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Home My WebLink About07-13-05 217 REV.150Q EX (&.00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128.0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY FILE NUMBER 21-05-0405 COUNTY CODE Y<AR NUMBER DECEDENTS NAME (lAST, FIRST, AND MIDDLE INITIAL) Goldie M Baker DATE OF DEATH (MM~DDNEAR) SOCIAL SECURITY NUMBER I- Z W C W o w c 184-12-4172 DATE OF BIRTH {MM,DD-YEARl nus RETURN MUST BE FILED IN DUPUCA TE WITH THE 4/11/2005 9/13/1919 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MlDOlE INITIAL) REGISTER OF WilLS SOCIAL SECURITY NUMBER ~ "Sw v"''' J,U~g X"'~ V~m ~ ~ Federal Eslate Tax Return Required Limited Estate o 2. Supplemental Return 04a. Future Intetest Compromise (dale of death after 12-12-82) o 1. Decedent MaIntained a living Trust (Attach copy of Trust) 010. SpclIJS<ltPoYertyCredM(d*ofd&alllbelween 12-31-91 and 1-1-QO;} 03 05 Rllmaindtr Reloo1 (date ofdllathpfiorto 12-13-62l Original Return Litigation Pl'Oc:eeds Received .-!- 8. Total Number of Safe Deposit Boxes 011. Electiol'\ to tax under Sec. 9113(A.) (A.\\attl Sch 0) nf~~DTO: Decedent Died Testate (A.ttach copy of Wm) I- z NAME w c z Robert M. Fre ~ FIRM NAME {If Applicable} ra .. .. 0 0 717243-5838 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (21 NONE 3. Closely Held Corporation. Partnership or Sole-Proprietorship (3) NONE 4. Mortgages & Notes Receivable (Schedule D) (4) NONE 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) (5) 6. Jointly Owned Property (Schedule F) (6) NONE z Dseparate Billing Requested 0 i= '" 7. Inter-Vivos Transfer & Miscellaneous Non-Probate Property -' (7) :> (Schedule G or l) l- ii: <:l 8. TOTAL GROSS ASSETS (total lines 1-7) w .. Funeral Expenses & Administrative Costs (Schedule H) (9) 9. COMPlETE MAILING ADDRESS 5 South Hanover Street Carlisle, Pennsylvania 17013 83,940 OFFICI SE ONLY ::0 2 ~:TJ~ $~ E ?-}~ 9f\1C"> · 0.3. C? ':b r=. 11 f"("l C m Co:) r::::>. .!;::.::O W -'- C5 CIl~6 :'? Co3 ':i\ 8 ." - =-;; ("'; r". rn .:.::0 r:--.-, )i! --l c.n U ') ".=,'~ <, a> 130,040 14. Net Value Subject to Tax (Une 12 minus line 13) 30,151 (0) 10,339 863 (11) (12) (13) (14) 244,131 10. Debts of Decedent. Mortgage liabilities, & liens (Schedule l) :10) 11. TOTAL DEDUCTIONS (total lines 9 & 10) 11,202 232,929 o 232,929 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 (SclIe<!uIe J) 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) 232,929 x .045 (15) 10,482 Z 0 i= 16. Amount of Une 14 taxable at lineal rate X .0 (16) 0 ~ :> 0- :E 17. Amount ofUne 14 taxable at sibling rate x .12 (17) 0 0 0 ~ 18. Amount of line 14 taxable at collateral rate x .15 (10) 0 19. Tax Due (19) 10,482 200 ~"S::,X-. 217 Goldie M Baker C dd 184-12-4172 Decedent's omDlete A ress: STREET ADDRESS 14 Green Meadows Drive CITY I~TATE IZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. CreditslPayments A. Spousal Poverty Credit 8. Prior payments C. Discount (1) 9,958 524 Total Credits (A+ B + C) (2) 3. InterestlPena\1y if applicable D.lnterest E. Penalty 4. Total Interest/Penalty (0'" E ) If Une 2 is greater than Line 1 ... Une 3. enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to r'equest a refund (3) o 5. (4) 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 5 + SA. This is the BAlANCE DUE. (58) Make Check Payable to: REGISTER OF I'o'ILLS, AGENT 10,482 10,482 o o o ,. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 2. 