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Home My WebLink About08-07-07 (3) ~ .-J 15056051058 REV-1500 EX (06-05) PA f1an2rtm..nt Of Reven'''' ~u ~~::~~=~~I Tax~~- ~~:9- INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 .~-,~~.g RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death 1337-42-8454 . 1105/15/2007 Decedent's Last Name 21 00516 1 EDGREN Suffix 11 Date of Birth 1111/0311914 Decedent's First Name II ELSIE MI 18 (If Applicable) Enter Surviving Spouse's Information Below (pause's Last Name Spouse's Social Security Number I SuffIX , l Spouse's First Name I 1 MI 10 THIS RETURN MUST BE FILED IN DUPUCA TE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW CJI:) 1. Original Retum c::::> 2. Supplemental Retum c::::> 3. Remainder Return (date of death prior to 12-13-82) 5 Federal Estate Tax Return Required c::::> 4. limited Estate c::::> c;t) 6. Decedent Died Testate c::::> (Attach Copy of Will) c::::> 9. litigation Proceeds Received c::::> 4a. Future Interest C.ompromlse (date of death after 12-12-82) 7. Decedent Maintained a living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) C) 8. Total Number of Safe Deposit BOxes c::::> 11. Election to tax underSec. 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 I STEPHEN J. EDGREN 1(717) 697-4693 Firm Name (If Applicable) I J REGISTER ~'r'US USE o~ First line of address 1399 BAKER DRIVE Second line of address I -...J :::-J ... I ) City or Post Office I MECHANICSBURG State ZIP Code I EJ 117055 """:1:. PI 1',) ...- Correspondent's e-ma~ address: EMANSE@JUNO.COM Under penalties of perjury, I declare that I ha'le examined this return, inclUding accompanying schedules and statements. and to the best of my knowledge and be~ef. it is true. correct and complete. Declaration of preparer other than the personal representali'le is based on all information of which preparer has any knowledge. SI PONSIBlE FOR FILING RETURN DATE 08/03/07 ADDREp 3 1 c...k~; Pr, i1~CLAH;r5't"-N:, If:{. (70SS- SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE /' DATE ADDRESS ~----~-- PLEASE USE ORIGINAL FORM ONLY L 15056051058 Side 1 15056051058 ...J ~J --' 15056052059 RFV-1500 EX Decedent's Name: ELSIE W EDGREN Decedent's Social Security Number RECAPITULATION 337-42-8454 1. Real estate (Schedule A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. 2. Stocks and Bonds (Schedule B) . . . . . . . . _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. 11,224.00 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. 27,483.34 6. Jointly Owned Property (Schedule F) c::) Separate Billing Requested . . . . . . . 6. 59,500.64 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) c::) Separate Billing Requested.. . .. . . . 7. 8. Total Gross Assets (total Lines 1-7). " . . . . . . . . . .. . . . .. . . . . . . . . . . . . . . . . . 8. 98,207.98 9. Funeral Expenses & Administrative Costs (Schedule H).. . . .. . . . . . . . .. .. .. . . 9. 981.02 10. Debts of Decedent, Mortgage liabilities, & liens (Schedule I) . . . . . . . . . . . . . . .. 10. 10,804.60 11. Total Deductions (total Lines 9 & 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 11,785.62 12. Net Value of Estate (line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . " . . . 12. 86,422.36 13. Charitable and Govemmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) ... . . . . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subject to Tax (line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14. 86,422.36 TAX COMPUTATION. SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of line 14 taxable at the 5pousal tax rate, or transfers under Sec. 9116 (a}(1.2) X .0_ 16. Amount of line 14 taxable at lineal rate X .045 86,422.36 17. Amount of line 14 taxable at sibling rate X .12 18. Amount of line 14 taxable at collateral rate X .15 15. 16. 3,889.01 17. 18. 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 3,889.01 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C) L 15056052059 Side 2 15056052059 -1 REV-1500 EX Page 3 Decedent's Complete Address: File Number 0~[00516 DECEDENrS NAME DECEDENrS SOCIAL SECURITY NUMBER ELSIE W EDGREN 337-42-8454 STREET ADDRESS -- --- - 770 SOUTH HANOVER STR~ET (CHAPEL POINTE NURSING CENTE~)______ CITY I STATE I ZIP CARLISLE PA I 17013 Tax Payments and Credits: 1. Tax Due (Page 2 line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 3,889.01 204.68 3. InterestlPenalty if applicable D. Interest E. Penalty Total Credits (A + B + C ) (2) 204.68 TotallnteresllPenally ( 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. A. Enter the Interest on the lax due. (5) (SA) 3,684.33 B. Enter the total of line 5 + SA. This is the BAlANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT 3,684.33 PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes a. retain the use or income of the property transferred; .......................................................................................... 0 b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 c. retain a reversion~ry interest; or.......................................................................................................................... 0 d . the - < ... . -the .. -Is " 0 . receive promse lor lITe 01 el r payments, oenen or care ( ...................................................................... 