Loading...
HomeMy WebLinkAbout08-19-0815056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po sox 2eosol 21 07 0597 Harrisburg, PA 17129-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 202-20-6926 ' ' 05/31/2007 03/26/1921 Decedent's Last Name Suffix Decedent's First Name MI _._. I SHANNON ', ' MARION P (If Applicable) Enter Surviving Spouse's Information Below Spouse°s Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILE D IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~~;` 1. Original Return ? 2. Supplemental Return ;;~~ ~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate 4a. Future Interest Compromise (date of ! J „„~ 5. Federal Estate Tax Return Required death after 12-12-82) ~~, 6. Decedent Died Testate ~ ~.,~? 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) _.,, 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death _.W 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number -`~ THOMAS E. FLOWER (717) 737-3405, - _ __ __ _ .-, _ _ Flrm Name (If Applicable) REGISTER OF WILT LS USE ONLY ~ SAIDIS, FLOWER, LINDSAY First line of address _ _ __ _ ~ ,, 2109 MARKET STREET Second line of address -~ `-' I .} ,; ; City or Post Office State ZIP Code _ DATE FILED ~•'- CAMP HILL PA ' 17011 Correspondent's a-mail address: Under penalties of perjury, 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. SIGNATU OF PERSON RESPONSIBL R FILI[JG RETURN ~. - - -- -- - __ ____- - - - DATE S__,~~-vg _ ADDRES JUDY .COOK, 2107 EAST COVENTRY LAND, ENOLA, PA 17025 SIrdNATO E OF PREPARER OTH~yt.T A RESENTATIVE i !~- 2~ DATE // , ~~ ~ _ _ -___ _ _ ~ - -- - _ ADD~tESS t Q L C --- f SAIDIS, FLOWER & LINDSAY, 2109 MARKET STREET, CAMP HILL, PA 17011 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 15056052059 REV-1500 EX Decedent's Social Security Number MARION P SHANNON .202-20-6926 Decedent's Name: RECAPITULATION 1. Real estate (Schedule A) . .......................................... .. L 132,409.60 2. Stocks and Bonds (Schedule B) 2, 16,481.65 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages 8~ Notes Receivable (Schedule D) ........................... .. 4. _. _ __ 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... .. 5. 2,501.52 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ..... .. 6. 8,757.25 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property d 7 542 150 09 ...... (Schedule G) ~"~.~~ Separate Billing Requeste . .. , . 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. 310,692.11 9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. 12,635.38 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. ..10. 11. Total Deductions (total Lines 9 & 10) ................................. .. 11. 12,635.38 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 298,056.73 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... .. 13. 1,000.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. 297,056.73 ', TAX COMPUTATI,Y ... ._~ _ .,.,_.,,.~. ~_ ,_ ,_., ,,,,~,~.._ ......_._~._ e ~ ~~ ON -SEE INSTRUCTIONS FOR APPLICABLE RATES _ ee 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 ', (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate x .0 45 296,056.73 16, 13,322.55 17. Amount of Line 14 taxable at sibling rate X .12 __ 17. 18. Amount of Line 14 taxable 1 000 00 150 00 , . at collateral rate X .15 18. . 19. TAX DUE ....................................................... .. 19. 13,472.55 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT t 15056052059 Side 2 15056052059 REV-1500 EX Page 3 r)pr_Pdent's Cemnlete Address: Flle Number 21 07 ! `0597 DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER MARION P SHANNON 202-20-6926 STREET ADDRESS MANOR CARE HEALTH SERVICES WALNUT BOTTOM ROAD CITY STATE ZIP CARLISLE PA 17015 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit __ ___ - - -- B. Prior Payments C. Discount (1) Total Credits (A+ B + C) (2) 3. InteresUPenalty if applicable 217 28 D. Interest _ _ _ _ ---- E. Penalty Total InteresUPenalty (D + 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) (4) (5) (5A) (56) 13,472.55 0.00 217.28 13,472.55 217.28 13,689.83 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 :.......................................................................................... ^ ^X b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ ^x c. retain a reversionary interest; or .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. ^ ^X 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ 0 ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or 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. §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 zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. 