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HomeMy WebLinkAbout09-26-14 1505610140 REV-1500 EX (01-10) OFFICIAL USE ONLY Department of Revenue Bu CountyCode Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 2 1 1 3 0 5 1 9 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 0 4 1 7 2 0 1 3 0 4 2 0 1 9 2 9 Decedent's Last Name Suffix Decedent's First Name MI B U R G E T T F C L Y D 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 ❑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(date of F1 5.Federal Estate Tax Return Required death after 12-12-82) OX 6.Decedent Died Testate 7.Decedent Maintained a Living Trust _ 8.Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 17 9.Litigation Proceeds Received 10.Spousal Poverty Credit(date of death 11.Election to tax under Sec.9113(A) between 12-31-91 and 1-1-95) (Attach Sch.O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number D O U G L A S G M I L L E R 7 1 7 2 4 9 2 3 5 3 REGISTER OF WILLS USE ONLY First line of address I R W I N & M c K N I G H T P C F Second line of address C'> o 6 0 W E S T P 0 M F R E T S T R E E T : �n m C-> City or Post Office State ZIP Code ;AAJ9 FIL BC C A R L I S L E P A 1 7 0 1 3 :73 rn Correspondent's e-mail address: :3 Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and'to the'dest of my McWedgtsanprgelief, it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which pr9parer has an knoedg MTU/W__X RE OF PERSON SPONSI E RETURN DATE�3� V ADDRESS 3541 SPRING ROAD CARLISLE PA 17013 SI REPRE RER THE T AN REPRESENTATIVE DTE AD S 60 WE T POMFRET STREET CARLISLE PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 J Continuation of REV-1500 Inheritance Tax Return Resident Decedent F. CLYDEBURGETT 21 13 0519 Decedent's Name Page 3 File Number Correspondents Name Daytime Telephone Number D O U G L A S G M I L L E R 7 1 7 2 4 9 2 3 5 3 First line of address I R W I N & M c K N I G H T P . C Second line of address 6 0 WE S T P O M F R E T S T R E E T City or Post Office State ZIP Code C A R L I S L E P A 1 7 0 1 3 Correspondent's e-mail address: 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 all information of which preparer has any knowledge. SI MATURE F PE NSIBL F R FILING RETURN Q DATE_ l / ADDRESS TT 15 WILD ROSE LANE MECHANICSBURG PA 17050 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: F- CLYDE B U R G E T T RECAPITULATION 1. Real Estate(Schedule A) . . .. .. .. . . 1 1 0 0 0 0 0 . 0 0 2. Stocks and Bonds(Schedule B) .. .. . . . . . .. .. . .. . . . . .. .. . ... . . . .. . .. .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) .. .. . 3. 4. Mortgages and Notes Receivable(Schedule D) ..... . . ... . . ..... . .. . . .... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E).. . . .. . 5. 6 9 1 6 9 . 9 0 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested .. . ... . 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested . ..... . 7. 0 . 0 0 8. Total Gross Assets(total Lines 1 through 7) .. . .. . . .. .. .. .. .... .. ... . . . 8. 1 1 6 9 1 6 9 . 9 0 9. Funeral Expenses and Administrative Costs(Schedule H) .. . .. .. . . . . . . . .... 9. 1 5 8 6 1 0 . 3 8 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) .. . .... . . .. . . 10. 8 7 6 5 . 6 0 11. Total Deductions(total Lines 9 and 10) . . .. . . ... . .. .. . . . .. .. . .. .... . . . 11. 1 6 7 3 7 5 . 9 8 12. Net Value of Estate(Line 8 minus Line 11) .. .. . .. .. . . . . .. . . . . . .. . . .... 12. 1 0 0 1 7 9 3 . 9 2 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) .. . . . .... . . . . . .. . . ... . 13. 4 0 0 0 . 0 0 14. Net Value Subject to Tax(Line 12 minus Line 13) .. .. .. . . . . . .. .. . .... . . 14. 9 9 7 7 9 3 . 9 2 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.0 - 0 0 15. 0 . 0 0 16. Amount of Line 14 taxable at lineal rate X.0_ 0 . 0 0 16. 0 . 0 ❑ 17. Amount of Line 14 taxable at sibling rate x.12 3 0 0 0 . 0 0 17. 3 6 0 . 0 0 18. Amount of Line 14 taxable at collateral rate x.15 9 9 4 7 9 3 . 9 2 18. 1 4 9 2 1 9 . 0 9 19. TAX DUE .. .. . ... ..... . . . .. . . . . . . . . . . . . . . .. . . . . .. . . . . ... . .... . . 19. 1 4 9 5 7 9 • 0 9 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Q Side 2 1505610240 1505610240 REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 13 0519 DECEDENTS NAME F. CLYDE BURGETT STREET ADDRESS 3605 SPRING ROAD CITY STATE ZIP CARLISLE I PA 117013 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 149,579.09 2. Credits/Payments A.Prior Payments 150,000.00 B.Discount 7,478.95 Total Credits(A+B) (2) 157,478.95 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) 7,899.86 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00 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; ...................................................................... ❑ b. retain the right to designate who shall use the property transferred or its income; ............................... X c. retain a reversionary interest;or ................................................................................................ 11R d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ 0 2. If death occurred after December 12,1982,did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ❑ 0 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 contains a beneficiary designation?.................................................................................................. ❑ 0 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 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 tax rate imposed on the net value of transfers to or for the use of the decedents lineal beneficiaries is 4.5 percent,except as noted in 72 P.S.§9116(1.2)[72 P.S.§9116(a)(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 INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT .ESTATE OF: FILE NUMBER: F. CLYDE BURGETT 21 13 0519 All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. 3605 SPRING ROAD, CARLISLE, PENNSYLVANIA 1,100,000.00 TOTAL(Also enter on Line 1,Recapitulation.) $ 1,100,000.00 If more space is needed,use additional sheets of paper of the same size. REV-1508 EX+(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: F. CLYDE BURGETT 21 13 0519 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 SOVEREIGN BANK-CHECKING ACCOUNT#1661337074 6,016.13 2. SOVEREIGN BANK-MONEY MARKET ACCOUNT#7673013983 6,280.12 3. M&T BANK-CHECKING ACCOUNT#9858887830 19,823.24 4. ORRSTOWN BANK-ACCOUNT#4000045383 19,820.09 5. WESTERN &SOUTHERN LIFE-ANNUITY#W0020603584 10,090.72 6. . WESTERN&SOUTHERN LIFE-ANNUITY#WO020736776 7,139.60 TOTAL(Also enter on Line 5,Recapitulation) $ 69,169.90 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(10-09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN RESIDENT DECEDENT ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER F. CLYDE BURGETT 21 13 0519 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOFFMAN-ROTH FUNERAL HOME 5,361.10 2. BOBBY WOODS 100.00 3. ST. MATTHIAS WOMEN'S ASSOC. 250.