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Home My WebLink About02-0741PEE/TIlTION FOR PROBATE and GRANT OF LETTERS Estate of fJ ~, k~ £ v~ ~ ~ ~~ ~' t ~'`' No. OBI "'~~~1 also known as To: Register of Wnills fo the Deceased. County of L "rte ~ ~ c ~ .L,~ nl N in the Social Security No. > 7 O ~ ~ 3 ~ Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age in the last will of the above decedent, dated l~ and codicil(s) dated (state relevant circumstances, e.g. renuncia/tion, death of executor, etc.) Decendent was domiciled at death in ~--.tc' ~ ~~ £ e l ~ ir,' F ~ County, Pennsylvania, with ~~~ -S last family or principal residence at ~3 ~ `' ~ `~' ~y3 l~ ~ ~ t` o ,v ~ 1~ ~ ~ ..Z as Z Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property $ (if not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ situated as fo1>,ows: , ~ s T v ^^- r S` :~ L. ~~~ a ~~/G o0 0 WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters theron. (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) v --~ ~ ,-, ~ ~ i (a l~! f ~~ a t M F_ S 'N a C ~ , o (j _Q t~ U '~ S' ~ ~C G ~ •~, v° °AVh'~ i ~~~ ~ lwii ~~ m OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA 1 COUNTY OF Cumberland ~ 5s The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed r~ b re~u e is 16th day2002 ~ - o 1~ ~ i ~ > lal ,rte Donna M. Otro actuag Reg.i^ er of Wills an jhe execut ~l X - - - named -- 19---- ~-' (list street, number and muncipality) No. 2l -~ca2-7 y/ Estate of ~~ he~.-~ C'~ K~EI tM ,Deceased DECREE OF PROBATE AND GRANT OF LETTERS ~~ AND NOW ~, .~~' , in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated described therein be admitted to probate and filed of record as the last will of and Letters - ~ are hereby granted to (7.) .pNE ~. ~/mES' FEES Probate, Letters, Etc. ......... ~~~.~4~J Sh~rt C tificates } .......... ~ o'?/. Dd • Q. d O R~tu cia on ................ ~ (7~`-r° ~ ~~yd TOTAL ~~~ Filed ....t~~a, ... ~?caa/...... . ~-Lc~ ~,~ c ATTORNEY (Sup. Ct. LD. No.) .4DDRESS PHONE STATE OF ALASKA- - ~~~~,y 0'746 OT111 v$-,Ol REV. 1-92 ORIGINAL ^ STATE COPY I CERTIFY THAT THIS IS A TRUE, FULL AND CORRECT COPY OF THE ORI AL CERTIFICATE ON FILE IN ~,I THE BUREAU OF VITAL STATISTICS, DEPARTMENT OF HEALTH AND SOCIAL C S, JU E~ A KA. /9 A~If7 1 ~ ~tJU~ DATE ISSUED STATE f3EGISTRAR TvPEIVRINT BIRTH CERTIFICATE NUMBED ~- CERTIFICATE CAF DEATH 15U o2ooi5s~ `~~~""~ rN _`- STATE FILE NUMBER PERMANENT -- RecoRDER~s No. K /~~-hJnh ~crn r nl ~r~ r yr r r~r.~r r r rrr..+ vvv,r i. ..". .,.... BUREAU OF VITAL STATISTICS-P.O. BOX 110675 Dnr=_ REC~Iy~p, { ~ 20U2 I BLACK IN JUNEAU, ALASKA 99817-0675 ~H1UUv L i t. DECEDENT'S NAME iFirsl Mldll4, Last) 1x MAIDEN NAME 2.5E% 3. DATE OF HEATH IMOnIA, Dey Wad ~ Male July 27, 2002 I Hubert 0 Keim A. SOCIAL SECURITY NUMRER Sa. AGE-last Birlhdry 5b. UNCER 1 YEAR Sc, VNDER 1 pAY 6 DATE OF BIRTH 1. BIRTHPLACE nC nf St F rei l t ' 179-09-9238 (ran) 85 Months Drys Houm Mirvl eb ry e or p (MOn11r, Dey, Wed ( a O camber 5 ,1916 Pennsylvania B. STATE OF DEATH 9a PU Cf OF DEATH (Check only orre; sea i nstvcflpns on Other a/de) OTHER ^ ' ALASKA HOSPITAL ^ ^ ^ ^ Omar (Specl(y) flesldence Nunlnq Moma DOA ®Inpatiant ERlOutpetNnt 96. FAGLITV NAME pf not instituNOn, Rive stmef end numbs 1 9c. CITY, TOWN, OR LOCATION OF DEATH I Providence Medical Center Anchorage 10. MARITAL STATUS 11. SURVIVING SPOUSE (1/wlb, plus mNden name) ~R ^ MARRIED L`7 WIDOWED ^ DIVORCED ^ UNKNOWN V IE R ^ NE E MARR D O 12a. DECEDENT'S USUAL OCCUPATION (Give kind 01 work done dudnp most of 12b. KIND OF BVSINE55IINDVSTAY 1J. WAS DECEDENT EVER IN 11.5. ARMED FORCES? m wrklnp tile. Dc noI use rtfired.) {~~y'F ^ ^ gw Salesman Pneumatic TOOLS UNKNOWN 113 YE5 NO w+ aa- RESIDENCE-STATE 1db. CITY, TDVJN OR LACATION Idc. STgEET AND NUMBER ~~ m~ =o Penns lvania Mechanicsbur 5319 Cobblestone Drive y ~ 1dd. INSIDE CITY LIMITS OR tde. ZIP CODE /5. WA5 DE OF HISPANIC ORIGtNt 18. RACE-Flliplno, Black, 17. DECEDENT'S EDUCATION SETTLED COMMUNli Y7 /Specily.lko pr Wa-II We, apeclly CuOa^. Nethq Wnile, etc ' (Speclry Onlyhlpheaf prods compleretn Meg/carr, F verto Riesn. ercJ : ElementarylSecondery (pd21 GoJlppe (1a or5~1 '1- ~~'']] 17055 {{~~~~ Whit:e L ~~ LjsYES ^ NO ^ UNKNOWN 11.J NO ^ YES Spselly ~.,..... ~ 18. FATHER'S NAME (Flnl, Middie. LesU 19. MOTHER'S NAME (Fist, i 'aRaidnn Surname) Hubert I. Keim Mar Elizabeth Donnelly 20e. INFORMANT'S NAME (Type/Pond Mb MAI['/NO ADDRESS(Streef and NUmberor RURt ROUIe Number, Cfly or TOWrt, Stefe, Zip :ode) 20c. RELATIONSHIP TO DECEDENT 17011 Diane Grimes 407 S`~in house Road Camphill Penns l ania Dau hter 21a METHOD OF DISPOSITION <Zag C OF DISP05RION /Name p cemetery, cremsfOry Or other place) 21c: CATION-City rn ~ n, State a •• ^Bpdal ®D,emabPn ^Rempya~homs~ate Evergreen Crematory Anchorage, Alaska ^ ^ SEE OEFINI110N ther /Specify': atlon ON OTHER SIDE 22e. SIGNA R F NER 5 fLICEN$EE .?R;ERSON ACI'1NG AS SU H 22b. NAME ANp ADDRE550F FACILITY Evergreen Memorial Chapels 1 - ~i Robert G. Jones o Box 100537 Anchora e Alaska 99510 23a To Ina b -o my knowledpa tleatn occvne0 at {he time, date, and place stated. 23b. DATE SIGNEp Complete items 23e-O only wnen (MOnfA. Dry, Wed cemrylna plyamian is not avaamla a+ urns or seam tp ~I certify cause of deatn. j Slpneture and TRle~ ITEMS 2a-N MUST 2a, TIME OF DEATH --~T3 DATE PRONOUNCED DEAD (Month, Dry, Kad 2S. WA5 GIAiE REFEgRED TO MEDICAL EXAMINERICOftONER? BE COMPLETED BY [L~~''''~~ ^Y I J No PERSON WHO U CES 821 M ~ Ju IY 2J ZOO2 ] jS ea PRONO N !,:orr WicaDp that used tM death. Dp rwt enlerlM mope Of dylnq, svchro~O~x or reapim[ory erteal. tlrOek, or heart failure. s,a na a 2T PRAT 1. Enter the dlaeaaea, inlvrle Appmklmete lute I DEATH ` ^ . / cavae /s List only one On each tins r ~ / / I / ) BMween Onset Bath ~/ ~~~ f1 ~ "eJ• ) {(1 1 11~~^-7.-,)I `/~y~ \ V I _/ FIneI ~ V" - IMMEDIATE CAUSE I~ ~' rn ~ - I l a 1 ---1 tllbeese or condlllon DUE TD IOR AS A CONSEOUE CE OF7? reewrnp m eeetm 1 V ~~~~~~ b- Secuentfally Ifat condlllons li ~~ ~ /OAA$ A GONSE DF): : any, leatllnp Io Immed ate cavae- UNDEfiLYING CAUSE E ~ c nter (d'sease o' m{vry that Inltleted DUE TO (OR AS A CONSEOUENCEOF) Z Z !, ants resvltrnp In tlaetM1l LAST _D d m o OTHER SIGNIFICANT COMDITlCNS conMb~i/Inq m deem 1 rwHrnl^ fl Intna vnderrying cavae plven In Part 1, PART II 28a WA5 AN AUTOPSY 28R WER TOPSY FlNDINGS . PERFORMED? CONSI RED PRIOR TO COMPL ON OF GU3E ^ OF DEAT1 `;.' ^ ^ Yea 6ZLNO Yea NO 29e. CERTIFIER CERTIFYING PHYSICIAN (PhyalclM certl/ylnp cease o/de~M when arplher o/Rc/sl hu pmnOmtced deaM arts comWeted (tern 23) ------ (Cneck Only One) --- -_ _ ha Desl of my knONladpe, death occurted due to the cauaMal and msnRer Y al0latl.-_- __-__-_-____-_._-___.-.r ~.- - -__~-- PRONOUNCING AND GEATIFYLNG YSICUN (MyelO/an 6olh prprrovno/np dMM and certiypnp ro atw of dMlll T_o the bast of my knpwladp_e, deal and N the tlma, dalA and plecA and Due to IM uuealel and mantror a afAed. -----------------------_______--_--...-_-_-.-_~-.-__ -_. _ ER MEDICAL E%AMt RICO N ^ SEE DEFINITION _ on the Oaala of- Ina! I IlpNron, In my ogNpn, deem oecurred et tin erne. dste, eM place, aM sae ro the eauee(al NM manna as sta;se. ON OTHER 510E 29b. SIGNATURE AND TITLE 0 C RTIFIER OF CAUSE DEA 2a naiE GNED ( nrh. Day, Wad 1 29d. NAME AND ADDRESS OF CERTIFIER WHO COMPLETED CAUS 271 (Typs/Pdnln eedlped !t /.02 2Ma LICENSE NUMSER Dr. Geor a Stewart 2741 DeBarr Road Anchora e Alaska 926 30. MANNER OF DEATH 31.1E ^MANNER OF DEATH^ IS OTHER THAN "NAT URAL^, ITEMS 31a - 31e MU3T BE COMPLETED. ® Netvrel ^ Pendlnq 31a. GATE OF INJURY 31b. TIME OF 31c INJURY AT WORK? 31d. DESCRIBE HOW INJURY OCCURREDT IEYents wlrlcn nau/fed In /n/vry) t Irnestlpetlon id ^ A (MOnIh. Dry, Wad INJURY ~ ~ cc en ^c wdnolb ~' Ne ^SUICiOe detertnlned 31e. PLACE OF INURY-Al home, alreal, 0annery. olfka, eta (SpeclM 31f.11%.ATION(Slreal aM Number of RUraI ROU[e Number, Cltyonn, Stale) ^ Homlelee 32. RfCORDER5 SIGNATVRE Ss. RECORDING DISIAICT 3r. dRE FILED (Month, Day, lbad _, ~ ~~i.i( ~~~,e :ni~~rmarion mere given is correcclt• copied Fi-Om an original a°rrificau• ut~deatil dui~• bled with me as _ .__. , 1 (~_. I -: (!-%r ~~Ihc ;>r,~ir.l1 certiFcate will he fon~rarded to the State Vital Reconjs OfF~~e hu- hrrmanenr Filing. i~VAl:?ta1NG: It is illegal to duplicate this copy by photostat or photograph. <(~ t<,; rhi; ~:rriF~ an~, 52.(1(~~~P~~H~OfP~~~ rv icc~',~-,/a:c .• -- ~,,, t ~~ ~ ~` 1-~t~.31 1ctr.i5rrar ~: , v' I o i °° b \\ oFA`99 s~ `4~~~ ~ 1 X' ~: ~ ~~tJu ------ -- ~-r-~,,, ~„~~ ;sic). i)ate 21-02-741 a] Rev. 2187 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • YtTAL RECORDS CERTIFICATE OF DEATH NAME OF DECEDENT (f rcv. Mbae. Lea) SE% SOCIAL SECURITY NUMBER GATE Of DEATN,MCrxh. DaY. 'kwl t. E~.~een M. Ke~.m =. Femme ~. 205 - 09 - 6345 +• 12-20-2000 AGE ILam BvtndaY! UNDER 1 YEAH UNDER 1 DAY DATE OF BIRTH BIRTHPLACE {Cay and PLACE OF DEQH (CMCCN orvy a+a -- lee ~nsuuceons on oNUr vde) MoMa r Day Noun , Mnww ,MOnm. Day •Merl SUU a Fcregn Cwmry) ~~and ~ ~ HOSPITAL: OTHER' I,.r% ^ EWOutpstUn ^ oDA ^ ItpN ^ RaarWnu J[ e~cN1 ^ (aS 8 5 Yn. , 2 -15-15 , Gnan r t y P w COUNTY OF DE/PH CITY, BORO. TWP OF DEATH EAGLET' NAME NI na urv~Ntwn. give seew and ntvnbwr NNS DECE~EN~--TI7DE HISPANIC ORIGINT RACE - Amsncan radian, BNCIC, Wtute. s1c. Nn ~1 Yaa U %yas. ep+ceT CuWn, ISperAyl Lowers A~~en Twp Cumbeh~and V1h~..te 5314 Cobb.2e~~ane Dn~ve ;''a'~"•P'""°R~'"•"° ,, ~ «, DECEDENT'S USUAL OCCUPRION KIND OF BUSiNESSIINDUSTRV , ,, YYAS DECEDENT EVER IN DECEDENT'S EDUCATION MARITAL STATUS ~ Mamsd SURY1Y8Ki SPOUSE W Idawd. IN wrN. ryva maoanrwna) E51 i can ad Nsvar U.S. ARMED FOR C (Goa knOdrock data drn9 mom d ra4inp Ws; M nd twe r ad 1 ~ ~~~ ~ I Yas ^ Ho Id EU~YtS•+~w ~I.9• Hoe(~ew~~e 71a TTb. - - - - - - (0.i2' 12 °'a51 Mcv(n.~ed Hubenz U. Ke~.m /2. 1]. 1.. tS. DECEDENT'S MAIltN6 ADDRESS (Strew. CMrTOrn, Suss. Zy CoMI NT S AC aaceden lived b ~ owen A e n ~ ^ Yr t]e i PA 5319 Cobb.~e~•tone Dn~ve . TUAL RESIDENCE . . . D d t7a. SUM decedala Meehan.t_e~btucg, PA 17055 «h~era Cumben~and ^ ~ "„ . 1~ „d, ,r " c;,y(pp,o. t>b. FQNER'S NAME IFvm. MiOdls. Lam) MOTHER'S NAME IFsm. M,pd4. Harden Suname) O'8n~e h P J ~d~~th Meadow n . aye ,.. ,,. INFORMANT'S NAME (TypwPrva Mrs. Hubeh.t t~. Ke.~m I NFORMANT'S MAILING ADDRESS (SVw. City/iwn, Selo, Zrp Code) 5314 Cobb2ea#one Dn~.ve, Mechan.