HomeMy WebLinkAbout12-30-13 1505610105
REV-1500 EX(o2-u)(FI)
fsytl OFFICIAL USE ONLY
PA Bu reau of Individual Taxes Department of Revenue P enn Y vania
County Code Year File Number
Bu ° `°`°°`
AX RETURN
Ha -
BOX 280601 INHERITANCE T ^' q
Harrisburg,PA 19128-0601 RESIDENT DECEDENT py `
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
04/17/2013 09/02/1962
Decedent's Last Name Suffix Decedent's First Name MI
Sears Leilani
L
............ ............ _. .
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
............._..... _.._.
Sears I Randall N
......
_..
Spouses Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
162-48-3933
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
GD 1. Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death
Prior to 12-13-82)
O 4.Limited Estate O 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 1 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION ULD BE DIRE T0: 7J
Name Daytime TeleigorQ)Number m
.....
John F. Lyons,Attorney (717) 238, -7 �r-11
-� (/> =a
_...
REGIS-ER WF r�I�LS UW)ONLY-,a,7
7 -71
First Line of Address C�l
_........ ....._..... ..........._ ......... ...........................
112 Walnut Street ' w ''
I Iµ
Second Line of Address CI i C
_... ..... ..... ..... ... _ _ ......_
City or Post Office State ZIP Code DATE FILED
Harrisburg PA 17101
Correspondent's e-mail address:jflyonslaw @msn.Com
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
ADDRESS
206 Briga L-Road, F ;:P.A 7025
SIGAkTURE O, EPARER OTHER • f�RE ESENTATIVE DAT
A7
ADDRESS
ADDRESS
112 Walnut Street, Ha risburg, A 17101
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610105 1505610105
J 1505610205
REV-1500 EX(FI)
Decedent's Social Security Number
Decedent's Name: Leilani L. Sears
RECAPITULATION
....................................................................................................................................................
.
1. Real Estate(Schedule A). . ...... .......... ... ... ............ ......... 1. 82,900.00
2. Stocks and Bonds(Schedule B) ... ... ..... . ... ... ......... .......... .. 2. 0.00
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ... .. 3. 0.00
4. Mortgages and Notes Receivable(Schedule D)........................... 4. 0.00
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). ...... 5. ':. 13,880.02
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 0.00
7, Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested...... .. 7. 0.00
8. Total Gross Assets(total Lines 1 through 7)..... ... ............... ... ... 8. 96,700.02
9. Funeral Expenses and Administrative Costs(Schedule H).. ................. 9. 27,227.22
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I)........... ... . 10. 3,047.31
11. Total Deductions(total Lines 9 and 10)..... ... ... ...................... 11. 30,274.53
12. Net Value of Estate(Line 8 minus Line 11) .............. ... ............. 12. 66,425.49
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. ; 66,425.49
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 ..............._.....................................__............................_...._......._.............. .................. ._...._.._....
transfers
X.0_ 15. ' 0.00
66,425.49
16. Amount of Line 14 taxable
at lineal rate X.0_ 16.
17. Amount of Line 14 taxable
at sibling rate X.12 17.
18. Amount of Line 14 taxable
at collateral rate X.15
19. TAX DUE ........ ............. ... ... ............ ...... ....... ..... 19. 0.00
..........._..........................................................................__..........;
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Side 2
1505610205 1505610205
REV-1500 EX(Fl) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Leilani L. Sears
STREETADDRESS
2065 Brigade Road
CITY STATE ZIP
Enola PA 17025
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
2. Credits/Payments
A.Prior Payments
B.Discount
Total Credits(A+B) (2) 0.00
3. Interest
(3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4)
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.......................................................................................... ❑ 0
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ N
c. retain a reversionary interest.............................................................................................................................. ❑ ■
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑
2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ 0
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation? ........................................................................................................................ 0 ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan. 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
(72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent[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(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S. §9116(a)(1.3)].A sibling is defined,
under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-1502 EX+(12-12)
Q7 pennsylvania SCHEDULE A
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN REAL ESTATE
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Leilani L. Sears
All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
Attach a copy of the settlement sheet if the property has been sold.
ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
1 1002 State Road,Duncannon,Perry County,PA 17020-sale to unrelated third party 82,900.00
(Settlement Statemetn attached)
TOTAL(Also enter on Line 1, Recapitulation.) $ 82,900.00
If more space is needed,use additional sheets of paper of the same size.
A.Settlement Statement (HUD-1) OMB Approval No 2502.0265
Il�ll�ll .
B, Type of Loan
6.File Number, 7.Loan Number: B.Mortgage Insurance Case Number
1. E]FHA 2. ®RHS 3. ❑Conv.unins. A06-155362-STG 910150245 448406623
4. ❑VA 5. ❑Conv.Ins.
C.Note: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown.Items marked
"(p.o.c)"were paid outside the closing;they are shown here for informational purposes and are not included in the totals.
0 Name 8 Address of Borrower: E Name 8 Address of Seller: F.Name 8 Address of Lender:
Michael Gordon Warner Estate of Leilani L.Sears,Randall N. Fairway Independent Mortgage
1208 411)Street Sears,Administrator Corporation,
West Fairview,PA 17025 1002 State Road ri652 Pin ecrest Drive,Suite 200
Duncannon,PA 17020 Piano, TX 75024
G.Property Location: H.Settlement Agent: I.Settlement Date'
1002 State Road DETHLEFS-PYKOSH LAW GROUP,LLC, 05/20/2013
Duncannon,PA 17020 Darrell C.Dethlets,Esquire
Phone Number:(717)975.9446
Perry County 2132 Market Street'
Camp Hill,PA 17011 '-
Place of Settlement:
2132 Market Street,Camp Hill,PA 17011 Disbursement Date.05/20/2013
J. Summary of Borrower's Transaction K.Summary of Seller's Transaction
100.Gross Amount Due From Borrower 400. Gross Amount Due To Seller
101,Contract sales price $82,900.00 401.Contract sales price $82,900.00
102.Personal property 402.Personal property
103.Settlement charges to borrower(line 1400) $6,370.96 403.
104. 404.
