HomeMy WebLinkAbout01-10-08
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GEORGE M. HOUCK
(1912-1991)
Mr. 1. Paul Dibert
Department of Revenue
Inheritance Tax Division
Harrisburg District Office
Strawberry Square
4th & Walnut Streets
Harrisburg, P A 17128-0101
Dear Paul:
CHARLES E. SHIE~DS, III
ATTORNEY-AT-LAW
6 CLOUSER ROAp
Corner of Trindle and Cloufer Roads
MECHANICS BURG , PAl 17055
January 4,2008
TELEPHONE (717) 766-0209
FAX (717) 795-7473
RE: Estate of Lois M. Bower
21-06-0850
Given the complexity of this Return and some of my apportionments, calculations and
explanations, it is likely worth your while to personally review it.
Thank you for your kind help in this matter. It is most sincerely appreciated.
CES/mjj
Enclosures
Very truly yours,
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Charles E. Shields, III
Attorney-At- Law
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15056051047
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
File Number
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Date of Birth
Decedent's Last Name Suffix
Decedent's First Name
MI
(If Applicable) Enter Surviving Spouse's Information Below
Souse'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 Return <:::)
2. Supplemental Return
c:;) 3. Remainder Return (date of death
prior to 12-13-82)
c::3 5. Federal Estate Tax Return Required
_ 6. Decedent Died Testate c::>
(Attach Copy of Will)
c::> 9. Litigation Proceeds Received c::>
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 12-31-91 and 1-1-95)
/ 8. Total Number of Safe Deposit Boxes
c::3 4. Limited Estate C)
c::> 11. Election to tax under Sec. 9113(A)
(Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
f'J
..
Correspondent's e-mail address: b e
7x.l1e.t
Under penalties of pe~ury, I declare that I have examined this return, 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.
0-
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Side 1
L
15056051047
15056051047
---1
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15056052048
REV-1500 EX
Decedent's Name: 13 0 w Er<..~ L 0 IsM.
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) c::> Separate Billing Requested . . . . . .. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) c::> 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, or
transfers under Sec. 9116
(a)(1.2) X.~ tJO
16. Amount of Line 14 taxable
at lineal rate X.o!l$ 3 j... 3 q q ...~ . 38'
17. Amount of Line 14 taxable
at sibling rate X .12 . 0 0
18. Amount of Line 14 taxable
at collateral rate X. 15 . () 0
15.
16.
17.
18.
19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... ................ 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
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15056052048
Decedent's Social Security Number
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REV-1500 EX Page 3
De'ceden\'s Complete Address:
DECEDENT'S NAME
File Number
al-()(g-!SO
LOIS
M.
130uJ El(.
STREET ADDRESS
3cStS" wESLey D/cfYE jff/J-r. 13~
___ n ________ _ __ _____________ _~ _ _ __
CITY
meCHANlcst3 u.~G-
- -- - ---:STATE jJA-~----
-
ZIP
17055'"
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
~lfJ 57'1. "
o
o
____n_______
t2_
Total Credits ( A + B + C )
(2)
o
3. Interest/Penally if applicable
D. Interest
E. Penally
o
-1)
Total Interest/Penally ( 0 + E )
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3) 0
(4) D
}I'
(5) I If; 571. '6
(5A) .573../9
(5B) f I~ /tf'.,t . R'S-
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.
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;.......................................................................................... D IZI
b. retain the right to designate who shall use the property transferred or its income; ............................................ D ~
c. retain a reversionary interest; or.......................................................................................................................... D IRI
d. receive the promise for life of either payments, benefits or care? ...................................................................... D ~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. D ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D M
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 1:8 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.
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (3) percent [72 P.S. 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 zero (0) percent
[72 P.S. 99116 (a) (1.1) (ii)J. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax 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 zero (0) percent [72 PS. 99116(a)(1.2)J.
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in
72 P.S. 99116(1.2) [72 PS. 99116(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 PS. 99116(a)(1.3)J. A sibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1502 EX+ (6-98)
SCHEDULE A
REAL ESTATE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
t3ow~ LCIS /11.
FILE NUMBER
,z1-tJ/p - 8S0
All real property 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 willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the rel_t facts.
Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. .-
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
C fEME II:~Y IJIFtD J WIL D wooD CE/11€TG72.y &., Df'
IVft.t/AAfS~R T; ;J/I..
r a/l! IJ1t/M A-JlG. SEC-': /J1 / !:71$, tv/LL)[.c)~oP #: :lS~
,91/ mE CE/J1~7j:"}eY ;'&.;f.AI)
(liS flrm SI1F~ ZJ€1'oS/7 Box. IA/VPNT[)!eY ..sufbmlTrGD
7j) "eEBEet!A ~1I-121l1C-K, 13 y ~"IIIS El. S L~TrC?e. t),c
Ot!-t: .:2'1/ UJf)4,)
"1/ s. ()t)
TOTAL (Also enter on line 1, Recapitulation) $ j IS, 00
(11 more space is needed, insert additional sheets 01 the same size)
THIS INDENTURE, MADE the n..h..n:r!:.~~.sinnn...___n.m. n___'h"___.n___.___. day
oLn~I)~.i.~mm_._nnnnnnn______'h___A. D., One Thousand Nine Hundred and n...h.m.I>()Et;\'___.I:Cll.l.1:.m ,___'nn"h between the
Corporation by the name, style and title of "THE WILDWOOD CEMETERY COMPANY" of the one part, andm.___.....n
. .n..~~I!nl?:t;h...Ln.!-lC?.v!Ell:m.n___"'hmn___. .nn___h...___.h......nn.
____._______n - __h_____U_n_ -n_--_____nn_n__________hU__n____n______n___ ____________ _u____n___hn__._______._______
of the second part:
WITNESSETH, That the said THE WILDWOOD CEMETERY COMPANY, for and in consideration of the sum
of ..nhQ!l.-"'..h.llActr.~ELf:LLi;~~1J...&:.h.QQl1QQ...'___.,... L.'...' .__,_... n""h'n.L. '.n.'_m'mA ..A.n~..Dollars, lawful money
of the United States, to them in hand paid by the said party of the second part, at the time of the execution hereof, the
receipt of which is hereby acknowledged, have granted, bargained and sold, and by these presents do grant, bargain
and sell unto the said party of the second part, and to n)~is ._____.nheirs and assigns, all that lot or piece of land in
WI L D WOO D CElli E T E R Y, in the township of Loyalsock, Lycoming County, State of Pennsylvania, situate
on_h______..~~:rn .____.m___n__.Avenue, in Sectionn.I1~11l n]<;.a.~.tm.Wildwood, and numbered on the plan
of said Cemetery; number "m .J'V/Cl 111.l!!<i.:r:.~.d.. X~f.:t;:>'__JC?~I!:. m__.c g.5.12 nh._____ .h.---...m----hm..._____nhmn._____.___....n___.hh
which plan is in the possession of the said Corporation for inspection by the said party of the second part,__m.h_:i~h_____
heirs and assigns, at all reasonable times, and which said lot of land contain8..___n___..__nn..___.
---..J~n.!!.1lphcl.~.~~......j.?nQ.QLmm........__h_....._...nm.hh....m.___...h n___mm__.nnsuperficial square feet more or less, THE
WILDWOOD CEMETERY COMPANY hereby covenanting to perpetually care for said lot (which covers mowing
the grass, resodding graves and filling sunken ground).
TO HAVE AND TO HOLD the said lot or piece of land above described unto the said party of the second
part'__...ng.~."'n.mm.heirB and assigns, to and for the only proper use and behoof of the said party of the second part,
_mnh.~.~....heirs and assigns forever, subject, nevertheless, to the charter, by-laws, restrictions, rules, limitations and
reservations which have been or may hereafter be made by the Managers of said Corporation. And for the purposes
above expressed the said THE WILDWOOD CEMETERY COMPANY, for themselves and their successors, do hereby
covenant and agree to and with the said party of the second partn'hn....__h1'~__"'...___n'hheirs and assigns, that the said
THE WILDWOOD CEMETERY COMPANY, and their successors, the said lot or piece of ground unto the said party
of the second part'mJ::l~.sn..._.heirs and assigns, against them the said THE WILDWOOD CEMETERY COMPANY, and
their successors, and against all and ever)' other person and persons whatsoever lawfully claiming or to claim by, from
or under them, or any of them, shall and will FOREVER WARRANT AND DEFEND.
THE WILDWOOD CEMETERY COMPANY doth hereby constitute and appoint.hn'1'().~l_S.Elrl_(l..\Tilll..Q.l.!'ihn
to be its attorney for it, and in its name and as and for its corporate act and deed to acknowledge this Deed before
any person having authority by the laws of the Commonwealth of Pennsylvania to take such acknowledgment, to the
intent that the same may be duly recorded.
IN TESTIMONY WHEREOF, the said THE WILDWOOD CEMETERY COMPANY,
hath hereunto affixed the common seal of its said Corporation, at Williamsport, Pa.,
the da)' and year first above written.
