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HomeMy WebLinkAbout08-26-14 (2) i J 1505610140 REV-1500 EX 101-11)(FI) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Number PO BOX 280601 2 1 1 4 4 2 3 5 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 0 2 2 3 2 0 1 4 0 6 1 8 1 9 7 3 Decedent's Last Name Suffix Decedent's First Name MI L I N E S H E L B Y E (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW © 1.Original Return 2.Supplemental Return C] 3.Remainder Return(Date of Death Prior to 12-13-82) n 4.Limited Estate 4a.Future Interest Compromise(date of 5.Federal Estate Tax Return Required death after 12-12-82) 6.Decedent Died Testate 7.Decedent Maintained a Living Trust 1 8,Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) 9.Litigation Proceeds Received 0 10.Spousal Poverty Credit(Date of Death El 11. Election to Tax under Sec.9113(A) Between 12-31.91 and 1-1-95) (Attach Schedule O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: 1 Name Daytime Telephone Number o ,) C> W I L L I A M A - D U N C A N 7 1 7 lb 9 7``-7 8�pr j .CJ c—. ,7 o d REGISTERlDF*kt*US94NLY Cn M rzrs rn mm First Line of Address <n C7 O Q 1 I R V I N E R 0 W o ° : m Second Line of Address f rrl k r— j: ca to � City or Post Office State ZIP Code DATE FILED C� C A R L I S L E P A 1 7 0 1 3 Correspondent's e-mail address: billaduncanhaltmanlaw.com Under penalties of perjury,t declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it Is tote,cVfFa1nkWmPIete.Dedaretittin of pr arer er than the personal representative is based on all information of which preparer has any knowledge. SIGN U OF PER N SP NSIBU&dR FILJ06 RETURN DATE ADDRESS 310 WALNUT STREET, ILING SPRINGS PA 17007 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 1505610240 REV-1500 EX(FI) Decedents Social Security Number DecedenrsNarne: SHELBY E • LINE RECAPITULATION 1. Real Estate(Schedule A) .. . . . .. . . . . . .. . . .. . ... . 1. 2 5 0 0 0 0 . 0 0 2. Stocks and Bonds(Schedule B) ,. . . . ... . . . .. . .. . . .. . .. .. . . 2. 1 3 1 5 8 0 9 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ... . . 3. 4. Mortgages and Notes Receivable(Schedule 0) .. . ... .. ... .. ... .. .. . .. . . 4. 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). . .. . .. 5. 7 5 9 4 3 6 9 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . .. . .. 6. 7. Inter-Vivos Transfers&Miscellaneous N Probate Property (Schedule G) Separate Billing Requested ... .. . . 7. 9 8 2 9 3 0 8. Total Gross Assets(total Lines I through 7) . . .. . .. ... . . .. ... .. . .. . 8. 3 4 8 9 3 1 0 8 9. Funeral Expenses and Administrative Costs(Schedule H) . .. . .. . .. . .. 9 2 3 1 ❑ 6 4 9 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) .. . .. 10. 1 8 3 8 0 8 • 8 1 Total Deductions(total Lines 9 and 10) .. . . . ... .. . .. .. . .. . 2 0 6 9 1 5 3 0 12, Net Value of Estate(Line 8 minus Line 11) . . .. 12. 1 4 2 0 1 5 7 8 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. 1 4 2 0 1 S . 7 8 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES I& Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X A _ 0 . 0 0 15. ❑ . 0 0 16, Amount of Line 14 taxable at lineal rate X.0,L5_ 1 4 2 0 1 5 . 7 8 16, 6 3 9 0 . 7 1 17. Amount of Line 14 taxable at sibling rate X.12 0 . 0 0 17. 0 . ❑ 0 18. Amount of Line 14 taxable at collateral rate X.15 4 9 9 . 0 0 18, 7 4 . 8 5 19. TAX DUE . . . . .. . . . . . . ... . . . . . . . . .. . . .. . .. .. . .. .. . .. ... . ... . . 19, 6 4 6 5 • 5 6 20, FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OFAN OVERPAYMENT ❑ Side 2 1505610240 150561024❑ REV-1500 EX(Fq Page 3 File Number Decedent's Complete Address: 21 14 0235 DECEDENTS NAME SHELBY E. LINE STREET ADDRESS 45 WEST VIEW DRIVE CITY STATE ZIP CARLISLE I PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2,Une 19) (1) 6,465.56 1 Credits/Payments A.Prior Payments S.Discount Total Credits(A B) (2) 0.00 3. Interest (3) 4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00 5. If Line 1+Une 3 Is greater than Line 2,enter the difference.This is the TAX DUE. (5) 6,465.56 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 ...................................................................... ❑ IZI b, retain the right to designate who shall use the property transferred or its income ......................... ❑ c. retain a reversionary interest ..................................................................................................... 