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HomeMy WebLinkAbout12-12-0815056051047 REV-1500 Ex (D6-D5) ~, I,'iAL t,~E ONLY PA Depanment of Revenue --~-_ _...,~..___,......._.„„ Bureau of Individual Taxes County Code Year Fie Nurn6ur PO BOX 280601 INHERITANCE TAX RETURN Hamsburg, PA 17126-o6o1 RESIDENT DECEDENT '2 t 4,.~" ~~ 6q 71. ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ',9 p l y ~ t S'o 0 6! 5"~z. o o &" ~ 9 p 6 t 4 z l Decedent's Last Name Suffix Decedents First Name MI L3uRNS Wi.~ z~A-~ , 7' (If Applicable) Enter Surviving Spouse's Information Below Spouse's last Name Suffix Spouse's First Name MI Spouse's Social Securty Number I ~`~ ~ ~ ~ ~.7 +, D ~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return p 2. Supplemental Return (~ 3. Remainder Return (date of death prior to 12-13-D2) t~ 4. Limited Estate ~ 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate 7. Decedent Maintained a Living Trust fl. Total Number of Safe Deposit Boxes - (Attach cnpy of wily (Attach cnpy of crust) O 9. Litigation Proceeds Received (~ 10. Spousal Poverty Credit (date of death p 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 T0: Name Daytime Telephone Number ~A-M r~ s Q o WM q- a! „7 17~ a 3 .Si ~ ~ Firm Name (If Applicable) - - r~ . ,... 2EC15 f-FRf)€~Vil L3 El 7F- Tq LY^ ~ r i ~~ i i i i7 i ~ r i ~ I First line of address -~ ~ ~ ~ c r- _ ;, ;,, ~-3 y s i ~v-r~ slr~ ~G r ~- r' . .,,. Second line of address i ~ :"~ C) 'V ~~' ' -.. -. J .:1 1~ .. , - ~ - DAtt°§It1ll ) c: '1 City or Post Office State ZIP Code - ---:,. ---~ v'+ a - Correspondent's e-mail address Under penalties of perJury, I dedem that I have examined this velum, inclutling accompanying schetlulas and statements, end to the best of my knowledge and belief, It is true, wrrect and complete. Declaration of preparer other than the personal representative is based on all in(ormabmi of which preparer has any knowledge. ._ ~ ._.._...__.~ _„_n.___._..____~~~.~.._.~_...~~ ...............____.__...~_~.., __........_.______~.,..._. SIGNATURE OF FE S N RE ONSIBL FOR F141NG RETURN DATF- ~1i,~5= ~~' ~u yf~ ~x r ~~ ~-off ADDRESS SIGNAT E OF PREPARER OT//HER THAN REPRESENTATIVE ~ DATE ,- ~, ,/tit. ~ i ~.~~ /~/: /.~c~ __. -EASE S ORIGINAL FORM ONLY .. Side 1 15056051047 15056051047 ~~ Jo ~ Ch ~- --~- ~- '~ v `3 ~ - -~ ~~~ ~~ -~- 15056052048 REV-1500 EX Decedent's Soci al S e curi t y Number /( Oecetlant's Nart a W~I ~(4[h ~ ,/JG(/nS / ~ a ~" { / ~ ~ / I b ~~Q RECAPITULATION 1. Real estate (Schedule A).. _ ...... .......... .................. .. t . 2. Stocks and Bonds (Schedule B) . ................................... 2 ~. I (7 ~ O I . ,3 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. .. 3. 4. Mortgages & Notes Receivable (Schedule D) ..... ......... ........ 4 6. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... 5 2 / ~ 7. 6. Jointly Owned Properly (Schedule F) p Separate Billing Requested .... 6 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested.... , . 7 f{~ ~ ~ ' ~ 'f. ~? , ~ ~ '. 8. Total Gross Assets (total Lines 1-7) .................................. 8 _....r:,,,,,~.'... I p y R .~ i 9. Funeral Expenses & Administrative Costs (Schedule H)_ ......... _ ...... 9 ~ O ' o.. L/ , S"3 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ... .......... 10 1 Y p , Y 1 71. Total Deductions (total Lines 9 & 10)_ ....... ..................... 11 ~'. Q ~,- y ~, ~ ~. 72. Net Value of Estate (Line 8 minus Line 11) ............................ 12 ~ ~ Y ~ Q ~ , ~ Z 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... 13 - '. (,1, p (') !; 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... 