HomeMy WebLinkAbout05-10-07
REV-1500 EX. (6-00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Metz er, Beatrice, L
DATE OF DEATH (MM-DD-Year)
DATE OF BIRTH (MM-DD-Year)
OFFICIAL USE ONLY
FILE NUMBER
2 1 -0 6 1 0 4 3
COuNTYCciiiE ---vEAR- - - N'UMBER--
SOCIAL SECURITY NUMBER
1 8 7- 1 6 - 5 8 2 6
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (date of death pnor to 12-13-82)
o 5. Federal Estate Tax Return Required
_ 8_ Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
David H. Stone Es uire 414 Bridge Street
FIRM NAME (If Applicable)
Stone LaFaver & Shekletski
TELEPHONE NUMBER
7177747435 New Cumberland PA 17070
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0.00 X _(15) 0.00
283,996.35 x .045 (16) 12,779.84
0.00 x 12 (17) 0.00
0.00 X 15 (18) 0.00
(19) 12,779.84
11/23/2006 10/1/1922
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
[KJ 1 Original Return
o 4. Limited Estate
[KJ 6_ Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after 12.12-82)
o 7. Decedent Maintained a Living Trust (Attach copy ofTrust)
o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
OFFICIAL USE ONLY
0.00
267,347.65
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
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62,619.12
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3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. JOintly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8_ Total Gross Assets (total Lines 1-7)
(6)
(7)
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329,966.77
9. Funeral Expenses & Administrative Costs (Schedule H)
(9)
(8)
---1
10. Debts 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. Chantable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 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 Line 14 taxable at collateral rate
19. Tax Due
20 [8]
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
45,970.42
(11)
(12)
(13)
45,970.42
283,996.35
(14)
283,996.35
'Decedent's Complete dress:
STREET ADDRESS
4837 Trindle Road
CITY I STATE I ZIP
Mechanicsburg PA 17055-
Ad
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
12,779.84
13.000.00
684.21
Total Credits (A + B + C )
(2)
13,684.21
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
0.00
904.37
0.00
0.00
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ................................ ........................................... 0 [Xl
b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 [Xl
c. retain a reversionary interest; or ...................................................................................................... 0 [Xl
d. receive the promise for life of either payments, benefits or care? ............................................................. 0 [Xl
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?............................................................................................... 0 [Xl
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ................. 0 [Xl
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 QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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PA 17019
DATE
PA 17070
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 PS 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(12) [72 PS 99116(a)( 1)]
The tax rate Imposed on the net value of transfers to orfor 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.
REV-15G8 EX + (6-98)
.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Metzaer. Beatrice. L
FILE NUMBER
21 06
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
1043
VALUE AT DATE
OF DEATH
2,760.00
311.85
106,171.22
374.36
47,364.76
121 .90
32,184.40
85.55
43,898.00
135.7 4
4,458.97
11 .48
2,163.08
5.75
2,155.47
6.48
ITEM
NUMBER
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
DESCRIPTION
Bankers Life Insurance Go.-Iong term care reimb.
