HomeMy WebLinkAbout06-27-07 (3)
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15056041125
REV -1500 EX (06-05)
PA Department of Revenue '*
~~~~:~~~~~~uaITaxes .. INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
OFFICIAL USE ONLY
County Code Year
2 1 0 7
File Number
042 8
Date of Birth
191182944
0420200 7
092 9 1 921
Decedent's Last Name
Suffix
Decedent's First Name
K E E FER
MI L DRED
MI
E
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's First Name
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
4a. Future Interest Compromise (date of
death after 12-12-82)
7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
10. Spousal Poverty Credit (date of death 0 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
r-..:>
717c245 :508n
*0 -.I:~~ ~~i~
REGISt WILLS lL'5E ONL 'G....:.) (_)
IO ::z:-
pr- ~~.~ I,
:z; !jj ~ I'~ . I
._ (f) ^ -')
JOO -0
3811 3:
XJ
-0-1 ~
)>
FILL IN APPROPRIATE OVALS BELOW
[&J 1. Original Return
o 4. Limited Estate
[&J
o
2. Supplemental Return
o
o
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
o
o
o
o
8. Total Number of Safe Deposit Boxes
J ANEADAMSESQ
Firm Name (If Applicable)
City or Post Office
State
ZIP Code
.-
o
DATE FILED
First line of address
64S0UTHPI
TTSTREET
Second line of address
CAR LIS L E
P A
17013
Correspondent's e-mail address:eSQadams@aol.com
Under penalties of pe~ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge.
SIGN UR F PER R S ON SIBLE FILING RETURN DATE
6/27/2007
RESS
1065 MUD LEVEL ROAD
OF PREPARE~~NTATIVE
SHIPPENSBURG
PA 17257
DATE
6/27/2007
PA 17013
A
6
CARLISLE
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056041125
15056041125
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g)
,
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15056042126
REV-1500 EX
Decedent's Name: MILDRED E. KEEFER
RECAPITULATION
1. Real estate (Schedule A)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1.
2. Stocks and Bonds (Schedule B)
.................................. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages & Notes Receivable (Schedule D)
........................ 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5.
6. Jointly Owned Property (Schedule F) D Separate Billing Requested . . . . . .. 6.
7. Inter-Vivos Transfers & Miscellaneous N,QD;Probate Property
(Schedule G) U Separate Billing Requested. . . . . .. 7.
8. Total Gross Assets (total Lines 1-7)
........................... 8.
9. Funeral Expenses & Administrative Costs (Schedule H) . . . . . . . . . . . . . . .. 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . . . . . . . . . . . 10.
11. Total Deductions (total Lines 9 & 10)
. . . . . . . . . . . . . . . . . . . . . . . . . . . 11.
12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . 12.
13. Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . 13.
14. Net Value Subjectto Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . 14.
TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a){1.2) X.O _
16. Amount of Line 14 taxable
at lineal rate X.O
17. Amount of Line 14 taxable
at sibling rate X. 12
18. Amount of Line 14 taxable
at collateral rate X .15
o
o 0
15.
o
o 0
16.
928712
8 6
17.
o
o 0
18.
19. Tax Due
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L
15056042126
Decedent's Social Security Number
1 9 1 1 8 294 4
0 0 0
7 8 6 7 0 3 7 7
0 0 0
0 0 0
5 9 3 8 6 9 9
6 5 2 5 6 3
3 0 8 8 2 7 1 7
1 1 6 1 4 4 3 5 6
2 6 1 0 9 4 6
2 1 6 7 8 9
2 8 2 7 7 3 5
1 1 3 3 1 6 6 2 1
2 0 4 4 5 3 3 5
9 2 8 7 1 2 8 6
o 0 0
o 0 0
11144554
o 0 0
11144554
D
15056042126
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REV-1500 EX Page 3
Decedent's Complete Address:
File Number
0428
DECEDiNT'S NAM!
MILDRED E. KEEFER ---
STREET ADDRESS
104 SHIPPENSBURG MOBILE ESTATE
---~_.._- _-_0-- ..-....------
CITY I STATE I ZIP
SHIPPENSBURG PA 17257
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
111 ,445.54
5,572.28
Total Credits (A + 8 + C) (2)
5,572.28
3. InteresVPenalty if applicable
D. Interest
E. Penalty
TotallnteresVPenalty (D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
0.00
0.00
105,873.26
A. Enter the interest on the tax due.
8. Enter the total of Line 5 + SA. This is the BALANCE DUE.
(SA)
(58)
105,873.26
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ...................................................................... 0 IRJ
b. retain the right to designate who shall use the property transferred or its income; ............................... 0 IRJ
c. retain a reversionary interest; or ................................................................................................ 0 IRJ
d. receive the promise for life of either payments, benefits or care? ....................................................... 0 IRJ
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... 0 IRJ
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ......... 0 IRJ
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .................................................................................................. IRJ 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (3) percent [72 P.S. ~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 zero (0) percent
[72 P.S. ~9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax retum are stili applicable even if the surviving spouse Is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~9116(a)(1.2)).
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted 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 decedent's siblings is twelve (12) percent [72 P .S. ~9116(a)(1.3)]. A sibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1502 EX + (6-98)
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SCHEDULE A
REAL ESTATE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
MILDRED E. KEEFER 0428
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 Droperty which is lolntlv-owned with right of survlvorshlD must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
NONE
0.00
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
0.00
REV-1503 EX + (6-98)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
MILDRED E. KEEFER
FILE NUMBER
0428
All property Jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
2.
