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Home My WebLink About06-23-05 ... T REV-1500 EX + (6-00) CAPB HpRL EplO CRAC KOTK ES C P o 0 R N R D E E S N T C o M P T U A T X A T I o N REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER D E C E D E N T COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG. PA 17128-0601 DECEDENT'S NAME (LAST. FIRST. AND MIDDLE INITIAL) Heise DOll las A. DATE OF DEATH (MM-DD-YEAR) COUNTY CODE SOCIAL SECURITY NUMBER OFFICIAL USE ONL Y 21-05-00085 YEAR NUMBER DATE OF BIRTH (MM-DD- YEAR) 165-46-8586 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE 01 16/2005 09/25/1954 OF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) REGISTER OF WILLS SOCIAL SECURITY NUMBER X 1. Original Return 4. Limited Estate X 6. Decedent Died Testate 2. Supplemental Return 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach copy of Will) (Attach copy of Trust) D 9. Litigation Proceeds Received D 10. Spousal Poverty Credit D 3. (date of death . Remainder Return prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (date of death between 12-31-91 and 1-1-95) (Attach Sch 0) THIS.SECl'l()N~ijS'TeaCOMP~El'EOlj.~~'C::()FlFlESPO"QE"CE'B."CQ;nFIQaN"tIAJ..TAXINFdFlMAT'ONSHc)l.Jt.O.ge.DIRECTED TO: NAME COMPLETE MAILING ADDRESS DOll 1as G. Miller Es . FIRM NAME (If Applicable) IRWIN & McKNIGHT TELEPHONE NUMBER 60 West Pomfret Street West Pomfret Professional Bldg. Carlisle, PA 17013 R E C A P I T U L A T I o N 717 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent. Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (1) (2) (3) 225,000.00 None None (4) (5) None 32,495.69 (6) None 24,529.14 63,111.41 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate. or transfers under Sec. 9116(a)(1,2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due 20. 0.00 169,855.14 0.00 0.00 x X X X ,0 0 .0 45 ,12 .15 VJ;RMvMSN'f< VERSE SIDE AND TO RECHECK MATH < < :'!HERE!if:,),PI;.I!A~~J1tIaQVE$tjijg!:A:!~~f~. '>> >. aESURE TO ANSWER ALL QUESTIQNS Copyright (c12000 form software only The Lackner Group. Inc. OFFICIAL USE ONLY c..) -0- (8) 257,495.69 (11) 87.640.55 (12) 169,855.14 ( 13) (14) 169,855.14 (15) (16) (17) (18) (19) 0.00 7,643.48 0.00 0.00 7,643.48 Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: STREET ADDRESS 120 Boyer Road CITY I STATE I ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 7,643.48 0.00 6,500.00 382.17 Total Credits ( A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty 6,882.17 Total Interest/Penalty ( D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (SA) B. Enter the total of Line S + SA. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WillS, AGENT ....... -. "'." '. '. '. -. -. -. '. 0.00 0.00 761. 31 0.00 761.31 ,':;::::::: :" :~;~fn~! i i HHj 1 ~ :,::'::.:'.:..;....-'.... .::i~1l1j!WI!!!!j!!!!r!!!!jJljl!!!!I!!!!r!!!!i!!!!i!!!lil!!!r!!!!i!l!)jllJiWIII!I!!I!!!!i!!i!!iiWI!iW!H!:i!iJIlII!liii!!!::.!;;.;":. ~ AN "X" IN THE APPROPRIATE BLOCKS :.:.:;::.:..:............ :::,,;,:,,:'::;;::;:;:;;;;::;:U!,,::;;:;;:;:;;:;;::;;:ii;,:;::,:;;:,:::::;;::::;:::;;;,;:;:;;:;,;::::;:;;::;;;:;::!:::::i:,;i:';;:;:;:;;;;;;;;;::::;:,;;::;:!:;;;:;:;;:,;:;;,:;;:;:::,;;::: PLEASE ANSWER THE FOllOWING QUESTIONS BY ,.. 1. Did decedent make a transfer and: a. retain the use or income of the property transferred' b. retain the right to designate who shall use the p' c. retain a reversionary Interest; or. . . . . d. receive the promise for life of either pa' 2. If death occurred after December 12, . without receiving adequate consir' 3. Did decedent own an "in trust or her death? . . . . . 