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Home My WebLink About05-04-06 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 KESSLER MOLLIE M 968 SILVER LAKE ROAD LEWISBERRY/ PA 17339 -------- fold ESTATE INFORMATION: SSN: 162-22-2845 FILE NUMBER: 2105-0767 DECEDENT NAME: EBERSOLE FREDA M DATE OF PAYMENT: 05/04/2006 POSTMARK DATE: 05/04/2006 COUNTY: CUMBERLAND DATE OF DEATH: 08/18/2005 NO. CD 006657 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $42/278.95 I I I I I I I I TOTAL AMOUNT PAID: $42/278.95 REMARKS: CHECK# 1001 SEAL INITIALS: MG RECEIVED BY: REGISTER OF WILLS GLENDA FARNER STRASBAUGH REGISTER OF WILLS REV-1500 EX (6-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 :REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY ,. FILE NUMBER COLNTY CODE YEAR N..MIER DECEDENTS NAME (lAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER .... Z EBERSOLE, FREDA M 162-22-2845 W DATE OF DEATH (MM-DD- YEAR) DATE OF BIRTH (MM-DD- YEAR) THIS RE1lJRN MUST BE FILED IN DUPUCATE WITH THE C W 08-18-2005 02-27-1925 REGISTER OF WILLS (J W (IF APPUCABLE) SURVMNG SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER C w [Z] 1. Original Retum D 2. Supplemental Return D 3. Remainder Return (dale of d8BIh prior 1012-13-82) ~ ~~cn D 4. Limted Estate D 4a. Future Interest Comprcmise (date of death after 12-12-82) [Z] 5. Federal Estate Tax Return Require:! (JO::~ w[LU [Z] D ~ IOO 6. Decedent Die:! Testate (Attach copy of WII) 7. Decedent Maintaired a Uvirg Trust (Attach cqlY ofTnsl) 8. Total Number of Safe Deposit Boxes (JD:::....J [Lal [L D 9. Litigation Proceeds Received D 10. Spousal Poverty Credit (dale of death between 12-31-91 am 1-1-95) D 11. Election to tax under See. 9113(A) (Attach Sch 0) c( ~ '.THIS....SECTION\MUST<BE;.COMPllE'tE[);1~CCJRRESRONDENCE'ANDC()NEIDENtIAl.:',.AXi.1fEORMlATlOO"'SHOOI.D';BEiDlRECTEDT0: z NAME COMPLETE MAILING ADDRESS w Cl MOLLIE M KESSLER 968 SILVER LAKE ROAD z 0 FIRM NAME (If Applicable) 0- LEWISBERRY, PA. 17339 en w D::: a::: TELEPHONE NUMBER 0 (J 717-938-4583 . 1. Real Estate (Sche:lule A) (1) 141, 620. 00 6f2F,ty IAL Us5i:>NL't:- ~i=.~ 534, 319. 76 _ --:1 C~) 2. Stocks and Bonds (Schedule B) (2) I -.< ~ 1J o. 00 ~} 3. Closely Held Corporatioo, Partnership or SoIe-Prq>rietorship (3) I I i:r~ J:'"- C::J 4. Mortgages & Notes Receivable (Schedule D) (4) o. 00 I C') -CJ "'<"1 34, 810 17 I ~~,.. '-~,,, 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) . "'~'.,' .... .. F (Schedule E) - ..,. !T Z . . (;~~ 0 6. Jointly 0Nned Property (Schedule F) (6) 6, 940. 96 N 5 w D Separate Billing Requeste:! 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) 917, 104 64 ::J ~ (Schedule G or L) c: 8. Total Gross Assets (total Lines 1 - 7) (8) 1, 634, 795. 53 <3: (J 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 14, 611. 66 w a:: 10. Debts of Decedent, Mortgage Liabilities, & Uens (Schedule I) (10) 1, 305 00 11. Total Deductions (total Unes 9 & 10) (11) 15, 916. 66 12. Net Value of Estate (Une 8 minus Une 11) (12) 1, 618, 878 . 87 13. Charitable and Governmental Bequests/See 9113 Trusts for whidl an election to tax has not been (13) 984 . 00 made (Schedule J) 14. Net Value Subject to Tax (Une 12 minus Une 13) (14) 1, 617, 894 . 87 SEE INSTRUCTIONS FOR APPUCABLE RATES Z 0 15. Amount of Une 14 taxable at the spousal tax ~ rate, or transfers under Sec. 9116 (a}(1.2) X .0_ (15) O. 00 1, 617, 894 87 .0 45 72, 805. 27 ~ 16. Amount of Une 14 taxable at lineal rate . X (16) ::J a. 17. Amount of Une 14 taxable at siblirg rate X .12 (17) o . 00 :E 0 18. Amount of Line 14 taxable at cdlateral rate X .15 (18) 0 00 (J . ~ 19. Tax Due (19) 72, 805. 27 20.0 I'CHECK'NERE.;IEj~~i~J.Cl~J"".frmF~'OE.U.;D\lERPAYMEN'F}1 . ~:~' .j.; .: :,.;, : '::;" "';;\!i1lt;te>;~;BE;'SURE;rnc>~WER;~~Q(JES\'[:I()NS'.,ON.".BEVERSE'SIDE.;AND'.~REOHECt(MATHi<1<;.\"..!..................... %# STf PA42021F.1 Cj (Yb, -7/ ~"', ,.> Decedent's Complete Address: .. STREB ADDRESS 36 CAMPBELL PLACE CITY CAMP HILL I STATE PA I ZIP 1 7 0 11 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 72,805.27 29,000.00 1,526.32 Total Credits (A + 8 + C) (2) 30,526.32 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 0.00 42,278.95 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT 42,278.95 PLEASE ANSVVER THE FOLLOVVlNG 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? . . . .. 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. [Xl 0 IF THE ANSWER TO ANY OF THE ABOVE QLESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjllY. I declare that I have examined tns return. irduding cccompanying sd1edules and statements, and to the best of my knowledge and belief, it is true, correct and ccrnplete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ('1'\ t;{~. 1)\, ~- ADDRESS &J6&" 5--/L v e ^ L Y-J-re X (J ~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE No ~ ~ ~ [ZJ ~ [:xJ DATk .57~ 'O~ l' ~ (,1,..' [ .r lJ c:n ~ y Pn /J33 7 DATE ADDRESS For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate im posed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. 99116 (a) (1.1) (i)]. 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. 99116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 99116(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. 99116(1.2) [72 P.S. 99116(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. 99116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. STFPA42021F.2 j ~ J R ('. ~ WALZ & WALZ ATTORNEYS AT LAW Newport, Pa. LAST WILL AND TESTAMENT OF FREDA M. EBERSOLE I, FREDA M. EBERSOLE, of Penn Township, Perry County, Pennsylvania, do make, publish and declare this to be my Last Will and Testament, hereby re- voking all Wills and Codicils at any time heretofore made by me. FIRST. I direct that all my just debts, funeral expenses, grave marker and the costs of the administration of my estate be paid out of my estate as soon as may be convenient after my death. SECOND. I give, devise and bequeath all my property of every nature and wherever situate to my husband, HOMER D. EBERSOLE, providing he shall survive me by thirty (30) days. THIRD. If my husband, HOMER D. EBERSOLE, shall die within a period of thirty (30) days after my death, I direct that he shall be deemed to have pre- deceased me and that the provisions of my Will shall be construed upon that assumption. During the portion of such thirty (30) days as my husband, HOMER D. EBERSOLE, shall actually survive me, he shall have the right to the use and enjoyment as life tenant of the property devised and bequeathed to him herein. FOURTH. In the event that my husband, HOMER D. EBERSOLE, predeceases me or dies on or before the thirtieth (30th) day following my death, I give, devise and bequeath all the rest, residue and remainder of my estate, whatso- ever and wheresoever situate, in equal shares to my two (2) daughters, namely: CAROLYN EBERSOLE HOOPER and MOLLIE EBERSOLE KESSLER. In the event that either of my children predeceases me, her one-half (~) interest in my estate shall go to my other daughter, then surviving. Page- 1 of 2 Pages " ~ .f'"".. WALZ & WALZ A"'ORNEYS AT LAW Newport, Pa. FIFTH. I nominate and appoint my two (2) daughters, CAROLYN EBERSOLE HOOPER and MOLLIE EBERSOLE KESSLER to be Co-Executrixes of this my Last Will; they are to serve as such without bond. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 3u day of bee c2,..(,V\~~r, 1983. ff g d-a- m. ~,?A~"J~ Fre aM. Ebersole (SEAL) The preceding instrument, consisting of this and one (1) other type- written page, each identified in the margin thereof by the signature of the Testatrix, was on the date thereof signed, published and declared by FREDA M. EBERSOLE, the Testatrix herein named, as and for her Last Will, in the presence of us, who at her request, and in the presence of each other, have subscribed our names as Witnesses hereto. (SEAL) EAL) Page- 2 of- 2 Pages 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 KESSLER MOlliE M 968 SilVER LAKE ROAD lEWISBERRY, PA 17339 .------- fold ESTATE INFORMATION: SSN: 162-22-2845 FILE NUMBER: 2105-0767 DECEDENT NAME: EBERSOLE FREDA M DATE OF PAYMENT: 11/04/2005 POSTMARK DATE: 11/04/2005 COUNTY: CUMBERLAND DATE OF DEATH: 08/18/2005 NO. CD 005974 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $29,000.00 I I I I I I I I TOTAL AMOUNT PAID: $29,000.00 REMARKS: CHECK# 107 SEAL INITIALS: JA RECEIVED BY: TAXPAYER GLENDA FARNER STRASBAUGH REGISTER OF WILLS ,. INHERITANCE TAX PREPAYMENTS SHEET FOR INFORMANT RETURNS LATER BEING FILED Full Name of Decedent FREDA M. EBERSO~E Date of Death 08-18-2005 Estate File No.: 2005-00767 Social Security Number 162-22-2845 Informant's Name and Address MOLLIE M. KESSLER 968 SILVER LAKE ROAD LEWISBERRY, PENNSYLVANIA 17339 Attorney's Name and Address (If applicable) ,(' STATE OF FREDA M. EBERSOLE 60-7269/2313 MOLl.IE M. KESSLER EXEC. 0571199801 CAROLYN M. HO.OPER EXEC. . < .,. 968 SILVER LAKE RD.. .' ... NI){~ ~j~5' LEWISBERRV, PA 1~9 t -. , .. " ,~"'::, .., ~~ I?