HomeMy WebLinkAbout10-28-08 /~G c~
15056071 ~O ~~
J 21
REV-1500 EX (06-05)
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Number
PO BOX 280601
Harrisbu PA t7f28-0601 RESIDENT DECEDENT 2 1 0 8 0 8 3 3
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
4 0 7 2 8 2 0 0 8 1 0 0 8 1 9 2 2
Decedent's Last Name Suffix Decedent's First Name
MI
R O T H G B O O K '
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
MI
R O T H A R L E N E Z
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
4. Limited Estate
~
4a. Future Interest Compromise (date of prior to 12-13-82)
~ 5. Federal Estate Tax Return Required
QX 6. Decedent Died Testate
(Attach Copy of Wiil)
~ death after 12-12-82)
7. Decedent Maintained a Living Trust
0 8. Total Number of Safe Deposit Boxes
9. Litigation Proceeds Received
~ (Attach Copy of Trust)
10. Spousal Poverty Credit (date of death
~ 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 Tele~ione Number
I V O V O T T O I I I 7 1 7 ~4 9~ 3 ~}
Firm Name (If Applicable) '-~ ?~ C7
~ --~- -
M A R T S O N L A
W
O F F I C E S REGISjfR~jLLS lyfi§ ONLIt< .,";
- "`_j o~ _ -. -~
First line of address '_~,-~-; ~-, ~_
` ~'
1 0 E A S T H I
G H
S T R E E T ~~ ~
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-
--r
Second line of address _
~`? ~ ~-~
-~
City or Post Office State ZIP Code DATE FILED
C A R L I S L E P A 1 7 0 1 3
Correspondent's a-mail address: L O T T O a7 M A R T S O N L A W• C O M
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
it is true, correct and com eclaration of preparer o sonal representative Is based on all information of which preparer has any knowledge.
SIGI~JAT F ~R N R SIBLE FOR FILING RETURN
~/ - DATE
30 S EE
SIGNAT O
LANE
3ER OTHER THAN REPRESENTATIVE
PA 1700
DATE
ADDRESS O Z13 4
10 EAST HIGH STREET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
BOILING SPRINGS
Side 1
1505607121 1505607121
1505607221
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: G• BOOK R 0TH
RECAPITULATION
1. Real estate (Schedule A) ........................................ 1.
2. Stocks and Bonds (Schedule B) .................................. 2. 4 4 2 5 9 5, 8 4
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages & Notes Receivable (Schedule D) ........................ 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5. 1 3 4 8 7 1 . 1 6
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property
(Schedule G) ~ S
1
eparate Billing Requested ....... 7. 9 1 0 0 6, 9 8
8. Total Gross Assets (total Lines 1-7) ........................... 8. 7 6 8 4 7 3, 9 8
9. Funeral Expenses & Administrative Costs (Schedule H) ........ ....... . 9. 5 8 4 , 0 0
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .... ........ 10.
11. Total Deductions (total Lines 9 & 10) ................... ........ 11. 5 8 4 , 0 0
12. Net Value of Estate (Line 8 minus Line 11) .................. ....... 12. 7 6 7 8 8 9 , 9 8
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule Jp ........... ....... 13. ,
14. Net Value Subject to Tax (Line 12 minus Line 13) ........... ....... 14. 7 6 7 8 8 9. 9 8
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) x.ooo 7 3 1 8 8 9. 9 8 15. 0. 0 0
16. Amount of line 14 taxable
at lineal rate X .045 3 6 0 0 0. 0 0 1s. 1 6 2 0. 0 0
17. Amount of Line 14 taxable
at sibling rate X .12 0. 0 0 17. 0. 0 0
18. Amount of Line 14 taxable
at collateral rate X .15 0. 0 0 18 0. 0 0
19. Tax Due ......................................... ....... 19. 1 6 2 0. 0 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
1505607221 1505607221. J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 08 0833
DECEDENT'S NAME
G• BOOK ROTH
STREET ADDRESS
801 North Hanover Street
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
t • Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount 81.0 0
3. InteresUPenalty if applicable
D. Interest
E. Penalty
(1) 1, 620.00
Total Credits (A + B + C) (2) 81 • 0 0
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.
