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Home My WebLink About04-13-15 1505610105 J REV-1500 EX(oz-ii)(FI) � Of°F'ICIAL USE ONLY PA De artment of Revenue pennsylvania P pE,qp,ME„ aE�E„�E Coianty Code Year File Number Bureau of IndividualTaxes INHERITANCE TAX RETURN �' �2 � I � PO BOX z8o6oi ,,"",7�� Harrisburg PA 1'71z8-o6o1 RESIDENT DECEDENT _ J/ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 01/12/2013 05/17/1927 DecedenYs Last Name Suffix DecedenYs N=irst Nthme MI Weigie Delores L (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Narrue MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUh�LICATE WITH THE REGISTER OF �ILLS FILL IN APPROPRIATE OVALS BELOW � 1.Original Return O 2.Suppiemental Return O 3. Remainder Return(Date of Death Prior to 12-13-82) p 4.Limited Estate O 4a.Future Interest Compromise(date of p 5. Federal Estate Tax Return Required death after 12-12-82) � 6.Decedent Died Testate O 7.Decedent Maintained a Living Trust _ 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 Schedufe O) CORRESPONDENT- THIS SECTION MUST BE COMPLETEO.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Gaytime Telephone Number William S. Daniels, Esq. � (717)243-3831 �v RE ER OF WILL�E ON�Y�7 � � � C? C7 ..�� T�J � C7 First Line of Address n't � � � t.n � 1--+ One West High Street � � r� rn w �,' � Second Line of Address ? 4� � -� c� � Suite 205 `�~' '�� - � '�'` c7 City or Post Office State ZIP Code : :`:�ATE FIL """ Carlisle PA 17013 �� µ � U' �' . N ..r,� CorrespondenYs e-mail address: hUmeP8flddalli@IS@OUtI00k.COm Under penalties of perjury,I dedare that I have examined this retum,including accompanying schedules and staterrie;nts,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 inforiTi�ation of which preparer has any knowledge. �IGNATURE OF PERSON RESPONSIBLE FOR FILING R RN ��EJ � SL�,��- �i �,�:,-,� y�� ,��.... ,�. �'� a�:�s ADD� ._ Douglas A. Weigle, 2320 W ut m Rd./Patricia A.Adams, 140 Airport Dr., Carlisle, PA 17013 SI AT �2E PARER OTHE AN R ES NTATIVE � DATE � � � 03/27/2015 ADDRESS William S. Daniels, Esquire, One West High Street, Suite 205, Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY� Side 1 � 1505610105 1505610105 � � 1505610205 REV-1500 EX(FI) RECAPITULATION 1. Real Estate(Schedule A). .......... . ................................. 1. 123,600.00 2. Stocks and Bonds(Schedule B) .......................... ............. 2. i 1,109.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . .... 3. 0.00 4. Mortgages and Notes Receivable(Schedule D).. .......... ......... .... . . 4. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 9,774.34 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 978.49 i 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 0.00 8. Total Gross Assets(total Lines 1 through 7)........... . .. . .... .... ...... 8. 135,483.10 i 9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 16,566.96 j 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1)............... 10. 46,940.24 11. Total Deductions(total Lines 9 and 10)...... . . .. . . . . . .. . ........ .. .. ... 11. 63,507.20 12. Net Value of Estate(Line 8 minus Line 11) .. . ... . . .. . . ..... ... ........ ... .. 12. _ 71,975.90 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . . . ....... .............. 13. 1 0.00 14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14. 71,975.90 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 1 000 --1(a)(1.2)X.0- . 15. 0.00 16. Amount of Line 14 taxable at lineal rate X.0 45 F 71,975.90 16.1 3,238.92 17. Amount of Line 14 taxable i at sibling rate X.12 0.00 17. 0.00 I s 18. Amount of Line 14 taxable 1 at collateral rate X.15 1 0.00 18 0.00 1 19. TAX DUE . . . ..................... . . ... . .................. .. . ...... 19. 3,238.92 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENTS NAME Delores L.Weigle STREET ADDRESS 140 Airport Drive CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 3,249.77 2. Credits/Payments A.Prior Payments 0.00 B.Discount 0.00 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) 0.00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 3,249.77 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.......................................................................................... ❑ N b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ c. retain a reversionary interest.............................................................................................................................. ❑ 0 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?.............................................................................................................. ❑ 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ 0 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a 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. 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. . _ � ...,,.�.v ' �— . ,. . , , � ,., - . � i ;'��R :..,� 2t�,ia�,.��` y ��`� � f, �rar.. , f�'ir�'�p'� S�' s.`*�`.%.P1w „ . - _. . . .. . � !�, I : ('�,� �� . . ;. a�. _ . � , : � , . . , . : , r - r. . . , . . . . . . . s . . 4 . y , , . _ . . . . ry . . , . , � , . . � . .. _ . . � , .I , DELORES: L. `WEIGLE, of North` Middlton Township, � Cumberland County, �•Pennsylvania, declare this 'to` be myRlast will - r and�;reir,oke:.�any:�wi1�L��reviousl-y,;.made b�►�:me.,-�� :�;�� to;1;�� ,; �;.;st:� I . I devise and� bequeath all of mp estate'- of� every nature and wherever situat� to my husband, BROCE:R� WEIQLE, providing he �shall .survive�.me by thirty �days: ` II .- 'Should my �husband, Bruce 'R. `Weigle; predecease 'me or die �on or..before�:the thirtieth day following my death, I devise and beqx�eath. al l of 'my estate of every nature and wherever situate in equal shares to .`such of my_�children, DOIIGLAS A: NEIGLE and PATRICIA A. ADAM3,::as surviti=e me by 'thirty 'days. III . . Should �my son; Douglas �A. Weigle;` or my `dauqhter, , Patricia A. Adams, .'predecease me or die 'on or before''the 'r b�`� . � thirtieth day �fo1-lowing �my?,`death`;-c�I` devis�' �nd beqti`e�th''�the "share� � 9`6 of such child to his .or her issue per stirpes livinq on the thirty-first day followinq' my' death; and should any of my said adult> �children� leav�e• no �such� issueS�lidinq� on the thirty�first day following my death,; I devise and bequeath the share'� of�� such child to my other child,- or to their issue per stirpes liv'ing` on `the thirty-first day followinq: my death. IV. Until distributed, no gift or beneficial interest t � ,.w.��x rv..j y,p..,�... .. . 1 1. .. F ; `, I ,. _ - shall be subject to anticipation or to voluntary or involuntary alienation. V. I appoint FINANCIAL TRUST SERVICES COMPANY of Carlisle, Pennsylvania or its successor in business, guardian of any property which passes either under this will or otherwise to a minor and with respect to whom I am authorized to appoint a guardian and have not otherwise specifically done so, provided that "this` appointment of a 'guardian shall not supersede the right of any fiduciary in its discretion to distribute a share where possible to the minor or to another for the minor' s benefit . Such guardian shall have the power to use principal as well as income from time to time for the minor' s support and education ( including college education, both graduate and undergraduate) without regard to his or her parent ' s ability to provide for such support and education, or to make payment for these purposes , without further responsibility, to the minor or to the minor ' s parent or to any person taking care of the minor . � VI . I direct that all taxes that may be assessed in � consequence of my death, of whatever nature and by whatever . � jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my estate . VII . I appoint my son, DOUGLAS A. WEIGLE, and my daughter , PATRICIA A. ADAMS, co-executors , or the survivor of them, � executor of this my last will . Should both of them fail to qualify or cease to act as executors , I appoint FINANCIAL TRUST SERVICES COMPANY of Carlisle, Pennsplvania or its successor in business, executor of this my last will . i , _ _- --- --- .__- -- —----�. _._..__..._.. .___ _ _ __._t..� ____ :.��„� , �� t . ... .. .. . � I VII , I direct that my executors and guardian shall not be required to give bond for the faithful performance of their duties in any jurisdiction. IN WITNESS� WHEREOF, I have hereunto set my hand this �� day of y�� `/ , 1996 . , . � �� DELORES L WEIGLE The preceding instrument , consisting of this and two other typewritten pages identified by the signature of the testatrix, DELORES L . WEIGLE, was on the day and date thereof signed, published and declared by DELORES L . WEIGLE, the testatrix therein named, as and for her last will , in the presence of us , who , at her reques in her presence, and in the presence of each other h ve subsc ibe our names as witnesses hereto. G`v \ � Gc�a✓ ��e'�_ GYG �� '�� ` ��'�''�-.� ,�Zj -/�---3 Z�/ `� . �-� 3 , REV-1502 EX+ (12-12) �� i � pennsylvania SCHEDULE A� � '� DEPARTMENT OF REVENUE REA� ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Weigle, Delores L. 21 13 0113 Ali real property owned sotely or as a tenant in common must be reported at fair market value.Fair markek value is defined as the price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule f. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1� 140 Airport Drive,North Middleton Township,Cariisle,PA 17013 123,600.00 Property Record Number 29-17-1585-120 Deed Book U,Volume 20,Page 1153 TOTAL(Also enter on Line 1, Recapitulation.) $ 123,600.00 If more space is needed,use additionai sheets of paper of the same size. ,..�.emnrn...T..rm._.n._.. s . OMB Approva� No. 2502-0265 .�'_ .' .. `�� HUD-1 4� 200.Amounts Paid by or in Behaif of Borrower 500.Reductions In Amount Due to Seller 201. De osit or earnest mone $1,000.00 501. Excess De osits Z0,548.07 Principal Loan Amount from Coldwell Banker Home $98 gg0.00 502. Settlement Cha� es to Seller � Z�Z" Loans 503. Existin loan s taken sub'ect to 203. Existin loan s taken sub'ect to 504. 204. Seller Paid Closin Costs $6,300.00 505. Z05. 5Q6. Seller Paid Closin Costs $6 300.00 206. 507. 207. 508. 208. 509. 209. Ad'ustments for items un aid b seller Ad"ustments for items un aid b seller 510. Ci /Town Taxes 210. Cit /Town Taxes 511. Count Taxes 211. Count Taxes 512. Assessments 212. Assessments 513. 213. 514. 214. 515. 215. 516. 216. 517. Z 1� 518. 218. 519. 219. 520.Total Reduction Asnount Due Seller $26.848.07 220.Total Paid b /for Borrower $106,180.00 300.Cash at Settiement from/to Borrower 600.Cash at SettlemenY to/from Seiler 301. Gross amount due from borrower line 120 $130,877.86 601. Gross amount due to seller line 420 $124,384.93 302. Less amounts aid b /for borrower line 220 106 180.00 602. Less reductions in amount due seller line 520 26 848.07 303. Cash X From To Borrower $24,697.86 603.Cash X To From Seiler �97,536.86 The Public Reporting Burden for this collection of information is estimated at 35 minutes per response for collecting,reviewing,and reporting the data.This agency may not collect this information,and you are not required to compiete this form,unless it displays a currently valid OMB control number.No confidentiality is assured;this dis osur� is mandatory.This is designed to provide the parties to a RESPA covered transaction with information during the settlement process. ��,,,' 1 " Initials '�•�r� • � � 401403556-SK HUD-1 Page 2 of 3 L. Settiement Char es � 700.Total Real Estate Broker Fees$8011.00 Paid From Paid From Division of Commission line 700 as follows: Borrower's Funds Seller's Funds 701. $4003.00 to Re/Max lst Advanta e 3 708 + $295 At Settlement At Settlement 702. $4008.00 to Coldwell Banker Residential Brokera e 3,708 + $300 $300.00 $7,711.00 703. Commission aid at settiement 704. 80�.Items Payable in Connection with Loan 801. Our ori ination char e 703.00 from GFE#1 802. Your credit or char e oints for the 5 ecific interest rate chosen $1 024.80 f om GFE AZ 1,727.80 803. Your ad�usted ori ination char es from GFE #3 $515.00 804. A raisal Fee to STARS 805. Credit re ort to CBC Innovis Inc. from GFE #3 $�•2z 806. Tax Service from GFE #3 807. Fiood Cert. Fee from GFE #3 808. 900.Items Required by Lender to Be Paid in Advance 901. Daily interest charges from 12/18/14 to Ol/01/15 @ 10.99/day Coldwell (from GFE #10) $153.86 Banker Home Loans 902. Mort a e Insurance Premium from GFE#3 Homeowner's Insurance 1 year to State Farm Fire And Casualty Company (from GFE #11) Q03. pr,`,R, c389.04 904. 1000.Reserves Deposited with Lender 1001.Initial de osit for our escrow account from GFE#9 $626.55 1002,Hazard Ins. Reserve 3 Month(s) @ 32.42 per Month(s)Coldweli Banker $97 Z6 Home Loans 1003.City Property Taxes 11 Month(s) @ 7.25 per Month(s)Coldwell Banker $79 75 Home Loans 1004.County Property Taxes 3 Month(s) @ 24.18 per Month(s) Coldwell Banker $7z.54 Home Loans 1005,School Taxes 7 Month(s) @ 122.68 per Month(s) Coldwell Banker Home �g58.76 Loans 1006.Aggregate Accounting Adjustment to Coldwell Banker Home Loans - $481.76 1007. 1100.Title Charges 1101.Title services and �ender's titie insurance to Guardian Transfer from GFE#4 1 484.50 1102.Settlement or closin fee to Guardian Transfer 225.00 1103.Owner's title insurance to Guardian Transfer from GFE#5 $227.50 1104.Lender's title insurance to Guardian Transfer $1 094.50 1105.Lender's title oli limit 98 880.00 �1p6,p;vner's title olic limit $123 600.00 '.=.ce^�s portion of the total title insurance remium to Guardian Transfer $1 189.80 - e�vr�cer's portion of the total title insurance remium to TRGC $132.20 - -_ --�,:-��>��;;�vro;,ection Letter to TRGC 125.00 1200.Government Recording and Transfer Charges from GFE #7 $195.00 i�n+_,Government recordin char es 1202.Deed (5pgs+ Statement of Value) $82.00 Mortgage(21 pages) 113.00 Releases • from GFE #8 1 236.00 1203.Transfer taxes 1204.Cit /Coun tax/stam s Deed 1236.00 Mort a e$ $1 236.00 1205.State tax/stam s Deed $1236.00 Mort a e$ 1206. 1300.Additional Settlement Charges from GFE#6 $19.50 1301.Re uired services that ou can sho for 19.50 1302.Flood Certification to STARS 8 343.00 1303.Ecscrow for Inheritance Taxes to Secured Land Transfers-Mechanicsbur 13D4.Home Ins ection to The Virtus Grou POC 300.00 13D5.Radon Testin to The Virtus Grou POC$100.00 1306.Pest Ins ection to The Virtus Grou POC$50.00 $2,275.00 1307.Electrical u rade and ins ection to Kevin's Electrical Service, LLC 900.00 1308.Radon S stem Instailation to American Radon Solutions Inc. $83.07 1309.Final Sewer/Water Bili- 10/17-12/18 to North Middleton Authori 1400.Tota1 Settlement Charges(enter on lines 103,Section]and 502,Section K) � 6,492.93 $20,548.07 If you have any questions about the setUement charges and loan terms listed on this form,please contact your lender.Settlement agent is not responsible for content of lender's assessments on HUD. The seller's and borrower's signatures hereon acknowledge their approval and signify their understanding that tax and insuranCe prorations and reserves are base on figures for the preceding year or supplied by others or estimated for the current year,and in the event of any change for the cuRent year,all necessary adjustments will be made between borrower and seller directly.Any deficit delinquent taxes or mo�lgage payoffs wiil be promptly reimbursed to the settlement agent by the seller. I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowtedge and belief,it is true and accurate statement of all receipts and disbursements made on my accqunt or by me in this transactior�.I further certify that I have received a copy of the HUD-1 Settlement Statement. BUYERS �� t � SELLERS L�'�� j Estate of Doloros L.Weigle,a!k/a Delores L.Weigie,a/k/a Dolores L. Ronald L. ick Jr. f Weigle --_ _ /. .s �"---�". (_�! . By:Douglas .Weigle,Co-Executor y� � � /� �.