HomeMy WebLinkAbout07-16-07
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RE'(-15oo EX + (6-00)
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG. PA 17128-0601
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
MOHN
DATE OF DEATH (MM-DD-Year)
MARTHA
H.
DATE OF BIRTH (MM.DD-Year)
04/25/2007 12/14/1921
(IF APPliCABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
[Xl 1. Original Return
D 4. Limited Estate
[Xl 6. Decedent Died Testate (Attach copy 01 Will)
D 9. Litigation Proceeds Received
D 2. Supplemental Return
D 4a. Future Interest Compromise (date of death aher 12-12-82)
D 7. Decedent Maintained a Living Trust (Mach copy of Trust)
D 10. Spousal Poverty Credit (dale of death between 12-31.91 and 1-1-95)
OFFICIAL USE ONLY
FILE NUMBER
2 1 -0 7 0 4 1 9
COuNTY'CoDE -vE~ - - NuMBER- -
SOCIAL SECURITY NUMBER
1 79- 1 2 - 4 0 5 9
THIS RETURN MUST BE FilED IN DUPliCATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
D 3. Remainder Return (date 01 death priorto 12-13-82)
D 5. Federal Estate Tax Return Required
_ 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
MARCUS A. McKNIGHT III 60 WEST POMFRET STREET
FIRM NAME (If Applicable)
IRWIN & McKNIGHT
TELEPHONE NUMBER
717 249-2353 CARLISLE PA 17013
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
D Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
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)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
(8)
(11)
(12)
(13)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
(14)
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
0.00 X _(15)
643,468.93 X .045 (16)
0.00 X .12 (17)
0.00 X .15 (18)
(19)
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. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > . BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
OFFICIAL USE ONLY
678, 330. e2,
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2,985.021..,-i
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681 ,315.84
28,046.82
6,800.09
34,846.91
646,468.93
3,000.00
643,468.93
R.'2V-1503 EX + (6-98)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
MOHN
MARTHA
H.
FILE NUMBER
21 07
0419
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
ORRSTOWN BANK - INVESTMENT HOLDINGS
SEE ATTACHED LIST OF SECURITIES/SHARES
VALUE AT DATE
OF DEATH
618,944.02
2.
1,452.00 SHARES COMMON STOCK - MELLON FINANCIAL CORPORATION
CUSIP #58551A10
$40.90 PER SHARE X 1,452.00 SHARES = 59,386.80
59,386.80
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
678 330.82
F.lEV-1509 EX + (6-98)
.
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
MOHN
MARTHA
H.
FILE NUMBER
21 07
0419
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. LINDA L. EMIG
28758 CYPRESS ROAD
SELBYVILLE, DE 19975
DAUGHTER
B
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JOINTL Y.OWNED PROPERTY:
LEITER DATE DESCRIPTION OF PROPERTY 'Io0F DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER. AITACH DEED FOR JOINTLY.HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 04/06 ORRSTOWN BANK 5,970.04 50. 2,985.02
CHECKING ACCOUNT #103006344
TOTAL (Also enter on line 6, Recapitulation) $ 2 985.02
(If more space is needed. insert additional sheets of the same size)
~EV-1511 EX + (12-99)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
ESTATE OF
MOHN
MARTHA
H.
Debts of decedent must be reported on Schedu Ie I.
21
07
0419
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Flowers 636.32
3. New Hope United Methodist Church - Funeral Luncheon 1,381.47
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees Irwin & McKnight 24,000.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills 457.00
5. Accountant's Fees
6. Tax Return Preparer's Fees Patricia A. Rosendale, CPA 350.00
7. Register of Wills, Filing Fee 30.00
8. Cumberland Law Journal - Estate Notice 75.00
9. The Sentinel - Estate Notice 137.03
10. Linda Emig - Reimbursement for Travel Expenses 955.00
11. Notary Fees 25.00
TOTAL (Also enter on line 9, Recapitulation) $ 28,046.82
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX + (6-98)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
,
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
MOHN
FILE NUMBER
MARTHA
H.
21
07
0419
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1.
Charles M. Kelso, Building Contractor - Repairs
850.00
2.
Continuing Care RX - Medical
69.52
3.
Green Ridge Village - Nursing
384.94
4.
Lutheran Home Care - Nursing
5,495.63
TOTAL (Also enter on line 10, Recapitulation) $
6 800.09
(If more space is needed. insert additional sheets of the same size)
"'v."",,.,*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
...- '''.
