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HomeMy WebLinkAbout12-24-08 (2)15056051047 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes ~ .~ INHERITANCE TAX RETURN ~ ~ D ~. ~ ~ ~ 33 Po Box 2aosol RESIDENT DECEDENT Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Date of Birth Social Security Number Date of Death ~ D~ 1 2 3~5.(n o 3 ~g ~o 08 / l / 9/ 9 Z l Suffix Decedents First Name Mt Decedents Last Name B u ~D I T T k s 7"rl ER (If Applicable) Enter Surviving Spouse's Information Below Suffix Spouse's First Name MI Spouse's Last Name /~ / A- Spouse's Sociai Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW O 2. Supplemental Return O 3. Remainder Return (date of death ® 1. Original Return prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 8. Total Number of Safe Deposit Boxes ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. betweenl2-31 91 andd 1tl1tg5)f death O 11 (Attach SchaO) nder Sec. 9113(A) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIALDaytimFe TelephOoneHNumbeE DIRECTED T0: Name Flrm Name (If AppllCable) REGISTER OF WILLS USE ONLY ~:l +^~.~ N ~ ~ .__~ ;; ~ , First line of address - ` 1 -:: ~.} Second line of address ' ;) "r~ I1pTE FILED :.t City or Post Office State ZIP Code ,:; .. A1CCH~NI CS~uR~ ~i4 /7oSS9.73S i , Correspondent's a-mail address: CeSh ~ efc~s3 aQ Comeasf, net Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which prepay DATE any knowledge. SIGNATURE OF PERSON RESPONSI FILING RETURN ADDRESS CHI~-2LES $• BuQDIT i C~oiSle~P~rt ~ odd DATE " ADDRESS CfJl~12lES E' .~NIELVS l••- (Q t~l~N.~c• ""-• QA, 1?oSS e nicsbc+ v - PLEASE USE ORIGINAL FOR ONLY Side 1 15056051047 15056051047 J X5056052048 REV-1500 EX Decedent's Social Securi ty Number T Decedent's Name: ~ST~/E"~2 7. r~GlR~I?T ~ ~ a ~ 2 // ~ 3 ` ~ S ~O RECAPITULATION 1. Real estate (Schedule A) . .......................................... .. 1. 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 9 ~p D 7 9 7 . / 7 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages & Notes Receivable (Schedule D) ........................... .. 4. 5. Cash, Bank Deposits t~ Miscellaneous Personal Property (Schedule E) ...... .. 5. at ; d ~ ~' 8 ~ oZ 8 '' 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. (~ Ci 7. inter-Vivos Transfers & Miscellaneous Non-Probate Property ,Schedule G) O S t Billi P t d 7 $ ~ 7 b O ' epara e ng ,eques e ...... .. . . / 8. Total Gross Assets (total Lines 1-7) .................................. .. 8. / ( ~ / O ,3 9 ,, ~ Z` 9. Funeral Expenses & Administrative Costs (Schedule H) ................... .. 9. a, 8 '7 3 S+ 7 3 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10. ~ 2 ~ 3 ~D , 8" 0 11 Total Deductions (total Lines 9 & 10) ................................. .. 11. ~ Q 9 7 a , $ 3 , 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. / ~ / Q Q (o ; ~p , & / 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. ~` I I ~ c 3 ~ /o G TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. ~~mount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .O D D O 15. D d 16. Amount of Line 14 taxable at lineal rate X .0~ ~ / / O B (o ~ , p 9 1s ~ g 9 $ 3 , D / 17. Amount of Line 14 taxable at sibling rate X .12 ~ ~ 17. ® ~ 18. Amount of Line 14 taxable ~ ~ G ~ at collateral rate X .15 . i8. . 