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Home My WebLink About01-0500 PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of ::;:Jl/~/U~L also known as 1-~~ - No. To: cl/~ (J 1- 000 Register of Wills for the County of CUMBERLAND in the Commonwealth of Pennsylvania Deceased. Social Security No. Y 3 to - ~.;1. - o.~ /?, The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older, appl.~ for letters of administration on the estate of (d.b.n.; pendente lite; durante absentia; durante minoritate) the above decedent. Oecendent was domiciled at death in &~ ~ Pennsylvania, with h 4 last family or principal residence at s~ 5" A '" ,{ r? ,,/)l. , . (list streett numb~r an~ municiPjlJity). J /i1, "1 r , . ~~ .J 7n~~L~1 {.rf!} ,6.::>0 /)')aA/~ i Y _I ~O J / , D~. t, t~ ~ 9 years of age, died at ( ). 'A.I;;f- ,~~./7dJ! Decendent at death owned property with estimated values as folllows: (If domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in Pennsylvania (If not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania situated as follows: (}-<J $ /1-, 6-t!-O ~ $ $ $ Petitioner_ after a proper search haS...- ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: Name THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. ,-. on ~ J 5 ~~;^-' & I ~/~af ~3 cu..... ~~ -g.g ~.;:: 3~ cu '- ~o C;; s::: 01) V) /c~~'- ;132 - </ OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND } ss The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal representative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed~nd subscribed f ~~ ?}, ~",J. before me this 01./ day of Lfi?tut- . .)lJ~, 'malle. ~ ~j. (l~a. .:U(;,~, lJ{s/J~{~ I Register l --- '" '-" Q) ~ ~ .... ~ c 01) CiS N 21-01-500 o. Estate of FERDINAND F. HOLLAND , Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW MAY?? t )4>> ?001, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that GLORIA J. HOLLAND is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to GLORIA J. HOLLAND in the estate of FERDINAND F. HOLLAND ~ ('. lIo~ ,>(J4.1. t.!.U. .:;)/(~. .oqriJ-- Register of Wills FEES Letters of Administration $ 50.00 Short Certificates( 1) . . . . . . . . .. $ 3.00 Renunciation ................ $ JCP $ 5.00 TOTAL _ $ 58.00 Filed . ~~. ~.2.'" ~9.q~..... A.D. ~~OO~ ATTORNEY (Sup. Ct. I.D. No.) ADDRESS PHONE MAILDED LETTERS AND ORDERS TO ADMINISTRIX MAY 23, 2001 ~'h" is to certify that the information here given is correcrly copied horn an original c~~tific~He of death d~l~ flied with me as [.h;,j Registrar. The original certifIcate will be forwarded to the State Vita] Records OffIce for permanenr rilmg. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee f()[ this certifIcate, $2.00 ~llln;,7;~ /.I," U OF D-;':-~ l"'~~\.' n Pftf->~ i'\~//-~",,'4'J'. "\. /~ ~/ . " :..t: - (~~/ I . ~~\<:;;. \. (~~,' ". \~~ ~Q; , ~-.I:: 1_~ ~ c.;l\,.-d !~~ .... \.. ,'.. '*~..>.>'c*' \. &"", ~"o." . /~l ""'- ~'" /~\~ -:....,,7.fl;;--.-.~{~\,!f ....", /'lENT \\ 1111'/ """"/r/J//IIIJ1 P 7234240 No. 'I;UL~~ R~~// fhn 111 C1 7 ~J J,j I!J- ), () (1'1 / [fate H 1 OS. ; 43 Rev 2/81 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH STAlE FILE NUMBER SOC'AL SECURITV NUMBER DATE OF OEATH .Me""'. Da,.;'.., .. \Yh,'..h 1'-1, d)oc I Pl..ACE ~ DEATH (Ct\ec" OflIy l)(lft -- 'ioH InSlnJCt.or'i 00 OItle. SlOe) HOSPITAL IllpG'oon' 10 ERlOuIpa".nl 0 7 LA ... FACtlJT\f NAME (II nol tn:.;l.I\J!lon. gl'<'e '.ihe-e! and numb6r J WOILI S\3''' ,t !-J"S:> \J WAS DECEDENT EVER IN U S. ARMED fORCES1 YuO NoKJ Did -- .... .. . DwnI/lij>1 17d.O :...~:.::oI MOTHER'S NAME If.... MoOdIe. MOlden Sulname, II. Ethel Carreras INFORMANT'S MAILING AOOAESS ISIr.... Col)lTown. SIrlIe, Z", Code' 2Ob5253 Meadowbrook Drive Mechanicsbur PlACE OF OlSPOSlTIOH . ....... 01 c.....,.ry, Cromaloty Of 0Ih0t PIKe 21c,st Harrisburg Crematory ;VPEJPRINT IN PERMANENT BLACK INK NAME Of DECEDENT If"" ModelIa Lasr, SEX 2 Male Ferdinand F. Holland Jr. .!~ DATE Of IN..IURV IMOflIh Day. 'rear) AGE (last Btrtt'ooay) UNDER 1 VEAR MOnlht DaY" - BIRTHPlACE ,Cory arod ew ~r i"eaiiS':tY1 60 v,. 5. COUNTV Of OE.IJH .... Cumber land DECEDENT'S USUAl OCCUP>UION i~t:"'~~~~~~:f J?j.rector of Operation ttb. Chemi DECEDENT'S .....UNG AllORESS (SIt.... C.ry/Town. SlaM. Zoo C_l 5253 Meadowbrook Drive 17.. saa.. Pennsylvania I.. 17111. Cumberland 2001 lICENSE NUMBER 011667-L 22b. the be!!1 01 my knowl8dge. death occurred allhe time, dale and place slaled (S.gnatlJfe and Tille) 210. TIME OF DEATH DATE PRONOUNCED DEAD (Mon"'. Day. Yeat) 24. 'I' t.i Lt I{"' M 25. \II\)..< <~\ ILl. J..(JO \ 27. PART I; Enler Ihe diseases. iOIUrieS Of compllcallOn$ which caused (he dealh Do not 8n1ar the mode at dying, such as cardiac 01 ,espltalory aff8sl. shock or heal1 tailur. l.sl Only 0,.. cause on each_ a Wen,) __~t)Jc L, f\'~ l vi VYl P~9tY\0- b 'Se~~~Ed~~ I c f\w~(~A~~\:~fu\\UcL ~ ---~------- d _=r:ASACONSEOUE:CE~ WERE AUTOPSY FINDINGS MANNER Of DEATH AIlAlLABLE PRIOR TO COMPLIITION OF CAUSE Of OE.IJH1 NalUlal ~ ,0 o Could IlOI be deterrTHoed J 436 - 62 -i>216 ="",0 MARITAL STATUS. Mamed N4_ Monied. W_, DNorced l5Pe<:"vl T4. Married 17c.IXI_.__in Hampden RACE. Amoncan In<lo<ln.lllack. WM.. OU; ISpectl;I loWhi te SURVIVING SPOUSE (If ..".. ~.,. maoen tlMTllill) Jean Herr - c.rylboro NAME ANOAllllRESSOF FACllITV 22C.8 Market Plaza Wa LICENSE NUMBER 17109 PA 17055 2Jb. 23c. WAS CASE REfERRED TO MEDICAl EXAMINERlCORONER1 ~ Not2r 2a. I ApptoxllI'Ial. ; lnlefVal between :~anddeA '~1~ 1(. W t~ :e,wb !2Wt~ PART": Olher ..nc.... COf"Idi&iona concnbuling &0 death. buI noI ...ulUng in _ UIlCIofIyu1g ca_ _ in PART I TIME OF 'NJURV IN..IURV AT VIIORK7 DESCRIBE HOW IN..IURY OCCURRED Accwjenf Pending InY.$I~iiJ;I~n o o o ~CE OF 'NJURY . AI homo larm~;e.1. 1000ory. offic. buiking, etc. ISpeclfyl JOo. HomicKie Vo.O NoD s..",Kle J!" 210. CERTlflEfllCt'eck oni,. ooel .Cf.RTlFVING PHYSICIAN lPhyslCldO ct"1I1lYlnq cause of <Jealh wheJ"l.jnOltH~' phySiC.an hdS P'Of"lOl.JflCed lledltl ana canpleled lIem 23) To the beat of my know~Qe. death occurred due ao the cause(s) and maf\ne, .. st..ted. . I ~ ~ o ~ z .PROHOUNCING AND CERTifYING PHYSICIAN (t')'j~4J1l tJolt: ~}t:)"O\)llLlll<J LJeoJlh ..Iud Lt!llil'(lIl(j 10 cause oll1edlh\ To the bu. 01 my knowlec:lgft, death occurred at lIle lime, dale, ~nd pl.ce. and due 10 the clluae(.. IInd manner... slaled. 'MEDICAl EXAMINER/CORONER On the be.is of examineUon lind/or investigation, in my opinion, death occurred at the lime, date, and place, and due 10 the c4luse(a) and m.nner as stated. . 11. S SIGNATURE AND NUMB~R . M IJ"'~A -1. ,) , 0 ' "-C JlVA./ - --~~._----~---. ltLLi6uJ..2J ./J?//Yj:; v.. 0 NoD M. JOC. _. LOCATION (Sg_. Col)lTown. Slala) o Jib. - ~:EMO~04bIH=-~_ t:ES~EDli~r2L__=~ ff( NAliEANDADORESSOFPERSONWHOCOMPLETED.CAU~EtDEATH j \ (IIem17)TVP8Ofp(lnI A ^^O ~W~, ~\e r\':>'>'-:lL \J.,,(JlqOI \,~ ~<krt'\ ~ IY 1 [J ~q Ie! '\f$\~~ e~ ~, ~\ Il et1 \") 0 II 32. DA.TE FilED (MOIIIh Day Yeall )'!1I<Ch 16~ ,),001 f IOo;;).;{)'1 Hf:\' I) !o\(l This is to certify that the information here given is correctly copied horn an original certificate of death duly filed with me as Local R~gistrar. The original cerrificare will be forwarded to the Stare Viral Records Oflice tor permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee fc)r this certificate. $2.00 /iC-"[iii/ii7i7i",'-;;'~"",,,,,,,,,,,,, 4"<.. tI.~'" OF P~A;---__ ~\\ ~'.:(" --------f!!.41 --:., ~~~ .. '\~"':. I~".~ tl&a...\~"" i~ ~: - _-_'}r \-p' ~ I~~. .. .~ \~~ '~~t _ ' _.;;~: ,:I:i:~ \t*~ :,:*1 \~ .".. ./~l ~ ~~. ./~\\' --:._:.t~i~~~_.f[~~ "" --~~~-~~;nENl $, I.II"'!/' ""/#01'111111 P 7234248 No. tf~~Jr'~~'~! K~ ~ Local Registrar 11 0./1/[.1, I 5~ .J.. 0 (:) I I' Date H 'O~ ~ 43 Ray 2.181 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH STAlE FILE NUMBER SOCIAL SECURITY NUIoI8ER StRTtwLACE (Cof't ....4 PLACE ~ DeATH (C"<<Jl 0I1fy IJIle -~ 'ift I(lSIIucttOtti on Oft\et '.SIOet ew ~rlear'iS,'v, HOSPITAL I~'_~ 1. LA ... fACILITY NAME (II not InsN'JltOn. give street and numllell ~cL.i S ~.( ,t \-lose. \J """'s DECEDENT EVER IN U S. ARMED FOf\CES1 _0 NoKJ TYPE/PRINT IN PERMANENT ~ACK INK NAME Of DECEDENT IF"SI 101_. COSI, SEX a.Male Ferdinand F. Holland Jr. AGE (LaSl 8....oaYI UNDER t YEAR Moncluo Dav- UNIlER t DIti 60 Yro 5. COUNTY OF OEArH .... Cumberland DECEDENt'S USUAl OCCUlWlON (~':o.~~:" "::' =:':l.::f . J?~rector of Operatio "". Chemi DECEDENT'S MAILING AOOAeSS (5/..... C"Y~. _. E'PCOOeI 5253 MeadcMbrook Drive 11.. SI;n. Pennsylvania t.. ,11>. Cou Cumberland 2001 LICENSE NUMBER 011667-L DATE PRONOuNCED DEAD IMonll>. Dav. Voa" 24. -, . 'i Lt If'lot as. \II\)"I,t, \LI. d,(J0 \ :1.7. NAT I: Ent., tNt disea..s, il\1uries Of' compQcat.ons which caused the dealh 00 nolenl.' lhe mode of dYlflg, such as caldiac 0' 18sp..,aCory atlas., shock or heart 'allYl. llSl onty ON cause: on u.cf\...... l l: .>- H~UlaI 00 Hom!C1de 0 AccKien' 0 Pending investtgillOn 0 y.,O No 0 SuICide 0 Coutd 00f, b8 delermllled [] DATE OF INJURY (Monlh. DaV. 'fea.) 3. 436 - 62 1'1, ;Joe \ g'::'v' 0 Did -- ..... -...up7 loIARfTAL STATUS. ......- N.~ Uan*t. WIdDwed. 0;-<*1 (Specolyt t4. Married 17c.IXI_.__in Hampden RACE . AmOf1Cat\lndIan.llIal:k. WI\tI.. 8IC (Spod)l taWhi te SURvIVING SPOuSE (If "'". :;''''' m.lI08f1 name) Jean Herr rwp coy- 17109 Market Plaza Wa LICENSE NUMIlER PA 17055 23b. a3c. ~s CASE REFERRED TO MEDICAl EllAMINERlCORONER1 -,;Q Nol'.lr H. t Approxwna.le :,,""""~n :~and_t rz. uJ t:> :7..- wb ~"2W\.~ PART", au- '9"l\cant condiliono conlrlbuling 10 daalh. bul _ ......ong in ,... u~ ca_ _ in IWlT I TIME OF INJUflY INJURV AT WORK? DESCRl8E HCHi INJURY OCCURRED. Y.. 0 No 0 101. :JOe. 211. 3011. 30l10. PLACE OF INJURY. AI horn.. falm, SlIeet:, factory, office building, elC ISP6C,lv) JOe. J a... 21... CEIITIFIER ,neck "'"v onel .CERTIFYING PHYSiCIAN IPh'fSIClc1n c~rt"Ylog cause 01 dtc>alh wtlel"l ..mother ptW~ldl1 hdS P'OIlOUnced IS~dlO ...too comptdoo llesn i!3\ ToU<le be., ot "'y knowtlH1g.. d..th occu.,ed due &0 th. cause(s) and manner.. .'.lH. ~ :;l o '0 ~ z .PRONOUNCING AND CERTIFYING PHYSICIAN jf'hVSlCwfl t....>tl: ;J'~(l0u' .c"ly .Jc.Jlh dl\d ..:t:lllty'(~ 10 l.du:>e ()lll~dUl\ To the tM>ti1 01 mW- knolllt'edgfl, death OCCUlted atll\e ttm., dale, and placo. ,and d". 10 .he cause(.) and manner.. sl~t.<I. 'MEDICAL EXAMINER/CORONER On the b..il ot examination and/or investlgal;on. in my op.nion. death occurred at Ihe lime, date, and place, and due to the c.use(s) and manner as stated.. . . . . . . . . . . . . . . . . . . . . .' ..' . . . . . . . . . . . . . .. .... ....................................... 11. REG'ST.~ S SIGNATURE AND NUMBER-;/. ..-. -. ----- .------.- . Ij 'I'I /) 1 k1LL~_LJ~ - - ~C If"a..