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Home My WebLink About04-15-14 (2) � 1505610101 REV-1500 Ex�°1_1°, � OFFICIAL USE ONLY PA Department of Revenue Pennsylvania .ME�.oFaE�E��E County Code Year File Number Bureau of Individual Taxes �EP�p � �• �� 'v�� PO BOX 28o6oi INHERITANCE TAX RETURN If'� Harrisbur ,PA i�128-0601 RESIDENT DECEDENT �� '�I ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY � � �w�� u�� l ■� l � � P � W� � J �� DecedenYs Last Name Suffix DecedenPs First Name MI z G A � �.�� (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI uw, �.m m � in oo pi�i Spouse's Social Security Number IIII THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1. Original Return p 2.Supplemental Return O 3. Remainder Return(date of death prior to 12-13-82) p 4. Limited Estate Q 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) Q 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) p 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 Sch.O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number A o S � K � � � '7 0 ,� �o � $EGISTER WIL�Q ONLY � � � d � �..� � t1'3 � --i � First line of address T,• r'- F--+ t..r� m / / A A R � �' � �' " u= :, c� c� Second line of address � � � � � ' C � � C> � ►-+ r rn � DATE FI City or Post Office State ZIP Code 'ti c c s �: o CorrespondenYs e-mail address: 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. S��TiU'RE�RSO�ESPONSJ,�LE� FILING RETURN ,�j DATE /� .O% iit�. .�� . a�(/�� ADD ES� � � � A .s SIGNATURE OF PR PARER OTHER THAN EP ESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 � 1505610101 1505610101 � 1505610105 REV-1500 EX DecedenYs Social Security Number �/�� /� � RECAPITULATION ��: �� • 1. Real Estate(Sehedule A). .. .. . .. .. . .. .. .. .. .. .. ... .. .. .. .. ... .. .. .. .. 1 � � � � /� �°O; O O ` �"��`" 2. Stocks and Bonds(Schedule B) . ... ... .... ..... . ..... .. .. . ... . . . .. ... . 2. � � � :� ��pC �3 �� , � . 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) .. ... 3. ' � � ' �a � Q 0 �. , � . �, � 4. Mortgages and Notes Receivable(Schedule D). .. .. ... . ... .... ... .. .. .. .. 4. ` , Q 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).. .. .. . 5. ' � 9' 7 g 6. Jointly Owned Property(Schedule F) p Separate Billing Requested . .. .... 6. . - ° � a Q. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property . D (Schedule G) p Separate Billing Requested.. .. .. .. 7. � ' 8. Total Gross Assets(total Lines 1 through 7).. .. .. .. .. .. . . . .. .. ... .... .. . 8. �� 3 9. Funeral Expenses and Administrative Costs(Schedule H).... ..... .. .. ... .. . 9. ' � � Q O 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule I) .. .. .... .... . . 10. � � 3 7 � 7 f ; , / , 11. Total Deductions(total Lines 9 and 10).. .. . .... .. . . . . .. .. . .. .. .... ..... 11. � 7 �, 3 ' + 12. Net Value of Estate(Line 8 minus Line 11) .. ...... .. .. .. . . . .. .. .. . . .. . . . 12. � � ' 7�6,; 7 z g 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ` an election to tax has not been made(Schedule J) .. .. .. .. . . . .. ..... .. ... . 13. V O O 0 14. Net Value Subject to Tax(Line 12 minus Line 13) .. . . .. ... .. � 7 � .. . .. .. .. .. .. 14. � � TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 � �� ' "� °� (a)(1.2)X.0- � � � :O O Q 15. � O 16. Amount of Line 14 taxable at lineai rate X A� � �� 16.� � a 17. Amount of Line 14 taxable D � at sibling rate X.12 � 17. 18. Amount of Line 14 taxable at collateral rate X.15 O O Q 18• 19. TAX DUE .. .... .......... ......... .. .. ................ ..... .. ...... 19. � p� 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 � 1505610105 1505610105 � REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME 7� _��l'�� - -- -- - -- STREET ADDRESS / e7 � - _ CITY _ — - -- ST E Z/ ��j fl� C �-- Tax Payments and Credits: �// n 1. Tax Due(Page 2,Line 19) ��) �j y%/ , ��S 2. Credits/Payments A.Prior Payments — — B.Discount Total Credits(A+B) (2) Q, 0 3. interest (3) o�00 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) _�j ��, �� 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:.......................................................................................... ❑ � b. retain the right to designate who shall use the property transferred or its income:............................................ ❑ � c. retain a reversionary interest;or.......................................................................................................................... ❑ � d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ � 2. If death occurred after Dec. 12, 1982,did decedent transfer properry 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?.............. ❑ � 4. Did decedent own an individual retirement account,annuity or other non-probate property,which containsa beneficiary designation? ........................................................................................................................ ❑ � IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. 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)J.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 stilf appkicable even if the sunriving 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)1• • 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 Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. _,-_se:Fr= ,_-d�;'� �� ,# pennsytvania ; SCHEDULE A � dEaARTMEVT OPFEVE�UE � .. .. iNtict�.ITA:'1Cc TAX RETi�RP; �EA►f. ESTATE i RES:CE"!T;;ECEOE�T � es3aT�af: �1�.� ��$�� T Mpaa .�l ,�C;�u '��3—(�/G'7C �ti reat propert�+owned sa?�ly� r as a tenant in camrts��mus?�e re�lrked at tair market vafue.�a�r ma�ker va��e:�de�inec as tnfi price a*�r-^i;:h�rop��r�� i�!CUiG'he ZX�>an,4£C'C�Lt�'e°_'!c' ... y v_`r'E. --.- -. . :n^SE�y � :��, �, �0'�:.E'.i?�!:^�u. .i 5p��. `�Oi^^aVif�C�easonable kr�o�led�=^�'��e re�evar,t faas Reai property that`is ioi�tl}r-ow�ecs+ui*.h�tghf of sur�ivorship must he rsisc?ased an 5chedule F, _--_._-- - ----- ---_".�,C(aC-: c -:J _i �..,E 5.._._^°r�-.. ?2:. .� �E�:� `tac hcFn 50'u. I '-��N! , !.� ;-�:? .; rn � `'".,F 7E'.:.:o"p:, r:w_..,...,.C,.ia �.'.'i2�.��i�-�,(l.:^n�Ce��.^:i�.;. ..C�,l;.::..,�. � ��".i�4?iii't ,y�M�CR . .., , . - _ � .,'fi UCr'f:".'t _.__.,__. .;i��; _._' _. __�_�. _�__.____'—� _ ___�._.j.__—_ u_� '- ` �rC�neP�y loC��c�' ut i, ��.S�Q��/ ` l/7/ la�y�n��'ke�" way I'�e��ia.+%�-��c�r�, FA l7�'.�C� ,, J j / _-_. ..__�_--/—�/-''-�_. ._..� 5 V i M�;niGn�(1fp�'JI', i.eri° t i?�CC'�1'.rIL�:i•�n �� /."� . V V+ V �� .. �.'E 5�3C°f_„�2C°:,;<52��C':C7G.^.i.?S!t_°2S�i�3Fe'u;�!1�P,$?`Sc'st=�. ��v-,5os�x+rs-set � ' � �`�J '�` � SCNEDULE B � COMMQNWEAL7H OF PENNSYLVANIA � STOCKS & BONDS j iNHERtTANCE TRX RETURN RESIQEPIT DECEDENT � � �STATE OF FILE NUMBER T��r�� T K�a ��G13-�'�G 7G -� Atl property jointty-owned with right of survivorship must be disclosed on Schedule F. �jE� VAlUE AT DATE VUMBER DESCRIPTiON OF DF.ATH �. } �e%c?� !''I��c�� Qr�+��`o�' ��'l k� P/�n ? ��, �13�./� /!(�,�r►�eP /'t S/)c?/'g5 .�/�.�:�g`�� : � �Pice �'� S�i?��eS ��3. �.� � �� G�,��^�� .��u.� �'efre�re�!r Ac��i�??� �1,9'33,�� /aBU��pu t/? �G!/'�L�r�'.�ol� ��i��iN.�n� .Tn Jestir��!7' � t ° FIQ!± � x ---_____ _ � ___._;�TAi.;„�sa art�,�r•ii ae 2. F�eca;:itafat��a,! ;S ,��G: �t� ;?f[?':Oi?Sr,t�S^Q€�#2d,rnSfrf 8d{lt1YJn$3 S#`•2055�#'�'4�33tPE@ S:ZBj �E�r-:5a8 Fx+,i.-sc; : ; scNEOU�E E � ��- �� : pennsylvania � � �EPARTM�NT aF REti�E�� i CA5H� BANK DEPOSITS & MISC, ; INHERiTANCf?AX RENRN � PERSONAL PROPERT1f � RESI�E�v"C Dc'CEDE!�T � _ ESTATE OFc rut nuMes�K. �A?c7J'q t� �;/t t� ot'�/�—�'1�,� .ndude�he proceeds of litigation and the da.e the oreceeds�r�ere received F}the es.ate. Ali property jointly owned with right of survivorship must be discfosed on Scheduie f. ,TE+� � ! VALUE AT QA7E NUMBER � DESCRIPTION L OF DEATN / ! _S��'� ��'c�� a x .Z�✓��y rom ' e s �ar90 � ��i � �l�c��ar� Va�u� � � : Cf��n B��k�� A��c�� i�/��i�7.�9�� k-�) .,�.5;.��8� �, l '� F �. 3y.� ; we ls Q� c 8a.�k, N � � ; ' r � `� 99 ' z �� .� � �" ' ��rtlan,c� G!� 9 ,7�'��-��13" � � �Q�y SQ�ur� .ro� �'.S�a:� �'/, ��'n�,./es ,�"/, ,�/.�.G'�' 3 � Fa�� c�of�p� � ; ��.SD/��1� c7?�`�c�� /�s�er,� �/' .�i�✓e�� i��s �G k � ± i ' ; � -- TOTAL(Alse:.nter c�:i Lne�, Recapituiatic�n) � i 1 . ��Z� , �/� if;nare space is needed,use additionai stieeks of paper of:he same s�ze. " �sEV-1511 EX+(10-06� i � �` � � SCNEDt�LE N ' COMMONWEALTH dF PENNSYLVANIA FUNERAL EXPENSES & ( WHERITANCE TAX RETURN j ADMINISTRATIV� COSTS � RESIDENT DECEDENT � ESTATE OF PILE NUMBER �?��...�/G�� r,??C?'�A �,TD .�/' G - Debts of decedent must be reported on Schedule L ITEM NUMBER DESGRIPTION i AMOUNT A. � FUNERAL XPENSES: �� /t/i ,. ��ck�i� F��r/ �10�►��, .z'�►�. ��nact#�P.�' ! � U�� Gre�lA7%'0�' �e��%ct ��lQ.�,('�' � P��?.�rTo�► o�` �e•t�t,�"�� ;c6s�� ' ; �%��sp�!'�e� C�►6mo?:on C��To.r�I► ��?5'G'.�� : ; ! Ge�t��;� C�t�`f� G'�r��'�qTc� C'�p��a� �9�.�� ; C o�'�i�e�' �1��'fi,�r';�a�-Qn ,�.3G'GG g. I AOtviWiSTRATIVE CQSTS: � 1. � Persona�Representa6ve's C�mm�ssions 1 ! � y Name of Persanai Representat;vE!sj _. _ � � � j 5treet Address _ i � ��h' — --___–--S.ate-------``� i I � Yaaris)Commission Pad: ' � - _, �. � h:tOff1EY�EES . i 3. ; �amity Exsmpticn_iif�eceden!`s addres;is r•o:the sams as clasmsr�s.attac�axe�anati^!�i i � � iCiaimae: i 1 Street Address ! ;' _ _ ` �"�`------------ -----.�.__ ___--State ---.L�P 1 ' i Reie6onshio of Claimant iu Decede�: � ; __- _. i { � �. E Proba;e Fees I i 5. � AccounfanCs Fees � � � 6. � Tax Rafom Preparer's Fees ; f 7. � i ' � ___ —4-- TOTAL(Also enter on fine 9,Recapitulatian)± S ,�� y��t/ (If m�re space is needed,insert additional shaets of the same size) RfV-1512 EX+ {12-081 ! � �� pennsylvania SCHEDULE I ` . OEPARTMENi OF REVENUE DEBTS OF DECEDENT, INHERP'ANC'c TAX RETURN MORTGAGE LIABILITIES & LIENS RESIOENT DECEDEMT I ESTATE OF FILE NUMBER +. �� ^� '��..�"'��U 7[! Report debts incurred by t e decedent prior to death that remained unpald at the date of death,irtciuding unreimbursed medicai expenses, P'EM VALUE RT DA?E NUMBER DESCRIRTION I OF 4EATH �. �W��l.s �a;A�c N�n�e Mo,�tr�a�e �,��:�P�%��'�� '�1C�7 00�. �� v�tcT;o�, ' "� .�. 'U!t��A,�r, Mrt10�► �n�+pq�y, �ac. work ra •rake cc�;� � �/yS.. .� � � . �?L�O..� �'atit� .Ion 3. ; Nq,�o�e� ��"oum,sfi��+ t��n��ipql Fees ��.�3!<'� I� , �,�;Q�� '/99'��.� �, j ��ve%� ��►�e�� -ty a.�� 1 , ; .�� '��/s /� �. pirec � �. �e��s I,�tt��d Am�ri�a� VI�Qten �9�'. �l� . � � �� ''.�1 i7�, r 7 v� o� � � �'F� ��ec��e l.(��1;tes ;� 3�.�. �� l: � i�G-� l��';/;t;�� `� /�. �'� �Q, �� a:�p i�,ll ��rer�e�rc��y �h��si�ian.� �-� 3��', �� r l, � 1/t/e,� S�a�e �'l'�S- A'L S '��9. �� a� ��i"/�er �r;� ��?�ft�lanc,^e Gt�?� .�e��uG> :�.�o�i��; ��.��'a�"� � ��3: �./C��/ S rt�%t ,Nas�i tal ;�,�,�, 7..�" i�l, S�eprs fr�� G.��e�'ear�!� �`it64nk, �11�A, `:.��5�, �� S, � ;QrscG✓e�' Cq�� c �, �� . '':�.f7�f' �� rrc��2�? �'iG��' ��'�"pQ�y. r^�� - �?G�'.,� �a��r� Z�� ..�� t 30'tA1(A�so enter or Line 10, �ezapitusationl �� I j��,�r �� —� If more space ts needed,'snsert add�tiona!sheets of the same siz2. �=V-i�:3��+ tU1-?C:? ,�i � pennsylvania " SCHE�ULE , { � DEpAATMENTOFREVEtviJE � BE��TICiARI�S � INHERIT0.M10E TA%RETUR?1 ! i R�SIDE�'T DECEDEN? ESTA7E OF: PIIE NUMBER: TA,�'1�l'A �„ � � �Of.,�y O/ T�f --- �� i K��A!;nh;SNIF ;0 DECE�JEPJT ! „�'OU!v:CR ,hARc ;,�p;g�� t iV:;�jc ANG kpDRcSS Of P�RS�JSv;;S?RtC�i'•iiiJG�-:��EKTY i Da Not List Trustee{s} 1 ��F ESTATE ` 3 s �F c�-^r n, ( ' t' S' r � `'b� � � I � AXA5_�D'., Y.al�Ti..iVs I:�CiU�e2 OU.(��L S.;OU58�GiS:i: JCGi's z.�G�ifa^S;O��Ut7tl°f ; ; Sec,91?�;a;('_.2;.; ; � ; �� '�,U�� /ke �.�� i 1,��' �'v _ , 8�� , ; y �i7� �y��k�� 4y .I��c�a�%:��r��, l�� /�G'.SG � � ;/ ; � � i °�dT�R+J�:r1k AMOUtv?S��JR DI�?k:��??t��:S S��J�t u.3��' '' <�1�5 25 VH+.�iiv"•!� Ie C�'R�' _�G_�:�j::R S��ET A.S��0°R�?�.�.3c�''.�f a A� - -- — --r �Y��,-r� � _� i NO�J-i�1XABLE�ISTRIBUTIO�lS . � � A. SPOUSAL diS�RI8�TI0N�tiNGEn 5EC7i�P;9?i�FO�.'!vHi:ti a.y=�cC"+iG1�_�-"?X 1�;��?'i+i�ci:: i.; � + i i B. !'lfARITABLE AtdQ GOL'ERNMEsI�;�i.Dl5TRIBUTIDNS: { 1 i i.' i ) � I TOTAI.OF PART II- ENTER TQ�AL NOh-FAXABLE O:STRi3tJTIt3�15 ON LiNE 13 OF RE��-1500 COVER SHE€Y. {$ �/, �� 's'more space+s needed,use add+tionai;heets of paper of ihe same size. COMMONWEALTH OF PENNSYLVANIA SHORT CERTIFICATE COUNTY OF CUMBERLAND ,a � i � � � I, GLENDA FARNER STRASBAUGH Register for the Pro.bate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 7th day of October, Two Thousand and Thirteen, Letters TESTAMENTARY in common form were granted by the Register of said County, on the estate of TAMARA JO K/NG , late of HAMPDEN TOWNSH/P /First,Middle,Last1 in said county, deceased, to BRANDON E SL/KE (Fi�st,Middle,Lastl and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 8th day of October Two Thousand and Thirteen. File No. 2013- 01070 PA File No. 21- 13- 1070 Da te of Dea th 7/15/2013 S. S. # n Regis r f i s puty NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL LAST WILL AND TESTAMENT OF TAMARA J. KING I, TAMARA J. KING of Mechanicsburg, Cumberland County, Pennsylvania,being of sound mind, memory and understanding, do make and publish this, my Last Will and Testament, hereby revoking all wills and codicils by me dated February 10, 2006. ITEM 1: I direct my Executor hereinafter named, to pay the expenses of my last illness and funeral expenses from the property passing under this Will as an expense and cost of administering my estate. It is my intention and I do hereby instruct my Executor that I do not want a viewing or a funeral service. I want to be cremated and the ashes to be released into the possession of my son, BRANDON E. SLIKE. ITEM 2: All expenses of administering my estate and all inheritance, estate and succession t�es, including interest and penalties payable by reason of my death, which may be assessed or imposed with respect to my estate, or any part thereof, wheresoever situate, whether or not passing under my Will, including the taxable value of all policies of insurance on my life and of all transfers,powers, rights or interests includible in my estate for the purposes of such t�es and duties, shall be paid out of my residuary estate as an expense of administering and with apportionment, and shall not be prorated or charged against any other gifts in this Will or against property not passing under this Will. ITEM 3: I give, devise and bequeath unto my beloved child, BRANDON E. SLIKE, the rest,residue and remainder of my estate, real, personal and mixed, whatsoever nature and �� kind and wheresoever situate. ITEM 4: I have purposely excluded as beneficiary my children, SHANNA E. SLIKE and NICHOLAS R. SLIKE because it is my belief and I have determined that my children SHANNA E. SLIKE and NICHOLAS R. SLIKE will benefit from the estate of their Father as well as the estates of their maternal grandparents. ITEM 6: In the event any beneficiary and I die under such circumstances that the order of our deaths cannot be established by proof, or should any beneficiary and I die as the result of a common disaster, it shall be conclusively determined for all purposes of this Will that I survived the beneficiary. ITEM 7: I hereby nominate, constitute and appoint my son, BRANDON E. SLIKE, of 6171 Haymarket Way, Mechanicsburg, PA 17050, to be my Executor of this my Last Will and Testament. ITEM 8: I hereby nominate, constitute and appoint JOHN F. K1NG, Esq., of Mechanicsburg,Pennsylvania, to be my Contingent Executrix of this my Last Will and Testament. IN WITNESS WHEREOF, I have signed this Will on this ��=� day of �� %,�`,C'...- , 2007. � � TESTATRIX , Signed, sealed,published and declared by the above Testatrix, TAMARA J. KING, as and for the last Will thereof, in the presence of us, who, at the request of and in the presence of �� TAMAR.A J. KING, and in the presence of each other, have hereunto subscribed our names as witnesses thereto. `�_'�'' �. -:.��:,��` ��(�:,��.�:�.� ��' ��.��,� �`l� �l�'� Witness Address ` � , ., h � , � t : , _ ,. i'� - � � iE�?�-� r��r�-,�-r-� �; C�Ri z� �7 L,� ' Witnes� Address COMMONWEALTH OF PENNSYLVANIA : . SS. COUNTY OF CUMBERLAND : I, TAMARA J. KING, Testatrix, whose name is signed to the attached or foregoing instrument,having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will;that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. . �z_-- 1 � TESTATRIX We, ��c�;�r�?��G'(�.- ��i �i1��'� and ,�' ��!( J rn � ��ae r�;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 the Testatrix sign and execute the instrument as Testatrix's Last Will; that TAMAR.A J. KING signed willingly and that TAMAR.A J. KING executed it as Testatrix's free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge the Testatrix was at that time eighteen(18) or more years of age, of sound mind and under no constraint or undue influence. � �� WITNESS .'i r� � i��✓' �� Z. WITN S ` Subscribed to and sworn or affirmed before me by the above-named witnesses, and subscribed to and acknowledged before me by the above-named Testatrix, this,�t� day of �� , 2007. ��..z� " ��,��..�-,..-:� NOTARY`P BLIC COMMONll4(E�1.LTH�F PEhlI��YLVANIA Plt1Tl�RitaL SEAL SH��.€��i°�'� :�EUiANS,Notary Public r�;�,�,4!��rri�;aur��,�au�hin County _.Il��_�Si"P�II3;a.Sl9l1�'x'�'� '��.m�=� 0104414222 Uniform Residential Loan Application This application is designed to be completed by the applicant(s) with the Lender's assistance. Applicants If this is an application for joint credit, Borrower and should complete this form as "Borrower" or"Co-Borrower," as applicable. Co-Borrower information must Co-Borrower each agree that we intend to apply for also be provided(and the appropriate box checked)when �the income or assets of a person other joint credit(sign below): than the Borrower (including the Borrower's spouse) will be used as a basis for loan qualification or �the income or assets of the Borrowers spouse or other person who has community property rights pursuant to state law will not be used as a basis for loan qualification, but his or her liabilities must be go�Wer considered because the spouse or other person has community property rights pursuant to applicable law and Borrower resides in a community property state, the security property is located in a community property state, or the Borrower is relying on other property located in a community property state as a basis for repayment of the loan. ca-aorrower A enc. Case.Numbe...�... r < >:<`�'Lende�:<�:zs. ...o�•�'..a.�e�.�.. r Case..Number.....•. M rtg g ...0•VA�.�.�Conventional�.�'Other(explain): 9 Y Applled for: �FHA � USDA/Rural Housin Service 0104414222 Amount Interest Rate No.of Months qmortiZation Fixed Rate Other(explain): $ 118,000.00 5.000 % 360 TYpe� �GPM �ARM(type): r'11�,�13'i�M. 20-30 YR E'.Q�,D N:IN— :::?:<::<::If'�::':;,,.,,,;:..<:::::.......;.,.•:.;•::,,.,.;•::..;....::...::::,:::.,;::,.:..;�:.:;:::,.,::,...,;;.,.;::::.:'�;''":<:'..:;,?".'.'::::>:::::>:::::#::>:`:::::;'•:::>::>::::>::::::>::>::><::>'::::>::::»:::::<:>::::>::::::>::::::>::!:»�:;:::>::>::::»::>::>::»:::�:s>::::>: •<:.:::;:>:::::::::.>:<:::�.�>:.>;>:.;:.;:.::.;:.::.:;:.;:«:::;;>;;:.;::.>:.::.::.;:.;:.::;.;;:;.;;;:. ':?:::<::>�:::z<;><:#::::':::::>;:'::;>:::>::>::::>::>::::>::::>::::>:::<i<:::;;:;:::::>::::»::>::::>::::>:s>::»::»::<;:::: . .. ..�Ri�P� '1'1t`..#t!F�1�#�' .............................. . ....................... .... . . ................................................................................�C.................:.M�Ic71�i;�;A(sf�;Pl�F�p�$.�.*:��::�.�5�1.:::::::::::.::::.:::::::::::::.::::::.:;:.::.::.;:.;:.>:<.;:.;:.:<.::.>:.>:.;;:<.:.>:.::.;:.;::.>;:.:.;:.::.;: Subject Property Address (street,city,state s ziP) No.of Units 6171 F�T �n�,Y, I�CHAT7I�G, PA 17050 1 Legal Description of Subject Property(attach description if necessary) �� qtispp�7 � Year Built 2001 Purpose of Loan Purchase Construction Other(explain): Property will be: Pnmary Secondary �Refinance 0 Construction-Permanent �Residence 0 Residence � Investment Complete thls line if construction or construction-permanent loan. Year Lot Original Cost I Amount Existing Liens I(a)Present Value of Lot I(b)Cost of Improvements I Total(a+b) Acquired $ $ $ $ $ Complete this Ilne if this is a reflnance loan. Year Original Cost Amount Existing Liens Purpose of Refinance Describe Acquired Improvements �made �to be made � � 2 139000.00 $ 113927.71 cost:$ Title will be held in what Name(s) � ,J HI�� Manner in which Title will be held ��°'L'L'Y Estate will be held in: �Fee Simple Source of Down Payment,Settlement Charges,and/or Subordinate Financing(explain) � Leasehold (show explration date) E�JI'1'Y Q� S�7F�.R' PFiD� .;::.:::.;;;::.::.::.;:.;:.;:.;;;:.>:.:;>:.:::.:;:.::.;>::.;:.;:.;:.;:.;:.;:.;;:.>:.;:.:...y.:{�.y.:y.�:.i..`.I...y..�...::::::.:;;:.>;:.::.;:.;:.;:.;:.::.:;:...;,.;�..y.:...y..�.y..:�.y.�.{.;.:'...�.y...;..: ..:.:.:.,::.....:�,y•::.;:.>:.>:.>:.;:.;:.;;:.;:.;:.;:.::.;:.::�....::;:...:::::::::::.;::.;�:::::::::::::::::::::::::::::::::::::::::.::::::::::::.::. :i:::i::::'r�11.f�.2i'l..Y��:•:t::::::::::::i::i::::::i::::i:::i::::i:ti:•,:•::i:•:::��':: :� ::.s.�,yN�y.y;�.yy�.��.�y� ... ��.Ri�IiCi�CV./.YY'�T.S:::� ...' ..M� '..: ` .::i:ti::::i:?::i::i::ii::i::i:•::i:::•:•:(% •.::.:::::::::::::::.�:::::::::.::::.:::::::n:�:::::::n ��1111��iY....................... ..Y+ . M.QY.�LY.YY. ::::::::i::i::::iii:•:i:::::•"F.C:$::::i::::::::i:?:i:::i::j::::i::::i::i}::i::i:::y;:;:y ....................................................... , .. W............................................................ ........................................................ Borrower's Name(include Jr.or Sr.if applicable) Co-Borrower's Name(include Jr.or Sr.if applicable) TI�,RA J IQI� Social Security Number Home Phone(incl.area code) DOB Yrs. Social Security Number Home Phone(incl.area code) DOB vrs. 206-50-7016 717/790-6088 �m 11��%195 16�� (mmlddlyyyy) sonooi Unmarried include sin le, De endents not listed b Co-Borrawer Unmarried include sin le, De endents(not listed b Borrower X Married divorced,Idawed g noP ag�s y. � �Martied � � 9 noP a bs y � ) divorced,widowed) 9 ❑Se arated �� ❑Se areted Present Address (street,city,state,ziP� Own Rent 07/03 No.Yrs. Present Address (street,city,state,ziP) Own Rent No.Yrs. 6171 F�l�'P (n�,Y , �GSS�G, PA 17050 Mailing Address,if different from Present Address Mailing Address,if different from Present Address � � If resldin at resent address for less than two ears com lete the followin : Former Address (street,city,state,ziP� Q Own �Rent No.Yrs. Former Address (street,ciy,s�afe,ziP) a Own �Rent No.Yrs. r r %;:�::::�::::::i::::::::t;::::S::r:::::::::::;;;::t::i::i::::::::::::::::::::::::::5::::i•�.;�.;:�::::.»�::��:k::5i::t:::::s::::::ii:::i::;:::::i...................:..:...:.....:....:..:...:..:......:.:.....:.:.::::::s::i:::::::::::::::i::::i;::�:::i:..;::;:..:;:;:::.:•:.:::.:>�:::;:::::::::::5::::2:::i::i::i::i::i:::::;5:::::iiii:::::::�::i::::;5::::i5 ::::::::r;E3bEM�111�1 <:;.: ;+• i �'..<:::»::>::>::»::»::»>::>::>::»:�.::�NIE!'LC�1f.:01t��IT:!I�i�'S� M '•:: •...:.;:.::;.::.::.;::.::.;:.:::.:::;.:, :»:>:::»>ss;:<:>:a::a::::::::>:::::»::»»:<:>::»::»:<::<a:::::::>::>::> f� A't�N...........................��h..Bbt.. YC11N�•>:<;:::>:<a::ss::s:::>s»::>::>::>:::<::»s»>:«:>::>s;::::>::»::>:s:<:::>:: Name&Address of Employer �Self Employed Yrs.on this job Name&Address of Employer Self Employed Yrs,on this job SELE7C'P L�ICAL 02/03 2501 �fi TFIIRD STR Yrs.employed in this line 000000000 Yrs.emplo ed in this line of worklprofession � of work�profession HAl2l2ISBUk�G , PA 171100000 02/02 PoSItiONTltle/Type Of BUSllless Business Phone(incl,area code) PosItIONTltle/Type of Buslness Business Phane(incl.area code) CASE � 717/243-4102 If em lo ed in current osltlon for less than two ears or If currentl em lo ed In more than one osftlon com lete the followin : Name&Address of Employer Q Self Employed Dates(from-to) Name&Address of Employer �Self Employed Dates(from-to) 0000 - _ Monthly Income Monthly Income PositlonlTitle/Type of Business Business Phone(incl.area code) PositloNTitlelType of Business Business Phone(incl.area code) Name&Address of Employer �Self Employed Dates(from-to) Name&Address of Employer �Self Employed Dates(from-to) Monthly Income Monthly Income $ PositionlTitlelfype of Business susiness Phone(incl.area code� Position/Title/Type of Business Buslness Phone(incl.area code) Freddie Mac Form 65 7/05 Fannie Mae Fortn 1003 7I05 �-27N �oeo�� NMFL#1003(APP1,APP2)Rev 11/10/2007 Page 1 of 4 Initials: VMP Mortgage Solutions,Inc.(800)521-7291 >:>;>:<:::>:::»>::>::»>::>::»:<::<::>:::>:::::::>::::>::>:.:>:<;:::.:::�:<:::::::»::::>::::<:..:.,.:....:.:......:::.:......:.:..:..:.:.......:.:..::::...:..:.:...;..:.......,.:..:..:::.....:.:...;....:.......:::.:...:..:......:..:.:.:.:......::::::::::.�::.�:::::::::::::::.;:::::::::::::::::.::.:::::::::::::::::::. :::.. <Y:: .. �::#.:::�� .. :: ..:::>:::::::<:<::;::::>::::>:::>::::>::::>:::::::>:::>::::::;::>::>:>::::»>:::::::::<::::::>:;>::> :::.>:.;:.::.;.>:.:.>::>::<::;<::>:::;::::::>:.;:.>:::>::::.:::.::.::::::::;::.;:.;:.;::s;:.>�:.;:.:�tr::�M�4�'�J:�I«....11��G!�i01�>�:�1 .;.�."� � . •.: : .> . :.: . .............. . .,� :�.. ..M .II�I��?r...H!�i�J�1�1..��.:.:��'�N:��...N.�`�?!R1�t�'�'I!�1�1.....................:.::::::::::::::::::::::.�::::::::::::.�::.�:::: Groea Monthly Income Borrower Co-Borrowsr Tolal ombineEx�ense�y Present Propoaed Base Empl.Income" g 5280.00 g g 5280.00 ent g Overtime irst Mortgage(P&I) 509.00 g 633.45 Bonuses ther Financing(P&I) 459.00 Commissions azard Insurance 25.17 Dividends/Interest eal Estate Taxes 138.00 138.50 Net Rental Income ortgage Insurance Other(before completin9, omeowner Assn.Dues see the notice in"describe 7.�� 7.91 other income,"below thef: .�� 5280.00 5280.00 1114.00 805.03 'Self Employed Borrower(s)may be requlred to provide additionat documenWtion such ao tau rsturns and Tinancial statements. Dascribe Other Income Notiee: Alimony,child support,or separete malntenence Income need not be revealed if the Borrower(B) B/C or Co-Borcower(C)does not choose to have it conaidered for repaying lhls loan. M011thly ARIOU�t . .. ........ .. .. .... ;::::<:::�i::�'.�'''�*�'�'.::�.Q:::�:�Ja��:�'��"'+�Ji::::::::::::::::�::::::::::::::::::::::::::::::t::::::::::::::::>:::::i:::::::::i::::?;::;i:i:i:i:;��:::;;:i:::>::::::::::::::::::'r':::::'r':::�:i:::<:�::::::::::::::::::::'r'::::::5 This Statement and any applicable supporting schedules may be completed jointly by both married and unmarried Co-Borrowers if their assets and Iiabilities are sufficiently joined so that the Statement can be meaningfully and fairly presented on a combined basis; otherwise, separate Statements and Schedules are required. If the Co-Borrower section was completed about a non-applicant spouse or other person, this Statement and supporting schedules must be completed about that spouse or other person also. Com leted Jointl �Not Jointl Cash or Market Llabilitiesand PledgedAsseb.List the creditor's name,address,and account number for all outstanding debts, ASSETS Va�U@ including automobile loans,revolving charge accounts,real estate loans,alimany,child support,stock pledges,etc. Descri t10� Use continuation sheat,if necessary.Indicate by(') those liabilities,which wili be satisfied upon sale of real estate Cash deposit toward purchase held by: $ owned or u on refinancin of tne sub ect ro e . LIABILITIES Monthly Payment& Unpald Balance Mo ths Left to a Name and address of Company $PaymenUMonths $ List checkln and savin s accounts below DISOGVEF2 FIN S�7C5 LT� 24/ 33 798.00 Name and address of Bank,S&L,or Credit Union I�iC.HD�TIA �if�os92no Name and address of Company $PaymenUMonths $ Acct.no. $7Q9,00 IQ7d�II�5/(�15E 40/ 8 301.00 Name and address of Bank,S&L,or Credit Union �`(��i16o552 Name and address of Company $PaymenVMonths $ Acct no. � Name and address of Bank,S&L,or Credit Union Acct.no. Name and address of Company $PaymenUMonths $ Acct no. � Name and address of Bank,S&L,or Credit Union @ = RC� BE P @ QASIl� Acct.no. * = 1�,7P IAj FtFjTIQ$ Name and address of Company $Paymenf/Months $ ,4cct.no. @� 37003.00 Stocks&Bonds(Company name/number $ &description) ��b��1001056529 Name and address of Company $PaymenUMonths $ Life insurance net cash value g �., 76924.00 Face amount: Subtotal Liquid Assets 8730.00 Real estate owned(enter market value g 155000.00 from schedule of real estate owned) �b��1000362043 Vested interest in retirement fund Name and address of Company $PaymenUMonths $ Net worth of business(es)owned g (�ASE ADi1� 261/ 17 4486.00 (attach financial statement) Automobiles owned(make and year) $ 4`�'4��820091806 Alimony/Child SupporUSeparate Maintenance $ Payments Owed to: Other Assets(itemize) $ Job-Related Expense(child care,union dues, $ etc.) Total Monthly Pa ments 325.00 Total Assets a. 163730.00 :;•.