HomeMy WebLinkAbout09-28-15 r
pennsytvania 1505614105
X17 OEV NTMENiocatv6vu¢ EX(03-14)(FI)
REV-1500 OFFICIAL USE ONLY
reau of Individual Taxes County Code Year File Number
Bu
Bu BOX 280601 INHERITANCE TAX RETURN nn I� - `-"1
Harrisburg, PA 17128-0601 RESIDENT DECEDENT d 1-� VI
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
01152015 03291928
Decedent's Last Name f Suffix Decedent's First Name MI
GRIEST BEULAH ; C
(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
1.Original Return O 2.Supplemental Return p 3. Remainder Return(date of death
prior to 12-13-82)
C=) 4.Agriculture Exemption(date of O 5. Future Interest Compromise(date of 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
C=) 7. Decedent Died Testate p 8. Decedent Maintained a Living Trust 9. Total Number of Safe Deposit Boxes
(Attach copy of will.) (Attach copy of trust.)
O 10, Litigation Proceeds Received OD 11. Non-Probate Transferee Return 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
O 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
THOMAS E. FLOWER (717) 243-5513
First Line of Address
'FLOWER LAW, LLC
Second Line of Address _
�10 W. HIGH STREET v�
City or Post Office State ZIP Code
CARLISLE PA 17013
Correspondent's email address: Tom@Flower-law.Com
REGISTER OF WILLS USE ONLY
REGISTER OF WILLS USE ONLY
DATE FILED MMDDYYYY
rV
n rT1
DAT.E_:FILED TAMP21)
J.
CO � ca
1
3
PLEASE USE ORIGINAL FORM ONLY o } n
Side 1 - cv ,`_- rn
—i O G7 Q
11111111111 IIIII IIIII IIIII IIIII IIIII IIIII IIIII 11111 IIII IIII
1505614105 1505614105 J
f 1505614205
REV-1500 EX(FI)
Decedent's Social Security Number
Decedent's Name: BEULAH C. GRIEST
RECAPITULATION
_......_... ....._............._..._................... ...,_.........................._._...._..........................._..._.._...
1. Real Estate(Schedule A). ...... . ... ... .. ...... .... ........... ... .. .. . 1.
2. Stocks and Bonds(Schedule B) . . . .. ... .. .. .... .. . . ... . .. ... .. .. . .. .. . 2. I
i
3. Closely Held Corporation,Partnership or Sble-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. 132,000.00 ;
8. Total Gross Assets(total Lines 1 through 7). . .. . .. .. ..... . .. . ... .. .. .. . . 8. j 132,000.00
f
9. Funeral Expenses and Administrative Costs(Schedule H)... .. ... .. .. . .. .. . . 9. 9,880.45
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1). ... .. . .. .... .. 10.
11. Total Deductions(total Lines 9 and 10). . .. . . .... ..... .. .. ..... ..... . . .. 11. { 9,880.45
12. Net Value of Estate(Line 8 minus Line 11) ... . .. .. ... . . .. .. .... . .. .. .. . . 12. ' 122,119.55
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. 122,119.55
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 __........._... __. ............................. .. ......._......._.....................................
.........
16. Amount of Line 14 taxable I
at lineal rate X.0 45 122119.55 16. ; 5,495.38
17. Amount of Line 14 taxable
at sibling rate X.12 � 17. 1 j
18. Amount of Line 14 taxable -
at collateral rate X.15 18.
19. TAX DUE ... .... . .. .... ... .. ... . .. .... . . .... . .. .. . .... .... . ... .... 19. i
5,495.38...1
......................................__......................_........__..........._....................__..................._._........
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
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 prepares has
any knowledge.
