Loading...
HomeMy WebLinkAbout07-02-15 S JPennsylvania 1505618627 3M464710.000 DEPARRAENT OF REVENUE Ex(03-14)(TP) REV-1500 OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN 21 15 0026 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW 10232014 08201919 Decedent's Last Name Suffix Decedent's First Name MI ROYER DORIS A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name M I THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 7 1. Original Return 0 2. Supplemental Return 3. Remainder Return(date of death ❑ prior to 12-13-82) 4. Agriculture Exemption(date of 7 5. Future Interest Compromise(date of 6. Federal Estate Tax Return Required death on or after 7-1-2012) death after 12-12-82) 0 7. Decedent Died Testate � 8. Decedent Maintained a Living Trust 9. Total Number of Safe Deposit Boxes (Attach copy of will.) (Attach copy of trust.) ❑ 10. Litigation Proceeds Received El 11. Non-Probate Transferee Return F 12. Deferral/Election of Spousal Trusts (Schedule F and G Assets Only) 0 13. Business Assets 14. Spouse is Sole Beneficiary (No trust involved) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number CRAIG A . HATCH , ESQ • 717-731-9600 First Line of Address 2109 MARKET STREET Second Line of Address City or Post Office State ZIP Code CAMP HILL PA 17011 Correspondent's email address: C - H A T C H a@ H H G L L P - C 0 M REGISTER OF WILLS USE ONLY REGISTER OF WILLS USE ONLY DATE FILED MMDDYYYY DATE FILED STAVE rn C> m�70 p C�' Q � f"r PLEASE USE ORIGINAL FORM ONLY � r-- �.i t� Side 1 3- ih3 N II'���IIII'IIIIIII'IIIIIIII'II�IIII�IIIIIIIIIIIII'IIIIIIII'I �� e-, -T7 -r1 -n ' 1505618627 15116--_,78627ry �' r �,. o Cn o 1505618635 REV-1500 EX(TP) RECAPITULATION 1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. *0 . 00 2. Stocks and Bonds(Schedule B) , , , , , , , , , , , , , , , , , , , , , , , , , 2, $20 -,880 • 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. $2 81 , 4 3 6 • 03 6. Jointly Owned Property(Schedule F) F1 Separate Billing Requested. . . . . 6. $0 • 00 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) F-1 Separate Billing Requested. . . . . 7. *701383 • 29 8. Total Gross Assets(total Lines 1 through 7) , , , , , , , , , , , , , , , , , 8. *3721699 • 32 9. Funeral Expenses and Administrative Costs(Schedule H), , , , , , , , , , , , , 9, $12 ,705 • 28 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1), , , , , , , , , . 10. $17 1882 • 04 11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . 11. *30 ,587 • 32 12. Net Value of Estate(Line 8 minus Line 11) , , , , , , , , , , , , , , , , , , , 12. *342 ,112 • 00 13. Charitable and Governmental Bequests/Sec.9113 Trusts for which an election to tax has not been made(Schedule J). . . . . . . . . . . . . . . . 13. $0 • 00 14. Net Value Subject to Tax(Line 12 minus Line 13), , , , , , 14. $3421112 • 00 TAX CALCULATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers urisier Sec.9116 (a)(1.2)X.o. $0 . 00 15. $0 . 00 16. Amount of Line 14Pable at lineal rate X.044- $3421112 . 00 16. $151395 . 04 17. Amount of Line 14 taxable at sibling rate X.12 $0 . 00 17. *0 . 00 18. Amount of Line 14 taxable at collateral rate X.15 $0 . 00 18. $0 . 00 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. $15-1395 - 04 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT X❑ Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the person responsible for filling the return is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE PAUL R • HOFFMAN , EXR • d go/ ADDRESS Z11111 �_r 6349 BENNINGTON ROAD MECHANICSBURG , PA 17050 SIGNATURE OF PREPARER OTHER THAN PERSON RESPO IBLE G THE RETURN DATE CRAIG A • HATCH , ESQ • � o`�i " ADDRESS 2109 MARKET STREET CAMP HILL, PA 17011 i11i1ig 11111iiiibi i�iiiii iiiii ilii ilii Side 2 1505618635 3M464810,000 REV-1500 EX(TP) Page 3 File Number Decedent's Complete Address: 21 15 0026 DECEDENTS NAME ROYER DORIS A STREET ADDRESS 100 MOUNT ALLEN DRIVE CUMBERLAND CITY STATE ZIP MECHANICSBURG PA 17055 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) $15,395 - 04 2. Credits/Payments A. Prior Payments $15,000 - 00 B.Discount $769 - 75 (See instructions.) Total Credits(A+B) (2) $151769 - 75 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) $374 - 71 5. If Line 1 + Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) $0 . 00 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred . . . . . . . . . . . . . . . . . . . . . . . . . . . . © El b. retain the right to designate who shall use the property transferred or its income . . . . . . . . . . . . . . X] El c. retain a reversionary interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 El d. receive the promise for life of either payments,benefits or care? . . . . . . . . . . . . . . . . . . . . . . 2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ ❑X 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? . . . . . ❑ 11 4. Did decedent own an individual retirement account,annuity,or other non-probate property,which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X❑ ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116 (a)(1.1)(i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent 172 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 step-parent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S.§9116(a)(1.3)]. A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. 3M4671 4.000 , REw1e02EX�t12_12, SCHEDULE A pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Doris A. Royer 21 15 0026 All real property owned solely or as a tenant In common must be reported at fair market value.Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. None TOTAL (Also enter on Line 1,Recapitulation.) $ $0.00 2w4695 2.000 If more space is needed, use additional sheets of paper of the same size. REV-1503 EX-(8-12) pennsylvania SCHEDULE B DEPARTMENT OF REVENUE INHERITANCE TAX RETURN STOCKS & BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER Doris A. Royer 21 15 0026 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Series EE U.S. Savings Bonds $20,880.00 TOTAL (Also enter on Line 2,Recapitulation) $ $20,880.00 2w4696 2.000 If more space is needed, insert additional sheets of the same size REV-1508 EX+(08-12) Pennsylvania SCHEDULE E EPARTMENTOF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RESIDENTDECE ENTTURN PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Doris A Rover 21 15 0026 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Bank of America Checking Acct. No. 4424 $274,749.12 2 M&T Bank Checking Acct. No. 9864191532 $6,686. 91 TOTAL(Also enter on line 5,Recapitulation) $ $281,436.03 2w48AD 2.000 If more space is needed,use additional sheets of paper of the same size. REV,-1509 EX+(01-10) pennsylvania SCHEDULE F DEPARTMENT OF REVENUE INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Doris A. Royer 21 15 0026 If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule a SURVIVING JOINTTENANT(S)NAMES) ADDRESS RELATIONSHIP TO DECEDENT JOINTLY OWNED PROPERTY: ITEM ,LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH OR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DEC®g•!PS VALUE OF MB NLER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE, VALUEOFASSET INTEREST DECEDENTS INTEREST None TOTAL (Also enter on Line 6, Recapitulation) $ $0.00 9w46AE 2.000 If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+(08-09) SCHEDULE G pennsylvania DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Doris A. Royer 21 15 0026 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM INCLLOETHE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % DECD'S EXCLUSION TAXABLE NUMBE THE DATE OF TRANSFER ATTACH ACOPY OFTHE DEED FOR REAL ESTATE VALUE OF ASSET INTEREST IFAPPLICABLE VALUE 1. ROYER FAMILY TRUST Bank of America Certificate of Deposit No. 1019 $44,752.68 100.0000 $0.00 $44,752. 68 2 Bank of America Certificate of Deposit No. 2801 $25,630. 61 100.0000 $0.00 $25,630. 61 TOTAL(Also enter on line 7,Recapitulation)$ $70,383.29 If more space is needed,use additional sheets of paper of the same size. 9W46AF 2.000 REV-1511 EX-(08-13) SCHEDULE H pennsylvania DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Doris A. Royer 21 15 0026 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Myers Buhring Funeral Home funeral goods & services $4,420.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: 2. Attorney Fees: $5,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: $475.50 5. Accountant Fees: 6. Tax Return Preparer Fees: 7, 1 Notary Fees $10.00 2 Cumberland Law Journal publication fee $90.00 Total from continuation schedules . . . . . . . . . $2,709.78 TOTAL(Also enter on Line 9,Recapitulation) $ $12,705.28 3W46AG 2.000 If more space is needed, use additional sheets of paper of the same size. Estate of: Doris A. Royer 21 15 0026 Schedule H Part 7 (Page 2) 3 Patriot-News publication fee $231.86 4 U.S. Postal Service postage $33. 92 5 Portion of Decedent's Social Security payment retracted from Bank of America checking account after date of death. $2,444.00 Total (Carry forward to main schedule) $2,709.78 REV-1512 EX+(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Doris A. Royer 21 15 0026 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH Messiah Lifeways nursing home bill $17,732.00 2 Paul D. Dalbey, DPM medical bill $8.48 3 Alert Pharmacy Services, Inc. medical bill $123.85 4 Philhaven medical bill $17.71 TOTAL(Also enter on Line 10,Recapitulation) $ $17,882.04 2w46AH 2.000 If more space is needed, insert additional sheets of the same size. REV-1513 EX+(01-10) SCHEDULE J pennsylvania DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Doris A. Rover 21 15 0026 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec.9116(a)(1.2).] 