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) DENNIS RALPH GUTSHALL 18,000.00 Street Address 3541 SPRING ROAD City CARLISLE State PA Zip 17013 Years)Commission Paid: 2. Attorney Fees: IRWIN & MCKNIGHT, P.C. 37,000.00 3. Family Exemption:(If decedents address is not the same as claimants,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: REGISTER OF WILLS 398.50 5 Accountant Fees: 6. Tax Return Preparer Fees: PATRICIA A. ROSEN DALE, CPA 750.00 INCOME TAXES AND FINAL FIDUCIARY TAX RETURNS 7. SOVEREIGN BANK-DATE OF DEATH VALUATION 20.00 8. THE SENTINEL-ESTATE NOTICE .210.78 9. CUMBERLAND LAW JOURNAL- ESTATE NOTICE 75.00 10. REGISTER OF WILLS-SHORT CERTIFICATES 20.00 11. S.W. BARRETT REAL ESTATE-APPRAISAL ON REAL ESTATE 750.00 12. ADVANCED SEPTIC SERVICES, INC. -CLEAN SEPTIC TANK 220.00 13. MIDDLESEX TOWNSHIP- PUMPING PERMIT 5.00 14. TRANSFER TAX(1%)AND COMMISSION (6%) @$1,100,000 77,000.00 15. REGISTER OF WILLS-ADDITIONAL PROBATE 450.00 TOTAL(Also enter on Line 9,Recapitulation) $ 158 610.38 If more space is needed,use additional sheets of paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent F. CLYDE BURGETT 21 13 0519 Decedent's Name Page 1 File Number Schedule H -Funeral Expenses&Administrative Costs -B1 ITEM NUMBER DESCRIPTION AMOUNT B. ADMINISTRATIVE COSTS: Personal Representative Commissions: 2• Name(s)of Personal Representative(s) CAROLYN GUTSHALL FRISCH KORN 18,000.00 Street Address 15 WILD ROSE LANE City MECHANICSBURG State PA ZIP 17050 Year(s)Commission Paid: SUBTOTAL SCHEDULE H-B1 18,000.00 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 F. CLYDE BURGETT 21 13 0519 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. PP&L-ELECTRIC 890.96 2. FRANK ROBERTO, TAX COLLECTOR-REAL ESTATE TAXES 4,559.33 3. COMAST-CABLE 23.33 4. CENTURYLINK-TELEPHONE 59.66 5. J. RODNEY FICKEL INSURANCE-HOMEOWNERS INSURANCE 1,252.00 6. SURBURBAN PROPANE-FUEL 197.35 7. EVERETT CASH MUTUAL-INSURANCE 725.50 8. KOUGH'S OIL SERVICE-FUEL 1,057.47 TOTAL(Also enter on Line 10,Recapitulation) $ 8,765.60 If more space is needed,insert additional sheets of the same size. REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT 6F REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: F. CLYDE BURGETT 21 13 0519 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec.9116(a)(1.2).] 1. RUTH SHAFFER Sibling 3,000.00 2 SUNNY DRIVE HARRISBURG, PA 17112 2. WILLIAM CARL GLEIM Collateral 10030 ISSAC DRIVE MIDWEST CITY, OK 73130 3. GARY GUTSHALL Collateral 173 REED ROAD NEW MARKET, AL 35761 4. DENNIS RALPH GUTSHALL Collateral 3541 SPRING ROAD CARLISLE, PA 17013 5. VICKI GUTSHALL MINNICK Collateral 67 ESTEP LANE EDINURG, VA 22824 6. CAROLYN GUTSHALL FRISCHKORN Collateral 15 WILD ROSE LANE MECHANICSBURG, PA 17050 7. MARK LEON GUTSHALL Collateral 183 KUTZ ROAD CARLISLE, PA 17013 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II. 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. ST. MATTHIAS LUTHERN CHURCH 4,000.00 3500 SPRING ROAD CARLISLE, PA 17013 TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 4,000.00 If more space is needed,use additional sheets of paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent F. CLYDE BURGETT 21 13 0519 Decedent's Name Page 2 File Number Schedule J-Beneficiaries -1 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE i TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec,9116(a)(1.2).] 8. ANDREA GUTSHALL BITTENBENDER Collateral 13115 FAWNBOROUGH ROAD MONTPELIER, VA 23192 9. TERESA LEA GUTSHALL WEARY Collateral 589 CARLISLE ROAD NEWVILLE, PA 17241 10. WANDA SHAFFER Collateral 2 SUNNY DRIVE HARRISBURG, PA 17112 G . p LAST WILL AND TESTAMENT I, F. CLYDE BURGETT, of Middlesex Township, Cumberland County, Pennsylvania, being of sound mind, disposing memory and full legal age, do hereby make,publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils heretofore made by me. — - 1. I direct my Executrix or Substitute Co-Executors, as the case may be,to pay all of my debts, funeral and administrative expenses as soon as.convenient after my decease. Furthermore, I direct that all state,inheritance, succession and other death taxes imposed or payable by reason of my death and interest and penalties thereon with respect to all property composing of my gross i; estate for death tax purposes, whether or not such property Y Passes under this Will, shall be paid r by the Executrix or Substitute Co-Executors of my estate. 2. My Executrix or Substitute Co-Executors may, at her or their discretion, compromise claims, borrow money, retain property for such length of time as she or they may deem proper; lease and sell property for such prices, on such terms, at public or private sales, as she or they may deem proper; and invest estate property and income without restriction to legal investments unless otherwise provided hereunder. 3. I authorize and empower my Executrix or Substitute Co-Executors to sell any realty and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale therefore, in fee simple, as I could do if living. My Executrix or Substitute Co-Executors is/are authorized and empowered to engage in any business in which I may be engaged at my death,for �930 such period of time after my death as seems expedient to said Executrix or Substitute Co- Executors. 4. I give,devise and bequeath all of my estate of whatever nature and wherever situate to . my wife,ANNETTA A.BURGETT,providing she shall survive me by sixty(60)days. 5. Should the gift in Paragraph No. 4 not*take effect, I give, devise and bequeath all of - - my estate of whatever.nature and wherever situate as follows: a. The sum of$4,000.00 to ST.MATTHIAS LUTHERAN CHURCH at Carlisle Springs,Cumberland County,Pennsylvania; b. The sum of$3,000.00 to my two(2)sisters,ALICE GUTSHALL and RUTH SHAFFER,share and share alike,providing they are living at the time of my death;and c. All the rest,residue and remainder in equal shares,share and share alike to the following,if they survive me: (1) My wife's nephew,WILLIAM CARL GLEIM; (2) My nephew,GARY GUTSHALL; (3) My nephew,DENNIS RALPH GUTSHALL; (4) My niece,VICKI GUTSHALL MMMCK; (5) My niece,CAROLYN GUTSHALL FRISCHKORN; (6) My nephew,MARK LEON GUTSHALL; . (7) My niece,ANDREA GUTSHALL BITTENBENDER, 2 (8) My niece,TERESA LEA GUTSHALL WEARY; and (9) My niece,WANDA SHAFFER. If any of the above-named persons should predecease me,I order and direct that the gift to such person shall lapse and the residue shall be distributed equally among those other persons who survive me. 6.* I nominate and appoint my wife, ANNETTA A. BURGETT,to be the Executrix of this my Last Will and Testament. In the event she.has predeceased me,failed to qualify or is not able or does not serve for whatever reason, I then nominate and appoint DENNIS RALPH GUTSHALL and CAROLYN GUTSHALL FISCHKORN to be the Substitute Co-Executors of this my Last Will and Testament,.whereby the said Substitute Co-Executors shall have the t same powers as are given to the original Executrix hereunder. 7. No person(s) shall benefit hereunder unless such beneficiary shall survive me by sixty (60)days. 8. No Executrix or Substitute Co-Executor acting hereunder shall be required to post bond or enter security in this or.any other jurisdiction. 9. No beneficiary may assign,anticipate or pledge his,her or its interest in any income or principal held or distributable hereunder, and no beneficiary's creditors may levy, attach or otherwise reach any such interest. 3 10. If any person entitled to share in any distribution under the terms of this my Last Will and Testament becomes an adverse party in any proceeding to contest the probate of this Last Will and Testament, such person shall forfeit his or her entire interest inherited hereunder and all provisions in favor of such person shall be declared void and of no effect. The share of such person so forfeited shall be distributed as part of the residue pursuant to Paragraph 5. hereof, except that if such person is entitled to share in the said residue,that interest shall be distributed proportionately to the other residuary beneficiaries. 