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12-05-14 (2)
1505610101 REV-1500 EX(oi_lo) PA Department of Revenue pennsytvania OFFICIAL USE ONLY Bureau of Individual Taxes °EPARTM-OF11EVE"�E County Code Year File Number PO BOX 28o6o1 INHERITANCE TAX RETURN �+ _� as Harrisburg,PA 1'7128-0601 RESIDENT DECEDENT �� 1 ; i 1 I G__/_ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY ' 10/28/2012 10/09/1944 Decedent's Last Name _ Suffix Decedent's First Name MSI CLARK —_ PESSE It= --- --- = (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI 1� N/A Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW M 1.Original Return Q 2.Supplemental Return O 3. Remainder Return(date of death prior to 12-13-82) O 4. Limited Estate Q 4a. Future Interest Compromise(date of p 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 1 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(date of death O 11. Election to tax under Sec.9113(A) between 12-31-91 and 1-1-95) (Attach Sch.0) z CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED_': Name _ Daytime Da hon Yt Tele P_ lumber '_c :0 Andrew H. Shaw � ' _ 1(717)243-71:5 t{ REGISTER�F WLL SE ONLY t•i fr r° First line of address <:+ -n 14 200 S. Spring Garden St 7 sv Mr! _ ' -Second line of address, �`- —� Suite 11 _ City or Post Office State ZIP Code DATEFILED ' Carlisle PA 117013 "--� Correspondent's e-mail address: andrew@ashawlaw.com Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SI NATURE OF PERSON RESPONSIBLE FOR KILING RETURN DATE 'M, \0 ADDRESS c 997 Pi town Road, iew' r , PA 17339 SIGN AT OF PREP -OT N REPRESENTATIVE DATE / ADMESS 200 S. Spring Garden Street, Suite 11, Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: Jesse R. Clark RECAPITULATION 1. Real Estate(Schedule A). ...... ...... ...... .... . ..... ............ .... 1. 195,000.00 2. Stocks and Bonds(Schedule B) .............. ................. ........ 2. 0.00 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. 0.00 4. Mortgages and Notes Receivable(Schedule D) ..... . ....... ............. . 4. 0.00 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 50,516.91 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 0.00 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested... ..... 7. 0.00 8. Total Gross Assets(total Lines 1 through 7).. .... ............. .......... 8. 245,516.91 9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 11,030.92 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) .......... .... 10. 217,994.27 11. Total Deductions(total Lines 9 and 10). ... .. ........ ........ ........... 11. 229,025.19 12. Net Value of Estate(Line 8 minus Line 11) . ..... ......... ... ............ 12. 16,491.72 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) ... ........ ............. 13. 0.00 14. Net Value Subject to Tax(Line 12 minus Line 13) . .............. ........ . 14. 16,491.72 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 00 0.00 15. 0.00 16. Amount of Line 14 taxable at lineal rate X.0 45 16,491.72 16, 742.13 17. Amount of Line 14 taxable at sibling rate X.12 0.00 17_ 0.00 18. Amount of Line 14 taxable at collateral rate X.15 0.00 18 0.00 19. TAX DUE .......... ....... . ... ...... ........... ......... ...... .... 19. 742.13 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 L 1505610105 1505610105 J REV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Jesse R. Clark STREETADDRESS 926 Petersburg Road CITY STATE ZIP Carlisle PA 17015 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 742.13 2. Credits/Payments A.Prior Payments 0.00 B.Discount 0.00 Total Credits(A+B) (2) 0.00 3. Interest (3) 30.12 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 772.25 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;or.......................................................................................................................... ❑ d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 0 2. If death occurred after Dec.12, 1982,did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ El 3. Did decedent own an"in trust for'or payable-upon-death bank account or security at his or her death?.............. ❑ Z 4. Did decedent own an individual retirement account,annuity or other non-probate property,which containsa beneficiary designation? ........................................................................................................................ ❑ ❑x IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S.§9116(1.2)[72 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined,under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. LAST WILL AND TESTAMENT OF JESSE R. CLARK I, JESSE R. CLARK,residing at 926 Petersburg Road, Carlisle,Pennsylvania, being of a sound and disposing mind, over the age of eighteen(18) years, and under no legal disability, do hereby make,publish and declare this to be my Last Will and Testament, hereby revoking all other Wills and Codicils heretofore made by me at any other time. Article I: I direct that my Personal Representative(s),hereinafter named,pay all my just debts and funeral expenses as soon after my death as practicable, including all property, state and federal death taxes assessed against me, my estate, or my beneficiaries, without proration among my