as a result, values quoted in fhis letter may increase or decrease and are not guaranteed. Claim Re4uirements • Copy of the certified death certificate{only one copy is required for the deceased) . • Fixed Annuity Claim Form � , Once we receive your claim requirements, allow 15 business days for processing. For more infonnation or assistance: please contact me at 800.950.1962, Monday through Friday, 8 a.m.to 5 p.m. Central`fime or the agent of record. Thank you, in advance,for your prompt response. We look forward to serving you. Sincerely, Cheryl McCollam(ext 36261) Claims Case Manager LCL-1005 r 8.31.2012 2012-13 � �}efilllS�/�.1/a�'"i'�a TENTATIVE Jul 1, 2 012 DEPARTI�tENT OF REYEldU� y REALTY TRANSFER TAX 2011 CObIlKON LEVEL RATIO REAL ESTATE VALUATION FACTORS The following real estate valuation factors are based on sales data compiled by the State Tax Equalization Board in 2011. These factors are the mathematical reciprocals of the actual common level ratio (CLR) . For Pennsylvania Realty Transfer Tax purposes, these factors are applicable for documents accepted from July 1, 2012 to June 30, 2013, except as indicated below. The date of acceptance of a document is rebuttably presumed to be its date of execution, that is, the date specified in the body of the document as the date of the instrument (61 Pa. Code � 91.102) . COUNTY C� COUNTY C� COUNTY C� �_ �,_ �, ToR Adams (1) 1.00 Elk 2.16 Montour 1.16 Allegheny 1.17 Erie 1.18 Northampton 2.66 Armstrong 2.41 Fayette 1.26 Northumberland 3.35 Beaver 2.94 Forest 3.57 Perry (1) 1.00 ' Bedford 1.27 Franklin 7.04 Philadelphia(2) *3.97 Berks 1.28 Fulton 2.48 Pike 3.90 Blair 5.95 Greene 1.34 Potter 2.52 Bradford 2.97 �Huntingdon 7.42 Schuylkill 1.79 . Bucks 9.24 Indiana 3.85 Snyder 4.84 . Butler 5.90 Jefferson 1.92 . Somerset 2.41 Cambria 2.91 Juniata 5.38 Sullivan 1.53 Cameron 2.02 Lackawanna 5.12 Susquehanna 3.06 Carbon 2.10 Lancaster 1.27 Tioga 1.36 Cent�re 3.47 Lawrence 1.03 Union 1.20 Chest�r 1.69 Lebanon 6.13 Venango 1.00 Clarion 2.89 Lehigh 2.80 Warren 2.73 Clearfield 4.95 Luzerne 1.00 Washington 3.27 Cli.nton 1.03 Lycoming . 1.25 Wayne 1.19 Columbia 3.60 McKean 1.33 Westmoreland 4.40 Crawford 2.29 Mercer 2.77 Wyoming 4.99 Cumberland(1) 1.00 Mifflin 1.80 York 1.16 Dauphin 1.37 Monroe 4.09 / Delaware 1.38 Montgomery 1.61 (1) Adjusted by the Department of Revenue to reflect an . assessment base change effective January 1, 2011. (2) Adjusted by the Department of Revenue to reflect STEB appeal decision issued on April 21, 2012. * Tentative factor for 2011 is not yet available. Page2of3 2012-13 DEVIATIONS FROM 1% LOCAL TRANSFER TAX Last Amended OS/23/2012 T'he Realty Transfer Tax in Pennsylvania is generally 2%of the sales prices; 1%to the state and 1%to local government. Some local Governments vary their portion. The following is a list of localities that impose something other than 1%. These figures represent the local portion only;the 1%state portion must be added for the total amount due. ALLEGHENY COUNTY CLINTON COUNTY • Bellewe Boro— 1%2% • Colebrook Twp.—'/2% • Bethel Park Municipality— 1'/z% • East Kating Twp.—'/z% • Greentree Boro— 1'/z% • Hampton Twp.— 1 I/z% � DELAWARE COUNTY • McCandless Twp.—1%Z% • Radnor Twp.— 1%z% • McKeesport City—2% • Upper Providence Twp.—2% • Monroeville Municipality— 1%Z% • Mt Lebanon Municipality— 1%z% ERIE COUNTY • Mt Oliver Boro—2% • Edinboro Borough— 1%z% • O'Haza Twp.— 1'/z% • Penn Hill Municipaiity—2% LACKAWANNA COUNTY • Pine Twp.—1'/z% • Scranton,City of—3.3% • Pittsburgh,City of�/Pittsburgh LUZERNE COUNTY • School Distnct—3/o • Pittsburgh,City of/Baldwin- • I�ingston Boro— 1%z% Whitehall School District—2'/z% • Wilkes Barre,City of—2%z% • Upper St.Clair Twp— 1'/z% . • West Deer Twp.— 1%z% MERCER COiTNTY • Whitehall Boro— 1'/4% • Farrell,City of—2% • Hermitage,City of— 1%z% BEP;KS COiJNTY • Sheakleyville Boro—0% • Reading,City of—4% PHILADELPHIA COUNTY CENTItE COUNTY. • Philadelphia,City of—3°/a . • Fergusen Twp.— 13/4% • Sta.te College Boro— 1 3/a% SOMERSET COUNTY • Taylor Twp.—%2% • Wellersburg Boro—'/z% CHESTER COUNTY WASHINGTON COUNTY • Coatesville,City of—2% • Peters Township— 1'/z% � • Tredy�'rin Twp.