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 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling 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 COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MARION P. SHANNON 21-07-0597 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 relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) x ~ ~ ~ fD ~ C Pz] O x m ~ ~ k m m ~. ~ ~ o ro ~ ~ `~ M a R a ~ Ho ~y ££ H m w z x ~ ~ Y ro a m ,7 H ~ -r v rr o w ~ ro ~ H m o a n a u m u O 'TJ ~ ~ b o n C o ~ v N N ro U~ O ° ~ ~ ~ ~ r o ~ z ~- m 0 0 a rn e 0 Y 'tl ~ N H n o 0 n ry ro o ~ O E Y m H b ~ o w ~ ~ ~ y ~ 0 m uCi r t " H.1 W S .gym n yro y H O ro 'y r• E H 7 ~ ~ ~ a ,^ ~ OO h q a ~ n 5 y o a ~ b z ~ m m ro r~ ty n ~ [ 0 o rar ~ z ~ H ~ '~ O O V c~Ra o~ m r ~ z a H m ro ~ m C r- ` ~ a W ;~] r, r- 0 0 O n K Ul w N 3 w x m \ ~. m H N ro w o t*7 { p r ~ ~ ~ rt .n i ~ E o o~ N W H H k oro w ° z ~ m ° ut r w ^C m n r• m N o H H o N - o 0 ~, 0• m N ~, ~ o \ ` m m H In ( G m ~ N y W o ro ~ ~' O N N [ rJ O o CTJ ~ TJ p v m O O m m z ~ m r- to [n b' ~ r- O r o O rt~ u ~ o b ~ \ y w ;~] N [*] ~ E o21 r q m b O ~ O O ~i o z ~ x~~~ r N r z K 0 F' O w x ~n H o 5tl m 3 5 in A7 ~ N "r. bf q O z I'I.3i o ~ N~ y w G1 4 z H ~' N K oY w~ Y~ O x ro ~ O ti ~ w Y ~ o ff ,ro [4 ny C I-~ o O~~~ 0 0 H O H ~ ~ O~ O ~ o ~ ~ z x `~ t~] ro o - ~ H y N ~ H ro -~ n ~ o ~o ~ H ~ ~ n ?~C to H H rn ~ ,ro O w y ~' H ~ n [fib m _~ zH a N N H r~ H. N -= ~ ~b ~ __ Z7 C o I~ R \ o J b7 0 ~ ~ o ~ a ~ ~ m H. __ ~ a - ~. w ~ .a ° `° N O ~ 6~ IJ7 w n rn o ~ ~ ~ ~ ~ w ~ o H N b. N 1D ~/1 lD ~A n0 W N ~ w w ,-r b ;~ b7 a o ~ rt 7 N ~ ~* ~ o z ~ o r o ~~ 1p O ~ 'T1 J N n b7 to N w N F, 0 0 ~ o r, O + N .~ o p~ w b ° F' N W ~ m N O p~j ti 6l N rt ~O Ul `C 7 H a m ~ 7 N ~ R ~' G 'L W m O ~ C~! xx ~ E k Y ti7 G1 ~ xx m ~ [9 ao O x I-n y ~. °' n O a ~ H ~ ro o m w x (D ~ ,'~' ro a R a rr o w ~t b n7 ~ m c a n m z n m m ~ N b ~ m - no m i Y .7 r] y. z C I o r N o O in ~ ~ r -.1 .YI H i ~ o C1 w o q H f1 0 +• 7C o x r H o b o M o 0 X1 0 n o C z o ~, n ~ Z ~ m g £ 5 H b ~ ° a y . a m~ a a H r m o m m r K w n ro y y H O b ay z~•°E y~ ~ o ~ x a n y m m r ~ am ~ C C,, ~ ~ n 5 Z 3 ~m m m C7 0 0 °: ~ z ~ [ H N N v o x te ~ r - ~ z m ~ m r r ~ x °i z o m k r• ~ m m n r- o O O n rt ~ w N ro w o t~l n H N O 'G R C~7 \ \ E l0 z a A N N t~ m ~ ro w ~ o z N m rwk o, II W n o H M N o N - 0 0 ~ a w N vl a o \ \ 07 m H o w o ~r7 ~ m m r .- lti N \ ~. ~ O ~ ro O N N O o o [*~] z T N N m m (n Y• ~ ~ Q1 E r• O ~-+ ~ r- ~ ` '~ v ~ k o o ` ~ E m N N ro ~ 0 c M o ~ .7 b M 'N'YC ~ W C" N C O W 'fin' b H O~ f~A N ~7 ~ibo x htl ,T h1 O N ."{' q O G K ~ ao y F+ ro lA ~ o r R1 [~ ro r VI J Hy' ggo ~ ~ ~°o yy~ a [+J ~ t7 H "i N 'ry' w x O ~ ~ ~ ~ ~ n w H H ~ Y ~ w ~ N N N b N O r m eb O O fC ozC1 zKo CT] \ 3 o z H E H k x ~ ~ ror~, r H ~ H H Cs1 O H H t=7 ~pb ~ ~~ H I-C H. ~ __ ~ '~ b ] r ~ o R ,Tl C N ~ ~, ~~ ~ N prj ~° H o ] y a m a .a ° `4 __ N O A 01 Ul ]~ rt -~ 01 O ~ N 3 3 •`"' a N R w N o ~-. --- b ~o 'n 61 N O N ~ m o n b n m N O N- rr ~ ~ N rr I~ O 'L' o ~ .. .. m I~ ,~ 'TJ -~ I-' O n b7 N ~ p ~ fA In O o I~ m p r .t+ o pp ~-' ~ o (V o °J rn w m CO ~P n o~~ f Courthouse Online -General Main Page 1 of 2 E, C ,tl, t General Info Dwelling Sketch Photo Outbuildings Site Info Land (Fair Market) Land (Clean and Green} Sales History Value Summary Value History Comments Map Assessment Office Tax Claim Prothonotary Clerk Of Courts Commissioners' Office Recorder Of Deeds Register of Wills Planning Commission Voter Services Domestic Re{ations Lobby Log Out Home Notes Respc General Information Parcel ID: 251,155.41-431.004 Owner: SHANNON, MARIO Owner Name & Address Property Identification Deeded Owner SHANNON, MARION P Control No 00518520 C/O JUDY COOK Unit/Lot No Mailing Address 2107 EAST COVENTRY Deeded Acres 0.23 LANE Old Map Number City, State, Zip ENOLA , PA 17025 Sales Property Location Date of Sale 10/01/1987 Municipality 251 - TOBOYNE Selling Price $40,000 TOWNSHIP 1 School District 5 -WEST PERRY SD Deed Book-Page 00469-00096 Neighborhood 251 - TOBOYNE Muiti-Parcel N TOWNSHIP 1 Situs Address Current Market Assessed 1 Market Land $10,000 Description Market Building $64,130 Total Market Assessed $74,130 Property Description Current Clean & Green Assess Property Type R: Residential With C&G Land Buildings Land Use Type 101: Residential 1 Family C&G Building Tieback Parcel C&G Assessed Tieback ID C&G Approved N Homestead / Farmsteai HS Approved Y FS Approved Y Make Informal Review Nate I Privacy Policy Terms Of Service Contact Us courthouseonline.com ...a better way to access public records.T"' Website and Services Copyright ©2000 http://www.courthouseonline.com/QuGeneralMain.asp?State=PA&County=Perry&Abbrev__ 5/19/~nnR Courthouse Online -General Main Page 1 of 2 General Info Dwelling Sketch Photo Outbuildings Site Info Land (Fair Market) Land (Clean and Green} Sales History Value Summary Value History Comments Map Assessment Office Tax Ciaim Prothonotary Clerk Of Courts Commissioners' Office Recorder Of Deeds Register of Wills Planning Commission Voter Services Domestic Relations Lobby Log Out Home Notes Respc General Information Parcel ID: 251,173.00-100.000 Owner: SHANNON, MARIO Owner Name & Address Property Identification Deeded Owner SHANNON, MARION P Control No 00518759 C/O JUDY COOK Unit/Lot No Mailing Address 2107 EAST COVENTRY Deeded Acres 3.82 LANE Old Map Number City, State, Zip ENOLA , PA 17025 Property Location Municipality 251 - TOBOYNE TOWNSHIP 1 school District 5 -WEST PERRY SD Neighborhood 251 - TOBOYNE TOWNSHIP 1 Sales Date of Sale 09/18/1987 Selling Price Deed Book-Page 00467-00149 Multi-Parcel N Situs Address LOWER BUCK RIDGE ROAD Description Property Description Property Type L2: Vacant Land, 1- 5 Acres Land Use Type 100: Residential Vacant Land Tieback Parcel Tieback ID Current Market Assessed 1 Market Land $23,230 Market Building $0 Total Market Assessed $23,230 Current Ciean 8~ Green Assess C&G Land C&G Building C&G Assessed C&G Approved N Homestead J 1=armsteal HS Approved N FS Approved N Make Informal Review Note http://www. courthouseonline. com/QuGeneralMain. asp?State=PA&C'ounty=Perry&Abbrev... 