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HomeMy WebLinkAbout08-31-15 pennsytvania 1505614105 EX(03-14)(FI) REV-1500 OFFICIAL USE ONLY Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year r File Number PO BOX 280601 -L%. Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 12162012 06191935 Decedent's Last Name Suffix Decedent's First Name MI Koonse Dorothy L (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW OW 1.Original Return C=3 2.Supplemental Return C=:) 3. Remainder Return(date of death prior to 12-13-82) C=:) 4.Agriculture Exemption(date of C=:) 5.Future Interest Compromise(date of C=) 6. Federal Estate Tax Return Required death on or after 7-1-2012) death after 12-12-82) C=:) 7.Decedent Died Testate C=:) 8.Decedent Maintained a Living Trust 0 9. Total Number of Safe Deposit Boxes (Attach copy of Will.) (Attach copy of trust) C=) 10.Litigation Proceeds Received O 11.Non-Probate Transferee Return C=:) 12. Deferral/Election of Spousal Trusts (Schedule F and G Assets Only) C=) 13.Business Assets C=:) 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 D. Koonse, Jr. 724)208-1035 First Line of Address 246 Ondrejko Road Second Line of Address City or Post Office State ZIP Code ------—------------ Smithfield FP7A -- 15478TM Correspondent's email address: REGISTER OF WILLS USE ONLY REGISTER OF WILLS USE ONLY DATEYILEMWIVI9917M,4 p ....... ryl C_r 71 CD CYD C_j- DATE-FIEEDrrSTANII)� CD "71 -T, PLEASE USE ORIGINAL FORM ONLY �-7 M Side I 1 56 4 0 1505614105 _! 1505614205 REV-1500 EX(FI) Decedent's Social Security Number i Decedent's Name: RECAPITULATION 1. Real Estate(Schedule A). ............................................ 1. ' 2. Stocks and Bonds(Schedule B) ....................................... 2. 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) . 3. 4. Mortgages and Notes Receivable(Schedule D)........................... 4. 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)...... 5. 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. ( � 12,770.03 r , 8. Total Gross Assets(total Lines 1 through 7)............................. 8. I 12,770.03 9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. I 7,394.50 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............... 10. 11. Total Deductions(total Lines 9 and 10)................................. 11. 7,394.50 12. Net Value of Estate(Line 8 minus Line 11) .............................. 12. 13. Charitable and Governmental Bequests/Sec.9113 Trusts for which an election to tax has not been made(Schedule J) ........................ 13. 14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14. 7,394.50 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 F-"--""""" (a)(1.2)X.0- 15. 16. Amount of Line 14 taxable at lineal rate X.0 45 332.75 16. 17. Amount of Line 14 taxable "� p at sibling rate X.12 i 17. 18. Amount of Line 14 taxable i $ at collateral rate X.15 � ,✓ 18. � � E 19. TAX DUE ......................................................... 19. 332.75 1 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Under penalties of perjury,I declare I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,correct and complete.Declaration of preparer other than the person responsible for filing the return is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS SIGNATURE OF PREPARER OTHER THAN PERSON RESPONSIBLE FOR FILING THE RETURN DATE ADDRESS Side 2� 1505614205 1505614205 REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Dorothy J. Koonse STREET ADDRESS 246 Ondrejko Road CITY STATE ZIP Smithfield PA 15478 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 332.75 2. Credits/Payments A.Prior Payments 432.91 B.Discount (See instructions.) Total Credits(A+B) (2) 432.91 3. Interest (3) 100.16 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 5. If Line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred.......................................................................................... ❑ 0 b. retain the right to designate who shall use the property transferred or its income ............................................ 