— 1%z% Page3of3 ,, , , 2012-13 �� A flivision of�hio Bar�it1e Insuran�e Campany A F'irstAmerican Co�any Title Alert 2012-13 �uiy 5, 2012 Reaity Transfer Tax Common Levei Ratio Factors & Local Deviations Purpose: To advise that the Pennsylvania Department of Revenue issued new Common Level Ratio Real Estate Valuation Factors effective July 1, 2012 through June 30, 2013, and to provide local deviation information. Background: The Commonwealth of PA State Tax Equalization Board ("STEB") establishes a common level ratio of assessed value to market value for each county for the prior calendar year. The new factors are issued at the July 1 effective date each year. Advisory: The attached Common Level Ratio Real Estate Valuation Factors took effect July 1, 2012 through June 30, 20'I3. � Also attached is our list of realty transfer tax deviations from the general 1%tax due to � localities (in addition to the 1% always due to the Commonwealth of Pennsylvania). Please be reminded to inform us of any modifications to these local deviations so that we can keep our list as up to date as possible. We thank you for your continued cooperation. Note: Under the Approved Attorney system,the scope of our relationship is limited to the functions of underwriting and the issuance of title insurance policies on your behalf and does not include closing or escrow services. We sometimes provide information and recom mendations with regarcl to your closing or escrow business as a cou�tesy to you. Moreover,some communications,depending on w hether noncom pliance could im pact on liability under our policies or closing protection I etters, should be considered directives. T his Advisory is being provided to you with those considerations in mind. WARNING:this Underwriting Communication is in#ended solely for the employees of Penn Attorneys/4hio Bar Title Insurance Company and its Approved Attorneys,and is not to be distributed to third parties,and any reliance by any other person or entity is � unauthorized.This Underwriting Communication is intended solely for the purpose of underwriting policies of Ohio Bar Title Insurance Company. � 900 State Street,Suite 320, Erie, PA 16501 (800) 352-2216 FAX(800)2342352 Pagelof3 • HUNTINGDON COUNTY ASSESSMENT OFFICE � ` � � � 233 PENN STREET 06/20/2012 HUNTINGDON PA 16652 � ' � 2013 PHONE: 814-643-1000 '' ' � ' 45-07-26 � . • � s SPRtNGFtELD TOWNSHlP . , ` . 21774 T69 P1 Ratio change from 40%to 8096 STOCKLEY CHRIS A ET AL 5 WOODED RUN DRIVE DILLSBURG,PA 17019-9114 I �� II� � I �� I I �� I � I� � il �� 1�1� i il il lillilil I I I III i�i i I I i �i I lii�i THIS IS I�OT A TAX BILL THE ASSESSMENT OF REAI ESTATE AS DESIGNATED BELOW HAS BEEN CHANGED IN VALUA710N. IF YOU ARE A6GRIEVED BY SUCH CHANGE, PLEASE NOTIFY THIS OFFICE. THE LAW PROVIDES FOR YOU TO APPEAL TO THE BOARD FOR RELIfF BY FILING A WRITTEN STATEMENT OF AN INTENTION TO APPEAL WITHIN 40 DAYS OF THE MAILED�ATE ON THIS NOTICE. THE STATEMENT MUST INCLUDE THE REASON BY WHICH SUCH PERSON IS AGGRIEVED AND THE ADDRE55 TO SEN�NOTICE OF THE TIME AND DATE OF APPEAL HEARING. FORMS FOR APPEAL ARE AVAILABLE FROM THE ASSESSMENT OFFICE OR AT HUNTINGDONCOUNTY.NET. ' $� $� . $� ' $6,520 $13,040 $6,520 $6 920 13 840 6�920 **The new assessed value of your prop represents 80% ppraised 1978 market value. To dete�mine 1978 marice�value,multiply by 1.25 1. Why is Huntingdon County changing the Predetermined Ratio? The court could order a reassessment or a taxing district could sue to force a reassessment due to needing court approval for their miilage rate at the current 40%ratio.The Ratio Change is the most cost effective method to remove the requirement for court approval for the county millage rate. Huntingdon County and at least one other local municipality have reached the general fund mitlage rate limit established by the Pennsylvania Legislature.The Commissioners are now required to receive court approval each year to maintain the current millage rate.The options available to the County are either to change the Predetermined Ratio or complete a countywide reassessment at a cost of approximately 3 million dollars. � " 2. Will the Ratio Change increase my taxes? No.. Pennsylvania law requires that a change in the Assessment Ratio must be tax revenue"neutral"to the County, al1 school districts and municipalities in the year after the ratio change. Each taxing district is required to reduce their 2013 millage rates to offset the increase in assessed value in their district so that the ratio change itself does not result in tax increase. � vania law does ermit Huntingdon County and the other taxing districts to increase their total real estate tax Pennsyl P milla e b u to 10%for 2013;however this has to be done with a separate vote after adopting a revenue neutral 8 Y P millage rate. Example of the changes between the 2012 and 2013 assessed values 2012: • HU�I1TINfiDON COUNTY ASSESSMENT OFFICE • • � �a 233 PENN STREET 06/20/2012 HUNTINGDON PA 16652 . PHONE: 814-643-1000 2013 .. . . � � 45-07-25.1 . � � � 22607 MADDENSVIILE PIKE : �" *• : + 21773 T69 P1 Ratio change from 4096 to 8096 STOCKLEY NANCY ETAL 5 WOODED RUN DRIVE DILLSBURG, PA 17019-9114 iiilii��flliiiiii�li�iilil�llii��lii�i�ili��i��i��i�i�i� THIS IS NQ�ATAX BILL THE ASSESSMENT OF REAL ESTATE AS DESIGNATED BELOW HAS BEEN CHANGED IN VALUATION. IF YOU ARE AGGRIEVED BY SUCH CHANGE, PLEASE NOTIFY THIS OFFICE. THE LAW PROVIDES FOR YOU TO APPEAL TO THE BOARD FOR RELIEF BY FILING A WRITTEN STATEMENT OF AN INTENTION TO APPEAL WITHIN 40 DAYS OF THE MAILED DATE ON THIS NOTICE. THE STATEMENT MUST INCLUDE THE RfASON BY WHICH SUCH PERSON IS AGGRIEVE�AND THE ADDRESS TO SEND NOTICE OF THE TIME AND DATE OF APPEAL HEARING. FORMS FOR APPEAL ARE AVAILABLE FROM THE ASSESSMENT OFFICE OR AT HUNTINGDONCOUNTY.NET. $2� $560 ` $280 $1�360 $2,�� $1,3fi0 $1� 3 280 1640 . • **The new assessed value of your pr represents 80 appraised 1978 market value.