DESCRIPTION
MERRILL LYNCH SECURITIES ACCOUNT
Account No. 69710918
Value and accrued dividends as noted in statement attached as Exhibit "B"
MERRILL LYNCH SECURITIES ACCOUNT
Account No. 69710919
Value and accrued dividends as noted in statement attached as Exhibit "C"
MERRILL LYNCH SECURITIES ACCOUNT
Account No. 69710920
Value and accrued dividends as noted in statement attached as Exhibit "0"
VALUE AT DATE
OF DEATH
288,077.81
279,777.12
3.
218,848.84
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
786,703.77
AEV-l504 EX + (6-98)
*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSEL V-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
ESTATE OF
MILDRED E. KEEFER
FILE NUMBER
0428
Schedule C-l 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
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
NONE
0.00
TOTAL (Also enter on line 3, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
0.00
REV-1507 EX + (6-98)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF
MILDRED E. KEEFER
FILE NUMBER
0428
All property Jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
NONE
0.00
TOTAL (Also enter on line 4, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
0.00
REV-1508 EX + (6-98)
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
MILDRED E. KEEFER
FILE NUMBER
0428
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property Jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
35,000.00
2.
1995 MOBILE HOME
Value Based on Sale Price
Settlement Sheet attached as Exhibit "E"
TAX AND LOT RENT PRORATION FROM SALE OF MOBILE HOME
209.82
3.
Settlement Sheet attached as Exhibit "E"
2006 CHEVROLET IMPALA L T SEDAN
Value Based on Sale Price
Bill of Sale attached as Exhibit "F"
MISCELLANEOUS PERSONAL PROPERTY
Values based on Sale Prices
Itemized List attached as Exhibit "G"
ALLlANZ SERVICE CENTER
Prepaid Funeral Expenses
14,100.00
4.
2,543.82
5.
7,533.35
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
59,386.99
REV-1509 EX + (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
MILDRED E. KEEFER
FILE NUMBER
0428
If an asset was made Joint within one year ofthe decedent's date of death, It must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. LESLIE T. KEEFER
1065 Mud Level Road
Shippensburg, PA 17257
Brother-in-Law
8
c
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENrSINTEREST
1. A. 10/2005 F & M TRUST 13,051.25 50. 6,525.63
Checking Account No. 33-21657
Value as stated on bank statement at Exhibit "H"
TOTAL (Also enter on line 6, Recapitulation) $ 6,525.63
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX + (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS. &
MISC. NON-PROBATE PROPERTY
ESTATE OF
MILDRED E. KEEFER
FILE NUMBER
0428
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSllIP TO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED Fon REAL ESTATE. VALUE OF ASSET INTEREST VALUE
(IF APPUCABLEj
1. MERRILL LYNCH RETIREMENT PLUS ACCOUNT 133,168.86 100. 133,168.86
Account No. M930140753
Value as noted on attached Exhibit "I"
2. MERRILL LYNCH RETIREMENT PLUS ACCOUNT 77,387.16 100. 77,387.16
Account No. M9304111 02
Value as noted on attached Exhibit "J"
3. MERRILL LYNCH RETIREMENT PLUS ACCOUNT 85,325.19 100. 85,325.19
Account No. M981448088
Value as noted on attached Exhibit "K"
4. MERRILL LYNCH RETIREMENT PLUS ACCOUNT 12,945.96 100. 12,945.96
Account No. M991601220
Value as noted on attached Exhibit "L"
TOTAL (Also enter on line 7 Recapitulation) $ 308.827.17
This schedule must be completed and filed ilthe answer to any of questions 1 through 4 on the reverse side 01 the REV.1500 COVER SHEET is yes.
(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
MILDRED E. KEEFER
FILE NUMBER
0428
ITEM
NUMBER
A.
1.
B.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Debts of decedent must be reported on Schedule I.
DESCRIPTION
FUNERAL EXPENSES:
FOGALSANGER - BRICKER FUNERAL HOME
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
State
Year(s) Commission Paid:
Attorney Fees JANE ADAMS ESQ
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
Slate
Relationship of Claimant to Decedent
AMOUNT
7,619.20
Zip
15,000.00
Zip
Probate Fees REGISTER OF WILLS - Probate and filing Inventory and Appraisement
Accountanfs Fees
Tax Return Preparer's Fees LUANN WAGNER (Estimated)
COMMONWEALTH OF PENNSYLVANIA - Income Taxes
ADVERTISING EXPENSES - Yard Sale
POSTAGE
SAILHAMMER REAL ESTATE - Commission on Sale of Mobile Home
DAVID R. BRESCHI, ESQ - Closing Fee on Mobile Home
DAWN M. SHOOP - Notary Fee on Sale of Mobile Home
740.00
500.00
18.57
14.50
7.19
2,100.00
100.00
10.00
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
26 109.46
REV-1512 EX + (12-03)
'*
SCHEDULE.
