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HomeMy WebLinkAbout12-10-14 ..1 1505611185 REV-1500 EX(02-11)(FI) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes PO BOX 280601 INHERITANCE TAX RETURN 21 14 0305 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 03122014 12101959 Decedent's Last Name Suffix Decedent's First Name M I ADAMS LARRY E (if Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name M I Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE - REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW 0 1. Original Return El 2. Supplemental Return El 3. Remainder Return(Date of Death Prior to 12-13-82) ❑ 4. Limited Estate ❑ 4a. Future Interest Compromise(date of ❑ 5. Federal Estate Tax Return Required death after 12-12-82) 0 6. Decedent Died Testate 0 7. Decedent Maintained a Living Trust 1 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) ❑ 9. Litigation Proceeds Received ❑ 10.Spousal Poverty Credit(Date of Death ❑ 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number L. LUNDBERG, PNC BANK, NA 717-744;-2265 s rn S..A REGIMR4 WILLS IIUONLI C7 n C:) ,7 1-4 ;r; ry First Line of Address O PO BOX 308 e-> , �I Second Line of Address r,a E 'n VIE :+ 4242 CARLISLE PIKE DATE FILED City or Post Office State ZIP Code CAMP HILL PA 17011 Correspondent's e-mail address: LINDA-L U N D B E R G a@ P N C- C O M Under penalties of pedury,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. SIGNATURE OF PERSON RESPONSIBLE FOR FII�PA RETUkZN )NIA. , Executor for trFe DATE Estate of Larry E Adams ADDRESS 4242 Carlisle Pike, P.O. Box 308, Camp Hill PA 17001-0308 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505611185 OM46473.000 1505611185 Estate of Larry E. Adams 177-52-5010 Executors (Page 1) Name PNC Bank, N.A. Address PO Box 308 4242 Carlisle Pike Camp Hill, PA 17011- Tax ID 22-1146430 .J 1505611285 REV-1500 EX(Fl) Decedent's Social Security Number Decedents Name: ADAMS LARRY E RECAPITULATION 1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 *861000-00 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. *3-1 380.0 0 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E) . . . . . 5. $741,610- 43 6. Jointly Owned Property(Schedule F) F-1 Separate Billing Requested . . . . 6. *0.00 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) F1 Separate Billing Requested- 7. *0.00 8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . 8. *830-,990- 43 9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . 9, *671545- 52 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule 1) . . . . . . . . . 10. *14-,216 - 56 11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . 11. *81,762-08 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . 12. *749,228-35 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J). . . . . . . . . . . . . . . . 13. *749,228- 36 14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . . . 14. ($0.01) TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15, Amount of Line 14 taxable at the spousal tax rate,or transfers under See.9116 (a)(1.2)X.0.0_ *0-00 15. *0 .00 16. Amount of Line 14 taxable at lineal rate X.0-4-5 *0.00 16. *0.00 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. *0 -00 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND.OF AN OVERPAYMENT El Side 2 1505611285 1505611285 OM4648 3.000 REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: 21 14 0305 DECEDENTS NAME ADAMS LARRY E STREET ADDRESS CUMBERLAND COUNTY CITY STATE ZIP LOWER ALLEN T"WP- PA 17055 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) *0-00 2. Credits/Payments A.Prior Payments *0.00 B.Discount $0- 0 0 Total Credits(A+B) (2) *0- 00 3. Interest (3) *0 .00 4. If Line 2 is greater than Line 1+Line 3,enter the difference.This is the OVERPAYMENT. Fill in box on Page 2,Line 20 to request a refund. (4) $0. 00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) *0 .00 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a retain the use or income of the property transferred . . . . . . . . . . . . . . . . . . . . . . . . © ❑ b. retain the right to designate who shall use the property transferred or its income . . . . . . . . . . c. retain a reversionary interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Eyd d. receive the promise for life of either payments,benefits or care? . . . . . . . . . . . . . . . . . . ❑ 2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ 0 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ❑ 4. Did decedent own an individual retirement account,annuity, or other non-probate property,which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after Jan. 1, 1995; the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the 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)]. 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. OM4671 2.000 REV-1502 EX+(12-12) pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Larry Adams 21 140305 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 decedents interest if owned as tenant in common. VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 205 Schuylkill Avenue Camp Hill Lower Allen Twp. Cumberland County, PA 17011 Actual Sales Price $86,000.00 TOTAL (Also enter on Line 1,Recapitulation.) $ $86,000.00 2w4695 2.000 If more space is needed,use additional sheets of paper of the same size. REV-1503 EX+(8-12) pennsylvania SCHEDULE B DEPARTMENT OF REVENUE INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER Larry Adams 21 14 0305 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. None TOTAL (Also enter on Line 2,Recapitulation) $ $0.00 2w4696 2.000 If more space is needed,insert additional sheets of the same size REV-15(A EX-(9-12) SCHEDULE C pennsylvania CLOSELY-HELD CORPORATION, DEPARTWEW OF REVENUE INHERITANCE TAX RETURN PARTNERSHIP OR RESIDENT DECEDENT SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Larry Adams 21140305 Schedule C-1 or C-2(including all supporting information)must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship.See instructions for the supporting information to be submitted for sole-proprietorships, ITEM NUMBER VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. None TOTAL(Also enter on line 3,Recapitulation) $ $0.00 2W4697 2.000 (If more space is needed,insert additional sheets of the same size) REV-1507EX+ (0413) pennsylvania SCHEDULED DEPARTMENT OF REVENUE MORTGAGES&NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER Larmz Adams 21 14 f% r%C All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH I Date of Death Value of Court Approved Restitution as a result of Commonwealth vs. Jeanette Thorpe $3,380.00 TOTAL(Also enter on Line 4,Recapitulation) $ $3,380.00 2W46AC 2.000 (if more space is needed,insert additional sheets of the same size.) REV-1508 EX-(08.12) pennsylvania SCHEDULE E DEPARTMENTOF REVENUE CASH, BANK DEPOSITS &MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Larry Adams 21 140305 Include the proceeds of litigation and the date the proceeds were received by the estate. All pr=ert jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Larry E. Adams entered into a Revocable Trust Agreement with PNC Bank, N.A. as Trustee on January 3, 2006. A list of the Assets of the Trust and the Date of Death Values is enclosed. The Trust is payable to the Estate upon Death and should be listed as Probate Assets. $636,440.56 2 PNC Bank, N.A. Checking Account #5004426343 Date of Death Balance including Accrued Interest of $0.01 $7,926.97 3 Verizon Return of Credit $17.11 4 Omnicare, Inc. Credit Balance for Prescription Drug Charges $150.71 5 Donegal Insurance Group Policy #51298720 Refund Cancellation of Renter's Insurance $59.00 6 Asbury Communities, Inc. Overpayment from April Rent $90.00 7 Cash found in Decedent's Apartment $40.96 8 Chuck Bricker Auctioneer Proceeds of Auction of Personal Property $15,190.00 9 Cumberland County Tax Bureau Refund 2013 local tax $93.00 10 PA Treasury Dept. Unclaimed Property (#77969052) $531.84 11 Great Road Settlement Services, LLC Refund duplicate payment 2014-15 Real