4. Did decedent own an In, which contains a beneficia, "1f death ~AA1! ,::m:II:I,::::::m::::::mmlmmmm::m":mmmmmmmmmmmmmw::::,::,:,:::!:: h IR~, 60 w:' --------- Car1h . C / ~t). // " / () /tt\Y6 ~ ~\;)r~\) ce,_______________________ Yes No ~~ o o ~ ~ o [K] IF THE A. YOU MUST COMP. ."", \J// 'W"", ",'- " // .JRN. , Knowledge and belief, it is true. .1 knowledge. DATE ~'!70~ DATE . :'::::: ': :,:, '::,~~ ~ ~: HHU]i~~\ For dates of death on or after July 1, 1994 and before January 1, 1995, the surviving spouse is 3% [72 P.S. 9116 (a) (1.1) (il]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P. S, 9116 (a) (1.1) (iil]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. dte imposed on the net value of transfers to or for the use of the For dates of death on or after July 1. 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent. an adoptive parent, or a stepparent of the child is 0% [72 P.S. 9116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 9116( 12) [72 PS 9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 9116(a)( 1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Copyright (c) 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev 6-00) '\ ... REV -1502 EX + (1-97) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT EST A TE OF FILE NUMBER Douglas A. Heisey ssg 165-46-8586 01/16/2005 21-05-00085 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 VALUE AT DATE DESCRIPTION NUMBER OF DEATH 1 120 Boyer Road, Monroe Township, Pennsylvania - SOLD - Settlement 225,000.00 Sheet Attached TOTAL (Also enter on line 1, Recapitulation) $ 225,000.00 (If more space is needed, insert additional sheets of the same size) Copyright (el 1996 form software only CPSystems,lne. Form REV-1502 EX (Rev. 1-97) ... ... REV-1508 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Douglas A. Heisey SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY SSfI 165-46-8586 01/16/2005 FILE NUMBER 21-05-00085 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jOintly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1 DESCRIPTION Members 1st Federal Credit Union - Savings Account VALUE AT DATE OF DEATH 29,210.63 2 Members 1st Federal Credit Union - Checking Account 167.56 3 Personal Property 3 , 117 . 50 TOTAL (Also enter on line 5, Recapitulation) $ 32,495.69 (If more space is needed, insert additional sheets of the same size) Copyright Ie) 1996 form software only CPSystems, Inc. Form REV-1508 EX (Rev. 1-97) .. .. REV-1510 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Douglas A. Heisey SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY SSif 165-46-8586 01/16/2005 FILE NUMBER 21-05-00085 This schedule must be completed and liled il the answer to any 01 questions 1 through 4 on page 2 is yes. DESCRIPTION OF PROPERTY % OF ITEM RELAW8h~f:{I~ t~b~~~B~U~:rfJf4~lfB~EJF t~X~SFER. DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE NUMBER ATTACH A COpy OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) 1 Fidelity Investments - 517.88 100.00% 517.88 0.00 Individual Account 219-083569 2 Fidelity Investments - 117,238.82 100.00% 118,318.69 0.00 PepsiCo 401(k) 3 Frog Switch Manufacturing - 2,427.89 100.00% 2,427.89 0.00 401(k) TOTAL (Also enter on line 7. Recapitulation) $ 0.00 (II more space is needed, insert additional sheets 01 the same size) Copyright (e) 1996 form software only CPSystems,lne. Form REV-1510 EX IRev. 1.97i .. .. REV-1511 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Douglas A. Heisey Debts of decedent must be reported on Schedule I. ITEM NUMBER A. B. SSif 165-46-8586 FILE NUMBER 21-05-00085 01/16/2005 DESCRIPTION AMOUNT 1 FUNERAL EXPENSES: Malpezzi Funeral Home - Funeral 4,805.76 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) I EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. 