HomeMy WebLinkAbout01-28-08 (2)
REV.tWO I?'.x + (6-00)
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
COMMONWEAL TH OF
PENNSYLVANIA
CEPARTMENTOFREV~NUE
DEPT. 280601
HARRISBURG, PA. 17128-0601
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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STROME
DATE OF DEATH (MM-DD-Year)
MARGARET SHAW
DATE OF BIRTH (MM-DD-Year)
09/30/2007 11/10/1917
(IF APPLICABLE) SURVIVING SPOUSES NAME {LAST. FIRST. AND MIDDLE INITIAL}
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[X) 1. Original Return
o 4. limited Estate
lXl 6. Decedent Died Testate (A\laCh copy of Will)
o 9. litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (A\laCh copy of Trust)
o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
OFFIC'AL USE ONLY
FILE NUMBER
2 1 -0 7 0 9 0 7
""CQl;NTY'C'Oo'E -YEA~ - - NUM8E - -
SOCIAL SECURITY NUMBER
1 74- 3 4 - 8 1 3 7
THIS RETURN MUST BE FILED IN DUPLICATE ITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
D 3. Remainder Return (date of death prior 12.13-82)
o 5. Federal Estate Tax Return Require
_ 8. Total Number of Safe Deposit Boxe
o 11. Election to tax under Sec. 9113(A) .. Attach Sch 0)
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THIS SECnON...MUSTBECOMPlETED.<Al..lCORRESPONDENCEANOCONFIDENTlAlfTAX:(NF.ORMATION:SHOUlDBEDIRECTED
NAME COMPLETE MAILING ADDRESS
DOUGLAS G. MILLER ESQUIRE 60 WEST POMFRET STREET
FIRM NAME (If Applicable)
IRWIN & McKNIGHT
TELEPHONE NUMBER
717 249-2353 CARLISLE PA 1701
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
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)
10. Debts of Decedent. Mortgage Liabilities, & Liens (Schedule I)
(1 )
(2)
(3)
(4)
(5)
(6)
(7)
(9)
(10)
11. Total Deductions (total Lines 9 & 10) (11)
12. Net Value of Estate (Line 8 minus Line 11) (12)
13. Charitable and GovemmentalBequests/Sec 9113 Trusts for which an election to tax has not been (13)
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate. or transfers under Sec. 9116 (a)(1.2)
0.00 X _ (15)
142,933.91 X .045 (16)
15,303.49 X .12 (17)
0.00 X .15 (18)
(19)
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
19. Tax Due
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
>>.......BE. SURETO ANSWEf{'Al...L. QUESTIONS ON REVERSE'SIDEAND .RECHECKMATH/<<:
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OFFICIAL USE ONL
105,497.88
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58,956.49
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15,303.49 ~- /
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19,815.50
1,704.96
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64 .03
1 :83 .42
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8,26 .45
ece en s ompl e e ress:
STREET ADDRESS 210 BIG SPRING AVE.
CITY I STATE I ZIP I
NEWVILLE PA 17241
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Tax Payments and Credits.
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
~
8i268.45
~
7'T2
7 000.00
413.42
3. InteresVPenalty if applicable
D. Interest
E. Penalty
Total Credits ( A + B + C) (2)
TotallnteresVPenalty ( D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + line 3 is greater than line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (SA)
8. Enter the total of Line 5 + SA. This is the BALANCE DUE. (58)
Make Check Payable to: REGISTER OF WILLS, AGENT
000
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;. ..... ......... ... ....... .., ... ...... ... ....... ............. .... ..... .... 0
b. retain the right to designate who shall use the property transferred or its income;...................................... 0
c. retain a reversionary interest; .or... . .. . ... .. . ... .... .. . . . . ...... . .. . .. ... . .. .. ... .. . .......... . . ... .... . . .. ... .. . .. . .. . ... . . . . .. " 0
d. receive the promise for life of either payments. benefits or care?.......................................................... 0
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?... ..... ... .......... ... ..... .......... ... ...... .... ....... ......... ....... .... ... ....... 0
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death2............... 0
4. Did decedent own an Individual Retirement Account, annuity. or other. non-probate property which
contains a beneficiary designation:?... ... .......... ........ .., .... .... ...... ... ....... .......... ..... ........ ........ ....... ......... 0
000
855 03 P
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No
00
00
00
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00
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00
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
ADDRESS
PA 17013
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. ~9116 (a) (1.1) (i)].
For dates of death on or after January 1. 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)].1
The statute does not exemot 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 ~
the surviving spouse is the only beneficiary. i
For dates of death on or after July 1, 2000: I
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. ~9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%. except as noted in 72 P .S. ~9116(1.2) [72 P.S. 99116(a)(1 )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. ~9116(a)(1.3)]. A sibling is defined. under Section 9102, as an .
individual who has at least one parent in common with the decedent, whether by blood or adoption.
.
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REV-1503 EX + (6-98)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
STROME
0907
MARGARET
FILE NUMBER
21 07
SHAW
All property jolntly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
2.
3.
DESCRIPTION
VALUE AT DATE I
OF DEATH I
12,508~54
I
19,971199
CITI SMITH BARNEY
ACCOUNT #724-03541-13409
BANK DEPOSIT PROGRAM PRINCIPAL
AT&T, INC.
477 SHARES @ $41.87 = $19,971.99
ALCA TEL-LUCENT ADR
57 SHARES @ $10.04 = $572.28
SHARES IDEARC, INC.
16 SHARES @ $31.10 = $497.60
SHARES LSI CORP
15 SHARES @ $7.46 = $111.90
QWEST COMMUNICATIONS INTL
162 SHARES @49.15 = $1,482.30
VERIZON COMMUNICATIONS
324 SHARES @ $44.97 = $14,570.28
ALLlANCEBERNSTEIN BOND FUND
1,133.722 SHARES @ $11.88 = $13,468.62
COMPUTERSHARE - ACCOUNT #3316831
834 SHARES AT&T
834 SHARES @ 41.87 = $34,919.58
572~28
497 .~O
111.ao
I
1 ,482.~0
!