�To determine 1978 market value,multiply by 1.25 1. Why is Huntingdon County changing the Predetermined Ratio? The court could order a reassessment or a taxing district could sue to force a reassessment due to needing court approval for their millage rate at the current 40�ratio.The Ratio Change is the most cost effective method to remove the requirement for court approval for the county millage rate. Huntingdon County and at least one other local municipality have reached the general fund miliage rate.limit estabiished by the Pennsylvania legislature.The Commissioners are now required to receive court approval each year to maintain the current millage rate.The options available to the County are either to change the Predetermined Ratio or complete a countywide reassessment at a cost of approximately 3 million dollars. 2. Will the Ratio Change increase my taxes? � • No.Pennsylvania law requires that a change in the Assessment Ratio must be tax revenue"neutral"to the County, all school districts and municipalities in the year after the ratio change. Each taxing district is required to reduce their 2013 millage rates to offset the increase in assessed value in their district so that the ratio change itself does not result in tax increase. Pennsylvania law does permit Huntingdon County�and the other taxing districts to increase their total real estate tax millage by up to 10%for 2013; however this has to be done with a separate vote after adopting a revenue neutral millage rate. , Example of the changes between the 2012 and 2013 assessed values 2012: . Ilnrnn��.�� .�. 1 A'!A .........I...a....1.... �t�'1n nnn . DEC-12-2013 05:55A FROM: T0:5331442 P.2 ��. : $UII .•' Life Financial' Sun llte Aeaurance Company of Caneds(U.S.) CHECK NO. 8�115805 October 3, 2013 Bradley A Farner - 304A Hillcrest Dr �' New Cumberland, PA 17070-3039 �� ' RE: Policy Number: KA00939723-1 Claim Number: CL-239029 Deceased: Melvin W �arner _ Dear Mr. Bradley A Farner: Enclosed is a check in the amount of $6, 778.92, which represents the claim settlement of this contract. The following information is for your records: Death Benefit: $7, 531.58 Federal Tax Withheld: 5753.16 You will receive an I.R.S. tax form from us in February of next year. This form will show any taxable portion of this distribution, alonq with the tax withheld, as shown above. If you should have any questions concerning this matt�er�please feel free to contact our offices at (800) 36�7-3653. Sincerely, Claims Administration Department . 1. 2013 10:40AM � No. 003b P. 3 w��M�es,►�. MAC X2302-02W 1 Hoiue Cslnpua Dea Moines,IA 50328-0001 Ct3STOMER ACCOUNT ACTIVITY STATEMENT , DATE 06/07f13 REQ BY' MA4 PAGE 2 � DALE E MAT�ER LOAN NUMB�R: 3340464 ACTYV�'Z'Y FOR PERIOD 12/07/12 - 06/06/13 PROCESS DUE TRANSACTIOI�T TRANSACTION . EFFECTIVE DATE DATE n�,TE CODE D�SC�IPTION OF TRANSACTYON ��r r�.��.w��.�w��.��r��rr�� TRANSACTION PRY1�. PA�p/ ESCROW PAIDf ----„------OTHER------------- AMQUNT BALANCE INTEREST BALANCE� AMOUNT CODE/DESCRIPTION ��r��'��1 1��r�/�� 04-02-13 06-13 175 PRZNCIPAL PAYNlENT 15.26 15.26 0.00 � 0.00 16,854.62 NEW PRINCIPALjESCROW BALANCES 04-02-13 05-13 373 PAYMENT 314.74 1X8,46 99.10 97.18• 16,869.88 � 583 .•86 NEW PRINCIPAL/ESCROTnT B�ALANCES � J3-21-13 OS-13 175 PRINCIP�, P�,YMENT 15.26 15.26 0.00 0 ,00 1,6,988.34 N'�W PRINCIPAL/ESCROW BALANCES 0 3-21-13 04-13 17 3 PAYNlENT . . � 314.74 7.69 - 99..87 97.18 • . 17 0 ' �,��`l� 486.68 l�w PRzNCIPAL/ESCROW HAL►ANC�S C3-12-�3 03-13 3 HAZ xNS , 483.00- 0.00 0.04 483 .00- 389.5p N�W PRINCIPAL/ESCROW BALANCES 02-25-13 04-13 175 PRINCIPAL PAYMENT 02-22-13 15.26 15.26 � 0.00 0.00 17,121.29 ' . NEW �RINCIPAL/ESCROW BALANCES �2-25-13 03-13 1?3 ' PA�'M�NT � 02-22-13. 31�.74 116.91 100.65 97.�1.8 17, 136.55 872.�0 NEW PRINGIPAL/ESCROW BAL�INCES 01-1�-�,3 03-13 175 PRINCZPAL PAYMENT 01�12--13 15.26 . 15.26 0.00 0.00 � 17,253.45 NEW PRINCIPAL/ESCROW BALANCES 01-14-13� 02-13� 1,73 P�YMENT � 01-12-13 � 314.74 116.