~Aj-#f~r ~ ' ./If-r . 'r'$ o!:,mJ.. ' 0-0 ~)~ ~~ &1~aJ .. 11111 ~ =-= _Sovereigli Bank- sovereignbank.com .- &~~.~ :jI: .2 :. ~ :. ?c b q ~ I: ~mt.. ~.' .A 107 /1~~L ~h OS? ~ ~ q qaO -1.1110 ~O? ... J"""" . ~ REV-1502 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER FREDA M EBERSOLE 2005-00767 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION RESIDENCE AT 36 CAMPBELL PLACE,CAMP HILL, PA sold at public sale 11/19/2005 VALUE AT DATE OF DEATH 141,620. TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed. insert additional sheets of the same size) 141,620.00 SlF PA42021 F.3 1 < 1 N A L ~ t. 1 1 L.t 1V1 L : For the Real Estate Property from the Estate of FRED/\. EBERSOLE II Date: Noven1ber 19, 2005 nwnp.r" Frp.r1~Fhp.rs() 1p Adrlrpss- ~f) r~nllrhp'll PI~re r~nlr Hill P:1 n~tf' ()r~~lp" N(nl(~mhp'r 1 qtb Jon!) ~::llp 1 o (,:::It1()1l" Sitp A lVH/P A 1 w:tlnnpp.r- wlnl~m r ~()wprs ntl1f'~r-W::lynp l( onr Proceeds of Sale: Cash: Checks: 1 ()u/n'Down oTR p.~l ~ <:.:t::ltp'-Propp.rty ~14. t1DO nn Total Proceeds of~~lp- $1 4f) non ()o LESS .SELLtRS EXPEr'rSES: Auctioneer's Fee: 30;0 of Total Real Estate Property $4,3"SO.OO Other Sellers Expenses Advanced by A.uctioneer: Advertising in -PersonalProperty-Settlement Sheet Mise (see list attacherl) N onp DEDUCT T-G'-fA-L-SELLERSSALE-8 EXPENSE- $4.'~R() D() TOTAL NET PROCEEDS TO ESTATE: $141 /,?O O() I (We) the sdler of goods. merchandise, and/or property sold at public auction on the above dates, acknowledge and accept this settlement of proceeds orsa!e. ~ .///J,.--' Date: November J 9, 2005 ~:;,; Ql:h-(~\;>;o-// Sellers Signature: REV-1503 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ,. ESTATE OF FREDA M EBERSOLE FILE NUMBER 2005-00767 All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION 1. 2 3 4 PPL CORPORATION 1625.240 shares@ $61.35 each SOVEREIGN BANCORP, INC. 3,857.7183 shares@ $23.95@ WACHOVIA SECURITIES ACT# 2973-8236 JANNEY MONTGOMERY SCOTT ACT# HB25 2974-3679 Accrued interest on account above Bank municipal Bond 5 VALUE AT DATE OF DEATH 99,708.47 92,392.35 91,577.00 229,839.31 1,574.92 19,227.71 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) STFPA42021F.4 534,319.76 ~ PPL Corporation Two North Ninth Street Allentown, PA 18101~1179 htto://www.oolweb.coml " 'ie ';''''~~$ ~~ ~ ~'<t~ ~ -,/" ~. .- ~" .... ~'~ ~ -<< - .'p'.pl ~:~- tiIB hi ... _ .-;,. tip",. '<9 -,;...... ~. Investor Services Toll Free Number 800-345-3085 .. 11,' Date September 9, 2005 Re: PPL Stock Account Type of Stock: PPL Corporation Common Stock CUSIP: 69351T-10-6 Account Number: 3099017152 Social Security Number: 162-22-2845 Account Registration: Freda M. Ebersole Date of Death: August 18, 2005 Number of Shares Currently Held: 250 In Certificate Form * 250 In Direct Registration * 2, 750.480 In Dividend Reinvestment Plan 3,250.480 TOTAL SHARES Nun1ber of Shares Held as of Date of Death: 250 In Certificate Form In Direct Registration 1,375 .240 In Dividend Reinvestment Plan 1,625.240 TOTAL SHARES $61.35 Closing market price of Common Stock on New York Stock Exchange on date of death or last business day prior to date of death. Other Comments: * There was a 2 for 1 conunon stock spl:it on August 24, 2005. The current market value is approximately $32.30 per share. PPL Corporation e INVE~Tg~ ~ ~hia A Buchman. lVlellon mVeSlOr .::>ervlces P.O. Box 3333 South Hackensack, NJ 07606 September 8, 2005 W Mellon ill Control Number Telephone Number Company I SOVEREIGN Name j BANCORP, INC. Account Key I EBERSOLE- J FREDMOOOO 1200509070007419 I 11800-522-6645 ---1 MOLLIE M KESSLER 968 SILVER LAKE ROAD LEWISBERRY PA 17339 RE: ESTATE OF FREDA M EBERSOLE Dear Sir or Nladam: Thank you for your inquiry reg hares in book form of the above referenced company. The closing Our records show this acc price on August 18, 2005 This letter contains ins tions for trans 'ng shares from an account when the owner(s) is deceased and the estate has been probated. not locate the stock certificate(s), or if the estate has not been probated, please call the toll-free number shown above to obtain further information and requirements. 50 Shares or Less More than 50 up to 250 Shares More than 250 Shares Submit items 1 and 2 Submit items 1, 2, 3 and 4 Submit items 1 through 5 or Submit items 1, 2, 3 and 5 Required Items 1. Completed Transfer of Stock Ownership form signed by the Executor or Authorized Representative. 2. The original stock certificates (if applicable). 3. Inheritance Tax Waiver (if applicable). If the deceased owner resided in one of the following states, please obtain an Inheritance Tax "\Vaiver from the state's Tax Departnl.ent Office. AL, CT, IN, MT: NC, NJ, NY, OR, OK, RI, SD, IN and Puerto Rico. 4. A certified copy, with original signature and seal affixed, of the Certificate of Appointment of Executor(s) dated with one year of the transfer. S. Medallion Signature Guarantee on Stock Ownership form. Note: All submitted documents will be kept as part of the permanent record of transfer and will NOT be returned. Please be sure you keep a copy for your records. Send the required items to: First Class/Resnstered/Certified Mail Mellon Investor Services POBox 3310 South Hackensack NJ 07606 Ovemight/Exoress Mail (only) Mellon Investor Services 85 Challenger Road Ridgefield Park NJ 07660 Visit Investor ServiceDirect@ at vVVv'W.melloninvestor.com/isd to sign up for Mlink, a secure server enabling you to view information or perform various transactions on your account. Sincerely, Mellon Investor Services o .0 o o W: 0, .0 ; 0' 0: o -0 : 0' 0: , , non ." ::O::I: s: Cl Cl 0 Cl ;;0 p.. n: s:: non I (J) tll:.s:: non ~ m)> m )> -IlJ (J) m)> )>)>)> -I -u m m I'1>)> -I "'0 0 m m,)> )> -I -u.s:: 0 r- 0 r 0 Z)> <;0 Z r- r- 02 < 0 m:z r 0 2.s::::O ;;o:z r 0 2 OJ r h; [ !: 0 U1 0 ;;0 ~ a ~::: .... c.n r-.." ~:o!:...... U1 m )> @:a !: 0 A ~ ~ G1 III O~' -<m(J)CIloo::::' m)> :Ul......e. 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Q \.n 'J ~ :~ <CIJ ~ ~~ Cltd tI1Z ~ 111 REV-1504 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP or SOLE-PROPRIETORSHIP ESTATE OF FREDA M EBERSOLE FILE NUMBER 2005-00767 Schedule C-1 or C-2 (Including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. N / A TOTAL (Also enter on line 3, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 STFPA42021F.5 REV-15D5 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-1 CLOSELY-HELD CORPORATE STOCK INFORMATION REPORT ESTATE OF FREDA M EBERSOLE FILE NUMBER 2005-00767 1. Name of Corporation Address City 2. Federal Employer 1.0. Number 3. Type of Business State Zip Code State of Incorporation Date of Incorporation Total Number of Shareholders Business Reporting Year Product/Service 4. TYPE TOTAL NUMBER OF NUMBER OF SHARES VALUE OF THE STOCK Voting / Non-Voting SHARES OUTSTANDING PAR VALUE OWNED BY THE DECEDENT DECEDENT'S STOCK Com man $ Preferred $ Provide all rights and restrictions pertaining to each class of stock. 5. Was the decedent employed by the Corporation? Dyes DNa If yes, Position Annual Salary $ 6. Was the Corporation indebted to the decedent? 0 Ves D No If yes, provide amount of indebtedness $ 7. Was there life insurance payable to the corporation upon the death of the decedent? Time Devoted to Business DVes DNa If yes, Cash Surrender Value $ Owner of the policy 8. Did the decedent sell or transfer stock of this company within one year prior to death or within two years if the date of death was prior to 12-31-82? D Ves D No If yes, D Transfer 0 Sale Number of Shares Net proceeds payable $ Transferee or Purchaser Attach a separate sheet for additional transfers and/or sales. Consideration $ Date 9. Was there a written shareholder's agreement in effect at the time of the decedent's death? If yes, provide a copy of the agreement. Dves DNo 10. Was the decedent's stock sold? Dves DNa If yes, provide a copy of the agreement of sale, etc. 11. Was the corporation dissolved or liquidated after the decedent's death? 0 Ves D No If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 12. Did the corporation have an interest in other corporations or partnerships? Dyes DNa If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C~2 for each interest. A. Detailed calculations used in the valuation of the decedent's stock. B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years. C. If the corporation owned real estate, submit a list showing the complete address/as and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent. E. List of officers, their salaries, bonuses and any other benefits received from the corporation. F. Statement of dividends paid each year. List those declared and unpaid. G. Any other information relating to the valuation of the decedent's stock. STF PA42021 F.6 REV-1506 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C-2 PARTNERSHIP INFORMATION REPORT ESTATE OF FREDA M EBERSOLE FILE NUMBER 2005-00767 1. Name of Partnership Address City 2. Federal Employer I.D. Number 3. Type of Business 4. Decedent was a 0 General Date Business Commenced Business Reporting Year State lip Code Product/Service D Limited partner. If decedent was a limited partner, provide initial investment $ 5. PERCENT OF PERCENT OF BALANCE OF PARTNER NAME INCOME OWNERSHIP CAPITAL ACCOUNT A. B. C. D. 6. Value of the decedent's interest $ 7. Was the Partnership indebted to the decedent? Dyes D No If yes, provide amount of indebtedness $ 8. Was there life insurance payable to the partnership upon the death of the decedent? 