~c~sbwc PA 17055 METHOD OF DISPOSITION DQE OF dSPOS1Yl0lI PLACE OF DISPOSITION • Nsme d Cwrlwery. Cnrrralory LOCIfTION ~ Ciryrtown, Slate. Zip Cods ~ Rwnoval bom $lale ^ ("+On'h' D•Y' ~! a otrrr Pyre Ch ema~ o n So etie•ty o i l ^ e b • rten.t n Bw a OprlMbn^ ahw(SP.carL ^ 12-25-2000 PA Cxema~on : Hann~~bun PA 17104 d 2ta. ttb. SMuN/RURE OF FUNERAL SERVICE L EN E OR PE ACTING AS SUCH , . =td. + . .F LICENSE NUMBER NAME AND ADDRESS OF FAGLITY C em ~ n Q C e-L O PA 09 ~ ad ~ >~ wc A 171 fa~cn.c~ , 22b. ~. 4100 Jone~s~tawn Koa C•emPlwa a one, when cart - B do f>.m d my MrgwNttpa, MaN occwrsd at IM tune. Oats and pars melee. INTENSE NUMBER DrQE SIGNED (Morph Da lbdrl plryaicWl r not avaaaDN w tuM of Mal" b (Srpnmure and Toe) y, . awtdy eauae a awn. n.. 23b. 2]e. beau 21.28 muw fr compNted by IM~~QOF DEQH p1 ,, Isuson wllo prorbrrrlca daaN. Oyi ty1 Q~ DATE PRONOUNCED DEAD (Mach. Day, Year) YNS CASE REFERRED TO MED~IiC?ALeF~IU~MINEFUCORONERI Vas ry i- l~ No^ _+ ` l JU M G rl. ri. 4 ~ ~ ~ . . 27. MpT 1: Emer tM dueasea, inryriaf a LpnlpliLanpn{ which 4uss0IM MaN Do not enter ItN npM of oyeq, auto sa cardiac a raeprcalory arraal, slack a IwaA IaNwe. I Appnaimau PART B: OtMr egnifleam conAtiorr corprlEtuy n Matn, but ~ vperv" Dwween nor rsau%np n do ulldsryirq c"aIa yvwr N P VtT 1. LW apy one uusa of each 1irw. , awl and deed) IMIIEDUTE CAUSE (Fvw arrsa a cagawn t I i d Lav.i~` reaWgn6eaU~)-~ a. DUE ! R CONSEOUENCEOFI: - ~ I SequareUSy aN cardilions D. a any, Madbg b eMndiala DUE TO (OR AS A CONSEQUENCE Off: ; tease. EnUr tINDERLYWO I CAUSE (Dasase a •MUY c- Ins, •mialedawns DUE Ip (OR AS ACONSEQUENCE OF): __ I rtRUbry n deseN U13T a YMS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF OEATN DATE OF INJURY TIME OF INJURY INJURY R IM7RK) DESCRIBE FLOW INJURY OCCURRED. PERFORMEOT AWLABLE Pft10R 10 (Mmes. DaY'barl OF OEATMKNI OF CAUSE Nwwd ~ Ibmicids ^ 17N ^ ~ ^ AttrMn ^ Pendirq Inreslrpalbn ^ tM ^ pb yes ^ tip SuiciM ^ COUW rot M Mtwmmea ^ ]Sb M ]ee- PLACE OF INJURY - Al home, harm, vrw. IaCIaY. orate LOCRION fSh'eel. Gry/T .Slaw) Wpdkrq. etc. t5pecpv) 3fr. 2M. Zs. 18a. ]M. WfTKIE1r l(:neU Or'W oral 't:ERTIFYMIG PHYSICIAN IPnrsc~an cerlayurq cause N Male when ananer Phvsrcan nas pronwrvRd aealn aro comlNeled Item 2]I To Ure best td my anowMdga, MaN oaxumd ttw b Ina oauwla) and manner a Mated ..................................................... 'PRONOUNGIKi AND CERTIFYING PHYSICIAN (Pt+yvcan mm yonourxinq death and cenpyerg b cause d deaml To /he beet of mY MnorNd9A, MaN twcwred a1 Ba11Nre, dale, arM Plata, and due to tM cause(a) and manner a staled .......................... 'MEDICAL EXAMINER/CORONER On the Dasis of e:am(natlon andlor investigation, in my opinion, death occurred at the Ilene, dale, and place, and due Yo the cause(s) and manner as atated ............................................................................ .......... ..... ..... .. ]la. - - - _ _.------ ~~~ ^ ]1c. ]Id. ~+ V NAME AND A ESS OF P SON WHO COM LETEO SE OF /7TNH, (Item 271 Type a P,ln tM, ~h ~~''~t~Le eK/~~ ~ ~~ ^ ~~ Cro~ rrn ricJe~tJ~ p ~ 1 G ]]. DATE FILED/n(Mmm. gay. Yeah ~.. ~Y~ .? I .7 0 o d WILL OF HVBERT O. KEIM 0 V I, HUBERT O. KEIM, of Camp Hill Borough, Cumberland County, Pennsylvania, declare this to be my last will and revoke any will previously made by me. ITEM I. I direct that all my just debts and funeral expenses, including my gravemarker and all expenses of my last illness, and any and all taxes and assessments imposed by any governmental body as a result of my death, whether on property passing under this will or otherwise, shall be paid from my residuary estate as soon as practicable after my death as a part of the expense of the administration of my estate. ITEM II. I give and bequeath all of my household goods, automobiles, jewelry, and all other articles of household and personal use, equipment and ornament, together with all insurance thereon and relating thereto, to my wife, EILEEN KEIM, provided she survives my death by thirty (30) days. Should my wife fail to survive my death by thirty (30) days, I give and bequeath all such items and insurance thereon to to be divided among those of my issue, per stirpes and not per capita, who survive my death by thirty (30) days with due regard for their personal preferences. The decision of my executor with regard thereto shall be final, binding, and conclusive on all parties. ITEM III. I give, devise, and bequeath all the rest, residue, and remainder of my possessions and estate of every nature and wherever situate to my wife, EILEEN KEIM, provided she survives my death by thirty (30) days. Should my wife fail to survive my death by thirty {30} days, 2 give, devise, and bequeath all the rest, residue, and remainder of my possessions and estate of every nature and wherever situate to those of my issue, per stirpes and not per capita, who survive my death by thirty (30) days. ITEM IV. I appoint my wife, EILEEN KEIM, executrix of this my last will. Should my wife predecease me or otherwise fail to qualify or cease to serve as executrix of this my last will, I appoint my daughter, DIANE M. GRIMES, of Camp Hill, Pennsylvania, executrix of this my last will. Should my daughter also predecease me or otherwise fail to qualify or cease to serve as executrix of this my last will, I appoint my son, ERIC D. KEIM, of Huntingdon, New York, executor of this my last will. D: \L WORK\W ILLS\G092596I. WPD ITEM V. In addition to the other powers and authorities granted to my personal representatives by Pennsylvania law and by the other terms and provisions of this will, I hereby give to my personal representatives the following powers and authorities effective without court approval and until actual distribution of all property: to compromise any claim or controversy; to make distribution in cash or in kind, or partly in cash and partly in kind, and in such manner as my personal representatives may determine and at valuations finally to be fixed by them; to invest in all forms of property, including any stock or other securities in any corporate fiduciary or its successor without restriction to investments authorized for Pennsylvania fiduciaries, as my personal representatives deem proper, without regard to any principle of risk or diversification; to retain any ar all assets of my estate, real or personal, without regard to any principle of risk or diversification; to sell at public or private sale, to exchange, or to lease for any period of time, any real or personal property and to give options for sales, exchanges, or leases, for such prices and upon such terms or conditions as my personal representatives deem proper; and to allocate receipts and expenses to principal or income or partly to each as my personal representatives deem proper in their sole discretion; and to serve as guardian of any property which passes, either under this will or otherwise, to a minor or to any person adjudged by any court of competent jurisdiction to be mentally incapacitated to care for such property or for such person's own affairs, and with respect to whom I am authorized to appoint a guardian and have not otherwise appointed a guardian or trustee with the power in the guardian to use principal as well as income from time to time for such person's education, support, and welfare without regard to the ability of the parents of such person to provide for such education, support, or welfare, and to make such payment for these purposes, without further responsibility, directly to such person or to the parent or any other person taking care of such person. ITEM vI. I direct that my personal representatives and fiduciaries shall not be required to give bond for the faithful performance of their duties in any jurisdiction. Iled WITNESS WHEREOF, I have hereunto set my hand this / day of ~~ /b (-~ 1996. ~~ a. ~~ HUBERT O. KEIM D:SLWORK\WILLS\GQ92546I.WPD 2 The preceding instrument, consisting of this and two other typewritten pages, each identified by the signature of the testator was on the date thereof signed, published, and declared by HUBERT O. KEIM, the testator therein named, as and for his last will, in the presence of us, who at his request, in his presence, and in the presence of each other, have subscribed our names as witnesses hereto. GEORGE A. AUGHN, III a t a~ ~' ~I DIANE B. JENKINS D:\LWORK\WILLS1G092596LWPD 3 ' COMMONWEALTH OF PENNSYLVANIA ) ( SS.: COUNTY OF CUMBERLAND ) I, HUBERT O. KEIM, being the testator whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the foregoing instrument as my last will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. ~~ D. ~~ HUBERT O. KEIM Sworn or affirmed to and acknowledged before me~;by the testator named above this. ~~day of 15! ~ ~ C~~iL 1996 . / ~ ~ fr( NOTARWL SEAL FRANCES ~ YAUGHN, Notary Pubik Hampden 1Wp., Cumberlond Co„ Pa My Commission Expires Aug. 4,1949 Notary Public COMMONWEALTH OF PENNSYLVANIA ) ( SS.. COUNTY OF CUMBERLAND ) WE, GEORGE A. VAUGHN, III, and DIANE B. JENKINS, the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the testator sign and execute the instrument as his last will; that he signed. it willingly; that he executed it as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the testator signed the will as witnesses; and that to the best of our knowledge, the testator was at the time eighteen or more years or age, of sound mind, and under no constraint or undue influence. Sworn or affirmed to and ., acknowledged before me this f day Notary Public G ORGE A. GH,N~, III DIANE B. JENKINS NOTARWL SEAL FRANCE5 T. YAUGHN, Notary Public Hampden IYVp., Cumberland Co,. PA My Commission Expires Aug. 4,1999 D:ILWORK\WILLS\G092596I. WPD .. J J1~ f;J, - J7 c., OFFICIAL USE ONLY REV-1500 EX + (6-00) CAPB HpRL EplO CRAC KOTK ES REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER D E C E D E N T COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 DECEDENT'S NAME (LAST. FIRST. AND MIDDLE INITIAL) Keim Hubert 0 DATE OF DEATH (MM-DD-YEAR) 21-02-741 NUMBER COUNTY CODe YEAR SOCIAL SECURITY NUMBER 179-09-9238 THIS REfURM MUST BE FILED IN DUPUCATEWlTH THE IAL REGISTER OF WILLS CU ITY 07 27 2002 PLICA L DL I X 1. Original Return 4. Limited Estate X I. Decedent DJecI Testate (Attach copy of WUO D 9. Litigation Proceeds Rec:efved 3 t. t . Remainder Return rlor to 12-13-82) 5. Federal Estate Tax Retwn Required 8. Total Number of Safe Deposit Boxes 2. Supplemental Return 48. Future Interest COmpromise (dlite of death after 12-12-82) 7. Decedent t.4alntalned a Living Trust (Attach copy of Trust) o 10. Spousal poverty Credit (date of death between 12-31-91.nd 1-1-95) 1 o 11. E*=tlon to tax under Sec. 9113(A) (Attach Sch 0) C P o 0 R N R D E E S N T C o M P T U A T X A T I o N NAME John DeLorenzo Es uire FIRM NAME (If Applicable) Go1dber Katzman & Shi man, P. C. TELEPHONE NUMBER COMPLETE MAILING ADDRESS 320 Market Street PO Box 1268 Harrisburg, PA 17108-1268 R E C A P I T U L A T I o N 1. Real Estate (Schedule A) (1) 163,900.00 2. Stocks and Bonds (Schedule B) (2) 35 ,352.21 3. Closely Held Corporation, Partnership or (3) None Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) (4) None 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 4 , 922 . 