Estate Tax $984.75 12 HCB Coins, LLC Sale of Coins and Currency $175.00 Total from continuation schedules . . . . . . . $79,910.53 TOTAL(Also enter on line 5,Recapitulation) $ $741,610.43 2W46AD 2.000 If more space is needed,use additional sheets of paper of the same s¢e. Estate of: Larry Adams 21 14 0305 Schedule E (Page 2) Item Value at Date No. Description of Death 13 Keystone Oil Products Credit Balance Refund Account #K5277 $198.53 14 Asbury Communities, Inc. Refund of Entrance Fee for Bethany Village $79,712.00 Total (Carry forward to main schedule) $79,910.53 ESTATE TAX SECURITIES VALUATION PAGE NO. 1 ACCOUNT: 3844398-741-27-27 Name of Estate: LARRY E. ADAMS UMA DATE OF DEATH: Wednesday, March 12 2014 ITEM CUSIP NO. SHARES/ DESCRIPTION PRICE HIGH/ASK LOW/BID MEAN SECURITY ACCRUED COMMENTS TICKER PAR VALUE DATE PRICE PRICE PRICE VALUE DIV/INT ---- --------- ---------------- ------------------------------ ----- ---------- ---------- ---------- ------------- ------------ ---------- 1) 0236BA406 597.6510 AMERICAN BEACON FUNDS 03/12 20.1400 20.14000 12,036.69 MUT FUND INTL EQT INSTL 2) 04314H204 408.8750 ARTISAN PTRNS FDS INC 03/12 29.8700 29.87000 12,213.10 MUT FUND INTL FD INV 3) 09253CS76 5,980.9810 SLACKROCK MUN BD FD INC 03/12 10.6300 10.63000 63,577.83 MUT FUND NAIL MUN INST 4) 256206103 282.8260 DODGE & COX FDS 03/12 43.3700 43.37000 12,266.16 MUT FUND INM STK FD 5) 269858304 106.5270 EAGLE SER 03/12 60.1500 60.15000 6,407.60 MUT FUND SMCAP GROW CL I 6) 277911491 3,540.3420 EATON VANCE MUT FDS TR 03/12 9.1700 9.17000 32,464.94 MUT FUND FLT RT CL I 7) 3814IW398 297.8680 GOLDMAN SACHS TR 03/12 45.8600 45.86000 13,661_.14 MUT FUND MID CP VAL INS B) 38142Y401 481.6690 GOLDMAN SACHS TR 03/12 31.5900 31.59000 15,215.92 MUT FUND GRW OPPT INSTL 9) 412295107 668.9210 HARDING LOEVNER FDS INC 03/12 17.4100 17.41000 11,645.91 MUT FUND " INTL EQUITY PR 10) 464287234 273 ISHARES TR 03/12 38.9300 38.4600 38.69500 10,563.74 NYSE Arca MSCI EMERG MKT 11) 464287804 75 ISHARES TR 03/12 111.0500 109.7900 110.42000 8,281.50 NYSE Arca CORE S&P SCP ETF 12) 464287879 56 ISHARES TR 03/12. 113.4400 112.3300 112.88500 6,321.56 NYSE Arca S&P SMLCP VALU 13) 464288414 569 ISHARES TR 03/12 106.8000 106.5200 106.66000 60,689.54 NYSE Arca S&P-NTL AMTFREE 14) 552983694 1,793.6630 MFS SER TR I 03/12 33.4000 33.40000 59,908.34 MUT FUND VALUE FD CL I 15) 56063JS64 1,254.4930 MAINSTAY FDS TR 03/12 19.8100 19.81000 24,851.51 MUT FUND EPOCH GBL EQT I 16) 7220124487 1,048.9480 PIMCO FDS 03/12 11.1900 11.19000 11,737.73 MUT FUND UNCSTR BD INST 17) 741479109 1,043.6000 PRICE T ROWE GROWTH STK FD INC 03/12 54.4900 54.49000 56,865.76 MUT FUND COM 18) 779578103 1,746.1730 ROWE T PRICE VALUE FD INC 03/12 34.5800 34.58000 60,382.66 MUT FUND COM 19) 779919109 532.5360 ROWE T PRICE REAL ESTATE FD 03/12 23.0700 23.07000 12,285.61 MUT FUND COM 20) 81369Y209 145 SELECT SECTOR SPDR TR 03/12 59.6400 59.1100 59.37500 8,609.38 NYSE Arca SBI HEALTHCARE 21) 81369Y407 125 SELECT SECTOR SPDR TR 03/12 66.7800 66.1500 66.46500 8,308.13 NYSE Arca SBI CONS DISCR 22) 890208400 1,788.8670 TEMPLETON INCOME TR 03/12 12.8400 12.84000 22,969.05 MUT FUND GLB BD ADVSOR 23) 884116500 299.1290 THIRD AVE TR 03/12 19.6700 19.67000 5,883.87 MUT FUND INTL VAL INST ACCOUNT: 3844398-741-27-27 ESTATE TAX SECURITIES VALUATION PAGE NO. 2 Name of Estate: LARRY E. ADAMS UMA DATE OF DEATH: Wednesday, March 12 2014 ITEM CUSIP NO. SHARES/ DESCRIPTION PRICE HIGH/ASK LOW/SID MEAN SECURITY ACCRUED COMMENTS TICKER PAR VALUE DATE PRICE PRICE PRICE VALUE DIV/INT ---- --------- ---------------- ------------------------------ ----- ---------- ---------- ---------- ------------- ------------ --_------- 24) 8915SH827 3,175.9700 TOUCHSTONE EDS GROUP TR 03/12 19.0000 19.00000 60,343.43 MUT FUND SANDCAPSELGR Y 25) 999527641 27,278.9600 BLACKROCK LIQ EDS TEMPFUND ADM SHS #H1 27,278.96 0.76 MANUAL PRINCIPAL CASH 26) 999527641 540.8200 BLA.CKROKC LIQ EDS TEMPFUND ADM SHS #H1 540.82 MANUAL INCOME CASH ---------------- ------------ Grand Totals 625,310.88 0.76 Total Principal plus Accrued interest and dividends 625,311.64 This report was prepared using APPRAISE Ver. 7.6.7 software, an EVALUATION SERVICES, INC. product. Phone 201 784 8500. Visit our web site at WKK.APPRAISENJ.COM. Please compare the data on this document carefully with your source document to verify its accuracy. ACCOUNT: 3844398-001-27-27 ESTATE TAX SECURITIES VALUATION PAGE NO. 1 Name of Estate: LARRY E. ADAMS REV DATE OF DEATH: Wednesday, March 12 2014 ITEM CUSIP NO. SHARES/ DESCRIPTION PRICE HIGH/ASK LOW/SID MEAN SECURITY ACCRUED COMMENTS TICKER PAR VALUE DATE PRICE PRICE PRICE VALUE DIV/INT ---- --------- ---------------- ------------------------------ ----- ---------- ---------- ---------- ------------- ------------ ---------- 1) 999527641 6,119.2400 BLACKROCK LIQ FDS TEMPFUND ADM SHS #H1 6,119.24 2.33 MANUAL PRINCIPAL CASH 2) 999527641 5,007.3000 BLACKROCK LIQ FDS TEMPFUND ADM SHS #H1 5,007.30 0.05 MANUAL INCOME cAsx ---------------- ------------ Grand Totals 11,126.54 2.38 Total Principal plus Accrued interest and dividends 11,128.92 This report was prepared using APPRAISE Ver. 7.6.7 software, an EVALUATION SERVICES, INC. product. Phone 201 784 8500. Visit our web site at WWW.APPP-ISENJ.COM. Please compare the data on this document carefully with your source document to verify its accuracy. -------- REV-1509 EX+(01-10) Pennsylvania SCHEDULE E DEPARTMENT OF REVENUE INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Larry Adams 21 140305 If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT JOINTLY OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDE`IT S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER ATTACH DEED FOR JCINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDBrPS INTEREST None TOTAL (Also enter on Line 6, Recapitulation) $ $0.00 9W46AE 2.000 If more space is needed,use additional sheets of paper of the same size. REV-1510 EX+(08-09) SCHEDULE G pennsylvania DEPARTMENTOFREVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Larry Adams 21 140305 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM INaIDETFENWEOFTFETRANSFEREE,TFEIR RELATIOWHP TO DECEDEW AW DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE NUMBEF THE DATE OFTRM9:SZATTACHACOPY OFTHE DEEDFORREALESTATE VALUE OF ASSET INTEREST OFAPPUCAeLE VALUE 1. Larry E. Adams entered into a Revocable Trust Agreement with PNC Bank, N.A. as Trustee on January 3, 2006. Please see Schedule E. $0.00 100.0000 $0.00 $0.00 TOTAL(Also enter on line 7,Recapitulation)$ 0.00 If more space is needed,use additional sheets of paper of the same size. 9W48AF 2.0D0 REV-15„EX-(08-13) SCHEDULE H pennsyfvania DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Larry Adams 21 14 0305 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1 Musselman Funeral Home and Cremation Services, Inc. $9,650.00 Total from continuation schedules . . . . . . . . . $1,300.91 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: $21,693.71 Name(s)of Personal Representatives)PNC Bank, N.A. Street Address 4242 Carlisle Pike City Camp Hill State PA ZIP 17011 Year(s)Commission Paid:to be Paid 2. Attorney Fees: $21,693.71 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: $663.50 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. 