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Home My WebLink About04-24-06 c:c.PY' --1 15056051058 REV-1500 EX (06-05) PA Department of Revenue '* Bureau of Individual Taxes .llloi' PO BOX 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year File Number Date of Birth 201-16-5610 12/25/2005 12/17/1926 Decedent's Last Name Suffix Decedent's First Name MI Desormeaux Josephine (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW . 1, Original Return 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number 4. Limited Estate ~ 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes Norman M. Yaffe, Esq. (717) 975-1838 Firm Name (If Applicable) REGISTER OF WILLS USE ONLY Yoffe & Yaffe, P.C. First line of address 214 Senate Avenue Second line of address Suite 404 City or Post Office State ZIP Code DATE FILED Camp Hill PA 17011 Correspondent's e-mail address:marissa.seeger@verizan.net Under penalties of pe~ury, I declare that I have examined this retum, including accompanying schedules and statements, and to the best of my knowledge and belief. it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON ~~. . ." -b-'f.€,cv1=-6Y 33 Battle Green Drive, Rochester, NY 14624 n___._ ...__~.___ ____._ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ~ ........'t-~ ,;JJ.., --- ADDRESS () ').-\ 1 .j.,.~ c~ ,1l..~ '-to y L.,-....i' \t.>> ~f '" I 7 U I ( PLEASE USE ORIGINAL FORM ONLY il[/iD~ DATE '(I,j (PC_ Side 1 L 15056051058 15056051058 -.J ~ 15056052059 REV-1500 EX Decedent's Name: Josephine Desormeaux RECAPITULATION 1. Real estate (Schedule A). . . . . . . . .. 1. 2. Stocks and Bonds (Schedule B) .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3. 4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5. 6. Jointly Owned Property (Schedule F) Separate Billing Requested 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested.. . . . . .. 7. 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8. 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I).. .. . .. . .. . . . . . . 10. 11. Total Deductions (total Lines 9 & 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 11. 12. Net Value of Estate (Line 8 minus Line 11) .. . . .. . .. . .. .. . .. . . . . . . . . .. . . . 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 16. Amount of Line 14 taxable at lineal rate X.O 45 15,440.74 17. Amount of Line 14 taxable at sibling rate X .12 1 B. Amount of Line 14 taxable at collateral rate X .15 19. TAX DUE. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 L 201-16-5610 Decedent's Social Security Number 9. 15. 16. 17. 18. 150,000.00 58,387.50 114,201.64 69,659.05 392,248.19 27,343.53 21,777.11 49,120.64 343,127.55 343,127.55 15,440.74 15,440.74 15056052059 ---.J '<EV-1500 EX Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Josephine__ Desormeaux STREET ADDRESS 1477 Long Pond Road, Apt. 431 ---- ,- ._._~---_. - "~------ DECEDENT'S SOCIAL SECURITY NUMBER 201-16-5610 (at death, Decedent was domiciled at #503 Erford Road, Camp Hill, PA 17011) CITY STATE Rochester NY ZIP 14626 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 15,44074 ------:;1,835.00 591.75 Total Credits (A + B + C ) (2) 12,426.75 3. Interest/Penalty if applicable D. Interest E. Penalty Tota/lnterest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 8 Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5) {5A) (5B) 3,013.99 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. 3,013.99 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transler and: Yes No a. retain the use or income 01 the property transferred;........... ...................... .................................................. 0 [iJ b. retain the right to designate who shall use the property transferred or its income; .......................................... 0 [iJ c. retain a reversionary interest; or.......................................................................................................................... 0 [Xl d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [K] 2. If death occurred after December 12, 1982, did decedent transler property within one year of death without receiving adequate consideration? .......... .................................................................................... .............. 