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HomeMy WebLinkAbout09-21-07 .-J 15056041147 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 OFFICIAL USE ONLY County Code Year INHERITANCE TAX RETURN RESIDENT DECEDENT 2 1 0 7 File Number 0333 Date of Birth 195070841 12282006 10221912 JONES THELMA MI E Decedent's Last Name Suffix Decedent's First Name (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW [!] 1. Original Retum 0 2. Supplemental Retum 0 3. Remainder Retum (date of death prior to 12-13-82) 0 4. Limited Estate 0 4a. Future Interest Compromise 0 5. Federal Estate Tax Retum Required (dale of death after 12-12-82) 0 6. Decadent Died Testate 0 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 0 9. Litigation Proceeds Received 0 10 Spousal pove\% Credit ~date of death 0 11. Election to tax under Sec. 9113(A) . between 12-31- 1 and -1-95) (Attach Sch. 0) CORRESPONDENT. THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number LISA COMBER HALL ESg 6103440136 ~~~ TWO WEST MARKET STREET, SUITE , .) REGISTER Of: ~LS US~L Y I.' ' . C" j".l ,L. Q ''-1 .="i ': ~~~i r.J N . / -' ,.:\., Firm Name (If Applicable) HALL LAW OFFICES, P.C. First line of address Second line of address :J~: N ... I, DATE FILED W ;" [ ") City or Post Office WEST CHESTER State PA ZIP Code 19382-3006 Correspondent's e-mail address: L C H Law@ms n . com Under penalties of p,erjury, 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. SIGNATURE P SON RESPONSIBL FO FILING RETURN DATE Robert A. Rubin 9 j 8 ~ 7 901 Pineview Drive, West Chester, PA 19380 ~IG TURE OF ifPAREj OTHER ;;~;~PRES~TA.TIVE _ ~ N~ '0 Lisa Comber Hall Esq AD RESS - ~ Two West Market Street, Suite 403, West Chester, PA 19382-3006 Side 1 9 L 15056041147 15056041147 .-J~ -.J 1505b042148 REV-1500 EX Decedent's Name: Thelma Ellen Jones RECAPITULATION 1. Real Estate (Schedule A).......................................................................................... 1. 2. Stocks and Bonds (Schedule B)............................................................................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3. 4. Mortgages & Notes Receivable (Schedule D).......................................................... 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E)................ 5. 6. Jointly Owned Property (Schedule F) D Separate Billing Requested............. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) D Separate Billing Requested............. 7. 8. Total Gross Assets (total Lines 1-7)....................................................................... 8. 9. Funeral Expenses & Administrative Costs (Schedule H)......................................... 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)................................ 10. 11. Total Deductions (total Lines 9 & 10)...................................................................... 11. 12. Net Value of Estate (Line 8 minus Line 11)............................................................. 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J)................................................. 13. 14. Net Value Subject to 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, of transfers under Sec. 9116 (a)(1.2) X ~ 16. Amount of Line 14 taxable at lineal rate X .045 0 0 0 17. Amount of Line fiiaxable at sibling rate X .12 6 2 , 0 5 3 4 9 18. Amount of Line 14 taxable at collateral rate X .15 2 2 6 , 4 7 4 3 0 19. Tax Due..................................................................................................... ................ 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 L 1505b042148 Decedent's Social Security Number 195070841 85,658 89 226,474 30 312,133 19 22,448 40 1,157 00 23,605 40 288,527 79 288,527.79 15. o 00 o 00 7,446 42 33,971 15 41,417 57 16. 17. 18. D 1505b042148 -.J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-07-0333 DECEDENTS NAME Thelma Ellen Jones STREET ADDRESS 4837 E. Trindle Road CITY I STATE \ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 41,417.57 0.00 Total Credits (A + B + C) (2) 0.00 3. InterestlPenalty if applicable D. Interest E. Penalty (3) (4) (5) (5A) (5B) TotallnterestlPenalty (0 + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 Line 20 to request a refund 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 tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. 