14 ~ ~ ~ l ~ O ! , Y ~,,, TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RA7E5 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 p -... -- (a)(L'Z)X.O.'~dJ ~ 1 ~3 ~O I + 7 ~, 15 ~ - C7,!Q1 Q. 16. Amount of Line 14 taxable ~ at lineal rate X .Oyu ',2 7 ~q. 3 y ~ , 6 $" 1s ~ ~ - ,$'" ? O . 3 h 17. . Amount of Line 14 taxable at sibliny rate X t2 17 ' 16. Amount of Line 14 taxable at collateral rate X .16 1 g 19. TAX OUE_....._........_.._ .. ........... ...... .. .. .. ... . .. . 19 ~:Z .~ 7Q..~ ~-. 20. FILL IN THE OVAL IF YOU ARE REOUES7ING A REFUND OF AN OVERPAYMENT t;:J Side 2 15056052048 15056052048 J ftEV-1500 EX Page 3 File Number Decedent's Complete Address: _ Wi~4irp _ L ~~ a14,S__ !V 1.L,n STREETADDRESS / _ --- ' ~3 _V I ~- ~at'n.~ _ _-_~Q~r. -- -- ~- - CITY ^ ~~ ~' ~~ STATE ~ _. _.ZIP I /~~ ___ (~ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2 CreditslPayments A. Spousal Poverty Credit --- -_._ e. Prior Payments _ /0, yoO, pO C. Discount .~~,j,.6'].,._. 3, InteresUPenalty if applicable D. Interest E. Penalty Total Credits (A+g+C) (2) ~~ y7~. 67 (1) l ~ S7a. 37 -i -------- Total InteresUPenalty (D + E) (3) 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. (4) 5. If Line i + Line 3 is greater than line 2, enter the difference. This is the TAX DUE. (5) 1. 096.70 A. Enter the interest on the tax due. (5A) B. Enter the total of Line .5 + 5A. This is the BALANCE DUE. (5g) _ / O 9 (~ 70 Make Check Payable to: REGISTER OF WILLS, AGENT k,l~{^.'~.'~..~~~~1'.??~fY+!,!!k~t'~l ltu`.3..:'T1r ~.~+',.il!}I,i?'~": TI ~{;~°.#,~t.b~t!81"*+'ein~ iEi..:,(F..rSi1u{,x{Iti~~.``~{iltk~'ftts ~f.I~Y..: ,:N~i. I},1t';TE, t t. ,; s t : vii' 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 propedy transferred .._... ... ..... .. ..... ^ h. retain the right to designate who shall use the propedy transferred or rts income; ._. .... ^ , c. retain a reversionary Interest; or ..... .. ........ ....... ... d. receive the promise for life of either payments, benefits or care?. .... ...... .. n 2. If death occurred after December 12, 1982 did decedent transfer property within one year of death without receiving adequate consideration9 . ........... ... ..........._ .............. ................. ..._ ~~... 3. Did decedent own an "in trust for" or payable upon de rth bank account or security at hls or her deathv _.. U ~Lt 4. Did decedent own an Individual Retirement Account, annmty or other non probate property which contains a beneficiary designation? ... .. [J IF TH9E~pvyA,rNn,~~SWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. ;x~lg 1%!;}~~`i~IS~Thts di kL .. , I 2 .~ 7Stk n., ,.. i, .. ~_ I ., !...vt, 1:.< s nu ..~?~~t1111 rt. {., tti= a, #rr Et~.AiG3pi. u. ,,} 3E., .,~SI t{}#. ~a.h .,a :; , ., .,. ' , a "i~, a,+tt ~i i,1i39,i`-~; For dates of death on or oiler 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 exei~ a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and tiling a tax return are still applicable even if the surviving spouse is the only benefciary. For dales 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)). A sibling is def ned, 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+ (6-99) y .. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER All property Jolntly~owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH t. `136,titr dl,, 1/ah'4a.d -we/lr~.f~pn ~.,.z C~3r.ys/sti /3~ 7JF ~z.. .~ 7G, l (n.37 Jti. 6 V4nfka.d- .. ~.,.:rc d41v„ey /Aa.Rc~ ~ l,m /s 7 ro !6 ~ ,~ ? ,~. .S-A.G.IJ7 Sl, {/a~~c~w,.i. - Sx..t-iA.., F~ f~a~C ~ loYc ~, , , .r J`4J,3~ ~i, l,136.6oYSa va~.quw,d ° ~•,w~ ct<~ Fu,L (g~>x.v3~f~ ~x,.