HomeMy WebLinkAbout04-16-08
REV-l500EX + (8-00)
t-
Z
W
C
W
o
W
C
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME (LAST, FIRST. AND MIDDLE INITIAL)
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICiAl USE ONLY
FILE NUMBER
2 1 -0 8 0 1 5 4
COuNTY"'COoE -YEA~ - - NuMsER- -
SOCIAL SECURITY NUMBER
CLOUSER
DATE OF DEATH (MM-DD-Year)
JOSEPHINE M.
DATE OF BIRTH (MM-DD-Year)
o 9 1 - 2 8 - 1 721
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
[Xl 1. Original Return
D 4. Limited Estate
D 6. DecedentDied Testate (AtlachcopyoIWiII)
D 9. Litigation Proceeds Received
01/16/2008 11/02/1930
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
z
o
i=
~
::>>
Q..
:t
o
o
S
SOCIAL SECURITY NUMBER
D 2. Supplemental Retum
D 4a. Future Interest Compromise (date 01 death after 12.12-82)
D 7. Decedent Maintained a Living Trust (Atlach copy ofTrust)
D 10. Spousal Poverty Credit (date 01 death between 12-31-91 and 1-1-95)
D 3. Remainder Retum (date 01 death pliorto 12-13-82)
D 5. Federal Estate Tax Return Required
_ 8. Total Number of Safe Deposit Boxes
D 11. Election to tax under Sec. 9113(A) (Atlach Sch 0)
w
~
:ll!: ~Ul
o It::ll!:
wll.o
:2:00
o 1t:..J
ltlD
c(
~
z
W
Q
Z
o
II.
Ul
w
It:
It:
o
o
THIS SECTION MUST BE COMPLETED.ALLCORRESPONDENCEANDCONFIOENTIALTAXINFORMATIONSHOULDBE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
ROGER B. IRWIN ESQUIRE 60 WEST POMFRET STREET
FIRM NAME (If Applicable)
IRWIN & McKNIGHT
TELEPHONE NUMBER
717 249-2353 CARLISLE PA 17013
z
o
~
::>>
t-
e:
<
o
w
0:::
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Clos1ely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mort!~ages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
D Separate Billing Requested
7. Inter.Vivos Transfers & Miscellaneous Non.Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. FUnElral Expenses & Administrative Costs (Schedule H) (9)
10, Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. ChaJitable and Govemmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
OFFICIAL USE ONLY
l"-o;l
g
0:>
::t""
-0
:;:0
18,813.44
t~O
',-. ~j.)
j-:';~O
I :,_i'~Fn
...?- --0
50,399.49 U') "?'.:.
00
'.1 Q '''n
-; '5s
.-\
:g
0'\
1.')
:x.
r-:?
N
o
(-,~)
"n
-\ I
,~
,'T1
(8)
69,212.93
4,929.60
7,204.07
(11)
(12)
(13)
12,133.67
57,079.26
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
(14)
57,079.26
15. Amo,unt of Line 14 taxable at the spousal tax
rate. or transfers under Sec, 9116 (a)(1.2)
16. Amclunt 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
0.00 X _(15) 0.00
57,079.26 X .045 (16) 2,568.57
0.00 X .12 (17) 0.00
0.00 X .15 (18) 0.00
(19) 2,568.57
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
, > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
o
d
· C
I t Add
ece ents omDle e ress:
STREET ADDRESS
i'073 CARLISLE PIKE
CITY I STATE I ZIP
CARLlSL.E PA 17013
Tax Payments and Credits:
1. Tax Due (Pagle 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
2,568.57
128.43
Total Credits (A + B + C)
(2)
128.43
3. InteresVPenalty if applicable
D. Interest
E. Penalty
TotallnteresVPenalty ( D + E) (3)
4. If Line 2 is greiater 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 + Linle 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check to: REGISTER OF AGENT
0.00
0.00
2,440.14
2,440.14
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 00
b. retain the right to designate who shall use the property transferred or its income; ........................................ D 00
c. retain a reversionary interest; or ...................................................................................................... D 00
d. receive the promise for life of either payments, benefits or care? ............................................................. D 00
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................. D 00
3. Did decedent own an 'in trust for' or payable upon death bank account or security at his or her death? ................. D 00
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ....................................................................................................... D 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.