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
MILDRED E. KEEFER
FILE NUMBER
0428
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. SHIPPENSBURG MOBILE ESTATES 557.84
Lot Rent
2. SHIPPENSBURG HEALTH CENTER 607.00
Medical Bill
3. EMS 897.75
Ambulance Services
4. CABLE TV 4.25
5. EMBARQ 2.26
Phone Bill
6. ADAMS ELECTRIC 98.79
Electric Bills
TOTAL (Also enter on line 10, Recapitulation) $
(II more space Is needed, insert additional sheets 01 the same size)
2167.89
~-""~.(*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
MILDRED E. KEEFER
SCHEDULE J
BENEFICIARIES
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS [include oUlri~ht spousal distributions, and transfers under
Sec. 9116 (a (1.2)]
1. LESLIE T. KEEFER Sibling
1065 Mud Flat Road 75% Residue, Checking
Shippensburg PA 17257 and Retirement Annuities
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. MEMORIAL LUTHERAN CHURCH 204,453.35
Shippensburg PA
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 205 005.85
..
FILE NUMBER
0428
(If more space IS needed, Insert additional sheets of the same size)
LAST WILL AND TESTAMENT
I, MILDRED E. KEEFER, of 104 SME, Shippensburg, Cumberland County,
Pennsylvania 17257-9533, do hereby make, publish and declare this to be my last will
and testament, hereby revoking all wills heretofore made by me.
1. I direct my personal representative to pay all of my debts, funeral and
administrative expenses as soon as convenient after my decease. I direct that all
inheritance taxes imposed or payable by reason of my death and interest and penalties
thereon with respect to all property, whether or not such property passes under this Will,
shall be paid by my personal representative out of my estate.
2. I authorize and empower my personal representative to sell any realty and/or
personalty owned by me at my death and not specifically devised or bequeathed herein,
at public or private sale or sales and to give good and sufficient deeds and/or bills of
sale therefore, in fee simple, as I could do if living. My representative is authorized and
empowered to engage in any business in which I may be engaged at my death, for such
period of time after my death as seems expedient to said representative.
3. I give, devise and bequeath all of my estate of whatever nature and wherever
situate as follows:
A. 25% to the Memorial Lutheran Church, Shippensburg, Pennsylvania, for
general purposes; and all the
B. Rest, residue and remainder of my estate to my brother-in-law, Leslie T.
Keefer.
4. I nominate and appoint Leslie T. Keefer to be the personal representative of my
estate, to serve without bond. If he cannot or does not serve, then I appoint Jane E.
Adams, Esquire, to be the substitute personal representative, with the same powers and
also without bond.
5. I suggest that my personal representative retain the services of Jane E. Adams,
Esquire, Carlisle, Pennsylvania in the settlement of my estate.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 25th day of
October, 2006.
'~~{::AE.ie&h-€A~
(SEAL)
Signed, sealed, published and declared by the above-named person as and for a last
will and testament, in our presence, who at said person's request, in said person's
presence and in the presence of each other have hereunto set our names as
subscribing witnesses.
-1thDfl<kJ_i ~
r~~1/r~
ACKNOWLEDGMENT AND AFFIDA VIT
WE, MILDRED E. KEEFER, RHONDA S. IRWIN and SARAH A. HARDESTY, the
testatrix and witnesses respectively, whose names are signed to the foregoing
instrument, being first duly sworn, do hereby declare to the undersigned authority that
the testatrix signed and executed the instrument as her last will and that she had signed
willingly, and that she executed it as her free and voluntary act for the purpose herein
expressed, and that each of the witnesses, in the presence and hearing of the testatrix,
signed the will as a witness and that to the best of their knowledge the testatrix was, at
that time, eighteen years of age or older, of sound mind and under no constraint or
undue influence.
'tW-dv ~ C ~YVl./
MIL RED E. KEEFER
{/};m/;v. J f}u~
RHONDA S. IRWIN
:ss:
COUNTY OF CUMBERLAND
Subscribed, sworn to and acknowledged before me by MILDRED E. KEEFER, the
testator herein, and subscribed and sworn to before me by RHONDA S. IRWIN and
SARAH A. HARDESTY, witnesses, this 25'" day ~f Octob<n' 2006.
/ / LU2ct"aa~
ro ary Public
\
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Jane Adams, Notary Public
Carlisle Boro, Cumberlanrl County
My Commission Expires Sept. 6, 2O+J8
H p;
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fonn HUO.' (3/86) ref Handbook 4305.2
A. Settlement Statement
u.s. Department of Housing and Urban Development
OMB No. 2502-0265 (exoires 9/3012006\
Madison B. TYPE OF LOAN
1. DFHA 2. DFmHA 3. DConv. Unins.
~ttle!"ent 4. nVA 5. nConv. Ins.
6. FILE NUMBER 17. LOAN NUMBER
erV1CeS MS1549
8. MORTGAGE INSURANCE CASE NUMBER
C. Note: mil orm . mm'snea to g ve you I ~~t~m~m C?' 1.'laUII.allleme~ COS ~._~_o,,!,:,!~ paiD to .na I y tne Iettleme~ eUlI'm_Ire snown I TitleExpress Settlement System
ttem. mlrked "(p.o.c.)" were plld oUblde the closing; they Ire shown here for InformeUGn purpose. snd Ire not Included In the totl"
~~~=~~~: :I~ 1~:I~r;: :c;.~~c:n:,"f:r::~~~~~~ ;~-:~r;:.r::: ::~~~:I~;dU~:.t~'o~~ g::.r:nl~60~t~~~ '~,:~~~~~01~'l.nIIUel upon . Printed 06/14/2007 at 15:14 DS
D. NAME OF BORROWER: Leroy F! Dunham and Gladys S. Durham
ADDRESS:
E. NAME OF SELLER: Estate of Mildred Keefer
ADDRESS: 104 ShiDDensbura Mobile Estate Shiooensbura. PA 17257
F. NAME OF LENDER:
ADDRESS:
