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Home My WebLink About11-23-05 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT BLACK ROBERT R 36 S HANOVER STREET CARLISLE, PA 17013 -------- fold ESTATE INFORMATION: SSN: 201-18-6894 FILE NUMBER: 2105-0256 DECEDENT NAME: SWIGERT HELEN L DA TE OF PAYMENT: 11/23/2005 POSTMARK DATE: 11/23/2005 COUNTY: CUMBERLAND DATE OF DEATH: 02/27/2005 NO. CD 006026 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $8,190.20 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: CHECK# 113 SEAL INITIALS: MW RECEIVED BY: REGISTER OF WILLS $8,190.20 GLENDA FARNER STRASBAUGH REGISTER OF WILLS z o i= ~ :J a.. :E o u x ~ . REV-1SDO EX (6-00) REV-1500 OFFICIAL USE ONLY FILE NUMBER 21 05 0256 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 INHERITANCE TAX RETURN RESIDENT DECEDENT coumv CODE YEAA NUMBER t- Z W C W U W C DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Swigert, Helen L. DATE OF DEATH (MM-DD-YEAR) 02/27/05 SOCIAL SECURITY NUMBER 201-18-6894 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER o 3. Remainder Return (dale of death prior to 12-13-(2) o 5. Federal Estate Tax Return Required 1 8. Total Number of Safe Deposit Boxes D 11. Election to tax under Sec. 9113(A) (Attach Sch 0) >- :z w Cl Z o 0.. '" W " c:: o u tl'li$~CTI($MO$T$l;itQMP~~Q;A'i;::CQ~~~~P.NP.~t~:A~CQ~~,p.i~lttmtitM'lN~8MAi1Q~$f:mQi;::U.$l;b.I~~C~P'tQ; NAME COMPLETE MAILING ADDRESS Robert R. Black 36 S. Hanover St., Carlisle, PA 17013 FIRM NAME (If ApliicaJle) Landis & Black TELEPHONE NUMBER (717) 243-2727 80,821.63 22,295.47 ....... ......................................... OFFICIAL USE ONLY DATE OF BIRTH (MM-DD-YEAR) 10/08/25 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) N/A W I- ::c:~'" u,,::c: w"-u zoo ulr...J 0..10 0.. <( ~ 1. Original Return D 4. Limited Estate C 6. Decedent Died Testate (Attach ""y of Will) C 9. Litigation Proceeds Received o 2. Supplemental Return o 4a. Future Interest Compromise (date of death after 12.12-(2) o 7. Decedent Maintained a Living Trust (Attach ""y of Trust) o 10. Spousal Poverty Credit (date of death betweoo 12-31-91 al'd 1-1-95) f",.~ '::-::::::1 C~-:2 cr1 c') -~() . "[1 :"'-1 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) (1) (2) (3) (4) (5) 3. Closely Held Corporation, Partnership Of Sole-Proprietorship .----.------------------------------------------------------------.-----.-----.------ ~ -. I" , ~-) 4. Mortgages & Notes Receivable (Schedule D) -------------------..----.----.-----------------------------------------------------. C'.) 13,611.47 -:1 ;'0 22,153.43 (8) 13,225.93 4,338.08 (11) 17,614.01 (12) 121,267.99 (13) "----w:-w--,,--"""",,:_~_,~_w_,~_,~:_w_'w,,:_w:_-_-_~,,_~:_-:_-_-_wQ_,g,Q_-_,~_-_-_ 138,882.00 (14)_______________________________________________________~_~_!!_~_~?:_~~_______ (15) ------___n________________n_______________________..________________________________ (16) (17) (18) (19) 18,190.20 18,190.20 z o ~ ..J :J t- o.. <( u w c:: 5. Cash, Bank Deposits & Miscellaneous Personal Properly (Schedule E) 6. Jointly Owned Properly (Schedule F) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) (7) (6) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) (9) (10) - 13. Charitable and Governmental Bequests/Sec 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) 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) -m--------------------_______________mmm_______m____________ X .0_______ 16. Amount of Line 14 taxable at lineal rate x.O_ 17. Amount of Line 14 taxable at sibling rate x .12 18. Amount of Line 14 taxable at collateral rate 121,267.99 x .15 19. Tax Due 20.0 j .