NUMBER
I.
SCHEDULE J
BENEFICIARIES
MARTHA
FILE NUMBER
21 07
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
0419
AMOUNT OR SHARE
OF ESTATE
1/2 REMAINDER
1/4 REMAINDER
1/4 REMAINDER
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
H
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)J
1.
LINDA L. EMIG
28758 CYPRESS ROAD
SELBYVILLE, DE 19975
BRADLEY CORNMAN
231 SPRINGFIELD ROAD
SHIPPENSBURG, PA 17257
ANITA WEAVER
11260 OLD MILL ROAD
SHIPPENSBURG, PA 17257
Lineal
Lineal
1.
Lineal
3.
1.
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
NEWBURG UNITED METHODIST CHURCH
PO BOX 68
NEWBURG, PA 17240
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)
3,000.00
$
3 000.00
Last Will and Testament
of
Martha H. Mohn
I, MARTHA H. MOHN, of Newburg Borough, Cumberland County, Pennsylvania,
declare this instrument to be my Last Will and Testament, hereby expressly revoking all Wills
and Codicils heretofore made by me.
ONE: I direct my Executor to pay all of my debts, funeral and administrative expenses as
soon as may be done conveniently after my decease.
TWO: I specifically, give, devise and bequeath the sum of Three Thousand and no/lOO
($3,000.00) Dollars to the NEWBURG UNITED METHODIST CHURCH, of Newburg,
Pennsylvania.
THREE: Upon my death, I give, devise and bequeath all of my remaining and residual
estate of every nature and wherever situate to LINDA L. EMIG and MELLON BANK, Co-
Trustees, subject to the following provisions:
a. The Co-Trustees will establish One trust to be allocated the principal to the
following with no principal share becoming negative:
To my daughter, LINDA L. EMIG.................................................50%
To my grandson, BRADLEY CORNMAN.....................................25%
To my granddaughter, ANITA WEA VER.......................................25%
b. The net income from each Trust Share will be payable by the Co-Trustees, to
my husband, HARRY A. MOH~, in monthly payments during his lifetime. The Co-Trustees
may invade the principal of the Trust for the benefit of my husband, HARRY A. MOHN, at its
sole discretion. The Co-Trustees in their sole discretion, may also invade the principal of the
Trust for the health, education or welfare of the named residuary Trust beneficiaries, being
LINDA L. EMIG, BRADLEY CORNl\,'1AN and ANITA WEAVER, from their respective
Trust Shares. Upon the death of my husband, HARRY A. .MOHN, the remaining trust
principal and accumulate income, the Trust will be distributed by the Co-Trustees to my
residuary beneficiaries as set forth above. If one of my beneficiaries has predeceased me or die
during the existence of this Trust, the principal and accumulated income shall be distributed
equally to the issue of my beneficiary who has died. If one of my beneficiaries has died without
living issue, then the share of my deceased beneficiaries shall be distributed equally to my living
beneficiaries. All undistributed income will be paid upon final distribution of the Trust principal
to the beneficiaries as set forth above.
c. The Co-Trustees shall have the following powers, in addition to those vested
III it by law, for my property held for the benefit of my beneficiaries, whether income or
principal, exercisable without Court approval and effective until the distribution of all property
under the terms of this Trust; the Co-Trustees, at their discretion, may compromise claims,
borrow money, or retain property for such length of time as it may deem proper. sell lease,
pledge, mortgage, transfer, exchange, convert or otherwise dispose of or grant options of all or
any portion of the Trust property for such prices, on such terms in pl,lblic or pri vate transactions
as it may deem proper, and invest Trust property and income without restriction to legal
investments.
2
d. The Co-Trustees will have the power to use a Corporate Trust to assist the
Co-Trustees. The Co-Trustees also retain the power to remove any Coporate Trustees, which
they have retained to assist them as Co-Trustees.
e. If one of the Co-Trustees is unable to serve, I appoint MARCUS A.
:McKNIGHT, III, Esquire, Trustee in their place.
FOUR: I appoint my husband, HARRY A. MOHN, to be the Executor of this my Last
Will. If he has predeceased me, failed to qualify, or ceased to serve as Executor, then I appoint
LINDA L. EMIG, to serve as Executrix of this my Last Will. If she is unable to serve I name
ANITA WEAVER and BRADLEY CORNl\IAN, Co-Executors in her place of this my Last
Will.
