HomeMy WebLinkAbout02-0544Register of Wills of Cumberland County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Estate of Helen B. Pakosh
also known as
Randall F. Byre and Patti L.
Petitioner(s), who is/are 18 years of age or older
(COMPLETE'A' or'B' BELOW:)
No. .Z/-oa- SYY
Deceased SocialSecuriryNo. 166-12-4386
tor:
A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the execut ors named in the last Will of
the Decedent, dated 08/03/1998 and codicil(s) dated None
State relevant circumstances, e.g., renunciation, death of executor, etc.
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents
offered for probate; was not the victim of a killing and was never adjudicated incompetent:
B. Grant of Letters of Administration
d. b.n.c.t.a; pendente life; durante absentia; durante minoritate)
Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and
heirs:
or principal residence at 618 Brookhaven Road, Borough of New Cumberland New Cumberland PA 17070
(list street, number, and municipality)
Decedent, then 79 years of age, died 06/01/2002 at New Cumberland, PA
(Location)
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property $ 78 , 000.00
(If not domiciled in PA) Personal property in Pennsylvania $
(If not domiciled in PA) Personal property in County $
Value of real estate in Pennsylvania $ 120 , 000.00
situated as follows: 618 Brookhaven Road, New Cumberland, PA
Wherefore, Petitioner(s) respectfully request(s)the probate of [he Iasi Will and Codicil(s) presented with this Petition ~.,,t eti-..r~.,•,.•
Decedent was domiciled at death in Cumberland County, Pennsylvania with his/her last family
17-b~ 11
Preparetl by the Pennrylvanla Bar Association
Copyright (c) 7996 form software only CP9ystems, Inc. Form I~ W-~ (1991)
Oath of Personal Representative
Commonwealth of Pennsylvania
County of Cumberland
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true
and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of
the Decedent, Petitioner(s) will well and truly administer the estate achording to law.
Sworn to or affirmed and subscribed
before me this~day of
~~
For the Register ~~
21-02-0544
Randall F. Byra //
L. Byra
No. 21-02-0544
Estate of Helen B. Pakosh Deceased
Social Security No: 166-12-4386 Date of Death: 06/01/2002
AND NOW, JUNE 7, 2002 ,inconsideration
of the Petition on the reverse side hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters QX Testamentary ~ Of Administration
d. b. n.c.t.a.; pendente liter durance absentia: durance minoritate)
are hereby granted to Randall F. Byra and Patti L. Byra
in the above estate and that the instrument(s) dated 08/03/1998
described in the Petition be admitted to probate and filed of record as the last Will of Decedent.
FEES
Letters........... $ _ 235.00
Short Certificate(s)...4. $ 12.00
Renunciation. $
Affidavits ( ) $
Extra Pages ( 2 ) .. $ 6.00
Codicil. $
JCP Fee.......... $ 5.00
Inventory. $
Other .. $
14-~
Register of
Attorney: James D. Bogor, Esquire
I.D. No: PA 19475
Address: One West Main Street
Shiremanstown. PA 17011
Telephone: 717/73 7 - 8761
TOTAL......... $ 258.00 MAILED TO ATTORNEY JUNE 7, 2002
Preparetl by the Pennsylvania Bar ASSOCIation Copyright(c)1996 form software only CP9ystems,Ina Form RW-1(1991)
v vlx~
i his is ro certif~,Y that the inf~rmacion here given is correcdv copied from an original certificate of dear6 duly filed with me as
Local Registrar. 1'he original certifcare will be forwarded u] dic SCICC Vital Kecords Office For permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
P?v for rhis ce"rificare, S~.OU
_.P 8208288
o.
21-02-544
IDS.:a RS• vm
yip ~ ~~~' ~
Local Registrar
JJN G 4 ~~0?
I)a[e
COMMONWEALTH Of PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
__
SEN 5(iC LSECU IIY UMBEfl OAIE OF UfAIN ~Mwyn, My,'mYl
1.
' 166 - 12 - 4386 a. June. 1.2002
Ac3uaN amb.N DNDERI YEAR LIlILERI DR- IWEDEiImN awrHPUCE -.~'o ~PLFce
a ~n
o
N~rr
MpMa • DaY• IWa . MNUba WY 1Yr ~Nla.a ru -- "Y Mavu•
r ~Mwm ry nrYl NDSP UL -
'
OTHER:
x 79 YY. i Iryalru C7 EWQynuull U
DOA [] ,Wtl"r°^9 ^ -..
•June 19x22 ,. Dante, Va
RavNrca~
• LouNTYOF DF
v
3
^
E..
.
1
H
wcNl
CITY BLVp.1NTCF DEATH fAC0.T'NAME In wIUw~Mw. y+e areal nl
rMn ~
YMSCECFDEM tX Xl5MNC011N]INf flFLE-Amxun bdan. BMdL W,Ma. apc ~
N
QuEberland New Clunberland
PmrLNa.n. I$ .YI
wW
~
a
bN
,.
p
~
DECEDENT'S USUAL OLLURQp)N I(INDCP W/SINESYWg151NY YwS OFCEMNi EVEp NI -•~OENi's EDUCATpN E ,E.
Idva Ybdapa Sxy pw
US MYEDiDI1CESi 5 W n ay m~ YNIIIAL STATU6-NYIy $Lpywp,D~~
a.vLayY.. ea Ml wra~rrol
~ M
N
E~~~ ~
Ya.
mYa wm..e. lu.a. r'.maw,Mm.l
:dw' DrwIYNlspeNm
• Yl Secret
M^ Nei
Dlx
Hol S '
I
,,..
l D
rit Flos i a1
DECEDENT'S Y4LIN
12
,l
d
.
G AODI,ESSryrwl. Caylbnn. Sly.LpCme1 CECFDENT'S
Y. W1
OW~ ,E.
618 Brookhaven Road AciuR n.. Y.Y_Pa
qp I„.^ r«
a.~.swN
Ni
pE
_
.
a
r
yDENCE ewaaYa ~
~~~ Mn•
,~ New O.unberland
Pa 17070 '
,
,„L CEnlberland "m°N^x "°'°iOiONN ~^^
FRNFA'B NAYEIF.Y. MinQa. LaW YrnN-'----- IF..®nalwapWlYbad New ~LIYIIl4Y7 and
~,~a
„. Herbert F. Jackson YDrNER's NAPE,F.a,MnY. YabwswwrNl
NroRWwrsNAMEOY,YP,;m ,,. Margie J Jackson
,y Randall F. ra INfoRYANrs YAkNq ACORE$$ISOW.CNy/ipa~. $Yb.zy CObl
NE,NDOOF gS{VSITN)N „.. 15 Scarsdale Drive Hill
Pa 17011
ON
,
~~A
FOF pISpOyTMJN PLACE Of g3PoSRMy1~NarrM dCamY
llwin.lyY.'YI aON•r P1Ya W.CrYnYYY LIX:FgN.LMLNm.9Wa. ZV COb
NIrRm^ nmNnlN gNMlm^ flwrovl Yan Aa4^
^
ISper/yL
f]
K
FUME ACTING AS SUCH „O. Jllnf'. Ej 2002 „cROllln rrfafn CEmete :,.
C H
ll
.
i
Pa
LCEHSF NUNBEp NAYF ANOADDREgSpf FA[:p1TY
„, 011654-L _ 903 ~~Eet St~~~
u
1 P
1
Ien9.. aa
o,~wrwYrMnrn.. buamM•M,m.a
a
Ya Iwy°IG•YAIU IS
YluamlW
IICEHSE NUMD
g
l
E GATE 410NE0
~ dbu
IYCM. LW. Yarl
,„.
Em N.„mmb
N
pU
wtln Yn ~ b TWE Of DEATH DATE HCED DEAp IMru.n. Da, Yer "„~ ~'~
_ pgpT
Y 1 VMSCASE gEFEflpEO tt]MEDICK EYAMINEWCORONEpY
1
I
' y
r~
,,. MRTL EMn IM JNaua
w
N
.
4a
Y[mwlu~IpmvN[n fA IM Ga•N DOmIWpIMnWaaIJ
LW Odywy Gma ryl a•IAYy. Y^q. sum aa[arbY arr alwY and.aMCaq Man laYwa
IApploaynab
PApT N: DoW yyyry,yNCYgywamlpEJYybbYll W
'mwr
~ T~~ EE IFaW 1
~~••n YvN(q Na YIGYarygYawpwrn PlATI.
WE IOpRAS ACCa15EWENCE t)Ft I
f ~~ ~ _
e
.
NYIN,u
ur.E.Y.IRUERUwD DL,F roIDn Ac Er~S M:
CMi[IOUran M+r c rte) ~
tl"~•"•"Y
q,E iOION A$ACCNSEWENCE OFI: r
laapepnarnl WT
1
a
____. _ ___ _ _ __ __ r
YMS ANADIOPSY WEpF AUTCPSYFINgN(i5 YANNEp Of DEATH ~ 0.VE OF IKIUNv
PERFtl1YEOf AWLA9LE PRIOP Ip iIYE OFINIUflY
INJURY Ai\gI1Ni pEgLPo9E1p.Y1NNWYq:pIry,ED.
coMnETroNDFCAD3E
IMmin wr. wan
~
of CERNp xpwY pm,r,,,a, ^
Ac[ANn ^ Pmgrw NwugYen ^ w. ^ No^
~ ^ NO~ Yaa ^ M ^ 3i•b• ^ CaaJm4owamwaE ^ PLACE OF
N
4. tl. ,
I
IURY..V IVny. Nrm, yr I
eal. anYy. oXka LOCATEMa ap'6av,5W1
,Ea. ,tl. ,,, pWUp. YC.lSpcavl ISESC
CF,E,IRER ICned vYY noel ~' ]W.
'
LIRFIFYWp PMYLCIINIFTyecYncmYyugcYrY ngMr yrvsc anlp MwYllrlr'
TnlM paalu,YYEmmlppa. ll•aN Oe[unM iw M
~~ em x]I SGNQURE AND TITLE ERilf
...... ... ^
ary MMmanmlaaYW... ...~ '
~
'PpONDVNDI,ID , s. •
A
ANDCERTIfYWOINYSK1AN iT uu cupupaNe pintllwl
Ta NY 4al of mYYro•YC9..E W ay alUy lYm y Yb plaA. •rp oua lolMyu 11 alv as aulao ..... ~ LICFN9E fXIM ORE 9NiNE0114 4y. ws1
] _~__
~ L / (p 'f , „C ~ .~
~
~
'MEDICAL E%AMINERICORONER
O
IM _
_..
NAME AMDADMESSOF PEfl$
CDYRETEDCWS~ ATN
DIY
~
PI TYpappuy
II
Baia o,aaamllvllo aM/ N9alw my opm an. O.YN OCCUnW a, IN IlmE paY antl pl aIYGU. LOIN auaalbaM
MmIM , lae .. `/
r
~
+~~- ~CA TPc FV`'ZV
...... L
`J
l,a.
RFf19TMp'$$KN LURE AN
D
N}IMSER ~- --
~ \ ~ 1'7 C ~ A
.
~~
~/,( ~ /
11.-4iI/~~•t:/ /''~, ~% .. ,. -a 6L[_/aV / I
I t
_~ ry~y
WIE INEDIM inN ]
21-02-544
BE IT REMEMBERED that I, HELEN B. PAKOSH, of New Cumberland,
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 all my just debts and funeral expenses be paid as soon
after my demise as may be convenient.
ITEM 2: I hereby give, devise and bequeath the following items to my
daughter, Patti L. Byra, as her sole and separate property:
A. All of my fur coats and jackets that I have at the time of my death; and
B. All of my sterling silver that I have at the time of my death.
ITEM 3: I hereby give, devise and bequeath the following items to my grand-
daughter, Tracy L. Byra, as her sole and separate property:
A. My diamond ring;
B. My diamond ring guard; and
C. My diamond necklace.
EM 4: I hereby give, devise and bequeath unto my son, Randall F. Byra, my
grandfather's gold pocket watch.
STEM 5: All the rest of my e~welry which I have at the time of my death,
hereby give, devise and bequeath unto my daughter, Patti L. Byra, and my daughter-in-
law, Judith M. Byra, to be divided amongst each of them as they mutually agree.
WITNESS:
~s~~~_
~J~tic.~ /ot /~'-~~~a-f~ (SEAL)
HELEN B. PAKOSH
ITEM 6: 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 issue, Randall
F. Byra and Patti L. Byra, in equal shares, per capita.
ITEM 7: I appoint my children, Randall F. Byra and Patti L. Byra as Co-
Executors of this my Last Will and Testament.
ITEM 8: I direct my Co-Executors, or their successor, 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 being my
intention that none of the aforesaid taxes, either federal or state, on any 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.
ITEM ~ I direct that my Co-Executors, or their successor, shall not be required
to give bond for the faithful performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 3rtl day of
August, 1998.
WITNESS:
S~._ ~ _
y
HELEN B. PAKOSH
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF YORK
We, HELEN B PAKOSH MARTIN MILLER ESQUIRE and NILES S.
BENN. ESQUIRE ,the Testatrix and the witnesses respectively, whose names are
signed to the attached or foregoing instrument, being first duly sworn, do hereby declare
to the undersigned authority that the Testatrix signed and executed the instrument as her
Last Will and Testament and that she had signed willingly (or willingly directed another to
sign for her), and that she executed it, at 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 Last Will and Testament as witness and that to the best of their
knowledge the Testatrix was at that time eighteen (18) years of aqe or older, of sound mind
and under no constraint or undue influence.
T STATRIX
S- ,~_
ITNE S
WITNESS
Sworn to and subscribed
before me this 3rd day
of August, 1998
~'G
NOT RY P BLIC
My Commission Expires
W3~aTIf3~ if'3I
Ca ~ I r. ? 7*{ Pt~bAO
b^.~r t l r., i ~ , ay
~/(yCanM rvr q ,a~ 2~,13~;a
eylvaNa fisiocwiwm oi`Nctzriei
Register of Wills of
Estate of
also known as
B. Pakosh
Personal fiepresentati~
Signature: ~ ~~r
R nd~1~t~Byr ~-~
Signature: ~ ~~ ~,
Patti L. Byra
Address: 15 Scarsdale Drive
Deceased Social Security No. 166-12-4386
Randall F. Byra and Patti L. Byra,
Personal Fepresentative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the
personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation
placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned
no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this
Inventory. I /We verify that the statements made in this Inventory are true and correct. I/VJe understand that false statements herein
are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities.
Attorne f: James D. Bogor Esquire
Y
I.D. No.: 19475
Address: One West Main Street
Shiremanstown, PA 17011
Telephcne: 717/737 - 8761
No. 21-02-0544
Date of Death 06/01/2002
Hill, PA 17011
Telephone: 717/761- 3303
Dated: 12/C9/G2
Description
(See continuation page(s) attached)
(Attach additional sheets if necessary)
NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the electi~
include the value of each item, but such figures should not he extended into the total of the Inventory.
CUMBERLAND County, Pennsylvania
INVENTORY
Value
Total: 161, 646.11
f the personal representative,
Prepared by :he Pennsylvania Bar Association
Copyright lc. +996 `orm software only CPSys[ems. Inc. Form SAW-~ (19921
INVENTORY
Estate of:
Date of Death:
County:
Helen B. Pakosh
06/01/2002
Cumberland
CASH:
Comcast Cable - Refund
J. C. Ehrlich - Pest control
contract - refund
Myers Harney Funeral Home -
Refund
Nationwide Mutual Ins. Co.
Auto insurance refund
Patriot News Co. - Refund
Personal property sold at
private sale
PNC Bank, N.A. - Checking
Account No. 5001043451, date
of death balance $3,223.48,
accrued interest $0.25
PNC Bank, N.A. - Savings
Account No. 5003143165, date
of death balance $15,381.60,
accrued interest $14.91
16.33
205.64
512.00
125.50
127.40
1,107.00
3,223.73
15,396.51
20,714.11
-1-
PERSONAL PROPERTY:
------------------
1962 Philadelphia Mint Set -
as per attached appraisal
1997 Chevrolet Malibu, Vehicle
Identification No.
1G1NE52M6V6114733 - sold at
private sale
Fur Coats and Jackets - No
value
Jewelry - as per attached
appraisal
Westmoreland Sterling Silver
Service for 8 - as per
attached appraisal
8.00
6,700.00
7,774.00
450.00
14,932.00
REAL ESTATE/PA
All that certain piece or
parcel of real estate having
erected thereon a dwelling
house being known and
numbered as 618 Brookhaven
Road, New Cumberland,
Pennsylvania. The property
was acquired by Frank S.
Byra and Helen J. Byra,
husband and wife, by Deed
dated September 18, 1956 and
recorded in the Cumberland
County Recorder of Deeds
Office, a copy of said Deed
being attached hereto and
incorporated herein. The
said Frank S. Byra died June
2, 1969 whereupon full ad
complete title to the within
described real estate became
vested solely in Helen J.
Byra, the decedent herein.
The said Helen J. Byra
became intermarried with
John J. Pakosh, thereafter
126.000.00
-2-
being known as Helen B.
Pakosh. The said John J.
Pakosh died July 7, 1998.
The above-described real
estate was sold pursuant to
an Agreement the the Sale of
Real Estate dated July 7,
2002, a copy of which is
attached hereto and
incorporated herein. Final
settlement took place on
August 12, 2002. A copy of
the Deed conveying said real
estate, along with a copy of
the Settlement Sheet, are
attached hereto and
incorporated herein. The
sale price of the real
estate was $126,000.00.
126,000.00
TOTAL RECEIPTS OF PRINCIPAL ............... 161,646.11
-3-
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARR188URG, PA 1 ]128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
N0. CD 001931
BOGAR JAMES D
1 W MAIN STREET
SHIREMANSTOWN, PA 17011
role
ESTATE INFORMATION: ssrv: tss-t2-n38s
FILE NUMBER: 2102-0544
DECEDENT NAME: PAKOSH HELEN B
DATE OF PAYMENT: 12/10/2002
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 06/01/2002
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
101 ~ $42.60
REV-1162 I:XI11-961
TOTAL AMOUNT PAID:
REMARKS: RANDALL F BYRA & PATTI L BYRA
C/0 JAMES D BOGAR ESQ
CHECK# 509
INITIALS: CW
SEAL RECEIVED BY:
$42.60
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
B pakosh
Helen
Name of Decedent e 1, 2002
Date of Death: Jun Admire, No•
02_0544
21-
Will No. required by
To the Register: of ate admwasstiated on or mailed
est sere estate on
Cour Ruleabove-captioned
the
1 certi o f thet Orphans es of
Rule 5.61a) beneficiarl
to the following
June 20, 2002:
Address
Name
Patti L• Byra
Randall F. Byra
Judith M. Byra
ra) Spandler
2765 Lewisberry Road
York Haven, PA 17370
15 Scarsdale Drive
Camp Hill, PA 17011
15 Scarsdale Drive
Camp Hill, PA 17011
703 Dunkel Street
Enhaut, PA 17113
Tracy B• (By under
ow been given to all persons entitled theret°
Notice has nexcept:
Rule 5.6 (a)
None ~~ -
g r Esquire
2002 James D• in Street
June 20, One West pA 17011
Date: ansto
Shirem737-8761 tati~
(717) Represen
personalfor personal
Capacity: Counsel tative
Represen
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. YeDSDt REV-1162 EXI71-96)
HARRIBBURG, Pq 1]t~8-O60t
RECEIVED FROM: PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 001572
BOGAR JAMES D ESQUIRE
1 W MAIN STREET I
SHIREMANSTOWN, PA 17011
ACN
ASSESSMENT
CONTROL AMOUNT
- --- -~ ,o„ NUMBER
ESTATE INFORMATION:
SSN: 166-12-4386
FILE NUMBER: 2
DECEDENT NAME:
DATE OF PgyMENT
POSTMARK DATE:
COUNTY:
DATE OF DEATH:
102-0544
PAKOSH HELEN B
08/28/2002
00/00/0000
CUMBERLAND
06/01/2002
TOTAL AMOUNT PAID:
REMARKS: PATRICIA L BYRA
C/O JAMES D BOGAR ESQUIRE
CHECK#507
INITIALS: VZ
SEAL
RECEIVED gy;
S 8, 037.00
MARY C. LEWIS
REGISTER OF WILLS
REGISTER OF WILLS
.
