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ESTATE SETTLEMENT AGREEMEN7 - ra -
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This Agreement is made the 3Cl t�day of 2075, by and among%athr�in�tal.
Huntzinger,the Ezecutrix of the Estate of Gloria Y. Mille , eceased; herein referred�.to as F�e.cutr,"�z; �d
Nathan D. Miller and Natalie K.Singer,beneficiaries of the es[ate, hereinaker collectively rqt@rred;aas
[he Beneficiaries. � �
In acrordance wi[h their desire that the administration of[he Estate of Gloria Y.Miller,deceased,be
terminated without the expense and delay of a Court accoun[ing,the parties hereto, in consideration of
the mutual covenants herein ezpressed, and intending to be legally bound hereby, agree that:
1. The estate of Gloria Y. Miller,who died 19 January 2013, is now winding
down the process of administration. Letters Testamentary having been duly granted the Executrix by the
Register of wills of Cum6erland County on the 5`"day of February 2013.
2. Under[he provisions of the decedenYs will, her residuary estate was given to
the foliowing benefciaries in[he fractional shares ret forth opposite their names:
Nathan D. Miller Y
Natalie K.Singer X
3. The parties understand tha[[his is an insolvent es[ate due to expenses
accrued through the need for prolonged Medical Assistance. The debts exceed the assets,and the
statutory dassification and order of disbursemen[s dictates the precedence for payment of obligations
so far as available funds may go. Therefore,there are no monies for distribution of gifts to beneficiaries
despite the decedenYs intentions.
4. The parties acknowledge[ha[the Executriz has received the assets and made
or shall complete the dis6ursements set forth in the Pennsylvania Department of Revenue inheritance
tax return, a copy of which is attached hereto as Exhibit A and made a part hereof,and the parties
accept the said instrument of record as full disclosure and satisfaction of accounting as has been
officially approved in the Pennsylvania Department ot Revenue Statement of Summary Accounting and
acceptance of said inheritance tax re[urn as filed to show[hat no inheritance taxes are due,a copy of
which Statement is also attached marked as Exhibit B hereto and made a part hereof.
5. The parties understand and agree that there is no balance of the estate assets
for distribution as se[forth in Exhibits A and B. Without intending to limit the rights or remedies of the
beneficiaries,the parties further agree to indemnify the Executriz and save[he Executrix harmless
against any undisdosed liability, loss, and expense(including, but not limited to, costs and counsel fees)
which the estate may incur,whether due to the Executrix's negligence or otherwise, as a result of
makingthe above-described determination without a Court audit.
6. Should any proper liabilities of the estate,whether fortaxes or otherwise,
arise or come to the attention of the Executrix or any of the other parties thereafter,the beneficiaries
agree to be jointly and severally liable therefore and the beneficiaries shall reimburse the estate in equal
shares for any said liabilities to be paid.
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7. The parties, and each of them, hereby forever fully release, compromise,
settle, and discharge any and all claims,demands, actions,or causes of ac[ion, legal or equitable,
absolute or contingent,vested or hereafter to accrue,which any of them may have against any o[her
party hereto or against the estate of Gloria Y.Miller,deceased,or the Executrix thereof, by reason of
any matter,cause or thing growing out of or relating to any property or assets of the said estate, or
growing out of or relating to any act of the Ezecutriz, in her administration of said estate,even if
attribu[able to negligence,and agree[hat any period for the limitation of aQions commence only at
such time as[he Executrix shall have obtained actual knowledge of such erroneous payments and that in
no event shall the period for collec[ion of any erroneous payments be less than two years after the
aaual discovery thereof bythe Ezecutriz.
8. The parties agree to execute such additional releases as the Executrix may
submit to them in order to confirm their discharge from any further liabiliry to the parties in connection
with the said estate.
9. The foregoing provisions which apply to the Executrix, shall apply also to any
fiduciary who may be appointed in connection wi[h any ancillary administration which may be required
in order[o complete administration, if any, in otherjurisdictions.
10.This Agreement may be executed in multiple counterparts and,when so
exewted, shall be binding upon all the parties,and their respective heirs, neM-of-kin, personal
representatives and assigns.
IN WITNE55 WHEREOF,the parties have hereunto set their hands and seals with intent to be legally
bound hereby the day and year first above written.
EXcE�C�UTRIX OF THE ESTATE OF GLORIA Y. MILLER
onre: '"�' �o i ' „ry"a� Yr� ���lsen��
� Kathryn M. Huntzinger
OENEFIC��DE1�7y@ W ILL OF GLORIA Y. MILLER
DATE � a`� �/S ll�ll /l�i// (SEAL)
Nothon D. Miller
DATE: �' � / /�[.Ct' 1/JJ�J �y�cJ (SEAL)
J
Namlie K.Singer
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ACKNOWLEDGEMENT
COMMONWEALTH OF PENNSYLVANIA
S5:
COUNTY OF CUMBERLAND
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On this che�_day of .�"/i L �,/ 2015,before me,a Notary Public personally appeared
Ko[hryn M. Huntringer,known to me(or atisfactorily proven)to be the pe�son whose name is
subscribed to the within instrument,and acknowledged that she executed same for the purposes
Ihereim m�tained.