105. 405. _
Adjustments for items paid by seller in advance Adjustments for items paid by seller in advance
106.City/town taxes to 406.Cily/town taxes to _
107.County taxes 0612012013 to 12/31/2013 $199.49 407.County taxes 0512012013 to 12/31/2013 $199.49
108.Assessments 0512012013 to 0613012023 $116.67 408.Assessments 0512012013 to 06/30/2013 $116.67
109.Sewer: 512012013 to 513112013 $23,22 409.Sewer: 512012013 to 513112013 $23.22
110 410
111. 411.
172 412,
120.Grass Amount Due From Borrower $89,610.341420,Gross Amount Due To Seller $83,239.38
200.Amounts Paid By Or In Behalf Of Borrower 600.Reductions In Amount Due To Seller
201.Deposit or earnest money $500.00 501.Excess deposit(see instructions)
202.Principal amount of new loan(s) $84,558.00 502.Settlement charges to seller(line 1400) $7,993.00
203.Existing loan(s)taken subject to 503.Existing loan(s)taken subject to
204. Lender Paid Borrower Costs $350.00 504.Payoff of first mortgage loan
I
205. 505 Payoff of second mortgage loan
206. Seller Assistance w/Closing Costs $3,000.00 506.Seller Assistance w/Closing Costs $3,000.00
207 507.
205, 508.
209. 509
Adjustments for items unpaid by seller Adjustments for items unpaid by seller
210.City/town taxes to 510.City/town taxes _ to
211.County taxes_ to 511.County taxes to
212.Assessments to 512,Assessments to
213. 513
214
514.
215 515.
216. 516.
217. 517.
218, 518.
219. 519.
220.Total Patd By/For Borrower $88,408.00 520.Total Reduction Amount Due Seller $10,993.00
300.Cash At Settlement From/To Borrower 600,Cash At Settlement To/From Seller
301 Gross amount due from borrower(line 120) $89,610.34 601.Gross amount due to seller(line 420) _ $83,239.38
302.Less amounts paid by/for borrower(line 220) ( $08,408.00 '602.Less reductions in arnt.due seller(line 520) ( $10,993.00
303.Cash Z From ❑ To Borrower $1,202.34 603.Cash ®To From Seller $72,246.38
The public Reporting Burden for this collection of information is estimated at 35 minutes per response for collecting,reviewing,and
reporting the data.This agency may not collect ti-is information,and you are not required to complete this form,unless,it displays a
currently valid OMB control number.No Confidentiality is assured;this disclosure is mandatory.This is designed to provide the patties to
a RESPA covered transaction with information during the settlement process.
Previous editions are obsolete Page 7 of 3 HUD-1
L. Settlement Charges
700.Total Real Estate Broker Fees $5,189.00
..- Paid From Paid Frorr.
Division of Commission(line 700)as follows: Borrower's Sellers
701 S 2,792.00 to Coldwel2 Banker Homestead Group (+$395) Funds at F.mds at
Settlement Svilement
702.S 2.397.00 to Century 21 Walak Associates
703.Commission paid at Settlement $5,189.00
704^ 1 P.o.c by
800.Items Payable In Connection With Loan
801.Our origination charge $961.00 (from GFE#1)
802.Your credit or charge(points)for the specific interest rate chosen $ (from GFE#2)
003.Your adjusted origination charges (from GFE A) $961.00
804.Appraisal fee to FIMC FBO FLS t P_o.c by 1(from GFE#3) $475,00
805.Credit report to FiMC for KROLL 1 P o c by y(from GFE#3) $17.92
806.Tax service to l P o C.by 1(from GFE#3)
807.Flood certification FiMC F90 FLS 1 P O.C.by > (from GFE#3) $9.75
808.
809.
810.
811.
812. -
900.Items Required By Lender To Be Paid In Advance
901.Daily interest charges from 0512012013 to 0610112013 @$8.3979 /day(from GFE#10) $100.77
902.Mortgage Insurance Premium for months. (from GFE 03)
_ to _
903.Homeowner's insurance for 1.00 years. $613.00 (from GFE#11)
to Farnham Insurance Agency $613-POC13
904 years.
r to -'
905 USDA Guarantee Fee to USDA $1,691.16
1000.Reserves Deposited With Lander
1001 Initial deposit for your escrow account (from GFE#9) $1,013.86
1002.Homeowner's insurance 3.00 months @$51.08 per month $153.24
1003 Mortgage insurance 2.00 months @$27.94 per month S55.89
1004.Propeny taxes months @$ per month $
1005.PA County Tax 5.00 months @S26.85 per month $134.25
1006.PA School Tax 12.00 months @$84.49 per month S1,023.88
1007.Aggregate Adjustment -S 343.39
1100.Title Charges
1101.Title services and lender's title insurance (front GFE#4) $1,072.50
1102.Settlement or closing fee S
1103.Owner's title insurance (from GFE#5)
11_04.Lenders title insurance S
1105.Lender's title policy limit S84,559.00
1106,Owner's title policy limit S 82,900.00
11C7 Agents portion of the total title insurance premium Dethlefs-Pykosh Law Group, LLC S 822.37
11CB Underwriter's portion of the total title insurance premium security Title $145.13
11C9 (Sale Rate - End. 100, 300, 8.1)
1110. Security Title (CPL Fee) $75.00
1111. Darrell C. Dethlefs (Notary Fee) $5.00
1112. Dethlefs-Pykosh Law Group (Tax Cart Reimb) $10.00
1113. ---
1114.
1115.
1200.Government Recording and Transfer Charges
1201 Perry County Recorder Government recording charges (from GFE#7) $200.00
1202.Deed S 60.00 ;Mortgage S 140.00 ;Releases 5 _
1203.Transfer taxes Perry County Recorder (from GFE#8) $829.00 $829.00
1204.City/County tax/stamps: - Deed$829.00 Mortgage S _
1205.State ta),Jstamps: Deed S 829.00 Mortgage S
1206 S
1207._ S
1208 $
1209 S
1300.Additional Settlement Charges -�
1301.Required services that you can shop for (from GFE#6)
1302. $
1303. $
1304.
1'•05 -1--'
1305. Gerald W. Durham Masonry
$1,900.00
1307 Penn Township (Sewer: 51112013 to 51.3112013) $60.00
1308.