0 ❑ c. retain a reversionary interest.............................................................................................................................. ❑ 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?.............................................................................................................. ❑ N 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ N 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation? IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. .' .. t_ 9.'^x a .- For dates of death on or after July 1, 1994,and before Jan.1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a step-parent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S. §9116(a)(1.3)].A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REV-1510 EX+(02-15) Iffpennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Dorothy J. Koonse 2113-0273 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 DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. `Richard D.Koonse,Jr.(Son)Transferred 3-29-2006 : Claiming value of property due to life estate - 9,732.00 0 9,732.00 2 Richard D.Koonse,Jr.(Son)Transferred 9-9-1991 3,828.28'.. ' 25 957.07. In Trust For Account at Citizens Bank#6144655670 3 Richard D.Koonse,Jr.(Son)Transferred 4-25-1995 3,641.44 .25: 910.36 In Trust For Account at Citizens Bank#6143884234 4' Richard D.Koonse,Jr.(Son)Transferred 4-13-1998 2341.19: 50 1,170.60 Checking Account at Citizens Bank#6103238386 TOTAL(Also enter on Line 7,Recapitulation) $ 12,770.03 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(02-15) Iffpennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Dorothy J. Koonse Z%-L's-01n Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL.EXPENSES _..... ..... ._...... 1' William G.Neal Funeral Homes,LTD. 7,394.50 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: 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: 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL(Also enter on Line 9, Recapitulation) $. 7,394.50 If more space is needed,use additional sheets of paper of the same size. ( COMMONWEALTH OF PENNSYLVANIA REV-1162 EX0 1-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG,PA 1 7 1 28-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 017283 KOONSE RICHARD D JR 710 MOORE RD WASHINGTON, PA 15.301 ACN ASSESSMENT AMOUNT CONTROL NUMBER fold 13100621 $166.81 ESTATE INFORMATION: SSN: FILE NUMBER: 2113-0273 DECEDENT NAME: KOONSE DOROTHY J DATE OF PAYMENT: 03/07/2013 POSTMARK DATE: 03/06/2013 COUNTY: CUMBERLAND DATE OF DEATH: 12/16/2012 TOTAL AMOUNT PAID: $166.81 REMARKS: CHECK# 1937 INITIALS: HEA SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS TAXPAYER COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(I 1-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG,PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 0 17289 KOONSE RICHARD D JR 710 MOORE RD WASHINGTON, PA 15301 ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- fold ——------ 13100628 $136.38 ESTATE INFORMATION: SSN: FILE NUMBER:. 2113-0273 DECEDENT NAME: KOONSE DOROTHY J DATE OF PAYMENT: 03/07/2013 POSTMARK DATE: 03/06/2013 COUNTY: CUMBERLAND DATE OF DEATH: 12/16/2012 TOTAL AMOUNT PAID: $136.38 REMARKS: CHECK# 1943 INITIALS: HEA SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS TAXPAYER COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(l 1-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG,PA 17126-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 017290 KOONSE RICHARD D JR 710 MOORE RD WASHINGTON, PA 15301 ACN ASSESSMENT AMOUNT CONTROL NUMBER :------- fold 13100624 $129.72 ESTATE INFORMATION: SSN: FILE NUMBER: 2113-0273 DECEDENT NAME: KOONSE DOROTHY J DATE OF PAYMENT: 03/07/2013 POSTMARK DATE: 03/06/2013 COUNTY: CUMBERLAND DATE OF DEATH: 12/16/2012 TOTAL AMOUNT PAID: $129.72 REMARKS: CHECK# 1944 