41,417.57 41,417.57 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;.................................................................................. 0 [!] b. retain the right to designate who shall use the property transferred or its income;.................................... 0 [!] c. retain a reversionary interest; or.................................................................................................................. 0 [!] d. receive the promise for life of either payments, benefits or care?.............................................................. 0 [!] 2. If death occurred atter 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 payable 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 [!] 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 atter 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 atter 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 exemDt 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 atter July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~9116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. ~9116 1.2) [72 P.S. ~9116 (a) (1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. ~9116 (a) (1.3)). A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-1608 EX+ (8-98) *' SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY CCJMMQNWEALTHOF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Jones, Thelma Ellen FILE NUMBER 21-47-4333 ESTATE OF Indude the proceeds of litigation end the dete the proceeds were received by the eslate. All property joInt1y-owned with the rtght of survivorshIp must be disclosed on schedule F. ITEM NUMBER DESCRIPTION 1 Commonwealth of Pennsylvania - Proceeds from Unclaimed Property Claim #99943692 VALUE AT DATE OF DEATH 62.50 2 Bank of America Certificate of Deposit #408139107 - Titled Thelma F. Jones or Ralph McCreight (Deceased; 000: 10/09/2003); Date Opened: 9/21/1999; Value as of 000 11.017.01 Accrued interest on Item 2 through date of death 12.49 3 Bank of America Certificate of Deposit #409373911 - Titled Thelma F. Jones; Date Opened: 11/21/2000; Value as of 000 25.098.43 Accrued interest on Item 3 through date of death 26.35 4 Country Meadows Associates - Refund of Nursing Facility Residence Fees 2.384.48 5 Daupin County - Restitution from Legal Claim 71.56 6 Highmark Blue Shield - Prescription Drug Plan Premium Refund 26.57 7 Highmark Blue Shield - Health Insurance Premium Refund 293.05 8 Marlon Center Bank Checking Account #6001282 - Titled Thelma F. Jones; Date Opened: 1/11/1988; Value as of 000: 556.90 9 Vanguard Prime Money Market Account #09901800041 - Titled Thelma F. Jones; Value as of 000 45.684.49 Accrued dividend on Item 9 through date of death 175.06 Total of Continuation Schedule See attached page TOTAL (Also enter on Line 5, Recapitulation) 85.658.89 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev.15GB EX+ (8-98) . SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Jones, Thelma Ellen IFILE NUMBER 214J7 -0333 ESTATE OF ITEM NUMBER 10 DESCRIPTION Tangible Personal Property - Decedent's Clothing, Furnishings, Jewelry, Householed Goods, Etc.; Estimated Value as of 000 VALUE AT DATE OF DEATH 250.00 NOTE: Decedent Resided in a Nursing Facility and Owned Limited Articles of Personalty TOTAL (Also enter on Line 5, Recapitulation) 85.658.89 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev.16ot EX+ (6-1181 . SCHEDULE F JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESlllENT DECEOENT ESTATE OF FILE NUMBER Jones, Thelma Ellen 21-07 -0333 If an a..et wes made Joint within one year of the decedent's date of death, It mUllt be reported on schedule G. SURVIVING JOINT TENANT(S) NAME A. SEE ATTACHED CONTINUATION PAGE "A" ADDRESS RELATIONSHIP TO DECEDENT B. C. JOINTLY OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DECD'S VALUE OF NUMBER NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR VALUE OF ASSET DECEDENTS INTEREST TENANT JOINT JOINTL V-HELD REAL ESTATE. INTEREST 1 A 9/16/1996 Bank of America Certificate of Deposit 39.439.88 50.000% 19.719.94 #402595593 - Titled Thelma F. Jones or Robert J. Faust; Date Opened: 9/16/1996; Value as of 000 A 9/16/1996 Accrued interest