IN WRNE55 WHEREOF, I hereunto set my hand and official seal.
h o1 Pennsylvanla �""C�# � �� �
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NOTARIAI SEAL
��'���'�ry��k NOTARY PUBLIC
�«�p�ppp Nov�mEa 73,IOti
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ACKNOWIEDGEMENT
STATE OF MARYLAND
55:
COUNTVOF �O'`�C9'� Je�✓
On this the a� day of �l.U�t 2015, before me,a No[ary Public personally appeared
Nathpn D. Miller, known to me (or sa[isfactorily proven)[o be the person whose name is subscribed to
the within instrument,and acknowledged that she executed same for the purposes[herein contained.
IN WI7NESS WHEREOF, I hereunto set my hand and o�cial seal.
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ACKNOWLEDGEMENT
COMMONWEALTH OF PENNSVLVANIA
S5:
COUNN OF CUMBERLAND
On[his the ��7 ri,day of - [ t 2015,before me,a No[ary Public personally appeared
Notalie K. Singer, known to me(or� atisfactorily proven)So be the person whose name is subscribed to
the within instrument,and acknowledged that she executed same for the purposes therein contained.
IN WITNE55 WHEREOF, I hereunto set my hand and offcial seal.
COMMONWEALTH OF PENPLSYLVANIA
Naanal Sea�
Ka[hleen Nissky, No2ry Publk ���� �L� � ����'��
SouN MIGGktm Twp..CVmRMaM CouMy
MY Commiisan Erdres SepC 10,20 V
MEMpEb GfXXAIVANU ASSOC4 ON OF 1qtM1 5
NOTARY PUBLIC
J15�561�1�5
REV-1500 E"�°''°'Fl, i�
vP�epadmentofRevenue pennrylvama oFFlcw�USEou�r
Bureauofln0iv10uatTd�PS -���" ���- CWntyCotle Year fileNumO¢r
ao eoxaaosoi � INHERITANCE TAX RETURN r/
Hamseurq an.�.za-o6on RESIDENT DECEDENT �� � �� � 7.�
ENTER�ECEDENTINFORMATION BELOW
Social Securi�y Number Oate ot Oeafh MM�DYYYY Dale of Birth MMO�YYYY
01/19/2013 07/17/7927
Decedenfs Las�Name Suffx Decetlenfs First Name MI
Miller Gloria Y
Qf Applica�le)Enter Survlving Spouse's Information Below
Spouse's Last Name Suffx Spouse's First Name MI
Spouse's Social Securiry Number
THIS RETURN MUST BE FILEU IN UUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Onginal fteNm O Z Supplemenlal Relurn O 3. Remaintler ReWm(D'ate of OeatM1
Prior lo tt-13-82)
O 4. Limitetl Estate O 4a FUWre interest Compmmise(date of p 5. Fetlerai Estate Tax Rewm Requiree
tleatM1 after 4-4-82)
(,� 6. �ecetlen101etl Tes�a�e O ). Deceden�Mainlainetl a Living Tmst � 8. Total Number of Sate Deposi�Boxes
(Ptlach Copy o�Will) (AVach Copy o�TmSL)
O 9. Gtigallon Pmceetls ReceiveG O 10.Spousal Povetly Cretli�(�a�e ol Dea� O 11 Eletlion to Taz untler Sec 9113(A)
Between 4-3t�9t ana t-L95) (n�Wcn Scneaule o7
CORAESPONDENT- THIS SECiION MUSi BE COMPLETED.NLL CDRRESPONDENCE PND GONFI�ENTIAL iW(INPoRMATION SHOULU BE OIRECTED TO'
Name DaNime Telephone Number
Wlliam S. Daniels p77)243-3837
REGISTER OF WILLS OSE ONLY
FirslLineofAdtlress � s
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1 West High Street 3 � � ci a
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Second�ineofAddress ", 'r �� ~ ��� �
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Suite 205 . �'" . � �
Cityoraostorcce Sta[e ziaCoae � -oaYeFiieo .
Carlisle PA 17013 � � �" -'
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correspo�de�r:a-max aaaress:humeranddaniels@outlook.Com ' s � �
unae�penawes o�����y,i aedaa mau na�e e.ammea m�s rewm'��emamy accw�pe�y;�g seneawes a�a s�a�emem:,am m me ees or my X�o�neege a�a eene�,
il is�me,correcl ana complete.�eclara�ian o�preparer omer�han Ihe personal representalive is hasetl on all informaHon of which preDarer has any knowletlge.
