HomeMy WebLinkAbout11-13-07
REV -1100 EX + 11-01)
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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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COMMONWEALTH OF PENNSYLVANIA I
DEPARTMENT OF REVENUE
DEPT. 280601 I
HARRISBURG. PA 17128-0801 I
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Williamson, Frank E.
OFFICiAL USE CNL Y
FILE NUMBER
21 07
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
0182
NUMBER
168-12-8966
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
6. Decedent Died Testate (Attach copy
of Will)
9. Litigation Proceeds Received
4a. Future Interest Compromise (date of death after
12-12-82)
7. Decedent Maintained a Living Trust (Attach
copy of Trust)
10. Spousal Poverty Credit (date of death between
o 3. Remainder Retum (date of death prior to 12-13-82)
o 5. Federal Estate Tax Retum Required
1 8. Total Number of Safe Deposit Boxes
4. Limited Estate
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IRM NAME (If applicable)
Law Offices of Susan E. Lederer
DATE OF DEATH (MNl-DD-YEAR)
DATE OF BIRTH (MM-DD-YEAR)
4811 Jonestown Road, Ste 226
Harrisburg, PA 17109
(1 )
(2)
(3)
(4)
(5)
(6)
(7)
177,000.00
34,270.10
None
None
477,512.92
None
133,565.48
02/11/2007
06/25/1920
(9)
(10)
32,901.08
12,172.49
(IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
1. Original Retum
2. Supplemental Retum
12. Net Value of Estate (Line 8 minus Line 11)
113. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
. made (Schedule J)
-t4. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15.Amount of Line 14 taxable at the spousal tax rate, x .00
or transfers under Sec. 9116(a)(1.2)
,
ELEPHONE NUMBER
717/652-7323
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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4. Mortgages & Notes Receivable (Schedule 0)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
1'10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
777,274.93 x .045
x .12
x .15
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OFFiCIAL~E: ONl.Y
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16,Amount of Line 14 taxable at lineal rate
17.Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
(-.~J
19. Tax Due
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(8)
822,348.50
(11 )
45,073.57
777,274.93
(12)
(13)
(14)
777,274.93
(15)
(16) 34,977.37
(17)
(18)
(19)
34,977.37
Copyright 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
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Decedent's Complete Address:
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STREET ADDRESS
10OClaremont Road
CITY
STATE PA
ZIP 17013
Carlisle
Tax Payments and Credits:
1. Tax Due (Page 1 line 19)
2. CredltslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1) 34,977.37
33,000.00
1,736.84
Total Credits (A + 8 + C) (2)
34,736.84
3. InterestIPenalty If applicable
D. Interest
E. Penalty
TotallnterestlPenalty (0 + E)
4. If line 2 is greater than line 1 + line 3, enter the difference. This is theOVERPAYMENT.
Check box on Page 1 Una 20 to request a refund
5. If line 1 + line 3 is greater than line 2, enter the difference. This Is theTAX DUE
A. Enter the interest on the tax due.
8. Enter the total of Line 5 + 5A. This is theBALANCE DUE
(3) 0.00
(4) --
(5) 240.53
(SA)
(58) 240.53
Make Check Payable to: REGISTER OF WILLS, AGENT
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PLEASE ANSWER THE FOLLOWING QUESnONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Old decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;............................................................................. ~ I
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d. receive the promise for life of either payments, benefits or care?...........................................................
2. If death occurred after Decerriler 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.
urIC_ pen8II/eI of perJwy. I declare thllll h8v8 exlmined ItIIa relUm, 1ncIu~ accomPlrlYinll IIChIdUIeI and _enta. .no to the best of my knowledge and belief. ft II true. correct .no complete. OecI8r81ion
aIher then Ie live is b8sed on III infonnation of which .. he. lI'1y .
SIGNATURE OF, SON RESPONSIBLE FOR FILING RETURN ADDRESS DATE
Fra E. iams Jr.
357 Old Stag,e Road
Lewisber I PA 17339
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DATE
ADDRESS
ADDRESS
DATE
11/'/07
4811 Jonestown Road, Ste 226
Harrisburg, PA 17109
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For da of death on r fter July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% (72 P.S. S9116 (a) (1.1) (i)l.
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse Is 0%
[72 P.S. fi9116 (a) (1.1) (i~l. The statutedoes not exemota transfer to a surviving spouse from tax, and the statutory requirements for disclosure
of assets and filing a tax return are stili applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate Imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% (72 P.S. fi9116 (a) (1.2)).
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. fi9116
1.2) (72 P.S. 59116 (a) (1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 59116 (a) (1.3)). A sibling is defined,
under Section 9102, as en individual who has at least one parent in common with the decedent, whether by blood or adoption.
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SCHEDULE A
REAL ESTATE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Williamson, Frank E.
FILE NUMBER
21 - 07 - 0182
All real propelW owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price
at which property would be exchanged between a willing buyer and a wining seller, neither being compelled to buy or sell, both having
reasonable I(nowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on
schedule F.
ITEM DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 House and Lot located at 2 Lantern Lane, Camp Hill, Pennsylvania, Parcel # 13-24-0807-137, 177,000.00
titled to Frank E. Williamson and Dorine C. Williamson (deceased) (settlement sheet attached)
TOTAL (Also enter on Line 1, Recapitulation) 177,000.00
. - .
*' SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Williamson, Frank E. 21 - 07 - 0182
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM DESCRIPTION UNIT VALUE VALUE AT DATE OF
NUMBER DEATH
1 343.1228 shares of The Southern Company, CUSIP No. 8492587107, titled 36.40 12,489.67
to Frank E. Williamson and Dorine C. Williamson (deceased) ($36.40/sh)
2 194 shares of Tyco International Ltd., CUSIP No. 902124106, titled to Frank 31.64 6,138.16
E. Williamson and Dorine C. Williamson (deceased) ($31.64/sh)
3 I 226.56627 shares ofVerizon Communications Inc., CUSIP No. 92343V104, 37.6825 8,537.58
I titled to Frank E. Williamson and Dorine C. Williamson (deceased)
($37.6825/sh)
4 135.399493 shares of Home Depot, CUSIP No. 437076102, titled to Frank E. 41.4025 5,605.88
Williamson and Dorine C. Williamson (deceased) ($41.4025/sh)
5 89.9375 shares of Dollar General, titled to Frank E. Williamson and Dorine C. i 16.665 , 1,498.81
Williamson (deceased) ($16.665/sh)
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TOTAL (Also enter on line 2, Recapitulation) 34,270.10
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SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMON'I'IEAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Williamson, Frank E.
FILE NUMBER
21-07-0182
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 Money Market held at Sovereign Bank, Account No. 0571107214, titled to Frank E. Williamson 304,276.19
or Dorine C. Williamson (deceased) (accrued interest $96.25)
2 Musselman Funeral Home and Cremation Services (prepaid funeral) 12,535.83
3 Coins in safe deposit box (appraised value) 131.55
4 Checking Account held at M&T Bank, Account No. 90617924, titled to Frank E. Williamson and 77 ,454.28
Dorine C. Williamson (deceased) (accrued interest $0.43)
5 1997 Saturn Sedan, titled to Dorine C. & Frank E. Williamson (sale price) 2,000.00
6 U.S. Savings Bonds (inventory attached) 66,067.76
7 check from Loyalton (refund of nursing home costs) 2,252.00
8 check from Tyco (pension payment) 1,251.17
9 check from Capital Blue Cross (health insurance refund) 136.40
10 check from Erie Insurance (auto insurance refund) 193.00
11 check from Erie Insurance (catastrophic insurance refund) 57.00
12 personal property 1,250.00
13 Commonwealth of PA (income tax refund) 380.00
14 US Treasury (income tax refund) 1,745.00
15 Riversource Life Insurance (refund of long term care insurance premium) 300.62
TOTAL (Also enter on Line 5, Recapitulation) 477,512.92
*' I
( -~ . SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY continued
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Williamson, Frank E. 21-07-0182
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM DESCRIPTION iVALUE AT DATE OF
NUMBER I DEATH
I
16 check from Cumberland County (nursing home refund) 7.130.00
17 I check from Erie Insurance (refund of home owners insurance) 72.00
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18 check from Pennsylvania American Water (refund of water bill) 14.00
19 check from AARP (health insurance refund) 266.12
Page 2 of Schedule E
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SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Williamson, Frank E.
