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HomeMy WebLinkAbout12-23-13 REV-1500 EX(0140) 1505610140 tlFNgAL IAEORLY PADepoMremW Revenue Cods Year File NWTIW PO Bureau of Individual Taxes INHERITANCE TAX RETURN Y H!*k PA 1 2 1 1 3 4 8 3 PA 1Ti28as9t RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Suffix Decedent's First Name MI K E T C H U M E L E A N O R M (NAppNcabia)Enter Surviving Spouse's tnFormodat Bafasr Spouse's Lost Name Suffix Spouse's First Name MI Spouse's Sods!Secu ft Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS PILL.ill APPROPRIATE OVALS BELOW ® f.Original Return 2.Supplarma tai Return [] S.Remainder Return(date of death prior to 12.13 Q 4.Limited Estate Q 49.Future Interest Compromke(data of 0 S.Fadand Estate Tex Realm Required death afksr'12-12$2) S.Decadent Oled Testate © 7.Decedent Maintained a Living Trust — &Total Number of Sate Deposit Boxes (Attach Copy of Will) (Attach Copy of Trusty 0 9,Litigation PYooaeds Received Q 10.Spousal Poverty Credit(date of death [] f t.Election to tax undersea 9113(A) between 1231-W and 14-" (Atiadt Sch.0) CORRESPONDENT•THIS SECTIONNRISTBECOMETS).ALLCORRESPONDENCEANDCONFNBNTIA LTAXiNFORhy1T10NSNOULOgD o: Name Daytime Te on;n Number ' D0U6LAS 6 MILLER 71 ?Lv94c,9 = r REOrsfER�tialD.9tatD�oNLwa �, Find We of address Cj '+ I R W I N B M c K N I6HT P C r— 1,n r- Second fine of address "n � O 1 ' -°,j h yv 6 0 W E S T P 0 M F R E T S T R E E T City or Post Office State ZIP Code DATE FILED .i C A R L I S L E P A 1 7 0 1 3 Comespondo ft•call address: Ord 010*1 1¢,Ideclamuretl have e&mn6d oft rexan, "s and stele ,andto are bear of my lum0edge so bead ft is Rp-wmplirki campleta" ea ahafprepeter area ore personal representative isbesedan all edom 0twhidlprwperer has aey knowledge . SIGNATURE OF PERTN SPO LEFORAU ,RETURN 1 ADDRM j 5896/T0WNLI E ROAD 167 NEW LONDON OH 44951 $lydNli FP ill EPRESE ATIrE .i 1J 3 t ADD 60 WEST POMFRET STREET CARLISLE PA 17013 PLEASE USE ORIGINAL PORM ONLY Side 1 1505610140 1505610140 1505610240 REV-1500 EX RECAPITULATION 1. Real Estate(Schedule A) 1 .. .. . . . . . . . . . . . . . . . .. .. . .. . . . .. . . . . .. . .. . . . 2. Stocks and Bonds(Schedule B) .. . . . . . .. . . . .. .. . . . . . . . . . . . . . . . . . . . . . . 2. 3 0 1 1 . 5 6 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. 1 6 5 5 . 1 9 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. ' 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested . . . . .. . 7. 8. Total Gross Assets(total Lines 1 through 7) .. . .. .. . . . . . . . . . . . . . . . .. . . . 8. 4 6 6 6 . 7 5 9. Funeral Expenses and Administrative Costs(Schedule H) 9. 1 3 0 3 ' 5 0 . . . . . . . . .. . . . . . . . . 10. Debts of Decedent,Mortgage Liabilities,and Liens Schedule I 10. 3 5 8 7 . 6 2 11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . 11. 4 8 9 1 . 1 2 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . .. . .. . . . . . . . . . . . . . . . . . 12. - 2 2 4 • 3 7 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . . . . . . . . . .. . . . . . . . . .. . 13. 14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . 14. - 2 2 4 • 3 7 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 16. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X _ 0 . 0 0 15. 0 . 0 0 16. Amount of Line 14 taxable at lineal rate X.045 0 . 0 0 16, 0 . 0 0 17. Amount of Line 14 taxable at sibling rate X.12 0 . 0 0 17. 0 . 0 0 18. Amount of Line 14 taxable at collateral rate X.15 0 . 0 0 18. 0 . 