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HomeMy WebLinkAbout03-02-0915056051058 -', REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes ~ INHERITANCE TAX RETURN PO BOX 280601 RESIDENT DECEDENT 21 08 00675 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 203-10-3956 06/02/2008 03/05/1920 Decedent's Last Name Suffix Decedent's First Name MI Mattern Ernestine K (If Applicable) Enter Surviving Spouse's 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 Original Return ~' 1 2. Supplemental Return 3. Remainder Return (date of death . prior to 12-13-82) 4. Limited Estate 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required death after 12-12-82) 1 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) Litigation Proceeds Received 9 under Sec. 9113(A) onax 10. Spousal Poverty Credit (date of death 11 ~ l . O ttach S A between 12-31-91 and 1-1-95) ( ) CORRESPONDENT - THIS SECTION MUST BE CO MPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Daytime Telephone Number Name Jayma A Wooditch (717) 731-0148 ~, ` Firm Name (If Applicable) c ; ~~ . , REGISTER~LLS USE LY j ~i7 ~ ; . First line of address ~' ~ ~ I ' 504 Indiana Ave ~~~ ` ~ '~ ~ ; ~ ~ _ _ . ~~ '" Second line of address _ ~7 ,=~_ ' ~ _ t--_ t, ~ ,~,> DATE FILED ~ ^i State ZIP Code City or Post Office Lemoyne Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return. including a it is true, correct and complete. Declaration of preparer o her than the personal SIGNATt1R$ OF PE/~ON RESPONSII~ FO % F~ I R~ET_U~/~- 504 I dian ve, Lemoyne, SIGN URE OF PREPAREf~ OTFfER 1 -- - - DATE HVURCJ Elwoo & Associates, Inc. 2260 Spring Rd, Suite 2, Carlisle, PA 170 PLEASE USE ORIGINAL FORM ONLY 15056051058 PA 17043 schedules and statements, and to the best of my knowledge and belief, e is based on all information of which prepa~er has any knowledge. Side 1 15056051058 15056052059 REV-1500 EX Decedent's Social Security Number oecedenrs Name: Ernestine K Mattern 203-10-3956 RECAPITULATION - 1 . Real estate (Schedule A) . ........................................ .... 1. 2 . Stocks and Bonds (Schedule B) .................................... ... 2. 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. 6. Jointly Owned Property (Schedule F) _: Separate Billing Requested .... ... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) Separate Billing Requested..... ... 7. 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. 9. Funeral Expenses & Administrative Costs (Schedule H)............ g. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10. 11. Total Deductions (total Lines 9 & 10) ................................ ... 11. 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 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. 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 .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 45 23,035.02 16. 17. Amount of Line 14 taxable at sibling rate X .12 17 18. Amount of Line 14 taxable at collateral rate X .15 ... 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 31,866.73 31,866.73 5,364.66 3,467.05 8,831.71 23,035.02 0.00 23,035.02 1,036.58 1,036.58 15056052059 Side 2 15056052059 REV-1500 EX Page 3 File Number Decedent's Complete Address: 21 08 00675 DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER Ernestine - K Mattern 203-10-3956 STREET ADDRESS --- ________ ____ 75 Cumberland Rd -- -- - ITY -~ STATE -_ -- Lemoyne TzIP PA 17043 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 1,036.58 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 0.00 3. Interest/Penalty 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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 1,036.58 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 1,036.58 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 ................................................................................................................... ....... ^ 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? ........................................................................................................ ...... ^ 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 Individual Retirement Account, annuity, or other non-probate property 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 July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Ernestine K Mattern 2008-00675 Include the proceeds of litigation and the date the proceeds were received by the estate. 