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02-0764
PETITION FOR PROBATE and GRANT OF LETTE/-RS Estate of RUTH .I . NY E No. ~~~~~ ~ w also known as To: Ri1TH I RENE NYE Register of Wills for the - Deceased. County of CUMBERLAND in the Social Security No. 17 2 - O l - 9 2 0 5 Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older an the execut__ rix named in the last will of the above decedent, dated May 3 , , 19~ $_ and codicil(s) dated (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in Cumberland County, Pennsylvania, with h er Iast family or principal residence at 23D Messiah Village, P. O. Box 2015 Upper Allen Township (list street, number and muncipality) Decendent, then R 7 years of age, died Auaus t 3, 2 0 0 2, at Messiah Village 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 8 3 0 0 , 0 0 0.0 0 (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ None situated as follows: WHEREFORE, petitioners} respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters Testamentary ' (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) theron. N u )) u J c ~ /_ U ~ ) ~, uL Betsy Esser aC ~.4 108 Old Ford Driv ~';, _ Camp Hill, PA 17011 ya u~ ~ o c m in OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ~ ss COUNTY OF CUMBERLAND The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly administer t~.e~state according to law. Sworn to or affirmed and subscribed `'~'~-~~ ~ ~~~~--{-~ r„ before me this 22nd day of Betsy H. Esser ~' Augus 2 0 0 a -. Donna M. Otto l.Gt ~fiegister r~-~~-,~ No. 21-2002-764 RUTH I. NYE a/k/a Estate of RUTH IRENE NYE ,Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW August 22nd 2002 , 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 May 3 , 19 8 8 described therein be admitted to probate and filed of record as the last will of RUTH I • NYE a/k/a Ruth Irene Nye and Letters Testamentary are hereby granted to Betsy H. Esser ~~ ~.~ Register of ills na M. Otto, 1St L~'eputy FEES Probate, Letters, Etc.......... $ 270.00 Short Certificates(4) .......... $ 12.00 Renunciation .............. $ x-Pages (5) $~~~ JCP TOTAL $ 30- 2 0 Filed , ,August 22nd, 2002 ... . . ..... . . . . Jerry R. Duffie (09601) Johnson, Duffie, Stewart & Weidner ATTORNEY (Sup. Ct. I.D. No.) 301 Market St., P. O. Box 109 Lemoyne, PA 17043-0109 ADDRESS _.(717) 761-4540 PHONE MAILED LETTERS TO ATTORNEY c/O CINDY ON 8/22/2002 s to certif<~ that the information here given is correctly copied from an original certificate of death duly filed with me as 1.,~..ra Registrar. The original certificate will be forwarded to the Stare Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certifcare, ;~?.OC ~' 8463597 No. iui laJ Rev 2187 NAME OF DECEDENT If rtv. Middle. ~a91 1. AGE (Lap Ramsay) UNDER t YFJ Montna D. / Vra. ' S. COUNTY OF DEATH Cumben~and I IIIII~`p~~ `_ ~~y'~' )I~ ~S`_ O~ q~ \lG ~ y ~' ~ ~Z o' s a •r ~9jMfN~ ~~~~`~'I _.~ ~ ,. c.~ ~ ,~ v Local Registrar v` (1r bate COMMONWEALTH Of PENNSYLVANIA • DEPARTMENT OF HEALTH « VITAL RECORDS CERTIFICATE OF DEATH STATE r4E NUMBER ~~~-•-~:" ~~=~y~y ~}~ ~ SEX SCCIAI SECURITY NUMBER DATE OF DEATH :MCmh. Day. rear) Ruth Inene Nye ,. Female ,. 172 - 01 - 9205 ., Augu~~t 3, 2002 UNDER 1 DAY DATE OF 81RTH BIRTHPLACE rely and PIACE Oi DEATH ICnecw ui~M n"e -- ,ee ~nvnx:innn rm inner see) __ __. Hours i MIrwIM M n. DaY r~l dale a yueyn l;ounbyl HOSPITAL. OTHER: 4 w29-1915 Hcvcn~bcvcg, PA Inpalyd ^ Ew1AnParr.m ^ DD, C „~ ~ RIWIr,u ^ s~YYI ^ ~. r aw. CRY. BORO, iWP OF DEATH FACILrtY' NAME In nul rnvnulwn. y,ve weal arw numeerr MNS pECEDENT OF HISPANIC ORIGIN? RACE - Amancan IMUn, &ack, WnNa. Nc. No XU ha l~ K lr.a. apacM Cuoan. lSPecNI Uppe~c A~~en Twp. ~ Me~~S~ah V.~b.~age wxrcarl.PuptoRican,«~ ,B (Uh~.te KIND OF BUSlNESSfINWSTRY YMS DECEDENT EVER IN DECEDENT'S EDUCATION MMI7AL STATUS-Marryd SURVIVING SPOUSE V S. ARMED FORCES? 5 n ev due con, at NevM Menra, WiOOwed, III wJa. gne maaen nanral Yaa ^ No © Elemenury/Secondary Couege Dtwrud(SpecM SU elCV4dOn ,,,. C~mmun~ea.~i.ovtJs ,z ,a. (u'21 12 11+as.) t1. S-fn ~e ,y. • n. DECEDENT'S MAILING ADDRESS (Sheet Ceyrtown. $lil.. IY Goael DECEDENT'S Ac7uAL ,Ta. Stau Penn~y~Van~<.a Dd ,To.^ Yw.aeclwnav.ein UnpeJC A en me 23D Me~e~ah Ue~~age RESIOENDE M~+ pp () B 4 X 2015 dn.r s,a`~` ~~~,,„{~,, Q o f? rf '°""`"'P' ns.^ w~.n.~a~rw la1vids. a ratnewr ,. Mechan~ca6wc PA 17055 t7G.Dwnty~Lld,I1S5L~~L FATHER'S NAME IFev. Mech. Lav) MOTHER'S NAME IFrv. A4dtlK~. Martlen Surname] Hah~eh J, NCfe ,,. Mabel Sch.~uaaen WFORMANT'S NAME(TypelPrw) INFORMANO PA 17011 ~L ~( zamp 111 ~ ~Ml n~ Ve nd~' (1 (j I-(1 8e-tty ~e~en . . ., . . , V O V~[.lA rV 2dG. 1 U ma. METHOD OF DISPOSITION DATE OF DISPOSITION PLACE OF pSPOSRgH-Name dfwmetary,Cnmabry LOCATION-CM/Town. Stall. Ip CoW Dwul^ Gerrlatcn® RenlorryeomSt-b^ IMarYt,DaXYew) orOlnerPUCSCnema~~e.on Soe~.e~ty o{~ ^ ~~n^ an«(spe~a! 2002 Augu~~ 8 Penne ~vania Cnema#~ne 2Td. Hann~.ebcut PA 17109 , 71a. ttG. ' SIGNRUREOFi SERVIC LICENSEE OR PERSONA 71NGASSUCH LICENSE NUMBER „~. NAMEANOATX)RESSOfFAC0.1TY Hems con oe.ce ~ ~ enn~sy vantia 09 b ~c:~,, (~ ,,,. un PA 171 ,x. 4100 Jone~S~own Rva.d Hann.c~ „~ Conlppl gams Y!a< only w111rI unlrying - , _ To IM Deal d my knowMags, deals oc<wred at IM ams, eau and puce salsa. LICENSE NUMBER DATE SIGNED (MoMtI. OaY 'bM1 PnyMCran 0 nd avallaGU al ame d deals b (Sgrytur0 and Teb) . • candy ow. a seam. Marne 2/-28 map GS COmpleIW Gy' a n OF DEATH DATE PRONOUNCED DEAD {Mahn, Day, Peat) VNS CASE REFERRED TO MEDICAL EXAMINER!C Yes ® M(U ORONER? No^ ..t . person Mro w«yurrc« ~ • V ~ I ) ~ 7 ^ ~) ~- M. tS. 21. 27. PART F. Enur IM dalases, Injurws « compacmons rrnkn caused IM deals. Do rbl wp IM mode al dying, sacs as carduc a rasp naldry anew, sndcx or Ivan IalWrx t Approxrmats ~ allervp Gaween PART K: Odyr sgnincpa corldAiorls corVrAWirB b deals, Gal rql rISUMMIQ n dIe WrOerfying Carted glen n PART I. Lip arvy ory cause on IaClllee. orw11 am awn ////'~~'~~ , WEDIATE CAUSE IFxus ~ ~ ~Q (~ . ~ N Q Ordindn v V""YYV s d t i y yV,~, d j+ y..t~ sa c sm -~ s r a ad - . rur gn e ll DUE7O(ORASACONSEOUENCEOF): Sepynoatty dal tadsiwy D.