Highmark-refund
Members 1st FGU-Gert. of Deposit #216700-45
Princ. $106,171.22, Int. $374.36
Members 1st FGU-Gert. of Deposit #216700-45 - Accrued Interest
Members 1 st FGU-Gert. of Deposit #216700-46
Princ. $47,364.76, Int. $121.90
Members 1st FGU-Gert. of Deposit #216700-46 - Accrued Interest
Members 1 st FGU-Gert. of Deposit #216700-47
Prine. $32,184.40, Int. $85.55
Members 1st FGU-Gert. of Deposit #216700-47 - Accrued Interest
Members 1 st FGU-Gert. of Deposit #216700-48
Prine. $43,898.00, Int. $135.74
Members 1st FGU-Gert. of Deposit #216700-48 - Accrued Interest
Members 1 st FGU-Gert. of Deposit #260622-45
Princ. $4,458.97, Int. $11.48
Members 1 st FGU-Gert. of Deposit #260622-45 - Accrued Interest
Members 1 st FGU-Gert. of Deposit #260622-50
Prine. $2,163.08, Int. $5.75
Members 1 st FGU-Gert. of Deposit #260622-50 - Accrued Interest
Members 1st FGU-Gert. of Deposit #260622-51
Princ. $2,155.47, Int. $6.48
Members 1 st FGU-Gert. of Deposit #260622-51 - Accrued Interest
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, Insert additional sheets of the same size)
267,347.65
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
Metzger, Beatrice, L
Decedent's Name
Page 1
21 06 1043
File Number
Schedule E - Cash, Bank Deposits, & Misc. Personal Property
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
17 Members 1 st FCU-Cert. of Deposit #260622-52 4,306.13
Prine. $4,306.13, Int. $13.31
18 Members 1st FCU-Cert. of Deposit #260622-52 - Accrued Interest 13.31
19 Members 1st FCU-Checking Acct. #216700-11 57.80
20 Members 1 st FCU-Money Management Acct. #21700-05 13,417.63
Prine. $13,417.63, Int. $14.05
21 Members 1st FCU-Money Management Acct. #21700-05 - Accrued Interest 14.05
22 Members 1 st FCU-Money Management Acct. #260622-05 7,194.54
Prine. $7,194.54, Int. $8.28
23 Members 1 st FCU-Money Management Acct. #260622-05 - Accrued Interest 8.28
24 Members 1 st FCU-Regular Savings Acct. #260622-00 25.05
25 Members 1st FCU-Savings Acct. #216700-00 101 .79
Prine. $101.79, Int. $.06
26 Members 1 st FCU-Savings Acct. #216700-00 - Accrued Interest 0.06
SUBTOTAL SCHEDULE E 25,138.64
GRAND TOTAL SCHEDULE E $ 267,347.65
REV-1510 EX + (6-98)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER.VIVOS TRANSFERS &
MISC. NON.PROBA TE PROPERTY
1043
ESTATE OF
MetzQer Beatrice. L
FILE NUMBER
21 06
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME Of THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE
NUMBER THE DATE Of TRANSFER ATTACH A copy Of THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST VALUE
(IF APPLlCABLEI
1 Bankers Life Insurance Co.-Annuity No. 7664859 5453.80 100. 5,453.80
Beneficiaries: Laurie Ann Snith, Jennifer Louise
Leighton, and W. Jason Metzger
2 Bankers Life Insurance Co.-Annuity No. 7664909 57165.32 100. 57,165.32
beneficiary is estate
TOTAL (Also enter on line 7 Recapitulation) $ 62,619.12
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX +(12-99)
.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Metzger. Beatrice. L
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
FUNERAL EXPENSES:
Parthemore Funeral Home-funeral expenses
1.
B.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s) Laurie Ann Smith
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address 9750 Carlisle Road
City DillsburQ
Year(s) Commission Paid: 2007
Attorney Fees David H. Stone, Esquire
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
1.
State P A
2.
3.
Claimant
Street Address
City
State
Relationship of Claimant to Decedent
4.
Probate Fees Cumberland County
5.
6.
Accountant's Fees
Tax Return Preparer's Fees
7.
2
3
4
5
6
7
8
US Treasury-payment of decedents final '06 1040
PA Dept of Revenue-payment on final 2006 PA40
Laurie Smith-Reimb. for Kings Jewelry
US Postal Service-postage & ins. to send jewelry
Cumberland Law Journal-advertising grant of letters
The Patriot News Co.-advertising grant of letters
Register of Wills-filing Inheritance Tax and Inventory
Reserve for closing expenses
FILE NUMBER
21
06
1043
(If more space is needed, insert additional sheets of the same size)
TOTAL (Also enter on line 9, Recapitulation) $
Zip 17019
Zip
AMOUNT
11,159.00
16,199.00
16,199.00
414.00
1,210.00
353.00
31.80
68.94
75.00
130.68
30.00
100.00
45,970.42
. '''.'''''''1'.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FILE NUMBER
Met7nf~r RA::ltrice L 21 06 1043
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
1. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1 Jennifer Louise Leighton Lineal 94,665.45
669 Brockton Curve
Eagan MN 55123-
2 Laurie Ann Smith Lineal 94,665.45
9750 Carlisle Road
Dillsburg PA 17019-
3 W. Jason Metzger Lineal 94,665.45
10412 Conistan Place
Cornelius NC 28031-
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
LAST WILL AND TESTAMENT
OF
BEATRICE L. METZGER
I, BEATRICE L. METZGER, of the Borough of New Cumberland, Cumber-
land County, Pennsylvania, declare this to be my last will and revoke
any will previously made by me.