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 size) EV-1511 EX+ (12-99) SCI~IEDIJLE H FUNERAL EXPENSES & COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Ernestine K Mattern 2008-00675 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t' Musselman Funeral Home -cremation 1,723.62 2 Food & beverages at reception 821.00 3 Church organist 50.00 a Minister 100.00 5 Memorial plaque 301.04 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 1, 593.00 Name of Personal Representative(s) Jayma A WooditCh Social Security Number(s)/EIN Number of Personal Representative(s) p V y • ~~ -(~ ~ ~'p_ street Address 504 Indiana Ave C;ty Lemoyne .state PA zip 17043 Year(s) Commission Paid: 2. Attorney Fees 0.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 95.00 5. Accountant's Fees 0.00 6. Tax Return Preparer's Fees 504.00 ~. Postage 42.00 s Safe deposit box key 10.00 9 Appraisal of jewelry 125.00 TOTAL (Also enter on line 9, Recapitulation) $ 5,364.66 (If more space is needed, insert additional sheets of the same size) REV-?512 EX+ (12-OS) ~ Pennsylvania SCHEDULE I DEPARTMENT or REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Ernestine K Matters 2008-00675 Rannrr dahtc incurred 6v the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets or the same size. ,~. .. ~v iva-vvvv ~~ ~ ~•~•vu win Diu iv-ruc.v. ~ ~.~~t ~irr ~~~ ~~~r~cn~Er~t OF ERNESTINE O. MATTERN I, ERNESTINE O. MATTERN, of the Borough of Lemoyne, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, da hereby make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void any and all Wills or Codicils at any time heretofore made by me. ARTICLE I DEBTS I direct the payment of all my legal debts and the expenses of my last illness and funeral from my Estate as soon after my death as conveniently maybe done. I authorize my Executor to expend funds from my Estate for the purchase, erection and inscription of a suitable grave marker. All the foregoing shall be considered expenses of the administration of my Estate. ARTICLE II BEQUEST OF JEWELRY I give and bequeath my jewelry unto my daughters, JAYMA A. WOODITCH and JENISE K MATTERN, or the survivor of them to be divided between them in as nearly equal shares as is practicable. ARTICLE III BEQUEST OF REMAINDER OF TANGIBLE PERSONAL PROPERTY I give and bequeath my automobile(s), household and personal effects excluding my jewelry (wluch I have disposed of in .Article II hereof) and other tangible personalty of like nature 013133-00001111.7.02/EGM/KLT/164626.1 (no~including cash or securities), together with any insurance thereon, unto my daughter, DENISE K. MATTERN, provided she survives me. If my daughter, DENISE K. MA.TTERN, predeceases me, I~give and bequeath the same unto my daughter, JAYMA A. WOODITCH, provided she survives me. ARTICLE IV REST, RESIDUE AND REMAINDER , I give, devise and bequeath all the rest, residue and remainder of my Estate, of whatever nature and wherever situate, as follows: A. Twenty five (25%) percent thereof unto my daughter, JAYMA A. WOODITCH, or her then-living issue, per stirpes, should she predecease me; and B. Seventy five (75%) percent thereof unto my daughter, DENISE K MATTERN, provided that should she predecease me, I give, devise and bequeath her share unto my daughter, JAYMA A. WOODITCH, if she survives