2. If death occurred afler December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. 0 3. Did decedent own an 'in trust for' or payabie upon death bank account or security at his or her death? .............. 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 No [i] IKJ [i) fil fil IKJ IKJ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G A.t4D FILE !T 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}J. 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. 99116 (a) (1.1) (ii)J. 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 retum are still applicable even if the surviving spouse is !he 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 !he child is zero (0) percent [72 P.S. ~9116(a)(1.2)J. 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. 99116(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. 99116(a)(1.3)J. 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-1503 EX+ (6-98) SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ELSIE W EDGREN FILE NUMBER 21-07-0516 All property jointly-owned With right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VAlUE AT DATE OF DEATH 11,224.00 US SAVINGS BOND SERIES EE, ISSUE DT 9/92, FACE AMT 10,000, SERiAl NR X3005066EE TOTAL (Also enter on line 2, Recapitulation) (If more space Is needed, insert additional sheets of the same size) REV-15GB EX+ (6-98) . '* COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF ELSIE W. EDGREN FILE NUMBER 21-07-0516 Include !he proceeds of litigation and the date the proceeds were received by the estate. All properly jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH D CHECKING ACCOUNT CITIZENS BANK, ACCOUNT NR 610070-120-4 5,422.79 0 SAVINGS ACCOUNT, MEMBERS 1ST FCU, ACCOUNT NR 118262..()() 25.06 a CHECKING ACCOUNT, MEMBERS 1 ST FCU, ACCOUNT NR 118262-11 85.59 4. APARTMENT ENTRANCE FEE REFUND, CHAPEL POINTE, NOT RECEIVED AS OF 05-15-07 21,000.00 5. PENNSYLVANIA RENT REBATE, NOT RECEIVED AS OF 05-15-07 500.00 6. REFUND OF UNEARNED PREMIUM ON MEDICARE SUPPLEMENT INSURANCE, GENWORTH LIFE AND ANNUITY INSURANCE COMPANY, POLICY NR 0110418011, NOT RECEIVED AS OF 05-15-07 I 449.90 TOTAL (Also enter on line 5, ~~l:;~pitulation) $ I 27,483.34 (If more space is needed. insert additional sheets of the same size) ~EV-1509 EX+ (6-98* COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULI F JOINTLY-OWNED PROPERTY ESTATE OF ELSIE W. EDGREN FILE NUMBER 21-07-0516 If en ...et we. made joint within one ye.r of the decedent'. dete of de.th, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. STEPHEN J. EDGREN 399 BAKER DRIVE, MECHANICSBURG. PA. 17055 ISON I 'I II /I I CI /I II I JOINTlY.OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MAD~ INCLUDE NAME OF FINANCiAl INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DE CD.S VAlUE OF NUMBER TENANT JOINT IDENTiFYING NUMBER ATTACH DEED FOR JOINTLY.HELD REAL ESTATE VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 110127/92 I SAVINGS ACCOUNT, MEMBERS 1ST FCU, ACCOUNT NR 118262-05 7,027.79 G' 3,514.40 [3 0 110/27/92 I CERTIFICATE, MEMBERS 1ST FCU, ACCOUNT NR 118262-40 . 30,384.84 GI 15,192.42 QJ 0 104/26/02 I MONEY MARKET, TO AMERITRADE, ACCOUNT NR 885..{)()9765 2.63 G 1.32 [3 0 104/26/02 I 1050 SHRS EXC, TO AMERITRADE, ACCOUNT NR 885-009765 81,123.00 G 40,561.50 D D 01 I D G 0 104126/02 I QUALIFIED DIVEOENO ON 1050 SHRS EXC, EX-DIV OT 05-11-07 D D D 0 PAYABLE 06111/07, TO AMERITRAOE, ACCOUNT NR 885-009765 I 462.00 G 231.00 D D 01 I D D D 01 I D D D 01 I D B D D 01 I D D D 01 I D~ , D D 01 , D t , D D 01 I D E3 D D 01 I D D D 01 I D I f TOTAL (Also enter on line 6, Recapitulation) $1 59,500.641 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) . . COMMONWEALTH OF' PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF ElSIE W. EDGREN FILE NUMBER 21..Q7-0516 [iJ o o o o Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION N P N E : COST OF PUBLISHING OBITUARY IN HARRISBURG PATRIOT NEWSPAPER G COST OF PUBLISHING OBITUARY IN CARLISLE SENTINEL NEWSPAPER G IFUNERAL BULLETINS 01 01 01 01 AMOUNT 1. t I" J 1 I , J l I l I I I I J 239.79 , 127.101 2.621 1 ) ] B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Pelllonal Representative(s} I Social Security Number(s)/EIN Number of Personal Representative{s} I U Street Address I City I IstateDZiP I Year(s) Commission Paid: I 2. Attorney Fees I 1 I 1 I I 1 1 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant I Street Address I City I I State 0 Zip I Relationship of Claimant to Decedent I 4. Probate Fees f [ I I J ( I I I I r I t 310.00 I J ] 30.77] 270.74 J 1 :1 ] ~ 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. IESTATE ADMINISTRATION - POSTAGE COST OF PUBLISHING NOTICE OF LETTERS TESTAMENTARY I : L TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert add~ional sheets of the same size) 981.02 REV-1512 EX+ (12-03) \';I '* COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, I MORTGAGE LIABILITIES, & LIENS J ESTATE OF ELSIE W. EDGREN Report debts Incurred by the dec:edent prior to death which remained unpaid IS of the dale of death, including unrelmburaed medica/expenses. FILE NUMBER 21-07-0516 B s I I L P L E L ITEM VALUE AT DATE NUMBER DESCRIPTION Of DEATH I I ~ 43.70) 1. /VASCULAR ASSOCIATES~~. ~ ; - 1.512.9?J 2. IMllLENNIUM PHARMACY SYSTEMS INC. I _ -.. - 3./ ICHAPEl POINTE - NURSING CARE - - -- - .. [ 9,248.