0 0 19. TAX DUE 0 • 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑ Side 2 L 1505610240 1505610240 J REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 13 483 DECEDENT'S NAME ELEANOR M. KETCHUM STREET ADDRESS 770 SOUTH HANOVER STREET CITY STATE ZIP CARLISLE PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A.Prior Payments S.Discount Total Credits(A+B) (2) 0.00 3. Interest (3) 4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00 5. If Line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; ...................................................................... ❑ ❑X b. retain the right to designate who shall use the property transferred or its income: ............................... ❑ ❑X c. retain a reversionary interest;or ................................................................................................ ❑ ❑x d. receive the promise for life of either payments,benefits or care? .................................................. .... ❑ ❑x 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)(1)]. For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent or a stepparent of the child is 0 percent[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 72 P.S.§9116(1.2)[72 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 Secfion 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REV-1503 EX+(8-12) pennsylvania SCHEDULE B DEPARTMENT OF REVENUE INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER ELEANOR M. KETCHUM 21 13 483 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. PNC INVESTMENTS-ACCOUNT#005-496553 3,011.56 TOTAL(Also enter on Line 2,Recapitulation) $ 3,011.56 If more space is needed, insert additional sheets of the same size REV-1508 EX+(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE ``ASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: ELEANOR M. KETCHUM 21 13 483 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. PNCBANK-CHECKINGACCOUNT 1,655.19 TOTAL(Also enter on Line 5,Recapitulation) $ 1,655.19 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(10-09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER ELEANOR M. KETCHUM 21 13 483 Decedent's debts must be reported on Schedule t. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERALEXPENSES: i. B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: 2, Attorney Fees: IRWIN & MCKNIGHT, P.C. 1,250.00 3. Family Exemption:(If decedents address is not the same as claimant's,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 6 Accountant Fees: 6. Tax Return Preparer Fees: 7. REGISTER OF WILLS- FILING FEE FOR PETITION TO SETTLE SMALL ESTATE 43.50 8. NOTARY FEES 10.00 TOTAL(Also enter on Line 9,Recapitulation) $ 1,303.50 If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES&LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER ELEANOR M. KETCHUM 21 13 483 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. CHAPEL POINTE AT CARLISLE-NURSING 2,681.50 2. CARLISLE REGIONAL MEDICAL CENTER - MEDICAL 613.45 3. CARLISLE DRMATOLOGY ASSOC PC - MEDICAL 15.00 4. HARTZELL EYE SPECIALISTS-MEDICAL 155.00 5. GEORGE BRANSCUM, MD-MEDICAL 7.99 6. CUMBERLAND GOODWILL FIRE RESCUE-AMBULANCE 84.20 7. CARLISLE DIGESTIVE DISEASE -MEDICAL 30.48 TOTAL(Also enter on Line 10,Recapitulation) $ 3,587.62 If more space is needed,insert additional sheets of the same size. REV-1513 EX-(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ELEANOR M. KETCHUM 21 13 483 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 [Include outright s ousel distributions and transfers under Sec.9116(aM.2)j 1. JOYCE HEICHEL, NIECE Collateral 10965 EAST ANCHOR DRIVE WALKERTON, IN 46574 2. JOHN COPLEY Collateral 5896 TOWNLINE ROAD 187 NEW LONDON, OH 44851 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. CHAPEL