3. Attorney's Fees IRWIN & McKNIGHT Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address 12,650.00 City Relationship of Claimant to Decedent State Zip 4. Register of Wills 303.00 Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 350.00 7. 1 Other Administrative Costs Chad Heisey - Help to Prepare 120 Boyer Road for Sale 500.00 2 Closing Costs - For Sale of 120 Boyer Road, Monroe Township, Pennsylvania 2,826.96 3 Cumberland Law Journal - Estate Notice 75.00 4 Dillsburg Excavating & Septic, tnc. - Inspection 462.00 5 Haar's Auction - Auctioneer 1,247.00 6 Michael S. Heisey - Help to Prepare 120 Boyer Road for Sale 500.00 Total of Continuation Schedule(s) 809.42 TOTAL (Also enter on line 9, Recapitulation) $ 24,529.14 (If more space is needed, insert additional sheets of the same size) Copyrightlc) 1996 form software only CPSystems, Inc. Form RE\I-1511 EX IRev. 1-97) .. , Estate of: Douglas A. Heisey Sac See if: 165-46-8586 Date of Death: 01/16/2005 Continuation of Schedule H-B7 (Other Administrative Costs) Item if Description Amount 7 Michael S. Heisey - Reimbursement of Repairs to 120 Boyer Road 70.65 8 Overnight - Mail 41.00 9 Register of Wills - Short Certificates 8.00 10 Restorecore - Bio Clean-Up 500.00 11 Roy D. Gottshall - Appraisal on Personal Property 60.00 12 The Sentinel-Legal - Estate Notice 129.77 809.42 , REV-1512 EX +(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Douglas A. Heisey SCHEDULE I DEBTS OF DECEDENT, MORTGAGE liABiliTIES, AND liENS SS# 165-46-8586 01/16/2005 FILE NUMBER 21-05-00085 Include unreimbursed medical expenses. ITEM NUMBER 1 DESCRIPTION AAA Ins/Agency - Car Insurance AMOUNT 106.80 2 Bank One - Credit Card - 4417 1211 4251 6916 10.00 3 Bank One - Home Equity Loan Payments 2,669.55 4 Bank One - Payoff of Home Equity Loan 59,521. 00 5 Members 1st Federal Credit Union - Visa Credit Card 459.14 6 Met-Ed - Electric 176.21 7 PA Department of Revenue - State Taxes 57.00 8 Sprint - Telephone 52.31 9 Waste Management - Trash 59.40 TOTAL (Also enter on line 10, Recapitulation) $ 63, Ill. 41 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1512 EX lRev. '..97' ~ REV-1513 EX +(9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIAR IES ESTATE OF Douglas A Heisey SSiJ 165-46-8586 01/16/2005 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116(a)(1.2)] 1 Janel Davis 2034 Pine Wood Way Oak Harbor, WA 98277 2 Jay M. Heisey RR3, Box 978 Miff1intown, PA 17059 3 Kristin R. Heisey 1927 Queenswood Drive Apartment F-206 York, PA 17403 4 Louella Heisey 85 Ridgeview Road Hummelstown, PA 17036 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) Daughter Father Daughter Other FILE NUMBER 21-05-00085 AMOUNT OR SHARE OF ESTATE 1/2 Remainder Frog Switch 401(k) 1/2 Remainder Fideli ty 401(k) I ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18. AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON- TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 0.00 TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) Copyright (c) 2000 form software only The Lackner Group, Inc. Form RE"-1513 EX (Rev. 9-00, ... ~ 1 ~ WAy!(g F. SR'l.t>f; Att.,rn~, 'it La... S South H.nover Street :.rli.ta. Pearu,lv.ni. l10H LAST WILL AND TESTAMENT I, DOUGLAS A. HEISEY, of the Township of Middlesex, County of Cumberland, Commonwealth of Pennsylvania, being of sound and dis- ~osing mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void all former wills and codicils by me at any time hereto- fore made. FIRST. I order and direct that all ~y just debts and funeral expenses be paid by my Executor or Executrix, as the case may be, hereinafter named, as soon as conveniently may be done after my decease. SECOND. All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, I give, devise and bequeath unto my wife, LOUELLA