11. I hereby suggest that my personal representative(s) retain the services of Irwin & McKnight,P.C. as attorneys in the settlement of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 16'h day of April 2010. (SEAL) F. CLYDE BUR TT Signed, sealed, published and declared by the above-named Testator as and for his Last Will and Testament, in our presence, who, at his request, in his presence and in the presence of each other have hereunto set our names as subscribing witnesses. ��/.�19(GC..I%'rC- cis"• �,�.�.��-�� 4 ACKNOWLEDGMENT AND AFFIDAVIT WE,F. CLYDE BURGETT, KAREN S. NOEL and SHARON L.SCHWALM,the Testator and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that.the Testator signed and executed the instrument as his Last Will and that he had signed willingly,and that he executed it _ as his fee and voluntary act for the purpose herein expressed, and that each of the witnesses,in _ the presence and.hearing of the Testator,signed the Will as a witness and that to the best of their knowledge the Testator was,at that time,eighteen years of age or older,of sound mind and under no constraint or undue influence. t F.ClffYDE BURGETT KAREN . OE SHARON L.SCHWALM COMMONWEALTH OF PENNSYLVANIA : : SS: COUNTY OF CUMBERLAND Subscribed, sworn to and acknowledged before me by F. CLYDE BURGETT, the Testator herein,and subscribed and sworn to before me by KAREN S.NOEL and SHARON L. SCHWALM,witnesses,this 16"day of April 2010. N to Public COMMONWEALTH OF PENNSYLVANIA Notarial Seal Roger B.Irwin,Notary Public Carlisle goro,Cumberland County My Commission Expires Oct.3,2012 5 Member,Pennsylvania Assoclallon of Notaries S.W. BARRETT REAL ESTATE AND APPRAISAL SERVICES File No.13.0138 APPRAISAL OF LOCATED AT: 3605 Spring Road Carlisle,PA 17013 CLIENT: Irwin&McKnight 60 West Pomfret Street Carlisle,PA 17013 AS OF: April 17,2013 BY: Stan A.Skowronek PA Certified Residential Real Estate Appraiser S.W. BARRETT REAL ESTATE AND APPRAISAL SERVICES File No.13-0138 06/25/2013 Irwin&McKnight 60 West Pomfret Street Carlisle,PA 17013 File Number: 13-0138 in accordance with your request,I have appraised the real property at: 3605 Spring Road Carlisle,PA 17013 The purpose of this appraisal is to develop an opinion of the defined value of the subject property,as improved. The property rights appraised are the fee simple interest in the site and improvements. In my opinion,the defined value of the property as of April 17,2013 is: $1,100,000 One Million One Hundred Thousand Dollars The attached report contains the description, analysis and supportive data for the conclusions, final opinion of value, descriptive photographs,assignment conditions and appropriate certifications. Respectfully submitted , S- Stan A.Skowronek PA Certified Residential Real Estate Appraiser Summary Residential Appraisal Report File No. 13-0138 The purpose of this appraisal report is to provide the client with a credible opinion of the defined value of the subject property,given the intended use of the appraisal. Client Namellntended user Irwin&MCKni ht E-mail NIA Client Address 60 West Pomfret Street City,Carlisle state PA 7IP 17013 Additional Intended users The Intended User of this appraisal report is the Client. No additional intended Users are permitted without the permission of thea raisers. Intended use The Intended Use is to.evaluate the property that is the subject of this appraisal to provide the Client with an accurate and adequately supported opinion of value. Property Address 3605 Slifiring Road city Carlisle stare PA zip 17013 Owner of Public Record Burgett,F.Clyde county Cumberland Legal Description Deed Book 20123 page 126 " Assessors Parcel# 21-04-0373-004 Tau Year 2012 R.E.Taxess 2542.00 Neighborhood Name Middlesex To h' Ma Reference 04-0373 Census Tract 0118.03 Pro a Ri hIsA raised X FeeSim le Leasehold I Other describe M research did IX I did not reveal any prior sales or transfers of the subject property for the three years prior to the effective date of this appraisal. PriorSate/Transfer: Date.11/30/2012 Price$1 Sources Courthouse Analysis of prior sale or transfer history of the subject property(and comparable sales,if applicable) Subject last transfered on November 30 2012 for$1.00 which was a transfer of wife to husband. Offerings,options and contracts as of the effective date of the appraisal None noted '�c+r� 'Ne�'fiborhooii Characlerist�cst s�� - - i ,� � :i- -OnetInlCHouslii T,rerid_s'�? � -fOrie.tln Hous] .;.,�2rese. Lan`i!'^11se%-, Location Urban X Suburban I lRural Property Values Increasin X Staple Declmin PRICE AGE One-Unit 40% Built-U Over 75% 25-75% Under 25% Demand/Su Shorta e X In Balance Over supply $000 s 2.4 Unit 0% Growth Rapid X Stable Llstow I Marketing Time LJ Under 3 mths X 3.6 mths Wer 6 mths 120 Low 10 Muld-Family0% Neighborhood Boundaries The subject is bounded on the north by Spring Rd on the east by 275 High 100 commercial 0% Mountain Rd on the south by Walnut Bottom Rd and on the west by route 696. 150 Pred. 40 other Vac 60% Neighborhood Description " The subject is located albna a secondary road populated.by homes of varying size style and quality, It is within close proximity to ammenities such as schools shopping and employment. Market Conditions Including support for the above conclusions) See Attached Addendum Dimensions See legal description Area 239.29 ac shoe Rectangular view Open country Specific ZoninClassification RF/OS Zoning Descd tion Residential Farm/O en Space* Zoning Com fiance X Le al Le al Nonconformin Grandfathered Use N0 Zonin ille al describe Is the highest and best use of the subject property as improved(or as proposed per plans and specifications)the present use? X Yes LJNo It No,describe. .Utilities Public Other describe Public Other describe Off-site Improvements—Type Public Private Electricity X 100 am water X Spring— street Macadam X Gas None Sanitary Sewer I I 1XIseptic Alley None Ll LJ Site comments Private water and Sanitary systems are common to the area and have no adverse affect upon marketability. The subject is not in a special FEMA flood hazard area per flood map#42041C0070Eldated 03-16-2009/Zone X.—Well is bad per family with a sprina on the property bein its only current water source. i. _. _... GENERAL;DESCRIPTION "FOUNDAfiIONI :EXTERIORDESCRIATION maieb5. ,e€INTERIOR.a-;. .ma0enals'. .,.3 units X One I lonew/Acc.unh I I 1concreteStab I Icrawispace Foundation Walls Cone Blk/Avg Floors C thin I/Av #of Stodes 2 X Full Basement I IPartial Basement Exterior Walls Vinyl/Ava Walls Plstr/AV e JX]Det. I lAtt I IS-DetJEndUn1t Basement Area 840 sq.ft. Roof Surface CompoShqie/Ava TdmiFinish Wood/Avg WEAsting 1.1proposed LJunderconst Basement Finish 0% Gutters&Downspouts Aluminum/Av-q Bath Floor Vinyl/Avg Design S IX Outside En /Exit DSumpPump Window Type Wood Frame/Avg Bath Wainscot Plstr/DW/Av Year Built 1940 Storm sashlinsulated Yes/Ava car Storalie Ll None Effective A e(Yrs)30 Screens Yes/AV X I DrWway #of Cars 4 Attic I None Heabn FWA HW Radiant Amenities WoodSlove s#0 Drivewa Surface Stone DropStair X stairs X Other Steam Fuel Oil Fre laces#0 Fence None Gara a #of Cars 0 X Floor Scuttle Coolin Central Air Conditionin X PatiolDeck Conc X Porch Wra carport #of Cars 0 Flnished Heated Individual Other Pool None FlAtt I Dec. Buift4n Appliances Refti erator X Ran elWen Dishwasher Dis osel Microwave WasherlD er Other describe Finished area above grade contains: 7 Rooms 4 Bedrooms 1.5 Baths 1,680 Square Feet of Gross Uving Area Above Grade Additional Features Wrap around porch. Rear patio. 