0 Yes D No If yes, Cash Surrender Value $ Net proceeds payable $ Owner of the policy 9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was prior to 12-31-82? Dyes 0 No If yes, 0 Transfer D Sale Percentage transferred/sold Transferee or Purchaser Consideration $ Date Attach a separate sheet for additional transfers and/or sales. 10. Was there a written partnership agreement in effect at the time of the decedent's death? Dyes D No If yes, provide a copy of the agreement. 11. Was the decedent's partnership interest sold? DYes DNo If yes, provide a copy of the agreement of sale, etc. 12. Was the partnership dissolved or liquidated after the decedent's death? DYes DNo If yes, provide a breakdown of distributions received by the estate, including dates and amounts received. 13. Was the decedent related to any of the partners? Dyes 0 No If yes, explain 14. Did the partnership have an interest in other corporations or partnerships? DYes D No If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest. A. Detailed calculations used in the valuation of the decedent's partnership interest. B. Complete copies of financial statements or Federal Partnership Income Tax returns (Form 1065) for the year of death and 4 preceding years. C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have been secured, attach copies. D. Any other information relating to the valuation of the decedent's partnership interest. STF PA42021F.7 REV-1507 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 0 MORTGAGES & NOTES RECEIVABLE ESTATE OF FREDA M EBERSOLE FILE NUMBER 2005-00767 All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. N / A TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 STF PA42021F.8 REV-1508 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FREDA M EBERSOLE FILE NUMBER 2005-00767 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. SOVEREIGN BANK ACT#0461074311 CHKG incl. accr. int 15,549.98 2 SOVEREIGN BANK ACT#1055449094 CD incl, accr. int 10,705.21 3 PERSONAL PROPERTY cold at auction 1,925.60 4 PNC BANK SAVING 5004149796 incl> accrued interest 6,629.38 TOTAL (Also enter on line 5. Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 34,810.17 SlFPA42021F.9 Sovereign Bank ESTATE OF SOCIAL SECURITY #: DATE OF DEATH: Freda M Ebersole 162-22-2845 August 18, 2005 Account #: 0461074311 Type: In the name of: Freda M Ebersole Date of Death Balance: Int.(YTD) from 1/1/2005 to Accrued interest to date of death: Other Info: Checking Open date: 3/8/1995 $15,535.25 7/29/2005 $14.73 $152.18 1()3r;~J' ~ ,r{VCf,CfB I Account #: 1055276438 Type: CD in the name oi: Freda M Ebersole ITF Erica Michelle Kessjer Date of Death Balance: $13,039.04 Int.(YTD) from 1/1/2005 to 7/31/2005 Accrued interest to date of death: $34.82 Other Info: 1 0/5/2000 ~f j p-J t-J ). ilL 11- e :J-~ ,~ Open date: $381.98 Account #: 1055449092 Type: In the name of: Freda M Ebersole Date of Death Balance: Int.(YTD) from 1/1/2005 to Accrued interest to date of death: Other Info: CD Open date: 8/27/2003 $1 O~686.02 7/25/2005 $211.69 ~~c ~G '-!.' ..! ..': .I ,." Page 1 of 1 1 O,6~~,O"1- I Ci 1/1 ~ 10, FINAL SETTLEi\1ENrr For the Personal Property from the Estate of Freda Ebersole Date:Noven1ber~ 19~2005 Ownp.r. Frp:rl~ Fhpr,() Ip: Arldrp". if) r:lmphp:ll Phrf' ('::tt11P Hin p~ 17011 O/ltP. ()fS~Ip:.N()vPt11hp:r lQlh Ion") S~lp I ()r.~ti()n' Sitp Ahovp: A lIc:tlonp:p:r. Wl111~m r Sowpr, ()thpr. Proceeds of Sale: Cash: $())1 00 Checks: ~) ,)14 00 Total Proceeds of S~lp.'$? ,s~~7 00 LESS SELLERS tXPENSES: Auctioneer's Fee: 20% of Total Personal Property $571.40 Other Sellers Expenses Advanced by Auctioneer:........ A.dvertising (2) Guide Ads @$11-S."50 (1) Patriot Ad @ $123.00 TOT AL$360.00 Misc ("pp 11"t ~tt~r.hprl) Nonp. -DEDUCT TOTAL SELLERS -SALES EXPENSE- $Q11 4.0 TOTAL NET PROCEEDS TO ESTATE: $ l,Q,)~ (\0 I (We) the seller of goods, merchandise, and/or property sold at public auction on the above dates, acknowledge and accept th is settlement of proceeds of sale. Date: November 19. 2005 /~I "> . Auctioneer SignatureL$~<_,__"';_<"'<-'" Sellers Signature: / DEC-05-2005 18:27 PNCBRNK 41; 768 3458 o PNCBAN< December 2, 2005 Ms. Mollie Kessler 968 Silver Lake Rd. Lewisberry, P A 17339 S( RE: Estate of Freda M Ebersole (Deceased) SSN: 162-22-2845 DOD: 08-18-2005 Dear Ms. Kessler: In response to your request for Date of Death balances for the customer not( above, our records show the following: Checking Account Account #5140142302 Established 10-25. )00 FREDA M EBERSOLE MOLLIE M KESSLER DOD balance: $13,881.65 + $0.26 accrued interest Savings Acconnt Account #5004149796 Established 11-10- '03 FREDA M EBERSOLE DOD balance: $6,621.45 + $7.93 accrued interest Please note that this office only provides date of death balances for deposit a :ounts (IRAs, CDs, Checking and Savings accounts). We do Dot process any fiIla :iaJ transactions or provide statements. If you need assistance with any of the items, please call 1-888-PNC-BANK (1-888-762-2265) or stop by your local PNC ank branch office. Sincerely, L:1~ Erica L Schlegel 1-800-762-1775 P7-PFSC.04-F 500 Pirst Ave. Pittsburgh P A i 5219 Me. -er FDIC P.02 TOTFIL P. 02 REV-1509 EX + (1-97) (I) COMMCNWEALTH OF PENNSYLVANIA INHERITAN:ETAXRETLRN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF FREDA M EBERSOLE FILE NUMBER 2005-00767 If an asset was made joint within one year of the decedenfs date of death, it must be reported on Schedule G. SURVNING JOINT TENA.NT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. MOLLIE M KESSLER 968 SILVER LAKE ROAD LEWISBERRY, PA. 17339 DAUGHTER B. c. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PRCPERTY %OF DATE OF DEATH ITEM FOR JOINT MACE Irdllle name of finarcia irstil1Jlion ard bai< accou1lUTtler or sinilar ider1ifyirg rurber. DATE OF DEATH DECO'S VAWE OF NUMBER TENANT" JOINT Attach deed for joir1ly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 10/2: /2000 PNC BANK CKG ACT#5140142302 13,881.91 50 6,940.96 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 TOTAL (Also enter on line 6, Recapitulation) $ 6,940.96 STF PA42021 F.10 (If more space is needed, insert additional sheets of the same size) / DEC-06-2005 18:27 PNCBANK 41~ 768 ..54':>t:l o PNCBAN< December 2, 2005 Ms. Mollie Kessler 968 Silver Lake Rd. Lewisberry, PA 17339 S( RE: Estate of Freda M Ebersole (Deceased) SS~: 162-22-2845 DOD: 08-18-2005 Dear Ms. Kessler: In response to your request for Date of Death balances for the customer note above, our records show the following: Checking ACCOUDt Account #5140142302 Established 10-25. )00 FREDA M EBERSOLE MOLLIE M KESSLER DOD balance: $13,881.65 + $0.26 accrued interest Savings Accollnt Account #5004149796 Established 11-10- '03 FREDA M EBERSOLE DOD balance: $6,621.45 + $7.93 accrued interest Please note that this office only provides date of death balances for deposit a :ounts (IRAs, CDs, Checking and Savings accounts). We do Dot proceSI any fina :iaJ transactions or provide statements. If you need assistance with any of the items, please call1-888..PNC-BANK (1..888-762-2265) or stop by your local PNe mk branch office. Sincerely, L~~ Erica L Schlegel 1-800-762-1775 P7-PFSC..04-F 500 first Ave. Pittsburgh P A 15219 Mer (:r FDIC r' . ~~ III TOTr;lL P. 02 FROM : FRX NO. Rpr. 10 2005 07:19PM P7 COMMDNWEALTH OF PENNSVLVAN!A nEPARTME~r OF REVENUE BURE~U OF INDIVIDUAL TAXES DEPT. 280601 ~~RISBURGJ PA 17128-0601 '* INFORMAT!ON NOTICE AND TAXPAYER RESPQNSE FILE NO. 21 05-0767 ACN 06104294 DATE 02-07-2006 RtIV-lSU EX AFP [09.0Dl EST. OF FREDA M EBERSOLE 5.5. NO. 162-22-2845 DATE OF DEATH 08-18-2005 COUNTY CUHBJ;R1AND '. .:. TVPE OF ACCOUNT D SAV:IN&S [X] CHECKING o TRUST o CERTIF. MOLLIE M KESSLER 968 SILVER LAKE RD LEWISBERRV PA 17339 REMIT P~VMENT AND FORMS TD: REGISTER :OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE.l .PA 17013 PNC BANK h~~ provided the De~artmRnt ~i~h tne ln~orma~ian li~ted below whiah'h~ been'used ift CBICulatl~g the potentIal tax dua, Th8~r records'indlaata t~t at the death o~ tha ~ove deCedeftt~ YQU,N8re a jolnt.ow~r~n~fi~iar~ of this account. If ~ou laBl thIs .1qfQr..tion is incorrec~, plgM~8 gbtain writtan correction .fro~ tho ~i~"~ial instltu~lon, ~~ch . eop~ to 'thh form'snd return it to the sDDve address. Thi~ account h tl!llxlSbb ifl ;;cx:ordBnce wl'tJ'J the Inheritance ,T8)( Lt!llWs of, thiia CoIII.ctnw881~ .