5/ 19/2008 REV-1503 EX+ (6-98) ~ SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MARION P. SHANNON 21-07-0597 All property jointlyowned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) MARION P SHANNON 2007 YEAR-TO-DATE STATEMENT O1/O1/2007 - 09/30/2007 Summary of your Putnam accounts • Beginning balance Exchanges Change Ending balance Fund name (as of Ol/Ol/2007) Additions in/out Withdrawals in value (as of 09/30/2007) PUTNAM AMERICAN GOVT INCOME-A $16,386.32 $0.00 $0.00 $0.00 $805.44 $17,191.76 Total year to date $16,386.32 $0.00 $0.00 $0.00 $805.44 $17,191.76 Total this quarter $16,615.98 $0.00 $0.00 $0.00 $575.78 $17,191.76 • PUTNAM AMERICAN GOVT INCOME-A Account income 7hisquarter Year to date Account number: 0018-0023821103 Dividends (reinvest) $176.42 $518.18 Account open date: 03/24/198b Capital gains (reinvest) $0.00 $0:00 MARION P SHANNON Average. cost basis $18,111.21 02/14/2007 DIV REINVEST 0.031 57.58 8.800 6.543 1,863.976 03/15/2007 DIV REINVEST 0.031 57.78 8.880 6.507 1,870.483 04/17/2007 DIV REINVEST 0.031 57.98 8.830 6.566 1,877.049 05/16/2007 DIV REINVEST 0.031 58.19 8.860 6.568 1,883.617 06/18/2007 DIV REINVEST 0.031 58.39 8.700 6.711 1,890.328 07/18/2007 DIV REINVEST 0.031 58.60 8.780 6.674 1,897.002 08/14/2007 DIV REINVEST 0.031 58.81 8.880 6.623 1,903.625 09/14/2007 DIV REINVEST 0.031 59.01 8.980 6.571 1,910.196 09130!2007 Ending Balance 9.000 1,910.196 $17,191.76 HISTORY OF YOUR INVESTMENT IN THIS ACCOUNT Initial amount + Additions + Exchanges - Withdrawals = invested on 01/01/1992 $75,413.58 $0.00 $0.00 $100,000.00 Capital gains and dividends distributed in cash since initial investment $0.00 Net amount + Change = invested in value -$24,586.42 $41,778.18 Ending Balance as of 09/30/2007 $17,191.76 PAGE 2 OF 4 SU200 Share Number Share Total Date Account activity detail Amount price of shares balance value 01/01/2007 Beginning Balance 8.850 1,851.562 $16,386.32 01/17/2007 DIV REINVEST 0.028 $51.84 8.830 5.871 1,857.433 PUTNAM INVESTMENTS >03879 3657871 ~~1 092033 MARION P SHANNON PO BOX 48 NEW GERMANTON PA 17071-0048 Founded in 1937, Putnam Investments began with the principle that a balance between risk and reward is the mark of a well-rounded financial program. Today, we manage money with a focus on consistent results, and this prudent approach remains the foundation of our investment philosophy. - -- - -- Total value as of 09/30/2007: $17,19 .76 2007 YEAR-TO-DATE STATEMENT 01/01/2007 - 09/30/2007 For help with your investments, contact: MR. MICHAEL B. COOK LEGEND EQUITIES CORP For help with your account, contact: Putnam Investments 1-800-225-1581 www.putnam.com ACCOUNT SUMMARY This quarter Year to date Beginning balance $16,615.98 $16,386.32 Additions 0.00 0.00 Withdrawals 0.00 0.00 Change in value 575.78 805.44 Ending Balance (09/3012007) $17,191.76 $17,191.76 Do bonds belong in your investment plan? Mutual funds that invest in bonds can help investors of all ages pursue rnultiple goals. Read about the potential benefits of fixed-income investing and Putnam's broad array of bond fund options in the latest issue of Putnam Investor, PAGE 1 OF 4 03879 3riFi7R71 M775R M S5n7 hnhM IMf1M REV-1508 EX+ (6-98) COMMONWEALI-H OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER MARION P. SHANNON 21-d7-0597 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. (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY OWNED PROPERTY ESTATE OF FILE NUMBER MARION P. SHANNON 21-07-0597 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• JUDY S. COOK 2107 E. COVENTRY LAND ENOIA, PA 17025 DAUGHTER B. C. JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST ~ ~ A. 06128/96 BANK OF LANDISBURG ACCOUNT #061379420 13,777.94 .50 6,888.97 2• A 06128196 BANK OF LANDISBURG ACCOUNT #2613794 . 1,703.90 .50 851.95 3• A MEMBERS 1st FCU ACCOUNT #3898-00 . 41.52 .50 20.76 4. A MEMBERS 1st FCU ACCOUNT#3898-05 , 1,991.13 .50 995.57 TOTAL (Also enter on line 6 Recapitulation) I $ 8,757.25 (If more space is needed, insert additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INFORMATION NOTICE FILE No. 50 BUREAU OF INDIVIDUAL TAXES AN D DEPT. 280601 ACN 07129747 HARRISBURG, PA 171za-g6Bl TAXPAY E R R E S P O N S E DATE 06-28-2007 REV-1543 E% I1FP (09-DO) TYPE OF ACCOUNT EST. OF MARION P SHANNON ® SAYINGS S.$. N0. 