REV. 1500 EX + (6-00)
CAPB
HpRL
EplO
CRAC
KOTK
ES
C P
o 0
R N
R 0
E E
S N
T
C
o
M
P
T U
A T
X A
T
I
o
N
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
o
E
C
E
o
E
N
T
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME{LAST, FIRST,AND MIDDLE INITIAL)
Pakosh Helen B.
DATE OF DEATH (MM-OD-YEAR)
OFFICIAL USE ONLY
(!.
COUNTY CODE
/ 7 0 g'- / /
21-02-0544
YEAR
NUMBER
SOCIAL SECURITY NUMBER
166-12-4386
THIS RETURN MUST BE FILED IN DUPUCATEWlTHTHE
06/01/2002 06 19/1922
IF APPLICABLE SURVIVING SPOUSE'S NAME LAST, FIRST, AND MIDDLE INITIAL
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
X 1. Original Return
4. LImited Estate
X 6. Decedent Died Testate
2.
4a.
7.
(Attach copy of Will)
o 9. LItIgation Proceeds ReceIved
Supplemental Return
Future Interest Ccmpromise(date of death after 12-12~82)
Decedent Maintained a Living Trust
(Attach copy of Trust)
3 date of death
. Remainder Return prior to 12.13~82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D 10. Spousal Poverty Credit D 11. Ejection to tax under Sec. 9113(A)
(date of death between 12.31~91 and 1-1-95) (Attach Sch 0)
THIS SECTION MUST BE CPMPtETE[)~ALL CORRESPONDENCE&<:QNFJDENTJAL TAX<JNfORMATION SHOUL[)BEpJRECTEO,TO,\:'
NAME COMPLETE MAILING ADDRESS
Copyright(c) 2000 form software only The Lackner Group, Inc.
1
James D. Bo ar
FIRM NAME {If Appllcable)
One West Main Street
Shiremanstown, PA 17011
TELEPHONE NUMBER
R
E
C
A
P
I
T
U
L
A
T
I
o
N
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or
Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent< Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
OFFICIAL USE ONLY'
(8) 207,467.64
(11) 18,520.89
(12) 188,946.75
(13)
(14) 188,946.75
(15)
(16)
(17)
(18)
(19)
0.00
8,502.60
0.00
0.00
8,502.60
(1)
(2)
(3)
126,000.00
None
None
(4)
(5)
None
35,646.11
(6)
None
45,821. 53
18,520.89
None
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate. or transfers under Sec. 9116(a)(1.2)
16. Amount of Line 14 taxable at lineal rate 188,946.75
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20.
x
X
X
X
<0 0
045
<12
<15
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
618 Brookhaven Road
CITY I STATE I ZIP
New Cumberland PA 17070
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
8,502.60
0.00
8,037.00
423.00
Total Credits ( A + 8 + C) (2)
8,460.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Totai Interest/Penalty ( 0 + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Cheek box on Page 1 Line 20 to request a refund (4)
S. If Line 1 + Line 3 is greater than Line 2. enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (SA)
B. Enter the total of Line S + SA. This is the BALANCE DUE. (SB)
Make Check Payable to: REGISTER OF WILLS, AGENT
'..:'.~t~X~~::X~~~~~::~~~::~6tt6~1'~~::~~~:~~i6~~'.:~~::~tX~:i~:~':~~ ::!:,:~',,: :l~':~'~:~:X~~:~:6~:~IX~~:~t6:~~~:wwwm
,. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; . ~ ~~x
b. retain the right to designate who shall use the property transferred or its income; .
c. retain a reversionary interest; or. . .
d. receive the promise for life of either payments, benefits or care?
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .
3. Did decedent own an ~in trust for" or payable upon death bank account or security at his
or her death?
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property
which contains a beneficiary designation?
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
0.00
0.00
42.60
0.00
42.60
o
o
[]]
[]]
[I]
o
Under penalties of perJury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief. It Is true,
correct and complete. Declaration of preparer other than the personal representative Is based on aJJ information of which preparer has any knowledge.
Randall F. Byra
15 Scarsdale Drive
-----------------------------------------------------
Cam Hill, PA 17011
James D. Bogar Esquire
One West Main Street
-- -shi;,-.;~~n-;to;.;n;- PA- -:Ci6i:C- -- - - - - - - - - -- - ------
DATE
12/09/02
DATE
For dates of death on or after July 1. 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. 9116 (a) (1.1) (il].
F8r dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is oah
[72 P .5. 9116 (a) (1.1) Oi)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets
and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 9116(1.2)
[72 ps. 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% [72 P.S. 9116(a)(1.3)]. A sibling is defined, under
'S~ction 9102. as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
" .::'~ -r'gnt ;Ci 2'::00 ~otm "ot~'Nare an!)' '!'he Lackner Group. Inc.
Form REV-1500 EX (Rev. 6-00)
ADDITIONAL Personal Representatives
Estate of Helen B. Pakosh SS# 166-12-4386 06/01/2002
****************************************************
Under penalties of perjury, the undersigned declare that they
have examined this return, including accompanying schedules and
statements, and to the best of their knowledge and belief, it is
true, correct and complete.
Signature
~E~.
Patti L. Byra
2765 Lewisberry Road
Name
Address Line 1
Address Line 2
City, State, Zip
York Haven, PA 17370
Date
12/09/02
COMMONWEALTH Of PENNSYlVANIA
DEPARTMENT Of REVENUE
INHIRnANa TAX DIVISION
DEPT. 280601
HARRlS8URG, PA 17128-0001 Please Print or Type
MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS lOCATED AND RETURNED TO ABOVE ADDRESS
COUNTY CODE FILE NUMBER SOCIAL SECURITY OR DEATH CERTIFICATE NUMBER
21 21-02-0544 166-12-4386
DECEDENT'S NAME ILAST, FIRST. MIDDLE) DATE OF DEATH
Pakosh, Helen B. 06/01/2002
ADDRESS OF DECEDENT ISTREET) ICITYI ISTATE}
618 Brookhaven Road New Cumberland PA
NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX
INAME}
James D. Eagar, Esquire
(STREET ADDRESS)
One W. Main St.
- REv..85 EX. (1.92)
~ti
SAFE DEPOSIT BOX
INVENTORY
(CITY)
Shiremanstown
(STATE)
PA
NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT. OF PERSON(S) PRESENT AT THE BOX OPENING
a. (NAME) (RELATIONSHIP)
Patti L. Byra Daughter
(STREET ADDRESS) (CITY)
2765 Lewisberry Road York Haven
(STATE)
PA
b. (NAME)
Randall F. Byra
(STREET ADDRESS)
15 Scarsdale Drive
c. (NAME)
(RELATIONSHIP)
Son
ICITY)
Calll' Hi 11
(RELATIONSHIP)
(STATE)
PA
(STREET ADDRESS)
(CITY)
(STATE}
NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED
INAME}
PN: Bank, N.A.
(STREET ADDRESS]
331 Bridge St.
, NAME OF PERSON MAKING LAST ENTRY
~" P.:> Pc..\:c:a,1i....
DATE OF CONTRACT TO RENT BOX NUMBER OF BOX
'-I,l"q<S )~ /2,
RESS OF PERSON(S) HAiliNG ACCESS TO BOX
IZIP CODE}
17070
(ZIP CODE)
17011
(ZIP CODE)
17370
(ZIP CODE)
17011
(ZIP CODE}
(CITY) (STATE) (ZIP CODE)
New Cumberland PA 17070
DATE AND TIME OF LAST ENTRY
'-l1\W2..
TITLE UNDER WHICH BOX IS REGISTERED
.\.1, B ~1(.\k>5k
b.INAME}
?t.17\~ l-, Bu j:tt..
{STREET ADDRESS} .
.1-1 ~ ~lu2A.uJ .,~
ISTATE}
l.tihM L~<-\" 1\..
..
l~. Pa~k
(STREET ADDRESS)
(,;,t€> BM9Ck ~ ~_
ICITY} (STATE}
tva.c E"" l!9 ,.l!r,. c;:l A:t .
NAME AND TITLE OF EMPLOYE TAKING THE INVENTORY
-1i.uv-S. D ~r ,~"U-
(ZIP CODEI ICITYI
~'107c
WAS A WILL IN THE BOX? DYES KINO If yes, a. Date of will:
b. Name ond address of personal representative, jf named in the will
(NAME)
(STREET ADDRESS)
ICITY}
(STATE)
c. Nam. Clnd address of attorney, if any
(NAME)
lSTREET ADDRESS)
ICITYI
(STATE)
(ZIP CODE)
n -r,i)
(ZIP CODE)
(ZIP CODE)
Page af
SAFE DEPOSIT BOX INVENTORY
INSTRUCTIONS
(1) Cash: Repart tatal anly.
(2) Stocks: list in detail every camman ar preferred certificate, warrant ar ather rights faund in bax. Stacks are
ta be designated by name af campany, certificate number, date af certificate, name in which stack is registered,
and number af shares and class af stack.
(3) Obligations of U. S. Government: Number af items, date of issue, face value, names in which registered
and type af awnership, i.e., jaintly held, payable an death, etc.
(4) Bonds: Designate by name, amaunt, serial number, ar ather designatian. (Bearer Bands)
(5) Bonk and Savings and Loan Passbooks: State name af depositar, number af baak, last date appearing in
baak, name af bank and branch, and balance.
(6) Jewelry, Coins, Stamps, Manuscripts, etc: list and describe as fully as passible.
(7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as
fully as possible.
(8) All other contents.
liTEM
NO.
ITEM DESCRIPTION
1
::2.
;
101(.,). I\Lt..l,.Ii,\...~ 111.i,ct P\-66Q..~
~ 11 ~ (....l<E? (ji-.:711"-~ ~ ~~(A IL. .~~
V'q'e .nd A 'U- ~~~.:a.::A~",-tb-( ./, . "~J11 {]u 0 {j... fl.
(J
:
.
I
I
I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECEIVING COPY OF
,CORRECT AND COMPLETE.TO THE BEST OF MY KNOWLEDGE AND BELIEF. SAFE DEPOSIT BOX INVENTORY, -
ISlG~7) DUtl}/1ArtL0 S1f3,-l:C-~ Q. Id.. j ../J!l.AIfY--
IPRINT NA'ft (' J PRINT NAME AND CHII.gt< APPROPR1~1~8E~OW: (1
I James D. Bogar ~ squire Randall F. Byra and Pattl. L. Byra
'>'Ri"lT TITLE CHEC)'.,APPRCPRIATE SOX:
-l..0- 0
: Attorney for Estate fuExeculor(trix) Administrator(lrix)
i n Estate qepresenlative 0 Joint owner of safe deposit box
NOTE: Attach additional 8%" x 11" sheet (5) if necessary or use duplicates of this page of form.
REV-1502 EX +(1-97)
SCHEDULE A
COMMONWEALTH OF PENNSYLVANIA REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Helen B. Pakosh SS# 166-12-4386 06/01/2002 21-02-0544
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
knowledae of the relevant facts. Real property which is jointly-owned with riQht of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
DESCRIPTION
NUMBER OF DEATH
1 All that certain piece or parcel of real estate having erected 126,000.00
thereon a dwelling house being known and numbered as 618
Brookhaven Road, New Cumberland, Pennsylvania. The property was
acquired by Frank S. Byra and Helen J. Byra, husband and wife, by
Deed dated September 18, 1956 and recorded in the Cumberland
County Recorder of Deeds Office, a copy of said Deed being
attached hereto and incorporated herein. The said Frank S. Byra
died June 2, 1969 whereupon full ad complete title to the within
described real estate became vested solely in Helen J. Byra, the
decedent herein. The said Helen J. Byra became intermarried witt
John J. Pakosh, thereafter being known as Helen B. Pakosh. The
said John J. Pakosh died July 7, 1998. The above-described real
estate was sold pursuant to an Agreement the the Sale of Real
Estate dated July 7, 2002, a copy of which is attached hereto an,
incorporated herein. Final settlement took place on August 12,
2002. A copy of the Deed conveying said real estate, along with
a copy of the Settlement Sheet, are attached hereto and
incorporated herein. The sale price of the real estate was
$126,000.00.
TOTAL (Also enter on line 1, Recapitulation) $ 126,000.00
(If more space is needed, insert additional sheets of the same sjze)
Cx:yright (c) 1996 form software only CPSystems, Inc. Form REV-1502 EX {Rev. 1-97)
UNDER AND SUBJECT TO Building and Use Restrictions
applicable to lots shown on said Plan of Lots, as recorded in .1
Misel. Book 114, P.ge 112, Cumberland County Records. :
II' 'II" .,
I 1
I :tIT. Ill[N TUI'Il!SH!P SChnot. ~
, EAL ESTATE TRANSFER rhx
, .. .. o'l'lt ;!.~.~.2.D.tO+r~/'.~
;:zt;:U( f .JZ...A..'x. ,.."",
. II ,,,'.Arr~
mitis ~ndtn1ttrt
jljlalle tbe 18th
dny of
Sept.. her
in the year of OUT Lord one rhoUJand niM
lmndred nnd Fifty"six
~etbleen
HIGHLAND PARK HILLS, INC., A Pennsylvania Corporation,
haYing its principal place of business in the Township of Lower
Allen, County of Cumberland and State of Pennsylvania,
(hereinafter called the Grantor ). of the ODe IIar4 and
FRANK S. BYRA and HELEN J. BTRA, his wife, of the i
Borough of Camp Hill, County of Cumberland and Stat. of Pen~sylTaDi~,
(hereinafter called the Grantee S), of the .other part:
Witneu.s;etb, That the said Grantor for and in eonaiderution of the sum or
Fourteen Thousaad Four Hundred Sixty Dollars ('14,460.00) hmful
nUlIll'). of the United Stfth".a of America, uuto it well and truly paid by the liaitJ
Grantee s :.It and before the scaling and delivery of ttw"c i're~enls, the receipt whereof it
hereby acknowledged, ha s grantcll. bargninc,l. ~olcl, llliencJ, ,'nfr.ofTl:d. releasC'd and
eon6nned, and by these presents doe s graut, bargnjll, Icll, alien, r.1J(coff, rdetlse and
coufirm unto the said Grantees, their heirs and Allign.,
ALL That certain lot of land situate in the Borough
of New Cu.ber1and, County oC CD.ber1and and State oC Pennsylvania,
more particularly bounded and described as follows:
BEGINNING at a point on the southerly line of Brookhaven
20ad, said point bein~ located two hundred fifty (250) feet
measured westwardly along said line from the southwest earner
of Brookhaven Road aad Crescent Court; thence southwardly alon~ the
wester17 line of Lot No. 13, Block D, on the hereinafter mentioned
Plan of Lots, one hundred twenty (120) feet to a pointj thence
westwardly along the northerly line of a proposed park area seventy
(70) feet to a pointj thence northwardly along the easterly line
or an eight (8) foot right-Of-way one hundred nineteen and ninety-
nine one-hundredths (119,,99) feet to a point; thence e~twardly
along the southerly line of Brookhavon Road by a curve to the
right having a radius or 320 reet, an arc distance of one and
ninety-four one-hundredths (1.94) feet to a point; thence continuing
along said line of Brookhaven Road north eighty-nine (89) deRrees
fourteen (14) minutes east sixty-eight and six one-hundredths
(68.06) feet to the place of Be~inninR"
BEING Lot No. 14, Block D, on the Plan of Section 1,
1lighland Park Hills and Drexel HillS, said Plan beinR recorded
in the Cumberland County Recorder's Office in Plan Book 7, Page 23,
and having thereon erected a single dwelling house No. 618 Brookhavec
Road., N,,,. Cumberland, Pennsylvania.
BEING a part of the premises which Drexel Hills LAnd
Company, by deed dated June 13, 1955 and recorded in Deed Book
l6-Q, Page 100, Cumberland County Records, granted and conveyed
unto Highland Park Hills, Inc., Grantor herein"
,...."~~':"-.\~l\
lll"I"':'T,\l".
;:~~r":J:(. <,:-:::
..1 "'J'
"'l;"- '"
"\' '.: '.1' '
~. '\":)1
'.' ,p.. ""., ~l
'''flU''''"...;
""""'''''"'''t
;;. '":;',:,',',~':;:'
..
';1~\.,
:~\ ::~~~.
f. "n...~".. '-.,
"".'..""...
li"'.'~.;~ '.~::'i,.
15uOk \<. -\/- \(.,i(?
:10-24-0'501- 31;,z...
~. ~
':'~'
~. ~;! il
.~ ~.;
.;:;
,.,. :;,'.
:t' .
,':
"
BoO~ f( 17-MGr167
'Q[:ogetb.e:r with.U and aingular bui1diDI'S improvemeD~. WIYI.
Ittrech~ allcya. p---se.. waten, w.,ler_conr&ee. right.. libertiel!l. privilegee. hereditam.cou
and ."ppurteuance8 wha180cTcr thereunto belonging. or in any wue appertaining. and the
reveraiODI and relDa.indera. reUb, i11lue. and pronta thereof. and all the cltate. right. title.
:nlm.L propej~. mill o.na al!llIllnn ~nmo(J[r or IDn MIa firllllYr I r laW1 Till or
otherwiAe howllOevcr. of. in, Ind to the same and every part thereof.
tlCo "abt anb to tJolb the .aid lot or piece of ground above described
hercdita.mCDtII Bad
prCWI,JCII h~l'eby granted, or mentioned and intended "0
tbe .aid Grantee s. 'their h.irll
to be, with the appu.rtenllllcce.. unto
and AJll!ligna, to and for
-.
...
.1....'1..1........
..~.....~....!". ...
t8
I
., ~
. .
." -, ... ....,
'~~.' ~
S0. ~~
:\!''' ::,
~ --;;:
I - ~:u
~i;
....... ~1lI
~~~
, ~r
~ ~
r-
'" ~
=
,
prorr ulle and hehoof of the Nid GrAntee!, their heir.
Hl~
~ ~ J~ =
.. -; .,l1c
~:.j
1!~i t I
f'orever.
'"
.....
kI.
"'Ii
Clfllll ~r COUIITS ...
~ IECOIIOU Of DUDS
_ ~ 4. /n; /!,'-';
<<~
CUMBERLAND COUNTY
I"EIINSYlV"'"
anb the said party of' the f'irst part
nO 81 by thele prelenLl COTenant, grant and a~rrc
to liIIn.d with the said Grantee s, 'thei r heirs. and Auigna. that
it the said party of' the f"irst part
1 i. QU()Ce8aO~ all
and singular the hercditamcnts and. premises herein described and granted. or mentioned
and intended 50 to be, with the appurtcnances. unto the said Grantee., their heirs
and Assigns, against it the said party of" tho f'irs't part
it,
SUcCf~ssors, and against all and every other Person and Penons whomsoever lawfully
claiming or to claim. the lIame or ::my part thereof.~;lH~B:H
~alXlUID;Sha11 and Will
W AF~RANT and forCTer DEFEND.
31n Witncllll Wbenol. .
s8al to b. atfixed.
BDltI....I.__ \
If,m!~ll&JH)n>II
STA'l'!: OF PENNSTL A N7A )
COUlITY OF CllllBKIl AND 1
the Grantor ha, hereunto caused i~s c~~,~~(,~~~&.
rG~: ' I: ..... ., .''1
;r;;t;; PAR~ RI~t~~~~;'D~
ATTEST! '-.~-~. ~i~';;:~ .:~.
~A'~""" '.........~\".
.-W...~..
. Sea ' ,,'
...,.. ....
55:
On tall, t~1 18th alJ of ~cptomDgr I 1956, '.!'ore ..,
. NtJtar7 PUblic, the undersigned of'fic:er, personallT appeared H. P.
N~m.mao, who acknowledged himself to be the President of RishlaDd
",:,;".'r'~ll', Inc., a corporation, and that he a9 such Presi.eot
/;;~~~~~~hori.ed to do so, executed the foregoing instrument f~r the
. ../ ~:f.~~~~:~_;.l~:.r.:". ~ioDt.1J.:.d b7 .icaing -the n.... of Hi<<hland Park
, i .. "'.~;~.--. ,-;..~,., .ee ... as President.
1"1 ~/.:'1:~""~-jIll WrYNESS lIHEtEOF. r beraanto sat '817
\ .....,.~..;~ ~""".-:~~_:
......~-9.~./L.... ~....'>J.
