HomeMy WebLinkAbout02-18-09 (2)1505607121
REV-1500 EX (os-05,
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO BOX 280601 2 1 0 8 0 1 1 7 8
Harrisburg PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
2 0 9 1 6 6 0 2? 1 1 2 6 2 0 0 8 0 1 1 3 1 9 2 6
Decedent's Last Name Suffix Decedent's First Name MI
P U R S L E Y D O N N A M
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
0 1. Original Return
4. Limited Estate
^X 6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
2. Supplemental Return
4a. Future Interest Compromise (date of
death after 12-12-82)
7. Decedent Maintained a Living Trust 1
(Attach Copy of Trust)
10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFDRMAiION SNODLD tat uIREGttU IU:
Name Daytime Telephone Number
G E R A L D J S H E K L E T S K I ? 1? ~~ 4 ~',4 ~` 5
Firm Name (If Applicable) ' ~ ~ ~ ~~ '~~
REGISTER. LS U _ONLY C J
S T O N E L A F A V E R S H E K L E T S K I ,- `l c~ I'~.
,.
First line of address ~ - ~ ~ . ~~ 't7 ~
4 1 4 B R I D G E S T
Second line of address
P 0 B O X E
City or Post Office State ZIP Code
.~.F .1
~ ~--- - ~
4
.c _ -i~
N
DATE FILED
N E W C U M B E R L A N D P A 1 7 0 7 0
Correspondent's a-mail address: GSHEKLETSKI(D.STONELAW.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 prepan3r other than the personal representative Is based on all information of which preparer has any knowledge.
SIGNATUR~C FjP~ SON RF~PO~ISIBLE fQ~ING RETURN D~ T ~~ ` r9
ADDRESS -
KAREN ANDREOLI 505 BARBARA DRIVE, MECHANICSBURG PA 17050
SIGNAT OT E ESE TIVE DATE
a//yf0 l`
GERALD J• SHEKLETSKI ESQ•414 BRIDGE ST•, NEW CUMBERLAND PA 17070
PLEASE USE ORIGINAL FORM ONLY
1505607121
Side 1
1505607121
J C~
J
1505607221
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: DONNA M• PURSLEY 2 0 9 1 6 6 0 2 7
RECAPITULATION
1. Real estate (Schedule A) ........................................ 1.
2. Stocks and Bonds (Schedule B) .................................. 2. 9 D 2 9 . 6 0
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages & Notes Receivable (Schedule D) ..................... ... 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .... ... 5. 2 5 8 1 9 8 . 7 6
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .... ... 6.
7. Inter-Vivos Transfers 8~ Miscellaneous N Probate Property
(Schedule G) ~ Separate Billing Requested .... ... 7. 1 1 3 5 1 6, 6 1
B. Total Gross Assets (total Linesl-7) ,,,,,,,,,,,,,,,,,,,,,,,, ,,, 8. 3 8 0 7 4 4. 9 7
9. Funeral Expenses 8 Administrative Costs (Schedule H) ............. ... 9. 2 1 8 8 3 . 3 0
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ......... ... 10.
11. Total Deductions (total Lines 9 8 10) ........................ ... 11. 2 1 8 8 3. 3 0
12. Net Value of Estate (Line 8 minus Line 11) ...................... ... 12. 3 5 8 8 6 1 , 6 7
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. 3 5 8 8 6 1. 6 7
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2)x.o _ 0 0 0 15. 0. 0 0
16. Amount of Line 14 taxable
at lineal rate X .045 3 5 8 8 6 1 6 7 16. 1 6 1 4 8. 7 8
17. Amount of Line 14 taxable
at sibling rate X .12 D D D 17, D. D D
18. Amount of Line 14 taxable
at collateral rate X .15 0 0 0 18. 0. 0 0
19. Tax Due .............................................. .. 19. 1 6 1 4 8. 7 8
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
1505607221 1505607221
REV-1500 EX Page 3
Decedent's Comalete Address:
File Number
21 08 01178
DECEDENTS NAME
DONNA M. PURSLEY __ _ ~ ______. ___~ ~ _
STREET ADDRESS
4902 CARLISLE PIKE _ ______ ___ ~_ _~
CITY - --- _ ------~---`STATE J ~ ZIP
MECHANICSBURG ~ PA ~ 17050
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19) (1) 16,148.78
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount 807.44
Total Credits (A + B + C) (2) 807.44
3. lnteresUPenalty if applicable
D. Interest
E. Penalty
Total InteresUPenalty (D +E) (3) 0.00
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) 0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference, This is the TAX DUE. (5) 15, 341.34
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 +SA. This is the BALANCE DUE. (5B) 15,341.34
Make Check Payable to; REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred : .............................................................. ........ ^
b. retain the right to designate who shall use the property transferred or its income; ....................... ....... ^
c. retain a reversionary interest: or ........................................................................................ ........ ^ 0
d. receive the promise for life of either payments, benefits or care? ............................................... ........ ^ ^
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ............................................................................... ........ ^ 0
3. Did decedent own an "intrust for' or payable upon death bank account or security at his or her death? . ....,... ^ 0
4, Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .......................................................................................... ........ 0 ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July t, 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)J.
