HomeMy WebLinkAbout07-25-14 1505610143
REV-1500 EX(02-11) ''f
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT DP REVENUE
PO BOX.280601 INHERITANCE TAX RETURN 21 13 1230
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
11 06 2013 12 it 1938
Decedent's Last Name Suffix Decedent's First Name MI
TOMEK HELEN A
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
X❑ 1. Original Return ❑ 2. Supplemental Return ❑ 3, Remainder Return(Date of Death
Prior to 12-13-82)
❑ 4. Limited Estate ❑ 4a Future Interest Compromise ❑ 5 Federal Estate Tax Return Required
(date of death after 12-12-82)
❑ 6 Decadent Died Testate ❑ 7.
Decedent Maintained Trust)a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) p
❑ 9. Litigation Proceeds Received ❑ 10. Gg,seI Dove �Jt a^atlDatges�f Death ❑ 11 Election to tax under Sec.9113(A)
(Attach Schedule 0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
MICHAEL L BANGS 717 730 7310
--o
REGISTER aOWILLS USE-ONLY
O
DD
First Line of Address
429 SOUTH 18TH STREET ��cT R cif
m
Second Line of Address
CEO '
O=
D ILED rt
City or Post Office State ZIP Code N
CAMP HILL PA 17011
Correspondent's e-mail address: mikebangs @Verizon.net
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 pre arer other than the personal representative Is based on all information of which preparer has any knowledge.
SIGNATURE61 PERSON ON RFI RETURN ) DATE
James J.Tomek,Jr. �/ a j Doi 7
ADDRES
270 Red Haven Road, New Cumberland, PA 17070
SIGNATU E OF PREPARER OTHER THAN REPPPSEqTATIVE DATE
Michael L. Bangs
ADDRESS V .-�
429 South 18th Street, Camp Hill, PA 17011
Side 1
1505610143 1505610143 J
J 1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name. Tomek, Helen A.
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1. 102 ,298 . 15
2. Stocks and Bonds(Schedule B)............................................................................. 2. 1 , 008 . 10
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages&Notes Receivable(Schedule D)........................................................ 4.
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 21 , 442 . 65
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous Nt Probate Property
(Schedule G) a Separate Billing Requested............ 7, 59,326 . 86
8. Total Gross Assets (total Lines 1 through 7)........................................................ 8. 184 , 075 . 76
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 19, 303 . 81
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 5 , 922 . 51
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 25 ,226 . 32
12. Net Value of Estate(Line 8 minus Line 11)... - - - - 12. 158 , 849 . 44
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J)............................................... 13.
14. Net Value Subject to Tax(Line 12 minus Line 13)............................................... 14. 158 , 849 . 44
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 15 0 . 00
(a)(1.2)X.00
16. Amount of Line 14 taxable
at lineal rate X .045 158 849 . 44 16. 7 , 148 . 22
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 00 18. 0 . 00
19. TAX DUE................................................................................................................ 19. 7 , 148 . 22
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. X
Side 2
L 1505610243 1505610243
REV-1500 EX Page 3 File Number 21-13-1230
Decedent's Complete Address:
DECEDENT'S NAME
Tomek, Helen A.
STREETADDRESS
839 Meadow Lane
CITY STATE ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2, Line 19) (1) 7,148.22
2. Credits/Payments
A. Prior Payments 12,000.00
B. Discount 357.41
Total Credits(A +B) (2) 12,357.41
3. Interest (3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) 5,209.19
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5)
Make Check Payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;.......................................................................... ❑ ❑x
b. retain the right to designate who shall use the property transferred or its income;........................ ❑ ❑x
c. retain a reversionary interest;or.............................................................................-......................