1, Paul R. Hoffman 6349 Bennington Road Mechanicsburg, PA 17050 205 of Residue: $68,422.40 Son $68,422.40 2 Darrell Charles Hoffman 5167 Elmwood Avenue Newark, CA 94560 20% of Residue: $68,422.40 Son $68,422.40 3 Roger Hoffman 533 CR 2119 Rusk, TX 75785 20% of Residue: $68,422.40 Son $68,422.40 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. [I NON-TAXABLE DISTRIBUTIONS A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ $0.00 swasAI 2.000 If more space is needed,use additional sheets of paper of the same size. Estate of: Doris A. Royer 21 15 0026 Schedule J Part 1 (Page 2) Item No. Description Relation Amount 4 Lyle Royer 3435 Ocean Park Blvd. , Ste. 107 Santa Monica, CA 90405 20% of Residue: $68,422.40 Step-Son $68,422.40 5 Lanny Royer 4295 E. Maplewood Ct. Gilbert, AZ 85297 20% of Residue: $68,422.40 Step-Son $68,422.40 Article IV General Provisions A. If any person or persons shall contest my will or in any manner attempt to have it or any trust or beneficial interest created by it declared invalid, the person or persons shall receive no benefits from or interests under my will, and my will shall be carried out as if the person or persons had predeceased me without issue. Provided, however, nothing in this paragraph shall apply to my spouse. B. If any part of my will is held to be void, invalid or inoperative, I direct that the remainder of my will shall be carried into effect as though the part was never in my will. On 4- . /6 , 19 i�at Riverside County, California, I hereby sign this document'and declare it to be my will. Doris A. Royer This document was signed and declared to be her will by Doris A. Royer in our joint presence. At her request, in her presence, and in the presence of each other, we hereby sign as witnesses to the execution of this will, believing that she is of sound mind and under no constraint or undue influence. We declare under penalty of perjury under the laws of the state of California tha thebove is true and correct. Executed on this day of , 16, at Riversid. County C if Executed-on �Gresiding at California./ residing at California. 3 COMMONWEALTH OF PENNSYLVANIA SHORT CERTIFICATE COUNTY OF CUMBERLAND IL ,l OF c ugje� I LISA M. GRAYSON, ESQ. D �v Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 15th day of January, Two Thousand and 1750 Fifteen, Letters of ADMINISTRA TION C.T.A. in common form were granted by the Register of said County, on the estate of DORISA ROYER late of UPPER ALLEN TOWNSHIP (First,Middle,Last) in said county, deceased, to PAUL R HOFFMAN /First,Middle,Last) and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 22nd day of January Two Thousand and Fifteen. File No. 2015- 00026 PA Fi 1 e No. 21- 15- 0026 Date of Death 1012312014 S. S. # 1 va/ of wrus Deputy NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL THE ROYER FAMILY TRUST DATED 09/16/1993 DECLARATION OF TRUST We, the undersigned, declare that we are creating a revocable living trust. The pertinent information with respect to the trust is as follows: Trustors: Clarence J. Royer and Doris A. Royer Initial Trustees: Clarence J. Royer and Doris A. Royer Trust Name: Royer Family Trust Family History: We declare that we are married and that we have no mutual children. Clarence J. Royer has two children from a previous marriage, namely, Lanny Royer and Lyle Royer. Doris A. Royer has four children from a previous marriage, namely, D. Charles Hoffman, Paul Hoffman, David Hoffman and Roger Hoffman. Article I Creation of Trust A. Trust Purposes. The Trustors establish this revocable living trust for the following purposes: (1) To avoid probate on the trust estate when they die; (2) To avoid death taxes depending upon the size of their estate when they die; (3) To provide a vehicle for the management of their financial affairs if either or both of them become disabled; and (4) To plan for the orderly distribution of their assets after the death of either or both of them. B. Trust Estate. The "trust estate" consists of the property, plus the proceeds and undistributed income of the property, that is listed in Schedule "A" and that is transferred to the trust: (i) by the Trustors; (ii) by their wills; (iii) as insurance proceeds 1 or pension benefits; or (iv) from any other person or source, if acceptable to the Trustee. C. Trust Estate is Communfir Property. All property listed in Schedule "A" and any property subsequently added to the trust estate by the Trustors, unless the contrary is expressly stated and this declaration is appropriately amended, is and shall remain the community property of the Trustors during their joint lifetime. Article II Distributions During Trustors' Joint Lifetimes A. Distributions During Trustors' Lifetimes. As long as either or both of the Trustors are serving as the Trustee, they may make distributions of trust income and principal as they deem appropriate. If neither Trustor is serving as the Trustee, the Successor Trustee shall make distributions of trust income and principal in accordance with the Trustors' wishes and directions. Any undistributed income shall be added to the trust estate. Article III Distributions upon Disability or Incapacity of a Trustor A. Distributions During Di ilii. If a Trustor is disabled or incapacitated the Trustee shall distribute for the benefit of the disabled Trustor the amounts of income and principal the Trustee deems appropriate for his or her comfortable support, health, care, general welfare and to maintain his or her accustomed standard of living. The Trustee shall take into consideration, in the distribution of income and principal, the requirements to qualify the disabled or incapacitated Trustor for public benefits. (1) In addition, the Trustee may distribute or apply trust income or principal or both for the health, education, support and maintenance of any person legally dependent upon the disabled or incapacitated Trustors for support. (2) Any undistributed income shall be added to the trust estate. 2 (3) The disability or incapacity of a Trustor shall be determined by separate notarized statements of opinion signed by two board certified licensed physicians or psychiatrists, or a declaration by a court of competent jurisdiction, or if a conservatorship has been appointed; third parties may rely on such evidence in dealing with the Trustee, and shall have no liability to the trust(s) or any trust beneficiaries for good faith dealings based on such reliance. B. Medical./Public Benefits Planning. Should a Trustor enter, or in the discretion of the Trustee be likely to enter, a skilled nursing facility, intermediate care facility, or a licensed community care facility, the Trustee shall plan and make distributions from the trust so that: (1) All payments of income and principal are made to the non- institutionalized Trustor in his or her name. (2) The institutionalized Trustor, or his or her authorized representative, may apply for and receive all available public resources. (3) The Trustee may retain, for the benefit of the non-institutionalized Trustor, the maximum resources permitted by Welfare and Institutions Code §14006.2, as amended from time to time. (4) It is the "intent" of the institutionalized Trustor to "return home." Article IV Distributions Upon the Death of One Trustor The first Trustor to die shall be called the Deceased Trustor, and the other shall be called the Surviving Trustor. After the death of the Deceased Trustor, the Trust shall be held, administered and distributed as follows: A. Deceased Trustor's Debts. Expenses and Taxes. The Trustee is authorized, but not directed, to pay, directly or by transfer of funds to the personal representative, all expenses of administration, debts, last illness and funeral expenses of the Deceased Trustor and any death taxes payable by reason of the Deceased Trustor's 3 death, whether on probate or non-probate property, all without apportionment or contribution from any person. Provided, however, that only assets which are includable in the Deceased Trustor's estate for estate tax purposes shall be used to pay these expenses and taxes. The payments authorized under this section are discretionary and no claims or right to payment by third parties may be enforced against the trust by virtue of such discretionary authority. B. Distribution of Personal Property. The Trustee shall distribute the Deceased Trustor's personal property as the Deceased Trustor shall direct in his or her Letter of Instruction. Any personal property not effectively appointed by the Deceased Trustor shall be divided and distributed as part of the remaining trust estate. C. Distributions During Surviving Trustor's Lifetime. As long as the Surviving Trustor is the Trustee, he or she may make distributions of trust income and principal as he or she deems appropriate. If the Surviving Trustor is not the Trustee then the Successor Trustee shall make distributions of trust income and principal in accordance with the Surviving Trustor's wishes and direction. Any undistributed income shall be added to the trust estate. Article V Distributions Upon the Death of the Survive ing Trustor On the death of the Surviving Trustor, the remaining trust estate, together with any additions received by reason of the Surviving Trustor's death, shall be administered and distributed as follows: A. Payment of Debts. Expenses and Taxes. The Successor Trustee is authorized, but not directed, to pay, directly or by transfer of funds to the personal representative, all expenses of administration, debts, last illness and funeral