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Home My WebLink About06-25-14 (2) � 15056101�1 REV-1500 °``°'_1°> � enns lvania ` ��f�M�� PA Department of Revenue P Y ..�,��._..��._..m��... OEO�PTnEnTOFxEVExUE County Code Year File Number BureauofIndividualTaxes INHERITANCE Ti4X RETURN ' `' PO BOX z8o6oi .� ' ` / !�: G Harrisburg,PA i�i28-o6oi RESIDENT DECEDE{VT �' ! � ��.�� `� ._ __.__ ___. _�__._.��_.��._ �...._,..�...�.x.�.��.�_�.._.�.�,,.....�..,�,..,�..,�.,y._a�a�.,. W,��...Y� ENTER DECEDENT INFORAAATION BELOW Sociai Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY .. .� .. , .. k .... , .. :^:i. ., . .:��.:�:�. .�, � {� ` �. `�° ��f �' �,�� ,.,� �'� �� %r�� E � L� �:; .. _, _ . �.,, DecedenYs Last Name Suffix DecedenYs First Name MI :. ; ,, ,:. '+��,,�� k t� F� ��. �:� ,_� T ' '� � �'; � � �� °� , , � ��- � . ..� � �. �_ � ,. � ,`�,. � .: (If Applicable)Enter Surviving Spouse's Information Below Spouse's�ast Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE I�IITH THE _ RE(aISTER OF ViIILL� FILL IN APPROPRIATE OVALS BELOW �► 1.Original Return � 2.Supplemental Return �3 3. Remainder Return(date of death prior to 12-13-82) �e 4.Limited Estate t� 4a.Future Interest Compromise(date of �"A 5. Federal Estate Tax Retum Required death after 12-12-82) � 6. Decedent Died Testate � 7.Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes (Attach Copy of Wiil) (Attach Copy of Trust) _"'.;,."� 9. litigation Proceeds Received C� 10.Spousal Poverty Credit(date of death �d 11. Election to tax under Sec.9113(A) between 12-31-91 and 1-1-95) (Attach Sch.O) __.�.._...._.__� _�. a,�.,,�,� ,� _.�._..:.<....:. CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULO BE DIRECTED T0. Name Daytime Telephone Number rv � , � ir ,� � �� / � 1`; } ��i'��. � k,e � `/ �� tw 7 s�r } � /+`� ��`{'� d� ��``� ..°�� '� �� Y�� -� � ,�,�+�} - , ?...�` �y - �, =t�°7 ,' . . . . 'F""'J ..._._--.�--� �''.�--�'� � F�:GI��'t ;o'dfl9}��6�t7£a�r°"f; f!f t_._ � ..� � �. , �Y� � � � ; c� First line of address s�_ °• _ ..,; , _ ,. _ .,, ,_.. � � a r::� , � c�o :i �j t�j 1 4 f� i 6''1 !,.�. l. f.� # C7 C'J ;-� � ; �� . ,,.. k.�-^ : a. _ � � ,. . _ - ` . '� , . . � p ti� G�: '_ ....� Second line of address I " � C.J r � t�� , � --i P,,_- fC�E . � ` �' C.J Cn O� _. '; ,._. .+ 'T1; Ci or Post Office State ZIP Code �"'��g�� ty _ -----__ __.__.�..___ _..__.__ ., � � � ��. �, � � � � CorrespondenYs e-mail address: �(`�� `{ ��„�'��x.,��t+,�°�"'� � ��'`"°" .__ .,_.....� �_______�.___._�_ ,_..,,,...�..��.m..�.,..�,n .,.....�-�k____ Under penalties of perjury,1 declare that I have examined this retum,including accompanying schedules and statements,and to the best of my knowledge and belief, R is true,correct and compiete.Declara6on of preparer other than the personal representative is based on all information of which preparer has any knowledge. _ 7 _��-�...._. _..... ._,..a......_..�..�........-e.. „�.,.....,._.-- �-,..�.. , .,..-� ,�.-m��.,...�,. ,.�-.� ,.. VATURE F PE ON R ONS LE OR FILI RETURN D TE _ __�_..--- .._�_— —�----�, ____._�___ _. ,_�,_�__� r_,��.n .._,.. ,.rv �,.�,�.. � =��.�1__r.��,(�.?5 l�. .. .. ADD ESS � . ,.. �c, � �� ; i : . �C iT�:� .,. a,.�!�ACLe�e�_9'_�`�4�". _�.�d1_1 �...p+�...._......�__""_.,:_.-,.�..�-fL. � �,r?—_r-A..-,.m-..r�_,..,.�_..,_m_._M...,�................�,.-m,r..a..,_�.,.4_x�.a.,..,,m:.,__..._: SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ._.. _....._. . _.__ ..- --___.,,__�.._____,__,__,__�.____.,_._,_...T�.�,.-,--m..�-.._,..,..�.-..�,.__..,_. _ ADDRESS .. .�._._...._ .._ _.__ . ._ .�. __....._. .�-- -__ __.<_,-,,>.-,...�.s.,.�_,_..,� ......:�� .�.,._�..,. ,m...,.- ms_..,_.,, ..,.,.f.� �,�,..._,: -.�,_.:-� .,:_-,. ..-_.._ PLEASE USE ORIGINAL FORM ONLY Side 1 � 1505610101 1505610101 �� 150561�105 REV-1500 EX DecedenYs Social Security Number DecedenYs Name.��'��,CI.Q-..A.. ��C.I.l.ld�,.._ _. I � � � �} __ _ . ___. __------° ___ __._... _ RECAPITULATION 1. Reai Estate(Schedule A). ...... ....... ... ............ ......... ... .... 1. �,l0 � ��°�� 2. Stocks and Bonds(Schedule B) ....... ..... ... ........................ 2. � ��'T ,° �� 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . .... 3. �� 4. Mortgages and Notes Receivable(Schedule D) . ..... ............. ....... . 4. "' - � 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. ' � i� �:�� < � � 6. Jointly Owned Property(Schedule F) �� Separate Biliing Requested ... .... 6. ' � 7. Inter-Vivos Transfers&Miscelianeous Non-Probate Property (Schedule G) ��"'�r� Separate Biiling Requested.,..... . 7. �� ° ex � � `� �� 8. Total Gross Assets(total Lines 1 through 7). ........ .............. ... . .. 8. �� ' � (� j��:� �m- ,�„ �� _.__... . _. ________.____._._� ..�_,_____ .______._.._._�_�___.____ ._�__.__._...�_..___,__.� __.�.,�_�. ,...,o,.....�... _,�,..�,:,„,�.......... .,:.,� .-...� , 9. Funerai Expenses and Administrative Costs(Schedule H)..... ........ ... ... 9. '�'��' � � a� ,�.� 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule I) ....... ... ... . 10. s 11. Totai Deductions(total Lines 9 and 10)... ...... ... .......... ....... ... . 11. , Y� �Nt,� �;. 'r,�}' � � r o, 12. Net Value of Estate(Line 8 minus Line 11) . ... ... ... ........ ...... .. . ... 12. ' ��;�' ��l�-� �°_�j�.�; 13. Charitabie and Govemmental Bequests/Sec 9113 Trusts for which , an election to tax has not been made(Schedule J) .. . ... .... ..... ... . ..... 13. o 14. Net Value Subject to Tax(Line 12 minus Line 13) .... ... . ... .. ..... ... .. . 14. ` � (�`'�" �:�•'�m ��" .�.__._._...._. _.....��,.��...�____.._r_._.�.�..p..�:,�_ :��,,r,��.�.�.� --��,. .,M<�.�_,�. ..,.�_ .�.�....��.��.�.�... „�. TAX CALCULATION-SEE INSTRUCTiONS FOR APPLICABIE RATES 15. Amount of Line 14 taxable at the spousat tax rate,or transfers under Sec.9116 ta)(1.2)X.0- . 15. . �e 16. Amount of Line 14 taxable ,�" ,�- •7 � �`�' 16. :;� �p:�� ,�`' 1 � '' � Y at lineal rate X.0� � � ,� ,_)�'7' � 17. Amount of Line 14 taxable r` � � � � at sibling rate X.12 • �� `� : 18. Amount of Line 14 taxable � �' at collateral rate X.15 • 18. ; • � � �� - < _ ,- .,,,; �, • ,4�, 19. TAX DUE ........ ..... . .. . ... ... . ..... .......... ... .............. . 19. _ 'L'� tP � �� r...°�'e' 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �'�;`% Side 2 � 1505610105 7,505610105 REGISTER OF WILLS CERTIFICATE OF CUMBERLAND COUNTY GRANT OF LETTERS PENNSYLVANIA � �� 6 _ �\ �'' :i'u , n . �� No. 2014- 00440 PA No. 21- 14 0440 �� Es ta t e Of: PA TRICIA A KORNEL UK � (First,Middle,LasU t�� ;:� a/k/a: PA TRICIA KORNEL UK PA TRICIA HOFBA UER �`� La te Of: HAMPDEN TOWNSHIP �` CUMBERLAND COUNTY t.,.. �� 4�. Deceased - Soci al Securi ty No: � WHEREAS, on the 7th day of May 2014 an instrument dated January lOth 2013 was admitted to pro�bate as the last will of PA TRICIA A KORNEL UK lFirst,Middle,LasU a/k/a PA TRICIA KORNEL UK PA TRICIA HOFBA UER late of HAMPDEN TOWNSH/P, CUMBERLAND County, who died on the lst day of May 2014 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, LISA M. GRA YSON, ESQ. , Regi s ter of Wi 11 s in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: KIMBERL Y A WEA THERWAL KS ---- - - - - who has duly qualified as EXECUTOR(R/X) and has agreed to administer the estate according to law, aZl of which fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYLVANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 7th day of May 20�4. �. r �{ , ��,z� � � r�t� �� J� I ,�9.5..,, �.s e � 2 y� f t�. �' Regis of Wills, J �..- �, ) �� ' ,r'r� , d,,., �,.;�� ,y A ; ,� j , , o .�- �` ,�. .� �� i !~;� DeP Y r - .. �\-, � f.. **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) Last Will and Testament . . N . C=� � � � '�'.