-'~"- '~:"...,"?;,~Mi;;~~./ ..=_.__
,
r;r.ff,' .;~.~
M " ~I
Y CommlSSlDn.Elrpire7 A J
CumberJ;)l'ld Count" I.~~:.~:' ~~58'
STANDARD AGREEMENT FOR THE SALE OF REAL ESTATE
lbil form ~DIl\I1leIlded. andlppnlYCd for, bul: not feSlrided to IIJe by,!be memben oflh8 r-ylvanil Auociltlon ofREALTORSe (PAR).
AJS.2K
S REL,l.TIONSHIP WITH PA LICENSED BROKER
'J;tJt!14 PHONE 7/7 76163lO
FAX 7/776/1'i5!5
o TRANSACTION LICENSEE
BUYER'S BUSIN S RELATIO~~HIP WITH PA LICENSED BROKER
BROKER (C.mp.ny) ~G.'/Ui. /{G'-fl dre] PHONE 7/7761t30!>
ADDRESS ~ L- r;r-t- I ~ 01 FAX 7/77611'iXJ
BROKER IS TIlE AGENT FOR BUYER. Designated gent(s) for Buyer, if applicable:
OR
Broker is NOT lhe Agent for Buyer and is alan: 0 AGENT FOR SELI..ER 0 SUBAGENT FOR SELLER 0 TRANSACTION LICENSEE
When the same Broker lsAgent for Seller and Agent for Buyer, Broker is a DualAgenLAII of Broker's licensees are also Dual Agenl8 UNLESS
there are separate Designated Agents for Buyer and SelIer. If the same Licensee is designated for Seller and Buyer, the Ucensee is. Dual Agent.
1
I
,
.
5
,
7
.
.
10
11
12
13
"
13
"
17
"
"
20
11
2Z
13
14
"
"
21
"
"
"
31
"
"
"
35
"
"
sa
"
"
41
"
"
..
..
..
"
..
..
50
51
"
"
54
"
..
57
51
"
I. r~i6 lIgrccmcnt, d.,,,,
SELLER(S), 7!ii I?t
-1&1 K/lj!t
Ju/:r
E.st:&tr:
,Is between
7, ,,;'tJO.2>
1
I
,
.
,
,
7
,
,
10
11
11
13
"
15
"
Q~R1.O ~'"'''::
(; tt :;tl !)OD "
$~ ~. 11
$V 1 i~l' (/0% 2Z
TOTAL $ _ _ . PO 23
(8) Deposits paid on account of purchase price to be held by Broker for Seller, unless otherwise stated here: 24
25
"
17
28
"
30
"
"
"
"
35
J6
"
"
"
..
41
"
"
..
..
..
47
, called "Seller,.. and
BUYER(S):
['''lit 1M/( /.0-"/ IIAI/t';1ut
,called "Buyer,"
2. PROPERTY (1-98) Seller hereby agrees to sell and ronvey to Buyer, who heRby agrees to purchase:
ALL THAT CERTAJIi lot or p'iece of pod wjth buildings and provemenls thereon en:cted, if any, known 85:
/ /.7;(001( tlVG1I 0t1P '" ~;.
in the ,,~O or </4.1 Pi'll
County or !! IiJ1lIJI2!./dAJf In the CommonweaJth or Pennsyl'fBoia, Zip Code /7b7tJ
IdenUncallon (e.g., To ID I#; Pan:el ,; Lot, Block; Deed Book, Pale, Recordlol Date)
..t 6, .N- tJPo'l- ..!&.t..
J. TERMS (1-02) M
(A) Purd\asePrice llt()lJ~
whkh will b. p,;d to S.II.. by lIuy.... r,",] :!
I. Cash or check at signing this Agreement: to( I. Of( ~ ",-,
2. Cash or check within _ days of the execution Of"'S Ag ent:
J.
4.
Cash, cashier's or certified check. at time of selllement:
It.
tJO.;l
(C)
(D)
(E)
~
, or before if Buyer and Seller agree.
e deed of special warranty unless otherwise stated here;
(F) Payment of transfer taxes will be divided equally between Buyer and Seller unless olherwise Slated here:
(G)
At time of settlement, the following will be adjusted pro-rata. on a daily basis between Buyer and Seller, reimbursing where applicable: taXes
(see Information Regarding Tax Proration); rents; interest on mortgage a.~sumptions: condominium fees and homeowner association fees. if
any; water andlor sewer fees, if any, together with any other lienable municipal service. The charges are to be pro-rated fOf the period(s)
covered: Seller will pay up to and including the date of settlement: Buyer will pay for all days following settlement, unless otherwise Slated
here:
4, FIXTURES & PERSONAL PROPERTY (1-00)
(A) INCLUDED in this sale and purchase price are all existing items pennanently installed in the Property, free of liens, including plumhing:
heating; lighting fixtures (including chlUldelieIS and ceiling flUls): water treatment systems; pool and spa equipment: garage door openers
and transmitters; television antennas; shrubbery, plantings and unpotted trees; any remaining heating and cooking fuels stored on the
Property at the time of settlement; wall to wall carpeting; window covering hardware, shades and blinds; built-in air conditioners: built-in
appliances; a1ld lhe ge/oven unless otherwis stated. AI included:
..,......c f ~
(8)
(C) EXCLUDED fixtures and items:
..
49
"
51
"
"
54
"
"
57
51
"
S. DATESlflME IS OF THE ESSENCE (1-02)
(A) The said date for settlement and all other dates and times referred to for the performance of any of the obligations of this Agreement are
agreed to be of the essence of this Agreement and are binding.
(8) For the purposes of this Agreement, number of days will be counted from the date of execution, by excluding the day this Agreement was
executed and including !he last day of Ute time period.
(C) 1be date of settlement is not extended by any other provision of this Agreement and may only be extended by mutual written agreement of
the parties.
(0) Certaln time periods are pre-printed in this Agreement all a convenience to the Buyer and Seller. Any pre-printed time periods are negotiable
and Dlay be c ang by slriking out the pre-printed text and inserting a different time period accepta.ble to all parties.. 8
BuyerlnlUab: C J-( AJS.2KPBgeloCS Sellerlnitiall:~~~ ,\..\1
m Pennsylvenl. Assocl.tlon of COPYRIGHT PENNSYLVANIAASSOClATlON OF RF..ALTORS<<I 200:
u:::!I REALTORSS' OtlO2
-,,,,,," --...----
w
.,
"
"
"
..
"
17
..
"
"
71
12
73
"
15
15
n
18
"
"
"
"
"
"
"
"
87
"
..
..
"
9Z
93
94
..
..
87
..
..
100
101
101
'03
'"
0. lYlVKluJU.J'l:!.l..VI'lll.l'l\:r1!.I'll..1 \I-U":J
o WAIVED. llUs sale is NOT contingent on mongage f1DlUlCing.
M ELECTED
'(A) This sale is contingent upon Buyer obtaining ~,g.:J.f finallStng as follows:
1. Amount of mortgage loan S ~ 10V
2. Minimum Tenn 50 years. I (
3. Typcofmortga e W1WI1t1UU
4. Interest rale. %; however, Buyet IlrftS to accept the Interest rate as may be committed by the mortgage lender, not to
exccedamuimumintcrestrateoC "1,~{) %.
5. Discount points. loan origination. loan placement and other fees charged by the lender as a peR:cntage of the mortg.1ge loan (excluding
any mortgage insurance premi.wna Of" VA funding fee) not to exceed _% (0% jf not specified) of the mortgage loan.
lbe interest rate and fees provisions required by. Buyer are satisfied if a mortgage lender makes available to Buyer the right 10 guarantee an
interest rate al or below the Maximwn Inlemlt Rate specified herein with the percentage fees at or below the amount specified herein. Buyer
gives Seller the right, at Seller's sole option and as permitted by the mortgage lender and applicable laws, to contribute financially, without
promise of reimbUfllcmcnt, to the Buyer and/or the mortgage lender 10 make the above tcnns available to Buyer.
(B) Within _ DAYS (10 days if not specified) of the execution of this Agreement, Buyer will make a completed, written mortgage application
for the mortgage terms specified above to a responsible mortgage lender. lbe Broker for Buyer, If any, otherwise the Broker for Seller, Is
authorized 10 communicate with the mo age nder for the purpo8e! of assisting In the mortgage loan process.
(C) 1. Morlpge commitment date Ou z..., . If a written commitment is not received by Seller by the above date, Ruyer
and Seller agI1!e 10 extend the mo commitment date until Seller termlnates this Agreement In writing by notice to Buyer.
2. Upon receipt of a mortgage commitment, Buyer will promptly deliver a copy of the commitment to Seller.
3. Seller has the option to tcnninatc this Agreement in writing, after the mortgage commitment date if the mortgage commitment:
a Is not valid until the date of settlement, OR
b. Is conditioned upon the sale and seUlement of any other property, OR
c. Contains any other condition not specified in this Agreement that is not sati~fied andlor removed in writing by the mortgage lender
within --1- DAYS after the mortgage commitment date in plIragraph 6 (C) (1).
4. IrthiaAgreement is terminated as specified in pamgraphs 6 (C) (I) or (3). or the mortgage loan is not obtained for selllement, all deposit monies
paid on account of purchase price will be returned to Buyer. Buyer will be responsible for any premiums for mechanic.!' lien insurance and/or
title search, or fee for cancellation of same, if any; AND/OR any premiums for flood insurance, mine subsidence in.'iW1UICC and/or fire iru;ur-
ance with extended coverage, or cancellation fee, if any; AND/OR any appraisal fees and charges paid in advance to Ihe mortga,ge lender.
(D) If the mortgage lender requires repairs to the Property. Buyer will, upon receipt, deliver a copy of the mortgage lender's requirements to Seller.
Seller will, within --L DAYS ofJeCCipt of the mortgage lender's requirement&. notify Buyer whether Seller will make the requimJ repairs
at Seller's expense.
i. If Seller chooses to make the required repairs, Buycrwill accept the Propeny and agree to the RELEASB set forth in paragraph 25 of this
Agreement.
2. If Seller chooses not to make the required repairs, or if Seller fails to respond within theUme given, Buyer will.. within ~ DAYS,
notify Seller in writing of Buyer's choice to terminate this Agreement OR make the required repairs at Buyer's expense and with Seller's
permisSion, which will not be UJU'e8SOrlably withheld. If Seller denies Buyer permission 10 make the requircdrqlairs, Buyer may, within
~ DAYS of Seller's denial, terminate this Agreement, in which case all deposit monies paid on 8(:l;ount of purchase price will be
returned promptly 10 Buyer and this Agreement will be VOID.
(E) ~lerAssist
.& NOT APPLICABLE
o APPLICABLE. Seller will pay:
o $ ,maximum, toward Buyer's costs as pennitted by the mortgage lender.
o
105
".
107
'"
".
'"
111
112
113
114
115
'"
111
'"
",
'"
121
'"
123
124
'"
126
121
".
126
130
131
13l
133
134
135
13.
137
'"
139
".
'"
'"
143
".
".
FlWVA, IF APPLICABLE
(I') It is expRlssly agreed that notwithstanding any other provisions of this contract, Buyer will not he ohligated to complele the purchase of the
Propcny described herein or to incur any penalty by forfeiture of eamesl money deposits or otherwise unless Buyer h given, in accor-
dance with HUDIFHA or VA requirements, a written statement by the Federal Housing Commissioner, \0 dministrntion, or a Direct
Endorsement Lender setting forth the appraised value of the Property of not less than $ (the dollar amounl to be
inserted is the salell price as stated in this Agreement). Buyer will have the privilege an on of proceeding with consummation of the con-
tract without regard to the amount of the appraised valuation. The appraised v Ion is arrived at to detenoine the maximum mortgage the
Department of Housing and Urban Development will insu~. HUD d t warrant the value nor the condition of the Property. Buyer should
satisfy himselflhcrself that the price and condition of the Pro acceptable.
Warning: Section lOlO of TItle 18, U.S.C.. Dc enl of Housing and Urban Development and Federal Housing Administration
Transactions. provides, ''Whoever for the purpg . . . influencing in any way the action of sllch Department. makes, passes, lI11ers or pub-
lishes any statement. knowing the same false. . . shall be fined under this title or imprillOned not more than two years, or both."
(G) U,S. Department of Housing an an Development (HUD) NOTICE TO PURCHASERS: Buyer's AcknowledRement
o Buyer has received the Notice "For Your Protection: Get a Home IOSJlCl:;tion" (see Notices and Infonnation on Property Condition
Inspections). Bu nderstands the importance of getting 1IQ independent home inspection and has thought aboutlhis before signing this
Agreement
Buyer's I .. Date
Certi on We the undersigned, Seller(s) and Buyer(5) party to this transaction each certify that the tenos of this contract for purchase are
o the best of our knowledge and belief, and that any other agreement entered into by any of these parties in COMection with this transac-
on is attached 10 this Agreement.
SPECTIONS (1-02)
(A) Seller agrees to pcnnit inspections by authorized appraisers, reputahle certifiers, insurer's representatives, surveYOl"ll, municipal officials and/or
BUYl:r as may be required by the mortgage lender. if any, or insuring agencies. Seller further agrees to pcnnit any other inspections required by
or provided for in the terms of this Agreement. Buyer has the right 10 altend all inspections.
(B) Buyer ~serves the right to make a pre-settlement walk-through inspection of the Propeny. Buyer's right to make this inspection is not waived
by any other provision of this Agreement.
(C) Seller will have heating and all utilities (including fuel(s)) on for the in.~~tions.
(D) All inspectors, including home inspectors, arc authorized by Buyer to provide a copy of any reports to Broker for Buyer.
8. PROPERTY INSPECI10N CONTINGENCY (1-02)
Other provisions of this Agreement may provide for inspections andlor certifications that arc not waived or altered by Buyer's election here.
o WAIVED. Buyer understands that Buyer has the option to request inspections of the Property (see Property Inspection Notices and
I.< Environmental Notices). BUYER WAIVES TIllS OPTION and agrees to the RELEASE set forth in paragraph 25 of this Agreement.
~ ELECTED
(A) Within _ DAYS (15 days if not specified) of the execution of this Agreement, Buyer, at Buyer's expense, may choose to have inspec-
tions andlor cenifications completed by licensed or otherwise qualified professionals (see Propeny Inspection Notices and Environmenlal
Notices). This contingency docs not apply to the following existing conditions andlor items:
7.
(B) Should Buyer elect to have a home inspection of the Property, as defined in the Pennsylvania 110me Inspection Law. (see information Regarding
the Home In.'ipCCtion Law) such home inspection shall be performed by a full member in good standing of a national home inspection a5ooci-
ation, or by a supervised by a full member of a national home inspection association, in IK:cordancc with the ethical standards and code
of conduc r ractice of that association. R'cf2.
HlI DuyerInlUals: AlS-2KPllge2of8 Sellerlnillals: ~JJ ~\)Y 146
\
"
"
63
..
"
..
"
"
..
10
11
"
73
74
75
10
11
10
"
..
"
"
83
..
15
..
"
II
II
..
"
"
"
..
"
"
"
"
..
'00
101
102
193
194
,OS
106
10'
10'
10.
110
111
112
113
"'
115
11.
117
118
'"
'20
121
122
123
".
125
126
127
'"
'"
130
131
'"
133
174
135
13.
137
138
13.
14.
'"
142
143
'"
145
147 ;Kif Buyer is not salisf1ed wilh the condition of the Property 81ltated in auy written rqxxt. Buyer will;
lU Option 1. WlUtln the time given (or completlnglnspectiolll:
14!J I. Accept the Property with the information stated in the report(s) and agree to the RELEASe set forth in parngraph 2S of this Agreement, OR
150 2. Tenninntc this Agreement in writing by notice to Seller, in which case all deposit monies paid on account of purchase price will be mumcd
151 promptly to Buyer and this Agreement will be VOID, OR
152 3. Enter inlo a mutually acceptable written agreement with ScUerproviding for any repairs or improvemenrs 10 the Property and/or any credit
153 10 Buyer at settlement. as may be acceptable to the mortgage lender, if any.
15. ~ Should efforts 10 reach a mutually acceptable agreement fail, Buycrmust choose 10 accept the Property or tenninate thisAgrecmenl within
155 the Unlc given for completing Inspections and according to the provisions in paragraph 8(C) (Option I) t and 2.
158 Option 2. Within the time given for completing Inspections:
157 ?f!! Accept the Property with the information stated in the report(s) and agree to the RELEASE set forth in paragJ]lph 2.5..Df this A&...reemenl,
158 ~ UNLESS the total cost 10 correct the conditiofill contained in the repon(.) is more than $ / 21l uC' .
158 U 2. If the total coot to correct the conditions contained in the repol1(s) EXCEEDS the amount specified in paragraph 8(C) (Option 2) 1.
160 ~ Buyer will deliver the report(s) to Seller within the time given (or Inspedlon.
151 \V a. Seller will, within ~ DAYS of RlCeiving the repon(s), inform Buyer in writing of Seller's choice to:
162 (I) Make repairlI before settlement so that the remaining cost to repair conditions contained in the report(s) is less than or equal to
163 the amount specified in paragraph 8 (C) (Option 2) 1.
llW (2) Credit Buyer at settlement for the difference between the estimated cost of repairing the conditions contained in the report(s)
165 and the amount specified in paragraph 8 (C) (Option 2) 1. This option must be acceptable to the mortgage lender, if any.
166 (3) Not make repairs and not credit Buyer at settlement for any casb to repair conditions contained in the report(s).
167 b. If Seller chooses to make repairs or credit Buyer at senlement u specified in paragraph 8 (C) (Option 2) 2, Buyer will accept the
166 Property and agree to the RELEASE set forth in paragraph 25 of this Agreement.
168 c. If Seller chooses not to make repairs and not to credit Buyer ar. settlement. or It Seller fails 10 choose any option within the time
no given, Buyer will, within ---L- DAYS:
171 (I) Accept the Property with the infonnation stated in the report(s) and agree to the RELEASE set: forth in paragraph 25 of this
172 Agreement. OR
173 (2) Tenninate this Agreement in writing by notice to Seller, in which case all deposit monies paid on account of purchase price will
174 be returned promptly to Buyer and this Agreement wiD be VOID.
115 9. WOOD INFESTATION INSPECTION CONTINGENCY (1-o2)
176 0 WAIVED. Buyer understands that Buyerhas the option to request that the Property be inspected for wood infestation by a certified Pest Control
m Operator. BUYER WAIVES TInS OPTION and agrees to the RELEASE set forth in pangraph 2.S of this Agreement.
178 it! ELECTED
178 ~) Within _ DAYS (IS days if not specified) of the execution of this Agreement. Buyer, at Buyer's ellpense. will obtain a written "Wood.
180 Destroying Insect Infestation Inspection Report" from a certified Pesl Control Operator and will deliver it and all supporting documenb and
181 drawings provided by the Pest Control Operator 10 SeDer. The report is to be made satisfactory to and in compliance with applicable Jaws, mort-
182 gage lenders, and/or Federal Insuring and Guaranteeing Agency requirements, if any. The inspection will include all readily visible and
183 accessible areas of all structures on the Property except the following structures, which will not be inspected:
".
185
'"
117
'81
'"
19'
,,,
19'
,,,
,..
19'
'96
,,,
181
'81
'"'
'",
'"'
203
'"
'"'
206 10.
'"7
'"'
'"'
'"
",
212
213
'14
215
'18
217
'14
21.
22'
22'
'"
22'
'"
'"
22.
227
22'
22.
'"
131
732
'"
(B) If the inspection reveals evidence of active infestation(s), Seller agrees, at Seller's ellpen5e and before settlement. to treat for active infesta.
tion(s), in acconlance with applicable laws.
(C) If the inspection reveals damage from active infestation(s) or previous infestation(s), Buyer, at Buyer's ellpense"has the option 10 obtain a writ-
ten report by a professional contractor, home inspection service, or structural engineer that is limited 10 structural damage to the Property caused
by wood-destroying organisms and a propo54i to repair the damage. Buyer will deliver the structural damage report and cot'R:ctive propo5al to
Seller within ~ DAYS of delivering the original inspection report.
(0) Within --'-- DAYS of receiving the structural damage report and corrective proposal, Seller will advise Buyer whether Seller will repair, at
Selh:~r's ellpense and before settlement. any structural damage from active or previous infestation(s).