~ -.o'nenn8yl~1i7 . Q~JOnS-IllaY be answer-aD gy caluog"'C11'i)' '(87.8~~---""" ...- -.-".--. ._--.... .... .-... .~.........;.~. -'--'-... .'. -' '--- COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING ANn PAYMENT INSTRUCTIONS Account No. 5140142302 Date 10-25-2000 Established Account Balanc8 Parcent Taxable AmDuni Subject to T.x Kate Potantial Tzx Du. x 13..881.91 50.000 6..940.96 .15 1..041.14 TAXPAYER RESPONSE To insure ~~O~gr gr~it to ~ur 8CCOunt~ tNa {2J copig~ af this notice mu~ ~agD~pa"Y ygur pBymBft~ to t~ Register o~ Will~. H~e ~h~ck payable to~ "Rggi$~r of Wills~ Agent". x NOTE 1 If 'ti!x pa~ments are lIIadca ..,i thin three (3) months of tha dG~d8nt.& date of de8th~ YOU .~y 'd8du~t a S~ discount of th8 ~xdue. Any i~hQr1t1nce tax dUB will beeo.v dvlinquent nin8 (9)' mgriths 8~tor ~R d~te of dg~th, Tax PAin [1]. A. 0 Tha abgVa inforlllBtlon end tax QUCI h; correct. 1. Vcu may choo5CI to r~~it pa~ent to tha RClgister of WillS with twa Dgpi85 of this natlca to abtDin e di~count or avoia int.~~$t, gr ~ou may check box "Aft and return thi~ no~i~Q ~a thu Rggj~*~r of Will~ and an official a$$~55~~nt will be i~suQd by the PA Departmant o~ RAVanUA. [CHECK ] ONE BLOCK ONLY ~. ~ The above l!I5SGt h~~ been or will be ....ElPlJrtsad ~"d tax paid with tha Puo":iYlvania Inl'leritatiGGt Tax r~t~rn to be filgd by thg decedent's ~epre5C1ntativg. c. c=J The above Ift~ormatian i~ incorrect 8nd/o~ dabts and d~uc~l~ns wa....e paid by yau. You must Caldplew PART 0 and/or PART @] bglolll. .' " PART I!1 TAX RETURN - COMPUTATION' OF LXNE 1. Date Establs'shad 1 2. Accouni: Ba1.nl;!V 2 S. Percent Taxable 3 4. Amount SUbject. to Tax 4 5, Debts and Dedu~tions .!i 6. AaDuni: Ta~abl. 6 7. Tax Rate 7 8. T~ ~ 8 TAX ON If you indicBts a diff.r.nt tax rate, plas$8 ~t.t. ~our relatlonsh1p '''to decedent: x x PART [!J DATE - .~ DEBTS AND DEDUCTIONS CLAIMED PAID ~ PAYEE DESCRIPTION AMOUNT PAID .=1. ~. .: =- .. : TOTAL tEnter on Line .5 of Tax Compu'lai:ion) , . . ~BrjurY1 X declare that th. fact$ I IlY 'kno"1'.d~8 and bell,-f. , I $ Under panalti8& of couplets tD the b.$t of havB rBPorted above are true, corrac~ and H.DME ( ) WORK' ( ) . REV-1510 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FREDA M EBERSOLE FILE NUMBER 2005-00767 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY %OF ITEM II\CLillE TI-E NtlME OF M TRANSFEREE. MIR RELATlONSHP TO DECEDENT MO TI-E DATE DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE NUMBER OF TRANSFER. ATTACH A COPY OF TH: DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPUCABLE) 1. All following Contracts have 2 daugh :::ers 0.00 for beneficaries equally. 0.00 2. AMERUS ACT#370863 31,094.53 100 31,094.53 3 . AMERUS ACT#391444-AMERICAN INV LIFE 16,040.93 100 16,040.93 4 . AMERUS ACT#364264-AMERICAN INV LIFE 81,233.99 100 81,233.99 5 . AMERUS ACT#364263-AMERICAN INV LIFE 2,043.13 100 2,043.13 6 . AMERUS ACT#360110-AMERICAN INV LIFE 5,437.92 100 5,437.92 7 . AMERUS ACT#360109-AMERICAN INV LIFE 17,434.46 100 17,434.46 8 . MIDLAND NATIONAL ACT#8500106287 702,687.42 100 702,687.42 9 . MIDLAND NATIONAL ACT#8500197639 61,132.26 100 61,132.26 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 TOTAL (Also enter on line 7, Recapitulation) $ 917 104.64 . . (If more space IS needed, Insert addItional sheets of the same size) SlF PA42021 F.11 AmerlJs Annuit~, GrcJup Co. 555 SO'.':1l11 Kar.ijaS A....e TI)!:eKa.. K5 666D3 1 ~-A:r':N CITY DecerrJber 13, 2005 AMERUS A llllUity. Group FREDi\ M EBERSOLE 36 CAMPBELL PL CAMP HILL PA 17011 RE: Contract#a7oaBa Dear Contract OVv'ner: Thank you 1br you\" request concerning your deferre':i annuity c~ntract. At American Investors Life. Vie are comrrlitted ~o pioviding you with tr,e best service in the industry. We are pl~.ased to be able to provide yo~ with the following contract values: Annuitant: FREDA Tv' EBE.RSOLE Plan: SPDA 8K5 Begjnnina Value as of: 02/21/2001 $30;000.00 Accurnulated Value as of: 08/18/2005 $32.294.53 Surrender Value as of: 08/18/2005 $31,094.53 CurrenLln7Arast R.ate: 6. 60Q~ Our Cllstomer Selvice Representalives appreciate the opportunity to assist you with YOUi service request. if you have any questions or cono~rns regarding your cor/tract, please caB us at GUi toB free number 1...888..266-.8489. Sincerely. Cecilia Morris Customer Services- -:'" ~;~~ _4..:.'\t1"!'.lTj1T'i l ~~ar:viNiP. 3sr~ )lC2' A\.tERlJS Lile 1. .gJ~.:SZ.5530 rCt1ST1)Mf? S":~'IC6l . ~?:tEI'..;c.~~ L~""\'ESTOit.S LIFE - ....~HUJ~ AmcrUs t\nntll!;, t,,{1'-ii" . ..- )~5 ~()lltll l>-.,Ul:-,tl:-, n~,'~ Topeka. K S 6h(\((-\ ~ ,1nil_ ~ )\'T~q 1('1'\ December 9, 2005 ,4 1l S. F ---- -sr._.._ V.firl ~"L .IK, jLli Anlluity Group Mollie Kessler 968 Silver Lake Road Lewisberry PA 17339 Re: Policy #391444 - American Investors Life Insured: Freda Ebersoie Dear"Ms. Kessler: Thank you for your recent request for information regarding the policy referenced above. The date of death value is noted below. Account Value: -August 1-8, 2-005 $16,040.93 -Date -of -Death: This is a qualified account. If -you should have any questions or need further assistance, please feel free to contact our office at 1-888-ANNUITY (1-888-266-8489). Sincerely, ~~~~ Andrea Snurtz Claims Specialist .AMERUS Life Al\fERICAN INVESTORS l.;IFE A. AiWER li.\ (-...,...., r'\merus Alllnm\.' ",;-;c,~,_ - 5 ;:;5 ,,-)(Hnli j,-~i~ i -1~'i~~. Topek~. KS 66603 1 _"U)(L r:.. 1''''11_ i tT\ December 9, 2005 .tt 1l1r:' ~ IF Tti:, _~ "iL..a... ~; c~- Alllluitv Grnun .... - - " ~ OJ. Mollie Kessler 968 Silver Lake Road Lewisberry PA 17339 Re: Policy #364264- American Investors Life Insured: Freda Ebersole UearMs.Kess1er: Thank you for your recent request for information regarding the policy referenced above. The date of death value is noted below. I nterest Amount: August 1-8, 2()fi5 $78,465.81 $2,768.18 $81,233.9B -Date uf Death: Principar Amount: - Account Value: If you should have any questions or need further assistance, please feel free to contact our office at 1-888-ANNUITY (1-888-266-8489). SillC~1 ~Iy, ~~~ Andrea Shurtz Claims Specialist A. AI\u:R US t:...,..... AME'RUS Life Al\'IERICAN INVESTORS LIFE AmerlJs Annuity Group Co. 555 South Kansas Ave Topeka, KS 66603 1-800-ANNUIT1' December 9,2005 AMERUS Annuity Group MaUle Kessler 968 Silver Lake Road Lewisberry PA 17339 Re: Policy #364263 - American Investors Life Insured: Freda Ebersole Dear Ms. Kessler: Thank you for your recent request for information regarding the policy referenced above. The date of death value is notecLbe1ow_ Date of Death: August 18, 2005 ~nte[est Amount $1,949.04 $94-.09- Principal Amount: Account Value: $2,043.13 If you should have any questions or need further assistanceJ- please feel free to contact our office at 1-888-ANNU1TY (1-888-266-8489). Sincerely, ~c\Jun. ~~"C- Andtea Shurtz Claims Specialist ,. AM:ERU\C,......."'! .Al\.aRl]S Life ! -888-252-5530 ArVIERICAN INVESTORS LIFE 18BB- ANNUITY .(" 'c'r0J.,tER <;ERVICE~ ,('! ~.~l'q,,~p~ SJ::IWIE="-F,' - AmerlTs Annuit~. Group C(L 555 South Kansas Ave Topeka. KS 66603 ! ~OO.ANNU1TY December 9,2005 AMERUS .!.41lnuity Group Mollie Kessler 968 Silver Lake Road Lewisberry PA 17339 Re: Policy #360109 - American Investors Life Insured: Freda Ebersole UearMs.Kess1er: Thank you for your recent request for information regarding the policy referenced above. The date of death value is noted below. Date -of -Beath: August -1-8, 2005 Account Value: $17,434.46 ThiS IS a qualified account. If you should have any questions or need further assistance, please feel free to contact our office at 1-888-ANNUITY (1-888-266-8489). -Sincere~y , ~~~~ Andrea Shurtz Claims Specialist An AM'ERlI'" ("_..> .AMER[TS Life AMERICAN INVESTORS LIFE . ~~ Mij;')~'J"ND NATIONAL .II"~ LJf~1 fl'SL -,~.fiI Ccmp~y ~ AnnuIty DIvis/on A i\1E.i}l""~' of tilt: SilmlYlons FJnao.:lo! G=up '~~,{ Novelnber 9: '005 Molly Kessler 968 Silver Lal e Rei Lewisberry. PA. 17339 Re: Contracts: Freda Ebersole, deceased E500106287,8500197639 Dear ?,,1~. I(esskr: The -o.ate-of-death-(-8-J-8- W05}-vatues -m the wn-ve contracts are: ~500 106287 $702,687.42 and 8500197639 S61,132.:L6. If you have questions~ please call us toll-free at 877-gg0-636i. \Ve are available l\.1onday through Thursday from 7 :30 am to 5:00 pm (CST) and Friday frorn 7:30 cun to 12:30 pln (CST). A ser"ice prcfessional within the Clainls and Benefit 'Depanment will be happy to taKe your inlportanl cali. Sincerely. it It.;)~f~ &L~~~ l...... u Conme Eaker, ACS, ALHe Claim and Benefits Specialist Claims and Benefits Department cc: File Annuit\' Division · ~ O. Box 739C7 · Ds; Mr)i~l;iS, I~wa 50325-0907 - ;:lr::l1a. B77 -556-0240 · F2>.: 877 .5$-C22t~ REV-1511 EX + (1-97) (I) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 2005-00767 ESTATE OF FREDA M EBERSOLE Debts of decedent must be reported on Schedule I. ITEM NUMBER A. 1. 2 3 B. 1. 2. 3. 4. 5. 6. 7. 