FILE NUMBER
21-07-0182
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF EXCLUSION I TAXABLE VALUE
NUMBER Include the name of the transferee, their relationship to decedent VALUE OF ASSET DECO'S (IF APPLICABLE) .
and the date of transfer. Attach a copy of the deed for real estate. INTEREST
1 13,835.533 shares of RVS Large Cap Equity Fund, 22.898.13 100% - 22,898.13
Class A, CUSIP No. 76931 H866, held at Ameriprise
Financial Services, Account No. 010124088237002, I
titled to Frank E. Williamson TOO Frank E. Williamson,
Jr. ($5.97/NAV)
I 100%
2 IRA held at Ameriprise Financial Services, Account No.1 13,733.75 13,733.75
010135461159002, Frank E. Williamson, owner, Frank
E. Williamson, Jr., beneficiary
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3 Annuity held at Ameriprise Financial Services, Contract, 91,623.34 100% I I 91,623.34
No. 930015398157004, Frank E. Williamson, owner,
Frank E. Williamson, Jr., beneficiary
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4 Annuity held at Ameriprise Financial Services, Contract 5,310.26 100% 5,310.26
No. 930033396712004, Frank E. Williamson, owner,
Frank E. Williamson, Jr., beneficiary ,
TOTAL (Also enter on line 7, Recapitulation)
133,565.48
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCI-EDU.E H
RN:RAL.EXPENSES&
ADI\IMS1RATlVECOSlS
ESTATE OF Williamson, Frank E.
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
B.
1
FUNERAL EXPENSES:
Musselman Funeral Home and Cremation Services
DESCRIPTION
2
St. Theresa's Mercy Services (honorarium)
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Social Security Number(s) I EIN Number of Personal Representative(s):
FILE NUMBER
21-07-0182
AMOUNT
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
I Street Address
City
State
Zip
2.
Year(s) Commission paid
Attorney's Fees Law Offices of Susan E. Lederer
City
Relationship of Claimant to Decedent
4.
Probate Fees
Cumberland County
5. Accountant's Fees
6.
Tax Return Preparer's Fees
7. Other Administrative Costs
1
checks for estate account
State
Zip
Total of Continuation Schedule(s)
TOTAL (Also enter on line 9, Recapitulation)
10,373.55
150.00
7,200.00
302.00
8.94
14,866.59
32,901.08
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SchedUe H
FLI1eIaI Expenses &
M1i1dcdWe Costs conIinJed
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21 - 07 - 0182
ESTATE OF Williamson, Frank E.
2
Service Oil Company (heating bill)
870.65
3
PP&L (electric bill)
180.73
4
Register of Wills (additional short certificates)
40.00
5
Kelly Financial Services (income tax preparation)
369.75
6
Leggett's (repair of sewer line)
683.00
7
Environquest (radiation mitigation)
765.00
8
Saturn (car repair)
519.63
9
Choice Security
45.00
10
Pennsylvania American Water (water bill)
175.33
11
Lower Allen Township
87.50
12
Register of Wills (additional probate)
250.00
13 Real Estate Expenses (Items 14 -18)
14
Commission Paid at Settlement
8,850.00
15
Transaction fee to The Homestead Group, Inc.
100.00
16
Notary Fee to Community Land Transfer, LLC
5.00
17
Deed Preparation to Reager & Adler, PC
125.00
18
Realty Transfer Tax
1,770.00
19
Register of Wills (additional filing fees)
30.00
Page 2 of Schedule H
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SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Williamson, Frank E.
FILE NUMBER
21-07-0182
Include unreimbursed medical expenses.
ITEM DESCRIPTION
NUMBER AMOUNT
1 Capital Blue Cross (health insurance) 136.40
2 Tyco (return of pension funds) 1,251.17
3 AARP (health insurance) 192.08
4 Claremont Nursing and Rehab (nursing home bill) 7,286.17
5 Claremont Nursing and Rehab (nursing home bill) 2.362.00
6 Bonnie Miller, Tax Collector (real estate taxes) 771.35
7 Bonnie Miller, Tax Collector (personal tax) 9.80
8 Privacy Guard (credit card guard) 17.98
9 PP&L (electric bill) 39.98
10 Pennsylvania American Water (water bill) 26.62
11 Comcast (cable bill) 49.57
12 Verizon (phone bill) 29.37
TOTAL (Also enter on Line 10, Recapitulation) 12,172.49
REV-1513 EX+ (9-00) *'
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SCHEDULE J
COMMONWEAlTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF Williamson, Frank E. I FILE NUMBER
21-07-0182
RELATIONSHIP TO AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON{S) RECEIVING PROPERTY DECEDENT OF ESTATE
Do Not List Trustee(s)
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
1 ! Frank E. Williamson, Jr. Son 100% of estate &
357 Old Stage Road Ameriprise accounts
Lewisberry, PA 17339
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r Enter dollar amounts for distributions shown above on lines 15 through 18, as appropri ~te, on Rev 1500 cover sheE t
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
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I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
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TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE
Decedent's Complete Address:
· 'STREET ADDRESS
100 Claremont Road
CITY
I STATE PA
IZIP 17013
Carlisle
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
34,977.37
33,000.00
1,736.84
Total Credits (A + B + C) (2)
34,736.84
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is theOVERPA YMENT.
Check box on Page 1 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is theTAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is theBALANCE DUE
(3) 0.00
(4)
(5) 240.53
(5A)
(5B) 240.53
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;............................................................................. ~ I
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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?..........................................................................................n..................... D ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... D ~
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation?..............................n..........................................................n.................... ~ D
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penaKies of perjury, 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
preparer other than the parsonal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS
Frank E. Williamson, Jr.
DATE
357 Old Stage Road
Lewisberry, PA 17339
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN
ADDRESS
DATE
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
Amy M. Moya
ADDRESS
DATE
4811 Jonestown Road, Ste 226
Harrisburg, PA 17109
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. 99116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0%
[72 P.S. 99116 (a) (1.1) (ii)]. The statutedoes not exemota transfer to a surviving spouse from tax, and the statutory requirements for disclosure
of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P .5. 99116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 99116
1.2) [72 P.S. 99116 (a) (1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116 (a) (1.3)]. A sibling is defined,
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
P.Ul-cr-W.......ty IIoocI-8hort ll'orm--Act IS_Amonaeel for Photo-Recordlna
Henry Hall, Ino., IndIana, Pa.
tEbi~
1Beeb,
sLkd\J~ i\ <:L~ I
MADE THE .'J I~
of our Lord one thousand nine hundred
da1l of August
and Sixty-Slx (1966)
in the 1Iear
)
BETWEEN
CHARLES E. DRAKE and MARGARET B. DRAfE, bis ~if~ 12- :":'
: tS?""
~ f\) C ~~;
~. U.~ ( ;,-,~'} ;:;;
=:i-: ~t In If'
~::: L/'Q-.....::J ~
r- '" ,""-' '-'0 :::l
~~ ,.~~-" ~ ~
~ 'to: .:.. -i
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aJU
FRANK E. WILLIAMSON and DORINE C. WILLIAMSON, his wife,
and
Grantees :
WITNESSETH, that in conside1"lLtWn of TWENTY-EIGHT THOUSAND FIVE HUNDRED
($28,500.00) ------------------------------------___________ Dollars,
in hand paid, the receipt whereof is hereb1l acknowledged, the said gramt()rs do hereby grant
and convey to the said grantees, as tenants by the entireties,
ALL THAT CERTAIN lot or tract or land situate in the Township of
Lower Allen, County of Cumberland and State of Pennsylvania, more
particularly bounded and described as follows, to wit:
BEGINNING at the point of intersection of the northern line of Lantern
Lane and the line of adjoiner between Lots Nos. .88 and 89- on the here-
inafter mentioned Plan of Lots; thence north Twenty-Six (26) degrees
Forty-Two (42) minutes Sixteen W5) seeonds west by said line of ad-
joiner One Hundred Thirty-Four and Two One-Hundredths (134.02) feet
to a point; thence north Sixty-One (61) degrees Forty-Seven (47)
minutes east Ninety-Three and Seventy One~Hundredths (93.70) feet
to Lot No. 90; thence south Twenty-Nine (29) degrees Forty-Seven
(47) minutes Sixteen (16) seconds east One Hundred Thirty-Five and
Sixty-Three One-Hundredths (135.63) feet by the western line of Lot
No. 90 to a point on the northern line of Lantern Lane; thence in a
westerly direction by the northern line of Lantern Lane on a curve
to the left with a radius of Six Hundred Forty-Eight and Fourteen
One-Hundredths (648.14) feet for a distance of Thirty-Seven and Eleven
One-Hundredths (37.11) feet to a point; thence continuing by same
south Sixty-Three (63) degrees Seventeen (17) minutes Fourteen (14)
seconds west Sixty-Three and Eighty-Seven One-Hundredths (63.87) feet
to the point and Place of BEGINNING.
BEING Lot No. 89 on the Plan of Lots, Section No.4 of Allendale
which Plan is recorded in the Cumberland County Recorder's Office
in Plan Book 11, Page 30.
HAVING THEREON ERECTED a two story brick and aluminum siding dwelling
with attached one car garage.