expenses of the Surviving Trustor and any death taxes payable by reason of the Surviving 4 Trustor's death, whether on probate or non-probate property, all without apportionment or contribution from any person. Provided, however, that only assets which are includable in the Surviving Trustor's estate for estate tax purposes shall be used to pay these expenses and taxes. The payments authorized under this section are discretionary and no claims or right to payment by third parties may be enforced against the trust by virtue of such discretionary authority. B. Distribution of Personal Property. The Successor Trustee shall distribute the Surviving Trustor's personal property as the Surviving Trustor shall direct in his or her Letter of Instruction. Any personal property not effectively appointed by the Surviving Trustor shall be divided and distributed as a part of the remaining trust estate. C. Division of Trust into Shares. On the Surviving Trustor's death, the Successor Trustee shall divide the trust estate into shares as follows: (1) The Trustee shall distribute the trust estate equally between Lanny Royer, Lyle Royer, D. Charles Hoffman, Paul Hoffman, David Hoffman and Roger Hoffman, outright and free of trust. (2) If a beneficiary named above predeceases the Surviving Trustor, the deceased beneficiary's share of the trust estate shall lapse and augment the residue of the trust estate. D. Distribution of Remainder. If, at any time before complete distribution of all trust estates under this declaration, no other disposition of the property has been directed by this declaration the remaining trust estate or estates shall then be distributed one-half to the legal heir or heirs of Clarence J. Royer,and one-half to the legal heir or heirs of Doris A. Royer. 5 Article VI Powers to Revoke or Amend A. Revocation. During the Trustors' joint lifetime this trust may be revoked, in whole or in part, by a document signed by both Trustors jointly or by either Trustor alone. If a Trustor who signs is not a Trustee, the document shall be delivered, personally or by certified mail, to the acting Trustee. On revocation, the acting Trustee shall deliver the trust estate or the revoked portion thereof to either or both of the Trustors, in either event as the community property of both Trustors. B. Amendment. During the Trustors' joint lifetime the terms of this trust may be amended, with respect to all or any part of the trust estate or terms, only by a document signed by both Trustors. If neither Trustor is a Trustee, the document shall be delivered, by a Trustor personally or by certified mail, to the Successor Trustee. C. After Death of Deceased Trustor. After the death of the Deceased Trustor, the Surviving Trustor may, in whole or in part, revoke or amend the Trust by a document signed by the Surviving Trustor. If the Surviving Trustor is not the Trustee the document shall be delivered, personally or by certified mail, to the Successor Trustee. D. Disability of Trustor(c,). All of the Trustors' powers to revoke and amend are personal to them. In the event of disability the powers may be exercised on a Trustor's behalf only by a conservator with court approval or by the holder of a power of attorney. The disability of one Trustor shall not prevent exercise by.the other Trustor of his or her power of revocation for the purpose of holding some or all of the property as community property outside the trust estate. 6 f i E. After Both Trustors' Deaths. After the death of both Trustors, no trust established by this declaration may be revoked or amended, except as may be authorized by a power of appointment expressly conferred by the terms of the trust. F. Rights of Trustee Upon Revocation. Upon revocation or withdrawal, in any case where the Trustors are not the Trustees, the Successor Trustee may withhold sufficient property to satisfy amounts due to the Successor Trustee and may require reasonable indemnification against liabilities properly incurred in administering the trust. Arficle VII The Trustee and the Trustee's Powers A. Number of Trustees. The following provisions shall govern the number of Trustees required for each trust created by this declaration: (1) As long as both Trustors are alive and able, they may act jointly as co-Trustees. (2) If either of the Trustors shall resign, become disabled or incompetent or for any other reason cease to act as Trustee, then the other shall serve as sole Trustee. (3) There need be only one Trustee for each trust for a beneficiary under age twenty-five (25). B. Selection of Successor Trustee(sl. Successor and additional Trustees may be selected by the Trustors, jointly or by one alone if the other is disabled, during their joint lifetime and by the Surviving Trustor during his or her lifetime. (1) Upon the death of the Surviving Trustor, or in the absence of a competent Trustee, the Successor Co-Trustees as needed for each trust created by this declaration, shall be: (a) D. Charles Hoffman; and, (b) Lanny Royer. 7 C. Failure of All Alternates to Act. If all of the designated alternates fail to qualify or cease to act as a Trustee, then the successor or additional Trustees, as needed for each trust created by this declaration, shall be selected, in order of priority: (1) By the Trustee of that trust then serving (including any Trustee who is then retiring but not a Trustee who is then being removed; (2) By a majority, but not less than two, of the then living, competent adult beneficiaries of the trust who are then willing and able to participate in the selection process; or (3) By the Court with jurisdiction over such matters. D. Qualifications. In making selections for a successor Trustee, or in any appointment that must be made by court order, the Trustors request that consideration be given to, but that selection not be restricted by, their preference that all co-Trusteeships under this declaration reflect a balance of experience in accounting, business, finance, real estate, and in legal or tax matters. E. Removal of Trustee. Any Successor Trustee may be removed by the Trustors, jointly or by one alone if the other is not competent, during their joint lifetime and by the Surviving Trustor during his or her lifetime. Under all other circumstances, or in the absence of a competent Trustor, any Trustee of any trust under this declaration may be removed by: (i) The decision of a 8 majority of the Trustees of that trust then serving; (ii) if any trust under this declaration does not have sufficient Trustees from which a majority can be obtained, i.e., two Trustees, any Trustee may be removed by a Trustee then serving and the concur- rence of a majority, but not less than two, of then living, competent adult beneficiaries of the trust; and, (iii) if there is only one Trustee then serving, the Trustee may be removed by a majority, but not less than two, of the then living, competent adult beneficiaries of the trust. F. Resignation.ion. A Trustee may resign at any time by a document signed by the Trustee and delivered personally or by certified mail (i) to either or both of the Trustors during their joint lifetime and (ii) thereafter to the Surviving Trustor during his or her lifetime, and (iii) under all other circumstances, or in the event no Trustor is competent, to the remaining Trustee or any one or more of the remaining Trustees, or to a duly selected successor Trustee who accepts the appointment. A resigning Trustee shall promptly deliver the trust estate or estates to the remaining or new Trustee or Trustees, accompanied by an accounting that is appropriate to the circumstances. G. Disability of a Trustee. The disability or lack of competence of a Trustee shall be determined by separate notarized statements of opinion signed by two board certified licensed physicians or psychiatrists; third parties may rely on such evidence in dealing with the Trustee, and shall have no liability to the trust(s) or any trust beneficiaries for good faith dealings based on such reliance. 9 H. Powers of the Trustee. The term Trustee includes the initial Trustees and any Successor Trustee under this agreement. Except as otherwise limited, the Trustee shall have all powers now or afterwards granted by California law and all those appropriate for the orderly and effective administration of the trust. In addition, the Trustee shall have the power: (1) To receive additional property from any source and to administer the additions according to the terms of this declaration. (2) To sell (for cash or on credit), convey, exchange, and purchase assets. (3) To improve, alter, lease (including for periods beyond the duration of a trust), partition and otherwise deal with and manage trust property. (4) To open, operate and maintain brokerage accounts to buy or sell securities, on margin or otherwise. (5) To acquire, exercise, grant or dispose of options, puts, calls, privileges or rights with respect to securities or other property including but not limited to rights to vote, grant proxies, subscribe, convert or assent to or participate in com- promises, releases, renewals or extensions, modifications, reorganizations, recapitalizations, consolidations, liquidations and the like, and to abandon or otherwise deal with any property or interests in any manner deemed to be in the best interests of the trust or trusts. (6) To invest and reinvest in preferred or common stocks, bonds, notes, debentures, mortgages, investment company shares, money market and mutual 10 (including index) funds, interest-bearing accounts, any other property, real or personal, foreign or domestic. (7) To