S1919,ATURE OF PERS RE O SIBLE R FILING RETURN O DAA
ADDRESS
CONNIE L. SHANK& MARY C. RHODES, 325 T UCHSTONE DR., CARLISLE, PA 17015
SIG ER OTHER THAN PERSON RESPONSIBLE FOR FILING THE RETURN DA E /
O� !r! !S
ADDR SS
FLOWER LAW, LLC; 10 W. HIGH ST., CARLISLE, PA 17013
11111111111111 IN Side 2
1505614205 1505614205
.REV-1500 EX (FI) Page 3 File Number
Decedent's Complete Address:,
DECEDENT'S NAME
BEULAH C. GRIEST
STREET ADDRESS
110 TOUCHSTONE DR
CITY j STATE ZIP
CARLISLE PA 17015
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 5,495.38
2. Credits/Payments
A.Prior Payments
B.Discount
(See instructions.) Total Credits(A+B) (2) 0.00
3. Interest
(3) 0.00
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. a
Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) ' 5,495.38
Make check payable to; REGISTER 4F WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred .......................................................................................... N ❑
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑
c. retain a reversionary interest .............................................................................................................................. ❑
d. receive the promise for life of either payments,benefits or care?...............................................................'....... ❑ E
2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑ E
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
containsa beneficiary designation? ........................................................................................................................ ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN,
For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer,to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a 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+(08-09)
pennsytvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
BEULAH C. GRIEST 21-15-
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OF DECOS EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPUCASUE) VALUE
1. RESIDENTIAL REAL ESTATE KNOWN AS 110 TOUCHSTONE DRIVE,
CARLISLE,S.MIDDLETON TWP.,CUMBERLAND COUNTY, PA
TRANSFERRED BY DECEDENT DURING LIFE TO MARY C.(GRIEST)
RHODES&CONNIE L.SHANK.DECEDENT RETAINED ITS USE AS
HER RESIDENCE. TRANSFEREES ARE DECEDENT'S DAUGHTERS. 132,000.00 100 132,000.00
GROSS SALE PRICE. (SEE ATTACHED SETTLEMENT SHEET)
TOTAL(Also enter on Line 7, Recapitulation) $ 132,000.00
If more space is needed,use additional sheets of paper of the same size.
A. Settlement Statement (HUD-1) OMB Approval No.2502-0265
FINAL
B.Type of Loan
1.❑FHA 2.❑RHS 3.®Corn.Unins. 6.File Number: 7.Loan Number. 8.Mortgage Insurance Case Number.
MM1383 6MM26625
4.❑VA 5.❑Conv.Ins.
C.Note:This form Is famished to give you a statement of actual settlement costs.Amounts paid to and by the settlement agents are shown Items marked
"(p.o.c}"were paid outside the dosing;they are shown here for informational purposes and are not included in the totals.
D.Name&Address of Borrower: E.Name&Address of Seller. F.Name&Address of Lender:
Donna C.Sherk Connie L Shank,Mary C.Griest Members 1st FCU
110ToudWone Cirde,Carliste,PA 17015 5000 Louise Drive,Medlanicsiwrg,PA
17055
G.Property Location: H.Settlement Agent I.Settlement Date:08/17/2015
110 Touchstone Drive Members 1st Settlement Company,LLC Disbursement Date:0 811 7/2 01 5
Carlisle,PA 17015 50001Aufse Drlve,Mechanicsburg,PA 17055
South Middleton Township
Phone:717-7956006 Fax 717458.6288
Place of Settlement TitleExpress
1166 Walnut Bottom Road,Carlisle,PA 17013 Printed 08/1 V2015 at 2:26 pm
by KL
J.Summar
of Borrowers
100. Gross Amount Due from Borrower 400. Gross Amount Due to Seller
101. Contract sales price 132,000.00 401. Conbadsaies p1oe 132,000.00
102 Personal property 402. Personal
103. Settlement charges to borrower Vine 1400) 3,88453 403,
104. 404.
105. 405:
Adjustments for items aid by seller in advance Adjustments for Items paid by seller In advance
106. Cityltowntaxes to 406. Cityltowntaxes to
107. County taxes 08/17/2015 to 12/312015 126.67 407. County taxes 08117/2015 to 12/3112015 126.67
108. School Tawas 08/17/2015 to 06!302016 954.43 408. School Taxes 08/17/2015 to 06/302016 954.43
109. 409.
110. 410.
111. 411.
112. 412.
120• Gross Amount Due from Borrower 136,965.63 420. Gross Amount Due to Setter 133,081.10
200. Amounts Paid by or In Behalf of Borrower 500. Reductions In Amount Due to Seller
201. Deposit or earnest money 501. Excess deposit(see instructions)
202. Prindpal amount of new loans) 8500.00 502 Settlement charges to seller(line 1400) 2,566.29
203. Existing 1 s taken subject to 503. Existing 1 s taken subject to
204. 504. Payoff of first mortgage ban
205. 505, Payoff of second moftage loan.
206. W&-
207. 507.
208. 508.
209. 509.
Ad'ustmentsfor Items unpaid by seller Adjustments foritems unaid by seller
10. Cityltowntaxes to 510. City/town lazes to
211. County taxes to 511. County taxes to
212. School Taxes to 512. School Taxes to
213. 513.