(3) 0.0 0
(4) 0.00
(5) 1, 539.00
(5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 1, 5 3 9 • 0 0
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 : ...................................................................... ^
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? ....................................................... ^
^
Q
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? ......... Q
^ ^
Q
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-1503 EX + (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
G• BOOK ROTH 21 08 0833
All property Jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION VALUE AT DATE
i.
M8T Investment Account 617593603• See attached OF DEATH
203,761•D9
1a• Accrued dividend on Item 1 300.96
2• Janney Montgomery Scott LLC investment account 237,938.25
7135-9311• See attached
2a Accrued interest on Item 2 595.54
TOTAL (Also enter on line 2 Recapitulation) I$ 4 4 2, 5 9 5 8 4
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX + (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
IN RESIDENT DECEDENTRN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
G• BOOK ROTH 21 08 0833
Include the proceeds of IitigaGon and the date the proceeds were received by the estate.
All properly jointty-owned with right o} survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
i. M&T Investment account 617593603, cash, principal 120,976.81
2• IM&T Investment account 617593603, cash, income ~ 13,894.35
TOTAL (Also enter on line 5, Recapitulation) I $ 13 4 , 8 71 • 16
(If more space is needed, insert additional sheets of the same size)
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
G• BOOK ROTH 21 08 0833
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 OFOEATH %OFDECD~S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER.ATTACHACCPYOFTHEDEEDFDRREALESTATE. VALUE OF ASSET INTEREST (IFAPPUCABI.E) VALUE
1. Janney Montgomery Scott LLC, IRA 7136-0121, beneficiary : 15 5 , 0 0 6 •9 8 10 0 • 5 5 , 0 0 6 • 9 8
Arlene Z• Roth, spouse, 1001
($154,409.72 +_597.26 accrued int)
2• Allen Z• Roth, son, 1/1/08 12,000.00 100• ,000.00 9,000.00
3• William B• Roth, son, 1/1/08 12,000.00 100•
4• Constance H• Henry, daughter, 1/1/08 12,000.00 100•
5• Dean G• Roth, son, 1/1/08 12,000.00 100•
,D00.00~ 9,000.00
,000.00 9,000.00
,000.001 9,000.00
TOTAL (Also enter on line 7 Recapitulation) ~$ 191, 0 0 6 9 8
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX + (10-06)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
G• BOOK ROTH 21 08 0833
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s)
Street Address
City State Zip
Year(s) Commission Paid:
2• Attorney Fees
3. Fatuity Exemption: (If decedent's address is not the same as claimants, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4• Probate Fees Cumberland County Register of Wills 569.00
5 Accountants Fees
6. Tax Return Preparers Fees
~. Filing fee, Inheritance Tax Return 15.00
TOTAL (Also enter on line 9, Recapitulation) I S 5 8 4
(If more space is needed, insert additional sheets of the same size)
~~ !~`i OFfiC~'
~•~ _
'~ ~~~; Ess~o~~,a~ coe~o.~ancN
LAST WILL AND TESTAMENT ~~~~u ie ~AH>>o
I, G. BOOK ROTH, of the Borough of Carlisle, Cumberland County, Pennsylvania, being
of sound and disposing mind and memory, do hereby make, publish and declare this to be my Last
Will and Testament, hereby revoking any and all former Wills or Codicils made by me.
ITEM ONE
I direct that all my legally enforceable debts, funeral expenses, testamentary expenses and
all death taxes shall be paid to the extent possible from the assets held or passing under ITEM SIX
hereof as soon as practicable after my decease and as part of the administration of my estate.
ITEM TWO
If my said spouse, ARLENE Z. ROTH, does not so survive me, then I give the sum of
Thirty-five Thousand Dollars ($35,000.00) to The First Church of the Brethren, Carlisle,
Pennsylvania, and the sum of Five Thousand Dollars ($5,000.00) to the Children's Aid Society of
the First Church of the Brethren; provided, however, that the foregoing bequests shall be reduced
pro rata to the extent that such bequests, in the aggregate, exceed five percent (5%) of my gross
estate.