beneficiaries. However, all property bequeathed or devised hereunder, either outright or in trust,is bequeathed or devised subject to existing mortgages, liens or encumbrances thereon. Article II: I confer on my Personal Representative(s) and/or any Trustee(s) appointed herein and their successors the right to sell or otherwise convert any real or personal property at public or private sale, at such time or times, in such manner,and for such price or prices,and on such terms and conditions as my Personal Representative(s) shall determine, and to execute and deliver good and sufficient conveyances, assignments, and transfers of the property, without liability of any purchaser for the application of any consideration; to borrow money and to secure 1 Jesse R. Clark its payment by mortgage of real or personal property,pledge of investments, or otherwise, without liability on the part of the lenders to see to the application thereof; to retain any investments at discretion; to invest and reinvest at discretion, as permitted under Act 28 of 1999, the"Prudent Investor Act"; to make distribution in cash or in kind; to allocate and distribute different kinds or disproportionate shares of property or undivided interests in property among beneficiaries, in cash or in kind, or partly in each; and all other powers given under the statutory and common law of Pennsylvania available at the time of my death and the power to do all acts and things necessary or appropriate in the management, administration and distribution of my estate. Article III: At the time of execution of this Last Will and Testament I am single. Article IV: At the time of execution of my Last Will and Testament I have the following children: A. MICHELLE L. BRANDT; B. DERON R. CLARK; C. DAWN M. CLARK. Article V: I hereby nominate and appoint my daughter, MICHELLE L. BRANDT, and my daughter,DAWN M. CLARK, as Co-Personal Representatives of this my Last Will and Testament. My individual Co-Personal Representatives shall not be required to furnish bond or surety. Article VI: I give, devise and bequeath my RESIDENCE to either MICHELLE L. 2 Jesse R. Clark BRANDT or DAWN M. CLARK, absolutely and in fee simple, with Forty-Five Thousand and 00/100 ($45,000.00) Dollars in value of said residence to the daughter not taking ownership of said residence and Twenty Thousand and 00/100 ($20,000.00) Dollars in value of said residence to DERON R. CLARK. If, for any reason,neither of my daughters choose to take ownership of said residence,I direct my Personal Representative(s)to sell said residence at public or private sale, and to distribute the net proceeds therefrom to my children as follows: A. 40% to MICHELLE L. BRANDT; B. 40% to DAWN M. CLARK; C. 20% to DERON R. CLARK. Article VII: I give, devise and bequeath all the rest and residue of my estate of whatever kind and description wherever situate, to my children in equal shares,per stirpes. [Remainder of page intentionally left blank] 3 Jesse R. Clark IN WITNESS WHEREOF, I have hereunto set my hand and seal this Qday of S � 2012. 4�.�(SEAL) Jesse R. Clark Signed, sealed,published and declared by the foregoing Testator as and for his Last Will and Testament, consisting of four(4)pages, in the presence of us, who at his request, and in his presence, and in the presence of each other, h hereunto set our hands as witn s ereto. 4 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND I,JESSE R. CLARK, Testator, whose name is signed to the attached or foregoing instrument,being 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. 'Swrn'� to or affirmed and acknowledged before me by JESSE R. CLARK,the Testator, this-G c day of_ p�� vel— , 2012. COMMONWEALTH OF PENNSYLVANIA Jesse R. Clark Notarial Seal Sarah D.Dieckman,Notary Public Carlisle Boro,Cumberland County My Commission Expires Nov.5,2013 Member.Pennsvivania Association of Notaries otary Public My Commission expires: COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND We, Ajz� k) -/ 1 - L") and 6ncif o LskC i'i the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testator sign and execute the instrument as his free and voluntary act for the purposes therein expressed;that each of us in the hearing and sight of the Testator was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. / Sworn to or affirmed and subscribed before me b S t c and Y 'An AiP(3- , witnesses, this day of s'" , 2012. otary Public My Commission Expires: COMMONWEALTH OF PENNSYLVANIA Notarial Seal Sarah D.Dieckman,Notary Public Carlisle Soro,Cumberland County 5 My Commission Expires Nov.5,2013 Member.Pennsmania Association of Notaries REV-1502 EX+(11-08) pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER Jesse R. Clark 21-12-1183 All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1 926 Petersburg Road,Carlisle,PA 195,000.00 TOTAL(Also enter on Line 1, Recapitulation.) $ 195,000.00 If more space is needed,insert additional sheets of the same size. atMr=N>�, oar va`� OMB Approval No.2502.0265 tl`R SINA. Settlement Statement (HUD-1) 9eRN ecJO�d� B. Type of Loan 6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number: 1.❑FHA 2.Q RHS 3.n Conv.Unins. 