68x70 pole building. Two 14x70 silos.Shed.Various other smaller outbuildin s. Comments on the Improvements Improvements are in average condition with no physical or functional inadequacies noted. Produced uitng Act mfm 800.230.9727 waw.9dwb.mm TnO form Copydgbt 0200'5-2010 ACI DMdon of 150 palms 9eM=Int,AM Rights Refomd. Page 1 of 0 (gPAR-)General PummEApPrwsai Report o92010 CPMl 3006262010 goncralpurPascaPPraisal�ePort ADDENDUM Client Irwin&McKnight Rle No.: 13-0138 Property Address: 3605 Spring Road Case No.: City: Carlisle State: PA 7Lp: 17013 Neighborhood Market Conditions List/Sale ratio approximately 98%.1 have considered relevant competitive listings and/or contract offerings in the performance of this appraisal and in the trending information reported in this section. If a trend is indicated,I have attached an addendum providing relevant competitive listing/contract offering data. Local multi-list data indicates stable market in the past calendar year with no appreciation in the subjects market area,with an average marketing time of 90-180 days. Economic trends and lending rates have remained favorable. Sales concessions are occuring more frequently; however,there is no known prevelance of unusual seller financing concessions or buydowns. There are new homes under construction in surrounding developements,as well as resales available in the neighborhood. Comments on Sales Comparison Comparable#1 Outbuildings Bank barn 54x86 Dairy barn 40x100 Bank barn 40x50 2 Silos Machine Shed 50x80 Livestock 40x84 various smaller outbuildings Comparable#2 Outbuildings Bank barn 75x40 Livestock 24x52 Livestock 24x40 Machine shed 30x112 Machine shed 30x40 Machine shed 25x32 Machine shed 34x80 various smaller outbuildings Comparable#3 Outbuildings Bank barn 50x90 Livestock 30x60 Free stall 66x148 various smaller outbuildings Subject's Outbuildings Pole building 68x70 2 Silos Shed 23x25 various smaller outbuildings Addendum Page 1 of 7 Summary Residential Appraisal Report File No. 13-0138 FEATURE SUBJECT COMPARABLE SALE NO.1 COMPARABLE SALE NO.2 COMPARABLE SALE NO.3 3605 Spring Road 896 Newville Road 425 Mount Rock Road 209 Shippensburg Road Address Carlisle,PA 17013 Shippensburg,PA 17257 Nevvville,PA 17241 Shippensburg,PA 17257 Proodmity,to Subject ?MM 19.03 miles SW 12.48 miles SW 22.90 miles WSW Sale Price $ 750,000 1.010,000 �4'. K�rzu750 000 $Sale PftefGmss Uv.Area $ 0.00 sq.ft. s 216.26 $ 529.35 sa.ft. 461.82 sq ft. Data Sour ) Courthouse Courthouse Courthouse Verification Source(s) VALUE ADJUSTMENTS DESCRIPTION DESCRIPTION -(-)$AC9USIInarI1 DESCRIPTION (-)$ACgUWNr1 DESCRIPTION +(-)$A4U5Werd Sale or Financing Unknown Unknown Unknown Concessions unknown Unknown Unknown Date of Salerrime R- IR- 02f2712012 0711412010 10/0512011 KNM Location Suburban Rural Rural Rural Leasehold/Fee Simple Fee Sim Is Fee Simple Fee Simple I Fee Simple Site 239.29 ac 151.81 Acres 217.89 Acres 153.19 Acres View Open country Open country Open country Open country Desian(y) 2 Story 2 Story 2 Story 1 Story 0 Quality of Construction Average Average Average Average I Y 73 Years 122 Years 10,000 212 Years 20.000 62 Years Condition Average WAveraqe Average Average Above Grade Tow lefts] saft Taw I" ears Raft Brand Wile, • Room Count 7 1 4 1 1.1 9 4 1.1 6T3 F 1.1 !6� 4 1 1 2,500 T Bftsr m;r I Aga�." Gross Livng Area20.00 1,680 sq.ft. 3,468 sq.ft. -35,760 1,908 sq.ft -4,560 1,624 sq.ft. 0 Basement&Finished Full Bsmt Full Bsmt Part Ssmt Full Bsmt • Rooms Below Grade Unfinished Unfinished Unfinished Partial Finish -1,000 Functional Utilitv Spring Fed Average Average Average HWSteam/None FWA/None FWAINone FWAINone Energy Efficient Items Typical Typical Typical Typical Garalle/Camort None 2 Car Garage -10,000 3 Car Garage -15,000 2 Car Garage -10,000 Porch/Patio/Deck WrpPor/Pto Porch 5,000 Parches 2,000 Porch 6,000 Outbuildings* Outbuildinne -20,000 Outbuildinne -20,000 Outbuildings* -20,000 J [X1- I , 50,76o F + xJ- $ 17.560 $ 23500 J Net Adjustment(Toud + X- $) -6.8 Nel Ad;. .1% Adjusted Sale Price %Is 699,240 .1% 1$ 726,500 RRi��C,,- R�4M GmssAgi. 4n st% of Cam ambles P Summary of Sales Comparison Approach The unadjusted price per acre range is$4,940,$4,635 and$4,896 respectively, The adjusted price per acre range Is$4,606.$4,555 and$4,742 respectively-SAY-$4,700. Subject acreage-239.29 ft$4,700 e:$1.124.663 SAY$1,100,000. Site Value comments A review of vacant land sales within the subject's market revealed only one suitable sale within a three year search of agricultural vacant land greater than 150 acres. One sale.of 240.05 acres at$1,080,000 or approximately$4,500 per acre. Subject site.239.29 A$4,500=$1,076805-SAY-$1,000,000. ESTIMATED LIRE RODUCTION.oR LJ REPLACEMENT COST NEW OPINION OF SITE VALUE........................................=$ 11000,000. Source of cost data Dwelling Sq.Ft.@$ ............ $ 0 Quality rating from cost service Effective date of cost data Sq.Ft.@$ ............ $ 0 Comments on Cost Approach(gross living area calculations,depreciation,etc) Cost Approach deemed poor indicator of value. The Garage/carport 0 Sq.Ft @$ ............=$ 0 • Estimated Remaining Economic Life-30 years Total Estimate of Cost-New ........ $ 0 Less Physical Functional 1 External Depreciation =$( 0i Depreciated cost of improvements................................=$ 0 'As-is"Value of Site Improvements................................=$ INDICATED VALUE BY COST APPROACH...................... =$ 0 Nm Estimated Monthly Market Rent s 0.00 X Gross Rent Multiplier 0.00 =$ 0 indicated Value by income Approach • Summary of Income Approach(including support for market rent and GRm) NIA Indicated Valueby: Sales Comparison Approach$1 1 100,000 Cost Approach(itcleveloped)S 0 Income Approach(Itcleveloped)s 0 Market Analysis consistently supports the estimated market value. GRM analysis and Cost Approach were found Inappropriate for this analysis. Supporting file information substantiates this estimate. This appraisal is made W-asis,- Usubject to completion per plans and specifications on the basis of a hypothetical condition that the improvements have been completed, 0 subject to the following repairs or alterations on the basis of a hypothetical condition that the repairs or alterations have been completed 0 subject to the foitavAng: Based on the scope of work,assumptions,limiting conditions and appraisers certification,my(our)opinion of the defined value of the real property that is the subject ofthis report is$ 1,100,000 as of 04/17/2013 which is the effective date of this appraisal. gPlaftMdudngACtoftwUe,BW.2346727x Adtwb.mm This ton Cap0ght 0 2oos2010 AcWon of ISO aere sam-Inc,Am Rights Reserved. Page 2014 (gPAR-)General Purpose AP�MSWRepan osamo PA0UJ00626010Dar- ppraisalreporc S.W.Barrett Real Estate&Appraisal Services Summary Residential Appraisal Report File No. 13-0138 Scope of Work,Assumptions and Limiting Conditions Scope of work is defined in the Uniform Standards of Professional Appraisal Practice as"the type and extent of research and analyses in an assignment"In short,scope afwork Is simply what the appraiser did and did not do during the course of the assignment ttinctudes,butisnot limited to:the extent to which the property Is Identified and inspected,the type and extent of data researched,the type and extent of analyses applied to arrive at opinions or conclusions. The scope of this appraisal and ensuing discussion in this report are specific to the needs of the client,other identified intended users and to the imended.useofthe report This report was prepared for the sale and exclusive use of the client and other identifiiedIntended users for the Identified Intended use and its use by any other parties is prohibited.The appraiser is not responsible for unauthorized use ofthe report The appraiser's certification appearing In this appraisal report is subject to the following conditions and to such other specific conditions as are set forth by the appraiser in the report All extraordinary assumptions and hypothetical conditions are stated in the report and might have affected the assignment results. 