~~ I C' I :~ I I r I I r ][ j I - 1'- 1 I I i I I -, I ~ f j I I ( 1 I j I I r ~ i , r ~ f , J I ~ - -=3 r 1 ! L .. - - ., ~ 3 i I - ~ - - -.-.-- = -- ---- - ~~--~--- - -~-~ i .. -1 i ~ 1 - .. . - --~- ~ j I ---1 I , - -- -- - '- - - =-__....J V"ll -""1 ,.... .. . - - I I i I I -----------------.-.-------.----------------__J __J l.. TOTAL (Also enter on line 10, Recapitulation) $ II 10,804.60 I H 1---, b B B (If more space is needed, Insert additional sheets of the same size) REV,1513 EX~ (9-00) . Sr....~ ~....9 .'. ~ COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF ELSIE W. EDGREN NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec, 9116 (a) (1.2)] James A. Edgren 2275 Duckabush Road, Brinnon, Wa. 98320 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) FILE NUMBER 21-07-0516 AMOUNT OR SHARE OF ESTATE SON G. Edgren PSC 68 Box 55, APO, AE 09706 GRANDSON ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-I500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE Timothy J. Edgren 9105 81st Street SW, Lakewood, Wa. 98498 GRANDSON Sharon R. Thomas 166 Georgia Hwy 81 SE, Oxford, Ga. 30054 GRANDDAUGHTER J. Hertzler 15038 Lovely Dove Lane, Nobelsville, IN 46060 GRANDSON J. Hertzler 3909 Seagate Drive, Melbourne, Fl. 32904 J. Edgren 106 Lincoln Inn Road, Columbia, SC. 29212 SON 9. Andrew J. Edgren 220 Gales River Road, Irma, SC. 29063 GRANDSON Jonathan D. Edgren 1706 Inglewood Drive, Cola, SC. 29204 GRANDSON B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DiSTRIBUTIONS ON LINE 13 OF REV-1SDO COVER SHEET (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) . ..10_ .. ~. ;!' ~.. - COMMONWEAlTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF ELSIE W. EDGREN NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY , ( TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 11 Emily E. Edgren 308 Carpenter St., West Columbia, SC. 29169 Karyll. Hoke 206 Dinius Ave., Middleburg, Pa. 17842 13. 2911 Powells Valley Road, Halifax, Pa. 17032 14. 8126 Timber Grove, San Antonio, Tx. 78250 332 Farmhaus Lane, Middleburg, Pa. 17842 FilE NUMBER 21-07-0516 AMOUNT OR SHARE OF ESTATE RELATIONSHIP TO DECEDENT Do Not List Trustee(s) GRANDDAUGHTER GRANDDAUGHTER GRANDSON GRANDDAUGHTER GRANDSON SON (( ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-l500 COVER SHEET 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 (If more space is needed. insert additional sheets of the same size) tERMS'A~D CONOrTlONSlPA Y~ENT INFORMATION: Department of the Treasury Circulars. Public Debt Series Nos. l-!lO and 3-80. contain the terms and oondttions !)O'/erning In;" bond. THIS BOND is NOT TRANSFERABlE AN~'~r. B~ ulEP'EOI1COLLATERAL. It may be paid 6 months after its issue dale, upon proper identlflcalion and request, by any financial Institution quali!iet> as ~ paying agent Thi, bOfld may also be paid by a Federal FfeservlSank or Branch or the Bureau of the Public Debt, Parkersburg, WV 26106.1328, ~ . . ., , ,,'; ;j j 0 0 m <0 Q. , ~ m g ~ i ~ ~ 2 '" i ~ ! ~ i "" Ii Ii? ~! m 8.J gj ! Tn 9 f en (:) -< ~ z - ~ s. 0 0 j ~ 0 i ;; 0 " 0 .. '..~,.g' .i . I;,'~;: ,. 'G' 1:D,. ""0; ~'~ ~ ;':' m z -.I . ", ,;?: :t: ::~. S; .~ ,-VI 0 :u i o-~i. ~Ilr z: '6! :',i XI l' ~! :Dl ! ~i i. *1 '}.Il ~! 1.- f 0: {. j;; J 'I Ii. i, . H ~ ~ ~.:; _j>~..-r.......;.,._i i ~ l '.':: J 1 _:~ ~1r~.1~)~tf1 ~ " ~"', S!l~Q ~~~ J.: .! . i , 1 Li '. ;!; \-.,1 ~ . t_,,; .... y ilJ"~/: (.:(;'2"'.:'fr..::n . ReV-ISOo 5c~cjw./e B I fem J (DoctA..ftlei1 Ie;.., t;'on) (IS;e LJ. ~'-e~ Sf'" Ie :1l- 2../-07- 65{ C, < ~~ Citizens Bank Checking Account Statement 1-888-910-4100 o OF 2 Call Citizens' PhoneBank anytime for account information. current rates and answers to your questions. US048 BR292 ELSIE W EDGREN 399 BAKER DRIVE MECHANICSBURG PA Beginning April 19, 2007 through May 17, 2007 17055 Checking SUMMARY Previous Balance Checks Withdrawals Deposits & Additions Current Balance 4,244.79 .00 - .00 - 1,178.00 + 5,422.79 = ELSIE W EDGREN Green Checking 610070-120-4 Balance Calculation Previous Balance TRANSACTION DETAILS Deposits & Additions Date Amount Description 05/03 1 , 178.00 US Treasury 310 Soc Sec 050307 710072383d SSA 4,244.79 Daily Balance Date 05/03 I MEMO --Important Notice Regarding Our Funds Availability Policy Our Funds Availability Policy discusses our rules about when we make funds from your cash and check deposits available to you. This policy is contained in your Deposit Account Agreement. Our general policy is to make funds from your cash and check deposits available to you on the first business day after we receive your deposit. Our policy includes exceptions that may delay the availability of deposits. In many cases, we have been providing same day availability for check deposits when our policy calls for next business day availability, generally. The purpose of this notice is to inform you that beginning July 23, 2007, for checks not drawn on Citizens Bank or Charter One Bank, we will follow our general policy of next business day availability for check deposits that was disclosed to you in your Deposit Account Agreement. Please refer to your Deposit Account Agreement for details on our Funds Availability Policy. If you have misplaced your Agreement, you can obtain another copy by visiting one of our branches or calling 1-888-910-4100. o o 1,178.00 Total Deposits & Additions Current Balance Balance Date Balance 5,422.79 5,422.79 Date