INITIALS: HEA SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS TAXPAYER pennsylvania BUREAU OF INDIVIDUAL TAXES NOTICE OF INHERITANCE TAX DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION APPRAISEMENT, ALLOWANCE OR DISALLOWANCE PO BOX 280601 OF DEDUCTIONS, AND ASSESSMENT OF TAX ON REV-1548 EX AFP (12-12) HARRISBURG PA 17128-0601 JOINTLY HELD OR TRUST ASSETS DATE 04-29-2013 ESTATE OF KOONSE DOROTHY J DATE OF DEATH 12-16-2012 FILE NUMBER 21 13-0273 COUNTY CUMBERLAND SSN/DC DEBORAH KOONSE ACN 13100627 246 ONDREJKO RD APPEAL BY DATE:06-28-2013 SMITHFIELD PA 15478-1414 (See reverse side under Objections) Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE -01 RETAIN LOWER PORTION FOR YOUR RECORDS E-- - REV-1548 EX AFP C12-12�------------------------------------------------------------------ NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE: 04-29-2013 ESTATE OF:KOONSE DOROTHY J DATE OF DEATH:12-16-2012 COUNTY:CUMBERLAND FILE NO. : 21 13-0273 S.S/D.C. NO. : ACN: 13100627 TAX RETURN WAS: (X) ACCEPTED AS FILED C ) CHANGED JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: CITIZENS BANK OF PENNSYLVANIA ACCOUNT NO. : 6144655670 TYPE OF ACCOUNT: C )SAVINGS C ) CHECKING (X)TRUST C )TIME CERTIFICATE DATE ESTABLISHED 09-09-1991 Account Balance 3,828.28 NOTE: TO ENSURE PROPER CREDIT TO Percent Taxable X 0.250 YOUR ACCOUNT, SUBMIT THE Amount Subject to Tax 957.07 UPPER PORTION OF THIS NOTICE Debts and Deductions - •00 WITH YOUR TAX PAYMENT TO THE Taxable Amount 957.07 REGISTER OF WILLS AT THE Tax Rate X •15 ABOVE ADDRESS. MAKE CHECK Tax Due 143.56 OR MONEY ORDER PAYABLE TO: "REGISTER OF WILLS, AGENT." TAX CREDITS: PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID C-) 03-06-2013 CDO17286 7.18 136.38 TOTAL TAX PAYMENT 143.56 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ■ IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. RFP RFVFRRF RTnP nF THTR FORM FOR TNSTRUCTTONS. WIT pennsylvania BUREAU OF INDIVIDUAL TAXES NOTICE OF INHERITANCE TAX DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION APPRAISEMENT, ALLOWANCE OR DISALLOWANCE PO BOX 280601 OF DEDUCTIONS, AND ASSESSMENT OF TAX ON REV-1548 IX AFP C12-12) HARRISBURG PA 17128-0601 JOINTLY HELD OR TRUST ASSETS DATE 04-29-2013 ESTATE OF KOONSE DOROTHY J DATE OF DEATH 12-16-2012 FILE NUMBER 21 13-0273 COUNTY CUMBERLAND SSN/DC RICHARD D KOONSE JR ACN 13100621 246 ONDREJKO RD APPEAL BY DATE:06-28-2013 SMITHFIELD PA 15478-1414 (See reverse side under Objections) Amount Remitted F — MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT .ALON.C. THIS L�N•E RETAIN. LOWER PORTION.FOR YOUR RECORDS - ------------------------------------------------------------------------------------------- REV-1548 EX AFP C12-12) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE: 04-29-2013 ESTATE OF: KOONSE DOROTHY J DATE OF DEATH:12-16-2012 COUNTY:CUMBERLAND FILE NO. : 21 13-0273 S..S/D.C. NO. : ACN: 13100621 TAX RETURN WAS: (X) ACCEPTED AS FILED C ) CHANGED JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: CITIZENS BANK OF PENNSYLVANIA ACCOUNT NO. : 6103238386 TYPE OF ACCOUNT: C )SAVINGS 00 CHECKING C )TRUST _.0 )TIME CERTIFICATE DATE ESTABLISHED 04-13-1998 Account Balance 2,341 .19 NOTE: TO ENSURE PROPER CREDIT TO Percent Taxable X 0.500 YOUR ACCOUNT, SUBMIT THE Amount Subject to Tax 1 ,170.60 UPPER PORTION OF THIS NOTICE Debts and Deductions - •00 WITH YOUR TAX PAYMENT TO THE Taxable Amount 1,170.60 REGISTER OF WILLS AT THE Tax Rate Y •15 ABOVE ADDRESS. MAKE CHECK Tax Due 175.59 OR MONEY ORDER PAYABLE TO: "REGISTER OF WILLS, AGENT." TAX CREDITS: PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID C-) 03-06-2013 CDC17283 8.78 166.81 TOTAL TAX PAYMENT 175.59 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. pennsyLvania BUREAU OF INDIVIDUAL TAXES NOTICE OF INHERITANCE TAX DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION APPRAISEMENT, ALLOWANCE OR DISALLOWANCE PO BOX 280601 OF DEDUCTIONS, AND ASSESSMENT OF TAX ON REV-1548 EX AFP C12-12) HARRISBURG PA 17128-0601 JOINTLY HELD OR TRUST ASSETS DATE 04-29-2013 ESTATE OF KOONSE DOROTHY J DATE OF DEATH 12-16-2012 FILE NUMBER 21 13-0273 COUNTY CUMBERLAND SSN/DC DEBORAH KOONSE ACN 13100623 246 ONDREJKO RD APPEAL BY DATE:06-28-2013 SMITHFIELD PA 15478-1414 (See reverse side under Objections) Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE ��.. RETAIN LOWER PORTION FOR YOUR -RECORDS F- - — REV-1548 EX AFP C12-12)-------------------------------------------------------------------- _-- _-__..