1-1 it. receive the promise for life of either payments,benefits or care? ....................................................... ❑ nX 2. If death occurred after December 12,1982.did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ❑ nX 3. Did decedent own an'intrust for'or payable-upon-death bank account or security at his or her death? ......... ❑ n 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. 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)(1)]. For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent (72 P.S.§9116(a)(1.1)(ii)].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 fax 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 f72 P.S.§9116(a)(1)1. • The tax rate imposed on the net value of transfers to or for the use of the decedents 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-(12-12) pennsylvania SCHEDULE A DEPARTMENT OF REVENUE REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: SHELBY E. LINE 21 14 0235 All real property owned solely ores a tenant In common must be reported at fair market value.Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. 45 WEST VIEW DRIVE 250,000.00 CARLISLE, PA 17013 [SEE HUD SHEET ATTACHED] TOTAL(Also enter on Line 1,Recapitulation.) E 250 000.00 If more space is needed,use additknal sheets of paper of the same size. REV-1803 EX+(8-12) pennsy[vania SCHEDULE B DEPARTMENT OF REVENUE �� ^& BONDS INHERITANCE TAX RETURN STOCKS�C RESIDENT DECEDENT ESTATE OF FILE NUMBER SHELBY E. LINE '21 14 0235 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. JANUS FUND ACCOUNT#37/305854318- 13,158.090 SHARES X$1.00 13,158.09 [SEE DOD INFORMATION ATTACHED) TOTAL(Also enter on Line 2,Recapitulation) $ 13 158.09 If more space is needed,insert additional sheets of the same size REV-1508 EX+(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC- RESID NT DE DECEDENT PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: SHELBY E. LINE 21 14 0235 Include the proceeds of litigation and the date the proceeds were received by the estate. All property Jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. MEMBERS FIRST CREDIT UNION SAVINGS ACCT. # 185912-00 27,721.85 [SEE DOD LETTER ATTACHED] 2. MEMBERS FIRST CREDIT UNION CHECKING ACCT.# 185912-11 5,795.77 [SEE DOD LETTER ATTACHED] 3. MEMBERS FIRST CREDIT UNION INVESTMENT SAVINGS ACCT.# 185912-05 25,021.86 [SEE DOD LETTER ATTACHED] 4. ALLSTATE REFUND 532.87 5. PA TREASURY'- PAY 173.06 6. PA TREASURY- PAY 2,277.45 7. ALLSTATE REFUND 292.21 8. 2011 SUBARU IMPREZA-TRADE IN VALUE 13,000.00 [SEE ATTACHED] 9. ALLSTATE REFUND 39.84 10. COUNTY TAXES PAID - PRORATED 05/12/14-12/31/14 511.88 [SEE HUD SHEET ATTACHED] 11. ASSESSMENTS- PRORATED 05/12/14-06130/14 400.29 [SEE HUD SHEET ATTACHED] 12. HOLY SPIRIT HOSPITAL REFUND 10.00 13. COMCAST REFUND 89.02 14. ALLSTATE REFUND 77.59 TOTAL(Also enter on Line 5,Recapitulation) $ 75 943.69 If more space is needed,use additional sheets of paper of the same size. REV-1510 EX+(08-09) pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER SHELBY E. LINE 21 14 0235 This schedule must be completed and filed It the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER.ATTACH A COT'OF THE DEED FOR REAL ESTATE VALUE OF ASSET INTEREST IIFAPRKA" VALUE 1. MUTUAL OF AMERICA-SEP - ELIJAH WOLTZ- NEPHEW 499.90 100.00 499.90 [SEE ATTACHED] 2. PA STATE EMPLOYEES' RETIREMENT SYSTEM 9,329.40 100.00 9,329.40 [SEE ATTACHED] TOTAL Also enter on Line 7,Recapitulation $ 9,829.30 If more space is needed,use additional sheets of paper of the same size. REV-1511 FX+(08-13) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER SHELBY E. LINE 21 14 0235 Decedent's debts must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOFFMAN ROTH FUNERAL HOME 3,933.99 2. MEMORIAL GARDENS CEMETERY PLOT& HEADSTONE & BURIAL 6,544.00 3. REVEREND HAND - CLERGY 400.00 4. ROYER'S FLOWERS 400.00 8. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City Stale ZIP Years)Commission Pak: 2 Attorney Fees: DUNCAN & HARTMAN, PC 9,500.00 3. Family Exemption:(If decedents address is not the same as claimants,attach explanation.) Claimant Street Address City Stale ZIP Relationship of Claimant to Decedent 4. Probate Fees: REGISTER OF WILLS 328.50 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. HELD IN RESERVE 2,000.00 TOTAL(Also enter on Line 9,Recapitulation) $ 23 106.49 If more space Is needed,use additional sheets of paper of the same size. REV-1512 EX-(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER SHELBY E. LINE 21 14 0235 Report debts incurred bythe decedent priorto death that remained unpaid atthe date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. BROWN'S PROPERTY MANAGEMENT-YARD MOWING &TRIMMING 40.00 2, PPL 147.30 3. ADVANCED DISPOSAL 41.97 4. US BANK-MORTGAGE PAYMENT-APRIL 1,123.93 5. CENTRAL PENN MANAGEMENT GROUP 25.00 6. UGI 206.50 7. DELUXE CHECKS 15.74 8. N. MIDDLETON TWSHP-WATER BILLING 83.17 9. CARLISLE MEDICAL GROUP, LLC 25.00 10. BROWN'S PROPERTY MANAGMENT-YARD MOWING &TRIMMING 80.00 11. PPL 38.28 12. PAYOFF OF FIRST MORTGAGE LOAN TO USBANK 165,395.10 [SEE HUD SHEET ATTACHED] 13. ATTORNEY FEES TO DUNCAN & HARTMAN, PC 250.00 (SEE HUD SHEET ATTACHED] 14. WIRE FEE-PAYOFF 20.00 [SEE HUD SHEET ATTACHED] 15. STATE TAX/STAMPS 2,500.00 [SEE HUD SHEET ATTACHED] TOTAL(Also enter on Line 10,Recapitulation) $ 183 808.81 If more space is needed,Insert additional sheets of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent SHELBY E. LINE 21 14 0235 Decedent's Name Page 2 File Number Schedule I -Debts of Decedent, Mortgage Liabilities, & Liens ITEM NUMBER DESCRIPTION AMOUNT 16. TAX CERTIFICATION TO SALZMANN HUGHES, PC 10.00 [SEE HUD SHEET ATTACHED] 17. NORTH MIDDLETON TOWNSHIP- FINAL WATER/SEWER BILLLING 40.15 [SEE HUD SHEET ATTACHED] 18. COMMISSION PAID AT SETTLEMENT TO HOOKE HOOKE & ECKMAN 12,500.00 [SEE HUD SHEET ATTACHED] 19. BROKER FEE TO HOOKE HOOKE AND ECKMAN 245.00 [SEE HUD SHEET ATTACHED] 21. BROWN'S PROPERTY MANAGEMENT-MOWING 40.00 22. PPL 19.25 23. UGI 74.95 24. POSTAGE 12.47 25. CARPET REPLACEMENT 875.00 SUBTOTAL SCHEDULE 13,816.82 GRAND TOTAL SCHEDULE I $ 183,808.81 REV-1513 EX,(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: SHELBY E. LINE 21 14 0235 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE ] TAXABLE DISTRIBUTIONS (Include outri ght spousal distributions and transfers under Sec.9116(a)(1.2).j 1. G. JEFFREY LINE Lineal 310 WALNUT STREET 100% BOILING SPRINGS, PA 17007 2. ELIJAH WOLTZ Collateral 30 SUSSEX DRIVE 499.00 CARLISLE, PA 17013 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. ]], NON-TAXABLE DISTRIBUTIONS: A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size. _1 48500041046 REV-485 EX(OS-04) SAFE DEPOSIT BOXINVENTORY PA Department of Revenue PLEASE USE ORIGINAL FORM ONLY Social Security or Death Certificate Number Date of Death County Code Year File Number Name Suffix First Name MI ©ADDRESS OE DEJJ ENT�TREE,T:t eW Car I I's I P: P��STATE: I�,jIP c E: ©NAME A ADD SS/O P RSO\NV7REOVESTING HE OPENING OF THE SAFE DEPOSIT BOX l/ NAME: r O 1 t > STREETADDRESS: 11 1.1--OI III CI rI STATEN ZIPOC E: NAME,ADDRESS AND RELATIONSHIP(IF ANY)TO DECEDENT,OF PERSONS)PRESENOAT THE BOX OPENING a. NAME: rb�W Se� �A r ?� RELATIONSHIP: C r STREjfESS.J CITY: STATE: CODE! b. NAME: RELATIONSHIP: i 1 STREETADDRESS: CITY: STATE: ZIP CODE: + c. NAME: RELATIONSHIP: IIi STREETADDRESS: CITY: STATE: ZIP CODE: I NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME: STREETADDRESS: I� �I ut I ft CITY. O STATE: ZIP ODE' NAME OF PER MA I G LAST NTR DATE ND T�/I) �Of F ST ENTRY I e lI t DATE OF CO CT TO T BOX NU B R F BOX I TIn UN i WHIC BO)S I R�FuESTED L 7 l/ NAME AND ADDRESS OF PERSON(S)HAVING ACCESS TO BOX a. NAME: 'Dhel{ q L b. NAME: STREETADDRESS:j ( I \ 1fi � STREETADDRESS: CITY:�r 1`�``I^ (-,`l STvATEI: IP DE: CITY: STATE: ZIP CODE: NAME AND TITLE OIF EMPLOYEE TAKING THE INVENTORY - Se c Line f u&,)r- WAS A WILL