0 [K] 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 [iJ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ IKJ 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 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 three (3) percent [72 P.S. 99116 (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 zero (0) percent [72 P.S. 99116 (a) (1.1) (ii)J. The statute does not exemDt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child 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 zero (0) percent [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 four and one-half (4.5) percent, except as noted ir 72 P.S. 39116(1.2) [72 PS. 39116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. 99116(a)(1.3)]. A sibling is defined, undel ~~r.tion 9102. as an individual who has at least one parent in common with the decedent, whether by blood or adoption. :IoV-1502 EX' (6-9. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE :STATE OF Josephine Desormeaux FILE NUMBER 2106-0026 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 joinlly-owned with right of survivorship must be disclosed On Schedule F. ITEM NUMBER 1. DESCRIPTION #503 Erford Road, Camp Hill, PA 17011 (see Exhibit 'A' Settiement Sheet dated 1/13/06 for VALUE AT DATE OF DEATH 150,000.00 sale of this asset), TOTAL (Also enter on line 1, Recapitulation) $ 150,000.00 (If more scace is needed, insert additional sheets of the same size) REV<503 EX+ (6-98) r, * COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF Josephine Desormeaux FILE NUMBER 2106-0026 All property Jolntly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH 900 shs Constellation Energy Group 51,111.00 2 300 shs Energy East Group 6,888.00 3 388.50 shs Prime Money Market Fund 388.50 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 58,387.50 REV-1508 EX+ (6-98) ~ _9:&._~_ ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Josephine Desormeaux FILE NUMBER 2106-0026 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. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH Hartford Auto Insurance rebate 208.00 2 Comcast Cable rebate 36.50 3 Sovereign Bank Demand Deposit alc #23310493237 22,965.25 5,338.61 4 Sovereign Bank Demand Deposit alc #2334019078 5 Sovereign Bank Certificate ale #0355004094 26,796.36 6 Sovereign Bank Certificate ale #2335251340 26,676.38 7 Sovereign Bank Certificate ale #2335251365 29,97465 8 Refund from Frontier phone account 12.26 9 Refund from MetUfe for Rochester apt. insurance 80.00 10 Refund from Hartford Insurance for homeowners Camp Hill 107.00 11 HSBC, Rochester, NY savings ale 2,006.63 TOTAL (Also enter on line 5, Recapitulation) $ 114,201.64 (If more space is needed. insert additional sheets of the same Size) REV-1510 EX+ (6-98) . . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Josephine Desormeaux FILE NUMBER 2106-0026 This schedule must be completed and filed if the answer to any of Questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NA.\lE OF THE TIlANSFEREE. THEil RElATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A copy Of THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST [If APPLICABLE) VALUE 1. Sovereign Bank IRA Cert. of Deposit alc #0358015261 (see statement of 21,206.97 100 21,2D6.97 bank for period 1/1/05-12/31/05 attached as Exhibit "S"). 