POINTE AT CARLISLE 770 SOUTH HANOVER STREET CARLISLE, PA 17013-4105 TOTAL OF PART 11-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. ESTATE OF : IN THE COURT OF COMMON PLEAS OF ELEANOR KETCHUM : CUMBERLAND COUNTY,PENNSYLVANIA : ORPHANS' COU/R2T DIVISION . NO. � /✓ yOJ ORDER OF COURT AND NOW, this Aeday of 2013, upon consideration of the Petition Under Section 3102 of the Probate, Estates and Fiduciaries Code for Settlement of Small Estate and the Praecipe to Attach Exhibits and Amend the original Petition, it is hereby ordered and directed that an Order be made authorizing John Copley to act as Fiduciary for the Estate of Eleanor Ketchum, and close the accounts with PNC Bank, N.A. and State Teachers Retirement System of Ohio, with the proceeds made payable to The Estate of Eleanor Ketchum, pursuant to Section 3102 of the Probate,Estates and Fiduciaries pursuant to Section 3102. BY THE CO T v) J. Thoma0k. Plaeey Common fees Judgq M::E -o r - r l• �i _a }T cr, rJ For Distribution: Douglas G. Miller, Esquire Attorney for Petitioner RECEIVED SEP 12 2013 IRWIN&MCKNIGNi PAW OFFICES R4 ESTATE OF : IN THE COURT OF COMMON PLEAS ELEANOR KETCHUM :CUMBERLAND COUNTY,PENNSYLVANIA i : ORPHANS'COURT DIVISION NO. PETITION UNDER SECTION 3102 OF THE PROBATE, ESTATES AND FIDUCIARIES CODE FOR c m SETTLEMENT OF SMALL ESTATE ® TO THE HONORABLE JUDGES OF SAID COURT: _ �? cn c � �.�,} �T -y . C± .t �•TI John Copley,Your Petitioner,files this Petition for Settlement of a Small E underlhe c a provisions of Section 3102 of the Probate,Estates and Fiduciaries Code and in wplfort the f avers that: (1) Your Petitioner, John Copley is a competent adult residing at 5896 Townline Road 187;New London,OH 44851,and is the nephew of the above decedent. (2) Eleanor Ketchum, died on December 4, 2012 at the age of 96 years, but prior thereto was domiciled at 770 South Hanover Strect, Cumberland County, Pennsylvania. A copy of decedent's Death Certificate is attached hereto as Exhibit"A." (3) Eleanor Ketchum died with a Will dated March 18, 1999, and a Codicil dated September 8,2003. No Letters have been issued.A copy of Decedent's Last Will and Testament and Codicil are attached hereto as Exhibit"B." (4) Eleanor Ketchum had no probate estate when she died other than the following: Checking account and investment account with FNC Bank,N.A., with a balance of$4,666.78, as of February 18, 2013. A statement from PNC Bank is attached hereto as Exhibit"C." A death benefit in the amount of $1,000.00 with State Teachers Retirement System of Ohio. Benefits with the State Teachers Retirement System is a non- taxable asset. (5) The heirs listed in Article V of the Codicil to the Last Will and Testament of Eleanor Ketchum are as follows: Joyce Heichel,Niece John Copley;Nephew Chapel Pointe at Carlisle (6) Your Petitioner avers that there are no creditors of the decedent. The expenses, costs of administration and attorneys fees to be paid for the estate exceed the _ assets of the Estate. Statements are attached hereto as Exhibit"D" WHEREFORE,.,your Petitioner respectWy requests that an Order be made authorizing John Copley to act as Fiduciary for the Estate of Eleanor Ketchum,and close the accounts with PNC Bank and the Sate Teachers Retirement System of Ohio,with the proceeds made payable to the Estate of Eleanor Ketchum,pursuant to Section 3102 of the Probate,Estates and Fiduciaries Code. I ay u .Miller,Esquire Supreme Court I.D.No.83776 IRWIN&McKNIGHT,P.C. 60 West Pomfret Street Carlisle,PA 17013 (717)249-2353 STATE OF OHIO COUNTY OF OuCOK� John Copley being duly sworn accord' to w,deposes