SIGNATURE OF PERSON RESP NSIBLE FOR FlLING eETURN ATE
� H�DR�.n.�� �� ��-h. � � S �J�� �
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Kathryn M. Hun�inger, 584 G s ad, Cadisle, PA 17 15 �/ y
SI HT EO E�AREftOTHERT RE S NTNT}1(E DATE �
XL a�'�' (..,s�
nooaEss
William S. Daniels, Humer and Daniels Law Offce, 7 W. High St., Suite 205, Cadisle, PA 77013
PLEASE USE ORIGINAL FORM ONLY
Sitle 1
L 1505610105 1505610105 �
J 150561�205
REV-1500 EX(FlJ pecetlenfs Social Sewnry Number
oe�ae�r:nnme: Gbna Y. Miller
RECAPITI/LATION
t Real Esta�e(ScheJule A). . ............................_ .. ........... 1. 0.00
2 Slocks antl Bonds(Schetlule B) ....... . ... . . . ... ... . . ....... .......... 2 0.00
3. Closery Heltl Co`poration,Partnership or Sole-Proprietorship(Schedule C) ..... 3. 0.00
4. Mortgages and Notes Receivable(Schetlule D). . ................. . . . . . . . . 4. 0.00
5. Casn. Bank�eposils antl Miscellaneous Personal Pmperty ISchetlule E). . . . . . . 5. 5,331.90
6. Jointly Ownetl Pmperty(Schetlule F) O SeparaYe Blllirg Requestetl . . . . . . . 6. 0.00
I. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Properry
(Schedule G) m Separale Bllling Requested.. . . .. . . ]. 27,784.30
8. TMaI Gross AsseGs(total Lines 1 through])... .... . .................. . .. 8. 33,11620
9. Poneral Expenses antl Administrative Cosls(Schedule H)..... . . . .. . . . . . . . . . 9. 3,423.50
10. �ebts o(Decetlent,Mortgage Liabili�ies and Liens(Schetlule I)... . . . . . . . . ... . 10. 306,625.87
11. Total Deductions Itotal Llnes 9 and 10). . . ................. ... . . . . . . . . . . ii. 310,049.37
t2. Net Value of Eslate(Line 8 minus Line 11) .. .. .. . .... .. .. . .............. 12. -276,933.17
13. CharitableantlGovemmentalBequesis�5ec9113Trustsforwhich
an elec[ion ro lax has no�been matle(Schedule J) .... . ................ . . . 13. 0.00
ta. Ne[Value Subjx[ro Tax�Line t2 minus Lir�e 13) .. ...................... 14. -276,933.17
TA%CALCULATION-SEE INSTRULTIONS FOR APPLIGABLE RATES
15. Amoun[of Line 14 taxable
a�Ihe spousal tax rate,or
imnsiers untler Sec.9116
(a)(12�X 0_ 1s ODO
�6. Amount of Line 14[azable
atlinealrate X.0_ 16. 0.00
1]. AmountolLinet4taxable
a�sibling rate X.12 », 0.00
18. Amounl of Line 14 faxable
atcollaleralrate X.15 ig, 0.00
+9. TAXDOE . . . .. . . . . . . .. . .. . . . . ... . . . . . . . . .......... t9. 0.00
20. FILL IN THE OVAL IF VOU ARE REqUESTING A REFUN�OF AN OVERPAVMENT O
Sid¢2
L 15�5610205 15056102a5 J
.�EV450�E%�FI) Pege3 FleNumE¢� 'J / � / �{-� O / C��
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Decedent's Complete Address:
�ECEOENT"a NAME
Glorla Y. Miller
STREETADDRE55 �� �
100 Claremont Roatl
.__ ____ . .._
CITV .. .. .. . . . . . ... . ... ' STATE i ZIP
Cadisle � PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2.Llne 18) 11) 0.00
2. CretliislPayments
A.Prior Paymen�s . 0.00
B.�iscount
TotalCredifs(AtB) (2) 0-00
3 Inrerest
�3� o.00
0. If Line 2 is greater Ihan Line 1 +Line 3,en�er Ihe difierence. This is the OVERPAYMENT.
Fill in aval on Page 7,Line 20 to rtques�a refuntl. (4) 0.00
5. If Line t +Line 3 is greater Nan Line 2,enter ihe 4iRerence.This is Ihe TA%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. Ditl decedent make a Ironsfer anB. Ves No
a. relainNeuseorincnmeoF�hepmperlyhansferred .__._ _.__ ..__._ ____ ❑ �
h. retaintherighlcotlesignaFewhoshalluselhepropeM��ansferretlori�sinmme ._...._....._._.__.__.____. ❑ �
c. reuinareversionaryinferesl ......... ____. _.__ __._ __._ ❑ �
e. receive�he pmmise far li�e of eilher paymen6,bene0ls or care� .._...... .._.... ....._ ❑ �
2. If tlealh occunetl afler Dec.12,1982.ditl decetlem transfer pmperry within one year of tlea�h
wiihoWreceivingadequateconsideration?. _....._ .. .____....__..__. ❑ �
3. �id deceden�own an"in�ms�for"or payaGe-uponaealh bank account or security at his or her deafh?.............. ❑ �
4. DitlOecedentownanindividualretirementaccant,annuityorothernonpmbatepmperty,which
contains a beneficiary desgnat�on� ........... ..._..... ........... .... ..... � ❑
.....................
IF THE ANSWER TO ANY OF THE ABOVE�UESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Por daroc of deoth on or aNer July 1, 1094.and before Jan.i, 7995,ihe tax rate imposed on the net value of tmnsfers to or for ihe use of ihe surviving spouse
is 3 percent[72 PS.§9116(a)(1.1)(ip.