on Item 1 through date 51.64 50.000% 25.82 of death 2 B 9/16/1996 Bank of America Certificate of Deposit 11.544.31 50.000% 5.772.16 #402595650 - Titled Thelma F. Jones or William H. Adams; Date Opened: 9/16/1996; Value as of 000 B 9/16/1996 Accrued interest on Item 2 through date 15.12 50.000% 7.56 of death 3 C 9/16/1996 Bank of America Certificate of Deposit 33.814.79 50.000% 16.907.40 #402595668 - Titled Thelma F. Jones or Samuel B. Adams; Date Opened: 9/16/1996; Value as of 000 C 9/16/1996 Accrued interest on Item 3 through date 44.27 50.000% 22.14 of death Total of Continuation Schedules See attached pages TOTAL (Also enter on Line 6, Recapitulation) 226.474.30 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1S00 Schedule F (Rev. 6-98) Rev-15GB EX+ (6.88) *' SCHEDULE F JOINTLY-OWNED PROPERTY continued cOMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEOENT ESTATE OF Jones, Thelma Ellen FILE NUMBER 21-47-4333 If an asset was made joint within one year of the decedent's date of death, It must be reported on schedule G. JOINTLY OWNED PROPERTY DESCRIPTION OF PROPERTY %OF ITEM LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DATE OF DEATH FOR JOINT MADE VALUE OF ASSET DECO'S VALUE OF NUMBER NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR INTEREST DECEDENrSINTEREST TENANT JOINT JOINTL Y-HELD REAL ESTATE. 4 D 9/16/1996 Bank of America Certificate of Deposit 17,410.74 50.000% 8,705.37 #402595676 - Titled Thelma F. Jones or Betty J. Pfeiffer; Date Opened: 9/16/1996; Value as of DOD D 9/16/1996 Accrued interest on Item 4 through date 28.80 50.000% 14.40 of death 5 E 11/411996 Bank of America Certificate of Deposit 10,961.21 50.000% 5,480.61 #402769081 - Titled Thelma F. Jones or Florence J. Gofton; Date Opened: 11/04/1996; Value as of DOD E 11/411996 Accrued interest on Item 5 through date 36.71 50.000% 18.36 of death 6 F 11/12/1996 Bank of America Certificate of Deposit 15,934.20 50.000% 7,967.10 #402784288 - Titled Thelma F. Jones or John G. Kurtz; Date Opened: 11/12/1996; Value as of DOD F 11/12/1996 Accrued interest on Item 6 through date 36.29 50.000% 18.15 of death 7 G 11/26/1996 Bank of America Certificate of Deposit 8,844.06 50.000% 4,422.03 #402815801 - Titled Thelma F. Jones or Jon Adams; Date Opened: 11/26/1996; Value as of DOD G 11/26/1996 Accrued interest on Item 7 through date 3.56 50.000% 1.78 of death Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA.1500 Schedule F (Rev. 6-98) Rev.16Oll EX+ (s...) *' SCHEDULE F JOINTLY-OWNED PROPERTY continued cOMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Jones, Thelma Ellen FILE NUMBER 21-07 -0333 If an asset was made Joint within one year of the decedent's date of death, It must be reported on schedule G. JOINTLY OWNED PROPERTY DESCRIPTION OF PROPERTY %OF ITEM LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DATE OF DEATH FOR JOINT MADE DECD'S VALUE OF NUMBER NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR VALUE OF ASSET INTEREST DECEDENT'S INTEREST TENANT JOINT JOINTLY-HELD REAL ESTATE. 8 H 11/26/1996 Bank of America Certificate of Deposit 8,844.06 50.000% 4.422.03 #40281793 - Titled Thelma F. Jones or Joseph Adams; Date Opened: 11/26/1996; Value as of 000 H 11/26/1996 Accrued interest on Item 8 through date 3.56 50.000% 1.78 of death 9 I 12/16/1996 Bank of America Certificate of Deposit 29.774.65 50.000% 14.887.33 #402850220 - Titled Thelma F. Jones or Robert A. Rubin; Date Opened: 12/16/1996; Value as of 000 I 12/16/1996 Accrued interest on Item 9 through date 43.20 50.000% 21.60 of death 10 J 12/16/1996 Bank of America Certificate of Deposit 47.994.14 50.000% 23.997.07 #402850246 - Titled Thelma F. Jones or Jeffrey W. Rubin; Date Opened: 12/16/1996; Value as of 000 J 12/16/1996 Accrued interest on Item 10 through date 52.21 50.000% 26.11 of death 11 K 1/17/1997 Bank of America Certificate of Deposit 13.449.23 50.000% 6.724.62 #402898211 - Titled Thelma F. Jones or Jo Ann Adams (a/kla Joanne Adams); Date Opened: 1/17/1997; Value as of 000 K 1/17/1997 Accrued interest on Item 11 through date 19.51 50.000% 9.76 of death Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98) ReY-1601 EX+ (6-98) *' SCHEDULE F JOINTLY-OWNED PROPERTY continued cOMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Jones, Thelma Ellen FILE NUMBER 21-47-4333 If an asset was made joint within one year of the decedent's date of death, It must be reported on schedule G. JOINTLY OWNED PROPERTY DESCRIPTION OF PROPERTY %OF LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DATE OF DEATH ITEM FOR JOINT MADE NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR IVALUE OF ASSET DECD'S VALUE OF NUMBER TENANT JOINT INTEREST DECEDENrSINTEREST JOINTL V-HELD REAL ESTATE. 