} ,&?d~ SIG o 3tb. LICENS NUMBER DATE SIGNE~Mo<"n IV Ye..., rv JtcN\O - 0 4b\ \ \-~ 31d"3 I~ 2.L ^ NAMEANDADDRESSOfPERSONWHOCOIolPLETED.CAU~EO DEATH \-~ (It~ti.iypeai~. ~c!d~'~ MO ~W..., (\.;.~e t\'::>.>0L [J ~i\\~ -yn(\~\q t~ ~f ~d\ ~t\ \ ') D tl 3a. /11< c /, 16JQS2L - e - CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: d~~ \.9. ~~./ Date of Death: Y;1aA.r~} I ~ J ~ ~~ I / Will No. f=: I LE NtJ, Admin. No. 0) 00 / -. OOSOO To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on Name Address Notice has now been given to all persons entitled thereto under Rule 5.6(a) except Date: 9" - ~ - 0 I Signature Name ~-t. ~-/ Address r;LCJ~ I A ,7: 1-1&1:- L,1:tJ 11I0 $OtLDIt WA'fNEL/1NO D'€, V fie 1<' ~C; I') AJ J 1Y1.s ,.'::J q ;J. II ~ Telephone (fdJ I) 9 q I -D ~ tf q Capacity: ~ Personal Representative ~ _Counsel for personal representative Ju~~~ /(;, .-;)3;) - 'I BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX HeGor,~ .. Rec.' ,..(DATE U ESTATE OF DATE OF DEATH FILE NUMBER P12 :c1~NTY 12-31-2001 HOLLAND 03-14-2001 21 01-0500 CUMBERLAND 101 HOGAN E ALLEN EUBANK & BETTS PO BOX 16090 JACKSON .02 JAN -4 ~~l ~v REV-1547 EX AFP c12-DDl FERDINAND F C!efh MS 3923t:urnbEdc Allount Relli Hed FA MAKE CHECK PAYABLE AND REMJT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ iE-V' :i54-j-Ex-AFP--(i2-:ooi--No'~"-icE--oF-'rNHEifiTAircE-TA;rA-PPRA-isEi.riNT~--AL1-owAircE-(fR------------ - - --- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX FERDINAND F FILE NO. 21 01-0500 ACN 101 ESTATE OF HOLLAND TAX RETURN WAS: (X) ACCEPTED AS FILED CHANGED DATE 12-31-2001 RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (1) (2) (3) (4) (5) (6) (7) .00 .00 .00 .00 6,200.00 132,121.47 295,369.48 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequestsj Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) (10) 8,694.15 66.507.63 (11) (12) (13) (14) NOTE: If an assessment was issued previoUSly, lines reflect figures that include the total of ALL ASSESSMENT OF TAX: 15. Allount of Line 14 at Spousal rate (15) 16. Allount of Line 14 taxable at Lineal/Class A rate (16) 17. Allount of Line 14 at Sibling rate (17) 18. Allount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TAX CREDITS: NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. 433,690.95 71;.201 78 358,489.17 .00 358,489.17 14, 15 and/or 16, 17, 18 and 19 will returns assessed to date. 358,489.17 X 00 = .00 X 045= .00 X 12 = .00 X 15 = (19)= .00 .00 .00 .00 .00 PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 · IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) . /6"""'c3;25(i . , REV-1 00 OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN DEPARTMENT OF REVENUE FILE NUMBER DEPT. 280601 RESIDENT DECEDENT ~-L - .eLl Q6.li..Q-D HARRISBURG, PA 17128-0601 COIJ\ITY CODE YEAR 1'l.f,l8ER DECEDENTS NAME (lAST, FIRST, AND MIDDLE INn-LIIl) SOCLlll SECURITY NUMBER I- Z HOLLAND FERDINAND F, 436-62-0216 W DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD- YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE C W 03/14/2001 10/20/1940 REGISTER OF WILLS '"' W (IF APPLICABLE) SURVMNG SPOUSE'S NAME (lAST, FIRST, AND MIDDLE INn-LIIl) SOCLlll SECURITY NUMBER C HOLLAND, GLORIA J. UJ 001. Original Return 0 2. Supplemental Return 0 3. Remainder Return (dale of death pror to 12-13--82) '- ::.::~U) 04 limited Estate 0 4a. Future Interest Compromise (date of death afIer 12-12-82) 0 5. Federal Estate Tax Return Required u""" UJtl.U 0 0 Iaa 6. Decedent Died Testate (Attach copy of Will) 7. Decedent Maintained a Living Trust (Attach copy of Trust) _ 8. Total Number of Safe Deposit Boxes u"'~ tl.<D tl. 0 9. litigation Proceeds Received o 10. Spousal PoveltyCredit (date of deelhbelween 12-31-91 ard 1-1-95) D 11. Election to tax under Sec. 9113(A) (Altacn Sch 0) << '- THIS SECTiON MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATiON SHOULD BE DIRECTED TO: z NAME COMPLETE MAILING ADDRESS UJ 0 HOGAN E, ALLEN CPA POST OFFICE BOX 16090 z a tl. FIRM NAME (If Applicable) JACKSON, MISSISSIPPI 39236-6090 '" EUBANK & BETTS PLLC UJ '" TELEPHONE NUMBER '" a 16011 987 -4300 u 1. Real Estate (Schedule A) (1) OFFICIAL USE ONLY 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous PersoMI Property (5) 6,200.00 Z (Schedule E) Q 6. Jointly Owned Property (Schedule F) (6) 132,121,47 !ci: D Separate Billing Requested ...J 7. Inler-Vivos Transfers & Miscellaneous Non-Probate Property (7) 295,369.48 :J I- (Schedule G or L) c:: 8. Total Gross Assets (total Lines 1 .7) (8) 433,690.95 <I: '"' 9 Funeral Expenses & Administrative Costs (Schedule H) (9) 8,694,15 W lr: 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 66,507.63 11. Total Deductions (total Lines 9& 10) (II) 75,201.78 12. Net Value of Estate (Line 8 minus Line 11) (12) 358,489,17 13 Charitable and Governmental Bequests/See 9113 Trusts for which an election 10 tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 358,489.17 SEE INSTRUCTIONS FOR APPLICABLE RATES Z 15. Amount of line 14 taxable at the spousal tax 0 358,489.17 xo---.!! !ci: rate, or transfers under Sec. 9116 (a)(1.2) (15) 0.00 I- 16, Amount of Line 14 taxable at lineal rate X .0_ (16) :J D. 17. Amount of Line 14 taxable at sibling rate X .12 (17) ::E 0 18. Amount of Line 14 taxable at collateral rate X 15 (18) '"' ~ 19. Tax Due (19) 0.00 20. 0 I CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT I STFPA42021F.1 > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < , Decedent's Complete Address: STREET ADDRESS 5523 MEADOWBROOK DRIVE CITY T STATE I ZIP MECHANICSBURG PA 17050 Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) 2. CredltS/Paymenls A. Spousal Poverty Credil B. Prior Paymenls C. Discounl (1) 0.00 3. Inlerest/Penalty if applicable D. Interesl E. Penalty Total Credils (A + B + C) (2) Tolallnlerest/Penally (D + E) (3) 4. If Une 2 is grealer Ihan Une 1 + Une 3, enter Ihe difference. This IS Ihe OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Une 1 + Une 3 is grealer than Une 2, enler Ihe difference. This is Ihe TAX DUE, (5) 0.00 0.00 A, Enler Ihe inleresl on Ihe lax due, (5A) B. Enler Ihe lolal of Une 5 + 5A. This is the BALANCE DUE, (5B) Make Check Payable to: REGISTER OF WILLS, AGENT 0,00 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS Yes o o o o IX] o conlains a beneficiary designation? , . , . , , . , , , . . . , . .. , .. .. , , , , , .. , , IX] 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES. YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN, Uooer penalties of pe~ury, I declare that I have examined this relurn, including accompanying schedules and statements, and to the best of my knowledge and belief, ~ is true, correct and complete Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SI~ERSON RESPONSIBLE FOR FILING RETURN ,WDRESS ' ~. ~ , 5020A WAYNELAND DRIVE, JACKSON, MS 39211 SIGNATURE OF PRE PARER OTHER THAN REPRESENTATIVE No !XI o !XI !XI o !XI DATE J{)-~t,b-() f DATE ADDRESS For dales of dealh on or after July 1, 1994 and belore January 1, 1995, Ihe lax rale imposed on Ihe nel value of Iransfers 10 or for Ihe use of Ihe survivin9 spouse is 3% [72 PS, 9g116 (a) (1,1) (i)]. For dales of dealh on or after January 1, 1995, Ihe lax rale imposed on Ihe nel value of Iransfers 10 orfor Ihe use of the surviving spouse is 0% [72 P,S, 99116 (a) (1,1) (II)] The statute does not exemDI 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 dealh on or after July 1, 2000: The lax rale imposed on the nel value of transfers from a deceased child twenly-one years of age or younger al dealh to or for Ihe use of a nalural parent, an adopllve parenl, or a slepparent of the child is 0% [72 PS, 99116(a)(1 ,2)], The tax rale imposed on Ihe net value of Iransfers 10 or for Ihe use of the decedent's lineal beneficiaries is 4,5%, except as noled in 72 P,S. 99116(1.2) [72 P,S, 99116(a)(1)1. The lax rate imposed on Ihe nel value of Iransfers 10 or for Ihe use of Ihe decedent's siblings is 12% 172 P,S, 99116(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. STFPA42021F.2 REV.1502 EX + (1-97) (I) COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER HOLLAND, FERDINAND F. All real property owned solely or as a tenant In common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell. both having reasonable knowledge of the relevant facts. Real property which is Jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH STFPA42021F,3 TOTAL (Also enter on line 1, RecapitulatIOn) $ (If more space IS neeceo, Insert addlllonal sheets of the same size) REV-1503 EX + (1-97)(l) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF HOLLAND. FERDINAND F. FILE NUMBER All property jolntly-owned with the right of survivorship must be dIsclosed on Schedule F. ITEM NUMBER DESCRIPTION 1. VALUE AT DATE OF DEATH STFPA42021FA TOTAL (Also enter on line 2, Recapitulation) $ (If more space IS neeced, insert additional sheets of the same size) , REV-1504 EX + (1-97) (Il COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY.HELD CORPORATION, PARTNERSHIP or SOLE.PROPRIETORSHIP ESTATE OF HOLLAND, FERDINAND F. FILE NUMBER Schedule C-1 or C-2 (Including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH STF PA42021F,5 TOTAL (AI~ enter on line 3. Recapitulation) $ (If more space IS needed. Insert additional sheets of the same size) REV.1505 EX + {1.97}{1} COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C.1 CLOSELY.HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF HOLLAND. FERDINAND F. FILE NUMBER 1. Name of Corporation Address State Zip Code State of Incorporation Date of Incorporation Total Number of Shareholders Business Reporting Year City 2. Federal Employer I.D. Number 3. Type of Business Product/Service 4. TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK Voting I Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK Com man $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? 