��,� /r By:Patricia A.Adams,Co-Executor T�e HUp-1 Settlement Stat�ment which I have prepared is a true and accurate account of this transaction.I have caused or wiil cause the funds to be disbursed in a cordance with this statenbent. , , �� Date S�ettlertie gent ` �'�� '� �^'�-'f1.,�,t�- � � �� 12/18/2014 •Any items marked"POC"were paid outside ciosing by:Bonower POC(8),Lende�POC(L},Mortgage Broker POC(M).Seller POC(S),Real Estate Agent POC{R),or Other POC(0). HUD-1 Addendum File Number: 401403556-SK Settlement Agent/Piace of Settlement: 140 AIRPORT DRIVE, Guardian T�ansfer Property Address: Cp,RLISLE, PA 17013 485 ST.JOHNS CHURCH ROAD , SHIREMANSTOWN , PA 17011 COUNTY: CUMBERLAND Phone : (717)901-8342 PARCELID: 29-17-1585-120 TOWNSHIP: NORTH MIDDLETON TOWNSHIP Seller(s): DOUGLAS A. WEIGLE, CO-EXECUTOR AND PATRICIA A. ADAMS, CO- EXECUTOR OF ESTATE OF DOLOROS L. WEIGLE,A/K/A DELORES L. WEIGLE, A/K/A DOLORES L. WEIGLE Buyer(s): RONALD L. DICK JR. Settlement Date: 12/18/2014 4:30:00 PM Disbursement Date: 12/18/2014 Loan Number: Mortgage Broker: 7132692810 �ender: Coldwell Banker Home Loans Buyer Charges Seller Charges New Loan Fees: Loan Origination Fee %to Coldwell Banker Home Loans $703.00 Loan Discount Fee%to Coidwell Banker Home Loans $1,024.80 Line 803 Total: �1,727.80 $0.00 Appraisal Fee to STARS $515.00 Credit report to CBC Innovis, Inc. ��'z2 Additional Settlement Charges: Flood Certification to STARS $19.50 Line 1301 Total: $19.50 $0.00 Title and Escrow Charges: Settlement/Closing Fee Buyer to Guardian Transfer $225.00 Notary fee to Guardian Transfer $40.00 Lender's Coverage to Guardian Transfer $894.50 Enhanced Policy Endorsements to Guardian Transfer $200.00 Insured Closing Protection Letter to TRGC $125.00 Line 1101 Total: ;1,484.50 $0.00 Owner's Coverage to Guardian Transfer $227.50 Line 1103 Total: ;227.50 $0.00 CERTIFICATION FOR NO INFORMATION REPORTING ON THE SALE OR EXCHANGE OF A PRINCIPAL RESIDENCE File Number:401403556 Property Address: 140 AIRPORT DRIVE CARLISLE, PA 17013 Closer: Shirley Keys Date of Settlement: December 18,2014 Sellers Gross Proceeds$123,600.00 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 1099-5, Proceeds From Real Estate Transactions. If the seller properly completes Parts I and I11,and makes a true response to assurances(1)through(6)in Part II (or a not applicable response to assurance(6)), 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 real estate reporting person must either obtain a certification 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 I. SELLER INFORMATION 1. Name of Seller: ESTATE OF DOLOROS L.WEIGLE,AIK/A DELORES L.WEIGLE,A/K/A DOLORES L.WEIGIE �----- 2. Forwarding Address of Seller: Phone: _��—�z�'16 "� �' ��J �%,�1�„ `7//� �'9 �� '� / 3. Social Security Number: � (Taxpayer I.D. Number) You are required by law to provide Guardian Transfer with your correct taxpayer identification number. If you do not provide Guardian Transfer with your correct taxpayer identification number, you may be subject to civil or criminal penalties imposed by law. Part II. SELLER ASSURANCES Check true or false for assurances(1)through (5),and true,false,or N/A(not applicable)for assurance(6). True False �i} ❑ (1) I owned and used the residence as my principal residence for periods aggregating two(2)years or more during the 5-year period ending on the date of the sale or exchange of the residence. � ❑ (2) I 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) I (or my spouse or former spouse, if I was married at any time during the period beginning after 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 least one of the fo�lowing 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$50Q,000 or less,and the gain on the sale or exchange of the entire residence is$250,000 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 her 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,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 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. True False N/A p ❑ � (6) If my basis in the residence is determined by reference to the basis in the hands of a 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(five)years prior to the date I sold or exchanged the residence. Part III. SELLER CERTIFICATION Under penalties of perjury, I certify that all the above information is true as of the end of the day of the sale or exchange. `�J �� L�� December 18.2014 Estate of oloros L.Wei le, a Delo�es L.Wei le,a/k/a Dolores L.Wei le Date If the seller makes a False res onse to any of the assurances in Part II of this form,we will be required to report the real estate proceeds to the IRS. A copy of the 1099-S will be provided to you at the time of,or immediately following,the closing. Information needed for reporting to IRS: Gross Proceeds(Sales Price)Allocation Proceeds Allocation %. According to IRS guidelines, if the sellers were husband and wife at the time of closing,who held property as joint tenants,tenants by the entirety,tenants in common,or as community property,they are considered a single seller and only one Form 1099-S will be reported to the IRS. However,if both parties allocate a percentage then a Form 1099-S will be reported for each. If the allocation field is left incomplete,the proceeds will be reported to IRS for this seller at 100%. REV-i5a3 EX+(8-i�) � pennsylvania SCNEDULE B DEPARTMENTOFREVENUE STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Weigle, Delores L. i 21 13 0113 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION ____ OF DEATH 1' Met Life,Policy Number 0057952512-Date of Death Value 1,109.00 TOTAL(Also enter on Line 2, Recapitulation) $ 1,109.00 If more space is needed,insert additionai sheets of the same size Decedent's Assets Itemization Form Item � Information Present Value of Property Property/Real Estate Address: ryd /�-�/�j�_�}� Owned by the Decedent �� Owners as listed on Deed: ,� �t� d �-�eh� �f ��t� $ y G�i, G� Check one: "Tenants in Common" / � / / "Joint Tenants with Right oi'Survivorship" �"Tenants by the Entirery" / ti Dare of Deed: 2 f�`"� . • If you answer Yes to any of the following Value at Death Value Now questions,fill in the dollar amount(s) in the far right columns. Bank Accounts i� Bank Account(s) Is this a joint account? Decedent's name �� $ S y�� Checking Yes No / Savings Yes �� No •$ $ . Yy 9�y,� If you answer Yes for either account,please submit a copy of the bank statement at the time of death and a copy of the original signature card. Nursing Home Personal yes No �/� $ $ Care Account Decedent`s Burial Burial Account(s) Prepaid Funeral Accounts yes No Yes No ✓ $ $ Yes No Yes No ✓ $ $ _\ � Stocks/Bonds/Other ��f/� //OQ. o D $ S //U 9 in Decedent's name S Insurance Policy(s) Beneficiary Living Yes�No Yes_�No $ $ �G 2U, G� Beneficiary Name ��/a� �c%;/c,` �,Q�,Gru�-�- j Life Insurance Policies Yes_,�No Yes ✓ No $ s �8 /b•�z Beneficiary Name.S�.rz �t n�e�t,. $ $ Yes No Yes No . Beneficiary Name 1 ACKNOWLEDGE THAT THE INFORMATION I HAVE SUPPLIED ON TH1S FORM IS SUBJECT TO THE PENALTIES SET FORTH IN S PA C.S.4904.{re(ating to unsworn falsification to aut6orities) //-iTif/�i.6 �.�.4.rr1 —.G�� — � ll-� Name (Please print clearly) Signature (Please sign in ink) Date 7l7- �� 3�f � . Phone Number (Please include Area code) � �'� . � � REV-i5o8 EX+(o8-iz) � � pennsylvania SCNEDULE E DEPARTMENTOFREVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RE7URN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FIIE NUMBER: Delores L. Weigle 21 13 0113 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 discfosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION _____ OF DEATH �. MetLife Insurance Company,Policy Number 15125747A 1,368.78 2, MetLife Insurance Company,Policy Number 802530771MS 7,620.63 3. Refund County Taxes(Sale of Real Estate) 14.14 4. Refund School Taxes(Sale of Real Estate) 7��9 TOTAL(Also enter on Line 5, R.ecapitulation) $ 9,774.34 If more space is needed,use additional sheets of paper of the samF�size. �'e�,� �z�a Y�� .�� Metropolitan Life Insurance Company PO Box 330 00316 Warwick RI 02887-0330 Met�ife January 30, 2013 PATRICIA ADAMS 140 AIRPORT DR CARLISLE, PA 17013-1105 NAME OF INSURED DOLORES L WEIGLE POLICY NUMBER(S) METROPOLITAN LIFE INSURANCE COMPANY POLICY 802530771 MS METROPOLITAN LIFE INSURANCE COMPANY POLICY 015125747A Notification of MetLife, Inc. Common Stock o = Please accept our sincere condolences on the death of DOLORES L WEIGLE. o — o = m In April 2000 MetLife converted from a mutual insurance company to a stock company. � = As a result, eligible policyholders were issued shares of stock. As the owner of the above o = policy, DOLORES L WEIGLE was issued shares of MetLife, Inc. Common Stoc k. o — o = o = To obtain information regarding the transfer of these shares, please have the executor or m = legal representative of the insured's estate call Mellon Investor Services, MetLife, Inc.'s � _ stock transfer agent, at 1-800-649-3593 Monday through Friday between 8 a.m. and o = 6:30 p.m., ET. o = ._, � f y�$;: . ' � � O MetL�f e Metropolitan Life Insurance Company Notice of Claim Payment BrlDist. Agency Date of Notice 500 SCHOOLHOUSE ROAD C -000 61 O1 0 201 JOHNSTOWN, PA. t59�5 NAME OF DECEASED DATE OF DEATH DIST PHONE NUMBER (6 i o) 398-0100 PATRICIA ADAMS 140 AIRPORT DR Please See Important Notice on Reverse Side CARLISLE PA 17013 1105 Policy Number This claim has been 15125747 A 802 5307 7 1 Ms � approved for the total of Codes Refer to the amounts a earin A A PP g Messages Below. in the boxes below. Items Payable V Items determining these Po(icy Amouni t o00.oo a000.oo � amot;rts are listed t� One-Year Term Insurance � �I the left. Additional Insurance 309.a t 4a2s.so � `� Dividends With Interest AmountHeldtorDeferredPayment Dividend to Policyholder 19.47 86.83 �� Terminal Dividend 40.oo t 05.00 �� Premium in Advance Interest on Claim Check lssued by(.5utomer Service Center Deductions Premium in Arrears Loan >GhBck;�prB��,�t��fl:.�� Loan Interest > 44g4 71 Y(311R:.St�EA#�£ :: _.._...................__ _ ..._..... TOTAL PER POLICY 1368.78 7620.63 SHARE PER POLICY 684.39 3810.32 t A. Our check for the balance d is attached below. '-�i � -.- ------.._� �L �� q � �� d., p�\. ` b � �'�� . � � �1., ��s��o93>P�;n��us.n. Detachstubbeforecashing � � �\ � / s`�4518SCRE(10/04) . ....,.m ir.�,,.,x rm.,..�.. y OMB Approval No. 2502-0265 ' - HUD-1 L± -` _ � _ = A. Settiement Statement (HUD-1) ,- � �� 4 ti� _ .; Page 1 of 3 =�r; -,- �B. Typ�e of Loan : _ -, 2.�RHS 3.�X Conv. Unins. 6. File Number: 7. Loan Number: 8. Mortgage Insu�ance Case Number: _ -, �.�Conv. Ins. 401403556-SK 7132692810 `;C, fVpTE: {�ts f�rm is fumished to give you a statement of actual settlement costs.Amounts paid to and by the settlement agent are shown. :t2:r:s;nariceii "(p.o.c.)"were paid outside the closing; they are shown here for informatianal purposes and a�e not included in the _=�:s. ;D. Narsie and Address of Borrower E. Name and Address of Seller F. Name and Address of Lender :�•rT; _ �:;�;�;�_ DOUGLAS A. WEIGLE,CO-EXECUTOR AND COLDWELL BANKER HOME LOANS s___ _ `� _��;n__ � PATRICIA A.ADAMS, CO-EXECUTOR OF 1 MORTGAGE WAY, - - -- - -- - ; ESTATE OF DOLOROS L_\YEIGLE,A/K/A MOUNT LAUREL, NJ 08054 �! � D�LORES L.`r'lEIGLE� A/K/A DOLORES L. �v�c� � 140 AIRPORT DRIVE CARLISLE, PA 17013 � G.Property Location H.Settlement Agent GUARDIAN TRANSFER 140 AIRPORT DRIVE, 485 ST.JOHNS CHURCH ROAD, ��E`c{_,�� i?J__ SHIREMANSTOWN , PA 17011 Phone : (717)901-8342 �_�,-- _�w_=�='�- Place of Settlement I.Settlement Date _--.-_--- ---- "-__-'-�G 12/18/2014 -_,. ,_ :' ',�=-= ':��=-�"�-�s'��;=^=� 1068 HARRISBURG PIKE CARLISLE, PA 17013 Disbursement Date 12/18/2014 ;�3, Summa of Borrower`s Transaction K. Summa of Selier's Transaction ;2pp,�f�qrty�t pue ft��n Borrawer 400.Gross Amount Due to Seller __ t�__��,�_�� 23 6�U.D0 401. Contract Sales Price 123 600.00 __ �,� � �,f,_r 402. Personai Pro e - '--t ��r-�� x--:.-r e-_ +^e:L00 $6,492.93 403. " ' - 404. -- 405. ; p 'us�ment for items aid b seiler in advance Ad"ustment for items aid b seller in advance _ `,_Y T_.��,.,-„X� 406. Ci /Town Taxes :;,�i. •v�un� �oxes 368.7400/ r 12118/14 to Ol/01/15 $14.14 407. Coun Taxes 368.7400/ r 12/18/14 to Ol/Dl/15 $14.14 108. :ssessments 408. Assessments 109. SchoolTaxes 1442.7600/ r12/18/1�to 07/01 15 770.79 409. SchoolTaxes 1442.7600/ r12/18/14to 07J01 15 770.79 110. 410. 111. 411. 112. 412. 120.Gross Amount Due from Borrower $130,877.86 420.Gross Amount Due to Seiler $124 384.93 ,�,,.,;_,.,m..,,, , 200.Amounts Paid by or in Behalf of Borrower 500.Reductions In Amount Due to Seller ZOl. De osit or earnest mone 1,000.00 501. Excess De osits 20,548.07 Principal Loan Amount from Coidwell Banker Home $98�gg0.00 502. Settiement Char es to Seller � Z�Z' Loans 503. Existin loan s taken sub'ect to 203. Existin loan s taken sub�ect to 504. 204. Seller Paid Closin Costs $6,300.00 505. 205. 506. Selier Paid Closin Costs $6,300.00 206. 507. 207. 508. 208. 509. 209. Ad'ustments for items un aid b seller Ad'ustments for items un aid b seller 510. Ci /Town Taxes 210. Cit Town Taxes 511. Count Taxes 211. Coun Taxes 512. Assessments 212. Assessments 513. 213. 514. 214. 515. 215. 516. 216. 517. 217. 518. 218. 519. 219. 520.Totai Reduction 6lmount Due Seller 26,848.07 220.Total Paid b /for Borrower $106,180.00 300.Cash at Settlement from/to Borrower 600.Cash at Settlemen�to/from Selier 301. Gross amount due from borrower line 120 130,877.86 6�1. Gross amount due to seller line 420 $124,384.93 302. Less amounts aid b /for borrower line 220 106 180.00 602. Less reductions in amount due seller line 520 26 848.07 3U3.Cash X From To Borrower $24,697.86 603.Cash X To From Seller $97,536.86 The Public Reporting Burden for this collection of information is estimated at 35 minutes per response for coilecting,reviewing,and reporting the data.This agency may not collect this infortnation,and you are not required to complete this form,unless it displays a currently valid OMB controi number.No confidentiality is assured;this disgtosure is mandatory.This is designed to provide the paRies to a RESPA covered transaction with information during the settiement process. ��`�j :.''`j Initiais f'.�,?1.:%�' 401403556-SK HUD-1 Page 2 of 3 L. Settlement Char es � 700.Total Real Estate Broker Fees$8011.00 Paid From Paid From Division of Commission line 700 as follows: Borrower's Funds Seller's Funds 701. $4003.00 to Re/Max ist Advanta e$3 708+ 295 At Settlement At Settlement 702. $4008.00 to Coldwell Banker Residential Brokera e$3,708+$300 $300.00 $7,711.00 703. Commission aid at settlement 704. 800.Items Payabie in Connection with Loan 801. Our ori ination char e 703.00 from GFE#1 802. Your credit or cha e oints for the s ecific interest rate chosen $1 024.80 f om GFE Az $1,727.80 803. Your ad'usted ori ination char es from GFE#3 $515.00 804. A raisal Fee to STARS fram GFE#3 $�•22 805. Credit re ort to CBC Innovis,Inc. from GFE �3 806. Tax Service from GFE#3 807. Flood Cert. Fee 808. 900.Items Required by Lender to Be Paid in Advance 901. Qa��Y�nterest charges from 12/18/14 to Ol/Ol/15 @ 10.99/day Coldwell (from GFE#10) $153.86 Banker Home Loans from GFE#3 902. Mort a e Insurence Premium ' Q�� Homeowner's Insurance 1 year to State Farm Fire And Casualty Company {from GFE#11) flr,�rc� c38°.04 :O� 1000.Reserves Deposited with Lender from GFE#9 $626.55 1001.Initial de osit for our escrow account 1002,Hazard Ins. Reserve 3 Month(s) @ 32.42 per Month(s)Coldweil Banker $97 Z6 Home Loans 1003.C�ty Property Taxes 11 Month(s) @�.25 per Month(s) Coldwell Banker $79 75 Home Loans 1004.County Property Taxes 3 Month(s)@ 24.18 per Month(s) Cotdwell Banker $72.54 Home Loans 1005.School Taxes 7 Month(s) @ 122.68 per Month(s) Coldwell Banker Home �858.76 Loans � 1006.A99regate Accounting Adjustment to Coldwell Banker Home Loans - $481.76 1007. 