IN THE BOX? ❑ YES NO If yes, a. Date of will: i b. Name and address of personal rep sentative,If named in the will NAME: STREETADDRESS: CITY: STATE: ZIP CODE: c. Name and address of attorney,if any NAME: I STREETADDRESS: CITY: STATE: ZIP CODE: L 48500041046 48500041046 REV-485 EX SAFE DEPOSIT BOX INVENTORY Page-2-of INSTRUCTIONS (1) Cash:Report total only. (2) Stocks: List in detail every common or preferred certificate,warrant or other rights found in box.Stocks are to be designated by name of Company,certificate number,date of certificate,name in which stock Is registered,and number of shares and Gass of stock. (3) Obligations of U.S.Government: Number of items,date of Issue,face value,names in which registered and type of ownership, i.e.,jointly held, payable on death,etc. (4) Bonds: Designate by name,amount,serial number,or other designation.(Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor,number of book,last date appearing in book,name of bank and branch,and balance. (6) Jewelry,Coins,Stamps, Manuscripts,etc:List and describe as fully as possible. ' (7) Deeds, Mortgages,Current Insurance Policies or other evidences of Indebtedness: List and describe as fully as possible. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT.280601 HARRISBURG,PA 17128-0601 ITEM ITEM DESCRIPTION NO. Co r II e I I CERTIFY UNDER PENALTY OF PERJU Y ABOVE RECORD IS PERSON RECEIVING COPY OF CORR TAN OMPLETE TO THE BE OF MY K WLEDGE AND BELIEF. SAFE D POSIT X INVENTORY: SIGN A SIONATU R / PRINT NAME 1\_,/ i �` PR NAM C AP O IvBox a Ow: J PRINT TIRE DATE CHECK APPROPRMTE BOX 1HE1ExaRldx) ❑mm inlstrarogW ) E=Ia Repie¢¢malive JWnt ownm of¢al¢tl¢I�¢It Eox NOTE:Attach additional 81h"x 11"sheet(s) if necessary or use duplicates of this page of form. The Department is authorized bylaw,42 U.S.C.§405(c)(2)(C)Q),to require disclosure of Social Seourlty numbers m connection with administering state lax laws.The Department uses the Social Security number to identify the decedent and personal repmsentatfves of the estate.The Commonwealth may also use the information in exchange of tax infomleEon agreements with Federal and local taxing aulhodties.The state law pmhjWts the Commonwealth's personnel from disclosing confidential tax infornatlon except for official purposm. MUTUAL OF AMERICA Quarterly Statement 3/31/2014 • $/30/2014 Customer 1D: 82.595211-9 Questions? Contact: Anthony DePiero Blue Bell Executive Campus 470 Norristown Road Suite 301 Blue Bell, PA 19422-2322 (610) 834-1754 -Or- Customer Service (800) 468-3785 Ms. Shelby E. Line 45 West Vw Carlisle PA 17013.8134 l�dtl..nrra,r.p.litllr�rpLh�t�dll�mdlr�IPdl...nni! alance S„*nmary Plan Type Employer Plan Number Closing Dollar Balance Simplified Employee Pension 018192-13-15 499.90 Total -0 Simplified m loyee ension Employer Number: 018192-D-1S Employer: Community Action Association of Pennsylvania Plan Summary Allocation of Future Contributions Description Dollar Balance Description Allocation% Opening Balance 498.66 Mutual of America Interest Accumulation 100% Investment Earnings 1.24 Closing Balance $49�I"T Mutual of America Interest Accumulation Activity Date Description Dollar Amount 03/31/14 Opening Balance - Employer 498.66 06/30/14 Investment Earnings 1.24 06/30/14 Closing Balance - Employer 499.90 Closing Balance $499., 0 Page 1 PH 0348989 MvruuorA.+rewcAL=tmuRANmCowAr;Y '.... COMMONWEALTH OF PENNSYLVANIA AM STATE EMPLOYEES' RETIREMENT SYSTEM 30 NORTH THIRD STREET,SUITE 150 $ Ma HARRISBURG,PA 17101.1716 .)5.. tA 1-800-633-5461 -R - www.sers.state.pa.us . RELEASE AND INDEMNIFICATION AFFIDAVIT FORM C TO OBTAIN DECEASED MEMBER'S RETIREMENT AND/OR DEATH BENEFITS Member's Name: SHELBY E LINE Member's SSN: XXX-XX-2376 State of Pennsylvania County Of Cumberland SS. G. Jeffrey Line certify that I am the named personal (Affiant's Name) representative for or beneficiary of the above-named deceased member ("Member") of the Pennsylvania State Employees' Retirement System ("SERS"), and that in consideration of the total sum of$9,329.40, 1 discharge and forever release SERS from further liability for payment of any benefits