0 Yes 0 No If yes, Position 6. Was the Corporation indebted to the decedent? If yes, provide amount of indebtedness $ 7. Was there life Insurance payable to the corporation upon the death of the decedent? DYes Annual Salary $ ONo Time Devoted to Business DYes ONo If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 8. Did the decedent sell or transfer stock of thiS company within one year prior to death or within two years if the date of death was prior to 12-31-82? DYes 0 No If yes, 0 Transfer Transferee or Purchaser Attach a separate sheet for additional transfers andlor sales. o Sale Number of Shares Consideration $ Date 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? If yes, provide a copy of the agreement. DYes ONo 10. Was the decedent's stock sold? DYes ONo If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? DYes ONo If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? DYes DNo If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOllOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calculations usee In the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of prinCipal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. STF PA42021F.6 REV-1506 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C.2 PARTNERSHIP INFORMATION REPORT ESTATE OF HOLLAND, FERDINAND F. FILE NUMBER 1. Name of Partnership Address Date Business Commenced Business Reporting Year City 2. Federal Employer 1.0. Number 3. Type of Business 4. Decedent was a D General State Zip Code ProducUService D limited partner. If decedent was a limited partner, provide initial investment $ 5. PERCENT OF PERCENT OF BALANCE OF PARTNER NAME INCOME OWNERSHIP CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? DYes D No tf yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? DYes DNo If yes, Cash Surrender Value $ Owner of the policy g. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years iffhe date of death was prior to 12-31-82? Net proceeds payable $ DYes DNo If yes, D Transfer D Sale Percentage transferred/sold Consideration $ Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales Date 10, Was there a wrillen partnership agreement in effect at the time of the decedent's death? If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? DYes D No If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated affer the decedent's death? DYes DNa DYes DNa If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? DYes DNa If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? Dyes DNo If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE A. Detailed calcuialions used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and esHmatad fair market valuels. If real estate appraisals have been secured, attach copies. D. Any other information relating to the vaiuation of the decedent's partnership interest. STF PA42021F.7 REV-1507 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF HOLLAND, FERDINAND F. FILE NUMBER All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1. VALUE AT DATE OF DEATH STFPA42021F.8 TOTAL (Also enter on line 4. Recapitulation) $ (If more space IS needed, Insert addlllonal sheets of the same size) REV-15oa EX... (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF HOLLAND. FERDINAND F. FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property Jolntly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 2 1994 GEO PRISM 4 DOOR SEDAN, VIN 1Y1SK5364RZ056396 1996 CHEVROLET LUMINA4 DOOR SEDAN, VIN 2G1WL52M8T9110652 1,700.00 4,500.00 STF PA42021F.9 TOTAL (Also enter on line 5. Recapitulation) $ (If more space IS needed, Insert additIOnal sheets of the same size) 6200.00 ~. \ : It:<M,iii~);,1;i;;:;;'j~W;;/"~:;;@V;' .',.' ~:}.;/. 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"^" YEAR MODEL BODY CHEV 90 LUM 4D ~ NEW/USED TYPE OF VEI-\\CU: "" ~, {If\()N'/j 06 .~ P~SS 000 TITLE NUMBER 7398122-02.,.- DUPLICATE VEHICLE IDENTIFICATION NUMBER 2G1WL52MdT~110b52 (MINER .iLL:; H) ~,"j 7-1 :;1..1" Ji\Cr~ s:_~'~ ~::.: ::',] IN'( \( ,~L~: ;) '-' I ~i _ /oj:) 39(:111 ODOMETER - TENTHS NOT INCLUDED 012"*".) ACTUAL MIU;,,:;::: 1ST LIENHOLDER (OR OWNER IF NO LIEN) DATE MQ ( DAV I ':"A r:'.us i;'l At~tT>,;lj~ . X' '.;~ OilO ~ JACKSON MS 3'1205 2ND LlENHOl.DEfl OA" MO I DAY I YR ..11- ,1 ) ',,,,- ~;~t~it~!{j~~~~}r *~:-. y LIEN SATISFACTION- THE-UNDERSIGNED HOLDER OF ABOVE DESCRIBED UEN(SI ON THE MOTOR VEHICLE DESCRIBED HEREON HEREBY ACKNOWLEDGES SATISFACTION THEREOF.}, I,: . :BY . ..,; (SIGNATURE AND T1~) '~/ .-*- <:;:';~ O~""''-'i~~,/.if2if'U <':~ :~,JJ;;)~f:W!:, > '.' ~ .~jr",.,1 ;'~:;~:" < :_~ I';" ,),:;~~.~ ,.>.....,.,..,.,." '''G'''''''''.NOTIn.Er;; -i" '.~. '!'\ ';":: ':'-, ."~"~~~'-'I- -t' /)"" ~j::-: ~ ., ~- .~'..'-'-' '- .>-,,~~~~.~:~: ..' ~ ~-\~(\., .,,~\ ~:~ ""."iu 'i;' '.-';,~;Z,," , V" tI ' '., j, ';";;~'~'; . '\ ',',;, ;.,:/;'lj~i! .- --; ~M $tateTuCommISSIOnher9byoerlifi8Slllalon/ ;.,.~, .~.,...t.~t~' ~ ~~~~h~~-t'e.e.'.~~-~::~~-_Y_~~' ~;,~'i~'~';;;~ :,-. ~.~ ,:.g1.1 , , ..~~ ':,t lSTUEN \~N~R\ 'THis " "DAY OF ~~l~~~ ~~~1'~: . . , ,~ .,-~ " 1 {l~~~)"" c'; ",:c' ..),~:~~.:. ~~l"-i{,', :'>~~;~-'- 'C ,_,~, . ~ -;-<..-., " ~Y ., ....... ~..;;:~., .';''- . ~ " ,; }J;:X~,'~\~~l:":, i;/U REV-1509 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY.OWNED PROPERTY ESTATE OF HOLLAND, FERDINAND F. FILE NUMBER If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S} NAME ADDRESS RELATIONSHIP TO DECEDENT A. GLORIAJ. HOLLAND 5020A WAYNELAND DRIVE JACKSON, MS 39211 SPOUSE B. c. JOINTLY.OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE IncllXle name of financial institution al'(l bari. accol.O runber or similar identifyil'Q runber DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT Attach deed forpinlty-held real estate VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 09/97 ALLFIRST BANK CHECKING ACCOUNT 2,779.49 50 1,3B9.75 2 A 12/97 RESIDENCE AT 5253 MEADOWBROOK DR. MECHANICSBURG, PA 17050 161,900.00 50 80,950.00 3 A 12/97 FURNISHINGS AND OTHER PERSONAL PROPERTY LOCATED AT 5253 MEADOWBROOK DR. MECHANICSBURG, PA 17050 98,334.00 50 49,167.00 4 A 12/97 ESCROW ACCOUNT HELD BY MORTGAGOR 1,229.44 50 614.72 TOTAL (Also enter on line 6, Recepitulation) $ 132121.47 (If more space IS needed, Insert additional sheets of the same size) STFPA42021F.10 Il allflrst Checks PaQe 3 of ., \I Denotes missing sequence number Number 08le Amount Number Date Amount Number O.te Amount Did you know that you 1466 03/13 $31. q8 1479 03/21 $13. q1 1492 03/28 $9.50 could earn a credit (0 1469' 03112 q6.90 1481' 03/22 6.80 1493 04/06 2,000.00 help offset your A TM 1470 03/12 21. 95 1482 04/02 31. q2 1494 04/09 32.q6 transaction fees by 1471 03112 3q8.31 1483 03/26 660.17 1495 04/09 98.00 letting us sa{ekeep 1472 03120 10.00 1484 03129 1,lS0.Q1 1496 04/09 65.89 your checks for you? 1473 03/14 60.00 1485 03/30 12.73 1498' 04/06 31.62 1474 03/14 197.Q5 1466 03/23 20.71 1500' 04/10 92.3Q 1475 U3/13 28.~~ 1487 03123 31.12 1501 U4/09 100.00 1476 03/12 Q,OOO.OO 1489' 03/27 7.56 1502 04/09 615.12 1477 03/19 39.93 1490 03/30 77.92 1503 04/10 12.35 1478 03/22 8Q.69 1491 04/02 120.00 1513' 04/10 2,Q70.7Q $12,529.Q2 ATM activity Dale Description Amount 03/22 ATM CASH WiTHDRAWAL 032201 13:0U -SO.OO You can wirhdraw from ALLFIRST other bank's ATMs up to HAMPDEN MECHANICSBURG PA three times each 03/28 ATM CASH WITHDRAWAL 032701 20:22 -SO.OO statement cycle without ALLFIRST any transaction fee. HAMPDEN MECHANICS BURG PA 04/05 ATM CASH WITHDRAWAL 040501 11 :22 -300.00 ALLFIRST HAM PDEN MECHANICSBURG PA -QOO.OO Other activity Date Description Amount 03/14 ACH INTERNAL DEBIT -15.98 CLARKE AMERICAN CHK ORDERS YMEG9722036271D 3114000006FERDINAND F HOLLAND20010734411773 -15.98 01535233 0004.98317453385 050 End 01 Day Ledger Balance Account balances are updated in the section below on days when transactions posted to this account. D.te Bltlltnce DlIte Balltnce Dille Blllance 03/09 $7,530.00 03/22 $4,764.45 04/02 $6,889.44 03/12 3,112.84 03/23 8,712.62 04/04 8,587.44 03/13 3,052.92 03/26 8,052.45 04/05 8,287.44 03/14 2,779.49 03/27 8,341.42 04/06 6,865.06 03/19 4,929.35 03/28 8,281.92 04/09 5,977.59 03120 4,919.35 03/29 7,131.51 04/10 88,406.65 03/21 4,905.94 03/30 7,040.86 'Easy, last, convenient...Turbo Tax online. To download, just go to allllrst.com and click on the Turbo Tax icon found in the Personal Finance and Internet Banking areas," 'Alllirstlnternet Bill Payment is now available. To enroll online today. just go to alllirst.com, logon to Internet Banking, and click on Blil Payment! ' The annual percentage yield earned reflects the amount of interest earned on the account during the statement period and the average daily balance in the account for that period. The interest rate paid will fluctuate according to money market conditions. About your Relationship Checking with Interest account. When you maintain an average daily ledger balance 01 $1.000 in your checking account; or $2,500 In your checking, money market and savings accounts; or $7,500 in all related accounts you will not be assessed the $10 monthly maintenance fee. Balancing your checkbook. Look on the back 01 your lirst statement page lor a last and easy way to balance your checkbook. What your le"n. mf!8n o Customer Service e Credit to your account o Important reminder e Charge to your account ~ Other banks' ATM transaction ~h~ PlIge 4 of 4 For questions about your statement or change of address information, please see page 2. ~'-."-"'~ '~'~"":>'T~- '. i i ./ OMS NO. 2502- 265 ,or A, u.s. OEPARTMENT OF HOUSING & URBAN DEVELOPMENT 'nFHA 2.0FmHA 3.e jCONV. UNINS. 4.~VA S.OCONV. INS. SETTLEMENT STATEMENT 6. ~REWER 1 L 1015114 e. MOKT<;A<;E INS \;A.. NOM"OK, c.= This fonn is furnished 10 give you a statement of actual settlement costs. Amounts paid to end by ttle setUemenf agent are shown. lIems marl<;ed '{POCr were paid outside the closing; they are shown here lor informationel pU/poses and ere not included in the totals. " "" (~,~REWfRllf) D. NAME AN E. ADDRESS OF >ELLER' . N~M' G\..ORIA J, HOLLAND BRQADVIEW MORTGAGE COMPANY DAVID L BREWER, JR and ELISABETH R. BREWER (Cormeny known as Elisabeth R Cale) G. PROPERTY LOCATION: H. SETTLEMENT AGENT: 23-2402316 L SETTLEMENT DATE: 5253 MEADOWBROOK DRIVE PURITY ABSTRACT COMPANY MECHANICSBURG, PA 17050 June 22, 2001 CUMBERLAND CO\.loty, PennsylvanIa PLACE OF SETTLEMENT 3329 Markel Street Camp Hill, PA 11011 ,. , 1400. , "ao ,"s ,co c a.. co .m>n. I ersona "''''' e emen arges orrower "a ~usme s or ems e, y a erme vance 'us an $ or .ms ., y a Sf/ntl tines oun wp axes 0 n y wp axes 1 .., 'y ., IY ax 0 , 00 ., 0 ax 14U'. 0 1'![ 120. GROS$ AMOUNT DUE FROM BORROWER 171,836.4B 420. GROSS AMOUNT DUE TO SELLER 162,118.97 AI R I'uu. ~ epos) Of earnes money xceS$ ...., ee ns clons 2(12. nnapalAmoun 0 ew oan(s} 150'. . omon arges 0 ear '"' XIS \ng oaf1 s i!. ensu lec 0 XISlng oan $I a ensu lec (I ayott01 IlfS 0 a,e ayo 0 . , ~ epoSI " ,as procee s ~us men s-Fofltems npal y e er ~us men s OT ams npsl y a er ouo wp axes 0 OU" wp ax" 2lf:-GiWTax to I ax oc ax oc ax 0 ,210. 1014. '2T5C 15". ,:m: 1219. 