1100.Title Charges from GFE�4 1 484.50 1101.Titie services and lender's title insurance to Guardian Transfer 225.00 1102.Settiement or closin fee to Guardian Transfer Prom GFE#5 $227•50 11�3.Owner's titie insurance to Guardian Transfer $1,094.50 1104.Lender's titie insurance to Guardia�'fransfer 1105.Lender's title poli limit 98 880.00 '��5.Otivner's title olic limit $123,600.00 - ��ent`5 Oortion or the total title insurance remium to Guardian Trensfer $1 189.8� -__ _ -��-.�:ri_er's�os�ion of the total title insurance remium to TRGC �z25.0o - - - -- � �ro=ert"son Letter to TRGC 1200.Government Recording and Transfer Charges frvm GFE #7 $195.00 � t�n�.Government reCof�in char ES 1202.Deed (5pgs+ Statement of Value)$82.00 Mortgage(21 pages) $113.00 Releases • from GFE #8 $1 236.00 1203.Transfer taxes 1204.Ci /Coun tax/stam s Deed $1236.00 Mort a e$ $1,236,00 1205.State tax/stam s Deed $1236.00 Mort a e$ 1206. 1300.Additionai Settiement Charges from GFE#6 $19.50 1301.Re uired services that ou can sho for $19.50 1302.Flood Certification to STARS 8 343.00 1303.Ecscrow for Inheritance Taxes to Secured Land Transfers-Mechanicsbur 1304.Home Ins ection to The Virtus Grou POC 300.00 1305.Radon Testin to The Virtus Grou POC$100.00 1306.Pest Ins ection to The Virtus Grou POC$50.00 $2,275.00 1307.Electrical u rade and ins ection to Kevin's Electricai Service,LLC 900.00 1308.Radon S stem Installation to American Radon Solutions Inc. $83.07 1309.Final Sewer/Water Bill- 10/17-12/18 to North Middieton Authori �6,492.93 $20,548.07 1400.Tota1 Settiement Charges(enter on lines 103,Settion]and 502,Section K) If you have any questions about the setUement charges and loan terms listed on this fortn,piease contact your lender.Settlement agent is not responsibie for co�te�t of iender�s assessments on HUD. The seller's and boRower's signatures hereon acknowledge their approval antl signiry their understandtng that tax and insurance prorations and reserves are base on figures for the preceding year or supplied by others or estimated for the current year,and in the event of any change for the Current year,all necessary adjustments will be made beiween borrower and seller directly.Any deficit delinquent taxes or mortgage payoffs will be promptly reimbursed to the settlement agent by the seller. I have carefuiiy reviewed the HUD-1 Settiement Statement and to the best of my knowiedge and belief,it is true and accurate statement of ali receipts and disbursements made on my accRunt or by me i,n/tqis transactio, .I fu�ther certify that I have received a copy of the HUD-1 Settiement Statement. BUYERS � ,� I �%/ ; i� SELLERS f,��:i�L�:� ,J `�`-� �� ;�... Estate of Doloros L.Weigle,alk/a Delores L.Weigle,a/k!a Dolores L. Ronald L.Dick Jr. � / Weigle --- C � � -._.____._'"_-�_. By:Douglas .Weigie,Co-Executor y��, - ./��v �_ By:Patricia A.Adams,CaExecutor r Th'e HUD-1 Settiement Stat�ment which I have,prepared is a true and accurate account of this Vansaction.I have caused or wili cause the funds to be disbursed�n aecordance with this staterrfent.�, Settlerlient�lgeM �`�" � � -�- Date T. �'�-�L,�.,.'� �� `.m � '-g' 12/18/2014 _ } 'Any items marked"POC"were paid outside closing by:Borzower POC(B),Lender POC(L).Mortgage Broker POC(M),Seller POC(S),Real Estate Agent POC(R),or Other POC(0). HUD-1 Addendum File Number: 401403556-SK Settlement Agent/Piace of Settlement: 140 AIRPORT DRIVE, Guardian Tranafer Property Address: CqRLISLE, PA 17013 485 ST.)OHNS CHURCH ROAD, SHIREMANSTOWN , PA 17011 COUNTY: CUMBERLAND Phone : (717)901-8342 PARCELID: 29-17-1585-120 TOWNSHIP: NORTH MIDDLETON TOWNSHIP Seller(s): DOUGLAS A. WEIGLE,CO-EXECUTOR AND PATRICIA A. ADAMS, CO- EXECUTOR OF ESTATE OF DOLOROS L.WEIGIE,A/K/A DELORES L. WEIGLE,A/K/A DOLORES L. WEIGLE Buyer(s): RONALD L. DICK JR. Settlement Date: 12/18/2014 4:30:00 PM Disbursement Date: 12/18/2014 Loan Number: Mortgage B�oker: 7132692810 Lender:Coldweil Banker Home Loans Buyer Charges Selier Charges New Loan Fees: Loan Origination Fee%to Coidweli Banker Home Loans $703.00 Loan Discount Fee°/a to Coldwell Banker Home Loans $1,024.80 Line 803 ToWI: $1,727.80 $0.00 Appraisal Fee to STARS $515.00 Credit report to CBC Innovis, Inc. ��.Z2 Additional Settlement Charges: Flood Certification to STARS $19.50 Line 1301 Total: $19.50 $0.00 Title and Escrow Charges: Settlement/Closing Fee Buyer to Guardian Transfer $225.00 Notary fee to Guardian Transfer $40.00 Lender's Coverage to Guardian Transfer $894.50 Enhanced Policy Endorsements to Guardian Transfer $200.00 Insured Closing ProteCtion Letter to TRGC $125.00 Line 1101 Total: $1,484.50 $0.00 $227.50 Owner's Coverage to Guardian Transfer Line liQ3 Total: $227•5D $0.00 CERTIFICATION FOR NO INFORMATION REPORTtNG ON THE SALE OR EXCHANGE OF A PRINCIPAL RESIDENCE File Number:401403556 Property Address: 140 AIRPORT DRIVE CARLISLE, PA 17013 Closer: Shiriey Keys Date of Settlement: December 18,2014 Seiler's Gross Proceeds$123,600.00 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 Interna�Revenue Service on Form 1099-S, Proceeds From Real Estate Transactions. If the seller properly completes Parts I and III,and makes a true response to assurances(1)through(6)in Part II (or a not applicable response to assurance(6)), 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 real estate reporting person must either obtain a certification 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 I. SELLER INFORMATION 1. Name of Seller: ESTATE OF DOLOROS L.WEIGLE,AIK/A DELORES L.WEIGLE,A/K/A DOLORES L.WEIGLE r--- 2. Forwarding Address of Seller: Phone: �'�i�� - �—�^s ' /�� " "�/� �� J 3. Social Security Number. (Taxpayer I.D. Number) You are required by law to provide Guardian Transfer with your correct taxpayer identification number. If you do not provide Guardian Transfer with your correct taxpayer identification number,you may be subject to civil or criminal penalties imposed by law. Part II. SELLER ASSURANCES Check true or false for assurances(1)through(5),and true,false,or NfA(not applicable)for assurance(6). True Faise �} ❑ (1) I owned and used the residence as my principal residence for periods aggregating two(2)years or more during the 5-year period ending on the date of the sale or exchange of the residence. � ❑ (2) I 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) I (or my spouse or former spouse, if I was married at any time during the period beginning after 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 least one of the foflowing three statements applies: The sale or exchange is of the entire residence for$250O,OR00 or less, 1 am married,the sale or exchange is of the entire residence for$500,000 or less,and the gain on the sale or exchange of the entire residence is$250,0�0 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 her 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,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 residence. � � res dence in an exch nge o which ect on1031 of the n'te nal Revenue Cohderappl ed e, I did not acquire the True False NlA p ❑ � (6) If my basis in the residence is determined by reference to the basis in the hands of a person who acquire the residence in an exchange to which section 1031 of the Internal Re�e�ue Code applied,the exchange to which section 1031 applied occurred more than 5(five)years prior to the date I sold or exchanged the residence. Part III. SELLER CERTIFICATION Under penalties of perjury, I certify that all the above information is true as of the end of the day of the sale or exchange. V� } �.� ' �� December 18.2014 U Date Estate of oloros L.Wei le,a/ a Delo�es L.Wei le,a/k/a Dolores L.Wei le If the selfer makes a False res onse to any of the assurances in Part II of this form,we will be required to repo�t the real estate proceeds to the IRS. A copy of the 1099-S will be provided to you at the time of,or immediately following,the closing. Information needed for reporting to IRS: Gross Proceeds{Sales Price)Allocation Proceeds Allocation °/a. According to IRS guidelines,if the sellers were husband and wife at the time of closing,who held property as joint tenants,tenants by the entirety,tenants in common,or as community property,they are considered a single seller and only one Fohe al�location'field,s left incohmpRete,t e proceeds wll be reported t IRS foratliis selle a 00°/99 S W��be reported for each. If t REV-15o9 EX+(o1-io) � pennsylvania SCHEDULE F DEPARTMENTOFREVENUE )OINTLY-OWNED PROPERTY INHERIfANCE TAX REfURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Weigle, Delores L. 21 13 0113 If an asset became jointly owned within one year of the decedenYs date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A•Patricia A.Adams 140 Airport Drive, Carlisle, PA 17013 Daughter B. C. ]OINTLY OWNED PROPERTY: LEfTER DATE DESCRIPIION OF PROPERTY %OF DATE OF DEATH ITEM FOR]OINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR CSATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR]OINTLY HELD REAL ESTATE. VP�LUE OF ASSET INTEREST DECEDENT'SINTEREST 1' A' 08/17/00 Wells Fargo Savings Account 1,914.44 50% 95722 Account Number: 3000017819294 2. A. M&T Classic Checking with Interest Account 42.54 50% 21.27 Account Number: 9852877464 TOTAL(Also enter on Lir7e 6, R�vcapitulation) $ 978�49 If more space is needed, use additional sheets of paper of the sarr�e size. Welcome to M&T Online Banking ��, Page 1 of 1 /f�� MARCH 21,2013 � � � �'` ,��^, IIIII �� .�-� ,� �-�..��.,�. � � � :�� '�i �,;�i ;I �i!,, „�.�� - �-�-�"�"�~� � Accounts Transfers Bill Pay Alerts Customer Service ACCOUNT SUMMARY>CHECKING DETAIL M&T Classic Checking w/Interest �� T�� r��r�. Related Links: Transfers &Loan Pavments � View/Edit Transactions Statements & Documents � Export Data � Order New Checks � ATM &Debit Card Overdraft Choice � FinanceWorksT"' � Aqplv for a Loan � Order Custom Card account Classic Checkin 7464� Total Balan e $a2.sa,_ 9 __ .. Available Balan e $42.54 ,,,.-�-- � _:____. Vew Calendar � View Calendar �\,s . ��.:��. . �,' Select Ran e �� . 01/10/2013 03/19/2013 ` Show 9 _ __ or- View From To i+Date Transaction Descriation Credits/Debits Total Balance 03/06/2013 SERVICE CHARGE -$4.95 $42.54 02/22/2013 CHECK NUMBER 0344 �'� �j'�- S��r-$195.00 $47.49 02/20/2013 CHECK NUMBER 0343 �=+�u. -$179.95 $242.49 01/31/2013 CHECK NUMBER 0342 /�� -{"- Cj�srt' - -$103.50 f-.'cyr f�'"�/�$422.44 01/30/2013 DEPOSIT Z)v,:cf'� �:h��rr �f+'—$100.00 $525.94 01/16/2013 WAL-MART#2574 CARLISLE /�yy�,� �liri,.r -$39.16 $425.94 01/14/2013 PIN PURCH FEE 01/14 M $0.50 $465.10 01/14/2013 CHECK NUMBER 0341 —��+-� ��`Nf�'�" �r� ,�ij,$20.00 $465.60 01/14/2013 CHECK NUMBER 0308 �"e�re+�w •-$83.07 $485.60 01/14/2013 MCDONALD'S F4619 CARLISLE � -$7.08 $568.67 �3 01/14/2013 GIANT 6112 01/14 M � • ; ��"' �'�i -$131.67 �$5�5�5-� j�w '"�1/10/2013 CHECK NUMBER 0309 �'�� "-$296.00 ;. ,$7II� > ,{ �� -� /1 ,: ,�,_. ...___ � . Depending on when your statement generates,you may not see a ful�90 days of history.If your statement has just been �� generated,you may get a message indicating that no transactions are available from 61 -90 days. i �� `,. O 2013 Manufacturers and Traders Trust Company.Users of this web site agree to be bound by the provisions of the M&T b Banking- Conditions.vew the Terms and Conditions,Privacv Policy or Securitv Information. https://onlinebanking.mandtbank.com/history/HistoryChecking.aspx?Id=1 3/21/2013 ..:..:.:1]l.i�..,,^.�.�..�n.. p 11!f .] IIYIIII 1 REV-1511 EX+ (08-13) � pennsylvania SCHEDULE H � DEPARTMENTOFREVENUE FUNERAL EXPENSES AND INHERITANCE TAX REfURN ADMINISTRATIVE COSTS RES[DENT DECEDENT ESTATE OF FILE NUMBER Weigle, Dolores L. 21 13 0113 Decedent's debts must be reported on Schedule I. ITEM — NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Ewing Brothers Funeral Home, Inc.,620 South Hanover Street,Carlis�e,PA 17013 3,091.84 2� Westminster Memorial Gardens, 1159 Newville Road,Carlisle,PA 17013 1,311.00 3. Baughman Memorial Works, Inc.,41 South Bedford Street,Carlisle, PA 17013 195.00 B. ADMINISTRATIVE COSTS: l. Personal Representative Commissions: 0.00 Name(s)of Personal Representative(s) DOuglBs A. Weigle and Patt'iCia A. Ad2mS Street Address 2320 Walnut Bottom Road and 140 Airport Drive city Carlisle state PA ZIP 17013 Year(s)Commission Paid: z• Attorney Fees: 7,185.23 3• Family Exemption: (If decedent's address is not the same as claimant's,attach explanatian.) 3,500.00 Claimant Patricia A. Adams street address 140 Airport Drive City Carlisie state PA Zip 17013 Relationship of Claimant to Decedent Dauqhter 4• Probate Fees: 103.50 5• Accountant Fees: 0.00 6• Tax Return Preparer Fees: 0.00 �• Advertising,The Sentinel(300.00)and Cumberland Law Journal(75.00) 375.00 s. M&T Bank, PIN Purchase Fee and Check Charge 13.25 9. Register of Wills, Receipt Number 1073125, Short Certificate 5.00 �o. Inheritance Tax Paid on Joint Savings Account 27.�4 ��. Additional Probate 240.00 Continued on Page 2(total of all Schedule H expense shown below) TOTAL(Also enter on L.irre 9, Recapitulation) $ 16,566.96 If more space is needed,use additional sheets of paper of the same size. Page 2 - Schedule H, Continued ESTATE OF DELORES L. WEIGLE FILE N0. 21-13-0113 Item Description Amount Number 12. Filing Fees (Family Settlement Agreement) __ 20.00 13. Reserve 500.00 Subtotal from Page 1 16,046.96 TOTAL (Entered on Page 1 of Schedule H) 16,566.96 ,m-u�.�,. ,:� n rrin. , � - Ewing Broth�rs Funeral Home, Inc. 630 South Hanover Street Carlisle, PA ]7013- � (7]7)243-2421 January 19, 2013 Patricia A. Adams 140 Airport Dr. Carlisle, PA 17013 Tl�e Funeral Service for polores L. Weigle We sincerely appreciate the confidence you have placed in us and will continue to,assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING [S AN ITEMIZED STATEMENT OF THE SERVICES,FACIL[TIES,AU�"OMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEML-'NTS. I. PROFESSIONAL SERVICES E3asic Services of Funeral Direcror/Staff . . . . . . . . . . . . . . . . . $1300.00 2. FAC[LITIES/SERVICES/STAFF/EQUIPMENT E3asic Use of Facility . . . . . . . . . . . . . . . . . . . . . . . • $200.00 Document Prep/Permanent Recording, , , , , , , , , , , , , , , , , , $325.00 EquipmenUExtra Staff&Time Off Premise Event , , , , , , , , , , , , , , $125.00 � 3. AUTOMOTIVE EQUIPMENT ' Vehicle to transfer remains to Funeral Home, , , , , , , , , , , , , , , , $295.00 Utiliq Car . . . . . . . . . . . . . . . . . . . . . . . . . . $135.00 C. SPECIAL CHARGES Direct Cremation . . . . . . . . . . . . . . . . . . . . . . . . $345.00 FUNERAL HOME SERVICE CHARGES . . . . . • • • • • • • $2725.00 THE COST OF OUR SERVICES, EQUIPMENT,AND MERCHANDISE THAT YOU HAVE SELECTED . . . . . . . . . . . . . . . $2725.00 Cash,4dvances Sentinel Obituary. . . . . . . . . . . . . . . . . . . . . . . . $241.84 ' Certitied Copies of'Death Certificate . . . . . . . . . . . . . . . . . . $30.00 l.ight Purple Marble Um, , , , , , , , , , , , , , , , , , , , , , $195.00 TOTAL CASH ADVANCES AND SPECIAL CHARGES . . . . . . . . $466.84 Total l�otal Cost . . . . . . . . . . . . . . . . . . . . . . . . . . $3191.84 SUB-TOTAL $3191.84 INITIAL PAYMENT/DISCOUNT/CREDITS 100.00 � ��hh' C��`a?