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age ar 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)j.
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)j.
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-7 503 EX + (8-96)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS ~ BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
UMBER
DONNA M. PURSLEY 21 08 01178
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUEAT DATE
NUMBER DESCRIPTION OF DEATH
1. UNITED STATES SERIES EE SAVINGS BONDS 9,029.60
TOTAL (Also enter on line Z, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX + (8-g8)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
DONNA M. PURSLEY 21 08 01178
Include the proceeds of litgation and the date the proceeds were recebed by the estate.
All propeAy jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION VALUE AT DATE
OF DEATH
1. VANGUARD FUND & ACCOUNT NUMBERS 0030-09888586404, 0021-09888586404, 72,847.36
0077-09888586404 AND 0036-09888586404
2. FIDELITY INVESTMENTS ACCOUNT 26G-741612 41,873.32
3. INTEGRITY BANK CHECKING ACCOUNT NUMBER 201014676 9,277.14
4. INTEGRITY BANK SAVINGS ACCOUNT NUMBER 401000410 23,034.70
5. INTEGRITY BANK ACCOUNT NUMBER 1015110 -CERTIFICATE OF DEPOSIT 11,105.05
6. INTEGRITY BANK ACCOUNT NUMBER 1018021 -CERTIFICATE OF DEPOSIT 9,142.40
7. INTEGRITY BANK ACCOUNT NUMBER 1018963 -CERTIFICATE OF DEPOSIT 8,729.46
8. INTEGRITY BANK ACCOUNT NUMBER 5009864 -CERTIFICATE OF DEPOSIT 6,054.31
9. INTEGRITY BANK ACCOUNT NUMBER 1024021 -CERTIFICATE OF DEPOSIT 5,299.00
10. INTEGRITY BANK ACCOUNT NUMBER 1024955 -CERTIFICATE OF DEPOSIT 10,151.39
11. 436.9 SHARES HERSHEY FOODS COMMON STOCK HELD THROUGH MELLON 14
837.64
INVESTOR SERVICES 11/17/08 CLOSING PRICE - $34.00 PER SHARE ,
11/19/08 CLOSING PRICE - $33.47 PER SHARE AVERAGE _ $ 33.73 PER SHARE
12. PNC BANK ACCOUNT NUMBER 11020071177 -CERTIFICATE OF DEPOSIT 9,363.59
13. WACHOVIA BANK CERTIFICATE OF DEPOSIT 6,483.40
14. TREASURY DIRECT ACCOUNT #1300-047-6436 30,000.00
15. FOR INFORMATIONAL PURPOSES ONLY -THE DECEDENT MAINTAINED A SAFE
DEPOSIT BOX AT INTEGRITY BANK. THE SAFE DEPOSIT BOX WAS TITLED
IN THE NAMES OF THE DECEDENT AND HER DAUGHTER, KAREN ANDREOLI.
THE SAFE DEPOSIT BOX WAS CLOSED BY KAREN ANDREOLI ON 11/25/2008.
