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HomeMy WebLinkAbout06-12-14 (2) -� REV-1500 EX(02-11) 1505610143 'L�17 OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Coae Year File NuMber Bureau of Individual Taxes oeoumtwrorwm4K PO 60x.280601 INHERITANCE TAX RETURN 21 13 01168 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 10 14 2013 06 23 1920 Decedent's Last Name Suffix Decedent's First Name MI FUGLESTAD EVELYN (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return ❑ 2. Supplemental Return ❑ 3.RReomainder Return(Date of Death ❑ 4. Limited Estate ❑ 49.wture interest Campramisa ❑ 8. Federal Estate Tax Return Required (date of death after 12-12-82) 11 6. Decaaent Died Testate ❑ 7. Decadent raalntafnod a Living TwSt 8, Total Number of Safe Deposit Boxes (Attach Copy of win (Attach Copy of Trust) ❑ 9. Litigation Proceeds Received ❑ 10,be�enPoverty9iCM rt(Date f Death ❑ 1 t•Ellectio 3o tax Sec.9113(A) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Numt>ei�:, 717 4T..2 2089 m C—_fri REGISTER-OFF IL-1.S USWONLPV q 7 ' r 1T1 N ' First Line of Address 8 N BALTIMORE STREET C,3 c-, o C3 C i.. Second Line of Address r— C11 (n 1 r t City or Post Office State ZIP Code DATE FILED CIO DILLSBURG PA /117. 019 �±/ Correspondent's e-mail address: '6:, G.- :r<r s.`vn tA Under penalties of perfury,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 ImmMedge. IGNATUR ERS RE5POtMisloE 90P FILING FETUS DATE as/j�cc7y, �� p yj Evelyn K. Hixenbaugh t 1 f I ADDRESS 750 Popular Road, Dillsburg, PA 17109 SIGNATURE OF PREPARES OTHER THAN PRESENTATIVE DATE ADDRESS Stone, Duncan& Linsenbach 8 N. Baltimore Street, Dillsburg, PA 17019 Side 1 1505610143 1505610143 J 1505610243 REV-1500 EX Decedent's Social Security Number Dedede�Vs Nam: FUGLESTAD, EVELYN RECAPITULATION 1. Real Estate(Schedule A).......................................................................................... 1. 61 , 240 . 80 2. Stocks and Bonds(Schedule B)............................................................................... 2. 25 , 327 . 4 0 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3. 0 . 00 4. Mortgages&Notes Receivable(Schedule D).......................................................... 4. 0 . 00 5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)................ 5. 118 , 457 . 63 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested............. 7. 8. Total Gross Assets(total Lines 1 through 7).......................................................... 6. 205 , 0 2 5 . 8 3 9. Funeral Expenses and Administrative Costs(Schedule H)..................................... 9. 9 , 432 . 17 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................. 10. 4 , 307 92 11. Total Deductions(total Lines 9 and 10).................................................................. 11. 13 , 7 40 . 0 9 12. Net Value of Estate(Line 8 minus Line 11)............................................................. 12. 191 , 2 8 5 . 74 ...................................... 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J)................................................. 13, 1 , 500 . 00 14. Net Value Subject to Tax(Line 12 minus Line 13)................................................. 14, 189 , 785 . 74 TAX COMPUTATION-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 .00 1 , 500 . 00 15. 0 . 00 16. Amount of Line 14 taxable at lineal rate X .045 16 17. Amount of Line 14 taxable at sibling rate X .12 17 18. Amount of Line 14 taxable at collateral rate X .15 188 , 285 . 74 18. 28 , 242 . 86 19. TAX DUE.......................................................................................................... "•• 19. 28 , 242 . 86 20. FILL IN THE OVAL IF YOU ARE REOUESTING A REFUND OF AN OVERPAYMENT. El Side 2 L 1505610243 1505610243 J REV-1500 EX Page 3 File Number 21 13 01168 Decedent's Complete Address: DECEDENT'S NAME Fuglestad, Evelyn STREET ADDRESS 100 Mount Allen Drive CITY___ Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 28,242.86 2. Credits/Payments A. Prior Payments B. Discount Total Credits(A +B) (2) 0.00 3. Interest (3) 0.00 4. It Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2,Line 20 to request a refund 5- If Line I +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 28,242.86 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;............. .................. ..... DX b. retain the right to designate who shall use the property transferred or its income;..... 0. 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 property within one year of death without receiving adequate consideration?............ ..................... ............-.....___...... .... ❑ IJ 3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?......... ❑ DX 4. Did decedent own an individual retirement account,annuity,or other non-probate property which contains a beneficiary designation?.....__....,,_............... ......... ......... .................. ................. IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS tSYES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PARTOPTHE 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 cif the surviving spouse is 3 percent[72 P.S.§9116(a) (1.1)(i)l, For dates of death on or after Janua,7,1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent 172P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax rXin are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: •The tax rate imposed on the net value of transfers from a deceased child 21 ears of age or younger at death to or for the use of a natural parent,an adoptive parenF,.or a stepparent of the child is 0 percent[72 P.S.§9116(a)J.2)]. •The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in (72 P.S.§9116(a)(1)). •The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3 A sibling is defined under Section 9102,as an individual who has at least one parent in common with the decedent,whether by bloohr adoption. pennsylvania DEPARTMENT OF REVENUE SCHEDULE A INHERITANCE TAX RETURN REAL RESIDENT DECEDENT - REAL ESTATE G ESTATE OF Fuglestad, Evelyn FILE NUMBER All real property owned solely or as a tenant I21 13 01168 re which property would be exchanged between l willing buyer and a wilting seller, neither being compelled to buy or sell, both having ar be rep at fair market value. Fair market value is defined as the price reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on schedule F. Attach a copy of the settlement sheet if the property has been sold. Include a copy of the deed showing decedent's interest if owned as tenant in common. ITEM NUMBER DESCRIPTION T DATE OF 1 Fickes Road, Dillsburg, PA (Tax Parcel ID: 49-000-MD-0056K-000000, Assessed VaTH $53,720 x Common Level Ratio of 1-b9 � I�{ 1,240.80 TOTAL(Also enter on Line 1, Recapitulation) 61,240.80 REV-1503 E%s(8-98) SCHEDULE B `C*0.+DNMEUTM OE MHERR A%RENNSN.vuR �u STOCKS & BONDS ANCE TETIRN RESDENr DECEDENT ESTATE OF Fuglestad, Evelyn FILE NUMBER 21 - 13 - 01168 All property Jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF 1 Con Edison Stock, per quote from Edward Jones, Days low was $55.30 DEATH 55.30 25,327.40 TOTAL(Also enter on line 2, Recapitulation) 25,327.40 pennsylvania SCHEDULE E i DEPARTMENT TAXRET RN CASH BANK DEPOSITS AND MISC. INHERITANCE TAX RETURN 1 RESIDENT DECEDENT PERSONAL PROPERTY �FILE MBER ESTA TE OF FUgleStad, Evelyn -Q1168 �. Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE OF NUMBER DESCRIPTION _ DEATH 1 PNC Bank Checking Account 5144166937 118,175,96 2 Con Edison Dividend 281,67 118,457.63 TOTAL{Also enter on Line 5,Recapitulation} ` REV-1511 Ex+(10.09) pennsylvania SCHEDULEH DEPARTMENT OF REVENUE I INHERITANCE TAX RETURN PUINERALE)GEWSAW RESIDENT DECEDENT MMSMWECOM FILE ESTATE OF Fuglestad, Evelyn NUMBER 21 - 13-01168 Decedent's debts must be reported on Schedule 1. ITEM NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT A. I Cocklin Funeral Home 2,458.17 B. ADMINISTRATIVE COSTS: 11 Personal Representative's Commissions Name of Personal Representatives) Street Address City State Zip Year(s)Commission Paid 2. Attorneys Fees Stone, Duncan &Linsenbach, PC 6,200.00 3. Family Exemption: (it decedents address is not the same as cWmant's,attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees Register of Wilts 35.00 Register of Wills 158.50 Register of Wills 15.00 b. Accountants Fees Fahnestock, 1040 Income Tax Return 50.00 6. Tax Return Preparer's Fees 7. Other Administrative Costs I Stone, Duncan &Linsenbach, PC Deep Prep and recording fees 200.00 TOTAL(Also enter on line 9, Recapitulation) 9,432.17 G SchedLeH COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN K�11111F7YC1YVG li _ AESIDENT DECEDENT ESTATE OF Fuglestad, Evelyn_ a FILE NUMBER 21 - 13-01168 2 York County Recorder of Deeds for Warrington Township Deed i 65.50 3 Administrative Reserve 250.00 I ' I I i I 1 Page 2 of Schedule H DEPARTMENT CF REVENUE INHERtTANC5 TAX RETURN DEBTS OF DECEDENT, MORTGAGE RESIDCNT DECEDENT LIABILITIES & LIENS LE NUMBER ESTATEOF Fuglestad, Evelyn 121 - 13-01168 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1 Messiah Lifeways 4,079.42 2 Messiah Lifeways 228.50 TOTAL(Also enter on Line 10,Recapitulation) 4,307.92 N� REV-1513 