�.5 101.41 97.18 17,268.72 775.32 NEW PRINCIPA�.,/ESCROW BALANCES �2-26-12 02�13 ].75 PRINCIPAL PAYM�NT � 7.5.26 15.26 0.00 0.00 17,384.8? • NEW PR��TCIPA�/ESCROW BA�,ANCES 12-26-12 01-13 173 PA,YM�TT 314.74 115.39 102.17 97.18 17,400.13 678.14 NFW PRINCIPAL/ESCROW BA��ANCES � Togetherwe'll�ofar �� Wa!!s targp Hortk MoR�eQe if a�visioo of Wilk Faogo 9a�,NA I�AlSfl Id 399801 - • - .. .. .. .. ••-- ..-..� � � Statement — �ELco l//SA COMMUNITY CREDIT UNION - 449 Eisenhawer Blvd • Harrisburg,PA 17111 Member Number �0000a4960 - Credit Card Number �000c�000c�000c�000c - Statement Date 03/31/2013 Credit Limit $7,500.00 RETURN SERVICE REQUESTED Credit Available $6,775.41 �75001854 2 AV 0.36 �14 C5 o�-si-�3 so Total Balance $724.59 Page 1 of 2 �Il�i�l�ln��ilill�l��lll�i��iii�i�i�l�ll�lili�li�iu��i� MELVIN W FARNER Get your tickets now for the 2013 Belco Annual Meeting&Membership Gala,to be held Sat., NANCY L STOCKLEY Apr. 13.Tickets are$25, and are on sale now at 216 REESER RD al)branches,or by phone at 800-642-4482.Jan CAMP HILL PA 17011-1923 us for an evening of dinner,door prizes,and music by the John King Dance Band!Tickets are going fast...get yours TODAY! � � � � . • . - � � Previous Baianc:e �338.61 New&�lance $724.59 pay�� $338.61 Past Due Amount $0.00 pq�G�i� $0.00 Minimum Payment Due $15.00 pw� $724.59 Payment Due Date 04/25/2013 ga�a�e Transfers $0.00 MINIMUM PAYMENT WARIVING:IF YOU MAKE ONLY THE MINIMUM PAYMENT �h q� $0.00 EqCH PERIOD,YOU WILL PAY MORE IN INTEREST AND IT WILL TAKE YOU LONGER past Due Amount $0.00 TO PAY OFF YOUR BALANCE.FOR EXAMPLE: �q�� $0.00 If you make no additional You will pay off die balance Md you will end up paying Interest Cha $0.00 ��y��ing this card a�l shown on this statement in an estima�ed total of... New Balanoe $724.59 �month you a .. about... Credit Limit $7,500.00 Available Credit $6,775.41 ��Y�minimum payment 8 Years $1,020.00 • Statement Closing Date 03/31/2013 $828.00 Da in&Ili C 31 $23.00 3 Y�� ($ayings=$192.00) ��pry�� 717-232-3526 If you would like information about a�edit counseling service.s,call 877-337-3399. Ca��Custommer Se�vice 717-232-3526 or 80�-642-4482 . Lost or Stolen Card . 800-642-4482 . +� �� v�� ' t � � � � � � � �� ,.� �, �� ►ELC� visa Payment �oupon COMI�At1NRY CREDIT UNION For prompt cxedit,retum this coupon with your diedc to the address shown below. °'�c�but�f�luntber `; �� Cred��ard Nu�'ber. " To#alfSafar�ce -P�ime�#.�.��e nate ' � �00000c4960 �000c�oocx�000c�000c $724.59 . 04/25/2013 �rr��unt pa�t t3ue .' :` .Current Amount'Due l�tinirnum�Pa�/r�ent Amo��Enc�sed $0.00 $15.00 $15.00 MELVIN W FARNER Belco Community Credit Union NANCY L STOCKLEY 449 Eisenhower Blvd Ste 200 216 REESER ROAD Hat'1'ISbUI"g, PA 17111-2302 CAMP HILL PA 17011-1923 ��I�liil��,�.i„ill��l,�i,��i�lli��ii�i�i,i��ii��i�liliiiilli�i � BUREAU OF INDIVIDWIL TAXES Penns Ivania inheritance Tax � pennsylvania Po aox 28o6oi y HARRISBUR6 PA 17128-0601 Information Notice DEPARTMENT OF REVENUE And Taxpayer Response REY-1543 E%DocEXEt�.a-�2� FILE NO.2113-0347 ACN 13119784 DATE 04-16-2013 Type of Account Estate of MELVIN W FARNER Savings SSN Checking Date of Death 03-20-2013 Trust NANCY L STOCKLEY County CUMBERLAND Certificate 216 REESER RD CAMP HILL PA 17011-1923 BELCO COMMUNITY CREDIT UNION provided the department with the informafion below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: Account No.3+4960 Date Estabtlshed 0�-29-2010 � REGISTER OF WILLS � Account Balance $2,416.20 1 COURTHOUSE SGIUARE Percent Taxable X 50� CARLISLE PA 17013 Amount Subject to Tax $1,208.10_ � ` I Tax Rate X 0.045 � NOTE*: If tax payments are made within three months of the � Potential Ta�c Que; . .,, $54.36, ._ � percent di�unt,+�n the tax � '.de�edent�d�te of deatfi,ded�uct a 5 With 59�o fliscaunt�(Tax x b J5� $(see NOl'E") due. Any inheritance tax due witl become delinqueni nine months after the date of death. Pa�. ��J 1: Please-Check the appropriate boxes below. � t A []No tax��due. 1 am the spouse of the deceased or I am the parent of a decedent who was - 21 years old or younger at date of death. � Proceed to 5'tep 2 on r�everse. Do not check any.other boxes and disr+egard the amount shown above as Potential 7ax Due. g Q Ttti�irtformation is The above information is correct,no deductions are being taken,and payment will be sent Correct. witM my respon&e. Proceed to Step 2 on reverse. Do not check any other boxes. � C �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent,child,grandchild,etc.)of the deceased. (Seiect correct tax rate at right,and complete Part � ��o I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships(including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriafe on the back of this form. E�set wjtl be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inherdar�ce tax#orm Return filed by#he estate represen#ative. 