~ , Decedent's Complete Address: STREET ADDRESS 119 Petersburg Road CITY Carlisle I STATEpA 'ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 18,190.20 0.00 9,500.00 500.00 3. InteresUPenalty if applicable D. Interest E. Penalty Total Credits (A + 8 + C ) (2) 10,000.00 TotallnteresUPenalty ( 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. A. Enter the interest on the tax due. (5) (SA) (58) 8,190.20 8. Enter the total of Line 5 + SA. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT 8,190.20 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes a. retain the use or income of the property transferred; .......................................................................................... 0 b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 c. retain a reversionary interest; or.......................................................................................................................... 0 d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. ~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ [KJ No [K] [K] [K] [K] Under penalties of pe~ury, I declare that I have examined this retum, indueling accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. DATE ADDRESS Same as above -------nu------------nu--n-_nu_n____n__nu_nu_nu_n____n_n---nn~----~nun------u__n*______nh_____n__n___________n___________nn___n---n--n--------n-nn~_______n____________n____n__n____u_______n__n______ For dales 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 PS 39116 (a) (1.1) (i)J. 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. 39116 (a) (1.1) (ii)l. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after JUly 1, 2000: The lax rale imposed on the net value of transfers from a deceased child !wenty-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. 39116(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. 39116(1.2) [72 P.S. 39116(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. 39116(a)(1.3)]. A sibling is defined, under Section 9102, as an Individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 E" + (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Swigert. Helen L. 21 05 0256 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 prop~ which is jointly-owned with ri!lht of survivorship must be disclosed on Schedule F. SCHEDULE A REAL ESTATE ITEM NUMBER 1. DESCRIPTION All that certain tract of land with dwelling house erected thereon, known as 119 Petersburg Road, Carlisle, PA 17013. See Cumberland County Deed Book "W", Volume 16, Page 230. Sold at public sale. See HUD attached hereto. Net proceeds $80,821.63 VALUE AT DATE OF DEATH 80,821.63 TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 80821.63 REV-1503 E" + (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF Swigert Helen L. FILE NUMBER 21 05 All property jOintly-owned with right of survivorship must be disclosed on Schedule F. 0256 ITEM NUMBER 1. DESCRIPTION 1,607.460 shares of Van Kampen US Mortgage Fund Class (A). See attached investment report, average. VALUE AT DATE OF DEATH 22,295.4 7 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 22295.47 - REV-1508 E:'X + (6-98) . COMMONWEAL TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Swigert. Helen L. FILE NUMBER 21 05 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. 0256 ITEM NUMBER 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11 . DESCRIPTION M&T Bank, checking account #960837. See attached letter. VALUE AT DATE OF DEATH 346.06 M& T Bank, certificate of deposit #031003910650893. See attached letter. $ 1,209.00 (Principal) $ .66 (Interest) M&T Bank, certificate of deposit #031003910675776. See attached letter. $ 7,029.79 (Principal) $ 79.07 (Interest) Bank of Landisburg, checking account #3712745. See attached letter. 