EX+(01.10) r j pennsylvania SCHEDULE J DEPARTMENT QE REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF Fuglestad, Evelyn FILE NUMBER 21 - 13 -0116$ NAME AND ADDRESS OF PERSON RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER (S), DECEDENT (Words) (SSS) RECEIVING PROPERTY DO"List Trustivoq I, TAXABLE DISTRIBUTIONS[include outright sppoousal distributions,and transfers under Sec.9116(a)(1.2)] 1 Robert W. Mann Nephew 10,000.00 12 Audobon Park, Dillsburg, PA 17019 2 James A. Hixenbaugh None 10,000.00 750 Pobular Road, Dillsburg, PA 17019 3 Keith A. Hixenbaugh Grand Nephew 30,000.00 700 Poplar Road Dillsburg, PA 17019 Enter dollar amounts for distributions shown above or lines i 5 through 18 on Rev 1500 cover sheet,as appropriate. H. NON-TAXABLE DISTRIBUTIONS: A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TOTAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 National Federation of the Blind 1,000.00 2 West Shore Humane Society 500.00 TOTAL OF PART It-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 1,500.00 REV-1513 EX+(01-10) pennsyhvania E SCHEDULE J RESIDENT ED RETURN BENEFICIARIES Continued RESIDENT DECEDENT ESTATE OF Fuglestad, Evelyn I FILE NUMBER 21 - 13 - 01168 NUMBER NAME AND ADDRESS OF PERSON(S) RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE RECEIVING PROPERTY DECEDENT (Words) Do Not List Trustees) ($$$) j, TAXABLE DISTRIBUTIONS[include outright spousal distributions,and transfers under Sec.9116(a)(1.2)] 4 Cindy Wakefield friend 111 Hallmark South 500.00 Hershey, PA 17033 5 Edith M. Houston Niece 226 Misty Lane 10,000.00 Hendersonville, NC 28739 6 Evelyn K. Hixenbaugh Niece 750 Poplar Road one hundred percent Dillsburg, PA 17019 of residuary estate I I i Page 2 of Schedule J F J REV-W EX(03-09) 3460009101 ESTATE INFORMATION SHEET pennsylvania FOR REGISTER'S OFFICE USE ONLY OEMRTMENT OF REVENUE County Code Year File Number DECEDENT INFORMATION:Enter data as it will appear on all documents submitted to the Department Decedent's Social Security Number Date of Death Date of Birth 110/1412013 06/23/1920 Last Name Suffix First Name MI Fuglestad ® Evelyn TYPE FILING: Fill in oval to indicate the nature of the return to be filed with the department. CIE) Probate Return O Joint Assets Only O Non-probate Assets Only O Litigation Purposes(no other assets) LETTERS GRANTED:Fill in oval to indicate the nature of the proceedings at the Register of Wills Office. (Attach additional sheets if explanation is necessary.) CID Testamentary O Administration O No Letters O Other(Please Explain.) ATTORNEY/CORRESPONDENT INFORMATION:Enter all information for the attorney or individual to receive tax information and correspondence. Last Name Suffix First Name MI Linsenbach ® Brian Q Supreme Court I.D.# _ Telephone Number 87360 (717)432-2089 �, Attorney/Correepon e-mail address: brian @stoneduncunc an.com First Line of Address 8 N. Baltimore Street Second One of Address City or Post Office State ZIP Code Dillsburg PA 17019-6960—� PERSONAL REPRESENTATIVE INFORMATION:Enter all information for the personal representative(s)of the estate authorized by the Register of Wills. Executor/Administrator Social Security Number Telephone Number (717)432-2148 Last Name Suffix First Name MI Hixenbaugh Evelyn ®K First Line of Address 750 Poplar Road OFFICIAL USE ONLY Second line of Address TRANSACttON COUNT City or Post Office State ZIP Code Dillsburg PA I 1-10 16 ` Complete general estate information questions and indicate additional personal representatives on reverse side. PLEASE USE ORIGINAL FORM ONLY Side 1 L 3460009101 3460009101 J PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND COUNTY,PENNSYLVANIA Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Letters as specified below, and in support thereof aver(s)the following and respectfully request(s)the grant of Letters in the appropriate form: Decedent's Information Name: Evelyn Fuelestad File No: a/k/a: (Assigned by Register) a/k/a: adfla: Social Security No: Date of Death: October 14 2013 Age at death:93 Decedent was domiciled at death in Cumberland County,Pennsylvania (state) with his/her last principal residence at 100 Mount Allen Drive.Mechanicsburg,PA 17055 Upper Allen Cumberland Street address,Post Office and Zip Code City,Township or Borough County Decedent died at Holy Spirit Hospital Camp Hill.PA 17011 East Pennsboro Cumberland PA Street address,Post Office and Zip Code City,Township or Borough County State Estimate of value of decedents property at death: If domiciled in Pennsylvania............................ All personal property $ 20 000.00 If not domiciled in Pennsylvania. , ......... ........ Personal property in Pennsylvania $ If not domiciled in Pennsylvania. .... Personal property in County $ Value of real estate in Pe nnsylvania.................. .... ............ ....................... $ TOTAL,ESTIMATED VALUE.... $ 20 000 00 Real estate in Pennsylvania situated at: (Attach additional sheets,ifnectusary.) Street address,Post Office and Zip Code City,Township or Borough County ® A. Petition for Probate and Grant of Letters Testamentary Petitioner(s)averts)he/she/they is/are the Executor(s)named in the last Will of the Decedent,dated August 7,2002 and Codicil(s) thereto dated State relevant circumstances(e.g.renunciation,death of ececutor,eta) Except as follows:alter the execution of the instrument(s)offered for probate Decedent did not marry,was not divorced,was not aparty to a pending divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa.G.S.§3323(g),and did not have a child born or adopted;and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. p+ NO EXCEPTIONS Q EXCEPTIONS © B. Petition for Grant of Letters of Administration (If applicable) c.t.a.,d.b.n.,d.b.n.c.t.a.,pendente lite,durante absentia,duraate minoritate If Administration,c.t.a, or d.b.n.c.t.a.,enter date of Will in Section A above and complete list of heirs. Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa.C.S.§3323(g)and was neither the victim of a killing nor ever adjudicated an incapacitated person. 0 NO EXCEPTIONS 0 EXCEPTIONS 1 c Petitioner{s},aRera proper search has/have ascertained that Decedent left no Will andwas survivedby the lowing spousaany'pIDdArrs(attach additional sheets, ifnecessary): rn o tl Name Relationship -.{ O tocyo -n -7 r> C> n ^ ;V ua m } -n Farm RW-02 rev./011112071 Page 1 of 2 Oath of Personal Representative official Use only COMMONWEALTH OF PENNSYLVANIA } } SS: COUNTY OF } Petitioner(s)Printed Name Petitioner(s)Printed Address Evelp K.Hixenbau h 750 Poplar Road Di Isburg,PA 17019 The Petitioner(s)above-named swear(s)or affirm(s)the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioners)and that,as Personal Representative(s)of the Decedent,the Petitioner(s)will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before Date me this_day of „Date By Date For the Register Date BOND Required: Q YES © NO To the Register of Wills: FEES: Please enter my appearance by my signature below: Letters . ... . ... ..... . . . . . . .. . $ Attorney Signature: ( )Short Certificate(s)..... . ( )Renunciation(s).. . . . . . . . �'` �� ( ) Codicil(s), . . ...-. ''* '' +' C ( )Affidavit(s).. . . . . . .. . . . ' Bond., .... . . ... .. Printed Name: Brian C. Linsenbach Commission, . . . . . . . . . . . . _ Supreme Court Other .. . ... . . ID Number: 87360 . . . .. Firm Name: Stone,Duncan&Linsenbach,PC -....... Address: 8 N Baltimore Street Dillsburg,PA 17019 ..... Phone: (X7)432-2089 Automation Fee. . . • . . .. . . . . . . . Fax: (717)432-0158 JCS Fee. Email: roan rnedunran rum TOTAL, . . . . . . . . . . . . . . . . . . . . $ 0.00 DECREE OF THE REGISTER Estate of Evelyn Fuglestad File No: a/k/a: AND NOW, in consideration of the foregoing Petition, satisfactory proof having been presented before me,IT IS DECREED that Letters Testamentary are hereby granted to Evelyn Hixenbaugh in the above estate and(if applicable)that the instrument(s)dated August 7,2002 described in the Petition be admitted to probate and filed of record as the last Will(and Codicil(s))of Decedent. Register of Wills Farm R 02 rev.10/1112011 Page 2 of 2 CAMyDm\W. oirru a,awtyn OF EVELYN FUGLESTAD BE TT REMEMBERED,that I,EVELYN FUGLESTAD,single woman,presently of 105 May Drive, Borough of Camp Hill, Cumberland County, Pennsylvania, being of sound mind, memory and understanding,do make,publish and declare this as and for my Last Will and Testament, hereby.revoking and making null and void any and all Wills and Testaments and writings in the nature thereof by me at any time heretofore made. ITEM 1: I direct that my hereinafter named Executrix pay all my just debts, my funeral expenses,and the expenses of the administration of my estate. With this direction, I authorize and empower my Executrix to expend for my funeral expenses and interment such amounts as she may consider necessary and proper,without regard to any limit that may be prescribed by a court of law. MM 2: I direct my Executrix to pay all inheritance, estate, succession, and legacy taxes of-whatsoever nature and kind,to which my estate,or the transfer of any property passing hereunder or otherwise passing by reason of my demise, may