which have accrued as a result of Member's death. I further certify to the best of my knowledge, information and belief that at the time of Member's death Member was not named as plaintiff or defendant in any divorce proceeding filed in any court within the Commonwealth of Pennsylvania and that Member's assets were not subject to equitable distribution incident to a divorce proceeding filed or pending in a Pennsylvania court. I further certify that I shall at all times hereafter keep SERS indemnified and held harmless against any and all claims, debts, and liabilities which may arise as a result of the payment of retirement or death benefits from Member's account. I understand that Section 5954 of the State Employees' Retirement Code provides that any person who knowingly makes any false statements or falsifies or permits to be falsified any record or records of SERS in an attempt to defraud SERS is guilty of a misdemeanor of"second ree (suc 'me subjects the guilty person to a fine and/or imprisonment). 7- Date Signature o , .._ ant G. Jeff ey_Line_ . 310 Walnut Street, Boiling Springs, PA 17007 Sworn to and subscribed before me this Affiant's Address day of Ju Lam( 20 I L•) =ADAMS.OF PENNSYLVANI AL SFAL S,Notary Puhlic mhedand County N ry Public ires March 15,2015 My Commission Expires:A4A 2e_-W 8EN67 I IIIIII VIII VIII VIII(IIII VIII VIII VIII VIII(IIII IIIiI Iilll IIII IIII Revised 1/07 J A N U S s April 23, 2014 DUNCAN & HARTMAN PC ATTN JOAN ADAMS 1 IRVINE ROW CARLISLE PA 17013-3019 REFERENCE: 02193452 Dear Ms.Adams: This letter is in response to a request for Janus account information. The account information provided below is unaudited. Date Fund/Account Transaction Share Price I Shares Dollar Amount 2/23/2014 37/305854318 Balance $1.00 13,158.090 $13,158.09 If you have any questions, or if Janus may be of additional assistance, please contact us at 800- 525-3713. Representatives are available Monday through Friday from 9:00 a.m.to 6:00 p.m. Eastern Time. Sincerely, Amanda Acosta Investor Services ZAUJAN5011 St MEMBERS III FEDERALCREDIT UNION REGULAR SAVINGS ACCOUNT: Account Number/Suffix 185912-00 Date Account Established 07/19/1999 Principal Balance at Date of Death $27,720.18 Accrued Interest to Date of Death $1.67 Total Principal and Accrued Interest $27,721.85 Name of Joint Owner None CHECKING ACCOUNT: Account Number/Suffix 185912-11 Date Account Established 07/19/1999 Principal Balance at Date of Death $5,795.63 Accrued Interest to Date of Death $0.14 Total Principal and Accrued Interest $5,795.77 Name of Joint Owner None INVESTMENT SAVINGS ACCOUNT: Account Number/Suffix 185912-05 Date Account Established 09/11/2013 Principal Balance at Date of Death $25,019.60 Accrued Interest to Date of Death $2.26 Total Principal and Accrued Interest $25,021.86 Name of Joint Owner None MEMBERS 1sT FEDERAL CREDIT UNION 4Lending son urance Support Specialist April 4, 2014 Estate of: Shelby Line Date of Death: 02/2312014 Social Security Number: 182-52-2376 5000 Louise Drive • P.O. Box 40 • Mechanicsburg,Pennsylvania 17055 • (800) 283-2328 • www.memberslstorg GARNET FORD INC. Mileage 613-17 1610 Wilmington Pike Chadds Ford, PA 19317 O VIN NO. 2 P H K (610)358-5600 6 6 1 PURCHASER'S NAME GREGG ALAN WOLTZ DATEAPR 22ND 7014 ADDRESS 30 SUSSEX DR CARLISLE FA zIPCODE 17 013 RESIDENCEPHONE (6101 361-9412 BUSINESS PHONE PERSON AI'R}i T3 U-AZIO ENTER MY .@le ORDER FOR XX 72 @2 MAKE YR. MODEL BODY CYL. COLOR NEW USED STOCK No. TO BE DELIVERED ON OR ABOUT APR 22ND 2014 ANEW VEHICLE Price of Vehicle 19 792.0 TERMS&CONDITIONS WARRANTY:THE PRINTED NEW VEHICLE WARRANTY OF THE MANUFACTUREF DELIVERED TO THE BUYER WITH THE SALE OF THIS VEHICLE,AND WHICH THE BUYER ACKNOWLEDGES,IS THE ONLY WARRANTY APPLICABLE TO THE SALE OF THIS VEHICLE.ADDITIONAL COPIES OF THE MANUFACTURER'S WARRANTY MA) BE OBTAINED FROM THE MANUFACTURER OR THE DEALER By REOUESTINC COPIES OF THE SAME" DISCLAIMER:THERE ARE NO WARRANTIES,EXPRESSED OR IMPLIED,INCLUDINC THE IMPLIED WARRANTY OF MERCHANTABILITY AND FITNESS FOR A PARTICUI AF PURPOSE MADE BY THE SELLER HEREIN EXCEPT THE WARRANTIES OF THE