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 property transferred or its income; c. retain a reversionary interest; or d. receive the promise for life of either payments, benefits or care? If death occurred after December 12, 1982,did decedent transfer property within one year of death without receiving adequate consideration? Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? Yes o o o o o o 3. 4. Did decedent own an Individual Retirement Account, annuity or other non-))rObate property which contains a beneficiary designation? o 0 IF 'IlIE ANSWER TO ANY OF 'IlIE ABOVE QUESl10NS IS 'YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF 'IlIE RETURN. No o [E] [E] [E] [E] o DATE 7 tJS- ADDRESS 35 CottaQe Place, Gillette, New Jersey 07933 SIGNATURE.OF PREPARER OTHER THAN REPRESENTATIVE ~-h-t .",..,.. ADDRESS ' ~ 5 South Hanover Street. Carlisle, Pennsylvania 17013 DATE For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% (72 P.S. Section 9116 (a)(1.1)(i)J. For da\esof death on 01" a1\& JarnJary 1, 1995, thew rate Imposed on the ne\value of transfers to orlorthe use of the surviving Spouse is 0% 172 P.S. Section 9116 (a)(1.1Xii)J. The statute does not exempt a transfer to a surviving spouse from lax, and the statutory requirements for disclosure of assets and filing a lax return are still applicable even If the survNiog spouse is the only beneficiary. For dates of death on or after July 1. 2000: The tax rate Imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent. or 9 stepparent of the child is 0%[72 P.S. Section 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. Section 9116(1.2) [72 P.S. Section 9116(a)(1)]. The tax rate imposed on the net va.lue ofuansfers to or for the use of the decedent's siblings is 12% (72 P.S. Section 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. 217 REV-1502 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER Goldie M Baker 21-05-0405 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 \so )ointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION House and Lot at 14 Green Meadows Drive, N. Middleton Twp., Cumberland County VALUE AT DATE OF DEATH 130,040 ALL THAT CERTAIN lot or tract of land situate in North Middleton Township, Cumberland County, Pennsylvania, bounded and described as follows: BEGINNING at a point on the North side of Green Meadows Drive on Stine Development Plan No. I recorded in Plan Book 6, Page 39, at line of Lot No. 20; thence in a westerly direction by the North side of Green Meadows Drive, a distance of One Hundred (100) feet to line of Lot No. 17; thence in a northerly direction by line of Lot No. 17, one hundred fifty (150) feet to a point on the sixteen (16) foot alley; thence in an easterly direction by said alley, one hundred (100) feet to line of Lot No. 0; thence in a southerly direction by line of Lot No. 20, now or formerly f Melvin B. Landis and wife, one hundred fifty (150) feet to the North ide of Green Meadows Drive. the Place of BEGINNING. BEING Lots 18 and 19 of Stine Development Plan No. I as ecorded in the Office of the Recorder of Deeds in and for Cumberland ;ounty at Carlisle, Pennsylvania, in Plan Book 6, Page 39. TIlE ABOVE described lot of land has thereon erected a one- story dwelling house, which has the mailing address of 14 Green Meadows Drive, Carlisle, P A 17013. SUBJECT to the building and other restrictions accompanying said recorded Plan. THE ABOVE described lot of land is all of the property which John B. Koontz and Frances A. Koontz, husband and wife, by deed dated September 17, 1960 and recorded September 17, 1960 in the Office of the Recorder of Deeds in and for Cumberland County at Carlisle, Pennsylvania, in Deed Book "Z.11 Volume 19, Page 961, granted and conveyed to Emory H. Baker and Goldie M. Baker, husband and wife. The said Emory II. Baker having died on August 18, 1996, title to the same remained vested by operation of law solely in his surviving spouse. Goldie M. Baker, whose Executrix is the Grantor herein. TOTAL (Also enter on line 1 Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 130,040 - -~_....._...