14,570.~8
I
13,468.~2
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34,919.~8
BANK OF NEW YORK - ACCOUNT #21900001702109
201.000 SHARES @ $36.79 = $7,394.79
7,394.~
,
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed. insert additional sheets of the same size)
105.497.8d
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REV-1508 EX + (6-98)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
STROME
MARGARET
SHAW
FILE NUMBER
21 07
0907
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. F&M TRUST 9,242 49
ACCOUNT #33-16831 I
NOW ACCOUNT I
2. F&M TRUST 5,000~00
ACCOUNT #015-2968144 44.614.fa
CERTIFICATE OF DEPOSIT
3. F&M TRUST
ACCOUNT #70-56885
MMA ACCOUNT
4. PERSONAL PROPERTY 1Oa.ra
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TOTAL (Also enter on line 5, Recapitulation) $ 58 956.49
(If more space is needed, insert additional sheets of the same size)
REV-1509 EX + (6-98)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
STROME
MARGARET
SHAW
FILE NUMBER
21 07
0907
If an asset was made joint within one year of the decedenfs date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DE~EDENT
i
SISTER :
A. ELEANOR S. REID
31 MIDDLE STREET
AMHERST, MA 01002
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JOINTLy.oWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF: ~~A TH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VALUE F
NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. 10/1992 COMPUTERS HARE 30,606.97 50. 15,303.49
731 SHARES AT&T
731 X $41.87 = $30,606.97
j
TOTAL (Also enter on line 6, Recapitulation) $ I
15,303.49
(If more space is needed, insert additional sheets of the same size)
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REV-1511 EX + (12-99)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
STROME
ITEM
NUMBER
A.
1.
2.
3.
4.
FILE NUMBER
MARGARET
SHAW
21
07
Debts of decedent must be reported on Schedule I.
DESCRIPTION
FUNERAL EXPENSES:
EGGER FUNERAL HOME
PASTOR
FIRST PRESBYTERIAN CHURCH - FUNERAL LUNCHEON
T & J MONUMENT SERVICES - ETCHING
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
City
State
Zip
Year(s) Commission Paid:
Attomey Fees IRWIN & McKNIGHT
Family Exemption: (If decedenfs address is not the same as claimanfs, attach explanation)
Claimant
Street Address
City
State
Zip
Relationship of Claimant to Decedent
Probate Fees REGISTER OF WILLS
Accountanfs Fees
Tax Return Preparer's Fees PATRICIA A. ROSENDALE, CPA
REGISTER OF WILLS - FILING FEE
NOTARY FEES
CUMBERLAND LAW JOURNAL - ESTATE NOTICE
THE SENTINEL - ESTATE NOTICE
REGISTER OF WILLS - ADDITIONAL PROBATE FEE
MIRIT GREAT AMERICAN VAN LINES, INC. - SHIPPING EXPENSES - FURNITURE
UPS - SHIPPING
MEDALLlAN FEE
PAUL STROME - REIMBURSEMENT OF TRAVEL EXPENSES
ACME STORAGE
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
0907
AMOUNT
7,71088
200 00
300 00
102 50
I
8,500.QO
I
302.qo
\
I
350.03
30.00
25.0D
75.0D
166.60
50.ob
1IO~~:~l$
5.0
764.8
73.1
1
19.815.5C
REV-1512 EX + (6-98)
..
'*
SCHEDULE.
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
STROME
MARGARET
SHAW
21
07
0907
Include un reimbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1. FIRST UNITED PRESBYTERIAN - OUTSTANDING OBLIGATION
VALUE AT DATE
OF DEATH
437,00
2. BOARD OF PENSIONS - REIMBURSEMENT OF PENSION
974;85
3. GREEN RIDGE VilLAGE - NURSING
205.69
4. CONTINUING CARE RX - MEDICAL
I
87.l:t2
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed. insert additional sheets of the same size)
1,704.96
R~_151~~+I.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
NUMBER
1.
SCHEDULE J
BENEFICIARIES
FILE NUMBER
NAME AND ADDRESS OF PERSON{S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
1.
PAUL F. STROME
3406 N. GREENVIEW AVENUE
CHICAGO, IL 60657
Lineal
47,644.64
1/3 REMAINDER
47,$44.64
1/3 REMAINDER
47,644.63
1/3 REMAINDER
15,~3.49
AT&T STOCK-
JOINT ACCOUNT !
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIA TE, ON REV-1500 COVER SHEE
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
2.
MARY L. STROME STAHL
18395 OLD HIGHWAY 18
MANHATTAN, KS 66502
Lineal
3.
ANN STROME GOLD
635 N. 7TH STREET
MANITOWOC, WI 45220
Lineal
4.
ELEANOR S. REID
31 MIDDLE STREET
AMHERST, MA 01002
Sibling
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
LAST WILL AND TESTAMENT
I, MARGARET SHAW STROME, of 525 Market Street, New Berlin, Union ~ounty,
Pennsylvania, being of sound mind and memory, do make, publish and declare this
to be my last will and testament, hereby revoking all former wills by me at any
time heretofore made.
ITEM ONE: I direct my hereinafter named Executor, Alternate Executor or
Second Alternate Executrix to pay all my just debts and funeral expenses and in
the event that I have not done so prior to my death, I direct my Executor,
Alternate Executor or Second Alternate Executrix to purchase and place a
suitable marker upon my grave, and should the circumstances require it, upQn the
grave of my husband, as soon as conveniently may be after my death.
PART I
ITEM TWO: I hereby nomi nate and appo; nt my husband, JOHN HA~lIL TON IPAUL
STROME, Executor of this my last will and testament.
I
ITEM THREE: I hereby nominate and appoint my son, PAUL F. STROME, pf
823 North Taylor, Oak Park, Illinois, 60302, Alternate Executor of this my ijast
will and testament in the event that my husband, JOHN HAMILTON PAUL STROME,\
I
should predecease me or in the event he should fail to qualify or cease to ~ct
as Executor of this my last will and testament, for any reason whatsoever.
~LlNA--,$.,/ ~ (SEAL)
lar ret Shaw Strome
a""'HAM c. .HOWALTC"
A.TTCIltNE"I' AT LAW
:I_ .aUTH THINC .T.
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Should the said JOHN HAMILTON PAUL STROME and PAUL F. STROME both predecease me
or in the event they should fail to qualify or cease to act as Executor and
Alternate Executor of this my last will and testament, I hereby nominate and
appoint my daughter, ANN STROME GOLD, of 1169 West W Avenue, Schoolcraft,
Michigan, 49087, Second Alternate Executrix of this my last will and testament.
PART II
ITE~I FOUR: I give, devise and bequeath all of my estate, both reall,
personal and mixed, of whatsoever kind and wheresoever situate, to my husband,
JOHN HAMILTON PAUL STROME, if he survives me by thirty days. If he does not so
survive me, I give, devise and bequeath all of my estate, both real, personal
and mixed, of whatsoever kind and wheresoever situate, as follows:
A. One-third (1/3) thereof to my son, PA~L F. STROME, of 823 Nortm
Taylor, Oak Park, Illinois, 60302. Should the said PAUL F. STROME
predecease me, I direct that his share of my said estate shall pass
to his children, per stirpes.
B. One-third (1/3) thereof to my daughter, ANN STROME GOLD, of
1169 West W Avenue, Schoolcraft, Michigan, 49087. Should the said
ANN STROME GOLD predecease me, I direct that her share of my said esta~e
shall pass to her children, per stirpes.
a.....HA... c. .HDWALTltlll
ATTOIIINIEV AT LAW
I a. .aUTH THIIIID .T.
