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Home My WebLink About07-31-07 ~ 15056041114 REV-1500 EX (06-05) PA Department of Revenue Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year AI 01 File Number lit Date of Birth 174-20-8715 01242004 10241928 Decedent's Last Name Suffix Decedent's First Name MI FRY (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix JOSEPH w. Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW m 1. Original Retum o 4. Limited Estate m D 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received o o o o 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy ofTrust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 8. Total Number of Safe Deposit Boxes 2. Supplemental Retum D o o 3. Remainder Retum (date of death prior to 12-13-82) 5. Federal Estate Tax Retum Required o 11. Election to tax under Sec. 9113(A) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ROBERT M. FREY Firm Name (If Applicable) 717-243-582-53 REGISTER OF I'.:> = = ....... FREY AND TILEY First line of address USE ONn... C r W () r- rTl :D :^ ..,\ (--; 5 SOUTH HANOVER STREET Second line of address .- '.-)0 - 9,1 ~ r) i> :tJB ~ C!! ;--"; City or Post Office State ZIP Code DATE FILED CARLISLE PA 17013 Correspondent's e-mail address: Under penalties of pe~ury. I declare that I have examined this retum, 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. ~O~SP~~GRETURN DA:~ I~ -,/~ 7 !r~ ~f~ Dr, Ctu:.tl~ Pt'J- 0013 SIGNATURE OF P PARER OTHER THAN REPRESENTATIVE "t' 4"--';' AoESS 2:bufuJ~aH>l 0+' (11t((\S~ fo... (1013 ~ ORIGINAL FORM ONLY Side 1 L 15056041114 15056041114 ~ --I 15056042115 REV-1500 EX Decedenrs Name: JOSEPH W. FRY RECAPITULATION Decedent's Social Security Number 174-20-8715 1. Real estate (Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. 2. NONE 3. NONE 4. NONE 5. 6. NONE 7. 8. 9. 119000.00 2. Stocks and Bonds (Schedule B) . . . . . . . . . .; . . . . . . . . . . . . ..., . . . . . . . . . . . . . 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . . . 4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . . . 6. Jointly Owned Property (Schedule F) [::JSeparate Billing Requested. . . . . . . . 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) [::JSeparate Billing Requested. . . . . . . . 4348.00 8. Total Gross Assets (total Lines 1-7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15894.00 139242.00 9. Funeral Expenses & Administrative Costs (Schedule H) . . . . . . . . . . . . . . . . . . . . 17430.00 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . . . . . . . . . . . . . . 10. 11. Total Deductions (total Lines 9 & 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 11. 10397.00 27827.00 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. 111415.00 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 L 16. Amount of Line 14 taxable at lineal rate X .0 ~ 17. Amount of Line 14 taxable at sibling rate X . 12 18. Amount of Line 14 taxable at collateral rate X . 15 0.00 111415.00 15. 0.00 111415 . 0 0 16. 17. 5014.00 0.00 0.00 18. 19. TAX DUE... . . . . . .. ... . .. .. . . .... . .. ... . . . . . .... ... .. ... . . . . .. .. 19. 5014.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT IT] Side 2 L 15056042115 15056042115 --I REV-1500 EX Page 3 174-20-8715 Dece(ient's Complete Address: File Number 21-07-0114 DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER JOSEPH W. FRY 174-20-8715 STREET ADDRESS 14 WILTSHIRE WEST CITY II STATE I ZIP CARLISLE PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 5014.00 4275.00 225.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits ( A + B + C ) (2) 4500.00 Tota/lnterest/Penalty ( 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) 0.00 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 514.00 A. Enter the interest on the tax due. (SA) B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT 514.00 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS c. retain a reversionary interest; or . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. receive the promise for life of either payments, benefits or care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. If death occurred after December 12, 1982, did 'decedent transfer property within one year of death without receiving adequate consideration? . . . .:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? . . 1. Did decedent make a transfer and: Yes a. retain the use or income of the property transferred; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 b. retain the right to designate who shall use the property transferred .or its income; . . . . . . . . . . . . . . .. 