ITEM THREE
I bequeath any automobiles or motor vehicles I may own at my death, my personal effects,
such household goods if any as maybe my individual property and not the property of my spouse
or owned jointly by me with my spouse, and other tangible personal property of like nature (not
including cash or securities), together with any existing insurance thereon, to my spouse, ARLENE
Z. ROTH, providing she survives me by thirty (30) days. Should my spouse predecease me or die
on or before the thirtieth day following my death, I bequeath such tangible personal property and
insurance thereon to such of my children as are living on the thirty-first day after my death, to be
divided between or among them with due regard for their personal preferences in as nearly equal
shares as practical and as they shall mutually agree. I direct that any of the foregoing articles not
selected by such children or about which there is no agreement shall be sold at public or private sale
by my personal representative, and I further direct that the net proceeds thereof shall be administered
and distributed as a part of the residue of my estate.
Page 1 of 7 Pages
. ~.~
[Initials]
ITEM FOUR
If my spouse, ARLENE Z. ROTH, is living thirty (30) days after my death, then I give, devise
and bequeath all of my estate, both real and personal property, unto my said spouse, absolutely. If
my said spouse does not so survive me, then I give, devise and bequeath all the rest, residue and
remainder of my estate, both real and personal property, unto my Trustees to be held or distributed
by such Trustees under ITEM SIX hereof.
ITEM FIVE
In the event my said spouse shall disclaim all or any portion of any devise or bequest made
to my spouse under the foregoing ITEM FOUR, then the amount otherwise payable shall be held by
my Trustees under ITEM SIX hereof. For purposes of the Trust established under ITEM SIX hereof,
my said spouse shall not be deemed to have predeceased me by virtue of my said spouse's exercise
of the right to disclaim set forth herein.
ITEM SIX
RESIDUARY AND DISCLAIMER TRUST
My Trustees shall hold the assets received under ITEMS FOUR and FIVE hereof, if any, for
the following purposes:
A. My Trustees shall pay the net income, at least quarter-annually, to my spouse,
ARLENE Z. ROTH, for life. In addition, my Trustees, in my Trustees's sole discretion, may invade
the principal of the Trust for the proper and adequate support of my said spouse.
B. My Trustees shall further pay to my said spouse, annually, such sum from the
principal of the Trust as my said spouse may request in writing, provided, however, that said sum
may not exceed the greater of Five Thousand Dollars ($5,000.00) or five percent (5%) of the
aggregate value, at the time of said request, of the principal of the Trust hereunder.
C. Upon the death of my said spouse, or upon my death if my spouse shall not survive
me by thirty (30) days, my Trustees shall distribute the principal of the Trust to my children,
WILLIAM B. ROTH, ALLEN Z. ROTH, CONSTANCE H. HENRY, DEAN G. BOTH, in equal
shares, absolutely.
D. In the event that any of my said children shall fail to survive my spouse and me, but
shall leave issue surviving, then such deceased child's share shall be held by my Tnistees and the
i.
[Initials]
Page 2 of 7 Pages
net income therefrom shall be used for the support, maintenance and education of the issue of such
deceased child. My Trustees shall use as much of the principal as it shall deem desirable for said
purposes. My Trustees shall distribute absolutely the principal of such share of such deceased child
to the issue of such deceased child per stirpes as each shall attain the age of twenty-five (25) years.
In the event that any of my children shall fail to survive my spouse and me and not leave issue
surviving, then such deceased child's share shall be added to the shares of my other children as if
originally a part thereof.
E. Notwithstanding any other provisions to the contrary, in no event shall any share be
distributed to any beneficiary later than twenty (20) years after the later death of my spouse or me.
ITEM SEVEN
POWERS OF EXECUTRIX AND TR STEES
In addition to the powers conferred by case law, by statute, and by other provisions hereof,
my Executrix and Trustees and their successors, shall have the following discretionary powers
applicable to all property held by them which powers shall be effective without order of any court
and shall exist until final distribution.