For dates oi dea�h on or after Jan. 1, 1995, the tax rate imposed on the net value of iransfers to or for the use of the suniving spouse is 0 percenl
�72 P.S.§9116(a)(1 1)(ii)].The staNte tloes not exempt a transfer m a surviving spouse from tax,and the s�aWtory requirements for disclosure of assets antl
flirg a Nax retum are siill appliraGe even if ihe surviving spouu is the only benefdary.
For dates of death on or afler July 1,2000:
. The�ax rate imposetl on�he net value of iransfers from a deceased child 21 years of age or younger at death to or for the use of a naWral paren�,an
adopfive parent or a stepparent of Ne child is 0 percent�72 PS.§9116�a)(12�].
. The Wx ate imposed on tl�e net value of hansfers fo orfor the use of�he decedenYs lineal benefiqanes is 4.5 percent,excep�as noletl in�72 P.S.§9116(a)(1)�.
• The tax rate imposetl on the net value of transfers to or for the use ot Ihe decetlenCs sblings Is 12 percem p2 P.S.§9116(a)(L3)�,A slbling Is define4
under Section 9102,as an intlividual who has at least orre parent in common wiN the decedent,whether by 61ood or adoptlon.
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II
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I, GLORIA Y. MILLER,widow, of the Borough of Cazlisle, Cumberland
�I County, Pennsylvania, declaze this to be my ]est will and revoke any will previousty
made by me.
I
I. I give azid bequeath all of my estate of every nature and wherever situate in equal
�� shares to such of my grandchildren,NATALIE KAY WAItK,and NATHAN
pARRELL MILLER, as survive me by thirty days.
]I. Should my granddaughter,Natalie Kay Wazk, or my grandson, Nathan Darrell
j Miller, predecease me o[die on or before the thirtieth day following my death, I
� give and bequeath the share of such grandchild to her or his issue per stilpes
living on the thirty-first day following my death; and should either my said
Igranddaughteq Natalie Kay Wazk, or my grandson,Nathan Da[rell Miller, leave
no such issue living on the thiriy-first day following my death,I give and
bequeath [he share of such grantichiltl co my o[her gran�diil� oc io hor oc 1,1�lasue
�. per stirpes ]iving on the thirty-first day following my death. ��
III. � I appoint PHILIP J. HITNTZINGER and I{ATHRYIV M. HiJNTZINGER, : �
Ihusband and wife,or the survivor of them, guazdian of any propedy which puses �
Ieither under this will or otherwise to a minor and with respect to which I am ��-'
authorized to appoint a guazdian and have not other specifically done sq provided
I ����
�___
_.._,� _�..�._.�_�,....,___.�-__ �..n.�.�... . --�--.
�', that this appointment of a guazdian shall not supersede the right of any fiduciary
in its discretion to distribute a shaze where possible to the minor or to another for
''�, the minor's benefic Such guardian shall have the power to use principal as well
�� as income from time to time for Ihe minor's support and education(including
Icollege education, both graduate and undergraduate)without regazd to his or her
pazenYs ability to provide for such support and education, or to make payment for
these purposes,without fuit6er responsibility,to the minor or to [he mi�or's
parent or to any person taki�g care of[he minor.
I V. All federal, state and other death taxes payable because of my death, with respect
to the property fortning my gross estate for tau purposes, whether or not passing
� under this will, including any interest or penalry imposed in connection with such
tan, shall be considered a part of the expe�se of[he adtninistration of my estate
and shall be paid out of the principal of my estate without appoRiomnent or right
of reimbursement.
,V. I appoint PHILtP J. HUIVTZINGER aod KATHRYN M. HUNTZINGER,
husband and wife,co-executors, or the survivor of them executor of this my last �
will. Should PMlip J. Huntzinger or Kathryn M. Huntzinger, fail [o qualify or
cease to act as executor, I appoint my granddaughter, NATALIE KAY WARK, �
and my grandson, NATHAN DARRELL MILLER, co-executors, or the � - J
�
u
survivor of them exewtor of[his my last wilL a
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,
�.. _�._ ..
_--.�.-�.,- _ _ - ----- -- ---=
�� VI. I direct that my executors or guardians shall not be required to give bond foc the
Ifaithful performance of their duties in any jurisdiction.
y�
i IN WITNESS WHEREOF, I have hereunto set my hand and seal this � day
I
of /�j0Ib1 L , 2006.
I
I ✓ub� /L�+�SEAL)
GLORIA Y ILLE �
The preceding instrurttent, consisting of this and hvo other typewritten pages
identified by the signature of the testatrix, GLORIA Y. MILLER, was on the day and
date thereof signed, published and declazed by GLORIA Y. MILLER, the testatrix
therein named, as and for her last will, in the presence of us,who, at her request, in her
presence, and in the presence of each other have subscribed our names as witnesses
hereto.
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i' pennsylvania SCMEDULE E
�� oeanarmenroFnevervue CASH� BANK DEPOSITS & MISC.