2 Kemper Sonus Annuity Contract #5005492148 (see Kemper statement as of 48,452.08 100 48,45208 [ I 11/22/04 attached as Exhibit 'C' adjusted by adding the contract interest rate of 4% per annum from 11/22/04 to date of death or $174.59). I i i I i TOTAL (Also enter on line 7 Recapitulation) $ 69,65905 (If more space is needed, insert additional sheets of the same size) REV.1511 EX+ (12.99). SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 2106-0026 ESTATE OF Josephine Desormeaux Debts of decedent must be reported on Schedule I. ITEM NUMBER A DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Myers-Harner Funeral Home, Inc., 1903 Market Street. Camp Hill, PA 17011 James R. Gray Funeral Home, 1530 Buffalo Road, Rochester, NY 14624 Resurrection Cemetary grave opening fee (to reimburse Stephen Malloy Desormeaux) Posl-funeralluncheon (to reimburse Marie Rhoads) Stephen Malloy Desormeaux 10 reimburse for cosl of grave marker 3,379.00 3,269.45 775.00 300.00 850.00 2 3 4 5 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 2. Name of Personal Representalive{s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City . Slate Zip Year(s) Commission Paid: Attorney Fees 'iof('-e. ~ ..../ofF"'" ,P.C. 17,62500 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant 4. Street Address City State .Zip Relationship of Claimant to Decedent 5. Accountant's Fees Probate Fees 382.00 7. 6. Tax Return Preparer's Fees 8 Yoffe & Yoffe, P.C. for mileage, telephone charges and misc. Advertisement of grant 01 letters Testamentary in Cumberland County Law Journal & Carlisle Sentinel Stephen Malloy Desormeaux to reimburse for trip to Carlisle, PA, mileage & hotel, to apply lor Letters T estarnentary 250.00 18500 328.08 9 27,343.53 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of Ihe same size) REV-1512 EX. (12-03) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF Josephine Desormeaux FILE NUMBER 2106-0026 Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH Selling expenses of sale of real estate #503 Erford Road, Camp Hill, PA 17011 (see Exhibit' A"). 18,798.74 2 Attorney fees to Gary Peralta, Esquire 780.00 3 Stephen Malloy Desormeaux (to repay for Rochester apt. deposit advanced 10/21/05) 1,700.00 4 Stephen Malloy Desormeaux to repay 1) for amount paid to nursing home to hold room while Decedent 498.37 was hospitalized $377.00; 2) ENT facial plastic doctor visit $10.10; 3) bill paid to Frontier phone company $21.71; 4) UGI bill paid $70.33; and 5) PA American Water bill paid $19.23 TOTAL (Also enter on line 10, Recapitulation) $ 21,777.11 (If more space is needed, insert additional sheets of the same size) ,EV-1513 EX+ (9-00) * COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES FILE NUMBER 2106-0026 ESTATE OF Josephine Desormeaux RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS pndude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1 Stephen Malloy Desormeaux son (/3 2 Marie Rhoads daughter 'j "3 3 David Desormeaux son '/3 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 $ 0.00 (If more space is needed, insert additional sheets of the same size) A lJ.S. DEPARTMENT OF l1OLJ~NG AND URB,\N DEVElOPUfNT SETTLEMENT STATEMENT Express Financial Services, Inc. 275 Grandview Avenue Suitl' 103 Camp Hill, PA 17011 (800)422-4169 FINAL Form Appr'O'l.rl QMB Nt'I. 2502-we~ 1YPE OF LOA.N 2 Fi.1HA VA s. 611 CONV. INS. 6. ESCROW FILE NUMBER: 00029326-003 YS ~. CONV. UNINS. 7. LOAN NUMBER; 0056648165 e. MORTGAGE INSURANCE CASE NUMBER: C. NOTE: This form is fum/shed Ie giY8 '/Ou a stotement of ectua/ seWoment costs. Amounts paid to and by Ihe settlement agent af8 shown. It8ms marked "(Po O.C.)" we'" paid QutskJotM eros/fig; they are shown hem for /nformaJionaJ purpose. and 8M not includ&<f In the tola/s. o NAME OF BORROWER: Lisa S. Oeserio ADDRESS OF BORRO'MOR: . f ~ . .;. E. NAME OF seLLeR: Estate of Josephine Desormeaux ADDRESS OF SELLER: AOURESS OF LENDeR: First Horizon Home Loan Corooratiorl 5901 College Blvd., 3rd Fl. Overland Park, KS 66211 503 Elford Road Camp Hill, PA 17011 Cumberland County 09-17-1042-022 f NAME OF LENDER: G PROPERTY LOCATION: H SETTLEMENT AGENT: PLACE Of SETTLEMENT: I. SETTLEMENT DATE: Express Financial Services, Inc. 275 Grandview Avenue, Suite 103, Camp Hill, PA 17011 1/1312006 PRORATION ClATE: L;t~. ';::-l'Ji~>):'~:::}~jZ~, 3i\~~="'1f\J .1-:-[ /!_- _ . - "_...,. DISBURSEMENT DATE: SUMMARY OF SELLER'S TRANSACTION 1/1312006 ~llirr~l;'6:--~.~'J~r; ~l'~: -'l\21!\''':\~J,li!~~T~..