12 L 1/17/1997 Bank of America Certificate of Deposit 10.199.12 50.000% 5.099.56 #402898245 - Titled Thelma F. Jones or Lilian Rubin; Date Opened: 1/17/1997; Value as of 000 L 1/17/1997 Accrued interest on Item 12 through date 14.80 50.000% 7.40 of death 13 M 1/17/1997 Bank of America Certificate of Deposit 10.185.34 50.000% 5.092.67 #402898278 - Titled Thelma F. Jones or James R. Adams; Date Opened: 1/17/1997; Value as of 000 M 1/17/1997 Accrued interest on Item 13 through date 14.78 50.000% 7.39 of death 14 N 9/21/1999 Bank of America Certificate of Deposit 21.232.00 50.000% 10.616.00 #408138248 - Titled Thelma F. Jones or Mary Lee Nycum; Date Opened: 9/21/1999; Value as of 000 N 9/21/1999 Accrued interest on Item 14 through date 18.53 50.000% 9.27 of death 15 0 9/21/1999 Bank of America Certificate of Deposit 11.856.59 50.000% 5.928.30 #408139164 - Titled Thelma F. Jones or Debra Adams; Date Opened: 9/21/1999; Value as of 000 0 9/21/1999 Accrued interest on Item 15 through date 10.34 50.000% 5.17 of death Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98) Rev-16GB EX+ (8-98) *' SCHEDULE F JOINTLY -OWNED PROPERTY continued CClIoNQNV\/EAL 'Ili OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Jones, Thelma Ellen FILE NUMBER 21-07 -0333 If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G. JOINTLY OWNED PROPERTY DESCRIPTION OF PROPERTY %OF ITEM LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DATE OF DEATH FOR JOINT MADE DECD'S VALUE OF NUMBER NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR VALUE OF ASSET INTEREST DECEDENrSINTEREST TENANT JOINT JOINTLY-HELD REAL ESTATE. 16 M 9/21/1999 Bank of America Certificate of Deposit 29.049.31 50.000% 14.524.66 #408139198 - Titled Thelma F. Jones or James R. Adams; Date Opened: 9/21/1999; Value as of 000 M 9/21/1999 Accrued Interest on Item 16 through date 25.35 50.000% 12.68 of death 17 p 12/17/1999 Bank of America Certificate of Deposit 47,989.00 50.000% 23.994.50 #408375610 - Titled Thelma F. Jones or Michael B. Rubin; Date Opened: 12/17/1999; Value as of 000 p 12/17/1999 Accrued interest on Item 17 through date 69.62 50.000% 34.81 of death 18 I 5/19/1995 Fidelity Investments Mutual Fund 68.559.94 50.000% 34.279.97 Account #0169-00006798514 - Titled Thelma F. Jones and Robert Rubin, JTWROS; Date Opened: 5/19/1995; Value as of 000 19 I 9/17/1985 Series EE Savings Bond #M10329361EE- 500.00 50.000% 250.00 Titled Thelma F. Jones or Robert Rubin; Date Issued: 9/17/1985; Maturity Date: 9/2015; Value as of DOD I 9/17/1985 Accrued interest on Item 19 through date 1.114.80 50.000% 557.40 of death Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98) Rev-16ot EX+ {S-IS) . SCHEDULE F JOINTLY-OWNED PROPERTY continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Jones, Thelma Ellen FILE NUMBER 21.{j7.{j333 If an asset was made Joint within one year of the decedent's date of death, It must be reported on schedule G. JOINTLY OWNED PROPERTY DESCRIPTION OF PROPERTY %OF ITEM LETTER DATE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT DATE OF DEATH DATE OF DEATH NUMBER FOR JOINT MADE NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR VALUE OF ASSET DECD'S VALUE OF TENANT JOINT JOINTLY-HELD REAL ESTATE. INTEREST DECEDENrSINTEREST 20 I 9/17/1985 Series EE Savings Bond #M10329362EE- 500.00 50.000% 250.00 Titled Thelma F. Jones or Robert Rubin; Date Issued: 9/17/1985; Maturity Date: 9/2015; Value as of 000 I 9/17/1985 Accrued interest on Item 20 through date 1.114.80 50.000% 557.40 of death 21 I 4/20/1990 Series EE Savings Bond #X1975721EE- 5.000.00 50.000% 2.500.00 Titled Thelma F. Jones or Robert Rubin; Date Issued: 4/20/1990; Maturity Date: 4/2020; Value as of 000 I 4/20/1990 Accrued interest on Item 21 through date 7.148.00 50.000% 3.574.00 of death TOTAL (Also enter on Line 6, Recapitulation) 226,474.30 