• - ,_NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE: 04-29-2013 ESTATE OF:KOONSE DOROTHY J DATE OF DEATH:12-16-2012 COUNTY:CUMBERLAND FILE NO. : 21 13-0273 S.S/D.C. NO. : ACN: 13100623 TAX RETURN WAS: CX) ACCEPTED AS FILED C ) CHANGED JOINT OR TRUST ASSET INFORMATION FINANCIAL INSTITUTION: CITIZENS BANK OF PENNSYLVANIA ACCOUNT NO. : 6143884234 TYPE OF ACCOUNT: ( )SAVINGS C ) CHECKING 00 TRUST C )TIME CERTIFICATE DATE ESTABLISHED 04-25-1995 Account Balance 3,641.44 NOTE: TO ENSURE PROPER CREDIT TO Percent Taxable X 0.250 YOUR ACCOUNT, SUBMIT THE Amount Subject to Tax 910.36 UPPER PORTION OF THIS NOTICE Debts and Deductions - •00 WITH YOUR TAX PAYMENT TO THE Taxable Amount 910.36 REGISTER OF WILLS AT THE Tax Rate x .15 ABOVE ADDRESS. MAKE CHECK Tax Due 136.55 OR MONEY ORDER PAYABLE TO: "REGISTER OF WILLS, AGENT." _TAX--CREDITS: PAYMENT RECEIPT DISCOUNT (+) DATE NUMBER INTEREST/PEN PAID C-) AMOUNT PAID 03-06-2013 CDO17284 6.83 129.72 TOTAL TAX PAYMENT 136.55 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. IIIIIIIIIIIIIIIIIIIIII 4 m G` o' r+Z etc?? IIII�IIIIIIIIIIIIIIIIIII C t"I of q III�IIIII D0312 U7 V7 ¢ m -4 Q C +> R00021PA waxo r, is < rts a 'Zp. 91, W 0` tr ), n C Made the F � day of ' 2006. Between .DOROTHY KOONSE, widow, of South Franklin Township, Washington County, Pennsylvania , hereinafter called Grantor, And RICHARD D. KOONSE JR., married, of Smithfield, Pennsylvania hereinafter called Grantee. Witnesseth, that the said Grantor in consideration of ONE DOLLAR ($1.00) and NATURAL LOVE and AFFECTION now paid to the Grantor by the Grantee, the receipt of which is hereby acknowledged, does hereby grant and convey unto the said Grantee and his heirs and assigns, that certain lot of ground situate in South Franklin and North Franklin Townships, Washington County, Pennsylvania, more particularly bounded and described as follows: BEGINNING at an iron pipe on the northerly side of former Township Road No. 530 (previously and erroneously designated in other deeds as Legislative Route 62126), common to property now or formerly of Galen E. Knupp and property now or formerly of Norman L. Walter; thence South 71* OC.' 30" East, a distance of 346.25 feet to a point; thence South 39" 16' East, a distance of 113. afegtto a spike;thence along property now or formerly of Robert O. Brown, South 10° 31' East 301.05 feet to a spike; thence along property now or formerly of Raymond H. Williams, South 79° 29' West 279.39 feet to a point; thence along property now or formerly of Melvin H. Moore, widower, the following ten courses and distances: North 16° 47' West, a distance of 25.36 feet; North 26° 02' West, a distance of 33.92 feet; North 19° 15' East, a distance of 38.17 feet; North 5° 13' West, a distance of 54.63 feet; North 43° 13'West, a distance of 44.67 feet; North 39° 32' West, a distance of 29.21 feet; North 64° 55'West, a distance of 21.20 feet; North 64°37' West, a distance of 36.89 feet; North 48" 19'West, a distance of 24.44 feet; and South 82° 33'West, a distance of 5 feet to a point;thence along property now or formerly of Galen E. Knupp, North 7° 26% 45" West, a distance of 308.75 feet to an iron pipe, the place of beginning. CONTAINING 3.479 acres, according to a survey of James F. Linden, dated June 27, 1964. The within conveyance is SUBJECT to a covenant which shall run with the land and be binding upon the grantees herein, their heirs and assigns forever,that no