and says that the facts contained in the foregoing Petition are true and 7john e of ge,information and belief. (SEAL) Copl ey Sworn and subscribed before me this-Q_day of April,2013. ` NPag l KAREN R BALE,NOTARY _* � - • STATE OF OHIO MY COMMISSION EXPIRES:II/Q015 0,n,mm�no•. e OF ELEANOR KETCHUM I, ELEANOR KETCHUM,presently residing at 7 Alliance Drive, Carlisle, Pennsylvania, being of a sound and disposing mind, over the age of eighteen(18)years, and under no legal disability, and mindful of the brevity of this life,having placed my faith and confidence in Jesus Christ,my Saviour and Lord, Who redeemed my soul through His shed blood and death upon Calvary's Cross for my sins and Who,by His resurrection,thus assures me of eternal life, and knowing that the life which I now live in this world is by faith in the Son of God Who gave Himself for me, do hereby make,publish and declare this to be my Last Will and Testament, hereby revoking all other Wills and Codicils heretofore made by me at any other time. Article I: I direct that my Executor, hereinafter named,pay all my just debts and funeral expenses as soon after my death as practicable, including all property, state and federal death taxes assessed against me, my estate, or my beneficiaries,without proration among my beneficiaries. However, all property bequeathed or devised hereunder, either outright or in trust, is bequeathed or devised subject to existing mortgages, liens or encumbrances thereon. Menges,Gent&McLaughlin,LLP Douglas H. Gent,Esquire Eleanor Ketchum 1157 Eichelberger Street Hanover,PA 17331 1 Article II: I give and grant unto my Executor appointed herein and his successors all the powers given under the common and statutory law of Pennsylvania at the time of my death, to be exercised in his absolute discretion,unless otherwise restricted herein, in any capacity to which such powers may be applicable. In addition to such powers,he shall have the following powers: A. To accept in kind and retain any property which I may own at my death, without regard to any principal of diversification, and to invest and reinvest in any form of property without restriction to legal investments for fiduciaries. B. To purchase.investments at a premium and, at his discretion,to charge such premium and the premium on any investments owned by me at my death either to principal or income. C. To give proxies and to join in any merger, reorganization, voting trust plan, or other concerted action of security holders affecting investments, delegating powers with respect thereto. D. To sell at public or private sale,exchange or lease for any period of time any real or personal property, and to give options for sales or leases. E. To borrow money and to mortgage or pledge any real or personal property. F. To register property in the name of a nominee or to hold property unregistered. Eleanor Ketchum 2 G. To compromise claims. H. To allocate any property received or charge incurred to principal or income or partly to each, without being obliged to apply the usual rules of trust accounting. I. In investing,reinvesting,purchasing, acquiring, exchanging, and selling property for the benefit of my estate or any trust created hereunder,they shall exercise the judgment and care,under the circumstances then prevailing,that men of prudence, discretion, and intelligence exercise in the management of their own affairs,not in regard to speculation, but in regard to the permanent disposition of their funds, considering the probable income as well as the probable safety of their capital. Article III: I hereby nominate and appoint