:""EaR^"�E T^*"�"" I PERSONAL PROPERTY
reesmervr oecEOEr�r
ESfATE OF: FILE NUMBER:
Miller, Gbria Y. 21-13-0143
Indude the proceeEs of litigation ane Me Date[he pmceeds were receivetl by[he estate.
All pmperty joinHy owne0 wi[h righ[of wrvlvorehip must be tliuloseE an Schedule F.
ITEM VAIUE AT DATF
NUMBER DESCRIPTION OF DEAtH
1, MBTCheckiigAcwunt#7220055 1,732.66
p, Claiemont Nursing and Rehabildafion Cen�er,Retund 3,59924
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TOTAL(Alw enter on Line 5, Re�pitula[ionj ; 5,331.90
I(mare space is needetl,use additional sheets of paper of Me same size.
P'f�5:�.-�.C13 L3<3 T.i2S5151 2EFP�],N =Fa � .•m �•
MdICI: i.�Ol?
Kathr,;r. �i Nuntzu�gzr
$�'•4 iieeasa� Rd
Carlisle, YA 1'.013
CeJI: :86-9'sl I
W o;4.�. '->3-Y?UG
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Fa�c: 2�3-5916
r^lease find attached the MNcT Unlance in C3luria Nlillrr's 5state.
Than}:s,
Kathy
_ _ _ _
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Spring Garden Office �
If you have any questions, please -
call our Telephone Banking Center � .
at 1-800-724-2440 -
Today's Date: Business Date: .
02/15/2013 02/15/2013
Time: 12:20 PM ��jp5:t � �—r,L.,�.
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Checkin9 Deposit BL732.88 ���ti�� ����
#�*1980
Total Balance: $1,732.66
4344/O6 68 M -
Thanks for vistting us today. �
We are happy to assist you!
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age: 1 Document Name: untitled —��- �� -
STFD 1 'PHF 'IR4NSACMS�50861TLAST PAGE OF TRANSACPIONS06.07
STMT CO 96 OP E6AN
ACTION COZD
PROD CODE DDA ACCT '720054 SHOR4' N:\ME MILLER GLORIA Y
CURR CODP� PAGE 1 SEARCfi FROM 112/12/18 THRU ll3B/�01�/CF.
ACTN POST EFFECTT_VE CHcCK DNMBER maal7 amGonl'P n/C
TR4CE ID DESCRIPTIO� 1, 759 .78
p7 .12 D
' 12/18
0] 23520047D0126 MO[V[TMENTAL LIFs iNsaaaN�F D 1, 732. 66
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i'' pennsylvania SCHEDULE G
�' oePAr+rnervrarnevenue INTER-VIVOS TRANSFERS AND
:""E"^""cET"`"�T°"" I MISC. NON-PROBATE PROPERTY
aesmErrr oEceoEert
ESTATE OF FILE NUMBER
Miller, Gloria Y. 21-13-0743
ThIs 5<hedule muR be mmple[ed antl filetl if[he answer to any of questions t[hmugh 4 on page[hree of Ne REW 1500 is yes.
17EM �ESCRIPTION OF PROPERtt
mcwce�vexu�vmeauussu�muvuunarsnivmoK�nvnuv DATEOfDEATH %OFOECD5 EXCLUS[ON TA%ABLE
NUMOER meonrtamu�. arnanmmorm�caorauuEsnrt. VALUEOFASSEf INTEREST �iinrue•ae� V/LUE
�� LincolnBenefitLife,#LBF1088376-Mnuity
Co-Benefcianes:
I� Natalie K.Singer,Granddaughter p7,7gq.pg 100 2n8429
Nathan Miller D.,Grandwn
I
TOTAL(Also enter on Line 7, Recapitulation) § 27.78429
I(more space is nee�ea,use adtli[ional sheets of PaOer of the same size.
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�_.�-
LINCOLN BENEFIT LIFE
qM [Lt9TRi¢ COMVRHY
January 25,2013 '
Natalie K. Singer
8 Lebo Rd.
Carlisle, PA 17015
Re: Gloria Y. Miller,deceased
Contrect No: LBF1088376
Ciaimant(s): Natalie K.Singer and Nalhan Miller
Dear Ms.Singer.
We are very sorry�o learn of your loss and extend our sincere condolences. We unders�and ihis may 6e
a ditficult time for you.
The conhact owner was receiving a series of peyments spread over a period o�lime under this annuily.
The beneficiary is now entitled to receive tha remaining guaranteed payments described bebw. Any
payments due a beneficiarywill he pald on the specified tlue dates,and theywill not be commuted or paid
in a lump sum. li ihere are multiple beneficiaries,each beneficiary will receive their respective share o(
any payment.
Frequency of payments: Monthly
. Amount of each payment 5776.97
Last payment date: February 1,2026
We Need Some Informetion ta Proceas Your Claim �
In light of this loss,we need some additional informatlon from you to help us process your claim. At your
earlies�convenience,please send us the foltowing documents in the enciosed postage-paid envelope:
• qaimanCs Statemen[(fuily completed and signed)
• Certitied copy of death certificate("certified"means an original document or copywith reised seal
or original stamp). UnForlunately,we ara una6le lo return an original death certificate submitled Io
us for this claim.