~yz,~~.3 S', 7941.3Sas~. /anJr.oid - /~/1- Lrnl7~•~ T.y C'xv~l~ro, 4 ~6, qYs~~~ ~ ~~ ~~. Gam. 1, ~a~ .,S h. ae ~~pf p za. 4 ~ ~s ~. A S ~ ~Cy U~ Ye.t~/s~ TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) ~~~. r. YSa. o0 ~qp, t0i.39 REV-1508 EX+ (e-9g) ~= ~ ". SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF './ ~7 W''lit.t l ~u/ S FILE NUMBER T ~ N ~' / - O S` 069? Include the proceeds of litigation antl the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH I n Z (JOy U4ic,k u!~/z~ ~t?(4c Aoo ~C /a lut) ~,Tj Oe/~. 00 ,~. I 14 cf.ouh,tJ RPCe""~a,dle - MCatc~ Fu ..e!.. ~' FAO. SO 3. ~r~~ 1«swr,„w Oc~:dtt~, lbb. S"o S ~.lo~{t..„~ ~K,.,,ss/i:,,y~ and N~I;sc.. Nvu a l ld G` y3~Y~' . e l, no~ - o ,~ 000. 0 TOTAL (Also enter on line 5, Recapitulation) S I 2 r! s~S (1f more space is needed, insert additional sheets of the same size) REV-1510 EX~{6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RE6IDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF _ ~] FILE NUMBER Wtl(,gN. /r IC04r~L5 R1- OS-D4A4, This schedule must be completed and filed If the answer to any of quesdons t through 4 an the reverse side or the REV-1500 COVER SHEET Is yes. REM NUMBER DESCRIPTION OF PROPERTY MCLUDE THE NAME OFTXE TRNIEFEREE,TNER REIATIDNSHIF iD DECEDENTAND 1HE DATE OF TRINSFER. ARAp1ACWY0F THE OEEO FOR REK ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST EXCLUSION IF APPLM,ABIE TAXABLE VALUE 1• 7oh.1 I'f'4N104.t~ Sr.~fc. yol (K) 11,4 SS6 iv09o d~-, Si5 h4 fr ~+t v<J~a.~ 1.a{„ ~RA9- Slit-1`.23 ~7 93,J9R` /a77/p 1i.}..J 70. 1. Varyuw-J s~~ - ago,~z,x~a ~~~ ~ q~,so~. ^ p ~~~rte'~+c~5.~ B~ /T~l ~E10~/C /~-2~i~.Ca.c. /~C.wvr{al r.f '-~4 vl~~~{ ~ ^ J~~t(SC' All yk(~Ot`w7s Shpw. a~- ~r~Ac.3o, ~ S l/w/u e~ TOTAL (Also enter on line 7 Recapitulation) S I t'/ 7 7, 3 2 A7 , ~' oq V~ ,oo (If more space is needed, insert additional sheets of the same size) REV-1511 EX+(10-06) ! SCHEDULE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF / _ nn FILE NUMBER p ~j Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 7. Nl uSxls .{ .. rr.ar ~ - ~u.dr. /u rELs u T uw~ I" r I Z.O {. S.S //~ / ~ , S ./ .. f~ rl O~~r i.G Vrrln C.rNl.Cr ' J+~ ~'in. r't 1<'° J ~ C~ ~ ~ C/~ t 20~1r +~ ~jiB« ~frtzrt,~~ _' ~Ai/`rev R ~'S1, Oo P.ry~, (u,,,„, Glrw.-k wv,..... - k.,r~/ e~ ~e~r~n~..k F ~ r^- ' l/~~ 'Ri NCI ~i' r' (7rpt Ki~~ .~/r,4Meiw/ .•77 ! 3Sp OG7 ~rr.) ~'/~,.t ~ .~ FIvw NJ 3 S"Or 00 /Ob, o0 B. ADMINISTRATIVE COSTS: 7. Personal Representative's Commissions Name o(Personal Representative(s) Street Address City Stale Zip Yeags) Co m mi ssion Paid: 2. 1 l / I, ' /~ Attorney Fees W 1)C y (IV QY~ p,/ ~ ~Ci ~Krv Y C, ~rSf'i w.a~eF(~ ~ S, So D . n c~ 3. Family Exemption: (If dece den~s address is not the same as claimant's, attach explanation) ~~(L S Claimant "~~/{(~ L. N4/~S ___- _. __-___. _._._. __ _.. ___. 3. ~47 (~ . oO e Street Address S$ Dldairs R~. _ ___. CitY_ Gave ~fl, ~~ State Zip '!Q/!_____ _ Relationship o/ Claimant to Decedent J~.7u S S., _.. _. 4. Probate Fees 3 g"b- © o 5. Accountants Fees J~,I /~ //~ 11 Cl M~iktJ ~'^~{+h Ant F~rJ~"W~. I'ruU' ~f.0 awr f~ r' / J ~~ Q'O 6. Tax Return Preparer's Fees 7' 1'~ [~ I'rir W. If7 / TOTAL (Also enter on line 9, Recapitulation) $ ',L.p, I p y . S3 (It more space is needed, insen additional sheets of the same size) REV-)512 FX~ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF ~ FILE NUMBER Report debts Incurred by the decedent prior to death which remained unpaid ae of the date of death, Including unreimbursed medical axoenses. tlr more space Is neetled. insert additional sheets of the same size) REV-1513 EX+19-0O) P SCHEDULE J commoNwEALTn of PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE Of // nn FILE NUMBER W`d~tr.