my nephew,JOHN COPLEY, as Executor of this my Last Will and Testament. In the event he predeceases me or is unable to serve as Executor,then I nominate my niece, JOYCE HEICHEL, as Executrix of this my Last Will and Testament. My individual Executor or Executrix shall not be required to furnish bond or surety. Article IV: I give, devise and bequeath all the rest and residue of my estate of whatever kind and description, wherever situate, absolutely and in fee simple,as follows: A. Twenty percent(20%)to CHAPEL POINTE AT CARLISLE, located at 720 Hanover Street, Carlisle, Pennsylvania,to be used at the sole discretion of the governing board of the organization; and 72dd/ zt� Eleanor Ketchum 3 B. All the rest,residue and remainder to be divided equally among my nieces and nephew, JANET WAKENIGHT,JOYCE HEICHEL, and JOHN COPLEY. In the event my niece,JANET WAKENIGHT, shall predecease me,then this share of my estate shall be divided equally between my niece, JOYCE HEINCHEL, and my nephew,JOHN COPLEY. IN /WITNESS WHEREOF, I have hereunto set my hand and seal this day of ' 1999. Eleanor Ketchum Signed, sealed,published and declared by the foregoing Testatrix as and for her Last Will and Testament, consisting of_,;� pages, in the presence of us, who at her request, and in her presence, and in the presence of each other,have hereunto set :'and,as tness g'th rettoo.. 4 COMMONWEALTH OF PENNSYLVANIA COUNTYOF CU018ERL RA O 1,ELEANOR KETCHUM,Testatrix,whose name is signed to the attached or foregoing instrument, being duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament;that I signed it willingly;and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by ELEANOR KETCHUM,the Testatrix,this day of_ 111 R a C 1+ 1999. r� Seal sally Lou uZZary Notary public Eleanor Ketchum ML I Hohy:Spdrng3s Boro,Cumberland Ceunry My.Ciimmissien Expires Sept 21,2002 L-. � 73 Lrfl1" MW4W Pi nnsyWaMa Association of Notares Notary Putilic My Commission expires: COMMONWEALTH OF PENNSYLVANIA COUNTY OF We,f GO P en�— and L a is L-i ,,7 d A r ,the witnesses whose names are signer a attached ttacth hed or foregoing instrument,being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instnument as her free and voluntary act for the purposes therein expressed;that each of us in the hearing and sight of the Testatrix was at the time 18 or more years of age,of sound mind and under no constraint or undue influence. Sworn to or armed and subscribed before me by-1 I O f4 L's IV C3 e,dd- and -L o r ; d t nv- ,witnesses, this j _day of,'j Z?)1r?9 e }1 ' 1999. Oic Notary Pu tc My Commission Expires: Notarial Seal Belly Lou Zary,Notary Public ML Holly SPr!�Berg, Caunry My ssimt Expires Sept 21,2002 Member,Pennsylvania Association of Notaries CODICIL TO THE LAST WILL AND TESTAMENT OF ELEANOR KETCHUM I, ELEANOR KETCHUM,presently residing in Carlisle,Pennsylvania,being of a sound and disposing mind, over the age of eighteen years,having made my Last Will and Testament dated the 18"'day of March, 1999, do hereby make,publish and declare this to be a Codicil to my said Last Will and.Testament. FIRST: I hereby delete Article IV as stated in my Last Will and Testament and substitute the following provision: Article IV: I give, devise and bequeath all of my jewelry,clothing, household furniture and furnishings, chinaware, silver,pictures,works of art,books,personal automobiles, and other tangible articles of a personal nature,not otherwise specifically disposed of by this Will, to my Personal Representative(s); and it is my wish that my Personal Representative(s) dispose of said property in accordance with a memorandum