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98) SCHEDULE F JOINTLY-OWNED PROPERTY CONTINUATION PAGE "A" ESTATE OF JONES, THELMA ELLEN FILE NUMBER 21-07-0333 SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Robert J. Faust 7474 E. Arkansas Ave. #2005 Nephew Denver, CO 80231 B. William H. Adams 1400 Quarry Lane Nephew Lancaster, PA 17603 C. Samuel B. Adams 291 Texaco Road Nephew Mechanicsburg, PA 17055 D. Betty J. Pfeiffer 1030 Pfeiffer Road Friend Marion Center, PA 15759 E. Florence J. Gotton 420 N. Bentsen Palm Drive, F-7 Friend (Former In-Law) Mission, TX 78572-9440 F. John G. Kurtz 9905 Broadmoor Lane Nephew Rowlett, TX 75089 G. Jon Adams 1304 E. Derry Road Grand-Nephew Hershey, PA 17033 H. Joseph Adams 1302 Prince Street Grand-Nephew Palmyra, PA 17078 I. Robert A. Rubin 901 Pineview Drive Nephew West Chester, PA 19380 J. Jeffrey W. Rubin 1456 Peachtree Battle Avenue Nephew Atlanta, GA 30327 K. Jo Ann Adams (a/kla Joanne Adams) 1302 Prince Street Nephew's Spouse Palmyra, PA 17078 (Niece by Marriage) L. Lilian Rubin 901 Pineview Drive Nephew's Spouse West Chester, PA 19380 (Niece by Marriage) M. James R. Adams 1302 Prince Street Nephew Palmyra, PA 17078 N. Mary Lee Nycum P. O. Box 132 1001 N. Manor Street Friend Marion Center, PA 15759 O. Debra Adams P. O. Box 875 Grand-Niece Victor, 10 83455 P. Michael B. Rubin 1003 Malibu Drive Nephew Marietta, GA 30066 REV-1151 EX+ (12-"' *' SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21-07-0333 ESTATE OF Jones, Thelma Ellen Debts of decedent must be reported on Schedule I. ITEM NUMBER A. FUNERAL EXPENSES: DESCRIPTION See continuation schedule(s) attached B. ADMINISTRATIVE COSTS: Personal Representative's Commissions 1. Robert A. Rubin Social Security Number(s) I EIN Number of Personal Representative(s): 194-42-6068 Street Address 901 Pinevlew Drive City West Chester State Year(s) Commission paid 2007 See continuation schedule(s) attached PA Zip 19380 Attorney's Fees See continuation schedule(s) attached 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant 2. Street Address City Relationship of Claimant to Decedent State Zip 4. Probate Fees 5. See continuation schedule(s) attached Accountant's Fees See continuation schedule(s) attached 6. Tax Return Preparer's Fees 7. Other Administrative Costs See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) Copyright (c) 2002 form software only The Lackner Group, Inc. AMOUNT 7,711.40 5,000.00 7,500.00 187.00 1,500.00 550.00 22,448.40 Form PA-1500 Schedule H (Rev. 6-98) Rev.1502 EX+ (8-88) . SCHEDULE H.A FUNERAL EXPENSES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Jones, Thelma Ellen IFILE NUMBER 21-07 -0333 ITEM NUMBER DESCRIPTION AMOUNT 1 Bowser-Munich Inc. Funeral Homes - Funeral/Burial Expenses 7,211.40 2 Marion Center Memorial Cemetery - Grave Opening Fee 500.00 Subtotal 7,711.40 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-A (Rev. 6-98) Rev-1H2 EX+ (6-88) *' SCHEDULE H.81 PERSONAL REPRESENTATIVE'S COMMISSIONS continued CO!IMQNWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RES/OENT OECEOENT ESTATE OF Jones, Thelma Ellen IFILE NUMBER 21-07-0333 ITEM NUMBER DESCRIPTION AMOUNT 1 Robert A. Rubin - Administrator's Fee 5.000.00 Subtotal 5.000.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B1 (Rev. 6-98) Rev-1SD2 EX+ (6-98) *' SCHEDULE H-82 A TIORNEY'S FEES continued COMMON~THOFPENNSYlVAN~ INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Jones, Thelma Ellen IFILE NUMBER 21-47 -4333 1 DESCRIPTION Hall Law Offices, P. C. - Estimated Legal Fees AMOUNT ITEM NUMBER 7.500.00 Subtotal 7.500.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B2 (Rev. 6-98) Rev-1HZ EX+ (6.9S) '* SCHEDULE H.84 PROBATE FEES continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESlOENT DECEDENT ESTATE OF Jones, Thelma Ellen IFILE NUMBER 21-07-0333 ITEM NUMBER DESCRIPTION Cumberland County Register of Wills - Probate Fee AMOUNT 187.00 1 Subtotal 187.00 Copyright (c) 2002 fonn software only The Lackner Group, Inc. Fonn PA-1500 Schedule H-B4 (Rev. 6-98) Rey.1502 EX+ (,-8,) *' SCHEDULE H.85 ACCOUNTANT'S FEES continued ~TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Jones, Thelma Ellen IFILE NUMBER 21-07 -0333 ITEM NUMBER DESCRIPTION AMOUNT 1 Accountant Fees - Estimated Accountant Fees 1.500.00 Subtotal 1.500.00 Copyright (c) 2002 fonn software only The Lackner Group, Inc. Fonn PA-1S00 Schedule H-BS (Rev. 6-98) .. Rev-1602 EX+ (6-98) . SCHEDULE H-B7 OTHER ADMINISTRATIVE COSTS continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Jones, Thelma Ellen IFILE NUMBER 21-47-4333 1 DESCRIPTION Commerce Bank - Returned Check Fee AMOUNT ITEM NUMBER 15.00 2 Cumberland County Register of Wills - Short Certificate Fee 16.00 3 Miscellaneous Estate Expenses 500.00 4 PA Department of Vital Records - Death Certificate Fee (Deceased Joint Owner - Ralph McCreight) 19.00 Subtotal 550.