me, otherwise, to her then-living issue, per stirpes. ARTICLE V UNIFORM TRUST TO MINORS ACT In the event any beneficiary of my Will has not reached the age of twenty-five (25) years at the time for distribution of his or her share, distribution of said share maybe made in the discretion of my Personal Representative after considering the age and needs of the beneficiary, either directly to the beneficiary or to a Custodian for such beneficiary until age twenty-five (25) under the Perulsylvania Uniform Transfers to Minors Act, 20 Pa. C.S.A § 5301 et seq., or the applicable Uniform Gifts to Minors Act or Uniform Transfers to Minors Act in the state of residence of such beneficiaryy as the case maybe. My Personal Representative may designate as such Custodian any institution or person, including my Personal Representative, qualified to act as a Custodian for such beneficiary under such Act in effect at the time such distribution is made. A receipt for any _-- ----- -- --- - - -------- _.. _ _ __ Z V IJ IJJ-VUVU 1/ 1 1..7.UL/CUIVUf~LI / 104VL0. I payment or distribution so made shall be a full discharge therefor to my Personal Representative, who shall not be responsible to see to, or be liable for, the application of such proceeds thereafter. ARTICLE VI POWERS OF PERSONAL REPRESENTATIVE My Personal Representative(s) shall have the following powers in addition to those vested in them by law and by other provisions of my Will applicable to all property, whether principal or income, including property held for minors, exercisable without court approval and effective until actual distribution of all property: A. To make distribution in cash or in kind, or partly in cash and partly in kind, and in such manner as they may determine. B. To retain any or all of the assets of my estate, real or personal, without restriction to investments authorized for Pennsylvania fiduciaries, as they deem proper, without regard to any principle of diversification or risk. C. To invest in all forms of property without restriction to investments authorized for Pennsylvania fiduciaries, as they deem proper, without regard to any principle of diversification or risk. D. 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 I' prices and upon such terms or conditions as they deem proper.. E. To allocate receipts and expenses to principal or income or partly to each as they from'time to time think proper. F. To compromise any claim or controversy: ~. t --------- -- -_ - ----- - - _ _ - - _ 3 1. G. To, make such elections, decisions, concessions and settlements in connection with all income, estate, inheritance, gift, generation skipping or other tax refunds and the payment of such taxes as my Personal Representative and/or Trustee shall deem appropriate, without obligation to adjust the distributed share of any person thereby affected. ARTICLE VII PERSONAL REPRESENTATIVE I name, constitute and appoint my daughter, JAYMA A. WOODITCH, Executrix of this my last Will and Testament. Should my daughter, JAYMA A. WOODITCH, fail to qualify or cease to so act, I name, constitute and appoint my daughter, JENISE K. MATTERN, alternate Executrix to complete the administration of my Estate. I direct that no fiduciary appointed .herein shall be required to post bond for the faithful administration of the duties required in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, this ~ day of ~ -C`?