Attest:
//<~/ /. -- .-;-
n.----n._..L.hu:.:.~::!..;.h_:~.:.:_h__:~h__._~:::.:~==__~..:..._....___~,:-=:-~
,. President -- . .
""""_h.._...n'h"'_"""?;~~
Secretary
State of Pennsylvania I
County of Lycoming r SS:
I hereby certify that on thi8.....~.r.~mm.__...day oL__..:"J?E~.l.m__.....A. D. 19.~.4.n, before me, the subscriber,
......---.~..r:.Cl.~.a.~X..P.~E.~~.<:.L.~~.~Z__<:()l!~JJ1.~.~:l.~.()r:.~.~_..___.. personally appeared h.n.'J:C?-'!!':Le;.~n.d.n.y.~!L.gJ9hn..__......h.
the attorne)' named in the foregoing Deed, and by virtue and in pursuance of the authority therein conferred upon
him, acknowledged the said Deed to be the act of the said THE WILDWOOD CEME.
TERY COMPANY.
WITNESS my hand and...h.._.!l.'?!:~~:hal...m.seal the day and year aforesaid.
..~{.6~~.~...1f~~
>-'J ~ --....,.~~~~~.--.-~-I~-~~:.iu;.r.~- J) l~i
DEED
THE WILDWOOD CEMETERY
COMPANY
TO
Kenneth l~___13_o_V'{_ex_u
Fur Lot No_ ___u 254
__u_ uSection "M"
bast
WILDWOOD
M,ClXn
A venue
Price, $.1.}~.()()
(Including perpetual care)
REV.l508EX '(1.97)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF B
o tV ~/ Lo/s 1Jt.
FILE NUMBER
2/-&, - J'SO
Include the proceeds of litigation and the date the proceeds were received by the estate All pro rty" tly . .
ITEM . pe JOin -owned With the right of survivorship must be disclosed on Schedule F.
NUMBER
1,
DESCRIPTION
;'J
"'" .
;JI,/(!' ,Slht/K eHG"C.KIA/ ~ Aee 7: Aft)" So 7 007 7/.z ~ -' P/'i/IIIC1PAf.
IS/H.A-N(!E
~ceJe. IAl!: 7l; D. D. P. 0 A.J I rem .# I
(St: e J/ /1-1. t( A- TI UJ/ {..C 7'nPe. A "T77tf t!IICD /7eDm PAle .13 /l-AJk)
C!..lfmfJ HIU flIlYS/(!.//MJ.,f' /~LY S~//ZtT I-I~SPITA-L/
fl/U; Jill) E7f S€lel/IC5 ;t?EF'H All)
.3.
If.
-I
jlJr()je WllfT/DlYl1L h~Tc: 7Jo1t: SliFE D€PoSIT ~oy. /AJVFN7lJ/lY
~ u 8 M I r-re1) It) I<E/!JE aM tB IIIl.tf.I ~J~ ~ .d Y C/)UN.r cz s LE T(l:P'<.
01= oc.r::J 't ,2/JOh /!'Ie. l.utJe]) ~, Irl9J1 A1()~:L A- (!szTJ;:::
~F OEPoslT wrn-l THe CEN7lUi ;/e:N/II/J.. ~IVFG7l$NCJ.l;
J
{!tJ/J1A/rrree ()If/ UJ/fffS; TAF tlA/lTEtJ /:iIE7/KJtJ/.5r {)HiI~
I/V 7~E /l-/IItJUlfr 01=' ~7S;t:::lotJ; 'b. AS PE1e NoTE" /JI/NJE
t3y ~t(tY~€Z.. " /1111 /lYtfttlKY #;!$' ,eEE7f/ /J1/HlE AS 10
7itE JlA-tlJJ/lY Or TNE C~71;::: Or ,tlET-JcJ~/r:
&RIeE;Sj1tIJ!LJsreE a/L;f/AI//1/6 7#b" (!aIUtEJIJT /f.J~AI-
VAl/f)/ ry ~F IT #/l 7Jf"fT /r /s t!H.lt.ltEIVTLY,,+
::TP/ItIT ~~T /# /f ~S6f' /PJIt)JV/lT /5 /f7Y/1-~#EZJ
70 safletJUt~ F jVflE;(!E/fr ,(./l/JE7f/tS (JataEJUT
1JIif/l- .#II) j//fLM.ll/)/JIcf.
III AIr; /1lt.1: IElesoAl/!-L TV
(~EE ITEM/ZeD INIlr:/VT/)~Y A-IrAeHlfFb)
I2ErHlViJ //?S CLoS€t?uT 10'fo
RFIuJ(!V OJ.! ENTte,f.IVCt: PEE/ I/JYESTMEJlT U.PON
E tJ r/Ul-h'(!J!F 7D 8€77Y.I//rY j/I~L../IGG', RECEIVeD ~M
M l.3urty CoMmuNITiES, lIVe. (S~E (!.()fY of (!.J.IEt}(
,4 TrA-CH~
s:
,.
VALUE AT DATE
OF DEATH
~
2/, " /7. 71
~ :1./3
~
l.fO.213
~.sJs.JS-
~ ~18(l.oo
-;
tf~ IZO.oo
! .,-
""7 /", (' .
TOTAL (Also enter on line 5, Recapitulation) $ ~ 7", 97 s. .s s-
(If more spaGe is needed, illseri additiollal sheets of the same size)
.J
~~
.. 1".( I') - .f~, -- ::'I"~lt.:-t(., ~:':~'1. +-:, C."!
;"'Ij:~:i~I!:
,j i ~~. r::-.:= u I~ ~ c,.;-=j
F' 1>"11,.;"."1 i
o PT\JCB,2\l\K.
November 27.2006
Charles E. S.lHclds, TIT
At10rneyat Lay,'
6 C]ou~et' Road
Mechanic.~hurg P A 17055
RE: Estate of Loi~ M. Bower. deceased
SSN: 166.14.6673
OeJD; 9/14/2006
Dear Mr. Shlelds'
In 1'C':spon:5c to )'OlH rt'quesl fen Dale of Death balances for the customer noted above, ,)UI'
re0ol'ds slww the following;
Checking Account
Acoountff5070077129
Bstablished 06/12/1968
LOIS M BOWER
DUD 03Jnncc: tll -'-, J 'j ./1) + 1;2. j 3 tleoY'Ht'.d inr...r~m
Sarl' DqlUlIit Bo.l.
#1728
EstablIshed 07/] 5/1983
LOTS M BOWER
Locukct:
MECHANICSBURG BRl\.NCH
2 EAST MATI\) STREET
MECHANICSBURG, PA 17055
(17) 69] -<l 0 ] 1
Please note tbat thIs office only provides date of death balances for deposit accounts
(IRAs, CDs, Checking and Savmgs (,\Gcounts). WI:' do not pt'(H'eSS an)" financial
transactions or provide statements. If YOll need assistance with any of these items,
please call I ~8g8.PNC~BANX (1-888-762.2265) or stop by your local PNC Bank branch
office.
Slflcerely.
C~(1J?lh!L /Jyj~~-
Racltelle Wells
] -800-762- ] 775
P'/-PFSC-04JF
suo firs! Ave
T'ilL;bLJlgl. P,i\ 15719
r\bnbc; FDIC
PROVIDft~;SERY,~9ES'REFUNO~OCOUN'T'
'/IIi .e;O.BOX67'.ii
'I;pONS~~tttOGKEN,'P~Tg428
. FIRST CHICAGO
THE FIRSITNA':qONAL BANKOF CHICAGO
_ a. ..... ._~._.. ...' ._...
;>"::':::,,;.::"::,::::.:
7:Q;2$22/719
87.2'00:6
" ;',' "', ,': ,_"'.:: ',0', '. _.d. '_ ,.:,_":. - _ ,_:: "_,_ _..:. ,_ ._ ,_ ,>'
AND ,28 :,C.ENTS *:*:~~ ** *'* *.*.*'** * *'* *'*"*,,*'** *,* * *,*,* ** ****,** *.* *'* *.*
.1': :':_" ': . ~;:"::":'....
.,.. ". - .
:t :{}~';:::::~;::"::r~.:-;'.;: ;-: :'" '-'- " ,_'~
.,.... .....,:.....
,,:,:,::';';:'":::-.:':';."-;-;>., ,",,'
."..:.....-...;.......- "
":':',:::"-:".':'""..- :'
-....'...-..._'.-.-.' "
· [rLOIS'M.BOWEl~ .<, .
;~~~~:~~.~~~~~,..~=~'.~~.655... .
;:.::;,.::::;:::.::,:
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.,....'".
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,'. ',-"-',,.....,::::;::.;:-...
,:-, ,-i ,','-:::'.,,:...
. ,.-.-...,...'.;......--.-.',.
..:::,;;:;:::'.;:.::;: .
'..' ..:::_'.:_._.:. :-, .
.....;;::;;;,:;-:::.;.-.;.:: .