0 o o o o No o o 0' o o o 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. [KJ 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 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 dec!'lased 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)]. rhe 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. 99116(a)(1.3)]. A sibling s defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. 217 REV-1502 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER ITEM NUMBER 1. DESCRIPTION Real Estate, 14 Wiltshire West, S. Middleton Township, PA VALUE AT DATE OF DEATH 119,000 TOTAL (Also enter on line 1, Recapitulation) (If more space is needed, insert additional sheets of the same size) 119,000 $ ALL THAT CERTAIN Unit, being Unit No. 14 (the "Unit"), of Meadowridge at Mayapple ViHage Condominium (the "Condominium"), located in South Middleton Township, Cumberland County, Pennsylvania, which Unit is designated in the Declaration of Condominium of Meadowridge at Mayapple ViHage Condominium (the "Declaration of Condominium") and Declaration Plats and Plans as recorded in the Office of the Recorder of Deeds of Cumberland County in Miscellaneous Book 518, Page. 333 and Right of Way Plan Book 11, Page 19, respectively, as amended in MisceHaneous B09ks 525, Page 1199; and 535, Page 17; and Right of Way Plan Book 11, Page 25 and 47 respectively, and as the same may be subsequently amended from time to time. TOGETHER with an undivided percentage interest in the Common Elements as more particularly set forth in the aforesaid Declaration of Condominium and Declaration Plats and Plans, as last amended. TOGETHER with the right to use the Limited Common Elements applicable to the Unit being conveyed herein, pursuant to the Declaration of Condominium and Declaration Plats and Plans, as amended. UNDER AND SUBJECT to any and all covenants, conditions, restrictions, rights-of-way, easements and agreements of record in the aforesaid Office, the aforesaid Declaration of Condominium, and matters which a physical inspections and survey of the Unit and Common Elements would disclose. THE GRANTEES, for and on behalf of the Grantees and the Grantees' heirs, personal representatives, successors, and assigns, by the acceptance of this Deed, covenant and agree to pay such charges for maintenance, repairs, replacements and other expel).ses in connection with the Common Elements, and the Limited Commop Blements appurtenant to said Unit, as may be assessed against him, her, them or it, or said Unit, from time to time by the ExecutIve Board of the Meadowridge Mayapple Condominium Association in accordance with the Uniform Condominium Act of Pennsylvania, and further covenant and agree that the Unit conveyed by this Deed shall be subject to a lien for all amounts so assessed except insofar as Section 3407 (c) of said Uniform Condominium Act may relieve a subsequent Unit Owner of liability for prior unpaid assessments. This covenant shaH run with and bind the Unit hereby conveyed and all subsequent owners thereof. THE ABOVE described property has the mailing address of 14 Wiltshire West, Carlisle, PA. THE ABOVE described property is all of the property which Mayapple Vanguarq Limited Partnership, by its deed dated March 11, 1997 and recorded April 21, 1997 in the Office of the Recorder of Deeds, in and for Cumberland County, at Carlisle, Pennsylvania, in Deed Book 156, Page 127, granted and conveyed to Joseph W. Fry and Joan B. Fry, husband and wife. 217 REV-1508 EX+ (6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Joseph W. Fry ITEM NUMBER DESCRIPTION 1 M& T Bank, Checking Account #9830435153 2 M&T Bank, Checking Account #9830435161 3 . Cash at Decedent's Home 4 Automobile, 4 Door Saturn 5 Refund, The Sentinel Subscription 6 Refund, Highmark BCBS Policy 7 Refund, Highmark BCBS RX Plan 8 Refund, U.S. Trl"lasury 2006 Taxes 9 Refund, Pennsylvania Department of Revenue, 2006 Income Taxes 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. FILE NUMBER 21-07-0114 VALUE AT DATE OF DEATH 563 601 35 2,500 28 100 205 240 76 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed. insert additional sheets of the same size) 4,348 ~ M&fBank 499 Mitchell Street, Millsboro, DE 19966 February 8, 2007 Robert M. Frey 5 South Hanover Street Carlisle, PA 17013 RE: Estate. of Joseph W. Fry Date of Death: January 24, 2007 Social Security No.: 174-20-8715 Dear Mr. Frey: In response to your request, please be advised that at the time of death, the above- named decedent had on deposit with this bank the following accounts. 1. Account Type....................... ....Checking Account Account Number.......... .......... ...9830435153 Ownership (Names ofl...............Joseph W. Fry Opening Date..... ......... ... ...... ... .07/08/02 Balance on Date ofDeath.........