hold property in the name of a nominee, or unregistered or in a manner that will allow title to pass by delivery or will otherwise facilitate proper administration. (8) To acquire, retain, improve or develop assets on any reasonable basis despite the normal duty of Trustees to diversify investments or to avoid or dispose of those that are unproductive, underproductive, or of a wasting or overproductive nature. (9) To hold, acquire and invest the trust estate or estates in commercial and other real estate. The Trustor also authorizes retention or acquisition of residential and tangible properties for use by the Trustors or other beneficiaries. (10) To acquire or hold properties jointly or in undivided interests with other persons or entities, including the Trustors, any one or more of the beneficiaries of this declaration and the estate of, and other trusts established by, the Trustors or any of these other beneficiaries; and properties may be purchased from, sold to or exchanged among or with, and funds may be borrowed from or loaned to, any of these beneficiaries, estates and trusts (including separate trusts under this declaration) at fair values and on fair and equitable terms appropriate to the Trustee's fiduciary responsibilities. (11) To enter, continue or participate in the operation of any business or other enterprise, including as a sole proprietor, as a general or limited partner, or as a shareholder, and to incorporate, liquidate, reorganize or otherwise change the form or 11 terminate the operation of the business or enterprise, and contribute capital or loan money to the business or enterprise. (12) To borrow funds, guarantee or indemnify in the name of the trust and to secure any obligation or mortgage, pledge or other security interest, including for a term extending beyond the period of the trust, and to renew, extend or modify; and such obligations may be entered into without personal liability of the Trustee, and lenders shall have no duty to see to the application of the proceeds. (13) To enter into leases, pooling or other arrangements for exploration, conservation, development and removal of minerals and other natural resources. (14) To prosecute, defend, contest or otherwise litigate legal actions or other proceedings for the protection or benefit of a trust or the Trustee; to pay, compromise, release, adjust or submit to arbitration any debt, claim or controversy; and to insure the trust or trusts against any risk and the Trustee against liability with respect to third persons. (15) To acquire and maintain life, disability or health insurance for any beneficiary; and with respect to any policies on the life of a Trustor or other beneficiary, to pay premiums or otherwise maintain life insurance policies in force and to convert or divide any policy that may be held with other trusts, a Trustor or other beneficiary or beneficiaries. (a) The Trustee shall be under no duty to pay premiums or otherwise maintain life insurance policies not owned by the Trustee or to keep informed or take action to keep the policies in force. 12 (b) The Trustee shall collect sums payable to the trust, trusts, or Trustee under any insurance policies, pension plans or other contracts, upon receipt of actual notice of a death or other event upon which such right of payment arises. (c) The Trustee shall have the power to take such action as he or she shall deem appropriate to enforce any claims of the trust estate under such policy, plan or contract. The Trustee shall also have the power to compromise, arbitrate or otherwise settle such claims, all at the expense of the trust estate but with no obligation on the Trustee to incur expenses or liabilities that cannot be paid from trust funds or for which the Trustee has no assurance of indemnification. (16) To employ attorneys, accountants, investment advisors, specialists and such other agents as it shall deem necessary or desirable. The Trustee shall also have the authority to appoint an investment manager or managers to manage all or any part of the assets of the Trust, and to delegate to said manager investment discretion. Such appointment shall include the power to acquire and dispose of such assets. The Trustee may charge the compensation of such attorneys, accountants, investment advisors, investment managers, specialists and other agents and any other expenses against the Trust. (a) The Trustee may enter into an agreement with each investment manager specifying the duties and compensation of such investment manager shall be retained. The Trustee shall not be liable for any act or omission of any investment manager, and shall not be liable for following the advice of any investment manager, with respect to any duties delegated to the investment manager. 13 (b) The Trustee shall have the power to determine the amount of Trust assets to be invested pursuant to the direction of a designated investment manager and to set investment objectives and guidelines for the investment manager. (c) The investment manager shall have the same power to invest and reinvest the assets of the Trust under its management that it would have if it were itself the Trustee of the Trust, subject to the guidelines established by the Trustee. (17) To account for and allocate receipts or expenditures to income or principal and to establish reasonable reserves out of income, all as provided by law, or in the Trustee's reasonable discretion. (18) To make divisions, allocations (including to independent shares) or distributions in cash or in kind, including in undivided interests, by prorata or non-prorata division, or in any combination of these ways (with no obligation to take account of the tax basis of the assets) in the discretion of the Trustee and there need be no physical division or segregation of various properties, trusts or trust estates or independent shares except as required for purposes of terminations, withdrawals or distributions, although separate records and accounts shall be maintained for undivided interests and for separate trusts and shares of the trust or trusts. (19) To distribute property to, or retain property as, a custodian for a minor (or other eligible) beneficiary under any applicable Gifts or Transfers to Minors Act. The Trustee shall have discretion to establish a custodianship termination age up to any age allowed by the Act, or may use any other appropriate means'of making 14 distributions under applicable law or terms of this trust agreement to a beneficiary who is disabled. I. Trust Accounting. As long as either or both Trustors are serving as Trustee, no accounting shall be required. If neither Trustor is serving as the Trustee, the Successor Trustee need account only to the Trustors or Surviving Trustor. After the death of the Surviving Trustor, the Successor Trustee shall, from time to time, but no less often than annually, account to the primary beneficiary or beneficiaries for whom the trust was established, if any, and if none then to those persons who are entitled to receive income distributions from the trust. J. Liability of Trustee. No Trustee of any trust created by this declaration shall: (1) Be required to obtain a bond. (2) Be liable to any beneficiary, person or entity for the Trustee's acts or failure to act, except for willful misconduct or gross negligence. (3) Incur liability to persons whose interests may have been affected for distributions made in good faith until the Trustee receives written notice of the event which affects the person's interest. (4) Be liable or responsible for any act, omission, or default of any other Co-Trustee, provided that he or she shall have had no knowledge of facts that might reasonably be expected to put him or her on notice of the offending act, omission, or default of the other Co-Trustee. 15 K. Compensation of Successor Trustee. The Successor Trustee shall be entitled to fair and reasonable compensation. The amount of compensation shall be an amount equal to the customary and prevailing charges for services of a similar nature during the same period of time and in the same geographic locale. The Trustee shall be reimbursed for the reasonable costs and expenses incurred in connection with the services performed under this agreement. L Delegation Among Trustees. Any Trustee may delegate to any other Trustee their duties, powers, and authority (except those involving distributions to beneficiaries), if allowed by law. (1) The delegating Trustee may revoke the delegation at will. (2) The delegation of any power, as well as the revocation of any delegation, shall be evidenced by a document signed by the delegating Trustee. (3) As long as the delegation is in effect, any of the delegated powers may be exercised by the Trustee receiving the delegation with the same force and effect as if the delegating Trustee had personally joined in the exercise of the power. M. A Majority of Trustees Required to Control. If two Trustees are acting, the concurrence and joinder of both shall be required. (1) When more than two Trustees are acting, the concurrence and joinder of a majority of Trustees shall control in all matters pertaining to the administration of any trust created under this agreement. 