220. TOTAL PAID BY/FOR BORROWER 169,157.00 520. TOTAL REDUCTION AMOUNT DUE SELLER 137,421.37 ,",': , ross moun ue ,om orrower ,oss oun ue 0 e e~e ." moun " y or Borrower (J..lne 220) I'" ." LIe on, ue e er ne 303. CASH ( X FROM) ( TO) BORROWER 2,079.48 603. CASH ( X TO) ( FROM) SELLER 24,697.60 The undersigned hereby acknowledge receipt of a completed copy of pages 1 &2 of thIs slateme\'\t & any a\\achments referred to herein. Banow" ~ . -' /f, (J. r," , {rft/ ELISABETH H BREWER Sell" ~LAs?kluzrd ar:f ~ ~C . . ~-~~~:' ~ii~~~$: ~t~.:- ':~1" '..,>';.,,:,,'. ~.- >.,:'. " ....'":! ~ ", . '00 TOTAL IVISI MMI I N ase o,;-pfice ommlSSlon me o es oows: o omrruSS.JOn 31 a e emen -= roo:- L "' ECfiOiirWITHTOAfr 000 nglna Ion " 0 0 02.--[oan Discount- % 10 pralsa " 0 ".,- '" .po 0 en e S nspec on " 0 0 00 '" " 0 " ervlce " 0 cumen "p " 0 0 HI. I IR 101. Interest From 06122/01 to 07/01/01 @ $ o gage nsuran remlum or mon s 0 :or azar nsurance remlum or years 0 000. RESERVES DEPOSITED WI"fRTEN1JER OCi1.Hazardnsurance ~mon o gage nsurance mon ~uii1V7T"'wplaxes mon 1 ax mon coo ax mon moo moo moo I~ ~ 101. SetUement or Closing Fee 1 s ac or Ie earc . Hie Examination nsure oSlng e er ocumen repara on Dry ees ':1\JT7illOrneySF""ees mcu eSB ovelemnum ers Itensurance In uoes a ove I em numDers S verage wne s verage "[0 to o o o Irs o o o o ,,-r L, SETTLEMENT CHARGES $ 161,900.00 @ 6.0000 % 34.270000/day ( 9 days 9,714.00 %) P.....OFROM BOAAOWEfl'S FUNOSAT SETTlEMENT 308.43 , po< moo , po< moo , po< moo , po< moo , po< moo 1,436.4' , po< m" , po< moo , po< moo enean Ie nsurance O. o o ~1WC TTT8C 1 0 1201. NM 0 Recording Fees: Deed $ IY uny amps: ee te a amps: evenue N 25.50; Mortgage $ ~. mp' = 1300. AD DITJITNA[" 1301. Survey e~~rclon HA to o o o = 1400. NT (E"nter onDne'--ilr3,SectloflJ ana eet on OlhlSIWOJIlIg.SUOa-../ 71.50; Releases $ o g ga o gage -~ ..gn'ng pa~TOfItl'" 'llI~ment. ~ ..gf1lttones ~Clmow].og. ,,,,,.ipl 0 a compl.l.o copy 0 page Cerlified lobea true copy. Settlement Agent J(~l~ . . :1~ PAIDFRQM SE""ER'S FUNDS AT SETTlEMENT .<~~ :<"7.'.~:~ 97.00 7.51 11,'55.0! (BREWERIBREWEAI \g) Allstate Insurance Company . . , ' Policy Number 00110275212/17 Your Agent: J Kelley & Son Ine (717) 737.6030 for Premh.lm Period Beginning: Dec, 11,2000 POLICY COVERAGES AND LIMITS OF LIABILITY COVERAGE AND APPLICABLE DEDUCTlBLES LIMITS OF LIABILITY (See Poll,--,' for Applicable Terms, Conditions and Exclusions) Dwelling Protection - with Buildlllg Structure Reimbursement Extended limits $140,476 . $250 All Peril Deductible Applies Other Structures Protection $14,048 . $250 All Peril Deductible Applies Personal Property Protection - Reimbursement Provision . $250 All Perri Deductible Applies $98,334 Additional living Expense Up To 12 Months family liability Protection $100,000 $1,000 each occurrence Guest MedICal Protection each person DISCOUNTS Claim free Protective Device Your premium reflects the follOWing discounts on applicable coverage(s): 5 % Home and Auto 5% 15% RATING INFORMATION The dwelling is of frame construction and is occupied by 1 family \k,~'.~:.~_~ 1~~gtt Page 2 PA070RBD Inlormabonasol ~rl.2000 , l:;;'~;:':i ~~~::_.'~;.t.:;-~~'i REV.1510 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER.VIVOS TRANSFERS & MISC. NON.PROBATE PROPERTY ESTATE OF HOLLAND, FERDINAND F. FILE NUMBER This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV.1500 COVER SHEET is yes DESCRIPTION OF PROPERTY %OF ITEM I!ULDE Tl-E NA.ME OF Tl-E TRANSFEREE, MIR RELATlONSHIP TO DECEOENT 00 M DATE DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE NUMBER OF TRANSFER. ATTACH A COPY OF M DEED FOR REAL ESTATE VALUE OF ASSET INTEREST (IF APPLICABLE) 1. KIDNEY CARE, INC. 403(B) PLAN TRANSFERRED TO GLORIA J. HOLLAND, SPOUSE 76,164.78 100 76,164.78 2 RENAL CARE GROUP RETIREMENT PLAN TRANSFERRED TO GLORIAJ. HOLLAND, SPOUSE 11,426.95 100 11,426,95 3 TIAA-CREF INDIVIDUAL RETIREMENT ACCOUNT TRANSFERRED TO GLORIAJ. HOLLAND, SPOUSE 58,735.11 100 58,735.11 4 DICHEM CONCENTRATE 401k PLAN TRANSFERRED TO GLORIAJ. HOLLAND, SPOUSE 35,179.10 100 35,179,10 5 AMERICAN CHEMICAL SOCIETY IRA TRANSFERRED TO GLORIA J, HOLLAND, SPOUSE 113,863,54 100 113,863.54 TOTAL (Also enter on line 7, Recapitulation) $ 295 369.48 STFPA42021F.l1 (If more space IS needed, Insert additional sheets of the same size) N .... I '.e N oe N ~ ,.., "r '" 0 0 C " N .... " " ~ -'- .:;:- -'- + + ',," -'- + I ., .. .. " ., - " " " " " ..., ..., -, " " ~ " .~ ::' ~ J ::' " -:> => ':l -, J ') ::> J '") -::> .~ ,- -< "" -< -:') .... ~ <-: ") -, --, '") .,., :\: 0') .~ 0') .;\.: .-< .~ -. -, ,... ~. " .,., ..., .~ '"') ., <:t <- ..., ..., ~ '- Q. " '" <( ~~ " " c, 0 N N c I: '" C! C ~ ... '.e '" ~ - ~ ti - '.e '" :: " " 0 " " ... '" ~. - < N "- ..: < ..: -<t ..,. ~ -- <", '0 a-. - 00 "" <:::> Cl:: 0 <:::> lOt) '" - V) VI ~ ... e '" .... "" ='I :: I: <", o. '" :a - '" '" ,,; -- (.) :E Ol .... .... '" .... ..., > ::: (ij -- .... ." ..... OJ :=> W ='I ~, ... .:::: .= ;:; '" Z c ... :::: \.) ?" '" .. '" .... 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'" U r r C :.:: - - > CJJ -<t t.D "-l ... ~ N X '~IC I An A'"'''''''' (;LNUlAl Comp:'lo} RENAL CARE GROUP, INC. RETIREMENT PLAN VALlC ADDRESS: EMPLOYER ADDRESS: DIRECT INOUIRIES TO: GULF COAST REGIONAL OFFICE 840 GESSNER SUITE 525 HOUSTON TX 77024-4257 PHONE: (800) 448-2542 RENAL CARE GROUP 440 BUSINESS CENTER V 784 MELROSE AVENUE NASHVILLE, TN 37211 (615) 844-8900 VALle FINANCIAL PROFESSIONAL 1-800-44-VALIC STATEMENT PERIOD: SSN. GROUP NUMBER: 01/01/01-03/31/01 436-62-0216 54057 1,,,lllllrllllllll.I.II'IIIIII.I..I'IIILIIIIIII.I.IIII.I.lllI FERDINAND HOLLAND 15480 5253 MEADOWBROOK DR MECHANICSBURG PA 17050-6B33 3~'Lt,' l~,~,f)~,~ OO:JO::" )O~ oc':'~<):::; VALle IS PLEASED TO PROVIDE THIS QUARTERLY STATEMENT WHICH COMBINES ALL VO EMPLOYER'S PLANlS). IT IS DESIGNED TO BETTER EXPLAIN YOUR BENEFITS AS WEL S!ATEjrooi::"iT:; VC,U RECEh'E. IF .,au HAVE ANY ':l.:E3TIOt~S r.::::Qt.r..:H~G YO!..!~ ....CCOUNT( FINANCIAL PROFESSIONAL AT 1-800-44.VALIC. OVERVIEW PLAN BALANCES ACCOUNT DESCRIPTION $14,950 4067246 4073865 4067249 DE~ERRALS-NASHVIlLE PRO~IT SHARING-NASHVILLE EMPLOYER MATCH~NASHVILLE TOTAL.S: $11,960 $8,970 $5,980 $2,990 so 01/01/01 03/31/01 = .l " , J I C j 1 , .1 . ] u ,. [ i " I . , i u - J . , -' ~ 7 .j . J ~ , " I 1 . l " l . 1 ~ , J c 1 j , ',' INVESTMENT SUMMARY 'U'-.'l INVESTMENT OBJECTIVE NET CHANQE ENOING % OF IN VALUE* BAL.ANCE BALANCE iii AGGRESSIVE GROWTH Allocation by Objective As of 3/31/01 gj NA FNDRS TRW PRe SMCP $477.02- $2,592.154 23.0% GROWTH & INCOME 0 NA STOCK INDEX $446.84- $3,219.97 28.6% CUR INC & CAP PRESERV II NA GOVl SECURITIES $63.60 $2,744.09 24.3% INT INC W/PRINC STBLTY FIXED ACCOUNT PLUS $32.85 52.713.96 -1.!......1% TOTAL $827.41- $11,270.66 100% -Net Change in Value" reflects any interest earned on fixed investment options and any chanaes in unit values for variable investment options. C154801 1111111111111111 I:illllll 11;1: I/![ 111:/1/ VALIC - The Variable Annuity Life lnsnrance Company VALle Online WWW.VALlC.COM 24 HOUR ACCESS TO VALle INFORMATION AND SER\1CES VALle by Phone 1-800-428-2542 ii ~ - - - - = - - ....... - = - = - = - - ~ Teachers Insurance and Annuity Association College Retirement Equities Fund 7~() Third Avenue I New York. NY 10017-3206 April 10.2001 1",111",111""1,1,11""11"1,,1,,,11,,,11,1,,,11 GLORIA 1. HOLLAND 5253 MEADOWBROOK DRIVE MECHANICSBURG. PA 17050-6833 P$TI[)97h(.O<) Dear GLORIA J. HOLLAND: We've received notification of the death of FERDINAND F. HOLLAND and we are very sorry to hear about your loss. We recognize that this is a difficult time for you and we will do our best to assist you. Just as we've helped your spouse build an asset portfolio with us, we hope to serve your present and future financial needs as well. You are entitled to a benefit from your spouse's TIAA-CREF contracts, which can continue to be invested or paid to you in a number of different ways. The following lists the total TIAA-CREF retirement annuity accumulation for which you've been named beneficiary. The accumulation represents funds from your spouse's retirement plan as of the date of death. The TIAA Traditional amount (if any) continues to increase as it is credited with interest earnings. The value of any funds in the TIAA-CREF variable accounts will fluctuate based on the investment performance of the respective accounts. Value as of March 14. 2001 $58,735.11 $0.00 TIAA Traditional TIAA-CREF Variable Accounts TOTAL $58,735.11 Your next step will be to transfer ownership of the accumulation to your name. Just call us and we'll help you make choices that will fit your needs and obiectives. We realize that you may be dealing with a lot of issues at this time. Depending on your situation, you can choose among a variety of options - from continuing to save and invest your accumulation to receiving payments if you need funds right away. If you're unsure about what to do at this stage, you can simply continue to save and invest the funds with TIAA-CREF for the time being and defer your ultimate decision until you are ready. Over Please TIAA-CREF Individual and Institutional Scnices SBCORROI (11107/00) . I . . 1121/15/21211211 12I~:58 7534228472 Dr CHEH PAGE 1212 . DI-CHEM, INC. 401(k) PLAN EMPLOYEE BENEFIT STATEMENT FROM 01/01/01 TO 03/31/01 FERD HOLIAND BIRTHDATE: RETIREMENT DATE: SOC. SEC. NO.: 10/20/40 10/20/05 436-62-0216 EMPLOYMENT DATE: PARTICIPATION DATE: 09/15/95 01/01/97 GAIN PJ:.Iot OF V!:S'J:'Et' - -- .&I.CCC>lTN'!jFUI-JO B).LANCE Loss COIJTl'lrs. TR.ANSF'ER END SAC . INTf.~IST :E:""FLO'tER l'U;::CI: I VJi.Bl. ii:C 13 C.Ol; er,oo ~H50. 13 c,co " (j.00 FIXED 51U. 15ti .07 0,00 40150. " 13;25, '7 " lCiS!O. " ......su:ra TOTAL U559. " lSli 07 0.00 0,00 12 ~':<: 5 . " lC~p;lC. " D:e:F:ERRA.L Fu;to '1i!lS6. " 431 .~4 HSS'. '" 0.00 2hS:.'l. " lOO :21'1.53. :'3 TOTAL '3226 " ::;"3. " 155' 05 0.00 JS1?9, 10 3203 91 .-. .-. - ?....- ?t4-?,. r""'" I Funl!l~te&:i5-nSe0edude contributions receivable to [he plan as of this v~luation date. 1400 Merro Blvd., S"it6220 Ea/fl., MN 55439 . American Chemical Society Supplemental Retirement pran Independent Plan Coordinators, Inc. P.O. Box 2747 FairfaxO Virginia 22031-2747 (8 0) 308-3515 STATEMENT PERIOD 01/01/2001-03/31/2001 TOTAL PLAN VALUE, $113.863.54 FERDINAND F. HOLLAND JR. 5253 MEADOWBROOK DRIVE MECHANICSBURG. PA 17055-6833 CURRENT YEAR CONTRIBUTIONS AMOUNT TRADITIONAL I~~ $0.00 $0.00 TAX YEAR 2001 2000 VALUE BY TYPE TRADITIONAL(T) ROTH IRA (R) CONVERTED ROTH IRA (C) TOTAL IRA ROTH IRA $0.00 $0.00 2001 20CC SI13, 863.54 $0.00 $0.00 $113,863.54 CONVERTED ROTH $0.00 N/A DEFERRED ANNUITY $0.00 N/A DEFERRED ANNUITY (V) $0.00 RATE FOR NEW CONTRIBUTIONS, 5.750 SOCIAL SECURITY NUMBER: 436-62-0216 IRA - FIXED ACCOUNT S~~~Y BEGINNING CONTRI- ENDING YEAR RATE * BALANCE BUTIONS WITHDRAWALS TRANSFERS INTEREST BALANCE T-87 5.95 2,483.54 0.00 0.00 0.00 35.64 2,519.18 T-88 5.95 11,301. 