19. TAX DUE ......... ........ ............. .. 19. ~ 9 ~53:• 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 15056052048 15056052048 J REV-?500 EX Page 3 File Number o? ~_ 08- y 33 Decedent's Complete Address: DECEDENT'S NAME ~ 5 Ty~R T. ~ttR~I TT STREET ADDRESS ~~~~' c~/cscN ~~NF CITY /1zECN~4N~CSB L{/p G STATE ZI P P•~ /7osS Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 0 B. Prior Payments ~38 ~,l1jr', Dp C, Discount x, 0 2 S, DO 3. Interest/Perialty if applicable Total Credits (A + B + C) (2) D. Interest O E. Penalty p Totai Interest/Penalty (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. (31 (4) ~ `~4~ 9S 3. o! ~`f0, .SoO, o0 D O 5. if Line 1 + Line 3 s greater than tine 2, enter the difference. This is the TAX DUE. (5) ~ 9~ Lf5"j,O/_ A. Enter the interest on the tax due. (5A) d B. Enter the total of tine 5 + 5A. This is the BALANCE DUE. (56) ¢ `f ~ ~/ s,~, 0/ Make Check Payable to: REGISTER OF W-LLS, 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 : ......................................... . [! c. retain a reversionary interest; or ......................................................_................................................._............. . d. receive the promise for life of either payments, benefits or care? ................................................................... . 2. ff death occurred after December 12, 1982, did decedent transfer prepe,rty 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?........_.. . 4. Did decedent own an ladividual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ....................................................... ' IF THE ANSWER TG ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART 4F 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. Far 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(al(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. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: BURDITT CHARLES B 1450 SHUGHART ROAD CARLISLE, PA 17013 PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT ACN ASSESSMENT CONTROL NUMBER -------- fold ESTATE INFORMATION: ssN: 002-12-3256 FILE NUMBER: 2108-0433 DECEDENT NAME: BURDITT ESTHER T DATE OF PAYMENT: 06/23/2008 POSTMARK DATE: 06/23/2008 COUNTY: CUMBERLAND DATE OF DEATH: 03/28/2008 AMOUNT 101 ~ 538,475.00 TOTAL AMOUNT PAID: REMARKS: RECEIPT TO ATTY SEAL CHECK# 1001 538,475.00 INITIALS: WZ RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REV-1162 EX(11-961 NO. CD 009916 TAXPAYER ~Hr~RLES E. SHIELDS, III ATT©RNEY=AT-LAW 6 CLOUSEP ROAri C'ornAr of Trincflc~ arul Clocsser Roads MECAANICSBURG. PA 17055 GEORGE M.HOUCK (1912-1991) June 23, 2008 Register of Wills Cumberland County Court House 1 Courthouse Square Carlisle, PA 17013 Re: Estate of Esther T. Burditt No. 21-08-0433 Dear Register of Wills: TELEPHONE (717) 766-02~J9 FAX (7i7) 795-7473 Please find enclosed a Check in the amount of $38,475.00 for estimated Inheritance Tax for the Estate of Esther T. Burditt. Thank you for your kind attention to this matter. Very truly yours, Charles E. Shields, III Attorney-At-Law CES/mjj Enclosure _ 60-1273/313 Date ^~~-~ G7i Zvc' Pay to the /~ ~ ~ y~J~~ order of Dollars 8 0.