1 Settlement Charges for Sale of 205 Schuylkill Avenue Property $3,154.75 Less Adjustment $1,010.72 $2,144.03 Total from continuation schedules . . . . . . . . . $10,399.66 TOTAL(Also enter on Line 9,Recapitulation) $ $67,545.52 3W46AG 2.000 If more space is needed,use additional sheets of paper of the same size. User Notes Probate Fees 1. Charles E. Shields, III, Esq. Reimbursement Probate Fees $663.50 Total $663.50 Grand Total $663.50 i Estate of: Larry Adams 21 14 0305 Schedule H Part 1 (Page 2) Item No. Description Amount 2 Stanley Murphy Memorial Service Reimbursement $1,089.66 3 Musselman Funeral Home Reimbursement for Monument Engraving Fee $211.25 Total (Carry forward to main schedule) $1,300.91 Estate of: Larry Adams 21 14 0305 Schedule H Part 7 (Page 2) 2 Wildeman and O'Brock, C.P.A. Tax Preparation Fee $425.00 3 PDS Tax Services Real Estate Tax $539.08 4 Freeman Real Estate, Inc. Appraisal Fee $350.00 5 Wildeman and O'Brock, CPA Tax Preparation Fee $145.00 6 Lower Allen Twp. Sewer/Refuse Service $122.70 7 Gingrich's Plumbing Services $284.58 8 Register of Wills 4 Short Certificates $20.00 9 Abstract Land Associates, Inc. Title Search Fee $100.00 10 SES Insurance Services $16.00 $4.00 $20.00 11 Karl Stine Final Clean Up Real Estate $125.00 12 PDS Tax Service Real Estate Tax $965.06 13 Chuck Bricker Auctioneer Auctioneer's Commission Advertising and Other Costs $3,500.00 14 PPL Electric Utilities 4/22/14 $14.44 5/27/14 $14.44 6/24/14 $14.44 7/24/14 $15.37 8/25/14 $19.21 9/9/14 $19.54 $97.44 Total (Carry forward to main schedule) $6;693.86 Estate of: Larry Adams 21 14 0305 Schedule H Part 7 (Page 3) 15 PA American Water 5/13/14 $15.23 6/12/14 $15.00 7/14/14 $15.00 8/11/14 $17.04 9/16/14 $20.53 $82.80 16 Gordon's Landscaping, LLC 6/2/14 $159.00 6/16/14 $106.00 7/2/14 $106.00 7/18/14 $159.00 8/22/14 $159.00 9/2/24 $106.00 10/3/14 $53.00 $848.00 17 Bethany Village Fee for March/April 2014 Invoice #697076 $2,775.00 Total (Carry forward to main schedule) $3,705.80 REV-1512 EX+(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN .MORTGAGE LIABILITIES& DENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Larry Adams 21 14 0305 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• PNC Bank, N.A. Principal Compensation Ito Date of Death $301.26 2 Internal Revenue Service 2013 Individual Income Tax $8,500.00 3 Pinnacle Health Hospitals Medical Service $150.00 4 PPL Electric Utilities Account #80330-74009 $14.33 . 5 Lower Allen Township Sewer/Refuse Service $122.70 6 PA Department of Revenue 2013 Individual Income Tax $2,819.00 Less Refund of $16.46 $2,802.54 7 PA American Water Water Service $30.23 8 Holy Spirit Hospital Medical Service $225.00 9 Bethany Village at Home Housekeeping Service $9.50 10 Internal Revenue Service 2013 Individual Income Tax $2,061.00 TOTAL(Also enter on Line 10,Recapitulation) $ $14,216.56 2w46AH 2.000 If more space is needed,insert additional sheets of the same size. REV-1513 EX+(01-10) _ SCHEDULE J Pennsylvania DEPARTMENT OF REVENUE BENEFICIARIES RIES INHERITANCE TAX RETURN oG'YGr lr /\I� G�7 RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Larry Adams 21 14 0305 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec.9116(a)(1.2).] 1. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. I[ NON-TAXABLE DISTRIBUTIONS A SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1 See Attached 1 TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ $749,228.36 9W46Ai 2.00D If more space is needed,use additional sheets of paper of the same size. Estate of: Larry Adams 21 14 0305 Schedule J Part 2B (Page 1) Item No. Description Amount 1 Grace United Methodist Church 313 Herman Avenue Lemoyne, PA 17043 25% of Residue to Grace United Methodist Church 313 Herman Avenue Lemoyne, PA 17043: $187,307.09 $187,307.09 2 Lincoln Chapel Laurelton, PA 17837 25% of Residue to Lincoln Chapel Laurelton, PA 17837: $187,307.09 $187,307.09 3 First Church of God Shiremantown, PA 17011 25% of Residue to First Church of God Shiremantown, PA 17011: $187,307.09 $187,307.09 4 American National Red Cross 2025 E. Street NW Washington, DC 2006 25% of Residue to American National Red Cross 2025 E. Street NW Washington, DC 2006: $187,307.09 $187,307.09 REV-1514 EX+(4-09) SCHEDULE K pennsylvania LIFE ESTATE ANNUITY OE3'PRiMBJf OF REVENUE 7 Bureau of Individual Taxes &TERM CERTAIN Po BCHECK BOX 4 ON REV-1500 COVER SHEET) Harrisburgsburg PA 17128-0601 (P1 ESTATE OF FILE NUMBER Larry Adams 21 14 0305 This schedule should be used for all single-life,joint or successive life estate and term-certain calculations. For dates of death prior to 5-1-89, actuarial factors for single-life calculations can be obtained from the Department of Revenue. Actuarial factors can be found in IRS Publication 1457,Actuarial Values,Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate below the type of instrument that created the future interest below and attach a copy of it to the tax return. ❑Will ❑Intervivos Deed of Trust ❑Other CALCULATIONLIFE ESTATE INTEREST NAME OF LIFE TENANT DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH LIFE ESTATE IS PAYABLE Life or Term of Years Life or ElTerm of Years Life or Term of Years Life or ElTerm of Years Life or Term of Years 1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $0.00 2. Actuarial factor per appropriate table '60/0' . . . . . . . . . . . . . . . . . . . . . . . 0.00000 Interest table rate- 3.5% ❑ 6% ❑ 10% [1Variable Rate % 3. Value of life estate(Line 1 multiplied by Line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $0.00 CALCULATIONANNUITY.INTEREST NAME OF LIFE ANNUITANT DATE OF BIRTH NEAREST AGE AT TERM OF YEARS DATE OF DEATH ANNUITY IS PAYABLE Life or Term of Years Life or Term of Years Life or ElTerm of Years ❑ Life or ❑Term of Years 1. Value of fund from which annuity is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $0.00 2. Check appropriate block below and enter corresponding number . . . . . . . . . . . . . . . . . . . . 0.000 Frequency of payout-❑Weekly(52) Bi-weekly(2Monthly(12) F—] Quarterly(4) F—]Semi-annually(2)H Annually(1)6 Other( ) 3. Amount of payout per period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $0.00 4. Aggregate annual payment, Line 2 multiplied by Line 3 . . . . . . . . . . . . . . . . . . . . . . . . . $0.00 5. Annuity Factor(see instructions) Interest table rate-❑ 3 1/2% ❑ 69/6 ❑ 10% ❑Variable Rate % 0.00000 6. Adjustment Factor(See instructions.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.00000 7. Value of annuity-If using 3.5%, 6%, or 10%,or if variable rate and period payout is at end of period, calculation is:Line 4 x Line 5 x Line 6 . . . . . . . . . . . . . . . . . . . . $ $0.00 If using variable rate and period payout is at beginning of period,calculation is: (Line 4 x Line 5 x Line 6)+Line 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $0.00 NOTE The values of the funds that create the above future interests must be reported as part of the estate assets on Schedules A through G of the tax return.The resulting life or annuity interest should be reported at the appropriate tax rate on Lines 13 and 15 through 18 of the return. If more space is needed,use additional sheets of the same size. 6W46AJ 1.010 -REV-1647 EX,(02-10) SCHEDULE M pennsylvania FUTURE INTEREST COMPROMISE DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT (Check Box 4a on REV-1500 ESTATE OF FILE NUMBER Larry Adams 21 140305 This schedule is appropriate only for estates of decedents who died after Dec,12,1982. This schedule is to be used for all future interests where the rate of tax that will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument that created the future interest and attach a copy to the tax return. F1 will F-1 Trust ❑Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. 5. If. For decedents who died on or after July 1, 1994,if a surviving spouse exercised or intends to exercise a right of withdrawal within nine months of the decedent's death, check the appropriate box below and attach a copy of the document in which the surviving spouse exercises such withdrawal fight. F1 Unlimited right of withdrawal Limited right of withdrawal Ill. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1.Amount of future interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ $0.00 2.Value of Line 1 exempt from tax as amount passing to charities,etc. (Also include as part of total shown on Line 13 of REV-1500.) . . . . . . $ $0.00 3.Value of Line 1_Rassing t4 Spouse ata iate.atetax rate Check one. 60/6, 3%, 00/0 . . . . . . . . . . . . . . . $ $0.00 (Also include as part of total shown on Line 15 of REV-1500.) 4.Value of Line 1 taxable at lineal rate Check one. 0 69/6, F1 4.5% $ $0.00 (Also include as part of total shown on Line 16 of REV-1500.) 