building shall be erected on the within tract nearer than fifty (50) feet to the center of Relocated Township Road No. 530. EXCEPTING AND RESERVING all the coal, as the same was conveyed by Daniel E. Moore to R. W. Dawson, April 2, 1907, and recorded in Deed Book 346, Page 532, which sale of coal carried with it broad mining rights, incidents, privileges and waivers. SUBJECT,ALSO,to any oil and gas leases and pipe line rights of way as the same may appear of record, and ALSO SUBJECT to electric power line rights of way as the same may appear of record. ALSO SUBJECT to any other exceptions, reservations, etc., set forth or referred to in prior conveyances in the chain of title. BEING the same parcel of land which Edward Mankey and Paulette Mankey, his wife by their Deed dated March 2, 1966 and recorded in the Recorder's Office of Washington County, at Deed Book Volume 1233, Page 121, granted and conveyed unto Richard D. Koonse and Dorothy Koonse, his wife. The said Richard D. Koonse died June 10, 1988, thereby vesting title by operation of law in Dorothy Koonse, Grantor herein. THIS CONVEYANCE is from mother to son and is therefore exempt from any and all realty transfer tax. PARCEL NO. 590-012-01-00-00-0015-00 &510-001-00-00-0029-00 together with the appurtenances. To Have and To Hold the sam'e'unto and forthe use of the said Grantee and his heirs and assigns, forever And the said Grantor for herself and her heirs, executors and administrators covenant with the said Grantee and his heirs and assigns to warrant and defend Generally the property hereby conveyed against any and all persons lawfully claiming-the same. NOTICE-THIS DOCUMENT DOES NOT SELL,CONVEY,TRANSFER,INCLUDE OR INSURE THE TITLE TO THE COAL AND RIGHT OF SUPPORT UNDERNEATH THE SURFACE LAND DESCRIBED OR REFERRED TO HEREIN,AND THE OWNER OR OWNERS OF SUCH COAL MAY HAVE THE COMPLETE LEGAL RIGHT TO REMOVE ALL OF SUCH COAL AND,IN THAT CONNECTION,DAMAGE MAY RESULT TO THE SURFACE OF THE LAND AND ANY HOUSE, BUILDING OR OTHER STRUCTURE ON OR IN SUCH LAND,THE INCLUSION OF THIS NOTICE DOES NOT ENLARGE, RESTRICT OR MODIFY ANY LEGAL RIGHTS OR ESTATES OTHERWISE CREATED,TRANSFERRED,EXCEPTED OR RESERVED BY THIS INSTRUMENT.(This notice is set forth in the manner provided in Section 1 of the Act of July 17, 1957, P.L. 984, as amended, and is not intended as notice of unrecorded instruments, if any.) Witness the hand and seal of the said Grantor fitness (SEAL) DOROTHY OSE NOTICE THE UNDERSIGNED, AS EVIDENCED BY THE SIGNATURE(S)TO THIS NOTICE AND THE ACCEPTANCE AND RECORDING OF THIS DEED,(IS,ARE)FULLY COGNIZANT OF THE FACT THAT THE UNDERSIGNED MAY NOT BE OBTAINING THE RIGHT OF PROTECTION AGAINST SUBSIDENCE, AS TO THE PROPERTY HEREIN CONVEYED, RESULTING FROM COAL MINING OPERATIONS AND THAT THE PURCHASED PROPERTY,HEREIN CONVEYED, MAY BE PROTECTED FROM DAMAGE DUE TO MINE SUBSIDENCE BY A PRIVATE CONTRACT WITH THE OWNERS OF THE ECONOMIC INTEREST IN THE COAL. THIS NOTICE IS INSERTED HEREIN TO COMPLY WITH THE BITUMINOUS MINE SUBSIDENCE AND LAND CONSERVATION ACT OF 1966. WITNESS: � J � o Z a � = p O O ' 4 N o_ � E; Z 3 ' ,� :3y CL CL bb U) �c FROM � CD CD a� � _ 2- CCD m '* CL O y cD 1t o o DOROTHY KOONSE. m s 0 m CD k m v Z Z `v- _3,,i TO o m o � 1 C `G CD 0 co CD Z CD Z `D . RICHARD D. KOONSE JR. 0 a n C) a o a o � � y CDD 4 Q (DD n = y o a cl� z Fees $ c m 0 40. o o , 0 0 CD co CD CDD c') 4 Z CD N v Sa mCCD C) m SWPA AREA AGENCY ON AGING cD o: LEGAL SERVICES FOR THE ELDERLY a 0 o c� m � CD m CYNTHIA P. SALAK, ESQUIRE ' g o 0 c0i 150 WEST BEAU STREET ,� ��� O SUITE 216 PLAZA BUILDING H 3 N WASHINGTON PA 15301 < 724-228-7080 1 $ a _ CD o_- N R. Q •- o M In Z co -n 3 N n LIFE LEASE AGREEMENT THIS LEASE AGREEMENT, made thisagw'` day of Q , 2006, by and between RICHARD D. KOONSE JR. hereinafter called "LESSOR," A N D DOROTHY KOONSE hereinafter called "LESSEE." WITNESSETH THAT: The parties hereto, intending to be legally bound, hereby covenant and agree as follows: 1. LESSOR