1,209.66 7,108.86 969.08 Sovereign Bank, checking account #167009843. See attached letter. $ 625.00 (Principal) $ .02 (Interest) Sovereign Bank, certificate of deposit #1625208811. See attached letter. $ 599.04 (Principal) $ 2.15 (Interest) Nationwide Insurance Co., refund 625.02 601.19 72.88 Nationwide Insurance Co., rebate 40.90 Sale of personal property at public sale, net proceeds 2,472.74 Sprint, refund 8.55 Dauphin Oil Co., refund 156.53 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 13611.47 REV-1510 E}( + (6-98) . SCHEDULE G INTER.VIVOS TRANSFERS & MISC. NON.PROBA TE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Swiaert. Helen L. FILE NUMBER 21 05 0256 DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER ATTACH A COPY OF THE DEED FOR REAl ESTATE. VALUE OF ASSET INTEREST VALUE (IF APPLICABLE) 1. TransAmerica Life Insurance Co., annuity #02PSL005901. 22,153.43 100. 22,153.43 See attached letter. 2. Sovereign Bank, #1675202830. Helen L. Swigert ITF 1,213.16 3,000.00 0 Amber Lea Baughman. See attached letter at Schedule E 3. Sovereign Bank, #1675207813. Helen L. Swigert IT 1,247.98 3,000.00 0 Amber Lea Baughman. See attached letter at Schedule E. TOTAL (Also enter on line 7 Recapitulation) $ 22,153.43 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 (If more space is needed, insert additional sheets of the same size) R~V-1511 EX + (12-99) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Swigert. Helen L. ITEM NUMBER A. 1. 2. 3. 1. 2. 3. 4. 5. 6. Debts of decedent must be reported on Schedule I. DESCRIPTION FUNERAL EXPENSES: Ewing Brothers Funeral Home, services. Rice Memorial Works, lettering. FILE NUMBER 21 05 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Robert R. Black Social Security Number(s)JEIN Number of Personal Representative(s) 184-26-2842 Street Address 60 Conway Street City Carlisle State PA Zip 17013 Year(s) Commission Paid: 2006 Attorney Fees Landis & Black Family Exemption: (If decedenrs address is not the same as daimanrs. attach explanation) Claimant NONE Street Address City Relationship of Claimant to Decedent State Probate Fees Landis & Black, advanced Accountanrs Fees Tax Return Preparer's Fees See Attachment Page(s) Zip TOTAL (Also enter on line 9, Recapitulation) $ 0256 AMOUNT 199.00 95.00 6,555.28 3,277.64 370.00 20.00 Schedule H( continued) 7. Sovereign Bank- Reclaim social security 8. S. Midd. Twp- Water and sewer 9. Judy Campbell, Tax Collector- Real Estate taxes 10. Dauphin Oil CO.-Fuel oil 11. PPL- Invoice 12. Orrstown Bank- Account charge 13.PPL- Invoice 14.Barret Real Estate- Real estate appraisal 15. PPL- Invoice 16. Marlin Lear- Lawn mowing 17. PPL- Invoice 18. Steve McCready-Additional Auctioneer Fee 19. Marlin Lear- Lawn Mowing 20. PPL- Final invoice 1,270.26 99.00 149.69 120.67 30.00 10.00 24.00 275.00 20.16 205.00 38.13 400.00 60.00 7.10 $13,225.93 R~V-1512 EX + (6-98) '* SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Swigert. Helen L. FILE NUMBER 21 05 0256 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 4,243.87 1. Perry Village, nursing home care. 2. Continuing Care RX, prescription medicines. 144.21 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 4,388.08 - REV-1513 EX ~ (8-om SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Swiaert Helen L. NUMBER I. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] FILE NUMBER 21 US RELATIONSHIP TO DECEDENT Do Not List Trustee(s) 0256 AMOUNT OR SHARE OF ESTATE 1. Sharon R. Thebes 464 Paige Hill Road Landisburg, PA 17040 2. Robert M. Thebes 4265 Knoxville Avenue Cocoa, FL 32926 3. NancyL.Thebes P.O. Box 570 New Bloomfield, PA 17068 4. Susan H. Naylor 692 Losh Road Shermans Dale, PA 17090 5. Stephen C. Naylor 125 Parkenson Road New Bloomfield, PA 17068 Lineal One-Fifth Lineal One-Fifth Lineal One-Fifth Lineal One-Fifth Lineal One-Fifth 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 needed, insert additional