202-20-6926 ^ CHECKING DATE OF DEATH 05-31-2007 ^ TRUSr COUNTY PERRY ^ CERTIF. REMIT PAYMENT AND FORMS T0: JUDY S COOK REGISTER OF WILLS 2107 E COVENTRY LN PERRY CO COURT HOUSE ENOLA PA 17025 NEW BLOOMFIELD, PA 17068 BANK OF LANDISBURG has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. Questions may be answered by calling C717) 787-8327. COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 061379420 Date 06-28-1996 To insure prover credit to your account, two Established C2) copies of this notice must accompany your Account Balance 13, 777.94 payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". Percent Taxable X 50.000 NOiE: If tax payments are made within three Amount Subject to Tax 6,888.97 (3) months of the decedent's date of death, Tax Rate X .045 you may deduct a 5Y. discount of the tax due. Any inheritance tax due will become delinquent Potential Tax Due 310.00 nine (9) months after the date of death. PART TAXPAYER RESPONSE _::::~ia<i'.E~ti~1II~: _::T1EI:t:t:~l~~~.'1~'1lfi~;:t:L1,:'1,1,t,{:,t:t,:~~'L."~ fI.E:,'{`.,...:Fil::al-l1'ii'.I'1'"4"C~"'!4.J!fF,~;~:F:::::;'R11~°::;:~~C%tYK[C'C%i1~i~C~l~:::::mr'ilk'CTE::::r~7::::::•p:E7::~:C~:::::37:Y8~'M!'/~Cfiill:'i~~ i~ A. ^ The above information and tax due is correct. 1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or you may check box "A" and return this notice to the Register of C 0 N E ~ Wills and an official assessment will be issued by the PA Department of Revenue. BLOCK B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the decedent's representative. C. ^ The above information is incorrect and/or debts and deductions were paid by you. Vou must complete PART ^ and/or PART ^ below. I f o u i n d i c a t e a d i f f e a :::::::::::::::::::::::::::::~ :;:;: ;:;:: ~:::::::::::::;-:;:::::;:::;:;:-;:;:;:,:::;:::::::::::::;:;::,~:::::::;:;::::::~~:::-::..,.,. PART Y r nt tax rate, please state your l a t i o n s h i t o d e c e d e n t: ::::::::.:::.:. :.:.:.:.:.:.:::.:....:.........:.:.:.:.:.:.:.:.:.:.:.....:......................................::::::.... re 2 ............. ss~ ~€~€~[isiiE~!LT!!#N:'~isi€~iiiii~~ ii TAX RETURN - COMPUTATION OF TAX 0 '°?!'€~~::~s,€:€~€€~€€€:;_~~_€;ss€;€€s~€€~~~€€~€~~€€~€;= N JOINT/TRUST ACCOUNT ::: ~:: ~:::~:~:::~ :::::::::::::::::::::::::::~:::::::::::::::::::-:-::~:::-::::::::::::::::::::::::::~:::::::::::::::::::::::::: LINE 1. Date Established 1 iiiii`:~€'`'isi'i':isiii=iii~i~ii~i':i~```s'z''`':'s':':~'''~~=i~'i~'' ii~ii 2. Account Balance 2 ~~ €'~`=~''~~=I~ ~ iii {f~ ~'~~`e''~'~~'~''~ ''~ ~ ~ fE~ ii€j€€'° 3 . Percent Taxable 3 -.X iiii's'iiiffi~ °'`': ~'': ~ ~ ~':~ ~ ~ ~ iii i~'i~ iiz~iii':i~ i ~':~ ~ ~':~ ~ ~ iEiEiiiii iii 4. Amount Subject to Tax 4 7 _ '`iii€~~€''€`€`€'€'~ €'€'~ ~€ ~~€'€ ~ ~ iiiii ~ss~`:s~ €'€'€'~ €'€'€'~' ~''ssi1 iii i 5. Debts and Deductions 5 ~ii~i~''''~'':~'':~':`'~ ~iijii~iii~~ fit'=€€i€€s~' 6. Amount Taxable 6 c~~€i~i~''•.':~i~'~''~i':'':~ii~1i~ri'•.~i~ ~':`:~':':`':~ii`~~i~i~Pi 7. Tax Rate 7 X 8. Ta x Due 8 PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID TAX P.AXERf~IGNATURE TELEPHONE NUMBER DATE TOTAL CEnter on Line 5 of Tax Computation) S Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of my knowledge and belief. HOME C ) i ~~. WORK C ) GENERAL 1NhUKMAIlUN 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance tax becomes delinquent nine months after the decedent's date of death. 3. A point account is taxable even though the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) which the decedent put in Joint names within one year prior to death are fully taxable as transfers. 5. Accounts established jointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are taxable fully. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in block "A" of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with your check for the amount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept 280601, Harrisburg, PA 17128-0601 in the envelope provided. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check block "C" and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent dying after 12/12/82: Accounts which the decedent Dut in ioint names within one (1) year of death are taxable fully as transfers. However, there is an exclusion not to exceed 53,000 per transferee regardless of the value of the account or the number of accounts held. If a double asterisk (>^) appears before your first name in the address portion of this notice, the 53,000 exclusion already has been deducted from the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the date of death. 3. The percent of the account that is taxable for each survivor is determined as follows: A. The percent taxable for joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A point asset registered in the name of the decedent and two other persons. 