214. 514.
215. 515,
216. 516.
217. 517.
218. 51&
219. 519.
220• Total Paid by1for Borrower 05,000.00 520• Total Reduction Amount Due Seller 2,566.29
300. Cash at Settlement fromho Borrower 800. Cash at Settlemonttoffrom Seller
301, Gross amount due from borrower(line 120) 136,965.63 601. Gross amount due to sellar(One 420) 133,081.10
302, Less amounts paid bylfor borrower(line 220) 85,000.00 602. Less reductions in amount due seller(One 520) 2,566.29
303. Cash p From ❑To Borrower 51,965.63 603. Cash ®To ❑ From Seller 130,514.81
tl.alamLabi •mreMyvtlYdl9mNrolm�On.Ne mfRMM6Vlrbtl.unC NYAtCmr.Y.wgNDry.Tb YOM�jnMtD DA+�.tIY pMW mi RESPA a+etMtliroo�en YNaeMkn Me
cenYnefGpoaeai
Previous editions are obsolete Page 1 of 4 HUD-1
REV-1511 EX+ (10-09)
ipennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
BEULAH C. GRIEST 21-15-
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' EWING BROTHERS FUNERAL HOME,PROFESSIONAL SERVICES 4,005.00
2. FUNERAL VEHICLES AND EQUIPMENT 890.00
3. CASKET,VAULT, REGISTER BOOK, MEMORIAL FOLDERS,NOTE CARDS 2,496.00
4. OBITUARY,CLERGY HONORARIUM,FLOWERS,DEATH CERTIFICATES 553.45
5. WESTMINSTER CEMETERY: GRANITE GRAVE MARKER, INSTALLATION,ENGRAVING, FEES 1,536.00,
e. 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: 400.00
7.
TOTAL(Also enter on Line 9, Recapitulation) $ 9,880.45
If more space is needed,use additional sheets of paper of the same size.
Ewing Brothers Funeral Home, Inc.
630 South Hanover Street
Carlisle, PA 17013
(717)243-2421
January 21,2015
Connie L. Shank
325 Touchstone Drive F
Carlisle, PA 17015
The Funeral Service for Beulah C. Griest
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES,FACILITIES,AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
Professional Services
Basic Services of PA L.F.D. 1,200.00
Bathing and Embalming 960.00
Other Preparation of Deceased 320.00
'Basic Use of Facility 275.00
Documentation Prep/Recording 375.00
FD/Staff Supervision ViewNisit/Service 375.00
Facility/Equip View/Visit/Service 375.00
FD/Staff for Interment Service 125.00
Total Professional Services -"----"--"-"----"d;Tf0ij0
Equipment
Transfer Deceased to Funeral Home 295.00
Hearse Usage 295.00
Safety/Lead Vehicle 150.00
Utility Vehicle 150.00
Total Equipment -------------------S9tf110""--
Merchandise
20G NG Copper Hammertone 1,025.00
#12 Guardian OBC 1,395.00
Register Book 28.00
Memorial Folders 36.00
Thank You Notes 12.00
Total Merchandise Selected -----------------
AT THE TIME FUNERAL ARRANGEMENTS WERE MADE,WE ADVANCED CERTAIN PAYMENTS TO
OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES.
Cash Advances
The Sentinel�Obituary w,Photo 239.45 -
Clergy Honorarium 125.00
Death-Certificates.-- ---•
30.00
Flowers 159.00
Total Cash Advances ------------------- 5'td5----
SALES TAX 0.00
SUB-TOTAL 7,944.45
INITIAL PAYMENT/DISCOUNT/CREDITS 8,346.7f / / '2/
vrf/V
TOTAL AMOUNT. -402.26
The unpaid balance over 30 days is subjected to a I %service arge per month- 12%per annum.
Page
Osiris Holding of Pennsylvania, Inc.