1309.
1400.Total Settlement Charges(enter on lines 103,Section J and 502,Section K) $6,370.96 $7,993.00
Previous editions are obsolete Page 2 of 3 HUD-1
Comparison of Good Faith Estimate(GFE)and HUD-11 Charges Good Faith Estimate HUD•1
Charges That Cannot Increase HUD•1 Line Number
Our origination charge At 801 $961.00 $961.00
Your credit or charge(points)for the specific interest rate chosen #802 $0.00 $0.00
Your adjusted origination charges #803 $961.00 j $961.00
Transfer!axes #1203 $829.00 $829.00
Charges That in Total Cannot Increase More Than 10% Good Faith Estimate HUD-11
Government recording charges _ - #1201 $200.00 $200.00
Appraisal Fee #804 $475.00 $475.00
Credit Report Fee #805 $50.00 $17.92
Flood Cert Fee #807 $9.75 $9.75
USDA Guarantee Fee #905 $1,691.16 $1,691.16
# $0.00 $0.00
# $0.00 $0.00
# $0.00 $0.00
# $0.00 $0.00
# $0.00 $0.00
# $0.00 $0.00
Total $2,425.91 $2,393.83
Increase between GFE and HUD-1 Charges S -32.08 or -1.32%
Charges That Can Change Good Faith Estimate HUD-1
Initial deposit for your escrow account #1001 $979.72 $1,013.86
Daily interest charges #901 $8.3979 /day $335.92 $100.77
Homeowner's insurance #903 _ $624.00 $613.00
Title Services/Lender's Title Insurance #1101 $1,112.50 $1,072.50
# $0.00 $0.00
# $0.00 $0.00
# $0.00 $0.00
_ # $0.00 $0.00
# $0.00 $0.00
# $0.00 $0.00
Loan Terms
Your initial loan amount is 1:64,558.00
Your loan term is 30 years
Your initial interest rate is 3.625%
Your initial monthly amount owed for principal,interest,and 5 413.57 includes
and any mortgage insurance is
®Principal
®Interest
®Mortgage Insurance
Can your interest rate rise? ®No.
❑Yes,it can rise to a maximum of %.The first change will be
on and can change again every after
.Every change dale,your interest rate can increase or
decrease by %.Over the life of the loan,your interest rate is
guaranteed to never be lower than %or higher than %
Even if you make payments on lime,can your loan balance rise? ®No. ❑Yes,it can rise to a maximum of$
Even if you make payments on lime,can your monthly ®No.F-1 Yes,the first increase can be on
amount owed for principal,interest,and mortgage insurance rise? and the monthly amount owed can rise to S
The maximum it can ever rise to is S
Does your loan have a prepayment penalty? ®No.
❑Yes,your maximum prepayment penalty is S
Does your loan have a balloon payment? ®No. ❑Yes,you have a balloon payment of S due in
years on
Total monthly amount owed including escrow account payments ❑You do not have a monthly escrow payment for items,such as property
taxes and homeowner's insurance.You must pay these items directly yourself.
®You have an additional monthly escrow payment of S 162.42
that results in a total initial monthly amount owed of 5 575.99 .This includes
principal,interest,any mortgage insurance and any items checked belcw:
❑Property taxes ®Homeowner's insurance
❑Flood insurance ®PA School Tax
EPA County Tax ❑
Note: If you have any questions about the Settlement Charges and Loan Terms listed on this form,please contact your lender.
Previous editions are obsolete Page 3 of 3 HUD-1
Certification
(continued from HUD-1)
I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief,
it is a true and accurate statement of all receipts and disbursements made on my account or by me in this
transaction. I further certify that I have received a copy of the HUD-1 Settlement Statement.
_ Seller or
Borrower: i "��'l ! � !i Date: 5'/ ' /-3 Agent: Date:
Michael Gordon Warner Randall N.Sears,Administrator
Estate of Leilani L.Sears
1208 4th Street 1002 State Road
West Fairview, PA 17025 Duncannon, PA 17020
1
The HUD-1 Settlement which I have prepared is a true and accurate account of this tr nsaction. I have
caused or will cause the funds to be disbursed in accordance with this statement.
�- 7
Date: Settlement Agent: Date: 2°
Darre ethlefs, Esquire
WARNING: It is a crime to knowingly make false statements to the United States on this or any other
similar form. Penalties upon conviction can include a fine and imprisonment. For details
see:Title 18 U.S.Code Section 1001 and Section 1010.
REV-1508 EX+(o8-12)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Leilani L. Sears
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, 97 EE US Savings Bonds-face value$6,000.00 with a date of death redemption value of$13,880,02 13,880.02
see attached valuation.
TOTAL(Also enter on Line S, Recapitulation) $
If more space is needed,use additional sheets of paper of the same size.
