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Home My WebLink About03-07-07 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT f!EV-1500 EX + (e-OOl '* CQMMONWEALTHOf PENNSYLVANIA .. DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG. PA 17128-0601 DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITlAL) McKinne Doris H. DATE OF DEATH (MM-DO- Yell') I- Z W C W o W C DATE OF BIRTH (MM-DD-Y8lI") 07/20/2006 09/16/1934 (IF APPUCABlE) SURVIVING SPOUSE'S NAME (LAST. FIRST. AND MIDDLE INITIAL) OFACIAl USE ONLY FILE NUMBER 2 1 -0 6 0 6 9 9 COlIffi'cooe -ver- - - iiUliER- - SOCIAl SECURITY NUMBER 1 5 9 - 2 6 - 7 5 3 3 THIS RETURN IIUST BE ALED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAl SECURITY NUMBER w ... lfI:~~ fd~8 ::c 111:... o D.m ~ lXI 1. OrIginal Retum o 4. Limited Es1ate lXI 6. Decedent Died Testate (AllaCh coPy of WI) o 9. LItigation Proceeds Received o 2. Supplemental Retum o 48. Future Interest Compromise (daIII of~ *12-12-82) o 7. Decedent Maintained a LMng Trust (AllaCh copy ofTIUIt) o 10. Spousal PovertyCredit(dalllof~belwe8n12-31-91 and 1-1-95) o 3. Remainder Retum (dalllofdelihprlorm 12-13-82) o 5. Federal Es1ate Tax Retum Required _ 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (AlIachSchO) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAME COMPlETE MAILING ADDRESS John M. Eakin Market Square Building FIRM NAME (If Applicable) !z w Q Z ~ II) ~ o o Mechanicsburg, PA 17055 TELEPHONE NUMBER 717 766-3172 OFFICIAL USE ONLY z o 5 :) l- ii: <C o w ~ 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held CoIporatlon. PartnelShip or SoIe-Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash. Bank Deposils & Miscellaneous Personal Property (5) (Schedule E) 6. JoinUy Owned Property (Schedule F) (6) o Separate BIDing Requestad 7. Inter-VIVOS Transfers & Miscellaneous Non-ProbaIB Property (7) (Schedule G or L) 8. Total Gross Assets (total Unes 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Deb1s of Decedent Mortgage liabilities. & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus line 11) 13. Charitable and Govemmental SequeslslSec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Sub]ectto Tax (line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 188,378.37 X ~ (15) X _ (16) X .12 (17) X .15 (18) (19) z o !;;c I- :) D.. ~ o o ~ I- 15. Amount of Line 14 taxable at the spousal tax rate, or transfers underSec. 9116 (a)(1.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Une 14 taxable at collateral rata 19. Tax Due 20.0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~~o . , "I 139,613.7-0=) -.l o 63,327.~ , "4 N (8) 202,941.02 11,651,05 2,911.66 (11) (12) (13) 14,562.71 188,378.31 (14) 188,378.31 8,477.03 8,477.03 :> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE A ,'t(ECHECK MATH < < ecedents ompl e e res 0 0 STREET ADDRESS . CITY I STATE T ZIP o · C I t Add s Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 8,477.03 4.000.00 200.00 Total Credits (A + B + C) (2) 4.200.00 3. InterestIPenalty it applicable D. Interest E. Penalty 5. T otallnterestlPenalty( D + E ) If Line 2 is greater than Line 1 + Une 3, enter the difference. This is the OVERPAYMENT. Check box on P~ge 1 Line 20 to request a refund (4) If Une 1 + Une 3 is .greater than Une 2. enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Une 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT (3) 4. 0.00 4.277.03 4.277.03 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN .X. IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes : a. retain the use or income of the property transferred; ........................................................................... 0 1XJ b. retain the right to designate who shall use the property transferred or its income; .................................... .... 0 IXl c. retain a reversionary interest; or ...................................................................................................... 0 IXl d. receive the promise for lite of either payments, benefits or care? ............................................................. 