(E) If Seller chooses to repair structural damage revealed by the report, Buyer agrees to accept the Property as repaired and agrees to the RELEASE
set forth in paragraph 2S of this Agreement.
(F) If Seller chooses not to repair structural damage revealed by the report or fails to respond within the time given, Buyer, within --'-- DAYS,
will notify Seller in writing of Buyer's choice to:
I. Accept the Property with the defects revealed by the inspection, without abatement of price, and agree to the RELEASE set forth in para-
graph 25 of this AgreemeDl. OR
2. Make the repairs before settlement, if required by the mortgage lender, if any, at Buyer's ellpense and with Seller's pennission, which will
not be unreasonably withheld, in which case Buyer accepb the Property and agrees to the RELEASE set fonh in pangraph 25 of this
Agreement. If Seller denies Buyer pennission to make the repairs, Buyer may, within --'-- DAYS of Seller's denial, tenninate this
A~ment in writing, in which case all deposit monies paid on account of purchase price will be returned promptly to Buyer and this
Agreement will be VOID, OR
3. Terminate this Agreement. in which case all deposit monies paid on account of purchase price will be returned promptly to Buyer and
this Agreement will be VOID.
RESIDENTIAL LEAD-BASED PAINf HAZARD REDUCTION ACf NOTICE REQUIRED FOR PROPERTIES
BUILT BEFORE J978 (1-02)
o NOT APPLICABLE
!sa' APPLICABLE
(kJ Seller represents that Seller has no latowledge concerning the presence of lead-ba.~ed paint andlor lead-ba~ paint hazards in or about the
Property, uniess checked below.
o Seller has knowledge of the presence of lead-based paint and/or lead-based paint hazards in or about the Property. (Provide the basis for
determining that lead-based paint and/or hazards ellist. the location(s), the condition of the painted surfaces, and other available infonna-
tion concerning Seller's latowledge of the presence of lead.based paint and/or lead.based paint hllZlUds.)
(B)
RecordslReports: Seller has no reports or records pertaining to lead-based paint and/or lead.based paint hazards in or about the Property,
unless checked below.
o Seller has provided Buyer with all available records and reports pertaining to lead-based paint and/or lead-based paint hazards in or about
the Property. (List documenb)
(C)
Buyer's Acknowledgement Buyer has received the pamphlet Protect .Your Family from Lead in Your H()1M and has read the Lead Wanting
Statement contained in this Agreement (see Environmental Notices). Buyer has reviewed Seller's disclosure of known lead-based paint andlor
lead-based paint hazards, as identified in paragraph IO(A) and has received the records and reports pertaining to lead-based paint and/or lead.
based paint hazards identified In paragraph 10(8). 17/0z..
Buyer's Inidals Date 7
RISKASSESSMENTIINSPECfION: Buyer acknowledges that before Buyer is obligaled to buy a residential d'welling built before 1978, Buyer
has ~ DAYS to conduct a risk assessment or inspection of the Property for the presence of lead-based paint and/or lend.based paint hazan1~.
WAIVED. Buyer undmtands that Buyer h8ll the right to conduct a risk assessment or inspection of the Property to determine the presence of
lead-based paint and/or lead-based paint hazards. BUYER WANES TI-lIS RIGHT and agrees to the RELEASE set fonh in parngraph 25 of
thill Agreemenl
ELECTED
I. Buyer, atB
lint
(D)
~
o
23. Buyer InIt1al$:
r's expense, chooses to obtain a risk assessment and/or inspection of the Property for lead-based paint and/or lead.based
. The risk a&SeSmJent aJXUor inspection will be compleled within.-l2- DAYS of the ellecution of 7if!penl Q..
C AlS-2K Page J of 8 Seller Initial.: . Q\"':y
I
'"
...
'"
'"
16'
'51
'53
154
'55
15'
157
,..
'"
'"
16'
'51
163
'64
16'
16'
'51
'64
'"
'70
171
172
173
'"
175
170
171
178
'"
'80
'"
167
'"
,..
185
,..
187
'81
'"
",
m
,,,
",
,..
105
",
'51
,..
,,,
'"
'"
'"
'"
'04
2"
'"
207
,..
'"
'10
211
212
213
'"
215
21.
217
218
110
22.
121
222
223
'"
22'
'28
227
22.
m
13'
231
'"
'"
'"
2. Within the time set forlh above for obtaloinllhe risk useament and/or Inspecdon of Ibe Property for lead-based paint llRdlor
lead-bBSed paint hazards., Buyer may deliver 10 Seller a written list of the specific hazardous conditions cited in the report and those
corrections requested by Buyer, along with II. copy of the risk lISSeSSment and/or inspection report.
3. Seller may, within ~ DAYS of receiving the list and report(s), submit a written corrective proposal to Buyer. The corrective proposal
wiU include, but DOt be limited to, the name of the remediation company and a projected completion date for corrective measures. Seller
wiU provide certification from a risk assessor or inspector that corrective measures have been satisfactorily completed on or before the
projected completion date.
4. Upon receiving the corrective proposal, Buyer, within ~ DAYS. will:
a. Accept the corrective pro!)OSld and the Property in writing, and agree to the RELEASE set forth in parngraph 25 oflhis Agreement. OR
b. Temtinate this Agreement in writing, in which case all.deposit monies paid on account of purchase price will be returned promptly
to Buyer and this Agreement will be VOID.
S. Should Seller fail to submit a written currective proposal within the time set forth in paragraph IO(D)3 of this Agreement, Buyer,
within -L DAYS. wiU:
a. Accept the Property in writing, and agree to the RELEASE set forth in paragraph 25 of this Agreement, OR
b. Tcnninate this Agreement in writing, in which case all deposit monies paid on accoUDt of purchase price will be returned promptly
to Buyer and this Agreement will be VOID.
6. Buyer's faUure to tl[erdse any or Buyer's options wJthin the time IlmiL'! specified In Ibis paragraph will constitute a WAIVER of
this contingency and Buyer atteptlllbe Property and agrees to the RELEASE set forth in pangraph 25 of this AAreemmt.
(E) Certification: By signing this Agroemcnt, Buyer and SeUer certify the accuracy of their respective statements. to the ~t of their knowledge.
Sl'ATUS OF RADON (1-02)
(A) Seller represents that Seller has no knowledge concerning the presence or absence of radon unless checked below.
o 1. Seller has knowledge that the Property was tested on the dates, by the methods (e.g., charcoal canister, alpha track, etc.), and with
the results of aU tests iDdicated below:
DATE TYPE OF TEST
23.
236
231
'"
23.
'"
'"
'"
'"
'"
'"
'"
'"
'"~
'"~
'"
'"
'"
'"
25411.
'"
'"
'"
'"~
'"
'"
'"
'"
'" 'SI 0 2
=:~IV ct'x\
217 ''''{!V RADON lNSPECI10N CONTINGENCY
268 ~ WAIVED. Buyer nnderstands that Buyer has the optton to request that the Property be lDSpected for radon by a certlfied Inspector (see Envtron-
269 :::lii: mental Nottces' Radon) BUYER WAIVES TIllS OmON and agrees to the RELEASE llet forth m paragraph 2S of this Agreement
270 ~ ELECIED. Buyer, at Buyer's expense, bas the optIon to obtam, from a certlfied lIupector, a radon test of the Property, and Wlll deliver a copy
271 of the test report to Seller wllhin _ DAYS (15 days If not specified) of the execution of this Agreemenl (See Envll'ODlTlental Notu:es'
271. Radon)
273 1. IT the test repon reveals the ~ence of radon below 0.02 working levels (4 picoc:urieslliter), Buyer accepts the Property and agrees to the
214 RELEASE set forth in paragraph 25 of this Agreemenl
275 2. IT the test report reveals the p~nce of radon at or exceeding 0.02 working levels (4 picocuries/liter), Buyer will, within ~ DAYS
2111 of receipt of the test results:
217 0 Option 1
VB a. Accept the Property in writing and agree to the RELEASE set forth in paragraph 25 of this Agreement, OR
279 b. Terminate this Agreement in writing, in which case all deposit monies paid on account of purchase price wiU be returned promptly to Buyer
UO and this Agreement will be YOID,_ OR
211 c. Submit a written. corrective proposal to Seller. The corrective proposal will include, but not be limited (0, the name of the certified miti-
282 gation company; provisions for payment, including retests: and a projected completion date for C()ITeCtive measures.
283 (I) Within~DAYSofreceivingthecorrectiveproposal.Sellerwill:
284 (a) Agree to the tenns of the corrective proposal in writing, in which case Buyer accepts the Property and agrees to the
285 RELEASE set forth in paragraph 2S of this Agreement, OR
288 (b) Not agree to the terms of the corrective proposal.
287 Should Seller not agree to the tenns of the corrective pr0p05al or if SeHer rails to respond within the time given, Buyer will, within
288 -L DAYS, elect to:
2811 (a) Accept the Property in writing and agree to the RELEASE set forth in paragraph 25 of this Agreement, OR
290 Off11 (b) Terminate this Agreement in writing, in which case all deposit monies paid on account of purchase price will be returned
, ~\V promptly to Buyer and this Agreement will be YOID.
292 Option 2
2113 a Accept the Property in wnl1ng and agree to the RELEASE set forth lD paragraph 25 of thIS Agreement, OR
2U b. Submit a written, corrective proposal to Seller. 1be corrective proposal will include, but not be limited to, the name of the certified miti-
2115 gation company; provi ions for payment, including retests; and a projected completion date for corrective measUre:l. Seller will pay a max-
296 imum of.$ toward the total cost of remediation and retests, which will be completed by settlemenL
297 (1) If t iiI cost of remediation and retests EXCEEDS the amount specified in paragraph 11(B) (Option 2) b, Seller will, within
'"~ ~' :::..L DAYS of receipt of the cost of remediation, notify Buyer in writing of Seller's choice to:
299 -; \\ (a) Pay for the total cost of remediation and retests, in which case Buyer accepts the Property and agrees to the RELEASE set forth
300 lJ' \ in paragraph 25 of this Agreement, OR
301 n-:A (b) Contribute toward the total cost of remediation and retests only the amount specified in paragraph II(B) (Option 2) b.
302 \(,,'CY (2) If Seller chooses not to pay for the total coot of remediation and retests. or if Seller falls 10 choose eilher option within the Ume
303 given, Buyer will, withi~ DAYS, notify Seller in writing of Buyer's choice to:
JO~ (a) Pay the difference between Seller's contribution to remediation and retests and the actual cost thereof, in which C3.'le
305 Buyer accepts the Property and agrees to the RELEASE set forth in paragraph 2S of this Agreement, OR
306 (b) Terminate this Agreement, in which case all deposit monies paid on account of pwchase price will be returned promptly
301 to Buyer and this Agreement will be YOID.
308 12. STATUS OF WATER (1.(12)
3011 (A) ~c:.ller represents that the Property is served by;
310 pt Public Water
311 0 On-site Water
312 0 Community Water
313 0 None
314 0
315 (B) WATER SERVICE INSPEcnON CONTINGENCY
3111 0 WAIVED. Buyer acknowledges that Buyer has the option to request an inspection of the water service for the Property. BUYER WAIVES
317 nus OPTION and agrees to the RELEASE set forth in paragraph 2S of this AgreemenL
318 0 ELEcreo
311 1. Buyer has the 'on, within _ DAYS (l.:l days if not specified) of the execution of this Agreement and at Buyer's expense, to deliver
320 to Seller a ttel1 inspection report by a qualified, professional water testing company of the quality and/or quantity of the water service.
:: Buy" 1nI...., G ~ AlS-2K P... 4.n ..." lnI....fJ::/3 \!'-'7
RESULTS (picocurieslliter or working levels)
COPIES OF ALL AYAlLABLE TFSI' REPORTS will be delivered to Buyer with this Agreemenl SELLER DOES NOT WAR-
RANT EmIER THE ME'rnODS OR RESULTS OF THE TESTS.
Seller has knowledge that the Property underwent radon reductIOn measures on the date(s) and by the methodes) mdicated below
DATE RAOON REDUcnON ME'I1:IOD
'"
'"~
'"
'"
'"~
,..
'"
'"
'"
,..
'"
".
'"
'"~
'"~
".
'"
'"
'"
'"
'"
'"~
'"
'"~
'"~
,..
'"
'"
'"
'"
'"
'"
",
'"~
,..
'"
'"
'"
'"
'"
'"
'"
'"
'"~
'"~
,..
'"
'"
'"
'"
'"
'"
'"
'"
,..
,oa
'"
'"
'"
,..
'"
'"
'"
'"
'"
'"
301
'"
'"
,..
".
".
'07
JOe
JOg
'10
'"
'"
'"
'"
31'
31.
317
31'
'"
'"
'"
'"
,,~,.~, "l>'~~~ ... ...~_.~ ~.... I
".
32.
32.
'"
32.
31.
'"
331
'31
33'
33.
33.
33'
337
'"~
'38
'"
'41 ~
'42
'"
'44
'"
".
34'
34'
34.
'38
351
'62
'63
".
'65
35.
351
'"~
35.
'"~
'61
'62
'63
,..
'65
'"
'51
'"~
'"
'"
311
312
31'
'"
'"
31&
J17
318
'"
,..
'61
'62
'63
,..
'"
".
'51
'"
".
'50
'91
'92
'"
,..
'"
'"
391
'98
'99
".
."
'"
'"
".
.os
...
.01
."
...
inspection company. Seller also agrees 10 re!!itore the Property, at Seller's expense, prior 10 settlement.
3. If the report reveals that the water service does DOC meet the minimum standards of any applicable govemmentalauthority and/or fails to
satisfy the requirements for quality and/or quantity set by the mortgage lender, if any. then Seller wiu. withi~ DAYS of receipt of
the report, notify Buyer in writing of Seller's choice to:
a. Upgrade the water service to the millimum acceptable levels, before settlement. in which case Buyer accepts the Property and agrees
to the RELEASE set forth in pllnlgl1lpb 25 of this Agreemcmt. OR
b. Not upgrade the waler service.
4. If Seller chOO5e!l not to upgrade the service 10 minimum acceptable levels, or fails to rellipond within the time ginn, Buyer will, within
........5.-DAYS.either:
a. Accept the Propeny and the waler service and, if required by the mortgage lender, if any, and/or any governmental authority. upgrade
the water service before settlement or within the time required by the mortgage lender, if any. andfor any governmental authority. at
Buyer's expense and with Seller's permission, which will not be unreasonably withheld, and agree to the RELEASE set forth in para-
graph 2S of this AgreemenL If Seller denies Buyer permission to upgrade the water service, Buyer may, within----1...- DAYS of
Seller's denial, lenninate this Agreement in writing. in which case all deposit monies paid on account of purchase price will be
returned promptly 10 Buyer and this Agreement will be YOID, OR
b. Terminate this Agreement in writing, in which case all deposit monies paid on account of purchase price will be returned promptly
to Buyer and this Agreement will be YOID.
13. STATUS OF SEWER (1-Q2)
(A) ~Ier represents. that the Property is served by;
l.l\' Public Sewer
o Individual On-lot Sewage Disposal System (See Sewage Notice 1)
o Individual On-lot Sewage Disposal System in Proximity to Well (See Sewage Notice I; see Sewage Notice 4. if applicable)
o Conununity Sewage Disposal System
o Ten-acre Permit Exemption (See Sewage Notice 2)
o Holding Tank (See Sewage Notice 3)
o None (See Sewage Nelice 1)
o None AvailablelPennit Limitations in Effect (See Sewage Notice S)
o
(B) . INDIVIDUAL ON-LOT SEWAGE DISPOSAL INSPECTION CONTINGENCY
o WAIVED.' Buyel 'acknowl6:igesthet Buyer has' the option to request an individual on-lot sewage dispoirnl inspeiction of the Property. BUYER
WAIVES TIllS OPTION and agrees to'the RELEASE set forth in paragraph 25 of lhisAgreemenL
o ELECTED
1. Buyer has the option, within _ DAYS (IS days if not ~pecified) of the execution of this Agreement and at Buyer'~ expense, to
deliver to Seller a written in~pection report by a qualified, professional in~pector of the individual on-lot sewage disposal system.
2. Seller. at Seller's expense. agrees, if and as required by the inspection company, 10 locate, provide access 10 and empty the individual on-
lot sewage disposal system. Seller also agrees to restore the Property. at Seller's expense, prior to settlement.
3. If the report reveals defects that do not require expansion or replacement of the existing sewage disposal system. Seller will, within
~ DAYS of receipt of the report. notify Buyer in writing of Seller's choice to:
a. Correct the defects before sett1ement. including retellts. at Seller's expense, in which case Buyer accepts the Property and agree~ 10
the RELEASE set forth in paragraph 25 of this Agreement, OR
b. Not correct the defects.
4. If Seller chooses not to correclthe defects, or if Seller fails to rtSpOnd within the time given, Buyer will, within --L DAYS, either:
a. Accept the Property and the system and, if requited by the mortgage lender. if any, and/or any governmental authority, correct the
defects before settlement or within the time required by the mortgage lender, if any, and/or any governmental authority. at Buyer's
sole expense and with Seller's pennis~ion, which will not be unreasonably withheld, and agree to the RELEASE set forth in para-
graph 25 of this AgreemenL If Seller denies Buyer permission to correcl the defects, Buyer may, within -L DAYS of Seller's
denial, tenninate this Agreement in writing. in which ca.'Ie all deposit monies paid on account of purchase price will be returned
promptly to Buyer and this Agreement will be VOID. OR
b. Terminate this Agreement in writing, in which case all deposit monies paid on account of purcha"C price will be returned
promptly to Buyer and this Agreement will be YOID.
5. If the report reveals the need 10 expand or replace the existing individual on-lot sewage disposal system, Seller may, within .......25......DAYS
of receipt of the report, submit a corrective proposal to Buyer. The corrective proposal will include, but not be limited 10, the name of the
remediation company; provisions for payment. including retest~; and a projected completion date for corrective measures. Within
~ DAYS of receiving Seller's corrective proposal, or ir no corrective propo8D.l Is m:eived within the time ~Iven, Buyer will:
a. Agree to the Ienns of the corrective proposal. if any, in writing. in which case Buyer accepts the Property and agrees 10 the RELEASE
set forth in paragraph 2S of this Agreement. OR
b. Accept the Property and the system and, if required by the mongage lender, if any, and/or any governmental authority, COITeCt the
defects before settlement or within the time required by the mortgage lender, jf any, and/or any governmental authority, at Buyer's
sole expense and with Seller's permission, which will not be unreasonably withheld, and agree to the RELEASE set forth in para-
graph 25 of this AgreemenL If Seller denies Buyer permission to colTeCt the defel;:ts, Buyer may. within ~ DAYS of Seller's
denial. terminate this Agreement in writing, in which case all deposit monies paid on account of purcha.~ price will be returned
promptly to Buyer and thi~ Agreement will be YOID, OR
c. Tenninate this Agmmtent in writing, in which case all deposit monies paid on account of purchase price will be returned promptly
to Buyer and this Agreement will be VOID.
14, NOTICES, ASSESSMENTS & CERTIFICATES OF OCCUPANCY (1-o2)
(A) Seller represents, as of Seller's execution of this Agreement. that loU public improvement, condominium or homeowner association assessment~
have been made against the Property which remain unpaid, and that no notice hy any govemment or public authority has been served Upoll
Seller or anyone on Seller's behalf, including notices relating to violations of 7.Oning, housing, building. .~afety or lire ordinances which remain
uncorrected. and that Seller knows of no condition that would constitute violation of any such ordinances which remains uncOlTC(:ted, unless
otherwise specified here:
(B) Seller knows of no other potential nolices (including violations) and asse~sments except as follows;
(C) In the event any notices (including violations) and assessments are received after execution of this Agreement and before settlement, Seller will
notify Buyer in writing, within ----L- DAYS of receiving the notice or aqessment, that Seller will;
I. Comply with notices and assessments at Seller's expense. in which case Buyer accepts the Property and agrees to the RELEASE set forth
in paragraph 2S of this Agreement. OR
Not comply with notices and assessmenfS at Seller's expense.