G. PROPERTY ADDRESS: 104 Shippensburg Mobile Estate, Shippensburg, PA 17257
ShiooensburaTownshio
H. SETTLEMENT AGENT: Madison Settlement Svcs.Chambersburg, LLC, Phone:(717).243.2121\Fax:(717).243.2646
PLACE OF SETTLEMENT: 8 Irvine Row Carlisle PA 17013
I. SETTLEMENT DATE: 0611412007
J. SUMMARY OF BORROWER'S TRANSACTION: K. SUMMARY OF SELLER'S TRANSACTION:
100. GROSS AMOUNT DUE FROM BORROWER 400. GROSS AMOUNT DUE TO SELLER
101. Contract sales orice 35 000.00 401. Contract sales nrice 35 000.00
102. Personal Pronertv 402. Personal Pronertv
103. Settlement charaes to borrower (line 1400\ 140.00 403.
104. 404.
105. 405.
Adiustments for items Daid bv seller in advance Ad'ustments for items Daid bv seller in advance
106. Cijv/town taxes 406. Citv/town taxes
107. County taxes 06/14107 to 12/31/07 43.47 407. Countv taxes 06/14107 to 12/31107 43.47
108. School taxes 06/14107 to 06/30/07 13.35 408. School taxes 06/14107 to 06/30/07 13.35
109. 409.
110. Lot Rent Proration 6/14-6/30 153.00 410. Lot Rent Proration 6/14-6/30 153.00
111. 411.
112. 412.
120. GROSS AMOUNT DUE FROM BORROWER 35 349.82 420. GROSS AMOUNT DUE TO SELLER 35 209.82
200. AMOUNTS PAID BY OR ON BEHALF OF BORROWER 500. REDUCTIONS IN AMOUNT DUE TO SELLER
201. Dennsit or earnest monev 500.00 501. Excess Denosit (see instructions\
202. Princinal amount of new loans 502. Settlement charnes to seller lIine 140m 2 210.00
203. Existinn loanls\ taken subiect to 503. Existinn loanls\ taken subiect to
204. 504. Pavoff of First Mortnane Loan
205. 505.
206. 506.
207. 507.
208. 508.
209. 509.
Adjustments for items unoaid bv seller Adiustments for items unoaid bv seller
210. Citv/town taxes 510. City/town taxes
211. Countv taxes 511. Counlv taxes
212. School taxes 512. School taxes
213. 513.
214. 514.
215. 515.
216. 516.
217. 517.
218. 518.
219. 519.
220. TOTAL PAID BY/FOR BORROWER 500.00 520. TOTAL REDUCTION AMOUNT DUE SELLER 2 210.00
300. CASH AT SETTLEMENT FROM OR TO BORROWER 600. CASH AT SETTLEMENT TO OR FROM SELLER
301. Gross amount due from borrower (line 12m 35 349.82 601. Gross amount due to seller !line 420\ 35 209.82
302. Less amounts naid bv/for borrower !line 220\ 500.00 602. Less reduction amount due seller (line 520\ 2210.00
303. CASH FROM BORROWER 34 849.82 603. CASH TO SELLER 32 999.82
:~::I~~~:: :.~~~ 1:::t~;~~~:::~~I~::~P~~~~~0~1:~~I:"~:~': ~'~~:~I: ::::~:;~~~~I~C::::~;s ~':.~~~~I:: J,~'r:~: ~~:,:e:,~t~~rt~~:'~: ~~I~'c;1 ~:~ ~~cr:~~::~~dfl~~ I return,
line 401 lbove constitutes the Gro.. Proceed. of this tnnllctlon.
You Ire required by llw to provtde the lItt1ement Igent (Fed. Tax 10 No: 1 with your correct taxpayer Identlflcltlon number. If you do not provide your correct taxpayer Identlflc.tlon
number, you may be lubJect to ctvll or crlmlllll pen.ttie. Imposed by Ilw. Under pen.ltl.s of perjury, I certify thlt the number .hown on thll It.tement II my correct taxp.yer IdentJflc.tlon number.
TlN:_"_._,_._"_ SELLER(S)SIGNATURE(S):
SELLERIS) NEW MAlUNG ADDRESS:
SELLERIS) PHONE NUMBERS: (H)
(W)
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
SETTLEMENT STATEMENT
File Number: MS1549
.00.", .'v...., '"'''00''''' ,................ .....v.....
PAGE 2
TitleExnress Settlement System Printed 06/14/2007 at 15:14 OS
L. SETTLEMENT CHARGES PAID FROM PAID FROM
700. TCTAL SALES/BROKER'S COMMISSION based on nrice $35 000.00 (Q) 6.000 = 2100.00 BORROWER'S SELLER'S
Divisioh of commission Iline 7001 as follows: FUNDS AT FUNDS AT
701. $ to SETTLEMENT SETTLEMENT
702.$ 2 100.00 to Sailhamer Real Estate
703. Commission naid at Settlement 2100.00
BOO. ITEMS PAYABLE IN CONNECTION WITH LOAN
801. Loan Orinination Fee %
802. Loan Discount %
803. Annraisal Fee
804. Credit Rennrt
805. Lender's Insnection Fee
806. Mortaaae Annlication Fee
807. Assumntion Fee
808.
809.
810.
811.