$.' 'd •`• ::»:;:.► 49217.00 Total Liabilities b. 119512.71 Freddie Mac Form 85 7/05 F e Mae Form 1003 7/05 Initia�s: �-21N (0507) Page 2 of 4 ;:>::>::::>::>::::>:>::»::>::»::>::>::>::>::»::>::>::>::>::>::>::::>::»::»::»::>::>::>::>:::::>:::::>::;>;:::>::>::>::>::;:»>::»>::>::»;::>..:.....................................:::..:..........:..::..>::;:.;:.;��;:::.;:>::»::>::::»::>::>::>::>::>::>:::::>::>:<:>:;::::�:;;;;::>;:::>::>::>:>::>::»::>;.>;;:><>::>::>:::�::>::>::>::::»>::>::>::>::>:::�»>�«::;:: :>:»::::>:t��::i4��'f;�::A�i�:::l;�.��.1`.Cl��:��. ::::;:::;:;;::::>::»::>:<:>::>:::�>::»:>:::>:«<::�»:::»::::>::>::::>::::>::»::»»:<:;::»>::>::>::::>:<:>;::::<:>::<:>::»::>::»::::>:::::>::>: .;:.;:.>;:.;:.;:.>:.;>:.>:.;;:.>:.;:.::.>:.>:.>:.::.>:.>:.;:.>:.>:.;:.;;:.::.::.;:.>;:.>:.::.::.::.:::.:;:.:;<.;:.>::>:.>;>:<.>:.:�:�::.;;:: .:::.�:::::::::::::::::::::::::::::::::::•:::•:.:�.�::::::::::::::::::::.:�::::::::::::::::::::::::. ................................................................................................................................................................................... ..............................•.::.:.::::::::.:::::.�:::::::..........................:................... Schedule of Real Estate Owned (If additional properties are owned, use continuation sheet.) ProPerty Address(enter S if sold,PS if pending sale Type of Present Amount of Mortgages �ross Mort9a9e insurence, Net O�R if rental being held for income) Property Market Value &Llens Rental Income Payments Maintenance, Rental Income � Taxes 8 Misc. 6].71 F� ln�aY H SF $ 155000 $ 37003 $ $ 1 $ $ 6171 F�T i�,Y 76929 1 Totals $ 155000 $ 113927 $ $ 2 $ $ List any additional names under which credit has previously been received and indicate appropriate creditor name(s)and account number(s): Alternate Name Credifor Name Account Number ;;»:•::•>:•:::•::•>:>:•::•::•>:•>:•.;�::.:....::..:.....::.: :::.....:......;.......,,.:.......;...,:�•::•::•::•;;:;:::•:»:�»::::•:::;;:.::•;»:•::•::•>:•::•::•::•::•::•::•:;:•;;>:;:;:•:::•::;::;:::•::::>:•::•;;:;;:•::�.:...;. • ..� �• •� <::::""'::'>:..,..,;..;....... •:. : . .. .;.. . . .,: �.,...'i'sE�::;i:Y::�E�>:'•3:'•i5'Si':�s::ii'Si�'SE22t�:E�::<'•:::i�E'•::E•`::�:'Si:ii:�iE�:<E�:: �<y. ,.. .. •.: •:� .?:�:�::�:2:�?:?:::3;::�::2�;;:;:�`;:;:�;5:;;:;;:i'ri'r'ri'r:�::•`:�::`•:?:�::�:�::�::�::�::�:i:::;::;:;;:;:::::::5:�;::;::%%.i:' . .............................................................. ::'r:'rii:'•>i:`•'r;s:�::`•:``•:�;;::`•;`;:`•:;Y:� .. . .�.. . ........................................... a. Purchase rice g If you answer"Yes"to any questfons a through i, please sorrowe� Co-Borrower use continuation sheet for explanation. Y„ No v.a No b. Alterations im rovements re airs c. Land if ac uired se aratel a. Are there any outstanding judgments against you7 � � � � d. Refinance inci.debts to be aid o 113,927.71 b. Have you been declared bankrupt within the past 7 yearsl � � � � e. Estimated re aid items 1,657.76 c. Have you had properly foreclosed upon or given title or deed in lieu thereof in the last 7 years? � � 0 � f. Estimated closin costs 2,304.00 d. Are you a party to a lawsuit7 Q � Q Q . PMI MIP Fundin Fee e. Have you directly or indirectly been obligated on any loan which resulted in foreclosure, transfer of title in lieu of foreclosure, or judgmentT (This would include such loans as home h. Discount if Borrower will a 1 180.00 mort�a e loans, SBA loans, home improvement loans, educational loans, manufactured I. Total Costs add items a throu h h 119 069.47 �mobile� home loans, any mortgage, financial obligation, bond, or loan guarantee. If"Yes," provide details, including date, name, and address of Lender, � � a � . Subordinate financin FHA or VA case number,if any,and reasons for the action.) k. Borrower's closin costs aid b Seller f. Are you presently delinquent or in default on any Federal debt or I. Other Credits ex lain any other loan, mortgage, financial obligation, bond, or loan � P � guarantee7 If "Yes;' give details as described in the preceding � � � � question. g. Are you obligated to pay alimony,child support,or separate maintenance? 0 � � � h. Is any part of the down payment borrowed? � � � � i. Are you a co-maker or endorser on a note? � � � � --------------------------------------------------------- j. Are you a U.S.citizen? � � � � k. Are you a permanent resident alien? � � � � m. Loan amount I. Do you intend to occupy the property as your primary � Q Q Q (exclude PMI,MIP,Funding Fee financed) 118,000.00 residence?If"Yes;' complete question m below. m. Have you had an ownership interest in a property in the last � � � � n. PMI MIP Fundin Fee financed three�years? o. Loan amount add m&n 118 000.00 �1) What type of properry did you own - - principal residence � � (PR),second home(SH),or investment propertv(IP)? p. Cash from/to Borrower 1069.47 �2) How did you hold title to the home --solely by yourself (S), S jo�'�n�t�ly with your spouse (SP),or jointly with another person (subtract j, k, i&o from i) y.� Ira ::.;•::..j�f(��::Ei:i;;';';;:':;:;:;i;:i::::::::s::::::::::::::::::::::::::�::::s::ii:::::::E::;::E::::Ei2:2:::::::;:E;ii:i:E'•ii::'ii;�::::#iii!:S:i<`'r'::::::i::::': .......................::.1'�/ki::�l.�''i.K�'�Q��:�1:/:��::i��:%��.�i�ri�u�� ...................................................................................................................................................................................... . ...... .................................................................................... Each of the undarsigned specificaliy represents to Lender and W Lender's actual or potential egenb, brokers, procassors, attameys, insurers, servicers, successors and assigns and agrees and acknowledges that: (1)the infortnation provided in this application is true and correct as of the date set forth opposite my signature and that any Intentional ar negligent misrepresentation of this infortnation contained in this application may result in civil liability,including monatary damages,to any person who may suffer any loss due to reliance upon any misrepresentatian that I have made on this appiication,and/or in criminal penalties including,but not limited to,flne or imprisonment or both under the provisions of Title 18, United States Code,Sec.1001, et seq.;(2)the loan requested pursuant to this application(the"Laan")will be secured by a mortgage or deed of trust on the property described in this applicatian;(3)tha property will not be used for any illegal or prohibited purpose or usa;(4)all statements made in this application are made for the purpose of obtaining a residantial mortgage laan;(5)the property will be accupied as indicated in ihis application;(8)the Lender,its servicers,successors or assigns may retain the original and/or an electronic record of this application,whether ar not the Loan is approved; (7)the Lender and its agents,brokers,insurers,servicers, successors,and assigns may continuously rely on the information containad in the application,and I am obligated to amend and/or supplement the infortnation provided in this application if any of the material facts that I have represented herein should change prior ta closing of the Loan;(B) in the event that my payments on the Loan become delinquent,the Lender,its servicers,successors or assigns may, in addition to any other rights and remedies that it may have ralating to such delinquency,report my name and account infortnadon to one or more consumer reparting agencies;(9) ownership of the Loan and/or administratlon of the Loan account may be transferred with such notice as may be required by law; (10) neither Lender nor its agents,brokers, insurers,servicers, successors ar assigns has made any representation or warranty, express or implied,to me regarding the property or the condition or value of the properry; and(11) my transmission of this application as an"electronic record" containing my"electronic signature," as thosa terms are defined in applicable federel and/or state laws (excluding audio and video recordings),or my facsimite transmission of this application containing a facsimile of my signature,shall be as effective,enforceable and valid as if a paper version of this application were delivered containing my original written signature. Acknowledgement.Each of the undersigned hereby acknowledges that any owner of the Loan,its servicers,successors and assigns,may verify ar reverify any infortnation contained in this application or o ain any m rmation or data relating to the loan,for any legitimate business purpose through any source,including a source named in this application or a consumer repoRing agency. Borrower's Signature Date Co-Borrower's Signature Date X X ;::;:.:>::>::>::>::>::>:><::::.;:.>:::>:»»:::>::>::>::>::>•::.;:.:»::>::>•:>::>::>:::>::>:::;:<><:»>::»; ::�.�.y..L..:�.Y.�...�..y..:.:.p..:�.y.:.`y...:.....:t.�..::...:..y.:.�.......:.........:.....:r.�y..,�.:..1.�.V..�..fi.:.........Y.:.�.y..�..................................:.;:.::.::.;:.::.:;:.;>:.>;;:.;:<::.;:::.::.::::.;::::.:::.::;::::.;. >;�::::.:::.::.::.;:.;:<:::<;;:<:;;:.;;:.;:.::;:.::.;:.;:«::<::<:;;:<.;;;:.;;:.;::.;:.;:<.;::.:;::.;::.�::.:.; �:.::I F'�'..!J. i�i:'#:!'W�I?�:::�`.�'i.�X:::CX.�'�....�.M�i.�.`I�I��iI!I�::�!✓�Il:�l:W!l�CI�I�.�'.��.:'�'..'7#M�4M�Q�.�i�:::i':i::::::::::::>:::::::::EE:::E:E:::::i:::i:;i::::::::::i;ii#;#<:r:;:;;;';<::i>;;<:<ii::�;'•;::i::;::i<z<:::;`: ....:...::................................................................ �:.�:::.:�...1'.'4. .iS�t! The following infortnation is requested by the Fedaral Govemment for certain types of loans related to a dwelling in order to monitor the lenders compliance with equat credit opportunity, fair housing and home mortgage disclosure laws. You are not required to fumish this information, but are encaureged to do so.The law provides that a lender may not discriminate either on the basis of this information, or on whether yau choose to fumish it. If you fumish the information, please provide both ethnicity and race.For race,you may check more than one designation.If you do not fumish ethnicity, race,or sex,under Federal regulations,this lender is required to nate tha information on the basis of visual abservation and sumame if you have made this application in person.If you do not wish to fumish the infortnatian, pieasecheck the box below. (Lender must review the above material to assure that the disclosures satisfy all requirements to which the lender is subject under appiicable state law for the particular type of Ioan applied for.) 80RROWER �I do not wish to fumish this information. CO-BORROWER Q I do not wish to fumish this information. Ethnicity: �His anic or Latino 0 Not His anic or Latino Ethnlcity: 0 His anic or Latino �Not His anic or Latino �American Indian or � � Black or �American�ndian or � O Black or RaC@: Alaska Native Asian Afican American RaCe: Alaska Native Aslan Afican American 0 Native Hawaiian or �Native Hawaiian or � ific Isla der�White Other Paci Is de White SeX: � Female �Male $eX: 0 Female 0 Male To be Completed by IntervieweP �nterviewer's Name(print or type) Name and Address of Interviewer's Employer This appllcation was taken by: J�I� ��q� �� Fp,�p g�gt� N.A. ❑Face-to-face interview Interviewer's Signature Date ❑Maii 5201 JOl�SRC1f�7 F�1D �Telephone Interviewer's Phone Number(incl.area code) ❑ Intemet HAFdiISBi7�G PA 17112 �0 21N �oso�� Page 3 of 4 Freddie Mac Fortn 85 7/05 Fannie Mae Fortn 1003 7/05 v::::::::::::::::::::::.:::::::::::::::.:i:'L:.::::::::::::i::i:}:i:i:i:::::'::iii:::ii:::::::.:.::..: :::..:.{.:..:...:.............:..:.:...:....:.....:'v::it:i:::v,:/y::�':+i:::.:...:.:::v::::....:.::.:'.:::::i:::i::v::�':i:i:i::vt:::{•:::::i:i:Li:i:�::::.:i::i:i:i:i::.::::i::::i::�:::::::}::: j� ``i`} 1�f� �}y�{ �1 t� : :/•:�:�i.��tt�:::��::•:::•::::•::::•:::::•:::•:•:::•:::•::•::::::::•::::::::::::::•:::•:::•::::::::•:::::•:::•:::•::::::::::::::::::::::•':::::::•:::•:::::•:::•:::',:;i ' .::.l�� i:��li•. +:?i::i:i::W��11\�i!�:�y�1�R �h'�i �:�:Y:L::Li'.?iiiii:y::.}';^::::::LLi'.i?il4ii}iii::iiyv::::v:Li:;::v:::.iiii'C}....:............ . ...... ............................... ..............................................:..:.:9 ..Y:::. ..............:..............::.. Use this continuation sheet if Borrower: A enc Case Number: you need more space to �� J HI� complete the Residential Loan Application. Mark B for Co-Borrower: Lender Case Number: Borrower or C for Co-Borrower. 0104414222 Former Address History B/C Street/ City State Zip Own/Rent Years/Months B C Previous Employment Emplover Citv/State Dates Monthlv Income Type of Business Position/Title Other Income B!C Description Monthly Amount B Subject PropertyNet Cash Flow(Income) $.00 *Subtotal* InstallmentOther Monthly Paymentand Unpaid Months Left to Pay Balance / / / / / / @ = To Be Paid @ Closing * = Not Included In Ratio AdditionalLiabilities Description Monthly Amount B/C Net RentalLoss $.00 B Subject Property Net Cash Flow(Loss) $.00 Caiifornia applicants: Pursuant to California Civil Code 1812.300(j)a married applicant may apply for a separate account. I/We fully understand that it is a Federal crime punishable by fine or imprisonment, or both, to knowingly make any false statements concerning any of the above facts as applicable under the provisions of Title 18,United States Code,Section 1001,et seq. Borrower's Signature: Date Co-Borrower's Signature: Date X X Freddie Mac Form 65 7105 �F e Mae Form 1003 7/05 -Y'IN (0507) Page 4 of 4 0104414222 Uniform Residential Loan Application This application is designed to be completed by the applicant(s) with ihe Lender's assistance. Applicants If this is an application for joint credit, Borrower and shouid compiete this form as "BoROwer" or"Co-Borrower," as applicable. Co-Borrower information must Co-Borrower each agree that we intend to apply for also be provided(and the appropriate box checked)when �the income or assets of a person other joint credit(sign below): than the Borrower (including the Borrower's spouse) will be used as a basis for loan qualification or �the income or assets of the Borrower's spouse or other person who has community property rights pursuant to state law will not be used as a basis for loan qualification, but his or her liabilities must be Borrower considered because the spouse or other person has community property rights pursuant to applicable law and Borrower resides in a community properly state, the security property is located in a community property state, or the Borrower is relying on other property located in a community property state as a basis for repayment of the loan. Co-sorrower .. ... . ... . ...................:.:::::::.::�::::::;.�:::::•.�.:•:::::::::::�:::::•>:•:•>:•::•::•:::.>:•:o:•:•::;.::.:::o:•: Mortgage VA Conventional Other(expiain): Agency Case Number Lender Case Number Applied for: Q FHA �USDA/Rural Housin Service 0104414222 Amou�t Interest Rate No.of Monihs. Amortizatlon Fixed Rate Other(explain): $ 118,000.00 5.000 % 360 TYpe� �GPM �ARM(type): ��1`� 20-30 YR FI7� LSN— ::::::>::::>I�::�:,<::,::::::::..:....::..•::::::::,:::::.>•.,:.,,'..:::,:.::.:,.'....;.,:•,.,.:.'.:`..''`<:::::.,;;:::::.:::':::'.:':::•�:::::>::::::>:::>:;::::::;':::«:::>:<:::>`.:>:::::#:::::::>?�::::::::::::>:::<;:s:::::::::#:<:::::;>::a;::::::::>::»::>::>:::::>:::«:�: . #� T.'k`. �f > #.. E ............. :::r:::i::s::::::i:::::::::s;::i::::::;::::2i::!:i::.:::a::::i::::::::::s::::::ggo-:<::::s::i:::;:i:::::::::;i:::; ::;::ii:i::i:i:::::::ii>iii�:::i:::i:::::::i:S:::;:::::i:igi::::3:ii::::;::::::::::::i:>::;::::•:i:ii::::::::::::::::,:::::., . . . .�'.4�. i�'�'��.1��.�.� ' ... ..............F��...��......�........�M......................:..::I].EF�p€8.t..3�„�.>��.:�•�i�J..>:.;:.>:.;:.::.:::.:�:.::.;:.;:.::.;:.:::.>:.»>;:;;>::<•;:<.>:<::::::::;::;::s>;:<:::<;::a,::»::;;:�:;::<::::<a:>: Subject Property Address (street,city,state&ZIP) No.of Units 6171 HA�Il41�T �,Y, NIDCHANIC58LA�G, PA 17050 1 Legal Description of Subject Property(attach description if necessary) �� Hnt�ncn� � Year Built 2001 Purpose of Loan purchase ConsVuction Other(explain): Property will be: Pnmary Secondary Refinance ❑Construction-Permanent �Residence �Residence � Investment Complete this Iine if constructlon or construction-permanent loan. Year Lot Original Cost Amount Existing Liens (a)Present Value of Lot (b)Cost of Improvements Total(a+b) Acquired Complete this Ilne if this ts a reflnance loan. Year Original Cost Amount Existing Liens Purpose of Refinance Describe Acquired Improvements 0 made �to be made QO CL�1 2 139000.00 g 113927.71 Cost:$ Title will be held in what Name(s) �,� �7 EQ�� Manner in which Title will be held ��D�'Y Estate will be held in: �Fee Simple Source of Down Payment,Settlement Charges,and/or Subordinate Financing(explain) �Leasehold (show expiretlon dafe) E¢7ITY C�1 S�7F.iC;T PFDPEErPY •;:;.>:.>:.;;:::.>:.:::.::.;:.;:.;:.;::.;::.::.::.::.::.::::;.:::.o-:.::�:.:::::<.>:•;:....:...............:::::::::::::::.>:s:;:<.;:<.»>:o-:...:>:,..;:......:.....:.......::....:.:..:...:..:.....:...::i:>:::::::::::i::i:::s:;:::;:r�:::::5•..,:.;:...:::::::::::::::::.:�:::::::::::::::;:::::.::.�::::::::::::.::.�::::::.�:::. :.:�;:<•;:.:;;»:.>;o-:.:;:.;:.;:.::<.::.;:.::.::.::.;:.::.;:�;;>:.::.>:<.>:.>:.;:.>:.o-�l�.,....:":Etri>i:::#:i2iiiiii#i:t:::::::::i::i:<;;E::�>::::� `::: , � i�t . ...::::::::::::::::.:�:.:::::::::::::::::::::::::::::::::::::. • . :: . ..• � ' '•.: �� .>::•>::.:::.::.::•:�:.::.::o-:..o-:.>:.>:••.A . .• ::.r:.::.s:.r:.>:.»::<::.�::::::::.�:::.::::.::..�::::::::.:�:::. .�::.:�::::::::::::.�::::::::::::::::::::::::::::::.::::::::.:: .. .... . .. .� .��7............................. �. ��...........�..:.;;:::::.:::::::::.�:::.�:•:::::::::::::.::� Borrower's Name(include Jr.or Sr.if applicable) Co-Borrower's Name(include Jr.or Sr.if applicable) T�1liA J ECIL� Social Security Number Home Phone(incl.area code) DOB Yrs. Social Security Number Home Phone(incl.area code) DOB vrs. 206-50-7016 717/790-6088 �m 11��%195 16�� (mrt✓dd/yyyy) schao� 0 Married �Unmartied(Include single, Dependents�ot Ilsted by Co-Borrowar) �Married 0 Unmartied(fnclude single, Dependents(not listed by Borrower) divorced,widowed) �O• a9 S divorced,widowed) no. agas ❑Se arated �� ❑Se arated Present Address �s�reet,city,state,ziP) Own Rent 07/03 No.Yrs. Present Address (street,city,state,ziP) Own Rent No.Yrs. 6171 HAY[�,t�'P �,7t , N�CH�NICSBLA�G, PA 17050 Mailing Address,if different from Present Address Mailing Address,if different from Present Address � If residin at resent address for less than two ears com lete the followin : Former Address (street,city,state,21P) �Own 0 Rent No.Yrs. Former Address (street,ciry,state,z�a) �Own �Rent No.Yrs. r r •::::.:�<.>•::::::::::.�::::::::::::::::::::::::::.�::::::t::::::..:.�:.�:::.>•::.;•;::>::S:i::i:ii5:::::::::;:::�::::::t::;::ri....,.............::..:.:..:....:.....;..:..:..:..:..::..:......::.;:;.>�::.�::,::::::::::.�:.:�..:::::.::::<::.>:::::.:::::::::::<:::t:.:::::::::::::::.�::::,!:.�:::::::::::.�::::: ?:iiiii:iiigb��'1� ;>:: :;:<::,::�'t: • ..�+>: :;;•''� ' . �.::::;:.::::<::::::::;;;:::: .. t . ��r�r::w�.�. � �.�:: �.x:>:;<::>;:;::::::::;«:><:::;:::>::: :::::::::;;�:��:::::<::::»::>::::::>;>::>::»:<:::::::::>:::::»::::>::::>::::::>.::; ...............:.�a..Bbr.r.�5.. •:>::>::�:>.>:::;:::::cc:::::::;::;::;::::::::::::::c:::::;::::c::::::::::::;::: . ........................................................... Name 8 Address of Employer Self Employed Yrs.on this Job Name&Address of Employer Self Employed Yrs.on this Job SELF CP MEDICAL 02/03 2501 �i � STR Yrs.empl�ed in ihis line 000000000 Yrs.employed in this line of wor profession � of work/profession HAitIiISBt]E�G , PA 171100000 02/02 POSltlonmtlelType of Business eusiness Phone(incl.area code) PositionlTltle/Type of Business Business Phone(incl.area code) CASE Ng1i�iG�Ct 717/243-4102 If em lo ed in current osition for less than two ears or if currentl em lo ed In more than one ositlon com lete the followin : Name&Address of Employer Self Employed Dates(from-to) Name&Address of Employer �Se1f Empioyed Dates(from-to) 0000 _ _ Monthly Income Monthly Income PositlonlTltle/Type of Business Business Phone(incl.area code) PositionlTltle/Type of Busines5 Business Phane(incl,area code) Name&Address of Employer �Self Employed Dates(from-to) Name&Address of Employer �Self Employed Dates(hom-to) Monthly Income Monthiy Income PositionlTitle/Type of Business Business Phone(incl.area code) Position/Title/Type of Business Business Phone(incl.area coda) Freddie Mac Form 85 7/05 Fannie Mae Form 1003 7/05 �-21N (oeo�� NMFL#1003(APP1,APP2)Rev 11/10/2007 Page 1 of 4 Initials: VMP Mortgage Solutions,Ina(800)521-7291 ,, � :.;>:.;:.:::.:>�:;�;.:.:�:.;:.;:.;;:.;::;.;;;::<.>:.:;��»:;::.;:.;:.:�.;::.;:.;:.>::.;:.;:.:�.:..;:y.:�.....:.:....:.:.:.:::..::...:.:.:....:.>..,,.:...:.;...:..:.:...,..:.......::..:.:...:.:....,.,....,..:........:.;..:..;...:......:....:.;..:�;....:�:;:.>:.>:.::.;>:.>:.;:.»;::;:.>�.>:.;>:.;::.;::�:.:�:<:.:;:.::.>;:.:�>�.>:.>:<.;>;::.>;:.::. > , .:.:<Y::: . }� ty�Y > �•N'.f' . . �:.:�. ::�?N:��::4�:�`.t�t�ll�1�:.;1!�N:::::::::::>:::::::::<::<::::::::::<;;:::�:::::::>::>:::�:::::::,:;:::::::::::::::s::::::;::�::::::: :::>:::<:>:::::::::;::::>::::>::::»::>:<:�>:>:::::::::::»<;::>:::<::::<:;;::;:<:::>:::�:>::;:::::.:> �.....HI«....M1��!4�1. >�1#M�::��M�:ll��?r:::�:{!C�J?�I�1. i�' � . t�l . ... .. ...................r..............:...................................'!Yr..i►1 . ii '.�i F.1 . ... . ............................................ Grosa Monthly Income Bonowar Co-Borrowsr Totel ombined Mo�nthly prsssnt Propossd Base Empl.Income" 5280.00 5280.00 ent $ Overtime irst Mortgage(P&I) 509.00 633.45 Bonuses ther Financing(P&I) 459.00 Commissions azard Insurance 25.17 Dividends/interest eal Estate Taxes 138.00 136.50 Net Rental Income ortgage Insurence Other(before completing, omeowner Assn.Dues 7.00 7.91 see the notice in"describe other income;'below the�: .QQ 5280.00 5280.00 1114.00 805.03 'SeIT Employed Barrower(s)may be rsqulred to provfde additional documentation such ao tax roturns and financial eletementa. Describe Other Ineome Notice: Alimony,child aupport,or separote malntsnanee income need not be revealed it the Borrower(B) B/C or CwBOrrower(C)does not choose to have It eonaidered tor repaying this loan. Monthly ArP10Ullt :::::::::::::::::::::::::::::::.:::•:::::::::::::::,::::::::::::.:�:::::::::::::::::::::::.:::::::.�:::::::::::::::.....:::.:..: . . ,'•d.'.'�y'� .....�''g:isjj�..n:::��1Q�'�:�� 's�J'iii'ii'r':i3�i'�3#::�i;ii:i:ii:::i::::?;'•`:;::::::i::::::i:i�:;:::::i:::;::E:::?:::::i�i?:::�::''S::iii#ii:i:2�iii::�:ii:i:3�i;:::i:i:>i:ii#::::">:;#:::'':':::::::iii ................ This Statement and any applicable supporting schedules may be completed jointly by both married and unmarried Co-Borrowers if their assets and liabilities are sufficiently joined so that the Statement can be meaningfully and fairly presented on a combined basis; otherwise, separate Statements and Schedules are required. If the Co-Borrower section was completed about a non-applicant spouse or other person, this Statement and supporting schedules must be comp�eted about that spouse or other person also. Com leted Jointl Not Jointi Cash or Market ��abflitiesand PlsdgsdAoseta.List the creditor's name,address,and account number for all outstanding debts, ASSETS V81UB including automobile laans,revolving charge accounts,real estate loans,allmony,child support,stock pledges,etc. DeSC i tlon Use continuation sheet,If necessary.Indicate by(") those liabilitles,which will be satisfiad upan sale of real estate Cash deposit toward purchase held by: owned or u on refinancin of tne sub ect ro e . $ LIABILITIES Monthly Payment& Unpald Balance th LeTt to P Name and address of Company $PaymenUMonths $ List checkln and savin s accounts below DISaOVEFt ETN 5VC5 LLC 24/ 33 798.00 Name and address of Bank,S&L,or Credit Union (n�FlO�TIA �if�os92no Name and address of Company $PaymenUMonths $ Acct.no. 8729.00 I�FII.S/C3�3A.SE 40/ 8 301.00 Name and address of Bank,S&L,or Credit Union ��$�160552 Name and address of Company $PaymenUMonths $ Acci.no. / Name and address of Bank,S&L,or Credit Union Acct.no. Name and address of Company $PaymenUMonihs $ Acct.no. � Name and address of Bank,S&L,or Credit Union @ _ 'Il� BE @ QASIl� Acct.no. * = 1V0'.0 IN RATIOS Name and address of Company $PaymenUMonths $ Acct,no. � 37003.00 Stocks&Bonds(Company name/number $ &description) ��b��1001056529 Name and address of Company $PaymenUMonths $ Life insurance net cash value $ Ti�,C,F�i., 76924.00 Face amount:$ Subtotal Liquid Assets 8730.00 Real estate owned(e�ter market value � 155000.00 from schedule of real estate owned) ��b��1000362043 Vested interest in retirement fund Name and address of Company $PaymenUMonths $ Net worth of business(es)owned g C�3AS'� �,I7D0 261/ 17 4486.00 (attach flnancial statement) Automobiles owned(make and year) $ 4��4��820091806 Alimony/Child SupporUSeparate Maintenance $ Payments Owed to: Other Assets(itemize) $ Job-Related Expense(child care,union dues, $ etc.) Total Monthi Pa ments 325.00 Totai Assets a. 163730.00 :>.$`` ::':`:;`:':.:r 49217.00 Total Liabilities b. 119512.71 Freddie Mec Fortn 85 7/05 F e Mae Form 1003 7l05 Initlels: �-211� (0507) Page 2 af 4 .,: .� �— �,��. .. w„��-�..x�� ,..� . .w.N,.��,�,�,�..�.,�.� %� �....�.�..,�.,�, :r. . . ;::::>::>::>::>:::»>�:»>::::»::>:::>:::::>::�>::>:<:::>::::»:::::>::::>::::>::::>::::>::»::;>::>::::>::>::>::>�:»::>::::>::>::»»:»::::::;:>:>::::..:..,.:>�..............................::.................:......:.............................::;::.;::::<:.»;:.;.:.;:.;;�.;.:;:.;:.>:.»:.;>:�::.>:.;:.;::.:�.::::.;�.>�:.:::::::.;:.>:.::.>:.>:.:;<.;:�::::. >::>::»::>:�Is:::J��:�#�:::I:�f��ki��!1'11�8`::'�.�i�t�'�tl:;:;:<:<;':':::;::':{:;<:>':«<:::><>:s::::><:;:;::::::><;<:>::>::>::�:::::<::>::::::<:>:<:>::::::;:>:::;:`:<::::::>:::>::::::::<>::::::>:::�::::�<:::;::::;:: ... . .................. ... ... .... .. ... ...... .. ..... .. ....... ... . .. ............... .... . . ... ... ......... ................. ..... Schedule of Real Estate Owned(If additional properties are owned, use continuation sheet.) Properly Address(enter S if sold,PS if pending sale Type of Present Amount of Martgages Gross Mortgage �nsurance, Net ol'R if rental bei�g held for income) Property Market Value &Liens Rental Income Payments Maintenance, Rental Income � Taxes&Misc. 61.71 �T Tn�Y H SF $ 155000 $ 37003 $ $ 1 $ $ 6171 HA7d�F1it[�T Ti�,Y 76924 1 Totals $ 155000 $ 113927 $ $ 2 $ $ List any additional names under which credit has previously been received and indicate appropriate creditor name(s)and account number(s): Alternate Name Creditor Name Account Number ..�,,,;. ............................. . z�'.!� a. Purchase rice If you answer"Yes"to any questions a through i, please eorrower Co-Borrower use continuation sheet for explanation. b. Alterations im rovemenGs re airs ves No vea No c. Land if ac uired se aratel a. Are there any ouistanding Judgments against you? � � � � d. Refinance incl,debts to be aid o 113,927.71 b. Have you been declared bankrupt within the past 7 yearsl � � � � e. Estimated re aid items 1,657.76 �' H u�the eof n the last 7 years�7 ed upon or given title or deed in � � � � f. Estimated closin costs 2,304.00 d. Are you a party to a lawsuit? 