13-0027 5315742 4.Q UA 5.Q Conv.Ins. C. Note: This form is furnished to giveyou a statement of actual settlement costs Amounts paid to and by the settlement agent are shown. Items marked 70.0.0'were paid outside the obsing,they are shown here for informationat purposes and are not included in the totals D. Name and Address of Borrower: E. Name and Address of Seder: Thomas R.Grosz F. Name and Address of tender: Alyssa Grote Michele t.Brandt,Co-Exeartor AmeriChoioe Federal Credit 5305 Oxford Drive Union Dawn M.Clark,Co-Executor 2175 Bumble Bee Hollow Road Mechanicsburg,PA 17050 Of the Estate of Jesse R.Clark Mechanicsburg,PA 17055 G. Property Location: H. Settlement Agent: 20-2339545 926 Petersburg Road AbstractAmerica Real Estate Settlement Solutions I• Settlement Date: Carlisle,PA 17015 65 Ken-Mar Drive Cumberland County,Pennsylvania Shermansdale,PA 17090514-4114 March 28,2013 Ph, (717) Place of Settlement JA4ZK Real Estate Services 128 E.Kfn Street,Ship nsburg,PA 17257 J. Summary of Bomrwet s transaction K- Summary of Settees transaction 100. Gross Amount Due from Borrower: mmar 400. G mmar ount Due to Seller: 101. Contract sales rice 195,000.00 441. Contract sates rice 102. Personal ro 402. Personal property 195,000.00 103. Settlement Char es to Borrower Lina 1400 7162.14 403. 104. 105. 404. 4djust for items ata b Seller in advance 405. Ad ustmants for Items aid b Seiler in advance 106. CoifownTaxes 0312$/13 to 12131/13 421.45 406.Co/Town Taxas 107. School Taxes 03126113 to 0613011303R8l13 to 12/31!13 421.45 t08. Assessments 524.03 407.SdtEa-eO3/28/13 to 06130113 524.03 to 408.Assto1104112.120. Gross Amount Due from Borrower 20310720.Groer 100. Amounts Paid b or in Behalf of Borrower 195.945--0$ 101. De d or earnest money500. Reductions In Amount Due Seller: 1,000.00 501. Excess da sit sae instruct ons 102. Prin' al amount of new bans 156 000.00 502. Settlement char es to Seller Lina 1400 Exfstin bans taken sub dto 12,758.88 A4 503. Fxistin Bart s taken sub'ect#o !05 504.Payoff First Mortgage to Wells Fargo Nome Mortgage 183,790.29 r.06 505.Pa n Second Mortgage ?07. 506. rog 507. Da posit dish,as r Ws .09. 508. id ustments for items unpaid by Setter 509. r10. Coilown Taxes Ad ustments for items unpaid b Setter r11. School Taxes to 510.Co/Town Taxes fp N2. Assessments to 511. School Taxes f0 ,13 512.Assessments to .14. 513. !f5. 514. '16. 515. :17. 516. .18. 517. 19. 518. 519. 70. Total Paid b/for Borrower 157,000.00 520. Total Reduction Amount Due Salter Z0. Cash at Settlement from/to Borrower 196.549.17 01. Gross amount duo from Borrower line 120 600. Cash at settlement to/from Seller 203 107.62 601. Gross amount due to Seller tine 420 195,945.48 QZ Less amount pail byRor Borrower(line 220 ( 157,000,00) 602. Less reductions due Sellar(fine 520 W. Cash From To Borrower ( 196,544.17) 46,107.62 603. Cash E]To o From Seller 603.69 The undersigned herAAV-%aGr edge re fpt of a completed copy of this statement&any attachments referred to herein a�+1 / Borrower Seller� ^� l•Ci,> L-"C nchete L.Brandt,Co-Lxeartor of the Esttaa!tte ooff JJesse R.Clar i� w M. -rte coo-T_� n CIa C for of he Estate of Jesse R.Clark V003S.is R�rrttrg COs'denror Itis oaflectimdirtame[fmisesNmemdet k6mintespwrespxeereraitec tp,revioelru adrep"'fro edafa TNSVrwY mayrt CdIGacisirformdkg atlymsendreq*odto mpios ,tHes d am*valid ONE oairdnmber.N000rfidertdty is sse"Ot the dSd0Sve is maid".THs is dasifredt0provkla MepaNes toe RESMccvaed basedMnvih lriormgion tlfinp the astUana't Page 1 of HUD-1 (13.0027.PFD/13-0027/32) L.Settlement Charges 700.Total Real Estate Broker Fees $9,754.04 D/vuion of commission(fine 700)as follows: Pe d FIM PddF«n 701. 4,675, to Prudential Home Services Grou a Ta-14% Sell" 702. 3,656.25 to JA/Lex Real Estate Services LLC Fuxb a F"b'a Note:Line 702IndudesAdiustment of 1 218.75 For e 1 Hemet 703.Commission paid at settlement 704. Referral Fee toRe1Max Rea 8,531.25 705. 1,218.75 800.Items payable in Connection with Loan 801.Our ar•matron char e $ 850.00 from GFE#1 802,Your credit or charge(points)for the spedfic interest rate chase. $ (from GFE#2} 803.Your adjusted origination Charges 'Ju4.,AReralsal feeto AmeriChoce Federal Credit Union from GFE#A $50,001 805,Credit Ra from GFE#3 rt to AMeriChoiCe Federal Credit Union 375.001 806,Tax service to from GFE#3 25.001 807.Flood certification (from GFE#3) to Amer Choice Federal Credit Union (from GFE#3) 808. 25.04' 609. (from GFE#3) 810• {from GFE#3) 811. (from GFE#3) 900.Items R ulmd b Lender to Be Paid in Advance {from GFE#3} 901.Daily interest charges from 03/28113 to 04/01/13 4@ $15.170000/day (from GFE#10) 60.68 902.Mort a e insurance remium for months to from GFE#3 903.Homeowner's insurance for 1.0 ars to Ailstate�khide and Pro Insurance Co. from GFE#11 904• 419.48 905. from GFE#11 1000.Reserves Deposited with Lender (from GFE#11) 1001,Initial deposit for your escrow amount1002. (from GFE f/9} - omeowner s insurance mon s 1,515.98, 1003.Mori a e insurance Per mon 1004.Property taxes months $ r month $ CHyfTown Taxes months@ $ $ CountyTaxes per month 1005. months r moth 1006.2014 Co/Twp.Tax 2.400 months $ $ 45.95 per month $ 91.90 1007.2013-2014 School Tax 10.000 months @ $ 167.78 per month $ 1,677.80 ,008. 