.......... ❑ ❑x
d. receive the promise for life of either payments,benefits or care?............................................................ ❑ ❑x
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?.................................................................................................................... ❑ ❑x
3. Did decedent own an"in trust for' or payable upon death bank account or security at his or her death?....... ❑ ❑x
4. Did decedent own an individual retirement account,annuity,or other non-probate property which L1 contains a beneficiary designation?.................................................................................................................. x
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving
spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after January 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of
assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent,or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in
[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)]. A
sibling is defined under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
Rev-1502 EX-(01-10)
SCHEDULE A
pennsylvania REAL ESTATE
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RE$IDENT DECEDENT
ESTATE OF FILE NUMBER
Tomek, Helen A. 21-13-1230
All real property owned solely or as a tenant In common must be reported at fair market value.Fair market value is defined as the price at which property would be
exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on schedule F.
Attach a copy of the settlement sheet if the property has been sold
Include a copy of the deed showing decedent's interest If owned as tenant In common.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Real Estate-839 Meadow Lane, Hampden Township,Cumberland County, PA(Tax Parcel 102,298.15
No. 10-18-1310-002). Property sold on 7/14/14. $91,080.52 received at closing; $11,217.63
withheld for inheritance tax escrow. Therefore,total due to estate is$102,298.15.
TOTAL(Also enter on Line 1, Recapitulation) 102,298.15
(If more space is needed additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule A(Rev.01-10)
Rev-1601 EX.(6.98)
SCHEDULE B
<..'r -,,.. , *.I
STOCKS'&,BONDS,
COM IWER ff LTHef PENN6nV/Jlu .
INHERRNILE T,VI RENiN
RESIOFxroECEOFin
ESTATE`OF FILE NUMBER
Tornek Helen A. 27-13=1230
All property jolnllyo"od with light of suMvanship must W disclosed on schedule F.
ITEM CUSIP - VALUE ATAATE.
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH -
1 Savings Bond-One Series EE Savings Bond 55.94
2 Savings Bonds-7 Series E Bonds 952.16
TOTAL(Also enter r-on Line 2, Recapitulation) 1,008.10
.
(If more space Is needed,additional pages of the same size)
Copyright(c)2002 form software only The Lackner Group,Inc. Fonn PA-1500 Schedule B(Rev.6-98)
REV-1511 EX.(10-09(
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX
RESIDENT DE EDENTTURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Tomek, Helen A. 21-13-1230
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 11,941.86
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State ZiD
Year(s)Commission Paid
2. Attornev'sFees Michael L. Bangs 4,000.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State ZiD
Relationship of Claimant to Decedent
4, Probate Fees 403.50
5. Accountant's Fees 500.00
6. Tax Return Preparer's Fees
7. Other Administrative Costs 2,458.45
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 19,303.81
Copyright(c)2009 form software only The Lackner Group,Inc. Forth PA-1500 Schedule H (Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Tomsk,Helen A. 21-13-1230
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Catholic Cemeteries 3,700.00
2 Maipezzi Funeral Home 8,241.86
H-A 11,941.86
Other Administrative Costs
3 Baron&Associates -real estate appraisal 375.00
4 Cumberland Law Journal-estate advertisement 75.00
5 Green Acres Junk Removal-removal of items from real estate(6/13114) 440.00
6 Green Acres Junk Removal-removal of items from real estate(6/18/14) 440.00
7 Green Acres Junk Removal-final removal of items from real estate 452.00
8 Lawn Smiths, LLC-maintenance at real estate 190.00
9 Lawn Smiths,LLC-maintenance at real estate 240.00
10 Lawn Smiths,LLC-final bill 120.00