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 either than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RE RN
'-1t'1 ~
ADDRESS 317 E. PORTLAND STREET
MECHANICSBURG
SIGNATURE OF PREPARER OT ER THAN REPRESENT~
"'3.
ADDRESS 60 WEST POM STREET
CARLISLE
DATE
Cf-{ ,- -0 ?'
PA 17055
DATE
vloior
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 orfor the use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)l. ~
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 lihe child is 0% [72 P,S. ~9116(a)(1.2)],
The tax ra~e 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. ~9116(a)(~
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 a~
individual who has at least one parent in common with the decedent, whether by blood or adoption. "
REV-1503, EX + (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
CLOUSER
JOSEPHINE
M.
FILE NUMBER
21 08
0154
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
SERIES EE SAVINGS BONDS -INVENTORY REPORT ATTACHED
VALUE AT DATE
OF DEATH
18.813.44
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed. insert additional sheets of the same size)
18813.44
REV.1508 EX + (6-98)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
CLOUSER
FILE NUMBER
JOSEPHINE M. 21 08
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.
0154
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
935.46
PSECU - SAVINGS ACCOUNT
2.
PSECU-CHEC~NGACCOUNT
44,767.86
3.
COINS - APPRAISAL ATTACHED
177.17
4.
CASH ON HAND
19.00
5.
MOBILE HOME
4,500.00
TOT At (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
50 399.49
REV-1510 EX + (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER.VIVOS TRANSFERS &
MISC. NON.PROBA TE PROPERTY
M.
FILE NUMBER
21 08
0154
ESTATE OF
CLOUSER
JOSEPHINE
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
ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE
NUMBER THE DATE DF TRANSFER ATTACH A COpy OF THE DEED FOR REAL ESTATE VALUE OF ASSET INTEREST VALUE
(IF APPliCABLE)
1. NEW YORK LIFE ANNUITY #51 017 825 ($44,412.78)
ACCOUNT CLOSED AND DEPOSITED IN TO PSECU
CHECKING ACCOUNT 01/08
TOTAL (Also enter on line 7 Recapitulation) $
(If more space is needed. insert additional sheets of the same size)
REV-1511 EX + (12-99)
.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FilE NUMBER
CLOUSER
JOSEPHINE
M.
21
08
0154
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
FUNERAL EXPENSES:
1.
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
City State Zip
Year(s) Commission Paid:
2. Attorney Fees IRWIN & McKNIGHT 4,000.00
3. Family Exemption: (If decedenrs address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees REGISTER OF WILLS 179.00
5. Accountant's Fees
6. Tax Return Preparer's Fees PATRICIA A. ROSENDALE, CPA 450.00
7. REGISTER OF WILLS - FILING FEE 30.00
8. NOTARY FEES 25.00
9. CUMBERLAND LAW JOURNAL - ESTATE NOTICE 75.00
10. THE SENTINEL - ESTATE NOTICE 166.60
11. REGISTER OF WILLS - SHORT CERTIFICATE 4.00
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
4929.60
REV-1512 EX + (6-98)
'*
SCHEDULE.
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
CLOUSER JOSEPHINE
M.
FILE NUMBER
21 08
Include unreimbursed medical expenses.
0154
VALUE AT DATE
OF DEATH
ITEM
NUMBER DESCRIPTION
1. PP&L - ELECTRIC
2. ALLSTATE -INSURANCE
3. CHURCH OF GOD HOME - NURSING
4. CUMBERLAND CROSSINGS - NURSING
5. DEBRA BASEHORE WIEST - TAXES
6. HEALTHSOUTH REHABILITATION - MEDICAL
7. OSL DBA ORTH INSTITUTE - MEDICAL
8. DARRYL K. GUISTWITE, M.D. - MEDICAL
9. SPECIAL EVENT EMERGENCY - AMBULANCE
10. THE STATE EMPLOYEE'S RETIREMENT SYSTEM - REIMBURSEMENT OF PENSION
11. CONTINUING CARE RX - MEDICAL
12. INTERNAL REVENUE SERVICE - 2007 INCOME TAXES
13. PENNSYLVANIA DEPARTMENT OF REVENUE - 2007 INCOME TAXES
195.24
69.94
1,616.90
3,221 .12
9.80
12.00
72.00
135.00
110.03
153.88
872.16
410.00
326.00
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
7 204.07
""'-""EX' ".