~~,~o„o.~. CBAI'~fK `~~`~~ ~`~~ ~®P' PNC Bank, N.A. 040 Central PA For .~a~.~~~~ i:03L3L273B~: 5005299~,1Lii' ~"'°"~ REV-1,503 EX+ (6-98) t ~: SCHEDl~LE B GOMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ~G12D11 ~ ~s7~,1~~ T. ~1-a8-Y33 All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same sizel Page 2 The Estate of Esther T. Burditt Wachovia Securities Account 1874-7697 WY38 Date of Death: March 28, 2008 Quantity Security Price Value Common Stocks 1,6y9 A T & T Incorporated (38.39/37.56) 37.975 64>519.53 12o American Electric Power (41.87/40.85) 41.36 4,963.20 12o Burlington Northern Santa (93.25/91.72) 92.485 11,098.20 83z Chevron Corporation (85.58/83.92) 84.75 70,512.00 2,95o General Electric Company (37.06/36.51) 36.785 108,515.75 124 General Motors Corp (19.4x/18.53) X8.975 2352.90 60o PPL Corporation (47.04/45.74) 46.39 27834.00 94o Toronto Dominion Bank (62.72/59.15) 60.935 57278.90 30o Union Pacific Corp (1x6.93/124.65) 125.79 37737.00 564 Verizon Communications (36.37/35.82) 36.095 X0357.58 1,20o Wm Wrigley )r. Company (6x.78/6z.lx) 62.45 74940.00 400 Wyeth (42.01/41.41) 41.71 16,684.00 x24 Xcel Energy, Inc. (xo.18f 1q.85) 20.015 4483.36 Mutual Funds -Open-End 7,107.401 American High Income Trust - Class A l 1.z2 79745.04 1579.438 Capital Income Bulder - Class A 57.52 90849.27 4365.936 Income Fund of America - Class A 17.86 77x975.62 10,992.1xx Lord Abbett Bond Debenture Fund - Class A 7.57 83,210.36 15463.356 Lord Abbett PA Tax-Free Fund - Class A 4.94 76,388.98 Mutual Funds -Closed-End 1,644 Nuveen PA Investment Qual (1x.76/xz.66) 12.71 20,895•x4 Money Market Fund 30457.04 Bank Deposit Sweep 1.00 30457.04 $ y6o,797.97 "The above information has been prepared solely for informational purposes and does not supersede the proper use of your Wachovia Securities client statement, which is considered to be the only official and accurate record of your account. If there are any discrepancies between this and your client statement, please call your local branch manager." REV-1508 Ek. (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF ~ ~ ~ p ~T T ~S T~E~ ~ FILE NUMBER ~/_O~~ ~33 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly.owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~ PNC ,C/i~ NK ,fF, l~erfi~ ~ llr~ivs.f ->rfi 3!0 Dot .~30 90 ,~. ~4'ccr. ~rv~ ~' ~(. o, d oir ~i'zy !{. G. Cfiecll:n~ ~r,~t. ~` 5"©7 009 2978 D. ,~ecr, ~ f do ~ ~ Zk~, c. t. Sa/iitys ,¢~ ,~ so3 DD? ~{o~Z C See Y1l~a~S~h /~ffu- a~ac.yGa/) ~, { /YI f T lj.~iYK' ,/~. Ss~v'~1~s ~ecf. ~ /So e `f2 Dda .~// 0 3 See valaa~ien ~e~fcr affa~l~ca~~ ,3 'ix9~ sc. 1Cr-;ck- KrQ~Ks ~f ; j wo old s~1-H.f ~ d sea~'~ nn~ chap rs 5. yid ~T~ (,. ©Id F~Itn9 Cab~rte~ ~ Sn~» Nofie : `~eGedemt Itr~~ vto IMonics ;n -E-P~ ~-nrwt of Ca51n or ~~-n '~n ~er• wallet' ©r o~e.rw~se. 'DGGedent had ~iYevl 0.~Jay a~` ~ ~-Gt' ~i~,rn~-h.