Calculated Value of Your Paper Savings Bond(s)
Calculator Results for Redemption Date 04/2013
Total Price Total Value Total Interest YTD Interest
$6,.0.0.0...0.O—$,1,3.,.8.8.0...0.2--$.7.,.8.8.0..02 _$_169..5.0__
Bonds: 1-97 of 97
Serial Series Venom Date Next Final Issue Interest Interest Value Note
Date Accrual Maturity Price Rate
c872382204ee EE f'_$100'04/1989�10/2013�.04/2019µ.,,,,,,$50.,00i _,$113.521
c872382203eeF EE_--'-,.,$100;102/1989"08/2013',-02/2019!,,�,,.$50.00,.., $113.52L,4.00%'!----$163.52
c872382202ee_L_EE $100_'l 1/1988„05/2013*111/2018',_. .,.$,5Q.00-'1 $113.52_�__4.00W__4163.52 i
'09/2013',,09/2018',:.,,,,,$50.00"--�.�116.80l-.,4.00%'...�$ 66. O'�
c87238220lee EE JL a
c872382200eev,,EE,,.,,,$100*.,07/1988'07/2013 ,.07/2018.6._.,,,,$50.00 -.,,$116,.84 ,,4.00%',,,„$166.80'
,1661763653ee,,,EE,,::,,,,-$50-1.03/1988„09/2013',,03/2018 -,,,,,$25.00,'.., .,,$60.06 ,,4.00%',,-,-- $85.06'
'07/2013 .01/201&' --,,,,,$60.06z-.,,4.00% -.,,.-,$85.06'
,,1661763652ee�--EE., -..--$50'�01/1988� __$25.001,
.166176365lee'...EE_'11,_.__$50!"l1/1987,'.05/20j3,',1l/2017,,'1_,_$25.001
1 61—
-,1661763650ee�,;"EE-,;,,,,$50"09/1987*,09/2013-1,,09/2017,-*,,--,,$25.00,-,.-,�$61..76-,,4.000/�,.,�--,�$86.7
,1661763648ee l,,EE,-',,,,$50".04/1987;-10/2013,',04/2017.:,-,,.,$25.00"'--, , $63.SO.-�.--4.00%',---,,-,$88.sO:,.-
,1661763647ee_,_,.EE.,_ _„_.$50"02/1987'08/2013;.02/2017;.,.,,_.,$25.00; ,.,,,_,$63.50- ,4.00°l0 _
___$63,50 4.00% ..... $88.50'
.1661763645eel,,,,EE_? _,.,$50:09/198609/2013 ,09j2016,'
.,$50:.09/198609/201311,09/2016,'_$25.00_',___.$75.40,:.,4.00%,.. $100.40'-,
�1661763644ee;!. EE-,'-,,.$50,'07/:L986�07/2013'-.07/2016'__,$25.00-, .$75.40, _4.00%',._$100.40'.
EE .,$50,.05/198605/2013 ,05/2016:.-,-.,$25.00-',,,,..$75.40:_.4.00%!
___$100.40;_
EE,. __$50',02/198608/2013,',02/2016 ____$25.00..._,.,.$77.40,.__4.00%,-__...$102.40; ,.
.,-„.$25.00-_.,_$77.40' „4.00°!a __� _,$102.40
,1661763641eei, EE----_$50 4�12/1985'-06/2013 J2/2015
.,1661763640ee EE,__.,__$50 10/1985"10/20137.10/2015 $25.00 7_,$79.44',_4.00%', $104.44-11 1
z
1661763639-,'-.,EE.........$5,0'07/1985-�07/2013;,07/2015,-. ,,-..$25.00 __ $79.44;,-.,4.00%,;_,.,$104.44,--,.
,-1661763638ee'.,EE--, ,,,-,,$50�05/1985".05/2013'.05/2015'-,-, $25.00;L..._ $79.,44.l,,,.4.00% _.,-$104.44,..
_„.$25,001.._,._.$81.54;_,4.00%'-,__$106.54:_”
.1661763637ee-- EE__�'_ .$500311985'09/2013,,03/2015.;_.
,1661763636ee,*., �__$50;12/1984 06/2013;,12/2014?-__.,$25.001_,.$8l.,54. _,.4.00%'__.•.$106.54.
EE_..
1661763635' EE __,$50�10/1984,10/2013*--10/2014 ___$25.90,-....$83..66.,--.4.00%',..--$108.66:1.
,1661763634ee,',,_EE_.`__$50�08/1984,,'.08/2013'-,08/201411.,„"-,$25.00,,-,,,,,...,$83.66,,-1.4.00%-"-.$108.66
7-
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1661763629ee;.-,EE-.;...-,$50,08/1983".08/2013',,08/2013,',-.-,$25.00;-,,,
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EE,-',,,,$200,'01/2000'1.05/201.3.,01/2030:-,-$100.00.4..,_-,$!52.,00;,,.0.63%y!....$152.00;,-
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,rl48575176ee -,EE:..,,_,$200',08/1999',05/2013;,08/2029.;.,,$100.00-,..„,-$55.20'.:.0.63% __$155.2011.1
,rl48569784eez,-EE.,-,,,$200',.06/.1999-05/2013',06/2029,',-.,$lOO..00� _-,$55.36,',"..0.63%:;-.,--$ISS.36'.-
.,rl48564143ee",.,,EE.. ,,,$200!;04/1999'1.05/2013'.', 04/2029,w,,-,,$100.00,x.,,,,,$58.48-1-,,0.63%t!_„.,$lS8.48,*...:
rl45670419ee,..EE _$200;02/1999 05/2013 ,02/2029 ,„_,$100.00=.v,.µ,,,$58.64
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.rl34140440ee,__EE-,,,.,.,$200':09/1998,05/2013;,09/2028°,.,_$.100,00;.�,,$62.,80:1,,,0.63%1;,,.,$162.80,.
5/2013!,0712028, _$100.00 _$162.96
T142966669ee EE �$200 07/1998�O
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-05/1998 z05/2013=-05/2028,e, $100,00., -,$163.121-11
,r142954849ee ,,EE., ,�,,,$200:03/1998":05/2013 03/2028 ._.-,$l00.,W,-.'
