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HomeMy WebLinkAbout11-18-08 (3)15056051058 REV-150 EX (06-05) pFFIC1Al USE ONLY PA Department of Revertue County Code Year... File Nwnber Btxea<t of IndNdual Taxes INHERITANCE TAX RETURN Q PO BOX 280601 21 n ~ ~~ v Harrisbtug, PA 171280601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death 184-12-4988 ' 08/27!2008 Decedent's Last Name Suffix HOLTRY Date of Birth 09/27/1916 Decedent's First Name GALEN Mt L (If Applicable) Enter Surviving Spouse'ts Information Below Spouse's Last Name Suffix Spouse's First .Name.... MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE _ __ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW °~,~- 1. Original Return K._~.~. 2. Supplemental Return r..:~~F 3. Remainder Return (date of death prior to 12-13-82) ,w_"°', 4. Limited Estate €~~"w? 4a. Future Interest Compromise (date of a°_:.„.~ 5. Federal Estate Tax Return Required death after 12-12-82) i'.~= 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 !"`~~~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS 8ECTION MUST BE COMPLETED. ALL CORREBPONDENCE AND CONFIDENTIAL TAX INFORMATION 8HOULD BE DIRECTED T0: Name Daytime Telephone Number LARRY L HOLTRY (717) 300-130 ' „ Finn Name (If Applicable) _ ~~ _ ~:~ REGISTER OF YVtL13 USE ON ~ _~. ' ' ~~ l ,, ' _ , l ~ .: ~ ~~ ~j ~ ..~' y , i -'~ _i!~ First line of address ` ,,;? Gt7 . ~ .:::J 61D BRENTON ST , , ~~ f-, -~~ ` r _:. ~ ., _ Second line of address _ _ _._ j ~a ; _. --i .. C ~ r .. ~! ~ j City Or Fbst Office State ZIP Coda DATE FILED (jl SHIPPENSBURG ' PA ' 17257-2 114 Correspondent's e-mail address: LHOLTRY(c9~COMCAST.NET Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my krawledge and belief, if 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 RESPgNSIBLE FOR FILING RETURN DATE 610 6RENTON ST, SHIPPENSBURG, PA 17257 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ADDRESS DATE PLIfA>6E vsE OR16~NAL FORM oNLY Side 1 15056051058 15056051058 J 15056052059 REV 1500 EX pecedent's Social Security Number GALEN L HOLTRY ..184 12-4988 Uecedenrs Name: RECAPITULATION 1. Real estate (Schedule A) ........................................... .. L 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 9 83,163.94 3. Closery Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages 1~ Notes Receivable (Schedule D) ........................... .. 4. 5. Cash, Bank Deposits ~ Miscellaneous Personal Property (Schedule E) ...... .. 5. 10,835.56 6. Jointly Owned Property (Schedule F) ~T b Separate Bifling Requested ..... .. 6. 5,938.61 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Prope-ty 7 25 990 43 (Schedule G) ~ Separate Biking Requested...... .. . , . 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. 225,928.54 9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. 13,117.32 10. Debts of Decedent, Mortgage Liabilities, & Liens (schedule I) .............. .. 10. 1,894.59 11. Total Deductions (total Lmes 9 & 10) ................................. .. 11. 15,011.91 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 210,916.63 ', 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... .. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. 210,916.63 .,.._.~.~,.,~..~._.... ,..._~__~,...,..~.~._,...,.~.._....._..._., ,..~...~..._._µ. _ __. _,.:~.,.,_~...~~......... TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES . _.._ _ _. .,__,... ,_..__:.____...~.._._,_. 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 _ _ - 16. Amount of Line 14 taxable __ at lineal rate x .045 210,91fi.63 16. 9,491.25 '' 17. Amount of Line 14 taxable _ at sibling rate X .12 ' ! 17. 18. Amount of Line 14 taxable at collateral rate X .15 ' 18. 19. TAX DUE ....................................................... ..19. 9,491.25 ': 20. FILL IN THE OVAL IF YOU ARE RE4UESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 Flb Number ..~..`..`..~ .~ .......r....- - ---- ---- DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER GALEN L HOLTRY -_ _ __ _ __ 184-12-4988 STREET ADDRESS 610 BRENTON ST _-_ _ -_-__ __--- CITY STA ZIP SHIPPENSBURG PA 17257-2114 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19} 2. CreditslPayments A. Spousal PoveRy Credit -.. B. Prior Payments _ _ C. Discount 3. InteresUPenalty if applicable D. Interest E Penalty 74.56 Totai Credits (A + B + C) (2) - Total interesUPenatty (D + E J (3) 4, ff line 2 is greater than Line 1 + Line 3, er>ter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 5. ff line 1 + Line 3 is greater than line 2, enter the difference. This is the TAX DUE. (5) A. Enter the krterest on the tax due. (~) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) Make Check Payable to: REGISTER OF WILLS, AGENT (1) 9,491.25 474.56 9,016.69 9,016.68 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 incorrx, of the property trdnsfemed :............................................................................. ............. ^ b. retain the right to designate who shag use