sheets of the same size) - . LAST WILL AND TESTAMENT OF HELEN L. SWIGERT I, HELEN L. SWIGERT, of South Middleton Township, Cumberland County, Pennsylvania, declare this to be my Last Will, hereby revoking all prior wills and codicils. FUNERAL EXPENSES FIRST: I direct the payment of my funeral expenses, including my gravemarker, as soon as may be convenient after my death. PAYMENT OF DEATH TAXES SECOND: I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of administration of my estate. DISTRIBUTION OF RESIDUE THIRD: I give the rest of my estate, in equal shares, to my five nieces and nephews, namely, Stephen C. Naylor, Susan H. Naylor, Sharon R. Thebes, Nancy L. Thebes, and Robert M. Thebes, or the survivors thereof PROTECTION OF BENEFICIARIES (Spendthrift Provision) FOURTH: No interest in income or principal shall be assignable by a beneficiary or available to anyone having a claim against a beneficiary before actual payment to the beneficiary. Provided, however, any beneficiary may assign any part or all of the beneficiary's interest in my estate to anyone or more of my descendants or to anyone or more of the beneficiary's descendants. POWERS OF EXECUTOR ~'DTH: I confer upon my executor the right to sell or otherwise convert any real or personal property at public or private sale, at such time or times, in such manner, and for such price or prices, and on such terms and conditions as my executor shall determine, and to execute and deliver good and sufficient conveyances, assignments and transfers of the property, without liability of any purchaser for the application of any consideration; to borrow money and to secure ;jIg initials I. its payment by mortgage of real or personal property, pledge of investments, or otherwise, without liability on the part of the lenders to see to the application thereof; to retain any investments at discretion; to invest and reinvest at discretion, without restriction to so-called "legal investments"; to make distribution in cash or in kind; to allocate and distribute different kinds or disproportionate shares of property or undivided interests in property among beneficiaries, in cash or in kind, or partly in each; and to do all other acts and things necessary or appropriate in the management, administration and distribution of my estate. APPOINTMENT OF EXECUTOR SIXTH: I appoint Robert R. Black, Executor of my will. WAIVER OF BOND SEVENTH: I direct that no fiduciary hereunder shall be required to furnish bond in any jurisdiction, and if any bond is necessary, no surety shall be required. INTERCHANGEABILITY OF LANGUAGE EIGHTH: Words used in the singular may be read to include the plural or the plural may be read as the singular. Similarly, the masculine form may be read to include the feminine and neuter; the feminine may be read to include the masculine and neuter; and the neuter may be read to include the masculine and feminine. HEADINGS NINTH: The headings used on the various paragraphs of this will are included for convenience only and shall have no legal significance. I have signed this will this ?-- 2 ~Jff day of {)t?.iaAJl ~Je", 2004. 'II~ :;f,/~ elen L. Swigert viZM!f~ {/ /1___ Wit'!!!vUU11.A://' / v< ~ j-5;? I. ACKNOWLEDGMENT and AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ) SS. COUNTY OF CUMBERLAND ) We, Helen L. Swigert, the Testatrix in and the undersigned witnesses to the will, the attached or foregoing instrument, who have signed the instrument, having been qualified according to law do depose and say: (a) that I, the Testatrix, do hereby acknowledge that I signed the instrument as my will, that I signed it willingly and as my free and voluntary act for the purposes therein expressed; and (b) that we, the witnesses, were present and saw the Testatrix sign and execute the instrument as her will, that she signed it willingly and executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the will as a witness and that to the best of our knowledge the Testatrix was at that time eighteen or more years of age, of sound mind and under no constraint or undue influence. ~ ;I,d~~ Helen L. Swigert, Teatrix ~M~ Witness c....