$167.04
.,.r139044661ee,,. EE -,,$2000 1/1998-',05/2013'0 1/202a
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Y139038353eel EE 1/2027,; $100.00;_.„,.„,$67.36. 0.63%, 167.36
.,rl35671937ee...,.,EE,.. ,,..$200'.10/1997"'05/2013:10/2027--,-.$I00.�O0� ,:,..,1$72.00 -,0.63%- -,.$172.00--
r13566547lee.".,,,EE-,: $200-'08/1997;05/2013;.-08/2027, $.100.00;..___.$72.16 ,,0.63W.,, $172.16:
0.63%: ��,$172.40'
rl35659259ee',,;-EE..,`_,.,$2-00 06/1997'05/2013":.-06/2027, $100,00,-,,-,,$72..40';
T135652814ee EE.. $200-04/1997'
10/2013°,04/2027 �,_$100,00--,,,,,$68.,08;,,,0.59%,-,,t,,$168.0811t.I 1,
$100
T135646179eel, EE -$200:-02/1997,108/201.3,'.02/2027,,'„.,,, oo.,,,,,,,$68.08,x,,1,0.59%,!,.,-"$168.08'
T131471367ee,� EE ,..$200 .121199606/2013-:12/2026 :r„_.$100.,00 -0.59%1,-_$168.08:
.,rl31464248eel,,,EE,.,.",.,,.,$200,11/1996'-05/2013°_11/2026 . ,.$100.00,,. , $68.08-, $168.08'
j121617127ee°_EE -$200 .09/1996109/2013 09/2026,'_-$100.00 _„_.$71..92"_:.,0.59%,«., $171.92'"
..rl21610856ee ,,..EE,--',,..,$200 .,07/199607/2013':007/.2026- ,,-...$100.00-'-,,z:.,:-.$71..92-' ,,0.59%",,,,.,,$171.9211I.:
,,r121604213eet,,EE,---. -,,,$200"05/1996�05/2013 -.�05/`2026--.,,$100..00,k,,,,,,,.$71.,92;',
0.59°1,';.,,-,.$171.92
r118445425ee ,EE,
,,:,.,.,.$200°.03/1996;,09/2013°.03/2026.':,
.,rl 15.478338ee,, EE
_",,,,$200--.01/1996 07/2013 ,01/2026,'-, ,_,$100.,00t,:,,,$100.00,* ,0.5.9%'-,--,,$200.00""-- ,--
rII5471093ee.. 5."!",-.-$100,00 $100,00 0.59% ._$200.00
EE,- 06/2013 12/202
-,rl 15463.685ee,,. EE ,$200 5 10/19915 JO/20131,10/2025, $100,00-':. $100-.80 0.5.9% $200.80
r115456l69eel.,,,,.EE...,, ,,,,$200iO8/l995�08/2013',08/2025'..,,,$100.,00--'l,,--$100.,80' .,,0.59%-----,$200.80i
:$100.,80.1-,,.0.5.9%",7:,-,$200.80'-"I
rl 1 1058026ee EE,.,.',,.,,,$200'04/1995;'05/2013:.04/2025-,., $100.00 $10400, ..:.4.00°/a $204.00
yl 1 1050680ee EE, ,.,..$200 02/1995',05/2013-�;:02/2025, $100 $1051 36,-
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.
,,rll1043280ee -,,.,EE_ $106.721_-4.00% ,-,-$206.72
rlll035672ee EE_,�',,._.$200{.11/1994>,05/2013:.11/2024:.:.
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01
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-c467555994ee]I,,,,EE.-, -.$55,08�--4.00%.-- '$105.08
.c467507341ee EEa_- $55.80' -,4.00%1� $105.80'
I,,_$l00'-OS/l9'4tO'/20l3 OS/2024�
,c437970115ee-,.,EE,,.,- ,,, ,$100,03/.1994:05/2013' ON
,c4 �,,EE-_,�:_$10,0i.01/1994i05/20131'
37919829ee, ,01/2024 .:.$50,00::._: -.$57-20:,,:,4.00%' $107.2011-
c437872084ee." EE 12/19931,1.05/2013�',12/2021,1, 0.100 .1 $107.56
$100
,c425576774eel,.,.,EE...i..,,,.$100-10/1993'.05/2013.-.,10/2023.:
$59,00
.c425524832ee,l EE -,,$100�,08/1993-,05/2013`,08/2023. 109.00,
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c410676089ee EE 04/1993 -,,.,,$60.44-,_4.00% v r$110.44;
,c394659255ee,,,."EE,.,",,,,$100--,.02/,1993,.,08/2013,,-02/2023,
c367522006ee,'._EE__
c367471823ee EE, ;.......$10.0=.,11/1992'.,05/2013:.,.11/2022
c 36090198 lee EE, 100.09/1992 109/2013 -09/2022 �$50.00'- $92,36'
c 360864170ee'..,,,EE,.., ,.:.$100 ".07/2013 -07/2022' $50,00 ,_, $92,36 % $142.36
c342771450ee -IIEE..:-.�',.r:,$100-OS/1992"05/.2013 -05/2022',.-,,,,,$50.00-
--4.00%'_--,$142.36 I
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.c330830412ee,.,,-EE..,.:,-,.-$100.1,02/1992,08/201.3,,02/2022-,-,.,.,,$50.,00*"-.�,,,,$95,.,20-VII
,c330777215ee,-.,EE--„,,,,$10012/1991', 00 _,$95,20 4.00% $145.20,".
-06/2013,,12/2021'�_.-�_$50.
c310357192ee-, ,.EE,.. $1001.10/1991110/2013-,,10/2021.1,..,,,,r$50..,00r- -,$98.08-_4.00% $148.08
0 08/19911,08/2013-,08/202l,�-..:,,,,$50,00
,c 295283792ee.':, EE
$10 "$98'.08 _4.00W.,.. $148.081
,c2670,10436eel,-,EE- $100 L05/1991'.05/2013 .05/2021y,--,,-,$50.,00- $98.08. W4.00b/b_ $148.08 s,
,c266947038ee,,.",EE,,-,-,,.,.$100'03/19911,,09/2013 -03/2021'.-.-, -$50.00,;,,.., $101.04
,c276833607ee,,,EE.-,-';",,-,,,$100-01/1991 07/2013z01/2021 --,,,,- $50.00:,,,z$101.04-,,4.00%'-,,,,,,$151.04F..t-
.c263819042ee,,.,.,,EE,.- ,;,,r$1001,10/1990:,.10/2013"1,10/2020',,,,,,,$50.00,";.,,,$104..081i,,4.00%-..-..1$154.08"
C259473423.ee.11-,,EE-,, ,,-,$l00_'O 8/1990;08/20l,3r,08/2020 , $50,001'-, $l04.08'--4.00% - -,,$154.08'
.C242927073EE.-,,,EE,..,�-,,$lQO i.06/1990},06/2013%06/202Q'_,-,.-$50.,00':,., $104..08.".,,,4.00%: -$154.08�
C242889327EE EE $100'03/1990;09/2013: 03/2020 $50.00' $107.16; 4.00% $157.16,
C22674 5079EE_EE.., 100''-0 1/1990 07/2013 ,O 1/2020., _$50,00--._4$107,16- 00%, $157.16
,C226706274EE",,,EE-,,,,., ,$100,11/1989x05/2013:.,11/2019, .,00'--,_-$107.l6,,.,4.00%, $157.16,
i09/20l3',.,09/20l9,',,, $50.M,...$110,32 _4.00% _$160-32,
,C211003,245EEI-',,,EE,,.,.,',..,.$100-09/.1989�
%5----$160.32
.,C210966055EE',-,,,IEE,,,,,7-.-,..,,,$loo,06/!9a9,�,,06/2013.,�.1.0612019,,,,,._,,,,$50.,00;,.�-$110.,32:-".4.00
-Totals for 97 Bonds_$.6,00.0,0.0-;
Notes
_M,,Not Issued_.,,...,.._.._....._..,.__,._. ._...._____.. _
NE Not eligible for payment ,._ ._._-..__..