0 lZl 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................. 0 00 3. Did decedent own an 'in trust fof or payable upon death bank account or security at his or her death? ................. 0 IXl 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ....................................................................................................... 00 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. Under penalties fA peljury, I decIlre thai I have examined this return, includi~ ~ying schedules lI1d stalemenls, lI1d il the best fA rny knowledge lI1d belief, it is true, oomlClll1d complete. DeclaraIion fA prepnr other 1hs1 the pelSOIlal ~ve iS~ClIl aJ!..l!.fQrml!liOn fA WhicI! prepnr has !I1Y knowledge. S.IGNATU.RE OF PE~~ON RjSPONS. IBL~ FILING ~~URN DATE 1.. /~_ ~ (rrlt~. 6 7 ADDRESS 2909 Armstrong Avenue Secane PA 17 18-4637 SIGNATURE OF PREPA TtiER . ::~r~~NTATIVE DATE / lit a( 01 ADDRESS Mark quare Building Mechanicsbun:J. PA 17055 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. ~9116 (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. ~9116 (a) (1.1) (ii)]. 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 it 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. ~9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedenfs lineal beneficiaries is 4.5%, except as noted in 72 P.S.~9116(1.2) [72 P.S. ~9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedenfs siblings is 12% [72 P.S. S9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX + (6-98) . SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT .ESIA.T.E OF McKinney. Doris. H . FILE.HUMBER 21 06 Indude the= of Iit!llatlon and the date the proceeds were l8C8ivedb.Ythe..eslate. All property. 1ntIy-ownecl WIth right of lurvlvorihip must be dlsclosecl on Schedule F. 0699 ITEM NUMBER 1. 2. 3. 4. 5. 6. 7. 8. 9. DESCRIPTION Members tst Federal Credit Union Checking Account 17250, see attached Members 1st Federal Credit Union Regular Savings Account 17250, see attached Members 1 st Federal Credit Union Money Management Account 17250, see attached Members 1st Federal Credit Union Life Savings Account 17250, see attached Orrstown Bank Account # 111000272, see attached Comcast-Refund AXA Equitable Life Insurance, see attached Orrstown Bank - Telephone Transfer Credit Charles Schwab Acct. 4134-3337, see attached 10. New York Life Insurance, see attached VALUE AT DATE OF DEATH 17,791.30 5,818.15 10,464.63 4,000.00 4,909.92 30.87 8,839.92 1.58 62,712.47 24,639.85 347.00 58.01 11. Miscellaneous Jewelry, appraised value, see attached 12. Verizon -Refund TOTAL (Also enter on line 5, Recapitulation) $ (lfroom.spacs Is l188d8d,insedBddilional sI1Il8ls of the same size) 139613.70 Jun 25, 2006 thru Jul 24, 2006 17250 st Send Inquires to: 5000 louis. Orlv. PO Box 40 M.chanlcsburg, PA 17055 www.m.mb....1.t.org Main Switchboard: (717) 697-1161 or (800) 283.2328 EZ Call: (717) 697-4372 or (800) 283-4372 TOO: (717) 697-5312 or (800) 283-2328 ext. 5312 T.I.Branch: (717) 795-6049 or (800) 237.7288 Statement of Accounts Account Number: DORIS H MCKINNEY 194 WILLOW MILL PARK RD MECHANICSBURG PA 17050-1760 Account Balances at Checking: Savings: Certificates: Loans: Money Management: MEMBERS 1st FEDERAL CREDIT UNION a Glance: 14,980.37 9,818.15 0.00 0.00 10,464.63 Page: 1 of 2 Your current Member Loyalty Reward level is Platinum Please read the enclosed insert regarding changes to your electronic services PIN that will take effect on August 7, 2006. CHECKING ACCOUNTS 11 - CHECKING Transaction Description Balance Forward Withdrawal ACH COMCAST CENTRAL TYPE: CENTRAL 10: 0000009547 Jun 28 Deposit Transfer,From rEi 00 Jun 28 . Check 001536 Tracer 0 009570 Jun 30 Deposit by Check Jun 30 o sit Dividend O. 250% . Annual Pen; eYle/d'EamedO. 250% from 06/0112006 through 0613012006 Based on Ali<./ance of 16, 725. 68 Ju(,Q5 Tracer 0705019735 Jul07 Check: racer 0707009160 Jul11 WithdrawalACH VISA TYPE: PAYMENT Withdrawal ACH VERIZON TYPE: PaymentREC Deposit by: Check Check 001539 Tracer 0724001402, Ending Balance Date Jun 25 Jun 26 Jul11 Jul21 Jul24 Jul24 Check#. 