$562.73 Accrued Interest $ 0.00 Total................................... ....$562.73 2. Account Type...........................Checking Account ., Account Number................. /:'. ...9830435161 Ownership (Names ofl...............Joseph W. Fry Opening Date.......................... .07/08/02 Balance on Date ofDeath.........$601.17 Accrued Interest $ 0.00 Total.......... ........................... ..$601.17 . Page 2 February 8, 2007 The above named decedent had a safe deposit box. For any additional information on the above accounts, including ownership, statements and closures please contact our High Street Carlisle branch at 717-240-4536. Sll1cerely, ' C~~.. Charlene Warrington, Records Management 1-888-502-4349 217 REV-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Joseph W. Fry FILE NUMBER 21-07-0114 DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER TRANSFER. ATTACH A COPY OF THE DEED FOR R~ ESTATE. VALUE OF ASSET INTEREST (IF APPUCABLEI VALUE 1. M&T, IRA 15,894 100.00% 15,894 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 .- 0 , 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TOTAL (Also enter on line 7 Recaoitulation) $ 15 894 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. (If more space is needed, insert additional sheets of the same size) ~ Western"Southern Life Assurance Company 980 Single Premium Deferred Annuity Prepared on 01/29/2007 Owner FRY JOSEPH W 14 Wiltshire West ST Carlisle PA 17015-7101 Page 1 of 1 Western-Southern Ufe appreciates your business. ~ - :--:: Annuitant Contract Number Contract Date Contract Type FRY JOSEPH W W 20598923 01/28/2002 IRA 1< 1< 1< INFORMATION ABOUT YOUR CONTRACT 1< 1< 1< = > Total interest earned during any contract year will be impacted by any withdrawals, including systematic withdrawals, from the contract during that year. For example, if you select the systematic withdrawal plan, the interest you receive will be less than the amount indicated by the effective annual interest -rate because interest is being paid out rather than accumulated. SUMMARY OF ACTIVITY 01/2812006 through 01/2712007 Beginning Contract Value plus Interest Credited* less Systematic Withdrawals Partial Withdrawals Surrender Charges Ending Contract Value Surrender Va/ue** $ 17,007.09 817.69 PARTIA.t~WITHDRAWAL ACTIVITY .00 1,986.25 13.75 15,824.78 15,824.78 Transaction Date OS/25/2006 12/04/2006 Description Partial Withdrawal Partial Withdrawal Amount $1,000.00 $986.25 Surrender Charge $.00 $13.75 * The effective annual interest rate for the contract year indicated above was 5.05% and is 3.40% for the current year. The Pacesetter guarantees interest rates each year for two 5-year periods. You are currently in the second 5-year guarantee period and the interest rate will again increase by .15%. The minimum guaranteed interest rate in years 11 and later is 3.00%. ** Amount available after deducting any applicable charges if you cancel your contract. For further information about your PACESETTER Annuity contract. including interest rates, contact your sales representative or call Annuity Operations. ANNUITY OPERATIONS Western-Southern Life Assurance Company PO Box 2918 Cincinnati, Ohio 45201-2918 1-800-926-1702 Customer Service Hours: Monday - Thursday, 8 a.m. to 6 p.m., Eastern time Friday, 8 a.m. to 5 p.m., Eastern time -20196" 117" . Western.;Southern Life Assurance Company I 01/25/20071 Contract Owner JOSEPH W. FRY 14 WILTSHIRE WEST ST CARLISLE PA 17015-7101 Thank you for allowing us to serve your financial needs. Western-Southern Life Assurance Company Annuity Operations P.O. Box 2918 Cincinnati, Ohio 45201-2918 1-800-926-1702 - - ~ - . ..- Annuitant JOSEPH W. FRY Contract Number W 0020598923 . . - --:.......:.... ---- FAIR MARKET VALUE AND REQUIRED MINIMUM DISTRIBUTION NOTICE *** PLEASE KEEP FOR YOUR RECORDS *"* In accordance with the Internal Revenue Service (IRS) requirements, this statement informs you of the fair market value of your Individual Retirement Account (IRA) contract. Likewise this statement informs you of the current Federal regulations governing Required Minimum Distribution ("RMD") for your contract. Fair Market Value The fair market value (FMV) is the contract value of the contract as of December 31,2006. The FMV shown below will be reported to the IRS by Western-Southern life Assurance Company. In May, we will mail IRS form 5498 (contribution information) to you if your contract received a contribution, rollover, transfer or conversion for the previous tax year. Form 5498 reflects the information reported to the IRS by Western-Southern