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LIKW'..UI.... ~A. 1T.aT
~~)~ ($EAL)
ar et S aw trome
C. One-th i rd (1/3) thereof to my daughte r, MARY LOU I SE STROME, of
1310 Washburn, Topeka, Kansas, 66604. Shculd the said MARY LOUISE STROME
predecease me, I direct that her share of my said estate shall pass t~
her children, per stirpes.
D. If any child predeceases me without leaving children to survive him
or her, I direct that the said deceased child's share of my estate 'sha:1l
pass to the SNYDER COUNTY TRUST CO~lPANY, of New Berl in, Pennsylvania, IN
TRUST NEVERTHELESS, for the benefit of my deceased child's spouse, for! and
during his or her natural life or until his or her remarriage, whichev~r
first occurs, for the following uses and purposes:
(1) To pay the net income therefrom to my deceased child's spouse
for and during his or her natural life in such periodic installments
as my Trustee shall find convenient, but at least as often as quarter-
annually.
(2) My Trustee may apply the net income from this trust for the
support or my deceased child's spouse, should he or she by reason of
age, illness, or any other cause, in the opinion of my Trustee, be
incapable of disbursing it.
(3) Upon the death or remarriage of my deceased child's spouse,
the then-remaining principal and any accumulated or undistributed
income shall be distributed to my surviving children, per stirpes.
ITE~1 FIVE: larder and direct that each of my children be given the
right to obtain any real estate or personal property which I may own at the time
of death, subject nevertheless to approval thereof by the rest of my said
[JRAHAM C. .HDW'" It
ATTORNEY AT ~w
3& "OUTH THIRD .T.
... D. 80X 553
LEWI..U"lJ. ,."'. 17.S7
~(1'/ft~~eJ ~(SEAL)
arg e haw Strome./
children, said item of real or personal property to be charged against the
ultimate distributive share of the said child.
I
I
ITEM SIX: I hereby authorize and direct my Executor, Alternate Exacutor
or Second Alternate Executrix without being required to furnish bond, to se\ll
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and dispose of all or any part of my real estate, in whatsoever state situa~e,
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at public or private sale or sales, for such prices or considerations and upon
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such terms and conditions as to my said Executor, Alternate Executor or Sec?nd
I
Alternate Executrix may deem best, and by proper deed or deeds, conveyances\in
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law, to be duly executed, acknowledged and perfected, to grant and convey the
same to the purchaser or purchasers thereof, her, his or their heirs and
assigns, free from all liability for or on account of the application of
th1
purchase money.
IN TESTIMONY WHEREOF, I have hereunto set my hand and seal to this mv
last will and testament typewritten on five (5) sheets of paper this ~f ~ ~ay
i
of ~~A,)
, 1985.
~.uL//.dJ~ (S~AL)
Mar ret ~~~;me i
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II"AHA.. c. .HaWALTI:..
ATTaltNI:V AT LAW
s. .aUTH THINg .T.
P. c. .ax S53
LItWI..Ultll. PA. 1.,.:'7
SIGNED, SEALEJ, PUBLISHED and DECLARED by the above named Testatri~,
MARGARET SHAW STROME, as and for her last will and testament, in our presence,
who, at her request, in her presence, and in the presence of each other, ha~e
hereunto subscribed our names as witnesses in attestation thereof.
residing at 2.~_~ ~;(~,f2ii
I 71-3 ~
residing at ,W (J d 13~ / ~ 0
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4.LJ:/.p/-//3
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JRAH....... c. SHOW.o.LTEIt
...TTORNlty AT LAW
s. .aUTH THIIU) .T.
... D. sax 55:1
LEWf..UIlIa. ....... 1'7.:a'7
3RAHAM C. IIHOWALTEIl
ATTOIlNEY AT LAW
35 .OUTH THllla .T.
P. D. .ax SS:I
LEWIIIIIUlla. ~A. 1'1837
:~C.\,\;Cv.l..cJG:.,'~Ei\j- AI'J[ ,1.FFIDA'/~r
COMMONwEALTH OF PENNSYLVANIA
5S.
COUNTY OF UNION
We, MARGARET SHAW STROME, ~C~~ ~ and
JuCL.o. ~
, Testatrix and the witness~s,
I
respectively, whose names are signed to the foregoing instrument, being filrst
duly sworn, do hereby declare to the undersigned authority that the Testatrix
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signed and executed the instrument as her last Will and that she had signe~
willingly, and that she executed it as her free and voluntary act for the i
purposes therein expressed, and that each of the witnesses, in the presenc, and
hearing of the Testatrix, signed the Will as witness and that to the best ~f
her knowledge the Testatrix was at that time eighteen (18) years of age ori
older, of sound mind and under no constraint or undue influence.
(S~AL)
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Witness
(stAL)
Subscribed, sworn to and acknowledged before me by MARGARET SHAW
me by ~fr\ (
STROME, the Testatrix, and subscribed and sworn to before
~~ and ~n.~
witnesses, this \C\'\h day of CQ~,--, 1985~
My Commission Expires:
~~r'\ -po LJ~
Notary Public
t::~:~i,;;:~~;;;:~{;E~~_f:~bb:'15 1 ?87
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Dow l' 1.13% Nasdaq 1'1.74%
Tue, Nov 13/ 2007, 11:18AM ET - U.S. Markets close in 4hrs 42mins.
Finance Search
ALU
( GET QUOTES) Symbol lookup
AT&T Inc. (T)
t . UJ ...IIITIUUMI
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Historical Prices
At 10:57AM ET: 39.49 ... 0.84 (2.17%)
IGol
SET DATE RANGE
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Start Date: Oct
Eg. Jan 1,
2003
\~) Daily
Weekly
Monthly
C) Dividends Only
End Date: Oct
2007
2007
Get Prices
First I Prev I Next I Last
PRICES
Date
Adj
Close*
41.87
Open
High
Close
Low
Volume
1-0ct-07
42.42
42.50
42.04 42.23 21,440,200
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MEANS MORE TIME TO
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http://finance.yahoo.com/q/hp?s=T &a=09&b= 1 &c=2007 &d=09&e= 1 &f=2007 &g=d
11/13/2007
~':YAaoor f'iNANCE
Dow l' 1.09% Nasdaq t 1.72%
Tue, Nov 13, 2007, 11: 18AM ET - U.S. Markets close in 4hrs 42mins.
Finance Search
["GET QUOTES) Symbol Lookup
Alcatel-Lucent (ALU)
E-M"'TRAOE
F.NANCIA'
I i:D ..8RITIIAD.
I No maintenance feti$.