M. HEISEY, absolut ly and in fee simple, if she survives me. For the purposes of thi my Last Will and Testament, a person shall not be deemed to have survived me unless he or she shall have survived me by more than ninety (90) days. ---- THIRD. If my wife, LOUELLA M. HEISEY, fails to survive me, then and in that event, I give, devise and bequeath all the said residue of my Estate unto such of my children who shall survive me, absolutely and in fee simple, in equal shares. FOURTH. If my wife, LOUELLA M. HEISEY, and all of my childre should fail to survive me, then and in that event, I order and direct that the said residue of my Estate be divided into two equal shares and distributed, as follows: .. t ~ W-'\'YI'Il!i F. 5H.\1I1': Attorney at La", S S...tb HlUlOYOr Street :arliote, Pe",,"vlva..i. 11013 (a) The first of said shares unto ny mother and father, JAY M. HEISEY and FAYE M. HEISEY, as tenants by the entireties; and (b) The second of said shares unto my father-in?law and my mother-in-law, NELVIN N. ~,fEAVER and VIRGINIA H. WEAVER, as tenants by the entireties. FIFTH. If one of the two shares designated in Item Fourth above should lapse for want of a beneficiary, then and in that event, I order and direct that the said lapsed share be added to the other share under said Item Fourth for ultimate distribution unto the surviving legatee or legatees under said Item Fourth. SIXTE. If my wife, LOUELLA M. HEISEY, should fail to survive me, or at or after my death, be subject to any legal disability whatsoever, then and in that event, I nominate, constitute and appoint FA_~IERS TRUST COMPANY, of Carlisle, Pennsylvania, to serve without bond as the Guardian of any property which shall pass, eit under this my Last Will and Testament or otherwise to a minor or to person who is then subject to any other legal disability whatsoever its discretion to distribute such share to the said minor or perso subject to other legal disability or to another for the benefit of the said minor or person subject to other legal disability. The said Guardian is hereby vested with the power to sell, assign, transfer, pledge, mortgage, lease, manage, control, retain, invest - 2 - \ ,.~ ~.j \\ \)-- 1 ~ WAYK& F. SR'\Ot: Attome" at Law 5 S_th H.1l09<< Street CarlisI". P"....."tv...ia 170l:l and reinvest the corpus or said guardianship in such securities and other property as shall be deemed prudent without being restricted to investments known as legal investments for riduciarie~ under the laws or the CotI1.I:1onvlealth of Pennsylvania. The Guardian shall have the power to ~lanipulate the proceeds of the guardianship in any manner that will guarantee maximum conservation or the guardianship funds and the greatest production of income ror the beneficiaries. I hereby authorize the said Guardian to expend any monies from principal or interest ror the benericiaries that in the sole discretion of the Guardian is deemed necessary ror their care, health, education, maintenance and general welrare; the word "education" shall be construed to mean a pre-college course, high school education, college education and post-graduate education. It is my intention that the foregoing powers may be exercised by the said Guardian without prior Court approval and without further responsibility to the benericiaries, their parents or to any other person or persons taking care or the minor beneficiaries. The age or majority ror all purposes concerning this my Last Will and Testament shall be deemed to be the age of twenty-five (25) years. SEVENTH. Should my wife, LOUELLA M. HEISEY, fail to survive me or at or arter my death, be or become subject to any legal disability whatsoever, then and in that event, I nominate, constituLI and appoint my brother-in-law, ELVIN M. WEAVER and his wire, LOIS WEAVER, as the Co-Guardians or the persons of such or my children who, being minors or subject to any other legal disability whatsoever at the time of my decease, shall survive me. If, ror - 3 - ~\ ~ ~ ~ 'I Q WAYIfE F. SH.