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B7 (Rev. 6-98) R.v.1612 EX+ (6.tS) . SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT Jones, Thelma Ellen FILE NUMBER 21-07 -0333 ESTATE OF Includ. unrelmbursed medical .xp.n.... ITEM NUMBER DESCRIPTION 1 PA Department of Revenue - Decedent's 2006 Income Tax VALUE AT DATE OF DEATH 338.00 2 United States Treasury - Decedent's 2006 Income Tax 819.00 TOTAL (Also enter on Line 10, Recapitulation) 1,157.00 (If more space is needed. additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) REV-1513 EX+ (9-00) *' SCHEDULE .. BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT NUMBER Jones, Thelma Ellen NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal oistributions.l. and transfers under Sec. l:I116(a)(1.2)] RELATIONSHIP TO DECEDENT Do Not Uat TN_la' FILE NUMBER 21-07 -0333 SHARE OF ESTATE AMOUNT OF ESTATE (Words) ($$$) ESTATE OF I. 1 Edna Kurtz 1317 Colonel Drive, #851 Garland, TX 75043 Sister 100% of Residual Estate Total Enter dollar amounts for distributions shown above on lines 5 through 18, as appropnate, 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00 Copyright (c) 2002 fonn software only The Lackner Group, Inc. Fonn PA-1500 Schedule J (Rev. 6-98) lHkof........ H......Sta..... May 31,2007 Courtesy Balance Statement Reporting for Date of: 12/28/06 Bank of America Deposit Product Services P.O. Box 2948, KS1-901-01-16 Wichita, KS 67201-2948 Mail To: Provided by: Sean Slaby 1-888-827-1812, x 7790206 ESTATE OF THELMA JONES CIO ROBERT A RUBIN 901 PINEVIEW DRIVE WEST CHESTER, PA 19380 Request Number: NH-33760 Customer Service Infonnation For additional information or service, you may call: tit 1-888-827-1812 Customer Service 1-800-288-4408 Hearing Impaired Customer Service Title of Account: Type and Term: Balance: $ 39,439.88 Title of Account: Type and Term: Balance: $ 11,544.31 Title of Account: Type and Term: Balance: $ 33,814.79 Or you may write to: 181 Bank of America Deposit Product Services P.O. Box 2948 Wichita KS 67201-2948 THELMA F JONES ROBERT J FAUST ROBERT A RUBIN POA C/O ROBERT RUBIN 18 MONTH FIXED TERM CD **Accrued Interest: $ 51.64 Account Number: 68100402595593 Status of Account: Date Opened: 09/16/96 Paid YTD: Current Balance: $ 1,959.34 $ 39,356.87 Account Number: 68100402595650 Status of Account: Date Opened: 09/16/96 Paid YTD: Current Balance: $ 573.51 $ 11,520.02 Account Number: 68100402595668 Status of Account: Date Opened: 09/16/96 Paid YTD: Current Balance: $ 1,679.90 $ 33,743.61 THELMA F JONES WILLIAM H ADAMS ROBERT A RUBIN POA C/O ROBERT RUBIN 18 MONTH FIXED TERM CD **Accrued Interest: $ 15.12 THELMA F JONES SAMUEL B ADAMS ROBERT A RUBIN POA C/O ROBERT RUBIN 18 MONTH FIXED TERM CD **Accrued Interest: $ 44.27 .. Accrued Interest is not included in the Balance la_otAnI........ a.......Sta..... Courtesy Summary/Balance Reporting for the Date of: 12/28/06 Page: Title of Account: THELMA F JONES Account Number: 68100402595676 BETTY J PFEIFFER Status of Account: ROBERT A RUBIN POA C/O ROBERT RUBIN Date Opened: 09/16/96 Type and Term: 18 MONTH FIXED TERM CD Balance: **Accrued Interest: Paid YTD: Current Balance: $ 17,410.74 1 $ 28.80 I $ 864.96 $.00 Title of Account: THELMA F JONES Account Number: 68100402769081 FLORENCE J GOFTON Status of Account: ROBERT A RUBIN POA C/O ROBERT RUBIN Date Opened: 11/04/96 Type and Term: 12 MONTH FIXED TERM CD Balance: **Accrued Interest: Paid YTD: Current Balance: $ 10,961.21 $ 36.71 $ 498.32 $ 10,917.33 I Title of Account: THELMA F JONES Account Number: 68100402784288 JOHN G KURTZ Status of Account: ROBERT A RUBIN POA C/O ROBERT RUBIN Date Opened: 11/12/96 Type and Term: 12 MONTH FIXED TERM CD