-:.,..... w � r� � =s —� � tT� � PATRICIA A. KORNELUK r� -�= c:� � =�'', ; ' :."7 -,. f'.... � i�� ,_. ._ .... ,. : ia'; � —,.. .._.. r��;:3. I, Patricia A. Kornetuk a/k/a Patricia Korneluk aik/a Patric�a,I�ofliaue�resrdin�in � � r�; � _;.3 '• �_._ �� the Borough of Hi.ghland Pa*k, County of Middi_esex, and Slate of T�e�a��'��'.�1,ha�g fi�xt� � _.D --! t"'s Q testameiitary capacity required by law do hereby mak� and publish my Last Will�l Te tament as follows: FIRST: I hereby revoke all prior Wills and Codicils. . SECOND: I direct that all of my just debts, my funeral expenses, and costs of administering my estate be paid as soon as practicable after my death. However, any debt or expense secured by a mortgage, pledge, or similar encumbrance of property which t �wn at my death need not be paid by my estate. Instead, suc�property may pass subject to said mort�age, pledge, or similar encumbrance. '�'�j� I �evis�e and beque�th my sniire.�stafe, �T!:et��ier rea?'�:'y�*s�r.�?; tangible or intangible, and wherever situated, and in equal shazes to my daughter, SU�ANN WEATHERWALKS, and to my daughter,KIMBERLY ANN WEATHERV�'ALKS. If my daughter, SUZANI�T WEATHERWALKS,predeceases me or fails to survive me by more than twenty-four(24)hours, then her share of my estate shall not pass to her issue. Instead, her entir.e share shall pass to my daughter, KIMBERLY ANN WEATHERWALKS, provided my said daughter survives me by more than twenty-four(24)hours. If my daughter, KIMBERLY ANN Vl%EATHERWALKS, predeceases me or fails to survive me by more than twenty-four�24) ho�ars, then her share of my :state .,�all not pass ;+�� '�er i��uE�. In�te�d, hzr entixF. :l:�r? s`�al1 �;as� to my daught?;; S[1%AN� WEATHERV�%ALKS, provided my said daughter survives me by more than t�Nenty-four (�4) hours. Tf l,�th rlanahters_ SUZANN WEATHERWALKS and • ' "' -'"--- '� `-^'-'� �� J ��..�� ' w.. r.�v� r, ivw �u �� vuiJ� ui\.1t ll�rl J11G41\. Vl 111�' �st��te srial) not pass ;t-. ;er issu�. In�tead; her entir�: ��:ar� shaJl i�as:;ta my daught��; S[17.,ANti WEATHERVt4'ALKS,provided my said daughter survives me by more than t��venty-four(24) hours. If both daughters, SUZANN WEATHERWALKS and KIMBERLY ANN WEATHERWALKS, predecease me of fail to survive me by more than twenty-four(24)hours, then my entire estate shall pass to my granddaughter, LQRA-LEE WEATHERWALKS-MII�'NICK. ��-<.��.,L:�.�.-- u. �Cr��-��-�--' Page 1 of 3 ___ _ __ _ _ FOURTH: I appoint my daughter, KIMBERLY ANN WEATHERVVALKS, as Executrix of my estate and direct that she not be required to furnish a bond in this or in any other jurisdiction for the faithful performance of her duties. In addition to other powers conferred by law, she is to have full authority to sell, convey, lease, encumber, or do any other activity with estate property that is needed in order to administer the estate, and this authority is to exist without the need for Court authorization in this or in any other jurisdiction. In the event my daughter, KINtBERI;Y .�NT� WEATHERWALKS, is unable or unwilling to act as Executrix either before or after my death, then I appoint my daughter, SUZANN WEATHERWALKS, as substitute or successor Executrix. She shall have the same authority as Executrix as my daughter, KIMBERLY ANl�i WEATHERWALKS, is endowed with and shall likewise not be required to furnish a bond in this or in any other jurisdiction for the faithful performance of her duties. -------------------------------------------------------------------------------------------------------------------- IN WITNESS WHEREOF, I have signed my name on this 10"' day of January,2013. /��.��. �_ �G��,�-��- Patricia Ei. Karnepuk The foregoing instrument was signed on the above date by the Testa.trix named above and was signed in our presence, we being present at the same time it was signed, and the above Testatrix declared to us that said instrument was her Last Will and Testament. We, Alma R. Marra and � �1�"i �� at her request and in her presence and in the presence of each other, have signed said instrument as witnesses on the above date. f-. .�^ �, ��--�� • f r "`�� 1901 Highway No. 27, Edison,New Jersey 08817 �� ^ residing at .�. �� c.�n��r-t ��, _ _ __ _ _ __ __ _ _ _ _ _ U�"� residing at `'�� _ �C-�i�G 1�"`�� '�?� . . �S�% �,-t i4� � f��; (;�'��6 3�? I, Patricia A. Korneluk a/k/a Patricia Korneluk a/Wa Patricia Hofbauer,the Testatrix, sign my name to this instrument this 10`h day of January, 2013, and I hereby solemnly, Page 2 of 3 � . sincerely, and truly declare and affirm to the undersigned authority that I sign and execute this instrument as my Last Will and that I sign it willingly, that I execute it as my free and voluntary act for the purposes therein expressed, and that I am eighteen years of age ox older, of sound mind, and under no constraint or undue influence. , � �4'�F—` -- ��c.C.4.et� (/�,c � Patricia A. Korneluk We, Alma R. Marra and ��'�� ,the witnesses, sign our names to this instrument this 10`� day of January, 2013, and we hereby solemnly, sincerely,and truly declare and affirm to the undersigned authority that the Testatrix signs and executes this instrument as her Last Will and Testament, and that she signs it willingly, and that each of us, in the presence and hearing of the Testatrix, hereby sign this Will as witness to the Testatrix's signing, and that to the best of our knowledge, the Testatrix is eighteen years of age or older, of sound mind, and under no constraint or undue influence. �'/ J j� '��--,-�c./•/t--�^—�--� �,�C_�"}-�Yu� � 1901 Highway No. ?7, Edison. Nev�Jerseti 0881? �` C, ��u �--• residing at `-�� -- �'��-�MO l,E`��f ��L, �.��-�. � �, �� 3c� STATE OF NEW JERSEY : . SS. COLNTY OF MIDDLESEX : Subscribed, solemnly, sincerely, and truly declared and affirmed to and acknowledged before me by Patricia A. Korneluk a/k/a Patricia Korneluk a/k/a Patricia Hofbauer,the Testatrix, and subscribed and solemnly, sincerely, and truly declared and affirmed to before me by Alma R. Marra and �� N� �� _________-� this 14°-%�Y�;�anuary, 2013. ,.� .�r' _ _ _ _ _ _ . _ _ _ verore me by ratricia A. Korneluk a/k/a Yatricia Korneluk a/k/a Patricia Hofbauer,the Testatrix, and subscribed and solemnly, sincerely, and truly declared and affirmed to beforE me by Alma R. Marra and _ �� ( (L3�r `I��C.� � , this l,�y��January, 2013. g i f ,/ / �� f .r� ,r '� .r �. , f,,�'•_ �'s. All�f'MO !.M , !R. � A Notary Pubiic of New lersey My Commission Expires�ugust 1,2011 Page 3 of 3 REV-1502 EX+ (01-10) �:.� � �� pennsylvania SCHEDULE A � ' DEPAfiTMENT OF PEVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ��r�ci� �� r��'�. All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION n ; 1. 7 � �, , � � , , ,� �, ' � l ,�'(„�� .,._ +.�^.�� 3 ti ', �xi.�xW,,� s z �1 ,�t �'�t �"�.,�� ., f �,� � y, ,.,. , �t�k� � � ; � , � �. _ -�..ti..��:,�—'°r � �`', \ t ,.} � �2 �+� a _. _ , ,t..� . �. .._?! { ;��..'. .. s �;... � � �a r �t ... Y� � :y� �1 ".„R,,;,- `'Ai � i �.. r„, .., . {.'..�.P t�. � , �..ti?"�� t._° `�' _ �.d�� K� �� f�C�r'r ,-+�.)��`��i t 1 , ^�� _ �r �:tA `'�� t�,,�� i ..�.?k 3.� �,�..3�^'�f,��.... �'�'r`.. "•.7 j � .{K,-C. �R..��:R.�:.�� . _1 ` �i = a'"'� °.�_�._"s,,� TOTAL(Also enter on Line 1, Recapitulation,) $ ��„��;:F'„�, ��vw;::�,� If more space is needed,use additional sheets of paper of the same size. �Il,. ��: .�.• I 1 � w � 6 ` �.� P ,x ,�C '� � ,;� ,�� ,. t�_ �. , �,•� �� i . ,._: . �, � � � _ GERTIFICAT� OF TIT�.E F'C�R A 1(Et�ii�8�,.� ��a;� ��. � �'.�- �`�=�%!:�: �,1,8 5 � �. �� ;�� ...�� . , � �.. � 3,4�5?OCi29�l�tJ09�,C1L1� i � � .