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
CLOUSER
NUMBER
I.
SCHEDULE J
BENEFICIARIES
JOSEPHINE
M.
FILE NUMBER
?1 OR
RELA TIONSHIP TO DECEDENT
Do Not List Trustee(s)
Lineal
Lineal
Lineal
0154
AMOUNT OR SHARE
OF ESTATE
1/3 REMAINDER
1/3 REMAINDER
1/3 REMAINDER
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.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
MICHAEL K. CLOUSER
317 E. PORTLAND STREET
MECHANICSBURG, PA 17055
KAREN L. SHEAFFER
1382 ARMSTRONG VALLEY ROAD
HALIFAX, PA 17032
DAVID C. CLOUSER
17922 25TH AVENUE EAST
TACOMA, WA 98445
2.
3.
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, JOSEPHINE M. CLOUSER, of Silver Spring Township, Cumberland County,
Pennsylvania, declare this to be my Last Will and Testament, hereby expressly revoking all Wills
and Codicils heretofore made by me.
1. I direct my executors to pay all of my debts, funeral and administrative expenses as
soon as may be done conveniently after my decease.
2. I authorize and empower my executors to sell any realty owned by me at my death
and not specifically devised herein, at either public or private sale, and to give good and sufficient
deeds therefor, in fee simple, as I could do if living.
3. I give, devise and bequeath all of my estate of every nature and wherever situate to
my three children, Karen L. Sheaffer, Michael K. Clouser and David C. Clouser, share and share
alike, the child or children of any deceased child taking the share their parent would have taken if
living.
4. I nominate and appoint Karen L. Sheaffer, Michael K. Clouser and David C.
Clouser, to be the executors of this my Last Will and Testament; they are to serve as such without
bond.
5. I hereby suggest that my personal representatives retain the services of Irwin,
McKnight & Hughes, as attorneys in the settlement of my estate.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 7,1
October, 1993.
day of
\ '. 'I /~i _!
\. /. ,/ ,'/1 /' / //
__ tit;L' ;t~ ;~) .~ /. I;;' :~<Ii-~t ( if" z/ (SEAL)
/} I JOSEPHINE M;-.cLOUSER
Signed, sealed, published and declared by JOSEPHINE M. CLOUSER, the testatrix
above named, as and for her Last Will and Testament, in the presence of us, who at her request, in
her presence and in the presence of each other have subscribed OUf names as witnesses hereto.
2
ACKNOWLEDGMENT AND AFFIDA VIT
WE, JOSEPHINE M. CLOUSER, BETZI A. MORRISON and CHERYL L.
CLELAND, the testatrix and witnesses respectively, whose names are signed to the foregoing
instrument, being first duly sworn, do hereby declare to the undersigned authority that the
testatrix signed and executed the instrument as her Last Will and that she had signed willingly, and
that she executed it as her free and voluntary act for the purpose herein expressed, and that each
of the witnesses, in the presence and hearing of the testatrix, signed the Will as a witness and that
to the best of their knowledge the testatrix was, at that time, eighteen years of age or older, of
sound mind and under no constraint or undue influence.
J
13ifi ~ ,~0\011
B t I A. MO .. SON .
f24 fc/~~b;r/
~ERYL L. CLELAND
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF CUMBERLAND
Subscribed, sworn to and acknowledged before me by JOSEPHINE M. CLOUSER, the
testatrix herein and subscribed and sworn to before me by BETZI A. MORRISON and
CHERYL L. CLELAND, witnesses this"?' day of October, 1994.
//} 1 /7 ..(;
. I lxi ") 01.-L.
( Notary Public
, ,
Notarial Seal -
'"'_~ 8. Irwin. Notary Putfc
M""""ls.e Boro' Cumbe~ ~
y CommlS~lon Expires Oct. 3, i 900
pm!)",,: reIY'c,:",,, 'r . "
. qt, ~nla~OOilbOIlD'~"v-
i I JV'Cl.riQS
G1 m::J
:...:- 0<
^ CJ) ::3@
Z Q.a.