-, , " U~~! Witness \';1J ~J ~ :J ~gt~iV~JiG-i-i uf PE"i";;' ,i ,; M..-:i NotarlaI Seal Susan K Guyer, Notary Pub8c Call1sle Bolo, Cumberland Coun!)t My C<mnissicn E>cpIres Sept. 4, 2007 Member. Poimnsylvanla Association Of NotarIGs .fV~85 EX + (1-92) ~R_ ~~ CC(())~1f COMMONWEAlTH Of PENNSYlVANIA DEPARTMENT Of REVENUE INIIRfl'ANCE TAX DIVISION DEPT. 280601 HARRI5IURG. PA 17128-0601 Please Print or Type MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS SAFE DEPOSIT BOX INVENTORY (ZIP CODE) ~u< 1'1013 ENT T THE BOX OPENING (RELATIONSHIp) ~XEcu.-r()R (CITY) (STATE) (ZIP CODE) (STATE) (ZIP CODE) b. (RELATIONSHIP) (STREET ADDRESS) (CITY) (STATE) (ZIP CODE) c. (NAME) (RELATIONSHIP) (STREET ADDRESS) (CITY) (STATE) (ZIP CODE) . NAME AND ADDRESS OF FINANCIAL IN5mUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED (NAME) ClfRLISLIE (STATE) (ZIP CODE) a. b. (NAME) (STREET ADDRESS) (STATE) (ZIP CODE) -- ft$ ~J6' WAS A WILL IN THE BOX? DYES ,(NO H yes, a. Dat. of will: b. Name and address of personal ~ntativ., if _mad In the will (NAM~ f\D~r R ~(..f< . E 5? (STREET ADDRESS) A> c. Name and acldr.s of attorney, if any (NAME) --1rs AfI,o {cf (STREET ADDRESS) (CITY) (STATE) (ZIP CODE) (CITY) (STATE) fZIP CODE' SAFE DEPOSIT BOX INVENTORY INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) Obligations of U. S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies ~r other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. Page of ITEM NO. j 1.- j ITEM DESCRIPTION I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECEIVING COpy OF CORRECT A 0 PLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF SAFE DEPOSIT BOX INVENTORY: SIGNATURE SIGNATURE PRINT NAME AND CHECK APPROPRIATE BOX BelOW: CHECK APPROPRIATE BOX: o Executor(trix) OAdministrotor(trix) o Estote Representative 0 Joint owner of safe deposit box NOTE: Attach additional 8'12" x 11" sheet (s) if necessary or use duplicates of this page of form. A~ U.S. DEPARTMENT OF HOUSING & URBAN DEVELOPMENT SETTLEMENT STATEMENT OMS NO. 2502-0265 ;: B. TYPE OF LOAN: 3.I!JCONV. UN INS. 4. OVA 7. LOAN NUMBER: 11 5. OCONV. INS. C. NOTE: This form is furnished to give you a statement of actual settlement costs. Amounts pa~d to and by the settlement <!gent are.shown. Items marked "[POC)" were paid outside the closing; they are shown here for informational purposes and are not Included In the totals. 1 0 3198 (10240.14.MALLIOS.PFDl10240.14.MALLI0SI12) D. NAME AND ADDRESS OF BORROWER: E. NAME AND ADDRESS OF SELLER: F. NAME AND ADDRESS OF LENDER: George J. Mallios and Estate of H~." L. ....e" (~fi Community Banks Tessie Mallios 100 East King Street 312 West Meadow Road East Berlin, PA 17331 Mechanicsburg, PA 17055 G. PROPERTY LOCATION: H. SETTLEMENT AGENT: ~- I. SETTLEMENT DATE: 119 Petersburg Road Martson Deardorff Williams & Otto ~r1isle, PA 17013 July 18, 2005 ::umberland County, Pennsylvania PLACE OF SETTLEMENT 10 East High Street Carlisle, PA 17013 J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION 00. t':gn~~ 400. t':g( DUE Tn ~"'I ",g. 01. Contract Sales Price 83,000.00 401. Contract Sales Price 83,000.00 02. Personal Prooertv 402. Personal Property 03. SetUement Charaes to Borrower (Line 1400) 4,126.82 403. 04. 404. 05. 405. p:>irl Hv n )6. Countyrrwo. Taxes 07/19/05 to 01/01/06 68.08 406. Countyrrwo. Taxes 07/19/05 to 01/01/06 68.08 )7. School Taxes to 407. School Taxes to )8. Assessments to 408. Assessments to )9. 