`� ��2t7CiL7HAQC]CI�64A� � ,�Q�,� � R�I�t�AI� ; � 73�t�3L183"�4t��T t�{>; � � VEHICLE IDENTIFIC.4TION NUMBER YEAR MAKE QF�!'cH C4G , L . `fVT!E hJUb98ER.-, � �� ., I^.,, �- I1H Ll ��Ix'�4 EkEMP7 �# �:: BOOY TYPE � DUP i� SEAT CAP � P(�IUR�TITLE 5�ATE�� OdOM.PflOCC�.DATE � :ODOM.1v71LES, ;� . ..��ODOM Sl'AY135 I~ •! �f �V Y ,!t T I ��'Gi l �'F.. I ... �� 1 :. I � � . : I•_.;. � , D/+TE°A TITLEn DATF OF ISSUE UMLADEN WEIGHT GVWR �GCWR f ` 'iITLE BflANDS i �. . OOOME?ER STA?US�,. � ( � � C=ACTUA!MILEAGE � 1=FAIL�AGE EX,OE�DS 7HE AARCHA�IIfE�L �',a,.,: S' '61MYI`9 � . � ,' 2=NOT 7t7E ACTlJAL€AILEqCaE-� � � � 3=Nt�T THE AC'fiWAL MICPAt'�E-0.,b1U��i S . � �'. �^' �' „, : ' TARiP�.AING VER4FIEq..� `:' � !. � � k �`�`�. ' ��. 4=£%E�dFT FClOM q60MECEA pISGt6S}JRE '. �: �� a�or�ET�� nz�c�.v��;��r�� j.��xa�.: �.�� REGISTERED OWNER(S) . Y'°� ��'�"}- : 11TLE.8RANbS � n„i , � � 0.-AN7lQUE VEHiCI� �,y /�y� yr,�tp �+ty� ' �'a'�,. C. bL4SSiC t��HICLE 1"ri P 1\i 4.�i R h V 11�i�Lw W h��./� � rl�.c�Tx r z,�3�sN' 4�,t"�'r . � D' G04LEf.`T�2,t6 VEHICI.,E : : . . .. F� O T OF COUNTAY ' : L411�F1 �G.,�i HEi\�A�R� ��. . G� ORtGItiAtL7tdF6b F6R;NON•UB . " t.� � �. .fi�y�� . D157�1�4{Y7{� / s £ � F . � npr��t � =t w..�� _ �: At�rticu�rupR�u�Yia�� u , � �70��.Vt1�� r..L�� 7,, � -� c:; Lo�art�a.:yera�G`�.,° ^��y�� ,,��` p: i�mras apo�ice usHres�€ �� ; � ME CHAI�I CSBURG Pd 7�'7C!5C1 �� s�� ;��`�� nr � . . �'�. �bAtl�{�(f'7HF..�'F�HI�i�� v �V V��NCL£t�rtTAGa�riE1S5 �6Utrt3,�;�, . � � Y,E,FkAOb 1(E�ILSLE � .. ;- ''X�� fSWAS A'fi'�f '�'. � FIRST LIEN FFlVOR OP: SECOND 7-l�td KAVOfi QF: s .�� v � . � �'., `. �.�� ` � � '' r i � i �i�� a. i � � `It 8 9ECOAd 3i81;170IGBf i5 Usted dpnn salistaaS�On vP ihe�tYst tfen3 i�e�fjPsl' �.ii� - . I'renholdei'must,forvra�l;thFS Title;1c 41�d BiYreaqi of Motee Vehwl�.s�iir�t�e r N �� FIRST LIEN PEIEASED � .. dpprapriate fortn artd fee. �', ;. i�� i ly� � i7ATE � r i�r�an . _ �:, � ' ; `., � . - py .� � �� SECOND IiEN RELEASED � �. F . AUTNORIZE�REPRESEMATNE � �ATE;�" � �.MAIIINGADDRESS� . .� �. gY:� . . �.. . '-' � � ��' � � AUTk1Qri4ZE0 PEPRESEN7A`FNE" Q�1rOd~i ��•�s ��a�rRZ c�c� KtiRt�Ei�UK � L4RA WEA7H�'RWA�� 6Ct LiJRI CI f�� °`� - MECHANZ��6UR� P� 1,7C1SC1 +�t161� ��'�;1"��' ' � • � � ;� � - 5 �- DEPARTMEN;T,�F TRAN$Fbf�T�TiON� � � � � . . : . � . � . s�' � . . . . . , . .. .... � . . p p Q.y� {,� y^ , }� u - I certiiy as of tho dafe ol issup. ihe offidni�records ot the Pennsylvenia Department �� t1�i3'X�1 � ' �-�[t�4'•��- *� � yz� • ! ', .ot TransPOdation teflect thet the.poreonis)or company named herein is�the lawtul owner „ � - . : � . . .. .. . . , .. . . . . - ot ox said vehiole. � � � . � Secretar�oP 14'atY�pipY(a�on - _ - , : ,.. a �_r ac.,-: . . . . . . � � .. � � � . � �y � . � � ........ . , • - i . .. •• = � � � � � ff a co-purchas�r other th�cT'-Yonr spo�5e is�listed�hd yt�u?,��rn fhe bqe H3`'�� _ susSCaisE�abo swoRN be listed as°Joirrt Tenants'With Right"af SUwrvar�hip f�'Jn•de�tf�af ora� TO BBFORE ME: � M�„nhv __ vEAR ow�7e!' 6tle gbes to surviviag abvner)�HE�K HE�tE 0 C7}harv+��t��„tiHe R � wil(6a�ssued as-"Tenanis i�i Common"(On deatN r5F onB rrivneC°ir�erASho,�� w. � @eU^�a`sed awrrerga�to hi87Ner helYS or estete):•! �� 4," P � r aEa � u �tui r- . �oatti . i iF Nd�IiEN:CHECK(�' �S THIS A#�EL77�QP YES�IhY,p�QU1R�b�,YE��.�{�� ;, ;J� . � � . . . � �—;"_."°' ; . . : , s Q . r l u; W � 1ST LfENHOLOER FiNAf3CIkL IN3T[TUSION NUMBEti ; y �� '. ,� . � � � ��LIENHOCOER NAME ' �� " � �� ^ � r . . . x.s°1p�F a ' � _ � � /� ��.� . � . � i STREE7 �� V� .� . . ` . : .- . s ,� _ . � :�. . . . . I CITY; �� ' �STA7� ' �t�� Y' � : W � . . �� . �s., i IF'Nb.2ND I.IEN,CHECK 0 fS TNIS AN ELT?(1F YE5,�ItJ flEQU1RE�}t'E$C�i�,.q�' � � . . ,._i-:: �i.h r,r: Nihe y KlgrSipne•d hM B1 �M s ^FW 110 1 Gatlfi 6t .I !�in.fn the vehkAC de5[�CW � f_— . , . . r��ft�4 F � � aenw s�mµ.�io ma emvmnrz�as.,�d om�.iepai.owi�s a«,t n;m.nare. �2ND UENHOLD�R��FIN4NCtAL.1MS71TUT14N�NUMdEFl: I ,`; ix ��r r �;,�Iq : _ u �' � � ' � �' n ° � 2ND EJENHOIDER NAMfi 4 fii � � 91GNATUftE Qc AFPLIi;AMt OP 4.r(VIURI:?fiU�.I'";.lt:k ��_y��.�_,� .:' .- 1'. � STREET O . � CtTY� '.STAT@ =Z1P . SI;NATIiRE[1Ft•O'AI'FI�C��JT�iIi1.EOFAU1HlHIZF.L'S�GNCR. . ., ��. ., � •' e e • • s _ i „ �M11 iM��Fa ... . .._ . . .. . .. .. ,_ .. . , . „ . _ .,.. . . � �Mi!lFsI1�Y91�iw�! '. �:. },� �r?•��_: . �„�}.`2_” . :i ' .. �IY 1!IFJ/1l'aYILGAV1�IMly SLLIIP�i�.� ��A._��\1' �l.. ��P'la7&J/V(�� YYI'S^V9Jl�A1l1IB�h9/�'f"h.:tR��Td"d�A.�YVa.•.,-,,.••..•.••m•_.•....,.•.•...•—•^...••••�T••.^ _•�••••a•.A.•J.a••^,•A.••.••'••a••�_ � ��J�I�&_�t... 9"'1��TiJ 4�1 �. ..�.�`..-r . �.. .'..� •� '.-., � � S�aL'JtG 'i(? 3�-!�1��F�MS ANi�CC?�DfTi(?NS tiN k3Q7H SI�ES�1�-fi-iiS�'i1RCFiASE AC;RE�iVP��d'�',S�l��.�'�f a�Gfi��'iO S��.L A,�iD�UYER,�GRE�S TQ��P��f-�"':�,� � � ; T?-iE FC16_�.<adY4NG"UNti'"VNHIGF� M�41dS'TH�MO�ILFIiViANUFAC"i1IR�U HC1ME AND AfYY 6i�EiU!(3fi dAt�°�C11�9�lIVATiO�4?F 4TE1��AS C1�5CRIt3E� _ _ _ __.._ •. , ; - - f `� rc l �P(-IOPJE ' � DAT� ___ � � . I � _. __. _ _ _ T -- --- --- - - -. �_ _ i ApOi��__g �SALESPERSON , , i . . . : . �� If . . . i _. .. ... _._....... ._...`-- ---_-_.____.i '--- ___._. .__ . . _ ___...`--`--. ..... . _.. :..:. __. . _.___.... . .----... � ..� I � R1` ._ . ... ' .. � t � .��1DrF�� . � .� ' _. .. .._---- -----'- -- ' ' ._' - ---..., -��--_. _--�- -------- .. .._._--� � i 1,4, �u i YEAR �BEDROOMS �. �LOUR SIZE I HITCH SIZE S t CCK NUt�toER j �:;=�pFi_ � L �W L {W .. .- __ i_.1. _-.._.� __ I- ----- - - _-- ------ � ��RiAL �P�E'IPI �COLOR i PROPOSED DELIVEFiY DATE � KEY(�IUNIBERS 4� Nlif��iBcR ---_ ` ❑_U�� ,._. _. -- __-- -----. , �.__ __. ._ __ _ I �OCATfQN I ii-VALUE THIGiCNESS1 TYPE QF INSULATIQ(N �T- . i I i-�EI�i�IG - 1 - _ i _ - 13��E PF61C��l1�B9�" � : J _-- - _ __. . _.---- l EXTEFsIOP, __ _ _ ---- - -- -__._.._ _._-- - ___._ --�--- --- -I- - — -. _ __.__ _ ___ __ -------- OPTIONAL EQUfPME(�1T FLOORS I ___ __ _--- -------- - -- -- _ ___ __ --.. ._. . --- --- i _ _--_ THIS INSUtAT10lV INFORMATION WAS FURNISHED BY TNE MANUFACTURER AND SUB-TOTAL I ---_.. _ -------- _ ---- ---- _ -- -- -------- --i�-- --- f--- .... !S DISCLOSED IN COMPLIANCE WITH THE FEDERAI TAADE COMMlSS10N RULE I � _. . ------ .. . _— --_. --- 1 16 CFR, SECT(ON 460 i6 -- ------------------------- ___ ___.__. _ _.... _ _.._.__._._ --._ . ___ - ----- - ------- _ __ OPTIONAL E�UIPMENT, L.ABOR AND ACCESSORIES i --_. . _ _. ----...___ _ � ____ ___-----._ -- _ _ ______ _ - - - � �ION-TAXABLE I�EMS � ----- _. _ ___ --- _ : __ ___.._ _- - --- -- -- --- - - --__ _ , VARIOUS FEES AND if�SURANCE . , l ___ ___ ----. _. _ _- ------ - -_ _- __--- ------ ----- --__ _._ -- - ---- - ...__ � _---------- _ __ __�_ --— _ C�A�hi P�JFi�NAS� �Fil�� - - - =----L---` . _ __ _ _.i ---_ - ______ � TRADE-IN ALLOWANCE � jJ��f�� __ -----. __ _ __ ---- — _ -- --- // --- / '�, LESS BAL DUE on above � ' ---- --. _.. _. - --- -- _ __ _ - --- , - . _ ------ — f � . � ' i�Ei ALLOWANCE � � �� . — _� � _. __ __..._ __ -- -- ---- — --- — CASH D01NN PAYMENT $ �� "__.___ G. _ __ - . -.._ ..___ . _._ .. __'_. __'. ..._ . .. _ �� . ..._.. _ .—__ ... .__. __. .._. .._._ �a^ � _ �, '�`� CASH AS AGREED � ,� �� ... / l . ___ ___. _ ___ __ __.._ __ _ -- - � ti� L�SS TOl'�1�.�Ft�131T'� --- $ ' - _ _ . -- ---------- --- ----- -- _SUB TOTAL $_---- _ ___--- _._. _-- --- - __ _ _ _--- . . __- -------------- �_____-------I---- _ _ _ _ __-- - -- _ _ _ __.___ Unpaid�atance of�ash Sale Price � PENIVSYLlfAN1A USE TAK�iAS BEEN PAID Ot�l"i iiS t-t�3fUlE .__---_. . . ___.- --_---.----...___ ._ ___ .. ___._ BX 1'�� S�L,�.�R, �S R�l'�lUI�E� BY ACT 23 OE 290t?. _. --- _-----__. . _ .� r .'.9 .s. ..._ � _, .a,t:�t,-,�#�., „",,. � ��[i� r, -------- ___ _ --------._. _ __._ _ _ __ - , . ,` �'. 