Balance: ** Accrued Interest: Paid YTD: Current Balance: $ 15,934.20 $ 36.29 $ 740.61 $ 15,870.40 Title of Account: THELMA F JONES Account Number: 68100402815793 JOSEPH ADAMS Status of Account: ROBERT A RUBIN POA C/O ROBERT RUBIN Date Opened: 11/26/96 Type and Term: 12 MONTH FIXED TERM CD Balance: ** Accrued Interest: Paid YTD: Current Balance: $ 8,844.06 $ 3.56 $ 419.16 $ 8,808.65 Title of Account: THELMA F JONES Account Number: 68100402815801 JON ADAMS Status of Account: ROBERT A RUBIN POA C/O ROBERT RUBIN Date Opened: 11/26/96 Type and Term: 12 MONTH FIXED TERM CD Balance: ** Accrued Interest: Paid YTD: Current Balance: $ 8,844.06 $3.56 $ 419.16 $ 8,808.65 .. Accrued Interest is not included in the Balance aallkofAnlerlc8.... H.......1ta1ll1~1. Courtesy Summary/Balance Reporting for the Date of: 12/28/06 Title of Account: Type and Term: Balance: $ 29,774.65 Page: THELMA F JONES ROBERT A RUBIN ROBERT A RUBIN POA C/O ROBERT RUBIN 18 MONTH FIXED TERM CD Account Number: Status of Account: Date Opened: 68100402850220 12/16/96 ** Accrued Interest: $ 43.20 Paid YTD: $ 1,327.57 Current Balance: $ 30,322.81 Title of Account: THELMA F JONES JEFFREY WRUBIN . ROBERT A RUBIN POA C/O ROBERT RUBIN Account Number: Status of Account: 68100402850246 Date Opened: 12/16/96 Type and Term: 18 MONTH FIXED TERM CD Balance: **Accrued Interest: $ 47,994.14 $ 52.21 Title of Account: Type and Term: Balance: $ 13,449.23 Title of Account: Type and Term: Balance: $ 10,199.12 Title of Account: Type and Term: Balance: $10,185.34 THELMA F JONES JO ANN ADAMS ROBERT A RUBIN POA C/O ROBERT RUBIN 12 MONTH FIXED TERM CD **Accrued Interest: $ 19.51 Paid YTD: Current Balance: $ 2,139.93 $ 48,877.73 Account Number: 68100402898211 Status of Account: Date Opened: 01/17/97 Paid YTD: Current Balance: $ 742.43 $ 13,409.72 Account Number: 68100402898245 Status of Account: Date Opened: 01/17/97 Paid YTD: Current Balance: $ 563.01 $10,169.16 Account Number: 68100402898278 Status of Account: Date Opened: 01/17/97 Paid YTD: Current Balance: $ 562.25 $10,155.43 THELMA F JONES LILIAN RUBIN ROBERT A RUBIN POA C/O ROBERT RUBIN 12 MONTH FIXED TERM CD **Accrued Interest: $ 14.80 THELMA F JONES JAMES R ADAMS ROBERT A RUBIN POA C/O ROBERT RUBIN 12 MONTH FIXED TERM CD **Accrued Interest: $ 14.78 "Accrued Interest is not included in the Balance BallkotAnl__ ~ H.........'1!I....... Courtesy Summary/Balance . Reporting for the Date of: 12/28/06 Page. Title of Account: THELMA F JONES Account Number: 68100408139107 RALPH MC CREIGHT Status of Account: ROBERT RUBIN POA C/O ROBERT RUBIN Date Opened: 09/21/99 Type and Term: 12 MONTH FIXED TERM CD Balance: **Accrued Interest: Paid YTD: Current Balance: $ 11,017.01 $12.49 $ 567.18 $.00 Title of Account: THELMA F JONES Account Number: 68100408139164 DEBRA ADAMS Status of Account: ROBERT RUBIN POA C/O ROBERT RUBIN Date Opened: 09/21/99 Type and Term: 18 MONTH FIXED TERM CD Balance: -Accrued Interest: Paid YTD: Current Balance: $ 11,856.59 $ 10.34 $ 589.03 $.00 Title of Account: THELMA F JONES Account Number: 68100408139198 JAMES R ADAMS Status of Account: ROBERT RUBIN POA C/O ROBERT RUBIN Date Opened: 09/21/99 Type and Term: 18 MONTH FIXED TERM CD Balance: **Accrued Interest: Paid YTD: Current Balance: $ 29,049.31 $ 25.35 $ 1,443.15 $ 28,988.16 Title of Account: THELMA F JONES Account Number: 68100408139248 MARY LEE NYCUM Status of Account: ROBERT RUBIN POA C/O ROBERT RUBIN Date Opened: 09/21/99 Type and Term: 18 MONTH FIXED TERM CD Balance: **Accrued Interest: Paid YTD: Current Balance: $ 21,232.00 $ 18.53 $ 1,054.79 $.00 Title of Account: THELMA F JONES Account Number: 68100408375610 MICHAEL B RUBIN Status of Account: ROBERT A RUBIN POA C/O ROBERT RUBIN Date Opened: 12/17/99 Type and Term: 18 MONTH FIXED TERM CD Balance: **Accrued Interest: Paid YTO: Current Balance: $ 47,989.00 $ 69.62 $ 2,139.69 $ 48,872.50 ..Accrued Interest is not included in the Balance BankofAnlerlca ............. ....... Courtesy Summary/Balance Reporting for the Date of: 12/28/06 Page ~ Title of Account: THELMA F JONES Account Number: 68100409373911 ROBERT A RUBIN POA Status of Account: C/O ROBERT RUBIN Date Opened: 11/21/00 Type and Term: 18 MONTH FIXED TERM CD Balance: ** Accrued Interest: Paid YTD: Current Balance: $ 25,098.43 $ 26.35 $ 1,087.85 $.00 If more than one person's name appears in the titling of an account (without a fiduciary, beneficiary or other designation), the account is a joint account. Please see enclosed Deposit Agreement and Disclosures booklet. .. Accrued Interest is not included in the Balance , . AfJank MARION CENTER BANK, 501 MAIN ST., P. O. BOX 195, MARION CENTER, PA 15759-0195 . 