0 � Q Q . PMI MIP Fundin Fee e. Have you directly or indirectly been obligated on any loan which resulted in foreclosure, transfer of title in lieu of foreclosure, or judgment? (This would include such loans as home h. Discount if Borrower will a 1 180.00 mortga e loans, SBA loans, home improvement loans, educational loans, manufactured 119 069.47 �mobile� home loans, any mortgage, financial obligation, bond, or loan guarantee. If"Yes;' 1. Total cos s add items a throu h h provide details, including date, name, and address of Lender, � � � � . Subordinate financin FHA or VA case number,if any,and reasons for the action.) k. Borrower's closin costs aid b Seller f. Are you presently delinquent or in default on any Federal debt or any other loan, mortgage, financial obligation, bond, or loan I. Other Credits(explain) guarantee? If "Yes;' give details as described in the preceding � � � � question. g. Are you obligated to pay aiimony,child support,or separate � � � � maintenance? � � � � h. Is any part of the down payment borrowed? i. Are you a co-maker or endorser on a note? � � � � --------------------------------------------------------• j. Are you a U.S.citizen? � � a � k. Are you a permanent resident alien7 � � � � m. Loan amount I. Do you intend to occupy the properly as your primary � Q Q Q (exclude PMI,MIP,Funding Fee financed) 118,000.00 residence?If"Yes;' complete question m below. m. Have you had an ownership interest in a property in the last � a a o n. PMI MIP Fundin Fee financed three ears? o. Loan amount add m&n 118,000.00 �� p( R)t second home(SH)tlo�r inv stment prope�nci��aPl>�esidence � Cash from/to Borrower 1069.47 �2) Flow did you hold title io the home --solely by yourself (S), S P• jointly with your spouse (SP),or jointly with another person (subtract j, k, I&o from i O 7 . . . . . . . ... :»:::<::::::>;:::::::::#>::>::;`:>:s:::::::::::::�<::<::::::::::'::::;::�<:::>::::;::#�::::;i�<:>::>::::::::::::>:::�::::>::»>`::>:::;::::::::::::.::'s :.;,.,>•.:>:,;:•,::.....::..,,.::.:.:..:....::•�:�i:i�4�#�::lk��wE�NT:;::::::;»::>:;:::::::>:::s:::::::#::::#�::�:z<`;::�.:::i:>:::::;`::'s:>:<:#::s:>:�:::::<:::::'s:`::::::::;<:::::::::r:::::::?::#:::::i::::::: .:>:•::.:::::::::.�::::::::::.:::::::::::::.�::::.:•:<.>:.».:.>.�:::::::::::::.:�.�::::::::::::::::::::::��::E,k,�,�,",��,f�..#�&�k.�.�.I�#V�...`.�".........................................,.,,............................. . ....,................ ................................................. ............................... Each of the undersigned specifically represents to Lender and to Lenders actual or potentlal agents, brokers, proceasors, attomeys, Insurers, servicera,successors and assigns and agrees and acknowledges that: (1)the Infortnation providad in this application is true and carrecl as of the date set Torth opposite my aignature and that any intentfonal ar negligent mlarepresentation of ihis infortnation contained in this epplication may result in civil liabllity,including monetary damages,ta any person who may suffer any loss due to reliance upon any misrepresentation that I have made on this application,and/or in criminal penalties including,but not limited to,fine or imprisonment or both under the provisions of Title 18, U�ited States Code,Sec,1001, et seq.;(2)the loan requested pursuant to this applicatian(the"Loan")will be secured by a mortgege or deed af trust on the property described in this application;(3)the property will not be used for any illegal or prohibited purpose or use;(4)all statements made in this applicatian are made for the purpose of obtaining a residentlal mortgage loan;(5)the pmperiy will be occupied as indicated in this applicatlon;(8)the Lender,its serv(cers,successors or assigns may retain the original and/or an electronic record of this application,whether or not the Loan Is approved; (7)the Lender and its agents,brokers,insurers,servicers, succassors,and assigns may continuously rely on the information contained in the application,and I am obligated to amend and/or aupplement the infortnation provided in this applicatlon if any of the material facts that I have represented herein should change priar ta closing of the Loan;(8) in the event that my payments on the Loan become delinquent,the Lender,its servicers,successors or assigns may, in addition to any other rights and remedies that it may have retating to auch delinquency,report my name and account infortnation ta one or more consumer reporting agencies;(9) awnership of tha Loan and/or administration of the Loan account may be transferred with euch notice as may ba required by law; (10) neither Lender nar its agenb,brokers, insurers,servlcers, successors or assigns has made any representation ar wartaniy, express or implied,to me regarding the property or the condltlon or value of the property; and(11) my transmission of this application as an"electronic record"containing my"electronic signaiure;' as thase tertns are defined in applicabla federal and/or state laws(excluding audio and video recordings),or my facsimile transmlasion of thls applicatfon containing a facsimile of my signature,shall be as effective,enforceable and valid as if a paper version of this applicatian were delivered containing my original written signature. Acknowledgement.Each of the undersigned hereby acknowledges that any owner of the Loan,its servicers,successors and assigns,may verify or reverify any informatian contained in thls app�ication or o in any in ormation or data relating to the loan,for any legitimate business purpose through any source,including a source named in this application or e consumer reporting agency. Borrower's Signature Date Co-Borrower's Signature Date X X .:::>::>:.>:.>:>:;::,.»::>:.>::.>:.::•»;::::>:::.::.;:.;;:.;::>:::::::.::;>;;:.;::::.::;.::.;:.:;:.:..:::......:........:.,,.:.:; ..;.:.,,:}:,..,,:...:�:y.:,:/.......:........,.....:.,...::......:..:..:.:.:.....:..........:.:.....;<.;:.>:.>:.>:.>:.»::.:�:.:;>•>;;:,:>:::.::.>�>;:.>:.�:::::.>:..:<.::::.>:.::::;.;:.::.;:.>::.;>:.>:..:; t� k� � y,� �* �. .i:::.�... :: :� . :.� . .��:�:::>::::::::::'::>::::<:s:::::::::<:>:::s::;:::,:<::::::;:=::::a::#::::>;::::::::::::::::>3a::s::>�:::>:::::s:::: ;•::.:<.;:.:::.:>:>::<.>:�:•::.>:.::::<;:::::::::::;::z::::::i::::::::>:e:::ics':::::::::s::�::::;:s::,.:>• >;; .:� �`�::i�.�.�..'�:.�i..�i��..�",�..�`.��.`��M. . ' + '' > :.:::c.::.::::::.:t.:;:.;:.;::::.>:.:::::.::::::.�::::::.:::.:::.:�::::::::..�.�:.�:.::.:..�r.�l;�.�.��1:4..�l.�:.�Y,Y:�i.�.`�I�FF� The following infortnation is requested by the Federal Govemment for certain types of loans related to a dwelling In order to monitor the lander's compliance with equal credit opportunity, iair housing and home mortgage disclosure laws. You are not required to fumish this infortnation, but are encoureged to do so.The law provides that a lender may not discriminate either an the besis of this information, or on whether you choose to fumish it. If you fumish the infortnatlan, please provide both ethnicity and race.For race,you may check more than one desipnatlon.If you do not fumish athnicity, race,or sex,under Federal regulatlons,this lender is required to note the informatlon on the basis of visual observatlon and sumame if you hava made this application in person,If you do not wish to fumish the Infortnatio�, pleasecheck the box below. (Lendermust revlew the above material to assure that the disclosures satis�y all requirements to which the lender is subJect under applicable stata law for the particular type of loan applied for.) BORROWER �I do not wish to fumish this informatian. CO-BORROWER O I do not wish to(umish this information. Ethnicity: 0 H;5 anic or Latino �Not His anic or Latino Ethnicity: � His anic ar latino �Not Hla anic or Latino a American Indian or � �Biack or American Indian or �Black or R8C8: Alaska Native Asian Afican American Race: C�Alaska Native �Asian Afican American �Native Hawailan or �Native Hawaiian or � th cific de �White t e Pacif s White S@X: �Female �Male SeX: �Female 0 Mate To be Completed by Interviewer Interviewer's Name(print or type) Name and Address of Interviewer's Employer This application was taken by: �� y�;I,Z.S F�,imp BAN[{, N.A. ❑Face-to-face interview Interviewer's Signature Date 0 Mail 5201 Jt�VES7.C7NID7 F�D �Telephone Interviewer's Phone Number(incl.area code) ❑ Internet HAFtFtISBikZG PA 17112 Freddie Mac Form 85 7/05 �21N (0507) Page 3 of 4 Fannie Mae Form 1003 7/05 ��- �,��-�,,,.�.� �.�-� . �.�..�-��.._„�.�.,� �u �.:Y. x-a. �,,�� .,. :::::::::.:::::::::::::.::::::::::::::.:::::::::.�:::::::::::::::::::::.:::::::::::::.......................................... .... ... . . >:�;::�::::::;:>:<:<:>:'::<>:<:»::�:�;'.:_:::::::::>::>::>;:�:`::>::::��<;::;::?::>::::::::::>::>:::::<::�:::`::::::<:::>::��'tl��:ll�i�l��`I'''':::° :: :.......: ::...:....:. ..:.;;;::_;�::�::�:'��:>`�>�:.�.;::":`°�°::�:`::��:::»»:::<::'::::�;<:<>:::;:::::::::;::,:::s::;::�:::s>::::>::::>:::::s;>;:<::::::;:::::>::>:::::.::::>::»>::::>:::: .... ... :..... .... .. ....... .QI�.�lF:E.�'�`f#��C�#��:I,�f�:#�4'�i..�1�:.:�'`.�':1.#!��'.�:i�!�J:::<:;.;:::.;�:.;:.:>::::.;:;:::<:<:;.:;:::::::>:<:::.;:.:::::;:>:>:::::::::>:<:<;>::.:::<::::::::;:::<::::;::>�:: Use this continuation sheet if Borrower: Agency Case Number: you need more space to �� J HI� complete the Residential Loan Application. Mark B for Co-Borrower: Lender Case Number: Borrower or C for Co-Borrower. 0109414222 Former Address History 6/C Street/ Citv State Zip Own/Rent Years/Months B C Previous Employment Empiover Citv/State Dates Monthiv Income �pe of Business PositionITitle Other Income B/C Description Monthly Amount B SubjectPropertyNet Cash Flow(Income) S.oO *Subtotal* InstallmentOther Monthly Paymentand Unpaid Months Left to Pay Balance / / / / / / @ = To Be Paid @ Closing * = Not Included In Ratio AdditionalLiabilities Description Monthlv Amount B/C Net Rental Loss $.00 B SubjectPropertyNet Cash Flow(Loss) $.00 California applicants: Pursuant to California Civil Code 1812.300Q)a married applicant may apply for a separate account. 1/We fully understand that it is a Federal crime punishable by fine or imprisonment, or both, to knowingly make any false statements concerning any of the above facts as applicable under the provisions of Title 18,United States Code,Section 1001,et seq. Borrower's Signature: Date Co-8orrower's Signature: Date X X Freddie Mac Form 85 7I05 �F e Mae Form 1003 7/05 -21N (0507) Page 4 of 4 MM � NN 0 � � m �� i--Y ` � � �' � �'� `° °'� r�^ ° �, ■ d Q Z � n � � � _ � W � �c��W � � � �G � .7, E �' �,Edy� °rc� v v� E V � _'�?'c�,c IC �> o c�� m e ��t�a°QLL ° U1l+� � �L `S +� s3. �.+- p ia �� _ � s.Z�c � � � ; a ~ (n tn U�1�J � _1'�O i- 1� � N O � t0 \ 'a � �. . � � 0 .-1 C N M — -- -- -- - _ � � � ��ff M OMf � c E W � � � (� � rl �-i N 3 a m mBi N f/� N �°`��2 M > ' — -- '" � � _`°� � • o oL n�yyy�� J ca d � Q � � � LV�� .. � � � � � U°a NK FJ p 0 L �;� 'C O O O p tn co '`"' ��= � - . � N O et (O N V o E p v u�� _ py N y� - a ti � CD M N o — -- - � � m ��°Et . �� y h� �-1 O! 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Una� � � '� � �i a°'i � � � a�S3cY `�i�X `Jic53in�YicY�n �v°��`!'i> '�c.°�LL�>�ao > mn—.�> e;� � � � �� a � v � � --$ �. � � m � � �� c E« '� � '� � C ''� � ° N € °'�i � w o � ��. �°t �� y m m c� � � a aa I�II II�I II�"IIII'II�II�III'IIIII�II'I III�I IIIII I�II�IIII�I�I�I II'I II'III�'II�I I � �� ' �Select MedicalCorporxtion Select Medical Corporation Select Medical 401 k Statement ; 401(k) Plan July 1,2013-Septem6er 30,2o�s , ENV#OP002965 OP 32020 T TAMARA K I NG � Customer Service Number: 1-800-890-4015 ', ' 6171 HAYMARKET WAY Intemet Address: www.401k.com ' MECHANICSBURG, PA 17050 Representatives are available 8:30 AM-8:00 PM in your time zone,any business day_ Get Your Statements Onlins ' Online statements offer many advantages over paper statements. For instance,you can view and print up-to-date statements whenever you like,and you can retrieve statements for any date, month,quarter,or custom date range within the previous 24 months. To sign up for online statements,please visit us oniine,go to Mail Praferences under the Your Profile tab,and update your defivery preference for savings statements and other notices. You must also provide us with a valid e-mail address so that we can : periodically remind you to view your statemsnts and other notices online. Your Account Summary Your Asset Allocation Beginning Balance $25,035.88 Fees -2•50 � Stocks 67% Change in Market Value 1,399.78 Ending Balance $26,433.16 � Bonds 32% Additional tnformation � � Short-term 1% i Vested Balance $26,433.16 I Your Persanal Rate of Return ' This Period 5.6% Year to Date 10.5% Your Personal Rate of Retum is calculated with a pme-weighted formula,widely used by financia�analysts to calcutate investment Your investments are currently allocated among the displayed eamings. It reflacts the results of your investrnent selections as asset classes. Percentages and tota{s may not be exact due to '� well as any activity in the plan account(s)shown. There are other rounding. Persona!Rate of Return fomwtas used that may yield different The Additional Fund Information section lists the allocation of rasults. Re�nember fhat past psrformance is no guarantae ot iuture your blended funds. � results. Market Value of Your Account Displayed in this section is the value of your account for the statement period,in both shares and dollars. ' Shares on Shares on Price on Price on Market Value Market Yalue ' lnve t t 6/30/2013 9/ 0/2013 /3 Oi3 09/30/ 0 on 06/30 13 on 0 /3 f3 ' Bt�nded�[md;�rastmen#s" ,'. " ' _ ' , ,.. : . ; ;�5,Q35:$� '��2$,�33;1fr: Large Ble�d _ Fid Freedom 2025 2,028.840 2,028.639 $12.34 $13.03 25,035.88 26,433.16 , ' ,. , _ ,,, _ ,,, __ ,, ... _ . ,; i�+aco t. �tel::. ; ; >! '` _ �,�8 ; :� Please read this statement carefullv. Anv error must be reported to Fidelity Investments within 90 A�ys ; 2965 OP002965 0001 20131007 OP4K ! ! Fidelity lnvestments; PO Box 673008, Dallas,TX 75267-3008 Page 1 of 6 � � Select Medical Corporation Statement Period:07/01/2013 to 09/30/2073 401(k) Plan Market Value of Your Account (continuedj Remember ihat a dividend payment to fund shareholders reduces the share price of the fund,so a decrease in the share price for the statemeM period does noi necessarily reflect lower fund performance. 'Some of your investrrients are dassified as a Blended Fund InvesUnent.Blended Investments may inGude a mixture of stocics,bonds andlor short-terrtt assets.Piease refer ko the"Additionai Fund Informadon"section to detertnine the allocation of your Wended investtnents'undarlying assets. Please refer to NetBenefits and other Plan infortnation,such as your SPD,for a description of your right to direct investrnents under the Plan. For information on any pian restrictions or limitations on those rights visit NetBenefits and click on"Plan Information". To help achieve long-term retirement security,you should give careful considsration to the benefi4s of a wefl-balanced and diversified invesUnent portfotio. Spreading your asssts among differeni rypes of inveshnsnts can help you achieve a favorable rate ot retum,while minimizing your overall risk of losing money. This is because maricet or other economic conditions that cause one category of assets,or one particular security,to petiorm very weli often cause another asset category,or another particular security,to perform poorly. If you invsst more than 20%of your retlrement savMgs in any one company or industry.Your savings may not t,e properly diversificd. Although diversification is rwt a guarantee against bss,it is an effective strategy to help you manage investment risk. In deciding how to invest your retirement savings,you should take into account all of your assets,including any retirement savings outside of the Plan. No single approach is right for everyone because,among other factors,individuals have different financlal goals,�fferent time horizons for meeting their goals,and dfferent tolerances for risk. It is also important to periodically review your investrnent portfolio,your investrnent objectives, ' and ihe investrnent opUons under the Plan to help ensure that your redrement savings will meet your retirerr�nt goals. Vsit the Department of Labor website httpJ/www.dol.gov/ebs�nvesting.htrnl for infortnation on individuat investing and�versif'icabon. Sorr�of the administrative services performed for the Plan were undsrvvritten from the total operating expenses of the Plan's investment options. Your Contribution Elections as of 10/07/2013 This section c�splays the funds in which your tuture contributions will be invested. Mvesbnent Percent Fid Freedom 2025 100%e Total �pp96` Emptoyse Emp/oyer Gontrfbuilons Confribution INatch This Perwd $0.00 $0.00 "�'�� Year to Date $0.00 $0.00 Vested Percent 100.00 100.00 Total Balance 20,037.31 6,395.85 Your Account Activity Use this section as a surrxnary of transactions that occurred in your account during the statement period. Fid Activiiv Freedan 2025 Beginning Balance ;25,035.88 Administrative Fees -2.50 Change in Market Value 1,399.78 End'mg Balance ;26,433.16 Dividends 8� Interest $0.00 2965 OP002965 0001 20131007 OP4K Fidelity Investments, PO Box 673008, Dallas,TX 75267-3008 Page 2 of 6 Select Medical Corporation Statement Period:07/01/2013 to 09/30/2013 401(k) Plan Your Account Information ; Use this section to ensure Fidelity's records of your informa6on is up-to-date. ' Generai information Participant Status Terminated Deferrals Before Tax Contributions 0% Employee Pre-Tax Catch-Up 0°!0 A Message From Select Medicai Corp. To make changes to your account or if you have questions about this statement,call the toll-free customer service center at � 1-800-890-4015 or visit the website at ww.401k.com. � i � � A Message from Fidelity Investments . ' � �idelity ViewpointsSM-Workplace Edition: is an electronic publication,offering a variety of articles to help you manage the money ' , in your workplace savings plans and make informed decisions regarding your othe�fi�ancial goals. Current issue now available: , Visit www.mysavingsatwork.com/viewpoints-statement To access performance information on the investment options available in your Plan-log onto www.netbenefits.com or call your � plan's toll-free number. � � Before investing in any mutual fund please carefully consider the investment objectives,risks,charges and expenses. For this and ; "" other information,calt or write Fidelity for a free prospectus. Read it carefully before you invest. i Fidelity Brokerage Services LLC, Member NYSE,SIPC,900 Salem Street,Smithfield, Rhode Island 02917. 459279,531246.4.0 ' � , -- i i Investment Fee Information � Fidelity Low-Priced Stock Fund assesses a short-term trading fee of 1.50%for shares held less than 90 days. � Fidelity Mid-Cap Stock fund assesses a short-term trading fee of 0.75%for shares held less than 30 days. TRP Small Cap Value assesses a short-term trading fee of 1.00%for shares held less than 90 days. TRP International Stock assesses a short-term trading fee of 2.00%for shares held less than 90 days. ; Fund Performance � A summary of investment performance for all funds available in the plan. Funds you own are marked with an asterisk. i As you review ti►is update,pJease remember that per/ormance data stated represenis past performance which does not guarantee future results. i tnvestment retum and principal vafue of an investment will fluctuate;therefore,you may have a gain or loss whan you sell your units.Cunent I performance may be higher or lower than performance stated. To learn more or to obtain the most recent month-end pe�lormance information, contact Fidelity using the intormafion listed on the first page oi this statement(your plan's tolf fiee number and/or website). ! Be%re investing in any investment option,please carefully considar the investment objectives,risks,charges and expenses.For this and other i information,caN or write Fidetity for a lree mutual lund or variable annuity prospec7us. Read it caralully belore you invest. ; Your holding period may differ from the time periods shown below. -Foreign investments,especially those in emerging markets,i�volve greater risk and may offe�greater potential retums than U.S.investments.This risk includes political and economic uncertainties of foreign countries,as well as the risk of currency 8uctuation. -Lower-qua(ity debt securities involve greater risk of default or price changes due to potential changes in the credit quality of the issuer. -tnvestments in mortgage securities are subject to prepayment risk,which can limit the potential for gain during a decli�ing interest rate environment and increase the potential for loss in a rising interest rate environment. : -Becausa of their narrow focus,sector funds may be mare volatile than funds that diversify across many sectors. -lnvestrnents in smaller companies may involve greater risks than those in larger,more well known companies. i 2965 OP002965 0001 20131007 OP4K Fidelity Investments, PO Box 673008, Daflas, TX 75267-3008 Page 3 of 6 I' � Select Medical Corporation Statement Period:07/01/2013 to 09I30/2013 401(k) Plan Fund Pertormance (continued) ( lncoption I Annual Total Retwn 9G I Avorayo Annual Total Rotuin X as of U8�/3Q+T0f3 � Cross Investment Dato 20f2 ?Of 1 20f0 1 Voar 3 Yoar 5 Yosr 10 Yoar Li/o Exn Ratio ��'.�'r14#. " .......:'. ....... .:: .... .... :. ..:< . .. ;:: ` ; .. ! ....... . .......�....... .. . .... ... .. Large Growth TRP Blue Chip Grth 06/30/1993 18.41 1.54 16.42 24.49 19.04 13.46 8.70 9.91 0.76 Large 81end Sptn 500 Index Inst OZl17/1988 15.96 2.09 15.01 19.30 16.23 10.00 7.53 9.82 0.06 TRP Div Growth 12/31/1992 14.85 3.53 13.26 19.98 16.28 9_97 8.07 9.21 0.67 Large Y�ue TRP Equity Income 10/31l1985 17.25 -0.72 15.15 21.63 15.51 9.36 7.96 11.09 0.68 Mid-Cap Growth Fid Mid Cap Stock U3/29/1994 14.93 -2.41 23.57 27.69 18.�3 14.46 9.82 11.83 0.&6 TRP Ntew Horizons 06/03l1960 16.20 6.63 34.67 36.10 26.09 19.51 13.24 11.47 0.80 A�d-Cap Blend JPM Mid Cap Val Sel 10/31l2001 20.19 2.17 23.12 24.59 18.56 12.66 10.55 11.50 1.17 Stnall Blend TRP Small-Cap Valus 06/30/1988 17.76 -0.60 25.25 26.29 17.92 11.03 11.21 12.15 0.98 Smail Valua Fid Low Priced Stic 12/27/1989 18.50 -0.O6 20J0 28.53 17.83 14.43 1125 14.55 0.80 Foteign TRP Intl Stock 05/09/1980 18.72 -12.33 14.48 15.47 6.90 7.98 7.81 9.46 0.85 �3tent#M�'��5. .:: ... ; . : ....::: � F d Fresdom 2050 : O6/01/� . 15.06 -5.57 14.90 . 15.08 11.03 7.65 WA : .4.08 ..0.82 Large Growth Fid Freedom 2040 09/06/2000 14.53 -4.63 14.62 14.33 10.74 7.72 6.75 2.52 0.81 Large Blend Fid Freecbm Income 10/17/1996 6.40 2.02 7.63 3.11 4.50 5.25 4.18 5.03 0.51 �'�_„ Fid Freedom 2000 10/17l1996 6.42 2.01 7.86 3.12 4.58 5.15 4.25 5.55 0.51 Fid Fresdom 2010 10/17/1996 10.43 -0.28 11.65 7.68 7.69 7.12 5.67 6.70 0.62 Fid Frsedom 2020 10J17/1996 11.77 -1.36 12.93 8.87 8.57 7.27 6.26 6.81 0.69 Fid Frsedom 2030 10/17l1996 13.47 -3.15 14.04 12.02 9.92 7.52 6.52 6.65 0.79 Fid Frsedom 2015 11/O6/2003 10.68 -0.34 11.75 8.02 7.89 7.16 WA 5.72 0.66 Fid Frsedom 2025' 11/O6/2003 13.15 -2.65 13.82 11.29 9.60 7.80 WA 6.13 0.73 Fid Fresdom 2035 11/06/2003 14.45 -4.59 14.46 14.04 10.61 7.78 N/A 6.16 0.81 Fid Frsedotn 2005 11/06l2003 8.82 0.18 10.57 5.59 6.36 6.18 WA 4.92 0.58 #�o�.....: ...... ..:: , _ , .............. .. ...... .... Intermsdiste-Tetm PlMCO Tot Rstum Adm 09/08/1994 10.08 3.91 8.56 -0.99 3.51 7.69 5.85 7.04 0.71 Stable Value MIP Ii GI 1 04/20/1993 1.35 1.47 1.57 1.14 1.36 1.56 2.77 4.29 0.5t Total retums are historical and inciude the change in share value and reinvestment of dividends and capital gain disUibuGons,if any. Cumulative retums are reported as of the periods shown.Life of fund figures are from commencement date to the period shown.Due to regulatory requirements the average annual total retums are reported as of the most recent calendar quarter for the periods shown and are calculated using a standard formula. The figures do not include the effect of sales charges,if any,as these charges are waived for cantributions made through your company's employee benefit plan. If sales charges were inciuded,retums would have been lower. Each fund's share price(except money market funds),yield, and retum wiil vary,and you may hava a gain or loss when you sell your shares. For funds no longer offered through your plan,short-term trac�ng fees will not apply to your account. Fidelity&okerage Services LLC,Member NYSE,SIPC,900 Salem Strest,Smithfield,RI 02917. 2965 OP002965 0001 20131007 oPaK Fidelity Investments, PO Box 673008, Dallas,TX 75267-3008 Page 4 of 6 � ; Select Medical Corporation Statement Period:07/01/2013 to 09/30/2013 401(k) Plan ' � Fund Performance (continued) j For a mutuat tund,the expanse rata is ihe tofa/annua!