1009.AggregateAdjustment $ 358.60 1100.Title Cha es 1101, Title services and lender's title insurance (from GFE#4) 1102. Settlement or closing fee 1,450.00 1103. Owner's utle insurance to Fidelity Natbnal Title Insurance Co. $ 1 }104. Lender s title insurance to Fidel ty Natrona,Title Insurance Co, from GFE#5 18500 1105. Lender'sttle of lmit $ 1,330.00 $ 156,000.QO 1105. Owner's title Ii Gmd $ 195 000.00 1147. enYs rtlon of thio total t 0e insurance remium to ABSTRACTAMERICA REAL ESTATESE f106. Underwrker's rtion of the total title insurance remium to Fidel' National Title Insuranoe Co. $ 22288.7 75.00 $ 1,2 25 1109• Closing Profedian tatter to FidafAy Natanai Title Insurance Co. `110. Overnight Delivery to USPS 111. Tax Certification $ 45.00 25,00 to AbstractAmerica Reasate Settlement Solutions 112. l Et15.00 113. 200.Government Recording and Transfer Charges 201.Government reLcordinq charges to Cumberland Count(Recorder of Deeds from GFE# 202.Deed $ 62.00 Mortgage $ 64.00 Releases $ 146.00 I 243.Transfer taxes Other $ to Cumberland County Recorder of Deeds (from GFE#8) 1,950.00 204.City/Countytax/stamps Deed$ 1,950.00 Mortgage $ 205.State tax/stamps Deed$ 1 950.00 Mortgage $ 206. 1,950.00 207. 300.Additional Settlement Charges 301.R wired services that u Can sho for from GFE#6 =162.'141 2413 Cot .Tax to Robert C,Cairns,Tax CClledr Se tIC Pum in to Sunda Se tic Services 344.Se tic In don to Sunda Se tic Services 305.See addit'l disb.exhbll $ 150,00to400.Total Settlement Cha es enter on lines 103,Section J and 502Sti 6y sigirg pe®s l dura su mert,ft sig"wies o*omwge rwdpt cf s=pletwcc y dpape2$3 dtNS tree /(, AbstradAmerica at to Battlement Solutions,Settlement Agent Page 2 of 3 HUD-1 (13-0027.PFD/13-0027/32) Comparisor.of Good Faith Estimate(GFE)and HUD-1 Charges Good Faith Estimate HUD-1 Charges That Cannot Increase HUD-1 Line Number Out origination charge #801 850.00 $50.00 Your credit or charge(points)for the specific interest rate chosen #802 Your adjusted origination charges #803 850.00 850.00 Transfer taxes #1203 1,950.00 1,950.00 Charges That In Total Cannot Increase More than 10% Good Faith Estimate HUD-1 Government recording charges #1201 250.00 146.00 Appraisal fee #804 500.00 375.00 Credit report #805 25.00 25.00 Flood certification #807 25.00 25.00 Title services and lender's title insurance #1101 1,330.00 1,450.00 Total 2,130.00 2,021.00 increase between GFE and HUD-1 Charges $ -109.00 or -5.12°/ Charges That Can Change Good Faith Estimate HUD-1 Initial deposit for your escrow account #1001 1,874.58 1,515.98 Daily interest charges #901 $ 15.170000/day 60.68 60.68 Homeowner's insurance #903 419.52 419.48 Owner's title insurance to Fidelity National Title Insurance Co. #1103 700.00 195.00 Septic Inspection #1304 450.00 150.00 .oan Terms Your initial loan amount is $156,000.00 Your loan term Is 30 years Your Initial Interest rate is 345000% Your initial monthly amount owed for principal,Interest and $700.51 includes any mortgage Insurance Is Q Principal ❑X Interest ❑ Mortgage Insurance 'an your Interest rate rise? Q No ❑ Yes,it can rise to a maximum of °Jo. The first change will be on and can change again every_months after . Every change date,your interest rate can increase or decrease by %. Over the fife of the ban,your Interest rate is guaranteed to never be lower than %or higher than %. Even If you make payments on time,can your loan balance rise? ❑x No ❑ Yes,it can rise to a maxrmum of$ Even If you make payments on time,can your monthly ❑X No ❑ Yes,the first increase can be on and the monthly rmount owed for principal,Interest,and mortgage Insurance rise? amount owed can rise to$ The maximum it can ever rise to is$ )oes your loan have a prepayment penalty? ❑X No ❑ Yes,your maximum prepayment penalty is$ )oes your loan have a balloon payment? ❑X No ❑ Yes,you have a balloon payment of$ due in_years on otai monthly amount owed Including escrow account payments ❑ You do not have a monthly escrow payment for items,such as property taxes and homeowner's insurance. You must pay these items direly yourself. 0 You have an additional monthly escrow payment of$248.69 that results in a total initial monthly amount owed of$949.20. This includes principal,interest,any mortgage insurance and any items checked below: ❑ Property taxes ❑X Homeowner's insurance ❑ Flood insurance © Co/Twp.Real Estate Tax ❑ Q School Real Estate Tax ote: if you have any questions about the Settlement Charges and Loan Terms listed on this form,please contact your lender. Page 3 of 3 HUD-1 (13-0027.PFD/13.0027/32) HLID-1 Attachment Borrowegs):Thomas R.Grosz and Alyssa Grosz Selle(s): Michele L. Brandt,Co-Executor of the Estate of Jesse R.Clark Dawn M.Clark,Co-Executor of the Estate of Jesse R.Clark 5305 Oxford Drive Mechanicsburg,PA 17050 Lender:AmeriChoice Federal Credit Union Settlement Agent:Abstract America Real Estate Settlement Solutions (717)514-4114 Place of Settlement:JA/LEX Real Estate Services 128 E.King Street,Shippensburg,PA 17257 Settlement Date:March 28,2013 Property Location:926 Petersburg Road Carlisle,PA 17015 Cumberland County,Pennsylvania Additional Disbursements Payee/Descrlption Note/Ref No. Borrower Seller Law Office of Andrew H.Shaw 250.00 Deed Preparation SMTMA 28.56 Final Water Bill Total Additional Disbursements shown an Line 1305 $ 0.00$ 278.66 Seller Loan Payoff Details Payoff First