hereby leases to LESSEE and LESSEE accepts, as LESSEE, the premises described as follows, (hereinafter referred to as "the leased premises"): An that certain lot of ground situate in South Franklin and North Franklin Townships, Washington County, Pennsylvania, more particularly bounded and described as follows: BEGINNING at an iron pipe on the northerly side of former Township Road No. 530 (previously and erroneously designated in other deeds as Legislative Route 62126), common to property now or formerly of Galen E. Knupp and property now or formerly of Norman L. Walter; thence South 71" 06' 30" East, a distance of 346.25 feet to a point; thence South 39° 16' East, a distance of 113.28 feet to a spike; thence along property now or formerly of Robert O. Brown, South 10° 31' East 301.05 feet to a spike; thence along property now or formerly of Raymond H. Williams, South 79° 29' West 279.39 feet to a point; thence along property now or formerly of Melvin H. Moore, widower, the following ten courses and distances: North 16° 47' West, a distance of 25.36 feet; North 26" 02' West, a distance of 33.92 feet; North 19° 15' East, a distance of 38.17 feet; North 5° 13' West, a distance of 54.63 feet; North 43° 13' West, a distance of 44.67 feet; North 39° 32' West, a distance.of 29.21 feet; North 64" 55' West, a distance of 21.20 feet; North 64° 37' West, a distance of 36.89 feet; North 48` 19' West, a distance of 24.44 feet; and South 82` 33' West, a distance of 5 feet to a point; thence along property now or formerly of Galen E. Knupp, North 7' 26' 45" West, a distance of 308.75 feet to an iron pipe, the place of beginning. BEING the same lot in which the LESSEE conveyed her interest to the LESSOR by Deed of the same date. 2. The term of this Lease shall begin on the date of this Lease and shall terminate one year from said date, unless extended, or sooner terminated, as provided in this Lease. 3. LESSEE shall have the option to renew this Lease from year to year. This said option granted by LESSOR is irrevocable. 4. This Lease shall terminate upon the death of LESSEE, or upon the permanent absence of LESSEE, unless terminated sooner in accordance with the provisions of this Lease. 5. The rent due hereunder shall be the payment by the LESSEE of the utility charges and taxes due on the real property. There shall be no other rental payments required under this Lease. 6. LESSEE acknowledges that the leased premises are accepted in an "as is" condition in each and every respect. 7. LESSEE shall procure at her expense appropriate fire and liability insurance coverage with respect to the premises. LESSOR shall not be responsible for insuring LESSEE'S personal property located within or without the dwelling. 8. LESSEE shall pay all real estate taxes. 9. At any time during the term of this Lease, the LESSEE may make, at her expense, additions to and structural changes and alterations in and upon any or all of the improvements now-or hereafter located on the leased land. 10. LESSOR shall not, in any way, sell or transfer the heretofore described property during the natural lifetime of the LESSEE without the written consent of the LESSEE. 11. LESSEE shall not be required to repair, replace or reconstruct any building or other improvement located on the leased land which may be damaged or destroyed at any time during the term of this Lease. 12. The language in all parts of this Lease shall in all cases be simply construed according to its fair meaning and not strictly for or against LESSOR or LESSEE. 