BEING the same premises which Vernon E. Roberts and Nelle C. Roberts,
his wife, by deed dated October 18, 1963, and recorded. in the Cumberland
County Recorder's Office in Deed Book "A", Volume 21, Page. 386, granted
and conveyed unto Charles E. Drake and Margaret B. Drake, his wife,
Grantors herein.
UNDER AND SUBJECT to certain restrictions as now of record and a certain
Twenty (20) feet wide storm, water and sewer easement through which the
northern lot line passes.
BOOK C-,22PAGE ::;/2
AND the 8aid grantor8 hereby C01lenant and agree that they and each of them will warrant
\1 generally the properly hereby conveyed.
t~"T <;;\ ~ll:. fown\~IP of LCt.'lJER (::)l\.1:::1\J
COOlOl8f. Cumbo CO. PI. , \ Cumbo CO. Pa.
16. R.., Eshle TrlnSh.r ~l !3:!II' Eitlll Trln'f~r T~~ ,
~I~ "~f.JI~'I",~~"J" ,
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IN WITNESS WHEREOF, 8aid grantors have hereunoo Bet their hand sand 8eal s
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" ~
.' ,
State of
PENNSYLVANIA
tss.
day of August
, 19 66 , before me,
County of CUMBERLAND
On this, the IS Ad..
the undersigned officer, per80nally appeared
Charles E. Drake and Margaret B.
Drake, his wife,
known to me (or satisfactOrily proven) to be the person s whose name s are subscribe tr;i'
withi~ instrument, and a.cknotIJledged that they executed same for the ~f)~~~
contained. .,;1;' .c'.r.... .
IN WITNESS WHEREOF, I hereunto zet m~/ ,nd and officia~8eal. (~cr'~'
"~~" L~~'l';~t.
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Title of Offic
I do hereby certify that the precise residence and complete p08t office address
of the within named gro.ntee is ~ ?-.--r.v 7 $'-.1' y ~ 4,"~
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RECORDED on this ___.___:2.====:......_.. dillY of .-c. _', u.. "u....___~~,.
A. D. uhf,.. in the Recorder's office of the said County, in Deed B.ook C_-
Vol. ___.~~._.___. Page ....._;l.')~.
Given under my hand and th2~~:f2~~~ t
cordsr.
O. 2502-0265 on
A. B. TYPE OF LOAN:
U.S. DEPARTMENT OF HOUSING & URBAN DEVELOPMENT 1-OFHA 2-DFmHA 3.l!ICONV. UNINS. 4. OVA S. oCONV. INS.
6. FILE NUMBER: /7. LOAN NUMBER:
SETTLEMENT STATEMENT 07.162 40797290
8. MORTGAGE INS CASE NUMBER: a~'bMORTGAGE INS CASE NUMBER:
6.2SOIFI671.86
C. NOTE: This fotm is fumlshed to give )'Ou II statemenl of aclual Hlllamenl co.sts. Amounts paid 10 and by 1M selllllment agent IIT8 shown.
Items marked '[POCr IWIIlI paid outside 1M closing: /My IItlI shown hare for infOrmational purposes end IItlI nol includM! in ilia Iola/s.
1.0 :we SWl!ETJ!.PFOI07.te2/111
D. NAME AND AOORESS OF BORROWER: E. NAME AND ADDRESS OF SELLER: F. NAME AND ADDRESS OF LENDER:
Evenne B. Sweet Estate of Frank E. WOllamson Mortgagelt, Inc.
2 Lanlem Lane 2 Lantem Lane 33 Malden Lane, 6th Floor
Camp HIn, PA 17011 Camp HIli, PA 17011 New York, NY 10038
G. PROPERTY LOCATION: H. SETTLEMENT AGENT: 66-0510988 I. SETTLEMENT DATE:
2 Lanlem Lane Community Land Transfer, LLC
Camp Hill. PA 17011 June 25, 2007
Cumberland County, Pennsylvania PLACE OF SETTLEMENT
2331 MarIcel SlIeeI
Camp HPI, PA 17011
J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION
100. GROSS AMOUNT DUE FROM BORROWER: 400, GROSS AMOUNT DUE TO SELLER:
101. Contract Sales Price 177 000.00 401. Contract S.... Price 177 000.00
102. Personal Propar/y 402. Personal ProoerlY
103. Seltlement Chlllll8S to Borrower CUne14oo) 8,784.48 403.
104. 404.
105. 405.
Arllustments For Items Peld Bv Seller in acIItence Ad/ustments Far Items PtticI Bv Seller In IIdv8nca
106. CllvlTown Taxes to 406. ClhdTown Taxes to
107. Countv Taxes 06125107 to 01101108 409.72 407. CounlvTaxes 06125107 10 01101108 409.72
108. SchoolT_ 06/25107 to 07101107 28.69 408. School Taxa. lIeI251D7 10 07101107 28.69
109. S_fTrash 06I25ID710 07/01107 5.77 409. SawarfTrash 06125107 10 07/01107 5.77
110. 410.
1'1. 411.
112. 412.
120. GROSS AMOUNT DUE FROM BORROWER 186,228.67 420. GROSS AMOUNT DUE TO SELLER 177,444.18
200, AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SEl.LER;
201. Deooslt or earnesl money 1 000.00 501. Excess Oeoolft ISee InsIl'ucllClfll
202. PrinciDal Amounl 01 New Loanls I 141 500.00 502. Selllemenl Clwaa 10 Seller IUne 1400 10850.00
203. Exlstlno loan s taken subled 10 503. Exr.Unoloan I liken lubIed to
204; 504. Pllyolf of IIrst Morlgage
205. 5l1!!. pallOJl of lecond MOnallle
206. 508.
207. 507. IDeDOSlt dlsb. al oroceeds
208. 508.
209. 509.
Adluslmenls For Items UnIHlId Bv Seller Arlluslmants Far Ilems UnDa/d BIf Saller
210. CIlYfTown Taxes to 510. Cltwrown Ta_ to
211. County Taxes 10 511. County Taxe. to
212. School Taxes to 512. School Tws to
213. 513.
214. 514.
215. 515.
216. 518.
217. 517.
218. 518.
219. 519.
220. TOTAl. PAID BYIFOR BORROWER 142,600.00 520. roTAI. REDUCTION AMOUNT DUE SEI.LER 10,850.00
300. CASH AT SETTLEMENT FROMfTO BORROWER: 800, CASH AT SETTU!MENT TOIFROM SELLER:
301. Gross Amount Due FRl/11 Borrower CUne 1201 188 228.87 801. Groll Amount Due To Saller lUna 420 177 444.18
302. L8SI Amounl Paid BYfFor Borrower CUne 220) ( 142,600,001 802. leiS Redudlonl Due SeUer (Une 520) ( 10,850.00
303. CASH ( X FROM)( TO) BORROWER 43,628.87 603. CASH ( X TO)( FROM) SEllER 166,594.18
OMBN
"""
Se~~A
'.)
~~l
The Undersigned hereby acknowledge receipt of . completed copy of pages 1 &2 of this Itatement & any attachments referred to herein.
-- .~.bvri<gf~
Seller
BY:
L. SETTLEMENT CHARGES
700. TOTAL COMMISSION B..ed on Price $ 177,000.00 II!I 5.0000 % 8850.130 PAlO FROIoI PAtOFROM
uMsion of Commiaion l1HIe 700 u ,.OI/ows: IIORRO\"IatS SELLER'S
7131. $ 8,850.013 to THE I"1UMESTl:AD IOKOUP, INC. FUNOS AT FUNOS AT
7132. S to SETTLEMENT SETTLEMENT
7133. Commission Paid at Salllement 8,850.00
704. Transaction Fee to The Homeslead IOroup, Inc. 100.00 1130.00
8130. ITEMS PAYABLE IN CONNECTION WITH LOAN
8131. Loan Orlllinatlon Fee % to
8132. Loan Discount 1.??oo % to CODY FINANCIAL MORTGAGE SERVICES, INC. 1,418.00
803. ApDrlllsal Fee 10 uiv.rallled Aopralsal Services 300.00
804. Crad" Report to CuuY F NANCIAL MORTGAIOI: SEKVI\;ES, INC. 513.1313
805. Lander's Insoectlon Fee to
806. Mll/'lc.... Ins. Aoo. Fee 10
8137. Assumption Fee to
808. Tax Servfce Fee to Mortllall8lt, Inc. 89.00
809. Procaulng Fee to CODY FINANCIAL MORTGAGE SERVICES, Ne. 225.00
810. ...Ioad Cer1. Fee 10 Mortoa .1l,lne. 10.00
811. AdminIStration Fe. to Mortga ell,lnc. 800.130
812. WI" Fee to MorIga ell, Inc. 19.00
813. Yi.1d Spread Premium 10 CODY INANCIAL MORTGAGE SERVICES, INC. POC:l908.77 L.nder
814.