'. 'OH~~i~fS\V0ID.Slxjij~~';'~~i~~~JVI;ISSUE
:. ' , -~, -, , .
;.:,.:..:::.;::::::::;:;:::::
1;.., .,,,. .
..-, ............:;.
-i:'.,':i"
. . .,:;::;.:..:::..::::;:....
,m
III B 7 200 b II. I: 0 7 . 11 2 :l 2 2 b I:
11 L, 0 2 . b 5 III
-C~P~IL~EMERGENCY~YSICI~S-~YP~---~LEASEDETACHA~ER~INEi---
-------
PROVIDER SERVICES REFUND ACCOUNT
HOLY SPIRIT HOSPITAL
800-355-2470
872006
PAYEE NAME & ADDRESS
LOIS M. BOWER
335 WESLEY DR APT
MECHANICSBURG, PA
ACCOUNT NUMBER
28333631
SERVICE DATE
08/25/06
POLICY NUMBER
103
17055
PATIENT:
LOIS M. BOWER
REFUND CHECK DATE
12/07/06
REFUND AMOUNT
$40.28
REASON FOR REFUND
INSURANCE PAID & PAT 063336102680005
36307
11/06
872006
i [S2:l(,.'
GGA. ASSOCIATES. INC. PROSPECT P/\RK PA 19076 IROOI h97-flIH'::
.
5 CI{G'f). E:
- IAlJI't3N n~y of /I4AJC/8LI!;:- rBfSO/lJ~Lry -
. --I. E~r_.eE__i3P~~.1 .._~l.J . _t!t...._....__ ... _ _.___.n_ -. ..___n_____.. nE? L:E._t!..'?:___.,g !.~~~_= tf.g
n['n.. _c.qJ!.~!i_.=_tie,~.sf)JL'1~t. -/f!-~rLJJ~.Jl t/..--~-r;J.- ~.Jf_.:l.~_yeat.J:~II.!_. ._ _ ... ..___~t2~~q____
_2._/2!:/)_-::_.Jp.!~d.__~,~__4~_~J_J:la!_~~~ ~~~~~$.1.t;:~L._ .._u_________
<<i .-;Wt.'&Jt!4t.fn'2L~l_ __ ____. .__________n__ _n__________ ____...._____m__________~?~'!1! _
.g-....-'!!r{-~~!{f_~/~-~d-(t4~t.--~-/-~/S O(~_______.______m________5_~~_~_______
... /l....p/t/._(!/t e.slt?tt!!',..I!J:f!~~-=-~/f;~'If--ttllJ.rt--!1~~iI--~1!-1/ ~~_______n__.1.>__~ C)~____
........- --.~ r..... &/t/. desK:-~L[~.t .5€.~-I~/bffl-*,~d __. .m_ ~1j,I'}O
~=~~~~~~~=
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m___________n_________ .I. _._dI1!PJir__/A.'!!fR-_....._____ -_____________._____.__________________ ..... .._ ...... ____ _________m__~_~~ _________
_____.__________ L~L__t!A~_LiLfl'A lJ.t___________._.________________________________._......_.. ___________~~_#_~p____ _
---------- ...-- !L____t!J.f!At____I&.~feA _,..'!jef.___________________n.n______ _n_n______________________ ---J~k.-Jl~L~en--
I~. .Illa-,-h~ _-"fjIlSllt!4?t_ ... ----.-----_._ _ _ _..__ ..._... .______u_ ._n_.. ._n __ _~_C!.t1I_~~______
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0 '" n VlI-< 2 N
0 :r: C/)m VJ N
0 H )>~ -l 0 V1
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"
Asbury Communities".,Inc.
6/ ~8/2007
Estate of Lois Bower
No. 130744
II\lVOIGEDATE'l 'i:i: ~ ,tr,t.;rv!OUNTJAPRLIEOD
,",':
6128/2007 516299 Refund Standard Entrance Fee 45120 00 0 00 45120 00
:HECK AMOUNT $45,120.. 00 TOTALS $45,120.00 $0 00 $45, 120.00
Sovereign Bank
,Gaithersburg MD
No. 130744
60-7269
2313
,;;, ,: ~<{:ji ",:,,; DAliE;;:'''":;;-,;i:~~/:'$
6/28/2007
130744
$45.120.00
Twenty Dollars and 00/1 00 Cents
VOID IF NOT CASHED IN 120 DAYS
Pf\17055
/)H~ ~/L
III 0 . ~ 0 7 ~ ~ III I: 2 ~ . ~ 7 2 b 9 . I:
2 7 7 . 7 5 ~ . 7 0 II.
SENe? cr t'If\W u.~" r..t,'.TFN~ l~dM8ER: lINDEr SIGhjl.~TURE IhlOISJ\TEf; CHEC.~ If FRAUDULEN7. PATEI\IT NUMBER5 ARE PRINTED WITH HEAT SEhJSITlVF INh {~ Vt/ILl_ DISp.PPEAH WHEhi BLOWlhlG Of'~ r~UB8ING
REV.':>J9 EX+ (1.971 .~
~ .~
COMMONWEALTH OF PENNS) LVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF /.3 ,-,a L
f)lAh:",- ~ t)/~ d.
SCHEDULE F
JOINTLY-OWNED PROPERTY
FILE NUMBER
2J-O~ -J57J
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. 'J'1t/JET L. SHIVELY
335" W~SLEY DR.IVE" IfP/: /03
fJGiHMY 7i;ttJF7CS
Mtf~HAN'ICSBU;(a.) fJA- 170 SS-
/ I 2. q i-ooP (DR..IIIE
HItR/2.15r3URG., fJA /7//2..
s, LuC/NOI1 ffl. PGIFFa<
c,
D Jl..U (8 HTef!
c;./f,;l/-NDLJ/I-tl ~J{1'bifi
JOINTLY-OWNED PROPERTY:
LETTER
ITEM FOR JOINT
NUMBER TENANT
1.
A.
l.
(}J.
DATE DESCRIPTION OF PROPERTY
MADE Include name of financial institution and bank account number or similar identifying number, Attach
JOINT deed for jointly-held real estate,
SJIOJ'24II c.Enr'P-"/ClI-r€ t>1= /JEf7~sJr '* /S"Z 12-
,tiT eEWTIf!.Ih r'E/yAI.5YLvAAlNf. CDA)~I:7e.-
rl I E'IVCE DF= THE l(IWr4V mE""TH~LJlsT
~ tiC> , 21. ')/
CIO{te~H
~
'Ill I/a 11'1ff. .11:>,1)01).. ()()
A~c~ /NT. ., 9 D;t. '1~
, ;;lb~ 9"~.'I3.
(5ff(; VA-l.UII-71/J,f) LGrTe;e /frr~Me1)
A-ttJ1J lIt.6o PNJnMI7Y~;= 1)A!ru; /LJST
f)/GIG/AlIl C!Bl!.l7h" PF /JEPt:J~/T tlJH/aH
/AJ1fS /(EF~~M1J /A! S~ ~d/lSlT
J90X /NJI~"fi;;ey M/II/t!H SH/JIt/J /TBII
tf;1f$ :JOIA/T ttlbA" 15SItIlAJ~G ~ h/AY
/~J ZtJO/).
1. /NI=M.lnA-1i,h'1k-- /1JorE: /Jj/~SI/llt: ~r:
WAs I{Ef:1t1feaJ i3 Y AlEkJ CE.1l1/ P: ..rfF /3 e 7:l
/111 I=A-~ Am/)ttIfT t!?r ~24~~P; t7O,($EG"
CtJfJy A7'?7J-e#ct>).
DATE OF DEATH
V AWE OF ASSET
'10 OF
DECD'S
INTEREST
DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
;.
;U;J 9o:l..lf2
~;
33.~, 4,J 9r.fe.7i
TOTAL (Also ente, on line G, Recapitulation) I $ ~ J 9' ~, 7 K'
(If morc space is needed, insert additional sheets of the same size)
CENTRAL PENNSYLVANIA CONFERENCE
THE UNITED METHODIST CHURCH
303 MULBERRY DRIVE / P.O. BOX 2053/ MECHANICSBURG, PA 17055-2053/ TELEPHONE (717) 766-5275
October 27,2006
Attorney Charles E. Shields, III
6 Clouser Road
Mechanicsburg PA 17055
Re: Estate of Lois M. Bower
Dear Attorney Shields:
This letter is in reference to your request to provide you with the value of the certificates
owned by Lois M. Bower at the time of her death, September 14, 2006.
The certificate was valued at Twenty Thousand Dollars ($20,000.00) and the interest that
had accrued from May 1, 2006 to September 14,2006 was $902.42. Interest on the
investment was last paid on May 1,2006.
The certificate, to which you referred in your letter for $75,000.00, had been reduced to
the $20,000 referenced above. On June 25, 2006, Mrs. Bower wanted to withdraw funds
from her account but could not locate her certificate, a copy of the "In Lieu of Lost
Note" which she signed on June 25,2006 for the $55, 000.00 is enclosed. Along with a
copy of the check issued at that time.