the property transferred or its income :............................... ............. ^ c, retain a reversanary interest; or ............................................................................................................. ............. ^ ^ d. receive the promise for life of either payments, benefds 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 mist for" or payable upon death bank accarnt or security at his or her death? . ............. © ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non•probate properly which contains a beneficiary designation? ........................................................................................................... ............. © ^ 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 Juiy 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the rise 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 aero (0) percent (72 P.S. §9116 (a) (1.f) {ii)). The statute ~ otn exempt a transfer to a surviving spouse from tax, and the statutory requirements for discbsure 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) pen~rit p2 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. §9118(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 isdefined, 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) scN~ou~~ s COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN ESTATE OF FILE NUMBER GALEN L HOLTRY ~ ~ " ~ ~ `~~ ~8 All property jointy-owned with right of sunhrorsMp must be disclosed on Scheduia F. ITEM VALUE AT LIATE _....___ ncero,nr,nu (1F r)FATH ~ • 563.822 Shares American Funds-Growth Fund of America CUSIP 399874106 NAV $30.71 2 1055.700 Shares American Funds-Investment Co of America CUSIP 461308108 NAV $2$.75 3 1977.871 Shares American Funds-American Balanced Fund CUSIP 024071102 NAV $17.29 4 1904.120 Shares American Funds-Bond Fund of America CUSIP 097873103 NAV $12.27 5 724.131 Shares American Funds-Capital Income Builder CUSIP 140193103 NAV $54.10 6 Municipal Bond -1, $10,000, Michigan Strategic Fund,12i15/32, 5.45%, pays 6115 A 1?J15 CUSIP 59469C4X8, Bid Price $88.37 7 Med Term Notes Series B -1, $25,000, Bear Stems,11129l22, 6.0%, pays 291h each month CUSIP 073928YB3, Bid Price $90.39 8 102 Shares Common Stock, Prudential, CUSIP 744320102, NAV $71.83 17,314.97 30,351.38 34,197.39 23,363.55 39,175.49 8,837.00 22,597.50 7,326.66 TOTAL (Also enter on line 2, Recapitulation) I $ 183,163.94 (If more space is needed, insert additional sheets of fhe same size) REV 1508 EX+ (6-96) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCI~IEDI~~E E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER GALEN L HOLTRY oZ ~" Ub' -GAB ~g Indude the proceeds of litigation and the date the proceeds were received by the estate. Ag property jolatly-owned with right of survivorship must be dlsctoaed on Schedule F. VALUE AT DATE 1 Citizens Bank,153 W Orange St, Shippensburg PA 17257, Accouni# 6200663894, Checking 2 Edward Jones,1331 S Seventh St, Chambersburg PA 17201, Account# 650-11576-1-1, Money Market 3 Menno Haven Inc, 2011 Scotland Avenue, Chambersburg, PA 17201, Refund Unused Nursing Home Exp 4 Highmark Medigap Health Insurance, Refund premium coverage after 8/27/08 5 Highmark BlueRxlMedco Drug Coverage, Refund premium coverage after 8127108 TOTAL (Also enter on line 5, Recapitulation) ; (if more space is needed, insert additional sheets of the same size) 7,215.55 2,544.59 873.85 178.38 23.19 10,835.56 REV-1509 EX+ (6.98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF GALEN L HOLTRY scNEOU~~ F JOINTLY-OWNED PROPERTY FILE NUMBER ~/-l~B-o{9P If an aasst wee made jolat within one year of the dscedsnYa data of death, k must 6s reported on Schedule f3. SURVMNG JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A• LARRY L HOLTRY 610 Brenton St, Shippensburg, PA 17257 SON B. C. JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRtP'fION OF PROPERTY INCLUDE NAME OF FlNANCIAL INSTITUTION AND BANK ACCOIMI f NUMSER OR SIMtIAR 10ENTIFYI NUMSER ATTACH DEED FOR JOINTLYaiELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET x OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENPS INTEREST t. A. .12!27/03 Citizens Bank,153 W Orange St, Shippenstwrg PA 17257 11,877.22 100 5,938.61 Accourltll 6244107867, 60 month Certificate of Deposft TOTAL (Also enter on line 6, Recapitulation)' i 5,938.61 (If more space is needed, inae-t additional sheets of the same size) F ' L_J REV1510 EX+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDYLE ~i INTER-VIVOS TRANSFERS 8~ MISC. NON-PROBATE PROPERTY ESTATE OF FlLE NUMBER GALEN L HOLTRY °~~ ~ v~"~89~ ITEM NU DESCRIPTION OF PROPERTY rr~uDE TfIE t~ of THE TRANSFEREE, tMEtR REIpT1ON81uPTO DECED@ITAt~ THE DATE of TRAlISFER. ATTACH A COPY ~ THE D®FOR (iEl1L ESTA7E DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION ~ APPlM1VBLE) TAXABLE VALUE 1 • IRA Certificate of Deposit, Account# 35004110111149 17,218.32 100 17,218.32 M&T Bank, 28 W~nut Bottom Road, Shippensburg, PA 17257 Beneficiary: Larry