~,x~e antt{ ~~ry snort; ~nann otnc dear b~~tt ~{~e ol~ o~ dcati,. iy, z7 c 37, ado SS 3.29 /3, jflG. ?e ~~ . 36 X25; 69.3.63 ~~o. o0 ~ ~ a.oa ~~ o. oa f .S, DD TOTAL (Also enter on line 5, Recapitulation) I $ /~ ~ L f g / Z g llf mnra cnara is .,oo~+~a ~~^^-+ --'-'~`°-- -' ' "' The 7h~nk+nq oehind The 'Money i'VIBY $, 20b$ Charles ~ Shields III Attorne}~ aY Law 6 Clause; Rd Corner of Trindie & Clouser i4te: i~anicsbura, .PA 170» RF: Esther i Bu;diCt SSh~: OQZ-12-3?56 D4D: 03-28-2008 wear IUIr. Shields: In response tc tiaur request far date of Death ba.larzces far flee customer Hated above, our ecorris show the fallav~~ing: Certificate of ;deposit ~ccaunt : ~ 100022309Q Established 03-21-200L E~7HER T BURDI `4' ~~I~ balance: ~ 29,OI9.w8 + I4.2 i accrued interest Interest paid 0I-OI-200a tiuv 03-%$-^~JO$ ~ 22i.~1 ~~I'D I i Checking Account ~ Account ~ Sb7bD929 ~ 8 Established 08-? 4-1984 E5T'r-~ER ~' ~~7~B1T'f' I~OD h~alancv: ~ 3?,280.55 ~ ~ 29 acc-usd interest Interest paid O1-0I=2008 thru b3-28-200$ $ 4.92 i'~'ia ~' ,avings Account ~ccaunt tt ~G30074052 Established 07-22-198' ~sT~~ ~r BURbITT' DAD balance: ~ i s,4? 6. i0 + 6.~b accrued interest Interest paid 07-01-201J8 thru 03-2$-2008 $ 63,bI ~`F~ Page 1 of y Please note L~1at this of"nce only provides date of death balances fcr deposit accounu (IRAs, CDs, Checking and Savings accounts). ~'e do rsnt ~r®cess an~r fi~uatncaad tramsacti~ns mr pro~-ide sLatemeais. If you newel assistance with an,r of ti~ese ;en7s. please cal! ?-88Q-P?~iC-BAND {i-&88-7b?-~2b>) ar stop ey your .local P'vC Bank branch office. Sincerely, r; if Larz A Robertson 1-840-76~-I ""'~ P7-PFSG-04-F 500 First Ave Pittsburgh, PA l~219 >tiTember FDIC Page Y ~f © -"-~~~~ 499 Mitchell Street, Millsboro, DE 19966 May 6, 2008 Charles Shields, III Attorney At Law 6 Clouser Road Mechanicsburg, PA 17055 RE: Estate of Esther Burditt Date of Death: March 28, 2008 8oc:a~ Securit3~ Nuzn.b: r: 002-12~-3256 Dear Mr. Shields: In response to your request, please be advised that at the time of death, the above- named decedent had on deposit with this bank the following accounts. 1. Account Type ........................... Savings Account Account Number ....................... 15004206021103 Ownership (Names off .............. Esther Burditt Opening Date ...........................Ol J28/89 (account closed 04/23/08) Balance on Date of Death.........$24,693.63 Accrtced Interest $ 0.20 Total ....................................... $24,693.83 The above named decedent did not have a safe deposit box. * If upon reviewing the information above, you believe there are additional accounts not referenced, please provide us with an account number and/or the name of any possible joint account holder. For any additional information on the above accounts, including ownership and any changes, closures andf or reimbursement of funds, please contact our Mechanicsburg Branch at 5219 Simpson Ferry Road, Mechanicsburg, PA 17050, or # 717-255-2031. Sincerely, ' ~ '' ~1,''~'1,~1 i~ ~~ Charlene Warrington, Records Management 1-888-502-4349 REV4510 EX + ~ f-977 ,- COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER 3uQDITT, ~S7iy~/1 T. ~/-o~- y3,3 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDLTHENAMEOFTHE7RANSFEREE,THEIRRELATIONSHIPTODECEDENTANDTHEDATEOFTRANSFER ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET °!° OF DECD'S INTEREST EXCLUSION ,F APPUCneLE TAXABLE VALUE 1 1-1Nr/DL,A1 QEIt1E'F!T Ll~E Lb. i4NNUITy T~eTrC~.Q,~t/ PLUS -~slc loSl Sal ~.~ '~ao, 0~0,~.2 /~o ~°o -- o - ~2r~, oy~. ~~ ,~F~vE/~le r~-~y •' C~.~-R~ E-s ~ . G.3 u 2d i T r, ~,~ o~ D~c~~r ~•5FE I~f,~L.y~Tto/l~ L E TT~71 s~TTi~GXEyJ~ a. a~~K~s ~/F~ ,pu a C~u~Ty ~. fi~ ~ p TNNKt TY ~ / ~7e26 ! ! ,y yZd.73 / /~ n~ -a - ~ , yZOr 7. @F/VEf=/C/ode'/ES fN ,~4[.l~-L orr~'-TN~,~ea 1~3~ SH~.~ZES .' C.~4~-~2~~ .B. r3u,eAITT~ se~v (96v~=N ,f~ttR~'Z~, .Sod/ Go,KLJD,/d ~BU~Iy't SOS (SEE' !/,lfL/t,/F TieN LE i ~~~' sSt T~.~-G'~~D/ 3. C I ~~ T s to/THIN O~YF Y~,¢/2 /'Efo~eE' ~ro•v. /~. EVAN Pu~e~Eu, Git~,~r Dson~ ~/„/n ~ ~sv, ov ~,~.~ _ Q .~ ~~ 5'SD.vo 4. S~ atE ,~ j~~/e ~ ~ soo, 00 , JJ r;/2~NOBfFllG'HTE'iQ ~/~~ C. ~'/Y1![,y PuRCEZG 7 ~Sp.oo * 1` , ~ . S~'ME I2J21~D7 ~SOO.oa E. CN/~nLE3 ~ut2.DITT~ Son/ 7(zo~o7 148.72 F s~Mr 917 Ja> ¢i oo. vo ~ ~ ' ~, s~rnE it r~/o'7 ~ ~,S o 00 oo. ~i, 248. 3,ooD.~c 8 , 298.7,2 H. S/f~t1E ! ~ f z7I°7 ~l, ©oo. ao T SAME ! I ~~~ g ~ DDD. OD J. Dontrv~} ~tgRpi'i-T W t fiE of 7~1E 5~4/t~ ~ CHflt21F'S QGtRO(T? 91707 ~/oo•v0 ~rl !00•0o f o©0.p0 3 -- o - S'A m E }(, i1~2~ jo7 f !, ooe.eo , ~Cont~KUed TOTAL (Also enter on line 7, Recapitulation) I $ ~5 7 (o p, 17 (If more soacP is ~oP7+p~ ~~~o~ ~~+~+~~;~-~~ _~ _ _, ... LINCOLN BENI~FI"r' I_.IFE C:Oti11'AN Y -- -L --- ---- ~, _ _ --- . i illenrGr•r a Alls[a(e Fueanc~r~ C;rnup Lincoln Benefit Life Company P~ Box 80469 Lincoln NE 68501-0469 CHARLES B BURDITT 1450 SHUGHART ROAD CARLISLE PA 17015-9251 April 25, 2008 Telephone: 1-800-LBL-WAYS Fax: 1-877-5~5-2689 W W~A'.aCCBSSaIISfafe.COf71 Your Representative HOME OFFICE Owner: Charles B [3urditt Annuitant: Charles B Burditt Tax Qualification: Non-Qualified The Surrender arrrount of $19,032.58 represents the net proceeds of your policy as of 04/24/08. Your proceeds have been electronically transferred according to your instructions. Contract Value as of 04/24/08 Gross Withdrawal Amount Federal Withholding Deducted Electronic. Transfer Amount Remaining Contract Value Please retain this information for your financial and tax retards. We hope you will consider us to meet your financial needs in the future. RE: Tactician Plus #AC1051544A $20,040.72 $20,040.72 X20.040.72 $1.008.14 $19,032.58 $0.00 BANKERS LII~^E AIVD CASUALTY COMPANY We specialize irz seniors May 12, 2008 Charles Burditt 1450 Shaghart Road Carlisle, PA 17015 Pol~ry 7672691 Esther Burditt, deceased Dear Mr. Burditt: We again wish to extend our sympathy to you and your family for your recent loss. The claim under the policy has been approved. Benefits have been calculated as follows. Death Benefit $44,420.73 Claim Interest @ 3.5% $ 31.25 Your Share $14,806.91 Federal Tax Withheld $ 483.82 Your Final Benefit Amount $14,354.34 The taxable amount on your share is $4,838.15. We will report this amount to the Internal