16 (2) When more than two Trustees are acting, any dissenting or abstaining Trustee may be absolved from personal liability by registering a written dissent or abstention with the records of the trust; the dissenting Trustee shall thereafter act with the other Trustees in any manner necessary or appropriate to effectuate the decision of the majority. N. One Signature Reouir Whenever the Trustors are serving as Co- Trustees hereunder, either Co-Trustee may sign any and all checks, drafts or other negotiable instruments whether they be for personal, business or other trust related expenditures. Either Co-Trustee may make a withdrawal from any trust savings plan, checking account, business or other trust account without the signature of the other Co-Trustee. Either Co-Trustee acting alone may convert, cash in, redeem, terminate, surrender for cash, cancel or otherwise manage or control any money market account, certificate of deposit, treasury bill or such other similar related money investment without the signature of the other Co-Trustee. The above powers may be terminated or otherwise limited by either Co-Trustee immediately upon the presentation of such written notice to the banking or lending institution. The Trustors and Trustees shall hold any banking institution harmless who relies upon these provisions in good faith, and who acts without actual notice of such revocation of the powers contained herein. 17 The Trustors may also deputize any Successor Trustee as an additional signature, to act alone, on any checking account or savings account transferred to this trust. O. corporate Trustee. Any corporation appointed as a Trustee must have been licensed by a governmental authority, have been in business as a corporate Trustee at least 10 years prior to its appointment and have at least 50 million dollars in trust assets under its direct control and authority. P. Successor Corporate Trustee. If any bank or trust company ever succeeds to the trust business of any corporate Trustee serving under this agreement, whether because of a name change, or any other form of reorganization, or if the corporate Trustee ever transfers all of its existing business to any other bank or trust company, the successor shall thereupon, without any action being required, succeed to the Trusteeship as if originally named. Article VIII General Provisions A. spendthrift Provision. The interests of trust beneficiaries under this trust agreement shall not be transferable by voluntary assignment and, to the extent permissible by law, shall be free from execution, attachment, bankruptcy and other procedures for the satisfaction of creditors' claims. 18 B. Final Termination Date. Any trust created by this declaration or by the exercise of any power of appointment in this declaration shall, unless terminated earlier, terminate 21 years after the death of the last survivor of the group composed of the Trustors and those of the Surviving Trustor's legal heirs living at the death of the Deceased Trustor. (1) At the time of termination, the trust estate shall be distributed to the primary beneficiaries for whom the trust was established, if any, and if none, then to those persons who are entitled to receive income distributions from the trust. (2) For purposes of distributions under this paragraph only, it shall be presumed that any person then entitled to receive any discretionary payments of the income of a separate trust is entitled to receive all of the income, and it shall be presumed that any class of persons entitled to receive discretionary payments of income is entitled to receive an equal share of the income. C. Definitions. For all purposes of this agreement: (1) The terms "child" or "children" mean the lawful blood descendants in the first degree of the parent designated; and "issue" and "descendants" mean the lawful blood descendants in any degree of the ancestor designated. The terms "child," "children," "issue," "descendant" and "descendants" or those terms preceded by the terms "living" or "then living" shall include the lawful blood descendants in the first degree of the parent designated even though such descendant is born after the death of such parent. The terms "child," "children," "issue" and "descendant(s)" shall include adopted children who need not have been minors at the date of adoption. (2) The terms "legal heir" or "legal heirs" shall refer to the person or persons who would then be the Trustor's heir or heirs, their identities and shares to be determined as if the Trustor had then died intestate, applying California law then in effect relating to separate property not acquired from a previously deceased spouse. (3) When distribution is to be made "by right of representation" or if 19 the manner of distribution is not specified, the property is to be divided and distributed as provided in California Probate Code Section 246 as it exists at the date of this agreement. (4) The term "care" includes, but is not limited to, maintaining the beneficiary in his or her regular residence, or elsewhere as may be appropriate, despite a need for extensive medical or personal care at a cost that may exceed the cost of care at a home for the elderly, a health care institution, or the like. The Trustor wishes the Trustee, to the extent practical, to exercise his or her discretion under these provisions to enable the Trustor, or any beneficiary of a trust created pursuant to the terms of this agreement, to live at home and in familiar circumstances if the beneficiary wishes and is reasonably able to do so with nursing, household and other assistance. (5) The term "education" shall include: (a) Any course of study or instruction at an accredited College or University granting undergraduate or graduate degrees; (b) Any course of study or instruction at any institution for specialized, vocational, or professional training; (c) Any curriculum offered by any institution that is recognized for purposes of receiving financial assistance from any state or federal agency or program; (d) Any course of study or instruction which may be useful in preparing a beneficiary for any vocation consistent with a beneficiary's abilities and interest; (e) Tuition, fees, books, supplies, living expenses, travel, and spending money to the extent that it is reasonable. (6) The term "personal property" refers to such items as furniture, furnishings, silverware, objects of art, china, clothing, jewelry, sporting equipment, automobiles, boats, airplanes, books, collections of personal property and other personal property normally kept at the Trustor's residence. 20 (7) The term "disclaimer" shall refer to a qualified disclaimer as defined in Sections 2042 and 2518 of the Internal Revenue Code of 1986, as amended from time to time, or any corresponding provisions of any subsequent federal tax law. (8) The masculine, feminine, or neuter gender, and the singular or plural number, shall each include the others whenever the context so indicates. (9) The headings in this declaration are for convenience only and are not part of the text. D. No Contest Clause. If any person or persons shall contest this declaration or in any manner attempt to have it or any of the trusts or beneficial interests created by it declared invalid, such person or persons shall receive no benefits from or interests under this declaration, and the trusts herein established shall be administered and distributed as if such person or persons had died before either of the Trustors without issue; provided, however, that nothing in this paragraph shall apply'to the Trustors or the Surviving Trustor. E. Govemina Law. Unless otherwise expressly provided, the meaning of the distributive provisions of this declaration shall be governed by the laws of the State of California in effect at the date of its execution; and to the extent permissible under applicable law, the validity of the provisions of this declaration shall be governed by the laws of the State of California in effect on that same date, unless invalidity can be avoided by applying the law in effect at another time or in another jurisdiction that has sufficient contact for this purpose with the trusts involved. If any provision of this declaration is invalid, the remaining provisions shall nevertheless be given effect. F. Trustee's Discretion to Move Trust At the Trustee's discretion, the situs of this Trust and of any trust created pursuant to its terms may, together or individually, be changed to another jurisdiction, whether by appointment of a successor Trustee in another state, by transfer of trust assets to another state, or by the Trustee's or a beneficiary's move to another state. 21 G. Execution. We certify that we have read the foregoing Declaration of Trust, and that it correctly states the terms and conditions under which the Trust Estate is to be held, managed, and disposed of by the Trustees. We approve the Declaration of Trust in all particulars, and request the Trustees to execute same. -7, Dated: lar hae J. Royer, Trustor Doris A. Royer, Trustor r_7 Dated: 19JAI Clar nce J. Royer, Trustee -4-A Doris A. Royer, Trustee STATE OF CALIFORNIA COUNTY OF R E&RIDIE On 19 before meJ a Notary C Public in and f said County an State, personhily appeared Clarence J. Royer and Doris A. Royer, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signatures(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand and official seal, Signature Robert J. Galliano K 0 Comm. #953200 r'Tt,'1y PUBLIC -CALIFORNIA 0 0 (,r,Ut\,TY Robert J GaMano K T 0 Com m.22 22 PUBt It., SAN DIEGO ,)-,', '-,6, 19S6 1,,,y Comm ExPlre'- SCHEDULE 'A' We hereby assign, grant, transfer and convey to the Trustees of the Royer Family Trust, all of our right, title and interest in and to the following property: (1) All interests in real estate, wherever located, including any timeshares, deeds of trusts and land contracts. (2) All checking, savings, money market and other cash accounts, including all certificates of deposit. (3) All stock brokerage accounts; all stocks; all bonds, including, but not limited to, U.S. Government bonds, corporate bonds, municipal bonds and bearer bonds; all mutual funds; and, all dividend reinvestment programs. (4) All promissory notes. (5) Safe deposit box(es). (6) All interests in partnerships, general or limited. (7) All mobilehomes. (8) All personal property, including all furniture, furnishings, silverware, objects of art, 'china, clothing, jewelry, sporting equipment, automobiles, boats, airplanes, books, collections of personal property and other personal property normally kept at the Trustor's residence. This transfer of assets shall be binding and effective as to our heirs and assigns. In our capacity as Trustees of the Royer Family Trust we hereby accept transfer and delivery of the above-stated assets. Executed on /(c , 19/3, at Riverside Coun California. ,�LLL h Clar nce J. Royer, ustor Doris A. Royer, Trustor Cla ence J. Royer, Tr stee Doris A. Royer, Trustee STATE OF CALIFORNIA ) COUNTY OF RIVERSIDE ) On �� , 19c before me, lc�/1�evu a Notary Public in and forlsaid County ana State, ersonall appeared Clarence J. Royer and P Y PP Y Doris A. Royer, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signatures(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand d official seal, - Robert J. Galliano Comm.