8 9 10 11 12 DESCRIPTION AMOUNT FUNERAL EXPENSES: Myers-Harner Funeral Home Inc Evergreen Cemetery opening and closing grave Rice Memorial Works 7,802.00 400.00 100.00 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) I EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: Attomey Fees Family Exemption: (~decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent Probate Fees 638.00 Accountant's Fees 5,000.00 Tax Retum Preparer's Fees CUMBERLAND LAW JOURNAL THE PATRIOT-NEWS CUMBERLAND COUNTY COURT HOUSE extra short certicates APPRASIAL FEE TITLE SEARCH FEE The Patriot News-advertising 75.00 181.56 40.00 275.00 30.00 70.10 SlF PA42021F.12 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 14,611.66 (// Myers-Harner Funeral Home, Inc. 1903 MARKET STREET . CAMP HILL, PENNSYLVANIA 17011 Robert H. Harner, Supervisor Phone: (717) 737-9961 STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Charges :ue only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will explain in writing below. If you selected a funenl that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you did not approve if you sel: d am~gements s1fE~ a di~ cr~mation or im~ediate burial. If we charged for embalming, we will ex~lain v:.hy below. For the Service of R. /~ I I"'l . S L Date of Death R / d 0 S- Charge to: !16LC-WF f.t~'>LlS1l) <iC e St,-lI(.';;< (/eKe ~fJ. \L~c;$ertl(.'/II'A. 17.s3.., Name Address City State A. CHARGE FOR SERVICES SELECTED: 1. PROFESSIONAL SERVICES Servrces of Funeral Director/Staff , , . . $ I NGi... Embalming. . . . . . . . . . . . . . . . . . . . .. S~. Other preparation of body Oil ~~rNc:r , pl.ltCr"-r~iJ € L 0 ~ l\.o-t::h r ~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $ Jr..Ja.. SUB-TOTAL OF PROFESSIONAL SERVICES. . . 2. FACILITIES AND SERVICES Use of facilities and services for viewing (Visitation/Wake) . . . . . . . . . S II\JCL.. Use of facilities and services for funeral ceremony.. .... .. . . . . $_ Use of facilities and services for Memorial Service ............... 5 ~ Use of equipment and services for gnveside service. . . . . . . . . . . . . -t 'N Q.. Other use of facilities AIS_ ...............................s_ SUB-TOTAL OF FACILITIES/EQUIPMENT........... A2 S_ 3. AUTOMOTIVE EQUIPMENT Vehicle to tnosfer remains to Funeral Home. Loci . . . . . . . . . . . . . . . . . . . . . . . . . .. s,., \( (J... Hearse (Casket Coach) Local...... ..... ........... ..... S~ Limousine Local.......... ... .............. S_ Family car Local........................... s_ Flower car or floral disposition Local.. .. . . . .. ... . ... . . .. ..... .. s J NCL Lead car/clergy car Local......... .... ....... ....... s~ Car for pallbearers Local. . . . . . . . . . . . . . . . . . . . . . . . . .. $_ Out of town tC2nspOrtation . . . . . . . .. ,_ 5_ S_ SUB-TOTAL OF AUTOMOTIVE EQUIPMENT........ A3 S_ TOTAL OF PROFESSIONAL SERVICES, FACILITIES AND AUTOMOTIVE EQUIPMENT .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. A . Other clOthing Cremation urn . . . . (Description) $_ $_ .......5_ OTHER 5_ $- S_ TOTAL MERCHANDISE SELECTED. . . . . . . . . . . . . . . C. SPECIAL CHARGES: Forwarding of remains to . . . B s~O~ CJt '- (Funeral Home) Receiving of remains from s_ (Funenl Home) Immediate Burial. . . . . . . . . . . . . . . .. s_ Direct Cremauon . . . . . . . . . . . . . . . .. $_ ,_ SUB-TOTAL OF SPECIAL CHARGES. . . . . . . . . . . . . . . . D. CASH ADVANCED Opening Grave ................. S_ Cemetery Equipment. . . . . . . . . . . . .. $_ Lot and Deed . ~ . . . . . . . . . . . . . . . . .. s~ Newspaper Nouces-Local ......... S~ Newspaper Notices-Out-of-town. . . . $_ Telephone & Telegrams........... ,_ Airfare...... .... ........... ._.. S_ Clergy/Mass Offering.............. $~ 00 Pallbearers. . . . . . . . . . . . . . . . . . . .. $_ Certified Copies of the Death .3 Cerrifjcate~-"~. (;..QC)/~:-)i):..... S~oc Police Es<;,ort . . 'A~ . . . . . . . . . . . . . .. s_ Flowers rr~l(.. Jf:J"$CS. !-Y~. ".I!~ s~~ Vault Service Charge..... S_ '- S_ S~ 5_ '- S_ SUB-TOTAL OF ADVANCES............... " .. ... . CS_ ItA u<...t?~ fJ( D S 7""lO- oa We charge you for our services in obtaining: (specify cash advances tbat are marked-up) B. CH~:~~ ~~~~~~~~~.~~~~~I~ (Description) I e G'~ '3 T'M:!.- ,,..J > lC-\.fCfL Other Receptacle ........ . . . . . . . .. S_ (Description) Outer buri21 container . .~':J ~ ~ oCr;) (Description) ~LL"'1k....tNll'O ~,vG/C.40r ~ Acknowledgement cards ...... _.... SJ 1\Jc.L. Register book(s} . . ... .... .... . .... S~ Memory folders ......... . .. . . .. .. sI ~ PC2yer cards. . . . . . . . . . . . . . . . . . . .. s_ Temporary grave marker........... $_ Buri21 dothing .. . . . . . .. . . . . . . .. .. S_ s 3;'00. f)O SUMMARY OF CHARGES A. Profession21 Services, Facilities and Equ~pment, and Automotive 3~td,ao EqUIpment . . . . . . . . . . . . . . . . . . . . .. S ~ B. Merchandise.... . . . . . . . . . . . . . . . .. s ':5 (;0- C. Special Charges .. . . . . . . . . . . . . . . .. S_ D. Cash Advances. . . . . . . . . . . . . . . . . .. s~otJl ~ .. TOTAL OF ALL SECTIONS. . . . . . . . . . . . . . . . . . . . . . .. i~"';J . ol) PAID AT TIME OF OR PRIOR TO =~:~~~:: :::::::::::::::::::::::::: :::: :~~ REASON FOR EMBALMING r::- "r c... I ~ 0 tV If any law, cemete I or crematory requirements have required the purcb2sc of any of the items listed above the law or requirement is explained below. Cc-r-t .t<.~.ae:-.s 0 O1co(.. g~JAL Co Al~l~ I agree that. have enmmed the items of goods and services selected move and found them to be: correct and according to the arnogements I have rc:quCSlcd. I adcnowledgc receipt of a copy of this Statement of Funeral Goods and Services Sc:lred. I represent that I have sufficient funds available for payment of the cash price: for the goods :md.services selected.. also ~gm to jiue paymcot of S ,e~" within ..30 days. J agree to be jointly and severally liable with anyone else: who signs below. A lare chuge ot S ~~ per mon amounting to S I~ 9"- pt:r year will be applied to the unpaid balance beginning t::C days from the dare of this agreement. I willaJso 1'21 to the FunenJ Director all reasonable COStS paid by the Funenl Director to collect amounts I owe under this agrtttDent. Those COStS may indude anomers' fees. coun COSI5 and other costs. Any additional services or merchandise: ordered or requested after the date of this agreement will be considered part of this ~grttmmt a cost thereof will be: reflected on the final bill or sut COt. (Seal) (Seal) (Purchaser) o of; MERCHANDISE CASKETS . . , . , . . . . , $ 550.00 to $ 6 . 800 .00 (A complete price list will be provided at the funeral home.) OUTER BURIAL CONTAINERS, , . . . , . $ 600.00 to $ 2 .180.00 (A complete price list will be provided at the funeral home.) Acknowledge cards per Box............. $ 10.00 Register book (sl . . . . . . . . . . . . . , , . . . . . . . . . $ 40 . 00 Memory folders per _, . . . , , . . . . . . . $ 40.00 Prayer cards per _ . , . . . , , , . . . . , . . . . . $ 40 . 00 Temporary grave marker. . . . . . , . , . . . . . . . . $ 40.00 Burial clothing, . . . . . . . $ 150 .00 to $ 150.00 Cremation urns. . . . . . . $ 125 .00 to $ 1 .455.00 Other Inside Crucifix $ 35.00 Ou ts ide Crucifix $ 35 .00 FORWARDING OF REMAINS TO ANOTHER FUNERAL HOME/MORTUARY This charge includes removal of remains, services of staH, embalming. receptacle for body, necessary authorizations, local tnmsportatlon to airport or railhead. It does not Include the services of staH. or the use at facilities for any visitation and/or rites or ceremonies prior to forwarding of the body. . . $ 1 r 995 .00 The cost of other than local transportation in vehicles of funeral home is $ 3.00 per ml1e. RECEIVING OF REMAINS FROM ANOTHER FUNERAL HOME/MORTUARY . This charge indudes temporary shelter of the remains, transportation of remains to cemetery or aematory and required services of staff. It does not include the services of staff br the use of facil- Ities for viewing or for funeral rite~/'Ceremonies. . . $ 990.00 IMMEDIATE BURIAL Price Range. . . . . . . . . $ 3,300.00 to $ 10,100.00 Our charge for an Immediate burial (without any attc'ldant rites or ceremonies) Indudes: . · removaJ and shelter of the remains · local transportaUon to cemetery · necessary services of staff and authorizations 1. Immediate burial without casket selected. Price of casket additional . . . . . $ 2. Immediate burial with alternative container. . . . . . . . . . . . . . . . . . . . . . . . . $ 3. Immediate burial with container provided by purchaser. . . . . . . . . . . . . . . $ 3,300.00 3,475.00 3,300.00 . . <9PenruylvanLa Funerai Directors Auocialion Form 000 1 Rey~d 4/94 . DIRECT CREMATIONS Price Range. . . . . . . . . $ 1.425.00 to $ 8.225.00 Our charge for a direct cremation without any attendant riles or ceremonies Includes: . removal of and shelter of remains and transportation to crematory If local. · cremation · necessary services of staff and authorizations. . S (Pennsylvania Rules and Regulations number 13.201 '60) requires that any human remains held 24 hours beyond death shall. be embalmed or sealed In a container that will not allow fumes or odors to escape or k'ept under refrigeration I If this does not conflict with a religious belief or medical examination.) Embalming after 24 hqurs and prior to cremation . . . . . . . . . . . . . . . . . . . . . . . $ Transportation to and from off-site refrigeration... . . . . . . . . . . . . . . . . . . . . S 550.00 800.00 195.00 Container (other than casket) . . . . . . . . . . . . . . $ If you want to arrange a direct cremalto!1, you can use an alternative container. Alternatlve containers encase the body and can be made of materials like fiberboard or composition materials (with or without an outside covering). The containers we provide ~re (specify container). 