� V� TOTAL AMOUNT DUE $3091.84 ��,J� o r V e' ��J � ��ece,ti�( 0 fhe unpaid balance over 30 days is subjected to a i.50%service charge per month- 18.0000%per annum. � _ - Ewing Brothers Fun�ral Home, Inc. 630 South Hanover Street rJ Carlisle, PA 17013- /'�rZ�/ (717)243-2421 � y � ''` ��`:� February 21,2013 Patricia A. Adams 140 Airport Dr. Carlisle, PA 17013 The Funeral Service for polores L. Weigle We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Ple�se feel free to contact us if you have any questions in regard to this statement. � THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES,FACILITIES,AU"I'OMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES Basic Services ofFuneral Director/Staff , , , , , , , , , , , , , , , , , $1300.00 2. FACILITIES/SERVICES/STAFF/EQUIPMENT Basic Use of Facility, , , , , , , , , , , , , , , , , , , , , , , $200.00 Document Prep/Peimanent Recording, , , , , , , , , , , , , , , , , , $325.00 Equipment/Extra Staff&Time Off Premise Event . . . . . . . . . . . . . . $125.00 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Home, , , , , , , , , , , , , , , , $295.00 Utility Car . . . . . . . . . . . . . . . . . . . . . . . . . . �135.00 C. SPECIAL CHARGES Direct Cremation . . . . . . . . . . . . . . . . . . . . . . . . $345.00 ,, FUNERAL HOME SERVICE CHARGES . . . . . • • • • • • • $2725.00 ` THE COST OF OUR SERVICES,EQUIPMENT,AND MERCHANDISE THAT YOU HAVE SELECTED . . . . . . . . . . . . . . . $2725.00 Cash Advances Sentinel Obituary. . . . . . . . . . . . . . . . . . . . . . . . $241.84 Certified Copies of Death Certificate . . . . . . . . . . . . . . . . . . $30.00 Light Purple Marble Urn, , , , , , , , , , , , , , , , , , , , , , $195.00 TOTAL CASH ADVANCES AND SPECIAL CHARGES . . . . . . . . $466.84 Total Total Cost . . . . . . . . . . . . . . . . . . . . . . . . . . $3191.84 SUB-TOTAL $3191.84 INITIAL PAYMENT/DISCOiJNT/CREDITS 3191.84 TOTAL AMOUNT DUE $0.00 The unpaid balance over 30 days is subjected to a 1.50%service charge per month-18.0000%per annum. ��Ci� � � � v .��`� � � F . : J C 'I .� . - 9F � � �li i I , � � � � c il I � �li 'il � i: tl � � � � � � � � ,.�� .� � .. � � �. i � ,-�,�1'.� � �. � .. � o ' �, i . -- ; ' � i� �- � ,� U � L 3 ` U i I i � I . 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NOTICE TO PURCHASER—IF THIS INSTRUMENT IS LOST, VOID IF OVER US S 1,311.00 604 E HIGH ST STOLEN OR DESTROYED,YOU MAY REQUEST CANCELLATION CARLISLE,PA 17013 AND R€ISSUANCE.AS A CONDITION TO CANCELLATION AND NON-NEGOTIABLE FOR INQUIRIES CALL(480)3943122 REISSUANCE,WELLS FARGO 8 COMPANY MAY IMP0.SE A . FEE AND REQUIRE AN INDEMNITY AGREEMENT AND BOND. Purchaser Copy F8004 nnazo3 12382263 � � � � . � � � _. . - . . . . � 4 CASHIER'S CHECK seRiaa.#: ss�ssoazis 0068,63 „-24 . � . � ��u� 1210(81 ACCOUNT#: 4861-007955 p�« PA7ftICIA A ADAlAS p,,,�,,,�,�„M: s0000,�e,�. January 15, 2013 c�«a�a i.o.: a+oonsa PAYTOTHEORDEROF ***WESTMINSTER MEMORIAL GARDENS*** ***One thousand three hundred eleven dollars and no cents*** : **$1,311.00** VOID IF OVER US S �,311.00 WELL$FARGO BANK,NA. NOTICE TO PURCHASER-IF THIS INSTRUMENT IS LOST, , 804 E HIGH ST STOIEN OR DESTROYED,YOU MAY REQUEST CANCELLATION ' C/�RLISLE,PA 17013 AND REISSUANCE.AS A CANDITION TO CANCELLATION AND NON-NEGOTIABLE FpR IN�UIRIES CALL(480)3943�2z REISSUANCE,WELLS FARGO 8 COMPANY MAY IMPOSE A . FEE AND RE�UIRE AN INDEMNITY AGREEMENT AND BOND. Purchaser Copy 0 , � i t - ` �/'�3 ✓,�1� " ?�Ja�� '�c� :� ; ,� �� 41 South Bedford Street Carlisle,Pa. 17013 Phone: 717-243-5480 Fax: 7t7-243-5687 ' �. E-Mail:carlisle@baughmanmemorials.com This form mav be sent bv e-mail,fazed or mailed Work Order# Death Date Inscription Order ,_ . r w .� �51� : . . . Name of Deceased: ��/ �r�S Date of Birth(£ult date please): /'�/9- j � C 9`�-7 Date of Death{fiilt aate please): � �' ` j� ��(„� . . Y c,�� ` / , L�st other names ou memorial. �'"�'�-t L`� 1 9` � Tvpe of Burial: ❑ Traditional Burial . �Cremation Stvte of Memorial: ❑ U ri t ❑ Slant&Base ❑ Slant❑ Bevel ❑ Flush�Bronze , Co1or of Memoriai: ❑ � ❑ Rose ❑ Black . �Brown Q Red n Other: . Inscriotion: �Year On ❑ Abbreviated Full Date ❑ Full Date Spelled Out Funeral Services Provided bv: Cemeterv Information � Name of Cemetery: GcJ F�f�1'YJ�h iS�� City Ct/4��f,f�� State: /'0� Sectioa: Lot: Grave No.: MAP Description of Location in Cemetery: Bill To: Customer Information . :':Name: ,�✓��l�'1�J� /7-f�l'Q��' Address: 1 �-� D /¢/�O�r t`J/� Ci�• C.�1�(,(�f l+ �f/�}- l 7 �� State: Zip Code: - !n Billing Phone'�iumber: `'7 � 7 —�(�S — o� `-��y Billing Fax: Order taken by: Date: o`Z,191�3Amount Dae: $ 1 q S�• � �,, Paymeat: $ � Q Cash �Check No.: ��{� ❑ Credit Card Master Cazd/Visa/Discover:#: --.._ Exp.Date: Code: Signature• � Date• � � 9 Note Comaletion of work is aouroumatetv 60 to 90 davs weat6er uermittin�. � i I I , - ---- -- ��Qr1Z_t'_��---- ------_ ______--------- --- ------ - _ ____ � --�� ----��-3-- i�-��-�-�-- ��Z�_�_C�co — ----___ .___------------ ---- -____ . __ _—, � � , � . __ _ --- --------- --- - ___ -------, - ------- ------- __--_------- - , � � � ---- ----_ ____ __ - -------------------- - ------s_ ---- --- � � � � � —----_---- ------_--___--_ _ , i ----- , _ --__. � � � . . .� - _. _ _ . _ �_.. � . , ..344 . 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I �� i sL�� !`� - - � ' Hr�noL/T�1Lz 0008/0126 - � + O3/S1/2033 10:3l:{9 ' 2891040457 #215 . 2891040457 #2158 02/12/13 $15.00 page 7 of 8 711090893 RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date : 2/19/2013 Cumberland County - Register Of Wills Receipt Time : 15 : 01 : 51 One Courthouse S quare Receipt No. : 1073125 Carlisle, PA 17613 WEIGLE DELORES L Estate File No . : 2013-00113 Paid By Remarks : BILL DANIELS CJ ------------------------ Receipt Distribution - -------------'--------- Fee/Tax Description Payment Amount Payee Name SHORT CERTIFICATE 5 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check# 1118 $5 . 00 Total Received. . . . . . . . . $5 . 00 �.�„-r-,-�rrn-m.. P, ,..�..-.-�-�-' � pennsylvania BUREAU OF INDIVIDUAL TAXES NOTICE OF INHERITANCE TAX DEPARTMENTOFREVENUE INHERITANCE TAX DIYSSION APPRAISEMENT, ALLOWANCE OR DISALLOWANCE PO BOx 28tl601 OF DEDUCTIONS, AND ASSESSMENT OF TAX OM REv-1548 DCAFP C11-14) w►R2ISBUR6 Pa 17126-0601 JOINTLY HELD OR TRUST ASSETS DATE 12-22-2014 ESTATE OF MIEIGLE DELORES L DATE OF DEATH 01-12-2013 FILE NUMBER 21 13-0113 COUNTY CUMBERLAND SSN/DC 202-20-4937 PATRICIA A ADAMS _ ACN 14114301 140 AIRPORT DR APPEAL BY DATE:02-20-2015 CARL ISLE PA 17013-1105 (See reverse side under Objections) A■ount Remitted -� MAKE CHECK PAYABLE AND REMIT PAYMENT T0: RE6ISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALON6 THIS LINE � RETAIN LOWER PURTION FOR YOUR RECORDS � -------------------------------------===--------�---�.,-=---------------..._t,._t_s,__,.:,.---�-----��_ E - 548 E AFP ClI=r4S - �-----� --- - NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HEID OR TRUST ASSETS DATE: 12-22-2014 ESTATE OF:WEI6LE DELORES L DATE OF DEATH:D1-12-2013 COUNTY:CUMBERLAND FILE NO. : 21 13-0113 • S.S/D.C. NO. : 202-20-4937 ACN: 14114301 TAX RETURN WAS: C ) ACCEPTED AS FILED fX) CHAN6ED SEE ATTACHED NOTICE JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: WELLS FAR60 ACCOUNT NO. : 003000017819294 TYPE OF ACCOUNT: ( �SAVINGS C ) CHECKING C )TRUST C }TIME CERTIFICATE DATE ESTABLISHED 08-17-2000 Account Balance 1,914.44 NOTE: TO ENSURE PROPER CREDIT TO Percent Taxable X 0.500 YOUR ACCOUNT, SUBMIT THE Amount Subject to Tax 957.22 UPPER PORTION OF THIS NOTICE Debts and Deductions - .00 WITH YOUR TAX PAYMENT TO THE Taxable Amount 957.22 RE6ISTER OF WILLS AT THE Tax Rate x .045 ABOVE ADDRESS. MAKE CHECK Tax Due 43.08 � OR MONEY ORDER PAYABLE T0: "REGISTER OF WILLS, AGENT." TAX CREDITS: PAYMENT RECEIPT DISCOUNT C+) DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID 11-13-2014 CD019908 .00 27.14 INTEREST IS CHAR6ED THROU6H 12-30-2014 TOTAL TAX PAYMENT 27.14 AT THE RATES APPLICABLE AS OUTLINED ON THE BALANCE OF TAX DUE 15.94 REVERSE SIDE OF THIS FORM INTEREST AND PEN. 1.46 TDTAL DUE 17.40 * IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. � IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRIJCTIONS. . � , , REV-1512 EX+ (1Z-12) � pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT� INHERITANCE TAX REfURN MORTGAGE LIABILITIES &LIENS RESIDENT DECEDENT ESTATE OF ^ FILE NUMBER Weigle, Delores L. __ 21 13 0113 Report debts incurred by the decedent prior to death that remained unpaid at the date of dea#h,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1• Department of Public Welfare 17,200.56 2. Church of God Home,Inc. 5,748.70 801 North Hanover Street,Carlisle,PA 17013 717-249-5322 3. Robin K.Sollenberger,Tax Collector for Real Estate Taxes 1,859.93 5 Hill Drive,Carlisle,PA 17013 4. PPL Electric Utilities 796.09 827 Hausman Road,Allentown,PA 18104-9392 800-342-5775 5. Carlisle Petroleum,Inc.,CPI Mechanical Contractors (Clean and Service Oil Boiler) 179.95 1524 East Commerce Avenue,Carlisle,PA 17015-9161 717-245-2382 6. Carlisle Petroleum,Inc.,CPI Mechanical Contractors(Fuel) 1,291.95 1524 East Commerce Avenue,Carlisle,PA 17015-9161 717-245-2382 7. State Farm Fire and Casualty Company via Fetterman Insurance Agency,inc.(717-249-4251)Hmownr 568.00 100 State Farm Place,Ballston Spa,NY 12020-8000 8. North Middieton Authority 435.04 240 Clearwater Drive,Carlisle,PA 17013-1100 9. Jones Plumbing(Install Exhaust Fan/Light Combination,Bathroom) 350.00 10. M&T Classic Checking with Interest Acct.,Service Charge 4.95 11. Real Estate:Sellers Paid Closing Costs to Borrower 6,300.00 12. Real Estate:Realtor's Commission 7,711.00 13. Real Estate:Transfer Taxes 1,236.00 14. Real Estate:Electrical Upgrade 2,275.00 15. Real Estate:Radon Installation 900.00 16. Real Estate:Final Sewer Bill 83.07 TOTAL(Also enter on Line 10; Recapitulation) $ 46,940.24 If more space is needed,insert additional sheets of the same size . �� l� I �� enns lv�r�ia � ��' � y �iII� DEPARTMENT OF PU3t.IC W[Lr�iiir . �� ( � October 21, 20t3 HUMFR & DANIELS LAW OFFICE� WILI_IAM S DANIELS ESO_UIRF FARMERS TRUST BLDG STE ?_05 ONE W HIGH ST CARLISLE FA 17013 �e: �oiores Vlieigle CIS #: �10251499 SSN: #�#-##-4937 Date of Death: 01/12/2013 F,ST�TF, R]ECO'�ERY STATEMENT OF CLAIM Dear Atky Daniels: Under State �nd �etlerai law, th� ��e�artrient �f Pui�iic Welfare (the De�artrt�ent) is reQuired to recc�ver medical assistance (��A) rEirn�ursement from the probate estates of deceased indivirJuais wha ��rere over a�e 55 when suc.h assistance was received. 42 U.S.C. �1396p(b)(1). 5Z P.S. � 14i2. This letter sets forth thE amount of the Departrrient's claim against zhe est�t�; �f the abc•�e referenced inuividual and expiains the obligations of executor�, adrninistratUrs, and persons re:,��ving estala property, Altho�agh the am�unt in the estate may be considerably less than tha� vv6�i�ch as owed #o the D�:par�ment, ��.ir clai2ra is against the esta�e, no one �Ise. ��at�ment of Claim Amouryt The Der�artir,ent rn�int.�ins a ciairn in the amount oF �17,200.56 agtiinst the above-mei�tio�ied e�tate. TP�is ciaom is for repayment of MA granted on behaif ��f the decedent. Enclosed is the Deparrr�r�ent'� itemizecl st�tement of claim. A portion of tl�is me�ical �xperis�, ��amely �1�.200.56, was incurred during th�; last six rnanths oi the decer;nnt's !if�:; therefore, it is a Cl�ss � clairn pursuant to Sectian 3392. o� the Decedents, Estates, ar;d F�duciaries �ode, 20 Pa�. C.�.A. 3392(3). The bal�nce of tf�e claim, namely .00, is tc� be ent�reci �s a priority Class .5.1 claim against the estate. '�'au should refer to Section 3?9"� �ar � mor�E� cornplete ex�lar.ation af the priority rules. If a lawsuit is i�led for injuries sustained by the decedent prior to death, then fihe Department may also ha�ie � lien ar�ainst the personal ir�jury artion. A statEme�k of �:l�in�: for that snjury� rela��d lien ��.�st be requested separately. �ur�au o`1'royrarn Irrtegrity � C�vi�ion of Tnird Party Liabiiity � Recovery Sectiun PO Eox�4E6 � Harrisourg, r'ennsyivani3 17105-84U6 .,....-y�s,..i�,-��:�:�nrn�.<.;fl�. , �►� pennsylvania � DEPARTMENT OP PUB�IC WELFRRE Your Responsibility to Provide Information to ith�e L�epartment Please acknowledge receipt of this letter and advise whether the Department's claim is admitted and when payment may be expected. When the estate accountin� is complete, please provide a copy. The Department audits all estate recovery claims and tr�erefore we require documentation to substantiate all deductions from the gross estate. The regulations governing huw the Department computes its estate recovery claim are found in 55 Pa. Code Chapter 25�i. These regulations are readily available on the Internet, in addi�ion to being carried in most local law libraries. In order to document computation of the amount due the Department, the following items should be submitted to the address below: 1. For real estate: a. Copy of the deed b. Copy of the latest tax assessment c. Copy of a current �ppraisal, if available z. Copy.of the funeral bill 3. Copy �f the statement nf the bur�ial acco�ant if �ne existe� 4. Co�y �f tr�e s�atement of the �ersonal care account balance at date af death, if the decedent was in a nursiny home 5. Copies of original and updated life ii�surance policy forms naming beneficiar�es 6. Copies of any and all stocks and ponds 7. C�pies of bank statements shoNving balances on the date of death 8. Copies of signature cards or other proof of when accounts were made joint 9. A list of any gifts or other transfers for less than fair market value made by the decedent (personally or under a power of attorney) Your i�espo�sibilities to the Departrnent �nder �tate la�v, executors �r administrators may be p�;sonally liable to p�y rhe Departmant's estate recovery r_;aim if they transfer estate propert�� v�;thout the Department's claim being paid. Persr�ns who receive that property without paying val!�able and adequate consideration to the estate may also be personally liable. The responsibilities �f the primary next of lcin;administrator/executor, is to advise the Department ofi any assets in the estate and tc Prsure that the r�maining money, after all funeral and administrativ� costs are deducted, is sent ta th� Dep�rtment. Accordingly, you mi.ist �ns�are the �Qpartment's daim is sakisfie� �Pfor� �?7�king distribution of asseks ta heirs. Bur�a.� :F u�og;'am Integfi�y j C)ivisicn c1`Third Party Liability � Recovery Section F'G�ox�348Ei ; i�<rr�sbur�, Pennsylvania 177.05-84�6 +�� pennsytvania �� UEPARTMENT OF PUBt_IC WE�FARE In�olvent �states and the Fiduciary RespUr��iboli#y ho Creditors If there are not enough estate assets to pay th? ciaims of all creditors in fult, then the executor or administrator has a duty to act in the best interest of creditors when administering th� est�te. If you must spend the estate's mor�ey to administer it, ycu must act prudently and make purchases as if the money were co��ning out of your awn poeket, The Department's approval is required if you expect the legal fees to exceed more than the greater of 6% of the estate assets or $1,000. Contingent fees for estate administration will generally not be approved. If you do not obtain approval, the Department rriay consider the excessive fees to be a transfer for less than valuable and adequate consideratior�. Sincerely, �� IVathan L. Snyder TPL Program Investic�ator 717-77�-6266 717-772-6553 FAX E�iclosure Burea+�v^f Proyr�m Tntegrity j Dh�ision of Third Party L�abiiilti � i2eco��.r��5eciion PO aax.8486 ; Narrisburn, Penn_rylvania 1ii.05-£?�a85 . • COMMONWEALTH OF PENNSYLVANIA BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY RECOVERY SECTION PO BOX 8486 HARRISBURG,PA 17105-8486 October 18,2013 STATEMENT OF CLAIM SUMMARY NAME Estate of WEIGLE,DOLORES ID 710 251 499 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 17,200.56 .00 17,200.56 DRUG .00 .00 .00 REIMBURSEMENT TO DPW 17,200.56 .00 17,200.56 _ -- _ - COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN- 23-6003113 Page 1 of 2 �11.I .I III11 11 . � + �.