#953200 Signatur '1. NOTARY PUBLIC-CAUFORNIA C V\•— SAN DIEGO COUNTY L A<f oN,o My comm.Expirse Jan.26.1996" FIRST AMENDMENT TO TRUST DATED 04/20/1996 FIRST AMENDMENT AND RESTATEMENT TO THE ROYER FAMILY TRUST DATED SEPTEMBER 16, 1901 Reference is made to that certain Trust Agreement dated 16th day of September, 1993 by the undersigned, CLARENCE J. ROYER and DORIS A ROYER, as Settlors. Pursuant to ARTICLE VI, SECTION B, granting Settlors the power to amend said Agreement of Trust, Settlors hereby amend said Trust and add ARTICLE III , SECTION C, to read as follows: ARTICLE III ,SECTION C: ADMINISTRATION DURING DISABILITY OF SETTLOR(S) Medicaid/Medi-Cal Provisions; All of the income and principle of any asset held by the Trustee, which is acquired in order to qualify for Medicaid/Medi-Cal support for the Settlor(s) , shall be for the sole-benefit of said Settlor(s) as per Medicaid/Medi-Cal requirements and regulations. If any additional provisions of this Trust Agreement are needed to qualify said Settlor(s) for Medicaid/Medi-Cal support, then it shall be deemed to include such amendments. In that connection, the Trustee shall have such authority to take such action as may be necessary to comply with such regulations. A. Opinion of Licensed Physicians : A Settlor shall be deemed dis- abled during any period when, in the opinion of two licensed physicians, the Settlor is incapacitated or disabled because of illness, age or any other cause which results in the Settlor ' s inability to effectively manage his or her property or financial affairs. A Settlor shall also be deemed to be disabled for purposes of this agr ement upon. the lelr= determination of a court of competent jurisdiction that/ the Settlor is incompetent, incapacitated or otherwise legally unable to effectively manage his or her property or financial affairs. B. Disability of a Settlor. If one of the Settlors should become disabled the Trustee shall provide as much of the principal and net income from the disabled Settlor ' s separate estate and as much of the* principal from the community estate, as is necesary or advisable, in the Trustee ' s sole and absolute discretion, for the health, support, maintenance and general welfare of the disabled Settlor, as well as for the payment of any valid obligations of the disabled Settlor ( including but not limited to the payment of any insurance premiums) , as determined necessary in the Trustee ' s sole and absolute discretion. During the period of disability of a Settlor, the Trustee shall continue to provide as much of the principal and net income from the Trust as is necessary for the education, health, maintenance, and support of the remaining competent Settlor and any minor children of Settlors who are dependent upon support from the disabled Settlor. C. Disability of Both Settlors . If both Settlors become disabled, the Trustee shall provide, in addition to the payments in paragraph B of this ARTICLE III , SECTION C, as much of the principle of the net income of the community estate as is necessary or advisable, in the Trustees sole and absolute discretion, for the health, support and maintenance and general welfare of the Settlors. D. Absolute Discretion of the Trustee. The Trustee shall make distributions to the Beneficiaries under this Article based solely on need, as determined in the sole and absolute discretion of the Trustee. Further, when making such distributions, the Trustee may consider non- trust sources of income and principal available to the Settlor(s) . Distributions shall first be paid from the Trust ' s community property if it is being applied to a community obligation. Similarly, distributions shall first be paid from the Disabled Settlor ' s separate property if it is being applied to a separate obligation of the disabled Settlor. E. Medicaid/Medi-Cal Special Provisions: Notwithstanding any other power, statement or provision in this trust: 1 . A Settlor shall be deemed to have a special disability upon that Settlor' s application for Medicaid/Medi-Cal support. 2. Upon the application for Medicaid/Medi-Cal the applicant- beneficiary Settlor shall resign as a Trustee of this Trust. 3 . The Trustee shall have the sole and absolute discretion to determine if the property held in Trust, whether real or personal, shall or shall not be available to the applicant-beneficiary Settlor. 4. The applicant-beneficiary Settlor shall not be able to obtain access to the principal of the trust by petitioning the Trustee to release said funds. 5. The Trustee will not be required to petition the court for the release of the funds upon the applicant-beneficiary Settlor ' s request. 6. Upon application to Medicaid/Medi-Cal, on behalf of the applicant-beneficiary Settlor, assets held by the Trustee( s) will be deemed to be in an irrevocable sub-trust for the duration of the applicant-beneficiary Settlor ' s life, as per Medicaid/Medi-Cal requirements and regulations. We certify that we have read the foregoing First Amendment and Restatement of the Declaration of Trust, and that it correctly states the modifications to be made to the Declaration of Trust. In all respects we hereby ratify and confirm the provision of the Declaration of Trust dated September 16, , 1993 . This First Amendment and Restatement is executed on in the County of Riverside, California. -kAJZfNCE J. ROYER DORIS A. ROYER Settlor/Trustee Settlor/Trustee STATE OF CALIFORNIA COUNTY OF RIVERSIDE -Z'0, On before ore me, AJO f��j the undersigned Notary, personally appeared Clarence J. Royer and�Doris A. Royer proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to the within instrument and acknowledged to me that they executed the same in their authorized capacity, and that by their signatures on the instrument the persons or the entity upon behalf of which the persons acted, excuted the instrument . Witness my hand and official seal T Leonard P. Cole K 0 Comm.#982487 rl NOTARY PUBLIC-CALIFORNIAM' LOS ANGELES COUNTY 0 NotaryPublic Comm Expires Feb.1.1997 � SECOND AMENDMENT TO TRUST DATED 04/21/2004 ( 1 0 u Codicil to Living Trust of Clarence J. Royer and Doris A Royer At the time of the formation of the Living Trust of Clarence J. Royer and Doris a Royer, Lanny Royer, son of Clarence J. Royer, and D, Charles Hoffman, son of Doris A. Royer, were designated to be Trustees,jointly, if and when both of us were deceased or incapacitated and no longer able to care for ourselves and make decisions for ourselves. Inasmuch as Clarence J. Royer was deceased on November 18, 2002, Doris A. Royer became the Trustee of the Trust. I, Doris A. Royer, Trustee, desire to make a change in one of the Trustees designated to administer the affairs of the estate after I am deceased, or in the event I should become physically or mentally incapacited and no longer able to make decisions for myself. Because of the fact that my son,David G. Hoffman, is now residing with me at 30932 Corte de los Santos, Temecula, Ca., and because of the fact that my son, D. Charles Hoffman., resides in Newark, California, a considerable distance from my residence, it is my desire to relieve him of the duty of Trustee of the estate, and to replace him with son David G. Hoffman, as Trustee at the time of my death or in the event of my incapacitation. I hereby affirm and declare that this change is being made with my free will and under no influence or advice or suggestion of any person. Signed this / day of 2004. .Doris A. Royer, Truste State of California, County of Riverside On i 2,1$� , 2004, a Notary Public in and for the said County and State, personally appeared Doris A. Royer(proved to me on the basis of Satisfactnr�v evidence to be the person whose name is subscribed to the within instrume_nt�, and acknowledged to me`that s-ie executed the same in her authorized capacity. WITNESS my hand and official seal loo6REJESH ARVIND PATEL Commission# 1430517 t � Notary Public-California Riverside County Signature My Comm.Expires Jul 14,2007 THIRD AMENDMENT TO TRUST DATED 10/04/2013 THIRD AMENDMENT AND RESTATEMENT TO THE ROYER FAMILY TRUST DATED SEPTEMBER 16, 1993 Reference is made to that certain Declaration of Trust dated the 16" day of September, 1993 made by CLARENCE J. ROYER, now deceased, and by the undersigned, DORIS A. ROYER, as