L Holtry, Son, Transferred 9117108 2 Irrevocable Burial Fund, Certificate of Deposit, Arxount# 4000019379 8,672.11 100 8,672.11 Insurer. Orrstown Bank, 77 East King St, Shippensburg, PA 17257 % Fogelsang~-Bricker Funeral Home,112 WKing St, Shippensburg PA Transferred 9!3/08 3 Cumberland County Veterans Administration -For Funeral Expense 100,pp 100 100.00 % Fogelsanger-Bricker Funeral Home,112 WKing St, Shippensburg PA Transferred 9130/08 This schedule must be canpleted and filed if the answer io any of questions 1 through 4 on the reverse side of the REV 1500 COVER SHEET is yes. TpTAt (Also enter on line 7 Regpitulation) 5, 25,990.43 (if mote space is needed, Yreert additional sheets of the same size) RESIDENT ESTATE OF GALEN L HOLTRY REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEp1~ILE H FUNERAL EXPENSES 8~ ADMINISTRATNE COSTS FILE NUMBER -d k-898 Debts of decedent must be reported on Schedule I. REM AMOUNT NUMBER DESCRIPTION A, FUNERAL EXPENSES: 1 • Fogelsanger-Bricker Funeral Home,112 WKing St, Shippensburg, PA 17257 8,897.00 Personal, Staff, Professional Services, Funeral Home, FacilitiesB~Equip, AutomotHle Equip 4600; Casket 1,775; Interment Receptacle 1,000; Monument Engraving 125; Grave Opening 525; Newspaper Notice 285; Clergy 100; Death Certificates 60; Flowers 212; Military Honors 215 2 Messiah UM Church, S Penn St, Shippensburg, PA 17257 Fellowship Facil'dy & Refreshments 233.70 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)lEIN Number of Personal Representative(s) _ SUeetAddress City State Zip Year(s) Commission Paid: 2. Attorney Fees 3. Fatuity Exemption: (If decedents address is not the same as claimant's, attach explanation) 3,500.00 claimant Larry L Hottry Street Address 610 Brenton St City Shippensburg state PA zp 17257 Relationship of Claimant to Decedent Son 4. Probate Fees 330.00 5. Accountant's Fees 6. Tax Return Preparer's Fees ~. US Postal Service, Certified Mail, Transfer Common Stock Prudential Shares #o Heir 3.12 s Cumberland Law Journal, Legal Advertisement of Death 75.00 s The News-Chronicle, Shippensburg Pa, Legal Advertisement of Death 63.50 ~o Register of Wills, Cumbertand County PA, Inheritance Tax Filing Fee 15.00 TOTAL (Also enter on line 9, Recapitulation) S 13,117.32 (fl more space is needed, insert additional sheets of the same size) REV-1512 Ex+ (t2-03) ( _ __ scN~ou~E ~ RESmENi DECEDENT ~ - - - I ESTATE OF FILE NUMBER GALEN L HOLTRY `~ l - `~ ~ J ~ ~,~ Report debts incurred by the decedent prior to death which remained unpaid as of the dab of death, hrduding unretmbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 ~ Menno Haven Inc, 2011 Scotland Avenue, Chambersburg, PA 17201 1,778.85 Nursing Home expenses July 2008, Room & Board fees August 2008 Citizens Bank Checking account# 6200663894 debited 8128108 2 UNUM Life Insurance Co of America, PO Box 1600, Jacksonville IL, 62651 115.74 , Retum of Sept 2008 Annuity Payment deposited Citizens Bank Checking Aa;oun~# 6200663894 $127108 TOTAL (Also enter on line 10, Recapitulation) 9 1,894.59 {If more space is needed, insert additional sheets of the same size) REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA CERTIFICATE OF GRANT OF LETTERS No . 2008- 00898 ~?A No . 2 / - 08- 0898 Estate Of: GALENL HOLTRY !First, Middle, Lastl Late Of : SHIPPENSBURG BOROUGH CUMBERLAND COUNTY Deceased Social Securi ty No : 184-12-4988 WHEREAS, on the 3rd day of September 2008 an .instrument dated February Ist 2002 was admitted to probate as the last will of GALEN L HOLTRY (First, Middle, Last) late of SHIPPENSBURG BOROUGH, CUMBERLAND County, who died on the 27th day of August 2008 and, WHEREAS, a true copy of the will as probated i:~ annexed hereto. THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wi 11 s in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARYto: LARRY L HOLTRY who has duly qualified as EXECUTOR(RIXJ and has agreed to administer the estate according i=o law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 3rd day of September 2008. **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) JRZ - 5.1 holtry.l January 28, 2002 LAST WILL AND TESTAMENT I, Galen L. Holtry, of 302 North Fayette Street, Shippensburg, Pennsylvania, being of sound and disposing mind, memory and understanding, da hereby declare this to be my will, hereby revoking any and all former wills and codicils thereto by me heretofore made. ~ a m~ ~ i~ ", I . ` • `-' ~ ~ W _'~_I ~~ _f tv's:._; '7 O ~ _? ,~, 1 I direct that all my just debts and fune~~ exp~se~;~;_..3 t including all expenses of my last illness, shall be paid f o my `,. estate as soon as practicable after my decease as a part of the expense of the administration of my estate. II. I give, devise and bequeath the residue of my estate of every nature and wherever situate to my wife, Esther M. Holtry, providing she shall survive me by thirty days. III. Should my wife predecease me or die on or before the thirtieth day following my death I give, devise and