815.
818.
817.
818.
819.
820.
900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE
901.lnlerest From 06125107 10 07101107 CD $ 24.5833001day ( 8dllYl %1 147.513
902. Marla"'e Insurence Pram/umIat months 10
903. HlZlIrd Insurance Premium for 1.0 years to
904.
!lO5.
10013. RESERVES DEPOSITED WITH LENDER
10131. Huard Insurance 3.1300 months S 59.17 allt' month 177.51
1002. Mll/'lc".lnsurance months s allt' month
1003. CitvfTown Taxes months $ oar month
1004. Counlv Taxes 5.000 months $ 84 .28 Oef month 321.413
1005. School Taxes 14.1300 months $ 142.52 per month 1,995.28
1006. months S oer month
1007. m nths ~ o.r month
1008. Aooreoate Adiustment months S oar month -517.95
11130. TITLE CHARGES
1101. Settlement or Closlno Fee to
1102. Abstract or TiUeSearch to
1103. Tille Examination to
1104. Tille Insurance Binder 10
11135. Eledronlc Oocument Prep. to Community Land Transfer LLC 513.00
1106. Clastrla S.rvice Leiler 10 CommunitY Land Transfer LLC 35.00
11137. Attorney's Fees 10
Includes abolllf fem numbers: I
1108. TIll I r o COUMUNITY LAND TRANSFER 1.243.75
(1ncJur1u abOIllf ilem numbers.llD2. 11133 & 1104
11139. Lender's Coverage $ 141,1300.00
1110. Owner's coveralle S 177,1300.00 1,243.75
11 1 1.~Endors.menls 100, 300, 8.1 10 Community Land ransfer, LLC 150.00
11 12. Notary Fee to CommunI Land Transfer 113.00
1113. Nolary Fee to Communi Land Transfer 5.013
1 114. Ovemlaht Fees & Handllno to Communi Land Trans .r, LL(; 15.00
1115. wire Fee to \;ommuni Land Transfer, LLC 113.00
1118. Deed Prep. 10 Re.ger & Adler, PC 125.00
1117.
1118.
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
12131. R.cordlno F.es: Deed S 38.50; Mortgage $ 84.513; Releases $ 103.00
1202. CltvlCounlv TaxlStam"l: Deed 1 7713.1313' Mortollle 1 770.00
12133. Slale TaxlSla""'s; Deed 1 7713.1313: Mortaao. 1 7713.013
1204.
1205.
13013. ADDmONAL SETTLEMENT CHARGES
1301. Survev to
13132. Pest Insoectlon 10
1303. Home Warranty 10 AHS 485.00
1304.
1305.
1400. TOTAL SETTLEMENT CHARGES (Enter on L1n.. 1133, S.cllon J and 502, Section Kl / 8,784.49 113,850.00
By Iigning page 1 GIN .......... the lIOn...... ~ '0CINpI of. compIeIed CGPt' ol.-ve 2 of IhIIIwD pege ......... II/,ei----
Cornmunlly Land Transfer,..LLC\/
1"'101.t.
Certifllld to be a true copy.
Selllemenl Agent
I01.~/07.'62J 17)
SOUTHERN A
COMPANY
/;'.,'0 tIJ Sit,,,, J..",. WorU'
0;0&.&1:111...:,." v, ,",w..ttnllllp
BVUal1
Stockholder Services
P.O. Box 54250
Atlanta, GA 30308-0250
BV COW'ler
Stockholder Servlc:esl11th Floor
30 Ivan Allen Jr, Blvd. NW
Atlanta, GA 3000e
Account Number
Account Statement
570893
2006
Sck~()
:.;)
11111111111111111111111111'"111'111,..1..11"11111111.1.1.1,1 ....r--_,\ ~ ''V'\, 1
FRANK E WILLIAMSON ~~ ,
& DORINE C WILLIAMSON JT TEN
2 LANTERN LANE
CAMP HILL PA 17011-8456
SO
11/06/06
12/16/06
$0.3875
536.9725
842587117
12/51/15 IALANCE fORWARD 325 . 6258
'3/13/16 CERTIfICATE SHARES DIVS IEINY 57.25 33.6236 1.U8. 326.7345
'3/13/1' PLAN SHAlES DIVS REIMY 84.15 53.6236 2.50l! 329.2315
06/12/06 CERTIfICATE SHAlES DIVS IEINY 38.75 52.3'11 1.1911 330 .4536 I
16/12/06 PLAN SHAleS DIVS ItIINV 88.13 32.3U8 2.7466 533.1802
09/12/16 CERTIFICATe slIMes DIVS IEINY 38.75 34.0648 1.1382 334.3184
19/12/16 PLAN SHARlS DIYS REINV 90.36 34 . 0648 2.6541 336. 9725
12/06/.6 CERTIfICATE SHARES 'DIVS IEINY 38.75 36.51'0 1.0593 338 . ani
12/16/06 PLAN SHAlES DIVS REIMY 91.83 36.58'0 2.5104 340.5422
. If SALE, price p8r share InclUdes $.02 broker commission and $.04 service tee paid by stockholder (seller).
· If PURCHASED on the open market, price per share Includes $.02 broker commission paid by company.
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12/29/06 lOt ...... 240.5422 340.5422 136.1600
~jb.;~:m~m~:::';:~~~;::!i;'!:mli'..~::,:'ijI:~~~!':."~J.i!!'''j:"iier:i.:'t~;:~~~~~!~~::;J:,::,::'';~'':r,:~~i~::bY:~\"
12/2'/06 ".00 85'..57 to.OO 88.21
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112,.552.59
Y"'!:.!~;~is..:'
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80."
Important Tax Return Document Attached - Form 1099-DIV Below
;.. IRS 2001 1040/1040A In.trvatlon. for Une Ib to .....rmllllll' dlYldMd. ...pal'tH In B0Il1b 0' 108lDIY .... eligible for I_r lex ...t..
PAYER'S -, .tr..t addr..., c ty, .~t., ZIP oocIe, Md ulephone no. 1. To~l ordinary 0lIl No. 1545-011
Southern CoIIp...y dlvidMd8 2006
241 Ralph 1tc8111 11vd 81n SC1100 8518.78 Form 1099-DIV
Atl...t., 8A 30388-3374 1.800.554-7126
RECIPIENT'S _. _ Addres. 1b II\IIIUfl.d PAYER'S F.....l
dividend. Id..,t. __...
$508. 7. 58-0690170
FRANK E WILLIAMSON 4. FederaJ Ineome RECIPIENT'S
& DORINE C WILLIAMSON JT TEN Tax Withheld Iclent. ~r
2 LANTERN LANE ....0 1'.128966
CAMP HILL PA 17011-8456
Dividends and
Distributions
Copy B
Far Recipient
Th'. ,. Importanl tlIx
'n'orm.t'on .nd I.
belllll fuml.hed 10
lhe Int.m.1 R_nue
SWVlllL I' you ....
lWIul..... to III e a
return. . negll..nc.
JIIInal~ or other
..nclion m.y bII
U:;:o,~:,,:~ y:u "
taxabl. .nd Ih. IRS
detllnn'n.. thelll
ha. not bIIen reported.
Form
KHp far your records Account No. 570893 1099-DIV
l.lructlon. 10 Raciplenbl: 8..'......... _I ""'-, dlvltIeftH 1hat _ _.. Incl.... tIIla _nt Oft II.. .. of Form 1040 or 1_ Also, ..pon h Oft SchWut. B CForm 10401 or ,......u1. 1 (Form
_I, If .....uirH. S.. 111. 1m-,... portion 01",. .llIOwlllln box 1.1hat IMI" lie .U,'III. lor"" 15" or 5" ..,.. 101........ Soo tho Form 1040 /1040A inotructio... lor _10 detIormi.. lhi. .moun!.
_n,... ellalbl. .....1llIl on line III, Form 1610 or 104GA. 8.. 4. 1m- llackllp wltIllloldlno. For .-'., . ,oyer _ hckup witIthold on c.rtoIn _'* ot. 21% .... ir_ did not II.. your
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-.. .. Ill. w_d. N_1nooo. If - ........ Incl.... .mou.... hlDnoino 10 .........r _n, you Ire conoid.rod . 110mb.. ..clpi.nt. Vou _ iii. Form lOll-DIU with tho IRS 10, _h of tho othe,
.......10 .how tholr ..... of lIMo I.......... - _ - fllml", . Form I_DIU 10 _h. A h......... or wi... I. not ......,rod 10 fill . noml.... _n 10 ._ MlOU'* _ by tho other.