THE CONTENTS OF THE SAFE DEPOSIT BOX INCLUDED THE SAVINGS BONDS
REPORTED ON SCHEDULE B, ITEM NUMBER 1, 1 COPY OF A POWER OF
TOTAL (Also enter on line 5, Recapitulation) ~ ;
(If mare space is needed, insert additional sheets of the same size)
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
DONNA M. PURSLEY 21 08 01178
Decedent's Name Page 1 Fiie Number
Schedule E -Cash, Bank Deposits, 8 Misc. Personal Properly
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
ATTORNEY SIGNED BY THE DECEDENT ON AUGUST 26, 2004, A DEATH
CERTIFICATE FOR HOMER PURSLEY, THE DECEDENT'S HUSBAND (DATE OF
DEATH JULY 14, 1993), MARRIAGE CERTIFICATE OF THE DECEDENT AND HOMER
PURSLEY DATED AUGUST 8, 1948, BIRTH CERTIFICATES OF THE DECEDENT
AND HOMER PURSLEY, AND CONTRACT BETWEEN THE DECEDENT, HOMER
PURSLEY AND ROLLING GREEN MEMORIAL PARK DATED MAY 24, 1973, FOR
TWO BURIAL VAULTS.
SUBTOTAL SCHEDULE E
GRAND TOTAL SCHEDULE E ~ S 258,198.76
REV-1510 EX + (8-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
ESTATE OF
SCHEDULE G
INTER-VIVOS TRANSFERS 8~
MISC. NON-PROBATE PROPERTY
FILE NUMBER
DONNA M. PURSLEY 21 08 01178
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAME ~ THE TRANSFEREE, THEIR RELATIDNSHIP TO DECEDENT AND
TFIEDATEOFTRANSFER.ATTACHACOPYOFTHEDEEDFDRREKESTATE.
DATE OF DEATH
VALUE OF ASSET
°M OF DECD'S
INTEREST
EXCLUSION
PFAPPUCASLE)
TAXABLE
VALUE
1. OLD MUTUAL FINANCIAL NETWORK ANNUITY L9053473 36,601.83 100. 36,601.83
KAREN ANDREOLI -TRANSFEREE (DAUGHTER)
2. RBC INSURANCE CONTRACT 0100007068 (IRA) 50,262.41 100. 54,262.41
KAREN ANDREOLI -TRANSFEREE (DAUGHTER)
3. METLIFE INVESTORS USA INSURANCE COMPANY 26,652.37 100, 26,652.37
ANNUITY CONTRACT 9200598675
KAREN ANDREOLI -TRANSFEREE (DAUGHTER)
TOTAL (Also enter on line 7 Recapitulation) I S 113, 516.61
(If more space is needed, insert additional sheets of the same size}
REV-1511 EX + (10-06)
SCHED~JLE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES ~
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
DONNA M. PURSLEY 21 08 01178
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. MUSSELMAN FUNERAL HOME, INC. 6,102.00
B.
1
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s)
Street Address
City
Year(s) Commission Paid:
State Zip
p, AttomeyFees GERALD J. SHEKLETSKI, ESQ. 15,000.00
3. Fatuity Exemption: (If decedents address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4• Probate Fees LETTERS TESTAMENTARY 310.00
5 Accountants Fees
6. Tax Retum Preparers Fees
7. LEGAL ADVERTISING -PATRIOT NEWS 134.30
8. CUMBERLAND LAW JOURNAL 75.00
9. SHORT CERTIFICATES -CUMBERLAND COUNTY REGISTER OF WILLS 32.00
10. FILING FEES -INHERITANCE TAX RETURN ($15.00) AND INVENTORY ($15.00) 30.00
11. RESERVE FOR CLOSING EXPENSES 200.00
TOTAL (Also enter on line 9, Recapitulation) I s ~ ~
(If more space is needed, insert additional sheets of the same size)
3
REV-1513 EX + (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF FILE NUMBER
DONNA M. PURSLEY 21 08 01178
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [nclude ou ' ht spousal disUibutions, and transfers under
Sec. 9116 (~a (1.2)]
1. KAREN ANDREOLI Lineal 358,861.67
505 BARBARA DRIVE
MECHANICSBURG, PA 17050
I ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 AS APPROPRIATE ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B, CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I S
(If more space is needed, insert additional sheets of the same size)
i
iC~.$`f l'4~I'~ ~ ~. ~ i ~ y ' , . '~;`
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LAST WILL AND TESTAMENT
OF
DONNA M. PURSLEY
I, DONNA M. PURSLEY, of Lower Allen Township, Cumberland County,
Pennsylvania, declare this to be my last will and revoke any will
previously made by me.