\DI( Attont.,,:at La... $ I_tit UIDGyer Street Carll.I., PMln."",anja 1701.3 any reason, it should become impractical for both of said Co-Guardians to act as such, then and in that event, I nominate, consti tute and appoint Ply brother-in-law, ELVIN M. I,YEAVER, to act alone as such Guardian. If, for any reason, either of the said Co-Guardians should fail to qualify as such or cease so to serve, then and in that event, I nominate, constitute and appoint the other to act alone as such Guardian. If, for any reason, both of said Co-Guardians should fail to qualify as such or cease so to serve, then and in that event, I nominate, constitute and appoint my sister-in-law, LORRAINE V. LEININGER, as such Guardian. EIGHTH. In the event that I should, by reason of physical or mental disability, become unable to take part in decisions for my own future, I order and direct that, where there is no reasonable expectation of my recovery from physical disability, I be permittee to die and that I not be kept alive by artificial means. It is my express desire that I not be permitted to suffer the indignities of deterioration, dependence and hopeless pain and that therefore, medication be mercifully administered to me only to alleviate my suffering, even though this may hasten the moment of death. LASTLY. I nominate, constitute and appoin t my "life, LOUELLA M. HEISEY, to be the Executrix of this my Last Will and Testament, but if, for any reason, she should fail to qualify as such Executr'x or cease so to serve, then and in that event, I nominate, constitu e and appoint my brother, MIC~AEL So HEISEY, to be the Executor herecf each to serve without bond. IN WITNESS WHEREOF, I, DOUGLAS A. HEISEY, have hereunto set m - 4 - W.A.nIK F. Sll.\lH; Attom.y at Law ; ~,,\t!h H.."oyer Str..t C Hhilh. PeandJ"t',ani. 11013 .. hand and seal to this, my Last Will and Testament which consists of five (5) typewritten pages to each of which I have affixed my , signature this _ [(~fi~ day of ~~~;I , A.D., One Thousan Nine Hundred Eighty-three (1983). . D~:L t/~' . ~ Douglas A. Heisey ~ (SEAL) The preceding instrument, consisting of this and four (4) other typewritten pages, each identified by the signature of the Testator, was on the date thereof signed, sealed, published and declared by DOUGLAS A. HEISEY, the Testator therein named, as for his Last Will and Testament, in the presence of us, who, at his request, in his presence, and in the presence of each other, have subscribed our names as witnesses hereto. /, i. .r i-I' : / IC./tI't/u.e /;. ~Nt4t.C J ~. il'J ..;. . '", .; l,tJ.::.,..-{~~1 . Z~"l,./ , 7)/ i~i d~ , J - 5 - ",;:iiu;-;;;, ~_ lID' J-\.' ',:~ /r,) 7.r\ .... '.;". ~'<I - :'G ~i' :;; '0" :.,f * = '..' - <~::J!;!J .. ~R~!t :t:~'&OJjNG:J ISO 9001 Certified i ~.. L_) "".5 :'_~ ~/ ;t ~~':'.(;(S~'~: P,A17Ct"i2; -- i? ~7} 243<24:>~ . F,ili. (71-') 243-13135 February 23,2005 Irwin & McKnight West Pomfret Professional Building 60 \Vest Pomfret Street Carlisle, PA 17013 Re: The Estate of Douglas A Heisey Social Security Number: 165-46-85~6 Dear Karen: In response to your letter dated February 14,2005, please find the answers to your questions. 1. The registered owner or owners: Frog Switch and Manufacturing Co. Production and Maintenance Employees 401 k Savings Plan FBO Douglas A Heisey. 2. Date account established is 10/01103. 