FIVE: My Executor may, at his discretion, compromise claims, borrow money, retain
property for such length of time, as he may deem proper; lease and sell property for such prices,
on such terms, at public or private sales, as he may deem proper; and invest estate property and
income without restriction to legal investments.
SIX: No Executor, Co-Executors or Co-Trustees acting hereunder shall be required to
post bond or enter security in this or any jurisdiction.
A.
IN WITNESS 'WHEREOF, I have hereunto set my hand and seal this ~ day of
September 2005.
Ei cvd1~ tJ.Jrr. ~ (SEAL)
.MARTHA H. MOHN
3
Signed, sealed, published and declared by MARTHA H. MOHN, the above named
Testatrix, as and for her Last Will and Testament, in the presence of us, who, at her request and
in her presence and in the presence of each other have subscribed our names as witnesses hereto.
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ACKNO"VLEDGMENT AND AFFIDAVIT
WE, MARTHA H. MOHN, SHARON L. SCHWALM and KAREN S. NOEL, the
testator and witnesses respectively, whose names are signed to the foregoing instrument, being
first duly sworn, do hereby declare to the undersigned authority that the testator signed and
executed the instrument as his last will and that he had signed willingly, and that he executed it
as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in
the presence and hearing of the testator, signed the will as a witness and that to the best of their
knowledge the testator was, at that time, eighteen years of age or older, of sound mind and under
no constraint or undue influence.
)rJ~/~.)r;~
MARTHA H. MOHN
COMMONWEAL TH OF PENNSYL VANIA
: SS:
COUNTY OF CUMBERLAND
Subscribed, sworn to and acknowledged before me by MARTHA H. l\IOHN, the
testatrix herein, and subscribed and sworn to before me by SHARON L. SCHWALM and
KAREN S. NOEL, witnesses, this 1 day of September, 2005.
Notarial Seal
Marcus A. McKnight.llI. Notary Public
Carlisle Bora.. Cumberland County
My Commission Expires Oct. 10, 2006
Member. Pennsylvania Association Of Nolaries
5
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I ORRSTOWN
1
,
I FINANCIAL ADVISORS
A Tradition of Excellence
Account: 5000 1474003 MARTHA H MOHN
INVESTMENT HOLDINGS AS OF 4/25107 (000)
Cusip No. Security Name Shares / Par 000 Price 000 Value Accrued Income
031162100 AMGEN INC 100.0000 $ 61.50 $ 6.150.00
037411105 APACHE CORP 1 00 0000 $ 76.30 $ 7.63000 $ 1500
193068103 COLDWATER CREEK 300.0000 $ 2160 $ 6A80.00
237194105 DARDEN RESTAURANTS 100 0000 $ 41AO $ 4,140.00
253393102 DICKS SPORTING GOODS 100.0000 $ 5680 $ 5,68000
256206103 DODGE & COX INTL STK 637.6410 $ 47.83 $ 30,49837
278642103 E-BAY INC 200.0000 $ 33.80 $ 6.760 00
3133XFAX4 FHLB 5 4% 4/28/11 25.0000000 100.656 $ 25,164.00 $ 67500
3133XFH41 FHLB 6 5/15/13 25,0000000 100031 $ 2500775 $ 656.60
3133XGZV9 FHLB 5 52 3/29/12 25,000 0000 100281 $ 25,07025 $ 9960
314172677 FED KAUFFMAN A #66 1.742.1600 $ 623 $ 10.85366
349631101 FORTUNE BRANDS 1000000 $ 8120 $ 8.12000
427866108 HERSHEY FOODS 200.0000 $ 54.80 $ 10,96000
469814107 JACOBS ENGINEERING 200.0000 $ 5170 $ 10,34000
48023P106 JONES SODA CO 100.0000 $ 26.10 $ 2,61000
493558GQ7 KEYS SO PA 4645/15 25,000 0000 100108 $ 25,02700 $ 51550
502424104 L3 COMMUNICATIONS 100.0000 $ 90.70 $ 9,070.00
524659208 LEGG MASON VAL TRUST 208.5070 $ 84AO $ 17,59799
596278101 MIDDLEBY CORP 100.0000 $ 141AO $ 14.140.00
'30934N625 FED MONEY MKT-PRI 187.073.2100 100 $ 187,07321 $ 67810