65 (Schedule E) 6. Jointly Owned Property (Schedule F) (6) None D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) 16 t 709.07 (SChedule G or L) 8. Total Gros. A..lIIs (total Lines 1-7) (8) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 12,167.39 10. Debts of Decedent, Mortgage Liabililies, & Liens (Schedule I) (10) 3 ,991.78 11. Total Deduc:tlon. (total Lines 9 & 10) (11) 12. Net Valu. 01 E_. (Line 8 minus Line 11) (12) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net Valu. Sub to Tax (Line 12 minus Line 13) (14) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 204 724.76 OFFICIAL USE ONLY 220,883.93 16.159.17 204,724.76 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(aXl.2) 16. Amount of Line 14 taxable at lineal rate 204,724.76 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Du. 20. (15) (16) (17) (18) (19) .0 0 .0 45 .12 .15 0.00 9,212.61 0.00 0.00 9,212.61 x X X X Copyright (c) 2000 form software only The Lackner Group, Inc. Fonn REV-l500 EX (Rev. .-00) , Deced'ent's Complete Address: STREET ADDRESS 5319 Cobblestone Drive CITY I STATE I ZIP Mechanicsbura PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. CreditslPayments A. Spousal Poverty Cred~ B. Prior Payments C. Discount (1) 9,212.61 0.00 8,000.00 421. 05 Total Cred~ ( A + B + C) (2) 8,421.05 3. InterestIPenatty if applicable D. Interest E. Penalty TotallnterestlPonalty ( D + E) (3) 4. If Line 2 is greator than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to roquoot a refund (4) 5. If Line 1 + Line 3 is greater than line 2. enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) B. Enter the total of Line S + SA. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT 1IIIIll:!l!ll!l!l!li!ll!l!ll!!lll!llll!!III!illl!illll11111111!!II!l!1]!IIIIIIIII!!llllllll!IIIIII!llllllll!IIII!]II!IIII!illll!I!I!!III!lllil!I!!!!I!II!IIIIIIJ!1illll!l]I!!ll!ll!lllllll!III!lllllill lllilll!!lllllll!mmmlllllllllltiilltlllllillllilllliilllllllllllllillll1IIIIIIIIIIIIllllllllllll!lill!l!lllllll!ll!l!I!!lllll1IIIIIIIIIIlllilll!iill!!llllllllll!lllmm PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yea No a. retain the use or income of the property transferred; . . . . . . . . . . . . . ~ ~ix b. retain the right to designate who shall use the property transferred or its income: . c. retain a reversionary interest; or. . . . . . . . . .. . . . . . . . . . . . . . . . d. receive the promise for life of either payments, benefItS or care? . . . . . . . . . 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Did decedent own an "in trust for" or payable upon death bank account or security at his orherdeath? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 D IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 0.00 0.00 791. 56 0.00 791. 56 o o [!] [!] Uncler penalties of perJwy, I declare that I have examined this return,lncludlng accompanying schedules ancl statements, and to the best of my knowledge and ballef, It Is true. correct and complete. Dec&ar.tlon of preparer other than the personal repreMntatlve Is basecI on .11 Information of whk:h preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN Diane M. Gr imes DATE i /a~ . );/ --~ll--~~H-fg!1~'?\-~6i~--------__m_mmm-- CHI ~/ Ie i) GNATU" Goldberg, Katzman & Shipman, P.C. DATE Ji!!!!i!!!!i::!':!:Jli!!lli!li!i!IIIIIIIII!llllilll!!1Ilill!IIII!I:illliil!lli!llllil!!!il!liil!!!I!llil!!11lillllllllllillilllllllllillli;I;II~~~~;11~~li~~i;'~;~~1;il~!~lilii~;~~I~~~~ii;ll;i;'i;I;;I ;ii;!t;i;!~ii;:;![;ii;i;i!;ii;!;iimi!li~)i!ili~ii)m~i~m For dates of death on or after July 1. 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. 9116 (a) (1.1)(j)~ For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only benefICiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 9116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 9116(1.2) [72 P.S. 9116(aX 1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12"/0 [72 P.S. 9116(aX1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in corrvnon wrth the decedent, whether by blood or adoption. CopyrIght (c) 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6.00) " REV-1502 EX +(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX ReTURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Hubert 0 Keim SS# 179-09-9238 07/27/2002 21-02-741 All real property owned lolely or as . tenant In common must be reported at f.lr market valu.. 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. R_I Dropertv which II IoIntlv-owned wRh rioht of lurvlvorahlD must be dloclooed on Schedule F. ITEM VALUE AT DATE DESCRIPTION NUMBER OF DEATH 1 5319 Cobblestone Drive, Lower Allen Township, Cumberland County, 163,900.00 PA - valued per listing agreement (attached to death tax return only) SCHEDULE A REAL ESTATE TOT At (Also enter on line 1. Recapitulation) $ (If more space is ne.ded, insert additional sheets of the same size) 163,900.00 . ....t., ~...... ~____ __.u...___ __................__ .__ I=nrm AI='V_1~ n (RlllU 1.Q7\ REV-1503'EX +(1-97) SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SS11 179-09-9238 07/27/2002 Hubert 0 Keim All property jointly-owned with right 01 survivorship must be disclosed on Schedule F. ITEM NUMBER 1 DESCRIPTION 729.327 shs in mutual fund held by American Express in Account No. 010645107128002 - valued per letter dated 10/18/02 (attached to death tax return only) 2 361.106 shs in mutual fund held by American Express in Account No. 020645107127002 - valued per letter dated 10/18/02 (attached to death tax return only) 3 340 shs Scotts Co Class A held by H&R Block in Account No. 12901233934 - valued per internet search (statement attached to death tax return only) UNIT VALUE 18.88 18.01 44.35 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems,lnc. TOTAL (Also enter on line 2. RecaD~ulation) FILE NUMBER 21-02-741 VALUE AT DATE OF DEATH 13,769.69 6,503.52 15,079.00 35,352.21 Form REV-1503 EX (Rev. 1-97) \ ' REV. 1508 EX +(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Hubert 0 Keirn SSfI 179-09-9238 07/27/2002 21-02-741 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right 01 survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 A11first Bank Checking Account No. 0050536974 - valued per letter 3,412.60 dated 9/18/02 (attached to death tax return only) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY 2 A11first Bank Checking Account No. 0050536974, accrued interest valued per letter dated 9/18/02 (att to death tax return only) 0.12 3 H&R Block Account No. 12901233934 - valued per statement dated 6/28/02 to 7/31/02 (attached to death tax return only) 0.08 4 Miscellaneous personal property 500.00 5 1986 Oldsmobile Delta 88 - valued per sales price 1,000.00 6 Comcast Cable - refund of account 9.85 TOTAL (Also enter on line 5. Recap~ulation) $ 4 922.65 (It more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1508 EX (Rev. 1.97) , REV-1510EX+(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Hubert 0 Keim SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY SSfF 179-09-9238 07/27/2002 FILE NUMBER 21-02-741 This schedule must be completed and filed if the answer to any of questtons 1 through 4 on page 2 Is yes. RELAV18hMllli~g~;'~~Yi~H!~~1.~F t'ilill'sFER. %OF ITEM DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE NUMBER ATTACH A COPY OF THE oeeD FOR REAL ESTATE. VALUE OF ASSET INTEREST QF APPLICABLE) 1 American Express Annuity Acct .lb,7u'1.Uf 100.00% 16,709 :07 No. 930026284798004 - valued per letter dated 10/18/02 (att to death tax return only) TOTAL (Also enter on line 7, Recao~ulation) S 16.709.07 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 fOf'm software only CPSystems, Inc. Fo,m REV-ISIO EX (Rev. 1-97) I REV-1511 EX +(1-97) CO~MONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Hubert 0 Keim Debts 01 decedent must be reported on Schedule I. ITEM NUMBER A. B. SS!; 179-09-9238 07/27/2002 FILE NUMBER 21-02-741 DESCRIPTION AMOUNT 1 FUNERAL EXPENSES: Cremation Society of Pennsylvania - cremation services 437.20 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Nurnber(s) I EIN Number of Personal Representative(s) Street Address City State Zip Veans) Corrmission Paid: 2. 3. Attorney's Fees Goldberg, Katzman & Shipman, P. C. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address 7,800.00 City Relationship of Claimant to Decedent State Zip 4. Register of Wills 270.00 Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 1 Other Administrative Costs Cumberland Law Journal - estate notice advertisement fee 75.00 2 Patriot News - estate notice advertisement fee 108.43 3 Register of Wills, Cumberland County - filing fee for Return & Inventory 25.00 4 Register of Wills, Cumberland County - short certificates 12.00 5 Postmaster - postage 14.80 6 Commonwealth of Pennsylvania - title transfer & plate renewal 87.00 Total of Continuation Schedule(s) 3,337.96 TOTAL (Also enter on line 9, Recao~ulation) $ 12,167.39 (tt more space is needed. insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems,lnc. Form REY-1511 EX (Rev. 1-97) Estate of: Hubert 0 Keim Soc Sec #: 179-09-9238 Date of Death: 07/27/2002 Item il Continuation of Schedule H-B7 (Other Administrative Costs) Description Amount 7 William Grimes - appliance removal 76.25 8 Boyd E. Diller, Inc. 36.25 trash removal 9 Callen Kimback, Inc. - car inspection 31. 