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Home My WebLink About01-16-15 J � pennsy�vania 15 0 5 61410 5 oevnarn�Hrorneiervue EX(03-14)(FI) REV��►/OO OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po Box 280601 INNERITANCE TAX RETURN � � l�'""�'""� �� Harrisburg, PA 17128-0601 RESIDENT DECEDENT ; �� ; a �� ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY �� 05012013 � � ;08091921 � DecedenYs Last Name Su�x Decedent's First Name MI ______.._.__.�_.__......._...._..._.....__.._....._._._........_..........._._�_....�._._....�_......._...__..��...._.._.�._._._._...._..__.....___.�._� _...__._.............._...._. , __._...._.__.._...._.__....._.._._........_..._.._..._............._.._.._.....�......_.......�......_..__..._..._._........_, __. ,.�.._. r.. _._ _ ;Verdekal � � ; ; Frances i ! J _. �..._......_............._...............: r_.........__.�_.__..�_e.______.....�.......__.._._.._........_._....__�.......�._...._......�.....�.............._......._......___ _.._.... F....._.,.,..._....._._._......_. . ..._......_._._........___..._......_......_......_..._....._.........__._.._.....__...... ..... (If Applicable)Enter Surviving Spouse's Information Below , Spouse's Last Name Suffix Spouse's First Name MI �.��_.__, ��_��__... .._. a._�...m_._.__�_...�____.��_ , t r..._..... �_�.___.�...._....�._.� �_____._.�.._,�.W..�... , � f n/a ' ' ' , ; ; , � ; , , , 3 + { '>...................................._„_.....,_._..,,.___._.........�,........,.�..__......_...W............,.............._,..........._.,.........._................,3 _.,_.-,,,.-,,,__.....'.....,.......W... �_�_M.«,,...........,..........................,..w,..........,...,..r..._.___. 3. ' THIS RETURN MUST BE FILED IN DUPLICATE WITN THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1. Original Return p 2.Supplemental Return p 3. Remainder Return(date of death prior to 12-13-82) p 4.Agriculture Exemption(date of p 5. Future Interest Compromise(date of � 6. Federal Estate Tax Return Required death on or after 7-1-2012) death after 12-12-82) � 7. Decedent Died Testate p 8. Decedent Maintained a Living Trust 1 9. Total Number of Safe Deposit Boxes (Attach copy of will.) (Attach copy of trust.) p 10. Litigation Proceeds Received p 11.Non-Probate Transferee Return p 12. Deferral/Election of Spousal Trusts (Schedule F and G Assets Only) O 13. Business Assets � 14.Spouse is Sole Beneficiary (No trust involved) CORRESPONDENT—THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number ;. . ._ ..�........ .. ........ ..... _.. ........_.. _..._... .�. .. ...... _....... . . ._.........�..... ___ _�__._. ._._�.._ _....... . �'Adam R. Deluca, Esq. ' _(717)249-1177 � _ __.. _.._�. �. .. . _ ... ... �� ...... ....._ _ _.._.... . _...... , _.....__ �. �_��... . .. � ..... _. ....._. _._..; First Line of Address ;61 West Louther Street _.________._______----..________.__.___._...__.__._�________.___.________.___. Second Line of Address �� _,_..��._._..____._..._.._ w._._�_..�...._�._..___.m.._��..�_._____.._.�.__._...__. _.......�.�__..�.m.._. City or Post Office State ZIP Code .. . _��.�.._ ___..._ _._.. ---.... . �..�.__._.. . _._._._....._� ...._, .�.r ;Carlisle i PA 17013 � ; _................�.............._._.........._..�......__..__.................�..._......_..._..._....._......._..... _.._.._....._.�_....._: s......................................._......_......_..._.................._......._....�.............._ :.............__......_._.. ..._........._....................._..�. adeluca@alliedattorneysllc.com � __.........: `� '.. � CorrespondenYs email address: ��j m O < � REGISTF'�O�'�N/ILLS U�NLY��;� ;;;7 ^� . �,..;J REGISTER OF WILLS USE�ONLY �� C a o -��y r-` ►--" rT� , �_ � �. , r�:.� DATE FILEQ MMDDXYYY t"' yw � ' Q� �; �,� -7 :7 , � , "'t'l . •—• ,_� � � --c.� � ^,_1 —s'1 ', (.'7 `. (.,) P""" Cy'1 DATE FI6�D STAMP � O ., � PLEASE USE ORIGlNAL FORM ONLY Side 1 I lilllllllllllllllllllllllllllillllll illll IIIIIIIIIIIIIIIII L 1,505614105 ],505614105 � � 1505614205 REV-1500 EX(FI) DecedenYs Social Security Number �ecedent's Name: FRANCES J. VERDEKAL � � �� RECAPITULATION r� � ___ 1. Real Estate(Schedule A). ... ... .... .... ... .... ... ... .... .... .... .. ... �. ; 465,000.00 ; �»�. ��_�.€ i 2. Stocks and Bonds(Schedule B) . ...... .... ... . ... ... .... . ... ... . ...... 2. ` ; w.__��..�,¢ 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) .. ... 3. : j �.�,....,��.�...��.,.�..,,�.,�...� 4. Mortgages and Notes Receivable(Schedule D) .. ..... ...... ... .... .... ... 4. ��j ;-�.�.�.�_�,.__�.�..�. ; i 5. Cash, Bank Deposits and Misceilaneous Personal Property(Schedule E). ... ... 5. 30,785.69 f -_-.a. .�,.�..,��..�..:.x.�,,.�..�-.�.. t � 6. Jointly Owned Property(Schedule F) O Separate Biiling Requested .... ... 