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Home My WebLink About02-26-15 r 1505610105 REV-1500 Ex(02.11)(F1) ennsytvania OFFICIAL USE ONLY PA Department of Revenue , P , L Y CountyCode Year File Number Bureau of Individual Taxes 1 PO BOX 28o6oi , INHIERITANC8 TAX RETURN Harrisburg,PA i7128 o6oi RESIDENT DECEDENT �/ ; I I(•i "� ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY _..................__......--......_... _........_—. .._..................._............_.........._........__.......__.....__..._.__. ...................................................................... j 07/03/2014 110/21/1923 j Decedent's Last Name Suffix Decedent's First Name MI Bulota j i Elizabeth i l (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI ,._...._........ -......._.._................................._.__......__....- .... - ...._...........__....__..._....._.._......__..... _._...... ..._ ............_............_.................................._..................._..._._......_........................ — ..__.. _....... i l i ! I Spouse's Social Security Number ......................... _._....... ___..._.._...._..........._..........._....._____........_..._...._.; THIS RETURN MUST BE FILED IN DUPLICATE WITH THE i.._...._.__._...._._.__.__ -...._—�__—..i REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW Glp 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death Prior to 12-13-82) O 4.Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) GID 6.Decedent Died Testate O 7.Decedent Maintained a Living Trust U 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9:Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NameDaytime Telephone Number ...___....._._.........._........._.._.._.__........-.........-- ..........................................---._..__..._.__...._._....__....._..........-.......__............_.......__.-...._....._..._._.._.. I_..........._......._..........................................._......._. .._.-......_........... __......_.......-.� Robert Van Horn, Esquire ;(610)740-0320 ..._......._................._._....-__................................................_.............._.........................._............_.......-- --....._.........................._............_......................_........-._................ ;.--- _ _ REGISTER OF WILLS USE ONLY C1 i c-r-1 M First Line of Address17) - M C-) ...............................__....................._........-._..................... ..........._.........._..........._......_........._..........._.........._.........._-......................_............_.........._................................. , 1123 North 5th Street --i Second Line of Address + ' "' N �J r-ry c� t-;) r-1 .................._.........._................_......._----........__..........._.........._....-_.........................................................--..... __......_...........-_....._............_ DATE FILED? ^L7 Tl City or Post Office State ZIP Code _.....- - „- t rt .................... f— rri l Allentown �.........PA_.... (18102 -_ ►- - �� 11 1—i CD f CZ) -� Correspondent's e-mail address:robertvanhom@verizon.net Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,come p .Declarati preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATOR -RESPa SIBL FO (LING RETURN DTE _ ADDRESS 2230 Highpoint Lane Slatington, PA 18080 SIGNATURE OF P RE OTHER THAN REP SENTATIVE DAT ADDRESS 123 North 5th Street, Allentow, PA 18102 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 J J 1505610205 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: Elizabeth Bulota RECAPITULATION --...._..........__.....__.._.......... _......... _............. 1. Real Estate(Schedule A). ............................................ 1. 1 r" 2. Stocks and Bonds(Schedule B) .............:......................... 2.+ 229,756.83 I 3. Closely Heid Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 4. Mortgages and Notes Receivable(Schedule D)........................... 4. 1 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5.1 358,181.68 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. j 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 1 425,622.02 8. Total Gross Assets(total Lines 1 through 7)............................. 8. 1,013,560.53 9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. I 35,218.00 j 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............... 10. 2,002.36 11. Total Deductions(total Lines 9 and 10)................................. 11.1 37,220.52 12. Net Value of Estate(Line 8 minus Line 11) .............................. 12. 1 976,339.98 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which i an election to tax has not been made(Schedule J) ........................ 