3!. � ``ez.: `.-'.�'+_.: i�ErA�.'. .. . .� -----_.. . . . . . .._. .....-- ---------._..__ . . BALANCE CARRIED TD OPTIONAL EQUIPMENT $ --- --_ --------__ __ __ ___. __-----------------�---------------- DESCRIPTION OF TRADE-IN YEAR s�zE Wheels aX�2S, lights, coupling and drawbar used in transporting X----- the urchased Unit are not included in the sale of the urchased MAKE._._._ .. . ._-... MODEL�-----_.-_.._ ...__...._-- _ ._-BEDROOMS P P --.__ __ __. . __._. ____ ._.._.__. Unit and shall remain the property of the Seller unless otherwise riTiE r,o. - seR�n�No. -- � co�oR stated in the Agreement as agreed to by the;parties or as --- - -- ---------- - - -- - - otherwise disciosed as required by federal, state or local ° AMOUNT OWING TO WHOM � , ' ----- ---------- -_ . _ _ __------------- law or rule. � ..� ' . s . e ❑ BUYER ❑ SELLER WILL PAY THE DEBT OWED ON THE TRADE-IN. , . , e, . ,� ----__ - - -----_----_ __ _.._--- BUYER(S)ACKNOWLEDGE RECEIPT OF A COPY OF THIS AGREEMENT AND THAT BUYER(Sl HAVE READ AND UNDERSTAND THE BAGK OF THIS AGREEMENT." � k �=.�.a,��"2�„? f�:��E*. _. ._;. t,., SELLER SIGNED X� ------ �--- ' — - - ----- BUYE . . . �`'" �� R .,.� •.. ^ �, _._.—____. ..--- �------ - -._._ ._.__. _._----�-- ' ' .,. . - ., Not Valid Unless Signed and Accepted by an ONicer of the Company or an Authonzed Agent SOCIAL SECURITY NO._ ` �`�-' �� ' � --�- ----.� :.__ ___. ._..- --._--- SIGNED X —____—_ BUYER , , _._ _. - ---- �,:.----- --- _ ., , _ By...._._._-._ . -�*-�t..--- A ravetl � � � � � .. �� - PP SOCIAL SECURITY NO._-�--!.---�/_.= ./---`----=--- i�ORM SOOPA ' A PLAIN LANGUAGE PURCHASE AGREEMENT Rev OS/09 Copyright�1983 JENKINS BUSINESS FORMS•(800)851-4424_ REV-1503 EX+(6-98) . v ' SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER �C�"(�1�► �- .� ��r►��?� t.,l.,�., All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH t. � � � } � �`, ''^� � t..F� ��.�..�7� � �-. '� �":'��;."�"' �4..'t �' a.,.. ��+��s ��:)�� .'''�_'.- ��,�< '" �n� ��'..f.,.�q ��'��_.�;..�1�� .:� TOTAL(Also enter on line 2, Recapitulation) $ � ��,�„�� (If more space is needed,insert additional sheets of the same size) � Page 3 of 3 • mputepshar� �� ' � Computershare PO Box 30170 College Station,TX 77842-3170 WithimUSA,US territories&Canada 800 649 3593 Outside USA,US territories&Canada 201 680 6578 � Hearing Impairetl(TDD) 201 680 6611 � www.computershare.com/metlife � MetL'rfe,Inc.is incorporated under the laws of the — State of DE. � PATRICIA A KORNELUK � Holder Account Number = C0029394768 Ticker Symbol MET CUSIP 59156R108 �:.�'��fi C u� �� fR e*;�� r��,E ..,":�c �F. �,�}fi ��;;�, '�"-' � 4 c,�;'�s�tr� � . y S��, 5 - s.�z# 3rsr r c'� �S� i `'��,,{{ y��,, �' '�' ' y�` �„��'��' �;a F �,�r� i ��t��t-�hi ��5'a�'�•� z+yr�,w � � j� }ifC � Fa"��'�a-�+� ',� :..�-� �-'�� ,*g i,�'. � 't i`t°� '�cs"'�k,�.� s.� �;�`� � '� � '� �`� + �k,�+ �4�'M p,� r� :. � _ �r ��. �"'�r .� s z, �- c� ..; { �j� �. .,� ��fi a:,+r �. i'. � t"�I^ +,�.tr�" �`a*��#g ��,a �s� � a � _ ._e . �,bf §t�14. .J'�!� s? r'' ,.,-° az ,�s;. , ,.s..,��' � �a.,z`,�'°"13'�.d`p�ias�+� Y.,e_ r�"�"'� c�m.,��i�lx�5:��;�<�:z��. � . "F' ..�,'S'�'� ^nr'� a � ! ,,�., :''��:i.e��a� � � €.� Account Information: Date: 14 May 2014(Excludes transactions pending settlement) Trust Interest Price Value($) (Share)Balance I Per Share 37.000000 50.92 1,884.04 (N)t CtiOfX)3.d.mix.051 G37_9672/OI6537/025tS49/i3 Page 1 of 3 � rnputersh�re — �� Com utershare = I e P � PO Box 30170 _ College Station,TX 77842-3170 = Within USA,US territories£r Canada 800 649 3593 � Outside USA,US territories£r Canada 201 680 6578 = 016 5 3? Hearing Impaired(TDD) 201 680 6611 ��I�I��,,,11111�1'��'��I�'��II�"II�"�I�I"��'��11 �.computershare.coMmetlife � MetLife,Inc.is incorporated under the laws of the � PATRICIA A KORNELUK State of DE. ,� 60 LORI CIR � MECHANICSBURG PA 17050-3665 Holder Account Number = = C0029394768 _ Ticker Symbol MET CUSIP 59156R108 " yy� ' �■t '�.""` �'J+ �� t�'�`� '� �m� ��F��:• ��1��t�� ",F '�k'�`�� ..'�t } 7��`: a �''s� M�`'r�� _ , .sE c . R .., .-. +�. f' �4 �`—�" '"e'..{ i Y":91' ,r�r sF �. j.�.�h�'�i9��{ Transaction(s) �� I Transaction Description Trust Interests CUSIP I Class I (Shares) I Description 07 Apr 2000 Opening Balance 37.000000 59156R108 Trust Interests 12 Jun 2013 TrustTransfer 21.000000 59156R108 Trustlnterests t4 Jun 2013 Decedent Trust Sales -21.000000 59156R108 , Trust Interests This Transaction Advice is your record of the indicated Trust Interests being credited to an account on the books of the referenced transfer agent.The Ttansaction Advice should be kept with your important documents as a record of your ownership of these securities.These Trust Interests are transferable only as permitted under the MetLffe Policyholder Trust Program.Please read the imporlant iniormation on the back of this form and in the MeIL'rfe Purchase and Sale Program Brochure. o� IMPORTANT:Carefully cut along the dotted line and return the form BELOW to the address provided. �C 01JEJA ------------------------------------------------------------------------------------------------------------------ Purchase Instructions Holder Name:PATRICIA A KORNELUK (See reverse side to SELL) If you wish to request a purchase,detach,compiete and return this form. Holder ACCOUnt Numbet' Make check in U.S.dollars payable to the MetLife Purchase Program. COO2939�+76H �1 V D Attached is a check in the amowrt of: ,,,�<:<'.:::::....:::::::::.:.::::::....�y,�,ra,::.:::.,:.:::::::,,.:.:�::::;::'':;;.:::.::.;.,<.::;.;:.;:.;,;,;, .... � . � ... I II'I�II IIII��III'III�II'I�I'I'�IIII'I'III'I�II I��I��II�I I�II I�'I • Nothirdpartychecks,moneyordersorcreditcardpaymentswillbeaccepted. 1�'1I�11�I��l��1�11��lll��1��'I�"��1��'�'�'��I�� • Please write your holder account number and the company name on your check. • This form should ONLY be used for MetLlfe,inc. Computershare • The enclosed amount will ONLY be applied to the account referenced to the right. PQ BOX 6��6 Minimum investment$250(except as described in the Purchase and Sales b�o�n��e�. Carol Stream, IL 60197-6006 DOOOOOOOMETL SPP3 C 0029394768 Please detach this portion and mail it to the address provided on the right. REV-igo8 EX+(ii-1o} � pennsylvania SCNEDULE E �� DEPARTMENT OF REVENUE CASH BANK , DEPOSITS & MI�C. INHERITANCE 7AX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE 0� FILE NUNiBER� � �.�r i G► a. ,� �r►'��c� Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH l . � �'��:.��,_�.- t.,ti�- )=��`�{�€v.�� r�._'��_�.> C,h��`r-�c� ��s��"�`� 225b �dC�?� �� ..�;�? � c�t�"�� t�..`�-�`� �'��'�' � � ��.��3 �_:�'k�iir��u _"• 6�� 1 t� tXX.��`��ta�Z`�t� �07'2„, ! �� i 1 � r l_ '��. {-r � � .�. ` „� '— '-'� =� 1 D C..�:�� 4 � �cc�� ¢:��a q'"'t;t 1 �� ?'c,�? ,,,a., .f.„?' $ � ��s ��: #� � x'.`.t � . �°i .�^ � „ , : ; � r C�r a '3 ��"��1 . ,,. f�� Y /� t� Jw. �� ,.`,�� C�1 �..t? j �._. �'�°� I S,a`�,!.. !! 9 C il ' �� .J ��" -f r ...; � � G�`�,'�� '�� ; a� r�^^� r°�.! `s' d i r�� -,��.� "t�'�� ,.�-. � {��$ �-��,�,4''� �, 6�. � i b' TOTAL(Also enter on Line 5, Recapitulation) $ � '� "'v "�� , � � 1 ,� �., .�,- If more space is needed, use additional sheets of paper of the same size. Account Details Print Friendly Page 1 of 3 ��s�tar +�I��:+��c�a�e� - ��?�e ��r�t ��tEU�� Balance S��nrt�ary:��3Z:3.�2 (available as of taday 05/03/2U?�+} ',,,,:��i�y 05rS);/?014 �!� `T��s�,�a�:tic�rrs Date Description Status $Amount $Available Balance Amount included in Available Balance �'S%t;l;20:.t� Cl�eck 4934 � -3,021.0� 323.42 Statement as of 04/24/2014 0�;'i�;Z011 Oniine Banking transfer from SAV 8302 C 1,7QC.00 3,34�.42 c�onfirr��ation� Z6447S59S8 Statement as of 02/22/2014 n;'/18,`201!.G C:heck <d9��' � -1,892.Q0 1,64-4.4Z �Zii�/201� SSA TREAS �10 DES:XXSOC SEC ID:36U241001U � 1,892.0� 3,536.42 S�/� INDN:PATRICIA A.., 02IQ�/2014 Cfieck 49?9 � -30.0� 1,b44.42 Statement as of 01/25/2014 Ci.t;'l.;i��01� Check 49�32 � --�,89Z.00 1,674.4Z !