06 10 Goldberg, Katzman & Shipman, P.C. - reservation for costs of closing of estate administration 100.00 11 Safeco Insurance Company - homeowners insurance premium 297.00 12 Lower Allen Township - sewer and trash service to residence 219.20 13 Bonnie K. Miller - 2003 County/Township real estate tax 623.68 14 West Shore Shopper - advertisement for vehicle 12.00 15 UGI gas service to residence 620.15 16 electric service to residence PPL 163.31 17 Pennsylvania American Water Co. - water service to residence 97.06 18 WMCA - condominium fees 1,062.00 3,337.96 , , REV-1512 EX +(1-97) SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, AND LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Hubert 0 Keim FILE NUMBER 21-02-741 SS!; 179-09-9238 07/27/2002 Include unr.lmbursecl medical exp.n.... ITEM NUMBER 1 10 11 12 13 14 15 16 17 DESCRIPTION AT&T - long distance telephone service AMOUNT 14.07 2 local telephone service 21. 41 Verizon 3 cellular phone service 21. 89 PCS One 4 Citicards Mastercard - credit card acct no. 5424-1801-7019-5843 1,525.38 5 Conner Rich Associates - unreimbursed medical bill 48.03 6 Denali Cardiac & Thoracic Surgery, PC - unreimbursed medical bill 106.35 7 Municipality of Anchorage - unreimbursed medical bill 13.64 8 Providence Health Systems-Alaska - unreimbursed medical bill 4.59 9 Alaska Pulmonary - unreimbursed medical bill 229.82 AK Emergency Medicine Associates - unreimbursed medical bill 6.32 Michael W. Eaton, MD - unreimbursed medical bill 8.28 Express Pharmacy Service - unreimbursed medical bill 45.00 H20 Co - water delivery 11.10 PP&L - electric service for residence 45.85 Bonnie K. Miller, Tax Collector - 2002 school real estate taxes 1,771.54 Alaska Heart Institute, LLC - unreimbursed medical bill 97.51 Pennsylvania Department of Revenue - 2002 personal income tax 21. 00 TOTAL (Also enter on line 10. Ree.p~ulation) $ 3.991.78 (If more space is needed. insert additional sheets of the same size) Copyright (c) 1996 formsottware onlyCPSystems, Inc. Form REV-1512 EX (Rev. 1-97) r REV-1513 EX +(9-00) SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Hubert 0 Keim SS/J 179-09-9238 07/27/2002 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS [Includeoutrlghlspousoldlslributlans.s" transfers under Sec. 9116(aX1.2)] 1 Diane M. Grimes 407 Springhouse Road Camp Hill, PA 17011 2 Eric D. Keim 8961 Turin Hill Court North Dublin, OH 43017 3 Jeffrey L. Keim 2260 Loussac Drive Anchorage, AK 99516 ""L"",!!,,~riIP Do Not LIat TruolM(.) Daughter Son Son FILE NUMBER 21-02-741 OF ESTATE 1/3 of Residue 1/3 of Residue 1/3 of Residue ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18. AS APPROPRIATE. ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS, A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET S (If more space is needed. insert additional sheets of the same size) Copyright (c) 2000 form software only The Lackner Group, Inc. 0.00 Form REV-1513 EX (Rev. '-00) . Index to Exhibits Pennsylvania Inheritance Tax Return Estate of Hubert O. Keirn, deceased Exhibit A: Grant of Letters Testamentary and copy of the Last Will and Testament Exhibit B: Copy of receipt for payment of Pennsylvania Inheritance Tax Exhibit C: Copy of safe deposit box inventory Exhibit D: Copy of listing agreement and addendum for real estate located at 5319 Cobblestone Drive, Lower Allen Township, Cumberland County, Pennsylvania Exhibit E: Copy of letter from American Express dated 10/18/02 regarding date of death balances Exhibit F: Copy of letter from Allfirst Bank dated 9/18/02 regarding date of death balance Exhibit G: Copy of statement from H&R Block for the period of 6/28/02 to 7/31/02 94309.1 ""tlflll1"IfIr>IlIl~""t~ .....) '~1.1~;. ~ .....\\,.\~..........,.""...;,.,. ..' If'.' ,:./_" .~. ',; '\"'- I '."< ' ~,-,\ ':.l/I'~ ' ,', I'''''' \.'" \ ,J '- 1'1) .1: - i .. L ~ ..I. ,~ .,\ '*'): ,'I i./.. . ~"/ .;'~' \ .'~' .",...."W'J .i'..~'._'\.. ,) .,., t~' ..... ...j....., 1:"\\ ''..,. " ')1\ i} ) '\~~' ' , '1.1 I! I ! l't!'l~t\'1 ~ . . WHEREAS, on the dated October 9th 16th 1996 Register of Wills of CUMBERLAND County, Pennsylvania Certificate of Grant of Letters No. 2002-00741 PA No. 21-02-0741 ESTATE OF KEIM HUBERT 0 (LAbl! ~lK~l, M1UUL~) Late of LOWER ALLEN TOWNSHIP CUM~bK~U LUUN1X/ Deceased Social Security No. 179-09-9238 day of August 2002 an instrument was admitted to probate as the last will of KEIM HUBERT 0 (LA~l, "lK~l, M1UUL~! late of LOWER ALLEN TOWNSHIP CUMBERLAND County, who died on the 27th day of July 2002 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, MARY C. LEWIS , Register of Wills in and for the County of CUMBERLAND in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to GRIMES DIANE M who has duly qualified as Executor (rix) and has agreed to administer the estate according to law, all of which fully appears of record in my Office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYLVANIA. IN TESTIMONY WHEREOF, of my Office the 16th day I have hereunto set my hand and affixed the seal of August 2002. ~,,/~ O~ e7/,IJ/ egls er of wl.lls ~.4UAouo/ **NOTE** ALL NAMES ABOVE APPEAR (LAST, FIRST, MIDDLE) '1 Cl'- ( C1'- ( \J '\. . WILL OF HUBERT O. KEIM I, HUBERT O. KEIM, of Camp Hill Borough, CUmberland County, Pennsylvania, declare this to be my last will and revoke any will previously made by me. . " :!:'1'E'M ::::. I d.irect that all my just debts an~ faner,a1.. e~e!l,seci' includi.::.S' my gravemarker and all expenses of my last illness, and any and all taxes and assessments imposed by any governmental body as a result of my death, whether on property passing under this will or otherwise, shall be paid from my residuary estate as soon as practicable after my death as a part of the expense of the administration of my estate. ITEM II. I give and bequeath all of my household goods, automobiles, jewelry, and all other articles of household and personal use, equipment and ornament, together with all insurance thereon and relating theretot to my wife, EILEEN KEIM, provided she survives my death by thirty (30) days. Should my wife fail to survive my death by thirty (30) days, I give and bequeath all such items and insurance thereon to to be divided among those of my issue, per stirpes and not per capita, who survive my death by thirty (30) days with due regard for their personal preferences. The decision of my executor with regard thereto shall be final, binding, and conclusive on all parties. )> ITEM III. I give, devise, and bequeath all the rest, residue, and remainder..of. my possessions and estate of every nature and wherever situate to my wife, EILEEN KEIM, provided she survives my death by thirty (30) days. Should my wife fail to survive my death by thirty (30) days, I give, devise, and bequeath all the rest, pesidue, and remainder of my possessions and estate of every nature and wherever situate to those of my issue, per stirpes and not per capita, who survive my death by thirty (30) days. ITEM IV. I appoint my wife, EILEEN KEIM, executrix of this my last will. Should my wife predecease me or otherwise fail to qualify or cease to serve as executrix of this my last will, I appoint my daughter, DIANE M. GRIMES, of Camp Hill, Pennsylvania, executrix of this my last will. Should my daughter also predecease me or otherwise fail to qualify or cease to serve as executrix of this my last will, I appoint my son, ERIC D. KEIM, of Huntingdon, New York, executor of this my last will. OIL WQRK\ WILLS\G092596L WPO , ,'- - , ITEM V. In addition to the other powers and authorities granted to my personal representatives by Pennsylvania law and by the other terms and provisions of this will, I hereby give to my personal representatives the following powers and authorities effective without court approval and until actual distribution of all property: to compromise any claim or controversy; to make distribution in cash or in kind, or partly in cash and partly in kind, and in such manner as my personal representatives may determine and at valuations finally to be fixed by them; to invest in all forms of property, .i:u.clnd:i.na. ;::::.~ stock or other :Jecurities in any corporatE? tid~.~dc;_l..-.:'- .,.~ :i..-:::: successor without restriction to investments authorized for Pennsylvania fiduciaries, as my personal representatives deem proper, without regard to any principle of risk or diversification; to retain any or all assets of my estate, real or personal, without regard to any principle of risk or diversification; to sell at public or private sale, to exchange, or to lease for any period of time, any real or personal property and to give options for sales, exchanges, or leases, for such prices and upon such terms or conditions as my personal representatives deem proper; and to allocate receipts and expenses to principal or income or partly to each as my personal representatives deem proper in their sole discretion; and to serve as guardian of any property which passes, either under this will or otherwise, to a minor or to any person adjudged by any court of competent jurisdiction to be mentally incapacitated to care for such property or for such person's own affairs, and with respect to whom I am authorized to appoint a guardian and have not otherwise appointed a guardian or trustee with the power in the guardian to use principal as well as income from time to time for such person's education, support, and welfare without regard to the ability of the parents of such person to provide for such education, support, or welfare, and to make such payment for ~hese purposes, without further responsibility, directly to such person or to the parent or-any other person taking care of such person. ITEM VI. I direct that my personal representatives and fiduciaries bond for the faithful performance of their shall not be required to give duties in any jurisdiction. I)' WITNESS WHEREOF, &r~b(y 1996. I have hereunto set my hand this ~ day of ~@~ HUBERT O. KElM O,\L WORKI WILLSlG092596L WPO - 2 - \.l-- 0\. \ ll'- ( \j " ~ ~. , The preceding instrument, consisting of this and two other typewritten pages, each identified by the signature of the testator was on the date thereof signed, published, and declared by HUBERT O. KEIM, the testator therein named, as and for his last will, in the presence of us, who at his request, in his presence, and in the presence of each other, have subscribed our names as witnesses hereto. ~u~~ GEORGE A. AUGEN, III Ld,~/ DIANE B. JENKINS Do\L WORK\ WILLS\GQ925961. WPD - 3 - COMMONWEALTH OF PENNSYLVANIA ) ( SS.: COUNTY OF CUMBERLAND ) I, HUBERT O. KEIM, being the testator whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that r signed and executed the foregoing instrument as my last will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein Sworn or affirmed to and acknowledged before me.Jby the testa~or., named above this .jZ!