- , ' � . .. . . ..��... �. -__--__._.-_ --1 I COMMONWEALTH OF PENNSYLVANIA �_ DEPARTMENT OF PUBLIC WELFARE October 18,2013 STATEMENT OF CLAIM NAME WEIGLE,DOLORES ID 710 251 499 CHURCH OF GOD HOME INC 801 N HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 09/24/12 - 09/30/12 01/14/13 55130094306370001 55130094306370001 1,393.42 408.92 DIAGNOSIS 1 : 3384 CHRONIC PAIN SYNDROME DIAGNOSIS 2: 0 PROC CODE: 000000 10/01/12 - 10/31/12 01/28/13 55130245383770001 55130245383770001 6,170.86 5,297.47 DIAGNOSIS 1 : 4280 CHF UNSPECIFIED DIAGNOSIS 2: 0 PROC CODE: 000000 11/01/12 - 11/30/12 01/28/13 55130245383780001 55130245383780001 5,971.80 5,094.60 DIAGNOSIS 1 : 4280 CHF UNSPECIFIED DIAGNOSIS 2: 0 PROC CODE: 000000 12/01/12 - 12/31/12 02/25/13 27130304022810001 27130304022810001 6,170.86 5,297.47 DIAGNOSIS 1 : 4280 CHF UNSPECIFIED DIAGNOSIS 2: 0 PROC CODE: 000000 01/01N3 - 01/12N3 02/25/13 27130354023440001 27130354023440001 2,107.60 1,102.10 DIAGNOSIS 1 : 311 DEPRESSIVE DISORDER NEC DIAGNOSIS 2: 0 PROC CODE: 000000 PROVIDER SUB TOTAL CHURCH OF GOD HOME INC 21,814.54 17,200.56 03 000747604 0001 Page 2 of 2 RESIDENT STATEMENT FROM 2- CHUR�H OF CyOD HOME, INC Statement Date Due Date ACCOUNT NUMBER 801 N HANOVER STREET CARLISLE, PA 17013 01/31/2013 Upon Receipt 802974 717-249-5322 � . : • • � $5,748.70 AMOUNT PAID $ Please make check payable to CHURCH OF GOD HOME, INC DOLORES L WEIGLE Remit To: c/o PATRICIA ADAMS CHURCH OF GOD HOME, INC 140 AIRPORT DRIVE 801 N HANOVER STREET CARLISLE, PA 17013 CARLISLE, PA 17013 Please detach and return this portion with your remittance to the address above. Comments - : � � . , --- — .� , . � : , , � , — - $0.00 $1,017.50_�� $30.60 � $3,966.00 �� $734_60 � $5,748.70 � _ --------- -- � _ — ----� 3 m��`.0 �3ie'�� h X' � �i�� z� � � F p ��Y�a� �� p��.�� '�.r��,��,.� s v -�`�' w��a'.��u� 3,�.�„��' p�ts� � �a '� v ......_,... �l ,.� . W;�, .�..�.,, ,�.,. ,Swe,-,g.K',,......,Rs�t�.�:W:.,.��:;�.''s��_..;,�^'. �i �i",1 t�'� '�a F��,..��m..;�<. o.._�� _.n::�T ��v�'� ��,�;`'��43 � ��3,�r. _.�Akn�'�._� ,..... ; < , , x_ ��.. a .�r„r9�_-�A , Balance Forward $5,717.70 a� $5,717J0 01/06/13-01/06/13 Patient Liability $19.00 $5,736.70 01/12/13-01/12/13 Telephone Basic Charges 1 $12.00 $12.00 $5,748.70 TOTAL BALANCE DUE: $5,748.70 ..,. ��. = 'o,�.�3.� G�S �'�c:.�..v��.�, c`�� c�- ��_ l C��.c� ��-.�r�— �.�c..�.� . � L�l-�-� v� ��.c ��.. �- �-1a--�.5 `M Pt C�r�C� �JY��c�-...: �--`c��:�•'t C..c��.- �,c�;��c ��.�� 'r� �; � c�- � j �� y H.« s � ��Y� ��((� �.._. ...1""A..,,w�""' . r' � � �� ,.��. ' �•� ,..�-��" � . .. r',. FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CHURCH OF GOD HOME, INC DOLORES L WEIGLE 802974 �ai in.� � RESIDENT STATEMENT FROM CHUR�H OF GOD HOME, INC Statement Date Due Date ACCOUNT NUMBER 801 N HANOVER STREET CARLISLE, PA 17013 12/31/2012 Upon Receipt 802974 717-249-5322 � ' = ' ' � $5,717.70 AMOUNT PAID $ Please make check payable to CHURCH OF GOD HOME, INC DOLORES L WEIGLE Remit To: c/o PATRICIA ADAMS CHURCH OF GOD HOME, INC 140 AIRPORT DRIVE 801 N HANOVER STREET CARLISLE, PA 17013 CARLISLE, PA 17013 Please detach and return this portion with your remittance to the address above. Comments � � .� ' - . � . . � : , , � __._ _ $986.50_J $1,022.10 �� $2,g74.50 �� _$0.00 II $734.60 —�� $5,717.70 i _ �- -- — ------� �- } y ��'�`��k�,��s� i-��„��2`�t��{�i��4�ra. �'� -t'�`� � 9, v � ' Y' �i�v,�� :.7 s'x��'y �'�;�p �� ty�'� *� { �� '_� �� e- � ,,� � '�.��r�. �� `" ��k. �'w�� °�'�:� __�,:.��`�., cea� ��. x�:_<s��",,.:�.� � ,��r ��; .��*�,'.-�.»W �, sa � d,:a; �. . ......�C�.,�� `� T�'�'� ��g` � a „_" _ , m.��f .�`$, ,a,� �zy;�`�.,st,s.,n.: ,�„� - ��i Balance Forward $4,700.60 $4 700.60� 12/31/12- 12/31/12 Telephone Basic Charges 1 $30.60 $30.60 $4,731.20 01/01/13-01/01/13 Patient Liability $986.50 $5,717.70 TOTAL BALANCE DUE: $5,717.70 FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CHURCH OF GOD HOME, WC DOLORES L WEIGLE 802974 RESIDENT STATEMENT FROM CHUReH OF GOD HOME, INC Statement Date Due Date ACCOUNT NUMBER 801 N HANOVER STREET CARLISLE, PA 17013 11/30/2012 Upon Receipt 802974 717-249-5322 � . : • • � $4,700.60 AMOUNT PAID $ Please make check payabfe to CHURCH OF GOD HOME, INC DOLORES L WEIGLE Remit To: c/o PATRICIA ADAMS CHURCH OF GOD HOME, INC 140 AIRPORT DRIVE 801 N HANOVER STREET CARLISLE, PA 17013 CARLISLE, PA 17013 Please detach and return this portion with your remittance to the address above. Comments -- -- � � .1 . • 1 '1 : � � � ---$991.50 --�--$2,876.85 �� $832.25�� $0.00 �� $0.00 �� $4,700.60 __ � — 1� _— �� ; � �� r� ��,� � "�# ��{T� x�� "�y�� a : ��tt '�a^� fi� � ��`r� � � a� z c ,1�. z@�te�� x� � ��+ ��.� �� .� '��„ •.....�:.:u,.......�,�..v,t,,=...Y.,....ti �� .a.,...�. a�,' ''a :: � .. P ��`, -_. d,�s . �....:.�ir�Q'��..��a-' `' �. d,�l��,S . y��cu�?P��, ..s�:� � .Y.... ,,,..,. ...aio..�..�- < t,..1� � ��I- ,�^:�k 3 �� vo��,rs._ a.�•-� Balance Forward $18,648.25 $18,648.25 09/24/12-09/28/12 Patient Liability $991.50 $19,639.75 09/24/12-09/30/12 Room&Board (7) $(262.00) $(1,834.00)� $17,805.75 �9/26/12-09/26/12 Pullups-Large (1) $15.38 $(15.38) $17,790.37 /30/12-09/30/12 Laundry (1) $34.75 $(34.75��v $17,755.62 09/30/12-09/30/12 Finance Charges (1) $5.67 $(5.67) $17,749.95 10/01/12- 10/05/12 Patient Liability $991.50 $18,741.45 10/01/12- 10/31/12 Room&Board (31) $(262.00) $(8,122.00)�/ $10,619.45 10/03/12- 10/03/12 Pullups-Large (1) $15.38 $(15.38) $10,604.07 10/11/12- 10/11/12 Pullups-Large (1) $15.38 $(15.38) $10,588.69 10/22/12- 10/22/12 Aloe Vesta Protectant#90 (1) $2.83 $(2.83) $10,585.86 10/24/12- 10/24/12 Pullups-Large (1) $15.38 $(15.38) $10,570.48 10/24/12- 10/24/12 Adult Wipes Refills (1) $2.88 $(2.88) $10,567.60 10/31/12- 10/31/12 Laundry (1) $34.75 $(34.75�'�v $10,532.85 11/01/12- 11/05/12 Patient Liability $991.50 $11,524.35 11/01/12- 11/30/12 Room& Board (30) $(262.00) $(7,860.00)a/ $3,664.35 11/29/12- 11/29/12 Wash, Blow Dry 1 $14.15 $14.15 $3,678.50 11/30/12- 11/30/12 Telephone Basic Charges 1 $30.60 $30.60 $3,709.10 12/01/12- 12/01/12 Patient Liability $991.50 $4,700.60 TOTAL BALANCE DUE: $4,700.60 �PYv't- ��-��a.�.. �1� +�. `i-�i�.Yv(��. �r G�c�.., � FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CHURCH OF GOD HOME, INC DOLORES L WEIGLE 802974 RESIDENT STATEMENT FROM CHURGH OF GOD HOME, INC Statement Date Due Date ACCOUNT NUMBER 801 N HANOVER STREET CARLISLE, PA 17013 10/31/2012 Upon Receipt 802974 717-249-5322 • � = � � � $18,648.25 AMOUNT PAID $ Please make check payable to CHURCH OF GOD HOME, INC DOLORES L WEIGLE Remit To: c/o PATRICIA ADAMS CHURCH OF GOD HOME, INC 140 AIRPORT DRIVE 801 N HANOVER STREET CARLISLE, PA 17013 CARLISLE, PA 17013 Please detach and return this portion with your remittance to the address above. Comments 1 1 .1 •1 •1 : � � � $7,860.00 $145.50—�10,111.65 $152.88 ��, $378_22—�C $18,648.25 � --- - �-- -----�L_ - ��- ��__ ,� � �� _ �� , s� � . � �.`� .,. "�:- � � �: �'�. � �3- r ,� s �, S x�� '.�..� �. . _...r.....,.m..� '� ,,,,�"'��,..- . . _u,.._ .,x;��.,,,, , r, . � ..,,,�.m,.< -.,"h' ,^«-,;� T_, ,-�. . -� .,. � .x;�- ,7 ......� r.� , f � ',"'tt�+z i� _. �_�. .._ s�� .�. Balance Forward $18,764.75 $18,764.75 09/30/12-09/30/12 Security Deposit Skilied (1) $8,122.00 $(8,122.00)✓ $10,642.75 10/03/12- 10/03/12 Pullups-Large 1 $15.38 $-1�5:38� $10,658.13 ��/11/12- 10/11/12 Puliups- Large 1 $15.38 $15.3$ $10,673.51 19/12- 10/19/12 Wash, Blow Dry 1 $14.15 $14:'� $10,687.66 10/22/12- 10l22/12 Aloe Vesta Protectant#90 1 $2.83 $Z.83 $10,690.49 10/24/12- 10/24/12 Pullups- Large 1 $15.38 _.$1�� $10,705.87 10/24/12- 10/24/12 Adult Wipes Refills 1 $2.88 $2.88- $10,708.75 1'__.�- 10/31/12- 10/31/12 Laundry 1 $34.75 �4� $10,743.50 10/31/12- 10/31/12 Telephone Basic Charges 1 $30.60 3U: q $10,774.10 10/31/12- 10/31/12 Wash, Blow Dry 1 $14.15 �"�r4�j $10,788.25 11/01/12- 11/30/12 Room&Board 30 $262.00 �$7,860.00 �{�,�ti-�c,� $18,648.25 �._ . TOTAL BALANCE DUE: $18,648.25 FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CHURCH OF GOD HOME, INC DOLORES L WEIGLE 802974 RESIDENT STATEMENT FROM CHURCH OF GOD HOME, INC Statement Date Due Date ACCOUNT NUMBER 801 N HANOVER STREET CARLISLE, PA 17013 09/30/2012 Upon Receipt 802974 717-249-5322 � . : • • � $18,764.75 AMOUNT PAID $ Please make check payable to CHURCH OF GOD HOME, INC DOLORES L WEIGLE Remit To: c/o PATRICIA ADAMS CHURCH OF GOD HOME, INC 140 AIRPORT DRIVE 801 N HANOVER STREET CARLISLE, PA 17013 CARLISLE, PA 17013 Please detach and return this portion with your remittance to the address above. Comments � � .� .� . � : • • , - . . --- -- ' $8,122.00 � $10,264.53 _ �_$0.00—][_ $116.22 II. $262.00 �, $18,764.75 I ------ --- — �--------- f '�.��,�{�$.�: ��L�ZS��M�'.W�vA�tnvYk� ��..�G�� (� � �W`s� +� �� W �3 �AL�.��}� �N�. iR �y� 9�.�SW��S�Y{� ��? ' �,'�., f�; � :2 £ �- �� z�'� �h�"�'' k:�3 '�.��e P �� ' sa �s, '� � '"'�'s�� 3,�� a �.:. v � �'� y �„+ � �,_��Ea, a„_ �- � „� b .,..; a`'2�,.,. �_� ,... �/, i �, ��_ � _�. , = .�,..r.� .l �.�' c �,� Balance Forward $531.10 $531.10 09/06/12-09/06/12 Wash, Blow Dry 1 $14.15 �$14.'�5; $545.25 09/14/12-09/14/12 Cut,Wash&Blow Dry 1 $26.80 _�26.80;� $572.05 ^Q121/12-09/21/12 Wash, Blow Dry 1 $14.15 �$14.1� $586.20 �24/12-09/30/12 Room& Board 7 $262.00 _��834.0O�:�u r�� $2,420.20 09/26/12-09/26/12 Pullups-Large 1 $15.38 r$15_.3� $2,435.58 09/27/12-09/27/12 Wash, Blow Dry 1 $14.15 �$14:'f5; $2,449.73 09/30/12-09/30/12 Laundry 1 $34.75 1$3d.7� $2,484.48 09/30/12-09/30/12 Telephone Basic Charges 1 $30.60 ,�:�� $2,515.08 09/30/12-09/30/12 Finance Charges 1 $5.67 s$5.67� $2,520.75 09/30/12-09/30/12 Security Deposit Skilled 1 $8,122.00 �.$122.OQ, � �G-� $10,642.75 10/01/12- 10/31/12 Room&Board 31 $262.00 $�122.00 ��tad 'na'" $18,764.75 �.__--.--- TOTAL BALANCE DUE: $18,764.75 FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CHURCH OF GOD HOME, INC DOLORES L WEIGLE 802974 RESIDENT STATEMENT FROM CHURC�FI OF GOD HOME, INC Statement Date Due Date ACCOUNT NUMBER 801 N HANOVER STREET CARLISLE, PA 17013 08/31/2012 Upon Receipt 802974 717-249-5322 $531.10 • � : � � � AMOUNT PAID $ Please make check payable to CHURCH OF GOD HOME, INC DOLORES L WEIGLE Remit To: c/o PATRICIA ADAMS CHURCH OF GOD HOME, INC 140 AIRPORT DRIVE 801 N HANOVER STREET CARLISLE, PA 17013 CARLISLE, PA 17013 Please detach and return this portion with your remittance to the address above. Comments � � . � •� • � : • • � . . _ I_ _ � $0.00 � $152.88 � __$11622_-��_ $262.00 i $0.00 � $531.10 _ I 3 ` '�1�� `� �� f k a J�,�� ' ,��E� �r�'1S�'�� 8�1+Slisar" �a�� I x �} � �� .��'��.,,...,..��--� �^�,:.:,�� c"`� „ � .�'a e, �� ' �. e.,_.��z.��'_. .:,.�a��."-'�'„ . _:.�.1��i��4��', ,�'�.�� ..;��` '� ' �..,`,��"� ......_an., :. . ,. ,,, � wr. . , c,.�.,.�.� Balance Forward $378.22 $378.22 08/01/12-08/01/12 Wash, Blow Dry 1 $14.15 $14.1� $392.37 08/06/12-08/06/12 Escort Fee$2.50/15 mins. 2 $2.50 $5.00 J $397.37 �8/06/12-08/06/12 Transportation 0-10 miles 1 $22.00 $22.00; $419.37 ;10/12-08/10/12 Wash, Blow Dry 1 $14.15 $14.15� $433.52 08/22/12-08/22/12 Wash, Blow Dry 1 $14.15 ,$��T:1�5J $447.67 08/30/12-08/30/12 Wash, Blow Dry 1 $14.15 $44.15 � $461.82 __ __.._ _� 08/31/12-08/31/12 Laundry 1 $34.75 $-34.75 $496.57 �__-J 08/31/12-08/31/12 Telephone Basic Charges 1 $30.60 $30.60 $527.17 08/31/12-08/31/12 Finance Charges 1 $3.93 ,�$_3.� $531.10 TOTAL BALANCE DUE: $531.10 FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CHURCH OF GOD HOME, INC DOLORES L WEIGLE 802974 RESIDENT STATEMENT FROM CHURCH OF GOD HOME, INC Statement Date Due Date ACCOUNT NUMBER 801 N HANOVER STREET CARLISLE, PA 17013 07/31/2012 Upon Receipt 802974 717-249-5322 • • = • • � $378.22 AMOUNT PAID $ Please make check payable to CHURCH OF GOD HOME, INC DOLORES L WEIGLE Remit To: c/o PATRICIA ADAMS CHURCH OF GOD HOME, INC 140 AIRPORT DRIVE 801 N HANOVER STREET CARLISLE, PA 17013 CARLISLE, PA 17013 Please detach and return this portion with your remittance to the address above. Comments 1 1 .1 • 1 •1 : � � � . ' i -- - -- $0.00 – - --$116.22 �$262.00 ��—$0.00 II - $0.00_�–�_ $378.22 i _-- -- --- —---� ��a�� "�C��a, ��`' �j� � �e �`harg�� a�ii�a�� ' �� ,� �� .z '�«, �,�� .a.y�� i P� ��. "�a��,.� +r; � ��"� �� 'r� ��H�m"�' ,� �,�� j,3 a� 3s `� � � ��. � ��...:.��''�� . ,,., . , . � � �� ..._w.v_..,...u........x............... �, nb',��"�S:.x6"�....*�•�.....,��_e'��...�.:a�.- 3� ..e....Y'��a�.. L. $� . � ,�_ a' .. � �4t J,'f�9g '�� Balance Forward $434.00 $434.00 07/11/12-07/11/12 Wash, Blow Dry 1 $14.15 $'i4.'f5� $448.15 07/11/12-07/11/12 Escort Fee$2.50/15 mins. 6 $2.50 �'f5.�0 $463.15 07/11/12-07/11/12 Transportation 0-10 miles 1 $22.00 �$�:QO�; $485.15 '19/12-07/19/12 Wash, Blow Dry 1 $14.15 `�-'F5; $499.30 u7/24/12-07/24/12 Wash, Blow Dry 1 $14.15 �$'f4.��5 $513.45 07/31/12-07/31/12 Laundry 1 $30.26 �D-2�� $543.71 07/31/12-07/31/12 Finance Charges 1 $6.51 ��51�� $550.22 08/08/12-08/08/12 Payment Check#270 $172.00� $378.22 ,� TOTAL BALANCE DUE: g3�g.22 FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CHURCH OF GOD HOME, INC DOLORES L WEIGLE 802974 RESIDENT STATEMENT FROM CHURCW OF GOD HOME, INC Statement Date Due Date ACCOUNT NUMBER 801 N HANOVER STREET CARLISLE,PA 17013 06/30/2012 Upon Receipt 802974 717-249-5322 � . : • • � $434.00 AMOUNT PAID $ Please make check payable to CHURCH OF GOD HOME, INC DOLORES L WEIGLE Remit To: c/o PATRICIA ADAMS CHURCH OF GOD HOME, INC 140 AIRPORT DRIVE 801 N HANOVER STREET CARLISLE, PA 17013 CARLISLE, PA 17013 Please detach and return this portion with your remittance to the address above. Comments • • : 1 1 .1 •� • � � • • � . - - - --- - $0.00 �� $434.00 �� _ $0.00 � $0.00 �� $0_00 ��$434.00 _ _ �� , ��,� �� x�� t�qr�� ' C�h� s�� i� ; � � � ,. �� 3 � � �� _ � �� a � � �,�� ; r � : � � � � � � ,_s��'� ."; �� .�s. �',�z�„*�.,��i ,�� <�.�.:,_•��, -s:..� .� � � ��- x� '� ,� a�ov�a ��_ � ° „ �.�. N ":�: � .,,. , _,.-.�_ _.�., �....�. - - �-- .. .,. e.� ,,., .. , �,,,» .- . _ �,.,.. ...o. , . . . Balance Forward $267.60 $267.60 05/27/12-05/27/12 Laundry 1 $4.48� $4.48 C'`�� $272•�$ 05/27/12-05/27/12 Room&Board (1) $(262.00) $(262.00)r $10.08 05/28/12-05/28/12 Laundry (1) $5.60 $(5.60)✓ •48 '20/12-06/20/12 Escort Fee$2.50/15 mins. 8 $2.50 �0.00>p'a'� $24.48 U6/20/12-06/20/12 Transportation 0-10 miles 1 $22.00 22.00 � $46.48 06/21/12-06/21/12 Wash, Blow Dry 1 $14.15 14.1 ' �'�� $60.63 �-_..,, 06/29/12-06/29/12 Cut,Wash&Blow Dry 1 $26.80 �26.8 �� $87.43 06/30/12-06/30/12 Laundry 1 $20.85 �85 * �� $108.28 06/30/12-06/30/12 Room&Board 1 $262.00 "� 262.00 : $370.28 06/30/12-06/30/12 OT-Self care mgt training 2 $31.86 63.72,�� $434.00 TOTAL BALANCE DUE: $434.00 FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CHURCH OF GOD HOME, INC DOLORES L WEIGLE 802974 �n�. ... wu.,n i RESIDENT STATEMENT FROM CHURCFI OF'GOD HOME, INC Statement Date Due Date ACCOUNT NUMBER 801 N HANOVER STREET CARLISLE, PA 17013 05/31/2012 Upon Receipt 802974 717-249-5322 � • : • • � $267.60 AMOUNT PAID $ Please make check payable to CHURCH OF GOD HOME, INC DOLORES L WEIGLE Remit To: c/o PATRICIA ADAMS CHURCH OF GOD HOME, INC 140 AIRPORT DRIVE 801 N HANOVER STREET CARLISLE, PA 17013 CARLISLE, PA 17013 Please detach and return this portion with your remittance to the address above. Comments 1 1 .1 •1 ' 1 : � � � . , —— – — — - — — — $0.00 � $267.60 � --$0.00 ��_. $0.00— r - - $0.00 ___J�$267.60 ._ _� �l�te : '�` ��ptiorr �', �� Y�t ��'�� ha�� a�� 1 ,, _ � . ..E _ �� 3 ��. 3 >,? "f:<�'r� , 11 13 ,�r t�`" �a�, �q �-a= _��. .�. ��.,...�_�._� �d��.� :. ... �,� �'�"��r, �C��$...1� �i� ....m.....,. �. z,�,,.��;� z � � � v.. 05/27/12-05/27/12 Room&Board ��= •r"�-•�- 1 $262.00 $262.00 r•c: � $262.00 05/28/12-05/28/12w Laundry - t�.