900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE
901. Interest From to ftj)~ Idav
902. Mortaaae Insurance Premium for to
903. Hazard Insurance Premium for to
904.
905.
1000. RESERVES DEPOSITED WITH LENDER FOR
1001. Hazard Insurance mo./1l) $ Imo
1002. Mortaaae Insurance mo./1l)$ Imo
1003. City Pronertv Tax mo.-@$ Imo
1004. County Pronertv Tax mo~$ 6.58 Imo
1005. School taxes mo~ 23.s9 Ima
1009. Annrenate Analvsis Adiustment 0.00 0.00
1100. TITLE CHARGES
1101. Settlement or closina fee to David R. Bresch! Esnuire 130.00 100.00
1102. Abstract or title search
1103. Title examination
1104. Title insurance binder
1105. Document Prenaration
1106. Notarv Fees to Dawn M. ShOOD 10.00 10.00
1107. Attomev's fees
lincludes above items No: \
1108. Title Insurance
lincludes above items No: \
11 09. Lende~s Coveraoe $
1110. Owner's Coveraae $ 35 000.00 .
1111.
1112.
1113.
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
1201. Recordinn Fees Deed $ . MortaaaeS . Release $
1202. C~v/Countv tax/stamns Deed $ . Mortaaae$
1203. State Taxlstamns Deed $ . Mortnaae $
1204. Title Transfer to Sollenberners Messenner Services IP.O.C.l 22.00 Buver
1205. Title Transfer to Commonwealth of PA IP.O.C.127.00 Buver
1300. ADDITIONAL SETTLEMENT CHARGES
1301. Survey
1302. Pest Insnection
1400. TOTAL SETTLEMENT CHARGES lenter on lines 103 Section J and 502 Section K\ 140.00 2210.00
HUO CERTIFICATION OF BUYER AND SELLER
0.1 Settlement St.t.ment and to the beat of my knowledge and bell", It I.. true and accurate Itetem.nt of all reclipts end dllburument. mad, on my .ccount
.r certify th.t I hlv, received I copy ofth. HUD.1 Setttement Statement.
~.J. h6J~,--,
.y..uam
Estate of Mildred Keefer
DATE: I,' ;r-l 0 7
WARNING: IT IS A CRIME TO KNOWINGLY AKE FALSE STATEMENTS TO THE
UNITED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON CONVICnON
CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TITLE 18:
U.S. CODE SECTION 1001 AND SECTION 1010.
SETTLEMENT AGENT:
~ &~ Chevrolet
Oldsmobile, Pontiac & Cadillac Inc.
730 EKing St
Shippensburg, Pa 17257-0098
(717) 532-2121
H&H CHEV PONT CAD INC
PO BOX 98
Shippensburg, PA 17257
Date: 05/15/07
Phone: 717-532-2121
H&H Chev Pont Cad Inc is purchasing from
the Estate of Mildred E Keefer a:
2006 CHEVROLET IMPALA L T SDN
VIN 2G1WT58K569178983
Check to the Estate of Mildred E Keefer
Th Estate of Mildred E
Leslie Keefer - Executor
-~~~~
Timothy M Nye - S s Manager
H&H Chev Pont Cad Inc.
$ 14,100.00
$ 14,100.00
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COMMUNITY
FSM OFFICES IN 0022 0014 3934 Y
FRANKLIN,
CUMBERLAND,
FULTON AND
HUNTINGDON STATEMENT OF ACCOUNTS
TRUST COUNTIES 33-21657
www.fmtrustonline.com
STATEMENT PERIOD
FROM THROUGH
'11I,11.11'11'.'.'.'.'11I 11.1'111.111I1111.11 .1111111111.11111 3-21-07 4-22-07 0
*********AUTO**SCH 5-DIGIT 17225 PAGE 1 OF 2
1471 1.4910 AV 0.530 17 3 47
MILDRED E KEEFER
LESLIE T KEEFER SR 12 ENCLOSURES
104 SHIPPENSBURG MOBILE ESTATE
SHIPPENSBURG PA 17257-9533 5
GO CLUB CHECKING WITH INTEREST ACCOUNT: 33-21657
PREVIOUS DEPOSITS/ CHECKS/ SERVICE ENDING
STATEMENT BALANCE CREDITS 3 DEBITS 14 FEES BALANCE
14,510.72 2,115.58 3,575.05 .00 13,051. 25
ACCOUNT/INTEREST INFORMATION
INTEREST PAID THIS YEAR 17.14
DEPOSITS/ CHECKS/
DATE ACTIVITY DESCRIPTION REFERENCE CREDITS DEBITS BALANCE
03-21 BEGINNING BALANCE 14,510.72
03-21 CHECK 4063 00100701760 46.76
03-21 CHECK 4064 00302105602 21. 00 14,442.96
04-02 CHECK 4068 00101603313 272.89
04-02 CHECK 4069 00301804816 23.50 14,146.57
04-03 US TREASURY 303 00077900000 1,070.00
SOC SEC 040307 8