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7Y. (TAXABLE FOR EACH SURVIVOR) B. The percent taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT X 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50i (TAXABLE FOR EACH SURVIVOR) The amount sub]ect to tax (line 4) is determined by multiplying the account balance Cline 2) by the percent taxable Cline 3). Enter the total of the debts and deductions listed in Part 3. The amount taxable (line 6) is determined by subtracting the debts and deductions (line 5) from the amount subject to tax (line 4). Enter the appropriate tax rate Cline 7) as determined below. *The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to ar for the use of a natural parent, an adoptive parent, or a stepparent of the child is Oi. The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not then have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The "Collateral" class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You legally are responsible for payment, or the estate subject to administration by a personal representative is insufficient to pay the deductible items. B. You actually Paid the debts after death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use plain paper B 1/2" x 11". Proof of payment may be requested by the PA Department of Revenue. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3% 6% 15% 15% 01/01/95 to 06/30/00 0% 6% 15% 15% 07/01/00 to present 0% 4.5%* 12% 15% COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE N0. 50 DEPT. 280601 TAXPAYER RESPONSE ACN 07129746 HARRISBURG, PA 17128-0601 DATE 06-28-2007 REV-1543 E% AFP (09-007 JUDY S COOK 2107 E COVENTRY LN ENOLA PA 17025 TYPE OF ACCOUNT EST. OF MARION P SHANNON ^ SAVINGS S.S. N0. 202-20-6926 ® CHECKING DATE OF DEATH 05-31-2007 ^ TRUST COUNTY PERRY ^ CERTIF. REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS PERRY CO COURT HOUSE NEW BLOOMFIELD, PA 17068 BANK OF LANDISBURG has provided the Department with the information listed below which has been used in calculating the potential tax due. Their records indicate that at the death of the above decedent, you were a joint owner/beneficiary of this account. If you feel this information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth of Pennsylvania. puestions may be answered by calling C717) 787-8327. COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 2613794 Date 06-28-1996 To insure proper credit to your account, two Established C2) copies of this notice must accompany your Account Balance 1 , 703.90 payment to the Register of Wills. Make check payable to: "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax 851.95 I3) months of the decedent's date of death, Tax Rate X .045 you may deduct a 5% discount of the tax due. Potential Tax Due 38.34 Any inheritance tax due will become delinquent nine C9) months after the date of death. PART TAXPAYER RESPONSE :~::3w~3k:'F#:~lL'E~_;;'.Ti'Y_ -'~L~~i'li!'Ef_.:.:Llt'F'I::i:~ ::::1~'CAt~~11:{:t?•f!~[::•1!1ilt~ t;:ilk~7t~t~t~f~C'E"~T~:T`i:{•~ ::~'p'ik'STt;~:i1Li'l~S~~C:i'~il~~C~'ii'E":€ II 1G:Cl~:'E1 L1~'ii ::`E`E7 fi RF Ll:l7:•.1!`:T:!'~[C:::: A. ^ The above information and tax due is correct. 1. You nay choose to remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or you may check box "A" and return this notice to the Register of C 0 N E ~ Wills and an official assessment will be issued by the PA Department of Revenue. B L 0 C K B. The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the decedent's representative. C. ^ The above information is incorrect and/or debts and deductions were paid by you. You must complete PART ~ and/or PART ~ below. PART If you indicate a different tax rate, please state your relationship to decedent: TAX RETURN - COMPUTATION LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due OF TAX ON JOINT/TRUST ACCOUNTS 1 2 3 X 4 5 6 7 X 8 PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID TAXPACYE R HONE NUMBER DATE TO7AL CEnter on Line 5 of Tax Computation) S Under penalties of perjury, I declare that the facts I have reported above are true, correct and complete to the best of/m7y~ knowledge and belief. HOME C ) ~~ ~ ~. ~-c a-C~-~ WORK C ) GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on information submitted by the financial institution. 2. Inheritance tax becomes delinquent nine months after the decedent's date of death. 3. A ioint account is taxable even though the decedent's name was added as a matter of convenience. 4. Accounts (including those held between husband and wife) which the decedent put in ioint names within one year prior to death are fully taxable as transfers. 5. Accounts established ]ointly between husband and wife more than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are taxable fully. REPORTING INSTRUCTIONS - PART 1 - TAXPAYER RESPONSE BLOCK A - If the information and computation in the notice are correct and deductions are not being claimed, place an "X" in block "A" of Part 1 of the "Taxpayer Response" section. Sign two copies and submit them with your check for the amount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. BLOCK B - If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one copy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept 280601, Harrisburg, PA 17128-0601 in the envelope provided. BLOCK C - If the notice information is incorrect and/or deductions are being claimed, check block "C" and complete Parts 2 and 3 according to the instructions below. Sign two copies and submit them with your check for the amount of tax payable