~~i~.c~ , 2002. ,~5 ~ 77~t/. ~ a ~'l/f'( SEAL) ERNESTINE O. MATTERN Signed, sealed, published and declared by the above-named Testatrix, as and for her Last Will and Testament, in the presence of us, who at her request, in her presence and in the presence of each other, have hereunto subscribed our names as witnesses. ~~or~~o ~ vc~8 ~2/ss,~ ~Z ~~V ~ r r 4 '3133-UVUV I/ I I.O.VUCVIwm~l/ Iuw~w• ~ - AFFIDAVIT AND ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA 5S COUNTY OF CUMBERLAND We, ERNETINE O. MATTERN, and u.L ~ p~_ k'~~~.f,L//~ ,the Testatrix and the witnesses, respectively, whose names are signed to the attached or ~regoing instrument; being first. duly sworn, do hereby declare to the undersigned authority that th~:Testatrix signed and executed the instrument as her Last Will and ~', : , that she had signed willingly and lrat she executed it as her free and voluntary act for the purposes thereui expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as witness and that to the best of his/her lrnowledge the Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. ERNESTINE O. MATTERN Witness ~ x ~`{~. /~~1155..~ ~~Z ~ ~ Witness • ~ Subscribe ,sworn to and a owledged before me by ERNESTINE O. MATTERN, Testatrix, aild and witnesses, this ay of , 2002. ~~ N Public ___ ----- __- --._ _- 5 ~ M&T Bank ACCOUNT N0. ACCOUNT TYPE 15004211883811 M8T PERSONAL SAVINGS 00 0 06123M NM 017 _- ERNESTINE 0 MATTERN 75 CUMBERLAND RD LEMOYNE PA 17043-1616 - - -- --- - INTEREST EARNED FOR STATEMENT PERIOD 0,03 INTEREST PAID YEAR TO DATE 0.22 15701 ACC~l1MT CIIMMARV NEST SHORE PLAZA ,l BE INN BALANC _ S S :. OTHER:.ADD 0lIS<:;.;:,: N ALS i< HE T TTONS ~ _ _ -.: REST PA _ __ - ItIG BALANCE N0. AMOUNT N0. AMOUNT 252.97 0 0.00 25 .O1 0,04 0.00 ACCOUNT ACTIVITY TI DATE - TRMISACTION DESCRZ ION _ ,. EKES B O?NER ~ADIiITIOl6_ M. NA HER SUBTitACTIOMS .<_ DAILY ; BALANCE.:::... 05-17-OS BEGINNING BALANCE 5252.97 06-18-08 INTEREST PAYMENT 0.04 r 253.01 06-24-08 CLOSEOUT 253.01 0.00 ENDING BALANCE 50.00 ANNUAL PER~ENTACE YIELD EARNED 0.11 DEPOSIT TICKET ~'~ '~ ~~ .; ~ ,_. ~~ `~--ACAS - -.-_ .'-- _. H '--- ~ , . - , ; . ~ ~ r i , , 60-72/2313 L, `t .~ 5 ~, I ~,: DATE (.. ,~ - ;: _. ~~ --~ DEPOSITS MAY NOT BE AVAILABLE FOR IMMEDIATE {ryrN~o,w~ _ tB 0~/<4/08 13:37 b,~ 02 L c' r t - SIGN HERE GOq CASH gECEIVEO IF R ° ~~~~#~3~69 JC • v~~ I EOVIREO) SUB 7OT~q~ =- transaction AMOUnt: Prior Da ~ ~~Sovereign Bank Y Closing L~"EO - ~0.©© ~Avai lahDePOSITOR'S _. ,- _ .561755205; .- ~.`. ~ , 0t+61343569u~ _.. .._ ~..-a- ------ ------ --- ----~-~ ---- - - - f - ~ Kelley Btue Book THE TRUSTED RESOURCE d. advertisement Home New Cars Used Cars Research & Explore News & Reviews Ready To Buy Classifieds L Used Car Prices I Search Used Car Listings I Certified Pre-Owned I Compare Vehicles I Perfect Car Finder I Most Rese~ Welcome Back ~ Sign In ~ Create Account ~ My KBB ZIP Code: 17043 Recently Viewed Horne > Used Cars > Sedans > Dodge > Stratus > 2001 > SE Sedan 4D 2001 Dodge Stratus SE Sedan 4D Trade-In Value Private Partv Value BLUE BOOK' TRADE-IN VAWE , ~.. , . Condition <~ ,~~ Value Excellent $2,475 Good $2,175 Fair $1,700 ~:.. o:~ Shopping Tools Free CARFAX Record Check Auto Loan from 5.44% APR Compare Insurance Rates Payment Calculator Find a Dealer LIST YOUR CSR FOR SA1E Special Package Offer! For one low price you can reach millions of used car shoppers. Learn more now BUY A USED CAR on Blue Book Classifieds"" Powered By /~tt~T~,? Dodge ~ E ~T STEP • Price New Cars Local Listings: View Dodge Stratus Search all Classifieds in 17043 Average Consumer Rating (485 Reviews) Read Reviews http://www.kbb.com/KBB/LTsedCars/PricingReport.aspx?WebCategoryId=38&Yearld=20... I /2I /2009 CG BUSER ~ SON 875 Market Street, Second Floor Lemoyne, PA I7043 (7I7) 972-1230 Diamond Mounting A Specialty Prompt Attention to Mail Orders July 27, 2008 Estate of: Ernestine Mattern C/O Jayma Wooditch Lady's 18K white gold ring containing one large brilliant cut diamond, twelve marquise cut diamonds and tweirty four single cut diamonds. The brilliant cut diamond weighs approximately 75pts and has a small chip on the girdle, internally it is of VVS clarity and J color. The marquise diamonds weigh approximately Spts each and are of VS to WS clarity and H-G color. The single cut diamonds weigh approximately lpt each are of VS to WS clarity and