XXXXX2944A SSA 15,216.57
04-04 ADAMS ELECTRIC D 00077900000
ELEC PAYMT
2094620407 15,170.11
04-05 DEPOSIT 00602508720 1,041. 00
04-05 CHECK 4072 00201804873 160.00 16,051.11
04-09 CHECK 4070 00500300687 468.29
04-09 CHECK 4071 00500902543 100.00
04-09 CHECK 4074 00100100033 440.00 15,042.82
04-10 CHECK 4073 00100300615 434.00 14,608.82
04-13 CHECK 4075 00100601200 600.90 14,007.92
04-18 CHECK 4076 00100501260 43.69 13,964.23
04-19 SHOP GETTYSBURG 00077900000 261. 56
CHECK PYMT 041807
4078 13,702.67
04-20 CHECK 4080 00301002653 656.00
04-20 INTEREST CREDIT 4.58 13,051. 25
04-22 ENDING BALANCE 13,051.25
CHECK SUMMARY
* INDICATES SKIP IN CHECK NUMBERS
CHECK NO
4063
4064
4068*
4069
4070
AMOUNT
46.76
21. 00
272.89
23.50
468.29
CHECK NO
4071
4072
4073
4074
4075
AMOUNT
100.00
160.00
434.00
440.00
600.90
DIRECT
INQUIRIES TO:
TELEPHONE:
F&M TRUST - SHIPPENSBURG OFFICE
13 SHIPPENSBURG SHOPPING CTR
SHIPPENSBURG, PA 17257
717-530-2100 OR 717-530-2101
COMMUNITY
F8M OFFICES IN 0022 0014 3935 Y
FRANKLIN,
CUMBERLAND,
FULTON AND
TRUST HUNTINGDON STATEMENT OF ACCOUNTS
COUNTIES
www.fmtrustonline.com 33-21657
STATEMENT PERIOD
FROM THROUGH
3-21-07 4-22-07 0
PAGE 2 OF 2
MILDRED E KEEFER
LESLIE T KEEFER SR
104 SHIPPENSBURG MOBILE ESTATE 12 ENCLOSURES
SHIPPENSBURG PA 17257-9533
5
GO CLUB CHECKING WITH INTEREST
ACCOUNT: 33-21657
CHECK SUMMARY
* INDICATES SKIP IN CHECK NUMBERS
CHECK NO
4076
4078*
TOTAL NUMBER OF CHECKS
AMOUNT
43.69
261. 56
13
CHECK NO
4080*
AMOUNT
656.00
3,528.59
TOTAL AMOUNT OF CHECKS
***
ANNUAL PERCENTAGE YIELD EARNED DISCLOSURE FROM
ANNUAL PERCENTAGE YIELD EARNED
AVERAGE DAILY COLLECTED BALANCE
INTEREST EARNED
3-21-07 THROUGH 4-22-07 ***
.35%
14,477.85
4.58
SERVICE FEE BALANCE INFORMATION FROM 3-21-07 THROUGH 4-22-07
AVERAGE LEDGER BALANCE 14,477.85 AVERAGE COLLECTED BALANCE
MINIMUM LEDGER BALANCE 13,046.67 MINIMUM COLLECTED BALANCE
14,477.85
13,046.67
DIRECT F&M TRUST - SHIPPENSBURG OFFICE
INQUIRIES TO: 13 SHIPPENSBURG SHOPPING CTR
SHIPPENSBURG, PA 17257
TELEPHONE: 717-530-2100 OR 717-530-2101
FSM
TRUST
CHAMBERSBURG
BOILING SPRINGS
MARION
MONT ALTO
NEWVILLE
SHIPPENSBURG
WAYNESBORO
CARLISLE
~14 4064
"""...
DAlT 3 -J3-t>7
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o ""
~..e lD =-=
MrMO -. . ;CI~.:-.--J~-, _
-':03BOI,::IOF.,: H-21F.5711. I,OF.I, "'O~
-------=-
03/21/07 Check #4064 Amount $21.00
Account: 332165
Statement Date 4/20/200
Page 1 of
-:14
3l21G7
MILDRED E. KEEFER
tlK SIJIP1'ENSBURG MOIlILIlESt"ATES
SHlPPENSBURC.PA 17251 Dm 3 -/3 -07
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J .,-,- C -. -' '. ." --.
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---' 7~~1j:~~
MNO ~2--. w
~03130~30~~ 33-21~57~ 1,0F.3 'OOOOOOI,~?b~
4063
03/21/07 Check #4063 Amount $46.76
MILDRED E. KEEFER ~14 406 B
IOfSlllPl'ENS8UllGMOIllLEESt"ATES 3321S
5HIPPENSlIURG.PA ]7251 nm.3 _..:l"'- ... Co 7
I "'-.J::.~ '1" <h' "\i~~" If" sf I $ ~7:1:_1!'/
~ r.r~~<<l~o-~.=
MNJ..:;r-)(i~ J9.1-X'J/ ~"? ~U~ ..
~03130~30~~ 33-21G57~ I,OGB ~aq~
.D3I~DDDD'D"
a.....Oal'eDO?
1010151601,177
04/02/07 Check #4068 Amount $272.89
6
~ MILOREDE..XEEFER ;r14 4069
ThlohaLSMLCClP'Vo'.... IMSI~~BrA'J15 __
'10.".'" .c::.c~ vO:u.::uu..cto I f ~ c ~A I7.ZI7 . I D&~ 3 - ""s- _ 00 7
... tllO.t li,~., .....Il:. ~ ~ t , .., ,~~ .\-_{,...... .
.,:;: I ~,j'Jll..~.h~5 11<",tT)" 'l:;".......,~... , $ ~J.J:"D
... .' w :J ....... :- ......~ -""..P-n
...., i +..-.....7'/ I V(~...~ -4i~~a--
~~! I:SiDII rl ~ ..q =-
rr c - i1iJST '-_'-' r....,...;
~ _~S}..~ j <;...~k ---..J: r: ~_ ~
::: I:D3HDI,3D~r. HMH~5?" I,D~~ -~~~~...