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 following criteria: A. The decedent was legally responsible for 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 additional space is required, you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation) $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2),or percent taxable(Line 3), please obtain a wri#ten correction from the financ�al institution an�attach i�to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held "in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%,3 owners=33.33%,4 owners =25%,etc.) b. Next,divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount.taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a different tax rate,please state .��, '��'��'� � ' � �' �� \ \..� �. � ,�a� � ��.��.. �. \ �, ��;;� , �a�� your relationship to the decedent: , �� ' �� , . � � 1. Date Established 1 �� ° �� ' ` �'� � �� ? ��i \ �� . �� \ 2. Account Balance 2 $ �"�? ��a ,'��a �y .., u . . .. . ,. . �� 3. Percent Taxable 3 X � �� ,��. ,�; �� w`a ?.. � �a �, �`.,.� � �� _ 4. Amount Subject to Tax 4 $ °� ��„� �� ` ��. �z� �� r. ��:. � .� . �.�� . „ a �� 5. Debts and Deductions 5 - � � ° �.� � � � �� a �.� ; � �.�� , � � �: 6. Amount Taxable 6 $ �` \�a �� a . . . �., � \: ��. �. ��a �y��\ �� `�� `�' \. � C,.\ .�\�. � �..�.. J :�.�\��c 7. Tax Rate 7 X ��,.�� . � � � . �. � � � e� �� ,�� a�� .,�� '�� '`,�� 8. Tax D u e O �P ��`.�?�� .��x��`��`�`° . �\`��?��Y��`�� "\� ..��`�a�,��2�` �� , �...�h . � � .. _ \ .. . �� ^?�\�� . . �. �,_, \�� \�� a . � "ti�\� i �� a� ��c�� 9. With 5% Discount(Tax x .95) 9 X ��:��u��.�;��:��. ��:��`��.�a��.�� Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills,Agent." Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. Work �� q�y�<< .� p�,�� Home Tax ayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT CUMBERLAND COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 � BUREwU OF INDIVIDUAL TAXES � en ns lva ni a Po do� 28060� Pennsylvania lnheritance Tax p y HARRISBUR6 PA 17128-0601 Information Notice DEPARTMENT OF REVENUE . REY-1543 EX DoeEXEC(�6-12) And Taxpayer Response FILE NO.2113-0347 ACN 13119785 DATE 04-16-2013 Type of Account Estate of MELVIN W FARNER Savings Checking � Date of Death 03-20-2013 Trust NANCY L STOCKLEY COUnty CUMBERLAND � X Certificate 216 REESER RD � CAMP HILL PA 17011-1923 BELCO COMMUNITY CREDIT UNIOM provided the department with #he information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Account Na 34960 Remit Payment and Forms to: � Date Established 04-29-2010 � REGISTER OF WILLS Account Balance $10,903.21 7 COURTHOUSE SQUARE Percent Taxable �'S0 GARUSLE PA 17013 Amount°Subjecf to Tax $5,451�.61 ,__ , � Tax Rate X 0.045 NOTE*: !f tax�payments are made within three months of the � Potential Tax Due. $245.32 decedent's date,of death;deduct a 5�percent discount on the tax :; . . , , ,. . , . . With 596 D�count(Tax x 0.95) $(see WOT'�*)` ' � due. Any inheritance taz due will become delinquent nine months after the-date of death. P�� $'��@p '�;Plesse check tMe appropriate boxes below. 1 A Q No ts�c is due. 1 am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at�date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. g �The ir�formation is � .The above information is correct,no deductions are being taken,and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. C �The tax r'ate is incorrect. � 4.5% I am a lineal beneficiary(parent,child,grandchild,etc.)of the deceased. (Select cvrrect ta�c rate at right,and complete Part � ��o I am a sibling of the deceased. . 3 on reverse.) � � 15% All o#her relationships(including none). p �Changes or deductions The information above is incorrect and/or deb#s and deductions were paid. (isted. Complete Part 2 and part 3 as appropriate on the back of this form. E Q Ass�t witl be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inh�ri#ance tax form Retum filed by the estate representative. ° REV-1500. Proceed to Step 2 on reverse. Do r�ot 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 following criteria: A. The decedent was legally responsible for 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 additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation) $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2),or percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held"in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%,3 owners=33.33%, 4 owners =25%,etc.) b. Next,divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a different tax rate please state �`��'�:��_.'`�°'�� ;��'�� a ��`��"��°�'� ��`�;��'�,�;� , , \\�� ,.. your relationship to the decedent: �� , r �.