ITEM I: I direct that my Executrix hereinafter named shall pay
all my just debts and funeral expenses as soon as conveniently may be
done after my decease from the residue of my estate.
ITEM II: I devise and bequeath all the rest, residue and
remainde of my estate of every nature and wherever situate in equal
shares to such of my children, JENNIFER LOUISE LEIGHTON, LAURIE ANN
SMITH and W. JASON METZGER, as survive me. Should any of my children
predecease me, I devise and bequeath the share of such child to his or
her issue, per stirpes; and should any such child of mine leave no
such issue living at the time of my death, I devise and bequeath the
share of such child to my issue, per stirpes, iivlng ac [he cime of my
death.
ITEM III: I appoint my Executrix and her successors guardian of
any property which passes, either under this will or otherwise, to a
miner and with respect to which I am authorized to appoint a guardian
Page 1 of 4
and have not otherwise specifically done so, provided that this ap-
pointment of a guardian shall not supersede the right of any fiduciary
in its discretion to distribute a share where possible to the minor or
to another for the minor's benefit. Such guardian shall have the
power to use principal as well as income from time to time for the
minor's support and education (including college education, both
graduate and undergraduate) without regard to his or her parent's
ability to provide for such support and education, or to make payment
for these purposes, without further responsibility, to the minor or to
the minor's parent or to any person taking care of the minor.
ITEM IV: I appoint my daughter, LAURIE ANN SMITH, Executrix of
this my last will. Should my daughter, LAURIE ANN SMITH, fail to
qualify or cease to act as Executrix, I appoint my daughter, JENNIFER
LOUISE LEIGHTON, and my son, W. JASON METZGER, Co-Executors of this my
last will.
ITEM V:
No fiduciary acting hereunder shall be required to post
bond or enter security for the faithful performance of his/her duties
in any jurisdiction.
IN WITNESS WHEREOF, I, BEATRICE L. METZGER, have hereunto set my
hand and seal this
, 1
day of
(C") ~ ),~\>~,,-
, 2000.
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\"'~ .... _=.:L .~ ,., j \-1\-C' h~r l.
· BEATRICE L. METZGER _: .
Page 2 of 4
SIGNED, SEALED, PUBLISHED and DECLARED by BEATRICE L. METZGER,
the Testatrix above named, as and for her Last Will and Testament, and
in the presence of us, who at her request, in her presence and in the
presence of ea~h other,
/ -. ~ l/,I
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have subscribed our names as witnesses.
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Address
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COMMONWEALTH OF PENNSYLVANIA:
:SS:
COUNTY OF CUMBERLAND
I, BEATRICE L. METZGER, the Testatrix whose name is signed to the
attached or foregoing instrument, having been duly qualified according
to law do hereby acknowledge that I signed and executed this instru-
ment as my last willi that I signed it willingly and that I signed it
as my free and voluntary act for the purposes therein contained.
() . c" -"\ .-t '-
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'\ BEATRICE L. METZGER '<.I
Sworn to or affirmed to and acknowledged before me by BEATRICE L.
METZGER, the Testatrix, this /7 ti. day of :~~& {'L , 2000.
/
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Notary Public
Page 3 of 4
NOTARIt.\L SEAL
CONSTM1CE '.. KG.PoLl, No-;:ary Pub!ir;
tJe,v Cu;"L,;r'3r.d, PA CUiTI0JrlarJd Co,
My Cor;:mission Expires April 13. 2003
COMMONWEALTH OF PENNSYLVANIA
:SS:
COUNTY OF CUMBERLAND
We,
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.A.,.;-, t' r.-\,-;,).-C.
and ~tdLy:~
the witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, depose and say that
we were present and saw Testatrix sign and execute the instrument as
her last will; that Testatrix signed willingly and that she executed
it as her free and voluntary act for the purposes therein expressed;
that each of us in the hearing and sight of the Testatrix signed the
will as witnesses; that to the best of our knowledge, the Testatrix
was at that time eighteen or more years of age, of sound mind and
under no constraint or undue
influencr_'--......" J' I
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Sworn to or affirmed
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wi tnesses, this / /
to and acknowledged before me by
and~~
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, 2000.
day of
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Notary Public
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NOTARIAL SEAL
CmIST.'~NCE I.. K/,r:Ll, Nc!tary Public
Ne',\' CL"';~~d:'~:!~d, PA Cu;ntjtr!ar~d Co.