6. ' � 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property � � (Schedule G) O Separate Biliing Requested..... .. 7 ; 9,731.37 ! ».�� .�..:,., ..�.w �...,,.,� .�.�.�.�,,�.; 8. Total Gross Assets total Lines 1 throu h 7 s. ; 505,517.06 � ( g ). ....... ... .... ... .... ....... � � 9. Funeral Expenses and Administrative Costs(Schedule H). ... .... .... ... .... 9. ; 75,457.43 � �„�..,�.,��.�.�»�,....,w_�»�� .� 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I). ... .... ....... 10. i 408.03 � � „��n>.��.� 11. Total Deductions(total Lines 9 and 10).... ........... ....... ... . ... .... 11. ; 75,865.46 ; �,��..�.m�.��,.�_._..�..................�,,.�,.�,�,��....,�.�.�-.m.�,n,s_..! ( 12. Net Value of Estate(Line 8 minus Line 11) ..... ... ....... .... .... ... .... 12. ; 429,651.60 : 13. Charitable and Govemmental Bequests/Sec. 9113 Trusts for which � �-_w.m��_..�„_,a,...��., �_�.�,,...�.. _.Wm..a., .�.�...�� an e�ection to tax has not been made(Schedule J) ..... . ... .... ... .... ... . 13. ; j ��. _.m:.�, ..,,.,.,.. ...,,.,,». ,..�w�..��., � :f 14. Net Value Subject to Tax(Line 12 minus Line 13) .. .... ... ... . ... . ...... . 14. ; 429,651.60 ; TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfersunderSec.9116 _...._......................................................................�.....�....�_..�.._....._..._.........._____._..........__.� ,...__............._._..._........__........._..._.._.._........_.........._......._.__..._...._...............,.._....�__...._._...E � (a)(1.2)X.0_ � 15. 16. Amount of Line 14 taxabie ,��µ��'��'�� µ�m��.�� ' at lineal rate X.0 45 i 429,651.60 : �g. ; 19,334.32 E 17. Amount of Line 14 taxable �Ty��F�� ` at sibling rate X.12 ; 17. � ��......��__..-_____._,�...�_...�_..�_.��..i �.. .�..�.�....�.�,�....�.� 18. Amount of Line 14 taxable � j at collaterai rate X.15 � 18. � ; , ��.�_____. .__�_...______-__�_._._�.___ _��_�_�___. ._-:._.a.,....-w..,.-...,A.,.,�_....:. .,....��..�,,.,...-.��..,.._.-.,..._w{ 19. TAX DUE .. ... ... .... .... .... .... ....... .... .. . .... ... . .. . .... ... . 19. i 'IJ,334.32 ! �._.......__..._................._..............._...__..__._._.._........__...._....�__........_�_........�._._...�..._...._......., 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Under penalties of perjury,I declare 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 person responsible for filing the return is based on all information of which preparer has any knowledge. SIGNATU�,2�F P��ESPO SI E F R FILING RETURN DAT�� i�r� _ i� ADDRESS 747 Mount Rock Road, Carlisle, PA 17015 SIGNA RE F PREPAR R ' T N� P�SON RESPONSIBLE FOR FILING THE RETURN DATE /�6 �� t� � ADDRESS 61 West Louther Street, Carlisle, PA 17013 I I'�I'I II'�I'IIII'��I'III'�II')II�II�I�II II'�I��I�I'�II I�� Side 2 � 15056],42�5 150567,4205 � REV-1500 EX (FI) Page 3 File Number �1 "' (�"' o��7 Decedent's Compiete Address: DECEDENT'S NAME Frances J. Verdekal STREETADDRESS 745 Mount Rock Road CITY STATE ZIP Carlisle PA 17015 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 19,334.32 2. Credits/Payments A.Prior Payments B.Discount (See instructions.) Total Credits(A+B) (2) 3. Interest (3) 553.30 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) 19,887.62 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 properry transferred or its income ............................................ ❑ � c. retain a reversionary interest .............................................................................................................................. ❑ � d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ � 2. If tleath occurred after Dec. 12, 1982,ditl decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ � 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ � 4. Did decedent own an individual retirement account,annuity or other non-probate propefij,which containsa beneficiary designation? ........................................................................................................................ � ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN, s 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 imposetl 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 tlisclosure of assets antl 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 step-parent 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. REV-1502 EX+(12-12) � pennsylvania SCHEDULE A DEPARTMENT OFREVENUE INHERITANCE TAX REfURN REA L ESTATE RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Frances J.Verdekal 21-13-0577 All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is tlefined 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• 745 Mount Rock Road,Carlisle,PA 17015(62.035ac land only Residual Lot 1 after subdivision)' 400,000.00 - *see attachments A and B 2. 