-. ..~-_..... and Urban D.velopment VMD 1"\~~ruwOt I.U. .c:Iu.t-u:m: B. Type: of Loan 1.[ JFHA 2.{ ]FmHA 4.[X)VA 5.[ )Conv.lnll, 3. [ ] conv,Unln8'16' File Number. 17.l.o8n Nwnber: I a, Mortgage Insufllnce Case.Number: 4005009n-CB 2021888759 .. THIS NOTE IS FURNISHED TO GNE YOU A STATEMENT OF ACTUAL 5ETIlEMENT COSTS. AMOUNtS PAID TO AND BYTHE SETT1.EMENT AGENT ARE SHOWN. ITEMS MARKED -(P.O.c.)- WERE PAID OUTSIDE THe CLOSING; THEY ARE SHOWN HERE FOR INFORMATIONAl PURPOSES AND NOT INCLUOED IN THE TOTAlS. D. Name and Address of Borrawer I E. Name and Addrtss of Seller TROY A. SHIVES OF BEVERlY e, SHEllHAMER, EXECUTRIX OF THE ESTATE OF 32 HAMILTON ROAD GOLDIE M. BAKER BOILING SPRINGS, PA 17007 C, NOTE: IF. Name and Addnss oflAncllir MEMBERS 1ST FEDERAl CREDIT UNION 5000 LOUISE DRIVE, MECHANICS8URG, PA 17055 ,PA G. PROPERTY LOCATION 14 GREEN MEADOW DRIVE. CARLISLE, PA 17013 COUNTY: CUMBERLAND PARCEL 10: 2~17-15810003 TOWNSHIP: NORTH MIDDlETON TOWNSHIP H. Settlement Agent ECURED lAND TRANSFERS - MEeHANl Place of Satlltmtnt 1088 HARRISBURG PIKE CARLISlE, PA RG J. SUMMARY OF BORROW!!R'S TRANSACTIONS K. SUMMARY OF &ELLEn TRANSACTIONS I 100. Gros. Amount Due From Borrower 400. Gro.. Amount Dlle To SaJIw i 101. Purchase Price $133.500.00 401. PuR:hase Price $l33,500iDO 102. Personal Property 402. Personal Property , 1 D3. Settlement Charp. to Sorrowr $7,418.32 403. , 104. 404. 105. 405. i AdJuatments. For Items Paid By S.u.r In AdVance Adjustments For...... Paid By Saner In AdVIInce , 106. CltylTown Taxes 406. CltylTown Taxes 107. CountyT811es 286.611yr6l241200s to 1/112008 $138.4.9 407. County Taxes 268.81/yr 81241200510 11112008 $138.49 108. Asseuments 40B. Adessmenls 109, SchooITlUeS 1,090.8OIyr6l24120D5 to 7/112005 $21.21 409. School Tams 1,Q9Q.8Olyr 612412005 to 7/112005 $21.21 110. 410. i 111. 411. 112. 412. I. Setllemtnt D...I : Dlsbu.....ment Date i 61241200511:00:001' AM/6/2412005 12D. Grou Amount 0Ue Frvm Borrower I $141,078.02 420. Gro.. Amount Due To StlUer I $133.659.70 200. Amoum. PaId By Or In Behalf or Borronr SOD. Reduction. In Amount D.. To S.II... 201. Earnest Money $1.000---:rn 501. Excess depolllt 202. Principal from Members 1 at Fecl8f81 Credll Union $136,350,00 5D2. Settl.......,t Ch.... To Selltr (llIe14OO) $9,649,90 203. ExIsllng loan(s) h1ken subject 10 503. Ex!sUng lDan(s) ~ S\lbIed. To 204. 504. Payoff of Flm MortgagllLoBn 205. 505. Payoff of Second Mortgage LOIIn 206. .... 207. S07. 208. .... 209. SO,. AdJu.tments For Items UnpeJd By Sen.r AdJut.""..,.. For Items Unpallt By S.O... 210. CltylTown Taxes 510. ClIylTown Taxes 211. County Taxes 511.CountyTIOOlS 212. Assessments 512. Assesamenls 213, 513. 214. Selel"sASsia\ance $3,460,00 514.Seller'"sAs8lstance $3,460.00 215. 515, , 216. 516. . 217. .. . 517. 218. ..-,0 518. 219. 519. 