11 Register of Wills-Short certificates 10.00
12 The Patriot News Co.-estate advertisement 116.45
H-87 2,458.45
Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1512 EX-(12-08)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Tomek Helen A. 21-13-1230
Report debts Incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 American Express 1,197.79
2 Bank of America 125.02
3 Behney Oil 1,051.55
4 Capitol City Oil 950.27
5 Donegal Insurance -Homeowners premium (partial payment) 495.50
6 Haband 39.97
7 Hampden Township-sewer/trash 155.05
8 Hampden Township-sewer/trash 155.05
9 Michael Logan,Tax Collector-2014 county/township real estate tax 584.15
10 Nationwide Insurance 47.60
11 PP&L Electric-10/3113 to 11/1/13 184.89
12 PP&L Electric-1111/13 to 12/3/13 155.89
13 PP&L Electric-1213/13 to 1/3114 95.13
14 PP&L Electric-113/14 to 2/3114 135.28
15 PP&L Electric-2/3/14 to 314/14 142.37
16 PP&L Electric-314/14 to 413114 201.03
17 PP&L Electric-4/3/14 to 515114 101.63
Total of Continuation Schedule See attached page
TOTAL(Also enter on Line 10, Recapitulation) 5,922.51
(If more space is needed additional pages of the same size)
Copyright(c)2008 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-08)
Rev-1512 EX+(12-05(
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT continued
ESTATE OF FILE NUMBER
Tomek, Helen A. 21-13-1230
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
18 PP&L Electric-5/5/14 to 614/14 35.30
19 PP&L Electric-6/4/13 to 7/3114 53.83
20 PP&L Electric-final bill 15.21
TOTAL(Also enter on Line 10, Recapitulation) 5,922.51
Copyright(c)2008 form software only The Lackner Group,Inc. Form PA-1500 Schedule I(Rev. 12-08)
REV-0513 EX-(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Tomek, Helen A. 21-13-1230
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSOMS)RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not List f.�M�. TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9118 a 1.2
James J.Tomek,Jr. Son
270 Red Haven Road
New Cumberland, PA 17070
Total
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet as apvr o nate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS -
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETJ
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule J(Rev.01-10)
B NO. 2-02
. A B. TYPE OF LOAN:
U.S.DEPARTMENT OF HOUSING$URBAN DEVELOPMENT 1.QFHA 2. FmHA 3.❑X CONY UNINS. 4. VA 5. CONY INS.
6. FILE NUMBER: 7. LOAN NUMBER:
SETTLEMENT STATEMENT 6. MoRTGACE INS CASE NUMBER:
C. NOTE: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown.
Items marled'IPOCJ"were pad outside the dosing;they are shown here for informational purposes and are not included In the totals
itl 3W (DICKERSON IVPFOrDICKERSON IVfa)
D. NAME AND ADDRESS OF BORROWER: E. NAME AND ADDRESS OF SELLER: F. NAME AND ADDRESS OF LENDER:
F.Lee Didkerson,1V James J.Tomsk,Jr.,Executor
1880 N.Union St. Estate of Helen A.Tomek
Middletown,PA 17057 270 Red Haven Rd.
New Cumberland,PA 17070
G. PROPERTY LOCATION: H. SETTLEMENT AGENT: 1. SETTLEMENT DATE:
839 Meadow Lane Yost&Davidson
Camp Hill,PA 17011 July 11,2014
Cumberlane County Pennsylvania PLACE OF SETTLEMENT
320 West Chocolate Avenue
Hershey,PA 17033
SUMMARY OF BORROWER'ST HAN6AU T! AMOUNT „��sLL Kti I SACTI
R. 400, GROSS OF SLFR.
Sales Price _ 135 OOO.00
101. Contract Saks Price 135,000.00 401. Contract
102. Personal Pro 402, Personal Property
101 Settlement Charges to Borrower Line 1400 5,131.51 403,
104. 404
105, 405.
ACRUStmonts For f
106. CiplifTown Taxes 07/12/14 to 01/01/15 276.87 406. C' !Town Taxes 07/12/14 to 01101/15 276.87
107. County Taxes to 407. County Taxes to
108. School Taxes 07/12114 to 07/01/15 2,021.28 408, School Taxes 07/12114 to 07/01/15 2,021.2E
109, 409.
110. 410.
111. 411,
112, 412,
120. GROSS AMOUNT DUE FROM BORROWER 142,429.66 420, GROSS AMOUNT DUE TO SELLER 137,298.1!
200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: SOD,REDUCTIONS IN AMOUNT DUE TO SELLER:
201. Deposit or earnest money 1,000.00 501. Excess Deposit See instru ns
202. Principal Amount of New Loans 502, Settlement Charges to Seller Line 1400 11,217.6:
203. Existing bans taken subject to 503. Existing loans taken subject to
204. 504. Payoff of first Mortgage
205. 505. Payoff of second Mort
206, 506.