Balance R e tJ-lC;oo 5Chei ~/e <<rf~ I ..., (DOCu.lMeIl1tt fl'O I{ ) I NEWS FROM CITIZENS --Buying, Building or Refinancing Your Home? Talk to us today about how you can get a quick pre-approval at a branch or by phone. Then shop for your perfect home with a valuable negotiating edge. Looking to switch your adjustable rate loan to a fixed rate? We've got the terms to fit nearly every budget. Whether it's a fixed or adjustable-rate purchase or refinance loan, or a first-time homebuyer [/s! ~ t,J, E~J;"ep! {}/! t!.. # ")., { -D 7- () .f;t; Send Inquires to: 5000 Louise Drive PO Box 40 Mechanicsburg, PA 17055 www.memberslst.org Main Switchboard: (717) 697-1161 or (800) 283-2328 EZ Call: (717) 697-4372 or (800) 283-4372 TOO: (717) 697-5312 or (800) 283-2328 ex!. 5312 TefeBranch: (717) 795-6049 or (800) 237-7288 Account Number: Statement of Accounts Apr 25, 2007 thru May 24, 2007 MEMBERS 1st FEDERAL CREDIT UNION *- 0- - N_ - (Xl =:::; ---- 0'1 0_ * 11888 1 AV 0.312 23775-11888 1I1I111111111111111111111111111111111111111111111111111111I1I1 ELSIE W EDGREN CIO STEPHEN J EDGREN 399 BAKER DRIVE MECHANICSBURG PA 17055 Account Balances at a Checking: Savings: Certificates: Loans: Money Management: 118262 Glance: 85.59 25.06 30,336.32 0.00 12,443.93 1 of 2 Page: Your current Member Loyalty Reward level is Platinum Please read the enclosed insert regarding our FREE seminars. CHECKING ACCOUNTS 11 - CHECKING Date Apr25 May 01 May 01 May 02 May 02 May 04 May 07 May 09 May 14 May 24 Check # 000158 000159 Transaction Descriotion Balance Forward Joint Owner: STEPHEN J EDGREN Deposit Transfer From Share 05 Check 000158 Tracer 0501003081 Deposit Transfer Fro.li1Share 05 Check 000159 tracer 0502020961 ...ec."....;~sb.,j c.etfle-1'1-'J (floi) Deposit EZ Call Transfer From Share 05 Check 000161 Tracer 0507024320 DOfl,.1 &"j~r U"cla,f4.ktr (F","e,~I) Check 000160 Tracer 0509015211 P~rry rtfiMO";,,!, (SfOlte:) Withdrawal ACH CREDIT CRD PMT,,, TYPE: CR CD PMT ID: 1~106539 Ending Balance \ Additions Subtractions 94.00 685.00 94.00- 685.00- 8,514.50- 900.00- 1,499.91- 11,000.00 Amount Date ,: 94.00 May 01; 685.00 May 02 4 Checks Cleared for 10, 193.50 . CHECK SUMMARY '>>', ;; Check-.# 000160 000161 Amount 000.00 8,514.50 SAVINGS ACCOUNTS 00 - REGULAR SAVINGS Date Apr 25 May 24 Transaction Descriotion Balance Forward Joint Owner: STEPHEN J EDGREN Ending Balance , I~,; ; s.:-'1 c Additions Subtractions Balance 0.00 94.00 0.00 685.00 0.00 11,000.00 2,485.50 1,585.50 85.59 85.59 ;- Date May 09 May 07 Balance 25.06 25.06 Reu-IJDO 5deL/e E[Ite~,qle"'3) (DocVt...m~nfa.f"(M) \ l;/s'; t W, E"lcii"<"'lf,' / e 4t 2/-07- 0.', I L 1"......_..:_.._.... __ .1:_11____' en N en N o o ...... m zl i g- I .., CD ::::I 31 CDr I (J:J (J:JI CD a. ~I 0- a a. S" (Q )> I I\.) "C 0 - 01 ~ ~ )> 01 (Q :" ;;u ~ CD :'" )> ,.... r 0 0 C P :" 0 I 0 n ~ n ...... 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(J fb 0 --- "l> ~ f.l.--. 0 \ .S' ~ ~ ...... x \J ~ --- (ii "-1 s (i> -h ;:0 I J;j III CD () -+ - c \.n. ::::I Q... a. --- ~ (JJ \5', -.J ~ ,\ ..""".... \, LOnln ~~ 0605010016 PA-1000 Property Tax or Rent Rebate Claim PA-1000 (09-06) PA Department of Revenue 2006 Check your label for accuracy. If incorrect, do not use the label. Complete Part A. Your Social Security Number Spouse's Social Security Number ~ r-~D;G,;R E'N Li.l I ' "',","'" ; ,,'" ' :r: I First Line of Address ;: 3! 9 9.~'~ ~ I Second Line of Address -II -'Jfs- iJJ I ',. .'". ., u I City or~ost Office :51 ll..L State f'1, Spouse's First Name ,;.,,', ,._,":'C,!_,,~<_,_-" X\o--:>:.;;.",,,-_~-- ,-., 'NvoC:;I(';..c'-'i.:, Coun!r Code Rel1-/506 5c.heLJe. E r tem S- (OOCUjt1C->1 t,::c..tio,,) E151~ W Ed n , J re 11 ,'.'Ie 2{-O]-DS1b If Spouse Is Deceased,fill in the oval. e::> "_<,:;-,,,,0,_ , E LS,1.E--" .1, I i J I , ., .. zip cod~1 ." 1 ::~:OiGl?i , '\--','i,#,,<:g'?-";'~~0t,j':~qi}'\\;-;Sf' School District Code "'.';;y'- ,:).~";; - _,;0 '" '. ~.. " ,_:',; -<-.:: i ;:,~-" :_' _,-:-l:,~~" ~~,,!;:_i Daytime Telephon~ Number ,'t.""":,, Claimant's Birthday t il'~l~4..; c),,''', ','-', _''' '_' - ;,__.:,_ .(. " :_',_.('"'._.~; '5:'" TOTAL INCOME received by you and your spouse during 2006. 4. Social Security, SSI, and SSP Income (Total benefits $ l'!.t l (;f:. divided by 2) 5. Railroad Retirement Tier 1 Benefits (Total benefits $ divided by 2) . . . . . . . . . . . 6. Pension, Annuity, IRA Distributions, and Veterans' Disability Benefits (Use 100% of 2006 Railroad Retirement Tier 2 Benefits) ........................................................... 7. Interest and Dividend Income ...................................................... LOSS 8. Gain or Loss on the Sale or Exchange of Property. . . . . . . . . If a loss, fill in this oval. e::> L06S 9. Net Rental Income or Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . If a loss, fill in this oval. e::> 10. Net Business Income Or Loss . . . . . . . . . . . . . . . . . . . . . . . . . If a loss, fill in this oval. Other Income. Itemize the amounts received from each of the sources listed below. l""1k &.Iaries, wages, bonuses, commissions, and estate and trust income...................... 11a. ....J ~ ~ 11b. Gambling and Lottery wlnnings,lncluding PA Lottery winnings, prize winnings, and the value of other prizes .................................................................... 