^ f any, I•ad"nW n InlrnWau DUE TO (OR AS A CONSEQUENCE OFl: 1 caw. Er,ur UNDERLYING ; CAUSE IDdwr p •RaY <. yty eYaalea IvMK{ OIAE TO IOR AS A CONSEOUE NCE OFI: I rest/arrq n daps) LAST d. MKS AN AUIOPSV PERFORMED? WERE AUTOPSY FINDKJGS AWaIABLE PRIOR iO DFFH~ ~ CAUSE MANNER OF DEATH ~ Nprap ^ ACtr6m /larn+cida ^ Pardvlg lnWprgilgn ^ GATE OF INJURY IMmn. Dav. near) TIME OF I WURY IWURY AT WORK7 ei ^ ~^ PESCRIt1E f%N(INJU~Y tJIA:VNHlu. ,M ^ ,~ 1~1 `~•' F" j_~{.,~ VM ^ pp Srxciaa ^ Could rol G dpsrmuua ^ ]da. M. PLACE OF 1 W URY - Al soma. farm, great lanary, olfica Gurld:Ig, e,c. ISPeo1v1 LOCATION ]Strew. GIy/T . Stale! ?r 2b. M. ~~ ~. CE1fTIF1ER tCneca Dray aryl SIGNATURE AND TITLE OF CERTIFIER •CERTIFYING PHYSICIAN (PnysY:yn ceruyeg rase d seam when arx,lnn Pnvscan Has pptpmced seam ano complelea Item 251 n^ ~~ (~., ,~ ~ p~ To Ule Ge11 of my krowNdgl, delm occurred ay b me cause(s) and manMr a salad ................ . .................................... ^ a,G. ~ J[.~ M r" t v` ) LICENSE NUMESER•~ p DATE SIGNED M/mm. rY`Yearl 'PRONOUNCING AND CERTIFYING PHYSICIAN 1PnYSCran axn wywr.rca+g Uealn m,d cemlyrnq to cat.se d seam! ^ 31e. M O CJ ~ 1 Z 1 ~ C ,td~ l7 ~lJ To tty Olet dT my knowudga, deem xcwrW at UII IYIII, dau, and plx1, and dw to IM causele) and manner as salad .......................... NAME AND ADDRESS OF PERSON WMO COMPLETE USE OF DEATH (Item 27) TYDe a Pnnl + L ,1 ~ .~ (~ ~ C .` 'MEDICAL EXAMINER/CORONER 1 1 , , ` YW On tM Gasie of \:sminatun and/or imestlgaswn, In my opinion, dn1T occurred at,ne lima, data, and place, and tlue to Ina cause(s) and ^ ~ (1~ rL. Y• (~ , J i ~~ ',-~ <<--n~~ t ~-~ manse! as atsted .. ... ..... ... .................................... .......... * .................................... ax. L ~.' ~ L'~ ~`2. ~ ~~ ,,.. ti REGI IR'S SMaNATUR .,TN~N)JM ER" CIATE FILED IMUnm. Oay. Pearl a1 /l ~oZDD .Z ~~cst ~i11 ~n~ C~TP~t~mPnt of RUIN I. NYE I, RUTH I. NYE, of the Borough of Camp Hi:11, Cumberland County, Pennsylvania, make, publish and declare this to be my Last Will and Testament, hereby revoking and making void any and all former Wills made by me. I. I direct that all my legal debts and funeral expenses, including my grave marker, and all expenses of my last illness, shall be paid as soon as practical after my decease as part of the expense of the administration of my estate. II. I bequeath my automobile, household and personal effects and other tangible personalty of a like nature (not including cash or securities), together with any existing insurance thereon, to my nieces, BETSY H. ESSER and MARCIA H. GRIM, to be divided among them by my Executrix with due regard for their personal preferences in as nearly equal shares as practical. ~, III. l I devise and bequeath the residue of my estate of every nature and wherever 'situate to the Trustee, hereinafter named, IN TRUST, f:or the following uses and purposes: A. To pay the net income therefrom to my sister, HELEN N. McCORMICK, for and during her lifetime in such periodic installments as Trustee shall find convenient, but at least as often as quarter-annually. Trustee shall make said payment directly to my sister, HELEN N. McCORMICK, or to any person or institution taking care of my sister. Trustee shall use no portion of the principal of this Trust for the benefit of my sister and ' ' only the net income derived therefrom shall be paid, periodically, to or applied for the benefit of my sister during her lifetime. B. Upon the death of my sister, HELEN N. McCORMICK, or in the event that my sister, HELEN N. McCORMICK, shall predecease me, this Trust shall terminate and the then-remaining principal together with any accimlulated and undistributed income shall be distributed, in equal shares, to my nieces, BETSY H. ESSER and MARCIA H. GRIM, provided that in the event that either of my said nieces, BETSY H. ESSER or MARC:L?3 H. GRIM, is not then living then I direct that her share shall be distributed to her then living issue, per stirpes. ~i IV. 'i Should any person entitled to a share of my estate not have attained the age of twenty-three (23} at the time of distribution to him or her then I devise and bequeath such share to DAUPHIN DEPOSIT BAI~IIC AND TRUST COMPANY, IN SEPARATE TRUST, to hold, manage, invest and reinvest the shares so received, and the accumulation of income thereon, and to use and apply the income or principal, or so much thereof as, in Trustee's discretion, may be necessary or appropriate for the person's support and education (i_ncluding trade school or college education, both graduate and undergraduate) without regard to his or her parent's ability to provide for such support or education, or to make payment for these purposes, without further responsibility, to such person or to such person's parents or to any person taking care of such person. Any principal or income not so applied shall be distributed to such person absolutely when he or she attains the age of twenty-three (23) years. If the person dies before attaining age twenty-three (23), t:he Trust shall terminate and such share shall be distributed to his or her personal representative. V. The interests of the beneficiaries hereunder shall not be subject to anticipation or voluntary or involuntary alienation. - 2 - VI. I appoint my niece, BETSY H. ESSER, Trustee of the Trust created pursuant to Paragraph III of this, my last Will. In the event. that my niece, BETSY H. ESSER, shall fail to qualify or cease to act as Tn~stee, I appoint DAUPHIN DEPOSIT BANK AND TRUST COMPANY, of L~ttoyne, Pennsylvania, Trustee of the Trust created pursuant to Paragraph III hereof. VII. I direct that all taxes that may be assessed in consequence of my death, by whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as part of the expense of the adminisi~ration of my estate. VIII. I appoint my niece, BETSY H. ESSER, Executrix of this, my last Will. iShould my niece, BETSY H. ESSER, fail to qualify or cease to act as Executrix, ~I appoint DAUPHIN DEPOSIT BANK AND TRUST COMPANY, o:E Leir~oyne, Pennsylvania, Executor of this, my last Will. IX. I direct that my Executrix, BETSY H. ESSER, and my Trustee, BETSY H. ESSER, or her successor shall not be required to post bond for faithful performance of her duties in any jurisdiction. X. I direct thit ,i~1% corr,orate fi~ilCic^ary Sllaii :tL-'CEI_vE.