\ _._~'-... '. ~ ;-"''':''- ... _'-. . J. SUMMARY OF BORRO'I'.ER'S TRANSACTION K 10 \. Contract Sale. Price 102. Personal Property 103. Settlement ch.rge. \0 Bo"ower (line 1400) 104 105 ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE' 150,000.00 401. ConlraclSales Price 402. Personal Property 6,444.60 403 404. 405. ,&.[)JUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE' 150,000.00 105. CitviTown Taxe. 406. Cilvrrown Tax.s 107 County T8)(eS 407. County T.... lOB. Assessments OH13/05 10 06130106 S7Us 408. A.....ments 01113106 to 06130/05 67B.46 109. 409. lID. 410. 111. 411 112. 412. 1\3. 413. 114. 414. 115. 415. 120. GROSS AMOUNT DUE FROIII BORROWER: 157,123.05 420. GROSS AMOUNT DUE TO SELLER: 150,67B.46 11.r:\i.t'..~$~:J<i;;;~'I;:\;'\'T';;';':\Ii.;,\'~i~;:;~01;Z~I'.J~~'''~,~' .~: '_.- .-: _ .~\irt ~4:jjj PJ 'T r])J~~ j~.',':~~(~1~1:.ii\ = J'~l=-~~~ ...~} ;,=,~tJ~.'''~~~ '. ..~~;: ~"_ ~_~:r J 201. Deposit or earnest money 2,000.00 501. E.case depo.11 (s.. in.INdion.) 202. Princip~1 amount of new loan($) 120,000.00 502. S'Ulement ehargea to Seller (line 1400) 21,784.50 203. E.i.ting 10.n(5) taken subject to 503. existing loan(s) lak.n subjecllo 204. 504. Payoff of first mortgage loan 205. 505. P.yoff ol.econd mortgag.loan 206. loan /I 0056648231 (second mlgl 2B,l '0.82 505. 207. seller assist 7,000.00 507. seller assist 7,000.00 20e. 508. 209. 509. taK 5VC fee to R.Max 2.00 ADJUSTMENTS FOR ITeMS UNPAID BY SELLER' ADJUSTMENTS FOR ITEMS UNPAID BY SELLER' 210 CityfTCMin Taxes 510 CI\VfT own T a.es 211- County Tax.. OH01l06 In 01/13106 12.24 511- CQuntv Tex.. 01/01/05 to 01/13/06 12.24 212. Asses30mwnu 512. ASSelsm&nl$ 213. 5'3. 214. 514. 215. 515. 216. 515. 217. 517. 2fB 51B. 219. 519. 220. TOTAL PAID BYIfOR BORPlOWER: 157,123.06 520. TOTAl REDUCnONS IN AIIIOUNT DUE Sel.l.ER: 28,798.74 ~r:~~1,t.":'t~~;~}.: {....~,T=L. :~I~;{~Z}~,i:~:'11~~~9~~ \,~j~ ' .. _' -'~~I~~'~\:J: .~\ .:~rf~f;r.II~;IJ' t~?'!if~L'~ :~ti~ -!.?j; :. --~ .~..", ~.i . , . 301 Gros. amounl due from Borrower ( line 120) 157,123.05 501. Gro.. amoun, due 10 S.Uer Cline 4201 150,678.46 302. Les. amount paid byllor Borrower ( lin. 220) 157,123.06 602 Less reduction In emount due Seller (iine 5201 28,798.74 303. CASH ( 0 FROM) ( iJ TO) BORROWER: 0.00 503. CASH (0 FROM) (iii TO I SELLER: 121,879.72 EXHiBIT "A" BASED ON PRICES 150.000.00 Q DIVISION OF COMMISSION (UNE 700) AS FOLLOWS 701. S 4.525.00 to REiMAX REALTY ASSOC. 702. I 4.475.00 10 RMPRO 703. Commission paid at &81tJamenl 704. transliidion fee to RelMaX' 6.000%' $9.000.00 f:..fJ.~ '~~~.'RI:.~,./,~\~~ L,';i;}1'1.'1~:;.!}m.,j'JJy"-~,-,.~,,,t:' -':'~ _. H ~:~ ...~-_. ",.!a./l'.. _ ,~~-~- - - - . 9.000.00 195.00 r\,~,,[\,~',!;l~~':.'l.I,Ti~.J.~""'i!ll,;rol.::::W,~'.~,,'!1.IT~It:J"'J'"r!~:".' .-~~.' .-..' ~ .~ -. .... .. i~-:..'; .._ :- . . '. ,-'-, " . '.0 "1 901. Int.r..t From 0 /13/0610 02101/06 @ $32.3010/~ay 0/. (19 ~ays) 902. Mortgage Insurance Premium lor Month{.) to 903. Hazar~ Insurance Premium lor 1 Yearo(s) to Enderolnsurance Auoc. 904. tax seNice fee to First Horizon Home Loan Corporation 905. flood deter loe to Fe~eral floo~ 613.72 (400.00) ~1(fu~~~;tI~;ltti~~-;~~3J~r.~~~rrl~)\J~~~Lt~l&=i<_-_.-" ~..--"~~--, ".:.1 -....""' h ._..- __ -- '"-_ :" -.- --_.~ l -~.~-q.___ ~'Tl 90.00 24.00 1001 1002. 1003. 1004. 1005. 1006. 1007. 1008 Haz.ud Insurance Mortgage Insurance City Property Taxes County Property Taxes Annual Assessments month. ~ . monlh. @ S months @ $ monlha @ S monttl5@ $ months @ $; montho @ S 33 33 p.r month per month per month 31.03 permonth 122.84 per montll per mon1h por month ~\f~~~J'~;l:~~'J~i~~,~?l:.' _~~:;-~-"..~~~:"'":'.~~~~ -.~ L_ -- .~_..., _ ,- '. ~. '; -; ~,- j':~~;:.. ~. .~ {. .. .-... -' . .'~'" i Aggregate A~justment 0.00 1109. 1110. 1111. 1112. 1113. SetUement or closing lee Abstract or title search TIlle examlnetion Title insurance binder Document preparation to Attorney Yoffe Nota'" lees Attorney'. Fees [Includes abavaltoms numbors: Title In!lurance to Exp~ss Financial Services, Inc. (Includes above item. numbers: 8.1..100"300"710 Reissue L.n~.rs coverage S 120.000.00 Owno(s coverage S 150,000.00 TAX CERT FEE 10 Expre.. Financial Services, Inc. COURIER FEE 10 Express FlIlllncia' Services, In", CSL to Slewart nle 375.00 1101. 