be subject, and to charge such taxes against my ( , residuary estate. It is my intention.that none of the aforesaid taxes, either federal or state, on any `N property required to be included in my gross estate,under the provisions of any state or federal law now in force or hereafter enacted, shall be prorated among the persons interested in my estate to whom such property is or may be transferred or to whom any benefit accrues. i ITEM 3: I give and bequeath the items of personal property of which I am possessed at the time of my death to the parties whose names appear on a list that is incorporated with this Will, and i signed by me. If no such list is located, the items of personal property should be considered part of my residuary estate. ITEM 4: I give and bequeath to the individuals or entities named below: A. National Federation of the Blind-One Thousand Dollars $1,000.00; B. West Shore Shelter of the Humane Society-Five Hundred Dollars$500.00; C. Edith Mann-Ten Thousand Dollars$10,000.00; D. James A Hixenbaugh-Ten Thousand Dollars $10,000.00; E. Keith A. Hixenbaugh-Thirty Thousand Dollars$30,000.00; and, F. Cindy Wakefield-Five Hundred Dollars $500.00. G. Edith M. Houston-Ten Thousand Dollars$10,000.00. H. Robert Wm. Mann -Ten Thousand Dollars $10,000.00. ITEM 5: All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate,whether it be real,personal or mixed, including property over which I have a power of appointment,I give,devise and bequeath unto my neice,EVELYN K, HIXENBAUGH, absolutely, intending that this bequest would include all of my interests in real property situate in Warrington Township, York County,Pennsylvania, which was purchased in 1471. ITEM G: in the event my beloved neice,EVELYN K.HDMNBAUGI- should predecease IQ me, I direct that my residuary estate by divided into three (3) equal shares, to be distributed as follows: A. One third(113)to Robert Wm. Mann; ( j B: One third(1/3)to Edith M. Houston; and `�-1 C. One third(113)to James A. Hixenbaugh, MM 7: I nominate,constitute and appoint my neice, EVELYN K.HIXENBAUGH to serve as Executrix of this my Last Will and Testament. In the event my neice, EVELYN K. HDMNBAUGH, should predecease me,fail to qualify,cease to act,or renounce probate,I appoint 2 KEITH A. HD(ENBAUGH, as alternate Executor of this my Last Will and Testament. ITEM 8: I direct that my hereinbefore named Executrix, or her successor, shall not be required to give bond for the faithful performance of her duties in this or any jurisdiction. IN,YTTNESS WHEREOF, I have hereunto set my hand and seal this day of 2002. 9VELYWFUG19LSVkD The preceding instrument,consisting of this and two(2)other typewritten pages,was on the day and date thereof signed,sealed,published,and declared by the Testatrix herein named,as and for her Last Will and Testament, in the presence of us, who, at her request, in her presence and in the presence of each other, have subscribed our names as witnesses hereto. OF u r t OF . 4 COMMONW LTH OF PENNSYLVANIA :SS COUNTY OF YORK We, E L Ff1GLESTAD, f and the Testatrix and t ewitnesses,respectively, W ose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby i declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and Testament, and that she signed willingly,and that she executed it as her free and voluntary act for the purposes therein expressed,and that each of the witnesses,in the presence and hearing of the Testatrix signed the Will as witnesses,and that to the best of their knowledge,the Testatrix was at the time eighteen(18)years of age or older, of sound mind, and under no constraint or undue influence. EVE L FUGLESTKD SWORN TO AND SUBSCRIBED OF 7ME THIS It DAY - n L d02. NOT PUB Naadd sat Jmet&K3me;2iaanY Pic 3 ri(v Shea�2002 ,' AseCC�attafNo1es19e T O 'o tQ d 'a a3i N m (Q W' w W W W W W W W w S N w d Q o, a o. a a. o, o. n a a C A Z z z z z z z z 3 � _ Z z z N N y r c C fn N N (O co f0 p CQ C f0 co CD CO m O W r CD z cn cn cn co to N ' T1 T T T -Zf7 n T T T n A) 0 O A � N � CD W O .w.. p p .W. . W O N J N N 69 69 Vi <A Vd 69 EA Vd to 69 69 N (Nj _ O N N N N N N N N N N :f1 N CD 7 A (00 O W co O co O co CO N O d S N O O co O O p p N O O l< 69 69 S9 69 69 j 69 <p <p 69 fA (fl cn A CO (O co co CO N CO w (p S w d (O O _ CL N o O O O N N NO A W p fI d O O N O N 5 C O O O O O O O O O p p O W 69 69 69 0 !f3 H! <A dd V! <A to 69 O) N W C) cn V N S C CD V V A d al O O co p A A i R K d O O 69 69 69 fn 69 fA 69 <19 <A V3 69 _ 0 -i W N A S (D N A N cn to i CO ,a V m G <A 69 69 69 <A <A 69 Vd 69 69 69 69 -CA 4 CA A ONST] 0) CO 0o CO C _O N O V C4 CO _ NN m V A A N Si N N o