66 0.00 0.00 0.00 162.21 11,463.87 T-90 5.95 87,170.83 0.00 0.00 0.00 1,251.19 88,422.02 T-91 5.95 11,296 .33 0.00 0.00 0.00 162.14 11,458.47 TOTAL 113,863.54 *EFFECTIVE ANNUAL YIELD IRA INFORMATION IS BEING FURNISHED TO THE INTERNAL REVENUE SERVICE 8S202210 PAGE 1 OF 1 REV.1511 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF HOLLAND, FERDINAND F. FILE NUMBER Debts of decedent must be reported on Schedule I, ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. MALPEZZI FUNERAL HOME 2,110.00 2 PARKWAY MEMORIAL CEMETARY 2,409.15 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative( s) Social Security Number{s) / EIN Number of Personal Representative(s) Street Address City State Zip Year{s) Commission Paid' 2. Attorney Fees 3. Family Exemption: (If decedent's address is oot the same as claimant's, attach explanation) Claimant GLORIAJ. HOLLAND Street Address 5253 MEADOWBROOK DR. (AT DATE OF DECEDENT'S DEATH) City MECHANICSBURG State PA Zip 17050 R.alionship of Claimant to Decedent SPOUSE 3,500.00 4. Probate Fees 5. .A.ccountant'sFees 6. Tax Return Preparer's Fees 675.00 7. TOTAL (Also enter on hne 9, Recapitulation) $ 8694.15 (If more space IS needed, Insert additional sheets of the same size) STFPA42021F.12 Malpezzi FUNERAL HOME -4i1\l'.. f I$lYV~'~"';1dl!:i.lJ.U F~ - - '~!it^"~;.~:,~:>,>~'@_ 8 _~tQrket Pla:.a Huy . _~lechanjCJbllrK, IJA J 70SS Phon" 697-4696 \(;,ha,/ j. .\Ialpm; Owner 1\1.1[ch 2(,. 2{)(i j Gloria Jeall ~H land :'25.; ~kadu\\ (lil.lok Dri\L: \kclul1lcsbur,'. PA J 7050 Th~ Funeral S(n ice for Ferdinand F Hulland Jr We sineereh appreciate the confidence VOll ha\ c placed ill us and will continue to assist vou in every \\av \\e call. Plcase feci free to comact us if you have am qucstlOns 111 regard to this statement. Tille FOLLOWlr-;" IS AN IlTMlZUJ STAITMLN r ell Till' SI'RVICES, FACn.rrIES, A\HOMOTlVE EQUJPMl'NT. ANll MFRCIlA7'IJISE THAT YOU SI:IXC rl'll WI!! 'I M..\KI:\" lllE FUNERAL ARRANGEMENTS. SELECTED MERCHANDISE; R~glSkr. prayer cJrJs THE COST OF OUR SERVICES, EQ\'IP~IE"T. V,D ~IERCHANDISE THAT YOU HAVE SELECTED C. SPECIAL CHARGES Cremation and services A 1 THE TIME 1'iJt'-,'ERAL ARRANGEMLNTS WERI' ~1.~j)I. WI' ,\DV ANCED CERTAlN PA YMENTS TO OTHERS AS AN ACCOMMODATION THE FOEEOWING IS AN ACCOUNTING FOR THOSE CHARGES. CASH ADVANCES Clergy/Mass Onering Organist Certified Copies of111e DC<.lth Cl'rtlllcak TOTAL CASH ADVANCES AND SPECIAL CHARGES $45111i S~5.00 $185111111 $100.00 $75.00 $40.00 S2065.00 SUB-TOTAL lNlTIAL PAYMENT I DISCO\JNT I CREDITS TOTAL AMOUNT DUE $211000 52110.00 J2 /J . ~-4c CA-~~ I.e.e,(J ~ (,.-9 '-- IS- -0 /0 I ~~ CEMETERY AGREEMENT Paorkwjly l"I~r~cr1.1 Ceme't"ry corp. 1161 Hi '3),l.;lnd Colony Pi\l"kway. !\1Cl<;3eland. MS 391:<7 601-853-"7696 P..wkway MemOt'lal (l1ereinaller"Seller"),and Celre'tel').' Core." Glori"- <..1. Uo I [ano! (PlNM ~ .......'sl...ctIy.. wlI -" on Burial Cor'\ifklole) -m..t>ove named ~r$Ons ar. 'elerred to In this Conj'ael as 'Purchase,: e term which wll be ooostrued to lneludtllhll slnovla., plural, mllSculil>8 and 161T1inlne. I! thi. Conlract is "'dnell by 01>8 Of mortl lhan (lne Purcha&ar,..act> 01 lhllm iolnU~ and _all~ M'lKl" \<) b& ~ \:11.\\ 0\ \11. \..ms, plWiaionJ and coo~W>ona aodlhonol1henol&or nole5 ,sl.."e<:l 10 below. 7:- 1. DESCRIPTION OF BURIAL RIGHTS. The Sur;.,1 RigI1l& covered by thls Ao'...menl.r. ahown by \/'la map oI...,ch garg.MIulIdlng on I~ In 11M 011.,. '" SEI..L. ER,.nd__ par\iQ\llarty~~.lM '~ol &1lrl-'AlghU 00M nQtlflC:luO.'ln.."...,.llEntomtNMnl/ln\MrMllt"', (optl'llng and ~_I). n""niM .nrl,.lrwl""m,,,,,tM1 ""itl......r.t.lv -L- Gr.~ Sp.~ "MI!lI8Oleum; T.lndem Slngll WMunln.ler Hldw: interior Exterlor -;?lLh14.1nb...anL L "/'0 '" BuIlding ..- ""'" '" SpIIce(.} No.(.) ...., MaxImum cukel dimenIionf _length 90", 31., heighl~. To8eSe~ 3. rTEMIZATIOHOFCHIJIOES <AI~Rigl'o\$ (u~InParl..1&bove) (8) Leas P,..conItructionOI$eQJI'II IC) leu Carlil\cale 0\IC0UI11 Olher011COU1'I1 (0) &rlaIRighl&AIt.rOl&ctount ./ (E) OU1.rBu'iaICorllllrll,v\ill. r4L1.Jt (F) F'9rpeluaICa,. (G) Op&ningD1ldC~gAIN~PIN() (H) Mau&oJ&",mllllal1ng/'CryplPlal. (I) Mamorial}{ MOO4Ime01 0 (JI installalionCh.ac,..bI M'mo,~um&l11 (K) Othe' Il\ Sallls Tll~ (M) P,ocessingFee (N) InscroplionWork \0) 1<;\aICashP'lce(....1hroO) lTEtoIlZATlON OF THE AMOUNT fiNANCED ! I I'I'-,e"",".. (2.) "'-Cllsl\ClotHt'>PII'f'MII\ B.Tradeln: C. TOlal Down Plyfnenl (2M2.B) "UI'ChaUr'a"'pprovJll !lign&lu~ 13\To\al~\1'2C) 4. PAYMEI'lT. The PURCHASEFl sl\.lll F11he SELLER lot such I1gt'l1$1n accordanoe wtth lh.IoIIr;rM~:::J,:url1J'wn~ THIS AGREEMENT IS ALSO SUBJECT TO THE TERMS AND CONOITIONS ON THE O'Tl-IER SlOE OF TH\S PI\PEA FEDERAL TRI)TH-IN-L.ENDING ACT DISCLOSURES DESCRIFTlON OF MERCHANDISE: o Chllc:khenl~merc/landiHbelngpurdla.sedfo(UHalanothe' --, c.mel.ry'snam. ... MEYOP.~onl.ll\ Manulae1ur.~c..lhnl1+ v......et Do"'"~/frr/C/1 _,m..m,.. GranllIS,z.(:.O (ICJ':11C1 2. B,onzlSlzeJ X IlflU , eomp.nion Granite Mance, 0" . ..iJlJ:L ' .~!: .~.. ~. l~ii .~, . - . .::u..L l~ .~ ,~ ...:LS:- _ s - ,~ . J;;[iiY : I" ,~~' ,~- .~- . , . Individual Granite Marker LETTER STYLE 1-1 a r w.AKER POSITION H.ad Foot I underSland lhllrll will De anadditionalcha'Qllloaddthedal.ollhe dllalhlolhemllmo"alor>ceinMalled "'~oa'ur. INSCRIPTION ANNUAL FtNANCECHARG.E AMOUNT FINANCED totAL OF P,t,VlAENT$ TOTA.l SALE PRIeI PERCENTAGE Th.amounltll.ertdll Theamounllwllll'lllw RATE Thfoollararnounltl1e ThllIOlalOOlll 0' my credil will COllI me. provlded 10 ITIII or on my paklatlellhaWlmlldllaD purc:haM lncIudlng my Thllooslo!myc~ilasa ""'" paym.ntslit ICl'IIIdullld. -" yeartyrate. , " . . . . DlJIIMonlhlybeOlnnlng .. My PAYMENT SCHEDULE W~I 61: Number _ Amounl $ IrregultrP'\'fIlenls ufollows (H aoy): $ on OEUNOUENCY CHARGe: In lIIa _nl any inslMlllmenl 0' tIlis Nole is not paid on or beforel.n (10) Oay$ aller ~ &hall blJcom. du..nd pa)lable. a DELINQUENCY CHARGE oIlI'o1I (5) een15ro'&achdQJlaroleach installmenl 110 unpaid (bul no.....nl 10 8Jl.CIIed S5.00 on any on. ina 1allmllnl)sha.lbecha,gedl/'ldreceiVllclb)'lhePayeo.. PREPAYMENT, III pey oM .arly, I may be enlltlad 10 I relund 01 part 0111\.1 financ. chargll. SeIIlhII contract (\ocumenls 10' aoy addiliOOlll in!onTIIoon aboul nonpaymenl, d.taull, any required re~ment IrIlull beJofllllla 8CI>lIdllllld dille, and prepay- menlpar.aJ1Ies.ndre!unds ~ This oem.lIry is operalinQ as a perpetual ca'l .:.mllety, which ff\ean&l!\atai*p8\O,l11l,.."e IUl'ld 10< its "*,,,_l'iu~ afllablWlllllln conlormll)' wilh Ih& IlMlleOIMi$SiISippi,Pe,pelualce,emeans 10 fT\Clint8in,repel'.andCII'1I1 orlt'leCllmelety. NonCE TOTHE BUYER: DO NOT SIGN THIS CONTRACT BEFOAEYOU'VE AEAO IT OA IT IF CONTAINS BLANK SPACES. YOO AAE ENTlTLEDTO A COPY OFntE COKTRACTYOO SIGN. UNDER THE LAWYOU HAVE THE RIGHT TO PAY OFF IN ADVANCE THE FULL AMOUNT DUE AND UNDER CERTJ.lN COK- OITlONS "''''^< OB1'''''M '" p"p.""'l. REF\JKO OF'\HETlME PRICE OlFFEP;'ENTII\I.. K'EEPTH1S CONTl'lACTTO PROTECT YOUR LEGAL FlIGIiTtl. NOTICE: SEE OTHEA SIDE fOA IMPOATANT INFORMATION. PURCHASER'S RIGHTTO CANCEL: IFTHIS AGREEMENTWAS SOUCITED AT A PLACE OTHERTHANTHE PLACE OF BU$lNESS OF THE SELLER, YOU MAY CANCEL THIS TRANSACTlON AT ANY TtME PRIOR 10 MIONIGHT OF THE THIRD BUSINESS DAY AFTER TIiE DATE OFTHISTRANSACTlON. SEETHE ATTACHEO NOTICE OF CANCEUATION FORM FOR N EXPlANATION OF THIS RIGHT. " 'N WITN'" "EOe. "''EN eoNe ' . ~ ~ / Couns _ 1, PURCHASE 3- 1) 2.PUflCHASER " - -'''J1J,:.:;'~.'1itt!~ /(In~ - City S1a1l ;ljp g.{!!'."7S"7'" (/-f.) .......Z9l-1'1..;f (0) ,,~A~ TIlle' IF BURIAL. RIGHTS CER"FICATE TO BE NAME(S) OntER THAN PURCHASER(S). THEN PROVIDE NAMES<Sj HERE: -. Phone No. Ag'"mentNo OM< 1.EmpIoyar o "N UCOOE 2.Ernp\a1e1 PINK: Conveyance -. W"'HTER~Ofds GREe....: CetMlIry FlIt YEUCM':PurchUer QOlOENFtOO:O\I'II' o~ REV-1512 EX" (1-97)(1) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF HOLLAND, FERDINAND F. FILE NUMBER Include unreimbursed medical expenses ITEM NUMBER 1. 2 3 4 5 6 7 8 9 OESCRIPTION AMOUNT 64,645.97 443.60 690.52 220.54 60.00 B7.00 25.00 225.00 110.00 GMAC MORTGAGE NUMBER 306675727 - DECEDENT'S PORTION ONLY UNREIMBURSED MEDICAL EXPENSES. QUANTUM IMAGING UN REIMBURSED MEDICAL EXPENSES - PULMONARY & CRITICAL CARE UN REIMBURSED MEDICAL EXPENSES . HOLY SPIRIT HOSPITAL UN REIMBURSED MEDICAL EXPENSES - CENTRAL PA MRI CENTER UNREIMBURSED MEDICAL EXPENSES. PA NEUROLOGICAL ASSOCIATES UNREIMBURSED MEDICAL EXPENSES - JOHN G. CALAlTGES, MD UNREIMBURSED MEDICAL EXPENSES. NEUROLOGICAL SURGERY UN REIMBURSED MEDICAL EXPENSES. ANDREWS AND PATEL ASSOCIATES STFPA42021F.13 TOTAL (Also enter on line 10. Recapitulation) S (If more space IS neeced. insert additional sheets of the same size) 66 507.63 ".oj ,,:::-_:(. ;. .. . BORROWER INFORMATION - "--. ---.---"-------- CO-BORROWER INFORMATION -----..------.--.--.,-----.,----,,- GMAC Mortgage Name: FERDINAND F. HOLLAND Acc.Ollnt Number: 306675727 Home Phone #': (717) 975-2056 Work Phone #: (717) 93$-3391 Name: Home Phone 'II: Work Phone #: GLORIA J. HOLLAND (717)975-2056 ~"1Q l 0,<(>',,', \', ~'_ ~" '9] OJ'O'I" I Geo.',' .',j (]O101 OO~9tO"OI.' Vtout., MASOI ONFOLtNC( '",11'",'11""1,1,1'",.11,,1,.1..,11.,,11,,1,1,,,11.\,1,,1 FERDINAND F. HDLLAND GLORIA ~. HOLLAND 5253 MEAOOWBROOK DR MECHANICSBURG PA 17050-6833 h _~ . l~ .{.'.:' l.iLiJ!.. 0(,- .e Lv' U 1> . - ) '" 1;r [15-" . 'I' ", ." ( -: ::.2.. :- / Plea$e verify your mailing address, borrower and co-borrower information Make necessary corrections on this portion of the statement, detach and mail to address listed for Inquiries on the reverse side Account Number 306675727 Details of Amount Due/Paid Principal and Interest Subsidy/Buydcnm Escrow Additional Products/Services Amount Past Due Outstanding late Charges Other Total Amount Due Account Due Date Account Information Current Statement Date March 02. 2001 Original Maturity Date January 01. 2028 Interest Rate 7.625 Current Principal Balance* SI25.291.94 SI.229.44 SI.594.50 SO.OO Current Escrow Balance Interest Paid Year-to-Date Taxes Paid Year-to-Date For questions on the servicing of your account, call 1-800-766-4622, See back for automatic payment sign-up information and express mail address. S915.18 So.oo S235.23 So.oo So.oo So.oo So.oo Sl.150.41 April 01. 2001 ./~/ \ Description Due Date I Tran, Date Transattion Total Interest Escrow Other Mortgage Payment 03/01/01 02/26/01 $1.15041 $11830 $79688 $235 23 Mortgage Ins Pmt 02120/01 $54 45 -$54 45 Mortgage Payment 02101/01 02120/01 $1.15041 $11756 $797.62 $23523 I I "This is your Principal Balance only, not the amount required to pay the loan in full_ " "SmartWatch" is a new personalized service that allows you to select and receive important information regarding your mortgage account, refinance, home equity, and other services. Register today by visiting www_gmacmortgage.com or call us at 1-888-302-4622. -1\ ., " ... ... .. ~ ., ~ ., -, ~ ,-.._" , , ~~ y~~::-: ", C) '; '" ~ It ."" ~ : ./~~>' "" ~ .