~. T~LowaS ~C5Urn1 ,4 /- O~ 0697 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE 1 TAXABLE DISTRIBUTIONS [include oufnght spousal distdhutions, and transfers under Sec. 9116 (a) (1.2)] ~• donn:~- /'hf ~c~ ~acc~~1'~-er - b -- C 7., A4u.~ /3,,r.u Givwd.t<v'•- 31 03~~ QL ~, -- _ St«.kc/ uu~n~J _ G,andJaeti .31 O3~rQ/o , S rN,a~gKer~te Row,,,~.,~ Skr. Dawf[/~' yb,.S,r~,,4y _ _-- 7, K0..c~ 4;ssoGF~ ,Star C~uj;(Ee~ "~lo. Sr6.4Y ~, PG fr. Neat,/,.;y S/c~a 'S°"~ YG. ssa.9~ q, SL,..l~7 c.. 44w„ Sp„«~~.- "19~; 367. ~I ~~IOO,o00 Ae$a~y}- F ~dcd Sy Nm,,-iarall. 41J~ xwJu.aq~e See A a~bcd .SGkedte/a aad ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROU GH 16, AS APPROPRIATE, ON RE V-1500 COVER SHEET It NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBU710N5 UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 7~ ~fa,.fvA/J (If more space is needed, insed additional sheets of the same size) FORM P~502 (GREENI P-SOR-B (BVFF) (11 -BD) Olrt-byi>~.me s~~inna.u..we.~.+. n: ~v.~~...m~v,~..... ,..xa.xu.... iH0 iN US< INITIALS DATE REFERENCE PREPAFEO BY CHECKED BY APPROVED _ BY I , i 1 _ i I I ~ 1 2 I . .. _.. i ( ! I I .. 2 3 _ I II i i I ~ I 3 4 I I ~ , l I I 4 ~__ 6 / ! ~ - (Y it-M. Y_C/ ____..__ ~ I ~ ~ D ~ O~j' 7 7 _..._ L ~ ~ I i ~ I I 5 6 _ _ _.. _..... ... _.._ __. _ ( I ; ~ 6 i ~ . __ I 1 ; ; } , . _. 9 /duo _ Dt k~~~ ~ _ 6 o~w-t lfk ~ Fti,~ /!.L 6 ~ ~ ~ ~ 9 , ~ ~. 1 ,o ~ ~ i ~ I ,o ,1 12 I _. 11 _^ _-- __ /~ _. ~CeK _~~~KL/ .J'~4,a 4{tws-C..- _... _... _ i _.~,.. 17I~ ~_I 71 ~1 - __.. „ 13 _. (70V.C/il.N~lti~ L:1C- /-h}W~etice. V/r .. ( ~ (.. ~~I QQ 13 14 L n -.. 15 -_- ~_ . _.__ __ I ., 15 I _ _.. {_..._. ~ I i6 17 I ~s<,e _ ~~~.wtc~ Re~e~P~,t~ .. ~ ~ 4 II j 16 20 -- I _~..v__. "'"___.~_._~_~_ + ._., -.~....1 __._ _. I -- L _s 19 20 21 ~ I _... _ _ i 22 23 '. _. ~ I ._ 23 __. i _ _._ _._ _. _.. ~ 24 25 26 _. _. ~ _. ~ "_ ,.. .._~ __.. 27 _. I 26 26 ~ - ~ _. 29 ... ._ _ ~ 29 -- _.~._ I i I 30 _. _. ~ 31 32 _ ._ _ _. _. I _.I ~ I _ ( ~ :. 32. PennMutual Beneficiary ACCOUnt STATEMENT OF ACCOUNT ACCOUNT NUMBER: 9220168007 iBWNCKKV i4899600926167731i MDG20060086478 1 AB 0361092318 BEGINNING RATE ANNUAL ~ ~~ ~~ ~ ~ ~ ~~ ~ ~ ~ ~~ ~ ~ ~~ ~ ~ ~ ~ ~ ~ ~ MONDAY YIELD m , n , u n , u ~ , m u u, u , u, , u u , BONNIE LEE HUZEY 8974 ROUTE 249 06/30/08 1.49 1.52 KNOXVILLE, PA 16928-9673 07/07/08 1.49 1.52 07/14/08 1.50 1.53 085478 07/21/08 1.46 1.49 07/28/08 1.46 1.49 Summary of BENEFITS, INTEREST, and REDEMPTIONS for the period: JULY 1, 2o oe THROUGH JULY 31, 2ooa Opening Balance Credits Interest Debits Other Charges Closing Balance 5.00 076,768.39 012.28 0.00 0.00 576,780.67 07/28/08 INSURANCE PROCEEDS 07/31/08 INTEREST PAID 76,768.39 12.28 76,768.39 76,780.67 If you need additional information on your Penn Mutual Beneficiary Account Please call the Account Servicing Center toll•free 1.800-343.2551 ONLINE ACCESS TO YOUR ACCOUNT IS NON AVAILABLE! GET ACCOUNT BALANCES. CHECK YOUR TRANSACTIONS. VIEW CHECKS. IT HAS NEVER BEEN EASIER TO MANAGE YOUR ACCOUNT. SIGN UP TODAY BY VISITING THE CUSTOMER SERVICE SECTION AT WWW.PENNMUTUAL.COM OR BY CALLING 1-800-343-2551 2008 y~$12.28 _ S12.28 S. ..,. ~..i..,.. ..,... ~.. ,...n rn ,.,wr w. nwd.... r,...,,.. ,.,. .................ncrwnu ,.