5.Value of Line 1 taxable at sibling rate(12%) (Also include as part of total shown on Line 17 of REV-1500.) . . . . . . $ $0.00 6.Value of Line 1 taxable at collateral rate(15%) (Also include as part of total shown on Line 18 of REV-1500.) . . . . . . $ $0.00 7.Total value of future interest(sum of Lines 2 thru 6 must equal Line 1) . . . . . . . . . . . . . . . . . . . . $ $0.00 If more space is needed,use additional sheets of paper of the same size. ?W46AN 2.000 LAST WILL AND TESTAMENT OF LARRY E. ADAMS I, LARRY E. ADAMS, of 205 Schuylldll Avenue o Camp Hill, (Lower Allen Township), Cumberland County, ]F:p�nsylvmdag o make, publish and declare this as and for my Last Will and PAwneat, CQ hereby revolting all other Wills and Codicils heretofore mag�ygme3 FIRST: I direct that all inheritance, estate, tray`49, successiOm > _c CD C> and death taxes, as well as my just debts and funeral expenses, of any kind' whatsoever, which may be payable by reason of my death, shall be paid out of the principal of my estate as the same can conveniently be done. SECOND: I give, devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, including any property over which I hold power of appointment and together with any insurance policies thereon, as follows: (a) Twenty-five percent (25 %) thereof unto the GRACE UNITED METHODIST CHURCH, 313 Herman Avenue, Lemoyne, Pennsylvania, strictly for the use of its building fund and for general maintenance of the buildings and grounds; and (b) '-Twenty-five percent (25 %) thereof unto the LINCOLN CHAPEL, of Laurelton, Pennsylvania, 17835-9998, strictly for the use of its building fund and for general maintenance of the buildings and grounds; and (c) Twenty-five percent (25 %) thereof unto-'the FIRST CHURCH OF GOD, of Shiremanstown, Pennsylvania, strictly for the use of its building fund and for general maintenance of the buildings and grounds; and (d) Twenty-five percent (25 %) thereof unto the AMERICAN NATIONAL RED CROSS, 2025 E Street NW, Ninth Floor, Washing- ton, D.C. 20006, to be used specifically for the National Disaster Relief Fund. THIRD: I nominate and appoint PNC BANK, NATIONAL ASSOCIATION, Executor, of this, my Last Will and Testament. I direct that PNC BANE, NATIONAL ASSOCIATION and its successor shall not be required to post security or a bond for the performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, this, day of November, 2005. -- (SEAL) LARRY E. ADAMS 2 Signed, sealed, published and declared by the above-named Testator as and ,for his Last Will and Testament in our presence, who, at his request, in his presence and in the presence of each other, have hereunto subscribed our names as attesting witnesses. ;201 Uc-44r Address /l/f. ! ? s Name AddressNam 3 LETTERS OF TESTAMENTARY Estate of: LARRY E.ADAMS LATE OF LOWER ALLEN TOWNSHIP CUMBERLAND COUNTY PENNSYLVANIA, DECEASED Issued: April 3,2014 Estate No: 21-2014-0305 LISA M. GRAYSON,ESQ. REGISTER OF WILLS&CLERK OF THE ORPHANS'COURT. Cumberland County Courthouse 1 Courthouse Square Carlisle,PA 17013-3387 REVOCABLE TRUST AGREEMENT by and between LARRY E. ADAMS Settlor and PNC BANK, N.A., Trustee 339135.1 REVOCABLE TRUST AGREEMENT I, LARRY E. ADAMS, currently of 205 Schuylkill Avenue,Camp Hill Post Office, Lower Allen Township, Cumberland County,Pennsylvania,hereinafter at times referred to as Settlor, after'consultation with my Attorney to assure that my wishes are being set forth accurately and in proper legal form,believing that my needs and interests will be best served by a Corporate Trustee,hereby transfer to PNC BANK,N.A.,hereinafter called the Trustee,a Pennsylvania bank and trust company,such property as may be delivered contemporaneously herewith, or at such time or times hereafter,that being transferred contemporaneously herewith being set forth in Schedule A hereto and incorporated by reference, to be held in Trust as follows. FIRST: Dispositive Provisions For My Benefit—During my lifetime. A. All of the net income shall be paid to me at least quarterly or shall be paid or accumulated and added to principal, as I may direct in writing; B. As much of the principal as I may from time to time request in writing shall be paid to me, or as I may otherwise direct; C. If, in the Trustee's opinion, I am at any time unable to act or to apply the payments to my own best interest and advantage, the Trustee may apply directly for my benefit as much of the income and/or principal as the Trustee may, from time to time, deem appropriate for my welfare,comfort, support or emergency needs,directly and without the intervention of a guardian, and may add to principal as much of the income as the Trustee deems advisable. D. Trustee shall keep true and correct books of account, which books of account shall at all reasonable times be open to the inspection of Settlor or his duly appointed representative. Trustee shall also quarterly render Settlor a detailed statement showing all receipts and disbursements on account of the trust estate and the manner and form in which the trust estate is invested at the time of the rendition of such statement. SECOND: Dispositive Provisions After My Death. Upon my death while the trust continues,the Trustee shall pay the then-remaining principal and income to my Executor or Administrator for disposition as part of my Estate. 339135.1 THIRD: Right to Revoke and Amend. I reserve the right to revoke or amend this trust,in whole or in part, at any time and from time to time by an instrument in writing, delivered to the Trustee and intended to take effect during my lifetime; except that the duties,powers, and liabilities of the Trustee shall not be changed without its written consent. The Trustee reserves the right, at any time upon thirty(30) days' advance written notice to me, to resign the trust and deliver the trust estate to me, after deducting therefrom its fees and any expenses then due and payable. FOURTH: Additions to Trust. Subject to the approval of the Trustee, either I or any other person or party may add property,real and personal,to the principal of this trust. FIFTH: Trustee's Powers. In addition to the powers granted by law, including but not limited to the Probate, Estates, and Fiduciaries Code of the Commonwealth of Pennsylvania,my Trustee shall have the following discretionary powers, applicable to principal and income, which shall be exercisable without leave of court and shall continue until distribution is actually made: A. To accept and retain any or all property at any time hereafter delivered or in any other manner hereafter acquired,including stock or other securities of the Trustee, or of a holding company controlling the Trustee; B. To invest in all forms of property(including,but not by way of limitation, real estate, all types of stocks,bonds,options, and participations in common trust funds and money market funds);without being confined to investments prescribed by statute and without being required to diversify; C. To buy investments at a premium or discount; D. TO hold property unregistered or in the name of a nominee; E. To give proxies, both ministerial and discretionary; F. To compromise claims; G. To join in any merger,consolidation,reorganization,voting trust plan, or other concerted action of security holders, and to delegate discretionary duties with respect thereto; 339135.1 -2- H. To borrow from PNC Bank,N.A.,or from others, and to pledge real or personal property as security therefor; and to loan cash or securities upon such terms and conditions as Trustee deems appropriate. I. To sell at public or private sale for cash or credit or partly for each,to exchange, to improve, or to lease for any period of time, any real or personal property; and to give options for sales, exchanges,or leases. J. To allocate any property received or charge incurred to principal or income or partly to each, without being obliged to apply the usual,rules of trust accounting; K. To distribute in cash or in kind or partly in each; L. To retain any part or all of my business