P5_ Includes 3month interest penalty,.�.,.:., ..�
M/LMatured and not earning interest
REV-i5og EX+(oi-io)
pennsylvania SCHEDULE F
f DEPARTMENT OF REVENUE
I JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Leilani L. Sears
If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G.
SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A. Randall N. Sears 2065 Brigade Road, Enola, PA 17025 Spouse
B.
C.
JOINTLY OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
LTEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 10/10/03 Sovereign-Money Market Account 50%
2. A. 12/27/86 Soverign-Checking Account 50%
3. A. Mass Mutual-Annuity 50%
4. A. Oppenheimer Funds 50%
5. A. Opennheimer Funds 50%
6. A. 2012 Ford Fusion-titled jointly 50%
all assets jointly held with surviving spouse
TOTAL(Also enter on Line 6, Recapitulation) $ 0.00
If more space is needed,use additional sheets of paper of the same size.
REV-1510 EX+ (08-09)
-'-
pennsylvania SCHEDULE G
tlj`�i ;f
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Leilani L. Sears
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECO'S EXCLUSION TAXABLE
INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND
NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1. Commonwealth of Pennsylvania Pension-Randall K Sears,surviving 750,688.43 50%
spouse is Transferee,zero tax due
TOTAL(Also enter on Line 7, Recapitulation) $ 0.00
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+ (08-13)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Leilani L. Sears
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Dailey Funeral Home 9,127.00
2. Walters Embroidery 82.68
3. Dailey Funeral Home-funeral photograph 45.00
4. Marysville Cemetery Association(cemetery plot) 212.50
5. GraveOpening 500.00
6. Pall bearer custom shirts 312.00
7. River of God(church and luncheon) 1,000.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 0.00
Name(s)of Personal Representative(s) Randall N. Sears
Street Address 2065 Brigade Road
City Enola State PA ZIP 17025
Year(s)Commission Paid:
2. Attorney Fees:
3,775.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 298.50
5. Accountant Fees:
6. Tax Return Preparer Fees: 400.00
7. Cumberland County Register of Wills-Renunciation 5.00
8. Mailing costs 12.22
9. Cumberland County Law Journal-adterisement 75.00
10. The Sentinel-advertisement 189.54
11. Cumberland County Register of Wills-Disclaimer 5.00
12. Settlement Costs-sale of 1002 State Street,Duncannon, PA(refer to Settlement Statement on Sch.A) 10,993.00
TOTAL(Also enter on Line 9, Recapitulation) $ 27,227.22
If more space is needed,use additional sheets of paper of the same size.
PRENEED.FUNERAL AGREEMENT AND ASSIGNMENT
EXHIBIT 1 —STATEMENT OF FUNERAL MERCHANDISEAND FUNERAL SERVICES
NOTE: THIS AGREEMENT.IS TO BE FUNDED BY THE ASSIGNMENT.OF INSURANCE BENEFITS
FOR THE BENEFIT OF J EZ LA&M Z, .Srjf C 4 :k_/,4 PA !'7��T
(Funeral Recipient/Insured) (Address) ;. (Phone)
IN AGREEMENT WITH AND ASSIGNMENT TO
(Funeral Provider Name)
GUARANTEED PROFESSIONAL SERVICES ' ' GUARANTEED MERCHANDISE
Services of Funeral Director and Staff $ X/`k Casket $ j y`I
Embalming(See Agreement and Below*) $ d Manufacturer �udit7G
Other Preparation $ Model Namely ,
Visitation Days at$ /Day $
�— Model Number
Funeral Ceremony/Memorial Service $ 'tt-
Other Use of Facilities and Staff(Specify) Exterior Description
$ Interior Description
Transfer of Remains to Funeral Horne $ Outer Burial Container $ 1�
If-beyond a' mile'radius; which is our service Model Name I LD 1,-A LIJ41 T I F '
area,there will be a charge of$ per mile one way. Model Number.
Family,Car(s) at$., each $.
Limousine 1 Hearse $ Manufacturer LIlk`
Cremation $ Constructed of qTf-F /0"
Forwarding/Receiving Remains $ Other Guaranteed Merchandise(Specify)
Other Services/Facilities/Equipment(Specify), $
flss�a•� Pa4,a&t- 'A ' Ahk
$ $
TOTAL GUARANTEED SERVICES $ TOTAL GUARANTEED MERCHANDISE is �•")
NON-GUARANTEED CASH ADVANCES
Death Certificates at$ (a $_ 'J Escort . $
Flowers S,'AfD'JA,_ P.4A E,w14,7IL $ Grave Opening and Closing .$,
,a
Music PasIT)t .1'rDF $ icx> Memorial Cards/Book $ %).Y_
%.Honorariums � �,� $ �}p:7 Clothing(Specify) $
Obituaries $ ..-_ Monument/Marker $
Hairdresser. $ Engraving $
Shipping Container . $ Sales Tax Estimate $
Other(Specify) $ Other(Specify) A,, - ( tLtP1�t $ACA'
We charge you for our services in,obtaining:
TOTAL NON-GUARANTEED CASH ADVANCES $ -I )!r
ADJUSTMENT is
TOTAL GUARANTEED AND NON-GUARANTEEb FUNERAL PRICE i -
*REQUIRED PURCHASES—Charges are only for those items that you selected or that are required:If we are required by law
or by a cemetery or crematory to use any items,we will explain the reasons in writing below.
EXHIBIT 1 ABOVE AND THE,PRENEED FUNERAL AGREEMENT AND ASSIGNMENT ON THE REVERSE SIDE
SHALL CONSTITUTE THE TERMS AND CONDITIONS OF THIS AGREEMENT.