745 Mount Rock Road,Carlisle, PA 17015(10ac specific devise and 7.754ac equal amount of 65,000.00 residue to Albert I.Verdekal)*see Will,attachment B and attachment C ' ' TOTAL(Also enter on Line 1, Recapitulation,) $' 465,000.00 ' If more space is needed,use additional sheets of paper of the same size. REV-15o8 EX+(o8-1z) � pennsylvania SCHEDULE E DEPARTMENTOFREVENUE CASH, BANK DEPOSITS & MISC. INHERITANCETAXREfURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Frances J.Verdekal 21-13-0577 Include the proceeds of litigation and the date the proceeds were received by the estate. Ail property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ACNB Esteeem Checking Acct#2169606(PO Box 3129,Gettysburg,PA 17325) 1,154.16 ' 2. ACNB Money Market Acct#1594915(PO Box 3129,Gettysburg,PA 17325) 4,361.22 ' 3, Sovereign/Santander Money Market Acct#2891022858(269 Penrose PI.,Carlisle,PA 17013) 1,409.16 4. SovereignlSantander Preferred Checking Acct#2891031709(269 Penrose PI.,Carlisle, PA 17013) 3,609.19 5. AMA Insurance Agency, Inc. (refund due to death) 37.53 ' g, Hearing Instruments, Inc.(Miracle-Ear Franchise)Refund for return of hearings aids 4,990.03 7.' The Sentinal Newspaper subscription refund 12.99 '' g. Aero Energy refund 53.86 '"_ g. Highmark premium refund 23.43 '' 10. Sale of miscellaneous personal property at auction(Rick Foreman Auctions-License#AU1163L) 11,536.50 11. Sale of 1997 Chevy Lumina,fair condition,100,000 miles 2,000.00 �2. Pro-rated school tax refund from sale of land 613.38 13. Pro-rated county tax refund from sale of land 9.24 14. Property tax rebate 975.00 TOTAL(Also enter on Line 5, Recapitulation) $ 30,785.69 ' If more space is needed,use additional sheets of paper of the same size. REV-1510 EX+(08-09) � pennsylvania SCHEDULE G DEPARTMENTOFREVENUE INTER-VIVOS TRANSFERS AND INHERITANCETAXREfURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Frances J. Verdekal 21-13-0577 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. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE INCLUDE THE NAh1E OF TF1E TRANSFENEE,THQR REfATI0N5HIP TO DKEDEM AND NUMBER hIEDAiEOFiRANSFQLAITACHACOPYOFhIEDEEDFORRFALESTATE. VALUEOFASSET INTEREST (IFAPPLICABLE) VALUE 1. Genworth Financial:Annuity Policy#05067092630 9,731.37 100 9,731.37 Transferee:Lois Littlehale(daughter)-Date of Transfer-8/28/13 TOTAL(Also enter on Line 7, Recapitulation) $ 9,731.37 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+ (08-13) � pennsytvania SCHEDULE H DEPARTMENTOFREVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Frances J. Verdekal 21-13-0577 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES, 1' Hollinger Funeral Home Traditional Service and Memoriai Package 5,325.00 ' 2. 12 ga steel vault(Hollinger Funeral Home) 1,325.00 ' 3. Red Cedar casket with cedar frames(Casbard Company) 1,665.00 '' a. Engraving Stone(Hollinger Funeral Home) 250.00 5. Newspaper advertisements Sentinal and Lancaster(Hollinger Funeral Home) 523.00 s. Grave opening(Hollinger Funeral Home) 1,000.00 �. Cemetery Equipment(Hollinger Funerai Home) 375.00 B. ADMINISTRATIVE COSTS; 1. Personal Representative Commissions 9,500.00 ' Name(s)of Personal Representative(s) Albert I. Verdekal ( Street Address 747 Mount Rock Road city Carlisle state PA ZIP 17015 Year(sj Commission Paid: 2015 13,000.00 ' Z. Attorney Fees 3. Family Exemption; (If decedent's address is not the same as claimanYs,attach expianation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees; 543.50 ' 5. Accountant Fees. 110.00 6. Tax Retum Preparer fees: �• see attachment 41,840.93 TOTAL(Also enter on Line 9, Recapitulation) $ 75,457.43 If more space is needed,use additional sheets of paper of the same size, ESTATE OF FRANCES J.VERDEKAL: FILE NO: 21-13-0577 ATTACHMENT TO SCHEDULE H ITEM NUMBER 7—MISCELLANEOUS ADMINISTRATIVE EXPENSES a. Deluxe Check-checks for Estate Account $29.20 b. Certified copies of Death Certificate $90.00 c. Estate Advertisement in Cumberland Law Journal $75.00 d. Estate Advertisement in Patriot News $99.66 e.Auctioneer commission/fees (Rick Foreman Auctions-Auctioneer ID#AU1163L) $1,993.50 f. Supplies for on-site auction preparation $81.34 g. Mark Raymond—lawn maintenance on property $340.00 h. Groff's Septic& Portable Toilet Service (portable toilet for auction) $75.00 i. R.T. Carey Trucking/Carey's Dumpsters, LLC (dumpster for auction prep/cleanup) $525.00 j. PPL Electric (electric bills for Decedent's home pending sale/transfer- 18 months) $1,912.24 k. Santander Account Maintenance fee $20.00 I.All costs associated with subdividing 10 acre specific devise to Albert I.Verdekal per Will E.L. Diffenbaugh Associates $8,253.45 fees to Dickinson and Penn Townships,fees to Cumberland Co. Planning Dept $1,734.00 Deed filing fee $148.00 *see Will, paragraph "Second", subsection 1 m.Staples—copy fee for oversized copies of land survey sent to beneficiaries $22.77 