409. 10. 410. 11. 411. 12. 412. 20. GROSS AMOUNT DUE FROM BORROWER 87,194.90 420. GROSS AMOUNT DUE TO SELLER 83,068.08 )(). AMOUNTS PAID BY OR IN BEHAl.F OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: >1. Deposit or earnest money 8,300.00 501. Excess Deposit (See Instructions) )2. Principal Amount of New Loan(s) 88,000.00 502. SetUement Charges to Seller tUne 1400) 2,208.80 )3. Existina loan{s) taken subiect to 503. Existing loan{s) taken subiect to l4. 504. Payoff of first Mortgage )5. 505. Payoff of second Mortgage 16. 506. Deposit retained by seller 8.300.00 17. 507. t8. 508. 19. 509. Adiustments For Items Unnaid Bv Seffer Aaiustments For Items unpaid ljy ~eller O. Countvrrwo. Taxes to 510. Countvrrwo. Taxes to 1. School Taxes 07/01/05 to 07/19/05 37.65 511. School Taxes 07/01/05 to 07/19/05 37.65 2. Assessments to 512. Assessments to 3. 513. 4. 514. 5. 515. 6. 516. 7. 517. 8. 518. 9. 519. O. TOTAL PAID BY/FOR BORROWER 96.337.65 520. TOTAL REDUCTION AMOUNT DUE SELLER 10,546.45 O. CASH AT SETTlEMENT FROMITO BORROWER: 600. CASH AT SETTlEMENT TOIFROM SELLER: 1. Gross Amount Due From Borrower (Line 120) 87,194.90 601. Gross Amount Due To Seller (Line 420) 83,068.08 2. Less Amount Paid BylFor Borrower (Line 220) ( 96,337.65) 602. Less Reductions Due Seller (Line 520) ( 10,546.45 3. CASH ( FROM) ( X TO) BOftROWER ' 9,142.75 603. CASH ( X TO) ( FROM) SELLER 72,521.63 'he undersigned hereby acknowlepge receipt oJ'a .com9leted copy of pages 1 &2 of thiS statement & any attachments referred to herein. Borrower . '/! / ' ' " '_," Seller E tat ~ L.5wi ,- / . . ,', , see '~J gert .- "Geof,ge J: r,4allio.~,/ . ,,-' "'" (.Ii.--.p, I 7! I/?,~, /1, y... .: c, c' :/' ,~^'." BY: . '-1, , v'-""" /1.00- ~W/ l. ___ ~ _' - ",..< j" 1:.-.- .j',' L. 7.'-' /l.l?<. ,), T~sie Mallios ' ,r..... .lI_ b{ r v .' Ci:,'l/(;- \ f'a!; . J. TOTAL COMMISSION Based on Price ~ ((i) 0/. PAID FROM PAlO FROM Division of Commission (line 700) as Follows: BORROWER'S SELLERS 01. $ to FUNDS AT FUNDS AT 702.$ to SETTLEMENT SETTLEMENT 703. Commission Paid at Settlement 704. to Ann. ITFMS PAVADI ." IN CONNF~TlnN WITH lOAN 440.00 801 . loan Oriainalion Fee 0.5000 % to Community Banks 802. loan Discount % to 803. Flood Certification to Community Banks 13.75 804. Document Preparation Fee to Community Banks 175.00 805. lender's Inspection Fee to 806. Mortaaoe Ins. App. Fee to 807. Assumption Fee to 808. 809. 810. 811. caM- IRED BY LENnFR TO BE PAID IN ADVANCE 901. Interest From 07/18/05 to 08/01/05 @ $ /day ( 14 days %) 902. Mortaaae Insurance Premium for months to 903. Hazard Insurance Premium for 1.0 years to 904. 905. 1nnn RF~FRVES D I FtdnFD 1001. Hazard Insurance months $ per month 1002. Mortaaae Insurance months $ oar month 1003. CountylTwo. Taxes months $ per month 1004. School Taxes months $ oar month 1005. Assessments months @ $ per month 1006. months @ $ oar month 1007. months @ $ per month 1008. months @ $ per month '1nn TITLE CHARt::;ES /101. Settlement or Closing Fee to 1102. Abstract or Title Search to 1103. Title examination to 104. Title Insurance Binder to 105. Auctioneer Fee to Steve McCardv 1,260.OC 106. Collateral School Taxes 05106 to Martson Deardorff Williams & Otto 1,289.60 107. Attorney's Certification Fee 10 Martson Deardorff Williams & Otto 515.00 (includes above item numbers: ) 108. Title Insurance to lawyers Title Insurance Comoanv (includes above item numbers: ) 109. lender's Coverage $ 110. Owner's Coverage $ 111. Endorsements 100/300/900 Lawyers Title Insurance Company 112. 113. 7nn GOVFR EcoRnlNG ANn TR4N~FER ~H4Rt::;FS 201. Recording Fees; Deed $ 38.50; Mortgage $ 46.50; Releases $ 85.00 202. City/County Tax/Stamps; Deed 830.00' Mortgage 830.00 203. State Tax/Stamos: Revenue Stamos 830.00: Mortgage 830.00 204. 