ITEM I: I devise and bequeath all of my estate of every nature
and wherever situate to my daughter, KAREN ANDREOLI, or her issue, per
stirpes.
ITEM II: Should my daughter, KAREN ANDREOLI, fail to survive me,
and leave no issue, I devise and bequeath all the rest, residue and
remainder of my estate, of every nature and wherever situate, as
follows:
A. One-half thereof to CAMP HILL UNITED METHODIST CHURCH.
B. One-half thereof to BUCKNELL UNIVERSITY.
ITEM III: I appoint my daughter, RAREN ANDREOLI, Executrix of
this my'~last will. Should my daughter, KAREN ANDREOLI, fail to
qualify or cease to act as Executrix, I appoint PNC BANK, N.A., Execu-
for of this my last will.
ITEM IV: No fiduciary acting hereunder shall be required to post
bond or enter security for the faithful performance of his/her duties
in any jurisdiction.
Page 1 of 3
IN WITNESS WHEREOF, i, DONNA M. PURSLEY, have hereunto set my
hand and seal this ~ day of ~r,Ld-~~!~ . , 1998.
~.
DONNA M. PURSLEY
SIQNED, SEALED, PUBLISHED and DECLARED by DONNA M. PURSLEY, the
Testatrix above named, as and for her Last Will and Testament, and in
the presence of us, who at her request, in her presence and in the
presence of each other, have subscribed our names as witnesses.
W' a Address '
Witness Address
COMMONWEALTH OF PENNSYLVANIA:
SS:
COUNTY OF CUMBERLAND :
I, DONNA M. PURSLEY, the Testatrix whose name is signed to the
attached or foregoing instrument, having been duly qualified according
to law do hereby acknowledge that I signed and executed this instru-
ment as my last will; that I signed it willingly and that I signed it
as my free and voluntary act for the purposes therein contained.
DONNA M. PURSLEY
Sworn to or affirmed to and acknowledged before me by DONNA M.
PURSLEY, the Testatrix, this ~~~` day of (~,~i~x-~.~ lggg.
s
' Nota Publi
Page 2 of 3 . __. _._ _ _.
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COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF CUMBE D
We, ~..~ and `._.-~'~~'`ct~ ~' ~ ,-~~ ,
the witnesses `whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, depose and say that
we were present and saw Testatrix sign and execute the instrument as
her last will; that Testatrix signed willingly and that she executed
it as her free and voluntary act for the purposes therein expressed;
that each of us in the hearing and sight of the Testatrix signed the
will as witnesses; that to the best of our knowledge, the Testatrix
was at that time eighteen or more years of age, of sound mind and
under no constraint or undue influe
Sworn to or affirmed to and acknowledged before me by~
emerald 3 y~~~ (~fSk~~ and Cons-~~nc." F~ L ~ ~ ~~~
witnesses, this day of ~(>>~.-~P~ , 1998.
~/ otary ublic
Page 3 of 3
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Vanguard®
December 19, 2008
ATTN GERALD J SHEKLETSKI ESQ
STONE LAFAVER 8~ SHEKLETSKI
POBOXE
NEW CUMBERLAND PA 17070
Estate of Donna M. Pursley
Dear Mr. Shekletski
P.O. Box 2600
Valley Forge, PA 19482-2600
wvvw.vanguard.com
We are responding to the letter we received notifying us of the death of Donna M.
Pursley, and requesting a valuation of her Vanguard account on November 16,
2008. The information requested is included on the enclosed account value
report.
If you have any questions about a transfer or a transition of assets, please call us
at 888-237-9045. Specialists are available on business days from 8 a.m. to 8
p.m., Eastern time.
Sincerely,
Steve Pavlak
Registered Representative
Enclosure(s): **Donna M. Pursley Account Value Report
51117046
Donna M. Pursley
4902 Carlisle Pike
Mechanicsburg, PA 17050-3079
Page > 1 of 1
. Vanguard
Client Services: 800-662-2739
Total report value: 572,847.36
(Total report value includes any accrued dividends.)