O O O p p ? A O O O O p A O O O O p O p 10/31/2013 PAYMENT RECEIVED -THANK YOU!!! 9,668.45 0.00 10/24/2013 MEDICARE PART B CO-INSURANCE 26.42 26.42 DOS 8/2-8/13/13 *** Nursing Care *** 10/01/2013 BARBER/BEAUTY SHOP 16.00 1.00 16.00 42.42 SET`STYLE 10/10/2013 RM/BRD -NURSING - SEMI-PVT 10/01-10/1 310.0010.00 3,100.00 3,142.42 10/13/2013 RM/BRD -NURSING -SEMI-PVT 10/11-10/1 310.00 3.00 930.00 4,072.42 10/13/2013 PREVAIL BRIEF 1.40 5.00 7.00 4,079.42 RESIDENT# CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 120604 4,053.00 26.42 0.00 0.00 0.00 $4,079.42 RESIDENT NAME EVELYN FUGLESTAD Forth P&91 Please make check payable to Messiah Lifeways at Messiah Village. A 1%finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you! If you have any questions or concerns about your bill,please address them directly to Fiscal Services at 790-8220. Thank You! v s VL M1,V[iV�VJ1Aq Form 1099•DIV (Keep for your records) Dividend Confirmation Payment Date Class Description Participating Dividend ( Gross f Deduction Deduction Net ShareslUnits Rate Dividend($) i Amount($) 1 Type I Dividend($) 15 Dec 2013 COMMON STOCK 458 $0.61500 281.67 0.00 WA 281.67 Year-T"atoPaid 1,126.66 (Loo 1,126.68 4 6 U T X E D I S + e01CD7000StR aaRX6A-(F2) wianv.G:YIt11PLE EAfErf FEArHNE&THE FACE Of M CHECK HAKA KEE 9FG[ekW W00 NWNE1L WW MuE UNCER aiXtgl 10V Wj.aeFAie3ECUMYENU0R9ENENt BAG(FAfeR M,,WA/EPMIIINMIeAegtgNKFFAifXtES. The Bank of New York Mellon 6P14a caFEdFaon Pittsburgh,PeMyNania 433 .. . . , PLEASE DEPOSIT THIS CHECK PROMPTLY. IMPORTANT;TAX RETURN.DOCUMENT`4TTACHED. Pay to EVELYN FUGLESTAD 150 POPLAR RD Chock Number.0000065246 DILLSBURGPA 11019.8952 15 Dec 2013 $***.2$1.67..** The sum of $""TWO HUNDRED AND EIGHTY ONE DOLLARS AND SIXTY SEVEN CENTS"" computamhareI P ko- Computershare Imo. 250 Royatl S6 Canton,MA 02021 AuIhMZed S19%ture(a) �}, a,ewerr.Hwuoxw.me,v:. 00000065248na 1:04330L600: L86"r30866* i6imputershare t' Computershare PO Box 43006 conEdiSOn Providence,RI 02940-3006 IMPORTANT TAX RETURN DOCUMENT ENCLOSED Within USA,US territories&Canada 800 522 5522 Outside USA,US territories&Canada 201680 6578 006844 www.computershare.com Iatrtlwllrlhnrrnrrrrllrrlr,rlrrtrrrprallrirrrrphhlllRl Recipient EVELYNFUGLESTAD 750 POPLAR RD Holder Account Number o DILLSBURG PA 17019.8952 00000355917 I N D Record Date 13 Nov 2013 Check Number 0000055246 SSNrrIN Corefied Yea OOICSOOOS.DomLae_P61.aDIS.155950 615A2MO68"ffiO6M4(ii Consolidated Edison, Inc. - Combined Dividend Payment!2013 Tax Form 1099-DIY ❑ Corrected(f checked) Account Number 00000355017 Form 1099-DIV-Dividends and Distributions 2013 Copy B-For Recipient Payees Fe Federal l 1 No.ending in 3.30 5510 Payers Federal ID No. 13-session This is Important tax Information and is being famished to the rudest Revenue Service.If you are required to file a realm,a negligeme OMB No. 1545.0110 pendty or other sanction maybe Imposed on you 0 this lame Is Waildeand the IRS dehxmhres dvekhas tort been nmented. DeparMient of the Treasury-IMema1 Revenue service Recipient EVELYN FUGLESTAD 750 POPLAR RD DILLSBURG PA 17019.8952 1a Total Ordinary m Dua ifed s Nondividend a FEDERAUNComE s Foreign Tax 7 Folagrt Couldry a Cash LlqudaGOn Dividends($) Dividends($) Disldbu0ons($1 TAIL WITHHELD Ifl Paid($) a1 Possession Dish.($)I Payer's Details 1126.68 1126.68 000 0.00 0.00 CONSOLIDATED EDISON,INC. C/O COMPUTERSHARE PO BOX 43006 - I�SFSSNIFn OUNCE 1i02621 Y' TAX PARCEL NO.: 44-000-MD-0056K-000000 Fickes Road,Dillsburg,Pennsylvania Warrington Township,York County DEED THIS DEED made this day of 4<r- 2013, by and between EVELYN K. HIXENBAUGH, Executrix of the Last Will and Testament of EVELYN FUGLESTAD, dec9ased,party of the first part,hereinafter called "Grantor", 77 -AND - - EVELYN K. HIXENBAUGH,�married woman, party of the second part, hereinafter called"Grantee". WHEREAS, the said THORA H. FUGLESTAD and EVELYN, FUGLESTAD, sisters, became in their lifetime seized, in fee, tenants by the entireties, of and in a certain parcel ofJ� ground, situate in the Township of Warrington, County of York, and Commonwealth of Pennsylvania,more particularly described hereinafter; and f WHEREAS, being so seized, the said Thora H. Fuglestad departed this earthly life on September 3, 2000, bequeathing her interest in the property by her Last Will and Testament in writing dated April 1.3, 2000, which was duly probated in the Office of the Register of Wills of Cumberland County, Pennsylvania on September 11, 2000, and can be located in Cumberland County File No. 21-00-00757, wherein and whereby she appointed as Executrix thereof the said Evelyn