~e~. RESERVE ASSET ACCOUNT CONFIRMATION STATEMENT BONNIE LEE HUZEY 8974 ROUTE 249 KNOXVILLE PA 16928 ACCOUNT NUMBER OPENING BALANCE CURRENT INTEREST RATE 190153495 $14,149.76 2.50% ANNUAL PERCENTAGE YIELD 2.53 Your signature on all checks drawn from this account MUST match your signature on the enclosed Claimant's Statement; otherwise your check will be reiected by rhP t,~.,t, ~.,a ...:n _,.. >__ ________ Checks drawn on the Reserve Asset Account are payable through State S[reet Bank and Trust Company, Boston, MA and clear through Federal Reserve Bank. If you or your bank have any questions, please call: 1-800-232-5246 or write Reserve Asset Account Claims Department One National Life Drive Montpelier, VT 05604 Principal and interest earned under the Reserve Asset Account are fully guaranteed by National Life Insurance Company and Life Insurance Company of the Southwest MK 1 110 National Life Insurance Company, Home Office: Montpelier, Vermont 60922 Life Insurance Company of the Southwest, Home Office: Dallas, Texas Administrative Offices: One National Life Dr. Mnntnnsrr Vrrtnnni name AWARD STATEMENT Department of the Treasury Financial Management Service Philadelphia Financial Center PO Box 51318 Philadelphia, PA 19115-6318 IN REPLY REFER TO: 310/295 FILE NUMBER: V 333 13 84 2 RETURN CORRESPONDENCE TO: Department of Veterans Affairs P.O.Box 7208 Phila., PA 19101-7208 cool n I OlJl 084020000261 JULY 22, 2008 BONNIE LEE HUZEY 8974 RT 249 KNOXVILLE PA 16928-9673 WE ARE AUTHORIZING PAYMENT OF S 10,058.77 TO YOU FROM GOVERNMENT LIFE INSURANCE POLICY V 3331384. A PAYMENT FOR S 10,058.77 IS ENCLOSED UNLESS YOU ASKED TO HAVE THE PAYMENT DEPOSITED DIRECTLY INTO YOUR BANK ACCOUNT. *THIS IS A ONE TIME PAYMENT. **THIS REPRESENTS 39 DAYS INTEREST PAID FOR THE PERIOD FROM THE DATE OF DEATH UNTIL .JULY 24, 2008. AMOUNT OF THIS INSURANCE POLICY ADDITIONAL INSURANCE YOUR BHARE YOUR BHARE AMOUNT DEDUCTIONS FROM YOUR SHARE AMOUNT AMOUNT OF THI9 (PAID-UP) LOAN LOAN INTEREST LIEN INSURANCE AWARD 10,000 ALL 10,000.0 S 10,000.00 AMOUNT OF EACH INSTALLMENT NO.INSTALLMENi9 (ORIGINAL) NO. INSTALLMENTS PREVIOUSLY PAID NO. INSTALLMENTS THI9 PAYMENT NO. INSTALLMENTS REMAINING AMOUNT ACCUMULATED PAYMENTS 10,000.00 4DDITIONS PREMIUM REFUND DIVIDEND DIV. INTEREST TOTAL DISABILITY PAYMENTS OTHER PLUB ADDITIONS ** 58.77 58.77 DEDUCTIONS PREMIUMS OUE LIEN LIEN INTEREST PRIOR PAYMENTS TOTAL DISABILITY OVEPPAYMENTS LESS DEDUCTIONS 10 THE TREASURY DEPARTMENT WILL ISSUE A PAYMENT FOR THIS AMOUNT I 10,058.77 QUESTIONS ABOUT YOUR INSURANCE? CALL US TOLL FREE AT 1-800-669-8477 VA FORM 29_5851 OPERATORS ARE ON DUTY MONDAY THROUGH FRIDAY 8:30 AM TO 6 PM EASTERN TIME SEP 1998 LAST WILL AND TESTAMENT OF WILLIAM THOMAS BURNS I, William Thomas Burns, of Camp Hill, Cumberland County, Pennsylvania, being of sound and disposing mind and memory, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils by me at any time previously made. Provision for Taxes ITEM I: I direct that all inheritance and estate taxes becoming due by reason of my death, whether such taxes may be payable by my Estate or by any recipient of any property, shall be paid by my Executor out of the property passing under this Will that is not specifically devised or bequeathed as an expense and cost of administration of my Estate. My Executor shall have no duty or obligation to obtain reimbursement for any such tax paid by my Executor even though on proceeds of insurance or other property not passing under this Will. Disoositive Provisions ITEM II: I may have placed with this Will or otherwise made known to my Executor a separate writing giving certain items of personal property to certain individuals. It is my intention that such items shall pass to such individuals to be distributed by my Executor in accordance with such writing. In the absence of such writing, or to the extent it is incomplete or ineffective, then all my property, real, personal, and mixed, shall be distributed in accordance with Items IV and V herein. ITEM III: I hereby make the following sp~;,ific bequests: (a) the sum of $100,000.00 to my daughter, Bonnie Huzey, or, if she does not survive me, to her issue, perstirpes; provided, however, that said