If Seller chooses not to comply with notices and assessmenlJJ. or fails wilhln [be time given to notlf'y Buyer If Seller will comply, Buyer
will notify Seller within ~ DAYS in writing that Buyer will either.
a. Comply with notices and assessments at Buyer'~ expense and agree to the RELEASE set forth in paragraph 25 of this Agreement. OR
b. Terminate this Agreement, in which case aU deposil monies paid on account of purchase price will be returned promptly to Buyer
and this Agreement wiU be YOID.
IrOuyer falls to notify Seller wilhln the time given, Buyer a<<epulhe Properly and agrees 10 the RELEASE set rnrth In para-
graph 15 of this AgreemenL
(D) Buy; i;.,~ ~t accesa 10 a public road may require issuance of a highway occupancy permit from the Department Of]rSportatio~
41. B"'''lnJUab,~l-\ AIS.'KPa",,,,. S.1I"lnIUab, Rf1,).. ()'V
2.
J.
'14
'"
'"~
'"
'"
'"
'"
'"
33'
33'
'34
'35
".
331
'"
33.
34.
34'
'42
34'
'44
'"
34.
341
34.
'"
'"
'51
.'62
'53
,..
'65
,..
'51
,..
'"
,..
'61
'"
'63
,..
'"
".
'51
".
'"
'10
on
312
'"
314
375
31.
'"
'10
319
,&0
'"
'"
'"
,..
'OS
'86
'"
,..
'"
39.
'51
'92
'93
'"
'"
,..
391
,,,
'"
<0.
'01
<0,
<0,
...
...
...
.01
...
'"
'"
."
'"
413
'"
415
.16
417
.16
".
'"
'21
422
423
.,.
42'
...
421
...
...
'"
'"
'"
'"
...
'"
".
'"
".
...
...
."
.42
'"
...
...
...
..,
...
...
'"
..,
'"
'"
...
.55
.50
451
".
'59
'"
."
.02
'"
".
455
'50
451
'58
...
'"
'"
412
473
.14
'"
".
411
'"
419
...
."
'"
.n
".
."
16'
'"
.58
...
4110
."
...
.n
...
."
."
491
...
lJ;i-) It required by law, within ---1L DAYS of the execution of this Agreement Seller WIll order lor tlellvery to !Suyer, un or OC:llJre setllC!llelll;
1. A certifi~tlon from the appropriate municipal department or departments disclosing notice of any uncorrected violations of zoning. hous-
ing, building, safety or rare ordinances, AND/OR
2. A certificate pennitting occupancy oCthe Property. In the event repair1lIimprovements an:: required for the issuance of the certificate, Seller
will, within ---L- DAYS of Seller's receipt of the requirements. notify Buyer of the requirements and whether Seller will make the
required repainfunprovements at Seller's expense.
U Seller chooses to make the required repairslimprovements. Buyer agrees to accept the Property as ~d and agrees to the RELEASE set
forth in paragraph 25 of this Agn:c:ment. If Seller chooses not to make the required repail'!llimproVemer1lS, Buyer will, within -----1- DAYS,
notify Seller in writing of Buyer's choice to terminate this Agreement OR make the repainlimprovements at Buyer's expense and with Seller's
permission. which will not be unreasonably withheld. U Seller denies Buyer pennission to make the required repairs or ifSeUcr fails to mpond
within the time given, Buyer may, within ~ DAYS, tenninate thisAgreement in writing, in which case all deposit monies paid on account
of purchase price will be retwned promptly to Buyer and this Agreement will be VOID.
15, TITLE. SURVEYS & COSTS (1-02)
(A) TIle Property is to be conveyed free and clear of ail liens, cncumbran~, and easements, EXCEPTING HOWEVER the following: existing
deed restrictions, historic preservation restrictions or ordinances, building restrictions, ordinances, ellllemcnts of roads, easements visible upon
the ground, easements of record. privileges or rights of public servi~ companies. if any: otherwise the title to the above described real e.~lale
will be good and marketable and such as will be insured by a reputable Title Insurance Company at the regular rates.
(8) Buyer will pay for the following: (I) Title 5eaIcll, title ill5urance andfor mechanics lien insurance. or fee for cancellation of same, if any;
(2) Rood insurnnce, fire insurance with extended coverage, mine subsidence insullUlce, or fee for cancellation of same, if any: (3) Appraisal
fees and charges paid in advance to mortgage lender, if any; (4) Buyer's customary settlement costs and accruals.
(C) Any surveyor surveys which may be required by the Title Insurance Company or the abstracting attorney for the preparation of an adequate
legal description of the Property (or the com::ction thereof) will be secured and paid for by Seller. Any surveyor surveys desired by Buyer or
required by the mortgage lender will be secured and paid for by Buyer.
(0) In the evenl Seller is unable to give a good and marketable title and such as will be insured by a reputable TItle Company at the regular rales, 85
specified in paragraph 15(A), Buyer will have the option of: (I) laking such title as Seller can give with no change 10 the purchase price: or (2) being
repaid all monies paid by Buyer 10 Seller on accounl of purchase price lUld being reimbursed by Seller for any costs incurred by Buyer for any iMpel:-
tions orcertilications obtained according to the terms of the Agreement, and for those items specified in paragraph 15(8) items (I), (2), (3) and in
paragraph 15(C), in which case there will be no further liability or obligation on either of the parties bereto and this Agreemenl will become VOID.
16, ZONING CLASSIF1CATlON (1-02)
Failure of this Agreement 10 contain the zoning classification (except in cases where the property {and each parcel theTeof, if subdividable I is zoned
solely or primarily 10 permit single-family dwellings) will render this Agreement voidable at the option of the Buyer, and, if voided, any deposits
tendered by the Buyer will be returned to the Ijuyc:r wiJ;hou~nypquimnent for court action.
Zoning Classification: iE!ti6Jd{qf04L
o ELECfED. Within ~ DAYS of the execution of this Agreement, Buyer will verify that the existing use of the Property as
is permitted. [n the event the use is nol pennitted, Buyer will, within the time
given Cor verification, notify Seller in writing that the existing use of the Propeny is not permitted and this Agreemenl will he VOID, in which
case all deposil monies paid on accounl of purchase price will be returned promptly to Buyer. Buyer's failun! to respond within the time
given will constitute a WAIVER of this contingency and aU other tenns or this Agreement remain in Cull force and errect.
17. iALNcmCE
NOT APPLICABLE
APPLICABLE
THIs DOCUMENT MAY NaT SHlL, CONVEY,TRANSFER, INa.UDEOR INSURB THE mu; ro 1HE COA.l"AND RIGHTS OF SUPPORT UNDI!RNEATIl mE SURFACE UNO
DESCRIBED OR REFERRED TO HEREIN, AND THE OWNER. OR OWNERS Of SUCH COi\L MAY HAVE 1HE COMPLETE LEOi\L R1G1ITTO REMOVE ALL SUCH COAL AND
INTHAT CONNEcnON, DAMAORMAY Rl!SULTT01HB SURFACEOP1HE lJ\ND ANOAN\' HOUSE, IIUIWINO OR OTHER ST1l.UcnJR.E ON OR IN SUal lAND. (This
noti~ is sel fanh in the manner provided in Section I of the Act ofIuly 17, 1957, p.L. 984.) "Buyer acknowledges thai he may not be obtaining the
right of pro~tion against subsidence resulting from coal mining operations, and thai the propeny described herein may be protected from damage
due to mine subsidence by a private contract with the ownen of the economic interests in the coal. This acknowledgement is made for the purpose
of complying with the provisions of Section 14 of the Bituminous Mine Subsidence and the Land Conservation Act of April 27, 1966." Buyer agrees
to sign the deed from Seller which deed will contain the afotuaid provision.
18. POSSESSION (1-02)
(A) Possession is to be delivered by deed, keys and:
1. Physical possession to vacant Property free of debris, with all StnJct\lres broom-dean, al day and time of settlement, AND/OR
2. Assignment of existing lease(s), together with any security deposits and interest, al time of settlement, if Property is lea'lCd al the
execution of this Agreement or unless otherwise specified herein. Buyer will acknowledge e~sting lelllle(s) by initialing said lease(s) at
tirne ofexeculion of this Agreement
(B) Seller will not enter into any new leases, written extension of existing leases, if any, or additional leases for the Property withoul the written
consent of Buyer.
19, RECORDING (3-85) This Agreement will not be recorded in the Office for the Recording of Deeds or in any other office or place of public record
and if Buyer causes or permits this Agreement 10 be recorded, Seller may elect to treat such act as a breach of this Agreement.
20, ASSIGNMENT (3-85) This Agreement will be binding upon the parties,lheir respective hem, penonal represenlative.'l, guardians and successon,
and 10 the exlenl assignable, on the assigns of the parties hereto, il being expressly undel1ll00d, however, thai Buyer will nol transfer or 8S.'lign this
Agreemenl without the written consenl of Seller.
21, DEPOSIT & RECOVERY FUND (1..02)
(A) Deposits paid by Buyer within -.-30.- DAYS of settlemenl will be by cash, cashier's or certified check. Deposits, regardless of the fonn of
payment and the person designated Illl payee, will be paid in U.S. Dollars 10 Broker or party identified in paragraph 3(B), who will relain them
in an escrow accollnl until con.surmnalion or tennination ofthisAgreernenl in conformity wilh all applicable laws and regulations. Any uncashed
check tendered as deposit monies may be held pending the acceptance of this offer.
(B) Upon termination of this Agreement, the Broker holding the deposit monies will release the deposit monies in accordance with the terms of a
fully executed written agreement between Buyer and Seller.
(C) In the event of a dispnte over entitlement to deposit monies. a broker holding the deposit monies is required by the Rule.~ and Regulations of
the State Real Estale Commission (49 Pa. Code ~35.327) to retain the monies in escrow until the dispnte is resolved. In the evenl of litigation
for the return of deposit monies, a broker will distribute the monies as directed by a [mal order of court or the written Agreemenl of the parties.
Buyer and Seller agree thai, in the event any broker or affiliated licensee is joined in litigation for the return of deposit monies, the attorneys'
fees Md costs of the broker(s) and licensee(s) will be paid by the pony joining them.
(D) ^ Real Eslate Recovery Fund exists 10 reimburse any persons who have obtained a final civil judgment againsl a Pennsylvania real estate
licensee owing to fraud, misrepresentation, ordeceit in a real estate transaction and who have been unable 10 collect the judgment after exhaust-
ing all legal and equitable remediCll. For complete details about the Fund. call (717) 783-3658, or (800) 822.2113 (within Pennsylvania) and
(717) 783-4854 (outside Pennsylvania).
2'- fNDOMINIUMJPLANNED COl\1.MUNITY (HOMEOWNER ASSOCIATION) RF..sALE NOTICE (1..02)
NOT APPLICABLE
APPUCABLE: CONDOMINIUM. Buyer acknowledges thai the Property is a unit of a condominium thai is primarily run by a unit ownCl1l'
association. gJ407 of the Uniform Condominium Act of Pennsylvania requires Seller 10 furnish Buyer with a Cenificate of Resale and copies
of the condominium declaration (other than plats and plans). the bylaws, and the roles and regulations of the association.
o APPLICABLE: PLANNED COMMUNITY (HOMEOWNER ASSOCIATION). Buyer acknowledges that the Propeny is part of a planned
community as defined by the Uniform Planned Community Act (See Definition of Planned Community Notice). ~5407(a) of the Act requires
Seller to furnish uyer with a copy of the Declaration (other than platsl and plans), the bylaws, the roles and regulations of the association, and
It Certific I8ini~l\ the provisiona set forth in 15407(a) of the Act ~ ~ '='
Buyer InIda1s: r AJS-2K Page 6of8 SeDer 1nIt1111s:/t(:i::I" ~
,..
'"
'13
414
415
'"
417
41.
'"
".
421
'"
'"
".
'"
".
421
".
...
...
'"
'"
'"
".
'"
...
431
".
".
...
.41
..,
'43
...
..,
44'
..,
44.
...
".
'"
'"
'"
.54
455
'"
457
'"~
'"
...
'"
'"
'"
...
...
...
..,
...
'"
'"
411
412
473
414
".
".
'1:-
".
".
'"
'"
'"
'"
...
."
."
..,
...
...
'"
..,
..,
."
...
m
...
'"
...
1:11I& lo'OLLOWlNGAPPUES TO PROPERTIES THAT ARE PART OIo'A CONDOMINIUM UK A l"LANNt'..U LUMMUNll r.
(A) Within ---1L DAYS of the execution afthi. Agreement. Seller will submit a request 10 the association for a Certificate of Resale and the doc-
uments necessary to enable Seller to comply with the Acl 'The Act provides that the association is required to provide these documents within
10 daya of Seller's request.
(B) Seller will promptly deliver to Buyer all documents received from the association. Under the ACl Seller is not liable to Buyer for the fajlure or
delay of the association to provide the Certificalc in a timely manner, nor is Sellcr liable to Buyer for any erroneous infonnation provided by
the association and included in the Cettificale.
(C) Buyer may declare this Agreement VOID at any time before Buyer's receipt of the association documenl5 and for .5 days thereafter, OR until
settlement, whichever occun first Buyer's ootice declaring this Agreement void must be in writing; thereafter all deposit monies will be
returned to Buyer.
(D) In the event the association has the right to buy the Property (right of first refusal), and the association exercises that right, Sellcr will reimburse
Buyer for all moniell paid by Buyer on account of purchase price and for any costs incurred by Buyer for: (I) Title search, title insurance and/or
mechanics lien insurance. or fee for cancellation of same, if any: (2) Aood insl1n1J\Ce and/or fire insl1n1J\Ce with extended coverage. mine sub-
sidence insurance, or fee for cancellation of same, if any: (3) Appraisal fees and charges paid in advance to mortgage lender, if any.
23. MAINTENANCE & RISK OF LOSS (1-02)
(A) Seller will maintain the Property, ground.. fixtures. and any personal property specifically scheduled herein in its present condition, normal
wear and tear excepiN.
(B) In the event any syslem or appliance included in the sale of the Property fails and Seller does not repair orreplace the item, Seller will promptly
notify Buyer in writing of Seller's choice 10:
1. Repair or replace the failed system or appliance before settlement or credit Buyer at settlement for the fair market value ofthc failed sys.
tern or appliance (this option must be acceptable to the mortgage lender, if any). In each case, Buyer accepts the Property and agrees to
the RELEASE set forth in paragraph 25 of this Agreement, OR
2. Not repair or replace the failed system or appliance, and not credit Buyer at settlement for the fair market value of the failed syslem or
appliance. If Seller does not repair, replace.or offer a credit for the failed system or appliance, or If Seller fallll to nollfy Duyer ofSeUer's
choice. Buyer will notify Seller in writing within ~ DAYS or before seulement, whichever is sooner, that Buyer will:
a. Accept the Property and agree to the RELEASE set forth in paragraph 2S of this Agreement, OR
b. Tenninate this Agreement, in wlUch case all deposit monies paid on account of purchase price will be returned promptly to Buyer
and this Agreement will be VOID.
(C) Seller will bear risk of loss from fire or other casualties unlillime of settlement. In the event of damage by fire or other ca.qualtie.\ 10 any prop-
erty included in this sale !hat is not repaired or replaced prior to settlement, Buyer will have the option of rescinding this Agreement and
promptly receiving all monies paid on account of purchase price or of accepting the Property in its then condition together with the proceeds
of any insurance recovery obtainable by Seller. Buyer is hereby notified that Buyer may insure Buyer's equitable interest in this Property as of
the time of execution of this AgreemenL
24. WAIVER OF CONTINGENCIES (1-02)
If this Agreement is contingent on Buyer's right to inspect and/or repair the Property. Buyer's failure to exerclse any of Buyer's options within
the time Umi'" set forth In this Agreement will constitute a WAIVER of that contingency and Buyer accepb: the Property and agrees to the
RELEASE set forth In paragraph 25 of this Agreement
25. RELEASE (1..02)
Buyer bereby releases, quit claims and forever discharges SELLER, ALL BROKERS, their LICENSEES, EMPLOYEES, and any om.
CER or PARTNER of anyone of them and any other PERSON, FIRM, or CORPORATION who may be Uab.le by or through them, from
any and all claims, losses or demands, including, but not Bmiled to, personal injuries and properly damage and all or the con.wquences there-
of, whether now known or nol, wbidt may arise from the presence of termites or other wood-boring inseds, radon. lead-based paint haz.
ards. environmental hazards, any defects In the Individual on-lot sewage disposal system or deficiencies In the on-slte water service system,
or any defects or conditions on the Property. Sbould Seller be In defaull under the terms of this Agreement, thl.. rdea5e does not deprive
Ruyer of any rijthlto pursue any I't'medles thai may be available under law or equity. Thl\ I't'lea.\e will survive selUemenL
26. REPRESENTATIONS (1-Q2)
(A) Buyer understands that any representations, claims, advertising, promolional activities, brochures or plans of any kind made by Seller. Brokers.
their Licensees. employees, officers, 01" partners are not a part of this Agreement unless expressly incorporated 01" stated in this Agreement. It is
further underslood that this Agreement contains the whole agreement between Seller and Buyer and there are no other terms. obligation.~,
covenants, representations, statements or conditions, oral or otherwise of any kind whatsoever concerning this sale. Funhennore. this
Agreement will not be altered, amended. changed, or modified except in writing executed by the parties.
(B) It is understood that Buyer has inspected the Property before signing this Agreement (Including nxtures and any personal property
specifically scheduled berdn), or hall waived the right to do so, and bas agreed to pun:hase the Property in its present condition unless
otherwise staled In this AgreemenL Buyer acknowledges thai Brokers, their licensees, employees, officers or partners have not made
an independent eJlsmination or determination of the stmcturalsoundness of the Property, tbe age or condition oftbe component., envi.
ronmenlal rondlUons, the permitted uses, or of conditions existing In the locale where the Property is situated; nor bave they made a
mechanical inspection of any of the systems contained therein.
(C) Any repairs required by this Agreement will be completed in a workmanlike manner.
(0) Broker(s) may perfonn services to assist ulU"epresented parties in complying with the term~ of this Agreement.
(E) TIle heading~, captions, and line numbers in this Agreemenl are meant only to make it easier to find the paragraphs.
27. DEFAULT (1-Q2)
(A) Seller has the option of retaining all sums paid by Buyer, including the deposit monies, should Buyer:
I. Fail to make any additional payments as specified in paragraph 3; OR
2. Furnish false or incomplete information to Seller, Broker(s), or the mortgage lender, if any, concerning Buyer'~ legal or financial sUltus,
or fail to coopernte in the processing of the mortgage loan application, which acts would re~ult in the failure to obtain the approval of a
mortgage loan commitment; OR
3. Violate or fail to fulfill and perform any other terms or condilions of this AgreemenL
(B) Unless otherwise cbecked In paragraph 27 (C), Seller may elect to retain those sums paid by Buyer, including deposit monies. in one of the
following manners:
I. On account of purchase price: OR
2. As monies to be applied to Seller's damages; OR
~ As liquidated damageg for such breach.
(C) 9\. Seller is limited to retaining sums paid by Buyer, including deposit monies, as liquidated damages.
(D) If Seller relains all sums paid by Buyer. including deposit monies, as liquidated damages pursuant to paragraph 27 (B) or (C). Buyer and Seller
will be released from further liability or obligation and this Agreement will be YOID.
28. MEDIATION (7-96)
o Nor AYAlLABLE
o WAIVED. Buyer and Seller understand that they may choose to mediate at 8 later date, should a dispute arise, but that there will be no obli.
~. gation on the part of any puty to do so.
ELECTED
(A Buyer and Seller will IIy to m10lve any dispute or claim that may arise from this Agreement !hrough mediation, in accordance with the Rules
and Procedures of the Home SellerslHome Buyers Dispute Resolution System. Any agreement reached through a mediation conference and
signed by the parties will be binding.
(8) Buyer and Seller acknowledge that they have received, read. and understand the Rules and Procedures of the Home Sellers/Home BUYerli
Di~pute Resolution System (see Medialion Notice).
(C) This agreement 10 mediate disputes arising from this Agreement will survive settlement.
581 BUYerlnitials:~ ! c,t/ AJS..2KPage70f8
,
."
.00
'01
'"
."
...
...
...
'07
,..
.ot
.10
&1,
&12
'"
&1.
'"
51.
517
&1'
'"
'"
'"
52'
'"
'"
&25
52.
127
.28
52.
53'
53'
53'
53'
'"
53'
'"
531
53.
."
'"
..,
..,
,..
...
'"
,..