The investment account Mrs. Bower had with the Conference Committee on Loans was
changed on May 21,2001 to read Lois M. Bower or Janet L. Shively or Lucinda Marie
Peiffer. .
If you need additional infoTI11ation please feel free to contact me.
Sincerely,
C~a~~
TREASURER-COMPTROLLER
Enclosures
COUNCIL Of-,J ;:71f\lA,NCE .AND ADi\l1INISTRATIO!\l
,
~'
r
TO: CENTRAL PA. CONFERENCE U. M. C.
COMMITTEE ON LOANS
IN LIEU OF LOST NOTE
This is to certify that investment certificate (#15212) issued to LOIS M. BOWER,
in the amount of SEVENTY-FIVE THOUSAND (75,000.00) Dated May 10,2001
, cannot be located.
WE WOULD LIKE TO REQUEST WITHDRAWAL OF A PORTION OF THE ABOVE
FUNDS AT THIS TIME. If original certificate is located, this document declares it to be VOID.
\~.~.~ ~
Signed
~
II e^ I'J[jc;~
Witness
?J . </1 o-fJ ~
Date~ :l. b~ )... ot "
If j - S C>-(nJ. c--{)
I
. -
DATE REFERENCE ACa. NO. AMOUNT
6;r)OJ (y, IVITHDRAWAL 25S(}O.OO 55,000.00
-..- ....\...
TOTAL I 55,00(1.00
VENDOR
CENTRAL PENNSYLVANIA CONFERENCE
UNITED METHODIST CHURCH
303 MULBERRY DRIVE, PO BOX 2053
MECHANICSBURG, PA 17055
DATE 6/29/06 CHECK NO. 2iJJ65
REMITTANCE VOUCHER - DETACH BEFORE DEPOSITING CHECK.
24165
rI M&TBank, N.A.
CENTRAL PENNSYLVANIA CONFERENCE
UNITED METHODIST CHURCH
303 MULBERRY DRIVE, PO BOX 2053
MECHANICSBURG, PA 17055
60-83
313
VOID IF NOT CASHED
WITHIN 90 DAYS
DATE
6/29/06
CHECK NO.
24165
$*55,000.00
PAY
TO THE
ORDER OF
LOIS 1'1. BOWER
OR JANET L. SHIVELY OR
LUCINDA r~RIE PEIFFER
325 WESLEY DRIVE P~T 136
4lECHANICSTIMlQG FA 17055
DIVISION ON LOANS ACCOUNT
NON NEGOTIABLE
III 0 :: L, ~ b :1 Ii" E: 0 j ~ :1 0 0 B j t.. ~ :
2 2 *' 7 t 5 b En II;
No.
15212
900 S. Arlington Ave., Room #119, Harrisburg, PA 17109
Date MAY 10, 2001
On demand we promise to pay to the order
of
LOIS M. BOWER
$<75,000.00
OR .JANET 1.. SHIVELY OR LUCINDA MARIE PEIFFER
***'~SEVENTY FIVE THOUSAND AND---------------------------NO/l00-------_____
Dollars
Without defalcation or stay of execution, for value received, with interest at6~%, per annum, waiving inquisi-
tion and exemption laws, and confess judgment for above sum without offset, with interest and costs of suit, and
with five percent for collection fees. There is a 1% penalty on all monies not left in the fund for a period of one year.
THE CENTRAL PENNSYLVANIA CONFERENCE COMMITTE2?O LO .S
THE UNITED METHODlS URCH
~, J -;1j- '_ ~" ~ ,-
TREASUImR CHAIRPERSON OF THE C
01994 Goes 4420
All Rights Reserved
No.
13872
303 Mulberry Drive, P.O. Box 2053, Mechanicsburg, PA 17055-2053
Date JUNE 29, 2006
of
LOIS M. BOWER OR JANET L. SHIVELY
On demand we promise to pay to the order
$~r20, 000.00
OR LUCINDA MARIE PEIFFER
~HHr-~-TWENTY THOUSAND AND--------------------------NO /100---------------------.. Dollars
Without defalcation or stay of execution, for value received, with interest a2 .50 %, per annum, waiving inquisition
and exemption laws, and confess judgment for above sum without offset, with interest and costs of suit, and with five
percent for collection fees. There is a 1 % penalty on all monies not left in the fund for a period of one year.
THE CENTRAL PENNSYLVANIA CONFERENCE COMMITTEE O~ LOANS
~ THE UNITED METHODIST .URCH j j
~ \.1
~ "",
. ( '4 . (..{..L) ..f'f .-
TREASURER CHAIRPERSON OF lIH COMMITTEE ON L
I
@1994 Goes 4420
All Rights Reserved
)- ___ / {j ( -7 0
RfV.,510 EX "('-97)
SCHEDULE G
INTER.VIVOS TRANSFERS &
MISC. NON.PROBA TE PROPERTY
FILE NUMBER
;Zl-O~ -r:fS7J
ITEM
NUMBER
1.
~I
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF /2 ~ L S AA
I,;) ~ tv E-~ / () /. "f.
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER.
ATTACH A COPY OF THE DEED FOR REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET
E () W!I-flf) ..:J7J IV Fs S 7lJCK. 13 R./)K IiileA6G
AetlJUIVI # ,J7{)-()q~30-I-O.
IN /,5 G>>7/Re" .4- a.~IJt( IV T j,{//J;) PI ~O E
~( '/
5 La3 if l?(!., T 7P -m/l-If)./ Fa; ()/f/ .t)~/!-T#
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-=---7
As re quested the date) of da te value, 09/13/2006, on Lois M. Bower's ccntracls are a5 follows:
Centrad 95-9490624 was $19,529.63 and
Centract 95-9638962 was $75,233.31.
r hope this helps.
Have a great day.
Thanks
Judi
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07/18/2005 13:59
7177319245
f<AREN
PAGE 01
LOIS M BOWER
421 W KELLER STREET
MECHANICSBURG, PA 17055-3732
EdwardJones
Jones Account Number: ?70-0Q2~O-1-n
Customer Name: LOIS M BOWRR
Destination: ESTATES
IR Number; 901272 Date: 06/~0I200:'i
Transfer On Death Beneficiary Designation Form
If the percentage is Jeft blank, the assets will be transferred in equal shares to the designated beneficiaries. Primary beneficiary
shares must equal 100%. Contingent beneficiary shares must equal 100 % for each primary beneficiary.
Primary Benefieiarv Desismations
% (whole numbers only) Name ,
. ~ % A r J\ N f. t L. ~H l V ~ L Y
%B .jJc..'jf'fPA M. Eif"f",cf
.~ %C -:lJkRiaf( W.SHi.VE~Y
%D
U.S. SSN (req) DOB (opt)
Ifr....J (:,,1);3 I~ 3... 7 - 1/..6-
'J-./o - ~"R 110 If 9 3-~ ,sf -{.it
:tolj-l/./I-1f7t7 ~ ~8- /'7
Address Phone (opt) W\.
4-?-1 ~. K fL..l- E (( :'it", 11\ ~
Cl ?. cr \.:..0 Cl 'Pc::p (l1'1I E:1>J). \q:lolJl.i ~ I" C<
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,
. ......ti.1~~if~i.!m~!j~I~!~::!::;j~j!
...... . . ... . .
.::. :!:.:::::~::::::::~:;:::::::::::~:::::
% (whole numbers only) Name
%E
%F
%0
%H
U.S. SSN (req) DOB (opt)
Address Phone (opt)
Conl~ent Beneficiary Desirnations
% (whole Primary Name
numbers) Beneficiary ......-ne.. ff 0
50 %.tL A lt7JR E w L. r ~ I f" ''\.
50 % -13- i-\ A )HO\ H tvI...-y 1: 1 ~ i R
%
%
%
%
%
%
U,S. SSN (req) DOR (opt) Address Phone (opt)
Iff' 70 .v..tJ.~ ~~~~
1'19 '" p. /;Lf -
% (whole Primary Name
numbers) Beneficiary
%
%
%
%
%
%
%
%
U.S. SSN (req) DOB (opt) Address Phone (opt)
II UII 111111 UU 1111 "" 11111111 U II 1111
Owner's initials
f,~.-e
200506200876BP1610102US
TODAGREE
DOC-NO~os0620-08768 SECTOR CODE: 001
1 of 2
07/18/2005 13:59
71 7731 9245
KAREN
PAGE 02
Account Name: LOIS M BnWRR
Account Number: ~7Q-n9230-j-O
Acknowledgment
I acknowledge that r have been furnished with the Edward Jones Transfer On Death Information Statement. r understand
that the TOD features of my Account have certain legal and tax implications, and, to be fully advised, I should seek
independent legal and tax advice prior to executing this Agreement. r acknowledge that neither Edward Jones nor any
of its agents has furnished such advice. By signing this Agreement, Owner(s) acknowledges that: (a) Owner(s) has
retained a copy of this Agreement; (b) Owner(s) has received a copy of the Edward Jones TOO Infonnation Statement;
(c) This Agreement contains a binding and enforceable arbitration in the sections titled IIArbitratjon Disclosure"
and "Agreement to Arbitration" starting 011 page 6, paragraph 6.