1
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ADVERTISEMENT
Historical Prices
SET DATE RANGE
Start Date: Oct
\,~) Daily
Weekly
Monthly
C) Dividends Only
2007
Eg. Jan 1,
2003
End Date: Oct
2007
Get Prices
First I Prev I Next I Last
PRICES
Date
Adj
Close.
Open
High
Low
Close Volume
1-0ct-07
10.10
9.94
9.94
10.04 6,933,300
10.04
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First I Prev I Next I Last
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At 10:58AM ET: 8.20 l' 0.17 (2.12%)
IGOl
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Trade first class,
pay coach.
Upgrade your
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http://finance.yahoo.com/qlhp?s= ALU &a=09&b= 1 &c=2007 &d=09&e= 1 &f=2007 &g=d
11/13/2007
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YAHOO"; FINANCE
Dow 1" 1.11% Nasdaq t- 1.79%
Tue, Nov 13, 2007, 11: 20AM ET - U.S. Markets close in 4hrs 40mirs.
Finance Search
LSI
( GET QUOTES)
Idearc, Inc. (IAR)
Ilt:iJtlrBde.
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Historical Prices
SET DATE RANGE
Start Date: Oct
2007
2007
Eg. Jan 1,
2003
End Date: Oct
Get Prices
PRICES
Date
Open
Low
Close
High
1-0ct-07
31.46
31.49
30.99
* Close price adjusted for dividends and splits.
Symbol Lookup
At 10:59AM ET: 22.54 ... 0.04 (0.18%)
4.70:Pv
SA\<1NGS ACCOl.f\ll'
NO ltlNtMUMS
IGol
Get Historical Prices for:
t,~) Daily
C) Weekly
Monthly
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First I Prey I Next I Last
Volume
Adj
Close*
31.10 939,600
31.10
First I Prey I Next I Last
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http://finance.yahoo .comlq/hp?s= IAR&a=09&b= 1 &c=2007 &d=09&e= 1 &f=2007 &g=d
11/13/2007
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YAHO'O! FINANCE
Dow t- 1.11% Nasdaq l' 1.79%
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: .i. I.~
Tue, Nov 13, 2007, 11: 20AM ET - U.S. Markets close in 4hrs 40mil1S.
LSI Corp (LSI)
o T "dd-:: Smarter
1 FidBli~ ~
Historical Prices
SET DATE RANGE
Start Date: Oct
End Date: Oct
PRICES
Date
Open
1-0ct-07
7.48
* Close price adjusted for dividends and splits.
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( GETQUOTE$) Symbol Lookup
.. Scottrade. !
MInliIr nNRAlSI/C
Up tit $l(J{J$ACt!
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Finance Search
i
At 11:00AM ET: 6.23 -t 0.07 (1.14%~
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INANC'AL"
[Gol
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ADVERTISEMENT
7.46
[D ....I!RI'I1I.ADE
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2007
2007
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2003
(,~) Daily
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http://finance.yahoo.com/q/hp?s=LSI&a=09&b= 1 &c=2007 &d=09&e= 1 &f=2007 &g=d
Get Prices
First I Prey I Next I Last
High
Adj
Close*
Close
low
Volume
7.50
7.36
7.46 8,023,500
First I Prey I Next I Last
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Ccw" 1.30% Nasdaq" 1.20%
FII, Oec >. :OU/, , 56PM ET U.S. Markets close in 4mins.
Finance Search
( GET QUOTES J Symbol Lookup
Qwest Communications International Inc. (Q)
iD AM&RITRAD&
Transfer today
and net up to $300
H:TUIIE Soecqrifioe_
Active Traders
,I FIdeIJ,.,
Get Historical Prices for:
ADVERTISEMENT
100
. FREE TRADes
Historical Prices
SET DATE RANGE
Start Date: Oct
Eg. Jan 1,
2003
(~) Daily
o Weekly
Monthly
o Dividends Only
End Date: Oct
2007
2007
Get Prices
First I Prev I Next I Last
PRICES
Date
Adj
Close*
Open
High
Low
Close
Volume
1-0ct-07
9.23
9.25
9.12
9.15 11,973,400
* Close price adjusted for dividends and splits.
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At 3:35PM ET: 7.08 -t 0.12 (1.72%)
Scotlfade'
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Copyright @ 2007 Yahoo! Inc. All rights reserved. erb~~~P..Q.li<;-y - T.!;lIm~.QtSe!yjC;:E! - C,QPYIigb.t!lPE.Qlicy - $.E!!}gf.~e<:lI;lC'lG~
12/14/2007
http://finance.yahoo.comlq/hp?s=Q&a=09&b= 1 &c=2007 &d=09&e= 1 &f=2007 &g=d
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Dow t 1.11% Nasdaq t 1.79%
Tue, Nov 13,2007, 11 :21AM ET - U.S. Markets close in 4hrs 39m'ns.
( GET QUOTES) Symbol Lookup
Finance Search
Verizon Communications Inc. (VZ)
1 Scotlrade.I
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ED "'.IImIADE
TRADE FREE FOR
~ DAYS + ~T.$lOO
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Active Traders
'. FItIeII~
At 1l:01AM ET: 43.50 ... 0.70 (1.64%P
100
FREE TRADES
E*jriftDfs~ciiiiti~,
Historical Prices
Get Historical Prices for:
/GO]
SET DATE RANGE
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Date
Open
High
Low
Close
Volume
Adj
Close.
End Date: Oct
2007
Eg. Jan I,
2003
(~~I Daily
C, Weekly
Monthly
C) Dividends Only
Start Date: Oct
2007
Get Prices
First I Prey I Next I Last
PRICES
1-0ct-07
44.46
45.47
44,39
45.40 18,006,400 44.97
* Close price adjusted for dividends and splits.
First I Prev I Next I Last
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http://finance.yahoo.comlq/hp?s=VZ&a=09&b=l&c=2007 &d=09&e= 1 &f=2007 &g=d
11/13/2007
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Dow 't 1.15% Nasdaq 't 1.79%
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Tue, Nav 13, 2007, 11: 22AM ET - U.S. Markets close in 4hrs 38rTlins.
Finance Search
(, ~ETQUOTE5 J Symbol lookup
AllianceBernstein Bond Corp Bd A (CBFAX)
!' IJ1 "'..lT1IADe
No maintenance fe&$. )
Qti,
Active Traders
,l FldeIIl7 >
[*-TRADE s'icuiiti'i,
100
FREE TRADES
Historical Prices
On Nov 12: 11.94 0.00 (0.00%)
,Scottrade'
**:rllNlUlS/F'C
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Get Historical Prices for:
IGoj
Start Date: Oct
l~) Daily
Eg. Jan 1, ~
2003 C" Weekly
Monthly
C) Dividends Only
2007
End Date: Oct
2007
Get Prices
First I Prev I Next I Last
PRICES
Date
Adj
Close*
Open
High
Low
Close Volume
1-0ct-07
11.88
11.88
11.88
11.88 0
* Close price adjusted for dividends and splits.