I,':OH '101, 30r..: '1'1- Hr. 5 ?...Or.~
...000000 B 50...
04/02/07 Check #4069 Amount $23.50
MILDRED E. KEIlFER "';:'14 407:1.
100SlIlP1'ENSDUllGMOIllLEESt"ATES :l:I2tCS7 '^ 1
SHII'PENSBURG.PA 17257 _ DATI' If - j. -....
fllL!r-l-1.. '1 R~~ I $ /..,;.~_~-
Ot.) CO >>... "" ~ ~ ~_ t-<.".] lIun --=---~ ~ !::S::'
_ . __ _ ~:"-:[_lJB~$ eaLs smJd B~t -'0
M"':&.~ S-..... hp.'l. --f~J{~~ ..
':03130~30r.1: :13"' i! IF.57n. ~O? I. ~'~illooo~'
04/09/07 Check #4071 Amount $100.00
\,
MlLDREDE..KEEFER ~14 4073
1005HIPI'ENSBtlRGMOIIILEESiATES . ....asr 7
5HIP1'EN5BURG, PA m51 . \. I / DATIl If -. l- _ c>
... <~r-<./ . - 0
I rhYro ~ ~"v-e ~c"''''fcl1 $ L/3'f. t:?
i_.~v"'y. Jt"r1d.Y~~~"Y-_~u lD!::S::'
I i:'IDII - r._ '-'
. -_liiJStI . . ,* ,...
Mr;iJt:=t;:~~ ~T~ ..
.':OH3ci"-:1!:1I;':--B;"2'l-~5ili" ~-OH" - .....00c;-~~--
04/10/07 Check #4073 Amount $434.00
MILDRED E. KEEFER "':'14 40 70
~~ESt"ATES. 3 ->-S"-t:>7
~ \..l..; DAlT
!'~~~12 c.r ~~1fi~s 1 $' "'It-/.-'i-::ier
'IlIEQO""'OI r I ~ \..,:::1: ~ _ . ___
-----E...... Jl'-"""Cl"'lI;CLlJB~71T /~LA" iD :=.:::-
-~....-t-r"J'-HJ"')~ ..
,:DJ~'f:301;1; ;'B'" 2l~ ~ 7.. I,O?O - ...0 ODOI,r.a-2<i..'
., 1:1- D oe;"3 ~
04/09/07 Check #4070 Amount $468.29
. D]]. a aOD III Q,.
O'lI'D51'i!'007 ,...
'"51.1."77"67 ~ MlLDREDB.1CE&PJR pS!14 4072
~~~~ ~~"o~~<<;'.Lu~u.:. I t ~:i!-~~:sr~--:---4_-'(-_.6''':J_
t1....moYMy)louwOUfd C.JI ____ " II QAq
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~ ~ ~
... ~-
::: I:03HO"~DIOC HM~'&5?" "O?~ -
-n
"':oaUO"30r.,: B-Hr.5?....07~
...00000 H,OOO..
04/05/07 Check #4072 Amount $160.00
MILDRED E. KEEFER ~14 4074
llll5HIPl'EIIlS8URC MOBILE fSl'ATES 33l!l1I7 I
SHlPPI!NSIlURC. PA Ins? DATE 'I - .. - C> 7
!,1.;Y..w_l~l!l~--f1c.t.~''f~ ~ ...... ~ I $ -q~;;'. t:>'C
nrt.OIDUtDI ~ 9 - /.1
fQ~~ J-I.~V' ~~ ~ -~~ . '=
'FfII.- C .
'1N-;;;;:-;;:5~t:~=:r -f2:(~~
':OH:l04:10r.,: B.n B!; 5 ?II. IoO?1o .~O-~~OO."
04/09/07 Check #4074 Amount $440.00
-_..
,I
Annuities
Merrill Lynch Funds
Retirement Plus@
Confirmation of
Activity
May 21, 2007
This notice is to confirm
activity processed on your
annuity contract. The
details are listed below.
1.11111.111..1.1.1.1.111.11.1...1.1...11...11.11....1..1.11111
Mildred Keefer
104 Shippensburg Mobile Est
Shippensburg P A 17257
'"
g
~
I Contract Information
In this form, the terms you and
your refer to the owner and
the co-owner, if there is one.
(For custodial accounts, you
and your refer to the beneficial
owner.) The terms we, our and
us refer to Merrill Lynch
Life Insurance Company.
Contract:
Issue date:
ML account:
Owner:
Annuitant:
M930140753
June 17, 1993
697 -10920
Mildred Keefer
Mildred Keefer
I Activity:
Financial Transactions
Date
Transaction
Number Transaction
of units Value
S 133,168.86
S 133,168.86
-912.63
-10,316.89
S 121,939.34
OS/21/2007
Death Benefit Payment:
Payment Details:
Total amount:
State premium tax:
Federal withholding tax:
Amount paid to beneficiary:
Messages
· This transaction represents payment of your beneficiary claim on this annuity. The
proceeds will be handled as you requested.
. If you notice any inaccuracy or discrepancy in this Confirmation, please
report it immediately by contacting Client Services by phone and then
re-confirm your communication in writing to further protect your rights.
Client Service contact information is indicated in the "At Your Service"
section below.