�7/()t3/20l<1 S�A TR.EA� .7I0 [?F`�:XY,SOC SEC ID:360241001D � 1,892.00 3,566.42 S�H TiUC�N;FATRICIA A.,. ii:i.%Q;:.!�'U�'-� ('heck �-1981 � -242.'�1 1,674.42 �Jlr`C��J201� Clieck 4980 � -185.28 i,916.83 Statement as of 12/24/2013 1?!20/2013 Check 4978 � -400.00 2,102.11 1�';�_1/�(".� ,�heck 4976 � -355.Q0 Z,502.17- i</17/201', C.17�cr �9%'3 C -18.Q0 2,85l.11 At;tr�:i�.01�� CiieCl< 49�? �; -350.00 Z,875.:t1 I�/_i 7/201� t,tiecK 4975 � -40�.fl0 3,225.11 12.%ii.!;?�13 SSA TPEAS 310 DFS:XXSOC SEC ID:360241U01l� � 1,862.00 3,625.Ii SSA tNDN:PATRICIA /?... i�j J C)i�C?1:; Check 49i4 C -25.Ot� 1,763.11 �'%09,/:2U13 E1eCCheCk 49%0 Ele�:.::hed< 4970 PSEG C ..J.76.16 1r788.1:t DE`_;:CHEC:i<PAYf�9"T C'rfE�k: �:�i97Q... 1Z;Q'1�<�1� Onli7e i�anking tr�i�sfer from SAV 8302 C :L,OQ0.00 1,9b4.27 C��t�irination# 1b52820465 https://secure.bankofamerica.com/myaccounts/details/deposit/print-friendly.go?adx=fefe343... 5/2/2014 Account Details Print Friendly Page 1 of 2 �l�a��*y� Mt��-ket ��vin�� $�4D2: ��aat�r�fi �,�tsa��y� �:.,_j;a;,c�� un�mary:�2�i.a� tav�iiabie as of today 45/0�/'�Q7�j �':eGV:[orfay ;}5/�i3/Z014 .t�iD T'��ansactiQns Date Description Status $Amount $Availabie Balance Amount included in Available Balance t:�'�j 2 ?�<01.4 Exrernai transfer fee - 3 Day - 04/7_3/2014 c -3.00 24.4� C:or�fi��mGtior;: 1.203�3428 Statement as of 04/24/2014 ;��..r'�'.3/:'O:i_�:a fr,t�r��st E�rr�ecl � O.C3� ?_7.49 ()=�;`�3;'ZC)1� "�Rf�NSFER PATRICI� A {<QP,NELUk: :I<zMC3ERl_Y � -1,000.00 27.45 V�IE/�TF-iFFtVV,�I_I< Ct��firmation# 032531_T666 0�%i�%?�1.�1 Online Banking transfer to CNI< 8603 Canfirrnation# r -1,7�O.Q0 1,027.45 ��847559��3 Statement as of 03/25/2014 0':��;�014 Interest Earned � 0.05 2,727.45 Statement as of 02/22/2014 0?/21j7_01t1 Int2rest Earnec! � 0.�4 Z,72?.40 Statement as of O1/25/2014 Ol/7_4/2U14 Interest Earned � 0,05 2,727.36 Statement as of 12/24/2013 t�/2�!�013 Interest Earr�etl � O,U6 Z,727.31 1�./0�%�0].3 Oniine 6anking transfer� to CHK 8G03 Confirmation# � -1,000.00 2,727.25 J.F3SZg7p465 ;._.;;_';:,'7O.i? r:i,eck �, -5�,550.00 3,727.Z5 J.�./�;;�07.� .4gent Assisted iransfer from CD �`509 � 7,3i7..77 56,287.25 C:onfirmati�n� 261.49I.22��0 1.i.!2��j201� Agent assisted transfer froi7i CD 3369 � 15,=z73.56 48,975.48 C�onfirrnation� 041.49Q3094 Statement as of 11/22/2013 11.;'%l;`<<�i�� Interest Earned C 0.53 33,50�.9Z ?.;;].2,'�013 N) -rL.R. cash withdrawal from SAV 8302 Sanking Ctr � -2,0�0.00 33,501.39 NIGHLANG PARK -=00902J.9 NJ... Statement as of 10/25/2013 .1.0!)4/2013 Inr�rest Earnzd � �.66 35,501.39 https://secure.bankofamerica.com/myaccounts/details/deposit/print-friendly.go?adx=6e 1 e89... 5/2/2014 o•: ; .,�,,. �I��t��A►�'1��1+�� '�� Yo�ar ��th�r ��our�t� # Your Certificate of Deposit Acc�unt� � :�,,� 4. ��ta��g?�' PATRICIA A KORNELUK Account Account number Interest rate("/o) Maturity date Balance Fixed Term CD 910 000 8280 6273 0.09 06/28/14 3,072.18 Fixed Term CD 910 001 2112 8663 �^ 0.06 09/24/14 3,053.05 Fixed Term CD 910 007 2510 1136 0.06 12/06/14 5,230.00 9 Mo Risk Free CD 910 001 4125 9871 0.11 06/30/14 5,020.68 Tota� d��i�yr�c:e -------— - - $7�°�,��.�'s Tir�.�,9 �R� F�aB�an�e --- $'1�,�d�.�`� Pa�e 7 of S BUREAU OF INUIVIDUAL TAXES Penns Ivania lnheritance Tax �� pennsylvania PO BOX��,,�"80601 Y .H!::ci(fSHUR6 PA 17128-0601 IClfO(fll$tlOrl NOtIC@ DEPARTMENT OP REVENUE "'"'-"', REV-1543 E%DocE%EC (OB-12) And Taxpayer Response � FILE NO.21 REVISED NOTICE Acrv �4�2�s4i * * * * * * DATE 05-21-2014 Type of Account Estate of PATRICIA A KORNELUK Savings X Checking Date of Death 05-01-2014 Trust KIMBERLY A WEATHERWALKS County CUMBERLAND Certificate 33 LIAM LN CARLISLE PA 17015-8814 METRO BANK provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: Account No.2843807187 Date Established 12-20-2013 REGISTER OF WILLS Account Balance $360.49 1 COURTHOUSE S(�UARE Percent Taxable X 100 CARLtSLE PA 17013 Amount Subject to Tax $360.49 Tax Rate X 0.045 Potential Tax Due $16.22 NOTE`: If tax payments are made within three months of the decedenYs date of death,deduct a 5 percent discount on the tax With 5%Discount(Tax x 0.95) $(see NOTE'} due. Any inheritance tax due will become delinquent nine months after the date of death. PART Step 1 : Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or 1 am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Pofential T�Due. g �The information is The above information is correct, no deductions are being taken,and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5% 1 am a lineal beneficiary(parent,child,grandchild, etc.)of the deceased. (Select correct tax rate at right,and complete Part � 12% I am a sibling of the deceased. 3 on reverse.) � 15% All other relationships(including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back of this form. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. BUREAU OF INDIVIDUAL TAXES Penns ivania lnheritance Tax r� �� Y�� pennS�/LV8t11c'a p�-+v�'2$0601 y HARRISHUR6 PA 17128-0601 Information Notice ' DEPARTMENT OF REVENUE "��"""� REV-1543 E%OocE%EL (OB-12) And Taxpayer Response FILE NO.21 ACN 14127342 DATE 05-21-2014 Type of Account Estate of PATRICIA A KORNELUK Savings Checking Date of Death 05-01-2014 Trust �* KIMBERLY A WEATHERWALKS CountyCUMBERLAND Certificate 33 LIAM LN CARLISLE PA 17015-8814 METRO BANK provided the department with the information below indicating that at the death of the above-named decedent you were a joint owner or beneficiary of the account identified. Remit Payment and Forms to: Account No.7760506182 Date Established 12-20-2013 REGISTER OF WILLS Account Balance $62,987.97 1 COURTHOUSE SQUARE Percent Taxable X 100 CARLISLE PA 17013 Amount Subject to Tax $62,987.97 Tax Rate X 0.045 Potential Tax Due $2,834.46 NOTE*: If tax payments are made within three months of the decedenYs date of death,deduct a 5 percent discount on the tax With 5%Discount(Tax x 0.95) $(see NOTE*) due. Any inheritance tax due will become detinquent nine months after the date of death. PART Step 1: Please check the appropriate boxes below. 1 A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed fo Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. g �The information is The above information is correct, no deductions are being taken,and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. � �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent,child,grandchild, etc.)of the deceased. (Select correct tax rate at right,and complete Part � 12% f am a sibling of the deceased. 3 on reverse.) � 15% All other relationships(including none). p �Changes or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back of this form. E �Asset witl be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax �f�ynheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. _ REV-1511 EX+(10-09) � pennsylvania SCHEDULE 1�1 DEPARTMENT OFPEVENUE FU N ERAL EXPE NS ES AN D � INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF /� FELE NUMBER `�c�;��i`c�.i a .}� `�r►��.C�-(�,�' Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. � .».ra _..,. ° ` `�. ; `�;.,�, _� �..,��.. 1 t,'�;,�. �� (�'�a,.��:'l � �l'�t�a�'t t��, �`� � ,c �;� ,�� $ �"�a� ',� � � ��, B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City ___State_ ZIP Year(s)Commission Paid: ___ 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address _.