bequeath the residue of • my estate of every nature and wherever situate to my son, Larry L. Holtry. In the event my son, Larry L. Holtry, predeceases me or dies on. or before the thirtieth day following my death, the residue of my estate shall be distributed to his issue, per stirpes, living on the thirty-first day following my death, anti in default of any such then-living issue, to his wife, Carol L. Holtry. IV. Any fiduciary under this will shall have the following powers in addition to those vested in them by law and key other provisions of my will applicable to all property whether pz-incipal or income, including property held for minors, exercisable without Court approval, and effective until actual distribution of all property: A. To retain any and all of the assets of my estate, real or personal, without regard to arty principle of diversification of risk. B. To invest in all forms of property including stock, common trust funds and mortgage investment funds without restriction to investments authorized for Pennsylvania fiduciaries as they deem proper, without regard to any principle of diversification of risk. C. To sell at public or private sale, to exchange or to lease for any period of time any real or personal property and to give options for sales, exchanges or ~' leases, for such prices and upon such terms or conditions Page 2 • as they deem proper. D. To allocate receipts and expenses to principal or income or partly to each as they from time to time think proper. E. To compromise any claim or controversy. F. To distribute in cash or in kind or partly in each. G. To hold property in their names without designation of any fiduciary capacity or in the name of a nominee or unregistered. V. I direct that all taxes that may be assessed in consequence of my death of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of the administration of my estate. vz. I appoint my son, Larry L. Holtry, as executor of this my will. Should my son predecease me, fail to qualify or cease to act, I appoint my daughter-in-iaw, Carol L. Holtry, as executrix of this my will. Should my daughter-in-law predecease me, fail to qualify or cease to act, I appoint Eileen Gaylor, on Boonsboro, Maryland, as executrix of this my will. Page 3 VII. No bond shall be required of any fiduciary hereunder in any jurisdiction. IN WITNESS WHEREOF, I hereunto set my hand and seal to this my last will and testament, consisting of five typewritten pages, the first four of which bear my signature in the margin for the purpose of identification this j'~~day of ~_,~~y--~,~+~,~_,~~~"~''''` 2~. (% ,~ ~ ( SEAL ) Signed, sealed, published and declared by the above-named testator as and for his last will and testament in our presence, who in his presence, at his request and in the' presence of each to set our hands as attesting witnesses. / / 1 We, Galen L. Holtry, ~_~'~~~ /i ~ and f ~ (/~.~~ the testator and the witnesses respectively, whose names are signed to the attached or 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 testament and that he executed it as his free and voluntary act for the purposes therein expressed and that each of Page 4 other have he the witnesses, in the presence and hearing of the said testator signed the will as witnesses and to the best of their knowledge said signer was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. Subscribed, sworn to and acknowledged before me by the above-named signer and subscribed and sworn to before_me by the above-name- witnesses this ~~ day of l z./ ~~ Notate Public Notarial Seal Carin 1. Wafter, Notary Public Chamberaburg Boro, Franklin County Commission Ex irea Ma 13, 2005 Page 5 ~GC,~ ~ ~_ Testator M m ~O T~ -~0 t C .. 0 v W R 0 d z _~ } v~ ~ yo, "~ ', ~ o' 8 ~ '~~ ~~I b0/Z0 3Jtid $' c c ~o t ~ ~ '~' ~ c ~' N C V ~ ~ •~ s~ ~~ ~~ .~ ~~ ~~ ~~s 7 N C1 ~ ~ ~ ~~~+ ~to ~ p ,,, ~ 1•~~=, ~~ ~ '~' ~° ~ _ ~ Y ~ ~ ~~ ~ ~ s~ m~ 3~ ~~ `„ $ ~ ~i ~r ~ r, ~' m C N 07 ~ ~ ~. a ~ O r r C ~j G ~ C_ d3 fll ,p cv ~ C1 ~ o~ m •- c~ m ~ a ~° co ~ ~~ -~~ ~~ a ~ ~~ ~~ ~~~~ ~~~~ ~ ~~ ,~ ~ ~ m ~ _ ~ ~~~~~ s ~ ~~~~ ~ ~~ ~~~~ ~ ~syMCy- ~ ~ ~ ~ ~ ~ ~ .~ O U lL ~ G ~ U LL ~ ~ N N 's E ~ ooQa~~~~N~~~~~~~~~~ ~ ~~ ~~ d m ci a ~~ S3NOC Q~MQ3 L9L6069888 TS~00 8002/0ZlLZ ~~ ~~ ~a ~. ~1a J 1 ~~ O ~, 0 0 ~, ~ N ~ `~ ~ ~~ as C ~ d ~. o ~~ Q 4 ~ a~ .~ z S N a ~ ~' gt. o ~ d N r 5~~ a~dMa3 m~ 0 '~i e ~~ a S3 c ~~ a ~~~ r ~ ~~ ~ ~~ ~ ~~ ~~° ~~ ti. m ~~ c~ ~~ ~ ~ ~ ~~ ~ ~ ~~~ m ~. i -- ~° r~ o ~~ ~" ~~ ~~ ~~ ~. ~ m ~~ b ~ ~ N m V ~~ r o ~ ~~ ,,,,, ~ G V ~ ~' ~ ~ ~ ~~~ ~r s~ ~U ~~. ~~ ~~ ~~ ~ ~~ c ~ 8 ~~ ~3 "' o ~ W ~ ~ ~ ~ ~ t5~~e ae~z~~ ~gt6069988 N tp r~ ~~ 8~ ~ ~ ~ ~ ~~ 1 ~ ~'S ~ ~ '~ ~ c ~~~ ~ ~ ~~~ ~ ~ ~ ~ c° U ~ ~ ~ Q p,. 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U~9, ti pp ~ ~ ~5 ~~ ~. o ~~ ~_~ r C 69 EA EA ~A E9 d} d3 EA fA E9 H ~ C y dl y ~ a d ~ ~ .~ m ~ per, ~ m dl ~ ~ .