A. To retain any property of any nature received by them for whatever period they shall
deem advisable;
B. To invest and reinvest all or any part of said property in such stocks, bonds, common
trust funds, securities, accounts, certificates of deposit (including, but not limited to, stocks, bonds,
common trust funds, securities, accounts or certificates of deposit of the Trustees) or other property,
real or personal, as in their discretion they shall deem proper, without regard to statutes limiting the
property which a fiduciary may purchase;
C. To sell, transfer, exchange or otherwise dispose of, any part of said property, for cash
or on terms, publicly or privately, or to lease, even for a term exceeding five (5) years or the duration
of any trust herein, without liability on the purchasers or lessees to see to the application of the
proceeds, and to give options for these purchases without the obligation to repudiate them in favor
of a higher offer;
D.
be necessary to carry out the provisions of any trust hereunder;
Page 3 of 7 Pages
To execute and deliver any deeds, leases, assignments or other instruments as may
„ ~:
[Initials)
E. To borrow money, including the right to borrow money from any bank and to
mortgage or pledge any asset of the estate as security;
F. To assume continuance of the status of any beneficiary with regard to death, marriage,
divorce, illness, incapacity and the like in the absence of information deemed reliable without
liability for disbursements made on such assumption;
G. To pay from the trust, or the income therefrom, all debts or claims against my estate,
or any taxes or similar charges on my estate;
H. To make any distribution hereunder either in kind or in money, or partially in kind
and partially in money. Distribution in kind shall be made at the market value of the property
distributed, and my Trustees, in my Trustees's absolute discretion, may cause the share distributed
to any distributee to be composed of property similar to or different from that distributed to any other
distributee;
I. To exercise any subscription right in connection with any security held hereunder, to
consent to or participate in any recapitalization, reorganization, consolidation or merger of any
corporation, company or association, the securities of which may be held hereunder, to delegate
authority with respect thereto, to deposit investments under agreements, to pay assessments, and
generally to exercise all rights of investors;
J. To invest in endowment, insurance or annuity policies on the lives of beneficiaries
of any trust hereunder;
K. To continue in any partnership, joint venture, joint ownership or other business
enterprise of which I am a part at the time of my death;
L. To compromise claims;
M. To continue for whatever period of time as they shall deem necessary any ownership
as a tenant in common or as a partner, in real estate or other property and to act as I could have done
had I been living;
N. To lend money to my estate or to any trust created hereunder or to purchase from the
estate or from any tnist created hereunder, at the market value thereof at the time of purchase, any
securities or other property tendered to them by my estate or any trust created hereunder at any time
and from time to time within a period of nine (9) months after my death;
Page 4 of 7 Pages
~~
.,i
[Initials
O. In the event that any amounts are payable hereunder or under any trust created
hereunder to a minor, or to a person otherwise under legal disability, or to a person not adjudicated
to bean incapacitated person, but who, by reason of illness or mental or physical disability is, in the
opinion of the fiduciary(ies) hereunder, unable to properly administer such amounts, such amounts
may be paid by the fiduciary(ies) hereunder in his, her or their sole discretion in any of the following
ways as he, she or they may deem best:
1. Directly to such beneficiary;
2. To a legally appointed guardian of such beneficiary for the benefit of such
beneficiary;
3. To a person having custody of such beneficiary for the benefit of such
beneficiary;
4. By the fiduciary(ies) hereunder using such amounts directly to the benefit of
such beneficiary.
Evidence of the application of payment of an amount in such a manner shall be a full and complete
discharge of the fiduciary(ies) hereunder to the extent of such payment or application. This
paragraph shall be applicable to payments of income as well as principal.
P. To employ agents, attorneys and proxies and to delegate to them such power as my
personal representatives and Trusteess consider desirable and to pay reasonable compensation for
such services as maybe rendered by such agents, attorneys and proxies;
Q. To conduct an inventory of any safe deposit box necessary to the administration of
my estate.
R. To do all other acts in their judgment necessary or desirable for the proper
management, investment and distribution of my Estate.
ITEM EIGHT
PROTECTIVE PROVISIONS
All income or principal held for the use and benefit of the beneficiaries of any tn-st hereunder
shall not be in any way or manner subject to anticipation, assignment, pledge, sale or transfer, nor
shall any such interest, while in the possession of my Trustees, be liable for or subject to the debts,
[Initials]
Page S of 7 Pages
contracts, obligations, liabilities or torts of any beneficiary, or to attachments, executions or
sequestrations under process of law.
ITEM NINE
APPOINTMENT OF EXECUTRIX AND TRUSTEES
I nominate, constitute and appoint my spouse, ARLENE Z. ROTH, as Executrix of my estate.