Mortgage to Wells Fargo Home Mortgage Loan Payoff 183,790.29 As of 03/01/13 Total Additional Interest 27 days @ Per Diem Total Loan Payoff 183,790.29 Adjusted Origination Charge Details Origination Charge 850.00 to AmeriChoice Federal Credit Union Total $ 850.00 Origination Credit/Charge(points)for the specific interest rate chosen Total $ Adjusted Origination Charges $ 850.00 WARNING: It is a crime to knowingly make false statements to the United States on this or any similar form. Penalties upon conviction can Include a fine and Imprisonment. For details see:Title 18 U.S,Code Section 1001 and Section 1010. (1 3.0027.PFD/1 3-0027132) HUD-1 Attachment- Continued Reserves Deposited with Lender Homeowner's Insurance 104.88 3.000 at 34.96 per month 2014 Co/Twp.Tax 91.90 2.000 at 45.95 per month 2013-2014 School Tax 1,677.80 10.000 at167.78 per month Aggregate Adjustment -358.60 month Total $ 1,515.98 Title Services and Lender's Title Insurance Details BORROWER SELLER Lender's title insurance 1,330.00 to Fidelity National Title Insurance Co. Closing Protection letter 75.00 to Fidelity National Title Insurance Co. Overnight Delivery 45.00 to USPS Total $ 1,450.00 $ 0.00 Owner's Title Insurance BORROWER SELLER Owner's Policy Premium 195.00 to Fidelity National Title Insurance Co. Total $ 195.00 $ 0.00 Lender's Title Insurance BORROWER SELLER `fees also shown above In Title Services and Lenders Title Insurance Details Lender's Policy Premium 1,180.00 to Fidelity National Title Insurance Co. Lender's Endorsement Charges 150.00 Endorsement Endorsement Charge ALTA Endorsement Form 100 50.00 ALTA Endorsement Form 300 50.00 ALTA Endorsement Form 8.1 (Environmental Protection Lien) 50.00 Total $ 1,330.00 $ 0.00 WARNING: It Is a crime to knowingly make false statements to the United States on this or any similar form. Penalties upon conviction can Include a fine and imprisonment. For details see:Title 18 U.S.Code Section 1001 and Section 1010. (13-0027.PFD/13-0027/32) REV-1508 EX+(6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Jesse R. Clark 21-12-1183 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F, ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH Personal Property,See attached auction receipt 4,704.00 2. 2009 Chevrolet Corvette 30,804.00 3. Micro Sprint race car 400.00 4. Ford wheels and tires 220.00 5. 1991 Ford Truck 500.00 6. Riding Mower 100.00 7. 2011 John Deere Zero Tum mower 3,600.00 8. 1986 Chevy Truck 300.00 9. 1996 Chevy Van 600.00 10. 2003 Harley Davidson- 4,500.00 11. Snowblower 100.00 12. NCFCU Bank Account,# 1,414.90 13. Wells Fargo Bank Account#3574231415 2,182.15 14. Wells Fargo Bank Account#5561746875 871.34 15. Wells Fargo Bank Account#5561746958 50.02 16. Metro Bank Account,#833363708 20.50 17. Sharp TV 150.00 TOTAL(Also enter on line 5, Recapitulation) $ 50,516.91 (If more space is needed,insert additional sheets of the same size) ROWE'S A[TCTION SERVICE (RH 79L) 2505 Ritner Highway • Carlisle,PA 17015 Bill Rowe (AU 1538L) 249-1978 215-1044 574-1008 Dave Rowe (AU 2295L) A ction Action Call "Rowe" For Satisfaction SELLERS NAME DATE ADDRESS PHON]a Z r - OTHER Z _,. �'` ' AUCTIONEER % AUCTION DATE/LOCATION I 7 CLERK % i DESCRIPTION OF MERCHANDISE t � jQ 6C.i--aG, -%Wq."JZA� ON\ - l} — I Commission the Auctioneers to sell the merchandise to the highest bidder by Public Auction. Merchandise to be sold as is & grouped as necessary to obtain bids. I certify that I am the owner or authorized represen- tative of the merchandise,goods and or property and have good title and the right to sell and that they are free from all incumbrances. I agree to accept all responsibility for providing merchantable title and for delivery of title to the. urchaser. I agre to hold harmless the Auctioneers against any claims of the nature referred to in this agree t. AUCTION SIGkATUkF, SELLERS SIGNATURE Total Sales (Clerking 'rickets Attached) $ ' 7 0 Lf Less Sale Expense: cLr3 % Commission Auctioneer $ w % Commission Clerks $ _ EJ-'- OTHER: TOTAL. SALE EXPENSE DEDUCTED $ SELLERS NET $ `'2 S Kelley Blue Book Page 1 of 2 A� Kelley Blue Book The Trusted Resource* I advertisement why ads? Your Blue Book Value 2009 Chevrolet Corvette Style:Coupe 2D Mileage:18912 � I Trade-In Value --- - ----------- Excellent Vehicle Highlights $31,404 MPG:City 16/Hwy 26 Max Seating:2 Very Good 111 $30,804 Doors:2 Engine:V8,6.2 Liter Good Drivetrain:RWD Transmission:Manual,6 Spd $29,804 EPA Class:Two Seaters Body Style:Coupe Fair $27,004 Country of Origin:United States Country of Assembly:United States Your Configured Options Our pre-selected options,based on typical equipment for this car. /Options that you added while configuring this car. Engine Comfort and Convenience Seats V8,6.2 Liter Keyless Entry ✓ Heated Seats Transmission Keyless Start ✓ Dual Power Seats ✓ Manual,6-Spd Air Conditioning Leather brivetrain Power Windows Lighting RWD Power Door Locks HID Headlights Braking and Traction Cruise Control Daytime Running Lights ABS(4-Wheel) Steering Wheels and Tires Power Steering Alloy Wheels Tilt Wheel Entertainment and Instrumentation AM/FM Stereo MP3(Single Disc) Safety and Security Dual Air Bags New Cars You Might Like 2013 Chevrolet Corvette http://www.kbb.com/chevrolet/corvette/2009-chevrolet-corvette/coupe-2d/?vehicleid=22... 