n. Postage fees for correspondence to beneficiaries $10.08 o. Mable G.Stilt,Tax Collector(School District tax pending sale of land 2013 and 2014) $2,196.92 p. Mable G. Stilt,Tax Collector(County and Township tax pending sale of land 2014) $224.77 q. Real Estate Agent Commission on sale of land (RE/MAX Delta Group and Spencer&Spencer) $16,000.00 r. Notary fees for sale of land—Robin J. Bassett, Notary $10.00 s. Real Estate Transfer Tax on sale of land $4,000.00 t. Seller Assistance on sale of land (see Settlement Statement) $4,000.00 $41,840.93 REV-1512 EX+(12-12) � pennsylvania SCHEDULE I DEPARTMENTOFREVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Frances J. Verdekal 21-13-0577 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• Kuhn Communications(final bill) 18.59 2. Century Link Acct#313951478(final bill) 55.05 3. PPL Electric Utilities Acct#07082-47250(bill prior to death) 334.39 TOTAL(Also enter on Line 10, Recapitulation) $ 408.03 If more space is needed,insert additional sheets of the same size. REV-1513 EX+(01-10) � �`,� pennsylvania SCHEDULE ) __. ' DEPARTMENTOF REVENUE gENEFICIARIES INHERITANCE TAX REfURN RESIDENT DECEDENT ESTATE OF: fILE NUMBER: Frances J. Verdekal 21-13-0577 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• Lois Littlehale 191 Old Cole Brook Rd.,Marietta,PA 17547 daughter 1/9+annuity 2. .Victor Littlehale 191 Old Cole Brook Rd., Marietta, PA 17547 grandson 1/g «-� 3. Natalie I. Littlehale 861 Martha Ave.,Lancaster,PA 17601 granddaughter 1/9 ' 4. Albert Littiehale 1531 Stone Mill Dr.,Elizabethtown,PA 17022 grandson 1/9 '' 5. Audra Strom 4720 East Prospect Rd., East Prospect,PA 17406 granddaughter 1/9 6. Vincent Verdekal 23570 Thornwood Dr.,San Antonio,TX 78264 step-son 1/9 7. Maria Verdekal 757 Mt.Rock Rd.,Carlisle,PA 17015 daughter-in-law 1/9 8. Albert I.Verdekal 747 Mt.Rock Rd.,Carlisle,PA 17015 grandson 1/9+specific devise 9. Sophia 0'Neal 7205 Otey Dr.,Lanexa,VA 23089 granddaughter 1/g ' 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: L B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: L 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, LAST WILL AND TESTAMENT OF FRANCES J. VERDEKAL I,FRANCES J. VERDEKAL, of 745 Mt.Rock Road, Carlisle, Cumberland County, Pennsylvania, being of sound and disposing mind,memory and understanding, do make,publish and declare this to be my Last Will and Testament,hereby revoking and making void all previous Wills and Codicils heretofore made by me. r, t1 �� FIRST �� I order and direct my personal representative hereinafter named to pay all of my last iliness, � v just debts, funeral expenses and expenses involved or connected with the administration of my estate as soon after my death as is reasonably possible. However,my personal representative need � (� not accelerate and pay those unmatured obligations which,in his,her or its opinion, it might be � � proper and more advantageous to retain or renew and pay as they become due and payable. If I do v \�� not own a burial plot or a grave marker at the time of my death,I authorize my personal � representative, in his,her or its sole discretion,to purchase a burial plot and to erect a suitable grave � , �_� marker at my grave, and to expend sums from my estate for this purpose. SECOND I give, devise and bequeath my entire estate,together with all insurance proceeds thereon of whatever nature and whatsoever situate to the following: 1. To my grandson, ALBERT VERDEKAL, a ten(10)acre parcel of his choosing from my land. My estate shall pay for any and all cost of subdividing the property in connection with the ten(10) acre parcel; and Page 1 of 8 v 2. My granddaughters, AUDRA LITTLEHALE, NATALIE LITTLEHALE and SOPHIA O'NEAL, shall each receive a watch I own at the time of my death. My granddaughter, SOPHIA O'NEAL, shall choose which watch she wants first. THIRD � I give, devise and bequeath the rest,residue and remainder of my estate,together with all `�J insurance proceeds thereon of whatever nature and wheresoever situate to my daughter-in-law, � ��} MARIA VERDEKAL,my daughter, LOIS A.LITTLEHALE,my granddaughter, SOPHIA ��, `�� p'NEAL, ,my granddaughter, NATALIE LITTLEHALE,my grandson,ALBERT LITTLEHALE, my grandson,VICTOR LITTLEHALE,my granddaughter,AUDRA LITTLEHALE, my grandson, ALBERT VERDEKAL, and my stepson, VINCENT � VERDEKAL,in equal shares, per capita. FOURTH � ersonal re resentative,after consultation with any heir or heirs of � It is my des�re that my p p � mine who survive me, and in his,her or its own discretion, choose such articles frorn my tangible i � personal property(exclusive of cash, stock certificates,bonds, and all other tangible evidences of � intangible personal property) as he, she or it believes will be useful to such heir or heirs or desirable for him or her or them to have, either