Revenue Service. We realize that the period following such a loss is a difficult time for individuals and families who may be coping with stressful decisions concerning financial matters. In order to assist you, a BANKERS BENEFITNOW ACCOUNT has been opened in your name for the amount of the insurance proceeds. This is an interest earning money market-type account with check-writing privileges. This account is under your individual and complete control and provides immediate and direct access to your funds. The starter kit for the BANKERS BENEFiTNOW ACCOUNT will be delivered to your under separate cover. Sincerely, JoAnna Thao, Claim Adjustor Life and Annuity Claims Dept. cc: BSO # 5094 222 Merchandise Mart Plaza Chicago, !L 60654-2001 REV-1511 EX+ (10-06) ~,~~~ SCI~E®~LE 1~ COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Bu2~D17T, ~STi~tE7c 7, 2/-D~- 5<.~3 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ,. ~u~~i~~,! w~ P2E~~i~ ~. I ~uN;FnAt m~~ ~T ~Nt~~~E~3 ~'~i 38 sl ,.~ ~oNClZS><R1urY1 ~ /NEV. r~ricHA~~z SND2 T.SL ~F1/E3 ~5 0, va "V'c/~r9nEEnl CE/i9 ~ T~G72 v ¢l ~S. UD ,S, E~N~/~rr~~i/U ~~ /J~~r~/t,~ i~.t »~ f_- fir B. I ADMfNISTRATIVE COSTS 1. Personal Representative's Commissions /~ .µ Name of Personal Representative(s) C~Q1'~GS ~, ~BUt~~ !! ~ ~ ~j trJOO.OD Street Address __-~~ SD _ S~t.~,q ~at"t__~DQ,t1 _ -- - - City C (i„r-~ i 5~~~ ,Jj State P~ Zip ~ 70 ~ 5 Year(s) Commission Paid: 2. Attorney Fees C ~~'~~ ~. ~~ r G'e~5 ~ r ~ .J~D~- Dom' 3. Family Exemption: (If decetlenYs address is not the same as claimant's, attach explanation) Claimant _ _____ __ _11%~,~/E __ ,~'L/G'I,~3LE_ _ _ __ __ _ /yONE Street Address City State _ Zip _. _ _ _ Relationship of Claimant to Decedent 4. Probate Fees ~ Olr, tr ~ na~ !S$1t6 4t $Iwrt Cert~ ~~Ga~-es '~ j ~ 7~ p0 5. Accountant's Fees ~-~ feS f"te-~~„ o~ ~KDn~~~ ~~urJt, ~r prep. of 6. Tax Return Preparer's Fees °~ar-~o`-'e O~~iD`FO,~~jjry~)ex Pl4' 4 ~ ~ 10~{ ~~ e'CG. ~~~ S0D OD 7. ,i¢d~l~~~, Daa/ i SsK t of slot c erfi,f ~s Sao, ma 8 /~dd~ ~ oral ~lrahafe ~e e s # G 2v, o0 9. ~i~'aJ Fee T ~~'isf~r e~ `i/i//s ~~.f, 00 lo. %Ydvc~f~sinq in ~'uM~r /t~c~ L.~u/ ~ONrn.~/ "75.00 !/. ~dy@ifisin~ f~I i/~ C aril's/e cfe~~he/ ~ /18.7a /Z. /~e~'n~darseh~enf ~, G'har/~s ~ S/,;cl~.s~ ~ {ar- boa%ye, crrr~,f y~ TOTAL (Also enter on line 9, Recapitulation) ~ ~, 73~ 73 (If more. SCIACP is nooAo~1 ~~^^-• -" ` p.z 13, la/j~I?Jl SS/8dS t~s1 `~gL!/G'4 nOK OT ~C11h/~P.~S ~S~e i~i:z~ S~~ea! a~~ clua~~ . ~~- /vo, ~/-0~- x/33 '~D .5~. f~irr • ~/ec. ~ ower ~v Sh. ~Gt/'~~Iq o~~r /Uo, ~~a,~h G~ ~a~ ~.sti. Gnl .2a©s~. ~l~L ~~a S~. Thant ,~;~,. ~ aoa s/ Lc ~ ~ , ~'~ ~Z~ Sh. Gc1ye~ 15~~ s!. Xc~/ 4s~~ ur~.;~s /1/~v~en /~.~ ~~b~~ '~s9 l.d ~-bbe~f Bong ~b2~f u re C 1, ?8 i5 ~?3.a~1 ~d 1~bbe~ P~ i ~c ~e .xnc. ~ ~.Df~ ~i~ lob, sI l / 7• SS 3 ?s.oa ~I i S'~ 19 a~r,s~ 3s~ . Bz ~zz~.67 a~ ~. ~~ ~/z~. ~o ~~ 3S, 33 ~7, S'n ~~?. vD ~a, 1713" • o l REV-15'12 EX+ (12-03i SCHEDULE 1 COMMONWEALTH Of PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, $c DENS RESIDENT DECEDENT ESTATE OF ~~ R ~ ~,~..T-~ ~S~~E~ T F1LE NUMBER Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. fTEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~ L3E7i-~~Ny V/Lt~FGE', Fi,hR/ ~~ya1CnL~ ~r raoirl. ~ oS ~, 9 6 3. a. ' y.