12/27/2012 i i Sollenbergers-Carlisle Record#: 18555 29 Westminster Dr Carlisle,PA 17013 (717)249-8149 For: Date:04/23/2013 TRAVIS ALLEN WILLOW Time:05:05 PM 997 PINETOWN RD / `7 3(o C hey TfU(_ LEWISBERRY,PA 17339 717-309-5833Clerks Initials:MND b e LL PACE3 C Vehicle Registration/Title Information Online Title Title Number 37983362 Sales/Use Tax 18.00 WID 13113 3427 017830 Motor Vehicle Fees 22.50 VIN 2GCEK14HXG.1131408 Other Fees 0.00 Year 1986 Make CHEV Odometer 123000 Tag Number State Payment Type Cash Total State Fees 40.50 Service Fees Messenger/Processing Fee25.00 Electronic Processing Fee 5.00 Plate Fee 0.00 Notary/Clerical Fee 5.00 Copy/Fax Fee 0:00 MV03 Form Fee 0.00 MV13 Form Fee 0.00' Other Fee 0.00 I/We swear that I/we have applied for the above item(s). Messenger Payment Type Cash Total Service Fee _ 35.0.0 Sworn and subscribed to before me on 23-Apr-2013. Total Amount Due 7550 Amount Tendered 75.50 Change Due _ 0._00 No Refunds on Service or Notary fees.We are notes responsible for the work the State fails to process. __Notary Seal _ _ Welcome to Sollenbergers-Carlisle Your Direct Connection with PENNDOT,"Online",State&Service Fees Apply 04/23%2013 05:05 PM Sollenbergers-Carlisle Record#: 18556 29 Westminster Dr Carlisle,PA 17013 (717)249-8149 For: Date:04/23/2013 TRAVIS ALLEN WILLOW Time:05:13 PM 997 LEWISBNETOWN RD 7339 cl')et/ 1 4aro V0_r) 717-309-5833 Clerks initials:MND SELL. Pei CE I&CO Vehicle Registration/Title Information Online Title Title Number 49930389 Sales/Use Tax 36.00 WID 13113 3427 018163 Motor Vehicle Fees 22.50 VIN 1GNEL19W7TBI93404 Other Fees 0.00 Year 1996 Make CHEV Odometer 187000 Tag Number State Payment Type Cash Total State Fees 58.50 Service Fees Messenger/Processing Fee 15.00 Electronic Processing Fee 5.00 Plate Fee 0.00 Notary/Clerical Fee 5.00 Copy/Fax Fee 0.00 MV03 Form Fee 0.00 MV13 Form Fee 0.00 Other Fee 0.00 I/We swear that I/we have applied for the above item(s). Messenger Payment Type Cash Total Service Fee 25.00 Sworn and subscribed to before me on 23-Apr-2013. _. ... Total Amount Due 83.50 Amount Tendered 83.50 Change Due 0.00 ''No Refunds on Service or Notary fees.We are not responsible for the work the State fails to process. Notary Seal. Welcome to Sollenbergers-Carlisle Your Direct Connection with PENNDOT,"Online",State&Service Fees Apply 04/23/2013 05:13 PM BILL OF SALE DATE Address 0jorl Pi ne--r Inon Le LA SCL �135q4 Sold d o03 Address i a r, a,(I For the sum ofL f ��s ori b Gw � Tk Seller Buyer Advanced Histoiy Search Page 1 of 2 Advanced History Search Business ESTATE OF JESSE (No. ***579 SILVER) Last Logon: 02/18/2014 11:58:11 Search Results: S4-SHARE DRAFTS(S 4), Date Range 11/1/2012-2/18/2014 Most Recent First M Another search Check Trans Effec Transaction Description Amount Ending Balance Date Date 01/31/14 01/31/14 DIVIDEND 1.02 $ 11,066.89 0.10 140101 140131 0.10 S1 12031.75 SHARE DRAFT CLEARED 0102 01/30/14 01/30/14 TRACE#0042130016-000095579 -1,032.50 $ 11,065.87 View Check 12/31/13 12/31/13 DIVIDEND 1.03 $ 12,098.37 0.10 131201 131231 0.10 S1 12097.34 11/30/13 11/30/13 DIVIDEND 0.99 $ 12,097.34 0.10 131101 131130 0.10 S 1 12096.35 10/31/13 10/31/13 DIVIDEND 1.03 $ 12,096.35 0.10 131001 1310310.10 S 1 12095.32 09/30/13 09/30/13 DIVIDEND 0.96 $ 12,095.32 0.10 130901 130930 0.10 S 1 11728.71 09/09/13 09/09/13 PAYMENT 1,371.17 $ 12,094.36 08/31/13 08/31/13 DIVIDEND 0.91 $ 10,723.19 0.10 130801 130831 0.10 S1 10722.28 07/31/13 07/31/13 DIVIDEND 0.55 $ 10,722.28 0.10 130701 1307310.10 S1 6512.05 07/30/13 07/30/13 PAYMENT 4,500.00 $ 10,721.73 06/30/13 06/30/13 DIVIDEND 0.51 $6,221.73 0.10 130601 130630 0.10 S 1 6221.22 05/31/13 05/31/13 DIVIDEND 0.53 $6,221.22 0.10 130501 130531 0.10 S1 6200.67 05/02/13 05/02/13 PAYMENT 620.50 $6,220.69 04/30/13 04/30/13 DIVIDEND 0.42 $5,600.19 0.10 130401 130430 0.10 S 1 5118.97 04/04/13 04/04/13 PAYMENT 4,808.00 $5,599.77 SHARE DRAFT CLEARED 0101 04/01/13 04/01/13 TRACE#0042260478-000095579 -603.69 $791.77 View Check 03/31/13 03/31/13 DIVIDEND 0.12 $1,395.46 0.10 130301 130331 0.10 S1 1395.34 02/28/13 02/28/13 DIVIDEND 0.11 $ 1,395.34 0.10130201 130228 0.10 S1 1395.23 01/31/13 01/31/13 DIVIDEND 0.10 $ 1,395.23 0.10 130101 1301.31 0.10 S1 1197.84 081440 01/24/13 01/24/13 TRANSFER 265.91 $ 1,395.13 FROM MEMBER 081440 12/31/12 12/31/12 DIVIDEND 0.10 $1,129.22 0.10 121201 121231 0.10 SI 1129.12 OTHER 11/19/12 11/19/12 WITHDRAWAL -285.78 $ 1,129.12 P-LAW OFFICES OF ANDREW H.SHAW https://www.liomebanking.nefcuonline.org/altematehistory.aspx 2/18/2014 Advanced History Search Page 2 of 2 11/14/121 11/14/121PAYMENT 1 1,414.901 $ 1,414.901 Data Range Search: Retrieve transactions for an account within a specific time period with the ability to filter the results by transaction category, a dollar amount, or number to display. History S4-SHARE DRAFTS (S 4) Date 1 Range November ! 1 ( 2012 j` To February 18 '2014 i i Limit El To These Transactions ACH Transactions i Amount Range _ To Number of Transactions Submit More Options Basic History Search 'Advanced History Search Specific Day Search C'Find a Draft Retum To Top https://www.homebanking.ncfcuonline.org/altematehistory.aspx 2/18/2014 t Wells Fargo Combined Statement of Accounts Primary account number: 3574231415 ■ October 17,2012-November 16,2012 ■ Page 1 of 5 Questions? JESSE CLARK V Available by phone 24 hours a day, 7 days a week: 926 PETERSBURG RD 1-800-TO-WELLS (1-800-869-3557) CARLISLE PA 17015-9211 TTY:1-800-8774833 En esparlol.1-877-727-2932 p 1-800-288-2288 (6 am to 7 pm PT,M-F) Online: wellsfargo.com Write: Wells Fargo Bank,N.A.