/und or c/ass operating expenses(before waivers or reimberrsements)paid by the/und and stated as a percent oi the fund's tota/net assefs. Where the invRStment option is not a mutual fund,fhe ligure dispfayed in t/w axpense rata field is intended to re/lact similar inlE�rmation. Howave�it may have bean ca�Wated using methodalogies that dif/ar/rom those usad Aur mutual iu►rcfs. MutuaJ fund data has bwPn ' j d�awn from fbe most recent prospactus. For►ron-mutuat fund imostment optbns,tlw inlb�mation has been provided by the trustee or plan sponsor. Whan►ro ratio is shown Ior these options it is due to the fact that nona was available. Newrtfwlass,thero may be If�as artd expensss asmciatod with the invesfinent optan. j Please nota that/or the non Fidatity/und oi tunds listad,the Expanse Ratio shown may solely re/Ject tha total operating expense ratio ot the fund,or may be a , combirwd rafio reflectiny both the tota/operating axpense raUo ot the furtd and the totai opetating expense ratios ol the underlying lunds in whiah it was invested. Please consuH the/und's prospactus Aor moro detail on a particular fund's axpense rata. : Additional Fund information Use this section to dstermine the asset ailocadon of your blended investments. �lended Mvestmenf Stocks Bonds Shart term Fid Freedom 2025 67% 32% 1% Blended Investmsnts must invest in more than one asset dass.The blended investment asset allocation above reflects_the stated neuVal mix or,if not availabls,the asset mix reported by Momingstar,Inc.,for mutual funds or by investrnent managers for non-mutuai funds. ' i j 1 � 2965 OP002965 0001 20131007 OP4K ' Fideiity Investments, PO Box 673008, Dallas,TX 75267-3008 Page 5 of 6 ' I � � i � Select Medical Corporation Statement Period:07/01/2013 to 09/30/2013 401(k) Plan Your Statement Glossary Average Annua/Tota/Return This is the hypotheticel rate of return that,if the investment opGon achieved it over a year's time,would produce the same cumulative total retum if the invesfinent option performed consistenUy over the entire period.A rotal retum is expressed in a percentage and teils you how much the investrnent has eamed or lost over dme,assuming that all divtdends and capital gains ars reinvested. Change at Market Value Tiis changs in value reNects the fluctuations in the price per share of the investment option because of changes in their unde�lying invsstments(stocks,.bonds or short term fnvestrnec►ts).In the Accouni Summary section of your statement,tfiis number is the total of atl changes in all af your investrnents dus to these types of fluctuations. Dlvidends In the investment options of your plan,induding mutual funds and company stock(if appiicabla),dividends are money paid to sharehoiders that comes from the investment income that the fund has eamed. Dopending on the rules of your plan,dividends on company stock may be reinvested into your retirement account or paid to you in cash. Market Value Market Value is the doilar value of the invesUnents in your acoount. You can calculate the market vaiue by using ths following formula: Market Value=Number of shares in your account x Price per share of the fund. Shares Shares are your units of ownership of each investment in your account. Share Price The value of one share of sach investment in your account is cailed share price. It is determined by taking the total value of the whole investrnent op4on on a given day and dividing it by the numbe�of shares outstanding. Vesring Vesting refers to your levsl of ownership in company contributions and any associated earnings. Whsn the company contributes money to your account,it resides in your account,under your name.This money becomes fully yours once you have satisfied the vesting requirements of your plan.You are always entitled to 100%of your contributions and any associated eamings. Some special information about other sections that may appear in your account statement Asset Aflocation Market Indices �- investments can be divided into three major asset classes: Stocks, A Market index can measure the general trends in fhe performance of Bonds,and Short Term Inveshnents. These asset classes represent particular market segments. You can use the appropriate maHcet index the different types of unde�lying securities that may be held in the to compare the performance(Average Annual Retum)of the options in investment option(s)you own.Please note that you may be invested in which you're invested. a biended fund where the fund holdings are invested in more than one � Standerd and Poor's 500 asset class_ The S&P 500 inco ♦ StOCks rporates a broad bass of 500 stocks,including industrial,udlity,and financial canpanies. Some of its stocks Stocks can add a growth component to your portfolio. Thsy have a greater influence on ths direction of the market. The rsprssent ownership or equity in a campany. Stocks have the 5&P 500 calculation takes this into account by giving greater ' � potentlal to outperform other types of investments over the long weight to these stodcs. The companies that make up the S&P term. However,stocks tend to have widsr price fluctuadons over 500 aze traded on the Ame�can and New York Stodc sFwrt periods of time than othsr securities. Exchanges,as well as the Over-The-Counter Exchange. � Bo�►d$ ♦ Barcla�rs Aggregate Bond Index Bonds can add an income portion to your portfolio. They This measures�e total reWm of over 6,000 high-quality bond represent a loan to a corporation or Govemment Agency,and issues,indu�ng govemment,corporate,and mortgage sectors. provide the opportunity for higher current income than short-term Bonds in this price-weightsd index have an average maturity of investrnents. Uniike short-term investrrrents and stable velue 10 years. inveshnents,bond prices fluctuate with changes in interest rafias. � MOl'gsn Stanley EAFE lndex ♦ Sho►7 TeI'm The MSCI EAFE Index(Morgan Stanlsy Capital Intemational Short term investments can add stabi{ity to your portfolio. They Europe,Australasia,and Far East, index)ls an unmanaged provide current iricome and seek to preserve the value of your index and includes ths reinvestment of dividends.It is designed investment. They also tend to provide the lowest retums over to represent the performance of developed stock markets the long term. Examples of these investments include outside the United States and Canada. The MSCI EAFE index cerGficates of deposit(CDs),Treasury Bills and Money Market is a registered service mark of Morgan Stanley and has besn Instruments. licensed for use by FMR Corp. : 2965 OP002965 0001 20131007 OP4K Fidelity Investments, PO Box 673008, Dailas,TX 75267-3008 Page 6 of 6 -------____-- — ----- r . � - .��s��w.�ak'�9 . i _ r� r:,'S.° �„^,,.��.,°^a �>, ._ •., ^-< `, ; �r�m d. -..b,m�^. ��.�._,. . . . r , , � . ,�r_�� 3 e aa at .,t u3 u k,�;`a'�s�b'`� � �t.,= � ; ..., i ° . �- ' :,_ . 4u ..� a�p,t��-;: ----ww„��,.._.. , ,. ..._�.m., _ ., _._�� ... - �....-,,, .�.,.�.. .�.,s-. _T-_ �...., __ .,..,-.... ._.. . �....�. 4,. -- . .,,. �a �� t,,�va, f'.ac s,.:v.1�Y��i�ci,� rty:!°`rtk:3Cr3 tt+,6 �!t ��h h.''�.�?yr.ski 1!+d.�`rr-r� ri �,d4�W��.,..��N!,�r?f+r,�r !�..,:.:� ;�w.r-'-� a,' _ .. . _ . . ..,,w _ ..�,.... ��t^;�'� <.+:F'€"3 . . "�,'71E.. '?�2'r._ ,w..�.. ... _.. �__.... ...._.�._....__,.__.__....__...._ .. .__ .__""_ ..,�.—'---�g— � .,.e.. . .. ...._ ..__. 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T_....._..__�_ ...__.___.____ ..._ j ia�r��i ivr"�Cvfcj {r'Tyj .S s'rS;c; 7sp :3t?�; ; „g."� s r �.�# �F�� 4 ; e 1 r� i�avmaric�t Vii�Y � ___....._._.....��. ��ci��,.<�:vb�.r.� i �_.__.� __s_ .___ �__._._. ..� �___�_.___-- i �, t�,a,�qFl ti��L?aft?Pl�7ii�1 i � i , — _._._ _.�___.�..� _ ..._,._. t�"�T�?�E't21='��A�! j�::�fi') (STATE? ��It'�CC?C?Fj.� 1 i ! ...__. _.___._...........�_...�. . __......._._.. --�..-...�..�.___�. ..,._..._.. .... .........r_-..w..._..:v.. .......____.__ ` 4, {idAi�i�l i£2c�7€vPiSHti� ' i i , ; .___ . ._____�__..�,__ ..�.,__e._ I ! Eg-r,�"tE�'.vr.:!�; ii.i_`rj �_...iS7tlT�i � t`cti`'i;rJi2ki i j � __._ ...�.__�___..�..._____..____ ..___ . _a__.�......_____ . ____.. ° N�.�k�$F:i3 iltlr�.z'Y.£�5 J��`�t3ANCiF�i,iNSTiFUTi�r�f WitEif�t'Ik�3AFk Ct�Pf�SlT Bt?X IS I.00AT�I? � _�.__.�_ -�-�._____�--__._ �.w___ _._.�.__.._�.._.._.�_..______ _�,___ � iN�ci i � `JV'��1s Faryc�B:�ni€ � ; __w.,...,�.....__._.__........_._.__�._..�._�____...�.___.__ __._____ 4 fS�R�ETNAME) (G;;v� �__15TATE) ___;�1��(UU�? i � 6�'t�Gar�isle P�k�;�ui#e 2'��E1 �Jl��;�ir,�;;.�,� P� i7i�au �_.__ _.... _ __�_. _ w _.; 0 P�tAHIE 4]�€'ER�[41��A349NPs��ST EC^FTl3Y '�1A7��4N�TIME OF l.AtST ElITRY 9 a Bs•�ns3v� �5ii9c� _._d _._ 712512€�13 3;23�m _ � _. _.__ DA7��L`+t�ihi`�FtRGi r�F�EN7 BQX Nl1MSfiR DF BOX ` T'fTtE UN[2�R 1M�!!�9$B4A?f iS�EMTEE3 ��' l 06t1512t�(�5 , E251 Ta��ra J Kin� ' ___ _ _..� .v_. �.�_�...� �*3AADAAB AN[5 A�ADR�SS�i��'�iiSC3N(S}iiAYlNG A4�i��3�T�Bt3X i '�'-�----- _.�- �.._.. _ 8. (Nkivl�l �-______ l6. (NHfNEj � Tarr�ara.;e�K;�____ _ i i ' ts i REET aD�R�ss) __,,.___. i � (STR��T A�t�R�SSi � �171 Haymarket Way ' .._.______,.__.. !, (c'rr) ;sr�r�; rz�P cc�ra�; � 4�•�-�� ._ ___ �_..... � ' Mechanicsbura PA 1705t; , Esrar-�? �z�P c� . r�an�€ANa�r��r�.f o��M�zs�vE�raxsN�THe n�vEr�ra�v ___ _.__.. __�__.�_. Linds��i NP Johr7�ran S�!�uice Pt�anager � � ._..__.._ � ._._ .._ .. W�S�i WILL iN THE BQX? i� XFS �NO !t ye5� a. Aste o1 r�ili: a__ {}Zf')OIZC}(j� I � b. iYaroia anai eddress ofi personai representatn�e,if namsd!n thc wilt ! i {hiAM1A&) � BC�fldQti E 5�ik� j i (STREET FdA(NE} {CITY} � (BTATE: f�l('CO�E) f ' 6`!�`1 H�yrmarEcet'+�Vay Mechanicsburg__ �� '�ZQSf� � � c. Name mnd eddress of attorney,it any � � (NRME) i ,��hr� F King ��q I . ._�_...�_ — - _� f37FdEET NAME) (CITY? fSiATE1 {�1('(;Q�,lE; � ! _^ Mechanicsburc,,� PA ?74u0 •iC1f+';t�!FA:�..l•,R?(Fe i Ot: _��•.» ' ...-�-- � ,_. a�►f�� ►��C��" �� l��#�F��' � .��'4 __ _.---�.; ___ � 1NSTRUC"�tON� _.._�...__ � � The Department is authorized u�der federal Isw+,42 U.S.C.§405{�),ta use the cfsc�dent's Soei��Sacurily number in� —A—`� ! administe�ing this skate tax law.The Qepartment€zses Social Secur�ty numbers to establish a dec�d�nYs iden4ity and � � ensure proper credit for tax payments. � � {7} Cash: Repart total oniy. 1 ! � i (2} Stocks: t,ist in detaii every common or preferred certifrcate,warrant or oxher rights found in box. Stacks ara to bs � � designaied by name of c�mpany,certificate number,date of c�rtiflcate,nama in which stock is registered, and � number af shares and cfass of stack. I � (3) Obiigations of U.S.6ovsrnment: Number of items,date of issue,face value,names in which registered and � type of ownership, i.e.,joinUy held,payable on death,etc. (4} Bonds: Designate by name, amount, serial numbar,ar other designatian. (Bearer Bonds� � � (5) Bank and Savings and Loan Passbooks: State neme of depositor, number of book, last date appearing in book, ; name of bank and branch, and balance. i (6) Jewelry,Coins,Stamps,Manuscripts,etc:List and describe as fuAy as possible. i (7) Qeeds,Mortgages,Current tnsurance Paticiss or other evidences of indebtedness: List and describe as fulfy i as possibie. � k {8} Ail other contents. , REM ITEM 4ESCRiPTtON NO. 1 US Passport for Brandon Slike 2 Commemorative Silver poliars for 1984 Olympic Games-2 3 1990 Cain proof set 4 Cash$2 5 Savings bond Series EE$50 to Brandon E Slike Seria!#90530966150 � 6 Savings bond Series EE$50 to Nicholas R Slike Seriaf#10534966T51 � 7 Savings bond Series EE$50 to Nicholas Robert Siike Serial#30568382177 8 Savings bond Series EE$50 to Shanna E Slike Serial#00530966752 i 9 Copy of iast will and testament of Tamara J King dated 2l1012006 10 Birth Certificate for Shanna Elizabeth S{ike t 1 Selective Service Card for Brandon E 51ike i2 Savings bond Series EE$50 to Shauna Siike Senai#L176915266 13 Social Securih,�card for Shanna Elizabeth Slike 14 Socia{Security card for Nicholas Robert Slike 15 Birth Certificate for Nicholas Robert Slike 16 Commonwealth of PA vehicle title for VIN#1 G8AJ52F74Z188074 17 Birth Certificate and Capy for Tamara Jo King 1 B Birth Certi�icate for Tamara Jo King 19 Birth Certificate and Birth Record for Brandon Eugene Slike 20 Social Security Card for Brandon Eugene Slike I CER FY UNDER PEPIALTY OF PERJURY THAT THE ABOVE RECQRD IS PERSOP!RECEIVING COPY OF C T AND COMPLETE TO THE BE MY KNOWLEDOE AND BELIEF. SAFE DEPOSIT BOX INYENTORY: Sf NAT RE ' SIO URH `Y� P E PRINT,NAM AND CHECK APPROPRIATE BpX BELOW: � � G. �PR�NT TITLE � pATE CHECK APPROPRIATE BOX: ��CAf V�� 1 Y�-Y lA- � ,�.�t2'y� �ExecuWr(Vix) �Administretor(vix) �Estate RepreseMadve (�Joint owner W safe depoeit hox NOTE:Attach additional8'!=°x 1"sheet(sj if necessary or use duplicates of this page of form. S,IN'077PA 13�19;Paye?�i 3 . Page °� of� SAFE DEPOSIT BOX iNVENTORY INSTRUCTIONS The Department is authorized under federai law,42 U.S.C.§405(c),to use the decedenYs Sociaf Security number in f administering this state tax law.The Department uses Social Security numbers to estabtish a decedent's identity and � ensure proper credit for tax payments. � (1) Cash: Report total only. (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 number of shares and Gass of stock. � (3) Obligations of U.S.Govemment:Number of items,date of issue,face value,names in which registered and � itype of ownership,i.e.,jaintly hefd, payabfe on death,etc. � (4) Bonds: Designate by name, amount,serial number,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 possible. (7} Deeds, Mortgages,Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possibte. (8) Ali other conterrts. ►TEM tTEM DESCRIPTtON NO. 21 Birth Record for Shanna Elrzabeth Siike 22 Copy of Deed for tract of land in Hampden Township,Cumberiand County,PA 23 Deed for tract of land in Hampden Township,Cumbedand Caunty,PA 24 Durable Power of Attomey for Tamara J King naming Brandon E Slike as POA-2 copies 25 Durabie Health Care Power of Attomey for Tama�a J King naming Brandon E Slike as POA-2 copies I I I . � f i I i � i CERTIFY UNDER PENALTY OF PERJU�tY THAT THE ABOVE RECORD IS PERSON RECEIVING COPY OF OR CT AND COMPLETE TO THE B T OF MY KNOWLEDGE AND BELIEF. SAFE DEPOSIT BOX INYENTORY: {C, T RE SIGNATURE � � � NANE PRINT NAME CHECK APPROPRIATE 80X BELOW: . s�� PRINT T E DATE CHECK APPROPRIATE BOX � � ��`� �Exlculot(iriz) �AdminiSUator(trix) � �� ]EsteU Representative [�Jant owner of safe Geposit box NOTE:Attach additional 8'/:" 1"sheet(s)if necessary or use dupiicates of this page of form. s't;P30'7PA!3-t t t Page 2 uf 2 Crown Banking� Account number:1010111T59161 ■ October 17,2013-November 18,2013 � Page 1 of 4 008217 1 AV 0.360 1218419 Questions? hhl��l�ilni��i�ldli�u�i��ih�illln�,.�in�lliinii��,�� TAMARA 1 KING Available by phone 24 hours a day,J days a week: � 6171 HAYMARKET WAY 1-884-TO-WELLS (t-8�-869-3557) MECHANICSBURG PA 17050-5236 TTY: 1-800-877-4833 En espanot: 1-877-727-2932 �a 1-800-288-2288(6 om to 7 pm PT,M-f) Online: wellsfargo.com Write: Wells Fargo Bank,N.A.(345) P.O.Box 6995 Fortland,UR 9J128-6995 0 0 0 � c � O � You and Wells Fargo Account options � Thank you for being a loyal Wells Fargo customer.We value your trust in our a check mark in the box indicates you have these � company and laok forward to continuing to serve you with your financial needs. convenienrservices with youraccounr. Go ro Z weflsfargo.com orca(!the numberobove ifyou have Z questio�s or ifyou would like[o add new services. Z z Online Banking � Direct Deposit [] Z Online Bill Pay � AutoTransfer/Payment� Z z Online Statements � Overdreft Protection �] Z z Mobile Banking � Debit Card z My Spending Report � Ove�draft Service � g 0 0 N � IMPORTANT ACCOUNT INFORMATI(�N � A V 01 v -----__— �n Give the gift that is always the right sizQ,shape,and color-a Wells Fargo Yisa°Gift Card N � � N Give your loved onas a Wells Fargo Visa Gift Card N Searching For gifts for your friends and family this season?A Wells Fargo Visa Gift Card is a great choice.Here's why: -Purchase online or at any Wells Fargo location. -Use it at all your favorite participating U.S.retailers and service providers-in person,online,or by phone. -Choose whatever denomination you want to give,between S25 and$500. -Give with confidence,knowing the money never expires. Get started on your holiday shopping today!Order your gift cards online at wellsfargo.com/giftcard. Account number:1070717759767 ■ October 17,2013-November 18,2013 ■ Page 2 of 4 � Att�V�t�l SY1111M181'�/ Account number: 1010111759161 Beginning baiance on 10/17 $5,368.42 TAMARA 1 KING Deposits/Additions 0.05 Pennsylvania account terms and cortditions apply Withdrawals/5ubtractions - 0.00 For Direct Deposit and Automatic Payments use Ending balance on 11/18 55,368.47 Routing Number(RTN): 031000503 Overdraft Protection This account is not currently covered by Overdraft Protection. tf yo�would like more information regarding overdraft Protection and eligibility requirements please call the number listed on your sWtement or visit your Wells Fargo store. Int�r�st summary tnterest paid ihis statement $0.05 Average collected balance 55,368.42 Mnual percentage yield earned 0.01% Interest earned this statement period $0.05 Interest paid this year 50.59 Transaction history Check Deposits/ Withdrawals/ Endingdaity Dnte Number Description AddiUons Subtractions balartce 11/78 Interest Payment 0.05 5,368.47 ..._._._....._.._..._�..__�._. . ..._........_..........._.........__ ........_._....._._.�. _,...._.,....._. .__ ... _. ._.._ _ .._...._ ._�...... . .._�... ..... �_.........�. ......_ _.....__. Ending b�ance on 11 J18 5,368.47 Totals 50.05 50.00 The Ending Daily Balance does not reflectony pending withdrawals or holds on deposited funds thnt may have been outstandinq on your accouni when your transactions posted. Ifyou had insu�ciertt available funds when a hansvction posted,fees may have been assessed. 0 A V � Monthly service fee summary � For a complete list of fees and detailed account information,please see the Wells Fargo Fee and Information Schedule and Account Agreement applicable to your account or talk to a banker.Go to wellsfargo.com/feefaq to find answers to common questions about the monthly service fee on your account. fee period 10/17/2073-11/18/2013 _ _ Star,dard monthly service fee 5'<�•00 ___ You paid 50.00 _ How to avad thQ rtanthly sarvice f�e Minimum required This fee period Have any ONE of the following account requirements • Average daily balance $750.00 $5,368.00 Q • Monthly automatic loan payment to a Welfs Fargo mortgage 1 0 ❑ • Combined balances in linked accounts,which may include 52,500.00 55,368.42 � - Average daily balances in checking and savings accounts • Combined balances in linked accounts,which may include $5,000.00 50.00 ❑ - Average daity balances in time accounts and FDIC-insured retirement accounts �o^ .:: • Combined balances in linked accou�ts,which may include $5,000.00 50.00 [] - Outstanding balances in consumer installment loans - Line amount in credit cards and consumer lines of credit IPlIP Kelley Blue Book Page 1 of 2 �� `; �E:'E��'�f g�1,�� nG�C Th�Trusted Resource`" �' � , �: • taet y�r cre�#�t re�rt&scc�re � • �.ks��x��i�� f��rnerica's#1 �nlin�prc�vider. Advertsement Why ads? Trade In to a Dealer 2004 Saturn lon Pricing Report Traae-it-i V�Sue $tyl@:1 Sedan 4D ��F�� ,- Mileage:ai,sao 4'� s ,, �,� �y, . � � v� i� _ _ , � � Vehicle Highlights '" x � Fuel Economy: Max Seating:5 ` '� ' City 20/Hwy 30/Comb 24 MPG 7rade-In Values valid for your area through 4/3/2014 Doors:4 Engine:4-Cyl,2.2 Liter Fair Condition Drivetrain:FWD Transmission:Automatic EPA Class:Sub Compact Cars Body Style:Sedan Country of Origin:United States Country of Assembty:United States ` Your Configured Options Our pre-selected opdons,based on typical equipment for thls car. ✓Options that you added while configuring this car. ', Engine Comfort and Convenience Safety and Security ', 4-Cyl,2.2 Liter ', ✓ Air Conditioning Dual Air Bags ', Transmission ' ✓ Power Windows , Wheels and Tires Automatic ' ✓ Power poor Locks I Steel Wheels Drivetrain ✓ Cruise Control ' I FWD ' Steering , Power Steering ' ' Tilt Wheel ' ' Entertalnment and Instrumentation ' , AM/FM Stereo , ', ✓ CD(Single Disc) ' Glossary of Terms Tip: Kelley Blue Book�Trade-in Value-This is the amount you can expect to receive when you trade in your car to a dealer.This value is determined based on the sryle,condition,mlleage and options �t's crucial to know your car's ��di�aced. true condition when you sell it, Trade-In Range-The Trade-In Range is Kelley Blue Book's estlmate of what you can reasonably expect so that you can price it to recelve this week based on the style,condition,mileage and options of your vehicle when you trade it appropriately.Consider having in to a dealer.Mowever,every dealer is dlfferent and values are not guaranteed. y0U f CYl@CI1df11C gl Ve y0U 8tl objective report. Kelley Blue Book�Private Party Value-This Is the starting point far negotiatlon of a used-car sale between a private buyer and seller.This Is an"as is"value that dces not include any warranties.Trie final price depends on the cafs actual condltlon and local market factors. http://www.kbb.com/saturn/ion/20U4-saturn-ion/1-sedan-4d/?vehicleid=3349&intent=trade-... 4/2/2014 Kelley Blue Book Page 2 of 2 Private Party Range-The Priva[e Parry Range is Kelley Blue Book's estlmate of what you can reasonably expec[to receive this week for a vehicle with stated mileage in the selected condidon and configured with your selected options,excluding taxes,title and fees when seiling to a private party. Excellent Conditlon-3%of all cars we value.This car looks new and is in excellent mechanical condition.It has never had paint or bodywork and has an interior and body free of wear and visible defects.The car is rust-free and dces not need recondidoning.Its clean engine compartment is free of Fluid leaks.It also has a clean title history,has complete and veriflable service records and will pass safety and smog inspection. Very Good Condition-23%of all cars we value.This car has minor wear or visible defects on the body and interior but is in excellent mechanical condidon,requiring oniy minimal recondidonirg.It has little to no paint and bodywork and is free of rust.Its clean engine compartment is free of fluid leaks.The Ores match and have 75%or more of tread.It alw has a clean tltle history,with most servlce records available,and will pass safety and smog inspectlon. Good CondiUon-54%of all cars we value.This car is free of major mechanical problems but may need some reconditloning.Its paint and bodywork may require minor touch-ups,with repalrade cosmetic defects,and its engine compartment may have minor leaks.There are minor body scratches or dings and minor interior blemishes,but no rust.The tlres match and have 50%or more of tread.It also has a clean title history,with some service records availabie,and will pass safety and smog inspec[ion. Fair Condition-18%of all cars we value.This car has some mechanical or cosmedc defects and needs servicing,but is s[ill in safe running condition and has a clean tlUe history.The paint,body and/or interior may need professional servicing.The tires may need replacing and there may be some repairable rust damage. c0 1995-2014 Kelley Blue Book Co.�,Inc.All rights reserved. <y`�2014 Kelley dJue E7ook Co.,Inc.Al)riynb reservetl 3/28,�2014-4:7{2014 Editiun Ior Vennsylva�ia 110i0.7he specrfic�nfo�rr�nNUn reyurcea ro tlete��i e tY,e v i e fo'this� trc f�r veh !e 's sup�tied by Ne person yene�eting Nrs ieporG Veh�Ue valua[ions are opNi�ons and may vary hom vehtcle ro vehlcle.AcNal valuntlons will vdry base0 up�n merket contlihons sFeuHcntro s,vehicle ci tlrtion or other purticutar clrtumstances pe�tinent to th�s Gar[icWar vehicle or tbe[ransac[ion or the pnrties m lhe transactlon.7hls report is mtentled for the mtlivitlual use of the Ue sun yer�emur�g this��eymt on,y antF shal! not be satd or transmrt[etl M anotl�er party.Kedey Blue Book assumes no responsibHify for errnrs or om�ssrons.(v.140•JO) http:Uwww.kbb.com/saturn/ion/2004-saturn-ion/1-sedan-4d/?vehicleid=3349&intent=trade-... 4/2/2014 ��'£�Ta��, ?€-GISTER OF :�'ILLS OF ,�,,�.r��i��n CCI�TI�_ PE��4S1�L��:�:�_-� ��E�£C3�:t��t.�CTH FP�=�\5'�y-i'�'��:.: t /►// .�(j /� �,r�`-'�<T� �r Vi�tF/��r/�NA � c��'•' •/ ' - /�r� t!;c'1L'^'^: _.�r��na't R�IIresemaiic�e�s+oi rne�:.s�a�e �� .�� s!�! K� u•°_��3Ce:j.t;:posels:i ar=d sa�i.$)that the It.iIii dDDc:ui iF�I^Trit;iCi�C�L'1ri�T �Z7i.0Y�litii�t'�2 a.l��[�i�:}ZTSQY:ai a5S�i5 tt'�:i;C4�'::�S;:tiu.� an.i ail or:i►e real estate in che Cotnmon��eatth�f Penns��i�•ania oi said D�ceden,,tr.at t�he�aluacion ptaced opnosite each i�e.n c�Fs•s:� i*��•�iicon represents it iair value as o:;I:e date o:the decedent�s de3ch_ and that Deceden� a�viaec no r�ai �state c��etsid� ot d2e vommou�vealch of Penns}'l�'ania excent ti:at«,°hich appears in a memosan�u:r.3t tl:e eilti oF ihis im'ent.�r.� i ��erif�:F�l7i[he 5[aten:enfs made in tri;�i7FCa;- Q,.,,,,�/' �f��, •7/1r\� �r�.�S�G�� tery are t*u�aitd correcL I ur.derstand that fals�sea.e- !!!ll�� /! nlents here;n are made sub�ect �o the nci�aitie� oi �� ;� Pa.C.S. � 49t}4 rzlati:�g to ur.s��-orn fa':sifcatior, :o t aa=.i�c.rities. ��G �e711!C5 U�'� �'� �7� _�tiarae��-- ';�'a;r.et ;Juv,•cme Cou.••z�.J. :!.^.;' . 1.=itu"I['t>=51 :_e'i e:3tt G�1:L% ..-.'_ �..�.Gr E _��itZ::�LGI`.i::� �7()�i j s_.-.: �:":+JJv J�� ♦v - � „�Jr o�t/!� � /' '7' � � � �`�� .si.� �; �^'��—�. � FIGF?RES ti1L'ST BE'F'OTf�LE�? i i � � � �/ Piece ��ot��' se�' ' A`/.50,C�` Cali�et �' �OCC ��ter�a�n..�� Gl��' �S�.G�' Ze��/ L�t�ode �oy ��e ��lev�sio�� ►r�ue�tr� %� 19q5 ��5;l�� vn�y Catic�e �CQy T�1�2 -��2V'�'i��'� ��ucec� �n ,�GG'% ��Z�.('G D��ex L�G' �e%✓is%v� �IOG'G�i y Pi�c� le�Tler li;�,n� r�c� set p�cr ��n��r�r �/��',G'G �2 e�� tA6��s, �►e�;� r�e,c��i�te� �y('GG �0�PG' �a��e, ��t/ �e,c��fe� ��i� �%��i�� fa6l� �e� ,�retA� re,�a��ec� ��'�G�' y Ga�.�tc%s �/�'C,�G f;tttcis ttrldirt�rrrai ShP.Cts 25 tteed�ti� ! �l / 7 �. V i��..� � �� '�}'.'S�'� �f?i']:: 'Str 4;Ye,yoru.^.�1sax:: ui.°C.:� cst5;_Vc.ow� .<-rc r..;t::..u.�.v -. vt�I�C�TSt'1\':i[?1J �3Y. 3i t�.e e�ec;tca�Qi i;iC . ' . . GCT.iOfl;a' YES3:C521FiS�lt'C :�,C{V�e :itt l�'+i::P. :11 ear^ iir;i!.Uu�suctt tlgu:'CS slt��ulJ n�t t�e e�ian6��ii.tn ti:c catai ot��hc�nrento:^�. r:C�.�'r;P�. C.S.;3_:e.:�„ <=ann%7.!-'r=u�1 r¢r, IV.I?.Gti � I�i VENTCIR�' REGISTER OF �'ILLS OF�/f.�.��,� COU�TTY, PEi\'�iSYLVA:vIA Cn�•[�i0�4�'EALTH dF PE� *�SY b'AVi,a � SS �,�"�l/'/l,f�U COUNTY OF �U��j��Q� Filz�umber Personal Renresentati�e(s)oi the Estate of �Q'�Q�d ✓Q �i �/�� deceasea,dzpose(s)and say(s)that the items appearing in the followira inve� ory ir:clude all of the personal assets wl2erever s�tuate and all of the real estate in the Commonwealth of Penns��1F•ania of said Decedent,that the valuation placed opoosite each item of said inventory represenu its fair value as of the date of the decedent's death, and that Decedent o�vned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this in�•entory. I verify that the statements made in this Inven- �� p ��k� ��__%��%7�r� tory are true and correct. I understand that false state- �� ments herein are made subject to the penalties of �/�/ � � e� � 18 Pa.C.S. � 49Q4 relatinj to uns��orn falsification to M L �? �-n autharities. �`�� U��i +� / �"� Attorne��-- {_7�'arne) (Sup�-en7e Court I.D. No.) (�cld�•ess) {"�elevhone) C«TE CF DEATM LAST RESIDENCE OcCEDENi'S SOC.8EC N^v /.�" �l' .� / 7� � '� Q .��'� -�" - � FIGURES MliST BE TOTALED L�'lgt�li�� C�pir.Fr��er �/Q�'�,G�% g,� r;/,�%t eoc'k Sfae%; ',��0.Gl�' �oua�e� ��sk ��'�G��/�C J'(en�mr� ,�1��'e �e�'r��'�� moc?�� S9�/`�57�z�G� �¢.35'4. O�i �e��0�e E��fe �ic��vy4✓e �O�C�� 7�t�� .�Q�i''��'(G' ��5�� !e��re Fl�� j>'✓en .��ra�e./ ��'; �f.��'�'�Z�O/ j,��G�l'C I�e��O�e C�te�s� Fi'�ze� ��75;G�� Ken�are �asl�e!� � �/��,QD GE ��-�;/e �/eL•f�rc ,Gry�� '/G'��'�" Ki�/��.sc�� ?��s� �'/�:@/1 ��4�GG D%sles�.o.;,;ny Se,T k;�C�er, �r�'��/� var;o�v.s po7"s an��;� �3r0�'� ��ve/�y,('3�.se�s ��' �,��J�.�ve%y,� ,�,,?c��`��'0 B�aks (f�v �iar�(� �C'C f.�itach additional sheeu as ne�ecl} y �� TOTAL: � �'�'�r ":OTI': Thc Mc�:aru;:duc:uf rcal c�wi�vuwiuc �hc C�uuuv��weelu��f Pennsylvania may, a.The el&CUOn or the personal representah��e �nclude the value o[ each i�em,but such figures shoutd noc be extended into the total of the lnventory. (See 30 f'a.G.S.��330I(b�j rorm R4Y-09 rev. lQ.l3.d6 Cocklin Funeral Home, tnc. Acct: Contract# 205 MEM4RAlVDUM OF SERVlCE SERVICES OF: Tamara Jo King DATE: (A) Services: Cremation Service Option 15 $2,195.00 Other Preparation of Remains �265.00 Transporter Cremation Container $250.00 Total (A) $2,7�0.00 (B� Cash Advance Items: Certified Copies $90.00 Coroner Authorization $30.00 Total (B) S12o.o0 i �� ` �/ � ��/,�, �.� ��1� ,% ` 1 Total Amount $2,830.00 Less Amount Paid �0.00 Due $2,830.00 7998 ESSELTE CORP.MELVILLE. NY � ` I ORIGINAL-F.F.D.OF A A � �� ' � 1 I � I DUPLICATE-CLIENT g� � D Z � i � ' j i i ( j TRIPUCATE-FUNERAL HOME N o o m V � o � T � JJ O � C� I � D -i C C O RI W ^ ��'�� A cmi � I `� �D i C i D I � < D (A T n n C � L� 3 < T � � < �1 C� -i 'S' D a a N e m o � m � I �� ; m � fD m m, ,�c n � � m °y' O z � � y m a, � m m v, � m m � n n n n a .; � �g m -i < a S � 3 3 � m i f < � � � � 3 -5',' m 0 m $? 3 S n R e3 � � � v o � x m � � � 4 n'� O o 3 D n z � I cQ m I O O � � � .� cD � -n y O d � O , � 'rt � � D O�n �O'S O � �' �i O m m � Z '. 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Oes Moin.es./A 50306-3411 Property address 61"?:HAYi�4ARi{EZ'WAY MECfiANiCSBURG PA 1705G Customer Service �-! Online �..� ' L, �,vel's+,`argo.cr,m `4-'� Fax �`�";' Te1e hone i-F36b-2'78-ii?G P i-8662:�4-8271 ��t��u�'��'��''��II��'��''i'��'��'��'��'�� /. POr±3n;.pli.deace Hours of operation lles tdoi:tes.IA SU306 �'•i:>n-Fri fi a.m.-10 p.tn. 1A7' 00146/1121461000146 035Q 1 ACQMTH 108 �`�`��«`� Sat£3 a.m.-2 F,.m.CI' =0!Payments TAMARA J KING PO BUX I!�t;� 6171 HAYMARKET WAY n� .*��r{ NF.,.;:�rk N.7 o�iC? MECHANIC58URG,PA 17050-5236 �j� ��j?#'��'" ��/` "��` GJr vr_r�.��t��_�acomrt:unicatiw;sru}a;:servic�calls. ��r-� �� Impoztant messages � O�ir records indicate youur mor.thly uayrnent.s Summary delinquer_i and a late charge has been assessed. In P3yment�principal andJor int�rest,eSCYOw,� $829.�9 Unpaid principal balance SlO9,C707..78 the future,p}ease make your payment on or be{ore Current monthly payment 09/O1 j13 $829.09 Interest rate �� e r�� 1��:;-->>y pJC) the�ue date to avoid late charges and adverse _ _ _ __ __ _._. creclit burea.i reporting If your paymert has been t�verdue payment{s)08�O1f l3 ��,'�g,pg Interest paid year-to-date ��.%�1�� sent,please d•,sregard this notice. Unpaicl l3te chsige(s} ��1.6� Taxes paid year to-date $1.,9t?�.i? Escrow balance $:4.Fi4- Total payment due 09J01/13 $1,689.$5 Activity since your last statement Date Description Total Principal Interest Escrow Other 08j15 School tax payment $i,543.13 CUMtiERLAND,�VALLF.Y SD __. _.� _ _— ----- --__._. _.--- _ ___. _ ___ _ _ _ ._ __ .__ t�g,i5 iate fF_iassessfd �3?a'r- _. _. ____ _ ___ __ _ __ ._ _ __ _ _ _. _-- _ . Late c?7arges are assessed after tiie close of busir.ess on tnv assessn:et�t date,i:d oniy after all payment�i F_eivr-d have been apalied. ±ri:u� '�4t:Gf zYH.:i f'-i�t?- `'!1'i .� -sc;; ' run::n.h Vru:�t� aut. �' .