RetV Installment Contract and Security Agreement
❑Osiris Holding of Pennsylvania LLC("LLC") estminster Cemetery LLC("LLC") ❑Prospect Hill Cemetery LLC("LLC") Contract#
StoneMor Pennsylvania Subsidiary LLC("Company") StoneMor Pennsylvania Subsidiary LLC("Company") StoneMor Pennsylvania Subsidiary LLC("Company")
Cumberland Valley Memorial Gardens("Cemetery") Westminster Cemetery("Cemetery") Prospect Hill Cemetery("Cemetery")
1921 Ritner Highway,Carlisle,PA 17013 1159 Newville Road,Carlisle,PA 17013 4855 Londonderry Road,Harrisburg,PA 17109
717-243-3541 717-249-2029 717-545-3777
LLC and Company(sometimes referred to collectively in this�jgreement as"Seller")are owners and operators of the Cemetery. THIS AGREE is made by and between Seller and
co f t t L,i k� h , S Q �L� ,� 141(a Lk j 6� � ...r i(� hereinafter called the"Purchaser".
WITNESSETH THAT Purchaser agrees to buy and LLC and Company agrees to sell to Purchaser,or his designated beneficiary in accordance with the terms hereof the following items to be provided or used at the above checked location.
1. DESCRIPTION OF BURIAL RIGHTS. The Burial Rights covered by the Agreement are shown by the map of such garden/building on file in the office of the CEMETERY,and are more particularly described below.
Burial Rights in: Grave Space(s) +Mausoleum: ❑Chapel ❑Garden ❑Tandem ❑Side-by-Side ❑Single❑Developed ❑Preconstruction
Lawn Crypt: ❑Double Depth ❑Side-by-Side Niche: ❑.Chapel ❑Garden ❑Single ❑Companion ❑Developed❑Preconstruction
❑Single ❑Developed ❑Preconstruction +Maximum casket dimensions are:length 85",width 29",height 26"
1st Choice 2nd Choice 1st Choice 2nd Choice
Garden Garden Building Building
Section Section Section Section
Lot Lot No.(s) No.(s)
Space(s) Space(s) Level Level
2. MERCHANDISE: 3. ITEMIZATION OF CHARGES LLC* Company*
(A)Burial Rights(as described in Para.I above) $
❑Check here if merchandise is being purchased for use at another cemetery. (B)Perpetual Care $
Cemetery's Name: (C)Less Certificate Discount $
(D)Second Right of Interment $
A.VAULT(S) #1.Description (E)Vaults) $
#2.Description (F) Um(s) $ `
(G)Mausoleum Lettering/Crypt Plate ; � $ -
.
B. URN(S): #1.Description (H)Memorial/Monument $
#2.Description (1) Granite Bases) $
(.l) Installation Charge Z $ $
C.MEMORIAL INFORMATION: (K)Caskets $
Memorial Design: Vase: Y/N (L)Initial Fee for Interment $
(M)Final Interment/Entombment/Inumment Fee $
Bronze Size X Granite Size X (N)Permanent Records&Processing Fee $ 3�5 A8 $ " 02 S
Location(Section,etc.) woo � �(��� 1 �� �. �� � (0)Other tL ryl r�t A- rT—r' i '1t t _ $ ___2� 0��
(P)Sales Tax 0 $
D.MONUMENT INFORMATION: 4. TOTAL CASH PURCHASE PRICE(A THRU P) $ 3(a
Type: C-WCt S S -,Jar Color: F fit, -Q
- ITEMIZATION OF THE AMOUNT FINANCED
Size: `d x ` - x P (1) Total Cash Price ..................................$ S.
Die: x x P (2) A.Down Payment❑Cash eCheck O Credit Card .....$ - r
B.Trade In: .........$
Base: x z P
Old Agreement No. r
C.Total Down Payment(2A+2B). $
E.CA Mode
): 3 Unpaid Balance of Cash Price(1 -2C) $
1.Mode1: Gauge: ( ) p ���������������� �
2.Model: Gauge: (4) Finance Charge ........••••.......................$ 1J
(5) Total Unpaid Balance(3 4) ........................$
*The LLC anS the Company shall each remain secondarily liable to the other for the sales of items and services provided by one another pursuant to this Agreement;however,Purchaser shall not be required to exhaust
—,ramalliac onainet that T('nr tha('.mmnnnv hefnrr.nrnneedino nosimt the nther.
the`uhLLhK ror such ngnts m accoroance The cost of your credit as a yeany rate. the Qouar amount me ueun win wst yuu. r uv auiuu,, ,,,, ., p , ........ •- _._-. _
with the following disclosure statement: j on your own behalf. have made all payments as scheduled. ing down payment of$
f % $ $ $ $
YOUR PAYMENT Number of Payments Amount of Payments First Payment Due Date Thereafter,Payments Are Due
SCHEDULE WILL BE: $ a Monthly on the
$
SECURITY:You are giving a security interest in the goods or property being purchased or in part of the funds paid under this Agreement held in a Merchandise Trust Fund.