~~PvEN Pyysic~~-.vs '~i qo. ~~ 3. ,P~. DE,A7." o~- ~rENaC ~~mo . o0 fZt~/lD~YLfy 9 A5lj k~Y ,¢~o[~iVT,~t~t/TS, TsFx G~ll~? /a ~v,~ ~ 9 7~'. o0 S ~ rc'/®E'LITy /M1E57/j1LeNT C~. ~RE?~IRN off= P~~L oYE~Z- ~i~Y/!?EN%~ ~kEL~TED To pis/oiv~ t/B: 3(0 7. ~,~. ~Ef'T. of /~'YFNU E f~ ~ S 2.~ CoNT!/YGt/Nl' G'A11.F' ~ ~~/f5T N[~ TiSi ~/LL> ~7~ 7. 7/ y ~~ _ DEp i D~ lLEYENU E ~2 S~ 7y /D. L~ONN/E K /,Y!/LL~~°, ,PE~Q ~'.~p/Ti¢ i,~-X f/O.00 TOTAL (Also enter on line 10, Recapitulation) $ / a , ~3 6. ~~ (1f more space is needed, insert additional sheets of the sama ~I~a~ REV-1513 EX+ (9-00) Cs. ~ _ - SCHEDUf.E J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Fs %y~~ ~ FILE NUMBER au2~~Tr, ~, ~ - o~ - 433 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] ,. cysrn c~3 ,~8. ,Qk,eD l T ~ ~~/ l3 C~2L /St F, ~fj /7o/S -~ G a,eDorJ GEE ~ui2De T T sp1~ J3 1 ;LD to l7 u /~,rt1E QED Brook, 7~a'~s 7~6 ~ ab 3. G r~~nl ~~N lKi2,0~T7' ~r.PG~~-z~ ~A-uGHT~ 10 3 330 1='~lR/nouNT ~R. ~`UGEWAT~~, rnD. 21437 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 18, AS APPROPRIATE, O N REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE OISTRlBUTIONS ON LINE 13 OF REV-1500 COVER SHEET S (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMENT OF ESTHER T. BURDITT I, ESTHER T. BURDITT, of the Borough of Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind., memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all prior Wills by me at any time heretofore made. 1. I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can conveniently be done. ~. All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, I give, devise and bequeath in equal shares to my beloved children, per stirpes; GORDON LEE BURDITT, GWEN ELLEN BURDITT PURCELL, and CHARLES B. BURDITT to thier own use and benefit absolutely. 3. I nominate, constitute and appoint my son, CHARLES B. BURDITT, to be the Executor of this my Last Will and Testament. In the event that he should predecease me or for any reason be unwilling or unable to act as such Executor, I nominate, constitute and appoint my daughter, GWEN ELLEN BURDITT PURCELL, to be Executrix in his place and stead. I further direct that they shall not be required to file bond or other security in the Office of the Register of Wills for the purpose of administering my Estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this -~1 /fit , day of ~ ~; ~ , A.D. 1994 (SEAL) ESTHER T. BURDITT Signed, sealed, published and declared by the above-named ESTHER T. BURDITT as and for her Last Will and Testament, in the presence of us, who at her request and in her presence, and in the presence of each other, have hereunto subscribed our names as witnesses. ___!~ F Cop~c/L d -~~¢~ ~rtw~s~ ~k.cru r~~1fc, ~ Gc/Lzt~lic2 , C'~c.i?irw~-~ -~,~-E=~~`l l~ ,cc2~~ ~~~.~` lyre ,~~a~-~~ ~rr~2~oN L ~E ~3Gr`21.~ l T% , ~~ /.vJ~ ~~~2-~-r~ o ~0-L ~ / ~L ~/ ~ G~ ~ ~ LCD ~~~lozr~`~ ~Gi-t- ~ZGw ~ Y"sz.rcJ `~~~ ~i-rrt-c-~ ~ ~ ~~~ ~`2l!.cy~~e i / /~