60934N621 FED MONEY MKT-INC 544 3300 100 $ 54433 $ 2.70
629491101 NYSE EURONEXT COM 100.0000 $ 8580 $ 8,58000
70884B117 PA IMIT SER 83 10 0000 6158 $ 615.80
73935X575 PINRSHS WA TER ETF 200.0000 $ 1940 $ 3,88000
73935X716 POWERSHARES INTL DIV 200 0000 $ 20.50 $ 4.10000
741479109 T ROWE GROWTH STK 40 8760390 $ 33.81 $ 29,61888
754212108 RAVENINDSINC 100.0000 $ 29 AO $ 2,94000
779547108 T ROWE PR EQTY IN FD 364 0334 $ 3106 $ 11,306.88
77954M105 T ROWE CAP APP 724.9880 $ 2177 $ 15.782.99
819215NR1 SHAL SO PA 3 9 9/12 25,0000000 101 187 $ 25,296.75 $ 14620
878155100 TEAM INC 400 0000 $ 34.60 $ 13,84000
91324P 1 02 UNITEDHEAL TH GRP 100.0000 $ 5310 $ 5,31000
922018106 VANG WIND FUND #22 564.6530 $ 19.69 $ 11,11802
922038203 VG GLOBAL EQUITY FD 4608530 $ 25.25 $ 11.63654
922908710 VG 500 INDEX ADM 540 126.9700 $ 13781 $ 17.49774
98956P102 ZIMMER HOLDINGS 1000000 $ 88.90 $ 8.89000
IP147499A SYMETRA LIFE 1.0000 $ 9,61388 $ 9.61388
321234.3844 $ 618.944.02 L 2.r98.70
CHARLENE L. FEUCHTENBE ER
TRUST OPERATIONS OFFIC R
SOLE INVESTMENT ACCOUNT:
OPENED 4/12/2006
THE CHECK BELOW REPRESENTS A DIVIDEND PAYMENT
To Inquire about your account, contact
Mellon Investor Services
Toll Free Number
OutSide the U.S (Collect)
Hearing Impaired
@ Mellon Financial Corporation
800-205-7699
201-680-6578
800-231-5469
Login to
Investor ServiceDirecf'l) at
www.melloninvestor.comlisd
Dear Shareholder:
We are pleased to enclose your common stock dividend in the amount of 22 cents per share, This represents the 449th consecutive quarterly dividend paid by the
Corporation to its shareholders,
Subject to the approval of the Board of Directors, Mellon Financial Corporation's common stock dividends are paid on or about the 15th day of February, May,
August and November. The common stock of Mellon Financial Corporation is listed on the New York Stock Exchange. The trading symbol is MEL.
Sincerely,
r;?0Lt7 ~
Robert P. Kelly
Chairman, President and Chief Executive Officer
If you would like to participate in Mellon's Direct Stock Purchase and Dividend Reinvestment Plan, please call, toll-free, the Mellon Investor Services Fulfillment
Center at 1-800-842-7629 to request a Plan Prospectus and the enrollment form. The offer to enroll is made only by Prospectus.
RATE
02200000
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RETAIN FOR YOUR RECORDS
-.. -- -- -- - - -- - - -- - ----- -- - - --- - --- - ---- - - ---- -- ---- - - --- ----- - - ---- ---- -- -- --- ---- -------- -- -- - - ---- -- ----- - -. - -. -- --. ----- ------ --- ----
SHAREHOLDER OF
TRANSACTION DESCRIPIlON
MELLON FINANCIAL CORPORATION
ACCOUNT KEY RECORD DATE
MOHN--MARTHOOOO 04/30/2007
PAYABLE DATE
DIVIDEND
CURRENT DIVIDEND
$319.44
INVESTOR ID
124981380850
TAX IDENTIFICATION NUMBER
ON FILE
05/15/2007
Please detach and retain this form for your records.
PLEASE DETACH BELOW
--- -- -- ---- -. - - -- - -- - -- - - -. - - - - - --- - - - -- - ---- -- --- - -- --- --- -- - -- --- -- -- -- -- --- -- ---- ------ -.. --- - - ---------- ---- - -.. ------ --------- --- ----
CHECK NUMBER: 76031168
-:, II J=lr":1 ::r....).. 11'100111,'. l::l ~ ..:" l-"1II:J"~ . lilt! :, ',:.1: l;;l ::1'" 11':1 =-.: 1::II:"'1j ~.'l:a.: I ~I /1100111,'. l::l ~ '.I! "' ~. ,., I ~ ~,' ~..',: 111;;l [OJ''' .'1"'" :1:1,""': 1:_: [III """ .., ~ IF" ~ ["~~d"'JI:t'i' ~
IH'A PAYABLE DATE CHECK NUMBER _
~ Mellon Financial Corporation 05/15/2007 76031168 433
PO BOX 3314
SOUTH HACKENSACK, NJ 07606-3314
PAYABLE AT MELLON BANK NA PITTSBURGH, PA.