First I Prev I Next I Last
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11.88
http://finance.yahoo.comlq/hp?s=CBFAX&a=09&b=1 &c=2007 &d=09&e= 1 &f=2007 &g=d
11/13/2007
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Computers hare
PO. Box 43078
Providence Rhode Island 02940-3078
Within the US, Canada & Puerto Rico 800351 7221
Outside the US, Canada & Puerto Rico 781 5754729
www.computershare.com/att
060418
MARGARET S STROME
3406 N GREENVIEW
CHICAGO IL 60657
',11111111"11,"1.1.1'11111111..11.1111.1..1.11"1111111111.1
For a change of address please call the above
number or visit us at www.computershare.com/att
Holder Account Number
C 0013853371
INO
171-3<-1 -~ 137
III "III 11111 ""I II1I11
Record Date
SSNfTlN Certified
10 Jut 2007
Yes
O/lICSI)l)7R.DOMEQS.A Tf97.52.1l2/Oti04IXlOti0418/i6
AT&T Inc.. Dividend Advice
Dividend Confirmation
Payment Date I
01 Feb 2007
01 May 2007
01 Aug 2007
CI D . f I Participating I Dividend / Gross I
ass escrlp Ion Sh Rate Dividend ($)
ares
COMMON 834 $0.35500 296.07
COMMON 834 $0.35500 296.07
COMMON 834 $0.35500 296.07
Year-lo-Date Paid ~ 888.21
Deduction I Deduction I Net
Amount ($) Type Divid~nd ($)
0.00 N/A 296.07
0.00 N/A 296.07
0.00 N/A 296.07
0.00 888.21
11l/IO /07
:; ;; I 17-?# 0 '0
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Your Payment Instruction
Amount Deposited
Account Number: 3316831
$296.07
NOT NEGOTIABLE
THIS IS NOT A CHECK
Please be advised that your dividend has been credited to your
account.
If payment cannot be made per the abc,'f i'l:;t'lctlor ? ctv ":~ wil' be
fe',V;":)""" vr,' -.C-:-':C_'
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FrI,.J. ~4, 28 . 4:02 ~, U.S. "1arkets closed.
AT&T Inc. (T)
E*TRADE
FINANe 'AL:
I
Historical Prices
SET DATE RANGE
Start Date: Oct
End Date: Oct
PRICES
Date
Open
1-0ct-07
42.42
* Close price adjusted for dividends and splits.
( GET QUOTES) Symbol Lookup
[;'J AM&RIT1\ADIi
Transfer today
,uld 9!!t up !n 8300
2007
2007
Eg. Jan 1,
2003
Scottrade.
,f!MtJ!IIllJNRI,~
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Finance Search
At 3:42PM ET: 41.37 .J. 0.43 (1.03%)
~~
Get Historical Prices for:
(f!) Daily
() Weekly
Monthly
() Dividends Only
First I Prev I Next I Last
High
Close
42.23 21,440,200
Volume
Adj
Close.
Low
42.50
42.04
Get Prices
First I Prey I Next I Last
f~ Download To Spreadsheet
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41.87
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Get Historical Prices for Another Symbol:
~ Symbol Lookup
· Splits
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Copyright@ 2007 Yahoo! Inc. All rights reserved. P-riY<:!~Y.P.Q1IG.Y - I!;!fmsQL$!i!ryi<;:~ - <:::9RyrigbJ1JE'f'9jiGY - ~l;1n9.feegp9Gk
12/14/2007
http://finance.yahoo.comlq/hp?s=T&a=09&b=1&c=2007&d=09&e= 1 &f=2007 &g=d
r-
THE BANK OF NEW YORK ::.;'4 ~3-5160382
PO. BOX 11258, NEW YORK. NY. 10236-1253
Dividends and Distributions
OM3,O 1 545J'1 C
VODAFONE GROUP PLC
TOLL FREE: 1-800-233-5601
HTTP://WWW.STOCKBNY.COH
AS AGENT FOR:
Account num~r Re<:ipient's PAYER'S Federal A. Depositary Fee
identification number identification number
21'0 0001702109 174-34-8137 13-5160382 $0,00
1a. T alai ordinary dividends 1b. Qualified DMdends 2a. Total Capital Gain Distr. 2b. Unrecap. Sec. 1250 gain
$902.82 $902.82
2c. Section 1202 gain 2d. Collectibles (28''10) gain 3. Nontaxable dislributions 4. Federal income lax wilhheld
$0.00 $0.00
6. Foreign tax paid 7. Foreign country or U.S. B. Cash liquidation distributions 9. Noncash Iiquidatian dislributions
possession
$0.00 UNITED KINGDOM
1001
MARGARET S STROME
3406 N GREENVIEW
CHICAGO IL 60657
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This is important tax information and is being furnished to the Internal Revenue Service.
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on you if this income is taxable and the IRS determines that it has not been reported.
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Dow ... 1.35% Nasdaq ... 2.08%
T
Tue, Nov 13,2007, 11:34AM ET - U.S. Markets close in 4hrs 26mins.
Finance Search
( GET QUOTES) Symbol Lookup
Vodafone Group pic (VOO)
iScDtlrade'
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Historical Prices
At 11: 14AM ET: 40.55 ... 3.75 (10.19%)
OJ AMERI11IADE
$9.99 trades.
No surprises.
IGoj
SET DATE RANGE
Get Historical Prices for:
ADVERTISEMENT
Start Date: Oct
End Date: Oct
(~) Daily
Eg. Jan 1,
2003 Weekly
Monthly
Dividends Only
2007
2007
Get Prices
First I Prey I Next I Last
PRICES
Date
Adj
Close*
Open
High
Low
Close
Volume
1-0ct-07
36.49
36.97
36.49
36.79 2,853,500
36.79
· Close price adjusted for dividends and splits.