Fuglestad, to whom letters testamentary were duly issued by the said Register of Wills on September 11,2000; and WHEREAS, said premises hereinafter was not specifically devised, but; however, was given under the rest and residue clause under Item No. 4(e) The balance to my beloved sister, EVELYN FUGLESTAD,provided she survives me by thirty (30) days; and WHEREAS, Evelyn Fuglestad failed to deed the property to herself prior to her death but was the owner of said property; and WHEREAS, being so thereof seized, the said Evelyn Fuglestad departed this earthly life on October 14, .2013, having first made her Last Will and Testament in writing, dated August 7, 2002, which was duly probated and registered in the Office of the Register of Wills of Cumberland County, Pennsylvania on November 5, 2013; and can be located in Cumberland County File No. 2013-01168, wherein and whereby she appointed as Executrix thereof the said Evelyn Hixenbaugh, AoiA. 2265 Page 4995 to whom letters testamentary were duly issued by the said Register of Wills on November 5, 2013; and WHEREAS, and whereby said premises hereinafter described was specifically devised, as stated in the Last Will and Testament under Item 5, "1 give, devise and bequeath unto my niece, EVELYN K HLYENBAUGH, absolutely, intending that this bequest would include all of my interests in real property situate in Warrington Township, Pennsylvania, which was purchased in 1971.." WHEREAS,the said Evelyn K. Hixenbaugh, Executrix of the Last Will and Testament of the said Evelyn Fuglestad, does undertake the conveyance hereinafter set forth. WITNESSETH, that in consideration of ONE DOLLAR ($1.00) in hand paid, the receipt whereof is hereby acknowledged, the said Grantor does hereby grant and convey unto the said Grantee,her heirs and assigns, ALL THAT CERTAIN tract of land, situate in the Township of Warrington, County of York, and Commonwealth of Pennsylvania, being more particularly bounded and described, as follows,to wit: BEGINNING at a railroad spike in the center line of Legislative Route 66022; thence through an iron pin offset twenty-five (25) feet from said railroad spike and lands of Thomas Ryan,North sixty-three (63) degrees twenty-six (26)minutes West, four hundred eighty-five and eighty-hundredths (485.80) feet to an iron pin at lands of Ira Miller; thence along the last mentioned lands, North twenty-eight (28) degrees one (1) minute East, six hundred sixty-five (665) feet to an iron pin; thence along other lands of the Grantor herein, South sixty-seven (67) degrees eighteen (18) minutes East, four hundred forty-five and sixty hundredths (445.60) feet to a railroad spike in the center line of Legislative Route 66022; thence in and along the center line of Legislative Route 66022 the following courses and distances: South twenty-nine (29) degrees twenty-two (22) minutes West, two hundred seventy-four and twenty-three hundredths (274.23) feet to a railroad spike; thence South twenty-nine (29) degrees thirty (30) minutes West, one hundred seventy-three (173) feet to a railroad spike; thence South twenty-five (25) degrees two (2) minutes West, fifty-five and twelve hundredths (55.12) feet to a railroad spike; thence South thirteen (13) degrees twenty-four (24) minutes West, one hundred ninety-eight and thirty-one hundredths (198.31) feet to a railroad spike in the center line of Legislative Route 66022 and the place of BEGINNING. CONTAINING 6.93 acres, according to a survey by Robert E. Stiffler, Registered Surveyor, dated January 20, 1968, and revised February 28, 1972. BEING the same premises which James A. Hixenbaugh and Evelyn K. Hixenbaugh, his wife, by their deed dated April 10, 1972, and recorded in the Office of the Recorder of Deeds in and for York County, Pennsylvania, in Deed Book 67-D, Page 485, granted and conveyed unto Thorn H. Fuglestad and Evelyn Fuglestad. The said Thora H. Fuglestad departed this earthly life on September 3, 2000, bequeathing her interest in the property to the said Evelyn Fuglestad. The said Evelyn Fuglestad departed this earthly life on October 14, 2013,and specifically devised her interest in this property to Evelyn K. Hixenbaugh, Executrix, who undertakes the conveyance, as Grantor herein. UNDER AND SUBJECT to all restrictions, reservations, easements, encumbrances, covenants, conditions and rights-of-way of record. TOGETHER WITH all and singular the hereditaments and appurtenances thereunto belonging or in anywise appertaining and the reversions and remainders, rents, issues and profits thereof and all the estate, right,title, interest, property, claim