(345) P.O.Box 6995 Portland,OR 97228-6995 You and Wells Fargo Account options Thank you for being a Wells Fargo customer.We appreciate your business and A check mark in the box indicates you have these understand that you are entrusting us with your banking needs.Let us assist you convenient services with your account. Go to In finding the right accounts and services to help you reach your financial goals. wellsfargo.com or call the number above if you have Please visit us online at wellsfargo.com,call us at the number at the top of your questions or if you would like to add new services. statement,or visit any Wells Fargo store-we'd love to hear from youl Online Banking Q Direct Deposit Online Bill Pay Q Auto Transfer/Payment Z Online Statements F1 Overdraft Protection Mobile Banking F] Debit Card My Spending Report Q Overdraft Service Q Summary of accounts Checking and Savings Ending balance Ending balance Account Page Account number last statement this statement Complete Advantage Checking 2 3574231415 2,182.15 0.00 Wells Fargo Money Market Savings" 2 5561746875 871.34 0.00 Wells Fargo Way2Save°Savings 3 5561746958 50.02 d.00 Total deposit accounts $3,103.51 $0.00 Sheet Seq=0004246 Sheet 00001 of 00003 02-Stoplhold information Account NamelAddress Account number 83336370 IBA JESSE R CLARK Short name CLARK JESSE R PETERSBURG RD TIN XXX-XX-7370 TIN Crt BR 1 CARLISLE PA 17015 Balance Data Current balance 20.50 Avail balance 00 Avail tomorrow .00 Memo balance •00 Customer Activity Hold amount 00 Stopslholds active Check CR balance .00 Date last contact 5291 Interest due .00 Date last alive 5-29-1 Int pd this year .00 Date last deposit 5.14-1 Int pd last year .26 Amount last deposit 1,000. Acct current rate ,Wq Previous Statement Data Account Data Last stmt date F42&1 Stat 0 Prod type 0 Last stmt balance 20.50 Statement oodelcyde I Checks/deposits since Date opened 6-04-1 Service charge typelplan 10 Processed thru 428-1 Combined stmtfnbr copies METRO , 888.937.0004 BANKmymetrobank.com Deposits may not be available for immediate withdrawal.For deposits made before 6:00 PM,that business day will be considered the day of your deposit. Funds from your cash and check deposits will be available to you on the first business day after the day we receive your deposit. 39 10:40 4/29/2013 1811 *****3708 TIrDDWdCIose $ 20.50 CARLISLE COMMONS STORE118 S-16 3MM 11/12 INT http://10.209.22.60:32037/A 1_Signature_90/entry?hatsg... 4/27/2013 REV-1511 EX+(10-09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Jesse R. Clark 21-12-1183 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: _ 1' Hollinger Funeral Home&Crematory, Inc. p__ 6,990.02 B. ADMINISTRATIVE COSTS: _ 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: 2. Attorney Fees: 1,9 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.) Claimant ` Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 394.50 5. Accountant Fees: - � 6. Tax Return Preparer Fees: 7• Auctioneer Fees ❑ L F1 11. TOTAL(Also enteron Line 9, Recapitulation) $1 11,030.92 If more space is needed,use additional sheets of paper of the same size. ,er b,11 Hollinger Funeral Home &Crematory, Inc. Eric L. Hollinger,Supervisor October 28,2012 Dawn Clark 997 Pinetown Rd. Lewisberry, PA 17330 The Funeral Service for Jessie R.Clark: We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. Professional Service-Cremation Package E. $ 5150.00 Merchandise-Memorials, Register Book No Charge Cloth Covered Casket $ 1060.00 AT THE TIME FUNERAL ARRANGEMENTS WERE MADE,WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. Cash Advances Death Certificates(10X 6.00) 60.00 Cumberland Co.Coroner Fee 25.00 Flowers 159.00 Minister 125.00 Patriot 221.02 Sentinel 190.00 Total Charges $3256.00 Current Balance: $6990.02 501 NORTH BALTIMORE AVENUE • MOUNT HOLLY SPRINGS. PENNSYLVANIA 17065 • (717) 486-3433 • FAX(717)486-3215 www.hoIlingerfuneralhome.com RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date : 3/20/2013 Cumberland County - Register Of Wills Receipt Time : 15 :33 : 57 One Courthouse Square Receipt No. : 1073513 Carlisle, PA 17613 CLARK JESSE R Estate File No. : 2012-01183 Paid By Remarks: DAWN CLARK CJ ---------------------- Receipt Distribution ------------------_----- Fee/Tax Description Payment Amount Payee Name SHORT CERTIFICATE 10 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Cash $10 . 00 Total Received. . . . . . . . . $10 . 00 RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Receipt Date : 11/08/2012 Cumberland County - Register Of Wills Receipt Time : 15 : 38 : 12 One Courthouse Square Receipt No. : 1072011 Carlisle, PA 17413 CLARK JESSE R Estate File No. : 2012-01183 Paid By Remarks : MICHELE L BRANDT CJ ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 260 . 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 16 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check# 1468 $319 . 