800-556-6262 . FAX 724-397-0010 April 12, 2007 Robert A. Rubin 901 Pineview Drive Wester Chester, PA 19380 RE: Thelma F. Jones Dear Mr. Rubin: The following is the information you requested on accounts owned by Thelma F. Jones at Marion Center Bank: Checking #6001282 Opened 1-11-1988 Title: Thelma F. Jones Date of death balance: $556.90 This account was not an interest bearing account. Thelma F. Jones was the sole owner of the funds in this account. Ms. Jones received an automatic deposit from the US Treasury into this account. The above referenced account was the only account Ms. Jones had at our bank. Please feel free to contact me if you have any questions concerning this report. Very truly yours, . '-~ 't-l~~~--,. Melanie Lydic V"T~ Customer Service Representative II ~ MARION CENTER BIG RUN PUNXSUTAWNEY CLYMER WILLOW SPRINGS DAYTON I fPJP I 7?A_~07 t::e:o") 01,;( ..(1'7 "'''''C''"'f n. / ....""^ ........-. ~ Vanguard' April 14, 2007 P.O. Box 2600 Valley Forge. PA 19482-2600 www.vanguard.com ROBERT A RUBIN 901 PINEVIEW DR WEST CHESTER, PA 19380-1868 Prime Money Mkt Fund 09901800041 Dear Mr. Rubin: We are responding to your letter notifying us of the death of Thelma F Jones, and requesting a valuation of her above referenced Vanguard account. Your request to transfer the account to the estate and to liquidate the funds is complete and a confirmation has been sent. As of December 28, 2006, the number of shares, the price per share, the value of the fund, and the accrued dividends (if applicable) were as follows: Prime Money Mkt Fund 45,684.490 $1.00 Value Accrued Dividends $45,684.49 $175.056 .EYrn! Shares Price If you have any questions or need further assistance, please contact a member of our Transition Specialist Team at 1-888-237-9045. We are available Monday through Friday from 8 a.m. to 8 p.m., Eastern time. Sincerely, Transition Specialist Team jc 50834191 Vanguard Marketing Corporation, Distributor. FiIIeIIIy f'1n"""""". May 15, 2007 Robert Rubin 901 Pineview Drive West Chester, PA 19380 Dear Robert: In response to your request originally dated April 10, 2007, the following is a list of the information that you requested regarding the account for Thelma Jones. 1.) The title of the account is Thelma F. Jones Robert Rubin JT WROS And the account was established May 19, 1995 2.) The date the account was registered as ajoint account was May 19, 1995 3.) The balance at the date of death (December 28,2006) was $68,559.94 4.) There were no additional accounts for Thelma F. Jones on our system The other information that was requested on the original letter can be located on the statement. Enclosed is a copy of the year end statement from December 31, 2006. If you have any questions or require any additional information please feel free to contact us at 877-208-0098. iV~~ rnU/#W1tYL Lynn MacPherson Fidelity Investments Institutional Operations Company, Inc. P.O. Box 770002 Cincinnati, OH 45277-0085 1 "7S)'1 ~-:: 1(' Cal.culated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 12/2006 Total Value 15 377.60 Total Interest 9377.60 YTD Interest 597.60 Bonds: 1-3 of 3 . Issue Next Final Issue Int t Interest V I Serial # Series Denom eres a ue Note Date Accrual Maturity Price Rate . ..){J ~?~Z~ll;E:. ;... .I;E:. ...:$1 Q,9Q9 j Q4/J~~9 19.4l?99?] 94,gO?Ol. ..$?,QOQ. 90;... $?,.~4.f3' 00; . 4~()Q~/oj $~~, ~~fI~9.9.,...... ~,~9~.~.~~E??~E:,~..,!=.E:.....L..$.!1.QQ(UQ~I!~f3?jO~I.~90?j..9.w~.Ql?L....$~()Q.:Q.().L,$~L~~.4:f39~. .4:Q()~!o.i... $~,~~~~.'-.9..L ......... .~J.Q~.~.~~.~~.;E:.L. J~E:.....~...$,!l.QQ~E()~n~f3?,lQ~l~QQ.?i .QW2.,Q.1.?~ ....l~Q():QQ.t..$!(.!,~.4.: f3(), ..4:9QO!~.;... $~,.~1..~~.'-9..,. ....... Totals for 3 Bonds: 6 000.00: 9 377.60. : 15 377.60: Notes NI ! Not Issued "....~"...~" ...v~..t-..... ....... "....."..u"..".."..........~....""... VA ,." VA."""" ""..........,." ....." 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