Note: If this is a joint acCOWlt with rights of survivorship, all joint tenants are required to sign this Agreement.
An agent under a Power of Attorney, a custodian, guardian or conservator cannot execute this Agreement.
Signature(s) ..0 "
X~~.~
Date 7- J~ - 6.1-
x
Date
~R;er~
r
Witness Signature(s) (Required when Account Owner is physically unable to sign).
Date
7- ,'"L. - oS-
x
Date
x
Date
NOTARY ACKNOWLEDGMENT:
PLEASE NOTE: The signing of this contract must be notarized Wlder the following conditions:
'" If an Investment Representative is not present at the time of signing by Account Owner(s).
'" When Witnesses are required to sign, see above.
On this day before me, , a notary public in and for the state of
. personally appeared to me known
to be the individual(s) described in and who executed the TOD Agreement, and aclmowledged that he or she signed
the same as his Or her free and voluntary act or deed, for the uses and purposes therein mentioned. Given under my
hand and seal this day of 20
Notary Public Signature
My Commission expires on
Rev 29 Apr 05
I 111111 1111111111 11111 11111 IIIIUIIII 11111 11111 1IIIIIftUIIII 11111111111111 1111111111111111111111111111111 111111111111111111
200S062008768P1610202US
2of2
07/18/2005 13:59
7177319245
KAREN
PAGE 01
LOIS M BOWER
421 W KELLER STREET
MECHANICSBURG, PA 17055-3732
EdwardJones
Jones Account Nwnhet:: 270-0Q2::\O-1-{)
Customer Name: LOIS M BOWRR
Destination: ESTATRS
IR Number; 901272 Date: 06J201200"i
Trdllsfer On Death Beneficiary Designation Fonn
[f the percentage is left blank, the assets will be transferred in equal shares to the designated beneficiaries. Primary beneficiary
shares must equal 100%. Contingent beneficiary shares must equal 100 % for each primary beneficiary.
Primary Beneficiarv Desimations
% (whole numbers only) Name .
. ~ % A r f.\ tJ t. t L.. ~HL V E' L Y
% B . IJ C1,., PA M.. E i f"t ~ ~
. ~ % C 7JAR'tolV W..,Sffl.V E L-Y
%D
U.S. SSN (req) DOB (opt)
Iyr-.J (:,,1):3 IA 3... 7 - 1/..6-
~I 0 -!Ii "VtJ I/- '7 ;;.. ~-'"
'-ocj-- /f.S'~1f7t7 dr :;l.8~ /'7
Address Phone (opt) WI!.
4-'>-' ~. KrL..l-En :'it", r\~
U"'-ce L:..o 1I 'PcJ'.(l I'll ~'P',q. \tl:ltii )II I"(C
II 1-1 \J~ k e: I..L..E: ~ ,S-r. nl)~3'
,
% (whole numbers only) Name
%E
%F
%G
%H
U.S. SSN (req) DOB (opt)
Address Phone (opt)
Cont~ent Benefici1U'Y Desimations
% (whole Primary Name
numbers) Beneficiary ./D-
50 % fL.A tt7JR E w L. If, ff["R,
50 %-J3-14AlfNAH M."'Yrl~iR
%
%
%
%
%
%
U.S. SSN (req) DOB (opt) Address Phone (opt)
IJY 70 .iU-l" ~t~ ,
I 'i~ '1 ~ . 'J. /'''1
% (whole Primary Name
numbers) Beneficiary
%
%
%
%
%
%
%
%
U.S. SSN (req) DOB (opt)
Address Phone (opt)
I~ I I111111111111111 NIII~I~lllllm
Owner's initials f. >1t.13.
2005062008168P1610l02US
TODAGREE
DOC-NO~OS0620-0876B SECTOR CODE: 001
1 of 2
07/18/2005 13:59
7177319245
KAREN
PAGE 02
Account Name: LOIS M BOWRR
Account Number: 27Q-092~O-1-0
I
Acknowledgment
I acknowledge that I have been fumished with tbe Edward Jones Transfer On Death Information Statement. I understand
that the TOD features of my Account have certain legal and tax implications, and, to be fully advised. I should seek
independent legal and tax advice prior to executing this Agreement. I acknowledge that neither Edward Jones nor any
of its agents has furnished such advice. By signing this Agreement, Owner(s) acknowledges that: (a) Owner(s) has
retained a copy of this Agreement; (b) Owner(s) bas received a copy of the Edward Jones TOO Information Statement;
(c) This Agreement contains a binding and enforceable arbitration in the sections titled "Arbitration Di$closure"
and "Agreement to Arbitration" starting on page 6. paragraph 6.
Note: If this is a joint account with rights of survivorship, all joint tenants are required to sign this Agreement.
An agent under a Power of Attorney, a custodian, guardian or conservator cannot execute this Agreement.
Signature(s) ..0 .
X~~.~
Date 7- J~ - 6j-
x
Date
~R;e:;-~
r
Witness Signature(s) (Required wben Account Owner is physically unable to sign).
Date
7- }'L - 0)
x
Date
x
Date
NOTARY ACKNOWLEDGMENT:
PLEASE NOTE: The signing of this contract must be notarized under the following conditions:
'" If an Investment Representative is not present at the time of signing by Account Owner(s).
'" When Witnesses are required to sign. see above.
On this day before me, ' a notary public in and for the state of
, personally appeared to me known
to be the individual(s) described in and who executed the TOO Agreement, and acknowledged that he or she signed
the same as bis Or ber free and voluntary act or deed, for the uses and purposes therein mentioned. Given under my
hand and seal this day of 20 ~
Notary Public Signature
My Commission expires on
Rev 29 Apr 05
1111111 ~lllllllllmllmlll~ 1111 11111 11111 IIIIIIHI'IOI 111111111111 111111111111 ~IIIIIIIIIIIII 0111111111111111111111
200506200B768P1610202US
20f2
APANY :
. .-V'l-C~ l'lCI,J_11J'L;:1 t1!~~IC.~!\".MI1 L"Vrl\;!
r ,I ~ Uc.
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r M.^ I~U. 4..):; j I Uti
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Change. of Beneficiary
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1'0 :Box 2:;'~
.Port Wl!(yn~ IN 46801-2348
TeL (800) 942-5500
i
r;.
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C..en.-.mtl
lnlu=.anon
...
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Ccmtract owner's name La ~ s m, Bo..!L't?1L Con~t't D:~~E 9 t.fq 0 (pJjj
!!....odal Seamty no. / & &, - I<./-,- (p ({i ~r t Phone no. '7 n - 7 ~ k,- .J f 6-~
,.
E
B..,neflclllry In aCCOlWmce wittl.ilit' p.ovU1antl oJ th1l' contract yoU. the rAnttact "wne;r. heJ:'el>y
- "~ - .- ;oe~tl~.. ttVoke all ionnltr ~gmnom. and c:lea to ~ the henefk:uuy as foUo"l'\"9' 5
----. ----------
Plmll:ry (you m~l haw I2t Iust "K~ pnmmy bnt-;fl~) - -.
y: Nami1 ,J~J'\il Shiva...~v
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Joint own~r's
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POD .:;urm -"8t9J.J;.L <f1f1~
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Page 1 of 2
E-'\('
/JiAti
Fixed Interest Plan
Annuity Statement
Prudential Annuity Service Center January 01, 2006 through December 31, 2006
P.O. Box 7960 .
Philadelphia, PA 19176
>01S46 3436S88 001 092001
LOIS lVi. BOWER
421 W KELLER ST
MECHANICSBURG, PA 17055-3732 ~
/ ' \)
~t- \i?~" .&)
~'.. '''-.
'.
Investment Professional:
JOHN L RIETHEIMER
PRUDENTIAL - PIF
150 CORPORATE CENTER DRIVE
SUITE 105
CAMP Hill, PA 17011-1759
.~
\/
-<'.. ..
rS>y Issue Date:
t1\.. Statement Date:
12/14/1994
12/31/2006
Annuity #:
Owner Name:
Annuitant:
96051696
LOIS M BOWER
LOIS M. BOWER
Type Non Qualified
For 24-hour access to your
portfolio performance, investment options, current account values and other information:
Sign on to our interactive Web site www.urudential.com
Or call our Annuity Service Center at ] -888-778-2888.
For other inquiries on your Annuity Contract, contact your Investment Professional at (7] 7) 975-8 1 E,O.
Please review your statement thoroughly and contact us if you fmd any information you believe to be inaccurate.
If we do not hear from you in 30 days, we will assume that all information is correct.
Your Portfolio
Your Annuity Activity
Beginning Value
Purchase Payments
Withdrawals
Contract Fees and Charges
Investment Performance
.. ....... .....
..Cur,l;elQ.t...P~iod...
Year-to-Date
. . . "." ... ...
.... ..... ....... ...,. ,....