3. N/a 4. N/a 5. Any interest to date and balance at date of death: I can provide the most current balance he has in the plan, although, since it is a "daily-valued" his account balance will fluctuate daily depending on his investments and, therefore, there is no accrued interest. At the end of the day on Thursday 2/17, his account balance was $2,431.47. His account balance on the date of his death 1/16105 was 52,427.89. I am enclosing a enrollment ~)rm for Jay M. deisey (father) to complete. Also sending a distribution fom1 ifhe would like to remove the funds. If so he would complete both fonus and return to Frog Switch-Attn: Susan Lash. If not just election of contributions and return to Frog Switch - Attn: Susan Lash. If you have any questions, please contact me at (717) 243-2454 ext. 238. Sincerely, <.:..-..... . , 5f' /....... ......... , ...., . ;:.=.".- t.+ .l__. . ~,.... ............. i/. /.. c' ___._ _ . _)~ ~ A:._. '. '----s~;~n K:{osh HR Benefits Mgr. ... tv 1st MEMBERS 1st FEDERAL CREDIT UNION REGULAR SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Interest Earned from 1/1/05 to Date of Death Name of Joint Owner 186879 -00 08/20/1999 $29,198.93 $11.70 $29,210.63 $11.70 None CHECKING ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Interest Earned from 1/1/05 to Date of Death Name of Joint Owner 186879 -11 08/20/1999 $167.56 $.00 $167.56 $.00 None VISA CREDIT CARD ACCOUNT: Account Number/Suffix Date Account Established Balance at Date of Death Name of Joint Cardholder 4287590001868799 03/06/2001 $459.14 None ~.: BERS ~.j~E. ~E~AL CREDIT UNION i\Lijrt~lt' tfr 0/t./ I- I Denise A. Wolfe (J-e Insurance Services Supervisor February 17, 2005 f7r::-) 1~~::r. /.~;;) .1.'),,<, d ~(~i3 \;;;p l~)f'i\ j~ '.Aj~ ~ ~I Estate of: DOUGLAS A. HEISEY Date of Death: 01/16/2005 Social Security Number: 165-46-8586 ,n i] SOOO Louise Drive . Po. Box 40 . Mcchanicsburg, Pennsylvania 17055 . (717) 697-1161 . www.mcmberslst.org -- ~ Gl 1-1 t ~ 0 1"'\ IV .... \1 0 <.~ rT III \ .... ';! III ~ ....- ....- UI .... ...... '" .... , <d .... UI ~ .... .... \ rT ." \J\ '" , In 1"'\ 1"'\ 0 II> , 1-1 rT \D ~ ~!A .... '" II> I '" ::I III 0> , 1"'\ 0 (1 .... II> .... , ~ ... 11 .... VI .... 0 , 0> ~ rT 10 0 '" '" 0> I l\) ~ III r:f III .... I 10 \ UI VI \ .... ...... \ ." rTlO ~ I ~g) l\) 1"'\ VI \ l\) \ <.\ III 10 t , rT III , 1"'\ (1 1 ~~ \~ ~ '" , , l\) \D '" \ . ~ po '" II> I t~ .... 0 II> , ",::I ~ 0 0 I ~: .., 0'" I l\) l-I ~~ I 1"'\ ~ \ In~ l\) g) , ~~ VI t' 1-1 I rT '1 0 , 0 , . ." ~ , ~~ ~ , ~ 0 , po ~ 0 , g) .In , 0 l.'I .... , ~ < , <. .... z I ." 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Lifetinles -- PepsiCo 401(k) PI"n for Hourly Employ.es .E'Ii.ntJh~Pi;lBe Retirement Savings Statemant DOUGLAS A. HEISEY 120 BOYER RD CARLISLE. PA 17013- . Customer Service: (800) 632-2014 FIdelity Investments Institutional Services Co. 82 Devonshire Street Boston, MA 02109 Your Account Summary Statement Period: 01/16/2005 to 01116/2005 a.glnnlng aalane. $118,318.&9 Ending Balance $118,318.69 Additional Information Your vested account balance Is unavailable. Please contact your Plan Sponsor for more informatIon. Your Personal Rate of Return ~'" r r~; j:j ~.~I'';' ~ ri, ,......-It-I(' L . ,...~H ,. ~:. t .....:t.r.,l'... ,:M.. _:", ".l.o\,'\. ~,1 '~!;,".JI\~14I' \1 -.'..... . - , , ' . H ;~: . "P, ., ,il, . .,~ . ... ? ~., ", ;', '1 \.1 ,,' ..,. ~ t \ J I I' . . . . ..l. \'l'J... \ ., ,. <f .h \, J~' t., " . . j i , Your Personal Rate of Return is calculated with a time-weighted formula, widely used by financial · analysts to calculate Investment earnings. It reflects the results of your Investment selections as well as any activity In the plan account{s) shown. There are other Personal Rate of Return formulas used that may yield different results. Remember that past performance Is no guarantee of future results. Your Asset Allocation Statement Period: 01/16/2005 to 01/16/2005 . ',' ;.. I.. ,-' '" ,-','"1. ,~:, ";, ,'''', ,'":,\,',0" -):1'-;' ,~." ,""!, ,-:. -~.'