11 c. Value of inheritances, alimony, and spousal support. ................................... 11d. Cash public assistance/relief. Unemployment compensation and workers' compensation, except Section 306(c) benefits. ...................................................... 11e. Gross amount of loss of time Insurance benefits and disability insurance benefits, and life insurance benefits, except the first $5,000 of total death benefit payments. .......... 11f. Gifts of cash or property totaling more than $300, except gifts between members of a household. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11g. Miscellaneous income that is not listed above. . . . . . . .. . . . . . . . . . .. . . . . . . . .. . . . . . . . . . . . .. 11g. 11b. 11c. 11d. 11e. 11f. I 11. Other Income. Enter the total of Lines 11a through 11g. ................................................ ...-- 12. TOTAL INCOME. Add only the positive income amounts from Lines 4 through 11. If your total income exceeds $35,000, you may not claim a rebate. .................... IMPORTANT: You must submit proof of the income you reported - Read the instructions on Page 5. L 0605010016 MI W OFFICIAL USE ONLY : Fill in only one oval in each section. 1. I am filing for a rebate as a: e::> P. Property Owner - See instructions _ R. Renter - See instructions c:::> B. OwnerlRenter - See instructions 2. I Certify that as of Dec. 31, 2006, lama: .. A. Claimant age 65 or older e::> B. Claimant under age 65, with a spouse age 65 or older who resided In the same household e::> C. Widow or widower, age 50 to 64 e::> D. PermanenUy disabled and age 18 to 64 3. Have you received Property TaxlRent Rebates in the past? 1. Yes _ 2. No e::> (See instructions) Deadline. June 30, 2007. Dollars Cents 0605010016 ---1 --I 0605120013 Rev-/soo SJ,eJ"J~ E ItemS" (bocuwre'7 t~f/oll) EI.$"e. LJ. Ed,jfe1'l fJ/e. 2/-o1-t>,>/! PA-IOOO 2006 Your Name: f/51 c ~L E~Jre V\ PROPERTY OWNERS ONLY 13. Total 2006 property tax. Submit copies of receipted tax bills. . . . . . . . . . . . . . . . . . . . . . . . . . .. 13. 14. Property Tax Rebate. Compare Line 13 to the maximum rebate amount determined by your income level in Table A and enter the lesser amount. .................................... 14. RENTERS ONLY 15. Total 2006 rent paid. Submit Rent C~rtificate and/or rent receipts ......................... 15. 16. Multiply Line 15 by 20 percent (0.20) ................................................ 16. 17. Rent Rebate. Compare Line 16 to the maximum rebate amount determined by your income level in Table B and enter the lesser amount. .............................................. 17. OWNER - RENTER ONLY 18. Property Tax/Rent Rebate. Add Lines 14 and 17, then compare total to the maximum rebate amount determined by your income level in Table A and enter the lesser amount. ............. 18. DIRECT DEPOSIT. If you want the Department to directly deposit your rebate check into your checking or savings account, complete Lines 19,20 and 21. 19. Place an X in one box to authorize the Department of Revenue to directly deposit your rebate into your. ...................................................................... 19. Checking Savings 21. Account number................................ 21. I An excessive claim with intent to defraud is a misdemeanor punishable by a maximum fine of $1,000, and/or imprisonment for up to one year upon conviction. The claimant is also subject to a penalty of 25 percent of the entire amount claimed. CLAIMANT OATH: I declare that this claim Is true, correct, and complete to the best of my know/edge and belief, and this is the only claim filed by membel'$ of my household. I authorize the PA Department of Revenue access to my federal and state Personal Income Tax records, my PACE records, my Social Security Administration records, and/or my Department of Public Welfare records. This access is for verifying the truth, correctness, and completeness of the information reported in this claim. I TABLE A - OWNERS ONLY TABLE B - RENTERS ONLY INCOME LEVEL Your maximum INCOME LEVEL Your maximum rebate is rebate is o to $8,000 $650 o to $8,000 $650 $8,001 to $15,000 $500 $8,001 to $15,000 $500 $15,001 to $18,000 $300 $18,001 to $35,000 $250 Date (;-12-07 plfEPAR R: I d re that I prepared this return, and that it is to the best of my knowledge and belief, true, correct, and complete. Preparer's Signature, if other than the claimant Date G-/J.-o7 Witnesses' Signatures: If the claimant cannot sign, but only makes a mark. 1. 2. City or Post Office ZIP Code Mecha ;cs6iA. Pet i 70 Si" Call 1-888-728-2937 to check the status of your claim or to update your address. L 0605120013 0605120013 --1 ~I~ Genworth Financial ~+~ Genvorth Life and Annuity Insurance Insurance Service Center P.O. Box 10824 Clearwater, FL 33757-8824 1-877-825-9337 000000005 0030017138 1 0486 001 1...111...111....1.1..1.1..1..111...11....1..11.1..1.1...11..1 THE ESTATE OF ELSIE EDGREN c/O STEPHEN EDGREN 399 BAKER DR HECHANICSBURG PA 17055-4004 Policy/Certificate No: Check No: Check Date: Check Amoun t : Date of Death: 0110418011 30017138 06/07/2007 $449.90 05/15/2007 REFlNJ OF UNEARNED PREMILN (l'II POLICY/CERTIFICATE CK0486 10-24-06 Kev- /500 SdedlAfe ;; 1:- tetvt (; (jJt>cu..W\e~1o,FoYl) r;;. Is I e LJ, Ed:! t'e n t/" e ::If: 2/- 07 -05/ h COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BU~EAU