22D. Totll Paid By/For Borrower 300. C..h AI S.lIIftment FrowntTo Borro..r 3Ql, Gross Amount Ove From Borrower (lina 120) 302. Less AmQunls Paid By/For Borrower (Une 220) I $140,810.00520. Toml Rltduclion Amount Due W... I 6OD. Cash AI Settlem.m ToIFrom..... $141,078.02 601. Gross Amount Due To Sellar (line 420) . r $140,810.00 602, LaSI Deducllonsl" Amt. Due To Sellar (line 520) I $13,109.90 T I $133,659.70 $13,109.90 303. Cash [X I From [ ] To Borrow.r $268.021603. Cash [Xl To [ ] From 8.11... $120.549.80 217 REV-150B EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Goldie M Baker SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ITEM NUMBER DESCRIPTION 1 M&T Bank, Checking Account #2678008505 2 M&T Bank, Savings Account #015004201600449 3 M&T Bank, C/D #031003912753108 4 F&M Trust, C/D #022-2977681 5 Valley National Bank, C/D #72581581 6 Household Contents 7 Bureau of Unclaimed Property, Prudential #4772463, Demutualization Cash 8 Bureau of Unclaimed Property, Prudential #4772464, Demutualization Cash 9 Refund, Penn Treaty Network America 10 Refund, The Sentinel 11 1995 Ford Escort Automobile Include the proceeds of litigation and the date the proceeds were received by the estate. All Drocertv lolntlv-owned with riaht of survivorshlo must be disclosed on Schedule F. FILE NUMBER 21-05-0405 VALUE AT DATE OF DEATH 5,250 9,643 10,048 45,382 10,085 500 768 398 139 2 1,725 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 83,940 rI M&TBank 499 Mitchell Road. Mitlsboro. DE 19966 Mail Code DE-MB-12 Phone (888) 502-4349 Fax (302) 934-2955 March 23. 2005 Frey & Tiley Attorneys At Law 5 South Hanover Street Carlisle, Pennsylvania 17013 Re: Estate of: Goldie M Baker Social Security: 184-12-4172 Date of Death: Avril 11. 2005 Dear Sir or Madam: Per your inquiry dated May 10,2005, please be advised that at the time of death, the above-named decedent bad on deposit with this bank the following: 1. Type of Account Checking Account Account Number 2678008505 Ownership (Names oj) Goldie M Baker * Beverly Schellhammer, FaA Opening Date 12/3I/81 Balance on Date of Death $5,249.52 Accrued Interest $ 0.14 Total $5,249.66 2. Type of Account Savings Account Account Number 015004201600449 Ownership (Names oj) Goldie M Baker * Beverly Schellhammer, FaA Opening Date 01/12/00 Balance on Date of Death $9,641.37 Accrued Interest $ 1.32 Total $9,642.69 3. Type of Account Certificate of Deposit Account Number 031003912753108 Ownership (Names of) Goldie M Baker. Beverly Schellhammer. Opening Date 02/15/05 Balance on Date of Death $10,000.00 Accrued Interest $ 47.57 Total $10,047.57 Please be advised, there was no safe deposit box found for the above decedent * For further account information, regarding ownership, closures andlor reimbursement of funds, etc., please call the North Middleton Oflice # 717-240-4521. Sincerely, 2fb-n~U~ Nancy Clagett Records Management RE: Goldie M. Baker DATE OF DEATH April 11, 2005 ACCOUNT INFORMATION CHECKING SAVINGS ~CERTIFICATE OF DEPOSIT SAFE DEPOSIT SHARES OF STOCK DATE OPENED 07/13/04 DATE CLOSED still open ACCOUNT NUMBER 022-2977681 ACCOUNT BALANCE AT DATE OF DEATH $ 45.000.00 ACCRUED INTEREST $ 381. 90 TOTAL ACCOUNT BALANCE $ 45,381.90 NAME(S) ON ACCOUNT Goldie M. Baker REGISTRATION OF ACCOUNT Individual --------------------------------------------------------------- ACCOUNT INFORMATION CHECKING SAVINGS ___CERTIFICATE OF DEPOSIT SAFE DEPOSIT SHARES OF STOCK DATE OPENED DATE CLOSED ACCOUNT NUMBER ACCOUNT BALANCE AT DATE OF DEATH ACCRUED INTEREST TOTAL ACCOUNT BALANCE NAME(S) ON ACCOUNT REGISTRATION OF ACCOUNT I-I Chatham Office V Banking/Just like it's supposed to be'!' May 20, 2005 Robert Frey 9 South Hanover Street Carlisle, PA 17013 RE: Goldie Baker Dear Mr. Frey: Mrs. Baker has a Certificate of Deposit with our bank, the account number is 72581581. The balance at the date of her death was $10,000.00. The account was a new account opened on 9/2/03 and as of this date there is accrued interest