1102. 1103. 1104. 1105. 1108. 1107. 1108. 1,251.88 5.00 tWM:w~~~~;;r~~:~~:;f~~~r:j~l{tl't~t(I~ltr...t-l~'~iF~;;:\,j!lt~~~~ -, ____.~_ ~l,.~. ~_=-~-.:_ .' - j;.'~'~:t ~_-~ ~ - ~_"_' ~~-p '. '~~_"1 40.00 35.00 1201. 1202. 120J. 1204. 1205. Recording Fees: Dee $ CitylCountv tax/stamo. S13le lax/stamos 38.50 Mortgage $ Oeed S De~$ 96.50 Relea.e 1 500.00 Mortoaae $ 1 500.00 Mort0800 S t3500 1,500.00 1,500.00 ~~.~l:E_!"'~jil"II-(?J~\_~,~:{IJ"";.3.(l?'''F Pj;'ltd9-_'--~ -. - "",,_ I~. -,.,. -~l~?f\'~~~' -.-...._ '-_ '. :. '.._... ~ ~2 1301. 1302. 1303. 1304. 1305. 1306. lJ07. 1400. Survey Pest Inspection Patriot Search Trash InherHance Tax IsS'ue Sew" -S.. attached for breakdown TOTAL SETTlEMENT CHA.RGES (Enl.ron line 103.SoctIon J. and. in. 502. Soctlon K) to Express Fonandal Services, Inc. to East Pensboro Twp to Attomey Yolfe 10 Ea.t Pensboro Twnsp 5.00 5.00 31.00 10.000.00 68.50 605.00 21,7M.50 25.00 6,<<4.60 I have Cllfllfulty I'9Viewed lhe HUD41 Settlement Sta\ement and to lhl best or my knowfedge and betieC. it II a tN. and ~le statement of -" receipt. and disbufSfNT1."b made on my aaount or by me tn thia trans.action. 1 furtne~ certify that I haw reoetved a eopy of the HUD41 SeWement Statement. ~ A@p4;/up l...Ua . eseno ". Borrowers ~~ preparod I... trull ard accurate account of....$ tranuctian_ s.tllemor>l Agem SeUIIA or will C8uee the funds to be disbul"1ed in accordance Dele WARNING: It ia . crim. 10 knowingly make false stetemen1s to the United Stales on ttlI5 Of any .imill!!lf form. f"enaltiea upon convictton can include a fine IInd lmprisonmlltll for datalls see: TrUe le U.S. Code Section 1001 and Section 1010. EXH'BIT etA" ~$crO'N Number: 00029326-003 YS f-JUD 911 DETAILED BREAKDOWN OF ITEMS PAYABLE IN CONNECTION WITH LOAN Total as shown on HUe page 2 Line #811 Buyer Amount 200.00 495.00 695.00 Description 812. commitment fee to First Horizon Home Loan Corporation 813. processing fee to World Capital Corp HUD 1200 DETAILED BREAKDOWN OF GOVERNMENT RECORDING AND TRANSFER FEES Buyer Seller · ;. Amount Amount 1202. City & County Tax/Stamps City Tax/Stamps: Deed $1,500.00 Total as shown on HUe page 2 Lln.. #1202 1,500.00 Buyer Amount Seller Amount 1203. State Tax/Stamps State Tax/Stamps: Deed $1,500.00 Total as shown on Hue page 2 Line #1203 1,500.00 HUD 1307 DETAILED BREAKDOWN OF ADDITIONAL SETTLEMENT CHARGES Total as shown on HUe page 2 Line #1307 Buyer Seller Amount Amount 150.0C 25.00 455. DC 25.00 60S.0C Description 1308. reimburse for work to Delores Pefley 1309. EMail Fee to Ellpress Financial Services, Inc. 1310. Home Warranty to American Home Shield EXHIBIT 'J\" -.~ Sovereign Bank JOSEPHINE DESORMEAUX 33 BATTLE GREEN DR ROCHESTER NY 14624-4932 INDIVIDUAL RETIREMENT ACCOUNT 6017 0035 6 STATEMENT OF ACCOUNTS DEPOSIT/CREDIT WITHDRAWAL/DEBIT STATEMENT FROM 1-01-05 PACE PERIOD THROUGH 12-31-05 1 OF 1 RETIREMENT ID NUMBER 1201165610 DATE TRANSACTION/DESCRIPTION SOCIAL SECURITY NO 201-16-5610 BALANCE ACCOUNT 000000358015261 TYPE- CERTIFICATE PRIOR BALANCE 01-31-05 INTEREST 02-28-05 INTEREST 03-31-05 INTEREST 04-30-05 INTEREST 05-31-05 INTEREST 06-30-05 INTEREST 07-31-05 INTEREST 08-31-05 INTEREST 09-30-05 INTEREST 10-31-05 INTEREST 11-30-05 INTEREST 12-31-05 INTEREST PRTOR CASH B1\L PLUS CREDITS t'LUS INTEREST LESS DEBITS NEW CASH BAL 20,987.00 .00 240.26 .00 21,227.26 20.32 18.37 20.36 19.72 20.39 19.76 20.44 20.45 19.82 20.49 19.85 20.29 DISBURSEMENTS FED TAX WITHHELD ST TAX WITHHELD CONTRIBUTIONS SINCE FOFt 2004 E'OR 2005 ROLLOVERS END OF 2005 TOTAL PLAN VALUE 21,227.26 FAIR MARKET VALUE OF PLAN AT THE RATE 1.140 MATURITY 01-26-06 .00 .00 .00 01-01-05 .00 .00 _00 21,227.26 20,987.00 21,007.32 21,025.69 21,046.05 21,065.77 21,086.16 21,105.92 21,126.36 21,146.81 21,166.63 21,187.12 21,206.97 21,227.26 THE FAIR MARKET VALUE INFORMATION IS BEING FURNISHED TO THE INTERNAL REVENUE SERVICE. BANK FIN NUMBER 23-1237295 1: n I' r.~'-;~l f; '.IV'~ ~~J \i.. ti'~ I~'~"" \~ . 