from a sentimental point of view or otherwise, and to deliver such articles to such heir or heirs or among such heirs in equal or unequal shares as determined by the further exercise of his, her or its discretion,provided no other heir objects to the distribution. All tangible personal property not so distributed is to be sold, either publicly or privately,by my personal representative, adding the proceeds of such sale or sales to my residuary estate and to be disposed of in equal shares among my surviving heirs after payment of my estate debts,taking into account the tangible personal property otherwise provided to them. Page 2 of 8 FIFTH Any devise or distribution under this Last Will and Testament which is payable to any beneficiary who may be under 25 years ofage or, in the judgment of my personal representative, mentally disabled, shall be held in a separate trust by my grandson,ALBERT VERDEKAL, as Trustee until such beneficiary reaches 25 years of age or during such period of disability. During the term of any trust created pursuant to this paragraph,the Trustee is authorized to expend and Japply so much of the net income and principal of each such trust as the Trustee shall consider � �� advisable for the health,maintenance, support, and education(including college education, � undergraduate and graduate)of each such beneficiary until he or she attains 25 years of age,or until �� all such amounts are paid out of trust. I direct that no Trustee shall be required to give or post bond � for the faithful performance of the Trustee's duties in this or any other jurisdiction. � SIXTH � � I grant my personal representative the following powers in addition to and not in limitation v` ` C of such powers as my personal representative shall hold by law: �\� (a) To retain all property received including the stock of any corporate fiduciary acting hereunder,provided such property remains productive. (b) To join in any corporation,partnership,recapitalization,merger,reorganization or voting trust plan;to delegate authority with respect thereto;to deposit investments under agreements and pay assessments; and generally to exercise all rights of investors, including but not limited to,the voting of shares. (c) To manage, operate,repair,improve,mortgage or lease on any terms any real estate held or owned by my estate. (d) To operate any business that I may own at my death. Page 3 of 8 (e) To invest any funds of my estate in any stocks, bonds,notes or other securities or properiy, real or personal,without regard to the principle of diversification or any other statute or general rule of law in his,her or its absolute discretion, it being my intention to give my personal representative the broadest investment powers possible,providing such investments do not unnecessarily prevent the prompt settlement of my estate. (fl To sell or otherwise dispose of any property,real or personal,tangible or intangible, � at any time fornling a part of my estate in any manner and on such terms and " conditions as my personal representative shall see fit in his,her or its absolute �� `'��- discretion. (g) To borrow money for the payment of taxes or for any other proper purposes in the administration of my estate, and to mortgage or pledge estate assets as security. �J� (h) To compromise claims without court approval including,but not limited to,any � controversies with the United States of America or the Commonwealth of � _ � Pennsylvania concerning estate and inheritance taxes on any interests that may pass S � � under this my Last Will and Testament. '� " on an division or distribution of in estate. (i) To distribute in cash or ui kuid up y y (j) To undertake any and all acts deemed necessary and proper by my personal representative for the proper,advantageous and prompt management of the settlement of my estate. (k) In general,to exercise all powers in the management of my estate which any individual could exercise in the management of similar properiy owned in his own right,upon such terms and conditions as to him, her or it may seem best and to Page 4 of 8 execute and deliver all instruments and to do all acts which he,she or it deems necessary or proper to carry out the purposes of this,my Last Will and Testarnent. � SEVENTH No interest of any beneficiary of my estate, either in income or in principal, shall be subject to anticipation or pledge, assignment, sale or transfer in any manner, nor shall any beneficiary have the power in any manner to charge or encumber his interest either in income or principal,nor shall , + the interest of any beneficiary,while in the possession of my personal representative,be subj ect to �� _ ; liability for such beneficiary. �,� EIGHTH `'\��` I nominate, constitute and appoint my grandson,ALBERT VERDEKAL, as personal � � representative of this my Last Will and Testament. In the event my grandson is deceased,unable or � � unwilling to serve or shall cease to serve for any reason whatsoever,then I nominate,constitute and �; appoint my daughter, LOIS A.LITTLEHALE, as personal representative of this my Last Will � and Testament. I direct that my personal representative shall not be required to give or post bond �� for the faithful performance of lus,her or its duties in this or any other jurisdiction. 