-' COmpenSatiCn UciSeCY p11 its regular scheduled fees for such services from time-to-time during which period the services are performed. IN WITNESS WHEREOF, I hereunto set my hand and seal this ,~~ day of ~ ~ 1988. j ~~,: ~~'. ') ~ ~ sEAL ~ Ruth I. Nye - 3 - Signed, sealed, published and declared by the above-named Testatrix, as and for her Last Will and Testament, in the presence of us, who, at her request, in her presence and in the presence of each other have hereunto subscribed our names as witnesses. (SEAL) ~;if-ate ~,~~,.x~r~..it,;~ (SEAL) `~._ - 4 - COMMONWEALTH OF PENNSYLVANIA . ss: COUNTY OF CUMBERLAND - I, RUTH I. NYE, Testatrix, whose name is signed to the foregoing instr~mient, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I ',signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Ruth I. Nye Sworn to or affirmed and acknowledged before me, by RUTH I. NYE, the C Testatrix, this 3 ~`-~- day of ~~ Y, t ~-~-~ , 1988. ~~_ , ~, --~~ - L Notary Publi. _ "~ My commission expires: (SEAL) IDIANNE LENI6, Notary Public My Commtsston Expires Dec. 21. 1989 Lemoyne, PA Cumberland County - 5 - AFFIDAVIT COMNB~NWEALTH OF PENNSYLVANIA . ss: I COUN'T'Y OF CUMBERLAND - We, "~,,~; ~~, ._ ~ "~~ and lr~~ `.v~.;~.. ~~ . `' ~tit'i~ the witnesses whose names are sign ` to the foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the Testatrix sign and execute the foregoing instr~mlent as her bast Will and Testament; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our lrnowledge, the Testatrix was at that time at least 18 years of age, of sound mind and under no constraint or undue influence. !~ c, Sworn to or affirmed and subscribed to before me by~'`"""` ~'`~~;~"`-and 'J.~,, -~ '. ` , ~~` ; ~~sses, this ~~ 'tip.-day of ~,~~ ;~Jv,,~1 , 1988. _ -, Notary Publ' My commission expires: (SEAL) OIANNf LfNIG. Rotary Public My Commission Expires Oec. 21. 1989 Lemoyne. PA Cumberland Connty - 6 - r; CERTIFICATION OF NOTICE UNDER RULE 5.6 a Name of Decedent: RUTH IRENE NYE Date of Death: AUGUST 3, 2002 Will No.: 2002-00764 Admin. No.: TO THE REGISTER: I certify that notice of beneficial interest 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 ~~i , 2002. Name Address BETSY H. ESSER 108 OLD FORD DR., CAMP HI SUZANNE A. GRIM 3808 OXBOW DRIVE DEANNE P GRIM CAMP HILL, PA 17011 . HCR-65 CURRIER ROAD ROBERT R. GRIM JR KILLINGTON, VT 05751 , . 3902 FAIRVIEW AVE. HOOD RIVER. OR 97031 170 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except None. Date: 9//6/0 t_ " natu Name: Jerry R. Duffie, Esq. Johnson, Duffie, Stewart & Weidner Address: 301 Market St. P. O. Box 109 Lemoyne, PA 17043-0109 Telephone: (717) 761-4540 Capacity: Personal Representative X Counsel for personal representative Rev. 1500 EX. (5.jJO) *' REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT [L:ER- I 21 __COUNTY CODEu YEAR._ -'..-'-'- SOCIAL SECURITY NUMBER c. I COMMONWEALTH Of PENNSYlVANl1>. DEPARTMENT OF REVENUE DEPT,280601 H~~RISBUR~, PA 17128.0601 m__' ~ z w o w Q w o DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) \ :~;~F~;~~~MIM:5D-_YEAR) 08/03/2002 _ \ ~;;2~;;:~ (MM.DD-yEARf- (IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST. FIRST AND MIDDLE INITIAL) >Fe""j"I, .. 1':,', ')~.' iq'::"3 02 00764 NUM13EJL__ -I- -I 172-01-9205 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OFWILLS__ SOCIAL SECURITY NUMBER w ----I g-'1 QriginalReturn U2.'~ppleme~taIReturn 0 3Rema\ndefRe\\.lrnldaieofdeath-priOrlo12.13~- ::.:: S II) 0 4. Limited Estate 0 4a. Future Interest Compromise (date of death after 0 5. Federal Estate Tax Return Required ~ f G 12-12-82) G ~ ~ I ~ 6 ~~~1ent Died Testate {Attach copy 0 7. ~o~~~~~~~aintained a Living Trust (Attach 1 8 Total Number of Safe Deposit Boxes <:t 0 9. Litigation Proceeds Received 0 10, Spousal Poverty Credit (date of death between 0 11.Elec1ion to tax under Sec. 9113(A) (Attach Sch O) _'~:.'.'.__~, <'=.:..'''.~,-,:<,_:<"",,,:,:,_,__:-><,,.<..,,:,_.:~,,'',_<:_}~~3,1,~~\~~?J:~J-~_~)::._._."..~.-__:~.-.._~:,"'""::,,,,:,::_:,:"~:',',_,,',~::'_"-'__,"__'.__..<.<::::'.""':._,._i_'.__.'T ." ~- I TH1$.l!!5CTIQI\I.I.\\lSU~aeQNlI'\.ll,tj;O;AtLC.Ol\RE!!liollP!!IIPl!:'A!lO'COIII~1llIlNTr"'Lr~\1.IIIFOIlM",TlOIII'SHOULQea'OfR"!!TSP'TQ:..' ~AME . COMPLETE MAILING ADDRESS Jerry R. Duffie -- -- -- _ _I FIRM NAME (If applicable) ~E~~::O~En~U~~::e,Stewart & W eidn~ i~~~;:,e~ lW643-0109 717/761-4540 ~ ~ ~ o Q 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule 0) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested 7.lnter-Vlvos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9, Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) .-1. ----- I- ---- ---" -'- --- (1) None ",,:r"/.;IA ,,<: un>,,\' -------- (2) 161,425.33 (3) None (4) None (5) 245,423.90 (6) None (7) None (8) 406,849.23 (9) 24,031.91 (10) 2,895.52 (11) 26,927.43 (12) 379,921.80 13, Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (13) (14) 379,921.80 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15.Amount of Line 14 taxable at the spousal tax rate, x .00 (15) or transfers under Sec. 9116(a)(1.2) z .045 (16) 0 16, Amount of Line 14 taxable at lineal rate x " ~ ~ (17) ~ 17. Amount of Line 14 taxable at sibling rate x .12 ~ 0 Q " 18. Amount of Line 14 taxable at collateral rate . 379,921.80 x .15 (18) 56,988.27 ~ 19. Tax Due (19) 56,988.27 CHECK HERE IF YOU ARE REQUEST(NG A REFUND OF AN OVERPAYMENT 20. 0 >. 