1 C"w'~\0\J ~ 0'1 0_ STATEMENT PBRIOD llf23f03 to 11/22f04 Kemper BONUS Annuity JOSEPHINE DPSORMBAUX JOSEPHINE DESORMEAUX CONTRACT II S00S49Z148 NON QUALIFIED ISSUE DATB 11/22/93 JOSEPHINE DESORMEAUX 503 ERFORD RD CAMP HILL, PA 17011 ~i: r;)J~;~1~;ii~n:;.~::.~r;;r~;r;;j:t~ ~~.; ~ ~;;~:;:;. ':.~: {\. t':~~'.~:~:.:;rt~~~1~f;~ttKt;t~. INVEST FINANCIAL CORP 2701 N ROCKY POINT DR 7TH FL TAMPA, Fl 33607 GAl 02999 WA# D2F K.BVIN C MASON BXT# PBL (aou 542-~T32 Run Data: 1I{22/04 CONTRACT /I 800504911<48 Page I of I DESCRIPTION BEGINNING VALUE AS OF 11 2 3 PAYMENTS WITHDRAWALS OR LOANS INTEREST ENDING VALUB AS OF 11 2 BONUS Annuity "635. U .... '.00 171'.59 "6"20.67 TOTAL CASH VALUE 7 CUIREHT I'ERIOO CONTRACT YEAR-TO-DATE INCEPTION-TO-DATE EFFECTIVE DATE DESCRIP110N OF TRANSACTION DOLLAR AMOUNT 11/22/1" RATl CHANGE fROM 4.007. TO 4.'1% "'442'.67 ~\<:> \I DOc';" ~\ck.M.-e..vL.-\- \ doV\'-\- ~ \.~~\l5'~) Q~ cY ~ ~ 2&>'7 ~~e~ *- sb\i ~ 48,171 .ctq @) \00u d.ooS ~::;~e~ MD K..per Inv..tor. Llf. Insur.nce C~any Adelni.tr8tJve Offlc.: 251. W..tfield Drlv. Elgin, IL "125-713' Cu.t~r S.rvlce: (aUl 421-51n - n ~,~,., ('::.f~,~~ ; "..!., 1:<-.(._... ~.., ,:. -~:',. ,. i. Lie"'" , ljl Kemper Innstors Life Insurance Company/"Tbe Company" AdministJ"afive Office: 2500 Westfield Drive Elgin, IL 60123-7836 (888) 397-8485 Claim Form - Annuity Contracts IMPORTANT: "Statement of Claimant" must be completed in all cases. If there are two or more beneficiaries or other claimants, each beneficiary must complete a "Statement of Claimant", Each beneficiary must make a separate statement. Statement of Claimant CONTRACT NUMBER(S): o Decedent Information - (Please print in ink or type) ~dSe"\.\\\06 First S ooG t8~l+B Residence at time of death 503- Street G R~DI<..~ ~~~-AlJ)( Middle Last Ro CAIJIAP \~\LL- City VA State l "1a\ \ Zip Name Dc:e. \ 7) \q~b d-cD5 \<:x:.~~ I ~i, Cp..~::::N.~ ~1 Place of De:uh Cause of Death DEe... ()''5 , , Date of Birch Date of Death . o Beneficiary or Claimant Information \ lfv'1-A.Ll..oi \)e:::S~~~ i Middl} c:: Last &--rrLE'" b,(2Ee~ \)~ QOC~TerL Street City S8S-~q~-OO3bC ~~ Date of Birth Day Time Telephone Relationship to Deceased Are you subject to back-up withholding? (Has the IRS contacted you direcdy to inform you that you are subject to back-up withholding?) o Yes ~o In what o.pacity or tide do you claim these proceeds of insurance? Check one: ~endlciary 0 Assignee 0 Trustee 0 Executor/Administrator o Other (Pk4Suxp/ain) S~\...J \ (PS -:s8 ~J, 383 Name First Social Security Numberrrax ID Number \-.J ~ \c\:1o~+ State Residence ~~ ~dr.8 Zip lqs~ SOV\ o Guardian 8 Payment of Fund (Piel1J~ I~/~ct Alt~rnativ~ l, II or III be/ow) . ALTERNATIVE I: SPOUSE PRIVILEGE I SUCCESSOR OWNERSHIP The spouse beneflciary of a Tax-Sheltered Annuity (TSA) may elect to rollover the proceeds into an IRA under the same contract, regardless of the issue date. D As the surviving spouse and sole primary beneflciary of this annuity contract, I wish to be designated as the successor owner. I understand that the contract will remain in force with the original effective date and no death benefit disrribution, will occur, Maturity Date of Contract: (Unless otherwise requested, the maturity date will be the original date selected at issue.) . ALTERNATIVE II: INSTALLMENT PAYMENTS - Not every option is available in accordance with IRS regulations. Contact the Claims Department to receive an estimate of your installment payment and the availability of each option. Proof of hirth is required with liD Lift Income options. Payment Frequency; 0 MonthJy 0 Quarterly 0 Semi-Annually 0 Annually o Continuation ofInstallmenr hymem currently in effect. o Income for a Specified Period - Indicate number of years (between 3 and 30): D Income for a Specified AmOUnt - Indicate amount desired (fixed accounts only): $ D Life J ncome o Life Income with Installments Guaranteed - Indicate number of years guaranteed: 0 5 0 10 0 15 0 20 0 25 0 30 o Life Income with Installment Refund (fixed accounts only) Funds in variable O)fitracts will remain in current subaccoums unless otherwise indicated: Fund: % Fund: % .. f. ~.:' ~n,;~,." lJ ' T". _\ )';~~_ (' ,(,,"I;C!;:J ..' ~ ~ ~~f"~.n ~.J (See Other Side) WITIIHOLDING INFORMATION. (Complete only if sdecting installment payments.) PUJ1Jt compltu A, B or C btlow. If this $tction is not computed wt art rtquirtd to withhold according to IRS standards, which currmtly aJlows 0 deductiom and a single status. A. 0 I elect not to have income tax withheld from my benefit payments. B. 0 I prefer tax withholding from each payment to be based on the number of deductions and marital status indicated. Number of Deduccions: EJ Single 0 Married 0 Married, but withhold at a single rate C. 0 Please withhold the following percentage or dollar amount from each payment: (Federitl LzUJ may tYquin th4t we withhoU 20% of the Iaxilhle 4ttUJunt on s(Jme qUAlified pLz7l$.) . AlTERNATIVE ill: SINGLE SUM PAYMENT - (If the procmis an: tQ be paid as one sttt/nnmt, paymntt wiU be matk under the Kemper Invmorr Im~diak Omwnimce Acrount (KUCAccount), iftiigibu. PI1J~t under this method is co~d to be a fiJl distribution fOr tax purpws.) Important N~ou rkct this opMn and thm choou to rollover annuity proceeds.'lou wiD n(Cd to Jq so within 60 days of your KLIC account "ch<<k book': ~ Single Sum Payment If you select this payout option, The Comp;my is tequired to withhold 10% of the taxable amount from YOUt payment, unless you elect otherwise. If you do not want any federal income tax withheld from your annuity proceeds, please check the box below. o I do not wish to have federal income tax withheld from the taxable porrion of the annuity proceeds, and understand that I am still liable fot payment of federal income tax on the taxable porrion. (Federitl uw may require that we withholJ 20% of the tmtabk 4mount on some q-ufUJ puns.) rt Beneficiary Designations (To be completed if selecting alternative I or II under payment of funds) Primasy Bcncficiary(ies) Contingent BeneGciary(ics) (Show percent each is to receive) % Relationship (Show percent each is to receive) % Relationship DStatement of Lose Contract (Compute only ifcontract is unavailabk for return) Cl I am unable to locate the original annuity contract. I agree to return the contract to the company if found. D Signatures I have carefully read my contract and agree to the terms and conditions of my selected payout option. By signing below, I am claiming annuity proceeds from The Company and agree that all required forms shall be made a parr of this claim. I undermmd that the eype. of payment option selected may not be changed after the first payment is received. 1 further understand that the furnishing of this form, or of any supplemental forms, by the Company shall not constitute nor be considered an admission by it that there was anyannuiey contract in force on the life in question. nor a waiver of any of its rights Ot defenses. The Company cannot be responsible for any expense incurred in connection with (he completion of rhe Claim Form. Notice to California Residents For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent cbim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. I understand that any person who, knowingly and with intenr (0 injure, defraud at deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information may be guilty of a criminal act punishable under the law. - ~~~ \a.V\ ~qjlOO~ Claiman Signature Date ( Agent Signature Agent Number ~ ~ ' Subscribed to and sworn btfor~e me this ;;; 7" dar;rJ :/--'~ ;;?C?~ ~~ -'1-~ I ~U".IUN"V.SR.""" C .. " E' No ry Public . Sea U lkleuyPublic in \he SI"tc tll New Y Ommls.SlOn or crm xplres MONROECOVNrY~~~ 3159-ANN-<l4 CcmIDIuiooExp_....3J.