bequest shall be reduced by any life insurance proceeds payable to my daughter as a result of my death; (b) the sum of $100,000.00, in equal shares to the then living children of my son, Walter Thomas Burns; (c) the sum of $50,000.00 to my stepdaughter, Marguerite Bowman, or, if she does not survive me, to her issue, perstirpes; Page 1 of 6 (d) the sum of $50,000.00 to my stepdaughter, Anna Bierce, or, if she does not survive me, to her issue, per stirpes; (e) the sum of $50,000.00 to my stepdaughter, Karen Neavling Bissette, or, if she does not survive me, to her issue, perstirpes; (f) the sum of $50,000.00 to my stepson, Peter Neavling, or, if he does not survive me, to his issue, perstirpes. ITEM IV: I give and bequeath all my household furniture and furnishings, automobiles, books, pictures, jewelry, china, linen, silverware, wearing apparel and all other like articles of household or personal use and adornment to my wife, Shirley Lester Burns, if she survives me, or if my wife does not survive me, to my children and stepchildren, perstirpes, to be distributed among them in as equal shares as practicable and as they may agree. If they are unable to agree, my Executor shall make such decision as to distribution. ITEM V: I give, devise and bequeath all of the rest, residue and remainder of my property, real, personal and mixed, to my wife, Shirley Lester Bums, if she survives me, or, if she does not survive me, in equal shares to the beneficiaries set forth In Item II above, perstirpes. Appointment of Fiduciaries ITEM VI: I nominate, constitute and appoint my wife, Shirley Lester Burns, to be my Executor. In the event of the death, resignation, refusal or inability of Shirley Lester Burns to serve as my Executor, I nominate, constitute and appoint my son-in-law, James Bowman, and my daughter, Bonnie Huzey, or the survivor of them, to serve as Co-Executors in her place. ITEM VII: If at any time any minor child or legally incompetent person shall be entitled to receive any assets hereunder, I hereby nominate, constitute and appoint my Executor to act as Guardian of the assets payable to such person. Said Guardian may receive and administer all assets authorized bylaw and shall have full authority to use such assets, both principal and income, in any manner said Guardian shall deem advisable for the best interest of such person, including college, university, post-graduate or other education, without securing court order. Said Guardian shall have all the rights and privileges as to the Guardianship and the assets thereof as are herein granted to my Executor as to my Estate and the assets therein. ITEM VIII: My Executor and Guardian are specifically relieved from the duty or obligation of filing any bond or bonds. Page 2 of 6 Powers of Fiduciaries ITEM IX: In the settlement of my Estate, my Executor shall possess, among others, the following powers to be executed for the best interest of the beneficiaries: (a) To sell either at public or private sale and upon such terms and conditions as my Executor may deem advantageous to my Estate, any or all real or personal estate or interest therein, whether owned by me severally or in conjunction with other persons or acquired after my death by my Executor, and to consummate said sale or sales by sufficient deeds or other instruments to the purchaser or purchasers, convAying a fee simple title, free and clear of all trust and without obligation or liability of the purchaser or purchasers to see to the application of the purchase money or to make inquiry into the validity of said sale or sales; also, to make, execute, acknowledge and deliver any and all deeds, assignments, options or