� �� `�� ,z�i ��. , � �� .� �� . 1. Date Established 1 �� .�` � �< .. � � \� \��-` �� r�. � , . . �\ . 2. Account Balance 2 $ .� � :� � �� \. , �.� � � �� .��.� , ..�. � - �� .: :� �� 3. Percent Taxable 3 X ��; � .� , �� , ��. °�� ,�� ,.� ,. ,.� � � .�� . �~��.� ... , � � � 4. Amount Subject to Tax 4 $ � �; � � �� a� -�� ,�\��,� �� . � � a , � �. �. � �.o • �� .:.,. . .. �� \��\\��•��`\ 5. Debts and Deductions 5 - � � � � � � � � a� �� • �, a. ; �: �� ,,.� ... �. �,� �:r � . ;�`��?�� 6. Amount Taxable 6 $ � �`� :. :`° �� , . o �, . �.�.�.. �� `� � ` ` ��,��`�� \.�� ,,� s�i � .� �� z� �� 7. Tax Rate 7 ��.��`� �"\ ��a� �,�,��,�� s�,�� X "l�.ra��.�\�� . ��'`�\"��i.�Q��Q ��?� ��.�� \�� .�a.�`��ria`?"�'��.��'',. ��'•,��,�a�'��.ia.a�.��\��. `sv��`?r��,�,�,�ac\��.��.�`:��.\��. 8. Tax Due 8 $ �� '�� c � ��_\ � \�,�� \�\� � ��, .�, �� o. \ � ��a ��`\� �' � � �C��`�� 9. With 5°/ Discount(Tax x .95) 9 �"` �' °' �,� �� ,��,�� y� X ��`�`��y`�rV`�a��w� � \� ��c� � \��. ��.�, a��,a�� \�\�.Q��`\�\, � :��a\�.��;�.�\'.��na@.�\`I��`�.��`.��\\�\��au��u\. ��\\Q�\��\ \��\\\�\\a\�..�Y�U\. \ Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills,Agent." Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. Work << �.� Home Ta ayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT CUMBERLAND COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 � BUREpU OF INDIVIDUAL TAXES � pennsylvania Penns Ivania lnheritance Tax PO BOX 280601 y DEPARTMENT OF REVENUE HARRISBUR6 PA ��28-D601 Information Notice REY-1543 EX DocEXEC(�l-12) And Taxpayer Response FILE NO.2113-0347 ACN 13119783 DATE 04-16-2013 Type of Account Estate of MELVIN W FARNER Savings Checking Date of Death 03-20-2013 Trust NANCY L STOCKLEY County CUMBERLAND Certificate 216 REESER RD CAMP HILL PA 17011-1923 _. _ . . :.. .. _.. _ _ _ � - __ . : ,�_ ..., _ , _ . ... ,. _ _ __ . _. _ :. _ , - ....,:,.._. _ _ BELCO COMMUNITY CREDIT UNION 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 ident+fied. Remit Payment and Forms to: Acxount No.34960 Date EstabUshed 0429-2010 � REGISTER OF WILLS Account Baiance $19,093.45 1 COURTHOUSE St�UARE Percent Taxak�le _ X.5� - CAR�ISLE PA 17013 Amount Subject to Tax $9,546.73 ` , , ' . Tax Rate � � X 0.045� � NOTE*: If tax payments are made within three months of the Poterrtial Ta�c Due $.429.60 . _ d��ent's date of dea#h,deduct a 5 percerrt�discotant;on the tax V1f�th 59�'a Discount�`Tax z O:g5)� $(see NCjTE*) due. Any inheritance tax due will become delinquent nine months after the date of death. Pl�' � ,�. : �i'�!� 1: Piesse check the appropriate boxes below. A ��to fiax�s due. 1 am the spouse of the deceased or I am the parent of a decedent who was � 27 years old or younger at date of death. � � Proceed fo Step 2 on reverse. Do not check any other boxes and disregarn►the amount shown above as Potential Tax Due. g �The in#ormation is The above information is correct,no deductions are being taken,and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. C �The#ax rate is incorrect. � 4.5% I am a lineal beneficiary(parent,child,grandchild,etc.)of the deceased. (S�1ec#correct tax rate at right,and complete Part � ��o I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships(including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back of this form. E Asset witt be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax ��her�tiu�tax farm Retum filed by the estate representative. REV-1�500. Proceed to Step 2 on reverse. Do noi 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 following criteria: A. The decedent was legally responsible for 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 additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation) $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2), or percent taxable(Line 3), please obtain a written correction from the financial ins#itution and attach i#to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held"in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%, 3 owners=33.33%,4 owners =25%,etc.) b. Next,divide the decedenYs percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a different tax rate,please state ;.. �" �''. . �; �.� `'�� '� :� �.`..".°....`,."��. "��; a. � � �� your relationship to the decedent: � � ' � .�� . : � 1. Date Established 1 \` i ' ''' � �� v� �'.''h�. . \\ .\ ..\ �. C\ .).`.\�\C 2. Account Balance 2 $ � �' � �� ::�� .. ;. :.� X , . 3. Percent Taxable 3 � � ,;� �� :�� .. � . , a..... . . �\ 4. Amount Subject to Tax 4 $ �,: b�°. � ,��:,� x ��,�,�,,��;\b� � ��.�,,��.�,� 5. Debts and Deductions 5 - �` r � �� ;.�_ �. ;,�: ,�� . .. . . , . ; �..� ..�r... .... .. ...4.Y� .� \� �..�3��\ .$.�� :.`h ��-.�\ 6. Amount Taxable 6 $ \\.� . �. � ,.. . �:. . ��\; �.