/I:J.ay of (lLC/U..{y/t..- ,1996. j1/AAOA ,--:I t;AAyL Notary Public . COMMONWEALTH OF PENNSYLVANIA ) ( SS.: COUNTY OF CUMBERLAND ) expres.4LJ r!?J€~:.~ k HUBERT O. KEIM NOTARIAL SEAl. FRANCES T. VAUGHN, Notary Public Hampden lWp.. Cumberland Co. PA My Commission Expires Aug. 9, 1999 WE, GEORGE A. VAUGHN, III, and DIANE B. JENKINS, the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the testator sign and execute the instrument as his last willi that he signed it willingly; that he executed it as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the testator signed the will as witnesses; and that to the best of our knowledge, the testator was at the time eighteen or more years or age, of sound mind, and under no constraint or undue influence. Sworn or affirmed to and Ii $ day acknowledged before me this of ~-r;"";;lJ!A ,1996. j;A/!/Cad,j W~ No ary Publ~c DolL WORK\ WILLS\G0925961. WPD ~a~;: GORGE A. GHN, III ~A>// d ~__~/ .- DIANE B. JENKINS NOTARlAI. sv.L FRANCES T. VAUGHN, Notary PublIC Hampden 1Wp.. Cumberland Co. PA My Commlulon expIres Aug. 9, 1999 COMMONWEALTH OF PENNSYLVANIA DEPAR,TMENT OF Fj,EVENUE BUREAU OF lND1VIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1712.8.0601 REV.1162 EXI11.96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT . GRIMES DIANE M 407 SPRINGHOUSE ROAD CAMP Hill, PA 17011 ------~- 1"ld EST A TE INFORMATION: SSN: 179-09-9238 FILE NUMBER: 2102-0741 DECEDENT NAME: KEIM HUBERT 0 DATE OF PAYMENT: 10/24/2002 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 07/27/2002 NO. CD 001769 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $8,000.00 I I I I I I I I TOTAL AMOUNT PAID: $8,000.00 REMARKS: CHECJ<#1009 SEAL INITIALS: JA RECEIVED BY: TAXPAYER MARY C. lEWIS REGISTER OF WillS RfV..tes EX+ (1.92) . SAFE DEPOSIT BOX INVENTORY COMMONWEALTH OF PENNSYlVANIA DEPARTMENT Of REVENUE INHERITANCE TAX DIVISION DEPT. 28D6<11 \1AIl.Il.\$iUlI.G, 1'" 11128-0001 .II... Please Print or Tvpe MUST BE COMPLETED BY REPRESENTATIVE Of fiNANCIAL INSTITUTION WHERE SAfE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS COUNTY CODE fiLE NUMBER SOCIAL SECURITY OR DEATH CERTIFICATE NUMBER ~l m.~)1 nq.oCl -Qd2.1 DATE OF D~ATH '\ \Cli \ SCC>~ (STAT.$]. (ZIP CODe) liO':::JS DECEDENT'S NAME (LAST, FIRST, MIDDLE) $Q,\ u\Q<r+ 0, ADDRESS OF DEC DENT ISTREET} ,ICIT'1) 63 \ ~ Cc.\o '0 le~~ Lxi vL.L I n \Q..c)('O '(\ i c'30'--\ NAME AND ADDRESS Of PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX (NAME) $\Q{lL m 6nf'<\e~i ~'t--oc.u---\-\\'tv (STREET ADDRESS) \.--\15l "('I '~ ~6, ~{Y'\ NAME, ADDRESS AND RELATlONSNIP (IF ANYI TO DECEDENT, OF PERSONtS) PRESENT AT THE BOX OPENING a. {NAME) (RELATlONSHIPl -r; \ of\", _ \Y1, 0" \1'N-:, ; \{x.,Q r \ l:.\-f IlL ({-,c9 m \ .l'jl ~ (STREfT ADDRESS (CITYI (STATE} "-'\ts ' ~O CQ'/)\ \ \ PR b. (~AM,E) r _ _. (~E T10NSHIPI _ lrYlY\ \.3Ju I i'<2- . A ICIT'1) \-n \ \, Pf-\ (STATEI \'-10\ \ (ZIP CODE) (ZIP CODE} 1,0\ \ (ZIPCODEI \STREB ADDRESS) II (RELA ON,* ~t\'I~::'I:)\.I\ 0"6 f>A (CITY} (STATE) \"\\bY (ZIP CODE} c. NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED P1\'\ +:, ~~ (STREET ADDRESS) \ (STATE) (ZIPCODfl ~\\\ ',dO ll\ b. (NAME) ~~ {ZIP CODEl (CITYI ISTREET ADDRESS) (STATE) (ZIP CODE) WAS A. Will IN THE BOX? DYES ~O If yes, 0. Date.,f will: b. Name and addre.s 0* personal repr.s.ntatlve, if narned in the will (NAME) (STREET ADDRESS) (CITYl (STATEl (ZIP COOE) c. Name and address of attorney, jf any (NAME) (STREET ADDRESS) (cm) (STATE) lZIP CODE) Page af SAFE DEPOSIT BOX INVENTORY INSTRUCTIONS (11 Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks OTe to be designated by l1'Ome of company, certiFicate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) Obligations of U. S. Government: Number 01 items, dote 01 issue, face value, names in which registered and type 01 ownership, i.e., iointly held, payable on death, etc. (4) Bonds: Designate by nome, amount, serial number, or other designation. (Bearer BondsJ (5) Bank and Savings and Loan Passbooks: State nome 01 depositor, number 01 book, lost date appearing in book, name 01 bonk and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe os lully os possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as lully as possible. (8) All other contents. ITEM NO. I ITEM DESCRIPTION ~ Inr"J,M \(j 'y-y-,y 'J I CERTIFY UNDE!l_PENA~TY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECEIVING COPY OF CORRECT ~ND COMPLETI TO THE BEST OF MY KNOWLEDGE AND BELIEF. SAFE DEPOSIT BOX INVENTORY, SIGNATU~' \\ \- ~ SIG~JURE 'J'/ /} ~ ~ . . -.-" //7 c./~. ^' - PRitT ~~-"""'-i ----7 ,-..' +E!~INT NAME AND CHECK APPR01.A.TE BOX BElOW, r Y"'I \n \ \J\ o,l'iJ /Y70-.1.-<r< 0 \1~ I \'J\n'i\O_ m C"-,r'(hO'\ Y ,,11(\, r\-r-,v- PRINT TITlE CHECK APPROPRIATE BOX, l~xecutor(triX) DAdministrotor(trixj I OE1>tate Repre\entoli.....e C Joint owner of sofe depo~it box NOTE: Attacn additional 8h" x 11" sneet (s) if necessary or use duplicates of this page of form. i I HIl,(- j q-cUUj nUN U j ; u~ rn HUnl:.::ilI:.AV GROUP FAX NO, 7177630290 p, 02/02 . CHANGE TO LISTING CONTRACT /"'\1 6 \ .~~.. l... ( b- k:....j _=#:: ICeS ;Z~1G 7 CLC PROPERTY BROKER (Com a y) SELLER _' ..,.;--. j,."c:..>- <Z. . DATE OF LISTING CONTRACT ~ -~I- 07 9 ~ ? ., LISTED PRICE $ I 7 &'/ 'iOQ Broker and Seller agree to change the terms of the above Listing Contract as follows: 1. 2. 3. Ending Date of the Listing Contqc;t is cha2fed to: Listed Price is changed to: $ I L. ~ 1 ()(") Appoint Designated Agent(s): Seller renounceS the agency relationships held wilh all licensees affiliated with Broker who are not Designated Age"" for Seller. Remove Designated Agent(s): 4. ~ All other terms and conditions of the Listing .9.ontract r"main unchanged and in full force and "ffect. / / SELLE~ Al2u'~'./ /JJ qlu./yh"i.-? DATe+--~/~:;~ SELLER f DATE I SELLER ' DATE BROKER (Company Name) -;T;.,._ g,-,_"",-~",-C C~"11"" J I ACCEPTED BY DATE ~?~(6L ~ penn.ylvant. A.eocietlon of COPYRIGHT PENNSYLVA.NIA AliSOClAT NO aF..ALTOtlS- 19'16 LJ::! REALTORSCIl ~/OI LISTING CONTRACT XLS EXCLUSIVE RiGHT TO SELL REAL PROPERTY This form recommended and approved for, but nOI restriCled 10 use by, the members of the Pennsylvania Association of REALTORSe (PAR) BROKER(COmp~~ =r; ~ ~ii.~~~EE(~;/ . .? L. . <> 2:l . /7?t::<; /- y.(>1'/ ~/:.r, PRICE $ /7,? 9~t.2 L PROPERTY Add.." 53/ Municipal%(ciIY, bo County (~', Zoning and Present Use Identification Num~r.iFor example. tax id!;(ltification number; parcel number; deed book, page. recording date) /3- Cil<l- 07'-13-/&1 2. STARTING & ENDING DATES OF LISTING CONTRACT (also called "Term") A. No Association of REALTORS@has set or recommended the term of this contract. By law, the length or tenn of a listing contract may not exceed one year. Broker and Seller have di.scussed and agreed upon the length or term of this contract. B. Starting Date: This Contract starts when sig~ ~ker and Seller, ~ss otherwise Slated here: C. Ending Date: This Contract ends on ,,~~. ;:;;,~ - .> '0 " " 1:! '" " " 13 " " " " C,H " 17 18 19 3. PURPOSE OF THIS CONTRACT Seller is hiring Broker to market Property and to find a buyer. Seller will refer all offers 20 and inquiries to Broker. Seller anows Broker to use print andlor e)ectronic advertising, including interior and exterior 21 photogra.phs. Broker is acting as Seller Agent, as described in the Consumer Notice. 22 4. BROKER'S FEE No Association of REALTORS@ has. set or ~~nded the Broker's Fee. Broker and Seller have 23 negotiated the fee that Seller will pay Broker. The Broker's Fee is ((Jo//') of/from the sale price and 24 paid by Seller. 15 5. COOPERATION WITH OTHER BROKERS Licensee has explained Broker's company policies about cooperating with 26 other brokers. Broker and Seller agree that Broker will pay from Broker's Fee a. fee to another broker who procures the buyer, 27 is a member of a Multiple Listing Service, and who: 28 A. represents tl)t' Seller (SUBAGENT). 29 o No ~Yes If Yes. amount: of/from the sale price. 30 B. represents a buyer (BUYER'S AGENT). A Buyer's Agent, even if compensated by Broker or Seller, will represent 31 the interests f)f the buyer. 3Z o No ~Yes If Yes, amount: of/from the sale price. 33 C. does not rePlJRnt either the Seller or a buyer (TRANSACTION LICENSEE). o No CY'Yes If Yes, amount: of/from we sale price. 6. PAYMENT OF BROKER'S FEE " A. SeUer win pay Broker's Fee if Property, or any ownership interest in it, is sold or exchanged during the term of this 37 Contr.act by Broker, Broker's agents, Seller, or by any other person or broker, at the listed price or any price 38 acceptable to Seller. 39 B. Seller will pay Broker's Fee if negotiations that are pending at the Ending Date of this Contract result in a sale. e. Seller will pay Broker's Fee after the Ending Date of this Contract IF: (1) A sale occurs within 3i1... days of the Ending Date, AND (2) The buyer was shown or negotiated to buy the Property during the term of this contract. SeUer wilt not owe Broker's Fee if the Propert,}' is listed under an "exclusive right to sell contract" with another ~J broker at the time of the sale. 45 7. BROKER'S FEE IF SALE DOES NOT OCCUR 46 A. Seller will pay Broker's Fee if a ready, willing, and able buyer is found by Broker or by anyone, including Seller. 47 A willinx buyer is one who will pay the listed price or more for the Property, or one who has submitted an offer accepted 43 ~&llu 49 B. If the Property or any part of it is taken by any government for public use (Eminent Domain), Seller will pay Broker 50 - 0 -:- of/from any money paid by the government. C. Jr a buyer signs an agreement of sale then refuses to buy the Property, or if a buyer is unable to buy it because of failing to do all the things required of the buyer in the agreement of sale, Seller will pay Broker: 53 (I) !;"i?% of/from buyer's deposit monies, OR )4 (2) the Broker's Fee in Paragraph 4, whichever i.s less. 55 8. DUAL AGENCY Seller agrees that Broker may also represent the buyer(s) of the Property. The Broker i.~ a DUAL AGENT 56 when representing both Seller and the buyer in the sale of a property. ';7 9. DESIGNATED AGENCY 58 o Not Applicable, 59 )Z/' Applicable. Broker may dc.