13.j 0.00 14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14.1 976,339.98 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfersunder Sec.9116 __...........................__........._..._........._..._.._........... -..._..._...__...._ ...................................._.......___....._ __..........._...._._...._-............_...........__........._..., (a)(1.2)X.0- 15. ------- 16. Amount of Line 14 taxable at lineal rate X.0 45 976,339.98 16. 43,935.30 17. Amount of Line 14 taxable at sibling rate X.12 I 17. 18. Amount of Line 14 taxable ' at collateral rate X.15 1 18. 19. TAX DUE ......................................................... 19. 43,935.30 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 J REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Elizabeth Bulota STREET ADDRESS 325 Westlet Drive, Suite 3105 CITY STATE ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 43,935.30 2. Credits/Payments A.Prior Payments B.Discount 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 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) 43,935.30 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.......................................................................................... ❑ 0 b. retain the right to designate who shall use the property transferred or its income............................................ ❑ E c. retain a reversionary interest...........................:.................................................................................................. ❑ E d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 0 2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ 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? ........................................................................................................................ ❑ M 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. LAST WILL AND TESTAMENT RECORDrE-D OFFI OF Rr_*1',1SER Or. Vi ELIZABETH BULOTA M- 14 OCT 17 P1 CLE i F 0 R P Iq AP' C 1, ELIZABETH BULOTA, of Camp Hill, Cumberland County, Penns0W4ft-,b of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament, hereby revoking all other Wills and Codicils heretofore made by me. FIRST I direct the payment from my estateofmy just debts and the.expenses of:my last illness and funeral as soon after my death as conveniently may be done. If there be no cemetery lot available for my interment owned by me at the time!,of- my death,-J' -authorize my personal representative to purchase-such.bernetery,lot.with*contraptc.for... perpetual:care,,using therefor funds from My estate in,sucK amount_,6s he�shall`60*nsider necessary and desirable, and I authorize my personal representative to cause-title to or ownership of such lot so purchased to be vested in such person as my personal representative shall designate. Further, I authorize my personal representative to expend funds from my estate, in such amount as my personal representative shall consider necessary and desirable for the purchase, erection and inscription of a suitable marker for my grave. SAIDIS SECOND HUFF,FLOWER & LINDSAY Ali my personal effects, clothing, furniture, furnishings, jewelry, automobiles, ATTORNEYS*AT-LAW 2109 Market Street Camp Hill,PA other tangible personal property of every kind, and -insurance thereon, I give in accordance with a memorandum which accompanies my will. To the extent that such memorandum fails to dispose of al.1 personal property or if the memorandum is not in, existence at my death, then such property shall be added to the residue of my estate THIRD To my beloved husband, STANLEY BULOTA, I give and bequeath one-third (1/3) of the residue of my estate, absolutely and in fee simple, if he survives me by thirty (30) days. If he should fail to survive me by thirty (30) days, then-this gift of one-third of the residue of my estate shall be further divided into two (2) equal shares, and distributed as follows: One such share I give to my husband's son, WILLIAM R. BULOTA, or his heirs. The other share I give to the same WILLIAM R. BULOTA, IN TRUST, NEVERTHELESS, for the-benefit of my.husband's.other son, CHARLES R..BULOTA,;t& be administered according- to. the, terms of the supplementalneeds trust established under,the Will of STANLEY BULOTA., a :All:,th6-rest, residue-and,tern indeeof my-estate;l give,....in.equal shareg' :tmy children, GAIL ANN-WALDEN, STEPHEN N. WALDEN and MARK D: WALDEN, p6r stirpes. FIFTH In addition to the powers conferred by law, I authorize any personal representative, trustee or guardian acting under this instrument, in his/her absolute discretion: SAIDIS HUFF, FLOWER (a) To retain in the form received, or to sell either at public or private & LINDSAY Ar=NEYS-APLAW sale any real or personal properly; 2109 Market Street Camp Hill, PA (b) To exercise any options to subscribe for stocks, bonds, or other investments. 