~ N N 3 ~ Q. ~ ~ ~ ~ ~ $ D q 'O g ~ ~ lE Q GI V C V N y t m y~~ ~ 'gyp ~ g~ •~~ -~ ~ 7 ~ ~ ~ bi N~ W 10 c O) ~ C ~ m f!1 G~ U g ~~ m~~ ~ f/1 m g L a ~ Ts ~ ~ m ~ ~ m ~o ~ cv F ri ~ ui ~ Fo c: ad ai ° r ~ ~ ~, d m CV G , w S3NOC Q~IdMQ3 L9L6069888 i9~00 8002/0T/iT ~ ~, ~~ ~~ ~m c~ a ~;:'fe,~ j/~~~vg Computershare Computershare Investor Services 250 Royall Skreet Canton Massachusetts 02021 www.computershare.com ESTATE OF GALEN L HOLTRY 610 BRENTON ST SHIPPENSBURG PA 17257-2114 September 12, 2008 Company: Registration: Holder Account Number: Our Reference: Dear Sir/Madam: PRUDENTIAL FINANCIAL, INC GALEN L HOLTRY 00021215741 PRU/0850100908/48950/73237 Thank you for contacting Computershare, Prudential's transfer agent. We appreciate the opportunity to be of service to you. v On August 27, 2008, on that date, the closing price was $71.83 per share. Should you have other account related questions, please call us at 1-800-305-9404 between the hours of 8:30 AM and 6:00 PM Eastern US time, Monday through Friday. A telecommunications device for the hearing impaired {T1Y/TDD) is also available at 1-800-619-2837. Sincerely, Service Representative Enclosure: None %°/ Prudential 000587 GALEN L HOLTRY 610 BRENTON ST SHIPPENSBURG PA 17257-2114 irrr~~~r a ~rr~r~r~r~r~rrr~rr~r~rrriirrr~ir~ a ~rrrii~~ nr~rirr~ Computershare Computershare Trust Company, N.A. PO Box 43033 Providence, Rhode Island 02940-3033 Within the US, Canada fr Puerto Aico 800 305 9404 Outside the US, Canada & Puerto Rico 732 512 3782 vvww.computers ha re.com/investor Prudential Financial, Inc. is organized under the laws of the state of NJ. Holder Account Number 00021215741 Company ID SSNlTIN Certified PRU Yes '~' Prudential Financial, Inc. -Direct Registration (DRS) Advice Transaction(s) Date ~ Transaction Description SharestUn is ~ CUSIP Description 25 Sep 2008 Transfer -102.000000 744320102 Common Stock Account Information: Date: 25 Sep 2008 (Excludes transactions pending settlement) Certificate Balance Current Direct T it t l Sh lU I CUSIP Class Held by You o ares n s a Registration Balance . Description 0.00 0.000000 0.000000 744320102 Common Stock r ~'~ :.i1fA,/2ES ' Prt:--`f~.i'2fC,~ 7"~ ~f~,n,~y .4. ,J~ Ley /~ IMPORTANT INFORMATION RETAIN FOR YOUR RECORDS. Triis advice is your record of the share transaction affecting your account on the books of the Company as part of the Direct Registratan System. It is neither a negotiable instrument nor a security, and delivery of this advice does not of itself confer any rights on the recipient. It should be kept with your important documents as a record of your ownership of these sham. No action on your part is required, unless you wish to deposit your existing cert~cates, sell or request a certificate, or transfer your book-entry shares. Upon request, the Company will furnish to any shareholder, without charge, a full statement of the designations, rights (including rights under any Company's Rights Agreement, if any), preferences and limitations of the shares of each class and series authorized to be issued, and the authority of the Board of Directors to divide the shares into series and to determine and change rights, preferences and limitations of any class or series. Assets are not deposrfs of Computershare and are not insured by the Federal Deposit Insurance Corporation, the Securities Investor Protection Corporation, or any other federal or state agency. 001CD40020 OOHSAB-PRU 40UDR PRU '~"' OO1CS009?.G.U.EQS.A_F84/000587/000705li Please see important PRNACY NOTICE on reverse side of statemeni r1 U . 'c .r"~..a ~ !' ,,, Citizens Bank~N October 8, 2008 LARRY L HOLTRY 610 BRENTON STREET SHIPENSBURG PA 17257 Estate of GALEN L HOLTRY Date of Death: Aug 27, 2008 SSN: 184-12-4988 Dear Sir/Madam: ,~~~,/o~ 525 William Penn Place Suite 153-2618 Pittsburgh, PA 15219 In accordance with your request, the attached information sheet has been provided in the above decedent's name as of his/her date of death. For IL or LC accounts, contact our Loan Department at 1-$00-708-6680. For all other inquiries, please call I-888-999-6884. Sincerely, Cheryl El-Walker Operations Services P~ ;~, ~~~~rr~~s f'.~'h',tC. ~, , s~; , ;~ _ r.'r ~t,' ~ t~ ~ C#izens Bankp Account Number 6200663894 Account Title GALEN L HOLTRY Date O ened 12/17/2002 Account T e Checkin Princi al Balance as of DOD $7215.55 Interest from Last Postin to DOD $ .00 Account Balance as of DOD $7215.55 YTD Interest to DOD $13.32 ~ Citizens Bank.° Account Number 6244107867 Account Title GALEN L HOLTRY OR LARRY L HOLTRY Date O ened 12/27/2003 Account T e Time De osits Princi al Balance as of DOD $11841.41 Interest from Last Postin to DOD $35.81 Account Balance as of DOD $11877.22 YTD Interest to DOD $251.21 PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES AND FILE N0. 