~ignalc licensees 10 represent the separate interests of Seller and the buyer. Licensee (identi- 60 ficJ abuve) is the Designated Agent. who will act exclusively as lhe Seller Agent. If Property is introduced to the buyer 61 by a lic~nsee in the Company whp is not representing the buyer. then that licensee is authorized to work on behalf of Seller. 62 If Licellsce is also the Buyer's Agent, then Licensee is a DUAL AGENT. 10. BROKER'S SERVICE TO BUYER Broker may provide services 10 a buyer for which Broker may accept a fee. Such M services may include. but are not limited to, deed/document preparation; ordering certifications required for closing; financial services; title transfer and preparation services; ordering insurance, construction, repair, or inspection services. Broker will 66 disclose 10 :)el\er if any fees are to be paid by Buyer. 67 II. OTHER PROPERTIES Seller agrees that Broker may list other properties for sale and that Broker may show other prop- 6B crtics lO prospective buyers, 69 12. CONFLICT OF INTEREST A conflic/ of in/ere.u is when Broker or Licensee has a financial or personal interest where 7D Broker or Licensee cannot put Seller's interests before any other. If Broker, or any of Broker's salespeople. has a confliL'lof 71 interest, Broker will nofify Seller in a timely manner. 72 '" Selle, Init;,I,: itl1:J;", XLS Page I of 3 m Pennsylvania iatlon of COI>YRIGIIT I>~:NNSYLVANIA ASSOCIATION OF REALTORS<<> 19% L.J:! REALTOR~~ 711)1 "'''',,- --"'-"_.~- " " '" " '" !~ " " " 25 16 " '" 10 " " " OJ 3J " J5 " 36 J1 '" 39 '" .0 " " ,j? " " " " ~~ '" " '" '" ;c 'J' " ~< " ;; " ," 56 " 5~ (,n ,., ~;' f'J S3 "' ~", ., '" "' "' f.'1 " " I: Brokerll..icensee Initials: " !y 13. SE;rTLEMENT & POSSESSION " A. 'Preferred ~ett!ement Date: I~ B. Seller will give possession of the Property to Buyer at settlement or on 3-e fl. 76 C. (]) If the Property, or any part of it, is rented, Seller will give any leases to Broker before signi is Contmc\. 77 (2) If any leases are oral, Seller will provide a written summary of the terms, including amount of rent, ending date, and 7B Tenant's responsibilities. 7~ (3) Seller win not enter into or renew any. lease during the tenn of this Contract except as follows: aD " B2 S3 "" "' ," " " Mortgage with U)~ 87 Address / ~_ _ Phone sa Acct. # ,...........- Amount of balance $ a9 Equity loan with -- 90 Address Phone ~1 Acct. # Amount of balance $ 92 Seller authorizes Broker to receive mongage payoff and/or equity loan payoff .infonnatlon from 93 the lender. 9~ Past Due Taxes Amount owed $ 9~ Judgments Amount $ 96 Type 97 Municipal Assessmenls Amount $ 9a Other 99 Amount $ 100 C If Seller, ill any timo.: on or since January], 1998, has been obligated to pay sUPPOI1 under an order that is on record in any 101 Pennsylvania cOllnty, list the county and the Domestic Relations Number or Docket Number: 10.2 15. MULTIPLE LISTING SERVICE (MLS) (Complete if Broker is a member of an MLS) 103 ft Broker will use a Mu]tip]e Listing Service to advertise the Property to other real estate salespersons, who can lell their 104 clients amI customers about it. SeUer agrees that the MLS, the Broker, and the Licensee are not responsible for mistakes 105 in the MLS description of the Propeny. 106 o Broker will not use a Multiple Listing Service to advertise fue Property to other real estate salespersons. 107 16. PUBLICATION OF SALE PRICE lOB A. Seller is aware that newspapers may publish the final sale price after settlemenl. 1U9 B. Seller will allow publishing of the sale price after Seller accepts an agreement of sale. 110 DYes 7No 111 17. SIGNS & KEYS Seller allows (where pennitted): 112 ftYes 0 No Sale Sign AYes 0 No Sold Sign 113 DYes 0 No Key in Office ;,zrves 0 No Lock Box 114 DYes 0 No 115 18. ITEMS INCLUDED IN THE PRICE OFTHE PROPERTY lIb /\. Included in the sale and purchase price are all exisling items permanently insfalled in the Property, free of liens. including IIi plumhing; heating; lighting fixtures (including chandeliers and ceiling fans); water treatment systems; pool and spaequipmenL \1'j garage uoor opener~ and transmitters; television antennas; shrubbery, p]antings, and unpotted trees; any remaining heating and 11'1 cooking fuels stored on the Property at the time of settlement; wall to wall carpeting; window covering hardware, shades, and 1~(I blinds; built-in air conditioners; built-in appliances, and the range/oven, unless otherwise stated. Also included: 1<'1 14. TITLE A. At settlement, Seller will give full rights of ownership (fee simple) to a buyer except as follows: (]) Mineral Righls Agreements (2) Other B. Seller has:r;('" o Yes/", No " :101 Ii:, "', "" '" DYes o No 'I' " 'n 'J-l DYes o No % DYes DYes o No o No % 'J~ DYes DYes o No o No 1I1~ Ii" 'U/ 1 U~ '00 l,ti 'II I". 1 ~:i I.,~ ib in 12:1 C',I B. 0 See att;u:hed sheet for addi(\onal items included in the sale. 19, ITEMS NOT INCLUDED IN THE PRICE OF THE PROPERTY The follo~ ile s are not indu e purchase and rice of the Property: A.~ 1 2~, :;'1, 1 ~6 lH B hems leased by the Seller C. 0 See atla",hed .~heet for additional items not included in the sale. 20. SELLER WILL REVEAL DEFECTS & ENVIRONMENTAL HAZARDS A. Seller (iacluding Sellers exempt from the Real Estate SeHer's Disclosure Act) will disclose all known materia] defects 1Jl and/(lr environmental hazards on a separate disclosure statement. A ma~erial defect is a problem 01 condition Ihat: (J) is 11 possihle danger to those living on the Property, or (2) hilS;1 significllnt, adverse effect on the value of the Property. B. 1f Seller fails 10 tell of known materia] defects and/or environmental ha7.ards, (I) Scll~r will nol hold Broker or Licensee responsible in any way; (2) Scll~r will pHltccl Broker and Licensee from any claims, law:mi\s, and actions thaI result; nJ Scllcr will P:1Y all of Broker's and Licensee's costs that re.~ult. Thi.~ includes allorneys' fees and cotJrHlrde!"ed pay- i:1:i lllellls or SL'ltlL'lllell1s (mnney Broker or Licensee pays to end a I:lwsuit or claim). HY 21. IF PUOPERfY WAS BUILT BEFORE 1978 The Residenlial LemJ-Based Paint Hazard Reduction Act says that any Seller 1~1I of property bJil1 before 1978 must give the buyer an EPA pamphlet titled Protect Your Family From Le(/d ill }(Jllr Home. The 1.11 Selle\" ah.o mJ~1 lell \he buyer and the Broker whut the Seller knows about lead-based pain! and lead-bused paint hazards that arc in or on tilL: property being sold. Seller must tell the buyer how the Seller knows that lead-based paint and lead-based paint IV h,l/.ards arc 01 the property, where Ihe lead-based paint and tead-ba.o;,ed paint hazards are, the condition of tbe painteo surfaces, \~l iUllJ ;IIlY other information Se]ler knows about lead-based paint and lead.based paint hazards on the property. Any Seller of a 14.1 prc-] 97K structure Illust also give the buyer any n:cords and reports that the Seller has or can get about lead-based paint or 1'15 kau-haseu [lailll hazards in or around the property being sold, the common areas, or other dwellings in multi-family housing. 14(; At:coruing to tho.: At.!. a Seller must give a buyer] 0 days (unless Seller and the buyer agree to a dilTerent period of time) from HI the time ,Ill :I:!l"l'o.:mclH of sale i" signed 1(1 have.\ "risk ;ls:;es:;ment" or inspection for po.~sible lead-based paint hilzards done 1~8 un the properly, Buyers limy choose nOI 10 h.lve the risk assessment or inspection for lead paint hazards done. If the buyer 1~9 o:hooscs not III 1]:Ive till: assessment or inspcction, the buyer must inform the Seller in writing of the choice. The A{:\ does not \';,0 ro.:4uire the Seller to inspect for lead paint hazards or to correct lead paint hazards on the property. The Act does nOI apply 10 151 housinl!, built ill IY7K or later, Seller Illi1i:IS; iJJ/: J In 1 ~~ loll In 133 1:\~ 1 3~, lJb 131 m XLS Pall:e 2 of 3 IlrokerlLicenSlLt Initials: 153 22. DEPOSIT MONEY 1~~ 1','j A.', Broker, of any person Seller and the buyer name in the agreement of sale, will keep all deposit monies paid by or for the \~'O i;,L buyer in an escrow account. If held by Broker, this escrow account will be held as required by real estate licensing laws 156 61 and regula~ions, Seller agrees that the person keeping the deposit monies may wait to deposit any uncashed check that is 157 15~ received as deposit money until Seller has accepted an offer. 168 I';S B. If Seller joins Broker or Licensee in a lawsuit for the return of deposit monies, Seller will pay Broker's and Licensee's 16S l~<l attorneys' fees and costs. 1M 11': 23. RECOVERY FUND Pennsylvania has a Real Estate Recovery Fund (the Fund) to repay any person who has received a final 151 Ir,? court ruling (civil judgment) against a Pennsylvania real estate licensee because of fraud, misrepresentation, or deceit in a real 162 'CJ estate tr,msaction. The Fund repays persons who have not been able to collect the judgment after trying all lawful ways to do Ili3 164 so. For complete details about the Fund, call (717) 783.3658, or (800) 822~2113 (within Pennsylvania) and (7t7) 783-4854 1&4 lG~ (outside Pennsylvania). 165 166 24. TRANSFER OF THIS CONTRACT 166 )',' A. Broker wi\} nOlify Seller immediately in writing if Broker transfers this Contract to another broker when: 167 Hi8 (I) Broker SlOps doing business, OR 168 16g (2) Broker forms a new real estate busi.ness, OR 16g :!a (3) Broker joins his business with another. 170 Seller agrees that Broker may transfer this Contract to another broker, Broker will notify SeHer immediately in writing 1/1 1.2 when a transfer occurs or Broker will lose the right to transfer this Contract. Seller will follow aU requirements of this 17l 1/3 Conlract with the new broker. m i:-1 B. Should Seller give or transfer the Proper:y, or an ownership interest in it, to anyone during the term of this Contract. all 114 I h owners will follow the requirements of this Contract. 17~ IiI> 25. NOTICE TO PERSONS OFFERING TO SELL OR RENT HOUSING IN PENNSYLVANIA Federal and state laws m 111 make it illegal Cor a seller, a broker, or anyone 10 use RACE, COLOR, RELIGION or RELIGIOUS CREED, SEX, DrSABI- 117 ",_ L1TY (physical or mental), FAMILIAL STATUS (chj,ldren under 18 years of age), AGE (40 or older), NATIONAL ORIGIN, 17B ; 'j USE OR HANDLINOffRAINING OF SUPPORT OR GUIDE ANIMALS, or the fACT OF RELATIONSHIP OR ASSOCI- 17g leG ATION TO AN INDIVIDUAL KNOWN TO HAVE A DISABILITY as reasons for refusing to $et!. l>how, Qr rem propenies, \3U rol loan money, or set deposit amounts, or as reasons for any decision relating to Ihe sale of propeny. m Ii<! 