I. ,... zooa G...roIlllOtn1cti..... Ibr Forme 10lIl, 1011, S41t, .... W'2G. Ac_ _. Im-.n occ_ numbo"" ~r _Itnod 10 dloll""u/.h your _Olllll.
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Wednesday, October 10, 2007, 4:18PM ET - U.S. Markets closed.
(~Q~~~) Symbol Lookup
Southern Co. (SO)
liD "'.IU11tAD.
iRAO!: FREE FOR
30 DAYS + GET$100
Q8..... ......A
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Finance Search
At 3:58PM ET: 36.77 ~ 0.42 (1.13%)
O f,"].j., (~"'i 11+.'"
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SET DATE RANGE
Get Historical Prices for:
IGol
Start Date: Feb
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Eg. Jan 1,
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Get Prices
First I Prev I Next I Last
PRICES
Date Open High Low Close Volume Adj
Close*
12-Feb-07 36.39 36.56 36.20 36.26 2,134,400 35.46
9-Feb-07 36.44 36.70 36.14 36.39 3,494,400 35.59
* Close price adjusted for dividends and splits.
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Dow'" 0.61% Nasdaq 't 0.27%
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Finance Search
Tyco International Ltd. (TYC)
[19~t ~
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I. Fidelity
At 4:02PM ET: 46.20 't 0.63 (1.38%)
Historical Prices
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Start Date: Feb
End Date: Feb
2007
Eg. Jan 1,
2003
(!) Daily
() Weekly
() Monthly
() Dividends Only
Sc k.c&.vCt..,/!5
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First I Prev I Next I Last
PRICES
Date Open High Low Close Volume Adj
Close.
12-Feb-07 31.49 31.88 31.46 31.86 1,656,500 107.03
9-Feb-07 31.80 31.81 31.41 31.48 1,622,100 105.76
· Close price adjusted for dividends and splits.
First I Prev I Next I Last
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10/10/2007
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Verizon Communications Inc. (VZ)
Active Traders.
I. Fidelit}f
At 2:10PM ET: 37.34 ..
f5.05~
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IGOI
SET DATE RANGE
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End Date:
2007
2007
Eg. Jan 1,
2003
(!) Daily
() Weekly
() Monthly
() Dividends Only
Start Date:
Get Prices
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PRICES
Your World..
Date
Open
High
Low
Close
Volume
Adj
Close*
STREAMING NEWS 100%
12-Feb-07
9-Feb-07
37.70
37.99
37.88
38.10
37.38
37.37
37.57 6,345,600
37.70 7,829,600
37.17
37.30
* Close price adjusted for dividends and splits.
First I Prey I Next I Last
~ Download To SDreadsheet
S!l Add to Portfolio tt Set Alert i'ii:l Email to a Friend
http://finance.yahoo.comlqlhp?s=VZ&a=O 1 &b=9&c=2007 &d=O 1 &e= 12&f=2007 &g=d
4/11/2007
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Dow ... 0.72% Nasdaq.... 0.730/0
Wednesday, Aprllll, 2007, 2:31PM ET - U.S. Markets close in 1 ho
Enter Symbol(s)
Symbol Lookup
Finance Search
The Home Depot, Inc (HD)
01-,'<:h :;"'Lllt2c
i, Fidsli~
[~;r~RH S[[URITIE5
Historical Prices
IGOI
SET DATE RANGE
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ADVERTISEMENT
Start Date: Feb
End Date: Feb
Eg. Jan 1,
2003
(!) Daily
() Weekly
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() Dividends Only
Get Prices
First I Prey I Next I Last
PRICES
Date Open High Low Close Volume Adj
Close*
12-Feb-07 41.62 42.01 41.27 41.44 18,480,700 41.20
9-Feb-07 41.22 41.42 40.91 41.00 9,320,000 40.76
* Close price adjusted for dividends and splits.
First I Prey I Next I Last
~ Download To Soreadsheet
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http://tinance.yahoo.com/q/hp?s=HD&a=O 1 &b=9&c=2007 &d=O l&e= 12&f=2007 &g=d
4/11/2007
SAVE THIS STATEMENT FOR TAX PURPOSES
Investment Plan Statement for Shareholders of 3890
. 5c~vLL~~.~S
DOLLAR
GENERAL.
00_.
If you have any questions regarding your
account, please contact Investor Relations at
1-800-368-5948 or at info@rtco.com.
Internet: rtco.com
FRANK E WILLIAMSON &
DORINE C WILLIAMSON JT TEN
2 LANTERN LANE
CAMP HILL PA 17011 8456
04 07 DIIa: 01 18 07 ~
RECORD [WE SfMRES ENROlLED If fEtNES1MENT
CertiIIcate and Soc* _ PIIn ShINe AllrMeb....1l
89.6819 89.6819
Issue#
3890
Account#
3202445008
Stock Symbol
DG
an: FULL REINVESTMENT
Amcult WIhheId Ram ~ HIlI Amount
Groa 1U,
$4.48
Date Descripllon , Fees IIIldIar Net DoI.~ == 'It8naaCiIii1 Total
Com Sh.-.. Shares in Plan
Balance Fornrd 89.6819
01/18 SHARES PURCHASED / DIV. $4.48 17.530000 0~2556 89.9375
. . ..
0.05000
Veer- To-D8te Investment Sum
Total TIIX ~
DIvidendI(S) WIIhheId($) IlMIItl._O(S)
$4.48
IU1d Market Value
CerIifIc8te Sh8ru Book Shares Plan Sh....
89;9375
$4.48
Feee IIM'or ComrnIIIIIanI TIIll FI8parIIbIe ~ PIId
PaId by 'Ibu(S) Feea IIM'or CommIaIona($)
Total
ACCESS YOUR.ACCOUNT ONUNEI
You can access and manage your account online through the Registrar and Transfer Company website. To login simply go to
www-rtco.com and click on "Online Services- to apply for a User ID and password. iP!!h
FRANK E WILLIAMSON & 'D'ansaction Form II!:!I
DORINE C WILLIAMSON JT TEN
2 LANTERN LANE P8rtIIII WIIhdr-.I ContInue Plan I*lIcIpIIIlon
CAMP HILL PA 17011 8456 ""acertlllcatetor I I
lhII ..... oIlharM
(PIeae ~ 85.00 1M)
SeIJ thIa runblIr 0""_ I I
~'~" be dalct8d
Total Sh....
89.9375
OPtional Investment
Make check payable to:
Registrar and 'D'ansfer Company
Amount enc:Ioeed In U.S. Dollars: I
Your 0ptI0nM cah InvMbnent
cen be . IIIIIXImum or $7.soo.oo per month
Full WIthdrawal T8rmN18 PIIn P8I1IclpeIlon
O ..... a oertIIIOlIIe for aI full shanta and
. check tor fIIIClIanIII 8h8I88
(PIeae IncIucIe ..00 1M)
O Sell all PIlIn sharlI8
(A $10.00 -... be deductId!ram IlRlI*daI
Price .)
17.530000
DOLLA"
--
-
Issuet: Acc:ouribJ:
3890 3202445008
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DO: Historical Prices for DOLLAR OENERAL'CP - Yahoo! Finance
Page 1 of2
~~5iJ
Dow.... 0.74% Nasdaq'" 0.74%
s~LG9_ SL*- ~J
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Wednesday, April 11, 2007, 2:33PM ET - U.S. Markets close In 1 ho
Enter Symbol(s)
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Symbol Lookup
Dollar General Corp. (DG)
liD AMEIIITRADE
A<..1lve Traders
2 Fidelity
iE*TRACE
~F . NAN c: I A L:
..~'_.,--,-~-<~..._.~,,_.._,_...._~~.
- -
- -
i TRADE FREE FOR i
4!5 DAYS -to ccr S 100 r
Historical Prices
Finance Search
At 2:12PM ET: 21.15 ....
IGol
SET DATE RANGE
Get Historical Prices for:
ADVERTISEMENT
Eg. Jan 1,
2003
(!) Daily
C) Weekly
C) Monthly
C) Dividends Only
Start Date:
End Date: Feb
Get Prices
First I Prey I Next I Last
PRICES
Date Open High Low Close Volume Adj
Close*
12-Feb-07 16.54 16.79 16.38 16.71 2,084,500 16.67
9-Feb-07 16.90 17.00 16.49 16.54 2,790,600 16.50
* Close price adjusted for dividends and splits.
First I Prey I Next I Last
~ Download To Spreadsheet
~ Add to Portfolio 'a Set Alert G Email to a Friend
http://finance.yahoo.comlqlhp?s=DG&a=01&b=9&c=2007&d=01 &e= 12&f=2007 &g=d
4/11/2007
" '
5c ~clu lL E. /' <1:.. 4e- '1rVl 1
Sovereign Bank
ESTATE OF
SOCIAL SECURITY.#:
DATE OF DEATH:
FrankE. Williamson
'. 168-12-8966
February 11,2007
Account #: 0571107214 Type:. MM Savings
In the name of: Frank E Williamson or Dorine C Williamson
Date of~eath Balance: $304,179.94
Int.(YTD) from 1/1/2007 to 1/31/2007
Accrued interest to date of death: $96.25
Other Info:
Open date: 6/15/1999
$271.02
Page 1 of 1
SECURCHOICE
. NOH NEGOTIABLE
I
UniChoice Coo~rati ve, Inc.