AGREEMENT AND ASSIGNMENT BY: AGRREEEM EN�TrAND ACCEPTANCE BY:
X
(Signature of Purchaser) (Date) (Signature of Provider's Authorized.Representative) 1� (Date)
IN't-c~ "�! -�- fJ 1575 . (,• �-= .,1 .C- .-1�7, �3-rhr�}
:(Address) (Phone) (Location) (Phone)
( 'ty,State) (Zip) (Ci ,State) (Zip)
w HOME SALES ONLY: You, the Buyer, may cancel this transaction at any time prior to the third business day after the
date of this transaction.See the attached Notice of Cancellation form for an explanation of this right.
PRENEED FUNERAL AGREEMENT AND ASSIGNMENT
AGREEMENT-The provider agrees to provide the funeral service as specified on Exhibit 1 in consideration of an assignment
of death benefits of life insurance or anntiity coverage with an initial face amount at least equal to the now-current total retail
price for the items selected.
PRICE GUARANTEE—The prices shown on Exhibit 1 are the now-current retail prices and are illustrated for the sole purpose
of establishing the amount of insurance required to.fully_fund this agreement. At the time the.goods and services are
provided, the then-current retail prices will be charged. If the retail prices then exceed the death benefits assigned and the
guarantee is not limited as described below, the.provider will supply and perform as.specified and accept the available
assigned death benefits as payment in full.
EXCESS BENEFITS—If the,actual,death benefits.exceed the then-current retail prices, the excess may be paid to the
beneficiaries. The beneficiaries may authorim payment of excess proceeds for additional items that are.desired but not
specified on Exhibit 1:
FREEDOM OF CHOICE—This agreement may be canceled at any time prior to the performance by the provider:Charges are
only for those items that are used. If required by law to use any items, the provider will explain the reasons in writing. The
purchaser, during his/her lifetime and thereafter, the purchaser's next of kin or legal representative retains the right to select
the provider that will supply the services and merchandise; however, if an alternate provider is so selected,this agreement
shall become null and,voWand the original provider agrees to then relinquish all claims,to the life insurance or annuity
proceeds.
CANCELLATION—The cancellation of this agreement doe NOT cancel the life insurance or annuity, which may only be
canceled according to the terms of the life insurance or annuity. Unless the.life insurance is canceled within 30 days of issue,
only the surrender value, if any,,will be refunded. In the early years of coverage, this may be considerably less than the
premiums paid.If the life insurance or annuity is canceled,penalties may be assessed.
LIMITATION OF GUARANTEE—If the purchaser funds this agreement with limited benefit life insurance coverage and the
funeral recipient dies during the limited benefit period or with life insurance or an annuity with an initial 1ace amount less
than the now-current retail prices for the items selected,the party responsible for the funeral must pay any difference between
the available death benefits and the then-current.prices.-
OBLIGATIONS—This agreement shall be void unless the purchaser applies for and has issued the life insurance coverage,
pays all premiums due,fully maintains the cash values intact,and the death.benefits thereof are.assigned to the provider.
NON-GUARANTEED CASH ADVANCES—Cash advances are amounts-established to pay for items which are not
guaranteed.At the time these items are provided,those responsible for payment for funeral expenses must pay any difference
between the current retail prices and the advanced amount.The provider may not allocate any portion of the cash advances to
pay for guaranteed items. _
EMBALMING—If you selected a funeral that may require embalming, such-as a funeral with viewing,you may have to pay
for embalming.'You do not have to pay for embalming you did not approve if you selected arrangements such as a direct
cremation or,immediate burial.If we charged for embalming,we will explain why below(or on the reverse side).
SUBSTITUTION—If the-provider is.unable to perform due to the unavailability of merchandise or other factors beyond its
control, it may substitute merchandise of like quality,in lieu of the merchandise selected.If the provider is unable to perform
or another provider is chosen, the life insurance or annuity proceeds may be available for-use with that provider; however,
prices and guarantees would be at the discretion of that alternate provider.
PURCHASER ACKNOWLEDGMENTS—By his/her signature on this agreement, the purchaser acknowledges receipt of a
completed copy of this agreement and acknowledges that a current General Price List,a current Casket Price List,and current
Outer Burial Container Price List,and the Disclosures Regarding Insurance Funding,and each of said documents,were made
available to him/her prior to his/her selection ofservices and merchandise.
ASSIGNMENT—In fulfillment of the consideration required under this agreement,the purchaser assigns to the provider the
right to receive-death benefits contingent upon the performance by the provider as specified on Exhibit 1. This assignment
remairis in effect until revoked in writing,with a.copy of said.writing having been received by Homesteaders Life Company
prior to such time as services or merchandise are provided by the-assignee provider. This assignment shall exist even though
an insurance beneficiary-is named. It notifies Homesteaders Life Company and directs them to pay benefits to the assigned
provider up to its legitimate interests as described above:The assignment shall not be effective until it been filed at the
home office of Homesteaders Life Company and it-shall be subject to any payments made or actions taken by them prior to its
filing.
INSURER RESPONSIBILITY—Homesteaders hife,Company is not a party to this agreement and is not responsible.forthe
fulfillment of its terns. The sole responsibility of Homesteaders Life Company shall be to pay the proceeds of the life
insurance or annuity. r.
SEE THE OTHER SIDE FOR ADDITIONAL TERMS AND PROVISIONS
01{If!".7m7 OII.:n1./e wen..rwi Un..m ne mnnvinMinn urilhnn/nmraee nnTinieCinn.