other writings that may be necessary or desirable in carrying out any of the powers conferred upon my Executor in this Item IX(a) or elsewhere in my Will. (b) To pay all costs, taxes, expenses and charges in connection with the administration of my Estate. My Executor shall pay expenses of my last illness and funeral expenses. (c) To distribute my Estate in kind or in money. If any assets are distributed in kind, they shall be distributed at their respective value(s) on the date(s) of their distribution. (d) To retain any investments I may have at my death so long as my Executor may deem it advisable to my Estate to do so. (e) To vary investments, when deemed desirable by my Executor and to invest in such bonds, stocks, notes, money markets, rEai estate mortgages or other securities or in such other property, real or personal, as my Executor shall deem wise, without being restricted to so-called "legal investments." (f) To mortgage real estate and to make leases of real estate. (g) To borrow money from any party to pay indebtedness of mine or of my Estate, expenses of administration or inheritance, legacy, estate and other taxes. Page 3 of 6 (h) To vote any shares of stock that form a part of the Estate and to otherwise exercise all the powers incident to the ownership of such stock. (i) In the discretion of my Executor, to unite with other owners of similar property in carrying out any plans for the reorganization of any corporation or company whose securities form a part of the Estate. (j) To distribute my personal property directly to the Guardian of the person of any minor beneficiaries hereunder. (k) To elect such settlement options as deemed most appropriate by my Executor with respect to any pension, profit sharing or other retirement plan in which I am a participant. (I) To do all other acts that, in the judgment of my Executor, are necessary or desirable for the proper and advantageous management, investment and distribution of my Estate. Miscellaneous Provisions ITEM X: Any person who shall have died at the same time as me, or in a common disaster with me, or who shall fail to survive me by ninety (90) days, shall be deemed to have predeceased me. ITEM XI: As used in this Will, the term "my children" shall mean my daughter, Bonnie Huzey, and my late son, Walter Thomas Burns; the term "my stepchildren" shall mean the children of my wife, Shirley Lester Burns, being Marguerite Bowman, Anna Bierce, Karen Neavling Bissette, and Peter Neavling. IN WITNESS WHEREOF, I have set my hand and seal to this my Last Will and Testament, consisting of this page, the next two pages, and the preceding three pages this/6 day of November, 2007. ~ %~,~w- i~..rs~rr~ wl~ William Thomas Burns Page 4 of 6 SIGNED, SEALED, PUBLISHED AND DECLARED by the above named Testator, William Thomas Burns, as and for his Will, in the presence of us, who, at his request, in his presence and in the presence of each other, have hereunto subscribed our names as witnesses in attestation thereof. ~~_- ') ~~~ ;~ ~ ~ Address _ ~y6 Cc/ys,h~~,.c~~ ,Q~ Address j L ~ /i~ z c~ ~~/ Address ~ - pis ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN SS. I, William Thomas Burns, the Testatorwhose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Sworn to or affi~(ned and acknowledged before me by William Thomas Burns, the Testator, this L(l 'day of November, 2007. ~.