interests held in this Trust so long as the Trustee considers it advisable to do so; and to conduct, alone or with others, any such business in which I am engaged,with all the powers of an owner or with respect thereto, including the power to delegate discretionary duties to others and to pay adequate compensation to any such person; to invest other property in such business,and to incorporate it or change its form. This power includes the right to take all appropriate actions to prevent, identify, or respond to actual or threatened violations of any environmental law or regulation. M. To disclaim, in whole or in part, any interests in property for any reason, including but not limited to a concern that such property could cause potential liability under the federal, state, or local environmental law. N. To engage attorneys and accountants to provide professional advice, direction, guidance, and support in administering of the Trust and to make payment of reasonable compensation to said attorneys for their services, including the drafting of this Trust Agreement and such other services as may reasonably, from time to time,be required. SIXTH: Concerning Self-Dealing,et al. No rule of law against self-dealing,divided loyalty, or conflict of interest shall be applied to render any transaction effected by the Trustee void,voidable, or otherwise subject to attack solely for violation of such rule, nor shall the Trustee incur any liability, nor shall any Trustee commission for acting hereunder be reduced, solely for violation of such rule. Any transaction which involves self-dealing,divided loyalty, or conflict of interest by the Trustee shall be judged by the rules of law which would apply to the same transaction at arm's length between strangers . free of any element of self-dealing,divided loyalty, or conflict of interest. Thus, by way of illustration and not of limitation,the Trustee is authorized,without giving any notice required by statute, to: 339135.1 -3- A. Employ and compensate any fiduciary or any affiliate as broker,agent, or professional advisor for any purpose. B. Borrow from the commercial department of any corporate fiduciary or any affiliate at current interest rates. C. Buy, retain, and sell any debt or equity security issued or underwritten by any corporate fiduciary or any affiliate and any debt security secured,supported,and/or otherwise enhanced by a letter of credit issued by any corporate fiduciary or any affiliate. D. Buy,retain,and sell any security of any investment company or trust registered under the Investment Company Act of 1940 to which any corporate fiduciary or any affiliate renders services for compensation. E. Buy property from or sell property to any beneficiary or fiduciary acting hereunder or otherwise on arm's length terms. An "affiliate"means any entity which owns, directly or indirectly, an interest in any corporate fiduciary, any entity in which any corporate fiduciary owns an interest, directly or indirectly, and any entity in common control with any corporate fiduciary. SEVENTH: Compensation. The Trustee shall be compensated in accordance with its standard schedule of charges in effect from time to time during the period of its services, and this compensation shall be paid from principal or income or partly from each in the sole discretion of the Trustee. Settlor hereby acknowledges receipt of Trustee's current fee schedule,which is subject to revision from time to time. EIGHTH: Excuse for Bond Neither the Trustee named above nor any successor Corporate Trustee with fiduciary powers shall be obligated to enter any bond or security for the faithful performance of any duty or duties in any jurisdiction in which they may be called upon to perform. NINTH: Payment of Proceeds of Trust If Trustee, in its absolute discretion, determines that the size of the Trust does not warrant continuation of the Trust, or if its administration would be impractical for any reason whatsoever, Trustee, without further responsibility,may pay the proceeds of the Trust to Settlor or Settlor's guardian or to any other person or entity nominated by Settlor. 339135.1 -4- TENTH: Resignation Trustee, in its absolute discretion, may resign for any reason by Settlor(s) and Beneficiary(ies), as the case may be,thirty(30) days' written notice. Any such resignation does not require approval of any court. ELEVENTH:Non-Assignment. No part of the income or principal of the property held under this Trust shall be subject to attachment, levy, or seizure by any creditor, spouse, assignee, or trustee or receiver in bankruptcy prior to actual receipt thereof. The Trustee shall pay over the net income and the principal to the person(s) herein designated, as his interests may appear, without regard to any attempted anticipation(except as specifically provided in this Agreement), pledging or assignment under the Trust, and without regard to any claim thereto or attempted levy, attachment, seizure, or other process against me. TWELFTH: Law Governing Trust. This Trust is created and accepted in the Commonwealth of Pennsylvania and shall in all respects be governed by its laws and shall have its situs at Cumberland County, Pennsylvania. Executed on __3 ,200to . WITNESS: 4� d SEAL Larry E.Adams The foregoing Trust is hereby accepted Executed on z> ,200 PNC BANK,N.A. By: _ AV P 339135.1 -�- COMMONWEALTH OF PENNSYLVANIA � SS COUNTY OF On this, the� ay of 20-4:�,before me, a notary public in and for the said Com o alth and unty, personally appeared LARRY E. ADAMS, known to me(or satisfactorily proven) to be the person whose name is subscribed to the foregoing Revocable Trust Agreement and acknowledged that he executed the same for the purposes therein contained.. WITNESS my hand and notarial seal. of u lic My Co ission fres; (SEAL) COMMONWEALTH OF PENNSYLVANIA Notarial seal Denise C.sullenberger,Notary Public Hampden Twp.,Cumberland County My Commission Expires Dec.1,2008 Member.Pennsylvania Association of Notaries t 339135.1 -6- COMMONWEALTH OF PENNSYLVANIA /�' SS COUNTY OF �-- �ei� /' On this the� day of4 _ 20��be re me, a Notary P 'lic, in and for the said Commonwe and Coun , ersonally appear d / .known to me or satisfactorily proven}, , <� of Trustee of PNC BANK, N.A., and being authorized to do so, acknowledged the foregoing Revocable Trust Agreement to be the act and deed of said Trustee,that the same might be recorded or filed as such. WITNESS my hand and notarial seal the day and ye rimes o P blic COM ONWEALTH OF PENN, VANIA Notarial Seal Denise sullenberger,Notary Public Hampden Cumberland County MY Commission Expires Dec.9,2008 Member,Pennsylvania Association of Notaries 339135.1 -7- ;VA 9122014 1:35:56 PM StnA� OMB Approval No.2502-0285 * A. Settlement Statement(HUD-1) B.Type of Loan 1.0 FHA 2E)RHS 3.0Conv.Un{ns. 6,File Number.' 7.Loan Number: R.Mortgage Insurance Case Number. 4.0VA 5.0 Com.Ins. ❑Other 20140950 C.Note: This form Is furnished to give you a statement of acduai sel8arnent casts Amounts paid to and by the settlement agent are shown. Items marked"(POC)"were paid outside the closing;they are shown here for Informational purposes and are not induded in the totals. D.Name&Address Clayton Gabert of Borrower. I-Name&Address The Estate of Larry I-Adams,4242 Carlisle Pike,PO BOX 308,Camp Hill,PA 17001-0306 of Seller. F.Name&Address of Lender, G.Property Location: Property Address 205 Schuyikrll Avenue Camp Hill,Pennsylvania 17011 PIN 23-0549-121 H.Seftlement Agent: Great Road Settlement Services,LI-C,6 S.17th Street,Camp F811,PA 17011,(717)731-1114U Place of Settlement: 6 S.17th Street Camp Hill,PA 17011 i I.Settlement Date: 912/2014 Proration Date: 9/212014 Disbursement Data: 9!2!2014 6' 2 e S �rdTrh_LUor''G ; 101. Contract sales price $86,000.00 401. Contract sales price $86,000.00 102. Personal property 402 Personal property 103. Settlement charges to borrower(line,1400) $1,787.00 403, 104. 404. 105. 