8E SURS'TO PiNSWER /ILL QUSSTlOII$ ON RSVERSE $IDE ANIl R1!CllEGK MATH<< Copyright 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-(0) Decedent's Complete Address: STREET ADDRESS 23D MESSIAH VILLAGE P. O. BOX 2015 CITY MECHANICSBURG STATE PA 17--- I ZIP 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 56,988.27 -~- 50,000.00 -------- 2,631.58 Total Credits (A + B + C) (2) 52,631.58 3. Interest/Penalty if applicable D. Interest E. Penalty TotallnteresUPenalty (0 + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box on Page 1 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enler the lolal of Line 5 + 5A. This is the BALANCE DUE. (5B) 0.00 4,356.69 4,356.69 Make Check 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;........ .............."...... ....................:...:.:..::.::.::.:::~ I 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?............."..................................................................................................... D ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?........ D ~ 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. Under penalties Of-perjury. I declare that I have examined this return, i-;:;cludirlg a~companying schedules and statements. ';rld to the best of my knowledge and belief. -ii is true, correct and complete. Oeclaration preparer i?!her than the personal repre~entative!~ ba~ed on all info!mation ofwhi.Ch preparer ~as any ~nowl~~. __._ SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS ,B'~.::/z~12---'-t g~~ 601ti:fURE?,~S6-NRESPON~FOR FILING R~T~ ADDRESS- 108 Old Ford Drive Camp Hill, P A 170_1~ DATE ~7~f~ 2:- DA E ADDRESS DATE' 30 I Market Street Lemoyne, PA 17043-0109 12/1 02.. Fa d s 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 ing spouse is 3% [72 P.S. 99116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii)]. The statute does not exemo'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 pa.rent, or a. stepparent of the child \s 0% [72 P .S. 99116 (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. 99116 1.2) [72 P.S. 99116 (a) (1)1. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12%l (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. *' SCHEDULE B STOCKS & BONDS , ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF NYE, RUTH I FILE NUMBER 21 - 02 - 00764 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER I DESCRIPTION UNIT VALUE \ VALUE AT DATE OF i DEATH --~.- 500.00 2,000.00 4 - $500.00 - Series HH Bonds - dated 08/1998 2 4 - $1,000.00 - Series HH Bonds - dated 8/1998 1,000.00 4,000.00 5,000.00 15,000.00 10,000.00 \ 10,000.00 25.715 103,682.88 17.744250 20,405.89 1.66501 9.99 1.7275' 266.04 9.28 4,185.28 1.590 928.56 4.2075 946.69 3 i. 3 - $5,000.00 - Series HH Bonds - dated i 8/1998 4 1 - $10,000 - Series HH Bond dated 8/1998 5 i 4,032 Shares BellSouth Corp.Connnon @$25.715p/sh. 6 1,150 Shares - Waypoint Financial Corp. Connnon ! @$17.744250p/sh 7 6 Shares - Agere Systems, Inc. Class A , @ $1.6650 p/sh 8 1154 Shares - Agere Systems, Inc. Class B . @$1.7275p/sh 9 451 Shares - AT&T Corp. i @ $9.28 p/sh. 10 584 Shares - Lucent Technologies, Inc. @ $1.590 p/sh II 225 Shares - AT&T Wireless @ $4.2075 p/sh TOTAL (Also enter on line 2, Recapitulation) -I I 161,425.33 *' SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEAL T\-l OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF NYE, RUTH I -I FILE NUMBER-' 21 - 02 - 00764 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorshIp must be disclosed on schedule F. ITEM NUMBER I DESCRIPTION VALUE AT DATE OF DEATH 1,520.10 Waypoint Bank - Checking Account No. 3000008943 Date of death balance, plus accrued interest. 2 Waypoint Bank - Guaranteed Money Fund - Acct. No. 3003000350 89,039.51 Date of death balance, plus accrued interest. 3 Waypoint Bank - Certificate of Deposit No. 400002111 30.138.06 Date of death balance, plus accrued interest 4 Waypoint Bank - Certificate of Deposit No. 415825899 30,002.61 Date of death balance, plus accrued interest 5 M&T Bank - Certificate of Deposit No. 3100391160833 47,865.69 Date of death balance, plus accrued interest 6 Belco Credit Union - Acct. No. 004400 - Certificate No. 15600 39,153.30 Date of death balance, plus accrued interest 7 Belco Credit Union - Acet . No. 004400 - Savings Acct. S-I 6,705.21 Date of death balance, plus accrued interest 8 Medcohealth - prescription drug refund due - claim filed prior to death 52.74 9 Cash refund - item of furniture returned. 408.53 10 Medea Health - prescription drug reimbursement - PharMerica charges 250.Q9 11 V erizon ~ refund - telephone service discontinued 0.06 12 Cash in decedent's possession' 132.00 13 Erie Insurance - premium refund 6.00 14 Decedent's household items at Messiah VilJage 150.00 TOTAL (Also enter on Line 5. Recapitulation) 245,423.90 '* SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT _1._ ESTATE OF NYE, RUTH I ITEM NUMBER A. Debts of decedent must be reported on Schedule I. DESCRIPTION FUNERAL EXPENSES: I Cremation Society I 2 Deissler's Flowers 3 Shoop's Cemetery - Cremation Interment 4 I, Romberger Memorials - Marker Inscription B. I ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Betsy H. Esser, Executrix Social Security Number(s) I EIN Number of Personal Representative(s): , Street Address 108 Old Ford Drive City Camp Hill State PA Zip 17011 Year(s} Commission paid 2003 2. Attorney's Fees Johnson, Duffie, Stewart & Weidner -- Jerry R. Duffie 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address I FILE NUMBER 21 - 02 - 00764 + \ I AMOUNT State 1,479.80 184.44 290.00 365.00 9,000.00 12,000.00 302.00 75.00 102.67 233.00 24,031.91 4. City Relationship of Claimant to Decedent Probate Fees Register of Wills - Cumberland County Zip 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 1 Other Administrative Costs Cumberland Law Journal - Legal Advertisement 2 The Patriot-News - Legal Advertisement *' Schedule H Funeral Expenses & Administrative Costs continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN I RESIDENT DECEDENT ,- -..--- --..- ---- ..