'"
,..
,..
55'
55'
'52
'"
55'
.55
55.
.57
."
."
...
'"
."
'53
...
'"
...
'"
,..
...
.70
571
'"
573
'"
'"
'"
577
'"
57.
'"
'"
."
'"
...
."
S.I~, IniU.J" ~r6 ;J:7
.~~
...
."
50'
."
...
.05
...
507
...
."
.10
'"
.12
.13
51.
'15
'19
511
51.
51.
'"
'"
52'
'"
".
52'
52&
.72
52.
52.
53.
.31
53'
53'
53.
.35
53.
537
53.
53'
...
..,
..,
&I,
...
'15
...
.57
...
...
.50
.51
55'
.53
".
'"
.56
557
'"~
'55
'"~
,&1
51'
'"
56.
51.
56'
517
."
."
.70
.71
'"
573
'"
'"
'"
577
'"
'"
56'
.11
51'
."
56.
'"
51'
~1 ..29. SPECIAL CLAUSES (1-02)
588 <^> The following are part or this Agreement It checked: 511
liB' 0 Sale & Settlement of Other Property 0 5"
S9G Contingency Addendum (PAR Fonn SSP) 0 5!1O
591 0 Sale & Settlement of Other Property Contingency 0 591
592 with Right to Continue Marketing Addendum 0 592
5" (pAR Fonn SSP-CM) 0 St3
6!l4 (B) 5"
m m
m ~
m ~
m ~
~ m
~O ~O
~ ~
602 SOl
603 Buyer and SeDer acknowledge receiving a copy 01 this Agreement at the time 01 signing. 503
IDol 604
6115 NOTICE TO PARTIES: WHEN SIGNED, lHIS AGREEMENT IS A BINDING CONTRACf. Return by tacslnille transmission (FAX) of this 60s
&06 Agreement, and all addenda, bearing the signatures or aU parties, constitutes acceptance of this Agreement. Parties 10 this tr'ansaCtion are advised 60&
&01 to consult an aUorney before signinllf they desire lqaI advice. 601
60& 60&
." I Buyer has naived the Consumer Nolke &II adopted by the State Real Estate Commission at 49 Fa. Code 135.336. 609
1110 Buyer has fftdved. statement of Buyer's estimated demn. costI before signing this Agreement. 610
611 , Buyerhu read and undentands the notk:el and explanatory Wormatlon set forth In this Agnement. 611
m ., Buyer has received a Seller's Property DIscI~re Statement betol'e.sign)ng this Alreem~1f required by law (see Informadon Regarding 512
m the Real EState SeUer Disdosure Lawt. . I1/A ~I?IJ/3lt je:5fAlii'f}l"lJftW 813
m ,q Buyer bas received the Deposit Money Nottee (for cooperadve sales when BfokJ for ~ er Is hOlding deposit money) before sJaning this 114
815 Agreement. &15
111 &1&
617 BUYER'S MAILING ADDRESS: . 111
Settlement of Other Property Conlingency Addendum (PAR FOnD SOP)
Tenant-Occupied Property Addendum (PAR Fonn lOP)
11.
611 BUYER'S CONTACT NUMBER(S):
."
."
."
623
."
62.
'"
.21
."
."
".
.31
.31
'"
."
'"
."
'"
'"~
."
. ,
-
'16
'"
I ."
../,,/11/ 7. .7012. '"
, 122
BUYER"/....
SSII
WITNESS
/
~v
DATE
WITNESS
BUYER
SSII
DATE....V", 1, ;Ztl:lZ-
d
WITNESS
BUYER
SSII
DATE
Seller hereby approves the above contract this (dale)
and in consideration of the services rendered in procuring the Buyer. S ler a to ay the named Broker for Seller a fee of "
of/from the herein S,%ified sale price. In !be evenl Buyer defaullS hereunder, any monies paid on accounl will be divided ;'.. c;lt fl'J"
Seller, ,t;"A , Broker for Seller, but in no event will the sum paid to the Broker for Seller exceed the above specified Broker's fee.
~lIer has received Ihe CollS\llDt!r Notice IU adopted by the Slate Real E&tale Commission at 49 Pa. Code 135336-
19" .>ner has received a statement of Seller's estimated closing cos~ before signing this Agreement.
il' Seller has read and uDderstands the notices and explanatory Information set forth in dUll Agreement.
27.5 WI "WJo.if; e.J
"tor+. \-\"...e""\, I't- \ 7 ~ 7 ()
7\7 q3J- /44-
DATE~
....
DATE qJJ\'rOl
."
'"
..,
....
...,
....
...,
....
...,
...
."
..,
."
...
...
...
."
65.0
...
...
."
..,
..,
...
..,
...
66'
...
...
.70
WITNESS
SELLER
SSII
SELLER 'Bif?="-
SSII ::J-08"-,...-.;7
~~-~
WITNESS
WITNESS
SELLER
SSII
DATE
Broker'slLicmsees' CertlDcatioDll (check aU that are applicable):
~ Regarding Lead-Based. Paint Ha2ardIJ Disclosure: Required If Property was built before 1978: The undersigned Licensees involved in
this li1Insaction, on behalf of themselvea and their brokefS, certify thai their statemenL, are true to the best of their knowledge and belief.
Acknowledgement: The Licensees involved in thill transaclionhave informed Seller of Seller's obligationnmder The Residential Lead-Bued
Paint Hazard Reduction Act, 42 U.S.C. 14852(d), and are aware of their responsibility to ensure compliance.
~
Regarding FHA MortgagCll: The undersigned LicenscC3 involved in this tranllaction, on behalf of them~elves and their brokers, certify that
the terms of this contract for purchll3e are true to the best of their knowledge and belief, and thai any other agreement enlered inlo by any of
these parties in connection with this transaction is attached to this Agreement
Regarding Mediation: The undersigned 0 Broker for Seller ~Broker for Buyer agree to submit 10 mediation in accordance with
paragraph 28 of this Agreement.
B~~~~~ :~LLER (Company N;;O;:!.ry~t;/ff/5>~ /4 kr
BROKERFORB~pan'N'''''' ~ctM.t. C~6Ib../A~<Ji!t'/:r.4r,
ACCEPTED B --t~t /..Llrtt# < cr-
171 AJS.2K Page II 018
SELLER'S COPY
DATE
/ ~
1/ 1,/. "::2
, L:i
1/ ~/ 7
DATE
~,
'"
."
."
."
621
'"
'"
".
'"
.32
'"
".
."
.59
'"
".
'"
....
..,
..,
'"
...
..,
...
...,
....
...,
.5O
65'
.il
."
...
.59
...
."
...
'5O
...
."
."
."
....
...
...
."
...
..,
."
671
Tax Parcel No. 26-24-0809-362
THIS INDENTURE,
MADE THE
/ :J. Y4-
(2002 )
day of August, two thousand two
BETWEEN
RANDALL F. BYRA and PATTI L. BYRA, Co-
Executors of the Last Will and Testament of
HELEN B. PAKOSH, late of the Borough of New
Cumberland, Cumberland County, Pennsylvania,
parties of the first part,
and
COREY~ HAMILTON and LORI HAMILTON" husband
and wife, of New Cumberland, Cumberland
County, Pennsylvania, parties of the second
part:
WHEREAS, the said HELEN B. PAKOSH by her Last Will and Testament,
duly proved and recorded in the Cumberland County Register of
Wills Office, Carlisle, Pennsylvania, in Docket Book No. 21-02-
0544, Letters Testamentary being issued on June 7, 2002, pro-
vided, in pertinent part, as follows:
ITEM 7: I appoint my children, Randall F. Byra and
Patti L. Byra as Co-Executors of this my Last Will and Testament.
NOW THIS INDENTURE WITNESSETH, that the said parties of the first
part, by virtue of the power and authority aforesaid, in said
Will contained, and in consideration of the sum of One Hundred
Twenty-Six Thousand and 00/100 Dollars ($126,000.00) to them paid
by the said parties of the second part, at and before the
ensealing and delivery of these presents, the receipt whereof is
hereby acknowledged, have granted, bargained, sold and conveyed,
and do hereby grant, bargain, sell and convey to the said parties
of the second part, their heirs and assigns forever:
ALL THAT CERTAIN lot of land situate in the Borough of New
Cumberland, Cumberland County, Pennsylvania, more particularly
bounded anq described as follows:
BEGINNING at a point on the southerly line of Brookhaven Road,
said point being located two hundred fifty ,(250) feet measured
westwardly along said line from the southwest corner of
Brookhaven Road and Crescent Court; thence southwardly along the
westerly line of Lot No. 13, Block D, on the hereinafter men-
tioned Plan of Lots, one hundred twenty (120) feet to a point;
thence westwardly along the northerly line of a proposed park
area seventy (70) feet to a point; thence northwardly along the
easterly line of an eight (8) foot right-of-way one hundred
nineteen and ninety-nine one-hundredths (119.99) feet to a point;
thence eastwardly along the southerly line of Brookhaven Road by
a curve to the right having a radius of 320 feet, an arc distance
of one and ninety-four one-hundredths (1.94) feet to a point;
thence continuing along said line of Brookhaven Road north
eighty-nine (89) degrees fourteen (14) minutes east sixty-eight
and six one-hundredths (68.06) feet to the place of BEGINNING.
BEING Lot No. 14, Block D, on the Plan of Section 1, Highland
Park Hills and Drexel Hills, said Plan being recorded in the
Cumberland County Recorder's Office in Plan Book 7, Page 23.
HAVING THEREON ERECTED a dwelling house being known as numbered
as 618 Brookhaven Road, New Cumberland, Pennsylvania.
BEING the same premises which Highland Park Hills, Inc., a
Pennsylvania Corporation, by deed dated September 18, 1956 and
recorded in the Cumberland County Recorder of Deeds Office in
Deed Book "K", Volume 17, Page 166, granted and conveyed unto
Frank S. Byra and Helen J. Byra, husband and wife. The said
Frank S. Byra died June 2, 1969 whereupon full and complete title
to the within described real estate became vested solely in
Helen J. Byra, the decedent herein. The said Helen J. Byra
became intermarried with John J. Pakosh, thereafter being known
as Helen B. Pakosh. The said John J. Pakosh died July 7, 1998.
The said Helen B. Pakosh died June 1, 2002.
UNDER AND SUBJECT to Building and Use Restrictions applicable to
lots shown on said Plan of Lots, as recorded in Miscellaneous
Book 114, Page 112, Cumberland County Records.
TOGETHER with all and singular the rights, liberties, privileges,
hereditaments and appurtenances whatsoever 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
said Helen B. Pakosh at and immediately before the time of her
decease, in law or equity or otherwise howsoever, of, in, to or
out of the same:
TO HAVE AND TO HOLD the said granted premises to the said parties
of the second part, their heirs and assigns forever.
AND the said parties of the first part, do covenant, promise,
grant and agree, to and with the said parties of the second part,
their heirs and assigns, by these presents, that the said parties
of the first part, have not done, committed, or knowingly or
willingly suffered to be done, any act, matter or thing what-
soever, whereby the premises aforesaid, or any part thereof, is,
are, shall or may be charged or encumbered, in title, charge or
estate, or otherwise howsoever.
IN WITNESS WHEREOF, the said parties of the first part have
hereunto set their hands and seals the day and year above writ-
ten.
Signed, Sealed and Delivered
f. in the p~fence of
\JL la.)y f)Lc' h.L
!l.JJ.l f 3~ (SEAL)
Randall F. Byra, Co xecutor of
the Estate of Helen B. Pakosh
f o:;r;c:- ~ ~c, (SEAL)
Patti L. Byra, C Executor of
the Estate of Helen B. Pakosh
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF tw y,berland. : SS. .
On this, the /~'-I:!.J. day of Qu.qU.s}- ,2002, before me,
the undersigned officer, personally aPpeared RANDALL F. BYRA:and
PATTI L. BYRA, Co-Executors of the Estate of Helen B. pakosh,
known to me (or satisfactorily proven) to be the persons de-
scribed in the foregoing instrument, and acknowledged that they
executed the same in the capacity therein stated and for the
purposes therein contained.
IN WITNESS WHEREOF, I
seal.
hJreu ~o set my hand and official
/
vUL yy
Notary Public
My Commission Expires:
EAL)
.
NOTARIAL SEAL .
TINA M. CRONEN, Notary Public
Camp Hill Bora, Cumberland counoZ3
M Comm.'!~n fi~ Ires Ma 10.2
CERTIFICATE OF RESIDENCE
I do hereby certify that the precise residence and complete
post office address of the within named grantees is
U I r brtoIUla.t;-tn f'c( )
/v't1-tp C'vL/l1lxrt Co. ~ CI, t-"f-J' 767(J
QU(jfLS+- I;)" 2002 ~,~ \\.Q~ ) l( C UJ( e/L ____
Jltt9rr:lsyjAgent for
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF CUMBERLAND
RECORDED on this day of
.
200 , in the Recorder's Office of the said County, in
Deed Book , Page
Given under my hand and the seal of the said office,
the date above written.
, Recorder.
,r
A-
U.S. DEPARTMENT OF HOUSING & URBAN DEVELOPMENT '-DFHA 2-oFmHA 3.~CONV. UNINS, '-oVA 5. DCONV. INS.
: I . w~. ",U'.Don:
SETTLEMENT STATEMENT 02400
8. MuR. UAl:>1:: INS ......."'0;; Nu.....BEtc:
c. "v,o: This form Is finn/shed to give you II stsiemont of actuaJ settfflment costs. Amounts paid to and by the setuement agent am shown.
Items marked "{pOCr W8f8 paid outside the closing; they 8IV shown here for Infamia/ionsl purposes and 818 not included in the totals.
" - (D24lll:W2~00J201
O. nAMo ~,v Auuncoo v, I o. '~oMN . n~cANu~O LcNDc/'\:
Corey Hamillon and Estate of Helen Pakosh Wayoint Bank
Lori Hamilton 101 S. George Slreel
York, PA 17401
G. PROPERTY LOCATION: H. SETTlEMENT AGENT: 25-1878915 I. SETTLEMENT DATE:
618 Brookhaven Road Keyslorle land Transfer, Ltd.
New Cumberland, PA 17070 August 12, 2002
Cumberland County, Pennsylvania PLACE OF SETTLEMENT
3421 Market Slreet
Camp Hili. PA 17011
,.
100. : O. A :
on "' .e, n" on . .e, "
arsons "'Pe y erSOl1a ropery
e emen arges 0 orrower "e
~us men s '" em, " y e Tina anca ~lJsmens 0' em, " y eertna vance
'y own axes 0 'y own axes
cun .... o'n oxe, 0 ~
" 0 00 " ~
euss 0 e e 0
120. GROSS AMOUNT DUE FROM BORROWER 130,920.31 '20. GROSS AMOUNT DUE TO SELLER 126,942.11
200. A Nns AID R: ~. 5 0 INA UNT U: 10 :iELLI:K:
epOSI Of earnes money '"" eposl ee ns uc ons
nnClpa moun 0 ew oans e emen arges 0 e e, "e
ISing oan s ensu Jec 0 t:: ISing oan s a ensu lec 0
ayo~1 o gage
:: .yo 0"'000 gage
~. eposl s . as procee 5
1usments or ems np81 y e e' 1~ens or ems npal y 'e,
'y own axes 0 'y OW" axes 0
auny axes 0 o'n axes 0
000 " 0 00 "
;lJ. :Sewer 0 ewer 0 ,.'"
.".C.
~
".. m.
220. TOTAL PAID BYIFOR BORROWER 105,812.00 520. TOTAL REDUCTION AMOUNT DUE SELLER 8.740.72
: ITIDu~e :
: . ross moun ue rom orrower lOe~ ross 0 '" ne
JU~. Less moun 31 y or OtrOWilr (Line '" e UClons "' '" '"
303. CASH ( X FROM) ( TO) BORROWER 25,108.31 603. CASH( X TO)( FROM) SELLER 118,201.39
OMS NO 2502.0265 .....
Th. ,nd,rnl,n'" he,e; ",now;;i ~"'Pl if,: oompleted ropy 01 p'ge, 1&2 of !hI, "ateme",' '"y "":7::;;0;;;:,n 6tPudD'
Borrower eJ:r[[,{., ~l!ZiJft~ Seller ~~ e 'P("JIu.--
ey ~ een a os
-,
L. SETTLEMENT CHARGES
00. M a.. on ce $ 126,000.00 @ 5.??oo % 6,300.00 PAlOF~ PAIOfRQlol
""" omm, ~ /fI8 8S: ws: 8ORROWER'S SEllER'S
o " aa Y sOCIa 00. FUNDSAT fUNOSAT
0 seTTlEMeNT SETTlEMENT
omm.SSIOfl .. a . emen
ran ac aa " oay SOClaes, ne.
800.1 YA I A
an rlglna on aa
n Iscoun
pprarsa " 0
, 0 apo'
a , nspec. a.
gage os. pp. ..
umplOll ..
n erwn Ing a. ayo, an
acumen repara on ayo," an
, eNlce a. ayom an
pIca IOn a. 0 ayo," an
ourler a. aYOln .n
, lea on 0 ayo," n
900.1 M R IR B D R B AI AD AN
901. Interest From 08112102 10 09101/02 @ $ 18.550000/day I 20 day' %) 371.00
gage nsurance r8mlumor mon .
'" nsurance remlum YO'"
'00.
1000. DEPOSIT WT
lOOt. azard Insurance .000 months 25.75 per monlh 77.25
gage nsurance mon . p., mon
,y own axes mon . pe' mon
oun y alias mon . po< mon
11UU::'. ticnOOllax ;i.UW monUls . 14.'Ol!:l per monm m."
~ mon . pe' mon
mon :=1 p.' mon
ggregae JUS men mon pe' mon
1100. fLE CHARGES
1101. Settlement or Closing Fee 10
.. m ,. ..
. TIlle Examination
Ie nsurance mer 0
oumon repara on 0 ,m ogar, squire
0'" ae. 0
orneys ee. 0
(lncu esa velemnum a's:
I e nsurance 0 ey' oo .n ranser, o ICY
,"cu esa ova I em num ern:
en ers overage
wners overage
n orsemens 0 .y, ne .n ranser,
oSlng roec on ae, 0 eysone n ranser,
" ecelp s eysone " rans '.
vermg 0 eysone . ranser.
00 " 0 o ,n aspere " o ecor
1200. GOVERNMENT I A
1201. Recordin9 Fees: Deed $ 29.50; Mortgage $ 56.50; Releases $ 86.00
oy ouny . amps .e :;: or gage
. ,,' amps: evenue p. or9age
e'~ ortgage SSlgnmen Cumberland County ecorderofDeeds
"00.
1300. AUUIIIUNAL SE fTLEMEN r I,;HAKI;;f;~
1301. Survey 10
., nspeclon 0
euse uy- ep 0 ow umera~roug
ewer p" ooe 0 ow um eran mug
''",. 1
1400. MENJ I,;HARGES (Enter on Lines 10J, section J and 502, Sa lion K) ., J.97/j.4:0 8,728.72
aySlQI\II'IQpeg'101ttl'S.\;!I'_.ll'IoognIIlonn'cIlnOwIooOgIrICllplOlaCOO'lpl'IeIlCOpyol_;t.oIm.._p,ll' '";W yy 1(1t111I/I~
/i
~:ruse~:n~~~~~:anstf r,Lla:
CerUned to be a true copy.
(a~400/a~400120 )
REV-150a EX + (1-97)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCET/IJ( RETURN
RESIDENT DECEDENT
ESTATE OF
Helen B. Pakosh
FILE NUMBER
21-02-0544
SSfF 166-12-4386
06/01/2002
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
NUMBER
1 Comcast Cable
10
11
12
13
DESCRIPTION
VALUE AT DATE
OF DEATH
16.33
Refund
2
J. C. Ehrlich
Pest control contract - refund
205.64
3
Myers Harner Funeral Home - Refund
512.00
4
Nationwide Mutual Ins. Co. - Auto insurance refund
125.50
5
Patriot News Co. - Refund
127.40
6
Personal property sold at private sale
1,107.00
7
PNC Bank, N.A. - Checking Account No. 5001043451, date of death
balance $3,223.48, accrued interest $0.25
3,223.73
8
PNC Bank, N.A. - Savings Account No. 5003143165, date of death
balance $15,381.60, accrued interest $14.91
15,396.51
9
1962 Philadelphia Mint Set - as per attached appraisal
8.00
1997 Chevrolet Malibu, Vehicle Identification No.
IGINE52M6V6114733 - sold at private sale
6,700.00
Fur Coats and Jackets - No value
0.00
Jewelry - as per attached appraisal
7,774.00
Westmoreland Sterling Silver Service for 8 - as per attached
appraisal
450.00
TOTAL (Also enter on line 5, Recap"ulation) $ 35,646.11
(If more space is needed, insert additional sheets of the same size)
'':~~.(~ight ~c) ~996 form software only CPSystems, Inc. Form REV-1508 EX (Rev. 1-97)
A~e
...-
Date:). qJvhe. 02..