��•,:�3�...,�.r 1 $5.60 $5.60 $267.60 TOTAL BALANCE DUE: $267.60 FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CHURCH OF GOD HOME, INC DOLORES L WEIGLE 802974 � T''!' '° II NVELOPE�F pAY�NG (' 1 7 ��j ..�� i I+ssessed - - RE�'E�PTFOR TqxES . Values BIII NO. La„3;Jmpr <m,, . @ 004488 7��.'�L��1�1�apL`AND --,�r,n� Mi�ieral Rates COUN7y " � Tota1 CUMBE �00213700f Discount 1�G'io° Rates RLqND O� TOWNSHIP __ Face Penalt CUMBERLqN �00069q00 I � 2° Rates �� B�RY 10% Q• ;k �y�� .00014300:� �-�-_.. 2% r ,o, O�� TAX AMOUNT - 2' 368•34 + tEs ��--`�� rf Pa� ��E-------> a aso. ,o e �Q• .� rf Paid �n °r After� 97 5368.34 . - R °r Before 5405,�g 477'J3 + K�0��"ENgOR �F NOT PAID BY 12/31,THIS BILL WIIL BE RETUR�/1/zoi3 ROB�N ��LEC TAXCLAIMBUR 4/3pjzo13 5/1/2ai3 6/30/2013 �/]/2pi3 �f OOJ�•(6 -� T AX AGqINST yp�R PR�PERTMOLLECTION AND FILING OF A LIEN 1,859•93 0 -a& rHUR �o_ . •FEB_NOV-DEC 6' MAY-�UN-SEP-OC7 7,�-249-G la l Tax Collector � � OTHERS ByqppT S'gnature �_$ Date paid - � Amount Pa�d ROBIN K SOLLENBERGER,TAX COLLECTOf2 � T�XPAYER'S COPY 5 HILL DRIVE KEEP THIS PORTION FOR YOUR RECORDS CARLISLE,PA 17013 -�— TEMP -RETURN SERVICE REQUESTED • ' • � ' � ��Illll�l�ll�ll�l��i��i��i�i�i�iil�lll�l�iioil��iilo�li��i 022719.x>.>.�,....t�xAUTO*'5-DIGIT 17013 IIIIIIIIIIIIIIIIIIIIII�IIII!�IIIIIIIIIIIIIIIIIIIII WEIGLE,BRUCE R 8�DOLORES 140 QIRPORT DR CARLISLE PA 17013-1105 To review the assessment data for this property, go to: vvww.courthouseonline.com>AssessmentOffsce>Cumberland>Pro�ertvRecords. 'i nen enier contro�� '1�0U�0d9 ana password CUHGYNZP . ___... ... ...............__......... ,_._ .___.. _____. __ __.. ......_... _ ...... _.. ..._.... ...........__..._... . ' _ _..__.......... .._.._.....__...,.... _. .......__..._.. . ..._ ■ ■ •� ►� • ��PlO�_��'!_r.7 i ■ � i� I ��/�11�1�"\l�l Q��'�u�.-.-�-��a�r.a 1 � � � � • Office Hours MAR APR JUL AUG TUES 10�THUR 10 6 Payable To: ROBIN K SOLLENBERGER,TAX COLLECTOR MqY,JUN,SEP,dCT THURS 10-6 5 HILL DRIVE APPT ONLY JAN,FEB,NOV,DEC� CARLISLE,PA 17013 Bi!I No: �$$ Bill Date: 311/13 PHONE(717)249-0747 Control No: 29003049 NIAP NO: 29-17-1585-120. Assessed Value: Land:22,500 Improvement: 101,600 Total: 124,FOOP —�nG y I Desc: 140 AIRPORT DRIVE Disa.�unt AIRPORT ACRES County RE _ 2.131 $259•17 264.46 29Q•°�� LAND LESS THAN 1 ACRE 0.143 $17.39 $17.75 $19.53 _ Acres 0.23 �Deed 0020U01153 County Lib _---- Munic.R.'E 0.694 _ $84.41 $86.13 $94.74 I I I �I I I 1111ll11L�-- I ----- --� $1 00 FcE FOR ADDITIONAL RECEIPTS� � �__ � T�x Payer TAX AMOUNT DUE $300.97 $368.34 $405.18 i WEIGLE,BRUCE R&DOLORES I 140 AIRPORT DR if Date Of Pa ment is or 3/1/13 thru 4/30/13 5/1��3 thru E'30/13 7l1/13 or Later J CARLISLE PA 17013-1105 , . .,� • : • : - �<< • ••:� .� �� • ��- •��.v . . .. „ ,� • . � � . _ __ _ .. _.. __._ ____ _ . _. . ... _ __. _ ___ _ _ __ Cumberland County Psnnsylvania , � � � � _ � � � . � � � • � • • • - � Bill No: 448s TAX COLLECTOR COPY - RETURN WITH PAYM�NT FOR PROPEFC CREDIT gill Date: 3/111s 140 AIRPORT DRIVE Cortrol No:29003045 WEIGLE,BRUCE R E�DOLORES AIRPORT ACRES M�F�P NO: 29-17-1585-120. 140 AIRPORT DR LAND LESS TtiAN 1 ACRE CARLISLE PF�17013-1105 Acres 0.23 Deed 0020U01153 Assessed Value: i and;22,50Q in�pravem�nt:1Q'i,600_Total: 124,�Oa=---�--Ity Payable To. � �isc�unt ROBIN K SOLLENF3ERG�R,TAX COLLECTOR � _ ____-------- 2.131 5259.17 �64 46 $2�4.$�- 5 HILL DR:VE �Count RE -- CARLIS�E,PA 17013 0.14" ___$17•39 — $17'� I Count Lib � Mun��,BLF__-- 0654 __ PHONE(717)249-0747 — -- I i � �--- -- -_- --- - I�Illllllllllllllllllllllll�llf►Illllll.11illllllll � ____ _ ITAX AN90UNT L�UE $360.97 $368.34 $405.'!8 ,_If Date uf Fa�;ment_I_s On __.__._�11/13 thr��4I30/13 5i'Si�3 thru_6I30/13 711N3 or LaterJ �TAX PAYER'S COPY- KEEP THIS �ORTION FOR YOUR RECORDS � r - . . -- Payable To ROBIN K SOLLENBERGER TAX COLLECTOR Uffice Hours. ,MAR,APR,JUL,AUG TUES 10�,THUR 10-6 5 HILL DRIVE CARLISLE,PA 17013 �"AY,JUN,SEP,UCT THURS 10-6 AQPT ONLY JAN,FEB,NOV,DEC; MAF NO: ZgP 7�588 120.249-0747 Bill No. 4483 Desc: Bill Date: 3!1/13 140 AIRPORT DRIVE Control No: 29f103Q49 AIRPORT ACRES Assessed V�lue: Land:22,500 improvement: 101,600 Tutal: 12A,140 � LAND LESS THAN 1 ACRE � Discount Face --+ Acres 0.23 Deed OU20U01153 County RE 2,13� -- Penalty � 5259.17 $264.46 ��gn.S� -�I IIII�IIIIIIIIIIIIIIIIIIII�IIIIII�IIIi�lflll�lfl CountyLib 0.143 — $17,3g $17.75 � I��I Munic.R/E _ O.6J4 $19.53 � $84.41 $86.13 �94,;Q ?ax Pay2r: WEIGLE.BRUCE R�DOLORES 140 AIRPORT DR TAX AMOUNT DUE $360.97 CARLISLE PA 17013-1105 $368.34 $405.18 If Date Uf Payme�t is on 3/1113 thru 4/30/13 5/1/13 thru 6/30/13 7!1/13 or Later - _ � To review the assessment data for this property,go to: vvww.courth ou seon I i ne,corn>As sessmentOffice>C umberla nd>PropertyRecords. Tl�en enter Control# 23�U3049 and password CUHGYNZP TAX 1NSTF?UCTIONS - READ CAREFULLY If serviced by a m�rtyage company, !crwarc!one portion oF ihis bill to company immediately. Keep remainder for your recera:,. If you req�aire an official receipt,send your check,twu ccpies and a selF-addressed stamped enveloNe. I�not�aid by 12�31i2013 this bill�Nill��t;eiurned to Tax Gaim Burtau for collection and filing ef a lien against your propert�. Faiure to r�ceive a bill does not re�ieve you froi�iiabJity for p;ompt paymenY. PJo��artial payments or postdateci r.hccFs will he accepted��;r.,pGy;;;"-,t mt;s±be recefved or U.3. ��o;t marked by the d�e aate. ��:�'��.� • * � � ' � � � � I�EVV INFORMATfON CURRENT INF�RMAT(ON - - �+lIAP �10: 29-'!7-'9 5$5-120. - ------ WEIGLc,$RUCE Ft R�70L�RES ------- S40 RIRPORT DR -- -- CARLISLE P,4 17013-1105 ��:,_ u _ � iu.� i SEND A SELF ADDRESSED STAMPED ENVELOPE IF PAYING RECEIPT FOR TAXES Bill No. 006429 BY FAAIL ' Assessed LandlImprovement :9ineral TOLal PAYABLE values o: 0 0 0 TO —-- -- Discount Face Penaltv ROBIN K. SOLLENBERGER,TAX COLI�y��IZER CAPITA - 5 HILL DRIVE Rates 00500000I 2/ �o� CARLISLE, PA 17013 County PPr C�n"ta R/F ___, MUNICIPAL PER CAPITA '�. Rates .00500000'��. 2% 10% DESC NA D—i-1�� - PP, TAX AMOUNT DUE -------> ae.so a�o.00 s+,.00 (� �� If Paid On or After 3/1/2013 5/1/2013 7/1/2013 \� (�� If Paid On or Befox�e 9/30/2013 6/30/2013 rnx DOLORES L.WEIGLE �� 'E� —�- — PAYER NA p1��-�NgE R TAXOCLAIAM BUREAU1FORICOLLEC'fION AND FIL NG OF A LiEN RpgqN K��LEC�� AGAINSTYOUR PROPERTY. 140 AIRPORT DR. -�p,X CARLISLE PA, 17013 OFFICE MAR-APR-JUL-AUG TUES 10-4& THUR 10-6; MAY-JUN-SEP-OCT HouRs: THUR 10-6;APPT ONLY JAN-FEB-NOV-DEC / / b Tax Collector Signature Date Paid Amount Paid 717-249-0747 OTHERS BY APPT ��I��'� �� i i un � i � � TAXPAYER'S COPY ROBIN K SOLLENBERGER,TAX COLLECTOR KEEP THIS PORTION FOR YOUR RECORDS 5 HILL DRIVE CARLISLE,PA 17013 TEMP - RETURN SERVICE REQUESTED � , � • . . �I�Illll�l�ll�ll�l��i�l�il��li�i�ii�il�lll�l�ii�il��iil��li��i 038836"""`"`"`�"""'"'AUTO"`5-DIGIT 17013 DOLORESL.WEIGLE IIIIIII IIIII II II IIIIIIIIIII I IIIII IIIIII 140 AIRPORT DR CARLISLE PA 17013-1105 . � � n � � \� . \; Pa able To: Office Hours: MAR,APR,JUL,AUG TUES 10�4,THUR 10-6 B��N�� 6429 y ROBIN K SOLLENBERGER,TAX COLLECTOR MAY,JUN,SEP,OCT THURS 10-6 Biii Date: 3/1/13 5 HILL DRIVE APPT ONLY JAN,FEB,NOV,DEC; Control No:29-003103 CARLISLE,PA 17013 PHONE(717)249-0747 OCC IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Discount Face Penalty COUNTY PC $4.90 $5.00 $5.50 $1.00 FEE FOR ADD�TIONAL RECEIPTS MUN PC $4.90 $5.00 $5.50 Tax Payer. - DOLORES L.WEIGLE TAX AMOUNT DUE $9•80 $10.00 $11.00 140 AIRPORT DR If Date of Payment Is on 3/1/13 thru 4/30/13 5/1/13 thru 6/30/13 7/1/13 or Late CARLISLE PA 17013-1105 � � � �� • . � � '�� • •� �'� • ��• •�1' '� • • ......................................................................................................................_..........._.............__............._.............__.............__........._._...._...............___....................._..... Cumberland County Pennsylvania � . � . • . . �- • � • � � •- � � • TAX COLLECTOR COPY- RETURN WITH PAYMENT FOR PROPER CREDIT Bill No: 6429 Bill Date: 3!1/13 DOLORES L.WEIGLE Office Hours: MAR,APR,JUL,AUG TUES 10�,THUR 10-6 Control No: 29-003103 140 AIRPORT DR MAY,JUN,SEP,OCT THURS 10-6 CARLISLE PA 17013-1105 qppT ONLY JAN,FEB,NOV,DEC; Payable To: OCC ROBIN K SOLLENBERGER,TAX COLLECTOR Discount Face Penalty 5 HILL DRIVE COUNTY PC $4.90 $5.00 $5.50 CARLISLE,PA 17013 PHONE{717)249-0747 MUN PC $4.90 $5.00 $5.50 I IIIIII IIIII IIII IIIIII IIIII IIIII IIIII IIIII IIIII IIII IIII TAX AMOmNTI DUE 3/1/13 thru 4 30 13 5/1/13 thru 6 30/�3 7/1/13 or La er TAX PAYER'S COPY- KEEP THIS PORTION FOR YOUR RECORDS � � • � • � � • - � � • � � • - � � • Payable To: Office Hours:MAR,APR,JUL,AUG TUES 10�d,THUR 10-6 Bill No: 6429 ROBIN K SOLLENBERGER,TAX COLLECTOR MAY,JUN,SEP,OCT THURS 10-6 Bill Date: 3/1/13 5 HILL DRIVE APPT ONLY JAN,FEB,NOV,DEC; Control No:29-003103 CARLISLE,PA 17013 PHONE(717)249-0747 OCC IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIII III Discount Face Penaity COUNTY PC $4.90 $5.00 $5.50 MUN PC $4.90 $5.00 $5.50 Tax Payer: DOLORES L.WEIGLE TAX AMOUNT DUE $9.80 $10.00 $11.00 140 AIRPORT DR If Date of Payment is on 3/1/13 thru 4/30/13 5/1/13 thru 6/30t13 7/1l13 or Later � CARLISLE PA 1�013-'J105 � '� .� r.. , „ '� '�� , . . ..y �' '�, '� , ' , •f ... � • � �t. �,� . . `Y ,`• . �t. y • a TAX INSTRUCTIONS - READ CAREFULLY If you require an official receipt,send your check,two copies and a self-addressed stamped envelope. If not paid by 12/31l2013 this bill will be submitted to a collection agency for deiinquent collection. Failure to receive a bill does not relieve you from liability for prompt payment. No partial payments or postdated checks will be accepted and payment must be received or U.S.post marked by the due date. �Il�an�Zlau! ' • ' � � ' • ' ' • NEW INFORMATION CURRENT INFORMATION Control No: 2s-oo3�os DOLORES L.WEIGLE 140 AIRPORT DR CARLISLE PA 17013-1105 111 ' II1 I � V � � .�}1" � �-�-�".s�,7�, c7rc- L74�Lcrc� LZ.�z.y/r.> � . ��v a4/ �.z� ;�, � C�a.�c�'i�� t� ' /'�.1>',��r „f'�,�, ��`✓�ya'�y �,os� I � �i � u�q�� G� �%3/��U/,� 1 _ / '� P �to the y/, ' �order o �Gv /C'� ----- I $ %�19-� � - �-� ._,__.. � s.�„�, ��f -----___ Dollars � �..�"... �,�,�, Bsck. WdS� F�0_'AI�{�MA � For �.ej�.c._..._��c�ti..�.� M' �:0 3 1D00 50 3�: 5 6 38 3 9 l 408��' 2013-2014 CARLISLE AREA SCHO()L DISTRICT REAL ESTATE TAX BILL Biils now due and payable To: Ty�Ty� Millage 2%Discount Face 10%Penalty Robin K.Sollenberger,Tax Collector 5 Hill Drive �h��* 12.6056 $1,405.11 $1,433.79 $1,577.17 Carlisle,PA 17013 Office Hours: See Reverse Side Phone: 717-249-0747 . PAY FULL AMT TOTAL $1,405.11 $1,433.79 $1,577.1'7 If payiog installment 1,pay$477.95 before 8/31 7h-8/31 911-10/31 1111-12131 Owner: 'Tax Assessment Reduced(HomesteadlFarmstead) Bill# 004594 Parcei zs-1�-�sss-i2o. , . WEIGLE, BRUCE R& DOLORES Issue Date 7/112013 �nd Use �01 140 AIRPORT DRIVE Location 140AIRPORTDRNE CARLISLE, PA 17013 BeginningAssessment $�za,ioo Homestead Exclusion $10,35$ �I�'I'I'I"�'�u��'I'��I'I�I'II"I'��'�I"'��I�'�I�'� Ad�ustedAssessment $113,742 n� IMPORTANT! Tau Reduction $130.57 READ INSTRUC7'IONS ON BACK 11��N��U��q��N III'I I III Illkll I _.. __ . . . x —_ — . . ___ _.�� -� � DOLORES WEIG�E ESTATE � ' ��-8��23�3 1 O O`�. PH.�1�-2as-s2aa �ICT REAL ESTATE TAX BILL I 140 AIRPORT DRNE . Face 10%Penalty CARLISLE,PA 17013 � � ��''�i�� $1,433J9 $1,577.17 8 �� i t�!! � ��/3 �C E �,�order of` � � �✓��' ,�lGuo /� � G�� eJ �F,,,... ��;�'.a G ftsae�t °" a St $1,433.79 $1,577.17 �� MEMBERS 1�` 9/1 -10/31 11/1 -12/31 FEDERALCBIDTf[ID7ION �MKe.m�,r�vass 'arcel 29-17-1585-120. . ��'"�"� d Use 101 �� ,{� _�..��_�.^_ � :aHon 140 AIRPORT DRIVE �: 2 3 L 3 8 2 2 4 1�: 2 L 8 5 2 6 7 0 6 5��' L 0 0 L e� ; BHomeste dSE cs s onn $10 358 E Adjusted Assessment $113,742 ° . 'Tax Reduction $130.57 .ii rn■m . . . . IF PAYING INSTALLMENTS,START WITH COUPON#1 AT THE BOTTOM -----------------------------------------------------------------------------------------------•----------�---------------- 2013-2014 CARLISLE AREA SCHOOL DISTRICT REAL ESTATE TAX BILL Bills now due and payable To: Tax Type Millage 2%Discount Face 10%Penalty Robin K.Sollenberger,Tax Collector 5 Hill Drive School' 12.6056 No Discount $477.93 $525.73 Carlisle,PA 17013 Office Hours: See Reverse Side Phone: 717-249-0747 TOTAL $477.93 $525.73 Installment 3(Discard if paid in Full) Before io/31 Aiter 10/31 Owner: 'Tax Assessment Reduced(Homestead/Farmstead) Parcel 29-17-1585-120. Bill# 004594 WEIGLE, BRUCE R & DOLORES Issue Date 7/1/2013 �and use �oi 140 AIRPORT DRIVE �ocation 140AIRPORT DRIVE CARLISLE, PA 17013 BeginningAssessment $t24,1o0 Homestead Exclusion $10,358 IIIIIIIIIIIII'��I'IIII'II'I'I"'III'I�IIIIIIIIIIIIIII�IIIIIII III Adjusted Assessment $113,742 IMPORTANT! Tax Reduction $130.57 READ INSTRUCTIONS ON BACK TEAR HERE ----------------------------------------------------------------------------------------------------�--...._..-----•------- 2013-2014 CARLISLE AREA SCHOOL DISTRICT REAL ESTATE TAX BILL Bilis now due and payable To: Tax Type Millage 2%Discount Face 10%Penalty Robin K.Sollenberger,Tax Collector 5 Hill Drive School' 12.6056 No Discount $477.93 $525.72 Carlisle,PA 17013 Office Hours: See Reverse Side Phone: 717-249-0747 TOTAL $477.93 $525.72 installment 2(Discard if paid in Full) Before 9/30 After s/3o Ownef: 'Tax Assessment Reduced(Homestead/Farmslead) Bjll# 004594 Parcel 29-17-1585-120. WEIGLE, BRUCE R & DOLORES Issue Date 7/1/2013 LandUse �oi 140AIRPORTDRIVE Location 140AIRPORTDRIVE CARLISLE, PA 17013 BeginningAssessment $�2a,�oo Homestead Exclusion $10,358 III IIIIIIII'I�IIIIIIII'�IIIIIII�IIIII'�I'II�III�'I�'IIIII'll"I� AdjustedAssessment $113,742 IMPORTANT! Tax Reduction $130.57 READ INSTRUCTIONS ON BACK TEAR HERE ----------------------------------------------------------------------------------------------------------------•---------- _.. 1111 I III 11141II .. 1 p• * PPL Electric Utilities � ; ; ; � 827 Hausman Road �`��w�+��+�,,. 105•79 + Allentown, PA 18104-9392 � �� 156•71 + Tel. 800.342.5775 Fax 484.634.3484 �� .._ 59•83 + www.pplelectric.com •.�`.� � 50•82 + 49•1� + 122•75 + E WEIGLE 132•74 + RPORT DR 118•32 + � [SLE, PA 17013 795•09 * Bill Account Number: 15090-70009 Dear Bruce Weigle: Thank yau for contacting PPi,Electric Utilities. �nciosed is a, statei:�ent af y�u►~account as you requested on 03/17/2014. We understand that you are not disputing your account balance and have requested this statement for information only. If we can assist you further, or if you have any questions,please call us Monday through Friday, from 8 a.m. - 5 p.m. at 1-800-342-5775. You are a valued customer and we appreciate the opporiunity to serve you. Sincerely, PPL Electric Utilities Enclosure (Statement of Account) Statement of Account-No Dispute 0 0 �3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 o a o 0 0 0 0 0 0 �� U U * � � f W �y m (11 (� � �� O O V O O �--� O O O M O O O v� O O M O O �O O O N O O �D p 0 N vl vl vl � O O � a ; 0 � �� O O � O O O O O O N O O O M O O O O O N O O M O O U A.'7 . • N O O �9 �' h � � � � M V�'1 F7 W N � 00 M O O � � 'j�J � � �O � � � � :.i O . d � E9 O � � 5i �U � o � t� oo �o a � .. � .. a�g A'�i o 0 o cv �o in v � � � � � pG o 0 0 0 0 bo � d � d � y A W � � M (�, � � � � V O O O O O O p � Ar �-'�'i GQ � V � 'Lt 77 O O O O O O O O O O O O O O O O O O O O p O O O O � L Q O O O O O O O O O O O O O O O O O O O O O O O O O � y,� Qy O O O O O O O O O O O O O O O O O O O O O O C C O W`y fA 69 fH 69 69 fR 69 69 69 69 6A 69 !�H 69 fR 6A H9 69 69 fR 69 fA 69 69 6A �i A� a+ M C O � u W�� L(.