Name - Fund r;~ Acoaurtit '.
i Number '~ Date
Opened - .'
Shares Price Per
Share••
Valu6` Accrued
Dividends
Prime Money Mkt Fund 0030-09888586404 09/29/2000 12,754.770 $1.00 $12,754.77 $15.01
Wellingtpn Fund lnv 0021-09888586404 09!13!1993 896.872 $23.24 $20,843.31 -
PA LT Tax-Exempt Investor 0077-09888586404 09/15/1993 2,268.057 $10.36. $23,497.07 $46.55
GNMA Fund Investor Shares Q036~09888588404 09/25/2000 1,523.091 - $10.28 $15,657,38 $33:27
Totals 572,752.53 594.83
- uoesn t mcwae accrues oiwoenos.
" As of the prior business date, 11/14/2006, since the report date is a nonbusiness day.
i 623202182 12/17/2008 11:58:01
~Fide~i~
i x v=s rw~,iwirs
December 19, 2008
STONE, LAFAVER & SHEKLETSKI
ATTN: GERALD J SHEKLETSKI
414 BRIDGE STREET
PO BOX E
NEW CUMBERLAND PA 17070
Dear Gerald J Shekletski:
We are responding to your request for information about Donna M Pursley's account
with Fidelity. The table below lists the account holdings and values as of 11/16/2008.
Fidelity account 2BG-741612: Donna M Pursley -Individual
Securi Descri tion CUSIP Quantit Unit Value Market Value
Fidelit Asset Mana er 50% 316069103 2,033.639 $10.62 $21,597.25
Fidelit Utilities 316128107 1,620.789 $1.2.51 $20,276.07
Total Value $41,873.32
We hope this information is helpful. For questions concerning account holdings or
instructions on how to transfer the ownership of the accounts, please call our Inheritor
Services Group at 800-544-0003 between 8:00 A.M. and 6:30 P.M. Eastern time Monday
through Friday or visit our website at www.fidelity.com.
Sincerely,
Fidelity Investments
Our file: W042253-15DEC08
Rre~e~age Se v,ces pn;~rced by Fldelity Brokerage Services LLC '.ie^ e2~ NYSE S!PC
,~ ~_ ccst~dy 'n ,eu~cme ~i s?roices oy National financial Services LLC'Ae-*-lx~ 4YSF Si~C
?.U Brs7^J~7~ ~;;:c~• fi JN d5277~003•;
vi u
February 11, 2009
Stone LaFaver & Shekletski
414 Bridgc Street
Post Office Box E
New Cumberland, PA 17070
Dcar Mr. Gerald J. Shekletski:
Integrity
B A N K
As per your request on February 11, 2009 for the Estate of Donna M. Parsley the Date of
Death balances on her accounts are as follows:
The Date of Death was on November 16, 2008 and that was a Sunday, so the last date of
interest was Friday, November 14, 2008.
Certificate of Deposits:
1015110 $11,1OS.05
1018963 $8,729.46
5009864 $6,OS4.31
1018021 $9,142.40
1024021 $5,299.00
1024955 $10,151.39
Checking Account:
0201014676 $9,277.14
Savings Account:
0401000410 $23,034.70
Karen Andreoli was the Power of Attorney on all of these accounts and they held a safe
deposit box at Integrity Bank.
If you should have any questions, please feel fret to contact me at (717) 920-4900
extension 230.
Sincerely,
G~
4.~G'~~ ~
arbara L. Tomc
Senior Customer Service Representative
,~#i M:trkrt Stmt Camp HiIC PN 17011 • Pbo,:s: 717-920-49b0.8Tl-1-HAVF.17' • Fsx 717-9211-49U4' • uiunu i:ttegrity+6sttkn»linernm
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Investor Ser~iceDirect - Accourn Balance As Of Specified Date - 1,1 Page 1 of 1
~ ~tox
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Felxuery 12, 20n~
DONNA M PURt54EY
PMB 22~
A902 CARLISLE PIKR
MEr,HANK:syURa PA ,7050.3079
Rapordlnp Comprny
THE HERSHEY COMPANY
CUSIP Numgar
Your Auount Key
PURSLEY-0ONNMflrKb
your Imesbr klantiFlaatlon
Nureper
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Dear Sharohokfor
The eoove eCCOUnt hoku a hook-carry mpnco at 439.9052 aharaa afTHE HERSHEY COMPANY tnMrrlON tiiack as of
11M6f2fJ0E.