Coin and Card Shop 244 W. Second St. (Rear, . Hummelstown. Po 17036. (71 7) 566-5866
A ~ p\O.iSo.\S ~\:.
l GIG "2. ?h' \.GG\L\ fvti'C\ 0'1 \ VI. i- S'e.."t
S1 8.
Wesl-vY\0'S€-\CI.V\ c\
Ser"-Jic..Q.
S-Ier li<j'
-fur ~.
Sl Y 5(),
Sil~-
& iY,~
Customer Signature: ~C~
~ PNCBAN<
July 3, 2002
James D. Bogar
One West Main Street
Shiresmanstown, P A 17011
RE: Estate of Helen B. Pakosh, deceased
SSN: 166-12-4386
DOD: 6/1/2002
Dear Mr. Bogar:
In response to your request for Date of Death balances for the customer noted above, our
records show the following:
Checking Account
Account #5001043451
Established OS/2111998
HELEN B P AKOSH
000 balance: $3,223.48 + $0.25 accrued interest
Savings Account
Account #5003143165
Established 02/28/2000
HELEN B P AKOSH
DODbalance: $15,381.60+$14.91 accrued interest
For Brokerage infonnation, please call 1-800-762-6111. INV #65629348
Please note that this office only provides date of death balances for deposit accounts
(IRAs, CDs, Checking and Savings accounts). We do not process any financial
transactions or provide statements. If you need assistance with any of these items,
please call1-888-PNC-BANK (1-888-762-2265) or stop by your local PNC Bank branch
office.
Sincerely,
Gac)~ uJJ-.Lt L
Rachelle Wells
1-800-762-1775
P7 -PFSC-04-F
500 first Ave.
Pitbburgh PA 15219
Member FDIC
TOTRL P.01
This estate jewelry appraisal was prepared by
Henderson & Co. Jewelers, Inc.
Windsor Park Shopping Center
Mechanicsburg, PA 17050
phone (717) 766-7771
For:
The estate of Helen Pakosh
618 Brookhaven Rd.
New Cumberland, PA 17070
C/o Randy Byra and Patti Byra
The appraisal was prepared June 14, 2002
The price of gold was approximately $318.00 per ounce.
The following equipment was used in preparing this appraisal:
Binocular Microscope
Refractometer
Polariscope
Dial Gauge
Table Gauge
Color Master Stones
Electronic Scale
The appraiser was David A. Henderson, GemOl~,the
Gemological Institute of America, no. 35612 ~~~
G.I.A. grading terminology was used in preparing this appraisal. ..
This appraisal was prepared for estate purposes only.
The values given represent a fair price that the items could
be expected to bring in a reasonable time period if sale was
necessary to settle the estate. This is based on prices obtained
for similar items in our area at the time this appraisal was
prepared, or recent auction prices for similar items.
This appraisal does not represent an offer to buy, nor does
Henderson & Co. have any stake in these items.
DIAMOND PENDANT
This pendant consists of a 14 Karat white gold wire basket
setting and a wide tapered bail in yellow gold. A single round
diamond is set into pendant. At time of examination, pendant
was on an 18 inch snake chain of 14 Karat yellow gold. Chain
is 1.4mm diameter with a lobster claw clasp.
Condition of pendant and chain - very good
DIAMOND: One Round Brilliant Cut Natural Diamond
Diameter: 5.83mm to 5.92mm, average 5.875mm
Depth: 3.91mm
Weight: .82 carat by formula
Clarity: SI1
Color: H
ESTATE VALUE.......................................... $2,500.00
c.z. SLIDE PENDANT
A single round cubic zirconium (synthetic) is bezel set in
a 14 Karat yellow gold (stamped). The bezel is attached to
a light weight, open work side pendant. Pendant is on a 22
inch long, 1mm wide box chain. The chain has a bayonet style
clasp with an omega safety.
ESTATE VALUE............................................. $50. 00
DIAMOND SOLITAIRE RING
One two-tone "Tiffany style" ring mounting in 14 Karat (stamped)
gold. A single round diamond is featured in this ring. The
ring consists of a four prong peg setting in white gold soldered
into a yellow gold rounded shank. The shank is 3.14mm wide
at the top, tapering to 1.5mm at the back.
DIAMOND: One Round Brilliant Cut Natural Diamond
Diameter: 6.51mm to 6.55mm, average 6.53mm
Depth: 4.2mm (approximately)
Weight: 1.09 carat by formula
Table: 4.2mm, 64.3%
Crown: lmm, 15.3%
Pavilion: 3.1mm, 47.4%
Clarity: SI1
Color: approximately I
Comments: This diamond has a
The stone's symmetry is fair.
is found in the center of the
slightly irregular frosted girdle.
A large cloud of pin points
stone.
~STAT~ "~lJ~........................................... $3,500.00
DIAMOND GUARD RING
This is a 14 Karat (stamped) yellow gold guard ring (double
shank insert ring). Ten round diamonds are prong set in the
ring. Five diamonds on each half of this guard ring curve
around the solitaire when it is inserted. One of the cross
bars is broken in the back of ring and another is cracked.
These must be repaired before wearing.
DIAMONDS: Ten Round Brilliant Cut Natural Diamonds
Diameter: 3mm each
Weight: approximately .10 carat each, 1.00 ct. T.W.
Clarity: VS
Color: H approximately
ESTATE VALUE............................................ .$750.00
HOLLOW CHAIN BRACELET
One very light weight chain bracelet stamped 18 Karat. This
yellow gold 7 3/4 inch chain is a hollow promotional weight
piece. These items have a very short life. Many small dents
are visible.
Width of chain is 7.7mm
Weight: 3.9 dwt.
ESTATE VALUE........................................... .$39.00*
* Scrap value of gold
ROPE CHAIN BRACELET
This is a 7~ inch long, 2.6mm diameter chain with a bayonet
style clasp. The yellow gold chain is stamped 14K. One major
repair joint may be seen on the chain.
Condition: fair
ESTATE VALUE ......................................................................................... $25.. 00
HAMILTON POCKET WATCH
This is a 10 Karat yellow gold filled watch with a 21 jewel
movement. The movement is serial number 2,587,607, made in
1932. This is lever set "Railway Special" watch.
ESTATE VALUE........................................................................................ $250. 00
GRADUATED BEAD NECKLACE
This is a completed add-a-bead necklace in 14 Karat yellow
gold. An 18 inch long fine rope chain holds beads graduated
from 10mm down to 4mm. Total weight: 3.7dwt.
ESTATE VALUE ................................................................................... $1 00.. 00
LADY'S GARNET RING
A single oval garnet is set in a four prong wire style basket
style setting. A split shank completes the ring. The yellow
gold ring is stamped 14 Karat.
GARNET: One Oval Natural Garnet
Dimensions: 8.4mm x 6.2mm
ESTATE VALUE .......................................................................................... $75.. 00
PEARL PENDANT
This is a simple cultured pearl pendant consisting of
rabbit ear bail with a fluted cup holding the pearl.
pendant was suspended from an 18 in long, .8mm yellow
box chain. The item is 14 Karat stamped gold.
a small
The
gold
PEARL: One Cultured Pearl (probably akoya)
Diameter: 7.7mm
Color: yellowish dark cream
Luster: fair
ESTA'l"E VALUE .......................................................................................... $40.. 00
MULTI-STONE RING
One yellow gold (stamped 14 Karat) lady's ring.
rubies, and sapphires are channel set in a woven
the top 1/3 of the ring. The ring is 9.2mm wide
tapering to 3.2mm wide at the shank.
Total weight of mounting and stones - 3.1 dwt.
Emeralds,
pattern on
at the top,
EMERALDS: Eight - 2mm diameter natural emeralds, probably
oiled.
Color: very light green
Clarity: moderate inclusions
RUBIES: Nine - 2mm diameter natural rubies, probably heat
treated.
Color: saturated red
Clarity: moderately included
SAPPHIRES: Nine - 2mm diameter natural sapphires
Color: medium
Clarity: light to medium included
ESTATE VALUE ............................................ $200.00
24" ROPE NECK CHAIN
One solid link diamond cut rope chain in 14 Karat (stamped)
yellow gold. This chain is 3mm diameter. The chain has a
bayonet style clasp.
Condition: very good
Weight: 14.2 grams
ESTATE VALUE ..............oo....................................................................... $140.. 00
20" ROPE NECK CHAIN
One solid link rope chain in
The chain is 1.4mm diameter.
with omega safety.
Condition: very good
Weight: 2.9 grams
14 Karat (stamped) yellow gold.
The clasp is a bayonet style
ESTATE VALUE ..........................................oo..oooo....oo..................oo......oo...... $35. 00
20" ROPE CHAIN
This is a 2.3mm diameter diamond cut rope chain in 14 Karat
yellow gold. The chain has a bayonet style clasp.
Condition: very good
Weight: 6.6 grams
ESTATE VALUE .....oo..........................oo........................oo........................... $70.. 00
REV-1510 EX +(1-97)
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Helen B. Pakosh
SSl/ 166-12-4386
06/01/2002
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
FILE NUMBER
21-02-0544
DESCRIPTION OF PROPERTY % OF
ITEM RELAW8~M~I~ t~~~~~5~~lt!~Jr~~~Al-~E6F t~~~RSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE
NUMBER ATTACH ACOPYOFTHE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE)
1 Transamerica Life Insurance 45,821. 53 45,821. 53
Company - Annuity Number
0200PB03735
TOTAL (Also enter on line 7, Recapitulation) $ 45,821.53
(If more space is needed. insert additional sheets of the same size)
S.Jcyright ;c) 1996 form software only CPSystems, Inc.
Form REV-1510 EX (Rev. 1-97)
o PNC1NSURANCE
331 Bridge Street
NewCumberland,PA 17070
June 25, 2002
James D. Bogar
One West Main Street
Shiremanstown. P A 170 II
Dear l'vlr. Bogar.
I have contirmed a date of death value for Helen Pakosh.s Transamerica ,-"nnuity.
Tne 61012002 value was 545.821.53.
Thank You.
!
.....1..r-t
Ill" I.
I '... .....:..----'
.,., I
T"""'-r"Ip....T ,"",{')f"\
.............--, ~v.~.t".
Licensed Financial Sales Consultant
3"2: '2.rici~t' St:.t':e~ ~ic'.'.) CJmhd",~rj ?e'~ns\ii'-:'~i!~i;-I 1 i[)7i:
1.1~~~~~
Transamcrica Life Insurance Company
4333 l!dgcwood Road NE
PO Box 3183
Cedar Rapids, Iowa 52406-3183
June 19, 2002
Randall F Byra
c/o Patti Byra
2765 Lewisberry Rd
York Haven PA 17370
RE: Annuity Nmnber(s) 0200l?B03735
Dea~ Randall F Eyra :
We have received netifieation, Helen B Pakesh, annuitant of the above
listed nen-qualified tax deferred annuity is deceased. Our office
wishes to extend since=e condolences for you= loss.
o~= reco~ds indicate tie follow~ng annuity information:
=~~~a=y 3e~eficia~y(ies
Helen B
1-" '"
_.e..-en :...;
Ra.:1dall
Pa:':csh
?_::::...:.:.:.ar:': :
C'N':'.e:: :
Fa>~8sh
F 3y::a
:"..:.=-=- 'l2..~~":2 as c:: '2': '2=-/::::2:
2at-:i L 3Y::-2-
t'.;::; /""'/ ~ /21\1'"\,;
U'-'I _-' Ju_
S45,9:7.29
c:: 1 :; 0 ~ (\:;
.... _, -' _ v . v....
S43,82:'.23
A::::~.:.:.y ?~~icy Dc~e:
~~=-l Val~e as c:: 06 :?,'2::2:
:=-:{3.;:~2 ::-::::..:..<)r::
a:tac~ec dcc~~e:::. ::e::ec:.s
cctiocs
27a.:..lab:"e
.-
t:;.e pri:na~y
je::e=ic~a=j(ies) :is:.ei a~cve.
"""-, ~
';:.," "';
v2-1'.:e
as c: :..~_e
c:
.::e=::J.
i.s
:'3.:{ pt.:.:-pcses
cnly a:'ld is
.. .. - ,
a q~a=a:::.ee= ~ea:~ =e~e:~~ a=c~~:.
~::=c~2d dcc~~e~:
,...----.-::: ~ ""':::
'---.. ---~~-
-;2:-'.e:.-a_
~ax i~~8=xa:io~ based on
~=~~3aIe=~=~ L~:2 ~~3~:.-a~ce Ccm~a~y's in~e:'-p:'-2:a:ion a~d should net ce
:.-e:~~c ~~~~ fo:.- yc~~ ;e:.-s~~a~ tax p:an~~~g. !: you have questions
::~:"'_::2:::::':":'~'; ~he d~:::=c:. :'=.:{ ccr:se~'c:er:.ces 'N'he!1 se~ec:"::.::g 2:1 option, yo 1':"
~,,:::. .:f
Nis~ :.~ ccns~l~ a
:a:<:
as.'\tisc:- .
11.e::'::;eo: of :he ~~~ON. Gmu?
Death Option Packet
0200PB03735
Please submit the following documents upon selection of an option,
defined below:
. Certified copy of the death certificate
. Original annuity policy
. Annuity Claimant's Statement
In claims with multiple beneficiaries, each beneficiary must complete
a separate Annuity Claimant's Statement. Each beneficiary may choose
an option that is different from the other beneficiaries. Once all
paper~ork has been received from all beneficiaries, our company will
begin processing ~~e dea~~ claim.
As primary beneficiary of this annuity, you have the following cptions
available for deat~ claim p~ocesslng:
Delay ~'le Lump Sum Payment up to 5 yea:=s from date of deat~
Ycu w~ll be respo~s:ble fc~ ~c~ifying
.......::::.T'!"-~.....~'!""a f-'nc'c::: ......~c...... --.-.. :-.-,-...,,...,......er ?,s::
_,-."c:._.~_".-, 1.4. ... p__ _ '-'-' :....c.....=.......... _ ...J...
de?::::.
t~e ccrnpa~y to remcve a~y
c: t~e fif~h yea~ fcllow:~g
the
I~c:~ie desi;~atic~ of te~e:i:ia=y(ies)
~--
'C.r.e
F_:lnui ty
Clairnar-.t's
S~a..:e::'.e:-_ -:.
Settlement Option
T:-..e a:::-.L:':":y ft.::'..cs '...":.:.._ 1:e c:.:,s::'..:=se.:::. ~ -. ;:e::i.odic pajlme:1"ts 0"',-2= a
~i~i~~~ of Zlve (2, yea=s :a~:~:a"ted C~ a rninirn~m val8e 0: $S,CCO.OO.
The ::e.:i:::d ca:1:1ot e:<::eec 'v'C'''::: life ex::ec-:=.:1cy and oavllie::.ts mus:: beain
- - - .. ... ....I
wi:ji~ c~e yea= f~:~ ~~e ~2~S cf dea~~. I~ addition to tte re~ul=ec
c.cc-":'::-.e:-.,:s list.ed 2::;::;72, ;:':"2.3.52 s'..:.l::mi-:: t.~-:.e :ollow-ir..g:
. ~.:-.::'..:..:..,:iz2.~icn P._;;~i=3.:.i::-~
(Ccnt.ac': ::;~= C::~~2
;-.,,,..
i:"'.=::~:7'"2.:icn)
Lump Sum Payment
~ie 2.::~~ity fu~ds
-,..-ill j:;e
.. . ,
::'~S.ci":'=S2C. ::J v:::..:.
in
2. lump sum payme~:..
Please ~cte, rega=i~2ss ~- w~i:i opti:Jn is chose~, the taxable 2.mo~~t
wil~ be reported C~ a Fo=~ 1~?9-~ t~e Ja::~a=y fallowing t~e
dis::ri:ct.:;:ion.
avai~able to you a:
Please cont.act ou= CII~ce :0= i~:::=~a:ic~ concerning prod~c~s
+-~..., ; <::
........-.....
':2.:ne.
Any additional questions regarding this annuity can be directed to the
Annuity Service Center at 1-800-553-5957. A Transamerica Life
Insurance Company representative will gladly assist you with any
question you may have regarding this annuity and help you meet your
financial goals.
Sincerely,
~0 UWfi
Carrie Allen
FMG Claims
1-800-553-5957
Enclosure(s) :
Annuity Claimants Sta~ement
Postage Paid Retu=~ ~nvelope
Death OpLion Packe~
-.. . ...-.............-........-. - - - - --. ~........._...-- -..._-- - - ~ --.. ~---~ ..........- ......._.........-_........_----_...~----_..- -....
I Transamerica Life Insurance Company
. Overnight Address: 4333 Edgewood RD NE, Cedar Rapids, L-\ 52+99
Service Office: P.O. Box 3183, Cedar Rapids. ]A 52406
Product: Foundation Builder
0200PB n~'735
Deferred Annuity Applicatiou _
Not for use in: DE, IN, KY, OH
I. OWNER INFORMATION af no Annuitant is specified in #2, the
Owner will be the Annuitant.)
.\tUST COMPLETE and SVBMIT the Trustee Certification FOlln
if a Trust is named as the Owner or Beneficiary.
c':st Name: .l1=-._;c ,Ii t:_~,
:...:tst 0Jame:
..'..2dress:
/..''J.; .i\
~ ;.;1
(':.::'/.:.....; /:"''''/''-i.li..f./L'F!\./ ;~.I
::ty. State: ".. j ,. . .:, / " ,'" ,I r"'i l
) ~ . I h ( .. -) ",' ./.. '1'--," 7.
:.p: j',;) ;:') - Te ep one: /I' ,~. ......,,/.....-'
Sate of Birth:./' Ii. i I.: :.. Sex: ,*"Female
S5;t: / f"": /~ . i).. - .'f '; ~?( p' Q ~Iale
1 b. J~~r4~v~~~ER(S) I
c::st "'ame:
:.....lSt :\ame:
.--'--,2dress:
::ty, State:
Telephone: (
cate of Birth:
Sex: ::::i Female
::::i ),;[ale
:_:;::
2. ANNUITANT I
., '5t ~ame:
Complete only if different from Owner
_,cSt :\ame:
-...:.c.ress:
Sute:
Telephone: (
c ate of Birth:
Sex: ::::i Female
::::i \lale
,...,:.
3. BENEfIC1ARY(IES) DESIGNATION
, '/~' ,....., ,I, I ,; P"I .
. :-::nar:I:I\;.I;':L~'-:,-,. .I L.- 'Ii......;..J,
~~:aticn5hip to .-\nr,uitant: (, j.-J I:'
_:mmg~nt.
?~!ationship to Annuitant:
!HIT I L. /./ 1/ /,',-'1
()J('€A/
.J. TYPE OF ANNUITY
:J ~on-Qualified
:; :R.-\ D SEP D ROTH IR.-\
r ontribmicn [or Tax Year
QuaiifIed Transfer Amount
R.ollover From:
, :,:-1 IRA Rollover
_ .LL_i , Date first established ordar.e of com'ersicn
:J "C3(b) D Keogh D Other:
s. POLICY INFORMATION
t./y
Mahe check payable to Transamerica Life
Insurance Cumpany.