1.The appraiser assumes no responsibility for matters of a legal nature affecting the property appraised or tide thereto,nor does the appraiser render any opinion as to the title,which is assumed to be good and marketable.The property is appraised as though under responsible ownership. 2.Any sketch in this report may show approximate dimensions and is included only to assist the reader in visualizing the property.The appraiser has made no survey of the property. 3.The appraiser is not required to give testimony or appear in court because of having made the appraisal with reference to the property in question,unless arrangements have been previously made thereto. 4.Neither all,not any part of the content of this report,copy or other media thereof(including conclusions as to the property value,the identity of the appraiser,professional designations, or the firm with which the appraiser is connected),shag be used for any purposes by anyone but the client and other intended users as identified in this report,nor shall it be conveyed by anyone to the public through advertising,public relations,news,sales,or other media,without the written consent of the appraiser. 5.The appraiser will not disclose the contents of this appraisal report unless required by applicable law or as specified in the uniform Standards of Professional Appraisal Practice. 6.Information,estimates,and opinions furnished to the appraiser,and contained in the report,were obtained from sources considered reliable and believed to be true and correct However,no responsibility for accuracy of such items furnished to the appraiser is assumed by the appraiser. 7.The appraiser assumes that there ate no hidden or unapparent conditions of the property,subsoil,or structures,which would render it more or less valuable.The appraiser assumes no responsibility for such conditions,or for engineering or resting,which might be required to discover such factors.This appraisal is not an environmental assessment of the property and should not be considered as such. P.The appraiser specializes in the valuation of real property and is not a home inspector,building commit: I,structural engineer,or similar expert,unless otherwise noted.The appraiser rid not conduct the intensive type of field observations of the kind intended to seek and discover property defects.The viewing of the property and any improvements is for purposes of developing an opinion of the defined value of the property,given the intended use of this assignment.Statements regarding condition are based on surface observations only.The appraiser calms no special expertise regarding issues including,but not limited to:foundation settlement,basement moisture problems,wood destroying(or other)insects,pest infestation, radon gas,lead based paint,mold or emmonmental issues.Unless otherwise indicated,mechanical systems were not activated or tested. This appraisal report should not be used to disclose the condition of the property as it relates to the presencelabsence of defects.The client is invited and encouraged to employ qualified experts to inspect and address areas of concent.If negative conditions are discovered,the opinion of value may be affected. Unless otherwise noted,the appraiser assumes the components that constitute the subject property improvement(s)are fundamentally sound and in working order. Any viewing of the property by the appraiser was limited to readily observable areas.Unless otherwise noted,attics and crawl space areas were not accessed.The appraiser did not move furniture,floor coverings or other items that may restrict the viewing of the property. 9.Appraisals imohring hypothetical conditions related to completion of new construction,repairs or alteration are based on the assumption that such completion,alteration or repairs will be competently performed. 10.Unless the intended use of this appraisal specifically includes issues of property insurance coverage,this appraisal should not be used for such purposes.Reproduction or Replacement cos figures used in the cos approach are for valuation purposes only,given the intended use of the assignment.The Definition of Value used in this assignment is unlikely to be consistent with the definition of Insurable Value for property insurance coverageluse. 11.The Act General Purpose Appraisal Report(GPAR—)Is not Intended for use In transactions that require a Fannie Mae 100411creddle Mae 70 form, also known as the Uniform Residential Appraisal Report(URAR). Additional Comments Related To Scope Of Work,Assumptions and Limiting Conditions �parTM PWKMU09AOsaft—.�0.234Arnm ft".mm ntif aQ*Y%Tl0atsa03aAaudpaeOh[SOCaftSMtesMADMiloFtWMd. Pape 3 of 4 (pPAR-)Gmed Purpxe Appraisal Report 642010 GPARt 1005262010 genmlpurpn—pwaisai re Summary Residential Appraisal Report File No.13.0138 Appraiser's Certification The appratser(s)certifies that,to the best of the appraisers knowledge and belief: 1.The statements of fact contained in this report are true and correct 2.The reported analyses,apinions,and conclusions are limited only by the reported assumptions and limiting conditions and are the appraisers personal,impartial,and unbiased processional analyses,opinions,and conclusions. 3.Unless otherwise stated,the appraiser has no present or prospective interest in the property that is the subject of this report and has no personal interest with respect to the parties involved. 4.The appraiser has no bias with respect to the property that is the subject of this report or to the parties involved with this assignment 5.The appraisers engagement In this assignment was not contingent upon developing or reporting predetermined results. fi.The appraisers compensation for completing this assignment is not contingent upon the development or reporting of a predetermined value or direction in value that favors the cause of the client the amount of the value opinion,the attainment of a stipulated result,or the occurrence of a subsequent event directly related to the intended use of this appraisal. 7.The appraisers analyses,opinions,and conclusions were developed,and this report has been prepared,in conformity with the Uniform Standards of professional Appraisal Practice. 8.Unless otherwise noted,the appraiser has made a personal inspection of the property that is the subject of this report. 9,Unless noted below,no one provided significant real property appraisal assistance to the appraiser signing this certification.Significant real property appraisal assistance provided by. Additional Certifications: Definition of Value: EMarketVafue oothervafue: Source olpefinition:USPAP The most probable price in terms of money which a property should bring in competitive and open market under all conditions requisite to a fair sale,the buyer and seller,each'acting prudently,knowledgeably and assuming the price is not affected by undue.stimulus. ADDRESS OF THE PROPERTY APPRAISED: 3605 Spring Road Carlisle PA 17013 EFFECTIVE DATE OF THE APPRAISAL:0411712013 APPRAISED VALUE OF THE SUBJECT PROPERTY$1,100.000 APPRAISER SUPERVISORY APPRAISER 1 Signature. � ���f, Signature: <---�' �•- 7- Name: Stan A.Skowronek Name: Steven W.Barrett SRPA SRA ASA State Certification ie RL001572L State Certification# GA000298L or License# of License# or Other(describe): State M State: PA state:PA Expiration Date of Certification or License: 0613012015 Erg7iredon Date of Certification or License: 06/3012015 Date of Signature: 0612512013 Date of signature and Report: 0612512013 Date of Property Viewing: 0512412013 Date of Property Viewing: 05/2412013 Degree of propenyviewing: Degree of property viewing: FA)Interior and Exterior QExterior Only Q Did not personally view XQinterior and Exterior QExtedor Only 00id not personally view �m, P,admd,Nnp ACI�.