Life Assurance Company. Since you will receive the Form 5498 after your April 15 tax filing deadline, you should retain records of any contributions, rOllovers, transfers or conversions to aid in the completion of your tax return. For specific tax information, consult your tax advisor and obtain free IRS Publication 590, "Individual Retirement Accounts" from the IRS by Calling 1-BOO-TAX-FORM (829-3676). Required Minimum Distribution Current federal regulations require you, as a contract owner, to take a Required Minimum Distribution (RMD) from your Individual Retirement Account (IRA) contract. Generally, if you are over age 70 1/2, you must take your distribution by December 31, each year. Generally, if you have more than one qualified retirement account, your total RMD for the year is the sum ofthe RMDs for each of your accounts. You may take your total RMD from anyone or more of your accounts, provided the'amount satisfies the required total. Failure to take your RMD may subject you to a significant IRS tax penalty. Your RMD amount for this contract for the 2007 calendar year is listed below. Please note any withdrawals taken from your contract in 2007 will be applied toward your RMD requirement for 2007. Western-Southern Life Assurance Company is required to report to the IRS that a minimum distribution is required with respect to your contract (but not indicate the amount) on IRS Form 5498 for the tax year 2007. Fair Market Value (FMV) as of December 31, 2006 is $15,764.26 . Your Required Minimum Distribution (RMD) for this contract for the 2007 calendar year is $808.42" based on a December 31, 2006, contract value of $15,764.26. 'Calculated assuming that the sole beneficary is NOT a spouse more than 10 years younger than the owner. 713HY- 030178 0701 ':-:~~"~-7-'--:--_ , . . - "- , '.\ '."!.: .' ,~.'.'.; ~ <.,., ; - j" ,: o IRA DSEP o SIMPLE CHANGE OF BENEFICIARY j-r" ~ ( I -:--'" .-' Individual Retirement Account Name of Financial Institution IRA Owner Information , Name , -.-.,..-. Social Security Number Date of Birth : : Address Home Phone Number Daytime Phone Number -/ City/State/Zip New Beneficiary Information Primary Beneficiary(ies) .I Name .r~ ~ \.~ Name Contip;ent BeneficiarY(i:).7 . ' -.r -',' .../,. ". \ '-'- i-., :::=. -::0 'A tL\ ' l.." ';- Q ; I,; '(.4 Rd}. Y'A {.:.. a h. I.. ~:~ 'P. Relationship Relationship Social Security Number/Tax LD. Number Date of Birth ? ,') rl , S' 2 ,~<:f:;' \ i \ 2 . a . "'q Sociai Se~urity Number/Tax J.D. .Number Date of Bi'rth J Cj ~::m~'?;p,! 1, C~Q.cL~. Address Address City/State/Zip C '~',Ji l.:..L.n City/State/Zip - v,~ \1 D\ "7" - Name Name Relationship Relationship Date of Birth Social Security Number/Tax J.D. Number Social Security Number/Tax LD. Number Date of Birth Address Address City/State/Zip . City/State/Zip I hereby designate the above as my beneficiary(ies). Unless otherwise requested herein, each payment made pursuant to this designa- tion: (a) shall be paid in equal shares to the primary beneficiary(ies) who are living at the time of my death; or (b) if no primary beneficiary(ies) shall be living at the time of my death, such payment shall be made in equal shares to the contingent beneficiary(ies) who are then living. I have the right to change this designation at any time. Spousal consent: (for use in community or marital property states) I agree to my spouse's naming a primary beneficiary other than myself. I transfer (transmute) any community or marita!.interest I have in this IRA into the separate property of my spouse. I agree to seek the advice of a legal or tax professional, as neeqed. Signature of Spouse Date ./ For IRA Owners Over A2:e 70~ IMPORTANT: If you have passed your required beginning date, changing your beneficiary may increase your required minimum distribution. Changing your contingent beneficiary will generally not affect your required minimum distribution. o This change is due to the death of the previously designated primary beneficiary. o This change is due to a reason other than the death of the previously designated primary beneficiary. \. Signatures I authorize the financial institution named above to make the changes indicated. This beneficiary designation supercedes any and all prior beneficiary designations by the IRA Owner. I certify that, to the best of my knowledge, the information provided on this form is true and correct and may be relied on by the Trustee/Custodian. I agree to seek the advice of a legal or tax professional, as needed. The Trustee/Custodian has not provided me with any legal or tax advice, and I assume full responsibility. I will not hold the Trustee/ Custodian liable for any adverse consequences that may result. r. ./ "'~\ , fl : ~'").t'!'