1VINTH I hereby declare it to be my expressed desire that my personal representative employ the law firm of Stephanie E. Chertok, Esquire, of Cumberland County, Pennsylvania, for legal advice and assistance regarding this my Last Will and Testament, they having considerable knowledge of my affairs, views and wishes respecting any matters that may arise at the probate of this instrument, the administration of my estate, and the execution of the powers herein mentioned. Page 5 of 8 IN WITNESS WHEREOF,I have hereunto set my hand to this my Last Will and Testament �/ this j�� day of � �� ,� � � ,2008. WITNESS: � '4 --�� _ � " �c�, e�) .,/� .� � FRANCES J� RDEKAL .f � �..:-, ' _ 1 �� .\ �, �; � C� a , � Page 6 of 8 ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA : : SS COUNTY OF CUMBERLAND : I,FRANCES J. VERDEKAL,the TESTATRIX whose name is signed to the attached or foregoing instrument,having been duly qualified according to law, do hereby acknowledge that I signed and executed the instiument 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. _ _ ___ _ - -- -- - -- --_--- � � �'r�� , �� . �\�� FR.ANCES �. VERDEKAL N � Sworn or aff�ed and acknowledged before me by FRANCES J.VERDEKAL,the TESTATRIX,this�day of� Y�1 UZcr� ,2008. � rj , � _ r ;�' �� , �� {� � -�� , �t , -- .y �t7} r r � E - s •�s�.�.�:� C —' . �� i-�-.' %S�. ��' � c' i. t u : � i;f�' L�rti 7`.d.`, �' F� ..._..�� ,.t: ),`t �: ---�-�-,:��..��_�_�....�_��._:_.._r Page 7 of 8 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA : : SS COUNTY OF CUMBERLAND : We i i:� .G �d �� %!Zi r -the witnesses whose names are attached to the foregoing document,being duly qualified according to law, do depose and say that we were � present and saw testatrix sign and execute the instrument as her Last Will and Testament;that she � � signed willingly and that she executed it as her free and voluntary act for the purposes therein J expressed; that each subscribing witness in the hearing and sight of the testatrix signed the Last � Will and Testament as witnesses and that to the best of our knowledge,the testatrix was at the time � 18 or more years of age, of sound mind and under no constraint or undue influence. � y � [�GJ��.�— �' -�� `�� /� ''`�f`� � � ��: � l. ��` f 1 Sworn or affirmed and subscribed before me by J}-��,}�o_ `� �-,��tx-�� and LG � �- 17Yi�t� this I$� day of �.��z�r 2008. , � � .�.. �-,------_•---- ; ; Y`,, __._____------_-- =--� ri r�:- ` ' � :' � �ei� �^i� ..=`� �.,��.y. �., `._,.. .,:`` . ��G, i, � �� ic F �" � �� — �� . � �_�i rt e� F'�--�-a� �'��ft:as!d��i�..�..;, ri�� , �t _..� , 3 ��..+W'--c�;� _ . C �--_,� �.�.. �. Page 8 of 8 • ' OMB N0.2502-0265 � A. B. TYPE OF LOAN: U.S.DEPARTMENT OF HOUSING&URBAN DEVELOPMENT 1.QFHA 2.QFmHA 3.QCONV.UNINS. 4.�UA 5.�CONV.INS. 6. FILE NUMBER: 7. LOAN NUMBER: SETTLEMENT STATEMENT 8. MORTGAGE INS CASE NUMBER: C. NOTE: This form is furnished to give you a statemenf of actual settlement costs. Amounts paid to and by the settlemenf agenf are shown. Items marked'(POCJ"were paid outside the closing;they are shown here for informational pu�poses and are not inGuded in the totals. D. NAMEAND ADDRESS OF 80RROWER: E. NAMEAND ADDRESS OF SELLER: F. NAMEAND ADDRESS OF LENDER: Wilbur E.Wol/,Jr. Albert I.Uerdekal,Executor Margaret S.Wolf Estate of Frances J.Verdekal 833 Mount Rock Road 745 Mount Rock Road Carlisle,PA 17015 Carlisle,PA 17015 G. PROPERTY LOCATION: H. SETTLEMENTAGENT: 45-4273976 I. SETTLEMENT DATE: 745 Mount Rock Road 8radley L.Griffie Carlisle,PA 17015 December 16,2014 PLACE OF SETTLEMENT 200 North Hanover Street Carlisle,Pq 17013 J.SUMMARY OF BORROWER'STRANSACTION K.SUMMARY OF SELLER'S TRPNSACTION 100. GROSS AMOUNT DUE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER: 101. Contred Sales Price 400,000.00 401. Contrad Sales Price 400,000.00 102. Personal Pro ert 402. Personal Pro ert 103. Settlement Char es to Borrower Line 1400 4,716.00 403. 104. 404. 105. 405. Ad'ustments For Items Paid 8 Seller in advance Ad'ustments For Items Paid B Seller in advance 106. SchoolTaxes 12/16/14 to 06/30/15 613.38 406. SchoolTaxes 12/16/14 to O6/30/15 613.38 107. Count Taxes 12/16/14 to 12/31/14 9.24 407.Count Taxes 12/16/14 to 12/31/14 9.24 108. Assessments to 408.Assessments to 109. 409. 110. 410. 111. 411. 112. 412. 