< j-::-.-' 1 " _, ,.... -,.,-,"..,- ,...... ~1" w....!, ,-.'; .7,f"!1 ".'.t:.:' "I. .. ,-',1 ; r". -,.. >T',." .-', I.::' .-;, ,-I, -. . ',' ~" ~ 1-4 . "., . '. ;~.'1 .~> r.:-:" ,~}; ~? c~ ;-1, .-::; '~'j. ,_,"jN., l:~-" r~; ,''t, .:,)'''0 m,;;:._",,, _;, ,.. ,",; ,.', ,",. I~.":l ,-" .-., j'-,'''',,''', '-', '-:' r:"' ,N~ ,~t, . -'. ~'--:, .4, .~e:-':N', "!, ,. .,:;-.N" ",.'" ;'-,,'~ ,.-', :-, ,.... . of . i.. ._ ':. )-~ -;~ I. L ,. ,':.....i.. c'", r, :-1 '~J r-. .. 'I.{:: I.. .... -, ;.:- .~.~ ..." ,'.'. :~~ ,~ -.,;:". :',..." ;-" <:::-'~!-.. 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'-:- ", 1.. .t. i',."-_~ ,~. .." , # ! {""", -~. ;' .'1-" _M T-, .-",; 1,'-.1 "ii" 1 .::' . ,-....A:-.~ > " ':~:. . -','- ,...... . I "', ~ ,"I,.. .,', ;::",..., r-O",-" ~t. ,~:. ,~II ,~:" .'"'!. ";, .-,(;::' ;~.,,-;; -:::"." .. ?~'-ll 1":""",', .~~ I J 1-1_. C':" ,'"., ,"', (~,. , I. ,.J L' (I; s -::. l. \-'l(': -,":',.." , ,. ~.. ,"', +- '-1 17=: I"'; ,-'... .~. 'I,.,'" ""1'." .....4. ,-1"-'1 ~'. ,-'" ,".'!. -r ... ""1 '~" "-::"":'1 -i "):. /--\ . i \ ,1\ \ ,_:1 J .. r-, .1., j' !.. _,j : 1 -i /1- -.."..., I'..... ,~t, ,Wx "', ':':. :N1~.,~, ;-::"','1, ~_'" ,".I, .,'" . ,N.,,:,~ c'!~ --11::"-', ,"f, ~t.. .~;~ t: : ,I H ',j J' -<1 1-" " ~'. :' -~l ,-. .::w. ~~ -',,-" f.":','",; .:i:.... "\..j"'1 ~:;:. :-, 1 ~ ": ."~."i .-:,. r.:' ;-~. -', '."'''l i:~: .:'~ '"?! T ''" (H,::)r . e ~ A. Settlement Statement LAW OFFICES u.s. Department of Housing and Urban Development IRWIN & McKNIGHT OMB No. 2502-0265 (exoires 9/30/2006) B. TYPE OF LOAN WEST POMFRET PROFESSIONAL BUILDING 1. OFHA 2. OFmHA 3. OConv. Unins. 4. OVA 5. OConv. Ins. 60 WEST POMFRET STREET 6. FILE NUMBER \7. LOAN NUMBER CARLISLE, PENNSYLVANIA 17013-3222 HASCOA5.05 2655005524 (717) 249-2353 8. MORTGAGE INSURANCE CASE NUMBER C. Note: TnlS orm Tsrurnlsnea~o gIVe you a sta emenl of aclual sememen COStS. "",ounts paid 10 and y Ine settlemenl agenl,are snown. \ TitleExpress Settlement System Ilems marked "(p.o.c.). were paid outside Ihe closing; they are shown here for information purposes and are nol included in Ihe lolals. WARNING: It is a crime \0 knOWlnp,ly make false stalements to the United States on Ihls or an~ other similar form. Penallles upon Printed 05/13/2005 at 08:58 JMR conviction can Include a fine and morlsonmenl. For details see: Title 18 U. S. Code SectIon 1 01 and Seclion 1010. D. NAME OF BORROWER: ANDREW W. HASCO and CAROL J. HASCO ADDRESS: 1827 W LISBURN ROAD. CARLISLE PA 17013 E. NAME OF SELLER: DOUGLAS A. HEISEY ESTATE ADDRESS: F. NAME OF LENDER: NORTHWEST SAVINGS BANK ADDRESS: P.O. BOX 1793 WARREN. PA 16365 G. PROPERTY ADDRESS: 120 BOYER ROAD, Carlisle, PA 17013 LOT 9. KEN.UN ESTATES Monroe TownshlD H. SETTLEMENT AGENT: I&M REAL ESTATE SERVICES, LLC, Telephone: 717.249.2353 Fax: 717.249.6354 PLACE OF SETTLEMENT: West Pomfret Professional Blda. 60 West Pomfret Street Carlisle. PA 17013 I. SETTLEMENT DATE: 05/1312005 J. SUMMARY OF BORROWER'S TRANSACTION: K. SUMMARY OF SELLER'S TRANSACTION: 100. GROSS AMOUNT DUE FROM BORROWER 400. GROSS AMOUNT DUE TO SELLER 101. Contract sales Dnce 225 000.00 401. Contract sales orice 225.000.00 102. Personal Pronertv 402. Personal Prooertv 103. Settlement charaes to borrower (line 140m 8286.12 403. 104. 404. 105. 405. Adiustments for items Daid bv seller in advance Adiustments for items oaid bv seller in advance 107. Countv taxes 05/13105 to 12131105 336.06 407. Countv taxes 05113105 to 12/31/05 336.06 108. School Tax 05/13/05 to 06130105 253.94 408. School Tax 05113105 to 06/30/05 253.94 109. 