`� Laan number 0104414222 ,;; Current monthly payment due $829.09 Total payment due 0�/02/13 $1,689.85 � *� After 09/16/13 a late charge may apply $31.67 ..,ecx here sr.y see '�AI�tARII J K1tJG _e.�erse for add•?^ss �>>r�et�r.n. ..._. _... ,., . "n�:..,. � . i��ry��fll��l�lnl��I��Ul�ili{�iin�,�lili�lr��ll�ilri�ll�� WELLS FARGO HOME MORTGAGE PO BOX 11701 NEWARK NJ 07101-4701 � 7�8 �10441,4222 � ],D�0�0829090086D76016898501658�,8 O�O�OQ01Z7323?8�29 1� CUSTOMER #: 5809908 162326 Gr�h�m Motor Company, Inc. *INVOICE* 1402 Holly Pike BRANDON SLIKE Carlisle, Pennsylvania 17015 6171 HAYMARKET WAY Tel. (717)243-3066 • {800}992-4743 • Fax(7 t 7}2d9-7998 MECHANI CSBURG, PA 17 0 5 0-5 2 3 6 PAGE 1 web Site: http: //www.grahammocors.com HOME:717-5 8 0-9 9 0 8 CONT: 717-5 8 0-9 9 0 8 E-mai1: service(�?grahammotors.com BUS: CELL: 717-580-9908 SERVICE ADVISOR: 112 KAREN MCBETH COLOR YEAR MAKE/MflDfL " VIN �ICEwse r Rs�.� :' NFILEAGE t�17 0UT TAG GRAY 04 SATURN ION 1G8AJ52F74Z188074 FTA0804 81880 81880 074 _ _ _ _ DEL. DATE PROD. DATE WARR. EXP. PROIVIISED PO N0.- 'RATE PAYMENT INV, QATE 25DEC04 I 25DEC04 D 16 :30 06DEC13 43 0 . 00 CASH 06DEC13 R;�. oPErtEt� R��DY oPT�ONS: DLR:GRAHAM ENG:2 .2 Liter 07 : 07 06DEC13 10 : 04 06DEC13 LINE OPCODE TECH TYPE HOURS LIST NET TOTAL A TvJILL NC?'T STA� RTTNNING ON START' SECURITY LIGHT '�4MES ON : : 125 REPLACE PASSLOCK SENSOR. CLEARED CODES. _ '7'F..RTFT1 �FVF;RAL `I'II�IES- !OK. 7 9� .77 92 .77 �1SWZTCH 47. �.1 47','11 47. 11 iOR: 92 . 77 OTHER: 0 . 00 TOTAL LINE A: 139 . 88 GNW�WnnUfUtLlFIPRl/Y .*�*�**�-�***�*ieik'R�****.J[.7F'kfF*.tY.,'klY�*it'k'k��*.7Y�*�k�k��**#*14iFt**�1ki�t . . 14G2 NUI�v PIKt: . . . . . .-:. •::�" . . . . _ __ . . .. C(�l.i3tE� Pfl liUl: nC:�t�,,t w: 6e� _ _ : :: s '� Krr ��: �:�,�s ,- >:,.,, � ,� =�;.. ',�� ale ,, � *� .., .:... . .,..,� :.. ,,, �- _ �. �XkXXJ(�Xkl�t4�� ' �. .. GISC Entrv �eth�: �wiaed � $, � "� _ 1ot31: � 14�.6 � ��" �� ,, � '�� ' � ��-' �� _ ��` �� . � £ ,y�" ' ; 'f ��.�'�'�i�9� -��f�r �� '��' � . . . . . �� _ .. „+:,m, «•C;.;6,.,I..�,� . . . . fr ��. . . . . . . 1z1�13 17:�`j��. ��s ; . . tj� . . .. ,� � . - � . Inu q: :62326 P�C�: �o56R 1ran�action ID: �,329si18t'"�s'Sl� '`' "'�,,,,,;.`�"'�f s �uorvd: Online Ba�ch�: '�i�s4 - �'�;r"`v� `�, � � � _ __ _ _ __ _ __ _ _ _ _ _ _ _ _ _ _ c��t�, r��v _ Ct�YYt `f(iUt CCESSORIES ARE SOLD AND AlL REPAIRS ARE "DESCR4PTION TOTALS rnuvwc� t� �nt UE;viEH5HIP AS-�S. 7HE DEAIERSHIP HEREBV EXPRESSLY DISCLAIMS ALL Thank WA(iRANTIES, EXPRESS AND —110�PL�ED, INCLUDING ANV IMPLIED WARRANTIES OF LABOR AMOUNT 92 � ']'] MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE, AND NEITHER ASSUMES NOR AUTHORIZES ANV OTHER PERSON TO ASSUME FOR IT ANY LIABILITY IN CONNECTION WITH THE YOU pARTS AMOUNT t�'] . 11 SALE OF PARTS OR PRODUCTS OR THE REPAIR. THE ONLV WARRANTIES ON PARTS AND ACCESSOHIES OR REPAIRS ARE THOSE WHICH MAY BE OFFERED BV THE MANUFACTURER OR THE �r GAS,OIL, LUBE O . O O ORIGtNAL PARTS DISTRIBUTOR ANO ONLY SUCH MANUFACTURER OR DISTRIBUTOH SHALL BE Your LIABLE FOR PERFORMANCE UN�ER SUCH WARRANTIES.CUSTOMER SHALL NOT BE ENTITLED TO SUBLET AMOUNT O . O O RECOVER FROM THE DEALERSHIP ANY CONSEQUENTIAL DAMAGES, DAMAGES TO PfiOPERTY, Business! DAMAGES FOR IOSS Of USE, LOSS OF TIME, LOSS OF PROFIT OR �NCOME, OR ANY OTHER MISC.CHARGES ' O. O O iNCiDENTAI DAMnGES. TOTAL CHARGES 13 9. 8 S By signing below, you acknowledge that you were notified of and authorized the ALl PARTS ARE NEW Dealership to perform the serviceslrepairs itemized in this Invoice and that you received UNLESS OTHERWI$� IESS iNSURANCE �. Q� (or had the opportunity to inspectl a�y replaced parts as requested 6y you.The vehicie INDICATED. SALES TAX is bein returned to ou in exchan e for our a ment of the Amount Due. $ .�}� DATE CUSTOMER SIGNATURE AUTHORIZEO OEALERSHIP REPRESENTATIVE SIGNATURE pLEASE PAY THIS AMOUNT 148 .28 UedIC1 Vv�2008 ADP(03I081 SERVICE INVOICE TVPE 2-2S12C-'AS-IS'-PENNSVLVANIA��OMER COPY Account � �� HAMPDENTOWNSNIP Statement 230 S SPORTING HILL ROAD � •' � • 1 ` MECHANICSBURG,PA 17050 � �* �' ti (717)761-0119(Township Office) ACCOUNT: 009489-000 �9F� =��4'� (717)909-7145(Utility Billing) SERVICE ADDRESS: 6171 HAYMARKET WAY FOpte co�'�` SERVICE PERIOD: 10t1/2013 to 12/31/2013 BILLING DATE: 10/1/2013 DUE DATE: 10/31/2013 .. TAMARA KING 6171 HAYMARKET WAY NO ACTIVE METER FOUND MECHANICSBURG, PA 17050-5255 Any portion of the sewer and/or trash charges which is not Residentiai Sewer 114.25 paia by 10/31/2013 is subject to a penalty of 10%. All Trash Service 40.80 returned checks are subject to a fee of$20.00. Just a reminder that curbside collection of bundled yard TOTAL CURRENT CHARGES 155.05 waste ends on November 1,2013. Residents may f,��,../�,,,�� ,,,,G��G!Cy GL�e�p7.4' continue to take yard waste to the Township's Yard Waste i Facility located in Technology Parkway. You must show your Resident ID card. The facility's hours are Monday- Friday and the first and third Saturdays of each month, 7:30am-3:OOpm. Please check the Township's website for additional information. •- PREVIOUS BAl.ANCE 155.05 NO USAGE HISTORY PqYMENTS RECEIVED -155.05 ADJUSTMENTS 175.05 ADDITIONAL BILLING 0.00 CURRENT CHARGES 155.05 TOTAL AMOUNT DUE 330.10 Payment � • � `/`./� .�0� TCTA1 �11111l11tl�T�11CC1V 'l/9f7A/��q� vv0.�ii^i P�V 11 V V�'�1 V�6i� � � �� PLEASE RETURN THIS PORTION ALONG W ITH YOUR PAYMENT PLEASE MAKE C11ECK PAYABLE TO: REMIT PAYMENT TO: HAMPDEN TOWNSHIP ACCOUNT: 009489-000 SERVICE ADDRESS: 6171 HAYMARKET WAY SERVICE PERIOD: 10/1/2013 to 12/31/2013 HAMPDEN TOWNSHtP BILIING DATE: 10/1/2013 230 S SPORTlNG HILL ROAD DUE DATE: 10/31/2013 MECHANICSBURG, PA 1�050 TAMARA KING 6171 NAYMARKET WAY I � � � � � MECHANICSBURG, PA 17050-5255 TRAVELERS�, Automobile Account Bill GUNN-MOWERY LLC Account No. 988012472 PO BOX 900 CAMP HIL�PA 17001 Please refer to this bii►ing account number oszn when calling or making payments. 818 Biiling Date: SEPTEMBER Q3,20t3 Due Date: SEPTEMBER 21,2013 QUESTIONS? CAL� US: TAMARA KING 6171 HAYMARKET WAY Automated Billing and Payment Information 1-800-550-7716 MECHANICSBURG PA 17050 availahip 7 davS a week Gaim Service 1-800•252-4633 Policy Questions or Ghange of Address (717) 761-4600 To view or pay your bill online visit mytravelers.com • • • • • . • • . • • Ever wonder about your insurance... What protection do I need? Wnat drives the costs? How can I prevent losses? Visit trvonesource.com to view short videos on these and other topics. Policy Payment Information Minimum Unpaid Policy Name Policy Number Policy Period Amount Due Balance Automobile 988012472 101 1 11/21/12 to 11/21/13 $129.34 $189.01 Prior Service Charge Due �5.00 $5.00 Service Charge This Month $5.00 $5.00 Total $139.34 $199.01 Please read important information on reverse side. Please datach and mail the lower�ortio�of this bifl with.yaur payment in the enclased e�vel��e to TRAVELERS,PO BOX 660307,DALLAS,TX 7526&0307. Thank you. - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Make checks payable to:Travelers/ndemnity and affiliaies 8t8 " 003620103277 F3116C26 ?949 09/d3/13 OHE656 GUNN-MOWERY LLC TAMARA KING AMOUNT ENCLOSED Billing Account No. 988012472 Please do not staple your UNPAID BALANCE payment to this stub. $199.01 TRAVELERS PERSONAL INSURANCE MINIMUM AMOUNT OUE PO BOX 660307 $139.34 DALLAS, TX 75266-0307 DUE DATE Il�i�l��il�nilihl�l�l��,rl�lii�ll�rl�rlr�l�i�lli��l��nl�) SEPTEMBER 21, 2013 0039383830313234373240393939399300001393400�0199D120 F!-QR'i7 . �F � � e _n�� . �..,- .�� <��.- �� _ � � � � � . � t ACCOUNT NUMBER DATE DUE AMOUNT DUE � ��V�� AL g DfRECTV. 249666``'4 Due Upon Receipt $43.26 � Pay online today at directv.com/myaccount � 5ummary � 9tstamentDats: 08/26l13 Previous Balance 90.84 t'age 1 of 2for. Payments 0.04 � � i TAMARA KING Current Charges&Fees 3.60 For Ssrvice a� Adjustments&Crediis -A8.28 ' 5171 HAYMARKET WAY Taxes _y.gQ � A$K ABOUT � MECHANICSBURG,PA 17050-5236 AmountDus .� � � 2�13l�tSHl�T{CKET � Ph�e�tManet Bu�Kea f acr��ty �� € 5tart End Deacripfion Amount s r a Previous Balance 90.84 � s s � Payment OAU Fees To contact us ca!!i,800-531-5000 Q8122 Primary N Free 3.60 qdjustmsms&Credits Entertainment contfnu�frnm DIRECTV. � 0&22 49/08 TOTAL CH�ICE Partial Morrth Credit -39.89 Credit Please call us to reactivate your services � — 08/22 09/08 DIRECN Protection Plan Partiai Morrth Credit -4.79 Gredit �y �v 08f22 Primary TV 3.6Q Credit Use Your Voke to Find Whatever Sales Tax 'Z•� you want to watch on TV with the ° OUNT DUE �•� DIItF.CTV app far Android&iPhone. � important Credit/Debit Card Notice• I.e�v more at directv.com/voice = For your conveuiance,in about 15 days from the Statement Date printed near the top of this�I� -�C � !��✓?f��',�� .� paga,any total outstanding account balance posted on this bill,will be automatically f%��/ +yT �l — charged to t�e cxedit/debit card wa have on file f�r yoar accovnt. �f'/�� / 3 lTl7 �? _ Impartant Equipment Return Notice � Look for an aquipment rehsn kit to azrive in the mail within ti�e next 7 days.Tf you do not ��„ �� '=-.' receive your kit,please cail us.You must return ati leased receivers to DIRECTV within one �� , week of raceiving the return kit to avoid being charged a non-returnad equipment fee on = your next monthiy bill. We are sorry to lose you as a customer and hope to welcome you b�k someday soon. 36 � � .�. DIRECTV. DATE DUE ACCOUNT NUMBER AMOUNT DUE PAYMENT ENCLOSED Due Upon Receipt 24966654 $43.26 Q Note my change of address on reverse side. t��„60� DO NOTYMlGTE Oi}IER COMYEKiS ONTtNS fOWYI To sign up for Auto BiU Pay,Sse Reverse. Please do nat send cash.Make chedc or money order payable to: #BWNHPWR #PBDIFFFED6# AT Ot 045273 02226Ei49 A"'3DGT DIRECN TAMARA KI1VG PO BOX 11732 fi171 HAYMARKETWAY NEWARK NJ 07101-4732 MECHANICSBURG PA 17050-5236 Illi��lil�n,�l�il��,��ul�lli�.i,��u,�.,,iill,ui��ni,,, lilli��i�,n��rill�i��hhl�ili�i��l�i�i��i�ln�.niiul�l�h OOOODOOOd000D�0U024966654 6 0028 OOOOOQ00 �0004326 6 _ _____—_- ---- ____._ _ u�. �---.�_�_uu_u_�n�_�_�_�_u_�_�uu-�---�_u_�_n�_�__ �u �n n �� . .... .�. ...... ...T..T.iiG(T.::T_ OOD241330219700000D�D00009838014 � Pennsylvania American Water �� ;, - 24- 1330 9 PO Box 371412 Pittsburgh, Pa. 15250-7412 AMOUNT DUE �98�38 �or Service To: 6171 Haymarket Way LT 12 DUE DATE AUg ��J, 2013 AMOUNT PAID ��Ili��i".�.�I�il�ll��ni,�lil,i.��i��fi��lli�r�nhllillli��l 023867 1 AV 0.357 3861-2386UOD3861 080 1 NCEQZB TAMARA J KING , � 6171 HAYMARKET WAY LOT 12 pENNSYLVANIA AMERICAN WATER MECHANICSBURG PA 17050-5236 PO 80X 371412 PITTSBURGH, PA. 15250-7412 Ih�i�lilln�nll��ii�l,�inln�l�rlr�„ut��IN��l,qn„��a� (�� Please check here lo add H20-Help to Others contribution to your monthly bil! L—I or tn fd�ange your address cr telephone nuntber.and prrnt inlormatron on reverse side. --------- ----_-�...................................................................................9-----------------y--------------------------------�__. .---............_---.. . C'ustvmer Account lnformation Bl!/in Summar Fer Service To: Tamara J King ----------Prior Balance--------------______._ 6171 Haymarket Way LT 12 Prior Water Balance $95.12 Account Number:2d-1330219-7 Payments prior to Jut 26,2013. Thanks! -53.02 Premise Number� 24-OA08365 Total prior balance,Jul 26,2013 42.10 ----------Curreni Water Charges---------- Bltltng Perlod& Mefer Informatfon Service Charge 1 s.�s Billing Date: Jul 26,2013 Water Vo/ume($,OD3101 x 4,300) 39.13 Bilting Period: Jun 21 to Jul 23(32 days) STAS PAWC Water - .08 Next reading an/about: Aug 22,2013 DS!-PAWC Charge 4.20% 2.2 2 Rate Type: Residential Total water charges,Jul 26,2013 55.02 ----------Other Gurrent Charges------___. Meter readings in current billing period: Late PaymentCharge 1.26 Meter Number N044738018 is a 5/8-inch meter. Tatal other charges,Jul 26,2013 1.2b Present-actual 513 7 00 Last-actual 509400 ---------AMOUNT DUE------------------ $9g_3� Gailons used 4300 `� l�,�2 � � __ _ _ _ — - - ___ - _ ._ � �� -�/`-��.��s�Cl Water Usage Comparisan Monthly usage in hundred gallons. � 6� ---- --- _- _. _-- _ _ _. tg ___ ___. _ . _ ____. 3 6 --_._-- . __-- --- L� �1 ��,i-�. ��2y�.�� 'l� � f 2 J A S O N D J F M A M J J 2 �I Q� � 0 u u e c o e a e a p a u u p ��Z✓ � i g p t v c n b r r y n I 3 U Messages to you from Pennsylvanla American Water � 'Any portion of the water charges which is not paid as of 8/20/13 witl be subject io a 1.5Q°o penalty. I *The due date pertains to current charges oniy.Any past due balance should be paid rmmediately. ( 'Approximately 4.57 percent, or$2.51, of State taxes are included in your current bdl. � �Fttarr;vP.�ulv � �013 the Distnbution Svstem Imorovement Charae(QSIC)increased irom 3.99%to 420%. Account Number Due Date Amount Due 79 900Q 863001202d 06 9/12/13 5173.39 veri�on �� . ' ' ` Account Information ; ��'�� S�t date: 8/19/13 _ �'�'��a1' TAMARAKING - ��:'�'' �na�e: ry�-�so-sosa ` : �tit.�rnai►itUf'ax�'+R+_r:i7eW 4�#aiYs ,� < �N°�'��'��'�� Account Summary Previous Balar�ce $86.7U No Payment Received $.00 , W@f1�Q111!�BWS. .. �. �.. ._�. _�.: Balance Forward S86J0 Promotions Ending This monih your disCOUnts on the toliowing items may p��g� be ending. Make changes to your account online at - Venzon.com Curreni Activity $79.99 __ _ _ _ 24 Mo.FiOS Digital Voice Discouni Taxes,Governmental Surcharyes and Fees $2,81 24—Monih Cornract Discount Verizon SurcMar es and Other Cha • g rgea&Credits $3.89 S8V@ Witll VBfIZOt1 ToW New Charges due by S�tembar 12,2D13 586.89 Did you krww you couid be eligible for savirgs wilh Vetizon services?Call us at 1-888-230-4805 today Amount Due 5173.39 to review�rour accoimt. N;20/mo.More+3100 BACK Paying$79.99/mo.tor FiOS 15/5 Mbps Imernef& Home Phone?Add fiOS 111 Prime HD tor$20/mo. more with a 2—yr.agml.&gel a$100 VisaC�prepaid card.Call 1-888-267-9116.Limited time otter. Availability vades.Taxes,tees,terms,RSN Fee and equipment charges apply. Questions about your bill or servics? Want AtttomatiC Payltlent? View your bills in detail at verizon.com or call 7-8�0—VERIZON(t-800-837-4966). Enroll below or at Verizon.com to authorize your financial When asked for your accowit number,please er�er 8630012024.Cuslomers wiih ir�sliiution to deduct the amou�of your montt�y bill from disabilities call 1-800-974-6006 TTY. the accoum associated wilh your enclosed check and send paymem di�ectly to Verizon.To discontirnie Automatic Paymerrt,call Verizon.Please keep a copy of this auttarization. � Please return remH slip with payment. To enroll in Automatic Payment(Sign and date belo ) Accoum Number: 79 9000 8630012024 Ofi � ,�3 New Charges Due: Sep 12,2013 ■ � Amount Due: St 73.39 ❑81913 By signing aDOVe 1 ve�ily tliat I have reviewetl and Make chedc payablfl to VefiIDn accepted me twms and andi9ons at � �a�.a a verizon.com/autapayterms torauto�5c biN peyment _ �Q�'�3qR 00040388 01 AV 0.360 VY081911 0184 XX TAMARA KING MCHNCS RG PAE tw 5d-5236 Illell�i�l�I�I�d��il�llf��l��l'�1�1n�11�1�1'll�l'll�'�IIII �II��P�I�lihd��d�ll��4�l�lll�y�q�y��i��iu��,��i po�B�o°c"s2oo4, DALLAS TX 75392-0041 ?9 9000 8630012D24 06N0�000008670 OD000017339 D5 I Phone Number Accouttt Number Date Due Page veri�n 717-7�-6088 79 9000 8630012024 06 9/12/13 2 of 3 Curren#Adivity Current Charpes 8/73 9/78 Double Play 79.99 Bundle Price includes: •FiOS Digitai Voice Unlimited 3Q.00 +FiOS Internei 15/5 59.99 •24 Mo.FiOS Digital Vo�ce DiscouM ihru Sep 7,2013 —5.00 ($5.00 oft Voice) •24—Momh Contract Discount thru Sep 7,2013 —5.00 {$5.00 ott IMemet) Current Charpes Sutrtotai t79.99 _ Current Activity Total 579.99 Taaces,Governmentai Surcharges and Fees PA State and Local Sales Tax 1.73 Telecommunicatior�.s Relay Service .OS E911 1.00 _. _ Total Taxes,Governmentai Surcharges and Fees 52.81 Verizon Surcharges and Ofher Charges&Credi4s PA Gioss Receipts Tax Surcharye 1.44 Federai Universal Servi;.e fee 2.45 _ ._ ___ _ _ Totai Yerizon surc�arges and Othar Charges& Credits �3.89 Lagal Notices Payment by CMdc Paying by chedc authorizes chedc processing w use of tha chedc information for a aie—tlme elecVonic hmd Vanster from your account For all payments usin�bank accamt information,we may re[ain[he infamation to send you electronic refunds or enanle your futwe electronic payments to us(io op[out,cali i-888-500-5358) tste Pay�rrcnt Chrpes To avoid a iate payment charge of 1.594 or$5.00,whidiev�is greater,on unpaid balances over$20 payment must be received befae Sep 20,2013. Gorrespondana Go ta verizon.comlcontactus or mail to PO Box 33078,Si.PetersDurg,FL 33733 Service Roviders Venzon PA prwides regional,local Calluig and related teatures,other voice services, and FiOS N service,u�less otharwise indic�ted.Verizon Laig Distanca prowdes long dist�nce catlu�g and other services ident�fied by"4LD"in the appticable bilied Iinn item.Usrizon Online provides Inte��et service,HMC service and FiOS N equipment. FiOS Is a registerad mark of Verizai Trademark Services LLC. Bankruptcy Mformation if you are or were in bankruptcy,this statemen!may include amowits ior pre—benkruptcy service.You shouid not pay pre—tankr�tcy am�wnts;they are for your inFwmation only.Mait bankruptc,r—relateC corresponde�ice te 500 Technoloyy Drive,Sude 550.Weldon Spring,MO 63304. VY0813110403880002 RC RF RG JH RM ' Or fax the documentation to 484-634-3484 and indicate "Attention: Lost Payments." We will credit your account upon receipt of the required documentation. We must receive this proof of payment within 15 days or we will consider your balance to be correct. We have attached a statement of account for your review. Your balance of$325.14 will become past due on September 6, 2013. If you cannot pay the bill in full, please contact us to discuss payment options. You can mail payments to PPL Electric Utilities, Two North Ninth Street, Cash Processing ��nter-G�NN1, Allentown, PA i8101 or�ake thern to a bi�l paym�nt center. Sincerely, PPL Electric Utilities Enclosure (Statement of Account) UR Lost Payment �',c;r, � Questions?Please � Visit us online at ��na� �� Page 1 `°' ° � contact us by Sep 4. pplelectric.com �� s'�::. 1-800-DIAL-PPL . � . - r. • . � s , (1-800-342-5775) 28593-05027 Sep 4,2013 ` Pr�ei��u�+��s M-F:8am to 5pm ',��5.3� ' Your Electric Usa e Profile Billing Summary (Billing details on back) 5ervice to: Batance as of Aug 14,2013 $gq_�p TAMARA 5LIKE Charges: 6171 HAYMARKET WAY Tota) PPL Electric Utilities Charges MECHANICSBURG, PA 17050 $231.14 Meter:31253859 Total Charges $325.14 unt DNe BY S�R '�,2023 $3�S.I8 This section helps you understand your year-tayear Account Batance elect�ic use by month. Meter readings are actuai uniess $325.14 otherwise noted. PPL Electric Utilities'price to compare for your rate is$0.08227 per kWh. �2p12 �20�3 This changes the ist of Mar,Jun,Sept,and Dec.Visit papowerswitch.com sa or www.oca.state.pa.us for suppiier offers. 3 4� Your Message Center � 3fi • 8udget Settlement Summary after 12 months: n" 27 We bilied you $1,456.96 a Incfuding this bill,you used $1,456.96 m is > a 9 ° • We have added$0.00 to this biil to settie your Budget = � F M A nn � J A s o N D B�«��8 Plan. � nnonins • With paperless biiling,you can receive and pay your g PPL Electric Utiiities bills o�line.The process is free, • . , quick,convenient and secure.To learn more or sign up, _ � visit ppleledric.com. Aug 2013 , 25 715 28 75F Aug 2012 31 1164 38 76F _ ' ' Payment Methods = Aug 10 Actual 90801 Online at. '— Jul 15 Actual `� Q BY phone:1-800-34Z-5775 = gppgs ppletectric.com or call BiIlMatrix{service fee applies) � 26 Days kWh Bilied 715 at 1-800-672-Z413 to pay using Visa, = MasterCard, Discover or debtt card. � ' � � . � By Mail: Correspondence should be sent to: i Sep 2012-Aug 2013 10638 887 2 North 9th Street Customer Services � Sep 2011-Aug 2012 10085 �PC-GENN1 827 Hausman Road — 840 Allentown, PA 18101-1175 Atlentown, PA 18104-9392 � Other important information on the back of this bill-� ;�,� ° �_ � Return this part in the envelope � pp� a �: provided with a check payable � � � ' � ' ' . � - to PP�E�ectric Uti�ities. 285g3-05027 Sep 4, 2013 $325.14 PPt-E{eCh1C lhttftiga .co�t.� /.�G'��'2/.Z� ��.� AV 01 007744 969258 28 A•}SDGT � Amount Enclosed: 1��l��tl�'�I'll'�11�t1�11��1�1��'��II�1�'I�J��11�� ❑� � � � rannaRa su � KE � � ❑❑ 6171 HAYMARKET WAY PPL ELECTRIC U7ILITIES MECHAN►CSBURG,PA 1705Q-5236 2 NORTH 9TH STREET CPC-GENN1 ALLENTOWN, PA 18101-1175 rll�•rl�li�li�.�.��.ii�l�lni��l�uni��.�..i�.irli�l�lu��rl 1 780U0�325148��0325142 2859305�27 BIIGII D8t8tIS - (Bilt AcCt.2$593-0502n Page 2 Your Su lier Contact Information 9 $�� Far questtans regarding the generation and�transmission previous Balance $9�� portions of this bi��,p�ea5e corrtact Your suppiier at: ealance as of Aug 14,2013 ppL E�ergyPlus,LLC PA Phane: � Custamer Services � 1-800-281-2000 Charges for-PPL EnergyPlus LLC PA P.O. BOX 25225 Generation&Transmission C�arges tEHIGH VALLEY, PA 18002 General Service Rate:EPLUS for 1ul 15-Aug 10 67 93 715 kWh � $0.09500[k�Nh GRO55 RECEIPTS TAX$4.26 _____---- $b7,93 Totai PPL EnergyPius, LLC PA Charges Mana e Your Account Charges for-PPL Electric Utilities Residential Rate: RS for Jul 15-Aug 10 Visit pplelectric.com for self-service options Q;�ribution Charge: 14.17 inciuding: Customer Charge 21.91 -View your bill,payment,and usage history. 715 kWh at 3.06400000C per kWh p.lfi -Make a payment,set up a payment agreement. System improvement Chg at 0.43000000'�6 _0.03 -Start/stop service. PA Tax Ad�Surcharge at-0.0730000096 _------- $36.21 -Enroli in paperless bitling,automatic bill pay, T�a�ppL Electric Utilities Charges $p,pp budget billing. Budget Pian as of Last Bill -Report an outage,check outage status,and more. View your rate schedule at ppleiecVic.com/rates or Other Charges for PPL Eledric Utilities 125.82 catt 1-800-342-5775 to request a copy Budget Bill Settlement � 1� _ Late Payment Charge - General Information Totai of Other Charges $12�.00 Generation prices and charges are set by the eiectric �ouett Du+�By 5ep 4,� ��+�# generation supp�ier you have chosen. The Public - $325.14 Utility Commission regulates distribution rates and Account Balance services. The Federal Energy Regulatory Commission regulates transmission prices and services. PPL Electric Utilities uses about$0.23 of this bill to pay state taxes and about$11.75 is used to pay the PA Gross Receipts Tax. Understandin Your Biil Budget Bilting-Plan that provides for equal monthly tate Payment Charge-Charge added if you do not pay your bill on time. payments. Custome�Sharge-Monthty bg sequipment,ma ntenan�e andf �ate Tax Adjustment SurchargeV Cha�e or credit on electric costs for b�I�ng,meter readin , rates to reflect changes in var�ous state�axes included in your advanced meteri�g when in use. bili. The surcharge may vary bY bi�� component. Distribution Charge-Charge for the use_of local wires, TY e s)of Meter Readin�s: transformers,substations and other equipment used to deliver ��ual-Reading by dis�ribut+on company. electricity to end-use consumers from the high voitage „;. transmiss�on lines. �_�=� System Improvement Charge -A char e used.to recoyer costs o�derpo p oG depsafenreJi abiepand e��lenbse��n eacilities m kWh(Kilowatt-hour)-The basic unit of electric energy for which most customer are charged. The amount of electricity u5u8tly chargdore�ecg�t icitY��ce�Pe�ki{owatt houers are �231_14 CD01 35A Rust Lane Boerne, TX 78006-8202 ' _._.___. Do not send a ments or correspondence to the address above. MERCANTILE �I�I�I �� III� lnravatlreSdution;Ercepttona/Results Toll Free#: 1-877-254-0957 �. °; _ _ ::. , . _ . �- �.� ��: 219531541827 October 31, 2013 ��rw 61711715 Secure online payment can be made at: � � www.mercantilewebpymt.com Pass Phrase: 78828 Make Check Payabie to: 1 AB 'A-01-8D7-AM-15779-62 ��I1��11��11�i1�11��11��16��11�lll�l�llill'�"�I�i� yI11��I111��I1��1�I��iJ��1�1'll�l'I�IIII��1��1�� TAMARA J KING EST MERCANTILE ADJUSTMENT BUREAU, LLC 6171 HAYMARKET WAY � PO BOX 9054 MEGHAI�ICS URG PA 17050-5236 WILLIAMSVILLE NY 14231-9054 !i�/�: i.� .�!�� PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT October 31, 2013 TAMARA J KING EST ACCOUNT NO: 219531541827 6171 HAYMARKET WAY REFERENCE NO: 61711715 MECHANICSBURG PA 17050-5236 SERVICE ADDRESS: 6171 HAYMARKET WAY CURRENT CREDITOR: UGI UTILITIES BALANCE: a18.96 Mercantile Adjustment Bureau, LLC has received authorization from UGI UTILITIES, to initiate coliection efforts to recover the total amount due as noted above. It is important for you to know that we are available to work with you on behalf of our client to help you satisfy the debt in a manner that is fair and equitable to all parties. Our account representatives are ready to assist you with making the arrangements necessary to resolve this matter. You may contact us at the toll free number below. MERCANTILE ADJUSTMENT BUREAU, LLC PH: 1-877-254-Q957 OFFICE HOURS: MON-THURS 8 AM -9 PM, FRI 8 AM -5 PM EST Please send payments or correspondence to MERCANTILE ADJUSTMENT BUREAU, ILC, PO BOX 9054, WILLIAMSVILLE NY 14231-9054. Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt o�any portion thereof, this office will assume this debt is valid. If you notify this office in writing within 30 days from receiving this notice that you dispute the validity of this debt or any portion thereof, this o�ce will obtain verification of the debt or obtain a capy of a judgment and mail you a copy of such judgment or verification. If you request of this o�c� in writing within 30 days after receiving this notice this office will provide you with the name and address of the original creditor, if different from the current creditor. This communication is from a debt collector. This is an attempt to collect a debt and any information obtained will be used for that purpose. Calls to or from this company may be monitored or recorded for quality assurance purposes. THIS COMMUNICATION IS FROM A DEBT COLLECTOR.THIS IS AN ATTEMPT TO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. CDP�FD 35A Rust Lane Boerne, TX 78006-8202 � ; Do not send a ments or correspondence to the address above. MERCANTILE �I�I�I � I II� ,.._ ,. mroovam�e sdurr«u�'�epnono�aesuns Toll Free#: 1-877-254-0957 �v�`� �`�=` 219531541827 November 14, 2013 -�t�i�.� �.= 61711715 Secure oniine payment can be made at: www.mercantilewebpymt.com Pass Phrase: 78828 1 MB "A-01-JBC-AM-00591-6 I�nlh��l��i��li�lnllllmhi�ili�i�lrll�ll�i"Ill�rin�li� TAMARA J KING EST 6171 HAYMARKET WAY � MECHANICSBURG PA 17050-5236 November 14, 2013 ACCOUNT NO: 219531541827 TAMARA J KING EST REFERENCE NO: 61711715 6171 HAYMARKET WAY MECHANICSBURG PA 17050-5236 CURRENT CREDITOR: UGI UTILITIES BALANCE: $0.00 MERCANTILE ADJUSTMENT BUREAU, LLC is in receipt of your$18.96 payment for the above mentioned account. Upon clearance of your payment, your responsibility for the above referenced account will be considered fulfiiled. MERCANTILE ADJUSTMENT BUREAU, LLC PH: 1-877-254-0957 OFFICE HOURS: MON -THURS 8 AM -9 PM, FRI 8 AM -5 PM EST Please send payments or conespondence to MERCANTILE ADJUSTMENT BUREAU, LLC, PO BOX 9054, WILLIAMSVILLE NY 14231-9054. Calls to or from this company may be monitored or recorded for qualiry assurance purposes. THIS COMMUNICATION IS FROM A DEBT COLLECTOR.THIS IS AN ATTEMPT TO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. ,.�,� �_.7,�..�,Q.,��. . ��,�,� ��.: ,��. ��:.�.� - STATEMENT OF ACCOUNT (1) CAMP HILL EMERGENCY PHYSICIANS Statement Date: September 22,2073 PO BOX 13693 ACCOUNT NUMBER: HYP4568588Q PHILADELPHIA, PA 19101-3693 Pffiient Name:TAMARA J KING Tax ID#: 2(1-4667340 Account Balance: $320.57 Amount Pending Insurance: $0.00 �I�Illliil��li�il��iilil��ili�l��u�i�li��ll�ihl��i�i��u�l�� APate�t(Cu ent). $320.57 082516-0�00�456b588�-Q6 AmountDueFrom ° ; #BWNJFDB Patient(Past Due): $o.00 � �` #OOOOOOHYP7788080# Pay This Arrwunt: S320.s7 TAMARA J KING 6171 HAYMARKET WAY PIEASE REMIT PAYMENT BY"PAYMENT MECHANICSBURG PA 17050-5236 DUE BY"DATE.THANK YOU. Please reter to coupon below for payment iostructions. Pay your bili securely online anytime at www.MyMedicalPayments.com Date # Description Charge Paid By Paid By Paid By Amou�t Due From PATIENT Frst Ins. Other I�s. Patient Adjusted Insurance BALANCE 07/15/13 'I 82950 CARDIOPULMONARY RESUSCITATION 5847.00 DX255.41 DR.TEPPI6fHOLY SPIRIT HOSPfTAL �1&13 BLUE SHIELD CONTRACTUAL ALLOWANCE 5-84721 08/1&13 BLUE SHtELD CLAIM DENIED-DEDUCTiBLE -80.00 5199.79 07/15t13 2 31500 EN[X�TR?.CHE9LJNTUB9TiON 3890,0(l _ _ DX.255 47 DR.TEPPIG/HOLY SPIRIT HOSPITAL 09/1&13 BLUE SH�ELD CONTRACTUAL ALIOWANCE 5-78922 09f16l13 BLUE SHIELD CLAIM DENIED-DEDUCTIBLE -S0. 