0 (/I 0
CD
::;::
m -f
CIl
fii 0
.......
CD . Dl
CIl . '"tiS:: Cii
(') .. (J1 )>
0" - , ,
-
C 0"0-0-
CIl 0-000
CD o ::::l::l::::l
...., ::lo.o..o..
0..---.-.
c.... (fl(flOO
0 ~WWS::
CIl ~(f)(f))>
CD
"0 COCO.....
::r () ~. ~. ~
:::i" 00 CO CO CO
(flCllCllo..
CD ffi--oo
~ 0..00::::l
-- _.., ..., a.
(j) ::lmm::l
OJ Q.mJTlg. .
:::. m:E~co()
:J Will 00 -
(Q XCIl (n"" I
CIl 9- -. .-. ;2. 0"
OJ 00 00 (Il ::::l 0
0 ::l~~QtO::l
:J to CO c5 -. 0..
a. CO 0. Cl. ? :E
CIl 0.. _. ._. CD 00
CIl ...... ::l =, Ci3 00 I
cr QOClOO()
:E .., -, - Q)
~ ~Ol 00
;:;> ::T
ICO(l) CD
I-"-' -a.
o-~3::Z5'
o ::l !l:! m
::l C '<. ,
?-WcoO".
0--< <.cl g m
~ cO --I 0. ><
_. <0 00 -. ,
OO0::lOOo-
0- O'Zo
CD W -'O::::l
S'a~ -0..
to -.,< ~
-o3g~oo
::J.~ CO moo
() W = m
~ g W tQ. ><
O.....W2:0
::::l~3~~
OOcogQ~
0.. x .....-0 CD
~co7OOo..
CD 3 -.,< _
-o"S.$-3Q '1J
6'::;;"" ~ 00 Y) ~.
..., c gJ .....::J CJ)(')
o~..... I mCD
_0."'0. I 0
15O'~zg 0
() ..., ~ -::l 0
~"8~~0.. 0
::Twc:o
CD7"':J::J
0.. ~ s: I::l.
o 0 .....:::r S"
..., 0 ::::l"1:ll
(ll::lCD(J) Y)-
Xo.o-.z .......CD
g. W 0 (:) I\)(il
oo-<::::l.- - (/I
::J 0....." ~-
to CD -. (i)
CD a. CJ'J ,.... W
0.. 5 (J1 C,. ~
o..~,<~g 0/:>.
~o'CO=,
(ll ::l ~ --
(Jl <11
<I'
ot:
-C!l
0. Cl.
<
1J Y)e!.
.......c:
OJ co CD
(Q
CD ex,
.......
w
0 ~
.......
....... 0/:>.
OJ
Z 0
CJ) 01 0/:>. W I\) ....... ~ :J
0-
CJl
en
m m m m m m CD
..,
m m m m m m (D'
(J)
c
511 01 ....... ....... ...... CD
Y) ::l
0 0 0 0 0 N 0
0 0 0 0 0 0 3 I
0 0 0 0 0 0
< < ~ ~ ~ ;;0
....... ....... 0/:>. I\) I\) ./:>. en
0 0 ....... 01 01 CJ) CD
0/:>. ./:>. 0 W W 0/:>. ..,
W <0 N -...j -...j co [
<0 W W -...j -...j ./:>.
CJ) CJ) -...j 01 01 <0 Z
....... I\) N W W 0
m m w w I\) -...j c:
m m m m m m 3
m m m m 0-
CD
..,
....... ....... 0 ....... ...... 0
I\) I\) co I\) I\) CJ) oUi
-- -- -- -- -- --
....... ....... ....... ....... ...... ....... 0) (J)
<0 <0 <0 <0 <0 <0 .....c:
co co <0 co co co CD CD
CJ) CJ) 0 -.j -...j <0
I
''1J I
.1\) N Yt..,
01 01 01 01 01 o ,;-
0 0 0 0 0
~ ~ ~ 0 0 OCD
0 0 0 0 0 0
0 0 0 0 0 0
.0/:>. 0/:>. S"
Yt -
ltl
-.j -...j -...j co co ....... ..,
CJ) CJ) W <0 <0 CJ) ltl
0 0 <0 01 ~ W (J)
0 0 I\) 0> CJ) 0 -
0 0 0 0 0 ,;:..