2 (c) To join in any plan of lease, mortgage, consolidation, exchange, reorganization or foreclosure of any corporation in which my estate or any trust may hold stocks, bonds or other securities; (d) To sell, transfer, convey, mortgage, pledge, lease or exchange any property, real or personal, which at any time may form part of my estate, for the payment of debts or taxes, or for any purpose of administration or distribution, for such prices and upon such terms as they, in their sole discretion, may deem wise, and to execute and deliver deeds of conveyance or transfer thereof; (e) To make settlements and compromises on such terms.as they, in their sole discretion may deem wise without the necessity of obtaining:any-court approval thereof, (f) To make distribution hereunder either in cash or.kind; ,as',th0 ,:.in their discretion may deem wise. SIXTH I do hereby nominate, constitute and appoint my husband; Stanley Bulota, -and my sons Steven N. and Mark D. Walden, to as Co-Executors-of this my Last Will and Testament. SEVENTH I direct that no personal representative, guardian, trustee or other fiduciary appointed under this instrument shall be required to give bond for the faithful SAIDIS 3UFF, FLOWER performance of his or her duties in any jurisdiction. & LINDSAY ATTORNM-AT•L1W IN WITNESS WHEREOF, I, ELIZABETH BULOTA, have hereunto set my hand 2109 Market Street Camp Hill,PA and seal to this my Last Will and Testament, consisting of three (3) typewritten pa est, the first two (21 of which bear my signature in the margin for identification, this / day of , 2003. r ELIZABETH BULOTA, Testatrix 3 Signed, sealed, published and declared by the above-named Testatrix, ELIZABETH BULOTA, as and for her Last Will and Testament in the presence of us, who have hereunto subscribed our names at her request as witnesses thereto, in the presence of said Testatrix and of each other. 7) ADDRESS 21 -LI C f�, 1e,.,w' ADDRESS t oft ,,.,..c -ice t- s-�- G�•wt'7 �-t t t 1 ��' —'T COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND WE, ELIZABETH BULOTA, "T o u rs , .lower . . s and aresigned to tie�r the Testatrix and witnesses, respectively whose names. g 'ng or attached instrument, being first duly swom, do hereby.: . declare to .the undersigned authority. that_:the. Testatrix szgned. arld executed -:the:; instrument as her Last Will and Testament,andt:that she.,.signed *11ingly arrd'thafi:th executed as 'her free and voluntary act fnr,the-purposes therein,expressed; and that, _ eachrof the.Witnesses, in 'the presence andl hearing:of the°Testatrix sigrtedlhe"Will last, ; witness and that to the best of their knowledge the Testatrix was at the,tihte fl8 or-,mdrer years of age, of sound mind and under no constraint or undue influence.,, EL17 TH BULOTA. Testatrix Witness 51 Witness SAIDIS Subscribed, sworn to and acknowledged before me by ELIZABETH BULOTA, CUFF,FLOWER the Testatrix, and subscribed to and swom or affirmed to before me by &t LINDSAY mQ� F/orc� ' and O,ew 0,6e,":4w' esses, thi ay of rnotwen-AT*LAW 2003. 104 Market Street Camp Hill, PA Notaryiic Notarial seal Seille Allshouse,Notary Public Carlisle Soro,Cumberland County 4 My Commission Expires Mar.29,2004 MARITAL AGREEMENT FOR MUTUAL WILLS x THIS AGREEMENT, made the IV_ day of !iP2003, by and between Elizabeth Bulota ("Wife") and Stanley Bulota ("Husband"), WITNESSETH: WHEREAS, on even date herewith, Wife and Husband have executed mutual Wills, duly witnessed and acknowledged, with the following dispositive provisions: 1. The Wills of both Husband and Wife leave one-third of the residue to the testator's spouse, if such spouse survives the testator by thirty days; otherwise, the same one-third of the residue passes to the children of the testator's spouse; and 2.. Both Wills further provide that the surviving spouse and one or more of the testator's sons shall be appointed to servd.as co-executors of the testator's estate;'.. WHEREAS, both Wife and Husband now desire to exchange legally-binding mutual' 1 .,assurances.-that the survivor of them cannot..revoke the items designated "I and."2" above; Nfy1W Ti ER?F. R ;. .ire consideratiort;:.afE th' ':mu'tUa,i,,,assurances.-,passirig. :b4twe n #kern;; and, intending-to be legally,boun-d;� the undersigned .Husband° arid''Wife'-do'" ` ,hereby covenant,and-.,agree that neither,bne;iaf°thiam shdll::ra.voke..or,amend' he .Will: ` ~_1 this ' day executed by-him-or-.her, without the.express:written consent,of. the''dth6i'' spouse. IN WITNESS WHEREOF, Wife and Husband have hereunto set their hands,and seals on the day and year.first above written. zge, (Seal) , (Seal} Elizgdeth Bulota (Wife), Stanley Bul a (Husband) Witness Witness SAIDIS TUFF, FLOWER & LINDSAY MORKYS-AT-(AW :109 Market Street Camp Hill,PA v RECORDED OFFICE OF REGISTER, CF IVYILLS CODICIL z01y OCT 17 FM 2 04 OF CLEF%.'