3120.78 TOTALS. $1,737.00 50.00 50.00 50.00 -St,418.43 80.00 5320.57 Important Messages: This sta[ement is for the dired treatment andlor supervision of cam you recenHy raceived from an Emergency Physician at Holy Spirit Haspital.The fees for this private physician are billed separatdy hom any hospiCal charges or other professional fees for which you may also be responsible. Therefore,should you rcceive a bill from the hospdal or other physicians for charges in connecLOn with this visit,it will rrot indude tlu items listed on this sqterrunt. "Payment Plans"Accepted Questions about this statement?/Liame de Lunes a Viernes? Call 1-800-355-2470 Monday through Friday 8:30AM -4:OOPM. Your automated system access code is 0801�5685880, or you can send email to billing_questions�iemcare.com. s,3aa-o�-,s,es �� Please detach and return bottom portion with your remittance. �� ------------------------ -------------------- TAMARA J KING ��,?.q✓�'.e�t� STATEMENT OF ACCOUNT 6171 HAYMARKET WAY Statement Date: September 22,2013 MECHANICSBURG PA 17050-5236 ACCOUNT NUMBER: HYP45685880 YOU MAY PAY THIS BILL WITH YOUR CREDIT CARD PatieM Name:TAMARA J KING PLEASE SEE REVERSE SIDE. Payment Due By: 10t13113 Make ChecklMoney O�der payable to: Amount Due: SS20.57 ��f��/ ?��„ AmouM Enclosed: .�.�� .s� �� ` Go Green-pay online at CAMP HILL EMERGENCY PHYSICIANS `^^"'"•MyMedicalPayments.can The insurance infamatlon in our file appears bebw.Please make any cortecdons PO BOX 13693 andlor addifions on Me reversa side of this form and retum it ro us.Thank yrou. PHILADELPHIA, PA 19101-3693 CAPOS CAPITAL BLUE CROSS L��III�6��IIIL��II��II�JL�I�I��JI�IJ��II��I�LI KPReolasaaasoo 23oas [] If your address has changed, check ihis box. and complete the reverse side of this form 0825160000045685880�0032057000000000D001 . < �,:.: .��.��n��. . . ��.. �..,�.�,,� _ � �.� �.� .. _ • • • . � • • • �nsurance: L�pTHER �^;MEDICAID ,��,M�,p1CARE ��_ NeW pddress: ComPa"y Narr'e: �---�� qddress ti� pddress'�' --�' Zip: pddress 2: Address 2� Z�P' State: gtate: City_ Express C1t`l� ,--�,American ��- TelePhOne' ,�^;Nlascercard Te1ephone: ❑Visa Ct'QC��C'BK�S' pLLGAR�s AS IT APPFARS ON CAR�` � e; NAME Nolder Nam r SPQVSE ��CHILD � BEqg ONLY Plan ,'�SE�F NUM '�� t;�n of Pat+ent: � 1 ,.J- � v�cn�nnASTERCARD M�...�>.n pela -- y` , ` �3_p;yn Nomber from sack o�v=sar U_�—� pOLICY#: ,,��ns-�' ONLY ----`y" AMERIGAN EXP�E�NUMBEP GRpUP ,pddltiona�,4•Ort9�oan E press� #: WEST SHORE EMS - ALS — :---- 205 GRANDVIEW AVE STE 211 � D1xJ� ' CAMP HILL, PA 17011-1708 � '---- WEST SHORE EMS Phone#: (800) 367-0512 Federal Tax ID: 23-2463002 ON REVERSE SIDE �Na v seixm t�nLrH sr�M PAnErvr►�anne: TAMARA KING �� 77��l� ' iNSURaNCe: CAPITAL BLUE CROSS DEC ��, Z NONE CALL NUMBER: 'I$'I�7H9A DATE OF CALL: ��5/2013 FROM: 6171 HAYMARKET WAY TO: HOLY SPIRIT HOSPITAL TAMARA KING ACCOUNT SUMMARY 6171 HAYMARKET WAY TOTAL CNARGES: 1146.35 MECHANICSBURG, PA 17050 PAYMENTS/AD,IUSTMENTS: 0.00 PLEASE PAY THiS AMOUNT: 1146.35 ._,.. DETACH ALONG PERFORAT/ON AND RETt/RN STUB WITH PAYMENT pESC�anON 4F CHARGE AUANTITY UNR PRICE AMOt1N'f SYRINGE(10CC/ 12CC} A0394 1.0 0.32 0.32 Total Charges 1146.35 DESCRiPT10N OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Totai Credits 0.00 PLEASE PAY THIS AMOUNT-INVOICE DUE UPON RECEIPT —► �1146.35 RETURNED CHECK FEE-$31.00 PATIENT NAME: KING,TAMARA J ce��NuMe�: 1311789A AMOUNT PAiD: 10/25/2013 IMPORTANT MESSAGES: WEST SHORE EMS-ALS 205 GRANDVIEW AVE STE 211 CAMP HILL, PA 17011-1708 Make Checks Payable to:WSEMS ❑VISA ❑MASTERCARD ❑DISCOVER 205 Grandview Ave Suite 211 Carci Number: Camp Hill, PA 17011-1708 C�/�/p�* Exp.Date: Zip Code: • Signature: Please caii Customer Service at 1-800-367-0512 or 717-763-2108 to add or make corrections to your insurance information, or to make arrangements for Telephone Number: Amount Paid: a payment plan. To pay online,the address is 'The CW2 No. is required to process your payment. It is the last https:/lwww.wsems.org/online-payments 3 digits on the back of your credit card, by your signature. . , . _ . _: � . �. . WEST SHORE EMS - ALS � ia`scovEJ ' 205 GRANDVIEW AVE STE 211 � � '____ CAMP HILL, PA 17011-1708 ON REVERSE SIDE WEST SH�RE EMS Phone#: (800) 367-0512 Federal Tax ID: 23-2463002 �f IL)LY SPIRCT HEAL7N SYSTEAI PATIENT NAME: TAMARA KING INSURANCE: CAPfTAL BLUE CROSS CBC INS1 CALL NUMBER: 1311789A DATE OF CALL: 07/15/2013 FROM: 6171 HAYMARKET WAY TO: HOLY SPIRIT HOSPITAL ACCOUNT SUMMARY TAMARA KING 8i71 HAYMARKETWAY TOTALCHARGES: MECHANICSBURG, PA 17050 PAYMENTS/AD.)USTMENTS: PLEASE PAY THIS AMOUNT: 1146.35 _ DETACH ALONG PERFOR.4TION AND RETURN STUB W/TN PAYMENT DESCRIPTION OF CHAR(3E QUANTITY UNIT PRiCE AMOUNT ALS EMERGENCY LEVEL 2 S0207 1.0 1043.55 1043.55 20GTT TUBING A0394 1.0 14.72 14.72 ANGIOCATH(14-24) A0394 2.0 6.72 13.44 EKG EIECTRODES(1) A0398 4.0 0.80 3.20 EPI 1 MG 1:10000 PFS A0394 1.0 8.16 8.16 ET TUBE HOIDER A0422 1.0 11.40 11.40 ETCO2(ADULT)FILTERLINE SET A0422 1.0 36.00 36.00 GAUZE PADS A0382 1.0 0.20 0.20 INF CONTROL GLOVES(PR) A0382 2.0 1.00 2.00 NSS 0.9% 1000cc Bag A0394 1.0 3.48 3.48 OP SITE A0394 1.0 1.92 1.92 STYLET A0422 1.0 7,gg 7.96 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE ,qMpV� PLEASE PAY THIS AMOUNT-INVOICE DUE UPON RECEIPT -► RETURNED CHECK FEE-$31.00 Continued on Ne�Page PATIENT NAME: KING,TAMARA J C+��NUMBER: 1311789A AMOUNT PAID: 08/15/2013 IMPC3RTANT MESSAGES: THIS CLAIM HAS BEEN SUBMITTED TO CAPITAL BLUE CROSS ON YOUR BEHALF. WE ARE NOT A PARTICIPATING PROVIDER AND THE CHECK WILL BE SENT DIRECTLY TO YOU. PLEASE FORWARD THE CHECK TO OUR OFFICE UPON RF('.FIPT. WEST SHORE EMS-AL5 205 GRANDVIEW AVE STE 211 CAMP HILL, PA 17011-1708 - WEST SHORE EMS - ALS � ',o�_�=� 205 GRANDVIEW AVE STE 211 ---- CAMP HILL, PA 17011-1708 ON REVERSE SIDE WEST SHORE EMS Phone#: (800) 367-0512 Federal Tax ID: 23-2463002 �HOIY SPIRIT HEAI.TH SYSfEM PATIENT NAME: TAMARA KING INSURANCE: CAPITAL BLUE CROSS � CBC INS1 ca�.�NuMSER: 1311789A DATE OF CALL: 07/15/2013 FROM: 6171 HAYMARKET WAY Ta� HOLY SPIRIT HOSPITAL ACCOUNT SUMMARY TAMARA KING 6171 HAYMARKET WAY TOTAL CHARGES: 1146.35 MECHANICSBURG, PA 17050 PAYMENTS/ADJUSTMENTS: 0.00 PLEASE PAY THIS AMOUNT: 1148.35 _ DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT _ DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT SYRINGE(10CC/12CC) A0394 1.0 0.32 0.32 Total Charges 1146.35 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Total Credits 4.00 PLEASE PAY THIS AMOUNT-INVOICE DUE UPON RECEIPT �► $1146.35 RETURNED CHECK FEE-$31.00 PATIENT NAME: KING,TAMARA J CALL NUMBER: 1311789A AMOUNT PAID: 08/15/2013 lMPORTANT MESSAGES: THIS CLAIM HAS BEEN SUBMITTED TO CAPITAL BLUE CROSS ON YOUR BEHALF. WE ARE NOT A PARTICIPATING PROVIDER AND THE CHECK WILL BE SENT DIRECTLY TO YOU. PLEASE FORWARD THE CHECK TO OUR OFFICE LlPAN RFf:FIPT WEST SHORE EMS-ALS 205 GRANDVIEW AVE STE 211 CAMP HILL, PA 17011-1T08 Piease Remit Paytnent To: � �, Silver Spring Ambulance & Rescue Assn Billing Office 13-202485 9/15/2013 $958.50 PO Box 726 New Cumberland, PA 17070-0726 QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-41l4 Fax: 717-214-6020 Email: info@ambulancebillingoffice.com Please visit our website to provide insurance or make payment, and Date of Service: 7/15/2013 20:41 for additional payment options and frequentiy asked questions: Patient Name: KING,TAMARA J. From: RESIDENCE www.ambulancebillingoffice.com To: Holy Spirit Hospital • � . . **Please read-this bill is your responsibility. **We have no insurance information on frle for you. Please provide your insurance information on the back o,f this bill or remit payment. Thank you. c; �fi :^a's � � ',-�r `^2- y.^��.�+.+ '4 �`� -.ssK�„{.- `� ��a.a..-....�.,r'^��`3,x.�.�,y�.+a.:.gf- ,��"�"'.,` �-5�+�"��'`c^� y i. . . . r;;� .�.:� „� ,.°��x�'�_ .. ',7;-. _ � e.�>, '4r�"�s , :.ae. .��e�+'t-.*�€�"�+'�:v ,�,r,+u�'""�`�'�'=�?-,�*'.,�'L,,ai��'.�"_��y � ft�,�«s. . :��"., 7/15/13 BLS Emergency Transport A0429 1.0 700.00 700.00 7/15/13 Mileage A0425 13.9 15.00 208.50 7/15/13 �xygen A0422 1.0 50.00 50.00 Total 958.50 OAO 0.00 �'�� '/�',�'� �'�� 's�'sr DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT. � We auep[payme�f in fvll by cfieck,*Credk card or el�ttronic Ptease!�lake Check Payabfe To: check deduttfon. Wease Indicate your paymenY choice below . and fifl in required information. If ather arrangements are Silver Spring Ambutance 8 necessary,ptease call us at 87`7-214-6018. Rescue Assn � � � ��. 13-202485 $ 95$.SO Credit Card: ❑MASTERCARD O VISA ❑AMERICAN EXPRESS Q DISCOVER Amount Paid: Please make any corrections to address below. _ _ __. _ _ _ __ _ _ Electronic Check Deduction ; � Please send a voided check OR provide information below: +` '� TAMARA J. KING 6171 HAYMARKET WAY - - MECHANICSBURG, PA 17050 *Returned checks-You will be responsible for atl incurred bank fees permissible under state law. � . . . � We have received the explanation of benefits (lj'�j from your insurance company(s) and have VLl applied whatever payments and/or adjustments are appropriate. Please make payment for the balance due of$75.00 OR take advantage of a T'!u Spir�Po/'Car�g 15% prompt payment discount and remit$63.75 on or before 09/14/2013. 45685880 Here are 3 convenient ways to pay: TAMARA J KING 1. Make payment online at www.hsh.org. 8171 HAYMARKET WAY 2. Mail tear-aff coupon below with payment MECHANICSBURG PA 17050-5236 in the enclosed envelope. 3. Call Customer Service below to make payment by phone. ' • . Patient Name: King ,Tamara J Previous Balance: S,00 Statement Date: 08/15/13 Total New Charges: S6,099.20 Service Date(s): 07/15/13 Payments/Adjustments: 56,024.20- Account Balance: 575.00 Account Number: 45685880 Please Pay This Amount: s75.00 t}R Medical Record Number: 438230 d,scpunted Amc�unt of�63.7� if paid or� ar before Q8l14/2013 . . * Please call Customer Senrice at 717-763-2138 Ins. 1: BLUE CROSS 36 to add or make co►rections to your insurance Ins. 2: information, or to make arrangements for a Ins. 3: payment plan. !f you are unable to make Ins. 4: payment, please contact the Patient Financial Advocate's Office at (71�763-2885 to discuss wfinancial assistance options. � � Please Note: Your physrcians wrll bill separate/y for professional services. Make Checks Payable To: HOty Spirit HOSpit81 Amaunt Number. �►muunt vue: ��Y ��y � 45685880 75.00 456858$0 J,.��/�� r.u��e x�: $63.75 � TAMARA J KING !f�;�id � 09>3�;�c7fi� 0�-Y ❑ � ❑ Q � � ❑ 503 N 218T STREET 3 ; CAMP HII�.PA 17011 cu,a N`�f✓,� ,,, CW2 No:� �.na� r�.`sw�u,�ca,�.. ..1, ADDRESS SERVICE RE�u ESTED Signaturc= AmountPaid: .�t�" �',��P3 3� �� , �- ❑ CMCk bmc if your addrass or insunrxe iniormatinn � � hn clnn�ad. P�erso make changes on wck. 'The CW2 No.is required to proc:ess your payment, ft is the I�t 3 digils on ihe back of your cradit card,bY Your sigmature. For Ameoc catd holders,it is the-0-digit number on the front of your card,above the car+i number. �0008932 �01 0.53 45685$80 11��1�1�11�'lllil'��1��1��1'llilnll��un�hllll�lr�ll��l TAMARA J KING HOLY SPIRIT HOSPITAL 6171 HAYMARKET WAY P.O. BOX 822183 MECHANICSBURG PA 17050-5236 PHILADELPHIA,PA 19182-2t83 DOOU456858800[110�L1000075��00100735��U�000113t1�0�01125�U�0006375091420139 _. _ .� a��.�,��.� ��r_�.m.�.�-�-.��,�� . ._ _ _ _ . � . '"(, Account Number : 45685880 ,��L� Previous Balance: �.00 �"j")TT Total New Charges: S6,099.20 u�i 1 Payments/Adjustments: 56,024.20- H O S P [ T a t Account Balance: 575.00 The Spirit of Cure»g Please Pay This Amount: $75,00 OR Discounted Amount of$63.75 if paid on or before 09/14/2013 . - . . Trans. Date Descriation Amount dl/15/13 NACL 0.9 1000 I52.50 07/15/13 IS CHLORIDE 23.00 O7/15l13 IS B�1N 23.00 U7/15/13 IS CREATININE 23.OU 07/15l13 IS VENOUS TCO2 23.00 07/15f13 IS BNP 303.00 O7/15/13 ISTAT GLUC 23.00 07/15/13 ISTAT IONI2ED CA 66.00 O7/15/13 ISTAT HCT 16.00 07l15/13 ISTAT SODIUM 23.00 07/15/13 ISTAT POTASSIUM 23.00 07/15/13 I STAT SOURCE .00 07/15/13 I STAT SOURCE .00 07/15/13 INTUBATION ASSIST 364.00 Q7/15/13 CRITICAL CARE 30-74 MIN 1,940.00 O7/15/13 CRITICAL CARE 75-104 MIN 972.00 OT115/13 INTUBATION-EMER-ENDOTREACHEAL 458.00 07/15/13 CARDIOPULMONARY RESUSCITATION 1,258.00 07/16/13 3 PORT PUMP SET 57.40 �7/16/13 EPI INJ PER O.1M6(PFS 1MG) 100.80 07/16/13 MA6 SULF INJ/500MGC1G VIAL) 35.00 07/16/13 SOD BICARB 8.4%SY 63.00 07/16/13 DEXTROSE 50% SYR 7U.00 O7/16/13 NACL 0.9 10U0 82.50 08/14/13 BC PYMT OP BU9 BLUE CROSS 36 3,452.14- 08/14/I3 BC C/A HOSP OP B09 BLUE CROSS 36 2,572.06- r r W . rn � ri:• . ,�s� � __. ,.. _ .: . .. _.. i ;i,.;;- .... .,. � ,._. _ - . . � . ��' _ _ ,... � :; <.; , ,, ; �..ct?c4:-:. `3�_..,_,.•:<, r,.sr:_. � l . _ . ..... .._ r .. . .... ,. .'� .. .. ._ . -._<� . . .. . . . . .. .... . . . _. . , . �`-�.. . _._. ti��7?;_ �• . . .: t• , . � , . , , .. _ . . .��.:, a ..i�..�_.. al.i-.'� : ��;�; �-'{.:� :`. _' `; � . .. . ..... ..._ . � .f.�. . ... tt3 . .�. ��_ . ., -i : .: ':.: ..:. .�., . ; ..�.'- �... ':. , .-.� ..� tyi.;. _ !4, .. . � �:.,. _ ,. . Phillips 8� Cohen Associates, Ltd. I II'II II I�'I II"'�II'I I'I'�IIII'II'II�'II)�IIJI'I��'(I'I I'II Ph 866-654-5605 • Fx 302-368-0970 PO Box 5790 � Office Hours: M-Th: 8am-9pm, Fri: 8am-6pm Hauppauge,NY 11788-0164 Saf: 8am-12pm RETURN SERVICE REQUESTED September 20,2013 Philiips&Cohen Associates, Ltd. Mail Stop:833 1004 Justison Street 19469184-112 138829662 Wiimington, DE 19801-5148 ,i��1�111i1i��i„��i��iin��i��i��iin�i��ii�i�ll�ilfl� I��,��,I�t�,��„u��,,,,��,�„��„��„�,��,�„� The Estate of: TAMARA KING 6171 Haymarket Way Mechanicsburg PA 17050-5236 Reference#: 19469184 Balance:$8512fi _...._...................._..........................._.............................._.............................._................................................................_..._.........._.......__..................._.......__...._...................................._...................._........._................_........... *"PLEASE DETACH AND RETURN IN THE ENCLOSED ENVELOPE WITH YOUR PAYMENT*" Re: Client: Citibank, N.A. ��,��1:� .C��*`�� '��`"�"�� Product: SEARS GOLD MASTERCARD ` �� ,� � -� Client Acct#: �"""*"*'"'1207 ,('_„�',,��,i"-Yl-C/� �' !,,/��} �`�.�:��?!�r'`�� Reference#: 19469184 Balance: $851.26 To the Estate of TAMARA KING: Our client Citibank, N.A. recently received notification that TAMARA KING passed away. Initially,on behalf of our client and our office,piease accept our condolences. This account was referred to our office because we are specialists in the area of deceased account care,and because TAMARA K(NG was a valued account holder. Please remember that oniy the estate is liable for payment of this debt. Payments from survivors or next of kin witl be accepted only on a voluntary basis. At this time,we are seeki�g information regarding the Estate of TAMARA KING, including information about who is handling the final affairs if there is not an estate so that we may ensure the proper handling of the account resolution. Please contact our office at 866-654-5fi05 to provide information about the estate,and to work with our Deceased Care Agents on an account resolution. Please make payments payable to Citi. Sincerely, Phillips&Cohen Associates, Ltd. Though our goal is to assist family members/loved ones du�ing this difficult time,we are required by law to provide you with the information below: **IMPORTAN7 CONSUMER INFORMATION** Unless you notify this office within thirty(30)days after receiving this notice that you dispute the validity of this debt or any portion thereof,this office will assume this debt is valid. If you notify this office in writing within thirty(30)days from receiving this notice,this office will: obtain verification of the debt or obtain a copy of a judgment and mail you a copy of such verification or judgment. If you request this office in writing within thirty(30j days of receiving this notice,this office will provide you with the name and address of the original creditor, if different from the current creditor. This communication is from a debt collector. This is an attempt to collect a debt and any information obtained will be used for that purpose. Phillips&Cohen Associates, Ltd. . 1004 Justison Street.Wilmington, DE 19801 .866-654-5605 iCSPCAL03112 ��$C�VER Discover More Card Account number ending in 8251 Open Date:Ju) 14,2013-Close Date:Aug 13,2013 Cardmember Since 2009 Page 1 of 4 ACCOUNT SUMMARY PAYMENT INFORMATION , Previous Balance $636.50 New Balance $793.�rJ _ - . . ___----- ___--_---- - --------------- ; Payme�ts and Credits - 50.00 Minimum Payment Due' $70.00 Purchases + $156.55 payment Due Date September 8,2013 Balance Transfers + $0.00 ��ncludes past due amount of: �35.00 Cash Advances + $0.00 Fees Chorged + �0•� late Payment Warning:If we do not receive yo�r minimum payment by the Interest Charged + $0.00 date listed above,you may have to pay a late fee of up to$35.00 and your New Balance $793.05 purchase ond balance transfer APRs for new transactions may be increased up to the Penalty APR of 29.99%variable. See Interest Charge Colcutation section following the Minimum Payment Warning:If you make only the minimum payment each _Transactions sedion for detailed APR information __ period,you will pay more in interest and it will take you longer to pay off your Credit Line S6,2C0 balance.For example: = Credit Line Avaifoble $0 IFyi�u makerxic�ditiofrpf charges Y4xrw�N.payoi�the a�dyo�v�'��up�1 . using thts cp►d`and esx�ttn4nih :, }solonce;sh�n�ri't�tt��, ps�n�g� � — Cash Advance Credit Line $1,600 ' f: ��i�q�};n= �,,4 �r��-$ � — Y'�,paY K . , � �.:.. ..x� . .: �...., ... ,:. , .,.,.. , .>..,:.....r,,. Cash Advance Credit line Available $0 Onl the minimum a ment 22 months 5793 = You may be able to avoid interest on Purchases. If you would like information about credit counseling services,call 1-80J-347-1121. — See reverse for details. = REWARDS = Contact Us Discover.com Cpshbock Bonus� Anniversary Month 1-800-347-2683 February Opening Balance $ 62.70 — New Cashback Bonus This Period = 5%Cashback Bonus + $ t.90 = Everywhere Else + $ t.18 — Redeemed This Period -$ O.Od — __- --- - --- - ------------_.. ---- — Cashback Bonus Balance $ 65.78 = To learn more,log in ot Discover.com Make Check poyable to Discover. NOTICE:SEE REVERSE SIDE FOR IMPORTANT INFORMATION Please fold on the perforation below,detach and return with your poyment. Pdyment .C,oupon � R Ray Online Pay by:Phone '� mber ending in s25t Account nu �Plenseslanotfold,clip,orstaple �.Discover.com Q 1=800�347-26$a -- - _- --_ _._ _ ____. _ ____ _-_. • • _ . Minimum Paymeni Due $70.00 �/ � � ---- --- --- �'-7 �,� New Balance a793.05 ti�lill��l�iiil�i��l�i��lllllll��i��ll��iil��l��l�llll � -- - - _ __- --_ ___- - 000302287 O1 AV 0.357 TO 13 SDS1RA13 1113 �-�4'�' �'s"� �� Payment Dve Dafe $eptember 8,2013 TAMARAJ KING °•• ___ _---.____ __-- --- -- - -- 6171 HAYMARKET WAY � Amount enclosed 3 �"�� MECHANICSBURG PA 17050-5236 PO BOX 71 d84 CHARLOTTE NC 28272-1084 (iil�llll��n��ili�i�lli�il�in�l�l��l�l�l��iiii��i�inliull��l Phona and Internef payments must be received by 5PM ET to be credited as of the same day. Address,e-mail or felephone ehanged?Note changes on reverse side. 0�00019866236Q9750802007930500881010007�00 TAMARA 1 KING Account number ending in 8251 Open Date:Jul 14,2013-Close Date:Aug 13,2013 Page 2 of 4 Important Information You must ensure that sufficient funds are availa6le in your bank account,and al)transactions must comply with U.S. law. See your CardmemberAgreemeni.Your Cardmember Agreement cuntains oll Ihe terms of your Account. You can set automatic payments for: (i)statement New Balance,(ii)stafement Minimum Payment Due,(iii)statement Minimum Payment Due plus a fixed Losi or stolen cnrds.Report immediately! Call 1-800-347-2683. dollar amounf,or(iv)Other dollor amount. If your scheduled"Other dollar What To Do If You Think You Find A Mistake On Your Staiemenf pmount"payment is not enough to cover the Minimum Paymenf Due as listed If you Ihink ihere is an error on yow�statement,write to us at: Discover,PO on your monthly billing statement,your scheduled poymeni for thot month Box 30421,Salt Lake City, UT 84130-0421. You must write to us within 60 Will be increased to cover the Minimum Paymenf Due. If the scheduled days nfter the error appeared on your statement. You may call us,but if you pQYment is greater than the Minimum Payment Due,any excess will be do we are not required to investigate any potential errors,and you may have aPp��ed in accordonce wilh your Cardmember Agreeme�t.If your scheduled to pay the amount in queslion. The Billing Rights Notice furiher explains your Payment is greaier than the New Balonce on your billing statement,that ri�lits. Please see your Cardmember Agreement or visit poyment will be processed only for the amount of your New Balonce.Your https;;/discover.com/billingrights for a copy ot this notice. autanatic payment amount may be(ess than the amount indimted on the billing statement based on cred�ts or payments after the Close Date. Payments.You moy pny all or pait of your Account balanc�at any time. If you enroll by phone in our automatic paymeni service,please fill-in the However,you musi�ay ai least the Min�mum Payment Due ythe Paymenf followin blanks below and retain the auihorization for o Due Date. Send only your payment and ihe bottom poition ot this stalement 9 y ur reca�ds. in the envelope proyided.Uo not send cash. If you pay by 4heck,you Amount: Full Pa Min Pa authorize us to use�nformation on your check to make an electrornc fund Y y Min Pay+ $ tru�,sfer from your account at the financial institution indicated on your check Other Amount$ ; Bank Routin #: ar to process tlie pa ment as a check tr nsaction.If a payment is processed g _ as nn eleclronic fund�transfer,the trans�er will be for the amount of the Bank Account# check.When we use informahon(rom your check to make an electronic fund trunsfer,funds may be withdrawn from your account as soon as the same Monihfy on the Paymenf Due Date Close Date day we receive your�oyment,and you will not receive your check back from your financial instituhon. _Day of month(insert datej fhe processiny of your payment inay be delayed�f you send cusl�, Credit Reporfing.We may report intormation about your Accouni to credit correspondence or other items with your payment,if you send the payment to bureaus.Late payments,missed payments,or other defaults on your Account any other uddress or if you use an envelope other than the one provided. may be reflected in your credit reporf.We normally report the slatus and Payinents received in proper form at our processing facility by 5PM local time ; on ony day will be credited to your Account as of that da .Payments received payment history of your Account to credit reporting ngencies each month.If D ou believe that our report is inaccurate or incomplete,please write us ai ihe at our processing facility aHer 5PM local time will be cre ited to your Account �ollowing oddress:Discover,PO Box 15316,Wilmington,DE 19850-531 b. N os of the next day. If you have misploced your envelope,send your payment Please include your nnme,address,home telephone number and Accounf a to Discover,PO Box 6103,Carol Stream,IL 60197•6103.Please allow 7-10 number. o days for delivery. I{your payment is retumed unpaid,we reserve the rigM to N resubmit it as on electronic debit. Payments made online or by phone will be paying Interest.Your due date is at leasi 25 doys after the close of each °v° aedited as of the day of receipt if made by 5 PM Eastern time. billing period(at least 23 days for billing periods that begin in Februaryj.We ° You can pay your monthly Minimum Payment Due,or a greater amount that W�II not tharge you ony interest on Purchases if you pay your entire balance f does not exceed your current Account balance,over the telephone or you can by the due date each month.We will begin charging interest on Cash setup aulomatic payments ihrouc�h o cusfomer service re�resentafive by Advances and Balance Transfers as of the later of the Transaction Dote or the calling 1-800-347-2683.Automatic payments for fhe billing period shown first day of the billing period in which fhe transadion posted to your Account. on your statement will be deducted on the Payment Due Date shown on that stutemenf,or the next automatic payment daie refen�ed to on your statement, How We Calculate Inferest Charges.We Use ihe Daily Balance Method unless you request o recurring payment date(e.g.,the 15"'day of the month) (including cun ent transactions)to calculate ihe Balance Subject to Interest Yhat occurs before your Payment Due Date or Close Date. If your scheduled Rate. For more information,please call us at 1-800-347-2683. payment date falls on a weekend or bank holiday,your payment will be galance Sub'ett to Interest Rate. Your stotement shows a Bplance Sub' processed the business day prior to the weekend or bank holiday. In order to � �ect schedule monthly paymenls by telephone,you witl need this sfatement and to Interest Rote. It shows this for each iransaction category. The Balance yuui bank account information.You will be asked to p�ovide the last four(4) Subject to Interest Rate is the average of the daily balances during the billing diyits ot ihe social security number of ihe primary borrower. By providing Period. tl iose numbers as your eledraiic signature,you will be.agreeing to this authorization to ullow us and your bank to deduct each payment you Credit ialunces, If your Account has o credit bolanc�,the amount is shown authorize,in the amount selected by you,from your bank account.You also on the froni of your billing statement. A credit balance is money that is awed authorize us to initiafe debii or credit enhies to your bank account,as to you. You may make charges agoinst this amount if your Account is open. applicuble,to corred un en or in the processing of such payment.You can We will send you a refund of any remaining balance of$1.00 or more ofter cancel a sclieduled payment by phone at 1-800-347-2683 or by mail at 6 months,or as otherwise required by applicable law,or upon request made Uiscover,PO Box 30421,Salf lake Ciiy,UT 84130-0421;however,we must to the address in the Contact Us sedion on page 3 at your billing statement. receive nolice at ledsi three business days in advance of the scheduled Discover may monitor and/or record telephone calls belween you and payment. If your payments may vary in amount,we wili lelf you on each Discaver representa!+ves for quality r�ssurance purposes. in'I�r�,hly billing statement when your payment will be made and how nwch it The Discover3�card is issued by Discover Bank,Member FDIC. TL23N CHANGE QF ADDRESS If correci on front, do not use.Please print clearly in blue or black ink,in the space provided. Street Address�— -- —— Home Phone � � ---- ------------ - — _ Work Phone --- ------- -- -----� �__ ' � I---- -- City L._ --- � Email Siate,Zip ( l.,__ — � To inake changes to your address, emai� or telephone number, visit Discover.com �__.:_.._a____._____ ��SC�VER Discover More Card Account number ending in 8251 Opcn Datc:Jul 14,2013 -Closc Datc:Aug 13,2013 Page 3 of 4 CONTACT US ______ _ _ _- -- _ _ -- __ __ _ - -_ _ , _ __ �. Web Mobile Phone Inquiry Mail Payments ! ' � Access your � Manage your Q 1-800-DISCOVER � Discover @ Discover ' acco�n t s ec u r e ly a c c o u n t a nyt i m e, (1-800-347-2683) PO Box 30943 PO Box 6103 ` � at Discover.com anywhere at TOD 1-80Q-347-7d49 Salt Lake City Carol Stream � � m.Discover.com UT 84130 IL 60197-6103 Transactions Trans.Dcte Post Date Merchandise Jul 12 Jul 14 WINE&SPIRITS 2106 MECHANICSBURGPA $ 21•18 Jul 14 Jul 14 TLF WESLEY BERRY FLOWERS COMMERCE MI 71•48 Restauronts Jul 12 Jul 14 PIZZA HUT#23011 MECHANICSBURGPA $ 25.97 Gosoline Jul 12 Ju! 14 SUNOCO HARRISBURG PA $ 37.92 — Fees TOTAI FEES FOR THIS PERIOD $ 0.00 — Interesl Charged TOTAL INTEREST FOR THIS PERIOD $ 0.00 — 2013 Totats Year-to-Date TOTAL FEES CHARGED IN 2013 $ 70.00 TOTAL INTEREST CHARGED IN 2013 S 85.49 � Interest Charge Calculation — Your Annual Percentage Rate(APR)is the annual i�terest rate on your occount. Current Billing Period:31 days — ANNUAL PERCENTAGE RATE BALANCE SUBJECT TO — TYPE OF BALANCE (APR) INTEREST RATE INTEREST CHARGE — Purchases 29.99% V 50.00 $0.00 Cash Advances 23.99% $0.00 $0.00 V=Voriable Rate — Informotion For You For more information about how interest charges ore calculated see your Cardmember Agreement or go to www.discover.com/inierestcharges NOTICE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION YAM/1RA 1 KING Account number-ending in 8251 Open Date:Jul 14,2013-Close Date:Aug 13,2013 Poge 4 of 4 N D w N N a W O N N � V O N DISC�YER �.