13. If any particular term, covenant, or provision of this Lease shall be determined to be invalid, illegal, void, or unenforceable, the same shall not affect the remaining provisions of this Lease which shall nevertheless remain in full force and effect and said term, covenant, or provision shall be deemed modified to conform with the law. 14. This Lease sets forth all the promises or representations, agreements, and undertakings between LESSOR and LESSEE relative to the leased premises. There are no promises, representations, agreements, or undertaking, either oral or written, between LESSOR and LESSEE except as set forth herein. No amendment, change, or addition to this Lease shall be binding upon either party unless reduced to writing and signed by both parties. This Lease shall be binding upon LESSOR and LESSEE, their heirs, executors, administrators, assigns, and successors, both LESSOR and LESSEE being duly authorized to execute the same. IN WITNESS WHEREOF, LESSOR and LESSEE have executed this Lease the day and year first above written. WITNESS: i RICHARD D. KOONSE JR., Legsor 6ZR"� 'q/--7 DOROTHY ON E, Lessee COMMONWEALTH OF PENNSYLVANIA ) SS: COUNTY OF WASHINGTON ) On this -» ' ` day of 9-4r , 2006, before me, a Notary Public, personally appeared, RICHARD D. KOONSE JR., known to me to be the person whose name is subscribed to this LIFE LEASE AGREEMENT and acknowledges that he executed the same for the purposes therein contained and desires said LIFE LEASE AGREEMENT to be recorded as such. IN WITNESS WHEREOF, I, have hereunto set my hand and seal. SEAL Notary Public COMMONWEALTH OF PENNSYLVANIA LcmilNotarial seal Debra Gevenosky,Notary Public y y Of Washington,Washington County Commission Expires Nov.10,2009 Member,Pennsylvania Association of Notaries COMMONWEALTH OF PENNSYLVANIA ) SS: COUNTY OF WASHINGTON ) On this day of_ /yl�yc.� , 2006, before me, a Notary Public, personally appeared, DOROTHY KOONSE, known to me to be the person whose name is subscribed to this LIFE LEASE AGREEMENT and acknowledges that she executed the same for the purposes therein contained and desires said LIFE LEASE AGREEMENT to be recorded as such. IN WITNESS WHEREOF, I, have hereunto set my hand and seal. SEAL Notary Public COMMONWEALTH OF PENNSYLVANIA Notarial Seal Debra Gevenosky,Notary Public City Of Washington,Washington County My Commission Expires Nov.10,2009 Member,Pennsylvania Association of Notaries 5B59AB' , F,UNERALPURCHASECONTRAfsT `WiMam y NeaC mieraC?-COmeS,Ltd. (STATEMENT OF FUNERAL GOODS AND SERVICES SiL,ECTED) p (Charges are only for those items that you selected or that are required.If we are required by law 925 7t((isml Avenue 3g5 Parr?tai�(er1 Street FEDERA B or by a cemetery or crematory to use any items,'we will explain the reasons in writing below.) washivermt,PA 1.5301 Was((»grott,PA 15301 Section 13.204.011 the Rules and Regulations of the Pennsylvania State Board of Funeral Directors requires this SuNeal' Suyen•fsor,?4t[cliac(T.'T6d(,cy.c. No.ylli contracttobesi nedb the person or persons arranging for the funeral service and by the funeral director. Te(ey(tottc724-2258122 w (A) OUR RVIrCE: . xxm.NedlPuftera(?fonuconl Date pec tG,2412 2' BASIC SERVICES OF FUNERAL DIRECTORBSTAFF ...... $ 110,0 . o -� EMBALMING....................................... $ Full name of deceased �of'A hU PR Kf�o TIS P Age i F¢ if you selected a funeral that may require embalming,such (Please'PRINT Name) D Z w as.a funeral with viewing, you may have to pay for Date of Death DC'C .Deceased is of person arranging services. ::i a Z, embalming.You do not have to pay for embalming you did (Give Relationship) ' U w not approve if you selected arrangements such as A direct i w w cremation or immediate burial.If we charged for embalm- (B) CASH ADVANCE ITEMS: Total(A)Forward $ 7 01 q,Sa a a a ing, we will explain why below. you I taint Z REASON FOR EMBALMING Tr�t� enrif(f� We charge yo In ng: ! a aW Open Grave.......................... �l o°�` /viEoJi(til >1c� �jOy-r 0.S) ................ $ OTHER PREPARAONOFTHEBODY .................. $ Z�f 9 Cemetery Equipment......................,........... $ USE OF FACILITIES,STAFF 4 EQUIPMENT: Lot and Deed ....................................... $ Funeral Ceremony(conducted at Funeral Home)........... $ Newspaper Notices-Local .....................(Rtt) $ Visitation/Viewing(conducted at Funerar Home).......... $-- � Newspaper Notices-Out of town............'