405. '6'ust �gYsT>`b ternsspa")`dSD rs�1fA:rr'acf�fia"�'�'+� "'t6fi )3stma-11ts�fb�{,,,_"`�PSI 18 a'd once ` !!t 106. CltyAown Was 406. City/town taxes 107. County taxes 922014 to 12!3112014 $177.23 407. County taxes 91212014 to 1213112014 $177.23 108. Assessments 408. Assessments 109. School Tastes 9122014 to 6/30/2015 $795.64 409. School Taxes 912!2014 to 6130/2015 $795.64 110. Refuse 91212014 to 91302014 $16.17410. Refuse 91212014 to 913012014 $16.17 .111. Sewer 912/2014 to 9/30/2014 $21-48411. Sewer 9/212014 to 913012014 $21.48 112. 412 120. Gross Amount Due from Borrower $86,79T.72 420. Gross Amount Due to Seller $87,010.72 - 201. Deposit or earnest money $10,DDD.00 501. Excess deposit(see Insbudons) 202. Principal amount of haw loan(s) 502. Settlement charges to seller(One 1400) $3,154.75 203. Existing Ioan(s)takers subject to 503. Existing loran(s)taken subject to 204. 504. Payoff of First mortgage ban 205. 505. Payoff of second mortgage loan 206. 506. Deposit or earnest money $10,000.00 207. 507. 208. 508. 209_ 509. (j$ s 'eh`Fsip teriis'fth an�h)i)ci:s`Ih �-,n?f�" r.. �I lam, '1y�`."'r�,n„7•„ ''�', usfine" oitlit;3ms rt. a rse 210. Cfty/town taxes 510. City/town taxes 211. County taxes 611. County taxes 212 Assessments 512. Assessments 213. 513. 214. 514. 215. 515. 216. 516. 217. 517. 218. 51B. 219. 519. 220. Total Paid by/for Borrower $10,000.00 520. Total Reduction Amount Due Seller $13,154.76 OEM, " ft':fi. r� 0�a "€at�et8e titft�€rXtin "rte Y 301. Gross amount due from borrower(One 120) $58,797.72 601. Gross amount due to seller(line 420) $87,010.72 302. Less amounts paid bylfdrr borrower(line 220) ($10,000.DD)602. Leas reductions In amount due seller(fine 5M $13,154.75) 303. Cash G FrornoTo Borrower $76,797.72 603. Cash 19 Top From Seiler $73,656.97 The Public Reporting Burden for this oogectim of Infomratlon Is estimated al 35 minutes per response for collecting,reviewing,and reporting the data This agency may not collect this Inrotmation,and you are hot required to complete this form,unless it displays a currently valid l3NB control number. No confidentiality is assured;this disclosure Is mandatory.This is designed to provide the parties to a RESPA c omred transaction with Information during Lha set0snard pnocsss. Previous editions are obsolete Page 1 HUD-1 PJN Atm 912120141:35:58 PM File Number:20140950 700. Total Real Estate Broker Fees Paid From Paid From iJivision of commission line 700 as follows: Borrowers Setter's 701. Funds at Funds at 702. Settlement Settlement 703. Commission paid at settlement 704. Transaction Fee to Bricker Auctioneers $1,200.00 AP). gf a pAln)ttri IN-WIO�(V{!it-11K. 801, Our origination charge (iron GFE#1)r 802. Your credit or charge(points)for the specific Interest rate Chosen (from GFE#2) 803. Your adjusted origination charges (from GFE A) B04. Appraisal fee (from GFE#3) 805. Credit report (from GFE#3) 806, Tax service (from GFE#3) 807, Flood certification (from GFE#3) 808, 9¢e,"�temsFt;:gAVIA d?E3y oder-E 13e1A�iiitiat :aiicei'` �;•- o, ter. _5 .r $' .n.. "r+i.. '`c�':v.' r'` F��te �''-ill' :•.. 901. Dally Interest charges from (from GFE s10) 802• Mortgage insurance premium for (from GFE 103) 903. Homeowners insurance for (from GFE#11) 904. 905. DRB e .�d51 '♦f11 ei;#,: c 'mr'' ��+ :� *a c> =� r` "'ill 1001.Initial deposit for your escrow account (from GFE#B) 1002,Homeowner's Insurance, 1003.Mortgage Insurance 1004.City property taxes 1005.County property taxes 1006. 1007. 1008. 1009. ?i'�r4:•`.i 1101,Title services and tenders title Insurance (from GFE 04) 1102.Settlement or closing fee 1103.Owners titre insurance to Great Road Settlement Services,LLC (from GFE#5) $823.00 1104.Lenders title insurance to Great Road Settlement Services,LLC 1105,tenders title policy lima 1108.Owners title policy limit$86,000.00 1107.Ageas portion of the total title Insurance premium to Great Road Settlement Services,LLD$a23oo 1108.Underwriters portion of the total 00e insurance premitim to Stewart 170a Guaranty Company$0.00 i 1109.Notary Fee to Cash 1110, i 1111, 1112. 1113. 1114. 1115•Reimburse tax cert to Bonnie Miller Tax Collector to Great Road Settlement Services,LLC $20.00 1200: ;�el`q- eP. i .,� ��1s'fer'x?f13rg�s�• .,5. �?� �sy , �- Sryi•.�.J. `�,t ' 1201.Govemmant recording charges (f dim GFE#7) $104.DO 1202,Deed$79,00 Mortgage Releases $79,00 1203.Transfertaxes (f MGFE#s) $880.00 1204.City/County taxtstamps Deed$860-00 $860.00 1205.State tax/stamps Dead$860.00 $860.00 1206, UPI Certification 1207,E-Recording Fee Deed$25,00Q y, $26.00 a�f{t�+ _t�t66lw:S�e..g.. _-�.Fia�Ti�� �`'✓'uYJC.�.'��....,'S"'.:�'�• -i. we'� s��,� � f �''��,.,,,'4�•�.�T`';�r i,..`f. 1301.Required services that you can shop for (from GFE#6) 1302.2014 County/Township Tax on 4/21/2014 to Bonnie Miller PODS$M.08 1303.2014-15 School Taxes to Bonnie Miller $984,75 1304.3rd Quarter Refuse to Lower Allen Township Authority POCS$52.7 1306.3rd Quarter Sawer to Lower Allen Township Authority POCK$70.0 1400.Total Settlement Charges enter on lines 103,Section J and 502,Section K) $1,787,00 $3,154.76 Hems marked"POC"were paid outside the closing by:Borrower(POCB),Lender(POCi.),Mortgage Broker(POCM),Other(FOOD),Red Estate Agent(POCR),or Seller(POCS). CFATIFICATION, - I have carefully reviewed tha KUD-1 Settlement Statement and to the tit of my knowledge and beef,0 Is A true and aaurale statement of all recelift and disbursements made on my account or by me in Vi saoion.I further certty that I have recatved a copy of HUD-1 Satgement Statement The Settlement Agent does not warrant or represent the accu of lnkwma dad by any party,including information concerning POC Nems and information supplied by the lender in this transaction appearing on this HUD-f ant Staleman ining to"Cornparison of Orad Fagh Estimate(GFQ sold HUD-1 Charges'and"loan Terms",and the parties hold harmless the Settle as to e a as h1 such matters. ;IiiIr ' E E ATE OF i LARRY E,ADAMS „�, n G tUj t Carle M Vogelso TrumslAdv1sor" To the beat of my:noafedge HUD-1 Settlement Statement which I have prepared is a true and aoaurate a=WM of the funds which were received and have baso or 41 be disbursed by the asp t# the attiament of this transaoGon. Jame_t A,Mi ,Esq. WARNI @ is a orlme to 4aowingty make false statements to the United States on this or any other similar form Penalties upon conviction can Include a fine and `9( For de}aels s`ew Title 18:U,S.Code Sectlon 1001 and Soction t01o. Previous editions are obsolete Page 3 HUD-1 Tax Parcel Number: THIS INDENTURE MADE THE day of� ,t {tP-6 ,in the year of our Lord two thousand and fourteen(2014). BETWEEN PNC BANK,N.A.,in its capacities as Executor of the Estate of LARRY E.ADAMS, a single man,deceased,and as Trustee of that certain Revocable Trust Agreement, executed the 3`d day of January 2006,by said LARRY E.ADAMS,as Settlor,Grantor, and CLAYTON GABERT,single man,currently of 3 Natures Crossing,Enola, Cumberland County,Pennsylvania,Grantee. WHEREAS,the said PNC Bank N.A.,in its capacity as Trustee aforesaid,was vested with title to thepremises hereinafter described,as per that certain deed executed an the 3'd day of January 2006,as is set forth more fully at large in that recital hereinbelow,in the Township of Lower Allen, County of Cumberland and Commonwealth of Pennsylvania;and WHI?:REAS,the pertinent terms of the aforesaid Revocable Trust Agreement read as follows, to wit: "SECOND.Dispositive Provisions After My Death. Upon MY death while the trust continues,the Trustee shall pay the then-remainingprincipal and income to my.Executor or Administratorfor disposition as part of my Estate.",and WHEREAS,the said Larry E.Adams,departed this earthly life,testate,on the 1P day of March,2014,and betters Testamentary were duly issued to the said Executor,by the Register of Wills of said Cumberland County,docketed to No.21-14-6305;and WHEREAS,the residential lands herein-mentioned were not specifically devised. NOW,THEREFORE,THIS IN ENTURE WITNESSETH,that the said PNC Bank,N.A. as Executor and as Trustee,as aforesaid,for and in consideration of the sum of EIGHTY-SIX Thousand and