---- --- -- ESTATE OF NYE, RUTH I 3 Register of Wills - Short Certificates - Stock 4 Register of Wills - file Inventory & Inheritance Tax Return 5 Reserve for close-out costs IFILE NUMBER' - 21 - 02 - 00764 -\- Page 2 of Schedule H 27.00 31.00 175.00 -. '* SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RE$IDENTDECEDENT L ESTATE OF NYE. RUTH I FILE NUMBER \ 21-02-00764 Include unreimbursed medical expenses. ITEM NUMBER 1 DESCRIPTION AMOUNT Messiah Village - decedent's fmal charges 2,250.08 2 Holy Spirit Hospital - fmal charges 15.90 3 PharMerica - prescription drug charges 302.04 4 Alert Pharmacy - prescription drug balance not covered by insurance 327.50 TOTAL (Also enter on Line 10, Recapitulation) 2,895.52 REV_1513 EX+ (9-00) *' I 1- SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ---------.-- NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY \ FILE NUMBER 21 - 02 - 00764 RELI\TIONSHIP Tcl ,--- AMOUNT OR SHARE _D.~;;~~I>L- -r OF ESTATE ESTATE OF NYE, RUTH I 2 I TAXABLE DISTRIBUTIONS (include outright spousal distributions) Betsy H. Esser 108 Old Ford Drive I Camp Hill, PA 17011 I Suzanne A. Grim 13808 Oxbow Drive Camp Hill, Pa 17011 I Niece I [Fifty percent Residue I. I Grand Niece lone-third of One- half residue lone-third of One- half Residue 3 . Deanne P. Grim I HCR-65 Currier Road Killington, VT 05751 \ Grand Niece 4 Robert R. Grim, Jr. 13902 Fairview Avenue Hood River, OR 97031 I Grand Nephew One-third of One- \half Residue I I . Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet I II. I NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT ! BEING MADE I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS I I TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET' I i~ ~~~ COMMONWEALTH OF PENNSYLVANIA BUREAU OF INDIVIDUAL TAXES DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 2BD661 NOTICE OF INHERITANCE TAX HARRISBURG, PA 17128-0601 APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 E% AFP (O1-OS) DATE 02-10-2003 ESTATE OF NYE RUTH I DATE OF DEATH OS-03-2002 FILE NUMBER 21 02-0764 COUNTY CUMBERLAND JERRY R DUFFIE ACN 101 JOHNSON ETAL Anount Remitted 301 MARKET ST LEMOYNE PA 17043,-4802 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 NYE RUTH I FILE N0. 21 02-0764 ACN 101 DATE 02-10-2003 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) .00 NOTE: To insure proper 2. Stocks and Bonds (Schedule B) (2) 161,425.33 credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule Cl (3) .00 submit the upper portion 4. Mortgages/Notes Receivable (Schedule D) (4) .00 of this form with your 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 245,423.9 0 tax payment. 6. Jointly Owned Property (Schedule F) (6) •00 7. Transfers [Schedule G) (7) .00 8. Total assets (g) 406,849.23 APPROVED DEDUCTIONS AND EXEMPTIONS: 24,031.91 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 2,89 5.52 11. Totai Deductions (11) 26.927.43 12. Net Value of Tax Return (12) 379,921.80 13. Charitable/Governmental Bequests; Nonelected 9113 Trusts (Schedule J) (13) .00 14. Net Value of Estate Subject to Tax (14) 379,921.80 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) • 00 X 00 = . 00 16. Amount of Line 14 taxable at Lineal/Class A rata (16) • 00 X 045 . . 00 17. Amount of Line 14 at Sibling rate (17) .0 0 X 12 .00 18. Anount of Line 14 taxable at Collateral/Class B rate (18) 379,921.80 X 15 56,988.27 19. Principal Tax Due (19)= 56,988.27 TAY f`_QFTITTCe DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID 10-29-2002 CD001786 2,631.58 50,000.00 12-13-2002 CD001961 .00 4,356.69 TOTAL TAX CREDIT 56,988.27 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 ^ IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" [CR), YOU MAY BE DUE A RFFlINO_ SFF RFUFRSF STOF OF TNTS FORM FOR TNSTRIH_TTnNR_1 -~e NI z ~v ~I G CD N ~ G ~ ~ X ~, m ° rn ~i ~ O ~ O tN ~ 9~ O O- ~ j N ~ G N O. N ~ O N ~ ~ ~ ~- ~ N N (SD N ~ O ~• ~ ~ r. O ~ ~ C~. ~ m ° 0 ~~ o ~ a ~ N o~ -a ~~ ~ 3 N ~ O ~r« ~ ~ _ n Q O N N ~ ~ ~o o~ ~; o~ ~~ ~~ O C1 ' ~ coo A~ n ~ ~, ~~ -~ p ~ d ~N O'G~ ~ ~ ~ ~ ~ ~ ~ 7a W 9~ ,L ~ ~~ ~ N ..,1 G z ~- `~ O CD ~ (D f~ z 3 N Z O may, ~ q ~ m~obo rn ~ 0~,. ~ 'r ~ ~ `~v- NI o x'.90 ~ fn rr ~ ~ tNt) O p ~ ~L .P o `'' St° N 'r2 rn v z m V f t~ ,; L~ l` L17 ,~Y l~ ~~i .~-~ O O o '~ ~ WVd ,~ o ,~, z~~~~ zo~~~ ~, L~~~ ~~~~ o '~ ~ ,~ ~ o ~', ~ ~ C7 "' n m G ~ ~~~N m -+ mid ~~~ ~'fl ~ m n ~ w ~ Z U' ~~~0 -mom Q C m .r•-' ,r ~;~ ;. ~6 Y Ni 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 RIO. CD 001786 JERRY R DUFFIE ESQUIRE 301 MARKET STREET P O BOX 109 LEMOYNE, PA 17043-0109 gold ESTATE INFORMATION: ssN: 772-o~-s2o5 FILE NUMBER: 2102-0764 DECEDENT NAME: NYE RUTH I DATE OF PAYMENT: 10/30/2002 POSTMARK DATE: 10/29/2002 COUNTY: CUMBERLAND DATE OF DEATH: 08/03/2002 ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ 550,000.00 TOTAL AMOUNT PAID: REMARKS: JERRY R DUFFIE ESQUIRE CHECK#101 SEAL INITIALS: JA RECEIVED BY: MARY C. LEWIS REV-1162 EX(11-961 550,000.00 REGISTER OF WILLS REGISTER OF WILLS 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 NO. CD 001961 DUFFIE JERRY R ESQUIRE 301 MARKET STREET P O BOX 109 LEMOYNE, PA 17043-0109 ------- fold ESTATE INFORMATION: ssN: »2-o~-s2o5 FILE NUMBER: 2102-0764 DECEDENT NAME: NYE RUTH I DATE OF PAYMENT: 1 2/ 1 7/2002 POSTMARK DATE: 12/13/2002 couNTY: CUMBERLAND DATE OF DEATH: 08/03/2002 ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ 54,356.69 REV-1162 EX(11-961 TOTAL AMOUNT PAID: REMARKS: BETSY H ESSER C/O JERRY R DUFFIE ESQUIRE CHECK# 103 INITIALS: CW SEAL RECEIVED BY: 54,356.69 DONNA M. OTTO DEPUTY REGISTER OF WILLS REGISTER OF WILLS a~ 1 a' W 2 O ~L! `~ o ,~ 3 w ~ ~ w Q 3~-~oe E" ~1 F- J cu ,Y m ~ Zt% 2 ~ ~ k °~aa 4 em z 0 O w !A J Z r 0 ~' V y.r ,i) W a 0 ~~ w~ ~ 0 OVwM C!) ~ ~ M NHa"' ~ ~ ~o ,3 O UJ ~+ O Ufa Q~ a~ O H ~ HN ~ W ~ va ~ ~ O~ ~~U~ U "~ U W ~ ~ ~ W ~ U N O ~' ~ N 0 ~ s_ .~[ !L{ ~ ~ r ~ T O -- O to L O m d. ~ ~ y ~ ~ ~ I- U + d _ ~ p ~ r ~a fir- i u. ~ Q d ~ .~ X O O "~ 4 ~ ~ c ~ G~ ~ w c c ~ _ ~ ~ ~ Z ~' W ~ ~ a~ ~ cu ~ °' 0 = ~ ~ U ~ ~ c ~ t6 LLO O ~~ U ~ E-- "= 64 Q~ O UOCD ~ ~ C C7 ~ ~ T M 4= N O to ~ N ~ '~ M mot' O ff3 @FJ .~ i s N ~ X 0 0 ~ ~ h- O Z d °~ ~ o ~ ~ ~ ~ .~ O- oo N ~ U ~ _ ~ .