�� :��ti�!'J J� Account number ending in 8251 PO Box 3008 September 24, 2013 New Albany, OH 43054-3008 Dear Tamara J King, This letter is to confirm your authorization received over the phone on September 19, 2013 for the `: intended post-dated payment to your DiscoverOO Card from your bank account, using the information listed below: Payment Amount: $727.24 Date Poyment Presented to Your Bank: September 24, 2013 Bank Account Number Ending In: 7387 No other action is required on your parf to make this poyment. Please call us at 1-800-347-3113 between the hours of Monday through Friday 8:00 am to 11:00 pm, and Saturday 8:00 am to 12:30 pm EST for any questions or concerns you may have regarding this — account. — Sincerely, = Nathan Sperry = Cardmember Assistance, Discover Card = 1-800-347-3113 = Monday through Friday 8:00 am to 11:00 pm, and Saturday 8:00 am to 12:30 pm EST — This is an attempt to collect a debt and ony information obtained may be used for that purpose. = Discover.com Discover Carcl,issuad by I�iscover Bank,member FDlC CON 100186 Page 1 of 1 - . .. . . . .. . _ PO Box 3008 New Albany, OH 43054-3008 Account number ending in 8251 Current Balance $727.27 Amount Now Due $39.22 �'��II�II��1��11��11�11�'�I��1�1��1111��'I�I��I��II --_-------_— _ ----- ----� _ :_ -_-' Amount enclosed LF11RA01 043493 � Tamara J King 6171 Haymarket Way Mechanicsburg, PA 17050-5236 PO Box 6103 Carol Stream IL 60197-6103 It�ill��ll�llll�(I�IUilii��lll�llnlu�lll'1�1'��I��I'�l�'�I� 000001986623609750802DD727270000QOODU03922 _ _ . , . �r ��r .,._. r T � N U OD O A W A �O � O CUSTOMER #: 5809908 Gr�ham 162265 Motor Company, Inc. *INVOI CE* 1402 Holly Pike BRANDON SLIKE 6171 HAYMARKET WAY Carlisle,Pennsylvania 17015 Tel. (717)243-3066 • (800)992-4743 • Fax(717)249-7998 MECHANICSBURG, PA 17 Q 5 0-52 3 6 PAGE 1 Web Site: http://www.grahammotors.com HOME: 717—5 8 0—9 9 0 8 CONT: 717—5 8 0—9 9 0 8 E-mail: service�grahammotors.com BUS: CELL:717-580-9908 SERVICE ADVISOR: 112 KAREN MCBETH CQLQR YEAR ' NFAKEIMODEI VIN': UCENSE/'REG.# ', MILEA�E!N/OUT TAG G��-' 04 SATURN ION 1G8AJ52F74Z188074 FTA0804 81808 81808 074 < QEL. D3#7E 'PROD. DATE WARR. E3(#'. PROM{S�D PQ N0. : R�iTE Pi0.YMENT IN1J.;DATE 25DEC04 I ` 25DEC04 D 16 : 30 03DEC13 44 0 . 00 CASH 03DEC13 R.O:.OPENED R�A#3Y ' OPTIONS: DLR•GRAHAM ENG:2 . 2 Liter 14 :29 03DEC13 15 : 16 03DEC13 LINE OPCODE TECH TYPE HOURS LIST NET TOTAL A' ON S�'ART IT V�1TLL START AND<SHUT; RIGIiT t}FF J :SECUR. ITY i,IGH'I'. CQMES `ON DASH. I25 CHECK !�'OR CODE�. CODE B2'360 & �3D33. >PI�.S��OCK SENSOR FAULTY. NEEDS PASSLOCK SENSOR. $2 2 5:0 0 FLUS T�1X _ : ->: _ ,_ 177 CCM 57. 09 57 , p9 PARTu� .: ' 0. 00 LABCIR: , 57. 09 OTHER»,.�,aa. O. Q:� T(JTAI�'! LINE A; : ` 57. 09 *********************�****�:�'**,**,******************** z _ �? : �� '� r- :.,�'�ry,� i ,� c� �' �, � _ __ . .. .. . y,,+� •x. �y�r9 . . . �. . _ . . �.� � �fi'. .. } . . . �'� .. � .. _ � . � k . �� .: . . .. .. ?Y� rt ..�. ;,, :; � . . ' . � �.t . - _. .. . . +✓. -�. � � . . CiRRFlfifl 11010R C(HYfWY �5` .. . . . . . . 196[ HOI.LV F!h:E �aet[u�. Na irdi> `,�:y"` � ; �.� � ,�„�„�.,, s .:�:��f s 1lercha+,t IU: 689tl f�:,��!� r � krt a: �al, .J ,� rr� ; ��. S�le k .� - ;� XY,?�J(�1�CX4�2 � DISC �ntrY(�tMu,d; �+l�d -' ; , � ;; Total: '� � �!.5"t _ _ � _ 12f0.;�13 15�1'=`� _ I�V�� lOLGW 1�l�I'L�, �'�� i0R1ES ARE SOLD AND ALL REPAIRS ARE f3ES�I�fF�ION TOTAiLS 9SHIP HEREBY EXPHESSIY DISCLAIMS ALL C�q '�n�q�p�� ING ANY IMPLIED WARRANTIES OF Thank Tran�tion ID� JI��JJ'tIO�QOJ �R PURPOSE, AND NEITHER ASSUMES NOR YOU LABOR AMOUNT 57. O9 L�, ,}�, T ANV L1ABI�ITY IN CONNECTION WtTH THE PARTS AMOUNT O . O O �� (�,� B�tCI1�� t1GUj�l THE ONLY WARRANTIES ON PAfiTS AND f0� VII�1� :OFFERED BV THE MANUFACTURER OR THE GAS,OIL,LUBE O . O O �NUFACTURER OR DISTRIBUTOR SHALL BE Your S.CUSTOMER SHAIL NOT BE ENTITLED TO � SUBLET AMOUNT O. O O �1!� '� � TIAL DAMAGES, DAMAGES TO PROPERTY, BUSI118SS. .'�-:lL`�'�.fu "" �'` OP PROFIT OR INCOME, OR ANY OTHER MISC.CHARGES ` � . �� were notified of and authorized the ALL PARTS ARE NEW TOTAL CHARGES 5 7. �9 C�sts��r C„c•, �d in this Invoice and that you received UNIESS OTHERWI$E' LESS INSURANCE 0 . �� parts as requested by you.The vehicle INDICATED. �mant of the Amount Due. SALES TAX 3 .4 3 � 7kWNii YOU! AUTHORIZED DEALERSHIP REPRESENTATIVE SIGNATURE PLEASE PAY - THIS AMOUNT : CQ .52 UE'SI@ICAP 02006 ADP(03/091 SERVICE INVO�CE TYPE 2-2S�2C-'ASIS'-PENNSYLVANIA��QLj�OL'iGR COPY �.U�1" 0104414222 Uniform Residential Loan Application This application is designed to be completed by the applicant(s) with the Lender's assistance. Applicants If this is an application for joint credit, Borrower and should complete this form as "Borrower" or"Co-Borrower," as applicable. Co-Borrower information must Co-Borrower each agree that we intend to apply for also be provided(and the appropriate box checked)when �the income or assets of a person other joint credit(sign below): than the Borrower (including the BoROwer's spouse) will be used as a basis for loan qualification or 0 the income or assets of the Borrower's spouse or other person who has community properly rights pursuant to state law will not be used as a basis for loan qualification, but his or her liabilities must be Borrower considered because the spouse or other person has community property rights pursuant to applicable law and 8orrower resides in a community properly state, the security property is located in a community property state, or the Borrower is relying on other property located in a community property state as a basis for repayment of the loan. co-sorrower A�enc�Case..Number.'..'.•. .'.'...�Lender..Case,.N,.�'�,, Mort.,a,•e„, 9 Y umber...'..,. 9 9 •�.�,VA�„��Conventional..��.......Other(explain): . Applied for: Q FHA �USDA/Rural Housin Service 0104414222 Amount Interest Rate No.of Months. Amortization Fixed Raie Other(explain): $ 118,000.00 5.000 % 360 TYPe� 0 GPM �ARM(type): �� 20-30 YR PT}� l�T— ::?:::::::<'<ir::�:.,:,.>.,.:.�::::::,..,,;;..:;�::.:...;.:::.;�.:::......:.::.�.....::,:.:;.,.>:..,;:::::.;�.::.:::::..<:.<:::;:�:::;��>��::::::>::::;::::::::>::>::>::;:::��:�;::::::<:::::::;::::::::::.::»:::?:::::::::::::::::>:::€�::>::::::;;::>:;::::>:::::::;:>::::::<:: :<:::::::::;::::>::<::<::::::>::>:<::<:::;:<:::.:::::»::::»:<:>::>:t:>::::>:;::::;::::<::::::::::::>:>:::::<:::>::: .�� .�.� . � ................................. ........................ :;:::<:>:::>::>::::<::::::::::»:<::<:::::::::::<:::;::::::::::::>:::::<:>::>::>:::::::;:::<:>::::.:>::>:::»»:::< . . .��.�� .. . . ......................................!�...�........�..�.�►.�..:.��.�.............��QS�:�E�.:4,��►...:�:::.::::::::::.:�:.::::::.::�:»>:«.>:<:.::.::.::.>:«<:.::.>:.;»>:.:>:<.>:.>:.>:.>:::.:.:::.>:.>:::: Subject Property Address (street,city,state a ziP) No.of Units 6171 HAYN�T I�,Y, NIDCHANI�G, PA 17050 1 Legal Descripiion of Subject Property(attach description if necessary) �� yy�pg,N � Year Built 2001 Purpose of Loan purchase Construction Other(explain): Property will be: Primary Secondary �Refinance 0 Construction-Permanent �Residence 0 Residence � Investment Complete this line if construction or construction-permanent loan. Year Lot I Original Cost I Amount Existing Liens I(a)Present Value of Lot I(b)Cost of Improvements I Total(a+b) Acquired $ $ $ $ $ Complete this Ilne if thts is a refinance loan. Year Original Cost Amount Existing Liens Purpose of Refinance Describe Acquired improvemenis �made �to be made � � 2 $ 139000.00 113927.71 Cost:$ Title will be held in what Name(s) � ,7 IQ�� Manner in which Title will be held ��D�'i'Y Estate will be held in: �Fee Simple Source of Down Payment,Settlement Charges,and/or Subordinate Financing(explain) �Leasehold �shaw expiretlon date) F.�[7I'!'Y CA�7 SI�.7P'�GT PRf�PEFZ7.'Y <::'s::>::::s:::>:»::::>::>::::>::s;::::>:>:>s!::::::::::::::>::»::>::s::::>::»ss:i:>:....::.�::.:;•,.::.:>•.::.::.::.;;:.;:.::.;:.;:.;:.>:.o-:.:::::.:>:;:...»:...:........:.....:......::..:...:..: :::.:....:::;;:.;>:.>;»::<,:;>;;:::.>:.>;:.;::..::::...:.�::::;::.::.>•:::::::::::::.:::;::,::::::::.:;>:.:::::::::::::::::::::.:�:. S f,�!! �,1 �y ;:::.>:.:�i• ,. . .��r.c�::�r:irr:i:;:Y:i::i<::::i::::::R?�; 'S: :�;•.r � . :t.:tt.;:.::<.:t<::.»::.>::::.>:.:::::.:::.;:.;»>:.>:<.:::•::;.>:,;::.:... �! �V ...............................��.�.' '��::� ..� � � '.: �. .::::::::::'<::::::::::::::::::::::::;:::i <�:::�ie::i$i::i:>:::::;:;;::::::::Si$:::::(.:::::;:i:::`,:;'<'<:5:'<f::S:::::t:2:::: . . ..47l.'.� ��7X.............................�i�.17��.'#:��.....................................:...;�:::::::::::::::. Borrower's Name(include Jr.or Sr.if applicable) Co-Borrower's Name(include Jr.or Sr.if applicable) TAN�FtA J KII� Social Security Number Home Phone(incl.area code) DOB Yrs. Social Security Number Home Phone(incl.area code) DOB vrs. 206-50-7016 717/790-6088 �m 11��%195 16 0l (mmlddlyyyy) schoo� Married �Unmartied(include single, Dependents�not Ilsted by Co-6orrower) Q Married �Unmarried(include aingle, Dependents(not Iisted by Borrower) divarced,widawed) �O• a9 $ divorced,widowed) no. agms ❑Se arated 00 ❑Se arated Present Address (street,city,state,ZiP) Own Rent 07/03 No.Yrs. Present Address (street,city,state,ZIP) Own Rent No.Yrs. 6171 HA�T i�,Y , N�,TTICS&�G, PA 17050 Mailing Address,if different from Present Address Mailing Address,if different from Present Address � If residin at resent address for less than two ears com lete the followin : Former Address (street,ciry,state,ZiP) �Own ❑Rent No.Yrs. Fortner Address (street,city,state,ziP) �Own Rent No.Yrs. r . •:::<::::::::::::::::.�::::::..;•::::::::::.:�;;:::::::.�:::.:�::.::::::::::::::::::::::.�::::::::::::::::.:�:::..:.::.........,,.;.:.:..:..........:..:......:..:.:.:.:......:•:::::<:f:i:i::5ri:::i:i�;:;�::5�;::;::,;..:.::::::::.::::::.�::::::::::.:�::::::::::::.�::::::::::::::.�:::::::::::::: .;, � ". E:;i:i:::i:::i:si::i:i::3E�E::l::2E:E:i:E::E;::::::::>i:itE<:E:::::!t:i2:::E:i::>i:fz:r::Fii:;E3''E�' '..':�:::i:£i8i;ii?::iEE;Efi:EE;Efi:iEE::::iii::ii:#�'!: � .:�C}��::EiE�{��.. ..`:: �. .2::::::::<::»::::r>o-t:;,.::,<::.:..�xiy.E'�64f'M'�.'.':>:?:i:::::;E:i:s::ii:d%:;i:>i:i:::::i:E:a:::E:6::i:::::;6:;i::E::::��i::>::iti>i::i ..................................................... ... .CI Q1fUl�'........ . . . �' . . ............. . . Cf1RUl�#'................'.......................................... Name&Address of Employer Self Employed Yrs.on this job Name&Address of Employer seif empioyed Yrs.on this job SEL57CT MEDICAL 02/03 2501 �fi THIRD STR Yrs.employed in this line , 000000000 Yrs.employed in this line of worklprofession of worklprofession HAI�iSe(�ZG , PA 171100000 02/02 POSltioll/Title/Type of Business eusiness Phone(inci.area code) Posltlon/Tltle/Type of Business Business Phone(Incl.area cade) CA,SE N�C�R 717/243-4102 If em lo ed in current osition for less than two ears or if currentl em lo ed In more than one osition com lete the followin : Name&Address of Employer �Self Employed Dates(from-to) Name&Address of Employer a Self Employed Dates(from-to) 0000 - _ Monthly Income Monthly Income Position/Title/Type of Business eusiness Phone(incl.area code) Position/Title/Type of Business Business Phone(incl,area code) Name&Address of Employer �Self Employed Dates(from-to) Name&Address of Employer �Self Employed Dates(from-to) Monthly Income Monthly Income $ Positlon/TitlelType of Business eusiness Phone(incl.area code) Position/Tltle/Type of Business Business Phone(incl.area code) Freddie Mac Form 85 7/05 Fannia Mae Form 1003 7/05 ��21N �oeo�� NMFL#1003(APP1,APP2)Rev 11/10/2007 Paga 1 of 4 Initials: VMP Mortgage Solutions,Inc.(800)521-7291 � �� . �.,.�..,�... �..��-�- ---��.��.�,.��,�.�,�,,.�. �-;�� -�R., , _ �,_�, ::::<:.:�::.:::.;�.::.:.;:.::.>::.::.;�.;:.:�::.;:<.>:.;:.;:::::::.::<.;:.;;:.>:.::.:::.;::t.:��..>:y.,:�..,N...:.:...u...:::.:......::...:..:.:....::..::...::::...:..:.:..::..:.....::.:::.:..::.:.........,:..:.........:.:.:...:..:;.....:..::..:.:.....::�::.;;:;.;;:.:;:.;:.;:;.>:.;:::.>:.::::.>:.>;:.::.:>:�:::.>�:.>:.:��.:>::.>::.;::.;:.:;�.;:::. > ��.N'1'�:.:y: .:. +?�. :.•� �.�•.�.»E:>:::sr:::<:::'i:zE:::r::::::::«<:::»::>:s:s::::z:>k:>s:c>!:»>:<s:::a::>�:Ea::i:> :�;:::':;?::`:i:it:>:::;fi;:i::::i::::::�>�:i:::::i;%:::::::::::::::::::;:::?;:i::i:::i::i<::::::::::::Yo•.iY1.1i.�'.... 77 . . .�i.'. . ::s . .y..:, . ..�................ . .. .. ..i«..IN. !G�M�».�k�C�.��Nt�:ll��#�:::l��U�1�M..��.::��4�:��...k91:��#�M�..1....�:...:.::..:.:..:.:.:::::.:::::::::::::::::::::::.�::::::::::::::.:::: Groas Monthly Income Bonowar Co-Borrower Total ombineEMenshly Prassnt Propoeed Base Empl.Income" 5280.00 g 5280.00 ent g Overtime irst Mortgage(P&I) 509.00 $ 633.45 Bonuses ther Financing(P&I) 959.00 Commissions azard Insurance 25.17 Dividends/Interest eal Estate Taxes 138.00 138.50 Net Rental Income ortgage Insurance other(berore comPietin9, omeowner Assn.Dues see the notice in•describe 7.00 7.91 other income^beiow ther: .00 5280.00 5280.00 1114.00 805.03 "Self Employed Borrowsr(s)may be required to provfde additional documenWtion such as tax returns and Tinanclal statemenb. Uascribe Other Income Notice: Alimony,chtld eupport,or separote maintsnance Incoma need not ba revealed if the Borrower(B) B/C or Co-Borrower(C)does not chooae fo have(t conaidered for repaying this loan. M011th1y AR10UIlt Y�r::S:S»:f::::::>:::5::i::::�i:::5:::::::::::5ri>:::i:::rrrfi:5i;::5::::5r::5::i:::::5:::i:�:>i:::i::5:::>r:S:;�>::f:::?2::::::SS:::5::,:::;,:...y....:..:............::... .::.:...:...:...............:::::.�.:::::::::::::.�::::::::::::::::::::::::::.::�:::::::.:�.�::::::.::.:::::::::.�::::::::::.::.:::::::::::::. •:S::s.•'s:•. :"��::. .Q::i��lpi�t�� 'iiii::::ii:di::::iiiii:i:ii:i:3ii?<i3i:i:iii:ii�:i:�i:i:::':i:::::::::i:5::;::::::::z::::i:::::::t:�;;»:::Si:'ri:i:'::i:i;::i>:::::::;:ii;:i�;:�::::'ri:::i'r::#::::?i:i:.i:`•:�: This Statement and any applicable supporting schedules may be completed Jointly by both married and unmarried Co-Borrowers if their assets and liabilities are sufflciently joined so that the Statement can be meaningfully and fairly presented on a combined basis; otherwise, separate Statements and Schedules are required. If the Co-Borrower section was completed about a non-applicant spouse or other pereon, this Statement and supporting schedules must be completed about that spouse or other person also. Com Ieted Jointl �Not Jointl Cash or Market Lta6ilitiasand PledgsdAaaete.Lisi the creditor's name,address,and account number for all outstanding debts, ASSETS V81U8 ineluding autamobile loans,revoNing charge accounts,real estate loans,al(mony,child support,stock pledges,eic. Descri t10� Use continuation aheet,if necessary.Indicate by(') those liabilities,which will be satisfied upon sale of real estate Cash deposit towa�d purchase held by: $ owned or u on refinanc(n of the sub ect ro e . LIABILITIES Monthly Payment& Unpald Balance ths Left to Name and address of Company $PaymenUMonths $ List checkin and savin s accounts below DISo0t1EFt ETN 5VC5 LtC 24/ 33 798.00 Name and address of Bank,S&L,or Credit Union �ni1�iCHD�TIP, �if�os92no Name and address of Company $PaymenUMonths $ Acct,na. 8729.00 IO�IIS/CI9ASE 40/ S 301.00 Name and address of Bank,S&L,or Credit Union �`(��160552 Name and address of Company $PaymenUMonths $ Acct.no. � Name and address of Bank,S&L,or Credit Union Acct,no. Name and address of Company $PaymenUMonths $ Acct.no. � Name and address of Bank,S&L,or Credit Union @ _ '.[C) 8� @ QiDSIl� Acct.no. 'k = NC'ri' IN RA'!.'IOS Name and address of Company $PaymenUMonths $ Acct.no. �� 37003.00 Stocks&Bonds(Company name/number $ &description) ��b��1001056529 Name and address of Company $PaymenUMonths $ Lifa insurance net cash value g � 76924.00 Face amount:$ Subtotal Llquid Assets 8730.00 Real estate owned(enter market value $ 155000.00 from schedule of real estate owned) ��b��1000362043 Vested interest in retirement fund Name and address of Company $PaymenUMonths $ Net worth of business(es)owned $ C�]ASE AVl�D 261/ 17 4486.00 (attach financial statement) Automobiles owned(make and year) $ �`(��4��820091806 Alimony/Child SupporUSeparate Maintenance $ Payments Owed to: Other Assets(itemize) $ Job-Related Expense(child care,union dues, $ etc.) Total Monthl Pa ments 325.00 Total Assets a. 163730.00 :;.�`` •�:. :�:::;;:::::;:::#;:;;:,.,►..., 99217.00 Total Liabilities b. 119512.71 Freddie Mac Form 85 7/05 F e Mae Form 1003 7/05 Initials: ��21 N (0507) Page 2 of 4 :�� ,,.��:�-_:�. � �,�-�.�.,,�.-<��.#.-�.��,�.a�„�,�,.� :::>::::>:::::>>:><::>.�::�»><:>::::>::>:::<:»»::>::>::::>::::::::�:�:<::::>:::>::>::::»:::<:::�:::<:::;>::>::::>:<:::::�>;:::<:>:::::::>:<:::;;>::>:.:.....................................:.;...:.,,.;.....:.:.;:.:�;;::.>��;:�.:�;.:;:;;:.;:.>:�:.::.>:.;:.::;:::�:;:.>:.;::;.::;:.:::;;>:.;:.;:.;::<.:.>:«.>:..:;.::.:::::.;;::.>::.�:::.::.:�>:.;:.;:.:::.:�<:.>:.: :::::>::>:::�E�:::14��1:'�:��k#itG�'s::�° I�:.: :< ��fwl'f'l�S.. :. :: . �tt'd:>::::<:::::::�::>::::::i:>::»:<;::;:>:::�:::s::::>::::>:::>:.'rs::s>:::<:»::>::.>.::a>:::::::::::s::»;:::::»:::<:>:::>::::::s::s::sa:::r;::::<:::::> ............................ .. ... .... .... ....... ..:.....::::•:::::.:....... ......... ... . ............ ..... ........... . . . . ....:...::•.:::.:....::::.�.:.......:::••::::::•::..,-....�:•:.::::::•:•::::.::.>:�>:>:•:�:•>;•<::::.::;;.;•.;:.:: Schedule of Real Estate Owned(If additional properties are owned, use continuation sheet.) Pf0perty Address(enter S if sold,PS if pending sale Type of Preaent Amount of Mortgagea Groas Mortgage Insurance, Net oP R if�ental being h21d fo�InCOme) Propeiiy Market Value &Llens Rental Income Pa ments Maintenance, � Y Taxes&Misc. Rental Incame 6].71 HA7�T ln�aY H SF $ 155000 $ 37003 $ $ 1 $ $ 6171 F]A7�T ieIl�aY 76924 1 Totais $ 155000 $ 113927 $ $ 2 $ $ List any additional names under which credit has previously been received and indicate appropriate creditor name(s)and account number(s): Alternate Name Creditor Name Account Number �;:.>::>:.::.;:.;;:.:::.::.>:.>:.>:.;:.;::..:...:::.... . :..::::::. .:......;..,.....:..:......:�:t:::i::i:<:ii;:2i:::::>E:::::i:::::::::::::::::si:i:;�i:::is>:::;:::::::::::::i::::::;;:;i:�ii;:?<:r::i<;:!::::%:s:::E;::::::i::::::::::::.,......................;:.:....:.:...::�:::::.:•::::::::<.::�:::.::•:::::::.�:.>:.::::::::::::::::::::: �::.::..:��';?'. .':".'.'.'':: •. : :::: . .........................................:.�::.:::::::.�:.::::: a. Purchase rice If you answer"Yes"to any questions a through i, please Borrowsr co-eo►rowe� use continuation sheet for explanation. b. Alterations im rovements re airs vee No ves No c, Land if ac uired se arate a. Are there any outstanding judgments against you? � � � a d. Refinance incl.debts to be aid o 113,927.71 b. Have you been declared bankrupt within the past 7 years? � � � a c. Have you had property foreclosed upon or given title or deed in e. Estimated re aid items 1,657.76 lieu thereof in the last 7 yearsl 0 � 0 � f. Estimated closin costs 2,304.00 d. Are you a party to a lawsuit? Q � Q � . PMI MIP Fundin Fee e. Have you directly or indirectly been obligated on any loan which resulted in foreclosure, transfer of title in lieu of foreclosure, or judgment? (This would include such loans as home h. Discount if Borrower will a 1 1B0.00 mortga e loans, SBA loans, home improvement loans, educational loans, manufactured i. Total costs add items a throu h h 119 069.47 �mobile� home loans, any mortgage, financial obligation, bond, or loan guarantee. If"Yes;' provide details, including date, name, and address of Lender, � � � � . Subordinate financin FHA or VA case number,if any,and reasons for ihe action.) k. Borrower's closin costs aid b Seller f. Are you presently delinquent or in default on any Federal debt or I. Other Credits ex lain any other loan, mortgage, financial obligation, bond, or loan � P � guarantee7 If "Yes;' give details as described in the preceding � � � � question. g. Are you obligated to pay alimony,child support,or separate � � O O maintenancel h. Is any part of the down payment borrowedT � � � O i. Are you a co-maker or endorser on a note? � � Q � --------------------------------------------------------- j. Are you a U.S.citizen? � a � � k. Are you a permanent resident alien? a � � � m. Loan amount I. Do you intend to occupy the property as your primary � Q Q Q (exclude PMI,MIP,Funding Fee financed) 118,000.00 residence?If"Yes;' complete question m below. m. Have you had an ownership interest in a property in the last � � � � n. PMI MIP Fundin Fee flnanced three years? o. Loan amount add m&n 118,000.00 �� wpR)t second home(SH),dor investment propertv(�p�?esidence � p. Cash from/to BoROwer 1069.47 �2) Flow did you hold title �o the home --solely by yourself (S), S jointly with your spouse (SP),or jointly with another person (subtract j, k, I 8 o hom i) O? :i::;::i#:i33ii:i::iii#:::tii::::::>:;:#'?:::':i:i:ii::iii3>:i;;iiiii3ii#i#i#i3;i:::i:i:::i:E;E:i::�;::ii>::;i:�:�;>:�::5:::?::;i:;�i:;:E::�::i:":E::::'..;,.:t:�:��:�:r:�::i:.�:�::.;.::�..+.�.::,Y..:�...y.:�:.a..�::�.y..r..;,.�y.:��.:,i....;:.>:::::::::�:s.:::r.:,:::::::::::::.�:::::::::::.;:.;::.;;:c.;:,>:::::;.>:.>:.;:;:.;:�.;;�.>:.::.::.;:.;:.;:.>:.::.;:.;:.:;:;.;»:.;:<.;::;.:>:.:�:<.>:.;:.;:.;; . . ................................................��.:�.�rM1ti�Ai:Y4*:��Ii:4R�M7�1.k.R;:�li�l�ii�'��W'�w1Yi�i��:!i:3:i33:i:F::i:i:i:3?:;:i;�i�d::::;:5ii::3:::.::::::::;iiiiir::#::':::;::ii::::ii::i:ri;::>:>:rri�::::::i:i;::::3;i:i#�i::;:i:iii:i ...............................................................................................................................................................................................................................................�.......................................�......... Each of the undersigned specifically reprosents to Lender and to Lender's actual or potentlal egenb, brokers, processors, attomeys, i�surers, servicers, successors and assigna and agrees and acknowledges that: (1)the Infortnation provided In this appllcatlon Is true and correct as af the date aet forth opposite my signature and that any intentlonal or negligent mlarepresentatlon of this infortnation contained in this application may resuit in civil liability,including monetary damages,to any perso�who mey suffer any loss due to reliance upon any misrepresentation that I have made on this applicatlon,and/or in criminal penaltles including,but not limited to,fine or imprisonmant or both under the provisions of Title 18, United States Code,Sec.1001, ei seq.;(2)the loan requested pursuant to this application(the"Loan")will be aecured by a mortgage or deed oi trust on tha property described in this applicetion;(3)the properry will not be used for any illegel or prohibited purpose or use;(4)ell statements made fn ihis appllcatlan are made for the purpoae of obtaining a residentinl mortgage loan;(5)the property will be occupled as(ndicated in this applicatlon;(8)the Lender,its servicers,successors or assigns may retain tha ariginal and/or an etactronic record of this application,whether or not the Loan Is approved; (7)the Lender and its agents,brokers,insurers,servicers, successors,and assigns may cantinuously rely on the informatfon contained in the applicatian,and I am obligated to amend and/or supplement the infortnation provided I�this applicatian if any of the material facts that 1 have represented herein should change prior to closing of the Loan;(8) in the event that my payments on the Loan become delinquent,the Lender,its servicers,successors or assigns may, in addition to any other r(ghts and remedies that it may have relating to such delinquency,report my name and account infarmation to one or more consumer reporting agenciea;(9) ownership of the Loan and/or administration of the Laan eccount may be transferred with euch not(ce as may be required by law; (10) neither Lender nor Its agents,brokers, insurers,servicers, successors ar assigns has made any representatlon or warranty, express or implied,ta me regarding the property or the conditlon or value of the property; and(11) my transmission of this application as an"elactronic record" containing my"electronic signature" as those tertns are defined in applicable federal andlor state laws(excluding audio and video recordings),or my facsimile transmission of this application containing a facsimile of my signature,shatl be as effective,enforceable and valid as if a paper version of this application were delivered containing my original written signature. Acknowledgement.Each of the undersigned hereby acknowladges that any owner of the Loan,ita servicers,successors and assigns,may verify or reveriy any infarmation contained in this app�ication or o ain a6t ny in�rmation or data relating to the Loan,for any Iegitimate business purpose through any source,including a source named in this appilcation or a consumer reporting agency. Borrower's Signature Date Co-Borrowe�'s Signature Date X X i:�;:;':,::�:::::g::::s:g>:»i:'i;:'�:r::::E::.:'s3's:::i::>::ii<it::::»i:#�:>°s::i:::;;i3'.;::}:::'s::::'si:'s:.:y.........:..........:.:...:..:t.�..:....:....:::..:�r.y..,........:..,.....:.:........,,:.:.,,;.;.:.:...................... .......:...,....:........:.;:.;:.:::...::.::.;:.;:.:::.::.;:<::.»>:.::.::.»:.::.>::.;:.>:::.>:.:<.::.>:• k��*�.i1��'�:t�:+:y:(�'' ,.:..''.t:,��::'A�i..'��ii��.��.'�?�.:i��.'.��'.M�#�+.�:2Et:::i;i:;:::::::::t:i:::i:i:#i:i:i�:i:::;::ti::ti:ii::i::`:::;::::i;t,iii:i:i:i:::ii::::iie:i:i:i3::i::i:i:i:i#i:: ;:::;:c:5:.>:::::::::;:::;::::;:::x,.i::i:i::>;::ri::::s:2::::::::;::::::s:::2Y:;;i<Y::::::::::>�i:i:2k:5:rs5::;:'��.�::�1s1;:!'r!�lM7#11'�1.�. I:s.�n%...�Y. The following Infortnation is requested by the Fedarel Govemment for cartain rypes of loans related to a dwelling In order to monitor the lender's compiiance with equal credit opportunity, fair housing and home mortgaga discloaure laws. You are not required to fumish this information, but ara eneouraged ta do so.The lew provides that a lender may not diseriminete either on the besis of this information, or an whether you choose to fumish it. If you fumish the information, please provide both ethnlcity and race.For rece,you may check more than one deslgnation.If you do not fumish eihnicity, race,or sex,under Federal regulationa,this lender is required to note the iniortnat(on on the basis of visual observation and sumame if you have made this application in person.If you do not wieh to fumish the Infortnation, pleasacheck the box below. (Lender must revlew the above materlal to assure that the disclosures satisfy ali requirements to which the lender is subJect under applicable state law for the particular type af loan applied for.) BORROWER �I do not wish to fumish this information. CO-BORROWER��do not wish to fumish this infortnation. Ethnicity: �H;5 anic or Latino �Not His anic or Latino Ethnlcity: � His anic or Latino 0 Not His anic or Latino �American Indian or � �Black or �American indian or � �Black or RaC@: Alaska Native Asian African American Race: Alaska Native Aslan Afican American �Native Hawaiian or � �Native Hawaiian or � t cific sl de White Ot er Pacific Is a de White S@X: �Female 0 Male Se%: 0 Female �Male To be Completed by Intervtewer Interviewer's Name(print or type) Name and Address of Interviewer's Employer This appilcation was taken by: J�II� ��Z� �,'[,g ��p g�„�g�, N.A. ❑Face-to-face interview Interviewer's Signature Date �Mail 5201 �70L�'S7.C1[n�7 Rf]AD �Telephone Interviewer's Phone Number(incl,area code) D lnternet HAii[iISBik� PA 17112 �-21N (0507) Page 3 of 4 Freddle Mac Form 85 7/05 Fannle Mae Form 1003 7/05 . . . � � . ,_,�. �.