MANUFACTURER.THE MANUFACTURER'S WARRANTY IS EXPRESSLY IN LIEU OF ALL OTHER WARRANTIES,EXPRESSED OR IMPLIED;AND ANY DISPUTE ARISINC UNDER THE TERMS OF SAID WARRANTY SHALL BE DETERMINED SOLELY BYTHE BUYER AND THE MANUFACTURER.THE SELLER HEREBY EXPRESSLY DISCLAIM: ANY IMPLIED WARRANTY OF MERCHANTABILITY AND FITNESS FOR A PARTICULAF PURPOSE, AND THE SELLING DEALER SHALL NOT BE LIABLE FOR CONSE OUENTOL OR INCIDENTAL DAMAGES FOR LOSS OF USE,LOSS OFTIME,LOSS OF PROFITS OR INCOME,OR ANY OTHER INCIDENTAL DAMAGES.Some states do not allow the exclusions or limitation of incidental or consequential damages,so the preceding limitation or exclusion may not apply to you. eWan syaawra ❑USED VEHICLE AS IS THIS MOTOR VEHICLE IS SOLD I WITHOUT ANY WARRANTY EITHER Price of Vehicle EXPRESSED OR IMPLIED.THE PURCHASER WILL BEAR THE ENTIRE TIRE EXPENSE OF 9 7 ^.@@ REPAIRING HE CORRECTING ANY DEFECTS THAT PRESENTLY EXIST ORTHAT MAY Factory Rebate N OCCUR IN THE VEHICLE. Less Trade-in Value 13 0 @0.00 ❑OR THE ONLY DEALER WARRANTY ON TIPS VEHICLE IS THE LIMITED WARRANTY Net Difference WHICH IS ISSUED WITH AND MADE A PART OF THIS CONTRACT. Service Contract Other R Tag k .TT V S R f 5 D Petition / TPApE-IN DESCRIPTION AND ALLOWANCE Year 'LM11 Make ,TTHAIcTT M.IJO IlIM21 nn Serial No JF1('hlGB64BHSJ 9650 Mileage 49692 TOTAL TAXABLE AMOUNT Tire No. Stock No. A7267 Sales Tax Payoff T.: meuanoe CO. PROGRESSIVE LICENSE,TITLE AND REGISTRATION FEES I'ANsf6B 1 WlteyI DOCUMENTATION FEE Agent EX'-RF'S:TVR' 1 Phone (9191 9R9_1009 Add... Eneetive Dales-Ram To i Q-LaO i 701 4 NESS'EpP.�R, )� 2 7.0 � y EXTENpEO SERVICE PLAN 2 350.00 ESTIMATED PAY-OFF ON TRADE-IN mm"he G B Mileage 1"F r.HAM ACTUAL PAYOFF ON TRADE-IN TOTAL DUE $ S Deposit wlm Order $ Balance Due $ 10 5�4 Total Down Payment $30,554.7- $ TOTAL LIQUIDATED OgMAGES;IN THE EVENT OF CANLELL9TION OR BREACH OF THIS gGgE N Sr E AMOUNT FINANCED BUYER.THE DEALER SHALL BE ENmLED TO RETAIN AS LIQUIDATED DAMAGES THE SUM OF 5 BWEq HEREBY ACKNOWLEDGES THE ABOVE PROVISION. Bayerb elBaall,re Purchaser agrees that this Order on the face and reverse side hereof and any attachments hereto includes all of the terms and conditions,that this Order cancels and supersedes any prior agreements and as the date hereof comprises the complete and exclusive statement of the terms of the agreement relating to the subject matters covered hereby, and that THIS ORDER SHALL NOT BECOME BINDING UNTIL ACCEPTED BY DEALER OR HIS AUTHORIZED REPREPENTATIVE.Purchaser by his execution of this Order acknowledges that he has read its terms an c» iy ns and has received a true copy of this Of 6r.I also certify that I am eighteen years of age or over. AccEPreo By _ AVIHOPIZEn PEPPE9EMATIVE WTE - XA R'SSIGNATURE / X LOPUPLXA9ERIJayYpeEb) ]MRemu'euntl 9emelee tampmy P080363a0(07/13) www.garnetford.com A. Settlement Statement {HUD-1} OMB Approval No,2502.026E F1NA! 1.❑FHA 2.❑RHS 3.®Conv.Unins. 6.File Number. 7.Loan Number. 8.Mortgage Insurance Case Number: 2014-044 5701785700 4.❑VA 5.❑Conv.Ins. C.Note:This form Is fumished to give you a statement of actual settlement coals Amounts paid to and by me settlement agents arc sham Items marked '(p.a.Ormho paid outside the Clasirg;they are shoxn here for informational purposes and are not InGUtled In the totals D.Name&Address of Borrower. E.Name&Address of Seller: F.Name&Address of Lender. George E.Teague,Deborah R.Teague Tim Estate of Shelby E Una Fulton Bank,NA, 50 Conifer Ridge Road,Cadlsle,PA 17013 45 West View Drive,Carlisle,PA 17013 One Penn Square,Suits 3D4,Lancaster,PA 17602 G.Property Location: H.Settlement Agent: L Settlement Date:05(1212014 45 West View Drive PA Real Estate Selitemenl Services,LLC Disbursement Date:05117!2014 Carlisle,PA 17013 354 Alexander Spring Road,CarGSle,PA 17015 North Middleton Township Telephone:717.2490333 Fax:717-249-7334 Place of Settlement TiOeExpres5 354 Alexander Spring Road,Cadlsle,PA 17015 Panted 0512!2014 at 9:49 am IbyKSC }190?1-+Gio44rAmouhi DUb;froth&iiiav_redir-�r'.' e""rt"F'II'+ ,O:�;yii9!8?k".