409. 110. 410. 111. 411. 112. 412. 120. GROSS AMOUNT DUE FROM BORROWER 233.876.12 420. GROSS AMOUNT DUE TO SELLER 225 590.00 200. AMOUNTS PAID BY OR ON BEHALF OF BORROWER 500. REDUCTIONS IN AMOUNT DUE TO SELLER 201. Deoosit or earnest monev 2.000.00 501. Excess Deoositlsee instructions\ 202. PrinciDal amount of new loans 171 500.00 502. Settlement charaes to seller !line 1400\ 2 826.96 203. Existina loanls) taken subiect to 503. Existina loan(s) taken subiect to 204. 504. Pavoff of First Mortaaae Loan 59 521.00 BANK ONE NA 205. 505. 206. eM" U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT SETTtEMENT STATEMENT File Number: HASCOA5-05 PAGE 2 TitleExnress Settlement System Printed 05/13/2005 at 08:58 JMR L. SefTLEMENT CHARGES PAID FROM PAID FROM 700. TOTAL SALES/BROKER'S COMMISSION based on price $225.000.00 = BORROWER'S SELLER'S Division of commission {line 700\ as follows: FUNDS AT FUNDS AT 701. $ to SETTLEMENT SETTLEMENT 702. $ to 703. Commission paid at Settlement 800. ITEMS PAYABLE IN CONNECTION WITH LOAN 801. Loan Oriaination Fee % 802. Loan Discount 0.500 %NORTHWEST SAVINGS BANK LR 887.50 803. Aooraisal Fee to NORTHWEST APPRAISAL SERVICES -(P.O.CJ 225.00 Buver LR 804. Credit Reaort to THE CREDIT BUREAU. INC. IP.O.C.\ 13.90 Buyer LR 805. Lender's Inspection Fee IP .O.C.\- 50.00 Buver LR 806. Mortqaqe Application Fee to NORTHWEST SAVINGS BANK 807. Assumption Fee 808. Flood Determination Fee to LSI NATIONAL FLOOD SERVICES (P.0.C.17.50 Buyer LR 809. Loan Processina Fee to NORTHWEST SAVINGS BANK LR 250.00 810. 811. 900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 901. Interest From 05/13/2005 to 06/01/2005 @$ 29.5800 Idav 19 Days LR 562.08 902. Mortaaae Insurance Premium for to 903. Hazard Insurance Premium for 1yr to TRAVELERS INS. CP.0.C.1561.00 Buyer LR 904. 905. 1000. RESERVES DEPOSITED WITH LENDER FOR 1001. Hazard Insurance 3 mo. ((j) $ 46.75 Imo LR 140.25 1002. Mortaaae Insurance mo. fro $ Imo 1003. City Property Tax mo. @ $ Imo 1004. County Property Tax 3 mo. @ $ 43.87 Imo LR 131.61 1005. Schoal Tax 13 mo. ((j) $ 187.59 Imo LR 2 438.67 1009. AqQreqate Analysis Adiustment to NORTHWEST SAVINGS BANK LR -181.24 0.00 1100. TITLE CHARGES 1101. Settlement or closina fee 1102. Abstract or title search 1103. Title examination 1104. Title insurance binder 1105. Document Preparation 1106. Notarv Fees 12.00 6.00 1107. Attornev's fees to IRWIN & MCKNIGHT (Seller.POCI (includes above items No: \ 1108. Title Insurance to STGC/I&MREAL ESTATE 1.483.75 fincludes above items No: \ 1109. Lender's Policv 117 500.00 - 1110. Owner's Policv 225000.00 .1 483.75 1111. End 100, End 300, End 900 to STGC/I&MREAL ESTATE 150.00 1112. , "...^^'I"'..__al ___..__ - .. " ." . -' ~ Michael J. Malpezzi, Owner Jeremy J. Shartzer, Funeral Director 8 il'Iarket Plaza Way. Mechanicsburg, PA 17055 Phone: (717) 697-4696 March 16,2005 Kristin R. Heisey 1927 Queenswood Drive Apt F-206 York, PA 17403 The Funeral Service for Douglas Arthur Heisey We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. SELECTED MERCHANDISE: Urn Cherry Register Package THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED C. SPECIAL CHARGES Cremation with Memorial Service AT THE TIME FUNERAL ARRANGEMENTS WERE MADE, WE ADV ANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. CASH ADVANCES Opening Grave Newspaper Notices - Local Clergy/Mass Offering Organist Certified Copies of the Death Certificate Flowers Fishburn UM Church Fishburn UM Social TOT AL CASH ADVANCES AND SPECIAL CHARGES $475.00 $165.00 $640.00 $2805.00 $360.00 $92.00 $200.00 $75.00 $120.00 $313.76 $100.00 $100.00 $4165.76 SUB-TOTAL INITIAL PAYMENT / DISCOUNT / CREDITS TOT AL AMOUNT DUE $4805.76 $4805.76