~,~ William Thomas Burns, Testator ~~A~"""" d~W~~-~G~f{7/71~CS7 Notary Public My Commission Expires: ~//~/Z.1~08 COMMONWEALTH OF PENNSYLVAMA Notarial Seal Herva Owings Baughman, Notary Public M3'[Comm scion EgpiresuJuly [2002008 MemEer, Pennsylvania AssoGation of Notaries Page 5 of 6 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF DAUPHIN w-e, games L. ~a-wman 'fYibl~ C L WQ ,e+'' and ~ ,the witnesses whose names are signe to the attached or foregoing i strument, being duly qualified according to law, do depose and say that we were present and saw the Testator sign and execute the instrument as his Last Will; that the Testator signed willingly and executed it as his free and voluntary act for the purposes therein expressed; that each subscribing witness, in the hearing and sight of the Testator, signed the Will as a witness; and that to the best of our knowledge, the Testator was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Swor~l.t~o oraffirmed and subscribed to bef4.re me b J(Z.j71pS~~~~71U'I'~Pi'7 ~(V((i7YlUS (• W~ and ~OVI.(C4 ~ ~~(GlaV71 , witnesses, this ~ Hay o Nov'fi ember, 2007. ,.~CUn ~~~~ ( ~9/yl r Notary Public My Commission Expires: y~iL/7,~/d8 F:\dbw\Wills\BUms\Wllilam - 2007 Will.doc Member, PennsyNanie Association of Notaries Page 6 of 6 M WCALTH OF PENNSYLVANIA Notarial Seal Harvn Owings Baughman, Notary Public Cily of Harrisburg, Dnnphin County !ay Commission Expires July 12, 2003 -~,, %~ fitness Mr. James L. Bowman C.P.A. 846 Wynnewood Rd. Camp Hill, PA 17011 H (717) 737-5820 W (717) 233-5167 eo 1 ~ C ~ ^I'1~ - _ -'~ " N : ,~ ';5 -p 0 Date: December 10, 2008 Register of Wills Cumberland County Courthouse 1 Courthouse Sq. Carlisle, PA 17013-3387 Re: Estate of William Thomas Burns File No. 2008-00697 PA File No. 21-08-0697 Date of Death 6/15/08 Dear Sir' `_~ . ,' T '"T' C~ `r-, ,, %:~: 0 a m n N _ _ {._1 Y~ f ._~ >IJ ~r' ~~;~ ,':~ ~~-; ,~;, +;, ,.., ,, °r? _.. t_, ,.~, -O ,, _--~ -- v Enclosed is a check payable to "Register of Wills, Agent" in the amount of $30.00 representing a payment of the County fee for the filing of the above PA Inheritance Tax return and inventory for the estate of William Thomas Burns. The two copies of the executed tax returns and inventory are also enclosed as well as a receipt for the final tax paid on the Estate. These returns were returned to me by you apparently because the required fees were not included. Thank You, James L. Bowman CPA .. ,:~..~ ,:.. <' -, COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 2RO60t HARRISBURG, PA t~126-0601 RECEIVED FROM: REV-1162 EX~11-96~ PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 010614 BURNS SHIRLEY LESTER 53 OLD FARM ROAD CAMP HILL, PA 17011 -------- mle Wwr~C.t.~/~ . nG~/!UW ~f.~rne. f - FCt- S`~LCr~ ACN ASSESSMENT CONTROL NUMBER ~~ T~ ~~, AMOUNT ESTATE INFORMATION: ssN: 1sz-14-6150 FILE NUMBER: 2108-0697 DECEDENT NAME: BURNS WILLIAM THOMAS DATE OF PAYMENT: 12/08/2008 POSTMARK DATE: 12/05/2008 COUNTY: CUMBERLAND DATE OF DEATH: 06/15/2008 REMARKS: CHECK#515 SEAL 101 ~ $1,096.70 TOTAL AMOUNT PAID: INITIALS: CJ RECEIVED BY: $1,096.70 GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER Shirley L. Burns, Executrix Estate of W. Thomas Burns 53 Old Farm Rd. Camp Hill, PA 17011 (717) 737 - 7427 Date: December 5, 2008 Register of Wills Cumberland County Courthouse 1 Courthouse Sq. Carlisle, PA 17013-3387 Re: Estate of William Thomas Burns File No. 2008-00697 PA File No. 21-08-0697 Date of Death 6/15/08 Dear Sir: Enclosed are two executed copies of Form Rev-1500 for the Estate of William Thomas Burns and Inventory of Probate assets of the Estate. I am also enclosing a check payable to "Register of Wills, Agent" in the amount of $1096.70 representing the Pa. Inheritance Tax due with the return. Thank You, ,~ ~ i v ~ Shirley L. Burns, Executrix Estate of William Thomas Burns Enclosures ~,,~ ~~. ~: a c ~ M O ^ G, \ J O ~~ ~~ 1 ~ ~ ~~ Q _ \ ..`/ `yam _~ r Y ~J V , ~~ ~ ,L ~-f~ ~~ ti ~ Q "~ ~ ;~ _f ~ ~ v ~.