50 Total Received. . . . . . . . . $319 . 50 REV-1512 EX+(12-08) Ir, pennsylvania SCHEDU/�LE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Jesse R. Clark 21-12-1183 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses, ITEM VALUE AT DATE NUMBER DESCRIPTION Of DEATH 1• Carlisle Glass Service 100.70 72. Walmart 93.77 J73. Advance Auto Parts- 108.11 F�4. tVCFCU, an for Chevrolet Corvette 22,088.00 F5] Mortgage with Wells Fargo 183,790.29 6. Closing Costs on sale of 926 Petersburg Road F-1t[�7 Additional Closing Costs on sale of 926 Petersburg Road 603.69 a�mrswee ash F 1 F-1 F- F-1 11 F-1 I ❑. • _ 1�11111� F-1 I F-1 �A .�ngl:r:7CS� F-1 1WI, F] IF Aw 1:1 IE TOTAL(Also enter on Line 10, Recapitulation) $1 217,994.27 If more space is needed,insert additional sheets of the same size. CARLISLE GLASS SERVICE NU 01 L I 230 EAST POMFRET ST. DATE. Ir,I I SO )? CARLISLE PA 17013 L . - , , 717-243-8800 FAX 717-249-1967 CASH CHECK VISA DISCOVER MASTERCARD NAME � .a � -%a . ADDRESS PHONE GLASS 1/16 118 3/16 1*14 3/8 -11/2 EDGE NOR-GLARE GLASS MIRRORS 1/8 3/16 1/4 EDGE PLEXIGLASS .060 1/16 1/8 3/16 1/4\3/8 1/2 EDGE STORM WINDOW WITH GLASS CORNERS LATCHES STORM DOOR WITH PLEXIGLASS N-1 SCREEN REPAIR CORNER-LATCHES '�'tHARCOAL METAL ALUMI METAL FIBERGLASS BLACK GREY PET PATIO SCREEN CORNER-ROLLERS CHARCOAL METAL ALUMI METAL FIBERGLASS BLACK GREY PET INSULATED GLASS INSTALLED IN FRAME WOODEN SASH WITH GLASS OR PLEXIGLASS LAMINATED GLASS SAFTEY GLASS 1/81/4 EDGE ^l%0PllnC P1 AC4C I IQ 2/IA 1/4 EDGE Mu «.*e complete a survey about today's store visit at: hffp://www.surve9.w8lMart.com You will need to enter the following online: ID 4: 7FNJXiWW4H4 AUt ��`'.�"►` AwN IN RETURN FOR YOUR TIME YOU COULD Service Is our best part. RECEIVE ONE OF FIVE $1000 WALMART SHOPPING CARDS S'#-cxre #t 07164 Must 18 or older and a lata! C 7 y 7 7 932-7861 resident t of the 50 U$ or DC to enter, No Purchase necessary to 135 Newberrw Parkway enter or win, To enter without Etters PA 17319 Purchase and for complete official rules vis## 3/06/2013 12:41:39 REG 04 www.enfrg.surveg.walmort.com. Cashier: Alyssa T. Sweepstakes Period ends on the date shown in the official rules, Survew rust be taken within TWO weeks ITEM OTY PRICE TOTAL of today. Esta encuesta tembikn se encuentra BATTERY-POWERSPORTS 1 E 2090430 en espanol en la Phaina del Internet } 20LBS 1 $91 .99 #91.99 THANK YOU _ 3 MO.FREE REPL 0 MO.PRORATED ------------------------------------ CORE BATTERY-POWERSPORT 92090430 20LBS 1 $10.00 $10.00 W- ;l m(i r tSub Total $101.99 e► T1 Tax E 6.0000j $6.12 Save money.Live better. Total $108.11 ( 717 ) 268 - 1260 Transaction #3401 MANAGER CHAD ROETING 60 NOBLE BLVD Willow, Travis CARLISLE PA 17013 CARD TYPE: Visa ST# 2574 OP# 00004400 TE# 95 TR# 03737 PRODUCT SERIAL # JCH12008124133 nCCOUNT BATT 75-3N 068113144213 79.97 X AUTH CODE: 003065 AMOUNT: $108.11 BATT CORE FE 068113107867 9.00 0 SUBTOTAL 88.97 TAI{ 1 6.000 % 4,80 Cardholder acknowledges receipt of CASH TOTALEND 100.00 93.77 goods and/or services in the amount of CHANGE DUE 6.23 total shown hereon and agrees to Per- form the obligations set forth in the # ITEMS SOLD 2 cardholder's agreement with the issuer. TC# 5770 6208 8270 2555 1421 #S##$##S###########$###S#$############$##### *111111l11llillllllllll111lllillliflllll{IIlllllllllllllllllllll�lllllllllllilllll{Illlfll Scan to RETURN items ++ RETURN OL13BATTERYIFOR*PROPER** 22K0512F1V1KP4 *RECYCLINGAND REFUND OF BATTERY* DEPOSIT OEPO5Ii WITN THIS RECEIPT e "Like" our store on Facebook Go to local.walmart.com Transaction #3401 02/18/13 11:13:50 Thank you for shopping at Advance Auto Parts WARRANTY INFORMATION AVAILABLE AT STORE Join Our binning Team! Go to AdvanceAutoParts,lobs or espanol.AdvanceAutoParts.Jobs Choose the Position and location you're ;interested in and follow the instructions to apply! $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ CUSTOMER COPY -Dau-)n CAO-04 - CCLY- P.O. BOX 658 XUWCV?ADjZLANI)ruwzALravorr Waow IIET? CU14BERLAIM, PA 17070 'Yotir commullity C*eIt Vnion www.NCFCUonline.org 800.716-2328 Date 11/16/2012 Time 16.11:59 Branch 1 EmployeeID 86 Device 201 Checks $22,088.00 Trans Number 0110 Member Number XXX440 Member Name JESSE R CLARK Eff.Date 11/16/2012 Deposit/Payment for: $22,088.00 , To Account L 8 Old Balance $22,054.01 New Balance $0.00 Principal Amt $22,054.01 IntAmt $33.99 DueDt 08/05/2015 Message NCFCUonline.org great rates! Received Disbursed $1 $1 $2 $2 $5 $5 $10 $10 $20 $20 $50 $50 $100 $100 Coin Coin Total Total Page I of I --------------------------------------------------- REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Jesse R. Clark 21-12-1183 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec.9116(a)(1.2).] 1• Michelle Brandt, 109 Shirley Lane,Boiling Springs,PA 17007 child 331/3% 2] Dawn Willow,997 Pinetown Road, Lewisberry,PA 17339 child 331/3%11 F 3] Tyler Ray Clark, 11 Southside Drive, Newville,PA 17241 grandchild 331/3%1 F] I F-1 I F-1 I F L:� ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: F-1 I FI I F-1 wwirri�� B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. F-1� _ r r•� 1 1 TOTAL OF PART II— ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ If more space is needed,use additional sheets of paper of the same size.