�ris` ?4004'1'GinseiA'rtie"unt'06e:fdrSd((er+r': - 101. Contrast sales pdve 250,000.00 401. Co =sales pdve ' 250,00000 101 Peasant eo ny 402. Personal Property 103. Settlement charges to bonower(iins 1400) i 10,286.18 403. 104, 404. 105. 405. Adjustments foriams paid b seller In advance Adjustments for items paid h seller in advance 106. Gtyllawn taxes to 406. COyAown taxes to 107. County taxes 05122014 to 12!312014 511.88 407. Canty taxes 0512t1M4 to 1WIM14 511.88 108. Assessments 05/122014 to 0SO02014 40029 408. Assessments 05122014 to 06(302014 400.29 109. 409. . 110. 410. 111. 411. 112. 412 120. Gross Amount Due from Borrower 201,178.35 420. Gross Amount Due to Seiler 250,91217 92004rAinourit9 Paldti"dr1nBehalf.bf:8driower}F2{4'.','�!a..W._'4t%k'a4`.=+%T.:g>�; ':500!f`*RCduC0on3`in'?ANb'7dtbuetn`SeOer," 4':'..•�.a�.'=kx�a-Pd.',>^1�+':.4 201. Deposit er earnest money 3,000.00 501. Excess deposit(see instructions) 202 princto amoten of nav iaan(s) 200,000.00 502. Settlement charges to seffm(one 1400) 15,565.15 203. 9tits bads)taken sublets to 503. Exists low(s)taken s ed to 204. 504. Payoff of first mortgage loan to USBank 165,395.10 205. 505. Payoff of seoand mod gage loan 216. 506. 207. 507. Inineitance Tax Esome a 6,700.00 208. 508. 209. 509. Adjustments far items unpaid b seller Ad ustmants for items unpaid by softer 210. GlyAays taxes to 510. Glyllown loxes to 1211. County lazes to 511. County taxes to 212 Assessments to 512 Assessmens to 213. 513. 214. 514. 215. 515. 216. 516, 217. 517. 218, 51& 219. 519, 220. Total Patd h ttor 8ormwer 203,O00.0D 520. Total Reduction Amount Due Seger 107,710.25 1700:'-Cashlal;S@ tllcintintfrtlm/to;BbrcoiveG 'S3T,i ''',Gd'?`;^'4c'+i,'.: t.`�t `6, Ga9ff:§U5eh14m2ritAotfrom.sa3tei. 'tl5� '!{$."Y ;""tom%:i, ,?;> 301. Gross amount due from bomber(One 120) 261,178.35 501, Gross amount due to seller(line 420) 250,912.17 3D2. Less anmunts paid byifa bomaverPine 220) 203,000.00 602 Lass reductions in amount due se0er(Ilne 520) 187,710.25 303. Cash © Pram Tp Harrower 58478.35 603. Cash QX To From Seiler 63,201.92 WMaartar awm@{rW 0Y8 was�,b;M�besGf Xnase:vb4+dNnXMNAT.iuM>+InMeMM6M0�XfsaRCa�,mnw4®aYw Mrrm,Yr.U�FOM .r�wxass 'revlous editions are obsolete Page 1 or 4 HUD-3 Y�P1J1 4 A,trrl'M117�' .700?:Total Real:Edts eea okeGFeesT:ii �3j!.•q j2,500.g0` 9Fdsion:of`odmmissl IIna200''asi/dloiJs!�,,:..,, :•<;.^:y,,ts� ^"' y^p.@Id�rq[n. y,;'IPTI 'F6oM. 701. $12500.1 0 .•<?.•,sr2a°,:'$'FC'i:.;:,,:B'briower,''s a+vC=5'@Ilef''s`,�?•': 702 f0 to Haake Hooke 8 Eticman .00 la T'`:FU'ri'dtaC:,; zj'EGriiis�&['j 703. Commission paid at sel0ement :.SeF[lehierit.<:SetfYem`efi4`: 704. Broker Fee to Hooke Hooke 8 Eckman 12,500.00 -800:C':Item7,P•a ablb'In;C'oonedtlodlivlth'L'ddBy: ?:;j�n"..51.�T.iyjaa�'S,�.,��.,,y i�wv;;,,.,.,.. ., 245.00 245.00 801. Our adgina0on charge Indudes -'w '+'."'.:'.Y.: >' Yx2�45...- .r.�... ( Orlglnatlon Pdn10.000%wf0.00) 5795.00 u"�',:•'-,=�:': 802. Your wedilwcharge(polnLS)fw the spedOc interest role chosen Prom GFE q1) 803. Your adjusted origination charges S Prom GFE 82) 804. Appralsal lee (from GFE A) 795.00 805. Credt report Premier A isds 3525.00 P.O.C.B (from GFE 83) -25.00 806. Tax service ,0 Cmdslar (from GFE 83) 92 from GFE#3 808 Flood certification to Core 'Flood Services; from GFE 83 0 ) 11.50 900:':.Items:Reulred8 l:ehdciltltie Pafdan''Advance.::::; , A ._s...:,: F,$` ..,;,•., +^,�V,h 901. Dally interest charges from from OS/17201410 06012014�)E26.7123/day from GFE 810 902. Mod a ea s Insum rdum Mon01510 ( ) 534.25 903. Homernvners Insuance far 1 ears to from GFE 83 904. USAA (from GFE 811) 769.26 months to from GFE 811 '100:. eserves be 'slted'wi `.L'ender:�.-rte•=^«.q:,.,;a?,;v,,g.;, I;: 1001. IdOd deposit for your eswow awuunt 1002.Hameownees Insurance (from GFE 89) 2,981.75 3 months S 64.11/month !192.33 100.3. Mod a Insuranse monhs S ymmlh 1004. Pre taxes months f hnonN 1005.County fazes 4 months E 67.781month $271.12 1006.School Tax 12 months iiii$ 248.0menth $2,981.76 1007.Aggregate Acgmtmenl $463.46 At00.1TlUe Cba es'7? X�ky'ati-ri'i9�iti;1;: ;,•.-r,r•,.y4:.,a,. ,✓,y;,;,'v,a.-a:4::,.;;..,.�,..-,w - < 1101.Tille servces and lender's 011e insurance ''E`" 'R"£'`� y' "s c^��/rd1 i ;i '>•.