205. Jnn. ADDITIONAL SETTLEMENT CHARGES J01. Survev to W2. Pest Insoectlon to W3. 2005-2006 School Taxes to Judv Campbell, Tax Collector 763.47 104. Over Niaht Fee to Martson, Deardorff, Williams & Otto 15.00 105. Final Water/Sewer to South Middleton Township Municipal Authority AccI# 011074 118.80 ~O(). TOTAL SETTLEMENT CHARGES (Enter on Lines 103, Section J and 502, Section K) 4,126.82 2,208.80 ly s~nlng page 1 ollhls ""lement, Ihe .gnaID"",, _owI"ge _pt of a OOmple~~"" two page ""lemanl ;ertified to be a true copy. L SETTLEMENT CHARGES Martson Deardorff Williams & Otto Settlement Agent ( 10240.14.MALLIOS /10240.14.MALUOS /12 ) HlO1176600 04/01/05-17 .27 .02 .N KAMPEN INVESTMENTS Investment Report CiencrCJ1WI1:; o( txfJerience . , January 1. 2005 - March 31. 2005 Page 2 of 2 Account Summary Fund Name/Symbol Opening Value Investments! Withdrawals/ + Investment + Change = Closing Value Fund/Account Number as 01 1/81/2005 + Contributions Redemptions Earnings in Value as 01 3/31/2005 Non-Retirement U S Mortgage Fund Class A (VKMGX) ($444.48) S22.182_95 40/417390 $22.407.99 $0.00 $0.00 $219.44 Total All Accounts $22.407.99 SO.H SO.H $219.44 ($444.48) $22.182.95 Account Transactions.. U S Mortgage Fund Class A (VKMGX) Fund/Account Number 40/417390 Account Owner Helen L Swigert Year-to-Date Dividends Year-to-Date Capital Gains Dividends are Capital Gains are $219.44 $0.00 Paid in Cash Paid in Cash Trade Transaction Dollar Share Shares This Date Description Amount Price Transaction Beginning Value as of 1j01/2005 $22.407.99 $13.94 01/31/2005 Income Div Cash $73.16 $0.00 0.000 02/28/2005 Income Div Cash $73.12 $0.00 0.000 03/31/2005 Income Div Cash $73.16 $0.00 0.000 Ending Value as of 3131/2005 $22.182.95 $13.80 Total Shares 1.607.460 1.607.460 1,607.460 1,607.460 1.607.460 Thank you for choosing Van Kampen Investments. Your satisfaction is important to us. If you notice any inaccuracies on your statement, please contact us within 60 days of receiving thiS statement. Add to Your Investment Helen l Swigert 125 Parkenson RD New Bloomfld PA 17068-9203 To make investments by mail, please complete. detach and mail this stub with your check. For address changes. visitvankampen.com or complete the reverse side of this form and return itto Van Kampen. Fund Name/Symbol Fund/Account Number US Mortgage Fund Class A (VKMGX) 40/417390 Investment Amount 11111111111111111111111111111111111111111111111 Total Amount $ $ S S S VAN KAMPEN INVESTMENTS P.O. BOX 219319 KANSAS CITY, MO 64121-9319 Please remember to include the ac count number on your check and specify the amount being invested above. .. . I! M&fBank 499 Mitchell Road, MiIIsboro, DE 19966 Mail Code DE-MB-12 Phone (888) 502-4349 Fax (302) 934-2955 March 23, 2005 Law Offices Landis & Black 36 South Hanover Street Carlisle, Pennsylvania 17013 Re: Estate of: Helen L Swigert Social Security: 201-18-6894 Date of Death: Februarv 27. 2005 Dear Sir or Madam: Per your inquiry dated May 05, 2005, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: I. Type of Account Checking Account Account Number 960837 Ownership (Names oj) Helen L Swigert * Stephen C Naylor, POA Opening Date 01/05/81 Closed 03/29/05 Balance on Date of Death $346.06 Accrued Interest $ 0.00 Total $346.06 2. Type of Account Certificate of Deposit Account Number 03/0039/0650893 Ownership (Names oj) Helen L Swigert * Stephen C Naylor, POA Opening Date 01/18/00 Closed 03/29/05 Balance on Date of Death $1,209.00 $ 0.66 Accrued Interest Total $1,209.66 Interest Posted YTD $ 4.06 ~ 3. Type of Account Certificate of Deposit Account Number 031003910675776 Ownership (Names of) Helen L Swigert * Stephen C Naylor, POA Opening Date 02/07/00 Closed 03/29/05 Balance on Date C!fDeath $7,029.79 $ 79.07 Accrued Interest Total --....