001536 001537 Additions Subtractions 47 . 82- 75.00- 10: 11653500M . 10: 91~33971Q\1DAT 70. 00- 35. 00- 3.95. 55.43- Balance 16,595.48 16,547. 66 17,791..66 17,716.66 17,952.24 17,955.68 17,885.68 17,850.68 17,846.73 17,791.30 18,~62. 44i 14;980. 37 14;980. 37 Date Jul07 Jul24 3,282 ..09- SA\lINGSACCOUNTS ,. .'.OJ.. 00- REGlJLARSAVINGS Date Jun25 Jun 28 Additions 'Subtractlons Transaction:D&.crlptlon f3!llanCeFoI'vII"rct . . OepositACH'SOCSEC . . 1,244.00' - - - Continued on following page - -- Ba'lance 5,810. 08 7,054.08 I\' 1~ MEMBERS I" -....- Send Inquires 10: 5000 Louisa Drlva PO Box 40 Machanlc:sburg, PA 17055 www.mambars1sLorg Main Switchboard: (717) 697-1161 or (800) 283-2328 EZ Call: (717) 697-4372 or (800) 283-4372 TDD: (717) 697-5312 or (800) 283-2328 ext. 5312 TeleBranch: (717) 795-6049 or (800) 237-7288 Jun 25, 2006 thru Jul 24, 2006 Account Number: 17250 Page: 2 of 2 Jun 28 Jun 30 Annual. Jun 30 .... .... JuJ 24 Transaction Description 10: 3031036030 Withdrawal Transfer To Share 11 o sit ~.. Additions Subtractions Balance Date 04 - LIFE SAVINGS 3.29 Balance 4,000. 00 4,003. 29 4,000. 00 4,000 . 00 Date Transaction Description Jun 25 Sa/anceForwatd Jun 30 Deposit Dividendi. 000% Annual Percentage Yield Eamed1. 010% ftom 0610.112006 through 0613012006 Jun30 WithdrawalTransfer To Share 00 Jul 24 EndingSa/ance Additions Subtractions 3.29- 05 -MONEY MANAGEMENT Date Transaction Description. Jun.25 Sa/anceForwatd Jun 30 . Deposit DividendTiered Rate ..... .. ..... . ... . .... .. . Annual Percentage Yield Eamed 1. 750% from 0610112006 through 0613012006 Jul24 EndingSa/ance Additions Subtractions Balance 10,449.69 .14.94 10,464.63 10,464. 63 YTD SUMMARIES TotalYearTo Date Dividends Paid NOTE: Total includes closed shares TOTAL DIVIDENDS PAID 00 REGULAR SAVINGS 04 LIFE SAVINGS 05 MONEY MANAGEMENT 11 CHECKING In addition. Identlficatlo security an ng your photo in ou . e([ on the type of tra e appreciate your ongol ORRSTOWNBANK A Tradition of Excellence Date 7/14/06 primary Account Enclosures Page 1 111000272 111111111111111111.1.11...111",11 .'" Doris H McKinney 194 willow Mill Park Road Mechanicsburg PA 17050 WE PUT THE LOW IN LOANS! ASK ABOUT OUR SPECIAL LOW RATE HOME EQUITY LINE TODAY! CALL 1-888-0RRSTOWN ABOUT THIS LIMITED TIME OFFER! CHECKING ACCOUNTS Account Title Doris H McKinney 50+ Interest Checking Account Number Previous Balance 1 Deposits/Credits 1 Checks/Debits Service Fee Interest paid CUrrent Balance 111000272 4,501.63 417.50 9.80 .00 .59 4,909.92 Check safekeeping Statement Dates 6/16/06 thru Days In The Statement Period Average Ledger Average Collected Interest Earned Annual Percentage Yield Earned 2006 Interest paid 7/16/06 31 4,688.28 4,688.28 .59 0.15% 6.07 Activity In Date Order Date Description 7/03 NA ANN PAY DFAS-CLEVELAND PPD 7/11 Check 209 7/16 Interest Deposit Trace No 000906602 005097020 Amount 417.50 9.80- .59. Balance 4,919.13 4,909.33 4,909.92 Date Check NO 7/11 209 * Denotes missing --- CHECK SUMMARY --- Amount Reference 9.80 005097020 check numbers ~---~---~._..-'. ----~ ,--_.,-- -:--.....-------------.-----.-'.- _..-------- _.__._--,~,~'--._._. -_.'~ ~l::I~ I 0'1. vnn~ I VVYI~ Ol-\I~") / I//:;'It!./O'+; Doris H MCKinney 194 Willow Mill ~uk Road. Mechanicsburg PA 17050 ~ct"-O-UO 1 1;4;:); Date e/15/06 primaxy Account bclo.urea 1IB PUT '1'8 WIt IN LOANS! ASK ABOtr.r OUR SPEC:IAIa LOW RATIl RClMB SQUITY LZNIl 'l'OOA'l'! CALL 1-888-0aRS'1'<MI ABOtJ'l' TH:IS LIM1"'1'm TDCB O..nR! CRaCKING ACCOUNTS ~1-$ Account '.r.:i.1:l~ Doris H McKinney 50+ :In1:ereat Cbe~ng Account Number Previous Balanoe 2 Deposits/Credits 1 Cheak./DeJ):its Serv.:i.~ Fee :Int.er..t Paid CUrrent Balance 111000272 4,909.92 3,567.50 8,t76.42 .00 .58 1.58 Check Safekeeping' S~~ftt Oat.. 7/17/06 thru Days In The Statement PeJ:'iod Averag-e Ledger Average Collected Inter..t .aJ:'l1ed Annu.l Percentage 'l'ield .arned 2006 :Interest Paid t"Aljl: 1 11 Page 1 111000272 8/15/06 30 4,990.7. 4,685.74 .58 O.l~' 6.65 ACtivity In Date Order Date Descript.ion 1/24 Deposit. 