1. Direct Cremation with alternative 2. ~oe:~~~~~~' . . cardboard' . . . . . . . . . $ Cremation Container 3. Dired Cremation with container provided by purchaser . . . . . . . . ',' . . . . . $ Date given 1,575.00 1,425.00 If. ~ L ..' _ "'T'I .. 9- o UJ ... UJ ... f"'\J ......:1 UJ Q:1 - .. ~ ~ 9; ~ ,'\ ~s Q ':i...-4 ~ g,.. g.. ~n \J C n ~~ ZIC ~~ n ( r;:, ~ OJ "( ~~ ~ ~ ~. ~ f.' ,,~r E. ( \J1 ... r o ... r n.J ~ o n.J ::;. ~ri -:::' ~ 0 =' .... ~ ~ \ t-~ ~~ C;~ ... 'f .. - \....... o ;- o \~ 0\ o~ O 1"-- r~ o \~ gr .... \~ \ \ \ \ \ "'-, qOC,o)'" ....):1'0):%2 z';orn ~-o~o 7-;~'J3t IOFtD~ ~~ rn=- U\ "'0 r-: . :>r"rn "'0'0:2 ~~m ~rn:%2 .... (/) o ~ o Cll ;; ..\...., \~. ~. C ).J .;;..:, ~u k J. \ ~ 'd?' o o ~ '" ....('- r--: r) 6> i'\ i', r-- .~ ('-. J ~ '? ~ CJ:) (.0) 0 -~ ~ ~c:; .-. Freda Ebersole Estate c/o Mo!1ie Kess!er 968 Silver Lake Road Lewisberry, PA 17339 --n"].ce -Ltemor=a' ....~~-7.-.- ~ 'W, I J VVU~" ~~ 417 W. Main Street New Bloomfield; PA 17068 (717) 582-2512 Invoice . 11/11/2005 135566 8/29/2005 ,., . . '. ~ ".' ",. ., " " , ,~".., ,." , .- ...." ~~: 1 Cemetery Inscription Freda Ebersole . Lynne Trace Order Total: Paymelits~ Balance Due: AlfflllR(J/!-c.lI11log.e..of 1-!6 % per JJJOlJtlJ (18% all II uaL[v) will be addet/ after 30 clays PLEASE TEAR THIS PORTION OFF AND RETURN WITH PAYMENT Rice Memorial Works 417 W. Main Street New Bloomfield, PA 17068 F am i1y: Ebersole Contract#: 135566 Balance Due: $100.00 Amount Paid: $100.00 $0.00 $100.00 . ./ RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, FA 17IT13 Rece+pt Date: Rece~pt Time: Recelpt No. : 8/25/2005 09:57:36 1041714 EBERSOLE FREDA M Estate File No. : Paid By Remarks: 2005-00767 MOLLIE KESSLER RSK ------------------------ Receipt Distribution ------------------------ Fee/Tax Description PETITION LTRS TEST WILL SHORT CERTIFICATE JCP FEE AUTOMATION FEE Check# 3042 Total Received......... Payment Amount 560.00 15.00 48.00 10.00 5.00 ---------------- $638.00 $638.00 Payee Name CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D CUMBERLAND COUNTY GENERAL FUN ~L CONSULTANTS INTERNATIONAL April 12, 2006 FREDA M. EBERSOLE ESTATE Mollie M. Kessler, Executrix 968 Silver Lake Road Lewisberry, Pennsylvania 17339 Dear Mollie: Ple~se find enclosed this statement for professional Senrices rendered on behalf of: CONSULTING & ESTATE SERVICES For Freda M. Ebersole Estate $5,000.00 Total $5,000.00 Thank you. Sincerely, flJ/ William R. Johnson WRJ/dmd 820 VOGELSONG ROAD YORK, PA 17404 USA 717.767.4899 . fax.717.767.6960 /' . CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, P A 17013 September 23, 2005 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Mollie Kessler RE: Freda M. Ebersole, ESTATE Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: September 9, 16, 23, 2005 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment Received $ 75.00 Total Amount Due $ o .00 ------ ------ Payment received August 6.. 2005 by Becky H. Morgenthal/Executive Director . PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEAL TH OF PENNSYLVANIA SSe COUNTY OF CUMBERLAND Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the CUlnberland Law J oUTIlal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the sanle as was printed in the regular editions and issues of the said Cumberland Law J oUTIlal on the following dates, VIZ: September 9, .16, 23, 2005 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law J oUIllal, a legal periodical of general circulation, and that he is not interested in the subj eet nlatter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. " Ebersole, Freda M., dec'd. Late of Camp Hill. Executrix: Mollie Kessler. 968 Sil- ver Lake Road. Lewisberry. PA 17339. Attorney: None. /1 / ( SWORN TO AND SUBSCRIBED before 111e this 23 day of Septenlber.. 2005 NOT ARI L SEAL LOIS E. SNYDER, Notary Public Carlisle Boro, Cumberland County My Commission~p~es Marc~ ,5,_2009 -2 ~ [be patriot -Ncws Now you know III Ord-er Confirmation Customer MOLLIE KESSLER Orderer Account Number 97345 Ad Order Order Source 0001377852 rholton rholton Fax Paver Paver Account Number 97345 Sales Order Taker Special PricinQ None MOLLIE KESSLER 968 SILVER LAKE ROAD PO Number ESTATE EBERSOLE MOLLIE Lewisberry P A 17339 USA Ordered By Customer Fax Customer EMail Customer Phone 717-938-4583 Paver Phone 717-938-4583 Tear Sheets o Proofs o Affidavits 1 Blind Box Promo Type <NONE> Invoice Text Materials Total Ad Cost $181.56 Payment Amount $0.00 Payment Method Amount Due $181.56 Ad Number Ad Type 0001377852-0' Legal Liners Ad Size : 1.0X 14 Li Color <NONE> Production Method Production Notes Ad Booker Product Information Classification # Inserts Run Dates PNCO: :Full Run 806-Estate Notices 3 9/8/2005, 9/15/2005, 9/22/2005 Run Schedule Invoice Text EXECUTRIX'S NOTICEEstate of Freda M. Ebersole, late of Camp Hi! . rl'HE PATRIOT NEWS THE SUNDAY PATRIOT NEWS Proof of Publication Under Act No. 587, Approved May 16, 1929 Corrunonwealth ofPelmsylvania, COlmty of Dauphin} 5S James L. Clark, being duly sworn according to law, deposes and says: That he is the Accounts Receivable Manager of The Patriot News Co., a corporation organized and existing nnder the laws of the Commonwealth of Pennsylvania, with its principal office and place of business at 812 to 818 Market Street, in the City of Harrisburg, County of Dauphin, State of Pennsylvania, owner and publisher of The Patriot-News and The Sunday Patriot-News newspapers of general circulation, printed and published at 812 to 818 Market Street, in the City, County and State aforesaid; that The Patriot-News and The Sunday Patriot-News were established March 4th, 1854, and September 18th, 1949, respectively, and all have been continuously published ever since; That the printed notice or publication which is securely attached hereto is exactly as printed and published in their regular daily and/or Sunday/ Metro editions which appeared on the 8th, 15th and 22nd day(s) of Septenlber 2005" That neither he nor said Company is interested in the subject matter of said printed notice or advertising, and that all of the allegations of this statement as to the time, place and character of publication are true; and That he has personal knowledge of the facts aforesaid and is duly authorized and empowered to verify this statement on behalf of The Patriot-News Co, aforesaid by virtue and pursuant to a resolution unanimously passed and adopted severally by the stockholders and board of directors of the said Company and subsequently duly recorded in the office for the Recording of Deeds in and for said County of Dauphin in Miscellaneous Book "'M", Volume 14, Page 317. PUBLICATION COpy -EXECUTR IX'S'NOTI'CE Estateot ,Fl"edacM;, Ebersolei, lat. 'Of Camp HilI;, ClJmberland-,Countyt-P~, deceased, Letters testamentary on thelast-,^,lIIand Testamentary:; of 'sald:,:;'decedennhavlng blten granted.to,the,undersUmed.all' persons Indebted, thereto 'are 'reauestedJo.- make ,Im- medlate'payment. and" tl10sehavlng :clalms or - demands..agalnst ,the:same,wlllpresent them without delavfor,setflementto1he;un-, , derslgned 'resfdlng~:at'968;:sJlver.;;-t;.akeRoad; , L:;ewlsberry;,PA,17339s.:' I :j., MolII.K8I.1.~,. ~ ;':~ Executrix, . ,)" I // / ~ .(.-:;:' 4" ~ Cd- ~~ .................................................. .ll.....~............. ~'?<\< ~Q,.;.'r..t. <:'. :e1t3?; .., ':' ...0 ~ . O~ . ~~-;,q.:. t9 '(r <r '1-'~i~ -'" \C:" 0,,- -:? 'V Sworn to and subscribed before,. ~~,. 22nd day ozse temb. ~!.~~" ~~ ~ '%~~ / 1 ) . /' ""':.o~ '1:>(/. ~ "- /J'L~/~ ';(r2p' ~ /~ t"'- ';c1.q, "" ~O,!,AR ~UBLIC /o")o/~ <! ;&~; /) My comnnSSlon expIres June 6, 2006 1o~....OO<1/' "'It.!' MOLLIE KESSLER 968 SILVER LAKE ROAD LEWISBERRY, P A. 17339 Statement of Advertising Costs To THE PATRIOT-NEWS CO. F or publishing the notice or publication attached hereto on the above stated dates 181.56 RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17G13 Receipt Date: Recetpt Time: Recelpt No. : 9/16/2005 11:38:04 1041942 EBERSOLE FREDA M Estate File No. : Paid By Remarks: 2005-00767 JA ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name SHORT CERTIFICATE Check# 104 Total Received.... ..... 