120. GROSS AMOUNT DUE FROM 80RROWER 405,338.62 420. GROSS AMOUNT DUE TO SELLER 400,622.62 200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER 201. De osit or earnest mone 5,000.00 501. Excess De osit See Inslrudions 202. Princi alAmount of New Loan s 502. Settlement Char es to Seller Line 1400) 20,010.00 203. Existin loan s taken sub'ed to 503. Existin loan s taken sub'ect to 204. 504. Payoff of first Mortgage 205. 505. Pa off oi second Mort a e 206. 506. Inheritance Tax Escrow 18,000.00 207� 507. De osit disb.as roceeds 208. 508. 209. SellerAssistance 4,000.00 509.SellerAssistance 4,000.00 Ad'�stments Fo�Items Un aid B Seller Ad'ustments For Items Un aid B Seller 210. SchoolTaxes to 510.SchoolTaxes to 211. Count Taxes to 511. Count Taxes �p 212. Assessments to 512.Assessments to 213. 513. 2�4• 514. 215. 515. 216. 516. 217. 517. Z�8. 518. 219. 519. 220. TOTAL PAID BY/FOR BORROWER 9,000.00 520. TOTAL REDUCTION AMOUNT DUE SELLER 42,010.00 300. CASH AT SETTLEMENT FROM/TO BORROWER: 600. CASH AT SETTLEMENT TO/FROM SELLER: 301. GrossAmount Due From Borrower Line 120 405,338.62 601. GrossAmount Due To Seller Line 420 400,622.62 302. LessAmount Paid By1For Borrower(Line 220) ( 9,000.00) 602. Le5s Reduclions Due Seller(Line 520) ( 42,010.00 303. CASH(X FROM)( TO)BORROWER 396,338.62 603. CASH(X TOJ( FROMJ SELLER 358,612.62 The undersigned hereby acknowledge receipt of a completed copy of pages 1&2 of this statement 8 any attachments referred to herein. Borrower �'�iZ1/�- �✓�j�/t/�L�' Seller Albert I.Verdekal,Executor Esfate of Frances J.Verdekal Wilbur E.Wolf,Jr. '� e �� J ' �IYGr�.�9��. CC��`F BY:��._ �( (�1��L�ln��kCC Margaret .Wolf A��G��- /� r�,� ' L.SETTLEMENT CHARGES 700.T07AL COMMISSION Based on Price $ % 16,000.00 PTIDFROM RUDFROM Division of Commission line 700 as Follows: eoaRoweas SELLER'S 701.$ 10,000.00 to Spencer&Spencer Realtors FUNosar FUNOSAT �OZ.S B4OOO.00 t0 RFJMAX Delta Group,IfIC. SETTLEMENT SETfLEMENT 703.Commission Paid at Settlement 16,000.00 704.Administration Fee to RE/MAX Delta Group,Inc. 195.00 800.ITEMS PAYABLE IN CONNECTION WITHIOAN 801.Loan Ori ination Fee % to 802.Loan Discounl % to 803.Appraisal Fee to 804. Credit Report to 805. Lender's Inspedion Fee to 806. Mort a e ins.A .Fee to 807.Assumption Fee to 808. 809. 810. 811. 900.ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 901.Interest From to @ $ /day ( days %) 902. Mortga e Insurance Premium for months to 903.Hazard Insurance Premium for ears to 904. 905. 1000.RESERVES DEPOSITED WITH LENDER 1001.Hazardlnsurance $ er 1002.Mori a e Insurance $ er 1003.School Taxes $ er 1004.Count Taxes $ er 1005.Assessmenls @ $ per 1006. $ er 1007. @ $ per 1008. $ er 1100.TITLE CHARGES 1101. Settlement or Closin Fee to Griffie&Associates,P.C. 300.00 1102. Abstred or Title Search to Tri-Count Abstrad Svcs. 135.00 1103. Title Examination to 1104. Title Insurance Binder to 1105. Document Pre aration to 1106. Nota Fees to Robin J.Bassett,Nota 7.00 10.00 1107. Attorneys Fees to includes a6ove item numbers 1108. Title Insurance to includes above item numbers: 1109.Lender's Coverage $ 1110.Owner's Coverage $ 1111. 1112. 1113. 1200.GOVERNMENT RECORDING AND TRANSFER CHARGES 1201.Recording Fees: Deed $ 79.00;Mortgage $ Releases $ 79.00 1202.Cil/Count Ta�Stam s: Deed �Mort a e 4,000.00 1203.State Tax/Stam s: Deed ;Mort a e 4,000.00 1204. 1205. 1300.ADDITIONAL SETTLEMENT CHARGES 1301.Surve to 1302.Pest Ins edion (o 1303. 1304. 1305. 1400.TOTAL SETTLEMENT CHARGES (Enter on Lines 103,Section J and 502,Section K) 4,716.00 20,010.00 BysigrirgpageldWssla�emenl,Viesig�a�aiesxknaNeEgereceiqdacanpeledc�yolpaga2oluisnwpagest . iffi at s,P.C. 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' �:�� . �. � . � �t a�3 €� 3��'§ � ^ � �� = f� Fy " )..' - .`. .��: . � 8 0 €E� �� 3$� �'bm �'€x€ <�� '� t� � 'I; � �� > 3�� r� ��y�� - ,.�--. � 1:E �--._'__�. Q� � x � _� 3 S`` � � >.,.5.- o �$ 7 ��3 m RE9 Ef �,��k� /¢� � � :�'•., ..-F.., � Z'�� m �� cain m�g i� £ �N R �1�� £¢: � \ I . � Z/''� N��°s � ��F��^ �z x4 �9£� d � �� !l� �A� /�•, �� I ' �,..r�''�. �1'�:.V � � ag � ` � )j/ , l. \! � T �+'� Cy � i - '� m�9 ' , �� , m W�a u�m $�s, � �o �j Y$�� ;o� �,Q/_". � `-,.., , � N-1��a�'s� :m � y� 9� � � � $��p �1�/''.. ' �i'� :� .. - C_Y C S5� $z D a �� 4 �� aE '_' Y",.'J� , q ' �(/I 3��80GCj � S n Q 2 3 4�q �"a �L' :, ', . � � � �x "s$ p z y� i �` �'. J . Q J Rl m Z e �:a�uDi � �� O c�i $� � �� g p�' '•��;� � .��'�� .- ' '6 SI . ' �� ' g0 � �A �� a m }�p a � �� _s�r,H��i•E'n. ��"�*w,.,:��`a,,,o,,,,�_ �.- ,� ,; � il i �ll r��k "c� � n � i x ="' � Da� F n �5� y� �� ;-"��^'-�� 5 �A o y _'- � T � m §m�5�� "s � / ��[�4� "��c.�.-.�, aH.x• �µ' � i Oi ; �5�� m=��;�"� % � ��;. r p°� . n-m,=,�-�.,.._� ii� - — — — -- — ��j�.