Trustors. This Declaration of rust was subsequently amended on April 20, 1996 and again on April 21, 2004. Pursuant to ARTICLE VI, SECTION C, granting the surviving Trustor the power to amend said Declaration of Trust, the undersigned Surviving Trustor hereby amends said Declaration of Trust and changes ARTICLE VII, SECTION BI to read as follows: ARTICLE VII, SECTION BI: Selection of Successor Trustee(s). (1) Upon the death of the Surviving Trustor, or in the absence of a competent Trustee, the Successor Trustee as needed for each trust created by this declaration, shall be in the following order: (a) Paul Hoffman (b) D. Charles Hoffman (c) Roger Hoffman. In all other respects the Declaration of Trust and the subsequent amendments are hereby ratified and affirmed. C6 0 I hereby affirm and declare that I have read the foregoing Third Amendment and Restatement, that it correctly states the modifications to be made to the Declaration of Trust, and that this change is being made with my free will and under no influence or advice or suggestion of any person. Signed this day of 2013. DORIS A. ROYER, SURY#ING TRUSTOR Sworn or affirmed to and subscribed before me by DORIS A. ROYER, known to me or satisfactorily proven, this 41 day of . , 2013. Notary Publi COMMONWEALTH OF PENNSYLVANIA Notarial Seal Betsy A.Barnhart,Notary Public West Cornwall Twp.,Lebanon County My Commission Expires Jan.27,2014 MEMBER,PENNSYLVANIA ASSOCIATION OF NOTARIES PA REV-1500 SCHEDULE E CASH, BANK DEPOSITS & MISCELLANEOUS PERSONAL PROPERTY Bank of America,' March 17,2015 Law Offices of Halbruner,Hatch &Guise, LLP Attn: Traci L. Sepkovic 2109 Market Street Camp Hill, Pennsylvania 17011 Regarding the estate of DORIS A ROYER Dear Traci L. Sepkovic: Thank you for contacting us regarding the estate of DORIS A ROYER. Listed below is the financial information you requested on the account(s)held in the name of the above referenced decedent as of the date of death of 10/23/2014: Deposit Accounts: Account Type Number Account Details Certificate of Deposit(CD) 1019 Balance at date of death: $44,678.70 Accrued interest: $11.75 ,. Current balance: $44,752.68 S Status: Active OPEN: 11/29/94 Title: DORIS A ROYER/POA PAUL RALPH HOFFMAN/THE ROYER FAMILY TRUST Certificate of Deposit(CD) 2801 Balance at date of death: $25,624.25 Accrued interest: $1.01 ScV Current balance: $25,630.61 Status: Active OPEN: 05/22/01 lT Title: DORIS A ROYER/POA PAUL RALPH HOFFMAN/THE ROYER FAMILY TRUST Checking 4424 Balance at date of death: $274,740.36 Accrued interest: $0.23 SC Current balance: $274,749.12 Status: Open OPENED: 12/18/92 Title: DORIS A ROYER/POA PAUL RALPH HOFFMAN Safe Deposit Box N/A Banking center name:N/A Banking center location:N/A Title:N/A Please also be advised that no Safe Deposit Box was found. 00-59-2728NSBW V0913 BankofAmerica'� Credit Accounts: Account Type Number Account Details Select One N/A Current balance: $N/A Status: Select One N/A Name of borrower(s)/cardholder(s)N/A Select One N/A Current balance: $N/A Status: Select One N/A Name of borrower(s)/cardholder(s)N/A Additional Information Please call the applicable toll-free number(s) listed below for additional information: Consumer accounts: 1.866.406.8426 Credit card accounts: 1.888.702.1161 Mortgage accounts: 1.800.285.6000 Safe Deposit Box: 1.800.432.1000 If you have any questions regarding the above referenced IRA, including beneficiary and account closure, please contact our CD/IRA unit toll-free at 1.888.827.1812. If you need additional assistance, such as obtaining statement copies or closing checking or savings accounts, please mail your written request to our legal correspondence center at the address below: Bank of America Enterprise Estate Unit PO Box 982238 El Paso, TX 79998-2238 If you have any questions regarding this letter,please call us at 1.302.455.6370, Option 7, Monday through Friday from 8 a.m. to 5 p.m. Eastern. Sincerely, Account Validation ZKIEIOF 00-59-2728NSBW V0913 M&TBank 499 Mitchell Road,Millsboro,DE 19966 Records Management Phone 888-502-4349 F ax (302)934-2955 February 24,2015 Law Offices of Halbruner, Hatch & Guise, LLP 2109 Market Street Camp Hill, PA 17011 Re: Estate of Doris Rover Social Security: 277-26-8489 Date of Death: October 23, 2014 Dear Sir or Madam: Per your inquiry on February 13, 2015, please be advised that at the time of death,the above-named decedent had on deposit with this bank the following: 1. Type of Account Checking Account Account Number 9864191532 Ownership(Names ofi Doris A Royer Opening Date 08/4/2014 Balance on Date of Death $ 6686.87 Accrued Interest $ .04 Total $ 6686.91 For any additional information on the above accounts,including ownership and any changes,closures and/or reimbursement of funds, please call the Carlisle Pike at 717-7951710. We were unable to locate any safe deposit box for the above-mentioned decedent. This letter does not include any accounts in which the deceased may have been listed as Power of Attorney,Custodian of Uniform Transfers, Representative Payee,or Trustee under a Written Agreement Sincerely, Brandi Lecates Records Management PA REV-1500 SCHEDULE O INTER.-VIVOS TRANSFERS and MISCELLANEOUS NON-PROBATE PROPERTY Bankof America'�I March 17,2015 Law Offices of Halbruner, Hatch&Guise,LLP Attn: Traci L. Sepkovic 2109 Market Street Camp Hill,Pennsylvania 17011 Regarding the estate of: DORIS A ROYER Dear Traci L. Sepkovic: Thank you for contacting us regarding the estate of DORIS A ROYER.. Listed below'is the financial information you requested on the account(s)held in the name of the above referenced decedent as of the date of death of 10/23/2014: De osit Accounts: Account T e ' Number Account Details Certificate of Deposit(CD) 1019 Balance at date of death: $44,678.70 Accrued interest: $11.75 Current balance: $44,752.68 - -� Status: Active OPEN: 11/29/94 Title: 'DORIS A ROYER/POA PAUL RALPH HOFFMAN/THE ROYER FAMILY TRUST Certificate of Deposit(CD) 2801 Balance at date of death: $25,624.25 Accrued interest:11.01 ,` C Current balance: $25,630.61 Status: Active OPEN: 05/22/01 Title: DORIS A ROYER/POA PAUL RALPH HOFFMAN/THE ROYER FAMILY TRUST Checking 4424 Balance at date of death: $274,740.36 Accrued interest: $0.23 SC Current,balance: $274,749.12 _ Status: Open OPENED: 12/18/92 Title: DORIS A ROYER/POA PAUL RALPH HOFFMAN Safe Deposit Box N/A Banking center name:N/A Banking center location:N/A Title:NIA Please also be advised that no Safe Deposit Box was found. 00-59-2728NSBW V0913 (( gg Bu } yrs Funeral Home Crematory October 31, 2014 Mr. Paul Hoffman 6349 Bennington Road Mechanicsburg, PA 17050 Dear Mr. Hoffman: Thank you for allowing us the privilege of serving you and your family. We know that financial statements can be confusing, so below is a summary of your account. Statement of Goods & Services $ 5,324.00 Less: Contract Addendums (75.00) Subtotal: Invoice# 11365 $ 5,249.00 Less: Discounts (829.00) Your Balance Due by November 23,2014 $ 4,420.00 We have enclosed a complete invoice for your records. Please call us at any time that we may be of service. With Warm Regards, Michelle L. Haag Treasurer Enclosure 11"ItA kq with TImse in Grief Robert"Bob"L.Buhrig,Jr.,ro.sup,ni-,•William"Bill"L.Christopher,ro Phone; (-i ,766.3.1'_1 • 1=as: (-('i 791.7291 • 37 East Main StrecI • MechanicsbitrL,PA 17054; • NN•NcNr.NI ers-Buluig.ami DirecIorsIi NlNer.,-Buhrig.com PA Auto License Brokers Mechanicsburg PA Auto License Brokers Mechanicsburg Record#: 43630 6483 Carlisle Pike Suite 104 Mechanicsburg, PA 17050 (717)691-6720 For: Date: 03/06/2015 PAUL RALPH HOFFMAN Time: 12:54 PM 7177950640 Clerks Initials:JRS Vehicle Registration Information Agency Fees 3/6/2015 12:54:54 PM JRS: VERIFICATION OF TRUST In store processed-Notary 0.00 DEATH CLAIM Agency amount paid 0.00 Check to state 0 0.00 Surcharge 0.00 Total Agency Fees 0.00 Service Fees Messenger Fee 0.00 Notary/Clerical Fee 5.00 Copy/Fax Fee 0.00 1/We swear that I/we have applied for the above item(s). Other Fee 0.00 Payment Type CASH Total Service Fee 5.00 Surcharge 0.00 Sworn and subscribed to before me on 06-Mar-2015. Total Surcharge 0.00 Total Amount Due 5.00 Amount Tendered 10.00 Change Due 5.00 No Refunds on Service or Notary fees.We are not responsible for the work the State fails to process. Notary Seal Welcome to PA Auto License Brokers Mechanicsburg Your Direct Connection with PENNDOT,"Online",State& Service Fees Apply 03/06/2015 12:54 PM PA Auto License Brokers Mechanicsburg PA Auto License Brokers Mechanicsburg Record#: 44298 6483 Carlisle Pike Suite 104 Mechanicsburg,PA 170.50 (717)691-6720 For: Date:03/23/2015 PAUL RALPH HOFFMAN Time: 12:41 PM 7177950640 Clerks Initials:JRS Vehicle Registration Information Agency Fees 3/23/2015 12:41:51 PM JRS: WRITTEN AFF In store processed-Notary 0.00 Agency amount paid 0.00 Check to state 0 0.00 Surcharge 0.00 Total Agency Fees 0.00 Service Fees Messenger Fee 0.00 Notary/Clerical Fee 5.00 Copy/Fax Fee 0.00 I/We swear that I/we have applied for the above item(s). Other Fee 0.00 Payment Type CASH Total Service Fee 5.00 Surcharge 0.00 Sworn and subscribed to before me on 23-1%lar-2015. Total Surcharge 0.00 Total Amount Due 5.00 Amount Tendered 5.00 Change Due 0.00 No Refunds on Service or Notary fees.We are not responsible for the work the State fails to process. Notary Seal Welcome to PA Auto License Brokers Mechanicsburg Your Direct Connection with PENNDOT, "Online",State& Service Fees Apply j i �Rssoc��` CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717)249-3166 Fax:(717)249-2663 February 13, 2015 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Craig A. Hatch, Esquire RE: Doris