....--.. __. ..... ...", ..
.-......................
... ..... .,., ..
"$38,108.65
.00
.00
.00
......$1,467.33
$38,108.65
.00
,00
.00
$ 1 ,467.33
Ending Value
Surrender Value
$$9,575.98
$39,575.98
$39,575.98
Portfolio Detail
J anuaJ-Y 0] , 2006 through December 3] , 2006
Fixed Investments
Account Value
as of December 31
] Year Fixed OJ/0]/20073.850%
$39,575.98
$39,575.98
Total Investment Value
Total Investment Value is the value of your annuity before the assessment of any applicable contingent deferred sales charge, rnaintenanre
fee, optional benefit fee or Market Value Adj)lstment.
Withdrawals made prior to the Statement lJate are reflected in the values shown abuve. The Maturity Date is the end uf YOUl Guarantee
Period. The surrendel value may change daiV to reflect the investment perfurmance of the Sub-Accounts in which you ale invested and
fluctuatiuns in UUl current fixed rates. Our current fixed rates are sensitive to inter'est rate fluctuatIOns ill the market.
i\!~f'1l1 Ii I;. Kk:itJI) ,-jnil'l' It \\ ;";jj
()bU:;JV.H), (:(:
Fixed Interest Plan
Annuity Statement
January 01,2006 through December 31,2006
Page 2 of ~
Your Benefit Values
The Annuity Death Benefit is shown as of the date of this statement and may fluctuate. For more details on how
the net death benefit is calculated, please review your prospectus. Certain terms and conditions detailed in your
prospectus may affect the actual death benefit.
Annuity Death Benefit
$39,575.98
The death benefit is paid out upon the death of the sole or last surviving annuitant. Please refer to your contract
or the annuity prospectus for an explanation of the features and benefits available under your contract.
Credits
Credits are provided based on cumulative Purchase Payments allocated. In certain circumstances the amount of
any Purchase Credit applied to your Account Value can be recovered.
Special Programs as of December 31, 2006
The following special programs have not been selected: Electronic Funds Transfer, Systematic Withdrawals
Some special programs may not be available due to age requirements, minimum account value, or other optional
programs selected.
Primary Beneficiary Information
JANET L. SHIVELY
!!!!'portant Messages
For eClbC of (CfCrCi'iCC, 'v~v'C L:8C a single set of defl!:ed tc!"'rns !!1 this ~!9.1:'?nlrnt In crrt::lln (~:::t8e~; YOllr contract nlay
use a different name for a contract feature than what is used in this statement.
Investment performance depicts the change in your contract's value during the period covered by this report due
to gains or losses in your variable sub-accounts and any interest you earned in a fixed allocation option.
Anlluily iB i:-iRUed by tile PrudeIlLialIiIHUrl:llIC{' Cumpany or J\lIwricH.
REV-1511 EX+ (12-99)
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF I'Q
U DWE1e, LOiS M.
FILE NUMBER
;;J. , - Oft, -850
ITEM
NUMBER
A.
Debts of decedent must be reported on Schedule I.
DESCRIPTION
1.
FUNERAL EXPENSES:
Mitt. PE2Z1 FUNflUt-L HomE: OF hlG"(J,H'+IYICt f>uR,6
~ TN € RhlEiL' FtJ;~ IS 1J ()~ /J1eaH AN' I(!S if!J &( Il~
t1 ddi-1t()lta! clefl/l, Ce"rfih'c41e.s
~.
J.
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s) .rAN E T t... .:5HIJlF/.--Y
Social Security Number(s)/EIN Number of Personal Representative(s) Iff -
Street Address J.3S: IVI?$L.EY ~'I AIr. J()3, i3smAJ/Y 7iiwc:-lfS'
City l>>eC!HA#/t!$ J31.l~G. State PA- Zip 170SS
2.
Year(s) Commission Paid:
Attorney Fees CH4R.L/:$ J:. SNI€t..lJS 7lI1 Estj.
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
4.
5.
6.
7.
8.
,.
II?,
II.
/2.
Claimant
IItJNE
Street Address
City
State _ Zip
Relationship of Claimant to Decedent
.. ...1 '- I 'I '$"" of short c.erti t,'ca f-es
Probate Fees J(AI\q 0 r;6 I raw ." "'"" I j
Accountant's Fees L eru.dDy) #Dff7raItJ1J J GrUN,I.()/L1t 1 ~. (es hirJ.)
Tax Return Preparer's Feej N- .Pt'f'I4,l cll)~&J: ID'Io) Pftq.()1 Est. 10lfll PA 4/1 tk .
II-tlllert/o/ng III Ct.uII\berl M\d LA.l() .Jol4rnltf
!i4rel"f;slfz3 i/l C4d/J/e Eyenill! Senf'ne.1 NlJfI.sfJo/IeI'
AJJi.J../0II41 \\Shbrt c.ert; f,'co.fes
A 11,,;11"1101 f/'DJ)(d~ Pus
F/~/I " ;1eh'j.'tJl1 ~ lJ/sSo/ve 7iwst
p, J, fl ,f A-~~ul1l/ ~~ ~lIhiuul'~Jt ~ )
AMOUNT
~ 90
8; 9' 9.
'1/, f. .0
f 7 '2. . Of)
(,VI/I liED
"7J lIS; t;f)
No AlE
,..,
10(,.00
~,s~.oo
~7S. 00
, I 07.99
~~.DO
"l-
I os. PO
fA, 5'. DO
., 3(). 00
TOTAL (Also enter on line 9, Recapitulation) $ Il;, ,()tf; 9'1
(If more space is needed, insert additional sheets of the same size)
I H I
iS~IIED. ,~'oI Esr DF l3()tp~ LL;/.f IJJ./ g 2./-o6-'?St;
I ~
_ 13.jJ511~,?......~~.~lC_...&k~~L-. _._....____._ ....___.__._...___..__.______.___._________1.[. .~o _
If. J_&im6tO:SUJ1tn.i ....t _eJu{1:lG5-~...-.S1/'.ti..rI~.JlL.-~t:.-(!.ertl~..
1hf',Ub'f"" r-;l!-'fi1Rjs.;t~~It>.I!R/li(,~,~: .._~....... /es.6 ;"J. . ~ 6.2. So
I
...-.-.......-1..--.--.. ......-.--- .... ......-.--.-.-- ..-...-....-.-..
., .-- _.._-.,..---_...----_.._-_.._~-.".._,_.."----.._--_._.._..--"'." - ._._.._-----_._~.._._.-...,------_..._.~-~"---_. _.- ,----'---- ,--
..... .___,___,_.~.____.___'.,__.._.___. ___.______.__".,_.~_.~_____.__.____.____.._._"._~__.__~m__~"_'...__~___,.,_.___.__.__._..__,_..,.__._.______.._..-. ---------.--.-,.------------------.
,_...... -_..---_.-.-.__.._.._."----~_.'"-_.-._._- ,---_._"'~..,....._-------_._--~._.----_._...~_._._._--.---.----
-~--_._._.- _.._...----,-_._._.--------_."-'.-_..~._--_.__._._._--'.---,-,_._._~~~-_..--_..,.._-~-_.~---"_._~---_._-- -_.._--.._.._--~....,--_.,,"--_. -........","--.-,.... -...._._-,.._"~-_..__.-.
-,,'-..--<.' ..,,"-'" - ,..-----'..-_._--~--------,---_.._--"'_...__....__..---~.~'-" _.._,,---~._._..-.,- ,_.--.._-_._---_.~ ~-~-_.__.__.._..,' ,~----'-"-"--.--~" --".... ._-_._._--~-~-_.._-,..._--_.__...-- --_.~------...._--_._~-'-----
---~-_.._._----' --,.__.._,....--..._-_._,,--,,_..__._._--~~_..~-~_.__.~~-'----~.~._-..__.-~.._-~--_.._- ......_._-,~._----_._----^"-_.__.,'-,~-."_.....-
-"-'~'~'-- --_.-"-~"-------'" -.~--~_._'.--------_..--~._--~-----~-'_.---.'"._--..-..~---._~_._-"_.._''''--.
Mar 30 07 04:06p
717-766-3229
p. 1
t:1.', ~.. . /... i.
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'~~~,:(;;:~'.~;;:~,/::: .
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1 B '.VEST CO,,"::'VEP STR=8
!,.\[CHAI-.liC5!}!JIK, h", 17(J5:5
PHONE 766-9351
'ww'Ii,ro!nermels.coll1
~ PERSON I-=LHARGE
DESCAIPTIOJl
.mll~~~'~'U "~
AMOUNT )
I'J \.
r ,..,,-
/ ~C)
w
cs
S'
10. 'S
\.
I
2 I SC:>-ffa.4e r~/
Il"~'~"" ('; .C>
. eGrL c:fd
. el
I
.~,
~
J;u,'(\(IA
SUB TOTAL
I{;o
4i
DELIVERY
CODE
ANNIVER, CONCRAT.