21 OS-D898 PO BOX 280681 TAXPAYER RESPONSE ACN 08151320 HARRISBURG PA 17128-8681 DATE 11-04-2008 REV-1543 IX I1FP (Oa-OB) TYPE OF ACCOUNT EST. OF GALEN L HOLTRY ^ savlNGs ~~I~~-G~yF ~ SSN 184-12-4988 ^ CHECKING DATE OF DEATH 08-27-2008 ^ TRUSr COUNTY CUMBERLAND © CERTIF. REMIT PAYMENT AND FORMS T0: LARRY L HOLTRY REGISTER OF WILLS 610 BRENTON ST CUMBERLAND CO COURT HOUSE SHIPPENSBURG PA 17257 CARLISLE, PA 17013 CITIZENS BANK OF PENNSYLVANIA provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a point owner/beneficiary of this account. If you feel the 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. Please call C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 6244107867 Date 12-27-2003 To ensure proper credit to the account, two Established copies of this notice must accompany 8 7 7.2 2 payment to the Register of Wills. Make check Account Balance $ 1 1 , payable to "Register of Wills, Agent". Percent Taxable X 50.OOD NOTE: If tax payments era made within three Amount Subject to Tax $ 5, 938.61 months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due $ 267.24 nine months after the date of death. P~T TAXPAYER RESPONSE 1 .,.> :.:., A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain CHECK a discount or avoid interest, or 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. dThe 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 estate representative. C. ^ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3^ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LINE I. 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 1 2 3 X 4 5 6 7 X 8 PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID 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 ) WORK C ) TAXPAYER SIGNATURE TELEPHONE NUMBER DATE .emit tp: MENNO HAVEN INC. 2011 Scotland Avenue hambersburg, PA 17201 17)263-8545 RESIDENT NAME: GALEN L HOLTRY SERVICE DATE FROM: C 8/1/2008 TO: 8/31/2008 BILL TO: LARRY HOLTRY 610 BRENTON STREET SHIPPENSBURG PA 17257 PLEA E PAY THIS -MOUNT » »> ($873.85) , AM UNT ENCLOSED: Please detach and return the top portion of this bill with your remittance Payment Due Date for this Statement is the 15th of the month. Orrice Use Only. Menno Village Nurs(ng ($873.85) FROM THROUGH DESCRIPTION QUANTITY TRANSACTION RUNNING 8/1/2008 8/31/2008 PRVSN-001-Menno Village Nursing 8/25/2008 8/25/2008 8/25/2008 - MH CORP Payment ($7,778.85) $0.00 8/1/2008 8/1/2008 BRIEF PANTS MED 4:CL0. 2 units @ $18.45 $36.90 $36.90 8!5/2008 8/5/2008 NEW-SKIN LIQUID 10M 00001 1 unit @ $3.22 $3.22 $40.12 8/5/2008 8/5/2008 CEPHALEXIN 500MG CA 00028 1 unit @ $5.00 $5.00 $45.12 8/fi/2008 8/6/2008 MENS CUT 1 unit @ $13.00 $13.00 $58.12 8/7/2008 8/7/2008 TRAZODONE 50MG TABL 00001 2 units @ $3.32 $6.64 $64.76 8/8/2008 8/8/2008 METOPROLOL SOMG TAB 00001 1 unit @ $4.74 $4.74 $69.50 8!8/2008 8/8/2008 METOPROLOL 50MG TAB 00062 1 unit @ $5.00 $5.00 $74.50 8/9/2008 8/9/2008 SENNA 8.6MG TAB 00030 1 unit @ $0.95 $0.95 $75.45 8/9/2008 8/9/2008 ARICEPT 10MG TAB 00030 1 unit @ $36.00 $36.00 $111.45 8/9/2008 8/9!2008 DIOVAN 160MG TABLET 00030 1 unit @ $36.00 $36.00 $147.45 8!9/2008 8!9!2008 TRAMADOL SOMG TAB 00015 1 unit @ $5.00 $5.00 $152.45 8/9/2008 8/9/2006 TRAZODONE 50MG TABL 00045 1 unit @ $5.00 $5.00 $157.45 8/11/2008 8/11/2008 DULCOLAX SUPPOSITORY 1 unit @ $0.50 $0.50 $157.95 8/12/2008 8/12/2008 BRIEF PANTS MED 4x20. 1 unit @ $18.45 $18.45 $176.40 8/18/2008 8/18/2008 SALINE BULLET 3ML 5 units @ $0.50 ~ $2.50 $178.90 8/18/2008 8/18/2008 DRESSING NON-ADHERE 3X4 5 units @ $0.50 $2.50 $181.40 8/19/2008 8!19/2008 BANDAGE STRETCH 3 N!S KI.ING 2 units @ $0.50 $1.00 $182.40 GALEN L HOLTRY DIRECT DEBIT WILL BE WITHDRAWN ON SEPTEMBER 15, 2008 PHARMACY QUESTIONS: DANIELLE @ 1-800-675-2279, X-1437 NORTHFIELD & NORTHGATE QUESTIONS: LISA RINE @ 217-5400. NURSING, ASST LNING, RESIDENTIAL & MV COTTAGE QUESTIONS: ESTHER @ 262-1009 OR LISA ANGLE @ 262-1010. PLEASE PAY TH/S AMOUNT »»» ($873.85) BEGINNING BALANCE: $7,778.85 PAYMENTS OR CREDITS: ($7,778.85) CHARGES: $326.15 ADJUSTMENTS: ($1,200.00) BALANCE DUE: ($873.85} Sct~E'AUc~ ~ STATEMENT OF ACCOUNT 9/3/2008 If~M~RK. Date: 09/09/2008 Gross payment amount Net payment amount 0226548_ _--.---_- I~i~Hn~wzKm n ~... f`a~ /~,~ ~._,'~ This Month 178.38 178.38 0226548 Direct Pay Central Region DATE AMOUNT Premium Refund 09/09/2008 178.38 *ONE HUNDRED SEVENTY-EIGHT AND 38/100 DOLLARS* ~~ PAY THE ESTATE OF GALEN L HOLTRY TO THE e ORDER OF 610 BRENTON STREET 'G/'J/~~ ~,,,y~ SHIPPENSBURG PA 17257 u`0226548n' i:036076~50~: 6 20 54 5 2 58~~i' meclco° • P.O. BOX 6052, Parsippany, New Jersey 07054-7052 Medco Health Solutions, Inc. EXPLANATION OF BENEFITS 0-E-000884001-01-02 000623 HOLTRY GALEN 2075 SCOTLAND AVENUE CHAMBERSBURG L PA 17201 Page 1 of 2 Member Number. ®7593001 Group Number: HRK019700150010 Check Date/Cfieck' No.: 09 J23/2008 - 4842784 Benefit Starting' Date: N/A Plan Provider: B UERX PLUS Carrier Number: 3620 This document contains information that ma have been masKed or aelerea to protect our rlvac of conrlaenrlal c Date .of Rx Amount Amount eductibl Copay djusted Total Explanation Serv-ice. Number Submitted- pproved Applied. Ap lied Amount Pa able Codes 05/08J2007 XXX5495------- ---- 358...29--..--- ----358-.-29.- ....... ......0-.00_---__ _.----68-.33-_---- -------0,00....... ------20500--......_-..-.-......