207• 507. (Deposit disb.as proceeds)
208. Purchase Money Note 35,000.00 508. Purchase Money Note 35,100 0i
209. 509,
id Bv Seller Adjustments For Items UnDaId
210. Cry/Town Taxes to I 510. C /Town Taxes to
211. County Taxes to 511. County Taxes to
212 School Taxes to 512. School Taxes to
213. 513.
214. 514,
215, 515.
216. 516.
217. 517,
218, 518.
219. 519.
220. TOTAL FWD BYIFOR BORROWER 1 36,000.00 520, TOTAL REDUCTION AMOUNT DUE SELLER 46,217.6'.
300. CASH AT SETTLEMENT FROM/T BORROWER: 600. CASH AT SETTLEMENT TOIFROM SELLER:
301. Gross Amount Due From Borrower Line 120 142,429.66 601. Gross Amount Due To Seller Line 420 137,298.1
302. Less Amount Paid B /For Borrower(Line 220) ( 36,000.00) 602. Less Reductions Due Seller(Line 520) ( 46,217.6
303. CASH( X FROM)( TO)BORROWER 1 106429.66 1 60a". CASH( X TO)( FROM)SELLER 91,080.5.
The undersigned hereby a owled a eceipt of a completed copy of pages tti2 of this statement&any attachments referred to herein.
Borrower �= � .t,E,,1�_ Sella/ James J. mek,Jf.,Executor Est f Helen A.Tomsk
F Lae Dickerson,IV
BY:
HUD-5(3,W RESH1 HB47C6.2
L.SETTLEMENT CHARGES
700,TOTAL COMMISSION Based on Price S o SNOFROA ANDFROM
Divsion of Commission line 700 as Follows: BORROWERS SELLERS
701.$ to Re/Max1stAdvantage FUNDSAT FUNDSAT
702,S to SEULEMENT SETTLEMENT
703.Commission Paid at Settlement
7D4, selling agency commission to Re/Max 1stAdvantage 495.00
I B IN C
801.Loan Or matron Fee % to
802. Loan Discount % to
603. Appraisal Fee to
804, Credit Report to
805. Lender's Inspection Fee to
806. Mortgage ins.App.Fee to
807. Assumption Fee to
806. Insured Closing Letter
809, Express Mail Fee
810. Tax CertMeation Fee
811,
REQUIRED 2N.ITEMS BY LENDER TO 13E PAID IN ADVANCE
901:Interest From to @ $ /day { days %)
902. MiP Totins.for Lifeaoan for months to
903. Hazard Insurance Premium for 1.0 years to
904.
905,
1000,RESERVES DERMITED WITH LENDER
1001,Hazard Insurance months $ per month
1002.Mortgage Insurance months @ $ per month
1003. Cipyfrown Taxes months @ $ per month
1004. County Taxes months @ $ per month
1005. School Taxes months @ $ per month
1006. months @ $ per month
1007. months @ $ per month
1008. months 0 $ per month
110 .TITLE CHARGES
1101. Settlement or Closing Fee to
1102. Abstract or Title Search to
1101 Title Examination to
1104. Title Insurance Binder to
1105. Document Preparation to Yost&Davidson ban documents 150.00
1106. Notary Fees to
1107. Attorney's Fees to Michael Bangs,Esq. 350.00
includes above item numbers:
1108. Title Insurance to Penn Attorneys a Division of Ohio Bar Title 1,150.00
337.50 to Penn Attorneys a Division of Ohio Bar Title 12.50 to Yost&Davids
includes above item numbers:
1109. Lender's Coverage $ 35,000.00
1110.Owner's Coverage $ 135,000.00
1111.
1112.
1113.
1200.GOVERNMENT RF-CORDING AND TRANSFER CHARGES
1201.Recording Fees: Deed $ 67.00;Mortgage $ 83.00; Releases $ 150.00
1202.C' !Coun Tax/Stam s: Deed 1,350.00:Mortgage 1135-0Z0
1203.State Tax/Stamps: Revenue Stamps 1,350.00;Mortgage 1,350.00
1204. UPI fee 2 Cumberland County Recorder of Deeds
1205.