% OF ELIZABETH BULOTA tt��ORPHAt4,S" Cr,Up t I, ELIzA hi'bQL',OTA),4he within named Testatrix, do hereby make and publish this Codicil of my Last Will and Testament dated April 14, 2003. FIRST I hereby amend Article FOURTH of my said Will to provide as follows: I. Thirty Thousand ($30,000.00) Dollars given by me during my lifetime to my daughter, GAIL and WALDEN, shall be treated,as an advancement (without interest) against that share of my estate hereinafter bequeathed intrust for her benefit; II. 1 give, devise and bequeath all the rest, residue and. remainder of.my estate, in three(3)-e0ual'shares ;perstupes A:.: to my sort, STEPHEN N. WALDEN; :. .. B. to my son, MARK D. WALDEN; and. C. to my Trustees, Stephen N. Walden and Mark D. Walden, IN TRUST, NEVERTHELESS, for the benefit of my daughter, GAIL ANN WALDEN, upon the following terms and conditions: 1. To hold, manage, invest and reinvest the principal so received, and the accumulation of income thereon; 2. To distribute to my daughter, GAIL ANN WALDEN, the sum of One Thousand Eight Hundred ($1,800.00) Dollars per month; 3. To invade the principal of this trust, from time to time, in their absolute discretion, to make such additional distributions as they deem necessary and desirable, for my daughter's health, maintenance and support, provided that, in their 1 sole judgment, her circumstances shall have so changed from those which prevail at the time I draft this Codicil, that my Trustees believe I would have so directed, had such altered circumstances existed during my lifetime; 4. All payments of principal and income hereby given shall be free from anticipation, assignment, pledge or obligations of the beneficiary, and shall not be subject to any execution or attachment; 5. When my daughter attains the age of sixty-five (65) years, all remaining principal and, undistributed income shall be distributed to her free of trust, and this trust shall.terminate: 6. Should my daughter fail to survive'until the termination-of. this trust, any remaining principal and undistributed income of this,trust shall be, distributed, in equal-'shares, per capita, to my grandichildrem. SECOND In all other respects I hereby ratify, confirm and republish my-Last Will dated April 14,.2003, together with this sole Codicil as and for my Last Will'. IN WITNESS WHEREOF, 1, ELIZABETH BULOTA,�have hereunto set my hand and seal to this Codicil to my Last Will and Testament this day of January, 2007. ELIZABETH BULOTA (4_4q"'ee7/1; 74 2 F RECORDED Oi FICE OF REGIST � 10,F IVILLS SECOND CODICIL 2-314 OCT 17 FM 2 09 OF CLC;,;; -7 ELIZABETH BULOTA 0 R P H A tS' 0 1!7 CUMBE,11,J.,1,*,1,-) 'I, ELIZABETH BULOTA, the within named Testatrix, do hereby make and publish this Second Codicil of my Last Will and Testament dated April 14, 2003 and first Codicil of January 16, 2007. FIRST I hereby amend Article.fIRST, Paragraph I. of my said Codicil of January 1.6, 2007, .to provide as follows: ' . ,' '.Thir.t.Y: Thousan.d.- -.($3Q.,,000..010).:-Doll.ars-:given� by me- during my. Jifetim� :to: MY loog htor,-G. Al L.-ANN': WALDEN,...Sholl; notl'be .treated as.an -advan6er*en't" "inst ago that share of Myestate bequeathed in trust.,for her-be i fit.: The. said lifetiixie gift shall be disregarded- and shall have no effect,whatsoever U06n the distnfbLftidn of my estate. SECOND In all other respects I hereby ratify, confirm and republish my Lost Will dated April 14, 2003 and my Codicil of January 16, 2007, together with this Second-Codicil, as and for my Last Will and Testament. IN WITNESS WHEREOF, 1, ELIZABETH BULOTA, have hereunto set my hand and seal 'A to this Second Codicil to my Last Will and Testament this 1-7 U_ day of 2010. ELI ETH BULOTA J f Signed, sealed, published and declared by, the above-named ELIZABETH BULOTA, Testatrix, as and for her Second Codicil to her Last Will and Testament in the presence of us, who have hereunto subscribed our names at her request as witnesses thereto, in the presence of said Testatrix and of each other. ADDRESS 16 W , HL; ---/* '1 arc u. • V_j ADDRESS ;3'z?tyK)1 U11194& c.�"selrt A A_ - COMMONWEALTH OF PENNSYLVANIA: :. COUNTY OF CUMBERLAND 1Ne, ELIZABETH`:.B:ULOTA, Thomas E. Flower and AK( o Vtifo!� the . ; 'Ties an.d_y�ritnesses, respectively.v+ hose names are. signad to-thefciregoing or att;tech, d ' instrurnenfi; being firsf ° r u�jr: 'sworn; '-do - hereby deciar6. fio }he' " Ur0cl ign.ed.