of$85.28. There are no other names on this account. Please contact us if you have any other questions. Thank you, C1AA-,~ ;Z:;;;..:n ~ Customer Service Rep. 375 Main Street. Chatham. New Jersey 07928. phone 973.701.2944. fax 973.701.2941 Commonwealth of Pennsylvania Treasury Department Bureau of Unclaimed Property AFFIDAVIT AND INDEMNIFICATION AGREEMENT Robert P. Casey, Jr. State Treasurer CLAIM NUMBER 99594863 STATE OF PENNSYL V ANlA COUNTY OF CUMBERLAND BEING first duly sworn, Beverlv Schellhammer ('Claimant(s)") deposes and represents as follows: THAT Claimant(s) resides at 35 C:ottage Pla"e, Gillette NJ 07933 THAT Claimant(s) has made a claim for unclaimed property held by the Treasury Department; THAT Claimant(s) is unable to present to the Treasury Department, as proof of entitlement to the Unclaimed Property, the following original property information: Property ID Property Description Cash Claimed Shares Issue Name Holder 4772463 Dernu[uaU,alion Cash $767.88 0.00 PRUDENTIAL F!NANCIAL INC 4772464 Demutualization Cash $398.16 0.00 PRUDENTIAL FINANCIAllNC because such property described above has been lost, stolen, destroyed, misplaced, or never received and Claimant, hislher heirs, assigns or successors have not received or enjoyed any benefit from the property or proceeds therefrom; THAT Claimant(s), in exchange for payment by the Treasury Department of said claim, agrees to at all times indemnify, save, defend, and keep harmless the Treasury Department, its employes and representatives, from and against any and all claims, demands, actions, or suits against them, whether groundless or otherwise, and any and all losses, damages, liabilities, costs and fees arising out of or in any way connected with the payment of the claim, particularly by reason of a claim for payment to any third person claiming an ownership interest therein or who may hereafter come into possession of the original security, regardless of whether such claims, actions, losses, damages, suits or liability arise in whole or in part from the gross negligence or willful misconduct of the Treasury Department; THAT Claimant(s) agrees that this Affidavit and Indemnification Agreement shall be construed in accordance with the laws of the Commonwealth of Pennsylvania; and THAT Claimant(s) acknowledges and understands that any information and/or documentation supplied with the claim, if false, will subject Claimant to prosecution under 18 Pa. C.S.~904, relating to unsworn falsification to authorities; the conviction of which could subject Claimant to prison term of p t two ye rs and a fine of up t 000. BEFORE ME, the'Jndersigned'authoril'j, on this d3Y personally 2ppea'ed if'::, e v ~ ~ it <; "- h. ...l t ~c-"'""'^'" ~ known to me (or introduced to me by I, to be t person whose name IS subscribed to the foregoing instrument, and acknowledged so he/she executed the same foJ=li!!! purposes and con id ration therein expressed and SUBSCRIBED AND SWORN TO ME this the 2- 0 day of "- A.D. 20 b -5 . Notary Signature: -/1. Printed. Name of Notary: My Commission Expires: NOTARY STAMP NOTARIAL SEAL ROBERT G. FREY. NOTARY PUBLIC BOROUGH OF CARLISLE, CUMBERLANO CO PA MY COMMISSION EXPIRES JUNE 27, 21ll16' Kl:t!l:Y Blue Bm>k. Private Part)' Pricing Report. Ford. [stun 51161054:33 PM I~~o~~ ~ .~ 'J"'/5":",n~"":t ~:'~~p~ NE.WC".RS 111iJ:~ REVIEWS lRATING;T A:t6E . 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"fl,";l"V'", .~,'.