or list I shall leave with my Will at the time of my death as a guide in disposing of the tangible articles hereinabove bequeathed to my Personal Representative(s). Any item of personal property not set forth on said list shall be disposed of as a part of my residuary estate." SECOND: I hereby add a new Article V to my Last Will and Testament to read as follows: Article V: I give, devise and bequeath all the rest and residue of my estate of whatever kind and description,wherever situate, absolutely and in fee simple,as follows: Menges, Gent& McLaughlin, LLP !�a - Douglas H. Gent, Esquire Eleanor Ketchum 1157 Eichelberger Street Hanover,PA 17331 1 A. Three Thousand($3,000.00)Dollars to my niece,JOYCE A.HEICHEL; B. Three Thousand($3,000.00)Dollars to my nephew,JOHN COPLEY; and C. All the rest, residue and remainder to CHAPEL POINTE AT CARLISLE, located at 720 Hanover Street, Carlisle, Pennsylvania,to be used at the sole discretion of the governing board of the organization. THIRD: I hereby ratify and confirm my said Last Will and Testament except in so far as any part thereof is revoked or modified by this Codicil. IN WITNESS WHEREOF, I,ELEANOR KETCHUM,Testatrix,have hereunto set my hand and seal to this Codicil to my Last Will and Testament dated the e day of 2003. P (SEAL) Eleanor Ketchum Signed, sealed, published and declared by the foregoing Testatrix as and for a Codicil to her Last Will and Testament, in the presence of us,who at her request, in her presence and in the presence of each other, have hereunto set our hands as witness stthereto. J��adj 2 COMMONWEALTH OF PENNSYLVANIA COUNTY OF L M �o j'r\R n d I,ELEANOR KETCHUM,Testatrix,whose name is signed to the attached or foregoing instrument,being duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Codicil to my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by ELEANOR KETCHUM, the Testatrix, this g� day of- �Q- e f -e.rn)o e Y 2003. Eleanor Ketchum Notary Put dc My Commissi . NIUMSeW B*LauZNy-NotaryPL"C COMMONWEALTH OF PENNSYLVANIA ORtioly90WBom.Glmbeft1dc0urav f4 E 0m9 sapt.21.2oos /� I 1lmeeer,Penn yinrigAss h*A ^rV,4wk COUNTYOFpIUYn6ev- cgnd f We, AIMA 6A55 snd Lopta L4n7c the witnesses whose names are signed to the attached or foregoing instrument,being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn to or affirmed and subscribed before me by �m to 811 55 and—=At L In Z witnesses,this��^_day of 12003. Notary Pu lic My Commission Expires: NDWW Seal B*LGU7•ery,Notary Pd* W Hdy WW Born.Urr Wlard County 3 t➢yon Expires Sept 21.2006 Liffi r,PwWgKaraa ASWCWoo Of Notaries PNC Bank Online Banking Page 1 of 1 .V Accounts Transfer Funds Pav Bills Alerts Customer Service .::smary Account Activity My Accounts summa Account List Conta,r P e Deposit Accounts -urt rvne Account Number BalanceV AvailableO Regular Checking Checking XXXXXX3459 $1,655.19 $1,655.18 - --• -- ---' Deposit Account Totals: $1,655.19 $1,655.1° Investment&Wealth Management Accounts Investment-Accounts.., Account Number Balance Alerts :atlividual Investment Account XXX6663 $3,011.59 Mobile Banki Online _ - Investment&Wealth Management Account Totals: $3,011.59 Overtly^_" PNC Kev:. 