9l-L
:r::t:al Premium: S
: :J.ranteed Pe:nod (Che::k One::
I 6, SIGNATURE(S) OF AUTHORIZATION ACCEPTANCE I
. Unless I have notified the Insurance Company of a community or
marital property interest in mis contract, the Insurance Company Voir:
rely on good fauh belief that no such imerest exists and will assume
no responsibtlity for inqUlry.
o To the best of my knowledge and belief, my answers to the question,
on thIS application are correct and true. and I agree that this applica-
tion becomes a part of the annuity contract when issued to me.
o ThIS application is subject to acceptance by Transamerica Life
Insurance Company. If this applicatlOn is rejected for any reason,
Transamerica Life Insurance Company will be liable only for return 0
purchase payments paid.
vVill this annuity replace or change any existing annuity or life insurance?
liZl)Jo 0 Yes (If ves, complete the following)
Co';;pany: '
Policy No.:
I HAVE REV1EwcD ylY EXISTING ANNUITY CO\cRAGE AND FIND
THIS CO\CR.;GE; S,YITABSE ,FORMY N,EED;:,,) / j
SlO'nedar:A :t:".1 //.'11":.'1""/1'../,1 /" I"L I.....I?__~)I:~:I
:;, I .City ", StJte, '1.' - {Date I
. '/1 I <( ',j J
Ovmer(s) Signatun< -.:i :,r:_'U_4;J'_.~ .~.~ J... -i....,..;.._4--:~;--'
Joint O\vner(s) Sign.:J.ture:
A.nnuit.:mt Signature: (if not O\\-l1er)
i 7. AGENT INFORMATION
Agent:
Do you have any reason to believe the annuuy applied for will
re:)lace or change an\" existing Jnnuitv or life insurance?
:J CJo 0 Yes '
I :-tA\C RE\lEWED THE APPLICA~rs EXI5TICiG ANNUITi
COVER-\GE .-\CiD Flt'-;D THIS CO\CR~GE IS SLIHBLE FOR
HI5/HER CiEDS.
Register~d A~en~icensed A,e~t Na~e,:
PleJse pnnt Flrst ~Jme: ....... ,. f"'r';: /.> ",
Please prim Last. Ci'l'Ile: L-v ().J
~~I~J. //"i
Signature: "/?j:~~-!. -f--J __ .'
. /'
B~Jnch Phone #~ ._/
,-_..
S5 # I TICi
.-\gem License ::;:
Firm "'ame:
Firm Address:
::JA
::JB
Dc
I@
8
Annuities are not FDIC insured.
Annuities are not obligations of any bank.
Rnandal institutions do not guarantee
performance by the insurer issuing the annuity,
nor is it insured by the FDIC, NCUSIF, or any
other federal entity.
REV-1511 EX +(1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCET;.:)( RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Helen B. Pakosh
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
B.
SSft 166-12-4386
FILE NUMBER
21-02-0544
06/01/2002
DESCRIPTION
AMOUNT
1
FUNERAL EXPENSES:
Radisson - Funeral meal
848.30
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s) I EIN Number of Personal Representative(s)
Street Address
City
State
Zip
Year(s) Commission Paid:
2.
3.
Attorney's Fees James D. Bogar Esquire
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
6,562.50
City
Relationship of Claimant to Decedent
State
Zip
4.
Register of Wills
258.00
Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
1
Other Administrative Costs
Borough of New Cumberland - Sewer/Trash
143.83
2
Castle Clean - Carpet cleaning
106.00
3
Henderson & Co. - Jewelry appraisal
160.00
4
Notary Fees for sale of real estate
12.00
5
Patriot News Co. - Advertising
40.60
6
PAWC - Water bill-final
54.50
Total of Continuation Schedule(s)
10,335.16
TOTAL (Also enter on tine 9, Recapitulation) $ 18,520.89
(If more space is needed, insert additional sheets of the same size)
:coyright(c) 1996 form software only CPSystems, Inc. Form REV-1511 EX (Rev. 1-97)
Estate of: Helen B. Pakosh
Soc Sec #: 166-12-4386
Date of Death: 06/01/2002
Item
#
Continuation of Schedule H-B7
(Other Administrative Costs)
Description
Amount
7
PPL Resources Inc Hldg Co - Electric bill-final
243.03
8
Re/Max Realty Associates, Inc. - Commission for sale of real
estate
6,300.00
9
Re/Max Realty Associates, Inc. - Transaction Fee
195.00
10
Recorder of Deeds - Realty Transfer Tax
1,260.00
11
RESERVES: Costs to conclude administration of Estate including
filing fee for PA Inheritance Tax Return, Inventory and First &
Final Account; preparation of Personal and Fiduciary Income Tax
Returns
1,000.00
12
Robin Gasperetti, Tax Collector - 2002-2003 School Taxes
899.83
13
Susan Wesner - House cleaning
200.00
14
Terry Wechann - Mowing and Trimming
175.00
15
UGI Corp Holding Co - Gas bill-final
60.53
16
Verizon - Cable bill-final
1.77
10,335.16
REV-1513 EX -+(9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCETIV< RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
Helen B. Pakosh
SSft 166-12-4386
06/01/2002
FILE NUMBER
21-02-0544
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I. TAXABLE DISTRIBUTIONS [Include outright spousal distributions, and
transfers under Sec. 9116(a)(1.2)]
1 Tracy B. (Byra) Spandler
703 Dunkel Street
Enhaut, PA 17113
Granddaughter Diamond ring;
diamond ring
guard; diamond
necklace
2
Judith M. Byra
15 Scarsdale Drive
Camp Hill, PA 17011
Daughter - in - Law
One-half of
jewelry
3
Patti L. Byra
2765 Lewisberry
York Haven, PA
Daughter
Fur coats and
jackets;
sterling
silveri
jewelry;
one-half (1/2)
of rest,
residue and
remainder
Road
17370
ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18. AS APPROPRIATE. ON REV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS,
A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
C':Joyright {c) 2000 form software only The Lackner Group. Inc.
0.00
Form REV-1513 EX (Rev. 9-00)
Estate of: Helen B. Pakosh
Soc Sec #: 166-12-4386
Date of Death: 06/01/2002
Continuation of Schedule J, Part I
(Taxable Bequests)
Item
il
Name and Address of Beneficiary
Relationship
Amount or
Share of Estate
4
Randall F. Byra
15 Scarsdale Drive
Camp Hill, PA 17011
Son
Gold pocket
watch;
one-half (1/2)
of rest,
residue and
remainder
.;((1' 01
b(i'in"1[
;nL l'rL
~, ,
.~.'.J.l'..:l'l('
, .~ f I' :n I ,
.~'(I'\'
~
~'il1J~
~~j-':
~11
I. 'I
, 1'1111 \ . ..
nlll,I'1
l!(
HELEN B. PAKOSH
BE IT REMEMBERED that I, HELEN B. PAKOSH, of New Cumberland,
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:
1 direct that all my just debts and funeral expenses be paid as soon
after my demise as may be convenient.
ITEM 2:
I hereby give, devise and bequeath the following items to my
daughter, Patti L. Byra, as her sole and separate property:
A. All of my fur coats and jackets that I have at the time of my death: and
B. All of my sterling silver that I have at the lime of my death.
ITEM 3: I hereby give, devise and bequeath the follOWing items to my grand.
daughter. Tracy L. Byra, as her sole and separate property:
A. My diamond ring:
B. My diamond ring guard; and
C. My diamond necklace.
ITEM 4: I hereby give, devise and bequeath unto my son, Randall F. Byra. my
grandfather's gold pocket watch.
n:::M 5:
AI! the r'?st of 'l1V jf!well'';' which I have 8t the time of my death. I
hereby give, devise and bequeath unto my daughter, Patti L. Byra, and my daughter.in.
law, Judith M. Byra, to be divided amongst each of them as they mutually agree.
WITNESS:
\\1-...." ~~- ~ ~/L<. /3
'- \-
'jf~ ~ / //1 d.~ HELEN B. PAKOSH
I ;~~LV/4 l~.tJ:<'?
/
'] ;
~,A"..,.;t. (SEAL)
ITEM 6:
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 issue. Randall
F. Byra and Palli L. Byra, in equal shares, per capita.
ITEM 7:
I appoint my children, Randall F. Byra and Patti L. Byra as Co-
Executors of this my Last Will and Testament.
ITEM 8:
I direct my Co-Executors, or their successor, 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 being my
intention that none of the aforesaid taxes, either federal or state. on any 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.
ITEM 9:
I direct that my Co-Executors, or their successor, shall not be required
to give bond for the faithful performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 3'" day of
August, 1998.
WITNESS:
~L'~~~~
~~!/4~:~
_ -J,[.L~, !J7
'J
tU...."~SEAL)
HELEN B. PAKOSH
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA
: 55.
COUNTY OF YORK
We. HELEN B. PAKOSH MARTIN MillER. ESQUIRE and NilES S.
BENN. ESQUIRE......, the Testatrix and the witnesses respectively. whose names are
signed to the attached or foregoing instrument, being first duly sworn, do hereby declare
to the undersigned authority that the Testatrix signed and executed the instrument as her
last Will and Testament and that she had signed willingly (or willingly directed another to
sign for her), and that she executed it. at 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 Last Will and Testament as witness and that to the best of their
knowledge the Testatrix was at that timp. eighteen (18) years of age or older. of sound mind
and under no constraint or undue influence.
J r) /) b .
,)lr.~<L. 13 7a4~
T\\"ATRIX
\l~,~~~~C .
ITNE S
~t-iWL' Y'&.J~
WITNESS /
Sworn to and subscribed
before me this 3rd day
of August. 1998
J[. L._
My Commission Expires:
C.""'!.I. r\:I,"o
~ " 1,,:.~..:
'..71' C.:;:l1"'~':'::"';-; (.-,,~:;:, 1~"'':!
ntl!lr, i,,~'i;&y'l\;iir.iJ l.iiUl;&;,J;-i(,I,.i\'~ii";,,
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
JAMES D BOGAR ESQ
1 W MAIN ST
SHIREMANSTOWN PA 17011
ALONG THIS LINE
OF PAKOSH
DATE 02-03-2003
ESTATE OF PAKOSH HELEN B
DATE OF DEATH 06-01-2002
FILE NUMBER 21 02-0544
COUNTY CUMBERLAND
ACN 101
Anount Renitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
_RETAIN LOWER PORTION FOR YOUR RECORDS ~
'ICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCI
ALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
HELEN B FILE N0. 21 02-0544 ACN 101
DATE 02-03-2003
TAX RETURN WAS: f X) ACCEPTED AS FILED [ ) CHANGED
B iSED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Nortgagas/Notes Receivable (Schedule D]
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E]
6. Jointly Ownetl Property (Schedule F)
7. Transfers (Schedule G]
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
DATE
08-28-2002 NUMBER
CD001572 INTEREST/PEN PAID (-] AMOUNT PAID
12-10-2002
CD001931 423.00 8,037.00
.DO 42.60
9. Funeral Expenses/Adm. Costs/Misc. Expenses !Schedule H) (q) 18,520.89
10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 00
11. Total Deductions
12 N
t V [11) - 18 S 0 89
. a
alue of Tax Return [1 188
946
75
13. Charitable/Governmental Bequests) Non-elected 9113 Trus ts (Schedule J] 2)
(13) .
,
.00
14. Net Value of Estate Subject to Tax [14) 188,946.75
NOTE: If an assessment was issued previously, Sines
reflect figures that inciude th
t 14, 15 andior 16, 17, 18 and 19 will
e
otal of
ASSESSMENT OF TAX: ALL returns assessed to date.
15. Anount of Line 14 at Spousal rate (15) .00 X OD _ OD
16. Anount of Line 14 taxable at Lineal/Class A rata (16) 188,946.75 X 045= .
8 502
60
,
. Anount of Line 14 at Sibling rate (17) DO 12 .
18.
Anount of Lin
14 t . X
= .DO
e
axable at Collateral/Class B rate (18) 00 15
19.
Principal Tax Due . X
- .00
TA C ED TS• a9)= 8,502.60
^ IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
REY-154) EN RFP f01-0S)
TOTAL TAX CREDIT 8,502.60
BALANCE OF TAX DUE .00
INTEREST AND PEN. .DO
TOTAL DUE .00
( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A ^CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS
[1) 126 ,000.00 NOTE: To insure proper
(2) .00 credit to your account,
(3) .00 subnit the upper por{ion
(4) .00 of this form with your
[5)_ 35 .646.11 tax payment.
(6) .00
m_ 45. 821.53
(g) 207,467.64
.)
;~
~~~
STATUS REPORT UNDER RULE 6.12
Name of Decedent: Helen B. Pakosh
Date of Death: June 1, 2002
Will No. 21-02-0544 Admin. No.
Pursuant to Rule 6.12 of the Supreme Court Orphans'
Court Rules, I report the following with respect to completion of
the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes X No
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete: N/A
3. If the answer to No. 1 is Yes, state the following:
a. Did the personal representative file a final
account with the Court? Yes No X
b~ The separate Orphans' Court No. (if any) for
the personal representative's account is: N/A
account informally tDodtheepartiesainri~terestatiYeSState an
X No
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
Date: 3/28/03 ~'
Si nature
James D. B r, Esquire
Name (Please type or print)
One West Main t.
Shiremanstown, PA 17011
Address
1717) 737-8761
Tel. No.
Capacity: Personal Representative
x Counsel for personal
(MAH:rmf/AM3) representative
r
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS COURT DIVISION
IN RE: ESTATE OF SARA MILLER, No. 21-2002-554
DECEASED
NOTICE OF CLAIM
Claremont Nursing and Rehabilitation Center files this claim against the Estate of
Sara Miller in the sum of $9,673.02 in accordance with the invoice attached hereto. The
sum of $9,673.02 is a priority claim under 20 Pa. C.S.A. § 3392(3) for the value of nursing
services performed for the decedent within six (6) months of death.
LATSHA DAMS & YOHE, P.C.
Date: y ~G • U 3
BY~ ~( u/ ~--
Kimber L. Latsha, Esq.
Attorney No. 32934
Steven M. Montresor, Esq.
Attorney No. 74244
P.O. Box 825
Harrisburg, PA 17108-0825
(717) 761-1880
Attorneys for Claimant,
Claremont Nursing and
Rehabilitation Center
szs9~
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS COURT DIVISION
IN RE: ESTATE OF SARA MILLER, No. 21-2002-554
DECEASED
CERTIFICATE OF SERVICE
The undersigned hereby certifies that on this date a true and correct copy of the
foregoing Notice of Claim was served via first-class United States mail, postage
prepaid, upon the following:
Abraham Law Offices
James Abraham, Esq.
513 N. Second Street
Harrisburg, PA 17101
Dated: y ~~ O3
~~~
82597
SARA MILLER
ADMITTED NOVEMBER 26, 2001
CHARGES DUE AND OWING AT JANUARY 31, 2003
December 2001 5,163.00
January 2002 4,530.04
Closed Guest Fund 20.02
TOTAL DUE AND OWING AT 1/31/03 $ 9,673.02
a~e~pnt ~~rsl~~
~ti Q~
~elzabilitation Center
December 5, 2001
Mr. Edmond Miller
124 W. Portland St. Apt 44
Mechanicsburg, Pa. 17055
~a`~ oa
~~ ~ _ ~~,U~ t~ l c,
r J~ y ~ ~.
~'d
~.~~A\ t ~~ e ..,C~.~Y
~~17 ~~~
RE: SARA MILLER -OUR RESIDENT ACCOUNT #4136
Dear Mr. Miller:
375 Claremont Drive
Carlisle, PA 17013.8805
main (7171 243.2031
fa: (7171 240.1952
Beginning with December 5, 2001 Medicare will no longer cover Mrs. Miller's stay here
at Claremont Nursing and Rehabilitation Center.
The next payment method is Resident Private Pay. It is our policy to request a Private
Pay Room Deposit of 55735.00 (31 Days X 5185.00/Day), which is to be held and applied
to the last month of Private Pay.
Kindly remit the amount requested and direct it to our Business Office at the above
address.
Should you have any questions, please feel free to contact Denise Lehman at (717) 240-
1908
Very truly yours,
J f , y A. alters
Assistant Fiscal Director
~ service agency of Cumberland County
375 C'aremont Drive
Caryl:>le ,PA 17013
71?1 243-2031
1212 P~TIENTL IE
Mi 1 l~~r, Sara A
u eIRTNDAIE +ssEx I6 MS
s PEO. rAx NO. een~~Epg~ ,. -
_ ~ pggpN:.., 7 COV D. 8 NL p. 9 GD. 10 L-R p. tl
f] PAi1EMADORES$
n u IA w lnE 91G n u nH 225TAT 23 NEOMAL RECOgp N0.
C
~ _ f] M - 1e m y 61
~ ., ~ ~
IbDE ~ - SPAN 3]
A
8
Sar;t r Miller. mDE vALUEtvoEg
Edm~`nd M! l ler a AM41Nf ^~ vuuE..
i24 WE+st Portland St Apt 44 b
:Nechanlcsburg, PA 17055 D `
62 REV. CP i AI DESLNIPIHJN d ,_.: `. a ... ~..;.
~,ty a _ ~ A6 HCPCS/RATES 0.5 SERV. GATE Afi SERV. UNRS {7 TOTAL CHARGES .
041c1 OXYGEN `~ / <6NONLOVEREDCHAgGES as
.. , . 1 168 t00
0x01 TGTAL CHARGES
28 5163:00
PAYER
51 PgOVIOEfl N0. 51 PRIOR PAYMEMS
a ~ 56 EST. AMOUM DUE 5g
. ,
NAME 59 P.REL EO CERT -
IC Jara SSN-HIC.-ID NO. 61 GROUP NAME
62 INSURANCE GROUP N0.
AUTH(A'ZATION COPES MESC 65 EMPLOYER NAME
6B EMPLOYER LOCATION
:o. ee cme •. , ~~r..: _ ...._ nncn ns: raoPa
Tt ]OE ]6
a ATIBY]IfIG PHrs ro
moTNeLnnsro
n EcooE
I
01/16/20@2
oEr m rle wA •xo Aee luxe A rurt:laear...
-..+ cm~ul Li'1
Carlisle PP. 17013
(7171 243'-2031
2PAnEVT NAME
Miller Sara A
IA SgTHOATE I6SE% tfi IAS
5 FED. iA%N0. 8' STATEYENf COVERS PERIOp Y 1 J O 4
FHAI ppppN;:.^ ICON O. fiNLD. 9GI D. 10480. It
23-6003119 010102 012302 023
13 PATIEMpppRESS
A ~C 21 p HR 22 $7AT 23 MEDICAL RECORD N0.
v `Fiji 7i7
o r W 12.0501 20 4136 " '° a.. .~ GI
~
~
OCCUR RRH/GE.SPM/
nwap
]]
al A
B
'
Sara A Miller ~ VALUE CODES
AMOUR d VAWE CODES.
«
Edmond Miller
a E
^~
124 West Portland St Apt 44 ' `
i
Mechanicsbur PA 17055 D
t2 REV. CD. 0.l DESLRIPnON d
'
0120 ROOM & BOARD - SEMI PRIV a HCPCS/RATES
185
00 45 SEgV. GATE ab SERV. UNRS 41 TOTAL CHARGES de NON~COVEAED CHARGES. Iy
0250 PHARMACY . 23 4255;00
0410 OXYGEN 1 83:04
1 192;00
0001 TOTAL CHARGES
.
I 25 4530;04
_ :. i
A PAYER
PRIVATE PAY 51 PROVIDER N0. SA PRIOR PAYMENTS 55 EST. pMOUM DUE 56
CLAREMONT
~]
81NSURED'$NAME ~ -~
Mi i ler Sara A 59 P.REL W CERT.~$SN-HIC. ~10 N0.
61 GROUP NAME
621NSU0.
01 1?9056241 4NCEGROUPNO.
O ]REA1MENi AURIORIUnON CODES ME6t 66 EMPLOYER NAME
66 EMPLOYER LOCAnON
4 PRIH DUG. CO. ~- ... - "... .
78930 2948 CODES
~ ~~~ iomoE a
x OmE
]6 ADM. DIAG. CD. ]) ELODE ]6
1P.C. ~ PRINCIPAL PROCEOVRE
caoE a*e
. 4019
«~ .
.:«:.. ..
62 ATfENdNp PNYS.N
w _ C27772 HARM, MD KENNETH R
cmP w]E e6 OTHFA PHYS, ID
4 PEMMK$
OTHER PMYS. g
65 A «
I-Y2 HCFA-IASp APPROVED OMB NO.OgB.A2]0 ~
,_____.
(VPY~1
------- -02/'13/2.042.
ICfA1RY ]11l CliI1VICAlIpl9 CIl ]IIE
NEVERY VRYlO ]MSMILAMIM[WOf AF4ff MEi~F.