8/01 NA ANN PAl: DJ'A8-Cl.ZVKLAND PPD 8/01 Miscellaneous Debit 8/15 Intere.t Deposit SEP-B-2006 FR1 10:17AM 10: Trace No 00"'035360 000906608 Amount 3,150.00 417.50 00"'012000 8,476.42- .58 Balance 8,059.92 8,477.42 1.00 1.58 PAGE: 1 "'orm 71.l (Rev. May 2000) Department of the Treasury Internal Revenue Service . . Decedent-Insured (To Be Filed by the executor with Form 706, United States Estate (and Genera!i~n-Skipplng T~ansfer) Tax Retum, or Form 706-NA, United States Estate and Generation-Ski in Transfer Tax Retum, Estate of nonresident not a citizen of the United States. Decedent's first name and middle initial 2 Decedent's last name 3 Decedent's social security 4 Date of death Mrs Doris H Me Kinney number (if known) 07/20/2006 159-26-7533 Life Insurance Statement 1 5 Name and address of insurance company AXA EQUITABLE PO BOX 1047, CHARLOTTE, NC 28201.1047 6 Type of Policy Adjustable Whole Life 8 Owner's name. If decedent is not owner, 9 Date issued attach copy of application. 09/28/1973 Decedent 12 Value ofthe policy at the 13 Amount of premium (see time of assignment instructions) '" $129.20 Annual 7 Policy number 73 418 471 10 Assignor's name. Attach copy of assignment. NA 14 Name of beneficiaries I?stateOf~ris ~ McKilUley 15 Face amount of policy 16 Indemnity benefits. . . 17 Additional insurance. . .. . . . . . . . . . . . 18 Termination Dividend. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Principal of any indebtedness to the company that is deductible in determining net proceeds . . . . . . . . 20 Interest on indebtedness (line 19) accrued to date of death . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Amount of accumulated dividends.(lncluding interest of $24.39) . . . . . . . . . . . . . . . . . . . . . . . 22 Amount of post-mortem dividends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 23 Pro rata premium refund. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Amount of proceeds if payable in one sum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Value of proceeds as of date of death (if not payable in one sum). . . . . . . . . . . . . . . . . . . . . 26 Policy provisions concerning deferred payments or installments. Note: If other than lump-sum settlement is authorized for a surviving spouse, attach a copy of the insurance policy. 27 Amount of instaliments . . . . . . . . . . . . . . . . . . . . . . . .'. . . . . . . . . . . . . . . . . . . 28 Date of birth, sex, and name of any person the duration of whose lite may measure the number of payments. 29 Amount applied by the insurance company as a single premium representing the purchase of installment benefits 30 Basis (mortality table and rate of interest) used by insurer in valuing installment benefits: 31 Were there any transfers of the policy within the three years prior to the death of the decedent? 32 Date of assignment or transfer: Month Day _ Year_ OMB No. 1545-0022 11 Date assigned NA $5,000.00 2,460.00 176.28 1030.48 151.21 21.95 $8,839.92 '" o Ves IZI No o Ves IZI No o Ves IZI No 33 Was the insured the annuitant or beneficiary of any annuity contract issued by the company? 34 Did the decedent have any incidents of ownership on any policies on hislher life, but not owned by himlher at the date of death? 35 Names of companies with which decedent carried qthet policies and amount of such policies if this information is disclosed by your records. The undersigned officer of the above-n.am1 i~U~ company hereby certifies that this statement sets forth true and correct information. Signature .' JV Title Vice President Date of Certification October 11, 2006 (HES) Instructions t \ You are not required to provide the Information requested on a form that is subject to Statement of Insurer -This statelJ'li st be made, on behalf of the Insurance the Paperwork Reduction Act unless the form displays a valid OMB control number. company that issued the poli~ 0 cer of the company having access to the Books or records relating to a form or Its Instructions must be retained as long as their records of the company. For purpo s of this statement, a facsimile signature may be contents may become material in the administration of any Intemal Revenue law. used In lieu of a manual signature a. if.used, shall be binding as a manual signature. Generally, tax retums and retum information are confidential, as required by section Separate statements - File a separate Form 712 for each polley. 