-"~\~,\ Signature'Pf IRA OWner UJ l':L r; . ~-: .J'~ , , \_L\.qq Date Authorized Signature of Trustee/Custodian Date orl1Ct.. Ii'H' Onh/ 'I FiDHKNCIAI. TRUST GG. Name of Financial Institution ~iIXJ IRA DSEP o SIMPLE CHANGE OF , BENEFICIARY i " Ir~ ! 1"'1- Individual Retirement Account IRA Owner Information Name JOSEPH ~.J P'ilY 14 ~.jILTS}IIRE 1rESI' S'T l74-20-B715 Social Security Number (-::~j1-'; <,Lit:;~;--;r-,' !,j Home Phone Number . 10-27-28 Date of Birth Address C...:.\RLTSLE P.A 17n:,3-7:0't Daytime Phone Number City/State/Zip New Beneficiary Information Primary Beneficiary(ies) Contingent Beneficiary(ies) JOliN- B FRY Name SPOUSE Relationship t'-~ ( "") ~.::" 'rJ \.r Name - . I l) '. i="r< '! f 1=<.'1 ~c 1:1 Relationship 182-27-99[:1'. Social Security NumberlTax J.D. Number SNlE Address ~-?O-_~G Date of Birth ,C; , ~ y;:. () c~ c. ~~.. Social 'S~curity Numbdrrrax' LD. Number .':1.. i) (' \] t:\ T h ,4, \,,\, \) '" 1 I " I' Address '7 - '7 g - IJ --f Date of Birth City /S tate/Z i p \ ' L >1'>0\-1. Dc-oS City/State/Zip N..\' ()'fiD43 Name Relationship Te.9. i Name ,-. I h \1..,....,.... '<<'"'1. \:J. l)~t'<"1\"t~r:< Relationship Date of Birth \C\\. L\7 ~!.~7~ Social Security Number/Tax I.D. Number t.,-q. Date of Birth ::- r, , ,.. Social Security Number/Tax J.D. Number Address ,? ~ <:;- Address ~-r n r:;.t C',.,...,. A \;.a City/State/Zip ~1 / ~ n CitylS'tate/Zip ,""! ,. "',) ~. ',4 no \~ I hereby designate the above as my beneficiary(ies), Unless otherwise requested herein, each payment made pursuant to this designa- tion: (a) shall be paid in equal shares to the primary beneficiary(ies) who are living at the time of my death; or (b) if no primary beneficiary(ies) shall be living at the time of my death, such payment shall be made in equal shares to the contingent beneficiary(ies) who are then living. I have the right to change this designation at any time. Spousal consent: (for use in community or marital property states) I agree to my spouse's naming a primary beneficiary other than myself. I transfer (transmute) any community or marital interest I have in this IRA into the separate property of my spouse. I agree to seek the advice of a legal or tax professional, as need.ed. Signature of Spouse Date For IRA Owners Over Age 70~ IMPORTANT: If you have passed your required beginning date, changing your beneficiary may increase your required minimum distribution. Changing your contingent beneficiary will generally not affect your required minimum distribution. o This change is due to the death of the previously designated primary beneficiary. o This change is due to a reason other than the death of the previously designated primary beneficiary. Signatures I authorize the financial institution named above to make the changes indicated. This beneficiary designation supercedes any and all prior beneficiary designations by the IRA Owner. I certify that, to the best of my knowledge, the information provided on this form is true and correct and may be relied on by the Trustee/Custodian. I agree to seek the advice of a legal or tax professional, as needed. The Trustee/Custodian has not provided me with any legal or tax advice, and I assume full responsibility. I will not hold the Trustee/ Custodian liable for any adverse consequences that may result. ~\ r, '. ,_ "",,:. n.~ x.. ILl Signaturq of IRA'Owner .--: -l.- . 1 ..................1 \ Date J' . a (-~ l '. Authorized Signature of Trustee/Custodian Date Ofl1c(' Use Only 787001B7I5 .:.,.... , 1;' ~.. .1. BEN 01/97 01997 Pension Manaaement ComDanv 217 REV-1511 EX + (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS I FILE NUMBER ESTATE OF Joseph W: Fry 21-07-0114 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Ewing Brothers Funeral Home, Funeral Services 9,395 2. Westminister Cemetery, Internment Fee 1,210 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s) I EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attomey Fees 6,500' 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 298 5. Accountant's Fees .' , 6. Tax Retum Preparer's Fees 7. Register of Wills, (3) Short Certificates 12 8. Register of Wills, Filing Fee for PA Inheritance Tax Return 15 TOTAL (Also enter on line 9, Recapitulation) $ 17 430 (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Jose hW. F 21-07-0114 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. VALUE AT DATE OF DEATH SCHEDULEr DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ITEM NUMBER DESCRIPTION 1. AT&T Credit Card, Miscellaneous 527 2. UPS, Miscellaneous 49 3. UGI 335 4. Judy A. Campbell, Tax Collector 132 5. George L. Ebener & Associates Realtors, Commissions 5,950 6. Recorder of Deed, State Tax/Stamps 1,190 7. Property Management, Inc. Resale Certification Fee 75 8. SMTMA, UtiI:Water 220 9. Cohick & Associates, 2006 Income Tax Preparation 185 10. Orrstown Bank, Final Condo Payments 639 11. PMI Condo Fees Final 307 12. Embarq, UtiI:Telephone 58 13. MetEd, Util:Electricity 100 14. Publishers Clearing House, Miscellaneous 22 15. Comcast, UtiI:Cable 25 16. M&T Credit Card .