IN U.S. DOLLARS
20510258551A10
MOHN-MARTHOOOO
5006077 01 AS 0.341 "AUTO TO 2 6791 17240-0437372 DOM00000152
l,ulll'II1 "','.111"',, ,11111, '11' 1111. I 1111" 11.1'111" 1.11
DIVIDEND PAYMENT 449
PAY TO THE
ORDER OF:
MARTHA H MOHN
BOX 437
NEWBURG PA 17240-0437
1 P A Y*--***-*****$ 31 9.441
.4- c: {iJ.;7i
AUTHORIZED SIGNATURE
1117 bO:1 ~ ;Lb8uI 1:0 ~:1:10 ;L.bO ;L..:
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BK: Historical Prices for BANK OF NY MELLON CP - Yahoo! Finance
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YahoWelcilitjn'e~l1whctfes41SV1'6tgn Out Help
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7/11/2007
~
ORRSTOWN
BANK
~~~~uw~~
A Tradition of Excellence
rn r ";..~rH""""
-......:..'\. I. - - . -_-.., .-.-._..-....\....~~ 1
May ] 0, 2007
77 East King Street
P.O. Box 250
Shippensburg, PA 17257
To: Irwin & McKnight
60 West Pomfret Street
Carlisle Pa 170] 3-3222
From: Traci Shaffer
Orrstown Bank
Customer Service Center
PO BOX 250
Shippensburg. Pa 17257
Re: Estate of Martha II Mohn
Date of death April 25. 2007
IT IS HERERBY CERTIFIED THAT THE ABOVE ;VA.lvIED DECEDElvT ON THE
ABOVE DATE. HAD THE FOLLOWING ACe '()UNTS f:VITH ORR5,'TOf:V;V BANK
CHECKING ACCOUNT
Account # Title of Account
] 03006344 Martha II Mohn
Linda L Emig
Date opened
4/24106
Principle
5970.04
Accrued Interest
0.20
SA ~7NGS AC('()UNT
Account # Title of Account
Date opened Principle
Accrued Interest
('f:RTlFI( 'A FE ()F DEN )SIT
Account # Title of Account
40000] 5865 1\1artha If Mohn
Irrevocable Burial Fund
Date Opened Principle
Accrued I!llercsJ
Lutheran Home Care
Care Advantap.-e, 2700 L...uther Drive
ChambersburJ, PA 17201
Bill To:
Orrston Bank
77 E. King Street
Shippensburg, PA 17257
Attn: Barbara Brobst
i Martha Mohn'
~4N:Mountain'Road
Newburg, PA 17240
Services Provided For:
~~\~1~-
Client Invoice With Current Activity
Client Branch Account # Period Ending Invoice #
Martha Mohn FR 308 03/31/2007 3256
Current Activity
Date Shift Caregiver Job Description H rs/U nits Rate Amount Miles Mileage Misc Chrg. Total
03/23/2007 11 :OOPM - 12:00AM Bowen, Denise NMCA Regular Weekday 1.00 $19.00 $19.00 0.00 $0.00 $0.00 $19.00
03/24/2007 12:00AM - 07:00AM Bowen, Denise NMCA Regular Weekend 7.00 $20.25 $141.75 0.00 $0.00 $0.00 $141.75
03/24/2007 11 :OOPM - 07:00AM Bowen, Denise NMCA Regular Weekend 8.00 $20.25 $162.00 0.00 $0.00 $0.00 $162.00
03/25/2007 04:00PM - 11 :OOPM Diffenderfer, NMCA Regular Weekend 7.00 $20.25 $141.75 0.00 $0.00 $0.00 $141.75
Sabnna
03/25/2007 11 :OOPM .. 12:00AM Angle, Mandy NMCA Regular Weekend 1.00 $20.25 $20.25 0.00 $0.00 $0.00 $20.25