First I Prey I Next I Last
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11/13/2007
-- ,
DDDHIST
Demand Deposit Display History
0022
10/11/07
Acct33-16831
Alpha key STROMMS.01
Request ALLTRANS
Last stmt 09/13/07
S --Date-- ----Description----- -Serial Nbr- -Reference- ------Amount------
09/25/07 CHECK 1539 00100601028 (1,853.94)
09/25/07 DAILY BALANCE 91242.49
10/01/07 THE BOARD OF PEN 00077900000 974.85
PENSION-CK 071031
1015509S02
10/01/07 DAILY BALANCE 10,217.34
10/09/07 FORCE PAY CHECK 1540 90073800006 (589.32)
(Eff date: 10/05/07)
10/09/07 DAILY BALANCE 9,628.02
10/10/07 TIME DEPOSIT CREDIT 90073800276 56.71
015-2968144
(Eff date: 10/09/07)
10/10/07 DAILY BALANCE 9,684.73
DDDHISTREQ DDDHISTBAL DDDMAIN DDDACCT DDDINT
Last page of information. GN20000I02
COMMAND ===>
F2=Retrieve F3=Exit F4=CRFwindow
F7=Backward
F~ 0~ 1rus+
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0022
10/11/07
.:t 015-2968144
~pha key STROMMS.01 Product Tl18
-----------Balances------------
Face amount 5,000.00 Branch
Compound value 5,000.00 Officer
AVAILABLE BAL
Initial deposit
5,000.00
5,000.00
ACTIVE
-------------Dates--------------
00015 Issued 07/07/2007
015 Maturity 01/07/2009
Opened 07/07/2001
Last int payment 10/07/2007
Next int payment 01/07/2008
Last activity 07/10/2002
Last principal change 00/00/0000
Recalc effective date 10/07/2007
-----lnterest
Rate
Accrued int
lnt adjustment
Last int paid
Total penalty
Information------
(RR ) 4.5000%
3.08
0.00
56.71
0.00
Account Type
TIME ACCOUNT
TDDINT TDDMISC
COMMENTS EXIST. SELECT CLIENT/CRF WINDOW TO SEE THEM.
COMMAND ===>
TDDHIST
TDDHISTMONEY
GN95000117
F2=Retrieve F3=Exit
F4=CRFwindow
F6=Toggle
r ~ ;Vi
[(us+-
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Request ALLTRfu~S
Last stmt 09/13/07
..;t 70-56885
~pha key STROMMS.01
S --Date--
* 08/13/07
* 08/13/07
* 09/13/07
* 09/13/07
----Description----- -Serial Nbr-
INTEREST CREDIT
DAILY BALANCE
INTEREST CREDIT
DAILY BALANCE
-Reference-
00000000000
00000000000
_ DDDHISTREQ
Only one page of information.
COMMAND ===>
DDDHISTBAL
DDDMAIN
------Amount------
152.63
44,479.66
135.24
44,614.90fl1
DDDACCT DDDINT
GN20000I04
F2=Retrieve F3=Exit
F4=CRFwindow
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'JU1.)lue the US, Canada & Puerto RluJ 781 5754729
www.computershare.com/att
MARGARET S STROME
& ELEANOR S REID JT TEN
3406 N GREENVIEW
CHICAGO IL 60657
tr(
For a change of address please call the above
number or visit us at www.computershare.com/att
Holder Account Number
1.11,,1111..11'111.1.1'1.111111 " 11,11",1,.1111'111111111.1.1
C 0013853380
IND
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Record Date
SSNrTlN Certified
10 Jul2007
Yes
llll I CSOIl7N.DOMEQS A TT,9752_R21O('(14 1910(,0419Ii(,
AT&T Inc. -Dividend Advice
Dividend Confirmation
Payment Date I CI 0 . f I Participating I Dividend I Gross I Deduction I Deduction I NE
ass escnp Ion Sh Rate Dividend ($) Amount ($) Type Dividend ($
ares
01 Feb 2007 COMMON 493 $0.35500 175.02 0.00 N/A 175.0
01 May 2007 COMMON 493 $0.35500 175,02 0.00 N/A 175.0
01 Aug 2007 COMMON 493 $0.35500 175.02 0.00 N/A 175.0
Year-la-Date Paid ~ 525.06 0.00 525.0
(oj,,? ,20 75t). 3 0
1:1:/ 1i .I~
Your Payment Instruction
Amount Oeposik
..-
$175.(
Account Number: 3316831
NOT NEGOTIABLE
THIS IS NOT A CHECK
Please be advised that your dividend has been credited to your
account.
If payment cannot be made per the above instruction, a check will be
forwarded to your registered address.
II
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ATT
002CS40035 OOl46A
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MARGARET S STROME
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3406 N GREENVIEW
CHICAGO IL 60657-1308
1.1"""111"11.'.1.1 , " 1 " ."..11.'111.'..'.'1"'1111"'11.1
For a change of address please call the above
number or visit us at www.computershare.com/att
Holder Account Number
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INO
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Record Date
SSNfTlN Certified
10 Jul 2007
Yes
00 I CS0078,DOMEQS.A TI,9752_l\2115333511533J5/i6
AT&T Inc. - Dividend Advice
Dividend Confirmation
Payment Date I CI 0 'pt' I Participating I Dividend I Gross I Deduction I Deduction I Net
ass esen Ion Sh Rate Dividend ($) Amount ($) Type Dividend ($)
ares
01 Feb 2007 COMMON 238 $0.35500 84.49 0.00 N/A 84.49
01 May 2007 COMMON 238 $0.35500 84.49 0.00 N/A 84.49
01 Aug 2007 COMMON 238 $0.35500 84.49 0.00 N/A 84.49
Year-to-Date Paid 253.47 0.00 253.47
to!)
Your Payment Instruction
Amount Deposited
Account Number: 3316831
$84.49
NOT NEGOTIABLE
THIS IS NOT A CHECK
Please be advised that your dividend has been credited to your
account.
If payment cannot be made per the above instruction, a check will be
forwarded to your registered address.
II
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ATT
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{ GETQUOTES )
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AT&T Inc. (T)
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Historical Prices
SET DATE RANGE
Start Date: Oct
Eg. Jan 1,
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2007
End Date: Oct
2007
Get Prices
First I Prev I Next I Last
PRICES
Date
Close
Adj
Close.
41.87
Open
Low
Volume
High
1-0ct-07
42.23 21,440,200
42.42
42.50
42.04
· Close price adjusted for dividends and splits.
First I Prey I Next I Last
f~ Download To Spreadsheet
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At 3:42PM ET: 41.35 ,J. 0.45 (1.08%)
~
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Copyright @ 2007 Yahoo! Inc. All rights reserved. E.ffit.f!!<YP.QlL9' - Tg,r:m~_QL$~r:vicJ~ - <;QPyrignl/1P.P.9H~.Y. - S~I}<:lf~~jl:l~ck
12/14/2007
http://finance. yahoO.comlq/hp?s=T &a=09&b= 1 &c=2007 &d=09&e= 1 &f=2007 &g=d
of
,7" -'
,.</' .,~: f;le,
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. CHARLES EGGER,"Super'/isor
71 '-776-3414
fr<AI~K .:. ::GC.::i( ,'::uneml Director
October 10, 2007
Funeral Bill for Margaret L. Strome
Date of death September 30, 2007
Professional Services $3,525.00
8 Death Certificates $6.00 a piece $48.00
Cemetery Opening $375.00
Transportation to New Berlin $170.00
Spencer 20 Gauge Casket $1,520.00
C-Box Burial Vault $875.00
Hairdresser $35.00
Obituary Sentinel $296.10
Coming Leader $96.25
Williamsport Paper $333.30
Elmira Paper $307.13
Lewisburg Paper $130.10
Total
$7,710.88
rrr.~bank
~,._ .'i'~.' '....0;.;
'"'d 'i.<..)' (, , 9 {"., "'-: --r
No. ',\i 1 ,,' \
(lFFICLAL C:,iECK
PAY
ONE THOUSAND SEVENTY FIVE DOLLARS AND 85 CENTS
TO THE
ORDER OF:
-j
)A fi.