26. NO OTHER CONTRACTS Seller will not enter into another listing agreement with another broker that begins before the 18;' !:'.l Ending Dale of this Contract. TH3 1"., 27. ADDITIONAL OFFERS ONCE SELLER ENTERS INTO AN AGREEMENT OF SALE, BROKER IS NOT REQUIRED 184 la~ TO PRESENT OTHER OFFERS. la, 28. ENTIRE CONTRACT This Contract is the entire agreement between Broker and Seller. Any verbal or written agreements la6 Ibi that were made before are not a part of this Contracl lai ,,''" 2!i. CHANGES TO THIS CONTRACT All changes 10 this contract must be in writing and signed by Broker and Seller. TaG log 30, SPECIAL INSTRUCTIONS The Office of the Attorney General has not pre-approved any special conditions Qf additiQnnl m ;~~ terms added by any parties, Any special conditions or additional terms in the Contract must comply with the Pennsylvania 190 191 Plain Language Consumer Contract Act. 191 1~I HJ '" m ADDITIONAL INFORMATION (OPTIONAL) ,YO 31. TAXES, UTILITIES, & ASSOCIATION FEES m A. At settlement, Seller will pay one-half of the total eal E tate Transfer Taxes, unless otherwise stated here: '"" ,go B. Real Estate Pmperty Tax Assessment $ Wage/Income Tax C. Estimated Utilities (trash, waler, sewer, ric, gas, oil, etc.) Yearly Taxes $ Per Capita Tax $ 2~U 2Ul 2", 2\\~ D. Association Fees $ Include: ,D4 E. Other 205 32'jYER FINANCING Seller will accept the following arrangement" for buyer to pay for the Property: tOn Cash 207 Buyer will apply for a mongage. Type(s) of mongages acceptable to Seller are: 20a tt'Yes 0 No Convemion~l 0 Yes 0 No FHA 209 ;{i' Yes 0 No VA 0 Yes 0 No m 0 Seller's help to buyer (if any): ?11 "1 Seller has read the Consumer Notice as adopted by the State Real Estate Commission at 49 Pa. Code ~35.336. : 1.', All Sellers must sign this Contract. " SELLER IS ADVISED TO CONSUI.; AN TTORNEY. ?14 'P DATE.1' 0:::- SS# 1& ~ :~4/ ~ v/o.I 11 ,") I I E-Mail I '> SELLER -If /16 :'17 Name (print; I /'( Mailing ~dress '-!u-, Phone #l.:1- I) ) (.. ( <-- ''-'S{ H FAX # :'lB i<, 7'2.'7 :'19 m SELLER Name (print) Mailing Address ~: :~~::;ffZii.r~~7F~~::~n,1Jt$Z DATE SS. 7:-1 :';'? 229 2JD XLS Page 3 of 3 192 '" '" m 196 '" '" "" "" 20> 202 '"' '"' 205 '"' '"' ,"a 2", 219 '" ?12 :'13 ?1~ 216 217 218 m 22Q m :122 ~23 224 m 220 m 12B 229 no . October 18, 2002 CHERYL L BAKER 320 MARKET STREET PO BOX 1268 HARRISBURG, PA 17108 IDS LIFE INSURANCE COMPANY AMERICAN EXPRESS FUNDS AMERICAN EXPRESS CERTIFICATE COMPANY AMERICAN EXPRESS BROKERAGE 701 DO AXP Financial Center Minneapolis, MN 55474 Thank you for your recent inquiry regarding HUBERT 0 KEIM's accounts. These are the values of the accounts as of 07/27/2002. Mutual Funds Account Number 010645107128002 020645107127002 Annuities - Post 1985 Account Number 93002628476 8 004 Total Value $13769.69 $6503.52 Total Value $16709.07 # of shares 729.327 361.106 @ Asset Value Per Share 18.880 18.010 # of shares Asset Value Per Share Please note that the values indicated for any Life Insurance product(s) reflect the gross death benefit at date of death, not the cash value. The date of death values provided are for estate tax purposes and are not a value to be paid. Accounts may be subject to market fluctuation as governed by each product. We appreciate the opportunity to be of service to you. Please contact us if you have any questions. Sincerely, Suzanne Lunemann Death Settlements Processing Team 70310 AXP Financial Center Minneapolis, MN 55474 888-723-8476 Enter 85193 Insurance and annuities are issued by IDS Life Insurance Company, an American Express company. American Express Brokerage (s provided by American Express Financial Advisors inc, American Express Financial Advisors Inc. MemberNASD. American Express Company is separate from American Express Financial Advisors Inc. and is not a broker-dealer. . !l allfirst . September 18, 2002 Goldberg, Katzman & Shipman, P.c. Ann: Cheryl L. Baker, CLA 320 Market Street, Strawberry Square P.O. Box 1268 Harrisburg, Pennsylvania 17108.1268 Allfirst Financial Center N.A. Po. Box 900 Millsboro, DE 19%6 RE: Estate of Hubert O. Keirn Date of Death: July 27, 2002 Sodal Security Number: 179-09-9238 Dear Ms. Baker: In response to your request, please be advised of the following accounts the above-named decedent had with this bank and their balances on the date of death. 1. Account Type........................... Relationship w/lnt. Checking Account Account Number....................... 0050536974 Ownership (Names 01)................ H.O. Keirn or Mrs. Eileen Keirn Opening Date........................... 08/28/64 Balance on Date of Death...........$ 3,412.60 Accrued Interest....................... .12 Total......................................$ 3,412.72 2. Account Type........................... Safe Deposit Box Account Number............::......... 00001000469100020020 Ownership (Names 01)................ H.O. Keirn or Mrs. Eileen Keirn or Diane M. Grimes Opening Date........................... 09/28/00 Balance on Date of Death...........$ N/A . . Page 2 September 18, 2002 This response does not apply to any assets held with AI/first Brokerage, where Allfirst Bank is serving as a trustee, nor to any credit cards owned by Bank of America bearing AI/first Bank's name. For further account information, closures and/or reimbursement of funds refer to below branch: 1200 Market Street, Lemoyne, PA 17043, telephone 717-255-2271. Sincerely, ~'A.-4//~~ . 'm.d. ~ Mary Anne Macielag Associate I/CIS (302) 934-2240 . -ttstR BLOCK financial advisors account statemen" Statement Period 06/28/2002 To 07/31/2002 Account Number 129 01233 934 . Your Representative JOHN K. RICHARDS (717) 238-9000 H&R BLOCK FINANCIAL ADVISORS THE 225 MARKET STREET BLDG 225 MARKET ST STE 100 HARRISBURG PA 17101 2126 l103ZtIIOl"'To.~ -..t.UTO n0401011_-:W1l"24 oolOllll2011 1...111...111"..1.1..1.1...11..1..11...11.1.....111.1..1.1..1 HUBERT KEIM & EILEEN KEIM 5319 COBBLESTONE DR MECHANICSBURG PA 17055-3479 Page 1 of Customer Objectives/Experience , Risk Tolerance of Investor: Moderate Income and Growth - - Investment Objectives: - - Investment Exper i ence: Stocks Bonds Years of experience 6 Trades per year 1 Average size of trade 100 If this information is incorrect, please submit changes in writing and mail to: H&R Block Financial Advisors, Inc., Compliance Dept., 751 Griswold, Detroit, MI 48226 Opt ions - - - - - - - - Account Summary - - Account Value Cash Stocks & Options Net Equity As of 06/28/02 % .08 18.160.00 100.0 18,160.08 As of 07/31/02 % .08 15,470.00 100.0 15,470.08 - - - Income Summary Source of Income Credit Interest This Month Year-to-Date .08 Account Activity Date Transaction Quant 1 ty Description Price AlIlOl.I1t Type 7/03 Sold 7/03 Check PaId 60- SCOTIS CO CL A ISSUED CHK N 12643099 46.000 2.682.16 1 2.682.16- 1 Your Portfo 1 io Quantity Description Symbo 1 Closing Price As of 07/31/02 Value Type 340 Stocks & Options SCOTTS CO CL A SMG Net Market Value of Priced Securities as of 07/31/02 45.500 15,470.00 15,470.00 End of Statement ~J:'1Il' as::VS:AC:::p C:;:lnll:' I:'na IUDna..."..... .Nl:ftaUATlnu UG" n.__'. ...:____1_. .. -'__,_____ .__ _ ..__..._~ uV'C!'Ie. c....... 320 bI:rRKE~r S~rRI<E~r S~rR.nrr~RERRt~ S~~i~;rRH; P.O. Bos ]268 H~RRISR1~RC, Pt:ti~~si~l.r~.~;vin 17108-1368 717.234.4161 • 717.'34.6808 (Fnx) GOLDBERG, KATZMAN ~ SHIPMAN, P.C. Arrc~R~eis ,rr L.rw October 24, 2002 ol~ co~~!~sFl. Register of Wills F. LEE. SHlhal~r. Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013 c~~1~v5E1, Josln.r D. LocK :~R~~J[.D B. I;~>,;:r~ Re: Estate of Hubert O. Keirn, deceased No. 2002-00741 ARl'FIIl2 L. CiOL.I)ISI'.R<i Dear Sir or Madam: ~ ~ y; i _ ~ ~~~~~ ~ i{:ARKS B. (iOLI)Rb;RG ~ 96 ~ - ~ 998 ~ Enclosed is check number 1009 in the amount of Eight Thousand Dollars ($8,000.00) as apre-payment for Pennsylvania Inheritance Tax for the above- referenced Estate. At your convenience, please forward to us a receipt for this Ro~,rl.l> >I. K:~rzr,,ru payment. P:vl. ~. F.shosrrrl \F:11. E-IE:~nE:Rli~~l~ If you have any questions, please feel free to contact me at the above ~. J.r,~ c~>I>1'ER ~ ~ telephone number. ~ Hl>~LAS E. I3RP,5SF:R )oti~~ :~. S~r~rr,.sR Very truly yours, ... .. :~1'RII. ~.. s~~~R:r`~,->;1-r:r,. Gt~~i~ H. BRUOK5 ,~FI'Pf~:R.ti(1A ~. SF111'rlA,'~ r '~ ~~ ~~_ ~~ JFRRr J. R15s~~ . ~ Che .Baker, CLA ~II<:F14FI. ~. c:R(>~:Ea~l _ , Certified Legal Assistant I I;F R , 11 r, r J ~~ s~rH:r~ta r:. GRI~~K Enclosure Joli~~ nF:L~~RF~zo ]x,11 ~~ R. Nlti~o~Kr. 84700.3 Ru~~cE L. ~IoaRis D.gr~1n A(. S"I~F.CAF:I. HF;rri~eR L. FER\SI.F.R C :IRLISLE OFFICE: 7I 7.24S.0S97 • PORK OFFICE: 717.843.7912 IN RE: ESTATE OF IN THE COURT OF COMMON PLEAS HUBERT O. KEIM, :CUMBERLAND COUNTY, PENNSYLVANIA Deceased :ORPHANS' COURT DIVISION No. 2002-00741 CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Hubert O. Keim deceased Date of Death: July 27, 2002 Will No. Admin. No. 2002-00741 To the Register: I certify that notice of estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on September 13, 2002: Eric D. Keim 8961 Turin Hill Court North, Dublin, OH 43017 Jeffrey L. Keim 2260 Loussac Drive, Anchorage, AK 99516 Diane M. Grimes 407 Springhouse Road, Camp Hill, PA 17011 Notice has now been given to all persons entitled thereto under RuleJ5.6(a) except N/A . ~= i ~ / l ~~/r Date 1 ~ ~ ~ e ~- Signature Name '„~ohn DeLorenzo, Esquire Address Goldberg, Katzman & Shipman, P.C. P.O. Box 1268 Harrisburg, PA 17108-1268 Telephone (717) 234-4161 Capacity: Personal Representative X Counsel for personal representative Register of Wills of Cumberland County, Pennsylvania (~ INVENTORY Estate of Hubert O. Keim No. 2002-00741 also known as Date of Death July 27, 2002 Deceased Social Security No. 179-09-9238 Personal Representative(s) ofthe above Estate, deceased, verifythat the Items appearing in the toNowirtg inverttary include aA ofthe personal assets wherever situate and aA of the real estate in the Commonwealth of Pemsylwania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedertrs death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvaniaexceptthatwhichappearsinamemorandumattheendofthisinventory. WVeverifythatthe~rr~adeinthislnventoryaretrue and correct. UWe understand that false statements herein are made subject tothe penalties of 18 Pa. C.S. Section 4904 relating to unsvuom falsification to authorities. Pe /~al Representative: , ~,~ Name Y /_~~C-, ~~ ~- ~ ~'~,~'-/yx'r'~ , ~~~C Attome : John DeLorenzo, Esq. f>'.?u ~ ~, I.D. No.: 72190 r~~ Address: Goldberg, Katrman & Shipman, P.C., 320 Market Street, Dated ~ 1 ~ u~ P.O. Box 1268, Harrisburg, PA 17108-1268 Telephone: 717-234-4161 Description 1. Real estate located at 5319 Cobblestone Drive, Lower Allen Township, Cumberland County, PA - valued per listing agreement 2. 