. If you have any questions, please contact your Merrill Lynch Financial Advisor
or contact Client Services as indicated in the "At Your Service" section below.
~ ....rill Lynch
Merrill Lynch Ufe Insurance Company
697/4432
May 21,2007
M930140753
page I of 2
MLB3618
0000015 (ENV-000181 000001 000585 MUC.OUTBAR.OUTl)
I Annuities
Merrill Lynch Funds
Retirement Plus@
Confirmation of
Activity
May 21, 2007
1...111.111..1.1.1.1.1...11.1...1.1...11...11.11....1..1.1..11
Mildred Keefer
104 Shippensburg Mobile Est
Shippensburg P A 17257
This notice is to confirm
activity processed on your
annuity contract. The
details are listed below.
o
o
:3
00
'"
I Contract Information
I n this form, the terms you and
your refer to the owner and
the co-owner, if there is one.
(For custodial accounts, you
and your refer to the beneficial
owner.) The terms we, our and
us refer to Merrill Lynch
Life Insurance Company.
Contract:
Issue date:
ML account:
Owner:
Annuitant:
M93041 I 102
January 17, 1994
697 - 10920
Mildred Keefer
Mildred Keefer
I Activity:
Financial Transactions
Date
Transaction
Number Transaction
of units Value
S 77,387.16
S 77,387.16
-600.00
-5,788.92
S 70,998.24
OS/21/2007
Death Benefit Payment:
Payment Details:
Total amount:
State premium tax:
Federal withholding tax:
Amount paid to beneficiary:
Messages
. This transaction represents payment of your beneficiary claim on this annuity. The
proceeds will be handled as you requested.
. If you notice any inaccuracy or discrepancy in this Confirmation, please
report it immediately by contacting Client Services by phone and then
re-confirm your communication in writing to further protect your rights.
Client Service contact information is indicated in the "At Your Service"
section below.
. If you have any questions, please contact your Merrill Lynch Financial Advisor
or contact Client Services as indicated in the "At Your Service" section below.
~MenUl Lynch
Merrill Lynch Ufe Insurance Company
697/4432
May 21, 2007
M93041 1 102
page I of 2
MLB3618
0000021 (ENV.000183 000001 000589 MLIC.OUTBAR.OUTI)
I
Annuities
Merrill Lynch Funds
Retirement PI us@
Confirmation of
Activity
May 21, 2007
1...111." 1..1.1.1.1.1...11.1...1.1...11...11.11.." 1..1.1..11
Mildred Keefer
1 04 Shippensburg Mobile Est
Shippensburg P A 17257
This notice is to confirm
activity processed on your
annuity contract. The
details are listed below.
o
o
o
:c
o
I Contract Information
I n this form, the terms you and
your refer to the owner and
the co-owner, if there is one.
(For custodial accounts, you
and your refer to the beneficial
owner.) The terms we, our and
us refer to Merrill Lynch
Life Insurance Company.
Contract:
Issue date:
ML account:
Owner:
Annuitant:
M981448088
July 20, 1998
697 -10920
Mildred Keefer
Mildred Keefer
I Activity:
Financial Transactions
Date
Transaction
Number Transaction
of units Value
S 85,325.19
S 85,325.19
-6,032.52
S 79,292.67
OS/21/2007
Death Benefit Payment:
Payment Details:
Total amount:
Federal withholding tax:
Amount paid to beneficiary:
Messages
. This transaction represents payment of your beneficiary claim on this annuity. The
proceeds will be handled as you requested.
. If you notice any inaccuracy or discrepancy in this Confirmation, please
report it immediately by contacting Client Services by phone and then
re-confirm your communication in writing to further protect your rights.
Client Service contact information is indicated in the "At Your Service"
section below.
. If you have any questions, please contact your Merrill Lynch Financial Advisor
or contact Client Services as indicated in the "At Your Service" section below.
~ MerrUl Lyncb
Merrill Lynch Ufe Insurance Company
697/4432
May 21, 2007
M981448088
page 1 of 2
MLB3618
0000037 (ENV-000190 000001 000603 MLIC.OUTBAR.OUTl)
.
Annuities
Merrill Lynch Funds
Retirement Plus@
Confirmation of
Activity
May 21, 2007
This notice is to confirm
activity processed on your
annuity contract. The
details are listed below.
1.11111...1..1.1.1.1.1...11.1...1.1...11...11.11... .1. .1.11111
Mildred Keefer
104 Shippensburg Mobile Est
Shippensburg P A 17257
o
o
::
""
N
I Contract Information
In this form, the terms you and
your refer to the owner and
the co-owner, if there is one.
(For custodial accounts, you
and your refer to the beneficial
owner.) The terms we, Durand
us refer to Merrill Lynch
Life Insurance Company.
Contract:
Issue date:
ML account:
Owner:
Annuitant:
M991601220
August 30, 1999
697 -10920
Mildred Keefer
Mildred Keefer
I Activity:
Financial Transactions
Date
Transaction
Number Transaction
of units Value
S 12,945.96
S 12,945.96
-794.60
S 12,151.36
OS/21/2007
Death Benefit Payment:
Payment Details:
Total amount:
Federal withholding tax:
Amount paid to beneficiary:
Messages
· This transaction represents payment of your beneficiary claim on this alIDuity. The
proceeds will be handled as you requested.
. If you notice any inaccuracy or discrepancy in this Confirmation, please
report it immediately by contacting Client Services by phone and then
re-confirm your communication in writing t?, further protect your rights.