___ City _ ___._ State ZIP Relationship of Claimant to Decedent_______ 4. Probate Fees: t��F�� 5• Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL(Also enter on Line 9, Recapitulation) $ � �� If more space is needed,use additional sheets of paper of the same size. 37 East Main Stree[ Wnikiny tivith Those in Grief Mechanicshurs�.PA 17055 � Robert`Bob"L.Buhrig,Jr.,FD,Supervisor Web:www.Myers-Buhrig.com Wiliiam`Bill"L.Christopher,FD Directors(u�Myers-Buhrig.com Phone:(717)766.3421 Fax:(717)795.7291 STATEMENT OF FUNERAL GOODS AND SERVICES SEI..EC.7,ED Chargcs are only for those items that you selected or that are required.If we arc required by law or by a ccmetery or crematory to use any items,we will explain the reason in writina below. If you selected a funeral that may require cmb�lming,such as a funeral wiih viewing,you may have to pay for embalming.You do not havc to pay for embahning you did not ap- prove if you sclec!ed arrangements such as a direct cremation or immediate burial.If wc charge for embalming,we will explain why below. For thc Ser��ice of ` ' Date of Death/Preneed Charge to: _ .._-- JNamc Address City State A.CHARGES FOR SERVICES SELECTED: C.SPECIAL CHARGES ___. 1.PROFESSIONALSF,RVICES lmmediate Burial......................................................................$ —.--_,;_.. Basic Services of Funeral Director&Sta(7� .............................$ ' Direct Cremation.......................................................................$ _ °f _.,. Fmbalming/Clinical Care..........................................................$ Anatomical Gill........................................................................$ Other Prcparation of Body........................................................$ Forwarding of Remains.............................................................$ . Dressing&Grooming ................................................$ Receiving of Remains...............................................................$ Casketing or Reposing................................................$ SUB-TOTAL OF SPECIAL CHARGES...................................C$ .. Cosmetology&Basic Resroration..............................$__ D.CASH ADVANCES Dignity/Sanitary Carc ..............................................................$ Wc�dicrr�e rori for nru�sen�iccs in ohlninrng: _-_.,. Other Preparation ol'Body with Dignity/Sanitary Care...........$ Grave Opening..........................................................................$ Additional Care for Aulupsy and/or ponalion ......................,..$ ._ Other Cemetery Charges...........................................................$ _° Additional Scrvice,r•of Funcral DirectodEmbalmer .....:..'....`....$ ' � °""" � Graveside Equipment&Setup..................................................$ Addilional Services ofNon-licensed Attcndant(s) ..................$ `". Cler* � "` ,�_,, , �Y............... � , , . .......................................................................... Sub-Total of Professional Services.............................................Al$ " r Deacon/Assistant.......................................................................$ _ 2.USE OF FACILITIF,S,EQUIPMENT AND SERVICES FOR: Altar Server...............................................................................$ -'"" I�areweli Vicwing .....................................................................$ _ Sexton.......................................................................................$ _. . Viewing/Visitation/Gathering...................................................$ __ OrganisUPianist.........................................................................$ FuneralCeremony.....................................................................$ Soloist/Cantor...........................................................................$ ..,. McmorialService.....................................................................$ [nstrumentalist...........................................................................$ _,... Gravesidc or Comrnittal Scrvice ..............................................$ _' Hairdresser................................................................................$ _.. Cremation................................................... ...............................$ Military Honor Guard...............................................................$ -,_..., , : _ _. Sheltering and/or Refrigcration......... .::...............$ '" ,` Coroner's Fees...................................... ............................$ _ r.. , Brcak between Functions.........................................................$ Certified Death Certificates.....................:::.~�'............................$ .- ,. Sunday&Holiday I:vents........................................................$ _ Flowers......................................................................................$ ,,. Other use of Facilities.Equipment and Staff...........................$_.��,e Reception..................................................................................$ ..�,, 9 P ��..- Monument Purchase..................................................................$ Sub-Total of Facilities,E ui ment and Services......................A2$ ` � °'` 3.AUTOMOTNE EQUIPMENT Monument lnscription...............................................................$ _" Care Transport Vchicle&Service to Funeral Home................$ ' Patriot News..............................................................................$ _` ` ... Lead/Clergy Vehicle.......................................................... .......$ Carlisle Sentinel........................................................................$ .,, Hearse/Puneral Cuach ..............................................................$ _ Newspaper.................................................................................$ _w,. Limousine ................................................................................$ _. Newspapec................................................................................$_�_ Flower/Sta117Equipment Vehicle..............................................$ _ Other.........................................................................................$ ,, TransfcrVehicle .......................................................................$ _. Other.........................................................................................$ .... Additional Vehicle(s)Time Charge..........................................$ ' Other.........................................................................................$ � Additional Vehicle(s)Mileagc Charge.....................................$ " SUB-TOTAL OF CASH ADVANCES.......................................D$ r Sub-Total of Automotive Equipment.........................................A3 S " —�--..,. SUB-TOTAL FOR SERVICES SELECTED...........................A$ �..4 t a 4 SUMMARY OF CHARGES .._ B.CHARGE FOR MERCHANDISE SELECTED: A.TOTAL FOR SERVICES SELECTED........................... ...$ " ��- B.TOTAL FOR MERCHANDISE SELECTED......................$ � Cas kct.................................. ..............................................$ ., ;� .., Other Receptacle:Alternative Container(cardboard)...............$ `°' '` C.TOTAL FOR SPECIAL CHARGES............................... $ ` � , � t ' ,. Cremation Urn(fidl sizc)...:....:' .............$ " ` D.TOTAL FOR CASH ADVANCES.......................................$ � ...... . ......... . , ,.... Outer Burial Container.......................�,....................................$ TOTAL OF SECTIONS A+B+C+D..............................................