7441 Allent~t81vd'
Harrisburg PA '7112
From the Prepai Funeral Tntat for 'the benefit of Frank E. Williamson
Account: 88699b04 February 22, 2007
I
S::J"",_cl~E ~ '"1" ~..V>-"\ :l.
533S
$ ***12,535.83
Musselrren funeral Home & Cremation
Services i1nc. .
324 H~l Avenue
Lemoyne p. 17043
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PNC BANK, N.A.
NORTHWEST PA 010
eo.73-433
7441
PAY
TO THE
ORDER
I OF
;;
i
FIVE HUNDRED THIRTY FIVE AND 83/100 **********************************1
DATE AMOUNT
February 22, 2007 $ ***12,535.83
Musselman eral Hare & Cremation
Services~ Inc.
324 H'l.Il'rtI'C:2 Avenue
Lerroyne P 17043
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Phone (888)502-4349
Fax (302) 934-2955
March 27, 2007
499 Mitchell Road, MiIIsboro, DE 19966 Mail Code DE-MB-12
Susan E Lederer
Law Office
4811 Jonestown Road
Suite 226
Harrisburg, Pennsylvania 17109
Re: Estate of: Frank E Williamson
Social Security: 168-12-8966
Date of Death: February 11.2007
Dear Sir or Madam:
Per your inquiry dated March 20, 2007, please be advised that at the time of death, the above-named decedent had on
deposit with this bank the following:
1.
Type of Account
Checking Account
Account Number
90617924
Ownership (Names of)
Dorine C Williamson *
Frank E Williamson *
Opening Date
08/28/64
Balance on Date of Death
$77,454.28
Accrued Interest
$
0.43
Total
'~---M__--_M__-_M____M__M___________'__________M_______________.._____________
$77,454.71
.------------------------------------------..-------------------------------
Please be advised, there ~'3S no safe deposit box fOWld fer the abo...;e decedent.
* For further account information, regarding ownership, closures and/or reimbursement of funds, etc., please caD
the Highland Park Office # 717-737-3322.
Sincerely,
-~;7.~~r.
Nancy Clagett
Records Management
- -- - - \.... -VVJ
COll1ll'lOnwelUlh at Pennsy/vInja
.DIIPartment .afT~on
Bureau of MotorVehldes
Harriaburg, F'A 17104-2518
MOTOR- VEHICLE VERIFICATION
OF FAIR MARKET VALUE BY
THE ISSUING AGENT.
5~~vlt. .~
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This form is used in conjUl:Jction With Forms MV-i, MV-4ST,
MV-217Aand an on-line rocessin Iicant Summa Statement.
TYPe OR PRINT ALL1NFORMAnON AS REQUESTED
FOR DEPMTMENT USE ONLY
McldII .
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PRICE: c:? , '00::). II 0
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E SEAL AND SIGNATURE OF SEl.LER ~ NOT REQUraso FOR VEHICLES PURCHASED OUT-OF-STATE
SUBSCR/SED AND /MIa *-thltJiwlt.l1av8 lad 8lId signed tI1lsfcrm ltI8rilll canpletlan,IUlCH/we
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Invoice #
01302
Creekview
Vendor # 192WI2
02/16/07 NO: 578340
Inv.Date Description GL Account #
12/10/06 Rent Refund 2130-
VoUcher-##
254075-01
TOTAL
Amount to Pay
2,252.00
2,252.00
Schutu LL ~
~ Vl-L .,
p
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TO. THE:
. ORDER
OF
..-..---..----...... ...----h..----------------..--__.___________.h.___________--...---------.-..h.._h...__.._____......._..
II' S?8 31..011' ':0 Ii 2 liD I.. 5 5 I..: ~ 50080 ~8 5 2 ~Oll'
]'Iease send all correspondence to:
~ TYCO PENSION SERVICE CENTER-
TYCO ELECTRONICS
· POBOX 8250
ROlLING MEADOWS IL 60008-8250
1-888-859-8097
S~dJLe..6.J
d,~~ ~
Earnin~s Statement
Payable Dale: 12-01-2004
Refll: 000013466
ID II: TYC()03043
Plan: 1873rrYR
OOOOOl21n Ill73-TYR-04AN1SSA
On the reverse side of tbis document, you will find:
- Electronic Deposit Authorization Fonn
- Address Correction Fonn
- Important Federal Tu Election Notice
FRANK E WILLIAMSON
2 LANTERN LN
CAMP HILL PA 17011-8456
iiiii
"""""'"
-=--
=
-
-
:Y~~~~:';:L~:~~;~.ltj!~;;:~~k!tfls1:~:~:>rt~~'~~~6a;'~1;:l[::~:b;:;"~c~~~t(b1J.~t~::~
BENEFIT 117.31 1 ,407.72
BENEFIT 1,198.80 14,385.60
;Lij~ijti~9~)t;;~;~~.~~v:'~;i,j1~(~21;D,!;~j!~s::~~ppd~~~f~~E:'" ';::;:~'e~r:..t04jjatc::i;:
FEDERAL 58.20 698.40
Federal Tax Election Form (please complete only one ofthefollowi7lg)
1) 0 I do not want Federal income tax withheld from my payment,
2) 0 I want to have Federal income tax withheld from my payment
based on the elections I have indicated below:
o Single 0 Married II of Exemptions _
Additional Amount Withheld $
Under PDUlltia (if perjury, I CIfTtijj1 thtlt I /11ft tmtitled to the abo.,e eIectiolU.
Requests for ftat doDar amo_t witbhoIdinC. or any election options that are
not couistent with those wbic:h are stated on this fonn will not be proc:essed.
P A State Tax Election Form (please complete only one of the following)
1) 0 I do nol want State income tax withheld from my payment
2) 0 1 want to have State income tax withheld from my
payment based at a rate 01'3.07% per pay period.
Additional Amount Withheld $
Undo penalties of perjury, I certifY tlltlt J am etlJitled to tile above elections.
Required Signature
Rejfl: 000013466/J873ffYR
Date
Current Federal Withholding Elections Current PA State Withholding Elections
Married 0 Exemption(s) No Withholding
,..... ,/,,, ~"'.. . "". '-' ':o' .nto: lNTERN~rlaN"AL l.:TD:'. ;':::>;" "",:"":,,,""'" ..,....Pl'iYmentN'umber.;'.U\tt7997li3.6.' <'.""",.,\ '/"''':''''''''
\{ l:~ i" "Ie ,'t,~~~N~'fE:'!"r,,~tij/>"i'2:l f(i:~;~~~]i~~i'Y;f~ r";
. ",."; ..' ." "-", ,.;:.. . 1$'~~:7';257;9LF.
=
=
.:-
-
l5
:
=
-==
FRANK E WILUAMSON
Your deposit was sent to:
Account Type: Checking Account #: **-*******-**7924 Amount: 1,257.91
The NonbemTNll Ccmpoay
Cbicaao. n. enl 0
Non Negotiable
=
==
=
· + Capital BlueCross
~~
m
5CJhul~ E;
./
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CHECK NUMBER:
30012847
GROUP I SUBGROUP 10:
00900001 _
03/06/07
FRANK E WILLIAMSON
C/O THE ESTATE OF FRANKE. WILLIAMSON
357 OLD STAGE RD.
LEWISBERRY, PA 17339-9563
...... Explanation Of Refund ......
Refund Reason : Subscriber Deceased-FrankE. WfIIlamson-800308656
Total Refund Amount:
$136.4C
Heallh care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, CapitsJ Advantage Insurance Compan~ and Keystone Health Plan" Central. Independenllicensees 01 the Biue Cros.
and Blue Shield .A9SOCiiilfOn.co-rnmlll'l1&:IftlIlS'1UUed by Call1t8t"8l11ElCrcsrln llScapactty-as-adminlstnltor of .........'a, ,.. end ~""~.~-a~l"" ..._..
.' ....,.".,:.,~;.-~;..;.,.. .
NF -49 (512005)
':"1
------...--...--.-.-.-.-
,!I ERIE INSURANCE GROUP
~ 100 Ene Ins, PI . Ene. PA 16530 ..:$c... h.t. ~ v~ G
EffiE. J
4-~ Vv"\ Il
NOTICE OF PREMIUM REFUND
'-if:..
OP'64G '10'
DATE
MO.\ DAY\Y.R.