OF INDIVIDUAL TAXES DEPT. 2B060I HARRISBURG, PA I7I2B-060I *' INFORMATION NOTICE AND TAXPAYER RESPONSE FILE ACN DATE NO.21 07-0516 07127682 06-20-2007 REV-lSti! EX AFP (09.00) Rev-J506 SJ.eJ",le F Ite~ (Q ClCIA.. f'1 ell tt<.t/'dl\) E:(s;~ LJ, E~te~ :r/ Ie 21-67- OS-It STEPHEN J EDGREN 399 BAKER DR MECHANICSBURG I TYPE OF ACCOUNT IiJ SAVINGS o CHECKING D TRUST o CERTIF, EST. OF ELSIE W EDGREN S.S. NO. 337-42-8454 DATE OF DEATH 05-15-2007 COUNTY CUMBERLAND PA 17055 REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 MEMBERS 1 ST FCU has p..ovided the Depa..tment with the info..mation listed below which has been used in calculating the potential tax due. Thei.. ..eco..ds indicate that at the death of the above decedent, yoU we..e a joint owne../beneficiary of this account. If yoU feel this info..mation is inco....ect, please obtain w..itten co....ection f..om the financial institution, attach a copy to this fo..m and ..etu..n it to the above add..ess. This account is taxable in acco..dance with the Inhe..itance Tax Laws of the Commonwealth of PennsYlvania. D',estions may be answe..ed by CAll in.. (717) 787-8'127. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 118262 - 05 10-27-1992 Account Balance Percent Taxable Amount Subject to Tax Tax Rate Potential Tax Due PART [!] Date Established To insu..e p"ope.. c..edit to you.. account. two (2) cDPies of this nDtice must accDmpany YDU" payment to the Registe.. Df Wills. Make check payable tD: "Registe.. Df Wills, Agent". x 7,028.79 50.000 3,514.40 .045 158.15 TAXPAYER RESPONSE NOTE, If tax payments a..e made within th..ee (3) mDnths Df the decedent's date of death, YDU may deduct a 570 discDunt Df the tax due. Any inhe..itance tax due will becDme delinquent nine (9) mDnths afte.. the date Df death. x [CHECK ] ONE BLOCK ONLY A. [] The above infD..mation and tax due is cD....ect. 1. YDU may chDDse to ..emit payment tD the Registe.. of Wills with tWD cDPies Df this nDtice tD Dbtain a discDunt D" aVDid inte..est, D" YDU may check bDx "A" and ..etu..n this nDtice tD the Registe.. Df Wills and an Dfficial assessment will be issued by the PA Depa..tment Df Revenue. B. [] The above asset has been D" will be ..ePD..ted and tax paid with the PennSYlvania Inhe..itance Tax ..etu..n to be filed by the decedent's ..ep..esentative. C. [] The abDve infD..matiDn is incD....ect and/o.. debts and deductiDns we..e paid by you. YDU must complete PART ~ and/D" PART ~ belDw. PART ~ TAX RETURN - COMPUTATION If yoU indicate a different tax rate, please state your relationship to decedent: LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8, Tax Due PART [!J DATE PAID PAYEE OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 X 4 5 6 7 X 8 DEBTS AND DEDUCTIONS CLAIMED DESCRIPTION AMOUNT PAID $ have reported above are true, correct and TOTAL CEnter on Line 5 of Tax Computation) Unde.. penalties of perjury, I declare that the facts complete to the best of my knowledge and belief. HOME WORK ( ( ) ) TAXPAYER SIGNATURE nAT.... TFI FP...nNJ: NIIMR!:D COMMONWEALTH OF PENNSYLVANIA DEP~RTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 - INFORMATION NOTICE AND TAXPAYER RESPONSE FILE ACN DATE NO.21 07-0516 07127681 06-20-2007 REY-1S43 EX AFP (09-00) R e.V - /SbD 5checf .-{je F 1:+eWJ .z. (POCW.,.,,z1l t-t:lf;d~ E/Slt W, ElJ "'e" {:'leAI21-{j 7-65/C EST. OF ELSIE W EDGREN S.S. NO. 337-42-8454 DATE OF DEATH 05-15-2007 COUNTY CUMBERLAND TYPE OF ACCOUNT o SAVINGS o CHECKING o TRUST [Xl CERTI F . STEPHEN J EDGREN 399 BAKER DR MECHANICSBURG PA 17055 REMIT PAYMENT AND FORMS TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 MEMBERS 1 ST FCU has provided the Deparbent with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Penneylvania. Questions m~y be 3nswe~ed by celling (717) 727-8327. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 118262 - 4 0 Date 10-27-1992 Established To insure proper credit to your account, two (2) copies of this notice must accompany your payment to the Register of Wills. Make check payable to. "Register of Wills, Agent". Account Balance Percent Taxable Amount Subject to Tax Tax Rate Potential Tax Due 30,384.84 X 50.000 15,192.42 X .045 683.66 TAXPAYER RESPONSE NOTE. If tax payments are made within three (3) months of the decedent's date of death, YOU may deduct a 5X discount of the tax due. Any inheritance tax due will become delinquent nine (9) months after the date of death. PART [!] A. [J The above information and tax due is correct. 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or you may check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. [CHECK ] ONE BLOCK ONLY B. [J The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return to be filed by the decedent's representative. C. [J The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ~ and/or PART ~ below. PART [!J DATE PAID DEBTS AND DEDUCTIONS CLAIMED If yoU indicate a different tax rate, please state your relationship to decedent: PART ~ TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 4 5 6 7 8 x X PAYEE DESCR I PH ON AMOUNT PAID TOTAL (Enter on Line 5 of Tax Computation) . Under penalties of perjury, I declare that the facts complete to the best of my knowledge and belief. have reported above are true, correct and HOME WORK ( ( ) ) TAXPAYER SIGNATURE Tel I:'Dun..u: ...IIIUDI:'D ~ ~ ~ - ~ - ~ - - ~ ~ - - ~ ~ - ~ ~ ~ === ~ - ~ iiiiiiiiiiiiiii iiiiiiiiiiiiiii !!!!!!!!!!!!!! WATERHOUSE RCV-ISO() Sc.4e.j,..Ie F C~ te.", 3) (r Ie*! 