$ _. ,., � .,... . Keepsake/Jewelry 4.:..;' ....: ......::: r...,...;.;......$ :, 5 Keepsake/Jewelry .......:: ......i., ..::�:..:......... .......$ ,' .�,!.; . Y__N�-�Price Guarantee Premium:A.......................................$ Kee sake/Jewel $ .. Y �i�l' Price Guarantee Premium:B.......................................$ Pry..................................................................... ,, Keepsake/Jewclry.....................................................................$ y,..:N, Price Guarantee Premiwn:D....................................... _ _,.. Memorial Packagc....................................................................$ TOTAL OFALL PRICE GUARANTEE PREMIUMS....................5 RegistcrBook............................................................................$ Memorial Folders/Prayer Cards................................................$ GRAND TOTAL...................................................................................$ ::,.:_. ScrviceBulletins.......................................................................$ _ _,,. PAYMENT............................................................................................$ Acknowlcdgement Cards..........................................................$ ,-. BALANCE DUE: -' ``'' PrintedObituanes.....................................................................$ .................................................................................$ DVDs........................................................................................$ Portraits.....................................................................................$ - REASON FOR EMBALMING Flag Case...................................................................................$ ❑Voluntarily Authorized by Family Temporary Grave Marker..........................................................$ ❑Viewing Burial Clothin ..................................$ • p'Other: <�' - ' g........................................ ' � ' �� "`.'fi'''" .,...�. ....r.............._..,..�........................................................_ - -- � - � Dressing&Grooming ................................................$ Receiving of Remains...............................................................$ Casketin ' �---•::......................................$� SUB-TOTAL OF SP ARGES...................................C$ ._.. Cosmc. �Iogy&Basic Restoratf�..............................$ D.CASH ADV-Ak E��C S�� Dignity/Sani Care ...........................................................::,� We chm��_rotr.foi•oru•sen�icec in oGtnirring: _.,_.. Other Preparatiort of Body�vith Dignity/Sanitary Care...........$�`� Grave Opening..:....:..................................................................$ Additional Carc forAuto s and/or ponation....................... $ ��"` P Y �, .. Other Cemetery Chargez .......................................$ _. .... .,.,�� ;_ ..._. Additional Serviccs af Funeral Director/F,mbalmer .:...: ..�...$�� Graveside I;quipment&Setup................. ..............................$ Additional Scrvices oi'Non-licensed Attendant(s) ..................$ ,. , , ,. Cler> ..................$ ""` , ,. : bY................................................................... . Sub-Total of Profcssional Services.............................................Al$ '` � � Deacon/Assistant........................................................... .........$ 2.USE OF FACILITIES,EQUIPMEIVT AND SERVICES FOR: Altar Server........................................................................... ..$ Farewell Viewing ....................................:................................$ ._. — Sexton....................................................................................... ViewingJVisitation/Gathering..................... .......................... Organist/Pianist.........................................................................$ Funeral Ceremony......... .�...........................$ ....,�..�..,...�:.::��::-:.:�.-.:::::.-.-.. ...- ..................._.�...-+ SoloisdCantor.................... .... _-. . . -� Memorial Scrvice.... .....:'":...'.....-........................................$ -.. Instrumentalist............�.�..1....................................................$ Graveside or mmittal Service.............................................. _ Hairdresser....................:::::.._....................................................$ _ : Crematio ......................................... ..........$ Military}ionor Guard............ - ..........$ ,N. Sheltering nd/or Re��igeration........ .:.....:. i.:................$�._ Coroner's Fees....................... ......... F...,.. . `..........$ ' Break bet�vee Functions .........................................................$ Certified Death Certificates........................_:....................:..... $ Swiday&Holida vents........................................................$ _.. Flowcrs......................................................................................$ _ Other use of Facilities. � uipment and Staff...........................$ _ Reception..................................................................................$ .,..,. Sub-Total of Facilities,Eq ' ent and Services......................A2$ �.`.�� `� Monument Purchase..................................................................$ " 3.AUTOMOTIVE EQUIPMENT ,, Monument Inscription.......... °" -�` ............. Care Transport Vehicle&Service to � nerat Home...............$ Patriot News..........�. ..................�..............................................$ ' Lcad/Clergy Vchicic..............................................................(.$ ,. Carlisle Sentinel......\,;`..........................................................$ Hearse/Funeral Coach .............................................................�`. Newspaper.......................�::.�::�,..... . ....$ , _ ,��........................... Limousinc .......................................... ....................................$� Newspaper.............................................:.-�...,,`......................$ _ -- FlowedStall%Equipment Ve � ..............................................$ '� Other....................................................................::::�..,............$ TransferVchic .......................................................................$� Other.............................................................................�.::::,$ _ Addition ehicle(s)Time Cl�arge..........................................$ � Other.........................................................................................$�'�. Additian Vehicle(s)Mileage Charge.....................................$ ° SUB-TOTAL OF CASH ADVANCES.......................................D$ � Sub-Total Automoti��e Equipment.........................................A3$ """` . ,. SUB-TOTAL R SERVICES SELECTED...........................A$ :�i '`: SUMMARY OF CHARGES _ ...,: B.CHARGE FOR M CHANDISE SELECTED: A.TOTAL FOR SERViCES b�CTED................................$ " CasheL...................... ....................................................$ B.TOTA[.FOR MERCHANDISE SEL�'FEA�....................$ ,, `' ., ., .......... . „ Other Receptacle:Alternative , ntainer(cardboard)...............$ ' ' `�s " C.TOTAL FOR SPECfAL CHARGES................�:..... .... $ :.. > _ Cremation Urn(full size)... .`.�.:. ..................$ ` D.TOTAL FOR CASH ADVANCES....................................... •" ` ' . .. ......... _.,. Outer Burial Container...:...................