-i :'J <::- ',\ 'f; " .; - ~~.;~\:-- :~~ ~f; l 1 I " I I I I I I I ;to .:~{ ~~{")..'1 , I ) I ".'. c:; .:~ I I J I I I .. 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N '" o o '" ~ e~ u,,,, 'a:! ..... ='1' ~~ ~ Ii"" - C2 8,g.. of> ~. ~ ~ ~. ~ ~ ~2i ~ ~ @~ N c:CD;. Q 51i31 ~ ~ ~~ ::J ...J iii 1-1- zz W~ :Ea: Wo !::;o.. ~~ en a: o LL W o in w (/) a: w > w a: w w (/) ~ '" 0> HealthAssurance. 2575 Interstate Drive Harrisburg, PA 17110 Explanation of Benefits Page 1 of 1 Payments made on behalf of: HEALTHASSURANCE I~IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII aT HIS IS N T A BILL Insured: Patient: Group Name: 10 Number: Claim Number: Date: Provider: Payee: Holland. Ferd Holland, Ferd DI-CHEM CONCENTRATE INC. 436620216 1107517762 03/22/01 PULMONARY & CRITICAL CARE MEDICAL ASSOCS EVANS DO,RICHARD Holland, Ferd 5253 MEADOWBROOK DR MECHANICSBURG. PA 17050 This is a statement of benefits only. <<you did not already pay 31 the time of service, please contact provider listed above to make payment arrangements. Procedure Date of Service Total Ineligible Amount Amount Code/Description From/To Charge Amount/Code at 100% at 0% 99291 03/02/01 MEDICINE 03/02/01 250 00 38.82 130 0.00 0.00 94657 03/02/01 MEDICINE 03/02/01 135.00 135.00 2006 0.00 0, 00 94657 03/03/01 MEDICINE 03/03/01 135.00 88.33 130 0.00 0.00 Totals: 520.00 :262" 15 0.00 0.00 Amount Amount at 0% at 0% 0.00 0 00 0.00 0 00 0.00 0.00 0.00 0.00 257.85 0,00 0,00 257.85 257.85 127" 15 Covered Amount less Deductible Less CoPay/Coinsuranee Benefit Total Benefit Paid Member Responsibility Description of Remarks/Benefits 130: INELIGIBLE : DOLLAR AMOUNT ABOVE REASONABLE AND CUSTOMARY CHARGE 2006: INCIDENTAL PROCEDURE Grievance Review Process A covered Individual has the right to dispute a denied claim thrt Grievance Review Process. If you wish to appeal a denial deci Customer Service Organization at 1-800-788-6445. Review YOI Document for further details regarding your right to dispute a d U ",) J 1.:: ( . J :' , 0..)0.5j L J ~; I 1 I , 8.:'.. 0 J j + ::::: '7 I ~'.L '1' 'c: I . J !.. , ::::: i' . ~; .l 1 ) 1 . i ~ t "J _, J' ,,"00' 10[) HOCK OM5......' '1l~ lo'~ J . HealthAssurance~ Explanation of Benefits Page 1 of 1 2575 Interstate Drive Harrisburg, PA 17110 Payments made on behalf of: HEAL THASSURANCE I~IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII TH I S IS N'OT A BILL Insured: Patient: Group Name: 10 Number: Claim Number: Date: Provider: Payee: Holland, Ferd Holland. Ferd DI-CHEM CONCENTRATE INC. 436620216 1108104436 03/29/01 PULMONARY & CRITICAL CARE MEDICAL A5S0CS EVANS DO,RICHARD Holland. Ferd 5253 MEADOWBROOK DR MECHANICSBURG, PA 17050 This is a statement of benefits only. If you did not already pay at the time of service, please contact provider listed above to make payment arrangements. Procedure Date of Service Total Ineligible Amount Amount Amount Code/Description From/To Charge Amount/Code at 100% at 0% at 0% 94657 03/04/01 MEDICINE 03/04/01 135.00 88 .33 130 0.00 0.00 0.00 Totals: 135.00 88 .33 0.00 0.00 0.00 Amount at 0% 0.00 0.00 Covered Amount Less Deductible Less CoPay/Coinsurance Benefit Total Benefit Paid Member Responsibility 46.67 0.00 0.00 46.67 46.67 88.33 Description of Remarks/Benefits 130: INELIGIBLE : DOLLAR AMOUNT ABOVE REASONABLE AND CUSTOMARY CHARGE Grievance Review Process A covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to appeal a denial decision, contact the Customer Service Organization at 1-800-788-8445. Review your Health Benefit Plan Document for further details regarding your right to dispute a denied claim. "00\ ~1~ "OC~ONlSMPl" 4398 5014 HealthAssurance~ 2575 Interstate Drive Harrisburg, PA 17110 Explanation of Benefits Page 1 of 1 Payments made on behalf of: HEALTHASSURANCE IIIIIIIIIIII~III~IIIIIIIIIIIIIIII oTH I S IS N T A BILL Insured: Patient: Group Name: 10 Number: Claim Number: Date: Provider: Payee: Holland, Ferd Holland. Ferd DI~CHEM CONCENTRATE INC. 436620216 1107517761 03/22/01 PULMONARY & CRITICAL CARE MEDICAL ASSQCS EVANS DD,RICHARD Holland, Ferd 5253 MEADOWBROOK DR MECHANICSBURG. PA 17050 This is a statement of benefits only. ff you did not already pay at the time of servics, please contact provider listed above to make payment arrangements. Procedure Date of Service Total Ineligible Amount Code/Description From/To Charge Amount/Code at 100% 99291 03/05/01 MEDICINE 03/05/01 250.00 38.82 130 0.00 99233 03/06/01 MEDICINE 03/08/01 375.00 130.53 ,30 0.00 99291 03/09/01 MEDICINE 03/09/01 250.00 38.82 130 0.00 Totals: 875.00 208. 17 0.00 Amount Amount Amount at 0% at 0% at 0% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 666.83 0.00 0.00 666.83 666.83 208 , 17 Covered Amount Less Deductible Less Co?ay /Coinsurance Benefit Total8enefit Paid Member Responsibility Description of Remarks/Benefits 130: INELIGIBLE : DOLLAR AMOUNT ABOVE REASONABLE AND CUSTOMARY CHARGE Grievance Review Process A covered Individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to appeal a denial decision, contact the Customer Service Organization at 1-800-788-8445. Review your Health Benefit Plan Document for further details regarding your right to dispute a denied claim. 1'<00' ""OHOC".ONlS"PL>< &l6S 100' J n'__'"- HealthAssurance~ 2575 Interstate Drive Harrisburg, PA 17110 Explanation of Benefits Page , of 1 Payments made on behalf of: HEAL THASSURANCE 111m 11111 11111 11111 111l1li11 1111 TH I S IS NOT A BILL Insured: Patient: Group Name: 10 Number: Claim Number: Date: Provider: Payee: Holland, Ferd Holland, Ferd OI-CHEM CONCENTRATE INC. 436620216 1107517760 03/22/01 PULMONARY & CRITICAL CARE MEDICAL ASSQCS MYERS MD,FRANKLIN Holland. Ferd 5253 MEADOWBROOK DR MECHANICSBURG. PA 17050 This is a statement of benefits only. If you did not already pay at the time of service, please contact provider listed above to make payment arrangements. Procedure Date of Service Total Ineligible Amount Amount Amount Code/Description From/To Charge Amount/Code at 100% at 0% at 0% 99291 03/10/01 MEDICINE 03/10/01 250.00 38.82 130 0.00 0.00 0.00 99233 03/11/01 MEDICINE 03/11/01 125.00 43.5i 130 0.00 0.00 0.00 Totals: 375.00 82.33 0.00 0.00 0.00 Amount at 0% 0.00 0.00 0.00 Covered Amount Less Deductible Less CoPay/Coinsurance Benefit Total Benefit Paid Member Responsibility 292.67 0.00 0.00 292.67 292.67 82.33 Description of Remarks/Benefits 130: INELIGIBLE : DOLLAR AMOUNT ABOVE REASONABLE AND CUSTOMARY CHARGE Grievance Review Process A covered Individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to appeal a denial decision, contact the Customer Service Organization at 1-800-788-8445. Review your Health Benefit Plan Document for further details regarding your right to dispute a denied claim. ..00' _rvoc...O"l-SMPlX ".~ 1001 J un.h. HealthAssuranceo 2575 Interstate Drive Harrisburg, PA 17110 Explanation of Benefits Page 1 of 1 Payments made on behalf of: HEAL THASSURANCE 11111111111111111111111111111111111 oTHIS BIS L N TAIL Insured: Patient: Group Name: 10 Number: Claim Number: Date: Provider: Payee: Holland, Ferd Holland, Ferd OI-CHEM CONCENTRATE INC. 436620216 1107818405 03/27/01 PULMONARY & CRITICAL CARE MEDICAL ASSOCS EVANS DO,RICHARD Holland, Ferd 5253 MEADOWBROOK DR MECHANICSBURG, PA 17050 This is a statemant of benefits only. If you did not already pay at the time of service, please contact provider listed above to make payment arrangements. Procedure Date of Service Total 'neligible Amount Amount Amount Code/Description From/To Charge Amount/Code at 100% at 0% at 0% 99232 03/12/01 MEDICINE 03/12/01 B5.00 27.61 130 0.00 0.00 0.00 Totals: B5.00 27.61 0.00 0.00 0.00 Amount at 0% 0.00 0.00 Covered Amount Less Deductible Less Copav/Coinsurance Benefit Total Benefit Paid Member Responsibility 57.39 0.00 0.00 57.39 57.39 27.61 Description of Remarks/Benefits 130: INELIGIBLE : DOLLAR AMOUNT ABOVE REASONABLE AND CUSTOMARY CHARGE Grievance Review Process A covered Individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to appeal a denial decision, contact the Customer Service Organization at 1-800-788-8445. Review your Health Benefit Plan Document for further details regarding your right to dispute a denied claim. NG<l\ ~1'" MOt.tl,OIG.!ihlll'l..>< $In .143 2 U___n_ HealthAssurance~ 2575 Interstate Drive Harrisburg, PA 17110 Explanation of Benefits Page 1 of 1 Payments made on behalf of: HEAL THASSURANCE IIIII~I~R N6~1~ ~~LL Insured: Patient: Group Name' 10 Number: Claim Number; Date: Provider: Payee: Holland, Ferd Holland, Ferd DI-CHEM CONCENTRATE INC. 436620216 1107818406 03/27/01 PULMONARY & CRITICAL CARE MEDICAL ASSOCS MYERS MD,FRANKLIN Holland. Ferd 5253 MEADQWBROOK DR MECHANICSBURG, PA 17050 This is a statement of benefits only. If you did not already pay at the time of service, please contact provider listed above to make payment arrangements. Procedure Date of Service Total Ineligible Amount Amount Amount Code/Description From/To Charge Amount/Code at 100% at 0% at 0% 99232 03/13/01 MEDICINE 03/'3/01 B5.00 27.61 130 0.00 0.00 0.00 Totals: B5.00 27.61 0.00 0.00 0.00 Amount at 0% 0.00 0.00 Covered Amount Less Deductible Less CoPay/Coinsurance Benefit Total Benefit Paid Member Responsibility 57.39 0.00 0.00 57.39 57.39 27.61 Description of Remarks/Benefits 130: INELIGIBLE : DOLLAR AMOUNT ASOVE REASONABLE AND CUSTOMARY CHARGE Grievance Review Process A covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to appeal a denial decision, contact the Customer Service Organization at 1-800-788-8445. Review your Health Benefit Plan Document for further details regarding your right to dispute a denIed claim. ,"001 '1~ NOCr..OHlS"'PlX 1177 6764 2_.