'I) (Ite.", 5") (P6c.l.I.l'I1ellf4f/tJ,y Elsie. W. ~dJ,.eYl f;/e #- 1.1-07- OS/b TD Waterhouse Investor Services, Inc. Member NYSE/SIPC 100 Wall Street t~ Y' Da.fe fYlo..Je. New York, NY 10005-3701 J"o;",i- www.tdwaterhouse.com ACCOUNT NO. I 438-07314-1-6 LAST STATEMENT PAGE 1 OF 2 PERIOD ENDING 04/30/2002 BRANCH INFORMATION 2000 LlNGLESTOWN ROAD SUITE 109 HARRISBURG, PA 17110 MONEY MARKET INTEREST TAXABLE DIVIDENDS NON- TAXABLE DIVIDENDS TAXABLE BOND INTEREST THIS PERIOD % LAST PERIOD .1! Sl 067 NYYN 1 34654 12743 001/002 ELSIE W EDGREN & STEPHEN J EDGREN JT TEN 399 BAKER DRIVE MECHANICSBURG PA 17055 CUSTOMER SERVICE: (800) 934-4448 ASSET ALLOCATION APRIL 30, 2002 MONEY MARKET ACCT - FDIC MONEY MARKET FUND STOCKS FIXED INCOME OPTIONS MUTUAL FUNDS UNIT INVESTMENT TRUSTS TOTAL PORTFOUO VALUE $28,507.50 100.0 $ 0.00 $28,507.50 100.0 $0.00 MARKET MARKET PORT DIV OR EST. ANNUAL ACCT QUANTITY DESCRIPTION SYMBOL PRICE VALUE PCT INT~ INCOME STOCKS CASH 525 EXELON CORP EXC 54.300 28,507.50 100.0 1.76 924 TOTAL ACCOUNT 28,507.50 100.0 924 P')O THIS PERIOD YEAR-TO-DATE THIS PERIOD YEAR-TO-DATE MARGIN INTEREST PAID DIVIDENDS CHARGED ACCRUED INT ON PURCHASES ~] WATERHOUSE ---- !!!!!!!!!!!!! ---- - ---- - ---- - - ~ ---- - ~ ---- - ---- === ---- === ---- - ---- ---- ---- ~ 1:'')0 ACCOUNT NO. I 438-07314-1-6 Rev -/!iOO 5c/,eju,/e F (J. tel11 3) (:;'f~1Y/ i{) (1 few, 6) (!oclA"'e"f~fldh; Elsie W. EdJr'{>h {','(e.# 2J-07-oSl' ACC'O - -N' . TD Waterhouse Investor Services, Inc. U 1 Member NYSE/SIPC 100 Wall Street [t>r O",fe mctJe STATEMENT New York, NY 10005-3701 T , ~ vOln' www.tdwaterhouse.com CUSTOMER NAME ELSIE W EDGREN & PERIOD ENDING 04/30/2002 PAGE 2 OF 2 ACCl' DATE ENTRY CASH ~n6 RECEWED DESCRIPTION QUANTITY DEBIT CREDIT EXELON CORP 525 5 ~()lIJ5 Ja.te wo..5 TOTAL Clcco\,\.,f 6l <2.lA. t ~ J 'tl III IQ CD o - .. o 0" !!!, :::J cc C" Dl iii :::J n CD ~ o o o ~ o o o ~ o I o o ~ o I o o ~ o , o o ZO"TI !.:;~ (\) 00 ..., om:::J - X n ::T -0 0 ~ ~ 3 00 (\) (\) am (\) >< ..., "C m ~ - 00 CD U> :::J "TI (\) n c: n 0 :::J ~ 3 It i ~ a. 00 (\) (\) ..., X -0 (\) -0 g g ~ ;::;: -. 00 (\) ~~~ e: 9: 00 0- c: iil (\) S a. ~ <' (\) CD a. 00 o W 01 en , 0, o "TI"T1 c: c: :::J :::J a. a. 00 00 a. a. iii' {g 0-0 ~ 00 (JJ ;::::;: (\) (\) a. a. U>U>O ~ ~ ~ ~ ~ :::J ga::i' 00 m cc 00 -0 C" o c: ~ a: d g: ::T n ~ CD (\) a. 0::10:;- :; CD <' n ~CDc:o !!l. ~ 3 a. 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AA HATFIELD, PA 19440 A FINANCE CHARGE OF 1.50 % PER MONTH (AN ANNUAL PERCENTAGE RATE OF 18.0%) WILL BE CHARGED ON ALL AMOUNTS 30 DAYS OR MORE PAST DUE STATEMENT OF ACCOUNT STATEMENT DATE: 06/30/2007 PHONE: 866-466-7779 EDGREN, STEVE (ELSIE EDGREN) 399 BAKER DR MECHANICSBURG EDGRSTEV GRP-CHAP +-FACILlTY PAGE 1 PA 17055 AMOUNT PAID PLEASE DETACH HERE AND RETURN TOP PORTION WITH YOUR PAYMENT - - - - - - - - - - - - - - -MILLENNImf PHCy-.-gys.-,-iNC ~2886 -BERGEY- Rb-.-,- -STB.- -AA -HATFIEi.D~ - P:;"- -1-9-4-4-0 - - - - - - - - - - - - -- ........... .n..... .... ." ............... ........................... ...... ... ........ ..... . .. ........ ............... ... '" ":":':"':::::':>:::""""'" "':::':':::"":""'::':::"::""":"':"":':"::""'::':::>:"""""'::"':""""""':':::.' :::'>':"::::::'> :.:oltt' . .:} iii ... 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'"' ............. ................. .......................................... . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .....AM..........Q.....UN.......m............o...m............. . .. ... ... ~j!t:~:~~;::\};;;~~i:~;;~:~~~if~:~~;~::;~~::~:~::::::::):::::::::::~;::::~: .00 PLEASE REMIT PAYMENT TO: MILLENNIUM PHARMACY SYSTEMS, INC. 12450 PERRY HIGHWAY, SUITE 200 WEXFORD, PA 15090 Chapel Pointe'afCarlisk Form PB-Ol 770 S. HANOVER STREET, CARLISLE, PA 17013 Mrs. Elsie W. Edgren Stephen Edgren 399 Baker Dr. Mechanicsburg, P A 17055 $9,248.00 Upon Receipt DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE $ - - - - - -- - -- - -. --. -- -. - -- - - -. - - - -- -- -- -- -- -- -- -- -- -- - - -- - -- - -- -- - -- -- -- -- -- -- -- - -. . -- - -- .AMQlJl'-f( 8EMllJEO__ Balance Forwa.rd 05/0112007 Room and Board Private-HC 05/01-05/31 05/14/2007 Room and Board Private-HC 05/01-05/14 31 14 2,940.00 12,818.00 6,510.00 6,308.00 9,248.00 Re V-/SOO 5ciedl( e r 'I e /11 * 3 (pt>CLt 1>1 r .,f", f ),,~ ;' e 0. E (J I-elj ~/! € -1/-f)7-0SI(; RESIDENT # 12901 CURRENT 9,248.00 OVER 30 0.00 OVER 60 0.00 OVER 90 0.00 OVER 120 0.00 TOTAL AMOUNT DUE $9,248.00 RESIDENT NAME Mrs. Elsie W. Edgren CHAPEL POINTE AT CARLISLE, 770 S. HANOVER STREET, CARLISLE, PA 17013 Form PB-Ol REGISTER OF WILLS CUMBERLAND County, Pennsylvania CERTIFICATE OF GRANT OF LETTERS No. 2007-00516 PA No. 21-07-0516 Es ta te Of: ELSIE W EDGREN (First, Middle, Last) Late Of: CARLISLE BOROUGH CUMBERLAND COUNTY Deceased Social Securi ty No: 337-42-8454 WHEREAS, on the 25th day of May 2007 an instrument dated February 6th 1995 was admitted to probate as the last will of ELSIE W EDGREN (First, Middle, Last) la te of CARLISLE BOROUGH, CUMBERLAND County, who died on the 15th day of May 2007 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA FARNER STRASBAUGH Register of wills in and for CUMBERLAND County, in the Commonwealth of pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: STEPHEN J EDGREN who has duly qualified as EXECUTOR(RIX) and has agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 25th day of May 2007. A '-1 /1 1 ( /; / iU71d!J-"&C'?L/U Register of Wills J !