and demand whatsoever of the Grantor, in law,equity or otherwise, of,in and to the same and every part thereof. TO HAVE AND TO HOLD the above described premises with the appurtenances unto the Grantee,her heirs and assigns, forever. AND the said Grantor, Executrix as aforesaid, for herself and her successors, covenant, promise and agree, to and with the said Grantee, her heirs and assigns, by these presents, that the said Grantor, Executrix as aforesaid, have not done, committed, or knowingly or willingly suffered to be done or committed, any act, matter or thing whatsoever whereby the premises whereby granted, or any part thereof, is, are, shall or may be impeached, charged or incumbered, in title, charge, estate, or otherwise howsoever. IN WITNESS WHEREOF, the Grantor has hereunto set her hand and seal the day and year first above written. WITNESS: GRANTOR: EVELYN . H 4AUG , Executrix COMMONWEALTH OF PENNSYLVANIA COUNTY OF SS. On this, the 2-3 day of 2-013, before me, a Notary Public, the undersigned officer, personally appeared EVELYN K. HLYENBAUGH, Executrix of the Last Will and Testament of EVELYN FUGLESTAD, deceased, known to me to be the person whose name e subscribed ai the within instrument, and acknowledged that she executed the same for the purpose therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and Notarial Seal. NOTARY pUjLIC CO..40"E OF PENNSYLVANIA Brian C, Linsen Seal Dillsbur �Ch' NO�rY PDblk MY Commission BOro, Yor1c County Medepq,pFnnsrtvan"%u"O March 11,2015 �SStXUT10N OF� I HEREBY CERTIFY that the precise address of the Grantee herein is: 750 Poplar Road Dillsburg, PA 17019 FOR THE GRANTEE e7 e,, . AI y� YORK COUNTYRECORDER OF DEEDS , 28 EAST MARKET STREET 4 ` YORK, PA 17401 it Randi L. Reisinger- 11 � i g Recorder Bradley G. Daugherty-Deputy Instrument Number-2014001753 Recorded On 1/13/2014 At 2:59:20 PM Book-2265 Starting Page- 4885 *Instrument Type-DEED *Total Pages - 6 Invoice Number-1081117 *Grantor-FUGLESTAD,EVELYN-EST *Grantee-HIXENBAUGH,EVELYN K User- MAG *Customer-BRIAN LINSENBACH *Received By: COUNTER *FEES STATE WRIT TAX PARCEL IDENTIFICATION NUMBER JCS/ACCESS TO JUSTICE $0.50 49000MD0056K000000 RECORDING FEES $23.50 Total Parcels: I AFFORDABLE HOUSING $15.00 PIN NUMBER FEES $11.50 $ COUNTY ARCHIVES FEE . 00 $2. 00 ROD ARCHIVES FEE $2 63.00 TOTAL PAID $65.50 I Certify This Document To 8e Recorded In York County, Pa. 9"�ER . nECOS . O Recorder Of THIS IS CERTIFICATIONPAGE PLEASE DO NOT DETACH THIS PAGE IS NOW PART OF THIS LEGAL DOCUMENT *-Information denoted by an asterisk may change during the verification process and may not be reflected on this page. Book: 2265 Page: 4890 r 4 f omputershare Computershare PO Box 43006 Con Edison Providence,R1029403006 IMPORTANT TAX RETURN DOCUMENT ENCLOSED VJi USA,US territories b Canada 800 522 5522 � Outside USA,US territories 8 Canada 201600 6578 1- 506844 www.computershare.com IrurPtiPitunriHtetiptptgiitNillFtilietrttrirtihilliil c Recipient EVELYN FUGLESTAD 750 POPLAR RD Holder Account Number DILLSBURG PA 17019 8952 C0000355917 I N D R. Record Date 13 Nov 2Di3 Check Number 0000065248 SSNfnN Cordfied Yes emcS09as.D®t.og-Mii.Enis.t 55950_6t M21MS44=6944r Consolidated Edison, Inc. - Combined Dividend Payment! 2013 Tax Form 1099-DIV Corrected(if Checked) Account Number 00000355917 Recipiard's ID No,ending M . "-"19510 Form 1099-DIV-Dividends and Distributions 2013 Copy 8-For Recipient Payers Federal ID No. 13.3965100 TMs Is hnportam taxinfommdon and is belog ftattlshed to the intenmi Revenue service.Nymare re4uIred to file antum,anegtigeme OMB No. 1545-0110 penalty or oMcrsatxtlon maybe Imposed onyou a 0tb Inme is to We end tha IRS determines that0has not been mponed. DepammM of the 7reamry-trtearol Revenue SeM4a Recipient EVELYN FUGLESTAD 750 POPLAR RD DILLSBURG PA 170138952 to Total Ordinary Pb Due NondMdend 4 FEDERAL INCOME s Fo"n Tex r Fere�tGUVry a Cash llOiAdaGort Dividends($) DMdends($) DIstdbWons($) TAXWrrni-D(r) Pald($) orUS.PosseWon DW.($)I Payer's Details 1126.68 1126.66 Do0 000 0.00 CONSOLIDATED EDISON,INC. C/OCOMPUTERSHARE PO BOX 43006 PROVIDENCE 11102840-3006 Form 1099-DIV (Keep for your records) Dividend Confirmation Payment Date Class Description Participating Dividend Gross Deduction Deduction + Net Shares/Units Rate I Dividend($) 1, Amount($) 1 Type ( Dividend($) 15 Dec 2013 COMMON STOCK 458 $0.61500 281.67 OAO WA 261.67 Year-To-Date Paid 1,126.68 0.00 1,126.68 4 6 U T X E D i S + 001CD70006rR eeRXBA{F2) 4.._._ a'4aNId6:'kUli&11E StfflY'ifA1URE5.iXEiACE 0FTC5 CHFtN H/SCetic nrrvnory m.�u`n n`w�"i-�n=.�-`.�''