to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official assessment (Form REV-1548 EX) upon receipt of the return from the Register of Wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter the date the account originally was established or titled in the manner existing at date of death. NOTE: For a decedent dying after 12/12/82: Accounts which the decedent put in ioint names within one C1) year of death are taxable fully as transfers. However, there is an exclusion not to exceed 53,000 per transferee regardless of the value of the account or the number of accounts held. If a double asterisk t**) appears before your first name in the address portion of this notice, the 53,000 exclusion already has been deducted from the account balance as reported by the financial institution. Enter the total balance of the account including interest accrued to the date of death. The percent of the account that is taxable for each survivor is determined as follows: A. The percent taxable for point assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF DIVIDED BY TOTAL NUMBER OF X 100 = PERCENT TAXABLE JOINT OWNERS SURVIVING JOINT OWNERS Example: A ioint asset registered in the name of the decedent and two other persons. 1 DIVIDED BY 3 CJOINT OWNERS) DIVIDED BY 2 (SURVIVORS) _ .167 X 100 = 16.7% (TAXABLE FOR EACH SURVIVOR) B. The percent taxable for assets created within one year of the decedent's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT X 100 = PERCENT TAXABLE OWNERS OR TRUST BENEFICIARIES Example: Joint account registered in the name of the decedent and two other persons and established within one year of death by the decedent. 1 DIVIDED BY 2 (SURVIVORS) _ .50 X 100 = 50% (TAXABLE FOR EACH SURVIVOR) The amount subject to tax Cline 4) is determined by multiplying the account balance (line 2) by the percent taxable (line 3). Enter the total of the debts and deductions listed in Part 3. The amount taxable Cline 6) is determined by subtracting the debts and deductions (line 5) from the amount subject to tax (line 4). Enter the appropriate tax rate (line 7) as determined below. 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%. The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have been adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one parent in common with the decedent, whether by blood or adoption. The "Collateral" class of heirs includes all other beneficiaries. CLAIMED DEDUCTIONS - PART 3 - DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are determined as follows: A. You legally are responsible for payment, or the estate sub,7ect to administration by a personal representative is insufficient to pay the deductible items. B. You actually paid the debts after death of the decedent and can furnish proof of payment. C. Debts being claimed must be itemized fully in Part 3. If additional space is needed, use plain paper 8 1/2" x 11". Proof of payment may be requested by the PA Department of Revenue. Date of Death Spouse Lineal Sibling Collateral 07/01/94 to 12/31/94 3% 6% 15% 15% 01/01/95 to 06/30/00 0% 6% 15% 15% 07/01/00 to present 0% 4.5%~ 12% 15% • St O MEMBERS 1St FEDERAL CREDIT UNION Send Inquires to: 5000 Louise Drive PO Box 40 Mechanicsburg, PA 17055 www.membersl st.org Main Switchboard: (717) 697-1161 or (800) 283-2328 EZ Call: (717) 697-4372 or (800) 283-4372 TDD: 1717) 697-5312 or (800) 283-2328 ext. 5312 TeleBranch: (717) 795-6049 or (800) 237-7288 i1b34 1 AV 6.372 11634-11b34 I~r~lllr~~lllrr~rrl~lrlrlr~~rllr~lrllrr~l~ll~~llr~~lr~rlrrl~ll MARION P SHANNON C/O JUDY S COOK 2107 E COVENTRY LN ENOLA PA 17025 Statement of Accounts May 25, 2007 thru Jun 24, 2007 Account Number: 3898 Account Balances at a Glance Checking : 1.52 Savings: 41.52 Certificates : 0.00 Loans: 0.00 Maney Management : 1, 991.55 Page : 1 of Are you looking for a way to invest your hard earned money? Consider a certificate from Members 1st. Ask an associate about our monthly specials or visit www.members1 st.org for more information. CHECKING ACCOUNTS 11 -CHECKING Date Transaction Description Additions Subtractions Balance May 25 Ba/ante Forward 1.52 Jun 24 Ending Balance 1.52 SAVINGS ACCOUNTS 00 -REGULAR SAVINGS Date Transaction Description Additions Subtractions Balance May 25 Ba/ante Forward 41.52 Joint Owner: JUDY S COOK Jun 24 Ending Ba/ante 41.52 05 -MONEY MANAGEMENT Date Transaction Description Additions Subtractions Balance May 25 Ba/ante Forward 1,991.13 Joint Owner: JUDY S COOK May 31 Deposit Dividend Tiered Rate ~ 0.42 1,991.55 Annua/ Percentage Yield Earned 0.250% from 05/09/2007 through 05/31/2007 Jun 24 Ending Ba/ante 1, 991.55 YTD SUMMARIES TOTAL DIVIDENDS PAID 00 REGULAR SAVINGS 0.00 05 MONEY MANAGEMENT 2.05 11 CHECKING 0.00 Total Year To Date Dividends Paid NOTE: Total includes closed shares 2.05 REV-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER MARION P. SHANNON 21-07-0597 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. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER.ATTACHACOPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 OMB SINGLE PREMIUM DEFERRED ANNUITY PAYABLE TO JUDY S. 150,542.09 100 150,542.09 COOK, DAUGHTER TOTAL (Also enter on line 7 Recapitulation) $ I 150,542.09 (If more space is needed, insert additional sheets of the same size) 'OIVI FINANCIAL LIFE INSURANCE COMPANY ANNUAL STATEMENT OF POLICY VALUES SINGLE PREMIUM DEFERRED ANNUITY CURRENT POLICY YEAR: JULY 31, 2006 -JULY 31, 2007 CONTRACT INFORMATION OWNER: MARION P SHANNON JOINT OWNER: ANNUITANT: MARION P SHANNON ~ POLICY NUMBER 01603740 PRODUCT NAME FIDELITY 5 TAX QUALIFICATION NON-QUALIFIED ANNUITY DATE OF ISSUE JULY 31, 2000 THANK YOU FOR CHOOSING OM FINANCIAL LIFE A5 A PARTNER IN BUILDING YOUR SECURE FINANCIAL FUTURE. IF YOU HAVE ANY ADDITIONAL INSURANCE NEEDS, PLEASE CONTACT YOUR AGENT OR OUR OFFICE AT THE NUMBER LISTED AT THE BOTTOM OF THE PAGE. CONTRACT ACTIVITY ACCOUNT VALUE AS OF JULY 31, 2006 $146,870.32 INTEREST RATE FOR CURRENT PERIOD 3.000% INTEREST CREDITED FOR CURRENT PERIOD $4,406.12 PARTIAL SURRENDERS (INCLUDING SURRENDER CHARGES) $0.00 ACCOUNT VALUE AS OF END OF CURRENT POLICY YEAR $151,276.44 *SURRENDER VALUE AS OF END OF CURRENT POLICY YEAR $151,276.44 'SURRENDER VALUE ASSUMES REPAYMENT OF ANY OUTSTANDING LOANS VIA PARTIAL SURRENDER. PARTIAL AND FULL SURRENDERS MAY BE SUBJECT TO SURRENDER CHARGES AS DESCRIBED IN THE POLICY. THE AMOUNT SHOWN REFLECTS ANY APPROPRIATE CHARGES. INTEREST RATE FOR NEXT YEAR INTEREST RATE FOR POLICY YEAR BEGINNING JULY 31, 2007 3.000% Agent name: IF WE CAN BE OFANYASS/STANCE, PLEASE CALL YOUR AGENT OR CALL US AT 1-888-513-8797. REV-1511 EX+ (12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8c INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER MARION P. SHANNON 21-07-0597 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A FUNERAL EXPENSES: 1' NICKEL FUNERAL HOME, BASIC PROFESSIONAL SERVICES 1,890.00 2. NICKEL FUNERAL HOME, EMBALMING 660.00 3• NICKEL FUNERAL HOME, OTHER SERVICES, EQUIPMENT AND TRANSPORTATION 6,559.86 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 Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Retum Preparer's Fees 7. PUBLISH LEGAL NOTICES, SENTINEL: 198.52; CUMB. LAW JOURNAL: 75 Zip Zip 3,000.00 252.00 273.52 TOTAL (Also enter on line 9, Recapitulation) I $ 12,635.38 (If more space is needed, insert additional sheets of the same size) OF A n j pRIGINPL.F C`1ENT pME o m w pUPl.1GAT E-FUNERALFI ~^.~ o~ A TRIPUpA m +9 q ~ ~ w ~' __~ N owm m CZf~ O D ~" 0 3 mac, ^< ~ N ~~~o ro ~ ~1 m ,1, , ~ m n~ m ? ~, ~ my ~ `~ ~2 "` Y C _ 3 m Z ~' '~ a -1 -n O m c ~ O N ~ ~ w 3 m y ~ s% a C~ ~_~ ~ x3'` ~m_~ ~ ~ [i?NaomO ~1 ~ti N T ~ O ~ T '- (~ '6 O y T O 9 ~~ ~ ~ n O -n -n w ~ m m. p-, 7 n T ~ro ~ m m '~ ~m m 3 = o C ~ ~ ~ ~ 'n ,~ m ~' ° N -~ D' n -~ m y m N ~~ . m m ~. c Z ° ~ -n G ' 7S ~ ~~ r 3. ~ w O' m N G m Z I ~ ~. o O rye 3 o..m c~ 3 m o m° 3 GZ ~ m 7!.... X N~ N. F~ ,,Z ~ -n C!~ m O '~ a a~ Z ~ r~ 91 ~ <~ '. D m o c °.: Z m m n m m m m a- n nm m~ m~ co ~ .c y 0 ~' m ~ .y 9 °' ~ m m9 ~ o, m C-. w~ o o Z O w o m-~ D f o m- _ r- ~^~`~ K Q a d m r ~~ "` 9 p 1 a '~33 ~ I~` o ~, f m w w p m 2, m ~ ~. O ~ ~ ~ I rte, Z v= °. m f Q °- °' c. o f v ~ ~ ~ 't.,.. ~ +, w w ~ ~ ~ in s ~,' Y ~ m ~ ~ ~C-o c 3 0 ~° m ~ c m m o ~ °.: ~ ~ w `~° ~ . ego r C 0 4 `° _ •v' ~ m o `o. 3 N ~ _~~ Z ~ o ~ ~. ~ m f_~'°' C> ~~°mm`d9 z -a o `^wu +~. a ~ w~ o ro m N ° a g m ° o a ~ ~ -~ va K o m i .o X 3 0 0 C~ G~ °' ~ I~ ~ ~.. ~ m m ~ m ~ ^' Z -~ ' = `n Z O F. m c ~ O ,~~, m w m O S O ~0- ~ ~ 0 x N ~. C~ n ~ co-'~ a. O '. $ ~ ~ ~ ~ ~~ ~ ~3~ ~~ D ~ £oNN ~" ~ ~ ~m ~ Q' Z - m -n I a d ~ d ti m - v' ~ io m a R° ~ rn ~ 1 "~ Y ~,I v N Q ~ ~ m 1 ~ ~ o =3 r= a ~ c ~ c ~ ~ ? a £, r vh m v ~~ O p, I ` Z ,~r'a~ m N _ a D ' - ,~ ~ ~ ~ a h 9 m m _ -n m m~ m Z r u~ I I F ~~'e. p~ ~~ ~. n ~. ~, m~ ~ b q _ d g ~- Q m~ a Q~ ~' °' ~."u m N~ O p ~ +~,,~.,.,. .~ - °' ~. ~. ~ ~. ~ ~ 2 z ~ ~. ., '. ~ `" ~ a °i m °, w. ~ ma'y' Q ' ' CD +.~ _ X1'1 ~ ~1 ~ O. ~ 10 r ~ `~ N m 1 ~ ~_ 1 ~ _ N 1 ~~ ; , 1 ~ `~ ~ ' ~~ T m~llN ~, ~ ~ 1 , ~ ' ~/ c7 ~ m ~ y n o 0 I ~ ~ ~~~.,>. ~ C" "^ ~ ~ ~ ~ m m S. 7 coon ~ i o f ,c w y 0 m r. - f ~ m d b q' m 1 ~ ~ ~ ~..~ ~ rn m ~ v r- ~ Q ~ N U, n~ m a O v o ' ~`~ o ..~ m -1 n w 4 n ~ ~~ 1 ~ _ w Q o ~ ~ ~ ~ ~ O ~ r ~ ~ ^~, rr~te,,,, o ~ o ~ y. ,Z ;S= w o m rS ~ j m r CNP I ~' ~ ~' ~~hh" u,, ww~~c ~~amZNW°am A"t,m ` r ~ m N in W C1 7; m Z m N o ' N m O ~ ~' ° m ^ `'~+ O ~ m 1 ~ I~ ' 1 ~ ~ ', m ~ ~ U5 ~ ~, f °. ~ n N w m "~ x `~ ~ ° N c n 3 m 3 ~ ~ G. .~y ~ ~ ~ n K_ 3 ~ ~ Y 6 N G, n -n y a ~ ~'"~. - t.,,~ _. ~~,.,~ r ~ a ? l , a~ ~ cn ~" m y m a m to -... m 'S A m p 1 ~~ m o N t r n m ~ ~ ~'c` ~~~am ~ ~~~m4 y ~ m ~ ~ m ~ *{, j'vcnm r C 7' P~ ti ~ w. m N ~. 6 -I w ~ O w T c 1 0 ~~ n= ~ Zo oar O ? Q'a ~o ~ ¢,m m `°' ~ r.. ' w d m a oNm:^A 9 .b O n o r v. ~ ., o~m~ a ~- m O ° ~'' ~ ~ m n a ~ w m ~,~D O O w ZR mom ~,y0 ~ O~ d N wC.w~N N 0~ 'L ~D CD ~ ~ Z ~ 6t N m ~3oN T am on .n'. m ~ tP N N N I C w c0 A O ~ 7~~ ~ ~ J ~ ~yyi., ~ r' 5 m N m ?7~"yM° x1 ~ }C' ~ ~ M1 m _' ~ w ~~~°- ~ ~ ~A ,gym J z •. ~ 1i ~ ~ N.