�7Aa '� a�i o 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 �W�uj �'��' s�s � � � s�s � � � c�s s��s � � c�n s�s � � � s�s s��s � s��s � � s��s s�s �3 a � u�� o ��~U �'O O p O O O M O O O O O O O O O O O O O O O O O O O p L� O O O O O h O O O O O O O O O O O O o O o O o O O � � O C O O O O� O O O O O O O O O O O O O O O O O O O � ss u� ss� cfl �s � yi �s vj va s� v� ss crj ss ss �v vs v� s�s � va ss s9 s� W C�"� O M M I� 01 Q1 M �O .�-� l� .-. 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E�� a�� o caLL sncK - p�,o� o ca��cuw �s�► n waerenrrrr . - Catiste Pebok++m,inc. �.Ls`l�s. , ,. ,•�"_9i+ r�,i,.'��, ��.?8�,,'��A�9 �_.:°'�I�I�y ��,�d4�`�S NG GCOOIJNG �REGFRIGERATION OOTHER OSOURCE: i�� '�•�'�� COMPLETE OMICOMPLEIGE(oxpla6n) i�i� ��;0�05�� e Maice r+w E� s�Nu�R BILL TO: AIR FlLTER INFO: CUSTOMER OUR �j�„ DA � � P.O. d P.O. NAME J �i^ ��, Fsr� ADDRESS � a r � /� oK CITY/STATE/ZIP �� ,�3 . HOME WORK PHONE PHONE TECHNICL4N CONTACT NO RISK CUSTOMER .�L NAME FLAT RATE S APPROVAL ; . v . ; 3� : _� .: � :. .. .. . .,,. >,. , .. �G�� $ � DIAGNOSTIC FEE C.� c��..� i°� ♦1 ��ti� 9.9�` 1' i\� / l��l --�— —�-- ----- - --� �--.— . ._—_— _.. .__ ,:—. -- — �.— __ ._. .. -- —.-._. _-.. — .—.—.-- _._ .�.. �.ra�. - 6U-295 DOLORES L WEIGLE 3t3 � 3 4 3 14Q AIRPORT DRIVE CARLISLE,PA 17013 pA,�-��,/,,��"� � �� : //��/�/f �/ � ORDEROF E 1.../ ✓ i��l��CL�___5��._a_� I .11 I•�J'� �j . � a ' . � � — Dt�LLP.]tS U �.� � �TOTAL "� ; /�1M&TBank �s��ta� � � /E 15% � �� yyyr - _� //_ �� ' TMENT MEMO '��!/��•oosy�/7_�/7isf - r-- -=,��,�✓ IYP . T �:03L302955�: 98 5 28 7 7464iN0343 � -- -- -- — -- re --- --— S� _ ___._ —- -- —— _ . =� - __ _--- — — - sa-amerasoumrn�aa�ns..��s- — — _.___.__--- _ — •TIC FEE equipme�or materia!fumished un61 final&complete payment is made,and �N(TIAL 'rf settlement is not made as agreed,the seifer shall have the rigM to remove DWGNOSTIC FEE same and the seller witl be heki harmiess for amr damages resuldn9� ADDI710NAL the removal thereof. X 'a ��vt �y- I 3 AUTHORIZEO S ATURE DATE – 70TAL/1MOUNT WE �� 1. S �2006 Aptora All Rights Reserved. �i i i i ♦ " j f0� 343 DOLORES L WEIGLE 017� 140 AIqPORT ORIVE . CARUSL&P0.17013 ��!//a(/� # �T�- 9 PAY707HE �/�� /�//n�j •-------�a��/ I �' I�7 Y�7 . OIIDCROF,� _ ._. . . ._-_. � /l /�'s �"-- �.f <tnc� �� ur— Dou.aRs 8 a.. �� , � /c�IMBeTBarik � �D��' ' � — `...""'"' ��3 //Ass M#f0_hi�,.n.i 1�w, /�/l.� '7�'G�=�=-i�. /r Air.�J �► .� �i:031302955�: 9852877464�'0343 . .. >os�3oetza� �,ot3rozite�3:ss:as-•j � • SUSa t110100100292Q _ - vT��a.J-�_��+�-.�i��?J�.�:J1iJSSTV1t�UlU:lLt'LJ � ,m� � . � ryr ii :L'N - .. ' _ �?7fr�1�.� � JTm� r . . � �t' Or"�� ;�, �n � ,. � 4 O��i G - _ .- . ^ N�� u � _ - - �=n �n ` _ . V p. 1 b n - ' . ._ .. , . �:� 1 of 1 ■i u � � ` • � statement STATEMENT Page: 1 CARLISLE PETROLEUM INC CPI MECHANICAL CONT. 717-245-2382 1524 E COMMERCE AVENUE CARLISLE, PA 17015-9161 Date: 03/17/14 BILL TO ACCOUNT #:7093 Reference M5. PATRICIA ADAMS SAME 140 AIRPORT DRIVE CARLISLE, PA 17013 CURRENT OVER 30 DAYSOVER 60 DAYSOVER 90 DAYS TOTAL_ DUE Previous Balance 55.45 0.00 0.00 0.00 55.45 -1,076.69 DATE REFERENCE QUANTI�TY DESCRIPTION CHARGES CREDITS AMOUNT O1/09/13309 ��'"�'��- `�y `1�I PAYMENT -296.00 �'�� -1372.69 Ol/23/135421 180.5 DYED #2 678.50 -694.19 02/15/1324845 TUNEUP 179.95 -514.24 02/18/13343 PAYMENT -179.95 -694.19 03/04/13MC PAYMENT -296.00 -990.19 03/27/1313549 170.4 DYED #2 655.87 -334.32 04/18/13CLSOUT �zsCouNT -334.32 05/22/13SA�E:1892253 CC PAYMENT -136.00 -470.32 06/21/13SA�E:1916988 CC PAYMENT -136.00 -606.32 07/22/135ALE:1944415 CC PAYMENT -136.00 -742.32 - 08/21/135A�E:1973940 CC PAYMENT -136.00 -878.32 09/23/135A�E:2008694 CC PAYMENT -136.00 -1014.32 10/21/13SALE:2037629 CC PAYMENT -136.00 -1150.32 10/31/1314562 139.8 DYED #2 517.12 -633.20 11/21/13SALE:2069178 CC PAYMENT -136.00 -769.20 �1 /23/135ALE:2102826 CC PAYMENT -136.00 -905.20 /15/1415688 192. 5 DYED #2 731.31 -173.89 O1/21/145ALE:2135129 CC PAYMENT -136.00 -309.89 02/21/14SA�E:2171997 CC PAYMENT -136.00 -445.89 03/12/1417800 177.6 DYED #2 701.34 255.45 03/14/14MC PAYMENT -200.00 55.45 E STATEMENTS AND ON LINE ACCESS CALL 717-245-2382 TO REGISTER CARLISLE PETROLEUM INC 7093 on balances of 30 days or over we will compute A FINANCE CHARGE OF 1.50% PER MONTH, .WhiCh i5 18% ANNUAL PERCENTAGE RATE. PAY THIS AMOUNT$ 55.45 17�•95 + 296• + 136• + 136• + 136• + 136• + 136• + Page 1 136• + 1�2�)1•95 * � i � � � �� - STATEM�NT Page: 1 CARLISLE PETROLEUM INC CPI MECHANICAL CONT. 717-245-2382 1524 E COMMERCE AVENUE CARLISLE, PA 17015-9161 Date: 03/17/14 BILL TO ACCOUNT#: 7093 Reference Ms. PATRICIA ADAMS SAME 140 AIRPORT DRIVE CARLISLE, PA 17013 . ': GURRENT ' OVER:3�QAYS=: �VER�{}G1AYS �V�R�a I�AYS TOTA�'�UE : Previous Balance 55.45 0.00 0.00 0.00 55.45 -1,076.69 DATE REFERENCE :QUAtVTITY DESCRIP'�'l01V �HARC�ES ' CRED(TS AMI�UN'P' 01/09/13 309 PAYMENT -296.00` -1372.69 01/23/13 5421 180.5 DYED#�2 678.50 -694.19 02/15/13 24845 TUNEUP 179.95 -514.24 02/18/13 343 PAYMENT -179.95 '_ -694.19 03/04/13 MC PAYMENT -296.00 � �✓ -990.19 03/27/13 13549 170.4 DYED#2 655.87 � -334.32 04/18/13 CLSOUT DISCOUNT -334.32 05/22/13 SALE:1892253 CC PAYMENT -136.00 � -470.32 06/21/.13 SALE:1916988 CC PAYMENT -136.00 f -606.32 07/22/13 SALE:1944415 CC PAYMENT -136.00 i -742.32 08/21/13 SALE:1973940 CC PAYMENT -136.00 4 -878.32 09/23/13 SALE:2008694 CC PAYMENT -136.00 -1014.32 10/21/13 SALE:2037629 CC PAYMENT -136.00 -1150.32 10/31/13 14562 139.8 DYED#2 517.12 -633.20 11/21/13 SALE:2069178 CC PAYMENT -136.00 -769.20 12/23/13 SALE:2102826 CC PAYMENT -136.00 -905.20 01/15/14 15688 192.5 DYED#2 731.31 -173.89 01/21/14 SALE:2135129 CC PAYMENT -136.00 -309.89 02/21/14 SALE:2171997 CC PAYMENT -136.00 -445.89 03/12/14 17800 177.6 DYED#2 701.34 255.45 CAR�.ISLE PE`CRC}i:�UM !NC , 7Q93 On balances of 30 days or over we will compute Continued... A FINANCE CHARGE OF 1.50% PER MONTH, which is 18%ANNUAL PERCENTAGE RATE. PAY THIS AMOUNT ■ � � \. _� . • � . • _—___ ��s�r-"�"��:•i.i— __"y f.�--' - '__ ^ � ! p � ` It�� S� v;�� I ' I � /� �,� 1.� J f s' '� � DOLORES L WEIGLE r� 3O9 �� t - »o a�watr arrvE � � CMUSLE.PA 17073 r" . . on� � �i �/ . �: � - ,, . . - . .. � '��aE , $� �9G.vU _- � . Dou.eas 8 � ��. � �a M&TBank _...:--�'� �� ..�,�� e a.�:.�.�� :0313 2 55i: 9852877464�'0309 ��..=,�..�� ------�.-��s�..�:�<-�_ >ost3oe�zs< �3ro�roe ts�st:sa .'� _ - susa .tiQo�000e2�Qeo ; .. . -- . � �� { 8 =" �=`= .`'�y = _�' �7i.� ' N f„' M �"-! � LO''f�..7t y�yC'1f�i7 !' .� . "' SL�SG fi117,ri1GGv�21G3� m 5y � " 1C m _ . _ , �,.7 g ,�� 40 m A� � • . .�p �i.Qts n . - - i .^.111 N �C� � r �,. p O l s =� - � - . p� �ri ��' . . _ � ; � N n - I f �� . 1 of 1 ■ i � � BUDGET STATEMENT - � Statement Date: 04/17/12 � CARLISLE�PETROLEUM INC Page: 1 CPI MECHANICAL CONT. 717-245-2382 1524 E COMMERCE AVENUE CARLISLE, PA 17015-9161 PLEASE INSERT AMOUNT PAID Customer No: 7093-1 Reference Ms. DOLORES WEIGLE SAME 140 AIRPORT DRIVE CARLISLE, PA 17013 To Insure Proper Credit Return This Stub With Your Remittance DATE REFERENCE QUANTITY DESCRIPTION CHARGES CREDITS Balance Forward 0.00 05/09/11 142 PAYMENT 205.00 06/08/11 146 PAYMENT 205.00 07/11/11 157 PAYM ENT 205.00 08/09/11 165 PAYMENT 205.00 09/06/11 7613 161.2 DYED#2 580.16 09/12/11 174. PAYMENT 205.00 10/06/11 183 PAYMENT 205.00 11/07/11 186. PAYM ENT 205.00 12/07/11 196 PAYMENT 205.00 01/05/12 9929 171.7 DYED#2 643.70 01/16/12 207 PAYMENT 205.00 01/17/12 22298 SERVICE CALL 163.70 02/09/12 214 PAYMENT 205.00 02/09/12 215 PAYMENT 163.70 02/15/12 22431 SERVICE CALL 132.45 03/07/12 219 PAYMENT 132.45 03/07/12 218 PAYMENT 205.00 Continued... ■i i � � BUDGET STATEMENT Statement Date: 04/17/12 � CARLISLE PETROLEUM INC Page: 2 CPI MECHANICAL CONT. 717-245-2382 1524 E COMMERCE AVENUE CARLISLE, PA 17015-9161 PLEASE INSERT AMOUNT PAID Customer No: 7093-1 Reference Ms. DOLORES WEIGLE SAME 140 AIRPORT DRIVE CARLISLE, PA 17013 To Insure Proper Credit Return This Stub With Your Remittance DATE REFERENCE QUANTITY DESCRIPTION CHARGES CREDITS 03/21/12 8186 168.7 DYED#2 674.63 TOTALS 2,194.64 2,551.15 This Credit Balance Is Being Applied Towards The New Budget Total -356.51 Your next Budget starts 05/01/12 Monthly Payments will be$ 148.00 Balance -356.51 � � °��`�� State Farm Fire and Casualty Company RENEWAL CERTIFICATE � f00StateFarmPlace P�L�YNUIu�E'fts �S;-8�-7)�3 eai�ston Spa,NV f202o-800o Homeownera Policy JUL 01 2013 to JUL 01 2014 P-13- 6713-FABC H W F ��p�� "�� JUL 01 2013 $568.00 WEIGLE, DOLORES L 140 AIRPORT DR Coverages and Limits CARLISLE PA 17013-1105 Sectionl A Dwelling $170,000 Dwelling Extension Up To 17,000 B Personal Property 127,500 C Loss of Use Actual Loss Sustained Deductibles-Section I All Losses 500 Location: Same as Mailing Address ' Section II • L Personal Liability $100,000 a Damage to Property of Others 500 a M Medical Payments to Others 1,000 _ Loss Settlement Provisions(See Policy) (Each Person} A1 Replacement Cost-Similar Construction 61 Limited Replacement Cost-Coverage B Forms,Options,and Endorsements Homeowners Policy FP-7955 Increase Dwlg up to$34 000 OPT ID pnnual Premium $568.00 Ordinance/Law 10'/0/ �17,000 OPT OL o Jewelry and Furs$1,500/$2,500 OPT JF Amount Due $568.00 Homeowners Policy Endorsement FE-3518 Premium Reductions Claim Record Discount 115.00 � w � Inflation Coverage Index: 246.3 Please help us update the data used to determine your premium.Contact your agent with the year each of your home's utilities(heating/cooling,plumbing,or electrical)and roof were last updated. � � Moving?See your State Farm agent. TI_�/._Q�,.�„c�y��,�� (��pa�, See reverse for�mportant informahon. 4316� �`2011 w'vl Ag t FETTERM INSURANCE AGENCY IN aea Prepared MAY 09 2013 E DR,NP,6H,N7 Telephone (717)249-4251 014 . � . . ..A., • State Farm Fire and Casualty Company RENEWAL CERTIFICATE i00 State Farm Place ��-�� '�� Ballston Spa,NV 12020-8000 Homeownefs PoliCy JUL 01 2012 to JUL 01 2013 P-13- 6713-F382 H W F ��T�� JUL 01 2012 $408 00 WEIGLE, DOLORES L 140 AIRPORT DR Coverages and Limits CARLISLE PA 17013-1105 Sectionl A Dwelling $162,600 � Dwelling Extension Up To 16,260 B Personal Property 121 950 � C Loss of Use Actual �oss Sustained Deductibles-Section I `. All Losses 1,000 , E � ` �� Location: Same as Mailing Address � � � � Section II L Personal Liability $100,000 � Damage to Property of Others 500 a M Medical Payments to Others 1,000 � Loss Settlement Provisions(See Policy) (Each Person) A1 Replacement Cost-Similar Construction Bi Limited Replacement Cost-Coverage B Forms,Options,and Endorsements Homeowners Policy FP-7955 Increase Dwlg up to$32 520 OPT ID 408.00 Ordinance/Law 10'/�/ �16,260 OPT OL Annual Premium $ o Jewelry and Furs$1,500P$2,500 OPT JF Amount Due $408.00 Homeowners Policy Endorsement FE-3518 Premium Reductions Claim Record Discount 94.00 � � Inflation Coverage Index: 235.7 Please help us update the data used to determine your premium.Contact your agent with the year each of your home's utilities(heating/cooling,plumbing,or electrical)and roof were last updated. � � � Moving?See your State Farm agent. T/__��e� �� qy�� See reverse forimportant informahon. �� FETTERM INSURANCE AGENCY IN ReP Prepared MAY 10 2012 5203 zoii i Ag t E 3A,DR,NP,er, Telephone (717)249-4251 014 03f1712014 09:37 717-243-0377 N M A PAGE 01I01 �ti�r��,,;i i� ��'p�i�a:�a�T>:iiti ��.G�6��a`�a��r NoFth Middietorl AUtF�ority PaBe 7 11 71201 4 9:31;42 AM DMSfch � z�� '�rWd�r pCl�� Account Pro�i�e ��y0� ��,�,�� 74i�-1100 � J ►ccount 09001000 0 BRUC�R.WE��-� Customer �i1Nng Addt'ess OWt18r BRUCE R,1N�IGl,E BRUCE R.W�IGLE 14U AIRPORT DR %PATRICIA AT7AMS CARLISLE 140 AIRPORT DR 7172498244 CARLISLE PQ 170131105 _ . ....:. _.... Transactions Cons Amoun# Balance oate �ue Date check �roup T�e Ba��h 8a.07 3:07 03101/2014 3/30/2014 Morrthly Bil� Bi1114�10�093356 z 01/30/Z014 1/30/2014 Monthly Payment REC20140131102219 -86.a7 d0 Monthly Bill Bt11131101733003 2 83.07 .07� 12/31/2U13 1l�012014 p 5,00 5.00 12113l2Q13 12I1312013 MoMhly Adjustment DEL131206150600 Onmer Posting Fees _g�.Z3 0.� 12I0912013 12/9I2013 Monthly Payment RF_C20131210105144 12l02/2013 12/212013 Monthly Adju6tment PEN131�203145308 0 e�.16 �7�' Penaltyr 83.0� 3-0� 11 l01/2013 11/3012013 Monthly BIII 8111130903082644 4 -83 0� �� 09l30/2013 8/30/2013 , Month�+ Payment REC20131001121954 8�11 611113D775113257 2 83.07 ,�7 .. : !� 09/p1l2U13 ,.9I3012013 Mo�chty .s�.z3 0.00 � 08/13/2013 8/13/2073 Monthly P�ymel�t REC20130613155928 � Montnl Adjustment P�N130731153259 0 4.16 -23 : 0713.112D13. 7l31/2013 Y . � .�. . Panariy -----� . ... .. 09l01/2Q13 7J3012013 Monfhty Bill Bi11130430151425 3 83,07 ��-� Month Payment R,EC20'{30611110438 -87.23 0.00 06l07/2013 6R/2013 ry p 4,�6 87.231 j 05/31l2013 5/31I2013 Monthly Adjustmerlt PEN130603102257 � ,;. Penalty ' . . Month Bill Bi11130304090620 3 83,07 83.47 OSro�t2019 5l30/2013 ry -ga.A4 O.oO 03/21/20�3 3/21l2013 Monlhty Payment REC20130322094315 �,+� Monthl Bill Bi11130102161602 7 -L� �� 94.44 94,4� �3l01/2073 3/30l2D13 Y �r ��f' �3,07 0.00 o1H112013 111112073 Monthly Payment R�C20130116140022 -y ` Montfil 8ill Bi11121101091654 3 ��`1 � B3.D7 � 12/31(2012 1130/2013 Y �..,_ -- Meb'�r`Readirtgs • �°�� Prevlous Cutrent ConsumptiOA Multlpller �allOnUsBge �� 1, 0�718/1�4 Actual 167 i89 2 1 Q BIII14010209335e 12/18/13 ACfual i85 187 2 1 2 BIII131101133003 ;' 1p/18113 Actual 181 16S 4 1 4 BiIt130903Qe2844 08%2D113 Adual 179 181 2 1 2 Si1113D715113257 B111130430151425 �, " 06J1 S/13 Actual 176 179 3 1 3 �'� 04/17/13 Actual �t73 178 3 1 3 9111130304090620 02118/13 ACtUaI '166 173 7 1 7 BIII130102161602 �J 12/14/12 Actual 163 166 3 1 3 BfIH211D1091654 +i 1Q119/72 Actual 160 163 3 1 3 B�II'i209047138U7 � `Vl � '� - -- ._ . .. __ � ^ •t� J f t,'� 4 v �� . � u 83•07 + 9,�•G4 + 87•23 + 87•23 + B3•Q7 + 435•04 * � a i� � -- . ' ��.� 308 DOLORE8 LWEIGL6 aia 1r0 NRFOfli DiWE CNilIBLErPA 17079 Dw18_�� ,� /j �/ �,�/ � =Po"�c�1'/-sf��L��16ts.� $ B.�4? � a� L� � �: ! ".�.d..o�. t.��►+o ��(C' .�, � ��r/.r�.r -i:0 3�i 30 29 5 5�: 98 5 28 7 7464rt0 308 � ---�---- --�-F� - ' 4 d - O =O C� >03131503fK � O=x�tam Saak ��.0 SAippeaabnzg, YJ1 17257 � Phoao: 717-532-6114 Bns Date: 01/11/2013 ' . � Bsanch/Tallax 0043/0222 � 01/il/2013 12:09:52 f 1 �f 1 . . . Yatrisha Adams �ob: 140 Airport Drive ,�• � Carlisle, PA 17013 Phone#1 Phone#2 Terms Invoice Date - - 7t7-249-8244 - - 7i7-385-2434Ce11_ — _ 15 Days 3/12/201 j Description Item Number Quantity Unit Price Extended Amount Install exhaust fan/light combo .��a�+c� misc 1 350.00 350.00 �ald �►n lo.�i,t�� PATRICIA A. ADAMS ��13 � Z O 91. � 140 AIRPORT DRIVE CAflUSLE, PA 17013-1105 ,� :.�c�(J ��f. _�,� , ,. � � a � �� .� i $ .��C7 0 0 _ �,� - � � p+�� 3 ��-'*,$ef;� L'! wn.'_F...6 nwraro�c Sovereign Bank �OJ PART OF THE SANTANDER GROUP i5��// ,...' ,._� . � ,. '.��i,� ./ / r ....... .'rs�C �--��. �� ` ._.__ �: 23L372691�: , --- -— 289 L0404 5 7�i 209 i � �, --. � � � � � � � , __� -�� f. � � _z � � � _�, ,a ._ . �; � , � �� i L� �6�an� ou n �' - ��.. f_., � �.�� _ �.��,��: � �O : �� Y� � � ��:�� yo�. business! � ��.:�.F� � .g�� 3so.00 � ► ��: .�'��.�� i i� � Welcome to M&T Online Banking � Page 1 of 1 �,. "�� ! ��,�� MARCH 21,2013 � �r �,* I � `'�� `�r � �..,., ..'. 4 Accounts Transfers Biil Pay Alerts Customer Service ACCOUNT SUMMARY>CHECKING DETAIL M&T Classic Checking w/interest �� $T�� Y'r�ur c.,,�r�i. Related Links: Transfers& Loan Pavments � View/Edit Transactions Statements & Documents � Export Data � Order New Checks � ATM &Debit Card Overdraft Choice � Finance WorksTM (Applv for a Loan � Order Custom Card accounc Classic Checkin 7464 :�'. Total Balance $a2.sa g _._.... Available Balance $42.54 . a Vew Calendar Uew Calendar �� . �-- - -.:. Show Select Range � _or- View From 01/10/2013 ! Ta 03/19/2013 � �+Date Transaction Descriation Cr ' L�"��;, Total Balance x:(:!�/ �` 'O —03/06/2013 SERVICE CHARGE -$4.