-authority that the Testatrix sig.nPd.b6d executed the°ir3sYrume�t:as. ; her:SeGor3d: Codicil b her Last-.Will,arjd Testament and that she signed willingly., and thafi.she.executed as her free an, voluntary ditt-for"the purposes':,t�iere'in expressed, and that'each of the witnesses, in the.-Pi and hearing of the ' Testatrix-signed the Will as witnesses and that to the best of their knowledge the Testatrikwas at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. ELIZ BETH BULOTA Witness Witness 2 Commonwealth of Pennsylvania SS. County of Cumberland On this, the /7 day of Xag&Sr 2010, before me, Nathan C. Wolf, the undersigned officer, personally appeared Thomas E.flower, Esq., known to me or satisfactorily proven to be a member of the bar of the highest court of Pennsylvania, and certified that he was personally present when the foregoing acknowledgment and affidavit were signed by the testatrix and witnesses. I have signed my name and affixed my seal. COMMONWEALTH OF PENNSYLVANIA Notatial Seal CaNathan.C;Wolf,NotaryPublic Cadisle Som,Cumberland County my Commfssiorr Expires AprI119,20112 la��sociaUon`Rffl arkts, Member,Pen S V,n ot y THIRD CODICIL RECORDED OFFICE OF OF REGIS THEIR, O V,'ILLS ELIZABETH BULOTA 2014 NOT 17 PM 2 py I, ELIZABETH BULOTA, do hereby make and publish this Third Codicil of rp iL&asfi w1il ORPRAvi-, COURT and Testament dated April 14, 2003. CUMBERLi,ItD I hereby amend any provision in my will or codicils for distribution for my daughter, GAIL ANN WALDEN, to be held in trust, and I direct that the same be distributed to her outright and free of trust. In all other respects I hereby ratify, confirm and republish my Last Will dated April 14, 2003 and my First and Second Codicils thereto, as and for my Last Will and Testament. IN WITNESS WHEREOF, I, ELIZABETH BULOTA, have hereunto set my hand and seal to this Third Codicil to my Last Will and Testament this l 7 day of , 2012. ELI BETH BULOTA Commonwealth of Pennsylvania ) SS. County of Cumberland ) On this, the day of , 2012, before me, the undersigned officer, personally appeared Eliza eth Bulota, known to me or satisfactorily proven to be the person whose name is subscribed to the foregoing codicil and acknowledged that she executed the same for the purposes therein contained. I have signed my name and affixed my seal. Notary COMMONWEALTH C! `. N8LVANIA �NOTSEAL THOMAS E.FLOWER,Notary public `- v Carlisle Som.,Cumberland ounty My Commission Expires October 26 2014 RENUNCIATION REGISTER OF WILLS Cumberland COUNTY,PENNSYLVANIA Estate of Elizabeth Bulota Deceased 1, Mark D.Walden in my capacity/relationship as (Prnul wv) son and designated executor of the above Decedent,hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to my brother, Stephen N.Walden October ,2014 �' .--4 _ �• ^�--�.. (Dxe) lBr++e> Marls D. Walden 1260 Averill Drive {SYneer.tddnaa) Batavaia,IL 60513 (Mi.sura,ZO) Executed in Register's Office Emcided ort of Register's Office Sworn to or affirmed and subscribed Before the undersigned personally app the before me this day party executing this renunciation and certified of that he or she executed the renunc' far the p 7 stated within on this, t3' f T, - , Deputy for Register of Wills otary blit My ission Expires: (Signature and seat of Notary or other official qual fW to admaiister oaths. show date of expiration of Notary's Commission.) OFF11CIAL SXAL Form RW-06 rev.10.1106 DAISY a Notuy,Public State of I1111120%M {p�Ostnmiss,on Expirss Oct 310).2016 REV-1503 EX*(8-v) pennsytvania SCHEDULE B LST DEPARTMENiOFREVENUE INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER Elizabeth Bulota 2014-00902 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1' Merrill Lynch Investment Account#898-12189. See attached statement of holdings 229,756.83 and DOD calculations. TOTAL(Also enter on Lane 2, Recapitulation) $ 229,756.83 If more space is needed,insert additional sheets of the same size t . ' Merrill Lynch Wealth Management Bank of America Corporation Historical Date of Death Valuation 898-12189 Elizabeth Bulota Date of Death 07/03/2014 Report Type : Date Of Death Valuation Date : 07/03/2014 Number of Account(s) 1 Processing Date 07/09/2014 MRS ELIZABETH,BULOTA Number of Security(s):6 325 WESLEY DR APT 3105 MECHANICSBURG PA 17055-3501 Account#898-12189 Shares Security High/Ask Low/Bid Mean and/or Div and Int Security or Par Description. Adjustments Accruals Value 1) 44,000.0400 GENERAL ELEC CAP CORP(36966TJA1) 107.66 SER NOTZ FLT%APR 15 2023 TRACE DTD:04/16/2013 MAT:04/15/2023 1.23% ` 07/02/2414 101.60000 100,60000 H/L 07/08/2014 100.21200 99.61900 H/L 100.705166 40,282.06 :..;r. �:.e.:rs?: - +vra'•'^;s=+•,::_ -`'1TcE'. 'Fe+ii<-a.:a}s,.::�K •' ,a"'1.'i:•v•>''-':',"'"_': 'C3'S<_�.,-'.�.�. <,:..,.,:-_«-:.