(z [Cj I{ c, / L-/7/'d /1 ,,;Yl;;~Z"/c-_ . / // Wj:)uty -~ U * *NOTE* * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) LAW OFF1CES SNELBAKER a BRENNEMAN LAST WILL AND TESTAMENT I, ELSIE W. EDGREN, of the Township of Monroe, County of Cumberland and Commonwealth of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void all former wills and codicils by me at any time heretofore made. I II, FIRST. I order and direct that all my just debts and II funeral expenses be paid by my Executor or Executors, as the case II may be, hereinafter named, as soon as conveniently may be done II after my decease. p II SECOND. I order and direct that all the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situated, be divided into two parts, to wit: one part consisting of assets equal to sixty per centum (60%) of my net distributable estate, hereinafter known as the "60% Part", and the other part consisting of assets equal to forty per centum (40%) of my net distributable estate, hereinafter known as the "40% Part", which Parts shall be distributed and disposed of as follows: A. I give, devise and bequeath the 60% Part of my residuary estate in equal shares unto my three (3) sons, namely, JAMES A. EDGREN, DAVID J. EDGREN and STEPHEN J. EDGREN, share and share alike. If any of my said sons should predecease me, I order and direct that said 60% Part shall be distributed only to those sons or that son who survive me, without substitution of issue for any deceased son, it being my express will II and intent that said 60% Part shall be distributed only "2 , ~j (-~'" c, -~-"I rn c..:.) i J i i I ., 1 " ".11 ~I >'~1':'! -, ~j'" '\ \:1 :~ J"'''J, 1 I \~ :s~ '>..'~.'. '';:''') '\" . \i"}' i' \,. \, i LAW OFFJCES SNELBAKER 8c BRENNEMAN to my surviving sons or son. B. I give, devise and bequeath the 40% Part of my residuary estate in equal shares among my grandchildren living at the time of my death, share and share alike. The term "grandchildrentr shall be defined and interpreted to mean the first generation children of my sons and daughters (whether the latter are living or deceased) and shall include natural or adopted children and those which may be born after the date hereof. I order and direct that the distributive share to any grandchild who has not attained the age of eighteen (18) years of age at the time of distribution shall be paid over and delivered unto the parents or parent of said grandchild as a testamentary trustee, IN TRUST, NEVERTHELESS, to hold, manage, invest, accumulate income and reinvest for the benefit of said grandchild and until said grandchild attains the age of eighteen (18) years, at which latter time said trust shall terminate and the net balance thereof shall be distributed and paid over to the beneficiary, absolutely. LASTLY. I nominate, constitute and appoint my son, namely, STEPHEN J. EDGREN, to be the Executor of this, my Last Will and Testament, but if for any reason he should fail to qualify as such Executor or cease so to serve, then and in that event, I nominate, constitute and appoint my sons, namely, JAMES A. EDGREN and DAVID J. EDGREN (or either of them who qualifies or continues to serve) to be the Executors hereof, each and all to serve without bond or other security as a condition of qualification hereunder. II IN WITNESS WHEREOF, I, ELSIE W. EDGREN, have hereunto set LAW OFFICES SNELBAKER B: BRENNEMAN my hand and seal to this, my Last will and Testament which consists of three (3) typewritten , if( affixed my signature this t,,_.1 pages to each of which I have day of <.:1el:""'7,L~ It./L-~t A. D., One /} (1995) . v Thousand Nine Hundred Ninety-five .~<('/ < ~l,~;,1 GJ:4A-e C(/. <PCe?//L.P~L/ Elsie w. gdgren ( SEAL) The preceding instrument, consisting of this and two (2) other typewritten pages, each identified by the signature of the Testatrix, was on the date thereof signed, sealed, published and declared by ELSIE W. EDGREN, the Testatrix therein named, as and for her Last will and Testament, in the presence of us, who, at her request, in her presence, and in the presence of each other, have subscribed our names as witnes / .~ j <""',~:.~"~./ . "// _;t--;""'--G-,r-/\ .. ,,~~~-'_ > ".,. (.- .:.'" II LAW OFFICES SNELBAKER 8< BRENNEMAN ( COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND) SS. We, ELSIE W. EDGREN, RICHARD C. SNELBAKER and JANET R. STEGNER, the Testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being I I first duly sworn, do hereby declare to the undersigned authority I that the Testatrix signed and executed the instrument as her Last I will and Testament and that she had signed willingly, and that I I she executed it as her free and vOluntary act for the purposes I therein 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 his or her knowledge the Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. I I ./ ,//' , ", 1 --/{\"';P'?'~'/0;'~~":'~c~~-=3.::;;."'-----"'""" Wi tness ,/ Subscribed, sworn to and acknowledged before me by ELSIE W. EDGREN, the Testatrix, and subscribed and sworn to before me by RICHARD C. SNELBAKER and JANET R. 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