No/100ths($86,000.00)DOLLARS,and other good and valuable considerations,to it in hand paid by the said Grantee,at and before the ensealing and delivery hereof,the receipt whereof is hereby acknowledged,has granted,bargained,sold,aliened,released,and confamed,and by these presents,by virtue of the power and authority in it vested by the Probate,Estate and Fiduciaries Code of the Commonwealth of Pennsylvania,does grant,bargain,sell,alien,release,and confirm unto the said Grantee,his heirs and assigns: ALL THAT CERTAIN house and lot of ground situate in the Township of Lower Allen County of Cumberland and Commonwealth of Pennsylvania bounded and described as follows,to wit: BEGINNING at a point in the northeast comer of the intersection of Columbia and Schuylkill Avenues;thence northeasterly along the northern line of Columbia Avenue,one hundred fifty nine and fifty-five one-hundredths(159.55)feet to a point in the southwest corner of the intersection of Columbia Avenue and Pinta Alley;thence westwardly along the southern line of Pinta Alley one hundred thirty-one and ninety-five one-hundredths(131.95)feet to a point in the southeast comer of !I F COMMONWEALTH OF PENNSYLVANIA ) SS: COXJNTY OF CUMBERLAND } On this,the P day of ) �" ,A.U.2014,before me a notary public, in and for the Commonwealth of Pennsylvania,personally appeared_ _ 2f cf}2 If{ ' A' of PNC BANK,NATIONAL ASSOCIATION,known to me(or satisfactorily prove to be th person whose name is subscribed on behalf of PNC BANK,N.A.in its capacities as Trustee and as Executor of the Last Will and Testament ofLarry E.Adams,aforesaid,and acknowledged that he/she executed the same in such capacities. IN WITNESS WHEREOF,I hereunto set my hand an official seal. No lic y commissio pires: ( A.L) CERTIFICATE OF RESIDENCE I do hereby certify that the precise and exact post of address of the within Grantee is: Attorney for ter tee ... .. ........ --------- That there are no easements, mortgages, notes, judgments, liens, pending suits, or bankruptcies adversely affecting the owner and the said premises other than those shown on the Title commitment under the above-referenced number except the following: 00 MOAT- Of NONE,write NONE on the blank line) That all labor and materials used in the construction of improvements on the above-described property have been paid for and there are now no unpaid labor or material claims against the improvements or the property upon which same are situated, and I hereby declare that all sums of money due for the construction of Improvements have been fully paid and satisfied,except the following: Ik (if NONE,write"NONE'on the blank line) That there are no leases,contracts to sell the land,or parties in possession other than Deponent except as follows: (if NONE,write'NONE'on the blank line) To be filled in If a safe—'The Seller is not a non-resident alien,foreign corporation,foreign trust,foreign estate or other foreign entity (as defined in the Internal Revenue Code and Income Tax Regulations). rJ Seller's U.S.employer identification number(or Social Security Number)Is:46-7445870 Sellers address(office address.if Seller is an eriby,home address if Seller Is an individual)Is: 4242 Carlisle Pike,PO BOX 308,Camp Hill,PA 170DI-0308, This affidavit may be disclosed to the Internal Revenue Service and is lumishad to Buyer to inform Buyer that withholding of tax Is not required under Becton 1445 of the Internal Revenue Code, INDEMNITY- IAIVE AGREE TO PAY ON DEMAND TO THE PURCHASERS AND/OR LENDER AND/OR TITLE COMPANIES(INCLUDING STEWART TITLE GUARANTY COMPANY)IN THIS TRANSACTION, THEIR SUCCESSORS AND ASSIGNS,ALL AMOUNTS SECURED BY ANY AND ALL LIENS,CLAIMS, OR RIGHTS NOT SHOWN ABOVE,TOGETHER WITH ALL COSTS,LOSS AND ATTORNEY'S FEES THAT SAID PARTIES MAY INCUR IN CONNECTION WITH SUCH UNMENTIONED LIENS,PROVIDED SAID LIENS,CLAIMS,OR RIGHTS EITHER CURRENTLY APPLY TO SUCH PROPERTY,OR A PART THEREOF, OR ARE SUBSEQUENTLY ESTABLISHED AGAINST SAID PROPERTY AND ARE CREATED BY ME, KNOWN BY ME, OR HAVE AN INCEPTION OR ATTACHMENT DATE PRIOR TO THE CLOSING OF THIS TRANSACTION ANDRECORDINQ OF THE DEEQ AND MORTGAGE. realize th*f the d Lendert/and Stewart Titl6/Guaranty Company are reVingYth!,~*rA,.t'�_ 4' I/We I -&A6'1A Plrasr nf 4V .4V (�� entatlons contained herein in purchasing same or lending money thereon and Issuing title policies and would not purchase same or lend money or issue a title policy thereon unless said representations were made. If Seller or Mortgagor is an entity,I have authority 6 sign on Its behalf. r THE ESTATE OF LARRY E.ADAMS Carrie M Vogelsd)-t4 or Trust Advisor Ptd Cry C_;HM 14, n 1� Sworn to and subscribed before me this 2nd day of September,2014. Notary Public In and for Pennsylvania -N Public: ubllc* My Commission Expires: ....of 'NOTE: This form Is to be filled in and signed case of sale. If no sale,it is to be filled in and signed by the Owner-Borrower. If there Is any new construction,the contractor must also join In this form or fill In and sign a separate one. If seller Is a non-resident alien,foreign corporation,etc., call your manager or underwriting personnel. File No.:20140950 PA STG Seller Mortgagor Affidavlt 05 Page 2 of 2 File No.: 20140950 CERTIFICATION FOR NO INFORMATION REPORTING ON THE SALE OR EXCHANGE OF A PRINCIPAL RESIDENCE This form may be completed by the seller of a principal residence.This information Is necessary to determine whether the sale or exchange should be reported to the seller, and to the Internal Revenue Service on Form 10995, Proceeds From Real Estate Transactions.If the seller property completes Parts I and III,and makes a"truer response to assurances(1)through(6)In Part 11(or a 'not applicable'response to assurance(5)),no Information reporting to the seller or to the Service will be required for that seller.The term"seller'Includes each owner of the residence that Is sold or exchanged.Thus,if a residence has more than one owner,a teat estate reporting person must either obtain a cert cation from each owner(whether married or not)or file an Information return and furnish a payee statement for any owner that does not make the certification. Part 1.Seller Inforrnation 1. Name: The Estate of Larry E.Adams 2. Address or legal description(including city,state,and ZIP code)of residence being sold or exchanged: 205 Schuylkill Avenue,Camp Hill,PA 17011 3. Taxpayer Identification Number(TIN). 46.74451370 4, Forwarding Addres,s., 4242 Carlisle Pike PO BOX 308 Camp HJ(1 PA 17001-0308 5. Phone Number, 717 730 2276 Part It, Seller Assurances Check"true"or'falser for assurances I through 5,and"true, "false,"or"not applicable for assurance 6: True False 1. 1 owned and used the residence as my principal residence for periods aggregating 2 years or more during the 5—year period ending on the date of the sale or exchange of the residence. 2- 1 have not sold or exchanged another principal residence during the 2-year period ending on the date of the, sale or exchange of the residence. 3. 1(or my spouse or former spouse,If I was married at any time during the period beginning May 6,1997, and ending today)have not used any portion of the residence for business or rental purposes after May 6, 1997. 4. At)east one of the following three statements applies: The sale or exchange is of the entire residence for$250,000 or less;or I am married,the sale or exchange is of the entire residence for W0,000 or less,and the gain on the sale or exchange of the entire residence,Is$150,000 or less;or I am married,the sale or exchange Is of the entire residence for$500,000 or less,and(a)I Intend to file a joint return for the year of the sale or exchange, (b)my spouse also used the residence as his or ter principal residence for periods aggregating 2 years or more during the&year period ending on the data of the sale or exchange of the residence,and(c)my spouse also has not sold or exchanged another principal residence during the 2-year period ending on the date of the sale or exchange of the principal residence. 