In the event that my said spouse shall predecease me or fail to act as Executrix, then I appoint my
son, ALLEN Z. ROTH, as Executor of my estate. In the event my said son, ALLEN Z. ROTH, shall
be unable or unwilling to so act, I appoint my daughter, CONSTANCE H. HENRY, as Executrix.
I nominate, constitute and appoint my spouse, ARLENE Z. ROTH, and my son, ALLEN Z.
ROTH, as co-Trustees of any trust created hereunder.
ITEM TEN
WAIVER OF BOND
I direct that neither my Executrix nor my Trustees or their successors shall be required to file
any bond in any jurisdiction to secure the faithful performance of their duties, nor shall they be
required to obtain any order or approval of any court for the exercise of any power or discretion set
forth in this Will.
IN WITNESS WHEREOF I have hereunto set my hand and seal this ~ 7 ~" day of
~,
Lj'7t,~c~Cl'U , .~cc'3 , ,
%~~ ~~~~'f' ~~ %~ (SEAL)
G. Book Roth
SIGNED, SEALED, PUBLISHED AND DECLARED by the above-named Testator, as and
for his Last Will and Testament, in the presence of us, who at his request, have hereunto subscribed
our ames as witnesses thereto, in the presence of the said Testator and of each other.
Page 6 of 7 Pages
COMMONWEALTH OF PENNSYLVANIA )
SS.
COUNTY OF CUMBERLAND )
We, G. Book Roth, No V. Otto III, and ~~ <<,-f~, „r _
•~ ~ ~ )~~ E'r ~ ,the Testator
and the witnesses, respectively, whose names are signed to the foregoing instrument, being first duly
sworn, do hereby declare to the undersigned authority that the Testator signed and executed the
instrument as his last Will and that the Testator has signed willingly, and that the Testator executed
it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in
the presence and hearing of the Testator, signed the Will as a witness and that to the best of his/her
knowledge the Testator was at that time eighteen years of age or older, of sound mind and under no
constraint or undue influence.
G. Book Roth, Testator
tnes
W' ess
Subscribed, sworn to and acknowledged before me by G. Book Roth, the Testator, and
subscribed and sworn to before me by No V. Otto III and C.l ~~~, ,--, , » ,~ . ,• ~"1 y ~ ~ .
the witnesses, this/; •---day of ;~ ,~ ; ,~ fti ~ . ~~~; ~;'
/' , ,
~' _ ,
i ~_
C L ~.
Notary Public
NOTARIAL SERI
CARL SLE IBO 0. C~IIMBERIAND COUNTY
MY COMMISSIOf~ EXPIRES DEC. 2 2006
Page 7 of 7 Pages
Estate valuation
Cate of Death: 07/28/2008 Estate of: G Book Roth, Agt
valuation Cate:v7/28/2008 Account: 617593603
Prccessinq Cate: 08/07/2008 Report Type: Gate of Ceath
N~~.•niser of Securities: 10
File ID: Roth, G Bcok, Aqt
Shares Security Mean and/or Div and Int Security
or Par Description High/Ask Low/Bid Ad;ustments Accruals Value
1) 300 ALTRIA GRCUP INC (022095103)
CCM
Pled York Stock Exchange
C7/28/2008 21.19000 20.81000 H/L
21.000000
2) 200 CARNIVAL CCRP (143658300)
PAIRED CTF
New York Stock Exchange
07/28/2008 37.83000 36.07000 H/L
36.950000
3) 700 EXXCN MCBIL CCRP (3023IG102)
CCM
New York Stock Exchange
07/28/2008 82.23000 80.65000 H/L
81.440000
4) 400 INTL PAPER CO (460196103)
COM
New York Stock Exchange
07/28/2008 23.60000 22.96000 H/L
23.280000