You may uee thle IelMr as rvlaoncc or your hmeinga in THE HERSHEY COMPANY COMMON 6YOCk.
Thank You for ~aing IfMO .ror aiervkeDimcr{".
SlnCnrCly,
BNY Mo1Wn Bta~MOMrner Srrvk:ra
5tuaq~ Pam NQ up P~~P ~ AMN gal CwPI~ 960'L V
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Hershey Co. (HSY) At 11:02AM ET: 35.95 t 0.15 (0.42%)
tr-vest your way, ~'TF~,AC~E
t~ ~a ~ ~~'
Historical Prices Get Historical Prices for: GO
SET DATE RANGE ADVERTISEMENT
;o~ Daily Hc3Vt.'~ Yals
Start Date: Nov 17 2008 Eg. Jan 1, _
Weekly
2003 ;
CF1~CkEa~ YQIJt"
._. Cr'~dit score
End Date: Nov ;~ Monthl
17 :2008 _ y This Mo-rtth?
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First ~ Prev ~ Next ~ Last 65Q'° (6Aey
PRICES 330
450
Date Open High Low Glose Volume Add 340.
Close*
310
17-Nov-08 35.67 35.82 34.31 34.31 1,445,100 34.00
* Close price adjusted for dividends and splits. EXf?I@I'Iert
840
First ~ Prev ~ Next ~ Last 73tl
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Hershey Co. (HSY) At 11;03AM ET: 35.99 t o.19 (0.53%)
~ ~ ~ '~
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SET DATE RANGE
Start Date: Nov 19
End Date: Nov 19
PRICES
2008
2008
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~, ~~,~
Date Open High Low Close Volume Adj
Close* t .+-
19-Nov-08 34.63 35.58 33.76 33.78 1,240,100 33.47
* Close price adjusted for dividends and splits.
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to have a piece
to call home.:
we'll work hard #w
help yvu keep it.
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C!
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~ ~L'38~~~
Wachovia Bank N.A.
Balance Confirmation Services
P O Box 40028
Roanoke, VA 24022.73]3
February 12, 2009
STONE LAFAVER dt SHEKLETSKI
ATTN: JENNIFER
414 BRIDGE STREET
POBOXE
NEW CUMBERLAND, PA 17070
Reference ID: 2686686
SUBJECT: Verification / CamBrnlation of Account and Balance Wormation provided for:
Castomer: DONNA M PURSLEY (SSNiF I~IXX-XXfi02'n
Date of Death: November 16, 2008
Delosit Accoant Information
Acoouat Account Date of Deaa6 Average Date Mahirity Iataed Accaued YTD Date
Type Nub Balance Balanoe~` Opeaad Dafe Rate Iden~ Idenat Paid Clcaed
CERTIFICATB OF 243 56,462.32 9/19/2008 9/19/2009 520.88 521.32
DEPOSIT
IFiGAL TITiE: 09/19/2008
• Date of death balanx does not include accrued interest
• If date of death acciurs on a weekend or a holiday, date of death balance does nat include any transactions that were
made during that time period.
Audrey Trautt
Servioenter Associate
Phone: (340)563-7323
ash; at
. ,....~ ... wvv + +a a ~ ~ • aa_ ++++ 1 11/1 tiV. C. U 1/ UL
iDti17T (Nowm6~rlt1o6~ 11AaIMeQ NYmpK: 621 00 61 31
Legacy Treasury p~recf~
wwwanaaurydkem,~-
,.aoo-r~.zs-re
1-304.484.8484 (Oubide the U.3.)