........... $ Memorial Service(Conducted at Funeral Home)............ $ Airfare ............................................. $ ''''''''" $ ,�,,q Clergy)Mass Offering USE OF STAFF AND EQUIPMENT: $ � g $ � Funeral Ceremony(conductee at another facility) .......... $ Pallbearers......... ............................... $ Visitation/Viewing ( conducted at another facility) ......... $ Certified Copies of Death CeRificate.........:.......�)O� $ Memorial Service (.Conducted at another facility)............$ Police Escort........................................ $ Graveside Service............................... $ Flowers ......... $ Vault Service Charge ................................. $ / ......... $ r'. TRANSFER OF REMAINS TO FUNERAL HOME.......... $ 2-ZS Total(B) $' $ ( Miles Transported) (C) OTHER ITEMS: Total(A)&(B) AUTOMOTIVE EQUIPMENT: $ Casket Coach(Hearse) Z50© $ Limousine ...:.................................. $ _ Cep Family Car...................................... $ Total(C) $ $ 1 �`7 Total(A)(B)&(C) FlowerCar....................................... $ 1 1 O Lead/Clergy Car................................. $ I 0 LESS: Preneed Adjustment/Allowance ❑INS ❑TR $( ) Car for Pallbearers ................................. $ Payment/Date( ) $( ) ........: $ ' Other(Specify) $( ) BASKET 20' GR ee Gask w....... $W— BALANCE$ -]3 LEGAL, CEMETERY,CREMATO OR OTHER REgUIRfEMENTS COMPELLING THE PURCHASE OF ANY ITEMS .LITERBURIALCONTAINER(AsSelected) $ LISTEDABOVE: Vn t'��utr tt Dt a e PYh/ The undersigned purchaser(s)hereby attest to the following:( )VWe did( d d not( )authorize embalming of the i CREMATION URN $ above named deceased.(2),I/We were shown a Casket Price List and an Outer Burial Container Price List before the showing of caskets and outer burial containers.(3)I/We were given/offered for retention a General price List upon the beginning of MISCELLANEOUS MERCHANDISE: a discussion.of funeral arrangements and/or selection of services and merchandise. AcknowledgmentCards .:........•................ $ � '50 TERMS:This is a CASH TRANSACTION,due in full o and,In all events,becomes PAST DUE . $ t} 5 AND DELINQUENT upon expiration of due date.A charge of j g /o per annum for UNANTICIPATED LATE PAYMENT " Register Book.... $ -�1 will be effective d c•1.y,S f o M *_6 oy t_`(� '''' Q de Memory Folders/Prayer Cards $ r I,or we,having read the above,accept Grid approve same,and Jointly and severally promise to make full payment therefor,Each purchaser understands that this promise to Jointly and severally make full payment means the Funeral Home has the right to collect the entire amount from anyone or more of the ••...,,.. $ purchasers wlthoji4esort to any claim against any other purchasers.This right exists regardless of.whather or not one or more of the purchasers have agreed among them elves ho7v much aDc wl��c gntdbute.to mak Iull payment.Receipt of a copy of this contract Is acknowledged. ......... $ MR. .a If I Receptacle(other than casket) s. $ M sfa�` '�" )'°" " � �" � _ Signatureta Wearing Apparel $ Pwdheser(s< ! . "„ /s•: St a A(idress - � J ., te i G 4cx 1587? Temporary Grave Marker ........................... $ S.S.No. City State Zip Code FORWARDING OF REMAINS TO ANOTHER FUNERAL HOME................... $ ) CRMN Signature of Purchaser(s) Street Address City and State Zip Code I—, I:I RECEIVING OF REMAINS FROM ANOTHER FUNERAL HOME................. . $ DIRECT CREMATION(As Selected) ...................................... $ Signature of Purchaser(s) S/ dress Cil and State Zip Code s IMMEDIATE BURIAL(As Selected) ...............:.......•'•.•.••••••.••••• $ ! We agree to render the service and furnish the S-8 PA Tntollel C 'OQN, ._ merchandise Indicated abovs. '' f � ��2��7 / f l A I` 0 CD my � o c$ J —= : • W � .a �v viral ap jj I/ yI I M � 1 � fj O00PCa 7 N��D (Dcn � c 1 � S!1 m � I - F P� �s 0-0 -to �z 9bu (`eeceved. FIS Nv� �r d ! 13 oa '�� s 7 t t. R d¢� �i