5) 792 JPMORGAN b CHASE & CO (46625H100)
COM
New York Stock Exchange
07/28/2008 40.65000 37.91000 H/L
Div: 0.38 Ex: 07/01/2008 Rec: 07/03/2008 Pay: 07/3 1/2008 39.030000
6) 207 KRAFT FOODS INC 150075N104)
CL A
• New York Stock Exchange
07/26/2008 31.13000 29.82000 H/L
30.475000
7) 500 M ~ T BK CCRP (55261F104)
COM
New York Stock Exchange
07/28/2008 69.89000 66.40000 H/L
68.145000
8) 300 PHILIP MORRIS INTL INC (718172109)
COM
New York Stock Exchange
07/28/2008 53.25000 SZ.34000 H/L
52.795000
9) 900 RCCKWELL AUTCMATICN INC (773903109)
CCM
New York Stock Exchange
07/28/2008 44.99000 42.86000 H/L
43.675000
10) 400 RCCKWELL CCLLINS INC (774391101)
CCM
New York Stock Exchange
O'i~9!2006 8.3:000 47.44000 H/L
47.875000
Total '~aL:e:
Total accrual:
total: S_'C-i,06?_.JS j~pluE~ )~tA~Kft pQ.~ui.iQA~- I~ I~ZJr9l6.~1
I~tUNSN {Yl/d~KCf INC4rkL i ~~j3`~i..35
6,300.00
7,390.00
57,008.00
9,312.00
30,911.76
300.96
6,308.33
39,072.50
15,838.50
17,970.00
i9,i50.G0
S~J3,7S1.09
5300.56
Faqe I
This report was produced with EstateVai, a product of Estate valuations & Pricing Systems, Irc. if you hate quest~oas,
please oontact Eb-P Systems at (6I9; 3i3-6300 cr www.e~.~ps;+s.ccm. ,Revision 7.0.4)
Trusted Advisors for Generations
Estate Valuation
_':31t~ V'urth 5usi~urh,u~n.~ ~I'r:+il
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Date of Death: 07/28/2008
Valuation Date: Estate of: G. Book Roth
07/28/2008
Processing Date: 08/29/2008 Account: 7135-9311
Report Type: Date of Death
Number of Securities: 11
File ID: G. Book Roth DOD 072808 2of2
Shares
P Security Mean &/or Div & Int Security
or
ar Description High/Ask Low/Bid Adj'ments Accruals Value
1) 5936.04 5 EMERALD MUT FDS (437691108; HSPGX}
HMEST PA GR A
Mutual Fund (as quoted by NASDAQ)
07/28/2008 11.32000 Mkt
11.320000 67,196.03
2) 858.33 HENDERSON GLOBAL FDS (HFOBX)
INTL OPPORT B
Mutual rr^und (as quoted by NASDAQ)
07/28/2008 20.62000 Mkt
20.620000 17,698.76
3) 10000 LAUREL HIGHLANDS PA SCH DIST GO REF BD (518705EG9}
Financial Times Interactive Data
DTD: 08/01/2003 Mat: 11/01/2020 4.2$
07/28/2008 93.80000 Mkt
93.800000 9,380.00
Int: 05/01/2008 to 07/28/2008
101.50
4) 10000 WEST SHORE PA AREA HOSP AUTH H REV BDS (955817DG3)
Financial Times Interactive Data
DTD: 12/01/2001 Mat: 01/01/2021 6.15
07/28/2008 101.43500 Mkt
101.435000 10,143.50
Int: 07/01/2008 to 07/28/2008
46.13
5) 15000 PITTSBURGH PA SCH DIST GO BDS (7252767N3)
Financial Times Interactive Data
DTD: 11/01/2005 Mat: 09/01/2023 4.3~
07/28/2008 93.95600 Mkt
93.956000 14,093.40
Int: 03/01/2008 to 07/28/2008
263.38
Page 1
This report was produced with EstateVal, a product of Estate Valuations &
Pricing Systems, Inc. ,.Tanney Montgomery Scott LLC assumes no responsibility for
accuracy or completeness of the information provided, the Date of Death and the
specific securities, which are valued. While we deem this information to be
reliable, •.ae do not warranty or guarantee its accuracy. This service is not
intended to constitute legal cr tax advice. You should cons~zlt with your tax
professional ar.d atr_orney to discuss estate seLriement and any legal ,.,atcers.