•:;:�- y 1102. Settlement or dosing lee o f from GFE 94 1,731.50 1103.Owners title Insurance 1104. Lender's Btle Insurance ea S tewart t e from GFE 85 415.00 1105. Lenders 0 policy 1im11 S 110 57,625.00 ZOO,Of10.00 lendMS Pdry - 1106.Owners litle policy limit$250,000.00 Owners Pricy 1107.Agent's portion d the total Otle Insurance premium 51,692.75 1108. Underwdtees portion of the total One Insurance premium $34725 1109.Auomey Fees to Ouncan d Hartman 1110.Wire Fee-Payoff to PA Real Estate 250.00 ill .. 20.00 ?MI. Govem emrec ratngc and'$mnsfer Charges'yY>q,,=,i:orxy .:.- :;..T:i;y,q;:>r;.,.:.✓;s:,:, 1201.Govemmenlrecording charges f .. ;,'�+'"+"''>='fix>t-'�'�x�.::: '.'•: '.:°.:a.? 1202.Deed *00 (from GFE 87) 174.00 Mortgage Releases 1203.Trans l fer oxes E 1204.Qty/County lax/slamps geed$2500.00 (Gam GFE 88) 2,500.00 Mod e 3 1205.Seale Tax/slamps Oeetl 52500.00 Mon 1205. e 5 2,500.00 Oeed3 Mon a eS ,1300i"Addltional'Sedlemedt Cha e's77S€; •::x'n "x`Kq.;;ipti:,�e%�;;:g;•;.>^__;;;rr_k,,c;-3 t,:; ,t, 1301.Regrind services that you n'shopfor F,%5 ''Lx '-?,hi??::=;i:" r,v m=. 1302. Tax Certlficallon (from GFE 861 100,00 1303. Final W9/Swr BIII to Salunann Hu free AuN RC. to North Middleton OdI 10. 1304. Ination Fea (o North RId a II HOA 5100.00 40.15 1305. o ' I CS74r1►{RAI!'II�r 'Pdd outside a/dosing by(B)onower,(Sider,(L)ender,(I)mmslw,B 10,266.18 15,565.15 ro(IC]er."CredI by tender shown on page 1."'Credit by seller shown on page 1. I revlou5 etlltlans are obs0le[e Page 2 Of 4 HUD-1 ..... ...... 111 111 v 11 11 ....... ........ ..... M. ME 1 11 Emmon- No= liar .. .... ... ... . . J,e MIMI -, I All MEEM:- 11 111 11 AI In . WS I'll I-`ql M, MR� I gl- �-f Na I have carefully reviewed the HUD-1 Settlement StateHUD CERTIFICATION F ment and to the best Of My knowed0 and belief,11 Is a true and accurate statement of ell receipts and dlybursements made on my account or by me In this transaction I further cenlly,that 1 have received a copy of the HUD-1 Settlement Statement. +�- WfRF168S;R47f Dl�a��1i George E Te gu aoorah R Teague 4A E OF SH Y NE FIN The HUD-1 Settlement Statement which I have prepared Is a We and accurate account of this transaction I have caused or will cause the funds to be disbursed In accordance with this statement TALENT � s 1 � SETTLEMFM AGENT DATE 11,0 WARNING:IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM.PENALTIES UPON CONVICTION CAN INCLUDE A FINE AND IMPRISONMENT.FOR DETAILS SEE TITLE 18:U.S.CODE SECTION 1001 AND SECTION 1010. Previous etll[lon5 are obsotete Page 4 of 4 Huo-i Name of borrower. Name of Seller. File Number George E.Teague The Estate of Shelby E.Line 2014-094 Deborah R.Teague TMeExprass Prepared 05/72/2014 at 2:23 Pm nem This page is fumished to give you an itemisation of the amounts shown on Lin"uor, noT.nl �Q11pr..,V" ;Ip Ror'fi1104 of the Settlement Statement (MAD-t). This page accompanies but is not a pan C$ +F$`,setttement statement.if a discrepancy exists,the informatin shown on the Settlement Stat 'I`;(HUD-i)applies. J luteot t.,,,�.et1;'��GTieht° ;.1AA0: 7I,Yle'6Harges_; - - A u ilpol r r,- �.i Ltine MI - 1101. Title serAces and lenders We Proureace 1,731.50 a.Overnight Mail i 20.50 b.Wire Fee 12.00 c. processing Fee 49.00 It Notary Fee 200 106.50 1102. SelliernentorcloshcIfee 1103. Ovrets file Insurance $ 41540 415.00 1104. LeMees We Insurance i 1,400.00 $ 11625.00 a.Endorsement 400 EPL-Residerfal 50,00 b.Fndxsement 100 No Violation 50.06 O. Endmement=Survey $0.00 d.Closing Service Leiter 75.00 (Total 1103-1Y104) LZQMM Iltlt00t._- '7g' I 4 IhE 1 a yl TFisA a' to '^ �'t1:69 1109. 1111. 1111Z . -- Total rto or. "1101"10 er . .`StTllerr 700°iftreXhames m ne': - - G a`-a Pbc or C,Ait ' rinp.11M Td' 1101. TWO 5erAces and landers Hge Insurance j a.overnight Mai to Salzmann H hes,P.C. 2050 20.50 b.Wire Fee to PA Real Estate 120D 1200 c. Pmcesslnq Fee to PA Real Estate 49.00 49.00 d.Nolmy Fee to Kamela Gammon 25.00 25.00 1104. Lender's figs insurance to Stewart Tlge GuammyIPA RE SS 1,625.00 1,625.00 315 ' — (I THE ESTATE OF SHELBY E. E 4 B � ate 5112f14 Date 5112714 e .Teagu Date 6f127t4 Oe araFr R.Teague