6103. Line 13 _ Report on line 13 the annual premium, not the cumulative premium to date of The time needed to complete and file this form will vary depending on individual death. If death occurred after the end of the premium period, report the last annual circumstances. The estimated average time Is: Recordkeeplng, 18 hours, 11 premium. minutes; Learning about the form. 6 minutes; Preparing the form. 23 minutes. Paperwork Reduction Act Notice. We ask for the Information on this form to carry If you have comments concerning the accuracy of these time estimates or out the Internal Revenue laws of the United States. You are required to give us the suggestions for making this form simpler, we would be happy to hear from you. See information. We need It to ensure that you are complying with these laws and to allow the instructions for the tax retum with which this form Is filed. DO NOT send the tax us to figure and collect the right amount of tax. form to that office. Instead, retum it to the executor or representative who requested It. 712.1 Cat. No. 1017V Form 712 (Rev. 5-2000) 570-271'-0962 Una 1 03:02:41 p.m. 01-25-2007 1/1 ~ Iii a 2 WalnutStreet DanvilJe, PA 17821 Hxre: (570) 271-1855 Fax: (570) 271-1D ToIlftee: (800) 626-1027 , . .' ,. . "',. DATE: FOR THE ATTENTION OF: FAX: FROM: TOTAL NUMBER OF PAGES (INCLUDING COVER SHEET): Dear John: " January 25, 2007 John Eakin 717-691-3281 Tiffany Kauffman 1 The date of death (July 20, 2006) value for Doris H. McKinney's Individual account at Charles Schwab was $62,712.47. Should you require anything further, please feel free to contact me at 570- 271-1855. Tif Y Investment Team Coordinator JAN-25-2007 THU 02:44PM 10: PAGE: 1 1. Silver Necldace and Bracelet 2. Miscellaneous Costume Jewelry 3. Opal Ring 4. Set Diamond Earrings 5. Miscellaneous Earrings, C~stum~ . ... 6. Acutron Watch. - . 7. 2 Sterling Crucifix medals @ 3.00 8. Earring Set and Pendant 9. Pendant Watch 10. 5 Old Wristwatches @ 5.00 11. 3 Gold Rings (Scrap Value) @lO.oo 12. Platinum Ring 13. Topaz Ring 14. 5 Costume Rings (Zircon) @2.00 15. Diamond Ring 14 Carat Gold 16. 2 Anklets @10.00 17. Silver Necklace $ 2.00 $ 5.00 $25.00 $25.00 $10.00 ~$10.00 $ 6.00 $20.00 $25.00 $25.00 $30.00 $20.00 $ 5.00 $10.00 $100.00 $20.00 $9.00 Total $347.00 REV-1510 EX + (6-98) . COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF McKinnev. Doris. H. SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY FILE NUMBER 21 06 0699 This schedule nut be llClIJlIlIl*ld and fled if the answer b any of questIonS 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INCUIlE THE _ OFTHEllWWERfE. ~ RElA110IISItP TO IlECEIlBlT NIl DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER THE 1lo\1E OF 11Wl8FBl AnACH A 0C1i"f OF THE DEBl FOR I8L mATE. VALUE OF ASSET INTEREST OF API'I.ICHl.El VALUE 1. Chase Life Insurance Company Annuity #FK4038759 30,176.46 100. 30,176.46 see attached ~, . -' 2. Chase Life Insurance Company IRA #FK4051565 33.150.86 100. 33,150.86 see attached TOTAL (Also enter on line 7 Recapitulation) $ 63327.32 (If more space is needed. insert addllional sheeIs of the same size) CHASE 0 John Eakin Attorney at Law Market Square Building Mechanicsburg,PA 17055 PIlLA 1'111., -"iv. . ~~ f) ~~ ~(~ fw;~/ I' ~p '''7~)''}p /"~~ / /$, (lDO, - -~ ~ J-{ - 6t- () 69j I )~_lt-1S~CS Doris H McKinney, Dec Contract No. FK4038759 ,& Claim No. CL 050186 26(1..1 .. drul.. August FK4051565 (fI \ ~~ t(A-'J3/~O/~ 14, 2006 Dear Mr. Eakin: please accept our sincere sympathies on the death of Doris H McKinney. We realize this is a difficult time and are committed to making the claim processing as simple as possible. According to our records, the beneficiary(ies) is/are: All surv~v~ng children