=23l87n 1`Afw.adh%*= Thb ram CWAM 010852010 AO ONift Of ISO 0WO SeNMft.AS Wph%R574NN P 4014 apoa,APpr4taat Hepar p512n3 GPMi 2005252010 w=nermv�roo�=aowssei�Rwa S.W.Barrett Real Estate&Appraisal Services Summary USPAP ADDENDUM FIeNo. 13-0138 Borrower. F.Clyde BURGETT(Estate) Property Address:3605,Spring Road City: Carlisle County: Cumberland State: PA Zip Code: 17013 Lender. Irwin&McKnight Reasonable Exposure Time My opinion of a reasonable exposure time for the subject property at the market value stated in this report is:80-180 days Additional Certifications I have.perforrned NO services,as an appraiser or in any other capacity,regarding the property that is the subject of this report within the three-year period immediately preceding acceptance of this assignment 01 HAVE performed services,as an appraiser or in another capacity,regarding the property that is the subject of this report within the three-year period immediately preceding acceptance of this assignment.Those services are described in the comments below. Additional Comments APPRAISER: SUPERVISORY APPRAISER(only if required): Signature: = �rs'�2� Signature: � � i _ Name: Stan A.Skowronek Name: Steven W.Barrett SRPA SRA,ASA Date Signed: 06/2512013 Date Signed: 06/25/2013 State Certification#: RL001572L State Certification#: GA000298L or State License M or State License#: or Other(describe): State M State: PA State: PA Expiration Date of Certification or License: 06130/2015 Expiration Date of Certification or license: 06/30/2015 Supervisory Appraiser inspection of Subject Property: Effective Date of Appraisal:04117/2013 (J Did Not 0 Exterior-only from street ❑interior and Exterior ftd du VAd 9I,—Aoo MA222 wwwAtlrd— USPAP IW OS112012 v A Court Ordered Processing\Decedents- NUI-MB3-02-10 - P.0.Box 841005 - Boston,MA 02284 e 0 5 May 24, 2013 RE CEIVED '2 9 � Law Offices MAY 31 2013 z Irwin & McKnight, P.C. IRWIIN&MCKNIGH3 60 W. Pomfret St. LAW© � � Carlisle, PA 17013-3222 K RE: Estate of Clyde Burgett Date of Death: April 17, 2013 y 6 Z Dear Mr. Miller: Per your request, enclosed please find the account information as of the date of death for the above-named decedent. For your information, accrued interest is not included in the date of death balance. B Please feel free to contact me if I can be of any further assistance. 5 Very truly yours, n 9 Linda Spavento Z Team Leader 617-514-5189 N �V 0 yb Y g5 S m E B v 5 U_ F d z Cs Sovereign Bank ESTATE OF F Clyde Burgett SOCIAL SECURITY#: 204-30-6237 DATE OF DEATH: April 17,2013 Account M 1661337074 Type: Checking Open date: 3/8/2012 In the name of: F Clyde Burgett Date of Death Balance: $6,016.13 Int.(YTD)from 1/1/2013 to 4/5/2013 $0.20 Accrued interest to date of death: $0.00 Other Info: Account M 7673013983 Type: Money Market Open date: 3/8/2012 In the name of: F Clyde Burgett Date of Death Balance: ' '$6,280.12 Int.(YTD) from 1/1/2013 to 4/5/2013 $3.12 Accrued interest to date of death: $0.00 Other Info: M&TBank 499 Mitchell Road,Millsboro,DE 19966 Adjustment Services Phone 888-502-4349 F ax (302)934-2955 May 14,2013 Law Offices . Irwin &McKnight,P.C. West Pomfret Professional Building MUIVED 60 West Pomfret Street Carlisle,PA 17013-3222 MAY 1.7 2013 1RMN&M 01 LAW OFF MS Re: Estate of F. Clydegett Social Security:204-30-6237 Date of Death:April 17,2013 Dear Sir or Madam: Per your inquiry on May 07,2013,please be advised that at the time of death,the above-named decedent had on deposit with this bank the following: 1. Type of Account Checking Account Account Number 405957 Ownership(Names of) AnneUd A,Burgett F Clyde Burgett Carolyn M.Frischkorn(POA) Opening Date 0910111967 Balance on Date of Death $21,647.03 Accrued Interest $ .01 -------------- Total $21,647.04 2. Type of Account Checking Account Account Number 9858887830 Ownership(Names qt) F.Clyde Burgett Opening Date 0912112012 Balance on Date of Death $19,823.11 Accrued Interest $ .13 Total $19,823.24 ORRSTOWN BANK A Tradition of Excellence 77 East King Street P.O. Box 250 Shippensburg, PA 17257 May 8, 2013 Re: Estate of F. Clyde Burgett Irwin&McKnight, P.C. Enclosed is the information requested for F. Clyde Burgett's accounts at Orrstown Bank. Please contact Vanessa Albright with any further requests or questions regarding this matter by the information listed below..Thank you Sincerely, Vanessa L Albright Customer Service Representative Orrstown Bank 717-240-0801 valbrijzht@orrstown.com ..... . . . . . .. 5/08/13 Time Deposit Inquiry 14:45:33 F Clyde Burgett Account number: 4000045383 Has messages 1 of 1 Original balance:. p 19, 809.16 YTD interest: 42 . 68 Current balance: 19, 809. 16 Next pmt date: 5/17/13 1=View 6=Viint T=Tset Control: From To Opt Posted InputSrc Rate T/C AFF Amount Balance 12/17/12 G .650000 651 .00 12/18/12 M 020 C B 19, 809 -16 19, 809.16 1/17/13 G 670 D 1 10.94 19, 809.16 1/17/13 G 673 D Y 10 .94 19, 809. 16 2/15/13 G 670 D 1 10.93 19, 809-16 2/15/13 G 673 . D Y 10 .93 19, 809 .16 3/15/13 G 670 D 1 9.88 19, 809 . 16 3/15/13 G 673 b Y 9.88 19, 809. 16 4/17/13 G 670 D 1 10.93 19, 809. 16 4/17/13 G 673 D Y 10.93 19, 809. 16 Bottom F4=Redisplay F7=Scan forward F8=Scan backward F16=Sort F17=Top F18=Bottom, F20=Fold/Unfold F22=Tran Codes I WESTERN—SOUTHERN LIFE ASSURANCE COMPANY CINCINNATI OHIO STATEMENT OF DEATH CLAIM SETTLEMENT INFORCE ; DEPT ANNETTA A BURGETT 6-21-2013 MAIL TO '980 5144 F CLYDE BURGETT PAYEE u W0020736776G CHECK #OC 01348955 HAS •SEEN ISSUED FOR $7,139.60 THE CLAIM ON THE ANNUITY LISTED ABOVE HAS BEEN APPROVED AND A CHECK FORD YOUR SETTLEMENT AMOUNT IS ATTACHED BELOW. ' WESTERN—SOUTHERN LIFE WILL o NOTIFY THE IRS THAT THE TAXABLE AMOUNT OF THIS PAYMENT IS $2,139.60 FOR THE 2013 TAX YEAR. IF YOU HAVE ANY QUESTIONS, CALL A WESTERN—SOUTHERN LIFE REPRESENTATIVE AT (800) 926-1702. AMOUNT -OF CONTRACT $7,139.60 a= r TOTAL PAYABLE THIS CONTRACT —',$7,139.60 all ' iL ��►P11t���c{�i��0�� AMOUNT OF THIS CHECK {1��OFFICE $7,139.60 Detach the check below. •17F900HN• 470 WESTERN-SOUTHERN LIFE ASSURANCE COMPANY „C CINCINNATI OHIO by STATEMENT OF DEATH CLAIM SETTLEMENT INFORCE DEPT 6-20-2013 MAIL TO 980 5161 BURGETT .F-_CLYDE PAYEE W0020603584 CHECK #OC 01347787 HAS BEEN ISSUED FOR $10,090.72 THE CLAIM ON THE ANNUITY LISTED ABOVE HAS. BEEN APPROVED AND A CHECK FOR YOUR SETTLEMENT AMOUNT IS ATTACHED BELOW. WESTERN-SOUTHERN LIFE WILL C NOTIFY,,THE IRS THAT THE TAXABLE AMOUNT OF THIS PAYMENT IS $90.72 FOR THE 2013 -.TAX YEAR. IF YOU HAVE ANY QUESTIONS, CALL A WESTERN-SOUTHERN LIFE REPRESENTATIVE AT (800) 926-1702. AMOUNT OF CONTRACT $10,040.32 p, t 2 4 2913 TOTAL PAYABLE THIS CONTRACT IRWIN& $10 40.32' LAW OFFICES INTEREST $50.40 AMOUNT OF THIS CHECK $10,090.72 I Detach the check below. •17BDDDDL• 376 219 North Hanover Street Cadisle,Pennsylvania 17013 717.243.4511 toll free 1.866.451.4511 fax 717.243.3723 www.hoffmanroth.com FUNERAL HOME & CREMATORY, INC. info@hoffmanroth.com May 24, 2013 Carolyn Frischkorn 15 Wild Rose Lane Mechanicsburg, PA 17050 Statement of Funeral Expenses for: Frank Clyde Burgett Date of Death:April 17, 2013 Account Id: 16856-097 PACKAGE: Traditional Funeral Service TRADITIONAL FUNERAL SERVICE PACKAGE $ 4,850.00 Sub Total: $ 4,850.00 TOTAL FUNERAL HOME CHARGES: $ 4,850.00 CASH ADVANCES: 25 Certified Death Certificates at$6.00 each $ 150.00 Newspaper Notice-Sentinel $ 165.60 Add'I Flowers $ 6.50 Flowers $ 159.00 Additional DC's $ 30.00 Sub Total: $ 511.10 Total Funeral Expense: $ 5,361.10 Total Payments Made: $ 5,331.10 Payments Made: Estate Of/from Irwin & McKnight Check 33818 May 15,2013 5,331.10 Balance: $ 30.00 SERVING OUR COMMUNITY SINCE 1907 • OWNER/PRESibENT 'WI'LLI'AM E. HOHMAN, VICE PR-ESIJDENT - ROBERT A.