0 -move incivaes assets held at different entities.Deposit and loan oroducts are held at PNC Bank f °s:ments.other than annuities.are held in a brokerage account with PNC Investments LLC.member •-jives are neio at the insurance carrier of record. Non-deposit investment orotlucts are not FDIC insured.are not ouaranteed b\ Interactive Demo I Online Banking&Bill Pay Guarantee I Service Aareement I Privacy Policy I ON- O Copyriaht 2013. The PNC Financial Services GrouD.Inc. All Riohts Resew-' Need Held?Call us at 1-888-PNC-BANK(762-22bu: -erslon:41.00.02 https://www.onlinebanking.pnc.com/alservlet/OnIineBankingServlet 2/18/2013 y o 0 �m -I m 0 -1 > m O � nm m N z am I3 t x �>p N r z c rj) D � mTti� z omm t < � zm6 za » ytl N " m$ Cdr. m° Iyy c m a < zb 33 D .n N �'~ m m a L' m y a � > DN �F G z3 m Dp 3 i 3 CM 0 mm S. E Oq Zpa op � �e a0 f� � 9 O 00 �°,x me z x ac € m z c 'o' z3 v n V'j o v 'r a ° m m --I a� a e7 z yµ. m and < .. C �, en .m m ; .� "a a 1 �.• 8u N p;'a 7 ° °o o� 4 a 4 C 2' N c 0 N o 0 0 o in a 0 0 ? w w w z W o o W o w n 0 Z9 ^ •z ? * C1 it OI e a a 2 e E a p � } 1 4 n 3 1 7, °3 3 A p o = w u 2 V1 3 S'. s � y s I f E k 0 STATETEACHERS 1 1 RETIREMENT SYSTEM OF OHIO i 275 East Broad Street Columbus,OH 43215-3771 /-� 1-888-227-7877 1w,m.strsoh.org n i[REMENT BOARD CHAIR ::AU HILL nETIRWEAT BOARD VICE CHAIR DALE PRICE SEC0ND-I2EQr EXECUTIVE DIRECTOR MICHAEL 1.NEHF In reply,please refer to: TH172MZ January 28, 2013 John Copley 5896 Townline Rd 187 New London OH 44851 Re: The account of Eleanor Ketchum, deceased Please provide our office with the item(s) checked below so that this account may be paid. ® Estate's Employer Identification Number(EIN)issued by the IRS ® A photocopy of the Letters of Authority from the court—we cannot pay by the Will If you have any questions,please call our Member Services Center toll-free at 1-888-227-7877. Member Benefits Enclosure r mnw1 Fan P&01 Chapel Pointe at c,,r,b e 770 SOUTH HANOVER STREET,CARLISLE,PA 17013-4105 OUESTIONS?CALL,- --%'•? 71 249-1363 RESIDENT#-! . " • UNIT: STMT"DATE t:: 12468 M-21-A 12/03/2012 Miss Eleanor M.Ketchum RESIDENTS Bed M21A Miss Eleanor M.Ketchum TOTRLAMOUNT bUE $2,681-50 'DATE DUE Upon Receipt • NOT PAY Total • due will •• electronically withdrawn from • bank account on 1 • NOT PAY '. ZE n N rx, Ax pESCttltjTlbNp } s Days1 CEfhRGES CRE©!TS BAUkNGs* Balance:-orward" 796.50 4/0412012 Payment ;`PhankYou!! 796:50; 0'00; 41171-301`2012'.'A t Meals $gnevolent 10/01-10/31 1 215;00 215.00 11/,.-30/2012 Contraetaal.Allowauce II 1 215004 0.00l, 1012612012 Nurse Visit 1 25:00 25 00 ?heart>palpltatio'ns 1,0%2912012 Trartsporfatton 4 16:00 4100: Clothes^to CRMC' 10731/2012 Transporkation 4 16.00 57.00; Walker to:CRMC 11/01/2012 TV Cable 1110141[30 1 12.00 69.00` 11%07/2012 lalr Care-Wash/S.et/Combout 1 10:50 79.50, 11/14/20121 Care Wasli7Set/Con bout 1 10.50: 90.0.0. 11119/2012,Transportation;` 4 16.00 106.00'.. s1Dr .Caney 11/26/20,12k mand Board Private-HC 11/2041/26 7 1,855.00 1,961.00 4EI)i2 012;1alr Care-WashlSet/Combout 1 10.50 1,971.50*onthly Fee 12'/01=12/31 1 710.00 2,681.50 Reminder: Please remember to notify us of any new insurance cards by bringing the cards to the finance office so that we may make a copy. Also,.please be sure to review all enclosures.Remember to sign and return necessary forms to us.(Ambulance,2013 Rate Sheet).Not all levels of care will receive all forms. RESIDENT# CURRENT OVER 30 OVER 80 OVER 90 OVER 120 TOTAL AMOUNT DUE 12468 2,681.50 0.00 0.00 0.00 0.00 $2,681.50 RESIDENT NAME Miss.Eleanor M.Ketchum Form PS-01 CHAPEL POINTE AT CARLISLE,770 SOUTH HANOVER STREET,CARLISLE,PA 17013-4105 REGIONAL MEDICAL CE'NTEK - - Patient Name Eleanor M Ketchum. D Online:at www.carlislermc.com Account Number 9539712 Date of Service November 20, 2012 r � ,(available 24/7) Service Type Inpatient Services ® By phone-717.960-1680 Insurance Name Aetna Medicare Repic Name of Insured Eleanor Ketchum. By credit card-:complete section below and return Policy Number MEBF92BD Amount Due From You $258.54 90,13y check-return section below with check Amountdue from you is$258:54 aspf:01/13/2013 for The.c her 9aIs listed below.do_nofretiect:the.discount that Inpatient Services.performed:onNovember20,!2012. ; .; you,andyourinsurancecompanyreceived Nursing 1;106.82 Total.Oharges $28;538.58 Pharmacy 3,005:39 Discounts/Adjustments Given -$19;666.59' Radiology 760.31 Insurance Payments Received $8613.43 Lab`; 3;032:77 Amount You Paid $O.OQ CardiovascularStudy 688.13 Re§piratory. 