equally. To process the claim, we will need the following documents: . A claim form completed by each beneficiary. (Copies enclosed). We would like to remind you that each beneficiary's signature must be witnessed by a notary public or an active agent with our company. . A certified death certificate (which must include cause of death). . The original contract. If lost, complete Section 5 on the claim form. In addition to the claim form, before payment can be made, we require a notarized affidavit from each of the children, listing all the surviving children of the deceased. As you may recall, the death benefit is the contract value as of the date of death, minus any applicable surrender charges. The final death benefit will include any additional interest which accrues between the date of death and the date of benefit payment. Interest will be calculated at the demand rate in effect at the time of payment. If you have any questions, please feel free to contact the Claims Department at 1-888-397-8485, option 1. We will be glad to assist you in any way possible. Sincerely, qLf7- ~7U-()<~:' 9 - Q)~:l~ ---- ~7 }~ Claims Examiner Chase Insurance Life and Annuity Company Enclosure(s) CHASE INSURANCE Administrative Office: 2500 Westfield Drive, Elgin, IL 60123-7836 IiEV-1511 EX + (12-99) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF McKinney Doris. H SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER Debts of decedent must be reported on SchedullL 21 06 0699 ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of PllISOIIlIl Representative (s) Helene Pruitt 7,200.00 Social Seaulty Numbel(s)/EIN Number of Personal Representatlve(s) Street Address 2909 Armstrong Avenue City Secane Stata P A Zip 17018 Year(s) Convnisslon Paid: 2. Allomey Fees John M. Eakin 3,750.00 3. Family Exemption: (If decedents address is not the same as claimants, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probata Fees Letters Testamentary 310.00 5. Accountanfs Fees 6. Tax Retum Preparel's Fees 7. The Cumberland Law Journal- estate notice 75.00 8. The Sentinel - estate notice 151.55 9. Mumma Jewelry appraisal 100.00 10. Register of Wills - Filing Fee 15.00 11. Register of Wills - Inventory 15.00 12. Patriot News - newspaper ad for wheelchair 34.50 TOTAL (Also enter on line 9, Recapitulation) $ 11.651.05 (If more space is needed. Insert additional sheets of the same size) REV-1512 EX + (6-98) . SCHEDULE. DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS FILE NUMBER 21 06 0699 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF McKinnev. Doris H. Include unrelmbursed medical expen.... ITEM NUMBER DESCRIPTION 1. Verizon- telephone VALUE AT DATE OF DEATH 67.91 'j!, 2,426.25 2. Pharmerica-' - 417.50 3. Return of Annuity Payment TOTAL (Also enter on line 10, Recapitulation) $ (If IllOI9 space is needed. i1sert addllional sheets of the same size) 2.911.66 - _""EX'. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULEJ BENEFICIARIES FILE NUMBER nnri!': H 21 06 MQQ RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not list Truatee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS [Include =ht ~ dlslributions. and transfers under See. 9116 (8 (1 )] 1. Richard J. Borda, Jr. grandson 1/12 of residue 33 Pleasanton Drive, East Berlin, PA 17316 2. Erica M. Borda granddaughter 1/12 of residue 194 Willow Mill Park Road, Mechanicsburg, PA 17050 3. Anthony J. Borda son 1/6 of residue 209 Stratford Road, Glenolden, PA 4. Maria Borda Logue daughter 1/6 of residue 8627 Wissahickon Ave., Philadelphia, PA 19128 5. Patrick R. McKinney step-son 1/6 of residue 15 Hunter Alexander Drive, Boydten, VA 23917-4135 6. Diane L. McKinney step-daughter 1/6 of residue 15 Hunter Alexander Drive, Boydten VA 23917-4135 7. Karen Borda Paul daughter 1/6 of residue 2739 Colorado Street, Philadelphia, PA 19145 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON UNES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART n - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON UNE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size)