A. Royer Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. ------------------------------------------------------------------ ------------------------------------------------------------------ Advertisement inserted on following dates: January 30, February 6, and February 13, 2015 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 ------------- Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director The Patriot-News Co. • 2020 Technology Pkwy the atr1otwXews Suite 300 Mechanicsburg, PA 17050 Now you know Inquiries - 717-255-8213 HALBRUNER, HATCH &GUISE, LLP 2109 MARKET STREET CAMP HILL PA 17011 STATEMENT ALL CHARGES ARE NET ACCT# NAME AD ORDER# DATE EDITION ADDTL. INFO. TYPE OF CHARGE AMOUNT 245301 HALBRUNER,HATCH&GUISE,LLP 0002326405 02/03/15 XXX Royer XXX $23.52 245301 HALBRUNER,HATCH&GUISE,LLP 0002326405 02/03/15 XXX Royer BASIC AD CHARGE $67.78 245301 HALBRUNER,HATCH&GUISE,LLP 0002326405 02/10/15 XXX Royer BASIC AD CHARGE $67.78 245301 HALBRUNER, HATCH&GUISE.LLP 0002326405 02/17/15 XXX Royer BASIC AD CHARGE $67.78 AFFIDAVIT CHARGE $5.00 TOTAL: $231.86 This is not an invoice. Please do not remit payment from this Statement. An invoice will be generated at the end of the month. --Thank you. NOTE: This Statement replaces the Order Confirmation which we previously sent with Proofs of Publication RECEIPT FOR PAYMENT LISA M. GRAYSON, ESQ. Receipt Date : 1/09/2015 Cumberland County - Register Of Wills Receipt Time : 12 : 49 : 37 One Courthouse Square Receipt No . : 1080117 Carlisle, PA 17013 ROYER DORIS A Estate File No . : 2015-00026 Paid By Remarks : LOIS A HOFFMAN HMW - - - - - - -- - -- -- - - ---- - - - -- Receipt Distribution --- - - - - - - - - - - - - ---- - - - -- Fee/Tax Description Payment Amount Payee Name PETITION LTRS ADM 310 . 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 10 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 35 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN RENUNCIATION 20 . 00 CUMBERLAND COUNTY GENERAL FUN --- ------------- Check# 1244 $425 . 50 Total Received. . . . . . . . . $425 . 50 RECEIPT FOR PAYMENT ------------------ ------------------- LISA M. GRAYSON, ESQ. Receipt Date : 1/22/2015 Cumberland County - egister Of Wills Receipt Time : 15 : 33 : 09 One Courthouse Square Receipt No. : 1080259 Carlisle, PA 17613 ROYER DORIS A Estate File No . : 2015-00026 Paid By Remarks : HALBRUNER HATCH & GUISE HMW ------------------------ Receipt Distribution ------------ ------------ Fee/Tax Description Payment Amount Payee Name SHORT CERTIFICATE 15 . 00 CUMBERLAND COUNTY GENERAL FUN ----- - ---------- Check# 196715 . 00 Total Received. . . . . . . . . H5 . 00 PA REV-1500 SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES and LIENS J-1- Form PB-01 AoNwa Lif � at MESSIAH VILLAGE 100 MT.ALLEN DR.,MECHANICSBURG, PA 17055 RESIDENT# I UNIT STMT. DATE 81321 255 D 02/28/2015 RESIDENT(S) PAUL HOFFMAN THE ESTATE OF DORIS ROYER 6348 BENNINGTON ROAD MECHANICSBURG, PA 17050 TOTAL AMOUNT DUE $17,732.00 DATE DUE 03/31/2015 DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE $ ------------ -- ---- ------------ --------------------------- ---------------------- — - ----------------------------AMUNT REMITTED_ DATE DESCRIPTION RATE Unit/ CHARGES CREDITS BALANCE Balance Forward 17,732.00 Page 1 RESIDENT# CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 81321 0.00 0.00 0.00 0.00 17,732.00 $17,732.00 RESIDENT NAME THE ESTATE OF DORIS ROYER FormPM1 N/A Please make check payable to Messiah Lifeways at Messiah Village. A 1%finance charge may be assessed on accounts for which payment has not been received by the due date. If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. PAUL D. DALBEY DPM' Closing Date: 12/10/2014 5KACEYCOURT, SUITE 202 MECHAN}CSBURG. PA17O55-9222 (717) 591'133G Balance Due: $8.48 Patient: OC}RISROYER 8413 Bill To: DOR|SROYER PAUL D. DALBEY. DPM C/O PAUL HOFFMAN 5KACEYCOURT, SUITE 2U2 63498ENN|NGTONRD K8ECHAN|CSBURG. PA 17056-9222 K4ECHAN/CSBURG. PA1706D Page: 1 PAUL D. DALBEY, DPM 0]R|GROYER 5KACEYCOURT, SUITE 2O2 33D MECHAN|CSBURG. PA 17065'9222 222MESSIAH CIRCLE |NECHAN/{|GBURG. PA17O55 AocmuntNumber: 6413 Closing Date: 12Y10/2014 Date: Coda: Description: Charge: Credit: 16'Sep-2014 11721 DEBRIDE MYCOTIC NAIL OORMORE $55�00 Paid byInsurance/Adjustments $48.52 ____________________________________________ ___________ DUEFROK8PAT|ENT $8.48 ] � ) 0 Total Due From Patient $8.48 Charges Marked ^ Have Appeared on m Previous Bill Your prompt-payment is appnsni Current Over 3DDays Over 6QDays Over 90 Dsvm Total Balance $8.48 $0.00 $0,00 $0D0 $8.48 ,/ ALE _19 North Baltimore Avc A FINANCE CHARGE OF 1.50 a PER MONTH Pxnxivtncv SF.RVT{FS,1NL. Mt t+olly Spring,, P:\ 17065 (AN ANNUAL PERCENTAGE RATE OF 18 . 0'6) OR A Responsive. Innovative. Reliahk. 8()0-2br,-995-1 0171496-8806 MINIMUM SERVICE CHARGE OF $ 1.00 WILL BE CHARGED w-w�i.AlerWharmaci.coin 1 /�II� ON ALL AMOUNTS 30 DAYS OR MORE PAST DUE STATEMENT F ACCOUNT : IF YOU RECEIVE A NEW INSURANCE CARD FOR YOUR PRESCRIPTIONS BE SURE TO SUPPLY US WITH A COPY. Date 12/31/2014 --—__..___. r,_PMT DUE-�,-0 l_/24_/15 r ROYER, DORIS ROYED 30 DAYS . 1 . 80 PAUL HOFFMAN GRP-7W 60 DAYS . 120 . 22 6349 BENNINGTON RD PAGE 1 MECHANICSBURG PA 17050 Amount Pai( PLEASE DETACK AND RETURN TOIL PORTION WITH YOUR PAYMENT ALERT PHARMACY SERV. INC.219 NORTH BALTIMORE AVE. MT HOLLY SPGS, PA 17065 e ` . E x , eTOTAL, ** THIS AMOUNT PAST DUE ** 1 r V 1 1 4 l PAS Y DUE j YOW-i ACUOUr,! T 18 C,OIv.,it?EI:fABLY f-'1�57"D1J>"! PLEA,, Fi t,.it?.. ..... TO DAY i i 1 �- - -_- -------------------- ---__ - . 0 0 srevious 4alance Charges this month Finance Charne= TOTAL C"ARGES Total Payment Credits�? AMOUNT 122 . 02 + . 00 -+ 1 . 83 - 123 . 85 - . 00 ` - 123 . 8 "�t= e-Ai t Mort Pharmacy Services, Inc at 1-800-266-9954 ve P,rmoung hoc,hrnring mut xfioirnas Account: Royer.Dods (656426) Program: Consult-Older Adults= -'.-, - Admit Date: 01/23/2014 Discharge Date: Card Number: Statement Date: November 6,2014 Please Pay This Amount: $17.71 Expiration Date: Security Code: Duc Dake: November 2l,2014 Amount Enclosed: $ Signature: 5709-33 1 Printed Name: PAUL HOFFMAN Please check this box if your address or insurance has changed and then complete the form on the back of this page. 6349 BENNINGTON RD MECHANICSBURG,PA 17050 Payment Arrangement Exists'? No ' Make Checks Payable To;PHILHA 4 EI17. <Detach Here and Return Top Portion Kath Your Payment. Bottom Portion is for Your Records> Please»tail your payment and this payment stub using the supplied pre-addressed envelope. (7f you are paying for multiple accounts with one payment,please include all payment stubs.) Summary Statement of Services(Detail on Reverse Side) Account: Royer,Doris(656426) Due Date: November 21, 2014 Program: Consult-Older Adult Statement Date: November 6, 2014 Admit Date: 01/23/2014 Previous Statement Balance: $17.71 Discharge Date: Payments Received Since Last Statement: $0.00 Total New Charges: $0.00 Amount You Now Owe: $17.71 The account balance for the services received is now due. All insurance activity,if any,has been processed and the remaining balance is due from you. If your balance is zero,please retain detail for your records. Services provided in the new calendar year may be subject to additional patient liability over and above the usual co-payment and co-insurance amount. Co-payments,co-insurance,deductibles and non-covered services will be your responsibility according to your health insurance coverage Please contact your insurance carrier with questions regarding deductible and co-insurance amount (s). Please remit the balance in full within fifteen (15)days using the enclosed reply envelope. Our office accepts checks and credit cards. If you are unable to pay your balance in full or need assistance in understanding your statement, please contact our office at (717) 270-2413 or toll free at 1(888)302-4710,Monday-Friday 8:00AM-4:30PM. Someone will be glad to assist you. Thank you for choosing Philhaven for your healthcare services. 0-59 j 283 South Butler Rd Mt Gretna,PA 17064-0550;Phone(888) 302-4710 or(717)270-2413 dhavtnBusiness Office Hours:Monday through Friday 8:00 am-4:30 pm Hasler PRIORITY MAIL 321L1"i.1 $05' 951 �•'•V ZIP 17011 011D10640858 Law Offices of HALBRUNER, HATCH & GUISE, LLP 2109 Market Street * Camp Hill, Pennsylvania 17011 (717)731-9600 •www.hhgllp.com { To: Cumberland County Courthouse Office of the Register of Wills One Courthouse Square Carlisle, PA 17013 , T Law Offices of im�'Am. 1UNK & GUILLP 2109 MARKET STREET-CAMP HILL, PENNSYLVANIA 17011 MARK E.HALBRUNER (717)731-9600-FAX: (717)731-9627 BRANCH OFFICE: CRAIG A.HATCH,CELA 3 WEST MONUMENT SQUARE,SUITE 304 Certified as an Elder Law Attorney by CORRESPONDENCE ADDRESS: LEWISTOWN,PA 17044 the National Elder Law Foundation Camp Hill Office (717)248-6909 CLIFTON R.GUISE WEB SITE: STACEY L.NACE Also Admitted to practice before the www.hhgllp.com Paralegal U.S.Patent&Trademark Office TRACT L.SEPKOVIC JOHN H.MCCULLOUGH Paralegal Of Counsel TRACI L.HILFERDING Paralegal June 29, 2015 Cumberland County Courthouse Office of the Register of Wills One Courthouse Square a Carlisle, PA 17013 © ; mI ms: � � n=. RE: Estate of Doris A. Royer r-- . File No. 2115-0026 A .� rn ry rtil rn a o Dear Sir or Madam: `n Enclosed for filing are the Pennsylvania inheritance tax return (in dupjicaf6) and l ventCnIIr for the Estate of Doris A.Royer. Please time-stamp the additional photocopy df each docment andn return them to our office in the enclosed envelope. Thank you for your assistance in this matter. Sincerely, Traci L. Sepkovic Paralegal Enclosures cc: Paul R. Hoffman, Administrator