TAX
(0
CARD
....._. LQ.V:~0-}... E9,.N'~'~"""'" ........,... ._.' .__. ....~..... ........... .-,'c._
-----~~..-_. ---_.---_..~.- --.. - -- - --. ~-_._------- -~~--- ..---. ....---------.....---------.---
- - - - . - - - . -.. - - - - - - - - - . - . - - ~ - - - - - - ~ .. - - - - - . . - - - - - .. - - - - . - - - - . . .. .. .. .. - - ...... - . . - .. .. . .. - - - - - -
. - P' .._. ."..._ ._. . . .. .u_ _"." _ _0" _ -."
FIRST NAME LAST NAME
DELIVER TO {o ( )'
ADDRESS 1'\1\,.9'/)'- 'Z ,:
/, Ii L:"
,~ "J
'7'
I',;> C) lJ~J ~
{- r-t
CITY
I PHONE
NO.
\..
STATE
APT
/A
ZIP
CODE
'\,
(~)..III92
V0015B 3 pi
REV-1512 EX+ (12-03) .
*r..
. "'-
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF
Bow~; LoIS IJI.
FILE NUMBER
i?./ - O~ -J'S-O
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM
NUMBER
1.
~.
DESCRIPTION
11/7/0fp elt. N. /01 "(Many [/;" a'lL, ba.Jfu1G1! &.u..e Oil YhonHtly
Fee ch {a-reS
1I1/7/{}f9 ck no. /02 Ct1l11f 11,'/1 12 rn lnfUt-c..y V?Jt ys i c i 4 f16 -foY"
c.1"';"";~cJ Ca.X~ ,J- l40ly Sp; fit HDSp~ f-al.
~, /Jt:lJt. of Re,VUZUt "br /A fO cJo~ ~WI rdurn
VALUE AT DATE
OF DEATH
,
I 33. Ff
~
if{).2B
3.
r
37. ~o
I
TOTAL (Also enter on line 10. Recapitulation) $/
I
2/1./&
(!: murE spac~ j~ needed, Irlsert addito:13; sheeb of tlll; 00lllli i.1lzBj
~
CHARLES E. SHIELDS, III
A7TORNEY-AT-LAW
6 CLOUSER ROAD
Corner of1hl1dlc and Clouser Roads
MECHAN1CSBURG, PA 17055
GEORGE M. HOUCK
(1912-1991)
TELEPHONE (717) 766-0209
FAX (7]7) 795-7473
November 6, 2006
Bethany Village
325 Wesley Drive
Mechanicsburg, PA 17055
In Re:
Estate of Lois M. Bower, Deceased
Dear Sir / Madam:
Please find enclosed Check No. 101 in the amount of $133.88 in payment of the statement
dated November 3, 2006. Please advise whether there are any further debts or credits outstanding
regarding Ms. Bower.
Thank you.
Very truly yours,
~,('//4~
Charles E. Shields, III
Attorney-At-Law
CES/mjj
Enclosure
cc: Janet Shively, Executrix
EST OF LOIS M BOWER DECO
JANET L SHIVELY EXTRX
335 WESLEY DR APT 103
MECHANICS BURG, PA 17055-3522
101
60-1273/313
041
~
~ PNCBANK
PNC Bank. N.A 040
Central PA
Dollars tD ~:.=~~~'
Fm;t~~
I: 0 \ ~:.1 ~ 2 7 :.1 B I: 500 4 B 7 b 70 7111
o ~O ~
A
,~~
-@:ethany Village
T 325 Wesley Drive
Mechanicsburg, PA ] 7055
11/03/2006 Upon Receipt
ACCOUNT NUMBER
2031
Statement Date Due Date
$133.88
AMOUNTPAID$ /3~,g'~
Please make check payable to BETHANY CENTER APARTMENTS
LOIS M BOWER
c/o JANET SHIVLEY
Remit To:
BETHANY VILLAGE
325 WESLEY DRIVE
MECHANICSBURG, PA 17055
Please detach and return this portion with your remittance to the address above.
Comments
PreBiII 0 - 30 31 - 60 61 - 90 > 90 BALANCE DUE
$0.00
I $133.88
$0.00
$0.00
I $0.00
$133.88
Balance Forward
10/03/06 - 10/31/06 Monthly Fee
(29)
$2,036.00
$(1,902.12)
TOTAL BALANCE DUE:
$133.88
FACILITY NAME
I BETHANY CE~~TER APARTMENTS
RESIDEI'-JT NAME
LOIS M BOWER
ACCOUNT NUMBER
2031
~
vUIlIlIlt:IIL~
PreBiII 0 - 30 31 - 60 61 - 90 > 90 BALANCE DUE
[._ $0..00 ~
$133.88
$0.00 ~i
$0.00
$0.00 ~
$133.88
Balance Forward
10/03/06 -10/31/06 Monthly Fee
(29)
$2,036.00
$(1,902.12)
TOTAL BALANCE DUE:
$133.88
FACILITY NAME
I BETHANY CENTER APARTMENTS
RESIDENT NAME
LOIS M BOWER
ACCOUNT NUMBER
2031
19/ /'
,VtS
,
CHARLES E. SHIELDS, III
A TJ'ORNEY-AT-LAW
6 CLOUSER ROAD
Comer ofTrindle alld Clouser Roads
MECHANICSBURG, PA ] 7055
GEORGE M. HOUCK
(l912-199] )
TELEPHONE (7]7) 766-0209
FAX 0]7) 795-7473
November 19,2006
Camp Hill Emergency Physiciat1;5
PO Box 13693
Philadelphia, PA 19101-3693
In Re:
Estate of Lois M. Bower, Deceased
Dear Sir / Madam:
Please finel enclosed Check No. 102 in the amount of $40.28 in payment of the statement dated
November 15,2006. Please advise whether there are any further debts or credits outstanding regarding
Ms. Bower.
Thank you.
Very truly yours,
~-f
Charles E. Shields, III
Attorney-At-Law
CES/mjj
Enclosure
cc: Janet Shively, Executrix
LOIS M BOWER
335 WESLEY DR APT 103
MECHANICSBURG PA 17055-3522
YOU MAY PAY THIS BILL WITH YOUR CREDIT CARD
PLEASE SEE REVERSE SIDE.
Make CheckIMoney Order payable to:
11..111.11111,1111,111,,111,11,,111,1,1111,1111,1111
CAMP HILL EMERGENCY PHYSICIA
PO BOX 13693
PHILADELPHIA, PA 19101-3693
STATEMENT OF ACCOUNT
Statement Date: NOVEMBER 15,2006
ACCOUNT NUMBERI
CUENTAS DEL PAC'ENTE: HYP2B333631
Patient Name: LOIS M BOWER
Payment Due Byl
Fecha De Venclmlento: 12106106
Amount Duel
Pague Eats Cantldad: $40.28
AmountEncl08ed/~O "Ii
Cantldad Paga: . lilt.
The mauranee Informallon In our file appears below. Plea... make a~ correctlona
and/or addRlonl on Ihe reverlllllae of Ihil form and naturn " 10 UI. Thank you.
MED HGS I'.oMIN MEOlCARE PART B
1116146873A
o 'fyour address has changed, check this box
and complete the reverse side of this form.
0825160000028333631000040280000000000006
EST OF LOIS M BOWER DECO
JANET L SHIVELY EXTRX ..f\ CfL) 17 ~
335 WESLEY DR APT 103 Date4 I
MECHANICS BURG, PA ""55-3522 () I · . '6
::;::,::::{ ~ ~ &-~(jr btt #$ 11 (). ~ =-_
~ ~ Dollars l.!J "....~~.
G~~Nl( ~.
:;'~Jf~~~~:~~DD~B7b7D~~ ~
102
60-1273/313
041
~!C'J'lI'lt..,<jmerKt...
. --.--. .........vlvv'ULlIU1~1--rCE.
N
.,.
CAMP HILL EMERGENCY PHYSICIA
PO BOX 13693
PHILADELPHIA, PA 19101-3693
STATEMENTOFACCOUNT (1)
Statement Date: NOVEMBER 15, 2006
ACCOUNT NUMBER!
CUENTAS DEL PACIENTE: HYP28333631
Tax 10 #: 20-4667340
AceountBa'ance: $40.28
Amount Pending
Insurance: $0.00
Amount Due from
Patient (Current); $40.28
Amount Due from
Patient Past Due: $0.00
Pa This Amount: $40.28
PLEASE REMIT PAYMENT BY
"PAYMENT DUE BY" DATE. THANK YOU.
Plea.e refer to COUpon below for payment
Instructions.