40.00 ---------------- $40.00 $40.00 CUMBERLAND COUNTY GENERAL FUN ,// ~ , Gary Troup 1000 Good Hope Road Mechanicsburg, PA 17050 GTroup1000@email.com Telephone Number: (717) 761-2724 Fax Number: (717) 920-0615 TO: Ebersole Estate 36 Campbell Place Camp Hill, PA 17011 Telephone Number: Alternate Number: Fax Number: E-Mail: INVOICE . ch;:'I;;~F!f1E'INVOlCE:NUMBERt1lfti.;.m~%it~i.'!=~t' 5509901 _,~;:'::t:~~'i!HlfDA TE-r.:.S!:':6f;i:.:1k~':H'~;fi{~''ii!!,.( "..',,-~,-,';:,;;.;.i~i;f',,:';;W;,,;':.;P.f:REFERENCB;(;'/i;:j;,\;:,~: :~:.;~+;....:tj'!ti~t": Internal Order #: 5509901 Lender Case #: Client File #: Main File # on form: 5509901 Other File # on form: Federal Tax 10: Employer 10: Lender: Ebersole Estate Purchaser/Borrower: N/A Property Address: 36 Campbell Place City: Camp Hill County: Cumberland Legal Description: Deed Book 126, Page 335 ::~:~"~.~,~)l~i1t~i{;"!;i;~ii;'r;~":: 1004 5ummary Appraisal Report Client: Ebersole Estate Slate: PA Zip: 17011-2516 ~[~:!M~~IS;';::;{;(::;l~\L,~y.': ....-'.: ,-:. .~...~:. 7" Check #: Check #: Check #: Date: 09/12/2005 Date: Date: Description: Check Description: Description: SUBTOTAL 275.00 275.00 " ",:':~;::',.,~'~i;:rr1~fJ~fr;~~~tm!~~M~:4~t~~;~;;:", SUBTOTAL TOTAL DUE $ Form NlV5 - "TOTAL lor WIndows' appraisal software by a la mode, inc. -1.S00-ALAMODE Gary Troup 275.00 275.00 0.00 SUE FROCK \ I I 1070 N. B~. . Dun Dr.~ CURRENT OWNER A=nJ. -.,u: .... Oxfoftj, PA 17310 $ SEARCH ONLY . PH: 717~~2 Fee: 3tk.c:r; . E!n"-A FAX: 717-124-1303 k _ ylf'k-) -:.L/ I~:::t I~M1E /{!-d7~ ClMRMTE/d%l Se8rct1~ lJ ADDRESS 3to~I~~~;tU/ PRESENT RECORDED OWNER \:1~D.~ f:~ t1l- 'i~~l.L- RECORD BOOK I ~f....p DEED OA.TEO DEED REC"D CONSIDERATION V, {)S LXX' CQ I 7-3l-~ ~-' ~-,-qS PAGES ~- LOCATION aMP AND PARCEl. l.AM) ~"4QJ TAXES LJl-ri..., SIltJ~ aoG / o4s~O ~ -,,;}ClJ'Y" TOTAl t 3cJ1 9 ctt) ~sr UCJRTGAGE 0IE-'VE8INO MTEDIREC'D BOOK PAGE MKXJNT ~~~L &IGIED BY ASSIGNED TO MORTGAGE OIE-YESN> DATEtVREC'D BOOK PAGE AMOUNT SIGNED BY TO MORTGAGE OIE-YEM'<<) ~nDIREC"D BOOK PAGE AMOUNT SIGNED BY ..-- ASSIGNED TO RECORDI!D JUDo--rra & l.SCS W~~'-. NOTE: AI ~.............. NOT~ w.... ...-...,.....,..... ~~ naI cMcIIl8d. ,. IIIbmIIian ~ henin.. GJnIdMIII.m IhauId naI be COIIIIdeNd _............ ~. Subj: Date: From: To: Your Order Confirmation 10/6/2005 9:15:34 P.M. Eastern Standard Time c1asssin~JL@QDco.~Qm KRrinllilg@aol.cQffi This email is to acknowledge your recent order with The Patriot-News. Order Confirmation Number: 0001396561 Order Price: $70.10 Ad Run Schedule(s): 6 day(s) beginning on 10/8/05 in PNCO (200:257) 6 day(s) beginning on 10/8/05 in Online (200:257) PNCO is the The Patriot-News. Online is www.pennlive.com. Your ad online may extend for additional days, included in the pricing. PN Plus is a weekly publication delivered to non-subscribers. All ads placed are subject to editing for style and propriety. If you have any questions about this order, please call the Classified Advertising Department at (717) 255-8142 between 8 a.m. and 4:30 p.m. Monday through Friday. Please do not reply to this e-mail. Thank you for choosing The Patriot-News. Now you know. Friday, October 07, 2005 Atnerica Online: KPrintlnc REV-1512 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FREDA M EBERSOLE FILE NUMBER 2005-00767 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT 1,305.00 1. 2005 Income tax Final Payment TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 1,305.00 STFPA42021F.13 !II Department of the Treasury Internal Revenue Service 2005 Form 1040-V Payment Voucher .. Use this voucher when making a payment with Form 1040. .. Do not staple this voucher or your payment to Form 1040. .. Make your check or money order payable to the 'United States Treasury.' .. Write your social security number (SSN) on your check or money order. 1,305.1 I Enter the amount I of your payment ........ ~ FDIA8601 12/15/05 1 030 FREDA M EBERSOLE 38 CAMPBELL PLACE CAMP HILL PA 17011 INTERNAL REVENUE SERVICE PO BOX 80101 CINCINNATI OH 45280-0001 162222845 BB EBER 3D D 200512 610 REV-1513 EX + (9-00) COMMONVVEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FREDA M EBERSOLE FILE NUMBER 2005-00767 RELATIONSHIP TO DECEDENT NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) 1. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] MOLLIE M KESSLER 1. 968 SILVER LAKE ROAD LEWISBERRY, PA.17339 DAUGTHER 2 CAROLYN M HOOPER 9618 NORTH HORSESHOE ROAD TALLAHASSEE, FL. 32317 DAUGHTER AMOUNT OR SHARE OF ESTATE 50% 50% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET n. 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. Diakon Lutheran Social Ministries donation of crafts 2. Goodwill Industries donation of clothing value 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) STFPA42021F.14 100.00 884.0 984.00 . Gift-In-Kind Acknowledgment Diakon Lutheran Social Ministries Thank you for your commitment to and support of our ministries. We greatly appreciate your gift-in-kind and wish to properly acknowledge receipt of such gift. Please provide the information below and return this form to: Diakon Lutheran Social Ministries Advancement Department 798 Hausman Road, Suite 300 Allentown, PA 18104-9108 Donor Name IJ1cii/l; e J</ e S 5 / ~ ( Print name ('/ I U t:' /. I . - ) v" ') (p j --J I J Lj ~ f ~ C( rvc:. City Lew ,s he / r '-I ~. .- V //r--(/ ~ j -I..:Jlj -/0 d' '-.J Fax "-"; /' 1::. v/t Ad dress State fJ4 Zip / 7 3 3 !:-;; Telephone '/'/ ,;' - Email Donor's Estimated Value of Gift $ /'15' l-' -7 I-. L-/ Special Purpose ,--t/lLtl, c-~L Jl.A-te--. tion: (Provide detailed description i.e. 1 CA 19" color portable television with remote) [~/t (;E'-c/L~~__(' ,', " ~)..{: - ,/ J--<:A:"-'- Donor Signature /Y){,,~- i/VJ R., Signature Note: This form is designed to provide helpful information. It is provided with the understanding that neither the person signing the acknowledgment, nor the organization on behalf of which the acknowledgment is made, is engaged in rendering legal or accounting advice or services. Documentation and record-keeping requirements for charitable contributions can be found in the following IRS publications: Charitable Contributions (Pub, 526) and Determining the Value of Donated Properly (Pub. 561). Acknowledament: This donated property described above was received on (date} /t}~- /.0 -.S - by the organization indicated above. No goods or services were given in exchange for such donation. By (signature} "~11!- ~ 'ji rifle /YZ~ _ Diakon Program/Facility ~t ~~ ti Dat~ 10 ~ It) 5 I Return Completed Form to Diakon Lutheran Social Ministries; Advancement Department 798 Hausman Road, Suite 300, Allentown, PA 18101-9108 Rev. 3-10-04 -II Nw.YourGoodwill.org . It f.iiIiiiiI' ..' . ~ ~10~g-G~~~~\:~'6'~~&Of Cent,,! pA inc. J PO Box 3155 Harnsburq PA 171 O~J Ph: (717) 232-1831 Fax: (7"1 T! 232-0"115 r--l U Goodvvi!! Industries of f\-1id-Eastern PA, !nc. 31 D Norill Wyomlssln~l Avenue Sllillin9ton. PA 19607 Ph: (6101777-7875 FC\y: /610! 7i7-QJJ1 JM,. J c - l...( - (\ :'J L'-:j C;:'T1 Of I Jj~ "BE., ,. "I IIJ'jlJt....1 ,1 ~l Il-.i IlhL._, JM,1E '.>1 UCJIJUk H'kJllf: 'I''\(j t , \' t Ke~~S,l-e-i'-'~" fL ~r~ CeI>- E:. kx_rs'(\1 ~ ~ .3 ~ CA'f^-p iQc-L I jJ L Cll', ?:IP CJJUL C"tr~p HJ-jl Pit 1113 c; [.L'I,IL /.[;[JRESc, I 'HE DONOR IS RESPONSIBLE FOR ASSIGNING VALUE TO DONATIONS. ESTIMATED VALUE OF DONATIONS f$ ,___ " l JC-..J l). (. (~, x 11/) ,.. Ii II' II /j i . t O-U:.A.1': l)e~~ SIGfJi..i URE Uf- D01,I:'Vi D Goodwill Industnes of Southeastern PA Inc 1048 North Plum Street Lancaster. PA 17601 Ph: (717) 394-0647 F8x: (717! 281-2367 BAGS PCS. CTNS. DESCRI PTION , I '13 I CLOTHING l \ 1 I I FURNITURE i I r I I 1 i i MISCELLANEOUS i i ! I \ I t I ! I ! ! I 1-1 I I I GOOD\^J!LL H,Ll,S NOT FURNISHED GOODS OR SERVICES TO THE DONOR IN EXCHANGE FOR THIS CONTRIBUTION. WE THAi~r~ YOU FOR YOUR TAX DEDUCTiBLE DONATiON THAT PROVIDES VOCATIONAL TRAINING OPPORTUNITIES FOR PERSONS WITH DISABILITIES AND OTHER SPECIAL NEEDS. ""....,..ti;'\~;.'\..............._..I. "-:iI"!!,' .........>.....~....~.I. .I......'.;S".....:.: .</,..,...,....."......,. ""'~' ""U_.. .....".,,'.,...,.. ~~f~~~t:::;;;~~1:.~1~;!~~~:~*;~i~*~~,~~; JWW. YourGoodwill.org iiOOdWiIIlndustries of Central PA, Inc. 1150 Goodwill Drive PO Box 3155 Harrisburg. PA 17105 Ph: (717) 232-1831 Fax: (717)232-0115 D Goodwill Industries of Southeastern PA. Inc. 1048 North Plum Street Lancaster. PA 17601 Ph: (717) 394-0647 Fax: (717) 291-2367 D Goodwill Industries of Mid-Eastern PA. Inc, 310 Nortll Wyomissing Avenue Shillington. PA 19607 Ph: (610) 777-7875 Fax: (610) 777-0441 DA1E q-;}o-o~ LOCATION I I ~ I rJlL.- ATlENDAHT'S INI1IALS ~IAME OF DONOR PHONE fl'\(H L't' g f 5;S:.I-e.c -fr)fl 0' <. rfl.-. ~ b ~ 12 s. /)1-< ADDRESS 31o C AM-ply { I P LAf L l-I;ll PA 17 [) \( ZIP CODE CITY E-S~eS rHE DONOR IS RESPONSIBLE FOR ASSIGNING VALUE TO DONATIONS. ESTIMATED VALUE ( $ OF DONATIONS de ,-.f x fVltrf }J~ !