03 21 07
REFUND AMOUNT $57 _ 00
POUCY NUMBER Q33 2050140 H
AGENT NO. AA7631
AGENT'S NAME CONSUMERS INS AGY
REASON 1
REF. NO. X366512
CHECK NO. 24366512
FRANK E WILLIAMSON
2 LANTERN LN
CAMP HILL PA 17011
AA7631
NON-NEGOTIABLE
_.__.._..- -- ----- -"~--~"".- - --
CODE
REASON Ill... n
C~~K" l..U
Premium Refund Oultto .
CacIe , . Policy c.nc.l1ed
Cacle2 . Policy ExilIted .
Cacle3 -Premium ReduCtIon
COde.4 . OverpaYf'll'lll'
1I.2"'~bb5~21t. I:Ob~~~2'jl881: ~2Ci CiCiCi b5~"'lt.
. ,
RiverSource Life Insurance Company
70100 Ameriprise Financial Center
Minneapolis MN 55474
An Ameriprise Financial company
Sc~v<.c E~ ~. k.., I S-
March 06, 2007
Claim Number :
Policy Number:
369168
9100-2384842
FRANK E WILLIAMSON
FRANK E WILLIAMSON JR
357 OLD STAGE ROAD
LEWISBERRY PA 17339-9563
DEAR FRANK E WILLIAMSON JR:
Please accept our condolences.
The attached check for $300.62 represents the death benefits due you under
this contract.
._--_..._'.._~-~.. '---. ._,". "'-
Premium:
Total payment:
$300.62
$300.62
If you have questions, please contact our office at the telephone number
below. Our associates are available to assist you Monday through Friday from
8 a.m to 5 p.m. Central t-ime.
Thank you,
RiverSource Life Claims
(888) 320-8741
'lI8ur._ .nd annuit.. er. iuuld by RiwrSource Wf. '''UrMea Coll'lplny rRivarSourc. Lila') an Amaripri. Fi......cl.1 company_ RlwrSourca Lif. alao IClI .. principal
in tile .... .ncI dil1ributlon of ita variabl. ..null)' COIllr_ IncI .,.ri.bl. life 1__ pollcla_ oa..r inforllll1ion ....rdln. ._utlon of IIla Ir.n.action IftCludln.
,he "_ of IIla '....lCtion will b. providlll ..pon wrllllln ....lIIIIt.
Detach And Retain For Your Records
OGL-LSlI04O 1D1120l17)
II- 6. 2 2 Ii ... a Ii .1'- .-: 0 Ii . Ii 0 0 ... b 51: 0000 2 2 ~ a *"_
Sc-~J vlL 6 v -::t~ h, I "
19826 THE ESTATE OF FRANK WILLIAMSON
-...u.s._NO.IIII2IO._......'a._._....
CHECK NUMBER 667613 DATE 06/08/07
INVOICE NUMBER DATE DESCRIPTION GROSS AMT. DISCOUNT NET AMOUNT
4864 PPRD REFUND 03/16/07 REFUND TO ESTAT 7130.00 0.00 7130.00
t! tAtM.-~ tJ~ Il
......
..- -....-...-.... ....-.-.......--........... ..~
County of Cumberland I TOTALS 7130.00 0.00 7130.00
PLEASE ADDRESS ANY CDRRESPONDENCl! REOARDINO THIS VOUCHER OR TRANSACTION TO THE OPPICE OP THE CONTROLLER. CUMBERLAND COUNTY COURT HOUSE. CARUSLE. PA. 17013.
---------.-.--------
. ,
" EriE! Insurance
~ Group
100 E"e Ins PI. . E"e. PA 16530 Sc:.,. ~ V~ G-
. ~
<J:~~ \1
NOTICE OF PREMIUM REFUND
DP1G4G 1/01
DATE
MO., DAYIYR.
07 02 07
FRANK E WILLIAMSON
C/O FRANK E WILLIAMS, EXECUTOR
357 OLD STAGE RD
LEWISBERRY PA 17339
AA7803
REFUND AMOUNT $ 72 . 00
POUCY NUMBER Q57 0104805 H
AGENT NO. AA7803
AGENT'S NAME CONSUMERS INS AGY
REASON 1
REF. NO. X597522
CHECK NO. 24597522
NON-NEGOTIABLE
I EriE! Insurance
Group
100 Erie Ins, PI. . Erie,PA 16530
.., "
'VOiD;tSG:,D:A.YSiJliFTER".DA'TE"
POSITIVE PAY PROTECTED
PAY
TO
THE
ORDER
OF
FRANK E WILLIAMSON
C/O FRANK E WILLIAMS,
357 OLD STAGE RD
LEWISBERRY PA 17339
Bank of America CuslomerConnection 64-1278
Bank of America. NA " " --a11
Atlanta, Dekalb County. Georgia
DATE CHECK NO. 24597522
MO./DAY/YR.
07 02 07
EXECUTOR
CODE
REASON ... n
C~~~K r L.!J
Premium Refund Due to
Code 1 . Policy CIII1CafIad
Code 2 . PolIcY Explrlld
Code 3 . Pramlum RlIducIIon
Code 4 . Overpayment
POUCY NUMBER AGENT
Q57 0104805 H AA7803
REF. NO.
X597522
EXACTLY *****72 DOLLARS AND 00 CENTS
$72.001
fAllecwm., _turn
UJ~~- back.
f>~ ~. ~-
, , " AUTHORIZED SIGNATURE
II. 2 It 5 t1 ? 5 2 2 II. I: 0 b . . . 2 ? a a I: 3 2 t1 t1 t1 t1 b 5 . Itu.
ClULI~1. 1\,;i:lU "" aler
PO Box 5600
Cherry Hill, NJ 08034
· INVOICE NO.
0629769
0629769
AlP Phone 1-866-777-8426 (Opt. 2,0,1,2)
COMPANY NO./NAME REMARKS
24 Pennsylvania AWW CREDIT REFUND
24 Pennsylvania AWW CREJ::)IT REFUND
Check No. - 74174394
Check Date - 07/30/07
Stub 1 of 1
INVOICE AMOUNT
9.00
5.00
-----------
S~J0Ll ~
~ ~ L'{
14.00
50361518 Frank E Williamson
Camp Hill, PA 17011
jllIl"'.i<.:l'''''''II-''''",,'F''',"'~ll ;'II"'''''''"I'.~')'~11i..''''''''''''''r''''~''''''''1''I/''''~''1F ",," ",., ~""';'" \"''''"''1f'~ '''''''1'''",
I
f
!
I
American Water
PO Box 5600
Cherry HilI, NJ 08034
PNC BANK, NA
NEW JERSEY
ll:ll1.
312
NO.
74174394
FOURTEEN AND 00/100 ********.........*,*...**'4'...******...*
DATE
07/30/07
PAY TO THE
OlmER OF
l"j
RWE DOOU_
$********14.00
VOIDKA KPTo DAYS
Frank E Williamson A I.
2 Lantern Ln ' II'
Camp Hill PA 170118456 .
. '-', ..... . '- _.. '-" - - -- - .. .-.--......-........-...-....... --. ..~._-- 'Utm{Clll.:t.ZiiJ:L..JSIGN.I\..'!:~~ffl.lL. _.._.
**~.******************~*******
.. .- - - ,.-.-. ....-.-.. -.'-..-.......,. .-.....-.-. "....
II' ? l. . ? l. :i 11l. II' I: 0 :i . 2 0 2 ? ? 0': 8D.:i 5 8 l. 8 0 r; II'
. ,
-
.
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.
Dale: 10131/07
Page 1 of 1
Check No. 0025798798
000006
FRANK WILLIAMSON
357 OLD STAGE RD
LEWISBERRY PA 17339 9563
/I A.Dn Health Care
.L:Ill.nl' Optionso
~
IF YOU HAVE ANY QUESTIONS CONCERNING THIS REFUND,
PlEASE CALL US TOU FREE AT 1-800-523-5800.
~:J,\O_ cLv~ G
J
~~,q
PAYEE: ESTATE OF FRANK E WlLUAMSON
.
...
I ~EG POUCYSYM POUCY HUM PROD CODE INSURED ACCOUNT NUM
i OBB W/L UAMSON 0 0134999081
j
CHECK AMOUNT
$*A.l401. .lU1It266.12
CHECK DESCRIPTION
YOUR ACCOUNT IS CANCEliED. THE REFUND CHECK BELOW
REPRESENTS MONTHLY PAYMENTS PAID BEYOND THE
CANCELLATION DATE.
Fann T'2>>a Pnnted in U.S.A.