-FILBURN'111-, SUPER V ISO'R-� S.W. BARRETT REAL ESTATE AND APPRAISAL SERVICES File W.13.0138 **INVOICE File Number:13-0138 06/25/2013 Irwin&McKnight,Doug Miller Esquire 60 West Pomfret Street Carlisle,PA 17013 Invoice#: 13.0138 Order Date: 05/10/2013 Reference/Case#: PO Number: 3605 Spring Road Carlisle,PA 17013 Appraisal Services $ 750.00 .............. Invoice Total $ 750.00 State Sales Tax @ $ 0.00 Deposit ($ } Deposit ($ } -------------- Amount Due $ 750.00 Terms: Payable Upon Receipt-Please,reference the file number Please Make Check Payable To: S.W.Barrett Real Estate&Appraisal Services 505 South Hanover Street Carlisle,PA 17013 Fed.I.D.#:236646.604 YOUR SINGLE SOURCE...Professional,Efficient Service THANK YOU PAYABLE TO: BILL#: 6357 CUMBERLAND VALLEY SCHOOLNOTICE RETURN THIS PORTION WITH A PAYMENT FOR FIRST INSTALLMENT/FULL PAYMENT BILL#: 6357 Frank Roberto,-Tax Collector BURGETT,F CLYDE 270 North Old Stonehouse Road BILL DATE: Property Location OFFICE HOURS Carlisle,PA 17015 er 7/1/2013 21-04-0373-004 M ,4 Tuesday, p Tuesday,4 pm-7 pm 3605 SPRING ROAD Thursday,10 am-1 pm LAND APPROX 239 ACRES November-February:By appointment only Additional Hours April 17 8.24:10 am-12:00 pm August 21&28:10 am-12:00 pm 3'81*1*'**"'5-DIGIT 17013 Phone:717-960-0716 BURGETT,F CLYDE 3605 SPRING RD Please Indicate: CARLISLE,PA 17013-8737 13 FULL PAYMENT O FIRST INSTALLMENT(NO DISCOUNT) .�I�InlIll.t..ul.li.nil'n .��I,�,Illllllll...11llnlllll 2%DISCOUNT FACE 10%PENALTY To 8/31/2013 9/1/13-10/31/13 11/1/13-12/17/13 } d. $1,756.48 $1,792.33 $1,971.56 HF ` 0 201 �@t��in�G':L'afai i�Oz�?44 � OR If paid on or before 8/31/13 $597.44 PAYABLE TO: BILL#: 6357 ' " ' in W41 iliallull ' RETURN THIS PORTION WITH A PAYMENT FOR SECOND INSTALLMENT BILL#: 6357 Frank Roberto,Tax Collector BURGETT,F CLYDE 270 North Old Stonehouse Road OFFICE HOURS Carlisle, PA 17015 BILL DATE: Property Location March October 21-04-0373-004 Tuesday,4 pm-7 pm 7!1/2013 Thursday,10 am-1 pm 3605 SPRING ROAD November.-February:By appointment only LAND APPROX 239 ACRES Additional Hours April 17&24:10 am-12:00 pm August 21&28:10 am-12:00 pm Phone:717-960-0716 BURGETT;=F CLYDE- 3605 SP.1#ING R_ D Please Indicate: CARLISLE; PA 17013-8737 13 SECOND INSTALLMENT O SECOND INSTALLMENT WITH PENALTY 7paid NO DISCOUNT before 9/30/13 $597.44 HF fter 9/30/13 $657.18 TAX • •- •• •• PAYABLE TO: BILL#: 6357 CUMBERLAND VALLEY SCHOOLDISTRICT 2013/2014 REAL ESTATE TAX NOTICE RETURN THIS PORTION WITH A PAYMENT FOR FINAL INSTALLMENT BILL#: 6357 BURGETT,F CLYDE Frank Roberto,Tax Collector OFFICE HOURS 270 North Old Stonehouse Road Property Location March-October Carlisle,PA 17015 BILL DATE: 21-04-0373-004 Tuesday,4 pm-7 Thursday,10 am-1 1 p pm 7/1/2013 3605 SPRING ROAD November-February:By appointment only LAND APPROX 239 ACRES Additional Hours April 17&24:10 am-12:00 pm August 21&28:10 am-12:00 pm r- 5� ,• ; Phone:717-960-0716 Please Indicate: BURGETT, F CLYDE r i 13 FINAL INSTALLMENT O FINAL INSTALLMENT WITH PENALTY 3605 SPRING RD JUL j � 2Ll,�t CARLISLE, PA 17013-8737 iKWiN&MCKNIGN`i' 1111111MIN02111 NO DISCOUNT LAW OFF ICES 7fpaid or before 10/31/13 $597.45 HFd after 10/31!13 $657.20 TAX • •' •- •' FRANK ROBERTO,TAX COLLECTOR TAXPAYERS COPY 270 N OLD STONEHOUSE ROAD CARLISLE,PA 17016 KEEP THIS PORTION FOR YOUR RECORDS TEMP-RETURN SERVICE REQUESTED r MAR 13 OFFICIAL COUNTY MUNICIPAL TAX BILL— ' �6"55'BY5@ 6���i5\iYill�U rtI(I���Il�ll1l1lllh111111011111ll1"'Jill III 111111111111111gI11 LAW OFFICES 030437""""'*`**'*"*AUTO"6-DIGIT 17013 8 411&PRI�lG RD DE CARLISLE PA 17013.8736 To review the assessment data for thispproperrttyy, go to: www.courthouseontine.com>AssessmentOffice>Cumberiand>PropertyRecords. Then enter control# 21000247 and password CUIYDBRU ....................................................................................................................................................................................................................................._.............................. ..._..............-............- 1,211 F Eflu'l 11912-3121 ON IN •- 1111kyll".1;1 1.1 • + 11t Payable To: FRANK ROBERTO,TAX COLLECTOR Office Hours: MAR-OCT TUES 4-7;THURS 10-1 270 N OLD STONEHOUSE ROAD NOV-FEB BY APPOINTMENT ONLY CARLISLE,PA 17016 EXTRA HRS APRIL 23&30 AND AUGUST 20&27 Bili No: 328 PHONE(717)960-0716 Bill Date: 3/1/14 Control No: 21000247 : MAP NO21-04-0373-004: MAP O: 2 SPRING ROAD Assessed Value: Preferred Land:99,100 Improvement:127,600 Total:226,700 LAND APPROX 239 ACRES Discount Face ena Acres 239.29 Deed 201237126 County RE 2.196 $487.66 $497,61 $647.37 County Lib 0.143 $31.77 $32.42 $36.66 Munic.RIE 1.38 $306.59 $312.86 $344.14 $11.00"FEE ADDITIONAL RECEIPTS Tax Payer: ,r^ BURGETT,F CLYDE 3541 SPRING RD TAX AMOUNT DUE /'5826.02 $W-88 $82.7. 7 CARLISLE PA 17013-8736 If Date Of Payment is on 3 t r 3 6/1!14 thr !30114 a e f ` a s' I ..........................................................................................................................................._..................................................................................................................................................................... PAYABLE TO: BILL#:6324 CUMBERLAND VALLEY SCHOOLDISTRESTATE TAX ICT 2014/2015NOTICE RETURN THIS PORTION WITH A PAYMENT FOR SECOND INSTALLMENT BILL#:6324 Frank Roberto,Tax Collector BURGETT,F CLYDE -OFFICE HOURS 270 North Old Stonehouse Road f` '``:='` :; ' •= Carlisle,PA 17015 BILL DATE: Property Location Ma-tch-October. 1 Tdaday,4 pm-7 pm 7/1/2014 21-04-0373-004 ..;fHl1'tsday,10 am-1 pm 3605 SPRING ROADi" r addbonal Hoge: Al�gust 20 8 27,10 am-12:00 pm LAND APPROX 239 ACRES s `"Vii, November-February: appointment only BURGETT,F CLYDE ` Closed Holidays 3541 SPRING RD 6ne:717-960-0716 CARLISLE,PA 17013-8736 '`;}; Please Indicate: r%•' •- :r. 13 SECOND INSTALLMENT 13 SECOND INSTALLMENT WITH PENALTY 7onor NO DISCOUNT If pafore 9/30/14 $672.39 9/30/14 $739.63 TAX COLLECTOR'S COPY TAX PAYERS COPY PAYABLE TO: BILL#:6324 CUMBERLAND VALLEY SCHOOLDISTRICT 2014/2015NOTICE RETURN THIS PORTION WITH A PAYMENT FOR FINAL INSTALLMENT BILL#:6324 BURGETT,F CLYDE Frank Roberto,Tax Collectors 'k' k` OFIF CE HOURS 270 North Old Stonehouse Road Property Location 'e Carlisle,PA 17015 p tarok-October: l' ti sday,4 pm-7 pm BILL DATE: 21-04-0373-004 '`?Thursday,10am-1 pm 7/1/2014 itional Hours: 3605 SPRING ROAD `"""'Add u-'.r: �"+ zsT^Y�lugust 20&27,10 am-12:00 pm LAND APPROX 239 ACRES �•, tovember-February: l8appointment only BURGETT,F CLYDE 'CLosad Holidays 3541 SPRING RD "} ^fir• t>_;`t:'u`` CARLISLE,PA 17013-8736 Please Indicate: tu;yiA't�" �� �.�fy:Phone:717-960-0716 O FINAL INSTALLMENT FINi4L INSTALLMENT WITH PENALTY FINAL INSTALLMENT NO DISCOUNT If paid on or before 10/31/14 $672.39 If paid after 10/31/14 $739.63 PAYABLE TO: BILL#:6324 CUMBERLAND VALLEY SCHOOLNOTICE Frank Roberto,Tax Collector Hours:See Reverse MUNICIPALITY:Middlesex Twp. BILL NO:6324 270 North Old Stonehouse Road Phone:717-960-0716 PROPERTY:3605 SPRING ROAD BILL DATE:7/1/2014 Carlisle,PA 17015 MAP CODE:21-04-0373-004 BURGETT,F CLYDE LAND - IMPROVEMIENT TOTAL ASSESSMENT $99,100 $127,600 $226,700 ME O H . ••„,,. $TEAD,EXCLUSION ,. _. , FARMSTEAD EXCLUSION R/E TAX RATE 8.898 8.898 FULL SCHOOL RIE TAX $881.79 $1,135.38 $2,017.17 THIS TAX IS DUE AND PAYABLE.YOU ARE HEREBY REQUESTED I HOMESTEAD cliEolT, $0 00 ' TO MAKE PAYMENT THEREOF. LESS,FARMSTEAf)cREoIT g0:o0: DISC LINT FACE PENALTY BURGETT,F CLYDE �� 10% 3541 SPRING RD ,ll> TAX AMOUNT DUE $1,976.83 $2,0 $2,?2 89 CARLISLE,PA 17013-8736 v'J1. 