~ p ~ ~ ~ U v ~, , ~ ~ ~ M ,-~ /Nmay p t3'~ ~ U tB tLS N o ~ ~~~~ ~ ~ ~U~ ' ~~ O ~ ' ~ C7 to .... N t0 tB ~ O~~ D.. (ll ~~ ai N O WZ N .t,A .~ O N cll N - ~ ~ U tLv W W .-= cV ch v' 0- W TUTU m ~ t7 O N °, ~ J e • t Register of Wills of Cumberland County, Pennsylvania INVENTORY Estate of NYE, RUTH I No. 21 - 02 - 00764 also known as A/K/A NYE, RUTH IRENE Date of Death 8/3/2002 Deceased Social Security No. 172-01-9205 Betsy H. Esser, Executrix The Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the real estate located in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. I/We verify that the statements made in this Inventory are true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C. S. Section 4904 relating to unsworn falsification to authorities. Attorney: Jerry R. Duffie I.D. No.: 09601 Address: 301 Market Street Lemoyne, PA 17043-0109 Personal Representative ~~ ~~~ __~ Signature:' .~~z :~..~ -r__ `,~,_ _ _ p~- --- - Betsy H. I?'sser, Executrix ' . Signature: Signature: Address: 108 Old Ford Drive Camp Hill, PA 17011 Telephone: 717/761-4540 Telephone: (717) 761-2138 Dated: /Z/ ~~ 'Z. Personal Property 4 - $500.00 -Series HH Bonds -dated 08/1998 2,000.00 4 - $1,000.00 -Series HH Bonds -dated 4,000.00 8/1998 3 - $5,000.00 -Series HH Bonds -dated 15,000.00 8/1998 1 - $10,000 -Series HH Bond dated 8/1998 10,000.00 4,032 Shares BellSouth Corp.Common 103,682.88 ~r~ $25.715 pish. 1,150 Shares - Waypoint Financial Corp. Common 20,405.89 @ $17.744250 p/sh 6 Shares - Agere Systems, Inc. Class A 9.99 a $1.6650 pish (Attach additional sheets if necessary) Total Personal Property and Real Estate $407,173.08 . Register of Wills of Cumberland County, Pennsylvania INVENTORY continued Estate of NYE, RUTH I No. 21 - 02 - 00764 -_ also known as A/K/A NYE, RUTH IRENE Date of Death 8/3/2002 Deceased Social Security No. 172-01-9205 154 Shares - Agere Systems, Inc. Class B 266.04 ~~ $1.7275 pish 451 Shares - AT&T Corp. 4,185.28 r~, $9.28 p/sh. 584 Shares -Lucent Technologies, Inc. 928.56 @ $1.590 p/sh 225 Shares - AT&T Wireless 946.69 ~~ $4.2075 plsh Waypoint Bank -Checking Account No. 3000008943 1,520.10 Date of death balance, plus accrued interest. Waypoint Bank -Guaranteed Money Fund -Acct. No. 3003000350 89,039.51 Date of death balance, plus accrued interest. Waypoint Bank -Certificate of Deposit No. 400002111 30,138.06 Date of death balance, plus accrued interest Waypoint Bank -Certificate of Deposit No. 415825899 30,002.61 Date of death balance, plus accrued interest M&T Bank -Certificate of Deposit No. 3100391160833 47,865.69 Date of death balance, plus accrued interest Belco Credit Union -Acct. No. 004400 -Certificate No. 15600 39,153.30 Date of death balance, plus accrued interest Belco Credit Union -Acct . No. 004400 -Savings Acct. S-1 6,705.21 Date of death balance, plus accrued interest Medcohealth -prescription drug refund due -claim filed prior to death 52.74 Cash refund -item of furniture returned. 408.53 MedCo Health -prescription drug reimbursement - PharMerica charges 250.09 Verizon -refund -telephone service discontinued 0.06 Cash in decedent's possession' 132.00 Erie Insurance -premium refund 6.00 2 i Register of Wills of Cumberland County, Pennsylvania INVENTORY continued Estate of NYE, RUTH I No. 21 - 02 - 00764 also known as A/K/A NYE, RUTH IRENE Date of Death 8/3/2002 Deceased Social Security No. 172-01-9205 Decedent's household items at Messiah Village 150.00 Belco Credit Union -Insurance paid to Estate 323.85 Total Personal Property $407,173.08 3 V ~~ PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF THE STATUS OF THE ESTATE. IF ESTATE IS NOT COMPLETED, FILE a 6.12 FORM YEARLY UNTIL COMPLETION. STATUS REPORT UNDER RULE 6.12 :- _~, Name of Decedent: RUTH i. NYE a/k/a RUTH IRENE NYE 1,~~ 0 Date of Death: August 3, 2002 Wil! No.: 21-02-00764 Admin No.: Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, 1 report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes X No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: . 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:. C. 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 informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: ~ / O ~ ~------ g ature J ry R. Duffle, Esq. hnson, Duffle, Stewart & Weidner 301 Market Street, P.O. Box 109 . ~ ~ Lemoyne PA 17043-0109 „_. .- :..~ `' ~" ' , Address , c~ (717) 761-4540 Telephone No. ~ •s ~ ;ti •.- k~ Capacity: Personal Representative ~~. o ~, ~ X Counsel for Personal Representative j tt ILRIiY R. DUFFIk'. f(ICH:IRD W. STEbVAII'r EDMUND G. MYLRS L A W O F P I C E S D }} ID W. DI l l~(:E Jox~soN IouN.451}ilr:E (t f PR61' B Rf Ll'IG b,,}ItE ~. n~~ FIE ~UFFIE JOHn It. Nlsosin~ MICH:11'.I. i. C:1SSIp}' MELISSA P_GRHSVY WADY. D. M;wLr.v November 27, 2012 Register of Wills Office n ~ ~ Cumberland County Courthouse m -r, One Courthouse Square ~ a ~ Carlisle, PA 17013 ~ ~ ~ .~ RE: Estate of Ruth I. Nye ~, o Date of Death: August 3, 280 Our File No. 7513-1 ~ _i Dear Register: Enclosed for filing, please find the following: ELlzntsErn D. SNOVER CAROI.YN B. MCCLAIN ]01{N A- LUCY ULVSSes S w usoN IULN A- PHIL LIPS 11 A'I Ili I~.W RIDLI?1' OF COUNSEL HORACE A. JOHNSON C. ROY WEIDNER, nt. CONS'fANCE P. BRUNT it ~s ,>n; ~., ~,_ ~_> e N CD F-~ z ~ rn ''^ ~ ~ ~~ _..~ o %~ b '~ ~~r r :' r~ cn o a~ t 1. 2 Original Pennsylvania Supplemental Inheritance Tax Returns. There is tax plus interest due in the amount of $285.14. Enclosed you will find a check made payable to Register of Wills, Agent attached to this Return. 2. 