I
.-...j .-...j ....... ....... ...... Y) <
N I\) I\) w w I\) !!!..
CJ) CJ) W <0 <0 CJ) c:
0 0 <0 01 (J1 W ltl
0 0 N 0> 0> 0
0 0 0 0 0 0/:>.
~ 0/:>. ,;:.. ,;:.. ./:>. 0/:>. ::0
0 0 0 0 0 0 0)
0 0 0 0 0 0 .....
:::R :::R :::R :::R :::R :::R ltl
0 0 0 0 0 0
~ 01 01 01 ~ 01 -<
....... ....... ~ N N W (D'
0/:>. 0/:>. ....... 0 0 0 a:
:::R *- :::R :::R :::R ~
0 0 0 0 0
Z
CD
0 0 0 0 0 0 ><
CJ) CJ) N en en en 0::
-- -- -- -- --. --
N N N N N I\) 0) ::l
0 0 0 0 0 0 .....-
0 0 0 0 0 0 ltl CD -
co co co co co co ..,
CD CD
(J)
...
....
:!! Q
::l ~
....... ....... 0 ...... ....... 0 0)
N N co N ~ 0) 0-
--. -- -- -- --
N N N N N N 0)3: Dl
0 0 0 0 0 0 -I>>
...... ...... N ....... ....... ...... CD... CD
CJ) CJ) 0 -...j -...j <0 c:
.,
;:;:
'<
Z
.. 0
-
CD
~
)> <
n. CD
<' ~
CD -
o
~
::0
CD
"C
o
;:1
~
<
CD
::J
.......
o
-<
11
"U~
.:J
.......
o
Dl
oct
.......
o
~
---
00
.......,;:..
--- ---
"''''
00
00
CP co
PSE(~
February 26, 2008
Account # 0091 XXXXXX
RECEIVED
FEB ::> ,...j nri(:p
,..~ I Lu..w
ROGER B IRWIN
IRWIN & MCKNIGHT
60 WEST POMFRET ST
CARLISLE, PA 17013-3222
IRWIN & McKN!GH 1
tAW OFFiCES
Dear MR IRWIN:
The following is the status of JOSEPHINE M CLOUSER's account with PSECU as of the date of death.
Joint Owner's Name
Date of Death
Date of Birth
no joint owner
01.16.2008
11.02.1930
Share
SOl
S 04
Description
Regular Shares
Checking Shares
Open date
09.06.1994
09.06.1194
Balance
$ 935.46
$ 44,767.86
Accrued Dividend
$0.48
$ 0.68
The dividend earned from January 1, 2008 through the date of death was $ 1.16. The decedent had no loans with us.
We do not have safe deposit boxes for our members. If you have any questions, please call 234-8484 in Harrisburg
or our toll-free number, (800) 237-7328. At the menu prompt, enter 6 and then extension 2227.
Sincerely,
I~ (;UCLtbA
Sue Walter
Member Service Representative
Finance Support Unit
Pennsylvania State Employees Credit Union
,'vlain Address: 1 Credil Unioll Place, Harrisburg, PA 17110-2990 . 717.234.8484 . 800.237.7328
. Mailing Address: PO. Box 67013, Harrisburg, PA 17106-7013 . 717 777.2100 (TO D) . 80004 72.1967 (TDD)
This credit union is federally Insured by the Notional Credit Union Adminlslrotion. Equal Opportunity Lender www.psecu.com
JOSEPHINE M
d/o/d _ JAN~~ORUySER ESTATE
16,2008
Appraisal by:
Harry E. Donson
CAR~ISLE COIN SHOP
25 Circle Drive
Carlisle, PA 17013
243-8943
}3 - 2 ~ 13-(//5
~
i? 7C
....-
t?~
1- L.. ~JV
..
~-"'-<z ~(%?..~) ijtf/y ~
l \ 'I ~ 2 ~ "JX.. f /:;(j If '6
P _kAf' <::::> [; /,-,,{ tI IS- -~ (3 r (I j. . ~
)- ~-' ~.
ft VV ~.