,.. .,',. ..",....,.,..,.,..." ..,.,...,.,..,.,..,."..,.11...,
082516-0000028333631_06
#BWNJFDB
#0000000HYP124050#
LOIS M BOWER
335 WESLEY DR APT 103
MECHANICSBURG PA 17055-3522
Account Detail
PATIENT
PIIIdBy P.1d By P.1d By Amount Du. From 8AL.ANCE
o.llI , Descmtlon Ch8rae Flrst,ns. Other Ins. P8llent Adluallld Insufllnce
08/25106 1 99291 CRITlCAl CARE, FIRST HOUR $926.00
DX:518.4 DR. MCGANNfHOL Y SPIRIT HOSP TAL
11108106 MEDICARE CONTAAC11JAL ALLOWANCE $724.82-
llf08106 MEDICARE PAYMENT $181.10- $40.28
Totals $926.00 $181.10- SO.OO SO.OO $724.82- SO.OO $40.28
Important Messages:
Thla slalllmentla for the direct lrMIrnent and/or superyjelon of ca... you -ttv ~ from an Emergency Physician at Holy Splrtt HoepIlaL The rea for lhla private phYSician
.... blUed Mpa/'IIllIIy rrom any hospital charges or other profeaelonal rea for which you may aJeo be -ponslble. Theretor8. should you~ a bill rrom the hospital or other
physicians for charges In connection with Ihla vlIJt, ft will not Include lhe Items IlIted on Ihle elatemenl
"Payment Plans" Accepted I Aceptamos "Planes de Pago"
Question about this statement? I Llame de Lunes a Vlemes?
Call 1-800-355-2470 Monday through Friday 9:30AM _ 4:00PM.
Your automated system access code Is 801-28333631, or you can send emall to
billing questlons@emcere.com.
Please detach and refurnbottom POrtion with your remittance.
+ + Favor de separar y mandar la parte de abaJo con el cheque. + +
REV-1513 EX+ (9-00) .
. ~ '*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
t30t<J1::~.1 LOIS /J1.
FILE NUMBER
;(/-0' -Jso
RELATIONSHIP TO DECEDENT
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s)
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)J
1. 1'Jf:f) I'/pre: VEe€t>1!:/I/T' Hus8~O PteE-
~ E f!B'fSl::7:> HE?{ (IP 2)
.Jtl.r1e+ l... 5h; velj
335 Wesler Drive
~. /D3, &M4AY 7i"lUefU
mec.h~n ic.sbu1' PA- 170 S~
PJJC (3I14/1.K.I ""1.( ~tu. (4s S IA ec e$$tu t
r=,A"sf $kllk f. /rust)
'f2L1Z. C!4r/isk ;J,~
Ca-Al,d H//~ iJ If /7 t:J II
~.
c/ IL~ ld"Y'
3
X."e.ottoa ~ d~4~
p,.u..er 1; Cb"$LI.~
1. b.D. cl4Wjh+~r
0hUj ~~MLU fr;>
3r~Gh;ldreY1.
AMOUNT OR SHARE
OF ESTATE
Vz cf n~t ft
est4J~ .
Yz. of net
eshik.
ItINRJ Jl'bnF: 77UfST HAs ~ew .iJlS$o[.,J'fl) JA)
FA-Yo//' /')/=" (J1f/f~r~. SN/YI5ZY /fS, ~~ ( 'L~hkr fJt:tj )
Pe77 7lt'/f/ 7P IfWO O/Z,(/~ t:J/= ~IlP~t!-r. loo?D Dfl1:S,'due.
fWD c.".D1 c.tc..S 7,",oU(yl.{ fNM..r~uUY j)J(AWN '"
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1. t1!Ef<f 7P IA/IJle IrTE n.tA-7 H~"tFI{Ol-/) F~/UlISHING-5 /AI THE
Hplt1€ A-7 tJAI~ TIME SIiA-Il€O 13 Y (JPCEt}ENT IfNI) iJtt.U~J(TBl
WERE EI7lIEfl THE fJetfSONAl. flbl'lFlZTy "p f)1fU6H7t:71 DR.. HAl)
/3EE1J (;/vf!FN 7i; IJl/-u(,;I7d. !U6IUF 71{A-N ,pi'll: YBhe 13~1U"
1).0.1>. 7J/D>E ITE1Yl.5 NoT Sd ~(,f/#ef) lJt<.. GIFr&7) ~
usrl!F.1J Ar selllE]), E. M.If,
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
34114r1IlSJ U J un;ted fl1effzod,'.sf ChuYGL.
fo'l hi alA:sf; t'7t> ~)C: Ifpi/-
JUIJ4dll.5 ~1I7' fJA /77lft)
st. P"kl Ca..Jv#.') IAn:Y lYJetftod;st ChLU"d,
J Lf '2. =1- m e ry)() r; 0.1 A-ve.
IN ill i cunsport" PA J 770 /
J.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
5~ Dille!
res;oIue.
5% ~f lief
rt:s/c/ut: .
(If more space is needed, insert additional srleets of the sam", size)
"
LAST WILL AND TESTAJ\1ENT OF LOIS N. BOWER
I, LOIS M. BOWER, of the Borough of .Mechanicsburg,
County of Cumberland and State of Pennsylvania, being of
sound and disposing mind, memory and understanding, do make,
publish and declare this to be my Last will and Testament,
hereby revoking and making void all former Wills by me at
any time heretofore made.
1.
I direct the payment of all my just debts and
funeral expenses as soon as conveniently may be after my
decease.
2.
All the rest, residue and remainder of my Estate,
real, personal and mixed, whatsoever and wheresoever situate,
I give, devise and bequeath unto my husband, Kenneth I.
Bower, to his own use and benefit absolutely.
3.
In the event, however, that my said husband should
predecease me, or should die at about the same time as I do,
such as in a disaster common to both of us, I direct that my
Estate be distributed as follows:
A. I give and bequeath five (5%) percent of my
net Residuary Estate to the Salladasburg United Metho-
dist Church, Salladasburg, Pennsylvania.
B. I give and bequeath five (5%) percent of my
net Residuary Estate to St. Paul's United Methodist
Church, Williamsport, Pennsylvania.
C. I give and bequeath to my daughter, Janet L.
Shively, one-half (~) of the balance of my net Estate.
-1-
'\
D. I give and bequeath the remaining one-half
(~) of my net Residuary Estate to The First Bank and
Trust Company of Mechanicsburg, Pennsylvania, Trustee,
in Trust for the following purposes:
(1) To pay the net income therefrom to my daugh-
ter, Janet L. Shively, periodically, for and
during the rest of her natural life.
(2) In the event that my said daughter should ex-
haust her o\vn assets, the Trustee shall have
discretionary authority to use and consume all
the remaining part of the principal of this
Trust Estate for the comfortable maintenance
and support of my said daughter, including
payment of medical, hospital and other in-
stitutional care.
(3) After the death of my said daughter, the re-
maining balance of principal in said Trust Es-
tate, plus any accrued income, shall be divided
equally between my grandchildren, Lucinda M.
Shively and Barton W. Shively; provided'however,
that each of them has reached the age of twenty-
five (25) years at the time when said distri-
bution is to be made to them. If either of
them has not reached the age of twenty-five
(25) years, the share of such one shall be held
in Trust by the Trustee until she or he reaches
the age of twenty-five (25) years, the income
of such share to be paid to my grandchild
periodically, and the Trustee to have the same
discretionary authority as set forth above as
far as the use and consumption of principal is
concerned.
-2-
r-
.,
(4) I direct that the interests of all beneficia-
ries in the Trust hereby created, whether in
the princiPfl or income thereof, shall be free
from liability to attachment or other legal
process issued at the instance of any creditor
or assignee of such beneficiary, and I direct
that no payment shall be made by way of anti-
cipa tion of sums \.rhich may thereaf-ter accrue
to any beneficiary.
(5) If the Trustee has taken into the Trust Es-
tate any real estate, and as Trustee considers
it feasible to sell the same, I hereby author-
ize, empower and direct the said Trustee to
sell at public or private sale or sales, and
to convey any such real estate to the purchaser
or purchasers thereof, and to give good and
sufficient Deed or Deeds for the same.
4 .
LASTLY, I nominate, constitute and appoint my hus-
band, Kenneth I. BOHer, to be the Executor of this, my Last
~'Jill and Testament. If he should predecease me, or for any
other reason be unable to act, or to continue to act, as such
Executor, I appoint my daughter, Janet L. Shively, to be the
Executrix in his place and stead. I further direct that she
shall not be required to file bond or other security in the
office of the Register of Wills for the purpose of adminis-
tering my Estate.
-3-
,.
IN WITNESS ~^lHEREOF, I have hereunto set my hand
and seal this '~/..::;;fday of January, A. D. 1983.
__~~:J21_:....._ '11A'T-?:.~U2::~'::::.-._ ( SEJlL )
Signed, sealed, published and declared by the
above-named LOIS M. BOWER, as and for her Last Hill and
Testament, in the presence of us, who, at her request and
in her presence, and in the presence of each other, have
hereunto subscribed our names as vlitnesses.
/'..',
( J,//__ //
~~(/ (~)' ,
/" ,- , /' ,/', (-" -
~L. . .f''.r ~_:-1ck'BL
I-
\"-"
~;/ ,5---- :-;?",/-, ~
----"' ~~.-d.(Z.;Cl.~,_L._.______
/
/"
-4-
:S r\Cl~D