�: ......,.,-..........................$ TOTAL OF SECTIONS A+B+C+D.............................................. ;'r , „: .. _.. Keepsake/.lewciry � f' $ `, Keepsake/Jewelry .............`. .............. $ ' . . Y-N Price Guarantee Premi : .......................................$ Keepsake/Jewelry ......... ............................. ..................$ . Y ,N Price Guarantee Pr mium:8.......................................$ Keepsake/Je�vel .. $ �'..N- Price Guarantee Prem�iitm>.Q... . . . $ " ................................................................... ................................. Memoriai Pack �e....................................................................$ TOTAL OF ALL PRICE GUARANTEE P��R'�IGI S....................$ R�gister Book..... .....................................................................$ Memorial Folders/Pr r Cards................................................$ GRAND TOTAL.................................................................................. r .','c:..; _ Scrvice Bullctins.................. ...................................................$ ..... PAYMENT....................................... .......i..... ..................................$ Acknowledgement Cards.............. ..........................................$ - y .. PrintedObituarics ..................................$ BALANCEDUE:.........................................::::�,� ...........................$ , -':_ .. DVDs.......................................................................................$ . Portraits.................................. .............................................$ REASON FOR EMBALMING Flag Case..................................................................................$ IJ Voluntarily Authorized b� Temporary Grave •er..........................................................$. ❑Viewing � Burial Clothing..............��..-„'::� ....................................$ UDther: , __—__.__—_.------_-------- __�.�_. �_ ter .ot m�.........................................................................:$"--- — Website Servicc.........................................................................$ ' If any law,cemetery or crematory requircments have required the purchase of any of the Audio/Visual Usc......................................................................$ items listed above,the law or requiremcnt is e�plained below.At minium, Other.... ........:... . .:... ....:.... ``.................................$ - ❑the cemetcry requires the use of a basic outer burial container/grave liner. SUB-TOTAL OF MERCHANDISE SELECTED....................B$ ':'`- f;�the crematory reyuires the use of an altemative(cardboard)container. t/We agrec that 1/we have csamined ihe items of good,services and cash advances selected above and found them to be wrrect and in accordance with[he anangements I/we have reques[ed. VWe ac- kno��ledge reccipt ol'a copy of this Statement oF Funeral GooJs and Services Selected. 1/We represen[tha[1/we have sutTicient funds availabte 1'or payment of the cash price for the good,services and cash advances selected. I/We also�gree to makc paymen[in full within thirty(30)days. (/We agree ro be jointly and severally liabtc with anyone and everyone else who signs Ihis agreement. A late charge of LS'%per month amounting to 1 R"/o per year w•ill be applied to thc unpaid balance beginning 31 days from the datc of[his agreement. UWe will also pay Myers-Buhrig Funeral Home and Cremarory,Lld. all reasonable costs incurred by Myers-[3uhri�Funeral Home and Crematory,Ltd.to collect any amounts 1/we owe under this agreement. T'hose costs may include but are not limited to attomey's lees. court cos[s and all olher rnsts. Any additional sen�ices or merchandise ordered or reques[ed after the dalc and/or signing of this agreement will be considercd par[of[his agreement and Ihe cost thereof will be reflected on the final bill and/or statement and are subject to the payment terms spccified herein. IN WI'I'NESS WHGRCOH,tmd intending to be legally bound.U�ve have executed this contruct lur Funeral Goods and Services Selected. (Purchaser) ` (Purchaser) (Purchaser� � (Date) % ; .,� _ (Purchaser) (Funeral Director)_ �� • ' ��,�' ��x-= Whilc:Insurance Company or Trust or Funeral Home Yellow:Myers—Buhrig Funeral Home and Crematory,Ltd Pink:Client Pamily Rev. 11/12 ' � Reset ) PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF Cumberland COUNTY,PENNSYLVAIVIA 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 Inforroation Name: Patricia A Korneluk File No: a/k/a: Patricia Korneluk (Assigned by Register) ��a: P8�cia Hofbauer a/k/a: Social Security No: Date of Death: OS/O1/2014 Age at death: 75 Decedent was domiciled at death in Cumberland County,Penn�,ylvania (stare)with his/her last principal residence at 60 Lori Circle MechanicsburE PA 17050 Hamnden Tovcroshin Cumberland Countv Street sddress,Post Offlce and Zip Code City,Townsttip or Borough County Decedent died at Holv Snirit Hosaital 21st Street Camv Hill PA 17011 Camv Hill Borou�h Cumberiand PA Street address,Post Oftice snd Zip Code City,Township or Borough County State Estimate of value of decedent's property at death: Ijdomiciled in Penxsylvania............................ All personal pmpetty $, 89,100.00 If not domiciled in Pennsylvania. ....................... Personal property in Pennsylvania $ If not domiclled in PennsyJvania. ....................... Personal property in County $ Value of rea!estate in Pennsylvania......................................................... $ 25,onn.on TOTAL ESTIMATED VALUE. ... $ 114.100.00 Real estate in Pennsylvania situated at: 60 Lori Circle Mechanicsburf;,PA 17050 Hampden Township Cumbertand (Attach additio�ral sheets,i(necessary.) Street sddress,Poat Office and Zip Code City,Township or Borough County ✓[� A. Petition for Probate and Grant of Letters Testamentarv Petitioner(s)aver(s)he/she/they is/are the Executor(s)named in the last Will of the Decedent,dated January 10,2013 and Codicil(s) thereto dated State relevant circarostaoces(eg.renuxciaaion,death of executor,etc) Except as follows: after the execution of the instrument(s)offered for probate Decedent did not marry,was not divorced,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 did not have a child bom or adopted;and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. Q NO EXCEPTIONS O EXCEPTIONS ❑ B. PetiNon for Grant of Letters of AdministraHon (If applicable) c.t.a.,d.b.n.,d.b.n.c.t.a.,pendente lite,durante absentia,durante minoritate If Administrallon,a�a or db.�r.��a.,enter date of Will in SecNon 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 ��Pa ('S_6'i323(a)and was neither the vicdm of a killing nor ever adjudicated an incapacitated person. _ _ _ ._ _ __ .__ . ; .,� , ' " [�"Track your expenses... �use(ifany)and heirs(attach g ❑FOOd ❑TranSpOrtatiOn �TAX-DEDUCTIBLE ITEM o ❑Clothin 1 p6 a ❑Credit Card ❑Utilities ❑Mortgage � �� ❑Entertainment ❑Insurance ❑Other: � ' '� � x�7•� '' S � `...1.'s BALANCE• � ..:.� ' � - . � FORWARD ..� ��. . � � � . �� _� i � S �. � � � ,- �� ? � f� { '" THI6ITEM �q"�3`' �� -.,. , a , ... _. . , , � _� � -- ,�.� ', _ ... . , �k_3 , . __ - ` . . i 4'�. u3rv�.�; f - - . ;- , . . ___.,__.___,. _ t{ � BA � � �. . ._..... . ... �� : �� ... �.ti, t 1',, r-�'. ,.._.v...3.s �,,. ;;. DEPOy��' � �� OTHER '�� BAIANCE � � � - ' FORWARD �_ �, d 1 1 '_�� !�f 7. ��I .;. ' '(�. � ..,,l.],_ ... . � � . . . . . � . ..�3 For added security,your name and account number do not appear on this copy. NOT NEGOT1,46LE :� Page 1 Of 2 ' _.. . . _.Tr .