WALTERS EMBROIDERY Invoice
4 SHERWOOD DRIVE
Date Invoice#
ENOLA,PA 17025
5/17/2013 3100
Bill To
RANDY SEARS
P.O.No. Terms Project
Due on receipt
Quantity Description Rate Amount
13 Embroider desgin over screenprinted design IN LOVING MEMORY 6.00 78.00T
OF LONI SEARS w/RIBBON
PA SALES TAX 6.00% 4.68
U
Total $82.68
) FMTY Connect. Page 1 of 1
XFINITY Connect pawnskewer2 @comcastne
+Font Size-
Re: Loni's vault picture
From:MarioFD @aol.00m Mon,Apr 22,2013 01:42 PM
Subject:Re:Loni's vault picture
To:pawnskewer2 @oomcast.net
I faxed them a form..you should call them at their 800 number,but the statement of death by funeral director should serve as a
notification rather than using up,a death certificate
Your are quite welcome Randy..it was truly an honor to take care of the love of your life and"She who must be obeyed"loll
Mario
In a message dated 4/22/2013 9:20:38 A.M.Eastern Daylight Time,pawnskewer2@oomcasLnet writes:
Thanks Mario.Am I remembering oorrectiy that you notify Social Security?Things are a bit of a blur and I am starting to tie up
the loose ends today
Thanks again for everything.I have received many comments about how nice everything looked
Sent via BlackBerry by AT&T
From:MadoFD @aol.00m
Date:Mon,22 Apr 2013 08:01:53-0400(EDT)
To:<pawnskewer2 @comcast.net>
Subject:Loni's vault picture
Hi Randy,
I ordered the extra picture you wanted,they will deliver to the funeral home.If you want to,you can make a check payable to
them for$45.You can also mail it to them at this address.Be!sure to put Dailey Funeral Home in the memo section
Evans Eagle Burial Vault Company
15 Graybill Rd.
Leola PA 17540
Thanks Randy,I will let you know when I have it.
Mario
http://web.mail.comcast.net/zimbra/h/printmessage?id=83900&tz=America/New York&xi... 4/26/2013
REV-1513 EX+(01-10)
pennsylvania SCHEDULE ]
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Leilani L. Sears
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 spousal distributions and transfers under
Sec 9116(a)(1.2).]
I. Randall N.Sears,2065 Brigade Road,Enola,PA 17025 Spouse 100%
2. Betty Bressler, 1006 State Road,Duncannon,PA 17020 Mother 0%
(interest Disclaimed-copy attached)
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE,
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II— ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size.
John F. Lyons
Attorney at Law
112 Walnut Street
Harrisburg, PA 17101
(717) 238-4777 71
(717) 238-4793 — Fax
AftylD No. 23859
COURT'OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
.
ORPHANS COURT DIVISION
IN RE: Estate of Leilani L. Sears, Deceased
No. 2013-00534
DISCLAIMER
1. 1, Betty Bressler, am the surviving parent of Leilani L. Sears who died on
April 17, 2013, domiciled in Cumberland County, Pennsylvania.
2. At the time of her death, Leilani L. Sears was married and is survived by
her husband, Randall N. Sears.
3. My daughter died intestate. As the sole surviving parent of a decedent
with a surviving spouse and no surviving issue, I bm entitled to an interest in her Estate
equal to Y2 of the intestate estate after payment of the first $30,000.00 to her s.urviving
spouse, pursuant to Pennsylvania Probates, Estates and Fiduciaries Code, 20 Pa.C.S.
2102(2).
4. At the time of her death, my daughter owned certain real property
commonly known and numbered as 1002 State Road, Duncannon, Perry County,
Pennsylvania ("Real Property") titled in her sole name and US Savings Bonds ("The
Bonds") also titled solely in her name (collectively referred to as "the Estate").
5. The Real Property was under contract of sale at the time-of my.daoghter's
death and the sale and purchase transaction was consummated. The net proceeds are
an Estate asset as are the US Savings Bonds which together total approximately
Eighty-two thousand ($82,000.00) Dollars and which are the assets I have an intestate
interest.
6. In my capacity as an intestate heir sharing in the Estate with the surviving
spouse, I hereby exercise the rights granted to me in Chapter 62, of the Probate,
Estates and Fiduciaries Code, 20 Pa. C.S. §6201-6207, and I hereby disclaim,
renounce, and refuse to accept the entire (100%) maximum fractional intestate share to
which I am entitled by law, which, according to law, shall pass to the surviving spouse.
7. Since the date of my daughter's death, I have not benefited from any
interest in The Estate assets identified paragraph 4 above or any other Estate assets.
8. As a result of the Disclaimer, the share so disclaimed will pass by law to
the surviving spouse, without any direction on my part.
9. In all events, I hereby reserve to myself, my heirs, Executors and assigns
the right to make additional disclaimers and renunciations within the appropriate'
statutory periods.
2
10. It is my intention that this Disclaimer constitutes a qualified disclaimer as
defined in Section 2518 of the Internal Revenue Code of 1986, 26 U.S.C. §2518, and all
regulations (and examples) thereunder. Any provisions of this Disclaimer which appear
to conflict with this intention shall be construed so as to accomplish that intention.
11. This Disclaimer is irrevocable and unqualified. I retain no power to amend
or,-evoke Disclaimer, in whole or in .part.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this �day of
2013.
fitness Betty Bressler
ACKNOWLEDGMENT
Commonwealth of Pennsylvania
. ss.
County of Cumberland
ON THIS, the i'`%' r< day of 2013 before me, a Notary Public,
the undersigned officer, personally appeared Betty Bressler, known to me (or
satisfactorily proven) to be the person whose name is subscribed to the within
instrument, and acknowledged that she executed the same for the purposes therein
contained.
IN WITNESS WHEREOF, I have hereunto set my hand and official seal.
Notary Public
My Commission Expires: COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Shelby A.Nelson,Notary Public
3 Hampden Twp.,Cumberland County
My Commission Expires Aug. 20, 2017
MEMBER, PENNSYLVANIA ASSOCIATION OF NOTARIES
REV-1512 EX+(12-12)
IL
17pennsytvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Leilani L. Sears
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. Hospice of Central PA 900.00
2. Cancer Survivor'sFund 50.00
3. AT&T-mobile telephone$140.26(112) 70.13
4. PA American Water$38.65(112) 19.32
5. PP&L$80.40(112) 40.20
6. Comcast Cable$203.16(112) 101.58
7. AT&T mobile telephone$140.26(112) 70.13
8. A.D.Reisman-landscaping on joint residence$118.91 (112) 59.45
9. H.B.McClure-replace water tank @1006 State Street property 1,665.00
10. Tru Green-lawn treatment(112)
11. Visiting Angels-nursing aid 71.50
TOTAL(Also enter on Line 10, Recapitulation) $ 3,047.31
If more space is needed,insert additional sheets of the same size.