ADDITIONAL SETTLEMENT CHARGES
1301. Survey to
1302. Pest Inspedion to
1303. 2014 school tax to Michael Langan,Tax Collector 10.18-1310-002 2,084.05
1304. sewer&trash-3rd quarter to Hampden Township #013619000 136.51 18.54
1305. Inheritance tax escrow to Yost&Davidson 9,115.0c
1400.TOTAL SETTLEMENT CHARGES Enter on Lines 103,Section J and 502,Section K) 5,131.51 11,217.6°
By signing page 1 of this statement,the signatories acknowledge receipt of a completed copy page 222 of this two page statement.
Certified to be a true copy. W Davidson
ment Agent
(DICKERSON IV IDICKERSON IV 19)
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BILL OF SALE
SELLER: ESTATE OF HELEN A. TOMEK
839 MEADOW LANE
CAMP HILL, PA 17011
PURCHASER: TORY J. HERRMAN
4908 SMITH STREET
HARRISBURG, PA 17109
This will certify that Tory J. Herrman_ has purchased a
2604 Saturn Sedan, V/1G8AZ52F44Z129119 for the amount of
$3 , 800 . 00 ,
The Seller hereby expressly disclaims all' warranties,'
either expressed or implied, including any implied warranty of
merchantability or fitness for a particular purpose . Seller
neither assumes nor authorizes any other person to assume for it
any liability in connection with the sale of the above
referenced item.
ESTATE OF HELEN A. TOMEK TORY J. HERP1W
Sworn to and subscribed
Before me this 10TH day"
}of1 December, 2013 -
NOTARY PUBLIC /
OMtW`OP PENNSYlVAN1A t "
Notarla15ea1
panna D.OradY.t'1o�'PuMk
Pere+�iBSwp•.cumod.5,20
Cpmmi55ba rioK of ta)rnnt�'."` .
MP,MOER,PFIaLSY�`1AN�A5�`
St
MEMBERS 151
FEDERAL CREDIT UNION
REGULAR SAVINGS ACCOUNT: 33236-00
Account Number/bufoc 4114/1983
Date Account Established $16,899.05
Principal Balance at Date of Death $0.35
Accrued Interest to Date of Death $16,899.40
Total Principal and Accrued Interest None
Name of Joint Owner
CHECKIN ACCOUNT: 33236-11
Account Number/Suffix 1/19/2006
Date Account Established $0.00
Principal Balance at Date of Death $0.00
Accrued Interest to Date of Death $0.00
Total Principal and Accrued Interest None
Name of Joint Owner
IRA SAVINGS ACCOUNT: 33236.10
Account NumberlSuffix 09/17/2013
Date Account Established $59,324.83 ,
Principal Balance at Date of Death $2.03
Accrued Interest to Date of Death $59,326.86
Total Principal and Accrued Interest James Tomek
Name of Beneficiary
James Tomek—Primary Owner
REGULAR SAVINGS ACCOUNT: 73230-00
Account Number/Suffix 06/1811987
Date Account Established $(7.00)
Principal Balance at Date of Death $0.00
Accrued Interest to Date of Death $(7.00)
Total Principal and Accrued Interest Helen Tomek
Name of Joint Owner 06/1811987
Date Joint Ownership Established
CHECKING G NT: James Tomek—Primary Owner
73230-11
Account NumberlSuffix 08/0111994
Date Opened $16.35
Principal Balance at Date of Death $0.00
Accrued Interest to Date of Death $16.35
Accrued Interest plus Principal Balance Helen Tomek
Name of Joint Owner 08101/1994
Date Joint Ownership Established
MEMBE S 1sT FEDERAL CREDIT UNION
Anderson
Lending Insurance Support Specialist
December 20, 2013
Estate of: Helen Tomek
Date of Death: 1110 612 01 3
Social Security Number: 179-30-6293
5000 Louise Drive • P.O. Box 40 • Mechanicsburg, Pennsylvania 17055 • (800) 283-2328 wwwtnetnberslst.org