~t>j SEUIl'\lJDEO. WHAT ARE YOU WAITING FOR? LEARN MORE " ,~ -".r';"~'~,~ REAL CUSTOMERS. REAL REASONS TO BUY. Eiii p(lg.e lof2 217 REV-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDeNT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Goldie M Baker FILE NUMBER 21-05-0405 This schedule must be completed and filed if the answer to any af questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE 'ffiANSFEREE. iHEIR RELATlOHSHIP TOOECEDEIfT "NO THE DATE OF DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER TRANSFER ATTACH A copy OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IFAPPUCAlllE) VALUE 1. Western Southern. Policy #W20696609 30,151 100.00% 30,151 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TOTAL (Also enter on line 7 Recapitulation) $ 30151 (If more space is needed, insert additional sheets of the same size) .;;lUO cr r crcXJ ,.tJ,t'~ e WESTEIlN-SOUTHERN LIFE 06-Z4-05 DEPT. Z500 CONTRACT NUMBER(S) WOOZ0696609 HAIL TO PATEE DECEDENT- BAKER GOLDIE M BEVERLY SCHELLHAMMER 35 COTTAGE I'L !ilLLETTE NJ onn THE CLAIH ON THE WESTERN-SOUTHERN LIFE ASSURANCE COMPANY ANNUITY LIsTED AIOVE HAS BEEN APPROVED AND A SETTLEMENT STATENENT IS PROVIDED BELOW. PROCEEDS HAYE BEEN PLACED INTO YOUR NEW PREMIER INTeREST-BEARING ACCOUNT AT NORTHERN TRUST. A.I'E~SONALIZED WELCOME PACKET, 'INCLUDING . YOUR CHECKIOOK, WILL IE DELIVERED TO YOU IN FIVE TO 10 WORKING DAYS. IF MULTIPLE SETTLEMENTS HAVE IEEN APPROVED. ALL PAYMENTS WILL BE COMIINED INTO YOUR PREMIER ACCOUNT. OUR GOAL IS TO SERVE AND ASSIST YOU DURING THIS DIFFICULT TINE. II' YOU HAVE ANY QUESTIONS AIOUT THE SETTLEMENT AMOUNT LISTeD BELOW. CALL A WESTERN-SOUTHERN LIFE REPRESENTATIVE AT (100) 926-1702 HONDAY THROUGH THURSDAT. 8.00 A.N. TO 6.00 P.M. EASTERN TINE AND FRIDAY. 8100 A.M. TO 5100 P.N. EASTERN TIME. STATEMENT OF CLAIM SETT\..EU&NT TNE IRS WILL BE NOTIFIED THAT TME TAXABLE AMOUHT OF THIS PAYMENT IS .150.74 FOR THE TAX YEAR OF Z005. AMOUNT Qf CONTRACT no .150.74 TOTAL PAYABLE THIS CONTRACT nO.150.74 TOTAL DErOSITED TO PREMIER ACCOUNT no .150.74 .....-.. TOTRL P.02 217 REV-1511 EX+(12-99) COMMONWEAl,H OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Goldie M Baker FILE NUMBER 21-05-0405 ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Auer Memortal Home & Cremation Services 109 2. Foster's Monuments, Inscription 75 B. ADMINISTRATIVE COSTS: 1. Personal Representative's CommissJons 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. Attorney Fees 9,721 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip RelaTIonship of Claimant to Decedent 4. Probate Fees 310 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Check cleared after date of death 35 8. Register of Wills, (6) Short Certificates 24 9. Register of Wills, Filing Fee for PA Inheritance Tax Return 15 10. Register of Wills, Additional Probate Fee 50 TOTAL (Also enter on line 9 RecaDitulation\ $ 10339 Debts of decedent must be reported on Schedule I. (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12'()3) 217 SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCe: TAX RETURN RESIDENT DECEDENT ESTATE OF Goldie M Baker FILE NUMBER 21-05-0405 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, Including unrelmbursed medical expenses. ITEM NUMBER 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. VALUE AT DATE OF DEATH DESCRIPTION Ben Soude~s Lawn Care and Landscaping Comcast, Cable Bankcard Services, Credit Card Bill Erma Lininger, House Cleaning PPL, Electricity Suburban Energy Services, Heating Oil Sprint, Telephone North Middleton Authority, Water and Sewer Nationwide Mutual Insurance Company, Homeown~s Policy West Shore EMS-BLS F&M Trust, Fee for date of death balance in each account Steve Naugle, Trash Removal Credit for School Taxes 6/24/05-7/1105 Credit for County Taxes 6/24/05-1/1/06 Federal Express,(3) Mailings 213 14 159 65 123 -167 70 55 135 32 15 230 -21 -138 53 25 TOTAL (Also enter on line 10 Rec3Ditulation1 $ (If more space is needed, insert additional sheets of the same size) 863 217 REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERiTANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Goldie M Baker 21-05-0405 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Truste.