5. During the 5-year period ending on the date of the sale or exchange of the residence,I did not acquire the residence In an exchange to which Section 1031 of the Internal Revenue Code applied. N/A True False B. If my basis in the residence Is determined by reference to the basis in the hands of the person who acquired the residence in an exchange to which Section 1031 of the Internal Revenue Code applied,the exchange to which Section 1031 applied occurred more than.5 years prior to the date I sold or exchanged the residence. Part Ill. Seller Certification Under penalties of perjury,each signatory to this Certification certifies that all of the above Information is true as of the end of the day of the sale or exchange, THE ESTATE OF LARRY E.ADAMS Segjtmbar 02,2014 CWJ \1 Date Carrie M Vogelgiono Trust Advisor LARRY ADAMS ESTATE -COMMONWEALTH VS. JEANETTE-THORPE Date Amount Paid Balance Due 5,000.00 01/03/07 100.00 4,900.00 02/16/07 100.00 4,800.00 04/11/08 450.00 4,350.00 07/29/08 75.00 4,275.00 04/14/09 55.00 4,220.00 06/22/09 50.00 4,170.00 09/18/09 40.00 4,130.00 12/06/10 50.00 4,080.00 05/13/11 100.00 3,980.00 03/13/13 100.00 3,880.00 05/07/13 100.00 3,780.00 07/05/13 50.00 3,730.00 09/05/13 50.00 3,680.00 10/04/13 50.00 3,630.00 11/04/13 50.00 3,580.00 12/05/13 50.00 3,530.00 01/06/14 50.00 3,480.00 02/06/14 50.00 3,430.00 03/06/14 50.00 3,380.00 Date of Death Balance 05/05/14 30.00 3,350.00 09/04/14 20.00 3,330.00 r i i COMMONWEALTH : IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA VS CP-21-CR-1268-2007 i CHANGES: THEFT BY DECEPTION UEANETTE L. THORPE OTN: K283273-4 AFFIANT: CPL. RICHARD TAMANOSKY IN RE: SENTENCING ORDER OF COURT AND NOW, this 18th day of March, 2008, the ' j Defendant having appeared for sentence and the Courtbeing r in receipt of a sentencing report, sentence is that -she pay the costs of prosecution, make restitution to Larry Adams in the amount of $4, 800, and that she undergo a period of supervised probation for 48 months subject to the following !. I special conditions: 1. That she pay not less than $75 per month towards the costs and restitution. Said payments to be made on or before the first -day of every month commencing Y Ma 1, 2008 . If any payment is missed, she shall be scheduled for aN robation revocation at the next available date. 2. That she maintain full-time employment. 3. That she be and remain in good behavior. ! i 4. That she comply with all other directions of her probation officer. The Defendant is also directed to submit to DNA testing as required by law. I I .e Supervision his waived. By the Wit, s - � 4 Edward E. Guido, J. Derek R. Clepper, Esquire Office of the District Attorney r Ellen K. Barry, Esquire Office of the Public Defender Probation _ ! Sheriff Victim Witness I .mlc i i Ma r. 28. 2014 2:45PM PNC Bank No. 9096 P. 2/3 IVI rn'u PN C. March 28,2014 Carol A Leiphart PNC Bank Wealth Management RE: Name: Larry Adams SSN: 177-52-5010 DOD: 03-12-2014 Dear Sir/Madam: In response to your request for Date of Death(DOD)balances for the customer noted above,our records show the following: Cbeelring Account Account# 5004426343 Established: 12-12-2005 LARRY ADAMS DOD balance: S 7,926.97+0.01 accrued interest Safe Deposit Box The decedent maintained safe deposit box#00055 LARRY ADAMS located at: Hampden _ 4242 Carlisle Pk Camp Hill,PA 17011 (717) 730-2200 , Please note that this office provides date of death balances.for deposit accounts(TKAs, CDs, Checking and Savings)_ We do not process any financial transactions or provide statements. If you need assistance with any of these items,please call 1-888-PNC-BANK(1-888-762-2265)or stop by your local PNC Bank branch office- Sincerely, National Financial Services Center PNC Bank,N.A. Member FDIC Page 1 of 2 COPYREV-485 EX(05-04) 48500041046 SAFE DEPOSIT BOX INVENTORY PA Department of Revenue PLEASE USE ORIGINAL FORM ONLY Social Security or Death Certificate Number Date of Death County Code Year File Number 177-52-5010 03/12/2014 i 2 i 00 _ _— _.. �_- Decedent's Last Name � — _ 05 ___.._....._......._._.__ Suffix First Name M! _._._,.__......._._......_._.. _..__. ....__........_._..._................._-...... Adams ! i Larry E .. ADDRESS OF DECEDENT STREET: CITY: STATE: ZIP CODE: 325 Wesley Dr.,Apt. 3125 Mechanicsburg PA 17055 NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX NAME' Linda J. Lundberg Vice President PNC Bank Executor of Estate of Larry E Adams STREETADDRESS. CITY: STATE: EP-CODE.- 4242 Carlisle Pike Camp Hill PA 17011 NAME,ADDRESS AND RELATIONSHIP(IF ANY)TO DECEDENT,OF PERSON(S)PRESENT AT THE BOX OPENING ` I a. NAME: RELATIONSHIP: Linda J. Lundberg, Vice President, PNC Bank Executor of Estate STREETADDRESS: --TIPCITY, STATE: -CODE. I 4242 Carlisle Pike Camp Hill PA 17011 b. NAME: RELATIONSHIP: Carol Koscienski,Admin.Asst., PNC Bank Executor of Estate STREETADDRESS: CITY: STATE: ZIP CODE: 4242 Carlisle Pike Camp Hill PA 17011 ' c. NAME. s RELATIONSHIP: I STREETADDRESS: CITY: STATE: ZIP CODE: NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME: PNC Bank,_NA., Hampden Office STREETADDRESS. CITY: STATE: ZIP CODE: 4242 Carlisle Pike Camp Hill PA 17011 NAVE OF PERSON G LASTTRY DATE AN TI E 9P LAST ENTRY DATE T T RENT BOX NUMBER MBER OF SO� Q� 1 TITL UNDER W CHI RE�QUETD Lam 3 NAME A D AD ESS OF PERSON(S)HAVING ACCESS TO BOX a. N AME: _„j^ b. NAME:tP't t"} S STREET S . /�'i { STREETADDRESS: r I DJ / lAve CITY' `J ST ZIP CITY: STATE: ZIP CODE: NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY Linda Lundberg,Vice President&Carol Koscienski,Admin.Asst. WAS A WILL IN THE BOX? ❑ YES NO If yes, a.Date of will: b. Name and address of personal representative,if named in the will NAME: PNC Bank N.A. Executor STREETADDRESS: CITY: STATE: ZIP CODE: 4242 Carlisle Pike Camp Hill PA 17011 ' c. Name and address of attorney,if any NAME: Charles E. Shields, 111 Esq. STREETADDRESS: CITY: STATE: ZIP CODE: a 6 Clouser Rd. Mechanicsburg PA .17055-1 _ 48500041046 48500041046 y , Page o2 of 2, REV-485 EX SAFE DEPOSIT BOX INVENTORY INSTRUCTIONS (1) Cash:Report total only. (2) Stocks:List in detail every common or preferred certificate,warrant or other rights found in box.Stocks are to be designated by name of company,certificate number,date of certificate,name in which stock is registered,and number of shares and class of stock. (3) Obligations of U.S.Government:Number of items,date of issue,face value,names in which registered and type of ownership, i.e.,jointly held,payable on death,etc. (4) Bonds:Designate by name,amount,serial number,or other designation.(Bearer Bonds) (5) Bank and Savings and Loan Passbooks:State name of depositor,number of book,last date appearing in book,name of bank and branch,and balance. (6) Jewelry,Coins,Stamps,Manuscripts,etc:List and describe as fully as possible. (7) Deeds,Mortgages,Current Insurance Policies or other evidences of indebtedness:List and describe as fully as possible. (8) All other contents. (4) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT.280601 HARRISBURG,PA 17128-0601 ITEM ITEM DESCRIPTION NO. I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECEIVING COPY OF CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SAFE DEPOSIT BOX INVENTORr, SIGNA SIGNATURE , PRINT NAME PR{NT NAME AND GHECK�Aj?PgO \ PRINT TITLE / ATEA } +t+�� CHECK APPROPRIATE BOX A -� ( i -9jExecutor(trix) El Administator(trix) E]Estate Representative El Joint owner of safe deposit box NOTE:Attach additional 81/2"x 11"sheet(s)if necessary or use duplicates of this page of form. The Department is authorized by law,42 U.S.C.§405(c)(2)(C)(i),to require disclosure of Social Security numbers in connection with administering state tax laws.The Department uses the Social Security number to identify the decedent and personal representatives of the estate.The Commonwealth may also use the information in exchange of tax information agreements with Federal and local taring authorities.The state law prohibits the Commonweatth's personnet from disclosing confidential tax information except for official purposes,