�5��' ° $42.54 02/22/2013 CHECK NUMBER 0344 _a0--••";; '��"' $47.49 ;J� c��. a 02/20/2013 CHECK NUMBER 0343 �u�-�+�c�c. -$179.95 '�' $242.49 01/31/2013 CHECK NUMBER 0342 �� "- Cjysrr - -$103.50 f;U+r ��'�'�,�$422.44 � 01/30/2013 DEPOSIT Z)d�f; �;h+rr C�–$100.00 $525.94 . 01/16/2013 VVAL-MART#2574 CARLiSLE �,.y,� �;,�.r -$39.16 $425.94 ��k � 01/14/2013 CHECK NUMBER 0341 M�-�d�srul ��`NJ�'3 - �i�f�� (�/�Q-�0.50,„,�,, Q'�' $465.60 �"-% T� -�P2�.�� h.:, Ea-r. 01/14/2013 CHECK NUMBER 0308 �'e�rr.�w:�t.-$83.Q7��" �' $485.60 01/14/2013 MCDONALD'S F46�"9 CARUSLE � -$7.08 $568.67 � ��3` 01/14/2013 GIANT 6112 01/14 M �,t�vu�j% ��`�_$296.0� �,, �`'� � $707.42 l � �/10/2013 CHEGK NUMBEft`0389 I� � � Depending on when your statement generates,you may not see a full 90 days of history. If your statement has just been generated,you may get a message indicating that no transactions are available from 61 -90 days. O 2013 Manufacturers and Traders Trust Company.Users of this web site agree to be bound by the provisions of the MB�T Web Banking- Conditions.Vew the Terms and CondiUons,Privacv Policv or Securitv Information. https://onlinebanking.mandtbank.comlhistory/HistoryChecking.aspx?Id=1 3/21/2013 ,-z=''"_.- • OMB Approval No. 2502-0265 1_ � ...:. _ HUD-1 {::' = � � � � ` A. Settiement Statement (HUD 1) 7--. �� z_. --_ .�� Page 1 of 3 ,8, Type of Loan _ _-- 2.�RHS 3.❑X Com. Unins. 6. File Number: 7. Loan Number: 8. Mortgage Insurance Case Number: _ - �.�Conv. Ins. 401403556-SK 7132692810 C. NOTE: "�is farm is fumished to give you a statement of actual settlement costs.Amounts paid to and by the settlement agent are shown. :.=-ns markec4 "(p.o.c.)"were paid outside the closing; they are shown here for informational purposes and are not included in the • --*�:o `;D. Name and address of Barrower E. Name and Address of Se{ler F. N�me and Add�ess Of Lender ^�,�_r, _ �_��;�,. � DOUGLAS A. WEIGLE,CO-EXECUTOR AND COLDWELL BANKER HOME LOANS __ _ � _,::;��r t PATRICIA A.ADAMS,CO-EXECUTOR OF 1 MORTGAGE WAY, - ��c = -- - � ESTATE 0'r DOLOROS L WEIGLE,A/K/A MOUNT LAUREL, NJ 08054 �r i CGLORES L.:VEIGLE,A/K/A DOLORES L. Y,IEiGLE ; 140 AIRPORT DRIVE CARLISLE, PA 17�13 G. Property Location H.Settlement Agent GUARDIAN TRANSFER 140 AIRPORT DRIVEr 485 ST.JOHNS CHURCH ROAD, ��E��,c �h _�� SNIREMANSTOWN , PA 17011 Phone : (717) 901-8342 .... =�"'==�-�`:� Place of Settlement i.Settlement Date -"-_--- --"- '-=-----.. 12/18/2014 -� � ,_-:- `�==- . '"--�- ='�-�'�'%`ti��? 1068 HARRISBURG PIKE CARl35lE, PA 17013 Disbursement Date 12/18/2014 3, Summa of Borrower`s 7ransaction K. Summa of 5eller's Transaction 2gp,Gsoss Amount pue from Barrower 400.Gross Amount Due to Seiler -_ - ,_�J�;.ri -�-w $123 60U.00 401. Contract Sales Price 123 600.00 :-= :_.�_�_ �,�.,�, 402. Personal Pro e --- _-- --- -�� ---:r. ^e"s4�0 $6,492.93 403. 404. : 405. qd•:�stment for items aid b seUer in advance Ad"ustme�t for items aid b seller in advance -_ ,,-�X� 406. Ci /Town Taxes - �_��s��+-axes 308.7400/ r 12J18/z4 to Ol/Ol/15 $14.14 407. Count Taxes 368J400 r 12/18/14 to Ol/01/15 $14.14 108. r.ssessmencs 408. Assessments 109. SchoolTaxes 1442.76Q0/ ri2/18/14 to 07/O1/15 770.79 409. SchoolTaxes 1442.7600/ r12/18/14 to 07/OS 15 770.79 110. 410. 111. 411. 112. 412. 120.Gross Amount Due from Borrower $130 877.86 420.Gross Amount Due to Seller $124 384.93 . . . .. . . .. . .. . ....... .... ■a �u..i. �.. . .. 20U.Amounts,Paid by or in Behalf of Borrower 500.Reductions In Amount Due to Seiler 201. De osit or earnest mone $1,000.00 501. Excess De osits Principal Loan Amount from Coldwell Banker Home 502. Settlement Char es to Seller 20,548.07 'Z�Z' Loans $98,880.00 503. Existip loan s taken sub'ect to 203. Existin loan s taken sub'ect to 504. 204. Seller Paid Closin Costs $6,300.00 505. 205. 506. Seller Paid Closin Costs $6,300.00 206. 507. 207. 508. 208. 5a9. 209, Ad'ustments for items un aid b seiler Ad"ustments for items un aid b seller 510. Ci /Town Taxes 210. Cit Town Taxes 511. Coun Taxes 211. Coun Taxes 51Z. Assessments 212. Assessments 513. 213. 514. 214. 515. 215, 516. 216. 517. 217. 518. 218. 519. Z1g, 520.Total Reduction Amount Due Seller �26,848.07 220.Total Paid b /for Borrower $1U6,180.00 300.Cash at Settlement from/to Borrower 600.Cash at Settlement to/from Seller 301. Gross amount due from borrower line 120 $130,877.86 601. Gross amount due to selier line 420 $124 384.93 302. Less amounts aid b /for borrower line 220 106 180.00 602. Less reductions in amount due seller line 520 26,848.07 303. Cash X From To Borrower $24,697.86 603.Cash X To From Seiler $97,536.86 The Public Reporting Burden for this coliection of infortnation is estimated at 35 minutes per response for collecting,reviewing,and reporting the data.This agency may not coilect this information,and you are not required to complete this form,unless it displays a currentiy valid OMB controi number.No confidentiality is assured;this dis osur� is mandatory.This is designed to provide the parties to a RESPA covered transaction with information during the settlement process. '�'r"j' . Initials ',��'� 401403556-SK HUD-1 Page 2 of 3 L. 5ettlement Char es � 700.Total Real Estate Broker Fees$8011.00 Paid From Paid From Division of Commission line 70� as follows: Borrower's Funds Se(ler's Funds 701. $4003.00 to Re/Max ist Advanta e$3 708+$295 At Settlement At Settiement 702. $4008.00 to Caldwell Banker Residential Brokera e$3,708+$300 703. Commission aid at settiement $300.00 $7,711.00 704. 800.items Payable in Connection with Loan 801. Our ori ination char e 703.00 from GFE #1 802. Your credit or cha e oints for the s ecific interest rate chosen $1 024.80 from GFE#2 803. Your ad'usted ori ination char es from GFE A $1,727.80 804. A raisal Fee to STARS from 6FE#3 $515.Q0 805. Credit re ort to CBC Innovis Inc, from GFE#3 $7.22 8�6. Tax Servi�e from GFE #3 807. Fiood Cert. Fee from GFE#3 808. 900.Ytems Required by Lender to Be Paid in Advance 901. Qaily interest charges from 12/18/14 to Ol/Ol/15 @ 10.99/day Coldweil (from GFE#10) $153.86 Banker Nome loans 902. Mort a e Insurance Premium from GFE#3 Homeowner's Insurance 1 year to State Farm Fire And Casualty Company Q�z (from GFE#11) pr.�-rg? c3�4.04 :04 1000.Reserves Deposited with tender 1001.Initial de osit for our escrow account from GFE#9 $626.55 1002.Hazard Ins. Reserve 3 Month(s)@ 32.42 per Month(5)Coldwell Banker $97 z6 Home Loans 1003.City Property Taxes 11 Month(s) @ 7.25 per Month(s)Coldweli Banker $79 75 Home Loans 1004.County Property Taxes 3 Month(s) @ 24.18 per Month(s)Coldwell Banker $72.54 Home Loans School Taxes 7 Month(s)@ 122.68 per Month(s) Co�dwell Banker Home 1005.Loans $858.76 1006.A99regate Accounting Adjustment to Coldweli Banker Home Loans - $481.76 1007. i 100.Titie Charges 1101.Title services and lender's title insurance to Guardian Transfer from GFE#4 1 484.50 1102.Settlement or closin fee to Guardian Transfer 225.00 1103.Owner's title insurence to Guardian Transfer from GFE#5 $227.50 1104.Lender's title insurance to Guardian Transfer $1,094.50 1105.Lender's title pofi limit 98 880.00 I'?^S.O��:ne�'s title palic limit $123,600.00 - ��e�:`s oortion or the total titie insurance remium to Guardian Transfer $1 189.80 -' " •r*:ePs aor[Eon of the totai title insurance remium to TRGC 132.20 ---- r-< --_ ^ _ �rQ`ectiion l.etter to TRGC 125.00 . . .. . . .. . .. . .. . . . . . , .. .. ... .. .. ■ i.i. . 1200.Government Recording and Transfer Charges fram GFE #7 $195.00 z�ni�Government recordin charqes 1202.Deed (5pgs+ Statement of Value) $82.00 Mortgage(21 pages) $113.00 Releases 1203.Transfer taxes • from GFE#8 $1 236.00 1204.Cit /Coun tax/stam s Deed 1236.00 Mort a e$ $1,236.00 1205.State tax/stam s Deed $1236.00 Mort a e$ 1206. 1300.Additional Settlement Charges from GFE#6 $19.50 1301.Re uired services that ou can sho for $19.50 1302.Flood Certification to STARS 8 343.00 1303.Ecscrow for Inheritance Taxes to Secured Land Transfers-Mechanicsbur 13D4.Home Ins ection to The Virtus Grou POC 300.00 1305.Radon Testin to The Virtus Grou POC$100.00 1306.Pest Ins ection to The Virtus Grou POC 50.00 $2,275.00 1307.Electrical u rade and ins ection to Kevin's Electricai Service, lLC 900.00 1308.Radon S stem Installation to American Radon Solutions Inc. 83.07 1309.Final Sewer/Water Bill- 10/17-12 18 to North Middieton Authori 1400.Total 5ettlement Charges(enter on lines 103,Section]and 502,Section K) $6,492.93 $20,548.07 If you have any questions about the settiement charges and loan terms listed on this form,please conlact your lender.5ettiement agent is not responsible for content of lender's assessments on HUD. The sellers and borrower's signatures hereon acknowiedge their approval and signify their understanding thai tax and insurance prorations and reserves are base on figures for the preceding year or supplied by others or estimated for the current year,and in the event of any change for the current year,ali necessary adjustments will be made between borrower and seller directly.Any deficit delinquent taxes or moRgage payoffs wiii be promptiy reimbursed to the settlement agent by the seller. I have carefuily reviewed the HUD-1 Settiement Statement and to the best of my knowiedge and belief,it is true and accurate statement of ali receipts and disbursements made on my account or by me io this transactio .I further certify that I have received a copy of the HUD-1 Settiement Statement. J � , ,� SELLERS BUYERS r ,- ,� � � � � �- i'� �'� Estate of Doloros L.Weigle,alk/a Deiores L.Weigle,alk/a Dolores L. ;�.fiui��G�i�,o /. - Wei le ---- Ronaid L. ic� k Jr. / 9 ' C �! . _.Y� `~-_'. By:Douglas .Weigle,Go-Executor y� � - � ��f ,� By:Patricia A.Adams,Co-Executor r' The HUD-1 Settiement Statement which I have prepared is a We and accurate account of this transaction.I have caused or wiii cause the funds to be disburse m aecordance with this stater�ent.�; , Settlet►tenfAgent `�� ,�� ; �-- Date t �� Y p�4a'�t,-4,r�« C.,i� � �'� " �F� 12118f2014 � •Any items marked"POC"were paid outside closing by:Bonower POC(B),Lender POC(L).Mortgage Broker POC(M),Seiler POC(S),Real Estate Agent POC(R),or Other POC(0). . . . ..... .. ... .. .... .. . ... . . . . . ■i u.n i.. .. . • � HUD-1 Addendum File Number: 401403556-SK Settlement Agent/Piace of Settlement: Property Address: 140 AIRPORT DRIVE, Guardian Transfer CARLISLE, PA 17013 485 ST.JOHNS CHURCH ROAD, SHIREMANSTOWN, PA 17011 COUNTY: CUMBERLAND Phone : (717)9�1-8342 PARCELID: 29-17-1585-120 TOWNSHIP: NORTH MIDDLETON TOWNSHIP Seller(s): DOUGLAS A. WEIGLE, CO-EXECUTOR AND PATRICIA A. ADAMS, CO- EXECUTOR OF ESTATE OF DOLOROS l.WEIGLE,A/K/A DELORES L. WEIGLE,A/K/A DOLORES L.WEIGLE Buyer(s): RONALD L. DICK JR. Settlement Date: 12/18/2014 4:30:00 PM Disbursement Date: 12/18/2014 � Loan Number: Lender:Coldwell Banker Home Loans Mortgage Broker: 713Z692810 Buyer Charges Seller Charges New Loan Fees: loan Origination Fee%to Coldwell Banker Home Loans $703.00 Loan Discount Fee%to Coidwell Banker Home Loans $1,024.80 Line 803 Ta�al: $1,727.80 $0.00 Appraisal Fee to STARS $515.00 Credit report to CBC Innovis, Inc. ��.z2 Additionai Settiement Charges: Flood Certification to STARS $19.50 Line 1301 Tatal: $19.50 $0.00 Titie and Escrow Charges: Settlement/Closing Fee Buyer to Guardian Transfer $225.00 Notary fee to Guardian Transfer $40.00 Lender's Coverage to Guardian Transfer $894.50 Enhanced Policy Endorsements to Guardian Transfer $200.00 Insured Closing Protection Letter to TRGC $125.00 Line 1201 Tatal: $1,484.50 $0.00 Owner's Coverage to Guardian Transfer $227•50 Line 1103 Total: $227.50 $0.00 CERTIFICATION FOR NO INFORMATION REPORTING . • • ON THE SALE OR EXCHANGE OF A PRINCIPAL RESIDENCE File Number:401403556 Property Address: 140 AIRPORT DRIVE CARLISLE, PA 17013 Closer: Shirley Keys Date of Settlement: December 18,2014 Sellers Gross Proceeds$123,600.q0 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 Internat Revenue Service on Form 1099-S, Proceeds From Real Estate Transactions. If the seller properly completes Parts t and III,and makes a true response to assurances(1)through(6)in Part II (or a not applicable response to assurance(6)),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 real estate reporting person must either obtain a certification 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 I. SELLER{NFORMATION 1. Name of Seller: ESTATE OF DOLOROS L.WEIGLE,A/K/A DELORES�.WEIGLE,AlK/A DOLORES L.WEIGLE 2. Forwarding Address of Sel�er: � �— Phone: �� -.._ '� /�_� � � �/�� '��a�il�_� �'9 /�1� l� " � 3. Social Security Number: � (Taxpayer I.D. Number) You are required by law to provide Guardian Transfer with your correct taxpayer identification number. If you do not provide Guardian Transfer with your correct taxpayer identification number, you may be subject to civil or criminal penalties imposed by law. Part II. SELLER ASSURANCES Check true or false for assurances(1)through (5),and true,false, or N/A(not applicable)for assurance(6). True False p O (1) I owned and used the residence as my principal residence for periods aggregating two(2)years or more during the 5-year period ending on the date of the sale or exchange of#he residence. � ❑ (2) I 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)I (or my spouse or former spouse,if I was married at any time during the period beginning after 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 least 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$500,000 or less,and the gain on the sale or exchange of the entire residence is$250,000 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 her 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,and(c)my spouse also has not sold or exchanged another principal residence during the 2-year period ending on the date of the safe or exchange of the 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. True False N1A O ❑ � (6) If my basis in the residence is determined by reference to the basis in the hands of a person who acquired the residence in an exchange to which section 1031 of the Interna{ Revenue Code applied,the exchange to which section 1031 applied occurred more than 5(five)years prior to the date I sold or exchanged the residence. Part III. SELLER CERTIFICATION Under penalties of perjury, 1 certify that all the above information is true as of the end of the day of the sale or exchange. y�J �y� � ��.,�..�c��,-- December 18.2014 Estate of oloros L.Wei le,a/ a Delo�es L.Wei le,a/k/a Dolores L.Wei le Date If the seller makes a False res onse to any of the assurances in Part II of this form,we wil{be required to report the real estate proceeds to the IRS. A copy of the 1099-S will be provided to you at the time of,or immediately following,the closing. Information needed for reporting to IRS: Gross Proceeds(Sales Price)Allocation Proceeds Allocation %. According to IRS guidelines,if the sellers were husband and wife at the time of closing,who held property as joint tenants,tenants by the entirety,tenants in common,or as community property,they are considered a single seller and only one Form 1099-S will be reported to the IRS. However,if both parties allocate a percentage then a Form 1099-S will be reported for each. If the allocation field is left incomplete,the proceeds will be reported to IRS for this seller at 100%. REV-1513 EX+ (01-10) �` pennsylvania SCHEDULE � DEPARTMENT OF REVENUE gENEFICIARIES INHERIfANCE TAX REfURN RESIDENT DECEDENT ESTATE OP: FILE NUMBER: Delores L. Weigle 21 13 0113 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. Douglas A.Weigle 207-44-5457 Son 50% 2320 Walnut Bottom Road,Carlisle,PA 17013 (717)258-3410 2. Patricia A.Ohler 184-36-6270 Daughter 50% 6074 Greenbriar Terrace,Fayetteville,PA 17222 (717)385-2434 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; 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size.