,~~ ~~ _D,..~_ B
. Y rn 7 . '7 n
Trusted Advisors for Generations
Date of Death: 07/28/2008
Valuation Date: 07/28/2008
Processing Date: 08/29/2008
'.';il:, V~~n~th ~iiticiueh:uina Trail
~iiitf~ :~
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~~~~~~~.jm~nnlinr.r~~ni
Estate of: G. Book Roth
Account: 7135-9311
Report Type: Date of Death
Number of Securities: 11
File ID: G. Book Roth DOD 072808 2of2
Shares Security Mean &/or Div & Int Security
or Par Description High/Ask Low/Bid Adj'ments Accruals Value
6) 10000 PENNSYLVANIA ST HIGHER EDL FAC REV BDS (70917N8U1)
Financial Times Interactive Data
DTD: 11/01/2005 Mat: 11/01/2033 5$
07/28/2008 96.78800 Mkt
96.788000 9,678.80
Int: 05/01/2008 to 07/28/2008 120.83
7) 28000 BANK AMER CORP SUB INTNTS BE (06050XXF5}
Financial Times Interactive Data
DTD: 06/08/2006 Mat: 06/15/2036 6.3$
07/28/2008 92.58680 Mkt
92.586800 25,924.30
Int: 07/15/2008 to 07/28/2008 63.70
8) 1000 ING GROEP N V (456837707)
PER HYB CAP SC
New York Stock Exchange
07/28/2008 22.00000 21.26000 H/L
21.630000 21,630.00
9) 404.73G OPPENHEIMER MULTI ST MUNICIFAL (683940209; OFABX)
PA MUN FD CL B
Mutual Fund (as quoted by NASDAQ)
07/28/2008 11.12000 Mkt
11.120000 4,500.66
10) 5618.392 OPPENHEIMER MULTI ST MUNICIPAL (683940407; ORNBX)
ROCH NAT MUN B
Mutual Fund (as quoted by NASDAQ)
07/28/2008 8.88000 Mkt
8.880000 49,891.32
11) 7801.48 Cash (CASH)
7,801.48
Total value:
Total Accrual: $237,938.5
Total: $238,533.79 $5S5.54
Page 2
~ ~r,n~~ A~uui~~'~u~n~~r ~~. ~it I i.l_: 11..~;I~~i~ \l~t~. ~ i~!`.i: A '>ff'(
Trusted Advisors for Generations
Date of Death: 07/28/2008
Valuation Date: 07/28/2008
Processing Date: 08/29/2008
Shares
or Par
1)
.':,I.-~ \~,rih .tiiu~(nrha:ina l~r.til
lurk. I':1 1 i }~) }-4)Ii1)'~
Estate Valuation ~~««.jn~,~~nlin~~.r~nn
Estate of: G. Book Roth a
Account: 7136-0121
Report Type: Date of Death
Number of Securities: 17
File ID: G. Book Roth DOD 072808 1of2
Security Mean &/or Div & Int Security
Description High/Ask Low/Bid Adj~ments Accruals Value
400 CRESCENT PT ENERGY TR (225908102)
TRUST UNIT
Other OTC
07/28/2008 34.93800 34.35950 H/L
34.648750 13,859.50
2) 1000 EUROSEAS LTD (ESEA)
COM NEW
The NASDAQ Stock Market LLC
07/28/2008 12.70000 12.04000 H/L
12.370000 12,370.00
31 87 FORD MTR CO DEL (34537u^^860; F)
COM PAR $0.01
New York Stock Exchange
07/28/2008 5.14000 4.60370 H/L
4.871850 423.85
4) 500 HEALTH CARE REIT INC (42217K106; HCN)
COM
New York Stock Exchange
07/28/2008 49.40000 48.13000 H/L
48.765000 24,382.50
5) 200 PLUM CREEK TIMBER CO INC (729251108; PCL)
COM
New York Stock Exchange
07/28/2008 46.56000 44.50000 H/L
45.530000 9,106.00
6) 1000 PROSPECT CAPITAL CORPORATION (PSEC)
COM
The NASDAQ Stock Market LLC
07/28/2008 12.86000 12.41000 H/L
12.635000 12,635.00
Page 1
This report was produced with EstateVal, a product of Estate Valuations &
Pricing Systems, Inc. Janney Montgomery Scott LLC assumes no responsibility for
accuracy or completeness of the information provided, the Date of Death and the
specific securities, which are valued. while we deem this information to be
reliable, we do not warranty or guarantee its accuracy. This service is not
intended to constitute legal or tax advice. You should consult 'Kith your tax
professicr_al and attorney to discuss estate settlement and any regal matters.