------ . 05f08/2007 _ XXX5495 358 29 273 33 0.00 6 00 $4.96 267.33 J 14 f 2007 10 ( XXX3032 50 09 - 50 09.-....... ....._0-.00...... .........6.00------ -----....0-.00...... ..........._2.49-----------------------.... . - . , 10/14%2007 ....... -- XXX3032 - . ..... ..---~ 50.09 ........ 8.49 0.00 8,49 41.60 0.00 J 10/14J2Q07: XXX3033 - 69 . 52 -.. .. -------69-._52.-------- ......0..00------ ------29_.00-... ---------0..00.----- ---------36..65-'----.....---------------- - 10/14%2007 .- --- -- XXX3033 _ . . --------~ 69.52 - 65.65 0.00 65.65 3.87 0.00 J PATI EIVT~~~TOT'i4L - ~ -~~~~~ ~~- - - ~ ~ 0.00 130.43- 0.00 23.19- 130.43 23.19 LANAl1UN GUUtJ: --..I f..you--.have-_.questi ons----about---this--. refund_~---.please--_cal_1-..the---cus-tomes--s on your pharmacy member ID card g 6 lata. .. _. _.. _~~-..-..-- --.-_ r-'i.Tfl -',--`TT--,~ ._,_.~;"^1s.L +~,~',:.~-~. aj~[.'~.7'rflrx ~~ axle '",~t ~~i', - _____ .. .. .:. . ~ ~ ~EJ)V~.ar me~lco® JPMorgan Chase Bank, N.A. 4842784 PO BOX 6052, PARSIPPANY, NJ 07054-7052 Syracuse, New York 50-937 213 GROUP NO. .MEMBER NO. DA'Z'E - RRR7RkR1tlk VOID AFTER 180 DAYS aav HOLTR.Y GALEN L ? TO THE ' ORDER OF Authorized Signatures This benefit provided by 61_UE RX II'484 2?8411' ~:0 2 L3093?9~: 60 L~~~8~~~0 506 211` ~. Q MsT Bank 499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12 Larry L Holtry, Executor Estate of: Galen L Holtry 610 Brenton Street Shippensburg, Pennsylvania 17257-2114 September 18, 2008 Re: Estate of Galen L Holtry Acc6u ntNurnber: 03004110111149 Date of Death August 27, 2008 Dear Sir or Madam: Per a memo from Cindy Unger at M8vT Bank, dated September 16, 2008, requesting at the time of death, the balance on the above referenced account(s) was: 1. Type of Account Account Number Ownership (Names ofi Opening Date Balance on Date of Death Accrued Interest Total Il?A 035004110111149 Galen L Holtry Larry L Holtry, Beneficiary 10/ OS/ 06 Closed 09/ 17/ 08 ,$16, 679.09 $ 539.23 17,218.32 * der further-acc®unt ax~formatioa, regarding a~raership, closures azid-/os reimbursesnent_-af funds, etc., please contact the Walnut Bottom Road Office # 717-532-2414. M&TBank. DOD Unit /Records Management Ol V\ 1 O~ 1J! ll V i l P. O. BO% 250 SHIPPENSB URG. PA 17157 m g ORIGINAL 60-1503 313 September 3, 2008 DATE "042604 PAY TO THE Fogelsanger Bric]cer Funeral Home Inc. ****************************** 8, 672.11 ORDER OF $ ~I~iFi~aTi~W~ ~ ~ ~ ~ .~w~w ~ ~ w~w ` BAt~iK ~ i ilii. 3 i V 4.~ DOLLARS CAS H ! E R' S CHECK VOID AFTER 6 ONTH~ Remitter ~' Galen Holtry _ ~ 4110 -°"`rq,, ACCT. NO. F AHAT® L03 00,60211' / fJ/;~~ J~ i 7~J / jI~I )PI'P!1/PQ/~Yd))L: SI--I--1Lr ~~1•'~, ~~. ~l ~ "/ l~~ ~Y II" I ~'l N J`` ~/ j% // ~' / - f ~ (l,,~jaH~~ ,SIX l~(~Yr~f~!-~i~ .SE'iL-~~~T`f -7G~~ ~lu' r>leral Services ~ ~ ~C .ll e,r.~vxP~!. i 'CHECK# ~~°- CREDIT -CARD / Name of Deceased. FOGELSANGER-BRICKER FUNERAL HOME, INC. OTHER //~~ ~an~c ~ou! LAST BALANCE $ ,~;~ ~ ~ ~~ INTEREST LATE PAYMENT ~~ CHARGE SUB TOTAL CREDITS LESS PAYMENT ~ / ~~ 7~. NEW BALANCE $ ~ ~, "~. ,~ r 06685 _ - [a~ _5 _ i t v L a n e ea_ n r. 5 e 1, n c k / o d e r a i ls. [:7~_____,-_ _~~- 0993 3-7615/360 y 299 DATE `~ f~ r'~.'/rl~F/-' ~-~: ~~G'~ ;+ ~ER OF ~pG~L•_~~.vr/= ~_-~ ~,~~c,~~.e F,v~C f~;:r~ ; .Zti'~ ~ $ /a~ ~~ a. J~L(/yl G1J?~G~L ~t fJ--[~~yL~, /- G'G/JL L~/X(~ ~~/~~ ~ ~~ DOLLARS 8 " a Citizens Bank Penns Ivania ~/~'/frNC>r ~t~ ~ ~ 4 FOR y~.~G 9~~°~ - _._ ..._. --~- ------ -- - __ _.. _ _._ .._--- _ ,-._..--- __....__- __ --- --~ -- 11'00099311' ~:036076L50~: 62L335820 n^ ~ u'' ORIGINAL i CCUUQ~~Y-04J7: 4110 ' ~ h.~ ~~ ~ i h ;~ ~~~ C~~c ~ G ~. Funeral Services ~en~rre~~ -- ~I <<-. I t' [CHECK # U ~ _ l~J CREDIT CARD __ L OTHER FOGELSANGER-BRICKS FUNERAL HOME, INC. Name of Deceased CyT~ia-n~ ~orr./ r, LAST BALANCE $ ~ ~ ~J . ~~ INTEREST rr LATE PAYMENT L~ ~~ SUB TOTAL CREDITS Ci LESS PAYMENT ~ ~ (J • NEW BALANCE $ -- 06714 ORIGINAL 4110 ~.~~~~r~. ~ ~ ~- 1 n < n~ v,~UY ~tr Funeral Services /~ ~e~nlisxea~ _--~ CHECK # v~ CREDIT CARD ^ OTHER a Jat~ ) - ~.~:~- o~r~ F~H~ A~T,ED ;~~_'. Y ACCT. NO. C~L•~ f7~'/)j I~L/ / U ~~ °'~~ ACCT. NO. F r 2~c'd i~/~,/~"k' ~~ ~~~ r~ i~/mod v I ~ I' ~1 ~~ / Name of Deceased FOGELSANGER-BRICKER FUNERAL HOME, INC. C~~an~c ~u./ LAST BALANCE $ ~- ~. y INTEREST L^-1 LATE PAYMENT CHARGE SUB TOTAL CREDITS ~~ LESS PAYMENT , NEW BALANCE $ ~ a~r 06704 1 / ~ ' d ~ ,nyisn i :_ t ~ ~ K: ,~ ,.J~:. STATEMENT OF ACCOUNT 8/5/2008 Remit to: RESIDENT NAME: Menno Village Nursing GALEN L HOLTRY 2011 Scotland Avenue ambersburg, PA 17201 7)263-8545 SERVICE DATE FROM: C7/1l2008 TO; 7/31/2008 BILL TO: LARRY HOLTRY 610 BRENTON STREET PLEASE PAY THIS AMOUNT »»»»»> $7'778.85 SHIPPENSBURG, PA 17257 AMOUNT ENCLOSED: Please detach and return the top portion of this bill with your remittance Payment Due Date for this Statement is the 15th of the month. Office Use Only. Menno Village Nursing $7,778.85 FROM THROUGH DESCRIPTION QUANTITY TRANSACTION RUNNING 7/1/2008 7/31/2008 PRVSN-001-Menno Village Nursing 7/24/2008 7/24/2008 7!24!2008 - MH CORP Payment ($7,889.07) $0.00 8!1/2008 8/31/2008 ROOMBED PREBiLI 31 days @ $240.00 $7,440.00 $7,440.00 7/1/2008 7/112008 BRIEF PANTS MED 4x20. 