1- / _ 'J~ (LV" j.L-L~ /12].- .2 <J -
I _ (cr;: R..e.t '5 il......f. '11.;:4, ~ 171 7 - ). 0 ~
c."t
l--
<-; ,I v -"-"- C 'L.. llJi-;~" 4.... .-
,]oV_
!t) -
-- c;.7V
,~
,
it
j '-
/ ;L or/(.)
~
19, 5",,"" E p"yi,o'J Doli",) ~
j_. 5,1 f)"'- H.l i fc, - c> - 5- f;" g~ -
J -.. ~ ( }. J h -;) ( i"'J
J _ t3 0" ~< 1: ou " s ~t1;, 10"" .--
1 'i' -
'J.. t ~I]!
7 .; ()
,
G _ ~I S n., (" ~u.. """,,- I) c [(;"v \
I ~ f fj'$-c?c y, Iv~' .;:,.1\ >v" ~
).. __ 1./... 1\ I c. l( .e I s --
If, }--~l 1"ry, ,t "0." ).1-0.,,) rl f , Ye I,
;}. _ :1'-., .rt.,.~, ~~ c.G~-
J [) - L 1-;\ t ,-, i ; '-', c..J,')./"< -...; \:..^-:- /l-~-;.. .~. '
~ .~ '\. \LJ~ '- l,- ~
'2 I _.",:b"'""~- F<-~)1.-:L~.~/,,-, c ,J-'~~~'-
~ . ..!;>-x 'Fe y '~7 ~\ i~..., HI ,-,J. -
d .-/
6 G~
to
?j,..,.,
".'V'
..--"
-'1f6
l-
1.32
l ~ 0
.
7rJ
,
I'~ f;
::? .:-0
t \" I . \ 1
;.J fJ-A-''"'-]. L OJ o-:,\.1-<v~ .
C f o-J~~ C o--V'V^'- ?~t~
Mar 24 06 10:52a
1J -U -U 0
...
~ ~ ~ ~
.... ...
~ N ~ j;;j
000 0
000 0
~ -..a -.. -....a
... ... ...
I'J ~ ~ f',)
~ ~ ~ ~
i:J N i\J ;;:;
000 0
: ~ ~ ~
~ ~ ~ ~
o 00 rD CD
N i\3 ~ tJ
o 0 0 0
o 0 0 0
-... -..a -..a -.I
~ ~ ~ ~
~ ~. ~. ~.
-" ......
o CJ 0 0
I\l I\) I\l N
...... .Do ~ .J:lo,
.... CD \I) <t>
m co (0 to
t\ ~ lS 8
~ ~ ~ ~
9 g g s-
a, ~ CD Ul
!: ~ i: ~
o 0 0 Dl
~ ~ ~ "1J
3' :i- 3' ::2,
-<<-<;i
c;-
.0
III
'<
~
<'
III
;;
-4 "ll
C ~
i z
o c
= ;!
iil'l
..
a ~
;- III
~ ii'__
(Q iD
w .....
i-.aE..
~::oo
:..... :.... .. :r,..
t.)1\)~C)
'"
W
<1l
!" C'l
(:)
"" 0
c;;
"tl
III
'<
Z
c:
iil
5'
(Q
3
CT
OIl
....
.....
...
o
....
~ ~
.g' .0
(") 1J
9 5
s- ::2
f/l CD
::0
00 s:
IJ1 0
!! ~
~' -<
iD
-0
CI>
~ '<
<'
II
iii
"ll
..
'<
Z
I:
;;
:;-
IS1
-4
!
~
co .t- w
(II <t> a>
'" 0> 0
i:::o <:> 0
000
S
-0
III
'<
Z
c:
Ul
3'
<Q
(") -0
~ t:3
~ S2
'" N
o 0
o 0
"" -'oj
... ....
N 0
"" ....
~ ~
o 0
c 0
"" ';-4
~ ...
s s
~ ~
g 8
'-.j ......
.... ....
o 0
N N
U> (.:>
t1l Ul
:-. ....
~ <0
<0 m
IU
~ :-.
3
CT
~
....
...
o
o
....
lil
."'0
III
'<
Z
c:
Ul
5'
,<0
aJ
..
it
:l
t'l
OIl
'"
i
..
a.