__"____ HealthAssu ranee" Explanation of Benefits Page 1 of 1 2515 Interstate Drive Harrisburg, PA 17110 Payments made on behalf of: HEAL THASSURANCE mIIIIUIIIII~II"illlllllllllll T HIS IS NOT A BILL Insured: Patient: Group Name: to Number: Claim Number: Date: Provider: Payee: Holland. Ferd Holland. Ferd DI-CHEM CONCENTRATE INC. 436620216 1108104624 03/29/01 PULMONARY & CRITICAL CARE MEDICAL ASSOCS GILROY MD,ROBERT Holland, Ferd 5253 MEADOWBROOK DR MECHANICSBURG. PA 17050 This is a statement of benefits only. H you did not already pay at the time of service, please contact provider listed above to make payment arrangements. flrneedure Date of Service Total Ineligible Amount Amount Code/Description From/To Charge Amount/Code at 100% at 0% 99232 03/14/01 MEDICINE 03/14/01 85.00 27.61 130 0.00 O. 00 Totals: 85.00 27.61 0.00 O. 00 Amount at 0% Amount at 0% o 00 0.00 o 00 0.00 Covered Amount Less Deductible Less CoPay/Coinsurance Benefit Total Benefit Paid Member Responsibility 57.39 0.00 0.00 57.39 57.39 27.61 Description of Remarks/Benefits 130: INELIGIBLE DOLLAR AMOUNT ABOVE REASONABLE AND CUSTOMARY CHARGE Grievance Review Process A covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to appeal a denial decision, contact the Customer Service Organization at 1-800-788-8445. Review your Health Benefit Plan Document for further details regarding your right to dispute a denied claim. NOO' S<l2ti NOCK ONLS"~l->< usa ~02~ 2 ... HealthAssurance~ Explanation of Benefits Page 1 of 1 2575 Interstate Drive Harrisburg, PA 17110 Payments made on behalf of: HEALTHASSURANCE 1IIIIIIIIIIIIIIIIIIIIIIIIIImllll oTH I S IS N T A BILL Insured: Patient: Group Name: ID Number: Claim Number: Date: Provider: Payee: Hal land, Ferd Holland, Ferd DI-CHEM CONCENTRATE INC. 436620216 1106822885 04/10/01 PULMONARY & CRITICAL CARE MEDICAL ASSOCS EVANS DO.RICHARD Holland, Ferd 5253 MEADOWBROOK DR MECHANICSBURG, PA 17050 This is a statement of benefits only. If you did not already pay at the time of service, please contact provider listed above to make payment arrangements. Procedure Date of Service Total Ineligible Amount Amount Amount Code/Description From/To Charge Amount/Code at 100% at 0% at 0% 99291 03/01/01 MEDICINE 03/01/01 250.00 38.82 130 0.00 0.00 0.00 31500 03/01/01 SURGERY 03/01/01 150.00 150.00 2006 0.00 0.00 0.00 36489 03/01/01 SURGERY 03/01/01 144.00 62.89 130 0.00 0.00 0.00 Totals: 544.00 251. 71 0.00 0.00 0.00 Amount at 0% 0.00 0.00 0.00 0.00 Covered Amount Less Deductible Less CoPay /Coinsurance Benefit Total Benefit Paid Member Responsibility 292.29 0.00 0.00 292.29 292.29 101.71 Description of Remarks/Benefits 130: INELIGIBLE : DOLLAR AMOUNT ABOVE REASONABLE AND CUSTOMARY CHARGE 2006: INCIDENTAL PROCEDURE Grievance Review Process A covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to appeal a denial decision, contact the Customer Service Organization at 1-800-788-8445. Review your Health Benefit Plan Document for further details regarding your right to dispute a denied claim. NOCl "Q6 Noco;ON,S"'~'.~ Ml1 'IC>S Healt;lAssurance" .. . ~. 2575 Interstate Drive Harrisburg, PA 17110 Explanation of Benefits Payments made on behalf of: HEAL THASSURANCE II1111I111111111111111111111111111I THIS IS NOT A BILL Insured: Patient: Group Name: 10 Number: Claim Number: Date: Provider: Payee: Holland. Ferd 5253 MEADOWBROOK DR MECHANICSBURG, PA 17050 Prooedure Date of Service Code/Description From/To U'20 02/19/0' HOSPITAL INP^TIENT 02/27/01 U200 02/27/0' HOSPITAL INPATIENT 03/14/01 U250 02/'9/0' PRESCRIPTIONS 03/'4/0' U258 02/'9/0' INJECT-THERAPUT/OIAG 03/'4/0' U259 02/'9/0' PRESCRIPTIONS 03/'4/01 U270 02/19/0' HOSPITAL OUTPATIENT 03/'4/01 U272 02/19/0' HOSPITAL OUTPATIENT 03/'4/01 U300 02/19/0' LA8/PATHOLOGY 03/ '4/01 U320 02/'9/0' RAOIOLOGY 03/'4/0' U352 02/19/0' CAT SCAN 03/'4/0' U384 02/19/0' HOSPITAL OUTPATIENT 03/'4/01 U387 02/'9/0' HOSPITAL OUTPATIENT 03/'4/01 U390 02/'9/0' HOSPITAL OUTPATIENT 03/'4/0' U391 02/'9/01 HOSPITAL OUTPATIENT 03/14/0' U402 02/'9/01 RAOIOLOGY 03/14/0' U4'O 02/'9/01 MEOICINE 03/14/0' U460 02/'9/01 MEOICINE 03/14/0' U480 02/'9/01 CAROlO STUOIES 03/14/0' U636 02/'9/01 INJECT-THERAPUT/OIAG 03/'4/0' U730 02/'9/01 CAROIO STUOIES 03/'4/0' U740 02/'9/0' MEOICINE 03/'4/0' U801 02/19/0' OIALYSIS 03/14/0' U92' 02/19/01 LA8/PA THO LOGY 03/14/01 U997 02/19/01 HOSPITAL OUTPATIENT 03/14/0' U999 02/'9/01 HOSPITAL OUTPATIENT 03/14/0' Holland, Ferd Holland. Ferd DI-CHEM CONCENTRATE INC. 436620216 24116643 04/30/01 HOLY SPIRIT HOSP HOLY SPIRIT HOSP Page 1 of 2 This is a statement of benefits only. If you did not already pay at the time of service, please contact provider listed above to make payment arrangements. Total Charge Ineligible Amount/Code 3,640.00 -5, 160.00 ~84 14,700.00 -4,800.00 184 96.00 96.00 115 1.345. 14 1 ,345. 14 115 31,225.82 3',225.82 115 11 ,976. 13 11,976. 13 115 1,252.75 1,252.75 115 9,986.00 9,986.00 115 2,863.00 2,863.00 "5 905.00 905.00 115 6,164.00 6,164.00 115 738.72 738.72 115 184.00 184.00 115 1,826.00 1,826.00 "5 752.00 752.00 1'5 10,687.00 10,687.00 115 566.00 566.00 115 310.00 310.00 115 5,653.18 5,653.18 115 225.00 225.00 "5 307.00 307.00 115 2,990.00 2,990.00 115 136.00 '36.00 115 10.50 10.50 115 Totals: 108,544.74 80,244.74 5.50 5.50 412 ,"00111Jll"'OnO""-OUPlX ~J 23 Amount at 100% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 <l.00 Amount at 0% o 00 o 00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Amount at 0% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Amount at 0% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Page2of2 ~ .~ Explanation of Benefits (continued) Procedure Code/Description Date of Service Total Ineligible From/To Charge Amount/Code Covered Amount Less Deductible Less CoPay jGoinsurance Benefit Total Benefit Paid Member Responsibility Amount at 100% Amount at 0% Amount Amount at 0% at 0% 28,300.00 0.00 100.00 28.200.00 28,200.00 105.50 Description of Remarks/Benefits 115: APPROVED - AMOUNT INCLUDED IN CONTRACTUAL ALLOWANCE 184: INELIGIBLE - AMOUNT ABOVE DEFINED PAY AMOUNT 412: INELIGIBLE - SERVICES OR SUPPLIES ARE NOT ELIGIBLE IN YOUR PLAN Grievance Review Process A covered individual has the right to dispute a denied claim through the Complaint and Grievance Review Process. If you wish to appeal a denial decision. contact the Customer Service Organization at 1-800-788-8445. Review your Health Benefit Plan Document for further details regarding your right to dispute a denied claim. J'J) 1 ) :.J . .j j ,: t 115')t + c. ~ j ':.Jr ;,.: HeaJtbf.ssurance. 2575 Interstate Drive Harrisburg, PA 17110 11111111111111111111111111111111111 oTH I S IS N T A BILL Holland, Ferd 5253 MEADOWBROOK DR MECHANICSBURG, PA 17050 Procedure Code/Description U164 HOSPITAL INPATIENT Date of Service From/To 01/30/01 02/02/01 U258 01/30/01 INJECT-THERAPUT/DIAG 02/02/01 U259 PRESCRIPTIDNS U270 HOSPITAL OUTPATIENT U272 HOSPITAL OUTPATIENT U300 LAB/PATHOLOGY uno RADIOLOGY U384 HOSPITAL OUTPATIENT U391 HOSPITAL OUTPATIENT U450 HOSPITAL OUTPATIENT U921 LAB/PATHOLOGY U9g3 HOSPITAL OUTPATIENT U994 HOSPITAL OUTPATIENT U997 HOSPITAL OUTPATIENT U999 HOSPITAL OUTPATIENT 01/30/01 02/02/01 01/30/01 02/02/01 01/30/01 02/02/01 01/30/01 02/02/01 01/30/01 02/02/01 01/30/01 02/02/01 01/30/01 02/02/01 01/30/01 02/02/01 01/30/01 02/02/01 01/30/01 02/02/01 01/30/01 02/02/01 01/30/01 02/02/01 01/30/01 02/02/01 Totals: Description of Remarks/Benefits Total Charge Explanation of Benefits Page 1 of 2 Payments made on behalf of: HEAL THASSURANCE Insured: Patient: Group Name: 10 Number: Claim Number: Date: Provider: Payee: Holland, Ferd Hal land, Ferd DI-CHEM CONCENTRATE INC. 436620216 1104626866 04/05/01 HOLY SPIRIT HaSP HOLY SPIRIT HaSP This is a statement of benefits only. If you did not already pay at the time of service, please contact provider listed above to make payment arrangements. Ineligible Amount/Code 1,515.00 -1,190.00 184 505.00 867 395.82 1,727.90 472.16 13.50 857.00 195.00 552.00 332.00 711. 25 136.00 3.18 6.36 10.50 5.50 1,727.90 395.82 115 115 472.16 13.50 857.00 195.00 552.00 332.00 711.25 136.00 10.50 6,933.17 4,733.17 Covered Amount Less Deductible Less CoPay/Coinsuranee Benefit Total Benefit Paid Member Responsibility 115 115 115 115 115 115 115 115 3.1B 412 Amount at 100% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 115: APPROVED - AMOUNT INCLUDED IN CONTRACTUAL ALLOWANCE 184, INELIGIBLE - AMOUNT ABOVE DEFINED PAY AMOUNT 412, INELIGIBLE - SERVICES OR SUPPLIES ARE NOT ELIGIBLE IN YOUR PLAN 867: INELIGIBLE DAYS NOT AUTHORIZED, MEMBER NOT RESPONSIBLE "00' 484'..OCKO'"!.O.....'X J. 1. 6.36 412 115 5.50 412 Amount at 0% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Amount at 0% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Amount at 0% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 ..0.00 0.00 0.00 0.00 2,200.00 0.00 100,00 2,100.00 2,100,00 115,04 ~- - -..', i': ,',.f::.-,.~ !!,........ ~:;S~:I.:; ~ : ~\.\;,/.' 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C/la: o u. w c in w III a: w > w a: w w III ;; N oj fJ Z N M M ~ .~ Questions? -~---,-- CLAIMS CUSTOMER SERVICE 952-546-0062 600-925-2272 24 HOUR AUTOMATED CLAIM INFO 952.593.6560 600-566-9311 Corporate Benefit Sen-ices of America 10159 Wayzata Boulevard Minnelonka, MN 55305-1503 20010~QlOOO2 [ Address Sen'ice Requested Claim No.:LC73327 Participant:FERD HOLLAND ID No:436620216.1 Address:5253 MEADOWBROOK DR MECHANICSBURG PA 17055 Patienl:FERD HOLLAND Patient Acct#:29141 Employer:DI CHEM INC Group No:10480.002 Processed On:04-30-01 By:KLV Benefit Year:2000 Claim Type:Medical Provider:PA NEUROLOGICAL ASSOC LTD 108 LOWTHER ST LEMOYNE PA 17043-2012 MIXED AADC 17D 40167 0.5824 AS 0.278 1...111..,111",.1,\,11""11..\"\,..\\",\\,,\,\,,,11,1,\,,I FERD HOLLAND 177 5253 MEADOWBROOK DR MECHANICSSURG, PA 17050-6833 Provider TIN:232441989 EXPLANATION OF BENEFITS - THIS IS NOT A BILL -. ..------,---... ---- ----, f"r~;;e';:u:e I Oate.is!Of I I Service I 99232 NOT ELlG 12-02-00 f()l)O\i-lt'll ~~ ~- r;~ ~ 0.00 0.00 - pr;~~:-T -;~eligiDle-I~~;;r--;:;~-----TI' --;~~,;~~-'-f6e~ r-ot;';r-- 'r--P~y;~;--.--l-pa~i;~~--1 Discount Amount I To Oed. To Copay I % Payment By Plan ; Responsibility Toldl Charges 87.00 87.00 87.00' 87.00 Accumulators Individual Deductible Family Deductible Payment To: Check Date Check No. 250.00 of 250 QQ 500.00 of 500.00 Notes a. __,=-xplanation ______ __~ Expenses are ineligible if incurred after the date coverage terminates. 12"()1-00 This submission supercedes any previous processing of these charges. Adjustment on previous claim, submission: l329119 Patient responsibility is the amount, if any. owed your provider. This may include amounts already paid to your provider at the time of service. You have the right to appeal a claim denied in whole or in part by written request within 60 days. To appeal this decision, write to us at CBSA, P.O. Box 27267, Minneapolis, MN 55427-0267. * We are accepting claims electronically through ENVOY/NEIC. Our Payor 10 is 41124. * Amount ~ ~ Corporate Benefit Services of America 10159 Wayzata Boulevard Minnelonka, MN 55305-1503 Address Service Requested MIXED AADC 170 48042 0.3840 AB 0,278 1,,,111,,,111,,,,1,1,11,,,,11,,1,,1,,,11,,,11,,1,1,,,11,1,1,,1 FERD HOLLAND 186 5253 MEADOWBROOK DR MECHANICSBURG, PA 17050-6833 l00I(l~18llOO1 Questions? ~ CLAIMS CUSTOMER SERVICE 952-546.