PREPAYMENT:If you pay off early,you will not have to payy a penalty and you may be entitled to a refund of part of the Finance Charge,
NOTICE:See the remainder of this Agreement(including.General Provisions on the reverse side hereof)for additional information about nonpayment,default,delinquency charge,security interests,any required payment in full before the
scheduled date,and prepayment refunds and penalties.
THIS AGREEMENT ARISES OUT OF A CONSUMER CREDIT SALE AND IS SUBJECT TO THE ADDITIONAL GENERAL PROVISIONS CONTAINED ON THE REVERSE SIDE
OF THIS AGREEMENT,WHICH ARE A PART OF THIS AGREEMENT.
This Agreement shall be binding upon the heirs,executors,administrators,successors and assigns of the parties hereto.
THIS AGREEMENT AND THE FAMILY PROTECTION CERTIFICATE,IF APPLICABLE,CONTAIN ALL THE COVENANTS AND PROMISES BETWEEN THE PARTIES,AND
NO AGENT, SALESPERSON, OR OTHER-REPRESENTATIVE OF EITHER PARTY HAS AUTHORITY TO MODIFY, ADD_TO OR CHANGE ANY OF THE TERMS AND
CONDITIONS CONTAINED IN THIS AGREEMENT AND/OR THE FAMILY PROTECTION CERTIFICATE.
NOTICE TO ASSIGNEES OF SELLER
Any holder of this consumer credit contract is subject to all claims and defenses which the debtor(Purchaser)could assert against the Seller of goods or services obtained pursuant hereto
or with the proceeds hereof. Recovery hereunder by the debtor(Purchaser)shall not exceed the amount paid by the debtor(Purchaser)hereunder.
NOTICE TO THE PURCHASER
(1) Do not sign this Agreement before you read it or if it contains any blank spaces.
(2) You are entitled to a completely filled in copy of this Agreement at the time you sign it.
(3) Under the law,.you have the right to payoff in advance the full amount due and under certain conditions to obtain a partial refund of the finance charge;to redeem the property if repossessed for
a default;to require,under certain conditions,a resale of the property if repossessed.
PURCHASER'S RIGHT TO CANCEL
If this Agreement was solicited at your residence and you do not want the goods or services,you, the Purchaser,may cancel this Agreement at any time prior to midnight of the third
business day after the date of this Agreement. (For an explanation of this right,see the attached Notice of Cancellation form.)
Recovery Fund:A Real Estate Recovery Fund exists to reimburse persons who have suffered monetary loss and have obtained an uncollectible judgement due to fraud,misrepresentation,or deceit in a
real estate transaction by a Pennsylvania licensee. For complete details call(717)783-3658 or 1-800-822-2113.
SEE REVERSE SIDE FOR ADDITIONAL TERMS AND CONDITION_$
IN WITNESS WHEREOF,Purchaser has executed this Agreement this 1`," day of i . By executing this Agreement,Purchaser ack o ledges receipt of a copy of this Agreement.
Counselor: 1.Purchaser7 '�
Signature Email rICA `1 Gt Q 1 Y' CIS,�� wDate of Birth M t
Seller by: 2.Purchaser fYl }
Authorized Representative Signature
Email Date!of Birth
NOTICE.Authorized Representative is signing on behalf of both LLC and Company. l C.., Z
This Agreement is not valid until signed by an Authorized Representative of the Seller. Address: t 15 r f)U c l ��I t'City_ ' ,�_
„w City StatE l Zip
If Burial Rights Certificate.to be printed in Name(s)other than Purchasers,then provide Name(s)here:
Home Phone Number: �}
1. Employer: ti ' 7 = t�C ones S X S
State License No. 2. Employer: Phone
WHITE COPY-,me Company's(Seller)Copy YELiow COPY-Records Corporate PINK COPY-Purchaser's Copy GOLD COPY- Purchaser's Copy
REV-1513 EX+ (01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
BEULAH C. GRIEST 21-15-
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS(Include outright spousal distributions and transfers under
Sec.9116(a)(1.2).)
I. CONNIE L.SHANK, 325 TOUCHSTONE DR., CARLISLE, PA 17015 DAUGHTER 1/2
2. MARY C.RHODES,52 GLADWYN DR., CARLISLE, PA 17015 DAUGHTER 1/2
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1,
TOTAL OF PART II — ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size.