1 If Paid On or Before 8/31/14 /31/14 5/14 NO CHECKS ACCEPTED\ALETEWAECEIJ 15; 2014 I III iiiiiiiiiii Jill J11111111e e� a •- I'll11 Jil Jil pill lills • lJilli O $67oe312.39 $6_7,34. nor be4 On or before 9/30/14 On or 1efore 10/31/14 INVOICE ® Insurance Croup IMPO ANT: This is your invoice from Everett Cash Mutual Insurance Co. For online payments and more,visit our website at www.evereftcash.com IOLICYHOLDER AGENT t Clyde&Annetta A. Burgett J. Rodney Fickel Insurance Agency Inc. .605 Spring Road 151 W. High Street :arlisle, PA 17013 P.O. Box#1 1 Carlisle; PA 17013 PHONE#: (717)249-2812 4 POLICY NUMBER: FO 808975 TOTAL PREMIUM:$1,101.00 PAYMENT OPTIONS 1 Annual Payment: $9,101.00 Mail By: 05/17/2014 a Semi-Annual*: 05117/2014 $555.50 *Includes$5 Service Charge 11/16/2014 $555.50 f 2 Quarterly*: 06/17/2014 $280.25 * Includes$5 Service Charge 08/17/2014 $280.25 11/16/2014 $280.25 02/14/2015 $280.25 i 3 Automatic Withdrawal from Bank Account-(Monthly Withdrawal):: Send Payment of: $275.25 By: 05/17/2014... _... _. :. ::.._. .. .Beginning on:08/01/2014 and on the. .1`st of every month(or 1st business day following:weekentl or holiday), $92.25 will be deducted from your account. Subject to changes to your policy. **Includes' $0.50 Service Charge PLEASE PAY BY POLICY INCEPTION TO AVOID CANCELLATION AND/OR LATE CHARGE.PLEASE NOTE:THIS IS THE ONLY NOTICE ISSUED. IMPORTANT:Please examine the policy listed above and notify immediately if any changes or corrections are necessary.If the policy is not wanted it must be returned promptly for cancellation;otherwise an earned premium will be charged by the company for the time it was inforce.Premium must be received —by Policy inception date. PREMIUM TOTAL $1,101 FO-3(1,0); F020(1.0); F0368(1.1); F0778(11.99); ML120(4.81); F04901(0402); FO358(0604); GL0810(0305); F00380(0800); F00675(1006); F02630(0604); GL2(2.0); F0706A(6.99); GL614A(1.1.99)1,. GL10(2.0); GL890(2.0); ML-452(2.0); F0320F(11.99); F0303(11.99); FO6(1.0) Issued Date INCI IRI=n COPY FI -AUT INVOICE mom® Insurance Group YORTANT: This is your invoice from Everett Cash Mutual Insurance Co. For online payments and more,visit our website at www.everettcash.com POLICYHOLDER AGENT F Clyde Burgett J. Rodney Fickel Insurance Agency Inc. Annetta A Burgett 151 W. High Street 3605 Spring Road P.O. Box#1 Carlisle„ PA 17013 Carlisle, PA 17013 PHONE#: (717)249-2812 POLICY NUMBER: UMB102594 TOTAL PREMIUM:$165.00 -PAYMENT OPTIONS 11 Annual Payment: $165.00 Mail By: 05/17/2014 16 Semi-Annual*: 05/1712014 $87:50 * Includes$5 Service Charge 11/16/2014 $87.50 12 Quarterly*: 05/17/2014 $46.25 * Includes$5 Service Charge 08/17/2014 $46.25 11/16/2014 $46.25 02/14/2015 $46.25 : --: : ._' .- 13 Automatic Withdrawal from Bank Account-(Monthly Withdtawel); -- - Send Payment of: $41.25 By: 05/17/2014 Beginning on 08/01./2014 and on the .1 st of every month'(or 1.st business'day following-weekend or holiday)F $14.25 will be deducted from your account.,.!Subject to changesto yourpolicy. *"Includes":$0.50-Service Charge PLEASE PAY BY POLICY INCEPTION TO AVOID CANCELLATION&AND/OR LATE-CHARGE.PLEASE NOTE:THIS IS THE ONLY NOTICE ISSUED. IMPORTANT:Please examine the policy listed above and notify immediately if any changes or corrections are necessary.If the policy is not wanted it must be returned promptly for cancellation;otherwise an earned premium will be charged by the company for the time it was inforce.Premium must be received / ,,ty Policy inception date. -- Issued Date 04/15/2014 INSURED COPY FI-AUT x�rl jsOD 4onpO t sjua. uo q . jad aalj aaqWnN auarabaS salS cr.. O ` --—- 6061:109 ,sip 383H.NJIS ' J 273NIO1SiL) 'A UO esn Idwaxa to pew-uoN euasoiaH"ltiimS Mol- 41l1 PawQ'cai 1 mmora myP s u4d-st•£'Plnbn ejGAsngwaa" O dluo esn;dwaxe xel as pew-uory ani IaSalO, S n�ol aAt(1 AaRa£66t VN. aSTti P?gr 1w wdd-91'£'Pw elgpsri�gwaa � jos ie arw jen3 lasolg Ains.4 of$►tlff 'am mins wdd-Si Vmnbn mgsmwoo 031NISd MUMMY aNV 0310M)A1010))V N330-SVN:.3)14AHi'SINl: " 1inj WN Q " llM4:JQ ... 3jNViYV"dlo F: :7Z.,3, 3J321.. 30WH5 Q 'fl(7'� ,Q A2i3AS13"SIHl Q "Hsvj Q ')ID3H3" `13tirVAWi1: ., f* 'A11vnNNY l NO 's7YQ OE 2l3AO siNrto:)av 11b" .. . Ol c73aav H1NOW a %q/i l 30 1S3�31NJ •SAWI. gl" laN. iRlal' aoig SUNG 31W 9895-91L"40 ICZSV911A1 C>Hd 17:44 L dd. 3i-1104. 9 L l X08 '0 'd'` ADVANCED SEPTIC SERVICES, INC 2 65Rkhord lane Landisburg,PA 17040 (717)789.4548 (800)250-3980 -PLEASE PAY FROM THIS INVOICE- r0�!! 2013 Cly�2 awfe--t" Ce,.- 141e PA /7013 $20 Late Fee Per Month on all Accounts over 30 Days+1.59/o Service Charge•$25 Check Return Fee Cleaning Septic Tank 1250 rAi z v Cleaning Holding Tank Trip Charge Baffle Labor ✓�►!� t Excavator " 9 Z Lenzyme '_. High Pressure letting Root/Cable Cutter Service Video Camera Service Electronic Tank/Line Locating Portable Toilet Service Septic Chemical Material: r�tscoL„t -' 10 Tax Total 2 to Customer's Signature MIDDLESEX TOWNSHIP ON-LOT SEPTA GE PUMPING PERMIT CE: $5.00 METHOD OF PAYMENT. CASH CHECK El CHECK# PERMIT NUMBER: 1 DATE ISSUED:A..- / L /3 PROPERTY OWNER'S NAME: D.pnnis ADDRESS. I SOVinC, Pd & VIisb , 61 1 CITY STATE ZIP CODE PROPERTY OWNER'S PHONE NUMBER: ADDRESS OF TANK LOCATION. S111111 CITY STATE ZIP CODE PARCEL NUMBER: PUMPING AREA: 44 An B C D TOWNSHIP LICENSED SEPTA GE PUMPER/HAULER TO BE USED: NAME. L LICENSE NO. DATE TANK MUST BE PUMPED BY: SIGNATURE OF OWNER: DATE: ISSUED BY. ua1 DATE. AUTHORIZED REPRESENTATIVE MIDDLESEX TOWNSHIP MUNICIPAL AUTHORITY 350 N.MIDDLESEX ROAD,SUITE 2, CARLISLE,PA 17013 PHONE:243-0674 FAX. 258-0793 TOLL FREE: 1-888-417-0674 WHITE-AUTHORITY PINK-PROPERTY OWNER KOVGN-'S OIL SERV P. O. BOX 1 16 NEWVILLE, PA 17241, PHONEa 77641543 or 776-5685 A1$9523 --- .DATE f. SOLD TO c4I X47 TERMS NET,15 DAYS: INTEREST OFI4% PER.MONTH ADDED TO ALL ACCOUNTS OVER 30 DAYS';.OR 15% ANNUALLY: PAYMENT O 'CHECK ❑.CASH ❑ THIS DEUVERY L) L)❑:CHARGE ,RECEIVED.`. <' ❑ A/C OLD BALANCE ❑ FULL ❑ NOT fULL i':.' THIS INVOICE HAS.BEE.N ACCURATELY COMPUTED AND AUTOMATICALLY PRINTED' p NA 1993 Clear Uftra low Sulfur Diesel Fuel Combustible Liquid,3.15•ppm sulfur ULSD. MV2 B2-Soy 199113 Ulna IOw:SUlfur Diesel Fuel Combusdble Wquld,3.15-ppm sulfur dyed ULSD. Non-road or tpx exempt use only. 0 ON 1223 Dped Ultra-low Sulfar.Kerosene Combustible Liquid,3.15-ppm sulfuf dyed ULSK. Non-road or tax exempt use only. REMARKS' CUSTOMER sIGN HERE - ^ G ? cr e� Gals. :Readln:g Star# _� v ? a{, Gals Reading-Finish ;� , ;,, ,� v ' Sales:Sequence N....mber n �� ,� 4 ,, Ar Price per Gallon:Cents 0F, j 6 ;� Product Cost . .`75 n „ 0 G 00 r Tax INVOICE i i QUANTITY DESCRIPTION AMOUNT 2113-104223 45.5 gallons FUEL OIL @$4.29901GALLON $195.60 C7 TRANSPORTATION 1.75 !A INVOICE SUBTOTAL $197.35 PLEASE PAY THIS AMOUNT $197.35 @� W Dyed Unmarked Heating Oil: Not for m use in highway or non-road %GZ 11locomotive or marine engines 05 td— N W SUBURBAN PROPANE 2115 PO#H068 Name:F C BUROETT "if Safety P&T is noted above see ix d' (� ACCT.#•2113-000239922-001 Driver ID Fees'an reverse for a description of this t9 m `tL� ITank Serial#: 214 Safety&Training Practices Fee W S Q� mm For inquiries,please call 800-776-7263 RECEIVED BY: F E- fk S or your local office 717-264-7184 > Q E F F } d {�} V Q Customer:Please see reverse item#1528421 OPR 5208 1108 CL .. VV O side for safety Information d F WRZC�1 G