� — -- - - —— - - —� -•• -- - -- • - -- �•wu1' - �-- - -- - • Gary L. Foster, Realtor SPENCER& SPENCER REALTY 1325 N. West Street, #1 Carlisle, PA 17013 717-386-9221 January 15, 2015 To Whom It May Concern: On January 12, 2015 I completed a walk through inspection of the property at 745 Mount Rock Road, Carlisle,PA 17015. The purpose of the inspection was to determine the value of the property for the Estate of Frances J. Verdekal. Specifically, I observed the 17.754 acres of land left to Albert I. Verdekal. Through the Market Analysis process, I have determined the value of the property to be $65,000.00. I do not have any interest in the property except to determine the market value. Sincerely, �� = ' �� 1� Gary L. Foster, Realtor Spencer& Spencer Realty THIS ANALYSIS HAS NOT BEEN PERFORMED IN ACCORDANCE WITH THE UNIFORM STANDARDS OF PROFESSIONAL APPRAISAL PRACTICE WHICH REQUIRES EVALUATORS TO ACT AS UNBIASED, DISINTERESTED THIRD PARTIES WITH IMPARTIALITY, OBJECTIVES AND 1NDEPENDENCE AND WITHOUT ACCOMMODATION OF PERSONAL 1NTEREST. IT IS NOT TO BE CONSTRUED AS AN APPRAISAL AND MAY NOT BE USED AS SUCH FOR ANY PURPOSE. ,/��.�� C. � 48500041046 REV-485 EX(05-04) SAFE DEPOSIT BOX INVENTORY PADepartmentofRevenue PLEASE USE ORIGINAL FORM ONLY Social Securiry or Death Certificate Number Date of Death County Code Year File Number _,__.._...__�.�. _____._.__�.______._m__�...._ .__,.__-. ._.__._____ ...___.___ _______e ' ' 05/01/2013 ;�21� ' 13� � 0577 -----.._._._..._.—.._.._..____._....._---......______.....__.: -----------.._.._..._._-----._.._..._.....-----------..: ;_......._.._....._..-� ----..._............. ._.... ._......__.....----._...----.._.._� Decedent's Last Name Suffix First Name MI ; _...__.._..__._....__--------...-- ? Verdekal Frances J =------..--._.._.__.._._..._...._-------------...._.._..----__._._.._.._._._...------..._._.� : _..__._...____._.......__... _..._--._.......--------.....__..._____.._._..---..__..._.__..-----._...._.__—_� _..... .. .._.... _.. _ .......... .................__...__._.__._._....._..._----.._..__....._.._...._.__......_.....__._..__..._..._..........._..-----____......._.....__._........................__---.._..._._..-------------------; ADDRESS OF DECEDENT STREET: CITY: STATE: ZIP CODE: ° 745 Mount Rock Road Carlisle PA 17015 NAME AND ADDRESS OF PERSON RE�UESTING THE OPENING OF THE SAFE DEPOSIT BOX NAME.Albert I. Verdekal, Executor of the Estate of Frances J. Verdekal STREETADDRESS: CITY: STATE: ZIPCODE: : 747 Mount Rock Road Carlisle PA 17015 � NAME,ADDRESS AND RELATIONSHIP(IF ANY)TO�ECEDENT,OF PERSON(S)PRESENT AT THE BOX OPENING a. NAME: RELATIONSHIP: Albert I. Verdekai, Executor qrandson STREET ADDRESS: CITY: STATE: ZIP CODE: 747 Mount Rock Road Carlisle PA 17015 b. NAME: RELATIONSHIP: Adam R. Deluca, Esq. none(Attorney for Estate) STREETADDRESS: CITY: STATE: ZIP CODE: 61 West Louther Street Carlisle PA 17013 c. NAME: RELATIONSHIP: STREETADDRESS: CITY: STATE: ZIP CODE: NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME: Orrstown Bank STREETADDRESS: CITY: STATE: ZIPCODE: 427 Villa e Drive Carlisle PA 17015 ' . NAME OF PERSON MAKING LAST ENTRY DATE AND TIME OF LAST ENTRY Frances J. Verdekal 6/23/08 0:00 am : DATE OF CONTRACT TO RENT BOX NUMBER OF 8aX 1 TITLE UNDER WHICH BOX IS REQUESTED 01/27/1995 59 Frances Verdekal NAME AND A�DRESS OF PERSON(S)HAVING ACCESS TO BOX a. NAME: b. NAME: Frances J. Verdekal STREETADDRESS: STREETADDRESS: 745 Mount Rock Road CITY: STATE: ZIP CODE: CITY: STATE: ZIP CODE: i Cariisle PA 17015 NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY none WAS A WILL IN THE BOX7 ❑ YES �] NO If yes, a. Date of will: 6. Name and address of personal representative,if named in the will NAME: Aibert I. Verdekal STREETADDRESS: CITY: STATE: ZIP CODE: 747 Mount Rock Road Cariisle PA 17015 c. Name and address of attorney,ff any NAME: Adam R. Deluca, Esq. STREETADDRESS: CITY: STATE: ZIP CODE: 61_West Louther Street „._ __ _ _ _M Carlisle PA 17015 ' � 48500�41046 4850�041046 � REV-485EX SAFE DEPOSIT BOX INVENTORY Page of 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 heid, 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. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT.280601 HARRISBURG,PA 17128-0601 ITEM NO. ITEM DESCRIPTION 1. The safe deposit box was empty. I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORO IS PERSON RECEIVING COPY OF CORRECTAND COMPLETE TO THE BE OF MY KNOWLEDGE AND BELIEF. SAFE DEPOSIT BOX INVENTORY: SIG � RE SIGNATUR � � �� PRINT NAME PRINT NAME AND HECK APPROPRIATE BOX BELOW: Adam R. Deluca, Es . Albert I. Verdekal PRINTTITLE DATE CHECKAPPROPRIATE BOX: �Executor(trix) �Administrator(trix) Attorney for the Estate 06/13/2013 �Estate Representative �Joint owner of safe deposit box NOTE:Attach additional 8'h"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 taxing authorities.The state law prohibits the Commonwealth's personnel from disclosing confidential tax information except for official purposes.