'" \,!
U<
$ 1,075.85
MIRIT GREAT AMERICAN VAN LINES, INC.
Location: 2571217
Issued By: MoneyGram Payment Systems. Inc. P.O. Box 9476. Minneapolis. MN 55480
.,.. '.
NAME
ADDRESS
~ /v'r:
CITY
SHIPPER DOES NOT 0
STATE
PHONE
NAME
(X)~~ R~ N011FIG.<1l0N CHARGES PRIOR TO DELIVERY '"
"-- \
',- ~.\ .
ADDRESS
CITY
STATE
PHONE
Shipment subject to a minimum of
"......... $
Transportation
Origin Service
BINDING ESTIMATE CHARGES '0 YES .p NO
Dest. Services
Valuation Chg.
Total Charges
Total Charges above cover only the articles and services indicated on binding estimate
accompanying this order for service, signed by representative of both the carrier and
shipper. Total charges are guaranteed for days from date of signing.
Non-Binding Estimated Charges
110% Collection Option (COD)
BALANCE WILL BE BILLED 30 DAYS AFTER DELIVERY
Payment in Cash or Certified Check, Traveler's Check or Bank Cashier's Check
Payable To
BILlING.JNFORMATION
NAME ~-.,;. l( " \
Type of Shipment
<s -\ \ () lj,)-Q
ADDRESS ;:...:;J.~- t J -,,"/n ~
. ) " ,--~
CITY Ii. t \ ,..., -t t')l-~ ,lj\,
o Chg. 0 PPD. 0 C.O.D.
STATE
(JU .:f
ATTENTION OF:
THE SHIPPER (OR HIS REPRESENTATIVE) BY HIS SIGNATURE HEREBY ORDERS THE SERVICES OUTUNED HEREIN TO
BE PERFORMED ON HIS BEHALF; AND FURTHER ACKNOWLEDGES THAT ALL ARRANGEMENTS REGARDING CON-
TACT WHILE EN ROUTE AND/OR AT DESTINATION, METHOD OF PAYMENT, AND NOTIFICATION OF CHARGES ARE AS
DESIGNATED BY HIM.
x
DATE
SHIPPER OR HIS REPRESENTATIVE
THE CARRIER, BY SIGNATURE OF ITS REPRESENTATIVE, HEREBY ACCEPTS THIS ORDER FOR SERVICES AND
AGREES TO PERFORM THE SERVICES OUTliNED HEREIN AND TO COMPLY WITH SUCH OTHER ARRANGE-
MENTS AS ARE SPECIFIED.
x
DATE
ADDITIONAL INFORMATION:
~"!' ~.? -"
I ./
-~! ".' ..."" ?
--
;'
NON NEGOTIABLE
AUTHORIZED SIGNATURE
Insurance Surcharge (when applicable)
Valuation
Containers, Packing & Unpacking
Storage-In-Transit at ZIP Location
Date In
Date Out
SIT Pickup and Delivery
Extra Pickups or Deliveries No, at ZIP{s)
Extra Labor, Special Services or Waiting Time
Bulky Articles
Additional Weight Additives
Advanced Charges
Shuttle Service
Self-Storage/Mini-Warehouse Pickups or Deliverie
Overtime Pickups or Deliveries
Other Additional Services
CUSTOMER'S DECLARATION of VALUE
THIS IS A TARIFF LEVEL OF CARRIER LIABILITY - IT IS NOT INSURANCE
You must select. in your own handwr~ina, one of the following two options for your shipment. The option you
select establishes your mover's maximum liability for your goods, subject to the rules contained in your
mover's tariff.
OmON 1: Full (Reolacementl Value Protection. " any article is lost, destroyed or damaged while in
your mover's custody, your mover will either 1) repair the article to the extent necessary to reStore it to the
same condition as when it was received by your mover, or pay you the cost of such repairs; Dr 2) replace
the article with an article of like kind and quality, or pay you for the cost of such a replacement. An adeli.
tional charge applies for tills option.
To select OatIon 1. you must write, on the line below, ~ a lump sum dollar amount fDr the ..
of your shipment that may not be less than $5000, m: an amount per pound that may not be less tuI
$4.90 ( ) per poun~hever is greater,,_ \ r , \ I
The value of my shipment Is: C \ \ '1/'... Q '1-- t )\, <:- (' JC" \ ,(..;- I t'>t1
You must also select one of the following deductible amounts that will apply for your sIipment
No 0eductibIe ( ) Inlllal $250 DeducIibIe ( } initial $500 DedudIbIe L-......-) InIIII
OPTION 2 Released Value of 60 Cents Per Pound Per Article. " any article is lost, destroyed br damaged
while in your mover's custody, your mover's liability is limited to the actual weight of the lost,
destroyed or damaged article multiplied by 60 cents per pound per article. This is the basic liability
level and is provided at no charge. It is considerablv less than the averaae value of housebokl aoods.
To select OatIon 2. you must write, on tile line below, the W9rds "60 ~ per pound".
The value of my shipment Is: frCf'..t+ ~C) ('eI+~-v ( \, yj [) ef ()rtl~~(
Your slanature Is reauired here: I acknowledge that I have 1) declared a value for my shipment and ~
a deductible amount, If appropriate, and 2) received and read a copy of tile "Your. \UtIdI Ii-
Responsibilities When You Moye" brochure explaining these provisiOlls.
Customer's Signature
Date
Extraordinary fUnusuall Value Article Declaration
I acknowledge that t have prepared and retained a copy of the "Inventory of Items Valued in Excess of $100 Per Pound
Per Article" that are included in my shipment and that I have given a copy of this Inventory to the mover's representa-
tive. I also acknowledge that the mover's liability for loss of or damage to any article valued in excess of $100 per pound
will be limited to $100 per pound tor each pound of such lost or damaged article (based on actual article w\lightj. not ttl
exceed the declared value of the entire shipment. unless I have specifically identified such articles for which a claim tor
loss or damage is made on the attached inventory.