{)062 800-925-2272 24 HOUR AUTOMATED CLAIM INFO 952-593-6560 800-566-9311 r-:. -. Claim No.:LE1 1283 Participant:FERD HOLLAND I 10 No:436620216.1 , Address:5253 MEADOWBROOK DR ! MECHANICSBURG PA 17055 j Patient:FERO HOLLAND I Patient Acct#:H011 FE078878 I Employer:DI CHEM INC 'I Group No:1 0480.002 Processed On:05--17..Q1 BY:LMW Benefit Year:2OOQ Claim Type:Med.ical Pro\fider:JOHN G CALAITGES 800 POPLAR CHURCH ROAD CAMP HILL PA 17011 i Provider TIN:251728668 L ---. ------l- ---- Pro<:edure Dafe(s) Of ServIce Provider Discount EXPLANATION OF BENEFITS - THIS IS NOT A BILL Payment By Plan 99253 liP PHYS 11-29-00 1------. TOlar Charges 125.00 125.00 Accumulators Individual Deductible 250.00 of 250.00 --I - Applied --I-aen r ToCopay . 'h Other Payment Applied To Oed 80, 100.00 100.00 Payment To: JOHN G CALAITGES Check Date 05-17-01 Check No. 1435 Notes Explanation ____~_~___ Patient responsibility is the amount, if any, owed your provider. This may include amounts already paid to your provider at the time of service. You have the right to appeal a claim denied in whole or in part by written request within 60 days. To appeal this decision, write to us at CBSA, P.O. Box 27267, Minneapolis, MN 55427-0267. . We are accepting claims electronically through ENVOY/NEfC. Our Payor ID is 41124. . 1'0000<106 !~ r Wi1l li4Zi I -- -patient --I I RespQnsiblllfY I Amount 100.00 CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT DATE PROVIDER EXPLANATION OF ACTIVITY PATIENT NAME CHARGES PAYMENTS NAME AND DEBITS AND CREDITS 010101 041001 BALANCE FORWARO DENIED INTERGROUP INS PLANe' 1002811 225.00 0,00 ~~ 6~~~ ~ I -U(1 'sTAteMENT CLOSING DATE- CURRENT PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CAL-lING OUR OFFICE :::'Q77 05/01/01 30-00 D~YS 00-90 DAYS INS PENDING TOTAL > 90 OAYS NEW6~~NCE PA'! THIS ~',IOUNT 225.00 0.00 225.00 225,00 SEND INQUIRIES TO: NEUROLOGICAL SURGERY,LTO. 920 CENTURY DRIVE HECHANICSBURG PA 17055 IRS.: 23-1945800 (7171 697-5800 ,. ':i~. r "f-' J~. (';'; .~:~ .. ',)~ ::.:" }~,' ...::,..':{:-};~':. ,:i~-,~\-' ',' ~:".\'~ ~.' ~:f):': ;:{;- ~'_.:;{,-.: ,~~' :'I:~.<: !~:!j~\:~:~'};~:},,~; S:,~;~~'!~~~~~~W~.~'~~ ,~;_:, 'k/:.~i-:~~ '.t\~~'(f<"~ .~;~ ~-,'~ ~:/.\, ;::;:'ft:~;,.:,,~:..r~r>;:;~ ~<.:\.:~ ~~*- ~ ... . , , . ~ ~ Questions? l CLAIMS CUSTOMER SERVICE 952-546..0062 800-925-2272 24 HOUR AUTOMATED CLAIM INFO 952-593-6560 800-566-9311 CoqlOrate Benefit Sen'ices of America 10 159 Wayzala Boulevard Minnctonka, MN 55305.1503 2001 O~Oluo01 Address Service Requested Claim NO.:LC73375 Participant:FERD HOLLAND ID No:43602Q216-1 Address:5253 MEADOWBROOK DR MECHANICSBURG PA 17055 Patient:FERD HOLLAND Patient Acct#:141430 Employer:DI CHEM INC Group NO:l0480002 Processed On:04.30-01 By:KLV Benefit Year:2000 Claim Type:Medlca! Provider:ANDREWS & PATEL ASSOCIATE 3912 TRINDLE RD MIXED AADC 170 40167 0.5824 AB 0.278 1,..111,..111""\,1,11""11..1,,1,..11,,,11,,1,1,,,11,1,1,,1 FERD HOLLAND 177 5253 MEADOWBROOK DR MECHANICSBURG, PA 17050-6833 ,: " . .,';'i:;~: '.""{l';~.h --~ .:.".. ~ ..,.-..... . -,- .~' ~/ .,;Yi~:.~ -::\ -~ fu,HJ<J-liJ(, ~~ -.. ~ r-:~ ~ , , l~Xl\M\I\'lIl\)~ Questions? [CLAIMS CUSTOMER SERVICE 952-546-{)062 800-925-2272 24 HOUR AUTOMATED CLAIM INFO 952-593~560 800-566-9311 f('"OM"~ (eJj] ~ Corporate Benefit Sen' ices of America 10159 Wayzata Boulevard Minnctonka, MN 55305-1503 <. 60 -" 6 r:.:~ ~ MIXED AADC 170 Claim NO.:LC73375 Participant:FERD HOLLAND ID No:436620216-1 Address:5253 MEADOWBROOK DR MECHANICSBURG PA 17055 Patienl:FERD HOLLAND pattent Acct#:141430 Employer:DI CHEM INC Group NO:l0480002 Processed On: 04-30-01 BY:KL V Benefit Year:2000 Cialm Type:Medicat Provider:ANDREWS & PATEL ASSOCIATE 3912 TRINDLE RD CAMP HIL PA 17011 Address Service Requested ~D167 0.5824 AB 0.278 1",111",111,,,,1,1,11,,,,11,,1,,1,,,11,,,11,,1,1,,,11,1,1..I FERD HOLLAND 177 5253 MEADOWBROOK DR MECHANICSBURG, PA 17050-6833 EXPLANA liON OF BENEFITS . THIS IS NOT A BILL Provider TIN:232382727 I----p;~~~u~;-I---O:~~~~~--~--.------=:~~s - -r~-~::i~~~---ll~~~~~\,e -.) N~~~;i-~- ~~~~d- -1" --::~~;~~-I-B; -1-:~~~1~7~~t --I ReS:~%~~~llltY 99239 NOT ELlG 112-02-00 110.00 110.00 110.00 110.00 a 000 I 110.00' .___.~0Qj__._11.00o., 250.00 of 250.00 500.00 of 50000 Payment To: Check Date Check No. Amount Accumulators individual Deductible Family Deductible Notes a. Explanation _ Expenses are ineligible if incurred after the date coverage terminates. 12-01-00 This submission supercedes any previous processing of these charges Adjustment on previous claim, submission: L281269 Patient responsibility is the amount, if any, owed your provider. This may include amounts already paid to your provider at the time of service. You have the right to appeal a claim denied in whole or in part by writien request within 60 days. To appeal this decision, write to us at CaSA, P.O. Box 27267, Minneapolis, MN 55427-0267. . We are accepting claims electronically through ENVOYfNEIC, Our Payor ID is 41124. . . " REV.1513 EX" (g-OO) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDEHi SCHEDULE J BENEFICIARIES ESTATE OF HOLLAND FERDINAND F FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trust,,(sl OF ESTATE I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)J 1. GLORIAJ. HOLLAND ITIN: 430-64-9677 5020A WAYNELAND DRIVE JACKSON, MS 39211 SPOUSE 358,489.17 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 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 neeced, Insert additional sheets of the same size) SlFPA42021F,14 11' .. . . .a , REV.1514 EX'" (1.97) (I) COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN (Check Box 4 on Rev.1500 Cover Sheet) ESTATE OF FILE NUMBER HOLLAND, FERDINAND F. This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5.1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5-1-89. Indicate the type of instrument which created the future interest below and attach a copy to the tax relurn. DWiII Dlntervivos Deed ofTrust o Other LIFE ESTATE INTEREST CALCULATION NAME(S) OF NEAREST AGE AT TERM OF YEARS LIFE ESTATE IS LIFE TENANT(S) DATE OF BIRTH DATE OF DEATH PAYABLE o Life or 0 Term of Yeers o Life or 0 Term of Yeers o Life or OTerm ofYeers o Life or OTermofYeers 1. Value of fund from which life estate is payable 2. Actuarial factor per appropriate table Interest table rate - 03 1/2% 06% 010% 3. Value of life estate (Line 1 multiplied by Line 2) ANNUITY INTEREST CALCULATION $ o Variable Rate % $ NAME(S) OF NEAREST AGE AT TERM OF YEARS ANNUITANT(S) DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE o Life or OTerm of Yeers o Life or OTerm of Years o Life or 0 Term of Years o Life or OTerm ofYeers 1. Value of fund from which annuity is payable $ 2. Check appropriate block below and enter corresponding (number) Frequency of payout- o Weekly (52) OB~weekly(26) o Monthly (12) o Quarterly (4) 0 Semi-annually (2) o Annually (1) o Other ( ) 3. Amount of payout per period $ 4. Aggregate annual payment, Line 2 multipiied by Line 3 5. Annuity Factor (see instructions) Interest table rate 03 1/2% 06% 0 10% 0 Variable Rate % 6. Adjustment Factor (see instructions) 7. Value of annuity .If using 3 1/2%, 6%, 10%, or if variable rate and periOd payout is at end of period. calculation is: Line 4 x Line 5 x Line 6 $ If using variabie rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 $ NOTE: The values of the funds which create the above future interests must be reported as pari of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13, 15.16 and 17. (If more space is needed, insert additional sheets of the same size) STFPA42021F15 REV.1647 EX + (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE M FUTURE INTEREST COMPROMISE (Check Box 4a on Rev.1500 Cover Sheet) " . I . FILE NUMBER ESTATE OF HOLLAND, FERDINAND F. This schedule is appropriate only for estates of decedents dying after December 12,1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and atlach a copy to the tax return. o Will o Trust o Other I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. 5. n. For decedents d0ng on or after July 1.1994, if a sur,,;-.1ng spouse exercised or intends to exercise a right of withdrawal within g months of the decedent's death. check the appropriate block and attach a copy of the document in which the sur,,;-.1ng spouse exercises such withdrawal right. 0 Unlimited right of withdrawal 0 Limited right of withdrawal m. Explanation of Compromise Offer: IV. Summary of Compromise Offer: 1. Amount of Future Interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................... .....,........... $ 2. Vaiue of line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on line 13 of Cover Sheet) ......... $ 3. Value of line 1 passing to spouse at appropriate tax rate Check One 06%, 03%, 00% ................ ........ $ (also include as part of total shown on line 15 of Cover Sheet) 4. Value of line 1 taxable at lineal rate Check One 06%. 04.5%. . . . . . . . . ......... $ (also include as part of total shown on line 16 of Cover Sheet) 5. Value of line 1 Taxable at sibling rate (12%) (also include as part of total shown on line 17 of Cover Sheet) .... $ 6. Value of line 1 Taxable at collaterai rate (15%) (also include as part of total shown on line 18 of Cover Sheet) . .... $ 7. Total value of Future Interest (sum of lines 2 thru 6 must equal line 1) . . .... ............... $ STFPA42021F.16 (If more space is needed. insert additional sheets of the same size) REV-1649 EX ... (1-97) (ll COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 0 ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) ESTATE OF FILE NUMBER HOLLAND, FERDINAND F. Do not complete this schedule unte.. the estate is making the election to tax assets under Section 9113 (A) of the Inheritance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate fonm must be filed for each trust This election applies to the Trus\ (mantal, residual A, B, By-pass, Unified Credit, elc.). If a trust or similar arrangement meets the requirements of Section 9113 (A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator 01 this fraction is equal to the amount of the trusl or similar arrangement included as a taxable asset on Schedule O. The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 9113 (A) trust or similar arrangement. DESCRlPT10N VALLE Part A Total $ PART B: Enter the description and value of all interests included in Part A for which the Section 9113 (A) election to tax is being made. DESCRIPTION VALLE Part B Total $ (If more space is neeoed, rnsert additional sheets of the seme size) STFPA42021F,17