The Internal Revenue Service requires ihal when the owner dies and we pay ihe remaining guaranteetl
payments to a beneficiary,we must pay out the remaining cost basis lirst. Theretore,lhe iaxa6le potlion
of each payment to the beneficiary may diifer from what applied to the owner dudng iheir Iifetime,and It
may chenge overthe remainder of the guaranteed period.
Lincoln Benefi[Lite Company
Life end Annuliy Clalms
P.O, Box 94272, Peleline,IL 60094-4212 Phone 877-499-8418 Fax 668�635�4523
January 25,2013
Paga 2
Atltlftionel Taz Intormation
Paymenis fmm an annuity may be tazable to ihe recipient. Please consult wlih your tax advisor or
attorney pnor to making anydecisions concerning the claim. If you have any questions,or if you need
assistance in completing the forms,pleese contact me at 7-877-499-641 Q Ext.24677.
Again,we exiend our sincere condolences on your loss. Thank}rou for your assistance.
Sincerely,
Nicole D.Levas
Sr. Claims Ezaminer
Enclosures
tEC-S�J E1. �9B-L9, I
i . pennsylvania SCHEDULE H ,I
� ocraAlnErvroFnEVErvuE FUNERAL EXPENSES AND 'I
ik1°a'T""«�^'"F""" ADMINISTRATIVE WSTS I
+esioex*oeceoervr
ESTATE OF FILE NUMBER
Miller, Gloria Y. 21-13-0143
�ecetlent's debh must be reparteE on Schedule I.
tTEM
NUMPER DESCRIPTION AMOIIM
a. FUNEFAL EXPENSES:
t.
0.00
e nonm�sraartve cosrs:
L PersonalRepresenta[iveCommissions: �,Q0�.00
Name(s)of Personal Reoresentative(s) KathfYn M. HUn�Zingef
. __
sneccnooress 584 Greason Road
' �ity Carlisie 5tate PA
—__. __ ___ .. . .. z�P 17015
Year(s�Commission Pai7'
�. Anorney Fees'. 7,500.00
3. Family Exemption: Qf decedenPs atltlress is not Ihe same as daimanPs,attach ex0ianation.)
Qaimant
5[reet AGdress
�'�, City Sta!e ZID � —
'�, Relationship of Claiman[to Decedent
4. Pmba[e Fees: 103_50
5. Acmuntant Fees: 0.00
6� Tax Retum Preparer Fees: Q.�Q
I
�� � Register of Wills,Filing Pamity Agreement 20.00
e. Cumbetland Law Joumal,Advertising 75.00
e. TheSantinei-Legal,Adve�ising 300.00
io. AOtlitionalPmbate 25.00
>>. Reserve 400.00
T07AL(Also enter on Line 9, Rewpitulatian) $ 3,423.50
If more space is needeE, use additional sheets of paper of Ihe ume sire.
2ECEIPT FOR PAYMENT
'________"__' Receipt Dame: z10517008
Receip y072965
p gpRNER STRASBRe9tyster Of Wills
ReceipC No. =
GLEND � and County
Cumber- gquare
One CourthPAse17Q13
Carlisle,
MILLER GLORIA Y ---
- - - No- � 2013-00143
Estate File ZELS
S7�wLIAM S DAN ______
paid eY Remarks : ----"-
- Receipt Distribution ----�
_________________ ______ Pa�ene Amount PaYee Name
20 . 00 CUMBERLAND COLJNTY GENERAL FUN
r^ee/Tax Description ��BEg�,pNp CO�TY GENER�L FUN
PETrTION LTRS TEST 15.00 CUMBERLAN� COtINTy GENERAL FUN
WILL 5 . 00 CUMBERL�`ID
AENUNCIATION 23 ,50 B�$AU OF RCOUNTYSGENEN1�i' F�
SHORT CERTZFZCATE 5 . p0 C�gERT.�+ND COUN21' �E�� FL7ii
JCS FEE 15 . 00 CUNIBER�ND COUNT1'
AUTOMATION FEE 15 00 Ct7�ERLAND
r�n7ENTORY __
;�H TpX RETL'RN —""" �103 . 50
Check# 1117 103 - SO
Toca1 Received. . - � � � � � '
0.EV-l5C tF+ (Ld-¢)
`i"` pennsylvania SCHEDULE I
�" oevaarmex*oraevenuE DEBTS OF DECEDENT�
:x�eannxce*nx a�uxi+ MORTGAGE IIABILITIES &LIENS
0.ESIDEW OECEDENT
ESTATE OF FILE NUMBER
Miller, Gbria Y. 21-13-0143
Report debtr inmrred by the dxedent prior to Eea[h that remained unpaid at the date of death,including unrnmburSeE meEfWl expensM,
'TEM VALUE AT�PTE
NUt49ER DESCRIPTION OF�fAiX
1� CommonwealM of Pennsylvania,Third PaAy Liability,Stalement of Claim Summary 306,625.87
i
il
�
TOTAL(Also enter on Line 10, Recapitulation) 4 306 625.87
If more spaa is neeGeQ insert aDOitlonal sheets oF[he same size.