1 unit Q $18.45 $18.45 $7,458.45 7/2/2008 7/2/2008 MENS CUT 1 unit @ $13.00 $13.00 $7,471.45 7/5/2008 7/5/2008 DIPHENHYDRAMINE 25M 00009 1 unit @ $3.45 $3.45 $7,474.90 7/8/2008 7/8/2008 BRIEF PANTS MED 4x20. 2 units @ $18.45 $36.90 $7,511.80 7/10/2008 7/10/2008 METOPROLOL 50MG TAB 00090 1 unit @ $5.00 $5.00 $7,516.80 7/10/2008 7/10/2008 DIOVAN 160MG TABLET 00030 1 unit @ $36.00 $36.00 $7,552.80 7!10/2008 7/10(2008 SENNA 8.6MG TAB 00030 1 unit @ $0.95 $0.95 $7,553.75 7!10/2008 7/10/2008 ARiCEPT 10MG TAB 00030 1 unit @ $36.00 $36.00 $7,589.75 7/10/2008 7110/2008 TRAMADOL 50MG TAB 00015 1 unit @$5.00 $5.00 $7,594.75 7/10!2008 7/10/2008 TRAZODONE 50MG TABL 00030 1 unit @ $5.00 $5.00 $7,599.75 7/11/2008 7/11/2008 ALPHABATH OIL 80Z 00001 1 unit @ $2.02 $2.02 $7,601.77 7/12/2008 7/12/2008 DIPHENHYDRAMINE 25M 00008 1 unit @ $3.43 $3.43 $7,605.20 7/12/2008 7!1212008 DIPHENHYDRAMINE 25M 00030 1 unit @ $3.93 $3.93 $7,609.13 7/19/2008 7/19/2008 HYDROCORTISONE LOTI 00001 1 unit @ $10.58 $10.58 $7,619.71 7/21/2008 7!21/2008 LORAZEPAM 0.5MG TAB 00030 1 unit @ $23.07 $23.07 $7,642.78 !, 7/25/2008 7/25/2008 BRIEF ADULT MED 6x16 1 unit @ $10.47 $10.47 $7,653.25 GALEN L HOLTRY DIR CE DTDIR DT EBITS WILL BE WITHDRAWN ON: AUGUST 15, 2008 PLEASE RETURN STATEMENT TOP WITH YOUR PAYMENT. BILLING QUESTIONS: (PHARMAGY, CALL DANIELLE @ 1-800-675-2279, X-1437) (NORTHFIELD-NORTHGATE, CALL LISA R. @ 217-5400) (ALL OTHER QUESTIONS: ESTHER @ 262-1009 OR LISA A. @ 262-1010) c-n•_'f~Ir 1_ M- .~:4 ' PLEASE PAY THIS AMOUNT »»» $7,778.85 BEGINNING BALANCE: $7,889.07 PAYMENTS OR CREDITS: ($7,889.07) CHARGES: $7,778.85 ADJUSTMENTS: $0.00 BALANCE DUE: $7,778.85 -------~ .~~ ~/ZZj ~i,-r~£~rj -~aa~ ~/77f-~' ~~ ~-~~ max;, ~ ~~ , --~ .- ~~ . `~ :~ Circle ;~~ , ~~,~ ~. # ~~- << j~ ~ l ~TM ~~" ~'~~_, Account Statement 1-888-910-4100 ~ of 4 Call Citizens PhoneBank anytime for account information, curtent rates and answers to your questions. Beginning August 19, 2008 through September 17, 2008 Checking SUMMARY Balance Calculation Previous Balance Checks Withdrawals Deposits & Additions Interest Paid Current Balance Bala»ce 7,310.44 Average Daily Balance 4,577.37 1,832.08 - Interest 5,034.70 - 1, 618.04 + Current Interest Rate , ~Oq, .75 + Annual Percentage Yield Famed , rO9b 2 , 062.45 = Number of Days Interest Earned 30 Interest Famed ,75 Interest Paid this Year 14.07 TRANSACTION DETAILS Checks' Drere is a break in check sequence Check P Amount Date 223 ,/~~ 53.23 08/19 Withdrawals Other Withdrawals Date Amount 08/27 /,/ 257.40 09/04 ~ f 1,371.30 09/05 .~, ~ 3,500.00 n Total Checks -~^': fG '!_~~ 1,832.08 GALEN L HOLTRY Circle thecking with Interest 620066-389-4 Previous Balance ------~.^, 7, 310.44 Check ¢ Amount Date 224 ~/ 1,778.85 08/28 Description Highmark CPA Eft 080827 900033210 Debit Memo Debit Memo TotalNHthdrawatt 5,034.70 Deposits & Additions Date Amount Description 08/27 09/02 ;/~/ ~' 115.74 125.00 Swiss Re Annuitypayy 080825 11290002a Edward Jones Investment 082908 065011576 ~ 09/03 ~ s/ 1, 377.30 US Treasury 303 Soc Sec 090308 Interest Date Amount Description 09/17 ~ .75 Interest Daily Balance Date Balance Date 08/19 7,257.21 09/02 08/27 7,215.55 09/03 08/28 5,436.70 09/04 Balance Date Balance 5,561.70 09/05 2,061.70 b,939.00 09/17 2,062.45 5,561.70 NEWS FROM CITIZENS --IMPORTANT NOTICE/CHANGE IN TERMS Effective November 1st, 2008, when you request a single copy of a check, document, or statement, we will waive the $25 per hour / $25 minimum Research/Reconciliation Fee. ALL other research or reconciliation requests will be subject to this fee. --Looking for high yields and easy access to your cash savings? Look no further! Citizens Bank offers savings and money market accounts with great rates and the peace of mind of FDIC ivlember FDIC ~ Equal Housinr; Linder n Total Deposits & Additions 1,618.04 lj Total Interest Paid .75 n Cuvent Balance 2,062.454 UNUM LIFE INSURANCE COMPANY OF AMERICA P.O. Box 1600, Jacksonville, IL 62651 Phone 800-265-7180 Fax 803-333-4936 ~/a • September 18, 2008 LARRY HOL"TRY 610 BRENTON ST S1-IPPENSBURG PA 17257 Insured Name: GALEN HOLTRY Policy Number: 11290002A Correspondence Number: 08510186 Dear_11r1r Hnl~jt~ - Thank you for contacting UNUM Life insurance company. The bank draft that was posted on August 27, 2008 in the amount of $115.74 was for the monthly payment of September 2008. The draft was sent from our office on 08/25/2008 in order to reach the bank and to be in the account on the day that it was due. All payments for this account were due on the 15S of every month. Since Mr. Holtry passed away in August 2008 the September payment needs to be returned to our office. If you have any questions, please call our office at 800-265-7180, Monday through Friday from 7:30 AM to 4:30 PM Central Standard Time. Sincerely, Gina Suttles Claims Services