No. 13 62 70 5 9
.:IIo.....~.,rt.~.:r:I...'.l:I;':r..:I.,~:r:_.[..~I....'~oI:r~.YIlI:l.II..~I..II~[...'I"...:r:I...'.l:I.~;I.I..~....1~~._..~'.:r:1I:a..\"...:1:I...'.1:1;
II...! '"....iJ'ji. ...........n....<......~..HeaJtticare
~OPti6ns.
~.
Check No,: 0025798798 ~
Check Date: 10/31/07 311
Pay
TWO;HUNORED SIXTY SIX AND 12/100 DOL.l..ARS UAU:lU'\U:lM.U.tlI:,t,uuuuu.uuuuu
L $n".: .. .~~~6.12 _J
RO
oaB
PS
W/L
PH PRDCDE
llAMSON 0
ACCT
0134999081
SC
950
WACHOVIA BANK, N.A.
'MImington,DE
TO THE ORDER OF ESTATE OF FRANK EW/LUAMSON
2 LANTERN LANE
CAMP HILL PA 17011
~ L;f~
0.0025 ?qB ?qBIII 1:0 ~. .00 2251: 20 ?qq 5 .01;1; ~OO"I
,<< .
~ueline Mindeck
From:
Sent:
To:
Cc:
Subject:
Michael G Papson [michael.g.papson@ampf.com]
Thursday, April 12, 2007 10:29 AM
Jacky@LedererLaw.com ..s; L _ _ n ,f _ .....
chad.d.zeaser@ampf.com C I\JL{LV \Q....- \.:1--..J ~~ f'LaS
Fw: 11653494 2 001
) ~.~
Jacky
Here you go
Ameriprise Financial Services, Inc. offers financial advisory services, investments,
insurance and annuity products. RiverSourceSM products are offered by affiliates of
Ameriprise Financial Services, Inc., Member NASD and SIPC.
----- Forwarded by Michael G Papson/Field/WH/AEFA on 04/12/2007 10:27 AM
Papson/Field/WH/AEFA@AMPF
Amy 2 Dufrain
To:
Michael G
04/12/2007 10:26 AM
cc:
bcc:
Subject: 11653494
FRANK E WILLIAMSON
2 001
DEATH SETTLEMENT
DELETE
REQUIREMENTS - PLEASE DO NOT
RiverSource Life Insurance Company
RiverSource Funds
Ameriprise Certificate Company
Ameriprise Brokerage
Financial Center
70100 Ameriprise
Minneapolis, MN 55474
April 12, 2007
MICHAEL GEORGE PAPSON
AMERIPRISE FINANCIAL SERVICES
4661 TRINDLE RD
CAMP HILL, PA 17011-5603
Dear MICHAEL GEORGE PAPSON:
We have received notification of FRANK E WILLIAMSON's death. The deceased's name appears
on the following accounts. Account values as of 02/11/2007 are
listed below. At the end of this letter, you will find a list of
beneficiaries shown in our initial review of the accounts
1
. (Ac~ount Information
Mutual Funds
Account Number
01012408823 7 002
01013546115 9 002
Ownership
Individual - TOO
IRA - beneficiary designated
Annuities - Post 1985
Account Number Ownership
93001539815 7 004 Individual
93003339671 2 004 P/O
Individual
LTC Premium Return
Account Number
91002384842 7 004
Ownership
Individual
Mutual Funds
Account Number
Share
01012408823 7 002
01013546115 9 002
Total Value
# of shares
Asset Value Per
$22,898.13
$13,733.75
3,835.533
1,170.823
$5.97
$11.73
Annuities - Post 1985
Account Number
93001539815 7 004
93003339671 2 004 P/O
Total Value
$91,623.34
$5,310.26
;......
The date of death values provided are for estate tax purposes and are not a value to be
paid. Accounts may be subject to market fluctuation as governed by each product. Please
note that the values indicated for any Life Insurance
product(s) reflect the gross death benefit at date of death, not the cash value. Values
for any proprietary mutual funds include accrued dividends as applicable. Values provided
for brokerage products are manually calculated, and should be used as estimates only. The
prices used to provide values are estimates obtained from outside sources believed to be
reliable. Ameriprise Financial provides these values as a service to its clients. Actual
values used in preparation of tax returns or for planning purposes should be verified by
your legal and accounting advisors.
Account Disposition
Account disposition is based on how an account is owned (the ownership type) .
The following information will help you understand the process that will be used to
settle the accounts. Accounts may be subject to market fluctuation as governed by each
product.
Disposition for Individual - TOO ownership Upon the death of the owner, all accounts
registered as individual-transfer on death pass to the named beneficiaries. Although the
assets do not become part of the estate for distribution, we understand they should be
included for inheritance and/or estate tax purposes.
Disposition for IRA - beneficiary designated ownership Upon the death of the owner, all
IRA accounts pass to the named beneficiaries.
To determine the distribution options available, please consult a tax advisor.
If all IRA accounts will not be fully distributed to the beneficiaries within the year of
the owner's death, we recommend the accounts be transferred into beneficial ownership by
year end. This ensures we are able to meet IRS Form .
5498 reporting requirements. Transferring to beneficial ownership is not a taxable
distribution to the beneficiary.
Disposition for Individual ownership
Upon the death of the owner/insured, all premiums paid after the date of death will be
refunded to the estate.
Disposition for Individual ownership
2
.
. ,
,T~e deceased was the annuitant on at least one annuity account previously ,listed, Upon
the death of the annuitant, aCCOunt proceeds typically pass to the beneficiaries named at
the time of death. If no beneficiary was designated the proceeds become part of the
estate for distribution. DEFERRED ANNUITY
NOTICE, The beneficiary!s) has the option of taking the annuity death benefit either as a
full distribution or under an annuity payment plan. If the
beneficiary!s) wishes to elect an annuity payment plan, we must receive written notice of
this election within 60 days of Our receipt of due proof of death..
Due proof of death is considered to mean Our receipt of a certified copy of the death
certificate, a completed death claim statement, and any other required claim documents.
If there are multiple beneficiaries, the 60 day window for electing an annuity payment
plan begins for ALL beneficiaries on the date we receive complete requirements from the
first claimant.
In order to be compliant with fair claims practices of many states we will be immediately
corresponding with the beneficiaries listed for any Life and Annuity accounts held by the
deceased client, Similarly we will be corresponding with the beneficiaries or claimants
of all accounts held by the decedent within a minimum of six months of the date of this
letter. Please contact us if you wish to see a copy of these correspondences.
We also request any information you may have that may facilitate Our efforts to contact
other beneficiaries on the accounts involving the deceased.
We appreciate the opportunity to be of service to you, Please contact us if you have any
questions.
In an effort to improve our process, we invite you to share your feedback with'us by
sending a Lotus Note to: Settlements Feedback.
Sincerely,
Amy DuFrain.
Death Settlements Processing Team
70100 Ameriprise Financial Center
Minneapolis, MN 55474
Death Settlements Processing Team:
Settlements
Life Insurance Claims:
Life Claims
800-297-6663, PIN, say Death
800-297-6663, PIN, say
Attachment: Beneficiary Information
Beneficiary Information
We have the following beneficiaries on record for the deceased"s accounts.
Account Number:
DeSignation:
PRIMARY BENEFICIARY
FRANK E WILLIAMSON JR
01012408823 7 002
SON
100.00%
ACcount Number:
Designation:
PRIMARY BENEFICIARY
FRANK E WILLIAMSON JR
01013546115 9 002
SON
100.00%
ACcount Number:
91002384842 7 004
3
. .D~sj.gnation:
No record on file.
Account Number:
Designation:
PRIMARY BENEFICIARY
FRANK E WILLIAMSON JR
93001539815 7 004
SON
100.00%
Account Number:
Designation:
PRIMARY BENEFICIARY
FRANK E WILLIAMSON JR
93003339671 2 004 PIO
SON
100.00%
When submitting the required documents please attach this cover sheet to the documents.
Please include all documents related to the claim or estate settlement including new
account applications, claim forms, etc. Please do not include any documents not related
to the death claim or estate settlement.
This will allow for quicker processing of your claim or estate settlement.
11653494
FRANK E WILLIAMSON
TO: Amy DuFrain S07/1654
Death Settlements Processing Team
70100Ameriprise Financial Center
Minneapolis, MN 55474
ATTN: MAILROOM
DO NOT SEPARATE ANY OF THIS MAIL. PLEASE DELIVER TO THE PERSON IDENTIFIED IN THE NOTE
ABOVE
> > > > > > > >
Amy DuFrain I Claims Analyst
Estate Settlements
Client Account Administration
Ameriprise Financial Services
70100 Ameriprise Financial Center I Minneapolis, MN 55474
Office: 1-800-862-7919, Option 5, 1 I Fax: 612-671-4538 ameriprise.com
Amy.2.Dufrain@ampf.com
SAO Forms tool can reduce errors and simplify preparation for meetings. Find the link
here.
*******************************************************************
***********
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