COMMOMYF LTHOFGENNSYWANIP
� BYPE4VOFPROGRMIIMWRIIY
ONISIONOFTIIRO VARttLUBIpry
3ELOVERVSELTION
PO BOX 00¢6
HARR159VRG.PA PIpF8d85
May 2],2014
STATEMENT OF CLAIM SUMMARV
NAME Esfateof MILLER,GLORIA
ID 280Y04461
MEDICAL � CLA553 CLASS5.i TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 166.91 t66.91
LONG TERM CARE P,580.24 2'/8,522.09 306,102.33
DRUG '13.C9 303.14 356.63
REIMBURSEMENTTODPW 21,593.13 2]9,032.14 3a6,625.81
COMMONWEALIH OP PENNSVLVANIA
DEPARTMENTOF PU9LIC WELFARE
EIN- 23b003113
Page 1 of 22
REV-I51]f%+(OLIO)
� pennsylvania SCHEDULE J
�"`p`�`�""p`�`�u` gENEFICIARIES
�xxEartaxcE ru Ae�uax
aEsmen oEceoenr
ESTATE OF: FILE NUMBER:
Miller, Gloria V. 21-13-0143
REUTIONSHIPTODECEDENT RMOUNTORSXNAE
NUMBER NAME AND A�DRE55 OF PERSON(S)RKEIVING PR�PERIY Do NOt Lis[Trv#ee(s) OF E4ATE
I TA%ABLE DISTRIBUTIONS[Intlutle outright spousal tlistribuHons and transFers unGer
Se[.911fi(a)Q.1).]
i. Nahan D.Miller,142 Jamestown Road,Uni[C,Ocean City,MD 21642 Grandson 50%
2. Natalie K.Singer,83 Lebo Road,Catlisle,PA 17015 Gandaughter 50%
ENTER DOLLAR AMOONTS FON DISiRIBUII0N5 SHOWN ABOVE ON LINES 15 THROUGH IB OF REVd500 COVER SHEE[AS APPROPAIATE.
11 NON-TA%ABLE DISrNBURONS
A, SP�USAL�ISrRIBUII0N5 UN�ER SEQIOH 9113 F00.WHICN PN ELECf10N TO TA%IS ROT TFKEN:
B. CHA2ITABLEAN�GOVERNMENTALOISrWBMONS:
1.
TOTAL OF PART II-ENTER TOTAL NON-TA%ABLE DIS�RIBMONS ON L[NE 13 OF REW15�0 COVER SHEEL $
If more spare is neeGeG,use atl0itional sAee[s ol paper of[�e same size,
l �� /�� �� �" �=�-��
NOTICE OF INHERITANCE TaX _.-"� pennsylvania
euaenu oF irv�ivIoun� iax[s APPRAISEMENT, pLLOWANCE OR ❑ISALLOWANCE � pEpqqine�vroFAeveHue
�HxearrqHce r� omsmn OF OEDUCTIONS pNU ASSESSMENT OF Tq%
PO BOX 000601 REVQ54l E% qFp (11-I4)
HAFRISlUftG PR 1]89-0601
DATE 02-09-2015
ESTATE OF MILLER GLORIA V
UATE OF OEATH 01-19-2013
FILE NUMBER 21 13-�143
COUNTY CIIMBERLAND
DANIELS WILLIAJM S p�N 101
STE 205 APPEAL UATE: 04-10-2015
1 W HIGH ST (SeereversesideuederObjectiotts)
CARLISLE PA 1]013-2951 Anount Renitted�
MAKE GHECK PAVqBLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17U13
CUT ALONG THIS LINE --� RETAIN L�WER PORTION FOR YOUR RECOROS !�
_'"""'__"'""___""""___""___""'__"""_'""__""'"_"""__"""_""'__'"'""__"'