03/26/2007 12:00AM - 07:00AM Angle, Mandy NMCA Regular Weekday 7.00 $19.00 $133.00 0.00 $0.00 $0.00 $133.00
03/26/2007 04:00PM - 11 :OOPM Murr, Ashley NMCA Regular Weekday 7.00 $19.00 $133.00 0.00 $0.00 $0.00 $133.00
03/26/2007 11 :OOPM - 07:00AM Bowen, Denise NMCA Regular Weekday 8.00 $19.00 $152,00 0.00 $0.00 $0.00 $152.00
03/27/2007 04:00PM - 11 :OOPM Murr, Ashley NMCA Regular Weekday 7.00 $19.00 $133.00 0.00 $0.00 $0.00 $133.00
03/27/2007 11 :OOPM - 07:00AM Bowen, Denise NMCA Regular Weekday 8.00 $19.00 $152.00 0.00 $0.00 $0.00 $152.00
03/28/2007 04:00PM - 11 :OOPM Diffenderfer, NMCA Regular Weekday 7.00 $19.00 $133.00 0.00 $0.00 $0.00 $133.00
Sabrina
03/28/2007 11:00PM - 07:00AM Bowen, Denise NMCA Regular Weekday 8.00 $19.00 $152.00 0.00 $0.00 $0.00 $152.00
03/29/2007 04:00PM - 11 :OOPM Diffenderfer, NMCA Regular Weekday 7.00 $19.00 $133.00 0.00 $0.00 $0.00 $133.00
Sabrina
03/30/2007 04:00PM.. 11 :OOPM iVlurr, Asniey NMCh Regula, W'*3kday 7.00 $1900 $133.00 0.00 $0.00 $0.00 $133.00
03/30/2007 11:00PM -12:00AM Angle, Mandy NMCA Regular Weekday 1.00 $19.00 $19.00 0.00 $0.00 $0.00 $19.00
03/31/2007 12:00AM - 07:00AM Angle, Mandy NMCA Regular Weekend 7.00 $20.25 $141.75 0.00 $0.00 $0.00 $141.75
03/31/2007 04:00PM - 11 :OOPM Diffenderfer, NMCA Regular Weekend 7.00 $20.25 $141.75 0.00 $0.00 $0.00 $141.75
Sabrina
03/31/2007 11 :OOPM - 07:00AM Angle, Mandy NMCA Regular Weekend 8.00 $20.25 $162.00 0.00 $0.00 $0.00 $162.00
Client Total: 113.00 $2,203.25 0.00 $0.00 $0.00 ..$2,203.25
/
Previous Balance Payments Adjustments Current Charges Unapplied Cash ! Amount Due
I
\
$0.00 $0.00 $0.00 $2,203.25 $0.00 ~ $2,203.25
Please pay this amount: $2,203.25 ~
D C\ c~\Ol \G'l
\ G \L* '. 2- q' ;::Ft 0
Thank you for allowing us to serve you, Payment due upon receipt. UQillcl) Cu.cJL C\\'O\?R ~I
luxLi-h\\lj -fut C'''FP\~'\l.C-\) @
Lutheran Home Care
Care Advantage, 270! I~uther Drive
Chambersburg, ."fo. 17201
Bill To:
Services Provided For:
Orrston Bank
77 E. King Street
Shippensburg, PA 17257
Attn: Barbara Brobst
Martha Mohn
4N. Mountain Road
Newburg, PA 17240
Client Invoice With Current Activity
Client
Branch
Account #
Period Ending
03/31/2007
Invoice #
Martha Mohn
FR
308
3256
Previous Balance Payments Adjustments Current Charges Unapplied Cash Amount Due
$0.00 $0.00 $0.00 $2,203.25 $0.00 $2,203.25
Please pay this amount: $2,203.25
Total Amount Due:
$2,203.25
Check #:
Amount Paid($):
Please Return This Form With Your Payment. Thank You.
Thank you for allowing us to serve you. Payment due upon receipt.
Lutheran Home C'lre
Care Adv"l.~age, 2700 Luther Drive
Chambersburg, PA 17201
Bill To :
'ded FO~~~\q1~ ..
oad .,j;
17240 .