----~------ ------- -..-. ____w.O' .-....-----__....__ __. . __ __..___ ___._w_ ..__...____ __ _____.. ____w_.._.__ _.. . $7,108.86 Interest Posted YTD .-------------..-----------...---...----------..---.....-...--.--..-..--.....---.......---.--.-------------.-.--'--_..-.'-_.>. $ 0.00 Please be advised, there was no safe deposit box found for the above decedent. * For further account information, regarding ownership, closures and/or reimbursement of funds, etc., please call the High Street Carlisle Office # 717-240-4536. Sincerely, ..-/ //.. .r ...."..") -2:ld -1'?-:'(. -/ ,:/~~)". l / - Nancy Clagett Records Management . . .' The Banh..of Landisburg ESTABLISHED 1903 P.O. BOX 179 · LANDISBURG, PA 17040 May 10, 2005 Landis & Black c/o Robert R. Black, Esq. 36 South Hanover Street Carlisle, Pa. 17013 RE: Decedent: SSN: 000: Helen L. Swigert 201-18-6894 February 27, 2005 Dear Sir or Madam: The information which you requested on the decedent, Helen L. Swigert is as follow: Account No. Princioal Accrued Int. Interest Rate Date Ooened Tvoe of Account 3712745 $ 969.08 N/A N/A 01/04/2005 Checking (DDA) Helen L. Swigert was sole owner of this account. If we can be of further assistance, please advise. Very truly yours, \. 'i!L~ ~ Flo Phillips Teller Two FP cc: Decedent's folder (t!JjjiCl11) I LiI\IIlIC:RI1DC' 717 7Qn ')')1') 01 ^ '''J c:.'J /. ":1110 (ol lrn~ II ^ P\ If'" r'\. ^ I r ,n,"" nr" . ,- .--'.- -~ ~-- ---------------- .._-----~ _'.~. u____ ____._~~.._.___. _ _..._________ Sovereign Bank ESTATE OF SOCIAL SECURITY #: DATE OF DEATH: Helen L Swigert 201-18-6894 Fe~ 27, 2005 v/ Account #: 1671009843 Type: Checking In the name of: Helen L Swigert Date of Death Balance: $625.00 Int.(YTD) from 1/1/2005 to 2/412005 Accrued interest to date of death: $0.02 Other Info: fonner Waypoint Bank # 1700027809 Open date: 1I131l998 : $0.46 Account #: 1675202830 Type: CD )n the name of: Helen L Swigert ITF Amber Lea Baughman // Date of Death Balance: $1,210.51 1/ v Int.(YTD) from 111/2005 to 113112005 Accrued interest to date of death: $2.65 Other Info: fonner Waypoint Bank # 1700009101 Open date: 101l6/1998 $2.93 Account #: 1675207813 Type: CD V In the name of: Helen L Swigert ITF Amber Lea Baughman Date of Death Balance: $1,245.25 Int.(YTD) from 11112005 to 113112005 Accrued interest to date of death: $2.73 Other Info: fonner Waypoint Bank # 1764215289 v/' Account #: 1625208811 Type: CD In the name of: Helen L Swigert Date of Death Balance: $599.04 Int.(YTD) from 1Il/2005 to 1131/2005 Accrued interest to date of death: $2.15 Other Info: fonner Waypoint Bank # 1792286698 Open date: 9/17/1991 $3.02 Open date: 4/25/1996 : $2.39 Page 1 of 1 - ..' . i.T.~~ 4 Transamerica Life Insurance Company 4333 Edgewood Road NE PO Box 3183 Cedar Rapids, Iowa 52406-3183 May 27, 2005 Estate of Helen L Swigert C/O Robert R Black Landis & Black 36 S Hanover St Carlisle PA 17013 RE: Annuity Number(s) 02PSL005901 Dear Estate of Helen L Swigert: Our office has received your request concerning the above listed non- qualified tax deferred annuity. A Form 712 is not issued on tax deferred annuities. The taxable portion of this policy will be reported on a Form 1099-R as taxable to the beneficiary upon receipt of the funds. The value as of 02/27/2005, the date of death for Helen Swigert is $22,153.43. The Primary Beneficiary on the Annuity was Steven Nailor. Any additional questions regarding this annuity can be directed to the Annuity Service Center at 1-800-553-5957. A Transamerica Life Insurance Company representative will gladly assist you with any questions you may have regarding this annuity and help you meet your financial goals. Sincerely, ])ni~rf{UJJMrl Denise Huston Claims Transamerica Life Insurance Company UA~J...... ~f +hA ~F'~nN ~~..~