729.327 shs in mutual fund held by American F~cpress in Account No. 010645107128002 18.88 -valued per letter dated 10/1 S/02 3. 361.106 shs in mutual fund held by American Expret;s in Axount No. 020645107127002 18.01 -valued per letter dated 10/18/02 4. 340 shs Scotts Co Class A held by H8R Stock in Account No. 12901233934 @44.35 - valued per intemet search 5. Allfirst Bank Checking Account No. 0050536974 -valued per letter dated 9/18/02 6. Allfirst Bank Checking Account No. 0050536974, accrued interest -valued per letter dated 9/18/02 7. H8R Block Account No. 12901233934 -valued per statement dated 6/28/02 to 7/31/02 8. Miscellaneous personal property 9. 1986 Oldsmobile Defta 88 -valued per sales price 10. Comcast Cable -refund of account (Attach Additional Sheets if necessary) Value $163,900.00 13,769.69 6,503.52 15,079.00 3,412.60 .12 .08 500.00 1,000.00 9.85 Total: 5204.174.86 NOTE: TheMerrbrandimdn3alestaieoulsidelheOorrrnor~aeaMhdPenr~Mar~ie mey,attheelection dthe penorml representative, indudethevaluedeach iiem,dtsuch figures should not be extended into the total of the Inventory. 320 Mnanti:~r S~rae:i:T • S~rHNYVnr;akv SQtrAkH. P.O. Box 1268 HARRISftCRG, YrNnsvi.vnvin 17108-1268 717.234.~16t • 717.234.6808 (FAx) U1~7 of co~~;.~E~. H. ~, F:E SHIPAIAI~ co~~hSH:~. Jost~~A D. Loci ~kxoi.u H. Koc.a~ AR"fHl"H 1.. GOI,DBF.RG (1951-3000? HARRY R. GOLUR[RG 0963-i998~ Ro~_v.i~ !~1. KA~ri~i.~~ P:v i. J. H;s~~osrro \ttn. Hr•:n~~r:ks~io~- ?. J ~~~ (:oo~~H.H ~1~110~1:1ti F.. BRh.'~SP,R JoFix :~. S i-~~ri.F:H dean, 'I,. S~rkA~.~c-Ki~r» GrY H. Baooh~ JH:EF~i-:u.~~~~ -). Sftii~ni:Y~ JF.aati ]. Ri~.SSo \([CI-fAh:I. ~. CROCkiV'/,I "a'no.tiias J. ~~'i~;wr.a jon~ DF:LoaH:~ro ]on~~ R. A~~oshY ~RoY<:~: L. A1~~aais DA~m ~I. S~rF:~_:h~~-i HH:A~rnr:a L. P:rrea~o GOLDBERG, KATZMAN c`a~ SHIPMAN, P.C. A ~- r o a N H: Y s n r L n w April 16, 2003 Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013 Re: Estate of Hubert O. Keim, deceased No. 2002-00741 Dear Sir or Madam: Estate: Enclosed are the following documents for filing in the above-referenced 1. An original and two (2) copies of the Pennsylvania Inheritance Tax Return. 2. An original and two (2) copies of the Inventory. 3. Check number 1042 made payable to "Register of Wills" in the amount of Twenty-five Dollars ($25.00) for the filing fee of the Return and Inventory. 4. Check number 1041 made payable to "Register of Wills, Agent" in the amount of Seven Hundred Ninety-one and 56/100 Dollars ($791.56) for the additional inheritance tax due and owing. Please time-stamp the extra copies and return them to me in the enclosed self- addressed, stamped envelope. If you have any questions, please feel free to give me a call. Very truly yours, Cheryl L. Baker, CLA Certified Legal Assistant Enclosures cc: Beneficiaries 84700.4 C;ARLISLF: Or•FtcF: 717.345.0597 • YoaK Orricr: 717.841.7913 ~~j ~\ STATUS REPORT UNDER RULE 6.12 Name of Decedent: HUBERT O. KEIM Date of Death: July 27, 2002 Will No. Admin. 2002-00741 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: State whether administration of the estate is complete: Yes X No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes No X b. The separate Orphans' Court No. (if any) for the personal representative's account is: Did the personal representative state an account informally to the parties in interest? Yes X No d. Copies of receipts, releases, joinders and approvals of formal or information accounts may be fi w' the Clerk of the Orphans' Court and may be attache to r P Date: ~ ~ ~ (~ ~ John DeLorenzo, Esquire Goldberg, Katzman & Shipman, P.C. 320 Market Street P.O. Box 1268 Harrisburg, PA 17108-1268 (717234-4161 Capacity: Personal Representative X Counsel for personal representative ~' ~ COMMONWEALTH OF PENNSYLVANIA BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, Pa 17128-0601 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 ER AFP (01-33) ~-;~: DATE 06-09-2003 ESTATE OF KEIM HUBERT 0 DATE OF DEATH 07-27-2002 FILE NUMBER 21 02-0741 JOHN DELORENZ~jESQJ~~J 1 ~ ~' ~ .~~ COUNTY CUMBERLAND ACN 101 GOLDBERG ETAL Amount Remitted PO BOX 1268 l~ ~" HBG „t;t'~~~PA..17108 MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~ ---------------------------------------------------------------------------------------------------------------- REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF KEIM HUBERT 0 FILE N0. 21 02-0741 ACN 101 DATE 06-09-2003 TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) 163,900.00 NOTE: To insure proper 2. Stocks and Bonds (Schedule B) (2)- 35,352.21 credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule C) (3) .00 submit the upper portion 4. Mortgages/Notes Receivable (Schedule D) (4) .00 of this fora with your 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 4,922.65 tax payment. 6. Jointly Owned Property (Schedule F) (6) .00 7. Transfers (Schedule G) (7) 16,709.07 8. Total Assets (g) 220,883.93 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9] 12,167.39 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 3.991.78 11. Total Deductions (11) 1 6 .1 q _ 17 12. Net Value of Tax Return (12) 204,724.76 13. Charitable/Governmental Bequests; Non-elected 9113 Trus ts (Schedule J) (13) .00 14. Net Value of Estate Subject to Tax (14) 204,724.76 NOTE: if an assessment was issued previously, lines 14, 15 andior 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) .0 0 X 00 _ .00 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 204,724.76 X 045 . 9,212.61 17. Amount of Line 14 at Sibling rate (17) .00 X 12 - .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) •00 X 15 - .00 19. Principal Tax Due (19)= 9,212.61 TOY CRFIITTC. DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID 10-24-2002 CD001769 421.05 8,000.00 04-16-2003 CD002466 .00 791.56 TOTAL TAX CREDIT 9,212.61 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 ZF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN 51, NO PAYMENT IS REQUIRED. 7R CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) 2ESERVATION: Estates of decedents dying an or before December 12, 1982 -- if any future interest in the estate is transferred in possession or enjoyment to Class B (collateral] beneficiaries of the decadent after the expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes at the lawful Class B (collateral) rate on any such future interest. ?URPOSE OF NOTICE: To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act 23 of 2000. (72 P.S. Section 9140). PAYMENT: Detach the top portion of this Notice and submit with your payment to the Register of Wills printed on the reverse side. --Make check ar money order payable to: REGISTER OF HILLS, AGENT REFUND (CR): A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an ^Application for Refund of Pennsylvania Inheritance and Estate Tax^ (REV-1313). Applications are available at the Office of the Register of Wills, any of the 23 Revenue District Offices, or by calling the spacial 24-hour answering service for forms ordering: 1-800-362-2050; services far taxpayers with special hearing and / or speaking needs: 1-SDD-447-3020 CTT only). OBJECTIONS: Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment of tax (including discount or interest) as shown on this Notice must object within sixty (60) days of receipt of this Notice by: --written protest to the PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR --election to have the matter determined at audit of the account of the personal representative, OR --appeal to the Orphans' Court. ADMIN- ISTRATIVE CDRRECTIONS: Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue, Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 17128-0601 Phone (717) 787-6505. See page 5 of the booklet ^Instructions for Inheritance Tax Return for a Resident Decedent" (REV-1501) for an explanation of administratively correctable errors. DISCOUNT: If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (5%) discount of the tax paid is allowed. PENALTY: The 15% tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation penalty is appealable in the sane manner and in the the same tine period as you would appeal the tax and interest that has been assessed as indicated on this notice. INTEREST: Interest is charged beginning with first day of delinquency, or nine (9) months and one C1l day from the date of death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of six C6%) percent per annun calculated at a daily rate of .000164. All taxes which became delinquent an and after January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2003 are: Interest Daily Interest Daily Interest Daily Year Rate Factor Year Rate Factor Year Rate Factor 1982 20% .000548 1987 9% .000247 1999 7% .000192 1983 16% .000438 1988-1991 11% .000301 2000 8% .000219 1984 11% .000301 1992 9% .000247 2001 9% .000247 1985 13% .000356 1993-1994 7% .000192 2002 6% .000164 1986 10% .000274 1995-1998 9% .000247 ZOD3 5% .000137 --Interest is calculated as follows: INTEREST = BALANCE OF TAX UNPAID X NUMBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR --Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days beyond the date of the assessment. If payment is made after the interest computation date shown on the Notice, additional interest must be calculated. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT N0. CD 002466 GOLDBERG KATZMAN &SHIPMAN PC ATTN: JOHN DELORENZO ESQUIRE 320 MARKET ST PO BOX 1268 HARRISBURG, PA 1 71 08-1 268 fold ESTATE INFORMATION: ssrv: ins-os-x238 FILE NUMBER: 2102-0741 DECEDENT NAME: KEIM HUBERT O DATE OF PAYMENT: 04/ 1 7/2003 POSTMARK DATE: 04/16/2003 couNTY: CUMBERLAND DATE OF DEATH: 07/27/2002 ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ 5791.56 TOTAL AMOUNT PAID: REMARKS: DIANE M GRIMES C/O GOLDBERG KATZMAN &SHIPMAN PC CHECK# 1041 SEAL INITIALS: SK RECEIVED BY: DONNA M. OTTO REV-1162 EX(11-96) 5791.56 DEPUTY REGISTER OF WILLS REGISTER OF WILLS