�,� �,.�,} ..�,��..�»��_ �„�.��.,,�.,�� . ��- „�. �. � � . . ;::«:>::>;::>::»:;:::.>:»»:�:::::>:;:�:>::�::;:::>�;:>::;;:>�::>;:>::>::>::::<:<:>:;::::::::::::::.::::>.;:::..:...:.....:..:...:......................................:....:....:�::::<:.>::..;...:.:..;:..;.:...:.::....;..:...:.:...:.>�:::::::;;;:«:::.�.::::::::.:<::::;>:.;•::::.::�::<:::;::::::::::..::::.>:;>:::::::.: <::::>::::>:��FN��11�1�i�'CI:�A.I�:::��i��'s1Y#�� . l��:'.�I«::�:..:.:.;: :: �9 C3� Ik� .�..C>AC�1:.��':C:�!�,�i�� .':;;:::s:<::::::>::<:::>:::::>::;::::>:?::::::::::::s::::::;:::::::'•:::#>::>:::�:»#:?:::::::::::>::;::::>:.s:::::;:::>:: :�<::<:::<:::::::>:<:::«::>::>:.:>::::::::>::>:::::>:::::::::><::;:,:>�::>:>:::>::::::><::::::<>::>::::::::::::::. ... . . '.�i4��1.............. � ::..... . .....:.:......:.:. :.....::..... :..:..... ..: ... .... .. . .. ....... ...................... .............. . ............. .... .. . . .. .... ........ ..... .. ..........g .. y... .:•....:.:. ......:::::.::....:•::•:••:::>•.;;.�::.;•.;:•:•:�>• Use this continuation sheet if Borrower: A enc Case Number: you need more space to �� J HI� complete the Residential Loan Application. Mark B for Co-Borrower: Lender Case Number: Borrower or C for Co-Borrower. 0109914222 Former Address History B/C Street/ City State Zip Own/Rent Years/Months B C Previous Employment Empioyer Citv/State Dates Monthlv Income Type of Business PositionITitle Other Income B/C Description Monthly Amount B SubjectPropertyNet Cash Flow(Income) $.00 *Subtotal* InstalimentOther Monthly Paymentand Unpaid Months Left to Pay Balance / / / / / / @ = To Be Paid @ Closing * = Not Included In Ratio AdditionalLiabilities Description Monthly Amount B/C Net Rental Loss $.00 B SubjectPropertyNet Cash Flow(Loss) $.00 California applicants: Pursuant to California Civil Code 1812.300Q)a married applicant may apply for a separate account. I/We fully understand that it is a Federai crime punishable by flne or imprisonment, or both, to knowingly make any false statements concerning any of the above facts as applicable under the provisions of Title 18,United States Code,Section 1001,et seq. Borrower's Signature: Date CaBorrower's Signature: Date X X Freddie Mac Form 85 7105 �F e Mae Form 1003 7/05 -21N (0507) Page 4 of 4 � . , .�,�. �.;��,��_�,��-�r� .�..��,.�� ,,�� ,� �. ,� . 0104414222 Uniform Residential Loan Application This application is designed to be completed by the applicant(s) with the Lender's assistance. Applicants If this is an application for joint credit, Borrower and should complete this form as "Borrower" or"Co-8orrower," as applicable. Co-Borrower information must Co-Borrower each agree that we intend to apply for also be provided(and the appropriate box checked)when �the income or assets of a person other joint credit(sign below): than the Borrower (including the BoITOwer's spouse) will be used as a basis for loan qualification or 0 the income or assets of the Borrower's spouse or other person who has community properly rights pursuant to state law will not be used as a basis for loan qualification, but his or her liabilities must be Borrower considered because the spouse or other person has community property rights pursuant to applicable law and Borrower resides in a community property state, the security property is located in a community property state, or the Borrower is relying on other property located in a community properry state as a basis for repayment of the loan, co-sor.ower ..'ort",.. A'enc'�Case'•..�.. M a.,e„�,� Number....'••. 9 ..,.'��Lender..Case,.".�� ",.�.VA'•... Y Number:::;::: 9 J �.Conventional..��.......Other(explain): ' Applied for: �FHA ❑USDA/Rural Housin Service 0104414222 Amount Interest Rate No.of Months. Amortization Fixed Rate Other(expiain): $ 118,000.00 5.000 a/, 360 TYpe� Q�PM ❑ARM(iype): �++/EI�1� 20-30 YR FI� NCtQ— 5:::::::::Il`:5::,:.:;.,:::::::::....',�.;,:.;•::,:,:::::..;•.,..::,•.,...,.:::.,,.:;::.>•,.:,,•:.;..:.:;::.>•..>•::::.,i::':"':::'::,';''':",:.:::::::Y2i;iY:ii::::::::::'•:>'S:iiii:::i::::::;:i!i:;:2:::;:::;:i:i:iy:;::::::::si5iif:ii:;s::::;:5:::ss:::::::::::iY::Y:>::::::: �::;::::::;::>::;:::::::::::::::::::i:::::>�:::::::>::i;i::::::::ii2:;:::::::::::::;::iE3i:i:::i::::3::::::::::::::Si2� ::::i:::::::i�:::i:>i:i:2:i:::::::::::i:ii2::$:f::::i:::SS:.::::::::;::;:::i:::::::i::?.:t:5::::;::::::::::'t:i:::2.5 . .........................................................:.::.:..:.i��'I'.1!`.:.��f��li��lA�k;f't��:,��1�:.�1�R.p:.:.Q�:�Cf.�:. �. ::::.::::.�:::.:.::.>:.:::::.:�::>:<:::::::::::::.:�::::::.:.�:s.:::.>:<.:::.::.;;:::::.>.�::: ...........�...�.................................::::.�:::::::.�::::::::.::::::::::.:.�::::::::«.>:.>:.>:.: Subject Property Address (street,city,state a ziP) No.of Units 6171 HA1�lA�t�,T F�,Y, �n*n'G58�G, pA 17050 1 Legal Description of Subject Properly(attach description if necessary) �� Year Built 2ooi Purpose of Loan purchase Construction Other(explain): Property will be: �Refinance ❑Construction-Permanent Pnmary Secondary �Residence �Residence 0 Investment Complete this line if construction o�construction-permanent loan. Year Lot Original Cost Amount Existing Liens (a)Present Value of Lot (b)Cost of Improvements Total(a+b) Acquired $ Complete this Ilne ii this is a reflnance loan. Year Original Cost Amount Existing Liens Purpose of Refinance Describe Acquired Improvements �made �to be made 00 ON 2 $ 139000.00 g 113927.71 cost:$ Title will be held in what Name(s) �p, J KIL�,,, Manner in which Title will be heid ��'I'LY Estate will be held in: �Fee Simple Source of Down Payment,Settlement Charges,and/or Subordinate Financing(explain) �Leasehold (show expiretion date) E¢JITY C�7 S�7FL.'T P1mI�ER7.'Y •;:.>:.::.;;:.::.::.;>:.::.::.;:.;;:.;:.:::.::.::.:::.::.::::::..::>:.>:.;:•>::os::.::.:......................:.::>:;:.;:.>:.::.::::.:::::::::r:....;,.:...:,,.......:....:.......::..:...:.:..:..:;.:.......:•::.;;;:>::;>:;:<.:;;:::.>;:.::.::•:::...s::.:...:::::::.;.::.;+::.::::.>::::}:s::::>:::2:::::::::::i:::::::::s::iis:2::::;:5:::i;s::::::::i: .. . i�3'i;;�::::::::>�i�ii�i;:i<'::ii�i:::i:::i�:!:i::�:::S::;iB:::E::E:::i::i:::ii:::i::E:E:�34�1N@fE':iEE:::E:i�::::::::i::::::::<::::::::::::;: `;: . • :: . ..• .. ••.: •. .i:::t:::::'<:::i::::::::::5:::::::;::::o...• .: . :.:.::::::::::.�:.:�.�:.:,::............................... . . . .....................Ilf.��t4. E...114E��R tL'.f#t�hE....................:.::::::��dM�trMf.'�►:Itit�.:::::::::::::::.�::::::.::.:::.:�::::.>:•;:»::.:::.;;:.>:.;:.::.:.:::.: BoROwer's Name(include Jr.or Sr.if applicable) Co-Borrower's Name(include Jr.or Sr.if applicable) TAN�IRA J KI1� Social Security Number Home Phone(incl.area code) DOB Yrs. Social Securiiy Number Home Phone(incl.area code) DOB vrs. 206-50-7016 717/790-6088 �m il��Y�%195 16�� (mmldd/yyyy) s�noai �Married �Unmarried(include aingle, Dependents�not listed by Co-8orrower) Q Married Q Unmerried(include single, Dependents(not listed by Borrower) � divorced,wldowed) �O• a9 $ ❑ divorced,widowed) no. agbs Se arated �� Se arated Present Address (street,ciry,state,ziP) Own Rent 07/03 No.Yrs. Present Address (street,ciry,state,ZIP) Own Rent No.Yrs. 6171 F]A�T �,SC , N�,NI�G, PA 17050 Mailing Address,if different from Present Address Mailing Address,if different from Present Address r If residin at resent address for less than two ears com lete the followin : Former Address (street,city,state,Zla) �Own ❑Rent No.Yrs. Former Address �street,city,state,ziP) �Own ❑Rent No.Yrs. r r ::.:o-:.:�::.:»>o-:::.:�:.>::::.:>:o-::.>:.::::::;>:o-::.:>:::::::::;.>::.:;::..:.................::::s::i::s::::::::::::ii::;:::::;ziri..:.,.,...........:..:.:..:.....;....:.....;..:..:...;:•i:,....::.;::::::i::::Y::<:::ii::r:::Y2::>:::�:.s•.:i:..:::::.�:;a�::::::::::.�.�::::::::::::::::::::.�:::::::::::::::::.�:::::::: :.. � • :::::.:�:::.:::::::::::::::.�:::::::::::<:::t:::::::::::::: £::'rE .IJfM��#'•iiiisE::::•::;a::::::::::<.:::;::;:;:.::.. •t•: • •:•� c ''• :::i:::$>i$i:i$:ii�E::::::::::i:3i:::i:::Si:iii:;:i::it:i:>i:i:i::fi:ie$:i:i;$i�i ...�. .:�� •�:.::5 �..�.�.. . ..: •: .:<.>:.>::.;s:.r:.rr::<.:::.:>::::< . :;:.:::::r>:<.>:<e.::::.::::.:•::.:.�:::.:•::::.:::..::::.::::::::: . . ... �. . . 1�. �...........................�il�l..gl�i�Ey�R(� ..................,,....::..:.�.:.::::::.�::::::::::::::::: Name&Address of Employer �Self Employed Yrs.on this job Name 8 Address of Employer Self Employed Yrs.on this Job SEL�7c.'T MEDICAL 02/03 2501 �Fl � STR Yrs.employed in this line 000000000 Yrs.employed in this line of worklprofession � of work/profession HA1�k2I5BCk�G , PA 171100000 02/02 PositfoNTltle/Type of Business Business Phone(incl.area code) PositioNTitlefType of Business Business Phone(incl,area code) c� r� n�/24s-41o2 If em lo ed in current osition for less than two ears or if currentl em Io ed in more than one ositton com lete the followin : Name&Address of Employer Self Employed Dates(from-to) Name&Address of Employer �Self Employed Dates(from-to) 0000 - _ Monthly Income Monthly Income PositionlTitle/Type of Business Business Phone(ncl.area code) Position/Title/Type of Business eusiness Phona(incl.area cade) Name&Address of Employer �Seif Employed Dates(from-to) Name&Address of Employer �Self Employed Dates(from-to) Monthly Income Monthly Income Position/Tiile/Type of Business Business Phone(incl.area code) Position/Title/Type of Business Businesa Phone(incl.area coda) Freddie Mac Fortn 85 7/O5 Fannie Mae Form 1003 7l05 �-21N (050�) NMFL#1003(APP1,APP2)Rev 11/10/2007 Page 1 of 4 Initials: VMP Mortgage Solutions,Inc.(800)521-7291 � � .p�. ....t �,��.��..��,�M�.,,.��.�.� �� , n.� . _ _.X , .,.w��_.�,�.�� . �. r� , .:::.;�.::.>::.::.:;;:.>:.>:.;:.;:;;:.:.:;.>:.>;:.>:.;:.;:.;;:.;:.;;:;;;:.;:.;:::.;:.;:.:::<.::..:::.:... ..:.:...................................::.::.;...:..:.:...,..:.......::..:.:..:..:....;.........:........:.;.:...;:..::.....:..:.:...:....:..:�:.;::.:�>:.;>;>:.;::.;;:.:�.:;.>:�::.>:.>:.>::.>:.;::<;.::.;:.;>::.::.;:.>::.::::.;;�::;.;;. :: N:::::"if:::: ::��'.' <:>�: .;:.�.�. .: :.� :� .:.. . . ::::::;;::><:�a.�� .# .. ....:..............................................:..... ...'t'f.tl«....IN..��►l�.�N.C�.�� ..I� . _:<>:::»:::?::::>::>::>:::::::>::::::>::::>::::>:>:::>::>::::>::>::>:«:::>;:::<::<::::<:;: . .. . .Il� .II��:::H�U..��.1�1..�''a�.:.�.ii�'��l... .:: ��..::::>::::::::::::::;::>::::>::::>:;:s:::>:::<:;::�:::::>:<:>:::::::>:::::::<::>::::<:::::<>:>::::::>:> � : . . �...N.�'!�1�M��'I�:k4:.........................................................:..:.:::.:: Groes Monthly Incoms Borrowar CaBorrower Tolal ombinaEMenshly present Proposed Base Empl.Income" g 5280.00 5280.00 ent $ Overtime irst Mortgage(P&I) 509.00 633.45 Bonuses ther Financing(P&I) 459.00 Commissions azard Insurance 25.17 Dividends/interest eal Estate Taxes 138.00 138.50 Net Rental Income ortgage Insurence otner(betore comPietin9, omeowner Assn.Dues �.00 �.9i sea the natice in"describe other income,"below th8f: .Q� 5280.00 5280.00 1114.00 805.03 `Seli Employed Borrower(s)may be rsqulred to provide additlonal daeumentation such eo tax returna and financial etatsmenls. Describa Other Income Notiee: Alimony,ehild support,or separete maintsnenee lneoma need not be revsaled it the Borrower(B) B/C or Co-Borrower(C)does not choose to have It considered Tor repay(ng this loan. Mohthly Amoullt ::::i:S:;::;::::::::::?2:>::::::::>:::55r::rr:::s;:::k:::e:Y;::i:;::;:<;:t::::::;;::5::>:2:::i:;::i;::SR:::::;;::R::::::5::>::i::::::�::::i>::i:::::>::i::...::::....:...............:....:...:..:.:..:........ 3a. �:�i.::i�.Q':��i �� s�'i::::2i::i'�ii;ii:i:>:':::'R•`:'c::::i:2'<:i::2:::i:;:::>::::;i;:S::i:i>;;::::ii::riiii::::.2::::;i;is3i:5:::i:::iiii:ii:iii:>::iis;::::::::::%:::;:?::::;:i::i:.`•:•`:�:� This Statement and any applicable supporting schedules may be completed jointly by both married and unmarried Co-Borrowers if their assets and liabilities are sufficiently joined so that the Statement can be meaningfully and fairly presented on a combined basis; otherwise, separate Statements and Schedules are required. If the Co-Borrower section was completed about a non-applicant spouse or other person, this Statement and supporting schedules must be completed about that spouse or other person also. Com leted �Jointl �Not Jointl Cash or Market Liadilitiesand PlsdgedAesets.List the creditor's name,address,and account number for all outstanding debts, ASSETS V81U8 ineluding automobile loans,revolving charge accounts,2al estate loans,alimony,child suppart,atock pledges,etc. Descri tiOn Use continuatlon sheet,If necessary.Indicate by() those liabilities,which will ba satisfied upon sale of real estate Cash deposlt towal'd purChase held by: $ awned or u on refinancin of the sub ect ro e . LIABILITIES Monthly Pa ment& Unpald Balance o t s Le to Name and address of Company $PaymenUMonths $ List checkln and savin s accounts below DISOG�7EEt FIN S't7C'S LLC 24/ 33 798.00 Name and address of Bank,S&L,or Credit Union � ��1��0892710 Name and address of Company $PaymenUMonths $ Ac�t.no. 8729.00 E07F�.S/C��ASE 40/ 8 301.00 Name and address of Bank,S&L,or Credit Union ��160552 Name and address of Company $PaymenUMonths $ Acct,no. � Name and address of Bank,S&L,or Credit Union Acct no. Name and address of Company $PaymenUMonths $ Acct.no. � Name and address of Bank.S&L,or Credit Union @ = 2b BE @ QA6II� Acct,no. * = 1�7P IN RATIQS Name and address of Company $PaymenUMonths $ . ,4cct.no. �,� 37003.00 Stocks&Bonds(Company name/number $ &description) ��b��1001056529 Name and address of Company $PaymenUMonths $ Life insurance net cash value $ yII1� 76929.00 Face amount: Sub4otal Llquid Assets 8730.00 Real estete owned(enter market value g 155000.00 from schedule of real estate owned) ��b��1000362043 Vested interest in retirement fund Name and address of Company $PaymenUMonths $ Net worlh of business(es)owned g CHASE ALTl,�D 261/ 17 4486.00 (attach financial statement) Automobiles owned(make and yea�) $ 4`��1$�820091806 Alimony/Child SupporUSeparate Maintenance $ Payments Owed to: Other Assets(itemize) � Job-Related Expense(child care,union dues, $ etc.) Total Monthly Payments 325.00 Total Assets a. 163730.00 :;•.�,;' �! •� ::::::;:;r 94217.00 Total Liabilities b. 119512.71 Freddie Mac Form 65 7105 F e Mae Fonn 1003 7/05 Initlals: �-2��1 (0507) Page 2 of 4 :<:;::.;:.::�;<,;::.;�::::.:�;>;>:.;;:.>:�>:>:.:::;.;:.;:.;;>:::.>:.;:.;:.;:.>:<.;:.;:.>:.::.;::.:<.:;;:.;:;:.;;>:;.:::.>;;>:.:::.;:.;:..:...�::.::.:...........�.:...:..,.,.,,..:.;.......,.:.....:�.;:�.::.;:.;:.;��:.::.;.;::.;;:;.;;;;;;;:.;:.:�:;.:<�:.::.:<.;:.:�::.;:;.>�:.>::.;:.;;:.>:;.:;::<.::.:<:.:::;:.::.::.;:.;;.:�::::.>:.::.::.:.;;:.::.;:.:�::.>:.; :s:::::<::><�Ir>::�'titi��'t��d::�4�1f�:: { :.. :�: :i��i�k��'.1'1��. �t�f'd::{:;::::.:::::::>:<:.::>;:«:::::>:::::::>::::>::>::>:::>::::<:<::::>::::»;::::::>;»::::::<::::::>::::>;:<::�::::>:�:>::::::�:<:»:::>::;:::::<::;:>:: ... ........................ . ....... .. ......... ........... ................................ . . .. ....... ............. ........:.::::.::::.:.�:::.::......:.:..::•.�:::::::::.::....::::::.::.......::.::::::::::.:.::..:.;.;::: Schedule of Real Estate Owned(if additional properties are owned, use continuation sheet.) Insurance, Property Address(enter S if sold,PS if pending sale Type of Present Amount of Mortgages Gross Morigage Net or R if rental being held for income) Property nnarket vawe a Liens Rental Income Payments Maintenance, Rental Income � Taxes 8 Misc. 6171 HA7�T In�ilC I3 SF $ 155000 $ 37003 $ $ 1 $ $ 6171 HA��'P ingLY 76929 1 Totais $ 155000 $ 113927 $ $ 2 $ $ Llst any additional names under which credit has previously been received and indicate approprfate creditor name(s)and account number(s): Alternate Name Crediior Name Account Number •.;.:•,:•:<.:::.:�:•.::.::.>::.::�:.::.:..:...;.,...:....:::.::.....:;:.....:..... ............ :•:�;>::>:::>:::::::::::s:><>::>i:#::z:>::::»::»::>:z:>::>s»::::::s::::;:<:::>:::�::>::»:::>;:>z.:z<:::::;::>:>�::>:;:::::::>:......:::..:..:..:..:...... ..:.:...�::::::.::�::::::.;;.:.�:..:•::...::...::::::::::::::.:•::::;.;::� ' ::::� :',: :• .: E�'.:•. ............................................................. a. Purchase rice If you answer"Yes"to any questfons a through i, please sorrowsr co-eorrower use continuation sheet for explanation. b. Alterations im rovements re airs ves No ves No c. Land if ac uired se aratei a. Are there any outstanding judgments against you? a � � � d. Refinance incl.debts to be aid o 113,927.71 b. Have you been declared bankrupt within the past 7 years7 a � � � c. Have you had property foreclosed upon or given title or deed in e. Estimated re aid items 1��`�•76 lieu thereof in the last 7 years? � � � � f. Estimated closin costs 2,304.00 d. Are you a party to a lawsuit7 Q � � � . PMI MIP Fundin Fee e. Have you directly or indirectly been obligated on any loan which resulted in foreclosure, trensfer of title in lieu of foreclosure, or judgment7 (This would include such loans as home h. Discount if Borrower will a 1 180.00 mortga e loans, SBA loans, home improvement loans, educatlonal loans, manufactured 119 069.47 �mobile� home loans, an9 mortgage, financial obligation, bond, or loan guarantee. If"Yes;' i. Total costs add items a throu h h provide details, includin date, name, and address of Lender, a � � � . Subordinate financin FHA or VA case number,if any,and reasons for the action.) k. Borrower's closin costs aid b Seller f. Are you presently delinquent or in default on any Federal debt or I. Other Credits ex lain any other loan, mortgage, financial obiigation, bond, or loan � P � guarantee? If"Yes;' give details as described in the preceding O � � � question. g. Are you obligated to pay alimony,child support,or separate o � o a maintenance? � � � � h. Is any part of the down payment borrowed7 i. Are you a co-maker or endorser on a note? � � � � --------------------------------------------------------• j. Are you a U.S.citizen? � a a o k. Are you a permanent resident alienT � � � � m. Loan amount I. Do you intend to occupy the property as your primary � Q Q Q (exclude PMI,MIP,Funding Fee financed) 118,000.00 residence?If"Yes;' complete question m below. m. Have you had an ownership interest in a property in the last n. PMI MIP Fundin Fee financed three ears? � � Q 0 o. Loan amount add m&n 118,000.00 �� p( R)t second home(SH)dor investment properlv(�p��esidence � p. Cash from/to Borrower 1069.47 (2) How did you hold tiile to the home --solely by yourself (S), S (subtract j, k. I&o from i) �O?y W�th your spouse (SP),or jointly with another person `:;::55<`•:<•>::s:;:::i::::2:::5::s:>t:s:::•>:::::::::::::::s:z:i:;::r;::s:::^,:;::z:.::::::::::::::;::i::i•:::::•:::::::::::i::s::i::i::.::;.:•<:>�::::::::::::::::::::.:::.:�:.::.:.............:.......:..:..:.:......;.....,..............::::::.�.��::::::<:::::.;�.>•:.;::.:.;�.�:.�<::::::::::.�:::::::::::.:�:::::::::o•::::::.>•:::. ;<:::::::fi`1�:::A��K��1Ai#s�[#G(�fii�l��`�::�C'k:�AC3I��h��1�tT<:s>::::»::::>:::<:�:::::;:::>::::>:::::<::<::>`::::>;::::>;:::i:::>:::.<.::':><::>::;>:::>'•?'::::;s::::>::::::i:::s>::>#:::s::s:::>:>;;>:;f:::::::::: ::::::.�::::::::::.::............................................................................................................................................................................................................................................................................ Each of the undersigned speciflcally represents to Lender and to Lenders ectual or potential egenb, brokers, processors, attomeys, insurers, servicers, successors and assigns and agrees and acknowledges that: (1)the Infortnation provided In this applicallon is true and correct as of the date set forth apposite my signature and that any Intentional ar negligent misrepresentation of this information contained in this application may result in civil liability,including monetary damages,to any person who may suffer any loss due to reliance upon any misrepresentation that I have mada on this appiicatlon,and/or in criminal penalties inciuding,but�ot limited to, fine or imprisonment or both under the provisions of TiUa 18, United States Code,Sec.1001, ei seq,; (2)the loan requested pursuant to this application(the"Loan")will be secured by a mortgage or deed af trust on the propeAy described in this applicatian;(3)the property will not be used for any illegai or prohibited purposa or use;(4)all statements made in thfs application are made for the purpose of obtaining a residen8al mortgage loan;(5)the property will be occupled as indicated in this application;(8)the Lender,its servicers,successors or assigns may retaln the original and/or an electronic record of this appiication,whether or not the Loan is approved; Q)the Lender and its agents,brokers,insurers,servicers, successors,and assigns may continuously rely on the infartnaUon contained in the application,and I am obiigated to amend and/or supplement the infortnation provlded In this applicatlon if any of the materlal facts that I have represented herein should change prior to closing of the Loan;(6) in the event that my payments an the Loan become delinquent,the Lender,its servicers,successors or assigns may, In addition to any other rights and remedies that it may have relating to such delinquency,report my name and account fnformallon to one or more consumer reporting agenciea;(9) ownership of the Laan and/or administration of the Loan account may be transferred with such notice as mey be required by law; (10) neither Lender nor Ns agenis,brokers, insurers,servicers, successors or assigns has made any representation or wamanty, axpress or impiied,to me regarding the property or the condlt(on or value af the property; and(11) my trensmission of this application as an"electronic record" containing my"electronic signature;' as those terms are defined in applieable federet and/or state laws(excluding audio and video recordings),or my facsimile transmission of this application containing a facsimile of my signature,shall be as effective,anforceable and valid as if a paper version of this application were delivered containing my original written aignature. Acknowled ement.Each of the undersigned hereby acknowledges that any owner of the Loan,iffi servicers,successors and assigns,may verify or reveriy any infortnation contained in this application or o in any�n ormation or data relating to the Loan,for any legitimate business purpose through any source,including a source named in this application or e consumer repoAing agency. Borrowers Signature Date Co-Borrower's Signature Date X X s>z::>?:Er,:>:>t::::::>::>:i�:::r:Ez::::s:»::t<:»::»;:E>:i>::>:::<:s:iit:>:i::#::>::>::>:>:>ais:ei:>�>::::��.r:.........�.r.:�.y.�..y.�.:y.:,...:�.:y.:::.�.Y...:�..y..�.:f.�..>�:�..y.:�.,y.y.;,/.�...y.�...:.�.,l.ie..x.�::t.y..�.;.:1.t.ii.I..�.:�.:t.f.M...�...:1.�.:.�..f;..•::E�'�I�if��4'rST::::::::::::::::::::::.;�.:::::.;•:.;•.;>;:::::;:::>:.»>:::»»::.>:.::::;:::.;�:;:;:;. 1��Lk . .IMFfti11:'t�:::lf+!Kl:�Fl:,1swF:R�l:s�::r:�•. t..'... . .:2:'r::3:::�::#:::::S::i3::::::;:::i:::::::::{:::i3i::::::::3::#:::t:3:iS::::33::3::5::`�:::::i:::t:i::•.'::#:::::3:� i:5::::::::f!ii::�l�Fl::H!�:4}1lR:�{:1�1:4::A<!✓f:�5:::;5:5!:�M:�I't1A� .:.....:::.......::::..:.......:•::•::...:::::::v.�.::..:....:........... . The fallowing infortnation is requested by the Federal Govemment for certain types oT loans retated ta a dweliing in order to monitor the lendars compliance with equal credit opportunity, fair housing and home mortgaga disclosure laws. Yau are not required to fumish this infortnation, but are encouraged to do so.The law provides that a lender may not discriminate either an the basie of thia information, or on whether you choose to fumish it. If you fumish the infortnation, piease provide both ethnicity and race.For race,you may check mare than one designation.If you do not fumish ethnicity, race,or sex,under Federal regulations,this lender is required to note tha information on the basis of visual abservation and sumame if you hava made this application in person.If you do not wish ta fumish the infortnatian, pleasecheck the box below. (Lender must review the above material to assure that the disclosures satisTy all requirements to which the lender is subJect under applicable state law for the particular type of loan applied for.) BORROWER �I do not wish to fumish this information. CO-BORROWER Q I do not wish to tumish this information. Ethnicity: 0 His anic or Latino �Not His anic or Latino Ethnicity: 0 Hls anic or Latino �Not Hls anic ar Latino Race' American Indian or Black or Race' American Indian or �Black or • 0 Alaska Native �Aslan �Afican American � Aiaska Native Aslan Afican American �Native Hawailan or O �Native Hawaiian ar a t e ac' c sl e White t erPaci clsl White S@X: Q Female �Male Sex: 0 Female �Male To be Completed by Intervfewer Interviewe�'s Name(print or type) Name and Address of Interviewer's Employer This application was taken by: ��I� �� ,j,g ��p g�{, N.A. ❑Face-to-face interview Interviewer's Signature Date �Mail 5201 JONE'SR.C7�ng.7 F�1D �Telephone Interviewer's Phone Number(incl.area code) � Intemet HARt2tSBi7RG PA 17117 �O 2�1�1 (0507) Page 3 of 4 Freddle Mac Form 85 7/05 Fannie Mae Fartn 1003 7/05 .a.��,..�..� � � �,��.� �.,� .�,_�.�.,.�._.�,�� ,�..�- :;:;;::i::ii:::::t:i#i;i<:::::''•i;:�::a;::::::Siii<ii!�:><.::::;i;:<;::i:ii;;i:t;;i::iiit#2:i::Y:iiii:isiiiiS:it2;#:::ii:i'�?...�,.�.+.�.�.`....y.y..�.y...��../.�.y.�.....�..}...�.y.�..:y.1.�..,..�..+..........::.....:....:/:�:�;':;3i:�>':'2...;:.,,,;..:..,....::`,::.r`:�:`:":::i;;;#;?:::::rF:::iii;;:;:i:::::i:i;2•'.2ii::iiiSiii:i::::::::i:<::::t:::::i::5i:l�:i::::::;it::::::;;::t:;�::::::i::: ..;•::.:t:<.2::::•::::::y::.i•..'::::::i•:::::.:t.:::�::i::>•.>::<:..:•:.:•>:::>:<.:::::ee.::.>:::�:::::::...>:vtH'Fli�liA#i!�.'.ly�' .::: : :.Ny��}�1y�F1t+�j r�*. y.�F1 y1� �} .�Y .. .. ..... ...... . . ....7!1. �1,'k,:5�?!f1„FiC{„�a„�,,.EiYi",M„k7�M;i",i1:ii:;1:1�::�jY#R"k�f:W�IT':f`�V(��3'I.::t<:>}:<:�:::5::::.>ri::$i:::.:.:::::.:}::5'ri>::}>:::;:.>:::,4::•::<.>:5:.:.:.'r:.}»::.}:.:.:1:.::.>:<::t::.::.>:• .......... .. .... ............. ......::::..:::•:.:..:•:.::::.::...::•::.;.y: Use ihis continuation sheet if gorrower: Agency Case Number: you need more space to �� J HI� comPlete the Residential Loan Application. Mark B for Co-Borrower: Lender Case Number: Borrower or C for Co-Borrower. 0109914222 Former Address History B/C Street/ Citv State Zip Own/Rent Years/Months B C Previous Employment Emplover Citv/State Dates Monthlv Income �pe of Business Position/Title Other Income B/C Description Monthly Amount B Subject Property Net Cash Flow(Income) 5.00 *Subtotal* InstalimentOther Monthly Paymentand Unpaid Months Left to Pay Balance / / / / / / @ = To Be Paid @ Closing * = Not Included In Ratio AdditionalLiabilities Description Monthlv Amount B/C Net RentalLoss $.00 B SubjectPropertyNet Cash Flow(Loss) $.00 California applicants: Pursuant to California Civil Code 1812.300(j)a married applicant may apply for a separate account. I/We fully understand that it is a Federal crime punishable 6y flne or imprisonment, or both, to knowingly make any false statements concerning any of the above facts as applicable under the provisions of Title 18,United States Code,Section 1001,et seq. 8orrower's Signature: Date Co-8orrowers Signature: Date X X Freddie Mac Form 85 7105 �F e Mae Form 1003 7/05 -21N �oso�� Pa9e a ora