DDNNA N PURSLEY
C/D KAREN P ANDREDLI
505 BARBARA DRIVE
NECHANICSHURG PA 17050--72x3
TREASURY RBTAIL SECTJRITIHS SITE
P.O. BUX 567
PITTSBURGH PA 15230-0567
PHQNB: (800) 722-2678
Payment9 made by direct deposit to:
~ ~; (717) 730-9316 ~~~~ SANK
-- Rfluting~-1'~a+ber:-~3~i3}8~8~-
.... .. .. ` : ° ~ . . ~ Confidential Name on Account: YCARF:N P ANARFAL,I
SAVINGS Account Number. Confidential
..-~ °'- No arithholdin
TRANSACTION HISTORY
- - -- - Fnr 1 Z~_
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Radawptian -5,00•
Intaraat Paynant lA3.yb
Tranaf~r Out -ts,saa
If YOU HAVE QUES710N8 CONCERNING Tt•IIS STATEMENT, PLEASE CONTACT YOUR TFiEA&URY RETAIL
3ECLlRIT{ES 6fTE AND PROVIDE YOUR ACCOUNT NUMBER
ACCOUNT HOLDINGS
F~1 t~LQ MUTUAL
~:., ~ ._
Ofd Mutual Flnancfal Network
421 S. 9'" Street
Lincoln, Netxaska 68501
PH 1.888.702.2184
FX 402.479.0198
OM FINANCIAL LIFE INSURANCE COMPANY
OM FINANCIAL LIFE INSURANCE COMPANY OF NEW YORK
12/24/2008
Stone LaFaver & Shekletski
Gerald J Shekletski
414 Bridge Street; PO Box E
New Cumberland, PA 17070
Policy: L9053743
Insured: Donna M Pursley
Deaz Mr. Shekletski:
We received letter in regards to the above policy. Our records indicate that. policy L9053743 is the
only policy held by the deceased with this company solely in her name. The date of death value as of
November 16, 2008 is $36,601.83. Policy L9053743 is a non qualified annuity held with our company.
If you should have any questions, feel free to contact our office at 1-866-702-2194, extension 13365.
Sincerely,
Kristina Hradecky
Life Claims Examiner
OM Financial Life Insurance Company
www.omfn.com
Old Mutual Financial Network is the marketing name for OM Financial Life Insurance Company (Home Office, Baltimore, MD);
and OM Financial Life Insurance Company of New York (Home Office, Purchase, NY).
....~. ~ ...vim ..+.-adv ~ . ui~ CJ1
RBC
Insur>anCe
laberty tJk irnues~ Company PO BOX 19087 (ireenviNe, SC 296Q2-9087 i.800234.5514 ~ Ttadl6~On8VFDOBd Arnt~ieS
i.800.423.9398 ~ Variable Lifa/Amuitles
January 7, 2009
Stone Lefever & Shekletski
Attn: Gerald J. Shekletski
Fax: 717-774-3869
Subject: Annuitant: Donna M. Pursiey
Contract: 0100007068
Dear Mr. Shekletski:
Thank you for your recent request concerning the above referenced
annuity contract. The value of this annuity contract was as follows:
Issue Date
Premiums Received
Date of death value
06/23/2004
$61,200.00
$50,262,41
if we can be of any addi#ional assistance to you please contact our
Customer Cara Center at i -800-234-5514.
Sincerely,
Customer Care Center
Adrt~idger~d by I~YI Buah~io Tr,~pnnetiOn buboirdrg U~ut~na Sen~ioas Capo~abn
TOTAL P.01
MetLife
P.O. Box 10366
Des Moines IA 50306-0366 M~t I.i f e
December 19, 2008
STONE, LAFAVER S SHEKLETSKI
ATTN GERALD SHEKLETSKI
414 BRIDGE STREET
NEW CUMBERLAND, PA 17070
RE: METLIFE INVESTORS USA INSURANCE COMPANY CONTRACT 9200598675
OWNER DONNA M PURSLEY
Dear Mr. Shekletski:
Thank you for your recent inquiry regarding the contract referenced above. Our records indicate that the
date of death and the account value on that date are:
Date of Death: November 16, 2008
Account Value: $26,652.37
If you have any questions, please contact your representative or call our Customer Service Center
at 1-800-255-9448 Monday through Friday between 8:30 a.m. and 6:30 p.m., ET.
Sincerely,
Eric S. Machholz
Senior Post Issue Representative
MetLife Annuity Operations and Services