~ ~ mac-- 3 ~ ~ c 'FaQ cn o ~ ~.. ~ ~ ~ ^ ~ m ~.O ~ t ~ d S1 ~ -. '. ~ H+ W io ~ _ cR m ~mmn 'J 6zN ~~ Nr ~ J d w ~ ~ <cD ~ O ~e Hi ~ w '9 ~ p n w w n "hp A ^- n p_ w o g 5 n •r• v o I ~~ ~ ~": w G O-~ ~~a m s= ~~. C7N Qa ,~ i n~ Y wn n. ~ 3 Q c~ Z~ 4 i ...i- S W '.j ~,t i N ,p S a m. 4~ w O m 'y D ~ ~ +x-, m ~°`° va= o O Z n ~ a a w N~~ m vNm'"°a "~ y ~n d N o v .~ ~ µ' m Y igc o m m 4° m t0 ?mom y `~N Nrm N l \ I w `° N a o ~m~ ~~ ~ ?~~ ~. 2 1 $ i m li a~ N 4'n REV-1513 EX+ (g-001 SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEF{CIAR{ES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER MARION P. SHANNON 21-07-0597 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE t TAXABLE DISTRIBUTIONS ]include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1 • CAROL KRAHN, 4927 MAURITANIA AVE, HARRISBURG, PA COLLATERAL $1000 2• JUDY S. COOK, 2107 E. COVENRTY LN, ENOLA, PA 17025 DAUGHTER $296,056.73 II 1 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS ZION LUTHERAN CHURCH, BLAINE, PA $1,000 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 OF MARION P. SHANNON I, MARION P. SHANNON, of New Germantown, Toboyne Township, Perry County, Pennsylvania, declare this instrument to be my Last Will and Testament, in manner and form following: FIRST: 1 hereby expressly revoke all Wills and Codicils heretofore made by me SECOND: I hereby direct my Executrix to pay all my just debts, funeral and administrative expenses out of my estate, as soon as practicable after my death. THIRD: I direct that all taxes which may be assessed in consequence of my death of whatever nature and by whatever jurisdiction imposed shall be paid out of my estate as a part of the administration of my estate. FOiJRTH: I give and bequea#h such of my personal property as may be listed on an unsigned memorandum kept with my Will to persons named thereon, provided they survive my death. Should such a memorandum not be found with my Will, it shall be conclusively presumed that none was prepared, and all of my personal property shall be considered a part of the remainder of my estate. ~~_~ FIFTH: I give and bequeath the sum of One Thousand ($1,000.00) Dollars cash absolutely to ZION LUTHERAN CHURCH, of Blain, Pennsylvania. SIXTH: I give and bequeath the sum of One Thousand ($1,000.00) Dollars cash absolutely to CAROL KRAHN, of 4927 Mauritania Avenue, Harrisburg, Pennsylvania. In the event CAROL KRAHN should predecease me, then in that event this bequest shall become null and void and shall pass under the remainder clause hereinafter as stated. SEVENTH: I give, devise and bequeath the remainder of my estate, real, personal or mixed, whatsoever and wheresoever situate, to my daughter, JUDY SHANNON COOK, absolutely. In the event my daughter, JUDY SHANNON COOK, should predecease me, then in that event I give, devise and bequeath the remainder of my estate, real, personal or mixed, whatsoever and wheresoever situate, to the BANK OF LANDISBURG as Trustee, IN TRUST NEVERTHELESS, for my grandchildren, namely, ERIN NICOLE COOK and MALLORY MACKENZIE COOK in equal shares. The income and/or principal of said Trust may be accumulated or expended for the education of such beneficiary as my TRUSTEE, in its sole discretion, may determine; and my TRUSTEE, in the expenditure of income and/or principal for such purposes, may, at its discretion, apply the same directly or pay the same to any person having the care or control of said beneficiary or with whom the beneficiary resides, without duty on the part of the TRUSTEE to supervise or inquire into the application of the funds by any person to whom payment is so made. The balance of such income and/or principal, or their share of the Trust, a r shall be paid to such beneficiaries upon their reaching twenty-two (22) years, or to such beneficiary's estate in the event of death prior thereto. EIGHTH: I hereby nominate, constitute and appoint my daughter, JUDY SHANNON COOK, to be the Executrix of this my Last Will and Testament. In the event that my daughter, JUDY SHANNON COOK, shall be unable to serve as Executrix for any reason, I then nominate, constitute and appoint my son-in-law, MICHAEL COOK, as Executor. No personal representative shall be required to file bond in this or any other jurisdiction. IN WITNESS WHEREOF, I hereunto set my hand and seal this ,~~ day of , 1997. ~~~ .~ ~ Marion P. Shannon 3 SIGNED, SEALED, PUBLISHED and DECLARED in the presence of: COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. I, MARION P. SHANNON, Testatrix, whose name is signed to the attached or foregoing instrument, having been duty qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. Sworn or affirmed to and acknowledged before me, by MARION P. SHANNON, Testatrix, this ~~-~~ day of4~ :~.) ~ art.( (.__. , 197, I ~W ~~ 1 i~.~x~..~~ ~~ Marion P. Shannon, Testatrix Notary Public ~,~_ __~~ NOTARIAL SEAL !AERLENE AIAAHEVt(A, Notary Pitlic Carlisle, Cumbwland County, Pa. f My Cammbsion E~irae Q~BB 4 __„~ ~_ V Y" ~ ~.. n^~^ {Stt' 4 ~l ~~y ~ +. i '. ? ~..f }5 ~`• f ',!, ~~! s ~ ~~~p. °"f F+.. .i ~. ~~* .~ . .~ ~, ~, , . 6' q ~ w p •~ ~~ ' ~77 f-~ a ~= ~o ~~ L~ as ~~' W`~ tea" W 30 ~z p ~- ~. ~. raa ° m W `'' U Q tO H 2~ Q N 1.. ~ o ~ ~ CL' U ~ M ~ C ~ ~ ~~~o UU ~~ O ~ ~ d ~ ~ U N ~ ~ C td C.7C~OU