(a) OF ESTATE I. TAXABLE DISTRIBUTIONS [include outright spousal disbibutions, and transfers under Sec. 9116 (a) (1.2)] Beverly Schellhammer Daughter 100% Residue of Estate 35 Cottage Place, Gillette, New Jersey 07933 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON.TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0 (If more space is needed, insert additional sheets of the same size) ---- j " LAST WILL AND TESTAMENT OF ~ .'\;. GOLDIE M. BAKER ~.::: I.. GOLDIE M. BAKER.. of 14 Green Meadows Drive in North Middleton -, ~J Township.. Cumberland County~ Pennsylvania.. being of sound and disposing mind~ memory and understanding.. do hereby make.. publish and declare this as and for my last Will and Testament, hereby revoking and making void any and all Wills by me at any time heretofore made. 1. I direct my hereinafter named Executor to pay all of my just debts and funeral expenses as soon after my death as may be found convenient to ,- do so. 2. All the rest, residue and remainder of my estate, real, personal and mixed.. and wheresoever th.e same may be situate, I give.. devise and bequeath unto my husband, Emory H. Baker.. his heirs and assigns, to the exclusion of my children, born and unborn, provided my said husband, Emory H. Baker.. shall survive me by a period of Ninety (90) days. 3. Should my said husband, Emory H. Baker, pre-decease me or fail to survive me by the aforesaid period of Ninety (90) days.. then in such event all the rest, residue and remainder of my estate, real, personal and mixed.. and wheresoever the same may be situate, I give, devise and bequeath to my daughter, Beverly A. Schellhammer, her heirs and assigns, of 35 Cottage Place, Gillette, New Jersey. 4. I hereby nominate, constitute and appoint my said husband" Emory H. Baker.. as Executor of thismy)ast Will and Testament but should he pre- decease me or fail to qualify then in such event I nominate" constitute and appoint my said daughter" Beverly A. Schellhammer.. as Executrix of this my last Will and Testament and I further direct that no person serving as Executor or Executrix shall be required to post any bond to secure the faithful performance of his or her duties in the Commonwealth of Pennsylvania or in any other jurisdiction. I further direct my said Executor to obtain the servic s of RobertM. Frey.. Esquire.. to settle my estate. It'" ).-,.~, "", ~.o: ~',z.i ~~-~I;: , e:, 1'< ,.~.. ' " ' , t~, ";l~U ',.:til;";: I i '\1,")<.J.1 .-,:ff...t;-;: 'l~).,'.iM.~ ~" ' ,,\, .: _~' ,_ ' .I.'\., " 'i~-. ' I ~ - :i! G ~ . r IN WITNESS WHEREOF I HAVE hereunto set my hand and seal to this my last Will a.nd Testament consisting of two pages this 17th day of October . 1968. ).':p, ,{~luL /7-.1 . Goldie M. Ba.ker 1)/ / )" I;><,-v' (SEAL) Signed, sealed:t published and decla.red by Goldie M. Baker:t the Testatrix above named, as and for her last Will and Testament, in our presence, who, in her presence, at her request, and in the presence of each oUter, have hereunto subscribed our names as attesting witnesses. l2e~ k 7-;,] ~."^ ;!].aL..}j~ ,