REV-1547 EX AFP (11-14) NOTICE OF 3NHERITANCE TA% APPRAISEMENL ALLOWPNCE OR
UISALLOWANCE OF DEOUCTIONS pND ASSESSMENT OF TA%
ESTqTE OF: M[LLER GLORIA YFILE N0. :21 13-0143 ACN: 101 UATE� 02-09-2015
TAX ftETI1RN WpS: ( X) ACCEPTED AS FILEU O CHRNGEO
APPRAISEO VALUE OF RETfIRN BASE➢ ON: ORIGINAL RETURN
l. Real Estate (SCM1etlule PJ (I) .DO ryOTE: To e e p�ope�
2. Siocks antl Bon05 lSCM1etivle BJ �Zj . 00 �eEit to Your a unL
3. Closely Neltl Sfock/Partners�ip Interes[ lSc�etlule Cl (3) .00 su�mlt [�e uppe�<portion
of f�is fa�m vit� you�
4. Mo�t9a9es/No[es PeceivaUle 6chetlole U) (4) •0� tax paYment.
5. CasM1/Bank Oeposits/Mlsc. pe�5ona1 F�ope�ty (Sc�eEule E) (5) 5,331.90
6. JointlY OwneO P�operty (Sc�etlule F] �6) ��0
�. r�a�sfe�: <smae�ie w <n 2].784.30
s. io[zi as�.�s ce� 3R lls za
APPROVED DEOUCTIONS ANO EXEMPTIONS:
9. Fune�al Ezpenses/Atlm. Costs/Misc. Expenses 6[heEule Hl �y� 3.4]3 50
10. oee2sinor[sage uae.i.uesi�ienx <scneauie i� �yo� 306.625 8]
ll. rotal �eeuctions �iy� 310,049.3]
iz qe2 vai�e of tax aeturn �yz� 276,933.17-
13. C�arviable/Governmen[al Beqoests; Nan-elec[eE 9113 T�us[s (SCM1etlule J) ��y� 00
ta, qec value ot sstace sub9ec< to ia� ���� 276.933. 1]-
NOTE: If an assessment vas i55ueE p�eviouslv, Lines 14, 15, 16. 1], 18 antl/o� 19 will
reflect fi9�res tM1at inclutle t�a YOYal of all returns assessetl to tlate.
ASSESSMENT OF TA7(:
I5. Amoun[ af Line l4 a< spousal rate 115) .00 X 00 - .00
�s. nmo��x oe �.�e ia [a.aeie ax ii�aal ra[e us> nn x o45 = .DO
n. amo��t or u�e ic ax smiina ram un nn x iz - ,�p
ie. pmo��< ot �ane it 2axaeie at caiia<erai re2e cie� . 00 x 15 ' .00
l9. P�Inclpal Tax �ue <l9)= .00
TA% CREOITS:
PRYMENT qECEIPi OISCOIINT U)
DAiE NIiMBER INTEREST/PEN PqID !-) AMOONT PpIO
TOTAL TAX PAVMENT .00
BAIANCE OF TAX OUE .00
INTE2EST ANO PEN. ,pp
TDTA� OUE .00
� IF PAI� pFTEF OATE INOICATEp, SEE FEVEFSE IF TOTAL OIIE IS PEFLECTEO AS q CFEDIT (CF)� Y�U MAY BE WE
F02 CALCULRTION OF AO�RIONAL INTEREST. G REFONO. SEE FEVERSE SIDE FOR INSTRUCTIONS.
RESERVATION'. Es�ates o�decedents dying on or be(ore Dec.12,1982-ii any future in�eres�in�he es�ate is Vansferred in possession
ar enloyment to collaterel peneficiaries of the tlecedent atter ihe expira0on of any esfate for life ar years,t�e commonwealih
hereby expressty reserves�he righ��o appraise and assess transfer inheri�ance taxes atthe lawlul colla�eral ra�e on any
such tuWre interest.
PAVMEM: De�ach�he top portion o!�his no�ice and submi�wilh your payment[o the Register o�Wills intlicatetl on ihe iron�of the
notice.Make check or money ortler payable to:Register af Wills,Agen�.
REFUND(CR): A refuntl a�a lax credl�not requestetl on the t�return may be requested by comple�ing an Applicatlon for Refuntl o�
Pennsylvania lnhen�ance and Estate T�(REV-1313)- Applica�ions are available at www.�nu¢oa oov or by
calling 1�800-362�2050. Services for�axpayers wilh special heanng and/or speaking neetls are availa�le a�
1-800-44�-3020. Please allow four ta six weeks irom the date a refund was granted to receive the check.
OBJECTIONS: Any party of in�etes�nol sa�isfied wi�h the appraisment,allowance or tlisallowance of tleduc�ions,ar assessment of�ax as
shawn on�his natice may oblec[wi�hin 60 tlays of��e tlate of receipt of this no�ice by:
L Filing an appeal online a�www-b - tl f -I t t on or before ihe appeal date itlenVfietl on ihe front ol this notice or
sentling a writlen pm�es��o'.
PA Depatlment of Revenue
Board of Appeals
PO BOX 281021
Harrisburg PA 1�1284021
2 Having�M1e matler determinetl at audl�oi tbe account of ihe personal representa0ve;or
3.Appealing to fhe Orphans'Couh.
ADMINISTPATNE Bmrs tliscovered on�his assessment s�oultl be atltlressed in writing to'.
CORRECTIONS: PA DepaM1mentoi Revenue
Bureau of Individual Taxes
Pcst Assessmen!Review UnB
PO BOX 280601
Harrisburg PA 1]128-0601
See insimctions br Inheritance Tax ReWm for a Resitlent Decedent for details on an atlministrative correction.
DISCOUNL Ii any tax tlue is paid within three months after the decetlent's death,a 5 percent discount of ihe tav paid is allowable.
INTEREST: In�erest is chargetl beginning nine monihs and one tlay imm tlate of tleath,ro ihe tlate of payment An in�erest calculator is
available at www.doreservicess�a e. a.us. Annual interest rates can be fountl on brm REV-161 L .
Any notice issuetl aiter ihe tax becomes dellnquent will reflect an in�erest cakulation to 15 days beyond ihe date af the assessment.
li payment is matle aker ihe interest calculation date shown on ihe notice,atltlitional interest must be calculatetl.