Orrston Bank
77 E. King Street
Shippensburg, PA 17257
Attn: Barbara Brobst
Account #
Invoice #
Client Invoice With Current Activity
Client
Martha Mohn
Branch
Period Ending
04/30/2007
3553
FR
308
Current Activity
Date Shift Caregiver Job Description Hrs/Units Rate Amount Miles Mileage Misc Chrg. Total
04/01/2007 09:30AM - 02:00PM Smetzer, Lisa NMCA Regular Weekend 4.50 $20.25 $91.13 0.00 $0.00 $0.00 $91.13
04/01/2007 04:00PM - 11 :OOPM Diffenderfer, NMCA Regular Weekend 7.00 $20.25 $141.75 0.00 $0.00 $0.00 $141.75
Sabrina
04/01/2007 11 :OOPM - 12:00AM Angle, Mandy NMCA Regular Weekend 1.00 $20.25 $20.25 0.00 $0.00 $0.00 $20.25
04/0212007 12:00AM - 07:00AM Angle, Mandy NMCA Regular Weekday 7.00 $19.00 $133.00 0.00 $0.00 $0.00 $133.00
04/02/2007 04:00PM - 11 :OOPM Murr, Ashley NMCA Regular Weekday 7.00 $19.00 $133.00 0.00 $0.00 $0.00 $133.00
04/03/2007 04:00PM - 11 :OOPM Murr, Ashley NMCA Regular Weekday 7.00 $19.00 $133.00 0.00 $0.00 $0.00 $133.00
04/03/2007 11 :OOPM - 07:00AM Angle, Mandy NMCA Regular Weekday 8.00 $19.00 $152.00 0.00 $0.00 $0.00 $152.00
04/04/2007 04:00PM - 11:00PM Diffenderfer, NMCA Regular Weekday 7.00 $19.00 $133.00 0.00 $0.00 $0.00 $133.00
Sabrina
04/04/2007 11 :OOPM - 07:00AM Angle, Mandy NMCA Regular Weekday 8.00 $19.00 $152.00 0.00 $0.00 $0.00 $152.00
Client Total: 56.50 $1,089.13 0.00 $0.00 $0.0~'E.Q~:~.;}'l~,
........"",_."'.':T~
Previous Balance Payments Adjustments Current Charges Unapplied Cash "~I.AmountDue:; "
~;:;;~~.~__~~~' 7
$2,203.25 $0.00 $0.00 $1,089.13 $0.00
Please pay this amount:
$3,292.38
\)C\. ~ 1 ,lOb .-~~
~ 1-~~
-ftx tJa~
? d. $llO'OQr3>
en u \ \ '-\ \ 01
CJuf: '2. QQ1'2.
Thank you for allowing us to serve you. Payment due upon receipt.
Lutheran Home Care
Care Adv'l'1tage, 2700 Luther Drive
Chambersburg. PA 17201
Bill To :
Orrston Bank
77 E. King Street
Shippensburg, PA 17257
Attn: Barbara Brobst
Services Provided For:
Martha Mohn
4N. Mountain Road
Newburg, PA 17240
Client invoice With Cummt Activity
Client
Martha Mohn
Branch
Account #
Period Ending
Invoice #
FR
308
04/30/2007
3553
Previous Balance Payments Adjustments Current Charges Unapplied Cash Amount Due
$2,203.25 $0.00 $0.00 $1,089.13 $0.00 $3,292.38
Please pay this amount: $3,292.38
Total Amount Due:
$3,292.38
Check #:
Amount Paid($):
Please Return This Form With Your Payment. Thank You.
Thank you for allowing us to serve you. Payment due upon receipt.
D
d t' C
I t Add
ece en s omple e ress:
STREET ADDRESS 4 NORTH MOUNTAIN STREET
CITY I STATE I ZIP
NEWBURG PA 17240
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
28,956.10
1.447.81
Total Credits (A + B + C)
(2)
1,447.81
3. Interest/Penalty if applicable
D. Interest
E. Penalty
0.00
Total Interest/Penalty (0 + 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 AGENT
0.00
27,508.29
27,508.29
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; .........................................._................................ D lXJ
b. retain the right to designate who shall use the property transferred or its income; ........................................ D lXJ
c. retain a reversionary interest; or ...................................................................................................... D lXJ
d. receive the promise for life of either payments, benefits or care? ............................................................. D lXJ
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?............................................................................................... D lXJ
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ................. D lXJ
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ....................................................................................................... D lXJ
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
ADDRESS
DE
ADDRESS
PA 17013
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. 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
indiyidual who has at least one parent In common with the decedent, whether by blood or adoption.