-<.x::u,s<+ .-r s a -a., '?. ,t»t ,s:-1i-` '2," a:.t,r-> ((}},, a:a:•r 's� .J..•-. ,_:.,t ? ;•334i :;..ry`:v, �$� v i .. .'? • _ ,P �' 4x_, s<vi'ix i'.'~•'�'}rE rt"' x'.!'1 `r i',.. Ertt, "t''�h. S�� Y3...t4';:.",'.ju4•+ + �.. r, EST-ti ':a w �.-r_: 004 : Ol2D. �y()T( Rn EC7i Co,•: C'. 3444T3r k 3'..•'-,'>:r ej.-,.r.1' V,L�� s T..,.:-.-. >.�,�. ... , w )r a:.T.: i .BSc:: „lt- :7... NY" •-r',... 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'm'd. ::h ,Y:ti;. ?.a.. =r, x:Y•�;w,:' iva:.. .�,<.,. .x a 3e^Z ice: ..�.�-�r-+ <r.••<. <.r'.'-1->tnyq'.,-=i;n .q.. ..r'.::�� :,G _.._u..e.. .__....,...., ...,..",-... u: a5?.•.,:..^,�„< .l}r... ,._._.:c`ti,e,9.,. ��s.:i.,.,.>:.,,.��<-.tFt _.,___Uf' _= .':..,_f. ..iz.. ,•�;�,"�.�t:_ ..-.h.-.=_-,::i'R... ._...<.i..:,::r_::�r `�-' ....-., Total Value $229,1,96.62 Total Accrual $560.21 Total $229,756.83 2 Total Security Value: $229,196.62 Total Accruals: $560.21 Total Combined Value: $229,756.83 The information herein has been obtained from a source we believe to be reliable,but we do not guarantee its accuracy or completeness.Merrill Lynch does not provide tax,accounting or legal advice.Any tax statements contained herein were not intended or written to be used,and cannot be used for the purpose of avoiding U.S.,federal,state or local tax penalties.Please consult your advisor as to any tax,accounting or legal statements made herein. Disclosures: •There is NO fee associated with the use of this application at this time. •Alternative Date of Death valuations are not available in this application.Please consult your tax advisor for assistance in obtaining this report. •Report may include trades that are not settled as of valuation date. •Ali security positions are based on trade date. •Money funds,money market and/or bondtfixed income mutual funds may or may not include dividends/interest accruals prior to month end payment. •For accounts with Credit and/or Debit card(s),the cash position may not reflect reduction for purchases of goods or services which are paid for by automatic debit on the Wednesday before the last Friday of each month. •Cash balance may not reflect outstanding checks written prior to valuation date or unsettled cash as of valuation date. •All items flagged"I"and highlighted In red reflect manually adjusted transactions(for price,shares,market value or security name)or positions with no available price. •Asset positions provided to Sank of America/Merrill Lynch from an outside financial institution(i.e.Annuities),may require the Securities Description line to be manually updated. •.Fee accruals are not captured in TMA accounts. •All mortgage backed securities have the paydown factor/amortization factor automatically applied. •If the account you are valuing is a•900°series account(international),the values will be reported based on the currency the account holds,not USD.Please also note that if this account is valued along with other USD accounts,you will not receive an accurate valuation;please run these accounts separately from USD accounts held in the clients household. The information herein has been obtained from a source we believe to be reliable,but we do not guarantee its accuracy or completeness. investment products provided are Merrill Lynch,Pierce,Fenner&Smith Incorporated: Are Not FDiC Insured Are Not Bank or State Guaranteed TMay Lose Value Merrill Lynch,Pierce,Fenner&Smith Incorporated is a wholly owned subsidiary of Bank of America Corporation,and a registered broker dealer and member of FINRA and SIPC. Merrill Lynch,Plame,Fenner&Smith incorporated Is not a tax or legal advisor.Clients should consult a personal tax or legal advisor before making tax or legal related investment decisions. Nothing discussed or suggested in these materials should be construed as permission to supersede or circumvent any Bank of America or Merrill Lynch,Pierce,Fenner&Smith Incorporated policies,procedures,rules,and guidelines. 3 REV-1508 EX+(o8-i2) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS &MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Elizabeth Bulota 2014-00902 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. +Deposit Refund from Asbury Community,Inc.(Bethany Village) 272,990.35 2i 'PNC Savings Ac d#5005798085 34,274.27 3 PNC Checking Acct#5004894497 46,714.39 I ;See attached bank statement as to items 2 and 3. 4 Merrill Lynch Disbursement. ; 2,500.00 5 Citigroup Class Action Settlement Distribution ; 806.19 4 6; -Apartment Contents-Lived Frugal Life Style r 500.00 , 7! Genworth Life Ins.Refunds(disability policy) 298.51 8� Refund State Farm Casualty Insurance 92.58 91 ;Refund AMA Ins. - - ~ - 5.39 i r E I I-- TOTAL(Also enter on Line 5, Recapitulation) $ 358,181.68 If more space is needed,use additional sheets of paper of the same size. REV-1510 EX+(08-09) i pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Elizabeth Bulota 2014-00902 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 INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE I. Merrill Lynch Investment Acct.