Cl ~ Gl~ .~1,0 CY . /i ~ /
Trusted Advisors for Generations
`7.;1:~ .ti~n~rh .tiu,~~urh.utn,i "I~r.+il
l~~irk. 1):~ I i ~U-~-~)fi~l`~
l\1\1\.~Ill tii )ll ~l 11 t`.CUlll
Date of Death: 07/28/2008 Estate of: G. Book Roth
Valuation Date: 07/28/2008 Account: 7136-0121
Processing Date: 08/29/2008 Re ort
p Type. Date of Death
Number of Securities: 17
File ID: G. Book Roth DOD 072808 loft
7)
8)
9)
10)
11)
12)
Shares Security Mean &/or Div & Int Security
or Par Description High/Ask Low/Bid Adj'ments Accruals Value
600 SENIOR HSG PPTYS TR (81721M109; SNH)
SH BEN INT
New York Stock Exchange
07/28/2008 20.99000 20.21000 H/L
20.600000 12,360.00
0.35 E 07/16 R 07/18 P 08/14/08 210.00
30 TRAVELCENTERS OF AMERICA LLC (894174101; TA)
COM
American Stock Exchange
07/28/2008 2.75000 2.32000 H/L
2.535000
6 VISTEON CORP (928390107; VC)
COM
New York Stock Exchange
07/28/2008 2.24000 2.09000 H/L
2.165000
911.808 VAN KAMPEN ENTERPRISE FUND (921130104; ACENX)
CL A
Mutual Fund (as quoted by NASDAQ)
07/28/2008 13.30000 Mkt
13.300000
10000 FORD MOTOR CREDIT CO LLC (345397SM6)
New York Bond Exchange
DTD: 10/28/1999 Mat: 10/28/2009 7.375
07/28/2008 91.99920 Mkt
91.999200
Int: 04/28/2008 to 07/28/2008
10000 CIT GROUP INC INTERNOTES BOOK (12557WBJ9)
Financial Times Interactive Data
DTD: 01/30/2003 Mat: 01/15/2013 6.25
07/28%2008 67.02730 Mkt
67.027300
Int: 07/15/2008 to 07/28/2008
Page 2
76.05
12.99
184.38
22.57
12,127.05
9,199.92
5,702.73
~anu,~~ ~;~r,u,~nn~~i~ 1~~~if t I { Alt~n!I,•~r: A"~ti~' , f~~~;R.A • ytN(.
Trusted Advisors for Generations
~?:;1.", A~>rth 5u~rlnch;u~u,i ~l'i;iil
Strife :\
~~~.~~~.jm.,~tulinr.w,m
Date of Death: 07/28/2008 Estate of: G. Book Roth
Valuation Date: 07/28/2008 Account: 7136-0121
Processing Date: 08/29/2008 Report Type: Date of Death
Number of Securities: 17
File ID: G. Book Roth DOD 072808 loft
Shares Security Mean &/or Div & Int Security
or Par Description High/Ask Low/Bid Adj'ments Accruals Value
13) 10000 GENERAL MTRS ACCEP CPSMARTNBE (37042GU20)
Financial Times Interactive Data
DTD: 01/28/2003 Mat: 01/15/2018 7.25
07/28/2008 46.96590 Mkt
46.965900 4,696.59
Int: 07/15/2008 to 07/28/2008 26.18
14) 10000 FHLMC REMIC SERIES 3376 (31397KZN4)
Financial Times Interactive Data
Mat: 11/15/2036 6.000 Fact: 0.71695151
07/28/2008 98.54031 Mkt
98.540310 7,064.86
Int: 07/01/2008 to 07/28/2008 32.26
15) 400 AMBAC FINL GROUP INC (023139504; AKF)
DEB 5.95 2103
New York Stock Exchange .
07/28/2008 7.46000 7.07000 H/L
7.265000 2,906.00
16) 1000 PIMCO HIGH INCOME FD (722014107; PHK)
COM SHS
New York Stock Exchange
07/28/2008 11.40000 11.14000 H/L
11.270000 11,270.00
0.12187 E 07/09 R 07/11 P 08/01/08 121.87
17) 15216.68 Cash (CASH) 15,216.68
Total Value:
Total Accrual:
Total: $155,006.98
$154,409.72
$597.26
Page 3
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