�,��,,�, � � � �� 7. Tax Rate 7 ' . � � :� � •� , � X \�� ° � �\�� \ � ,� \�� :� �. .� , � ..,. . �, 8. Tax D u e 8 $ �� .�� _��;. ��. �. . ��.�z�� ;��.��.\� �� . � � . � , ` �s ��\ �� 9. With 5%Discount Tax x .95 9 ��`�; ; � �� • ,.� � � • • . ��\�`��\ � � \ �� `.Q "� �a.��.�'�� `•>.�` . � � a.��.fi:\`� ��\u�� .��"�`��`�`�.w�� .`��`�...��'e�� Y��\ Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills,Agent." Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and � belief. Work a�r�r� � �-uGrC F Home �t �, j Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT CUMBERLAND COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 • 8��►� � INDIYIDUAL 7AXES � pennsylvania PO dOX 280601 Pennsylvania lnheritance Tax HARRISBURG PA 17128-0601 Information Notice DEPARTMENT OF REVENUE � REV-15f3 E%DocEXEG(�E-12) And Taxpayer Response FILE NO.2113-0347 ACN 13119786 DATE 04-16-2013 Type of Account Estate of MELVIN W FARNER Savings Checking Date of Death 03-20-2013 Trust MANCY L STOCKLEY County CUMBERLAND X Certificate 216 REESER �2D CAMP HILL PA 17011-1923 _ _ ��,. _ ., . _ _ _. - - _ _ . ,,. _ � .. _ __ _ . . _._ _. _. . . _ -,. : ._ __ _ BELCO COMMUNITY CREDIT UNION provided the department with the information below indicating that at the d�ath of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: Account No.34960 � Date Established 0429-2010 REGISTER OF WILLS ... Account Balance $65,353.74 1 COURTHOUSE S(�UARE Percent Taxable X 50 � CARUSLE PA 17013 Amount Subject to Tax $32,676.87 Tax Ra#e : . ` X 0.045 . , _ , ,. : - ' NOTE`: If tax payments are made within three months of the Potential Tax Due: ,: $_1,470.46 � dec,ed�nt's date of death,deduct:a 5 percent;discourrt on the tax With 596�1�i�ouht("faic z'0:95) $(see NOTE'}` dt�e: Any inheritanc�tax due will beco�me delinquerrt ni�e months after the date of death. P�� S��? 1:Please:check the appropriate�xes below. 1 - �► [��#a�c is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger-at date of death. Proceed to St�ep 2 on reverse. Do not chedc any other boxes and disregard the amount shown above as Potential Tax Due. g �The information is The above info�mation is correct,no deductions are being taken,and payment will be sent _ co�. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. C �The tax rate is incor�ect. � 4.5% I am a lineal beneficiary(parent,child,grandchild,etc.j of the deceased. (Select correct tax rate at right,and complete Part � 12% I am a sibling of the deceased. . 3 on reverse.) � 15% All other relationships(including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back of this form. E Asset wiN be reported on The above-identified asset has been or will be reported and tau paid wi#h the PA Inheri#ance Tax ` inheritatnce tax form Retum filed by the estate representative. REV-1�00. 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 following criteria: A. The decedent was legally responsible for 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 additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation) $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance{Line 2),or percent taxable(Line 3), please obtain a written correction from the financial institutio�and at#ach i#to this for�n. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held"in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%, 3 owners=33.33%, 4 owners =25%,etc.) b. Next,divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxabte. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. '��"��\� 'S v��: � � �; a`� �"�a.xp �" '�.�� Z�� . . `a��`\�'z ��`\: If indicating a different tax rate,please state ��.�,�� .� � , � �� your relationship to the decedent: �� .�� .�� a`� � �t � ��`� ��.� �� .�ti�� .�� x�� `�. ::.z�� `, 1. Date Established 1 ��\a'�� a �`;"�� '� ��'�'�`�� .r��s � s �. �� `� . . .� � � � 2. Account Balance 2 $ �� - r, , � A�� .„ � _ �� \ 3a. �� . � \ \ . �� b �� 3. Percent Taxable 3 X ��„ ��. � � � ; � ��.� � �� • � �t � �� y��°��.��'h:. , �� `�x �`�. � . ��`.\a��.�� 4. Amount Sub�ect to Tax 4 $ \ - ��\��`��\ �` ��",�� . � u �``�. , � \ � � � \��. \ he J � ?�'t.�� \ � `� � � � � �� a;�"� � �� . ��.��\ � � �`��r�� ., . . .� � . � �� 5. Debts and Deductions 5 - a�.� , � � �� ; � � � �� a� ��"�� \�`C��, ��\\ '�;��.�� : \ �� \�� a ...� �l�. \h`Z\� �a.�. \ . :��\�;`\?��\\\��, 6. Amount Taxable 6 $ � � � � �.�� .� �.� � ��.,, �� `� � ��`�� '��a�\�� 7. Tax Rate 7 X �.�� .�c a �� r�� :,��.� -�, � �,., �� ,a. ��"��'� � ��3�� `��.., � �� ♦a ��\ �\�� o\�� ,�� ,�-�� 1u�� \�\��'�� \'��:��. `�` �M\�`�� .� � �a� ��a\� � �� Q � `� �\�\��?��` �`��\��\� .�"aS Z � 8. Tax Due � �P ��\ �� \ � �` �\�� \.� �.� �' �\�� \\\��\�c�'`� �� \� ��\ � �� \�`�� :�"��.�i �� a.� ?��Z.`��.��. 