-4
o
or
iii'
o c:>
i:I <:)
Cl 0
:>
"
CD
"
o
i
..
a
~I
iii
;;I.
:;:r'
II
!!.
"
1J :;Il
'" CD
'< GO
Z n a:
c: c .,.
~. ;.:~
<Q ::>
...
J>
II)
5' i
I
-4
I:)
..
!.
C'l
0-
c
U\
o CD
c :'
gc..
ilt' 5\
t..a ~ a/\1)
~ ~ ~:i; 2:
... ... 'tD- ::I
~~LJco
I .
m
ci
.. n
nr~
It:
'1l(/l
II ill
Ie: <
3 -,
. n
::I It
"0
c..
!.<i
III -
'"III
iil
~.
o 0
i:::o 0
... 0
C>
W
o
-4
'<
'i
g 0
8 g~iw,~
7"<:1>
... '"
<:> 0
Q
c 0 CD;
b 0 ..
g co! I \
N 1\l;~11
~ W c,;
III 0>
(II C.I'
:... ~
N '"
o
IlJ -
III :l
~~I
:;i "I
III .
;;IZ
III 0
2....
?
~
'"
.....
.!.
::I ~ i
""
...
Q 0
b b
<:> 0 ,.
~cO
~Ii?
~ g~\~
I ~
(,) N
, I~'
~ ~ I
o
III
'<
(II
2
S:
ai,
Ill,
iii'
::I
n
'"
p.2
::2
;0
ell)
f/I"
ell 0
~ :;
m
::2
-
;::;:
':<:
C")" ~
l:: "'0 g)
30""
tTlD"-'
CD ::a. ~la
:!.Ol\)
III C)
:= C)
Q. CD
n :::
o :,;.
: 01
::J )-
co s:
III
OJ
II)
~.
:l
2.
:l
'R
C')
c
3
m 0-
~ )0 ~
~ ~ D7
~:s='
III ,g c..
c 5.0
~-<g
CD UI
:;"
I&)
(/I
Ul;o::OCi"Url
C) :r
II 1\ 1\ II II !!l
Q);o;oO"tl~
('0 <1l <1l 0::1,
81!J~i~-<'
as!:i'<-<]
~~8 '"
C)
.g
III
'<
1:1
CJ
co
tlI
...
o
-
....
/
CONTINUING CARE RX #001
;.:20 S SECOND ST
NEJ,WOHT Pli 17074
" * R TAT E MEN T * *
~;t<Jtf:)mf.~nt Date:
1/31/08
Page:
f\ccount #: 100042896
JOSEPHINE CLOUSER
CHUHCI..! OF. GOD PEFU30N
801 NORTH HANOVER 5T
CARt_ISLE! PA 1701~3
A!~Y QUESTIONS CALI_ MIRANDA @ 800-675-2279 EXT 1406
1
Date Descriptiun Gty Amount
._..___._._....___....... ......._..._.......___.._...._._..__.._..,...____________n_________________ __________
"j ... t"l ~...~. / ('):::~
of.' '.,' " " ,.".,..,.
. .' -., .... ....
1/1~:,,/t}~:3
FTt:.\,/i.ous I~';:ll~:'jr)Ce
!"';,:-:,1;:
... .... . ".- ... .... .....
::J ;;.::: ). "/ ~.J ~j ./
IV-PUMP-BAXTER 6201 RENTA
SODIUM CHL o. 9% BAG 250ML
7
250
...... '. ......., R..._........,.
!...~ :!~. :fr ~:) ;.:::: ~} (:) 'o.?, ;.:::: ~::t
E:nd .i.nq \:;<:;llE!nC(.:~ -- PEIY th is amount
-.
---------- '.
CUT' r-' 0.' n t;
f>ast I)ue
~~; t .-.60 d a q s
Past Due
61-90 days
775.96
84.00
12.20
872. 16
Past Due
90+ days
(\i\!Y OUESTH:H.i~~) '..J';!....!.. i.1n~i\ND{\ (~ tlOO"-67S..-2279 EXT 1406
~:? t). ;.:? ()
....... ..... .... ~.....
.I ./ ::;.. ':';t:)
.00
...~............_..'~ ,".",._,._.. .._...._M...._...._.........._.............., ,.__._..________ -----------
.00