~ (06105) i:"-'~',fn " l'T" 9~,C-"';~ L~i,I\.;" ; I LAST WILL AND TESTAMENT OF JOSEPHINE DESORMEAUX I, Josephine Desormeaux, of Cumberland County, Pennsylvania, being of sound mind and memory, do make, publish and declare this my Last Will and Testament, hereby revoking any and all wills by me heretofore made. FIRST: I direct that my funeral be conducted in a manner corresponding with my estate and situation in life, and that all my just debts and funeral expenses be paid and satisfied by my Executor hereinafter named, as soon as conveniently may be after my decease. SECOND: I give, devise and bequeath all of the rest. residue and remainder of my estate, both real, personal and mixed, of whatsoever kind and wheresoever situate, to my children, stephen Malloy-Desormeaux, Marie Rhoads and David Desormeaux, share and share alike; providing however, that is Stephen Malloy-Desormeaux predeceases me, then his share shall be devised and paid to David Desormeaux. THIRD: I hereby nominate. constitute and appoint my son, Stephen Malloy-Desormeaux, to be the Executor of this my Last will and Testament. If the said Stephen Malloy-Desormeaux is unable or unwilling to serve as such, I then appoint my daughter-in-law, Eileen Malloy-Desormeaux to serve in such capacity. I direct that my personal representative be excused from entering and/or filing any bond to assure the proper performance of his/her duties. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 27th day of November, 2002. -,,;-., TESTATRIX a A' J~~;t:.J~'J ~~ (SEAL) ~NE DESORMEAUX . . '.\ k,J ..; ,'If' t _: -l',-"l-J'V ~.'~:~llJ~ . PAGE 1 OF 2 PAGES ) \\'j 0\ ",,~ .., WJi' ')\)0i., ~1 , . ~, ' OJ:,>:'::::' ::U\~:j\):.l" J-l" O"~6D 10 Register of Wills of Cumberland County INVENTORY Estate of Josephine Desormeaux Also known as Estate No. 2106-0026 Date of Death 12/25/05 Social Security No. 201-16-5610 , Deceased Stephen Malloy-Desormeaux , Personal Representative(s) of the above Estate, deceased, verify that the items appearing on the following inventory include all of the personal assets wherever situate and al] of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory (PEF S 3301). I1We verify that the statements made in this inventory are true and correct. l/We understand that false statements herein made are subject to the penalties of 18 Pa,C.S. Section 4904 relating to unsworn falsification to aurhorities Name of Attorney: Norman M. Yoffe, Esq. I 07135 LD. No.: P I R ,Stephen Mallov-Desormeaux ersona epresentatlve: . Address: 33 Battle Green Drive Address: 214 Senate Avenue, Suite 404 Rochester, NY 14624 Signature:~ Vvl.":c.tk1 C'p~,,)"(Y'rCQ~ " ~ Date: 03/30/06 Camp Hill, P A 17011 Telephone (717) 975-1838 Description Real Estate: 1. #503 Erford Rd (E. Pennsboro Twp.) Camp Hill, PA (for title see Cumberland County Record Book 177, Page 827 Personal Estate: 1. Hal1ford Auto Insurance Rebate 2. Comcast Cable Rebate 3. Sovereign Bank Accounts: a. Demand Deposit alc #23310493237 b. Demand Deposit alc #23341119078 c. Cel1ificate alc #0355004094 d. Certificate alc #2335251340 e. Certificate alc #2335251365 4. Refund from Frontier phone account 5. Refund fI'om MetLife fOl' Rochester apt. insurance 6. Refund from Hartford Insurance for homeowners Camp Hill 7. HSBC, Rochester, NY savings alc 8. 900 shs Constellation Energy Group 9. 300 shs Energy East Corp. 10. 388.50 Prime Fund shares @ 1.00 per share (Attach Additional Sheets if necessary) $150,000.00 $208.00 $36.50 $22,965.25 $5,338.61 $26,796.36 $26,676.38 $29,974.65 $12.26 $80.00 $107.00 $2,006.63 $51,111.00 $6,888.00 $388.50 Total $322,589.14 Value o :=0 rTi:;:J "T! -0 0 :u::r: r- -Pm '> ::z; ::IJ ",::::cn:;:>-;: ::"7 (") 0 ,-:;0" (')c " ::IJ :D-; J:::.- r-..> c.-..;:> = 0' ;00. -0 ::u N .&"' > ::x CO c....> --J C' -11 -')-1 (~) !Ii NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory. I~W_Ll PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT L-UIVIIVIUNWtAL I H Uf- PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 ECEIVED FROM: YOFFE NORMAN M WEST SHORE OFFICE CENTER 214 SENATE AVENUE SUITE 203 CAMP Hill, PA 17011 n_n_ fold ESTATE INFORMATION: SSN: 201-16-5610 FILE NUMBER: 2106-0026 DECEDENT NAME: DESORMEAUX JOSEPHINE DATE OF PAYMENT: 04/24/2006 POSTMARK DATE: 04/24/2006 COUNTY: CUMBERLAND DATE OF DEATH: 12/25/2005 REV-1162 EX(11-96) NO. CD 006589 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $3,013.99 I I I I I I I I TOTAL AMOUNT PAID: $3,013.99 REMARKS: CHECK# 3773 SEAL INITIALS: MG RECEIVED BY: REGISTER OF Will !'; GLENDA FARNER STRASBAUGH REGISTER OF WILLS