My Cor,'rliss:JiI Expires April 13. 2003
Page 4 of 4
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MEMBERS 1st
FEDERAL CREDIT UNION
REGULAR SAVINGS ACCOUNT:
Account NumberlSuffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
216700 -00
04/23/2002
$101.79
$.06
$101.85
None
CHECKING ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
216700 .11
06/19/2003
$57.80
$.00
$57.80
None
MONEY MANAGEMENT ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
216700 -05
04/26/2002
$13,417.63
$14.05
$13,431.68
None
CERTIFICATES OF DEPOSIT:
Account Number/Suffix
Date Certificate Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
216700 -45
08/26/2005*
$106,171.22
$374.36
$106,545.58
None
216700 -46
12/27/2005
$47,364.76
$121.90
$47,486.66
None
CERTIFICATES OF DEPOSIT:
Account Number/Suffix
Date Certificate Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
216700 -47
02/13/2006**
$32,184.40
$85.55
$32,269.95
None
216700 -48
06/26/2006***
$43,898.00
$135.74
$44,033.74
None
.Purchased by transfer of funds from 216700-05
..Purchased by redemption of certificate 216700-42, originally established 3/16/05
...Purchased by redemption of certificate 216700-40, originally established 6/25/04
SOOO Louise Drive . l~o. Box -1-0 . Mechanicsburg. Pennsylvania 170SS . (717) 697-1161 . www.memberslst.org
Representative Payee Account
REGULAR SAVINGS ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
MONEY MANAGEMENT ACCOUNT:
AccountNumbe~Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
CERTIFICATES OF DEPOSIT:
Account Number/Suffix
Date Certificate Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
CERTIFICATES OF DEPOSIT:
Account Number/Suffix
Date Certificate Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
.Purchased by transfer of funds from 260622-00
Estate of: BEATRICE L. METZGER
Date of Death: 11/23/2006
Social Security Number: 187-16-5826
Name of Account: Beatrice Metzger
260622 -00
02/28/2005
$25.05
$.00
$25.05
None
260622 -05
08/24/2006
$7,194.54
$8.28
$7,202.82
None
260622 -45
07/01/2005*
$4,458.97
$11 .48
$4,470.45
None
260622 -50
02/06/2006*
$2,163.08
$5.75
$2,168.83
None
260622 -51
04/04/2006*
$2,155.47
$6.48
$2,161.95
None
260622 -52
07/05/2006
$4,306.13
$13.31
$4,319.44
None
tMBERS 1ST FyPE:tL CREDIT UNION
~;r~r /(/tkrL
Denise A. Wolfe /
Insurance Services Supervisor
January 9,2007
BANKERS LIFE AND CASUALTY COMPANY
Lift! DivisiDn · 222 MndtllUlist! MtIIt Plaza
Chictlgo, IL 6tJ654-2tHIIJ . Tl!lep/lone: Jl2-J96-MHItJ
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0,> y
~
1051
David Stone, Attorney
PO Office Box E
New Cumberland PA 17070
February 12, 2007
POlicy
7,664,909
HE: Beatrice Metzger
Dear Mr. Stone:
Per my prior letter, enclosed is a copy of the beneficiary designation,
signed by the Power of Attorney, naming the Estate as primary benefici-
ary of Beatrice Metzger. In order to process this claim, we will need
estate documents. We will accept a Small Estate Affidavit if it applies
in your state. The Commuted Value death Benefit is $57,165.32.
If you have questions or concerns, please feel free to contact us.
Sincerely,
:;=c~
Life/Annuity Claim Department
LCBKB 833245
&t.
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aooe:l (Cl7/12)