~/~~ SIGr~ATURE. OF DONOR ] BAGS PCS. CTNS. DESCRIPTION d~ CLOTHING FURNITURE MISCELLANEOUS I I GOODWILL HAS NOT FURNISHED GOODS OR SERVICES TO THE DONOR IN EXCHANGE FOR THIS CONTRIBUTION. ww. YourGoodwill.org / ( Goodwill Industries of Central PA.. Inc. 71 ~ HO r'O~""'I'11 D-;'ve I I I~ U uu..'-I I It --! PO Box 3155 Harrisburg, PA 17105 Ph: (717) 232-1831 F2.>:: (717) 232-0115 r:ac,Q~I' .:~-. :,.t< '8.".',:.'1' :....-1. '.'. ,'. a.:'....~...:'::j(i:~ 'Y' a.T:OtL~'E A,'RE'''' . D GoocbNill Industnes of Mid-Eastern PA. Inc 310 North Vvyolllissing Avenue Shillington. PA 19607 Ph: (610) 777.7875 f=a!': (6101 777'-0441 n L-J Goodwill Industries of Southeastern P.A.. Inc. 1048 hlorU I PILII] Sll eel Lancaster. PA 17601 Ph: (717) 394-0647 Frlx' (717) ~!11-2367 'JdL DESCRIPTION DATE ic - '-f-C .~, LOCATION lll-. IJAI& OF DOt lOH ,~~,~'f!I" '( III t.lee 'a:. \,"-, 3 (~ C In 71 /J b~ /1 P tHe" .;... I /....... ,', " ,I . I / .,/) '/ - /1- ..........1..........".._/.1/,',.1' \.....Jr..11~+'~::L~_.L_ _" '., _ . /. v~ E .r-V,ll. ;.DDHESS . r:IT',' f\T1Tj-JDAf JT'S I:'~~ t IAL~, I CLOTHING I FURNITURE -\ MISCELLANEOUS i PHONE ,........ r- ;!.>It-i 1+ b ~ (' /r.! ~~ ZIP COOE I I I I I i I i I I \ I I ! \ i I I '1 I i I I iHE DONOR IS RESPONSiBLE FOR ASSiGNING VALUE iO DONAiiONS. ESTIMATED VALUE r OF DONATiONS l $ I, c:;:: I ~ ,,) (--,....-l. J '1 .. {tV ~ Xl', . /.-6' '. '}I....;' SIGNATURE OF OQtJOR /1 / j----/'?C1' ]"';v GOOD\^J!LL H/~,S NOT FURNISHED GOODS OR SERVICES TO THE DONOR IN EXCHANGE FOR THIS CONTRIBUTION, WE THANK YOU fOR YOUR TAX DEDUCTIBLE DONATION THAT PROVlOES VOCATIONAL TRAiNiNG OPPORTUNITIES FOR PERSONS VviTH DISABILITIES AND OTHER SPECiAL NEEDS. JWW. You rGoodwi II. org ~ Goodwill Industnes of Central PA. Inc. V I 1150 Goodwill Drrve ~ PO Box 3155 Harrisburg. PA 17105 Ph: (717) 232-1831 Fax: /7171 232-0115 . I GoodWill . , . ... . 'ct ft' d'. . ~ f I J . .': . .. "~. ' --- it - fJ ,~--. ':f- Q- iIi. -ti - ,~ -~, .e --k ,- -". ~ . ~ ~ / \ r ~ ' \ I ... '" ~ ~ ~". II LJ Goodwill Industries of Mid-Eastern PA, Inc. 310 North WYOnllssing Avenue Shillington, PA 19607 Ph: (610) 777-7875 Fax: (610) 777-0441 11 LJ Goodwilllndustnes of Souttleastern PA. Inc. 1048 North Plum Street Lancaster, PA 17601 Ph: (717) 394-0647 Fax: (717) 291-2367 DAT[ q - J-o - {'\ ~ ,OCAna" J \ 'd- Am,;f?rtIlACS l BAGS PCS. CTNS. DESCRIPTION sl CLOTHING FURNITURE MISCELLANEOUS I 1 r'JAf..1E OF Datlon, PHOI~E 'j~ \,e'. '; i Ad l '\l';}~ '\:: [: F ,2:;>, Qr.. E b <.":: 0..., I v_ AnnRFSS 1e., (7 ;tIll ,) b~ 1/ ,')/ ~ (.. \?. / Cl. ;!hn ,) fJ; /!. JJFJ , E-MAIL ADDRESS . CITY ZIP CODE j 7 () II rHE DONOR IS RESPONSIBLE FOR ASSIGNING VALUE TO DONATIONS. I J ESTIMATED VALUE r $ OF DONATiONS l .;? ~.;J ~j ro. ~I (-. /,\ X ~:.(1J !~/ ~~...,;')'-" ':-i-h-c"7"..Ji;/~J SIGNATURE OF DONaI.' . /. GOODWILL HAS NOT FURNISHED GOODS OR SERVICES TO THE DONOR IN EXCHANGE FOR THIS CONTRIBUTION. - -~---~--------------------- --------------------- - - ------------------ -- ------ --~---- -------- . , .:...... i J. -2_ ~',,/ ,.~ lC ! ) (!~~ \~ \CJ ( \_J ,,- t..., , ) ~\~ ~ f /~~ 'Z 'ft ' -- .t;. i' (( I _t; ~ ~. t\,.i) d' t ,. C,l.::, - _ - ~ .'1 l....: - - ....-'.,... ~-) ( i/ ') . ') f. ' 'r-'" ,..J ,....-...,~' !\-....- J :) @6 5,eD57 II'; _r....--... I L.t ;-.\ Ie,:.; '..' ,- '''''' ....... '.._~-- J .' 1 C () c.. , ;- ~.) ([\:~$3 . OJ ~ 1. <- "-f ''"'\ , " (, L. ,) \..... '-r;;; ~?5t (~l r\- ~ 'W to ,0,-) (lit C; <:;<' <; @ ~IO.C>(:' c~ \~O,'?: ..,-;-- ,.; ,.. I i.. e ~ @ s '3 C() I j '7;,ll: lc s t A~C l( 5 Q t I '1.00 ~ J-~ .Ql ~;'-'~ c A-t:c;-s @ S. 00 tt; lto ,~ 'I ' .:--,1 (_.:' ( ) .:::l\C [.S e DC;,(;0 $ ,Iou , I 1 \ ,; ) \ d) (l-..- )r i-::J \~ ') v"" j'.\ fi ).. "'- '.' J >-eJ'- _ ~ 0" '" d- I?)\~+h j(J! LJ-L - ~ :3 0 J ..f~}'i) ,.,- L_ .J \ / J CA.U\L &1 ':) .- ':) "D () ~d5.Q: ~"-l c c P,-1-s - b ) D ,()D ~ 1 {).o'C REV-1514 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN (Check Box 4 on Rev-1500 Cover Sheet) ESTATE OF FILE NUMBER FREDA M EBERSOLE 2005-00767 This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death on or after 5-1-89. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. D Will D Intervivos Deed of Trust D Other LIRE )'ESTATE .....INTEREST<CALCUl.ATION NAME(S) OF NEAREST AGE AT TERM OF YEARS LIFE ESTATE IS LIFE TENANT(S) DATE OF BIRTH DATE OF DEATH PAYABLE DLife or DTerm of Years D Life or 0 Term of Years D Life or D Term of Years o Life or D Term of Years 1. Value of fund from which life estate is payable 2. Actuarial factor per appropriate table Interest table rate - D 3 1/2% D 6% 0 10% 3. Value of life estate (Line 1 multiplied by Line 2) ANNUITY INTEREST CAllCl.Jl.ATION $ D Variable Rate % $ NAME(S) OF NEAREST AGE AT TERM OF YEARS ANNUITANT(S) DATE OF BIRTH DATE OF DEATH ANNUITY IS PAYABLE D Life or 0 Term of Years D Life or D Term of Years D Life or D Term of Years D Life or D Term of Years 1. Value of fund from which annuity is payable 2. Check appropriate block below and enter corresponding (number) Frequency of payout - DWeekly (52) D Bi-weekly (26) o Quarterly (4) D Sem i-annually (2) D Annually (1 ) 3. Amount of payout per period 4. Aggregate annual payment, Line 2 multiplied by Line 3 5. Annuity Factor (see instructions) Interest table rate D 3 1/2% D 6% D 10% 6. Adjustment Factor (see instructions) 7. Value of annuity -If using 3 1/2%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 $ o Monthly (12) o Other ( ) $ 0.00 D Variable Rate % $ $ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest( s) should be reported at the appropriate tax rate on Lines 13, 15. 16 and 17. (If more space is needed, insert additional sheets of the same size) STF PA42021F.15 REV-1647 EX + (9-00) SCHEDULE M FUTURE INTEREST COMPROMISE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT (Check Box 4a on Rev-1500 Cover Sheet) ESTATE OF FREDA M EBERSOLE This schedule is appropriate only for estates of decedents dying after December 12, 1982. This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in possession and enjoyment cannot be established with certainty. Indicate below the type of instrument which created the future interest and attach a copy to the tax return. o Will D Trust 0 Other FILE NUMBER 2005-00767 , I. Beneficiaries NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO NEAREST BIRTHDAY 1. 2. 3. 4. 5. n. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within 9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse exercises such withdrawal right. D Unlimited right of withdrawal m. Explanation of Compromise Offer: D Limited right of withdrawal IV. Summary of Compromise Offer: 1. Amount of Future Interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $ 2. Value of Line 1 exempt from tax as amount passing to charities, etc. (also include as part of total shown on Line 13 of Cover Sheet) ........... $ 3. Value of Line 1 passing to spouse at appropriate tax rate Check One 06%, 03%, 000,10.......................... $ (also include as part of total shown on Line 15 of Cover Sheet) 4. Value of Line 1 taxable at lineal rate Check One o SOlo , 04.5%................................. $ (also include as part of total shown on Line 16 of Cover Sheet) 5. Value of Line 1 Taxable at sibling rate (12%) (also include as part of total shown on Line 17 of Cover Sheet) ........... $ 6. Value of Line 1 Taxable at collateral rate (15%) (also include as part of total shown on Line 18 of Cover Sheet) ........... $ 7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. $ (If more space is needed, insert additional sheets of the same size) 0.00 SlF PA42021F.16 REV-1649 EX + (1-97) (I) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 0 ELECTION UNDER SEC. 9113(A) (SPOUSAL DISTRIBUTIONS) ESTATE OF FILE NUMBER FREDA M EBERSOLE 2005-00767 Do not complete this schedule unless the estate is making the election to tax assets under Section 9113 (A) of the Inheritance & Estate Tax Act. If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust. This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit, etc.). If a trust or similar arrangement meets the requirements of Section 9113 (A), and: a. The trust or similar arrangement is listed on Schedule 0, and b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0, then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to the amount of the trust or similar arrangement included as a taxable asset on Schedule O. The denominator is equal to the total value of the trust or similar arrangement. PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's surviving spouse under a Section 9113 (A) trust or similar arrangement. DESCRIPTION VALLE Part A Total $ 0 . 0 0 PART B: Enter the description and value of all interests included in Part A for which the Section 9113 (A) election to tax is being made. DESCRIPTION VALLE Part B Total $ (If more space is needed, insert additional sheets of the same size) 0.00 SlFPA42021F.17