#898-10861 333,551.35 100 333,551.35 2 Merrill Lynch Investment Acct.#898-14513 92,070.67 100 92,070.67 See attached statements as to items 1 &2 for holdings and D.O.D. calculations. Note: Decedents 3 children were named beneficiaries. TOTAL(Also enter on Line 7, Recapitulation) $ 425,622.02 If more space is needed,use additional sheets of paper of the same size. Merrill Lynch Wealth Management Bank of Anwfta Corporation Historical Date of Death Valuation 898-114513 Elizabeth Bulota TOD Date of Death 07/03/2014 Report Type Date Of Death Valuation Date 07/03/2014 Number of Account(s) 1 Processing Date 07/09/2014 MRS ELIZABETH BULOTA Number of Security(s):4 TOD BENEFICIARIES ON FILE 325 WESLEY DR APT 3105 MECHANiCSBURG PA 17055-3501 Account#898-14513 Shares Security High I Ask Low i Bid Mean,and/or Div and int Security or Par Description Adjustments Accruals Value 1) 45,000.0000 GENERAL ELEC CAP CORP(36966TJAI) 121.11 SER NOTZ FLT%APR 15 2023 TRACE DTD:04/16/2013 MAT:04/15/2023 1,23% 07/02/2014 101.60000 100.60000 H/l. , 07/08/2014 100.21200 99.61900 H/L 100.705166 M 45,317.32 _, ,>. .,...,:.�a-..s- :, .... .. _ ..• _ .. .,r : ,- - - <-i's >•, ,<a::l��- :,E. 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Total Value $91,859.99 Total Accrual $210.68 Total $92,070.67 Total Security Value: $91,859>99 Total Accruals: $210.68 Total Combined Value: $92,070.67 The information herein has been obtained from a source we believe to be reliable,but vw do not guarantee its accuracy or completeness.Merrill Lynch does not provide tax,accounting or legal advioe.Arty tax statements contained herein were not intended or written to be used,and cannot be used for the purpose of avoiding U.S.,federal,state or local tax penalties,Please consult your advisor as to any tax,accounting or legal statements made herein. 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Nothing discussed or suggested In these materials should be construed as permission to supersede or circumvent any Bank of America or Merrill Lynch,Pierce,Fenner$Smith Incorporated policies,procedures,rules,and guidelines. 3 • Y ' Merrill Lynch Weald management Bank of America CoMoraUon Historical Date of Death Valuation 898-10861 Elizabeth 8ulotaTOD Date of Death : 07/03/2014 Report Type Date Of Death Valuation Date 07/0312014 Number of Account(s) 1 Processing Date 07/09/2014 MRS ELIZABETH BULOTA• Number of Security(s) :40 TOD BENEFICIARIES ON FILE 325 WESLEY DR APT 3105 MECHANICSBURG PA 17055-3501 Account#898-10861,E Shares Security 4— High/Ask Low/Bid Mean and/or Div and Int Security or Par description Adjustments Accruals Value 1) .186.0000 ALBEMARLE CORP COM(012653101) New York 07/03/2014 72.55000 72.02000 H/L 72.285000 13,445.01 .,E :aT"`: :-3r- f.-a •3P.>W-ra;f•S`}h{'r ^,.E....-`�.Fh\Y,-r.�7T.:-',,.• - - '?" ..T."• ,',r` d _e,,..''.'�- .r .,`�`�.Y'.,,sc. ?:s..••",�az•.g' Y� �' ::#',. -r t t °'• '• ? i'.+`r`a_'`.� T . 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Fc' �� '.z�i..?,i ,sr..tvd.:d,'::s_'.' `"":.: _w�'�»i;:_. :_±;z,'s;�^,.Mr.:tuk,' Total Value $332,861.65 Total Accrual $689.70 Total $333,551.35 Total Security Value: $332,861.65 Total Accruals: $689.70 Total Combined Value: $333,551.35 The information herein has been obtained from a source we believe to be reliable,but we do not guarantee its accuracy or completeness.Merrill Lynch does not provide tax,accounting or legal advice.Any tax statements contained herein were not intended or written to be used,and cannot be used for the purpose of avoiding U.S.,federal,state or local tax penalties.Please consult your advisor as to any tax,accounting or legal statements made herein. Disclosures: •There is NO fee associated with the use of this application at this time. •Alternative Date of Death valuations are not available in this application.Please consult your tax advisor for assistance in obtaining this report. 