3,a\�� \��e ��y �� 9. With 5% Discount Tax x.95 9 X �.�,��:a�a�. � �..��.��,��;..�.��.,�;��.�.. , . a. „.,..� „. � � ��:�.�\��a��os��a�.s'��a��..�s.�a��.�a��w��a��a��".��.��V��v.��.\\��a��r�� Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills,Agent." Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and belief. Work �7��-`��,� -lio� �'� � � e , Home `��7-�ZS-d �( �. 3U.�.3 Ta ayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT CUMBERLAND COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020 _ � StAtEAU OF INDIVIDUAL TAXES '� pennsylvania Po aox 2ae6oi Pennsylvania lnheritance Tax HAfLRISdUR6 PA 17128-0601 I�formation Notice DEPARTMENT OF REVENUE REY-1543 EX DocEXEL(�8-12) . And Taxpayer Response FILE NO.2113-0347 ACN 13119787 DATE 04-16-2013 Type of Account Estate of MELVIN W FARNER Savings Checking Date of Death 03-20-2013 Trust NAMCY L S70CKLEY County CUMBERLAND X Certificate 216 REESER RD CA�1P HILL PA 17011-1923 �E�co cc��u�i TY CRED I T ut�i or� provided the department with the information below indica#ing that at the dea#h of the above-named decedent ou were a join#owner or beneficiary of the account identified. Remit Payment and Forms to: Atxount-AIo.34960 Daie Estabfished Od-29-2010 REGISTER OF WILl.S � Account 8alance $11,542,56 1 COURTHOIfSE SQUARE CARLISLE PA 17013 Perc:ent l�a�cable ` X 50 . Amount Subject to Tax $5,771.28 , _ , , ; Tax Rate . . X 0.045 . Potent�at Tax Due $25g,71 NOTE*: If tax payments are made within three months of the = � � �� ' � de�edent's date;of�death;'deduct a 5 percent-discoqr�-o�the tax iAlith 59�6�coiaitt(T'ax z 0:95) $(see NO'1'�`)� due. Any inheritance tax due will become delinquent nine months after the date of death. p� �� :i�ase ci�ck the ap�ro�riate boxes below. � A �t��c is due. 1 am the spouse of#he deceased or�am the paren#of a decedent wfio was � 21 years olcl or younger at date of death. Proc;eed to Step 2 on reverse. Do not check any other boxes and disr�egarrd the amount shown above as Potential Tax Due. g ❑The information is The above information is correct,no deductions are being taken,and payment will be se�t «�rract. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. C �Tfie ta�c rate+s incorrect. � 4.5% I am a lineal beneficiary(parent,child,grandchild,etc.)of the deceased. (Select coRect tax rate at right,and complete Part � 12% I am a sibling of the deceased. . 3 on reverse.) � 15% Ail other relationships(including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. . listed. Complete Part 2 and part 3 as appropriate on the back of this form. � Asset witl be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return 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. r PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for 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 additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total (Enter on Line 5 of Tax Calculation) $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2),or percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this forrro. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held"in trust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%, 3 owners=33.33%,4 owners =25%,etc.) b. Next,divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. ��`Z��\�� Q �� .�� a � �a�� '.� Z� .. `� ta � "` Z� . \: If indicating a different tax rate,please state �� s , �� ; ��: � � � �� your relationship to the decedent: �` ��k�,��\ �y� ��yP��z=°� a; � °� � � � �\� 1. Date Established 1 �, � � � . . � . . . . .� . . ,�. .. � � 2. Account Balance 2 $ ,� .a , .,... .� _. ,��, � , . .. � .; . :;� \.. � 3. Percent Taxable 3 X �� ' �� `� `:�� \ � � . , � .. . , .,�.` ,��a a� :� � , 4. Amount Subject to Tax 4 $ � �. �� _ � � � r � � �'� 5. Debts and Deductions 5 : '�°� �� . •.. .... . •a � � . �� \ , 6. Amount Taxable 6 $ "� � � � �� \�: , X �� :a"� �. ..?. .r .�.�� `.��`�� , rp 7. Tax Rate 7 ,�� ' , � � \ \ :�� .�',' ��.�..�. ��. � �� .� � ��. �� 8. Tax Due 8 $ ; ,. � � �° � � , .�� ` ' �a� ` � �. . �. �. . ?�ti 9. With 5°/ Discount(Tax x.95) 9 X �� ';� " s,��`�� . ��' �'� �� ..' ��.a.. �� O �� .��.��:��s ��`��a��..�..��.��a��\�a�� Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, � � along with a check for any payment you are making. Checks must be made payable to "Register of Wills,Agent." Do not send \ payment directly to the Department of Revenue. � Under penalty of perjury, I declare that the facts I have reported above are true,correct and complete to the best of my knowledge and ^ belief. ` �u Work 7J7-7� �s I Jo� � .��, c�tr � S��K( Home �7��-SZ y- o - � � Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT CUMBERLAND COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ON LY: 1-800-447-3020