- 481 17. Bon Ton Credit Card 102 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 10,397 217 REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF J hW F SCHEDULE J BENEFICIARIES FILE NUMBER osepr . -ry 21-07-0114 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 outright spousal ~istributions, and transfers under - Sec. 9116 (a) (1.2)] 1 Gary D. Fry Son 1/3 of residue of the estate 30 Chatham Drive, New Jersey 08043 2. Barbara F, Stewart Daughter 1/3 of residue of the estate 926 Rockledge Drive, Carlisle Pennsylvania 17013 3. Teri L. Thumma Daughter 1/3 of residue of the estate 1215 Stratford Drive, Carlisle Pennsylvania 17013 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET fl. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE .' : B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART" - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0 (If more space is needed, insert additional sheets of the same size) ... R.~ LAST WILL AND TESTAMENT OF JOSEPH W. FRY I, JOSEPH W. FRY, of South Middleton Township (405 Raymon Avenue, Boiling Springs) Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament hereby revoking and making void any and all Wills by me at any time heretofore made. 1. I direct my hereinafter named Executrix to pay all of my just debts and funeral expenses as soon after my death as may be found con- venient to do so. 2. All the rest, residue and remainder of my estate, real, personal and mixed, and wheresoever the same may be situate, I give, devise and bequeath to my wife, Joan B. Fry, her heirs and assigns, to the exclusion of my children born and unborn, provided my said wife, Joan B. Fry shall survive me by a period of Ninety (90) days. 3. Should my said wife, Joan B. Fry pre-decease me or fail to survive me by the aforesaid period of Ninety (90) days, then in such event all the rest, residue and remainder of my estate, real, personal and mixed, and wheresoever the same may be situate, I give,: devise and bequeath in equal shares to such of my children as shall survive me by a period of Ninety (90) days, the sha,re any deceased child would have received to pass to such of his or her issue as shall survive me by a period of Ninety (90) days, per stirpes, and if there be no such issue then the same shall lapse and be added to the remaining share or shares per stirpes. At the present time 1 am the father of the following three (3) children: Gary D. Fry, Teri F. Thumma, and Barbara F. Stewart. Page 1 of 2 Pages j' 4. Should any person less than Twenty-one (21) years of age be entitled to distribution from my estate, in such event I nominate, constitute and appoint Farmers Trust Company and its successors, 1 West High Street, Carlisle, Pennsylvania, as guardian of the .estate of each such person and authorize and direct it to receive and to invest the same, and to pay the income arising therefrom, together with so much of the principal thereof as in its opinion is necessary or desirable to be expended for the proper maintenance, support and education of such person, to or for the benefit of such person, and upon such person attaining 21 years of age to pay to him or her the then remaining principal together with any undistributed income. 5. I her.eby nominate, constitute and appoint .my said wife, Joan B. Fry as Executrix of this my Last Will and Testament but should she pre- decease me or Iail to qualify, then in such event I nominate, constitute and appoint my three (3) children, Gary D. Fry, 'Teri F. Thumma, and Barbara F. Stewart, or any of them, as Co-Executors, and I further direct that none of them shall be required to post any bond to secure the faithful performance of his or her duties in the Commonwealth of Pennsylvania or in any other jur isd tetion. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will and Testament written on two pages this 2nd day of October, 1981. ~~ ~-'1 (SEAL) Signed, sealed, published, and declared by JOSEPH W. FRY, the Testator above named, as and for his Last Will and Testament, in our presence, who, in his presence, at his request, and in the presence of each other, have hereunto subscribed our names as attesting witnesses. ~ 1.... 1. , rYC? Page 2 of 2 Pages