1 copy of Page 1 of the Inheritance Tax Return that we ask that you time-stamp and return to us. 3. Check in the amount of $15.00 representing the filing fee for the Supplemental Inheritance Tax Return Thank you for your assistance in this matter. Should you have any questions, please contact the undersigned Very truly yours, J NSON, F`FI~, STEWART &WEIDNER Dana Wieseman Estate Administration Paralegal Enc. c: Betsy Esser, Executrix :527319 301 MARKET STREET P.O. BOX 109 LEMOYNE, PENNSYLVANIA 17043-0109 WWw.JDSW.COM 717.761.4540 FAX: 717.761.3015 MAILQ~DSW.COM JOHNSON, DUFFLE, STEWART &WEIDNER, P. C. 1505610105 REV-1500 EX (03-11J (FI) g'y! eons lvaMa OFFICIAL USE ONLY PA Department of Revenue P . Y County Code Year File Number Bureau of Individual Taxes ~~~~~~ Po Box zBO6ot INHERITANCE TAX RETURN q I .112 , \ ~ I / Harrisburg, PA t7tz6-o6ot RESIDENT DECEDENT L... ll (-J (p'`f' ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYV Decedent's [ast Name Suffix NYE (If Applicable) Enter Surviving Spouae's Information Below Spouse's Last Name Suffix Date of Birth MMDDYVYY 04/29/1915 Decedent's First Name MI RUTH I Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WRH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW O 1. Original Retum ~ 2. Supplemental Return O 3, Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-32) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 6. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy o(Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Dale o(Death O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TA%INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Jerry R. Duffle (717) 76 +1_+4540 ;` ~ Q aOrn First Line of Address 301 Market Street Second Line of Address City or Post Office Lemoyne Azr* ^' ca ,~c a Cn 'ti .~ ,~ c~ ~ c7 Q rA j G ~ ~ ~ n ; ° ~ f-. . b --( r..... ~-. ~ ~ State ZIP Code DATE FI® w~ -,~ PA 17043 Correapondent's a-mall Under penalties of perjury, I dadare that I have examinetl this return, inclutling accompanying schedules and statements, antl to the best or my knowledge and belief, it is true, wrrect and complete. Declaration of preparer other then me personal representative is basetl an all Information of which preparer has any knowledge. SIGNAT RE F PERS ,rSPONSIBLE FOR FILING RETURN /p'ATE ~~/ < ~ ~ Z. ADDRESS 552 Lucinda Lager.(Ylechanicsburg, PA 17055 SI A UBC~F EPAR OTHER THAN REPRESENTATIVE DATE PA 17043 Side 1 1505610105 15056101D5 J J 1505610205 REV-15D0 EX (FI) Decedents Name: RUTH I. NYE Decedent's Social Security Number RECAPITULATION 1. Real Estate (Schedule A) ........................................... .. L 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 1,394.32 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. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... , . 6. 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested...... .. 7. B. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. 9. Funeral Expenses and Administrative Costs (Schedule H) ............. ...... 9. 165.00 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ......... ...... 10. 11. Total Deductions (total Lines 9 and 10) ........................... ...... 11. 12. Net Value of Estate (Line 8 minus Line 11) ........................ ...... 12. '. 13. Charitable and Governmental Bequests/Sec 9113 Tmsts for which an election to tax has not been made (Schedule J) .................. ...... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) .................. ...... 14. 1,229.32 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_ 15. 16. Amount of Line 14 taxable - '. at lineal rete X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 iZ 18. Amount of Line 14 taxable 1 32 229 184.40 . , . at collateral rate X .15 18. 184.40 ' ................................... 19. TAX DUE .................... .. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 155610205 1505610205 J REV-1500 EX (FI) Pege 3 n"......le.~•b f`mm~ln4u Arlt'f rwcc• DECEDENTS NAME RUTH I. NYE - --. - --- __ STREET ADDRESS 23D Messiah Village PO Box 2015 _ CITY STATE PA ZIP 17055 Mechanicsburg, Tax Payments and Credits: i. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount 3. Interest 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. File NU~'_ ~~_ ~~~~~ Total Credits (A+B) (2) (5) (1) 184.40 (3) (4) 101 285.41 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 ...................................... ...... ^ c. retain a reversionary interest ........................................................................................................................ ...... ^ ^ ~ d. receive the promise for life of either payments, benefits or cere? ............................................................... ....... If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death 2 . without receiving adequate consideration7 ....................................................................................................... ....... ^ 3. Did decedent own an "in trust for' or payable-upon-0eath bank account or secudty at his or her death? ....... ....... ^ Did decedent own an individual retirement account, annuity or other non-probate properly, which 4 . contains a benefciary designation? ................................................................................................................. ....... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1,1994, and before Jan.1,1995, the lax rate imposed on the net value of transfers tc 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 fax, and the statutory requirements for disclosure of assets and fling a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling 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-15a} E%+(Bazj Pennsylvania Y7 UEPAPTMENT OF REVENUE INHERRANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER NYE, Ruth I. 21-02-0764 If more space is needed, insert additional sheets of the same size Date of Death: 08/03/2002 Valuation Date: 08/03/2002 Processing Date: 11/27/2012 Shares Security or Par Description 1) Sfi.376 TERADATA CORP DEL (88076w103) COM New York Stock Exchange No pricing information 2) 56.376 NCR CORP NEW (62B86E108) COM New York Stock Exchange 08/02/2002 08/05/2002 Total Value: Total Accrual: Total: $1,399.32 Estate Valuation Estate of: Nye Estate Account: 11999 RepoLt Type: Ddte of Death Number of Securities: 2 File ID: nye Mean and/or Div and Int Security High/Ask Low/Bid Adjustments Accruals Value N/A 25.99000 24.29000 H/L 25.02000 24.18000 H/L 29.732500 1,394.32 $1,394.32 $0.00 Page 1 This report was produced with EstateVal, a product of Estate Valuations s Pricing Systems, Inc. if you have questions, please contact EVP Systems at (818) 313-6300 or www.evpsys.com. !Revision 7.1.1) REV-].511 EX+ (10-09) ~, ~ pennsylvania DEPARTMENT OF REVENGE INHERITANCE TAX RFNRN RESIDENT DECEDENT FUNERAL EXPENSES: ESTATE OF FILE NUMBER NYE. Ruth I 21-02-0764 Decedent's debts must he reported on Schedule 1. A. 1. B. 1. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Pald: SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS Z. Attorney Fees: 3. Family Exemption: (If decedent's address Is not the same as claimant's, attach explanation.) Claimant a.oer end.a« 4. 5. 6. 7. City State _ Relationship of Claimant t0 Decedent Probate Fees: Accountant Fees: Tax Retum Preparer Fees: Cumberland County Register of Wills' Filing Fee for Supplemental Retum TOTAL (Also enter on Line 9, Recapitulation) I # If more space is needed, use additional sheets of paper of the same size. State ZIP ZIP 150.00 15.00 165.00 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1128-0601 RECEIVED FROM: ESSER BETSY H 108 OLD FORD DRIVE CAMP HILL, PA 17011 mle PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT ESTATE INFORMATION: ssN: t~z-of-s2o5 FILE NUMBER: 2102-0764 DECEDENT NAME: NYE RUTH I DATE OF PAYMENT: 11/29/2012 POSTMARK DATE: 1 1 /28/201 2 COUNTY: CUMBERLAND DATE OF DEATH: 08/03/2002 REV-1162 EX~11-961 N0. CD 016848 ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ 5285.41 TOTAL AMOUNT PAID: REMARKS: RECEIPT TO ATTY 5285.41 CHECK# 3394 INITIALS: HEA SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS __ __ ___ ~~ ,- ~_ •. O ~fl ]1 N• s 0 ~. N ~ +' a0 ~ N 7 W O ~ M O H ~ W __. "~ ~ V -° 3C "'~ ~ C WqV 4_4. ¢ vUp 0 4 ]C N Z G C W W 01 N W 2 J J d K N = V d c ~ V W ° cX O ~ _ ~ ~ N ~~f ,~ ^~ ^d :P. o o a c ~ p K p Ey c W r-1 i= P f"~ .O ~~ J ~~ E~ < O ~~ \ O r ~ W L' O ~ u'. U j C) ~ycn ~i ~ W o O N :~U ~~ Q ~~z ~a W OC p ~ N ~ W ~ W ~ Z Q K U ~ U O -` arm BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 288681 HARRISBURG PA 17128-0601 JERRY R DUFFIE 301 MARKET ST LEMOVNE NOTICE OF INHERITANCE TAX APPRAISEMENT. ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX RECORDED D~FICE OF REGISTER OF'3n'iLLS ?~i3 FEB 19 P:;'I 11 32 CLERK OF ORPHANS' COURT PA ~~~E{t4.6I~ND CD., PA u) .00 (2) 1,394.32 (3) .00 (4) .00 I5) .00 CUT ALONG THIS LINE ---- ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV-1547 EX AFP (12-11) NOTICE OF INHERITANCE TAX APPRAISEMENT. ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF: NYE RUTH IFILE N0.:21 02-0764 ACN: 101 DATE: 02-11-2013 TAX RETURN WAS: C X) ACCEPTED AS FILED ( 7 CHANGED APPRAISED VALUE OF RETURN BASED ON: SUPPLEMENTAL RETURN N0. O1 1. Real Estate (Schetlule A) 2. Stocks antl Bones (Schetlule B) 3. Closely Heltl Stock/Partnership Interest (Schedule C) 4. Mortgages/Nofas Receivable (Schetlule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Seh¢dule F) 7. Transfers (Schedule G) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expanses/Atlm. Costs/Misc. Expenses (Schetlule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (7) .00 ~ pennsylvani DEPARTMENT OF REVEN UE REV-1547 EX AFP (89-12) NOTE: To ensure proper cretlit to your account. submit the upper partio of this form with your tax payment. (e) 1.394.32 (9) 165.00 (lo) .DD 11. Total Detluctions (11) 165.00 12. Nat Value of Tax Return (12) 1,229.32 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schetlule J) (13) .00 14. Net Value of Estate Subject to Tax (14) 381.151.12 NOTE: If an assessaent was issued previously. Lines 14, 15, 16, 17, 18 and/or 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 16. Amount of Lin¢ 14 taxable at lineal rate 17. Amount of Line 14 at sibling rate 18. Amount of Lf ne 14 taxable at collateral rate 19. Principal Tax Due TAX CREDITS: DATE 02-11-2013 ESTATE OF NYE RUTH I DATE OF DEATH 08-03-2002 FILE NUMBER 21 02-0764 COUNTY CUMBERLAND ACN 101 APPEAL DATE: 04-12-2013 (See reverse side under Objections Asount Reeitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 ns) .00 x 00 - .00 us) nn x 045 = .00 (ln nn x 12 - .00 na) 381,151.12 x 15 = 57,172.67 (19)= 57,172.67 PAYMENT DATE RECEIPT NUMBER DISCOUNT (+) INTEREST/PEN PAID (-) AMOUNT PAID 10-29-2002 CD001786 2,631.58 50,000.00 12-13-2002 CD001961 .00 4,356.69 11-28-2012 CD016848 90.56- 285.41 TOTAL TAX PAYMENT 57,183.12 BALANCE OF TAX DUE 10.45CR INTEREST AND PEN. .00 TOTAL DUE 10.45CR ~ IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL OUE IS REFLECTED AS A CREDIT (CR). YOU MAY BE DUE FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE FOR INSTRUCTIONS. ~~` pennsylvania DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES REC C. C"�R�InTA E TAX REV-1607 EX AFP (12-12) INHERITANCE TAX DIVISION � ' ACCOUNT PO BOX 280601 R s _ E c i HARRISBURG PA 17128-0601 "��j t �"' �`_ �I—S DATE 03- 1013 MR 22 P�� 1 Ll� ESTATE OF NYE18-2013 RUTH I DATE OF DEATH 08-03-2002 CLERK t FILE NUMBER 21 02-0764 ORPHANS' COU ! COUNTY CUMBERLAND JERRY R DUFFIE CUMBERLAND co., DA ACN 101 301 MARKET ST Amount Remitted LEMOYNE PA 17043-1662 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 NOTE: To ensure proper credit to your account, submit the upper portion of this form with your tax payment. CUT ALONG THIS LINE -- - -RETAIN LOWER PORTION FOR YOUR RECORDS - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - -- - - - - - - -- -- - - - - - - - - - -- REV-1607 EX AFP (12-12) * * INHERITANCE TAX STATEMENT OF ACCOUNT *** ESTATE OF:NYE RUTH I FILE NO. : 21 02-0764 ACN: 101 DATE: 03-18-2013 THIS STATEMENT PROVIDES CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 02-04-2013 PRINCIPAL TAX DUE: 57,172.67 PAYMENTS (TAX CREDITS) : PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID t-) 10-29-2002 CDO01786 2,631.58 50,000.00 12-13-2002 CDO01961 .00 4,356.69 11-28-2012 CDO16848 90.56- 285.41 03-04-2013 REFUND .00 10.45- TOTAL TAX PAYMENT 57,172.67 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.