6;248.73 Nursing- 4;836:00 Supplies 2,937<91 Occupational Therapy 690.68 Amount Due From You $258:54. Therapy 1,240.02 0 Emergency Room 2,332.52 Cat Scan 1,759.30 TOTAL CHARGES $28,538:58 ® II �mYfdC♦16ti0 o• 0 3269-HMASTMT-1570691-1359982180.P;6983281-1-212;32952908-1;1 As of today,we have not received paymentin full on your account. immediate payment is required, please'contact our business office today. FOR CREDIT CARD PAYMENT,PLEASE FILL OUT BELOW... OTERCARD [DISCOVER Y�S�1 OA li �EX AP 361 Alexander Spring Rd. Y CARD NUMBER EXP. REGIONAL Carlisle,PA 17015 SIGNATURE SECURRYCODE PATIENT NAME STATEMENT DATE DATE DUE Eleanor M Ketchum 01/13/2013 UPON RECEIPT Patient Financial Services: ACCOUNT NUMBER AMOUNT DBE AMOUNT PAYING 717-960-1680 9539712 $258.54 121 E]Check box i/address below is incorrect orchanged and indicate change(s)on back. —'— REMIT THIS PAYMENT STUB TO: 954049A(PC2) 006862 0101 ELEANOR M KETCHUM CARLISLE REGIONAL MEDICAL CENTER 770 S HANOVER ST PO BOX 281442 CARLISLE, PA 17013-4105 ATLANTA, GA 30384-1442 4E I'�I'�'I�'ll�ll�'I'III�II'I�dll4"I��I'��I�Lp4'lll�ll'll�ll' I�'�I'I�'I�d4411641�111111�1441"�II'�I"IIII'I�I'llll'�'I�Jq 00000953971200000025854 ELEAN0RMKETCHUM 6 CARUSIE Account lnforma(ion _ MOD 1» I c e Nt�r e R Account# 9537905 Patient Name: ELEANOR M KETCHUM FINAL-NOTICE Date of Service: 11/01/12 01/30/13 Balance: $354.91 We are writing to inform you that your balance is past due and a payment in full has not been received or a suitable payment arrangement established. This is a request for immediate payment in full on or before ten days from the date of this letter. Pay your account in full by check, money order or credit card payment using this form and enclosed envelope. If we receive no response from you this account will be referred to a national collection agency. If you have already sent your payment please disregard this letter. You may also pay your bill online at www.carlislermc.com. Thank you. Carlisle Regional Medical Center Questions? Telephone: 855-843-0549. Servicio an espanol, por favor Ilame: 1-866-301-0426. 858 --------PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT OR MAKE PAYMENT BY-CREDIT-CARD: np pp pp pp np ❑ VISA Card Number Signature Total Paid I�����II�III�IIII�II'�II�'������IIII011IIIII�I��I���II�D�II�11 ❑ MC Code Carlisle Regional Medical Center ❑ DISC Signature Expiration Date 366 Alexander Spring Road ❑ AMEX Carlisle, PA 17015 Statement Datexa�5�w`s':.++zr^'r+t1'x .0 SHOW AMOUNT PAID HERE tye Fay'r fliSi`AntO011t i $ Account#: 9537905 JON819537905173 317041391762 52691000346010014 ® Mail all Correspondence to: Il�l�lll�rl.I"lll'11�'1�"I��Ir�lll�ll�"l���lll'�"1111'�l�"" Carlisle Regional Medical Center Eleanor M Ketchum PO Box 281442 5896 Townline Road 187 Atlanta, GA 30384-1442 New London, OH 44851-9409 00000953790500000035491ELEANOR N KETCHUM 8 OAi rrm 1 !ate C - IV N N N f4N m 1a mZ� D. 5p ma' m p (2'} at Pn m3 Z m iffi6 Q. 50 Zvtm;o y jOD n W '� w rrl ml',plmm m z 1 m m o WOO O g m mr5fz' a r m�4 m r- o mD m ZC) - o. m -� Ole: .r'I :t; Z o° mm 0 a j „„i E> azfh v ;d? htintp o o m N m Gtr:D i."i1 rn 0 0 O . :tmv G O. 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