Customer's Signature
Date
IA 1"...._...;....". .,nn" UII gl". DCI....TI....r.: .....,... 1?an ""OTOQ D~ 1-4411DD411~S:: MV 117"-Q IR~1\ "'A?-AQllt\
FORM # 898 rev 01/0;
). ~ r:
.
TICKe(jeSS Confirmation - STROfV1E/PAUL - C37YJA - PAUL STR
From: Southwest Airlines (SouthwestAirlines@mail.southwest.com)
Sent: Sun 9/30/07 6: 12 PM
To: PFSTROME@hotmail.com
<~JA
SOUTHWEST
~.........
~
Receipt and Itinerary as of 09/30/076:12 PM
Ch et:: It l~
24~
IN AgVANCE
Check In Online
Confirmation Date: 09/30/07
CID: 99439561
Received: PAUL STR
PaS$!f1ge,.'I1'pim~~~g
P e
STROME/PAUL
STROM IJOY
umber
00001022360146
- None Entered -
Sun Oct 07
RoutingDetaiJ~
2076 Depart CHICAGO-MIDWAY (MDW) at 8:00 AM
Arrive in BAL TIMORE-WASHNTN (BWI) at 10:45 AM
1660 Depart BAL TIMORE-WASHNTN (BWI) at 9:40 PM
Arrive in CHICAGO-MIDWAY (MOW) at 10:40 PM
Gosta"'cJ~aYm,~t$!Pmm~fY "ii!
Air $ 485.58
Tax $ 50.02
PFC Fee $ 18.00
Security Fee $ 10.00
Total Payment: $563.60
Current payment(s)
/07 VISA xxxxxxxxxxxx1178 Ref 526-2338440864-1 $281.80
09/30/07 VISA xxxxxxxxxxxx 1 ef 526-2338440865-2 $281.80
Fare Calculation:
ADT- 2 MDVVWNBWI YL 182.00 BWIWNMDW M70WNR 79.00 $261.00 ZP6.80 XFMDW4.50
BW/4.50 AYMDW2.50 BW12.50 $281.80
Valid only on Southwest Airlines. NON REFUNDABLEI STANDBY REQ UPGRADE TO YL All
travel involving funds from this Confirm no. must be completed by 09/30/08. Any change to this
itinerary may result in a fare increase.
http://bvl0lw.bavl01.mail.live.com/mail/PrintShpl1::lc;:ny?tvnp=rnP~~!HTPA'Tf'1''\~rl,,=Qh'10rlh;1 " 1 (\/0/'"1(\(\'7
NAIIUNAL
CAR R E N TAL
RA 412992213 Inv 40013505090
Rental 04-OCT-2007 11:19 AM
BAL T I KJRE ARPT
Return 07-OCT-20D7 03:48 PH
BAL T I KH: ARPT
PAUL STR()f
Vehicle # 7F200426
Hodel MALIBU LT
Class Driven FCAR Class Charged ICAR
License# 63SE67 State/Province MA
MIKms Dri ven 829
MIKms Out 17866
MIKms In 18695
KPI(j LLP
Contract 10 5239842
Charges No Un j t Pr i ce
T & H 4 Days 38.95
UNLIM M/KM 0 M/Kms
COW/LOW 4 Days
DOLLAR CFF 1 Renta I -15. 00
CUSTOMER FACILITY CHARGE
COCESS I ~ RECOVERY FEE
VEH LIC FEE RECOVERY
SALES TAX @11.500 r.
FFTXRSU
..........A.....o.....'......._ ._
SMITH'S GAS MART.
71l
SUNOCO
600 SECOND STREE
HIGH SPIRE, PA 17034
DLR~: H342423726001
10/07/07 10:27:24
Pump~: 6 /Self
Product:Regular
Gallons 13.310
$/Gal $ 2.679
Fuel Sale $ 35~
Total sal~~~, ~
XXXXXXXXXXXX1178
VIS
Trans# 002294
Approval# 04935B
14499s33c6
THANK YOU FOR
YOUR 81 JS f Nr;"CC'
I
Amount
155.80"
0.00"
0.00.
-15.00.
13.00.
14.24"
1.60"
19.51
0.27
i
pill
Total Charges
Paid By
Amount Due
I<<: 8447
* Ta)(able Items
Sib j set to Aud i t
Your Emerald CIJJ NlInver is 763892673
Frequent Flyer HiW9466 Credit to
MER I CAN A I RLI ~S
FFTXRSU i s a recoupnent of tax on
Frequent FI ier mi les earned
We hope you enjoyed driving your
upgraded Emerald Club vehicle.
Customer service Number 1-800-466-3334
usn 0.00
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1001 A~=A~IO~ BLVD
BALTIMORE ~D 21242
DATE 12/27/27 3:37PM
Ir-~i;..)(:::IC::Eit '22~117
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i..)ISA
ACCOi.)f"F >.f~aER
XXXX xxxx XXXX 1178
PUMP ?R~DjCT $/3
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NEWVILLE POST OFFICE
NEWVILLE, Pennsylvania
172419998
4134870241 -0097
10/05/2007 (800)275-8777 03:33:26 PM
Sales Receipt
Sale Unit
Cty Price
Final
Price
~'.-oduct
0escription
C~lr.AGO IL 60657 Zone-4
P~cel Post
21 lb. 4.6 oz.
$17 . 02
--------
--------
h$L1B PVI:
$~7.02
$17.02
CHICAGO IL 60657 Zone-4
Parcel Post
21 lb. 8.8 oz.
--------
--------
Issue PVI:
$17.02
T ota 1 :
$34.04
~~~~~~xxx~
875
PaId by:
Vlsa
Account #:
Approval #:
T f'ansact i on #:
13 903112423
Order stamps at USPS.com/shop or call
:~300-Stamp24. Go to USPS.com/clicknship
~J) f;rint shipping labels with postage.
'For' ether information call 1-80Q-ASK-USPS.
Bi;l#: 1000301700653
Clerk: 03
~~1 salas final on stamps and postage.
qe-f:.Jnds fe:r guaranteed sel~vj ces onl y.
Thank you for your business.
~~~~~~~.~*~~~*x****************x********
~,~~~~.~..y~.*~*~~***~******************
HELP US SERVE YOU BETTER
~n to: http:,I/g,:. ga 11 up, com/pas
TELL US ABOUT YOUR RECENT
POSTAL EXPERIENCE
YOUR OPINION COUNTS
~~~~~*~~~~~~~..xx~**********x**********x
~~~~$.~~~~~~*~~~*X***YY~****X*~*.*******
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INTEREST CHECKING (...9581)
Check Number: 7290
Post Date: 10/12/2007
Amount of Check: $200.00
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INTEREST CHECKING (...9581)
Check Number: 7289
Post Date: 10/10/2007
Amount of Check: $300.00
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