9 •Report may include trades that are not settled as of valuation date. •All security positions are based on trade date. •Money funds,money market and/or bondited income mutual funds may or may not include dividends/Interest accruals prior to month end payment. •For accounts with Credit and/or Debit card(s),the cash position may not reflect reduction for purchases of goods or services which are paid for by automatic debit on the Wednesday before the last Friday of each month. •Cash balance may not reflect outstanding checks written prior to valuation date or unsettled cash as of valuation date. •All items flagged"I"and highlighted in red reflect manually adjusted transactions(for price,shares,market value or security name)or positions with no available price. •Asset positions provided to Bank of America/Merrill Lynch from an outside financial institution(.e.Annuities),may require the Securities Description ilne to be manually updated. •Fee accruals are not captured In TMA accounts. •Ali mortgage backed securities have the paydown factor!amortization factor automatically applied. •If the account you are valuing is a"900"series account(International),the values will be reported based on the currency the account holds,not USD.Please also note that if this account is valued along with other USD accounts,you will not receive an accurate valuation;please run these accounts separately from USD accounts held in the clients household. 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Nothing discussed or suggested in these materials should be construed as permission to supersede or circumvent any Bank of America or Merrill Lynch,Pierce,Fenner&Smith Incorporated policies,procedures,rules,and guidelines. 10 REV-1511 EX+ (08-13) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Elizabeth Bulota 2014-00902 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Parthemore Funeral Home 4,109.45 2 Funeral Luncheon 2,056.70 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: 2. attorney Fees: Robert Van Horn, P.C. (Includes Item 6 below) 25,000.00 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: Cumberland County 730.50 5. Accountant Fees: 6. Tax Return Preparer Fees: 7• Legal Notices 276.16 8 Executors expenses for travel to Cumberland County,PA,for hearing on Petition relating to lost Will. Steve Walden 264.80 Mark Walden 355.55 9 Flower Law,LLC Re: Lost Will Petition/Hearing 925.00 10 Richard Elluis,CPA.(2014 tax matters) 1,500.00 TOTAL(Also enter on Line 9, Recapitulation) $ 35,218.16 If more space is needed,use additional sheets of paper of the same size. REV-1512 Ex+(12-12) -JNL-pennsytvania SCHEDULE DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES&LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Elizabeth Bulota 2014-00902 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 Reimbursement to PSERS 1,783.92 4, 2 Chase Cardmember Service 218.4A A I.M-WO 3fft%ft' -.a.`a"^G' . ....... .-+.. .,... _...,. ..... «..,.-. ..,..,... r.,,.«.. . - ......._. ....,....�.�v-...�......L.w.:..T'�.,. .........a.. ..... t lR'Id.k L�+WY Y+itw'n+� dui ,d[OfF.� t .14i: J WIZ —4 TOTAL(Also enter on Line 10,Recapitulation) k__ 2,002.36 If more space is needed,insert additional sheets of the same size. 12-10-14;09. 16AM;PNC MECHANICSBURG BRANCH ;717-691-4076 # 1/ 2 V 44- /. LV 11 11./11.. . .. --.... .. � . �• N 1 `7 December 912014 Wanda Wert Mechanicsburg Branch PNC Bank RE: Name:Elizabeth Bulota SSN:207-141863 DOD:07-03.20 .4 Dear Mr.Van Horn: in response to your request for Date of Death(DOD)balances for the customer noted above,our records show the following: Checking Account Account 45004894497 Established:04--24-2005 EUZABETH BULOTA DOD balance: $46,714.09+0.30 accrued interest Interest paid 01-01.2014 thry 07-03-2014$2.56 YTD Savings Account Account#5005798085 Established:08-12-2008 ELIZABETH BULOTA DOD balance: $34,273.54+x..73 accrued interest - Interest paid 01-01-2014 thru 07.03.2014$13.67&+YTD Please note thatthis office provides date of death balances for deposit accounts(IRAs,CDs,Checking and Savings). We do not process any financl,al transactions or provide statements. if you need assistance with any of these items,please call 1888-PNC-BANK(1-888-762-2265)or Stop by your local PNC Bank'bmnch office. Sincerely, National Financial Services Center PNC Bank,N.A. Member FDIC Page 1 of 2 REV-1513 EX+(01-10) pennsylvana SCHEDULE ] DEPARTMENT OF REVENUE BENEFICIARIES C CCT Tw Com+ INHERITANCE TAX RETURN BENEFICIARIES - RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Elizabeth Bulota 2014-00902 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. piWilliam R Bulota P.O.Box 159 Stevenson,Washington 98648 Step-son _ 180,000.00'! �p�...�...�..�.,,._�.....�.. 9.p��...�..�9� �----- 1/3 of Residue _ 1 s 2 ?Ste hen N.Walden 2230 Hi h oint Lane Slatin ton,PA 18080 on 7F3. Mark D.Walden 1260 Averill Drive Batavia,IL 60513Son I � 1/3 of Residue� - _... - - --...__....._......_...... ......... 4. iGail A.Coleman 20 HILLCREST DRIVE MECHANICSBURG,PA 17055 jDaughter '1/3 of Residue 1 I- L I k k - -- k 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: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. E' , 1 E [ I I TOTAL OF PART H-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.