H-G color. The ring weighs approximately 6.70 cts. Total fair market value, approximately $2,200. i Lady's 14K white gold ring containing one cushion cut blue sapphire and eighteen single cut diamonds. The sapphire measures approximately 11.8mm x 9.8mm and is of VS clarity and medium pale blue color with strong color zoning. The diamonds weigh approximately 2pts each and are of VS to WS clarity and I-H color. The ring weighs approximately 4.05 dwt. Total fail market value, approximately $1,800 Lady's 10% irid platinum ring containing eight single cut diamonds. The diamonds weigh approximately 1.Spts each and are of SI to VS clarity and I-H color. The ring weighs approximately 2.25dwt. Total fair market value, approximately $175 y ~/.~~~~ Charles G Buser III G.G., I.S.A Total Fair market value: The price in the market place in which the item would change hands between willing buyer and willing seller, neither being under any compulsion to buy or sell and each having reasonable knowledge of the relevant facts, i.e., the price in the market place in which the item is most commonly sold to the public. Also taken into consideration was a reasonable and realistic time frame for willing buyer and willing seller to reach an arms length transaction within the appropriate market -~c j Reset F~ INVENTORY REGISTER OF WILLS OF COMMONWEALTH OF PENNSYLVANIA 1 SS COUNTY OF J LAST RESIDENCE Personal Representative(s) of the Estate of deceased, depose(s) and say(s) that the items appearing in the following inventory include all of the personal assets wherever situate and al l of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I verify that the statements made in this Inven- tory are true and correct. I understand that false state- ,., ments herein are made subject to the penalties of j ~ ~ . Lam, ,. I8 Pa.C.S. § 4904 relating to unswom falsification to authorities. Attorney -- (Name) (Supreme Court I.D. No.) (Address) (T'elephone) DATE OF DEATH l~~C~f' ~`~~ ~' !~F'L~~l1L~~ :~, ~.~ COUNTY, PENNSYLVANIA File Number DECEDENT'S SOC. SEC. NO. FIGURES MUST BE TOTALED 1 6'~t ~` ~ ~ ~~ ~LG~I~ ~ ~~ ~i~ ~'~- r"o''15 ~'1,~~ ~-/~ ~~1 ~~'uC~ `~ ~~ ~/~; c ~ ~ ~ , l~ ~~- ~ ~ ~;~~. ~ ~ ~, ~ . `'~ (Attach additional sheets as needed) ~ Discover More Card Account Summary Cardmember since 2003 Closing Date: June 10, 2008 page 1 of 2 ,Account number ending in 8530 Previous Balance 6720.35 i= Payment Due Date July 9, 2008 Paymer-is And Credits - 0.00 Minimum Payment Due 664.00 Purchases + 1,744.51 Credit limit 610,000.00 Cash Advances + 0.00 Credit Availoble 67,510.00 Balance Transfers + 0.00 ^- Cosh Credit limit 65,000.00 Firarrn Charges + 24.90 Cash Credit Available 65,000.00 New Balance 62,489.76 You may be abb to avoid Periodic Finance Charges, see the ~-^ reverse side For details. ~~ Cashback Bonus® opening Cashback Bonus Balance 6 34.85 New Cashback Bonus Eamed + 4.09 .~ 5% Coshback Bonus + 7.78 _ ~ Cashback Bonus® Since Anniyersa~yr Date ____________ ~~^_ _~hbcxk Bonus Bolancs 6 46.72 ~~~~~~'~-T ~-1-~--~--~~---- 513.66 of April 10: ;How Can We Help You? 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Request a k~ w quote online or use the Knowledge Builder to read what the exports say about popular insurance questions. ~~~~ Visit Discovercard.com/insumncecenter today: GTi 1 rn N ~ C ~ ~ Rl ~ X v ~ A ~ j "~ O p -y- ~ ~ C~i Q. ~ C J ~ ~ x ~ ~ ~ . N ~ W .J 'D ~ CJ C ? cp p A D V ~ cD Ao ._+ D ~ fD y N m Q -a ~ Vpp ~ ~ ~ ~ OO G ~ p W ~ ~ 1 t9 ~ C1 ~ T ~ CJ o v 0 n -~ 0 z Z -~ 0 z a s &~ ~~ ~~ ~- ~ ~ • ~ ~ ~ ~ ~ ',. ' ~ A~ _ {py~" ~ ~ ~ ~ ~ ~~~r~. - ~ *' •S'~ 1 ~ ~ ~ ~ ~ i~ee,. 1~~~ ~ - ~y~ y z C] c~ ~ C~ 'o ~-I N r cn ~ o roo a ron~ ~o roow y ~ 'L7 U1 W ro O ~ O ~ .A ~ ~' [A r- O' ~ '17 ro O O ~ ty bro w ~Hw a ~ ~ o' cr cn w ~ ~ "C3 S]. O r• Cri ro ~ ~ ro O C O O :U ~ r-O n~-+, a T'~C wo ~ H b ~ R+ ~.a n ~n ~ ~a r- ro ro ro o o r~ ~* w w rp to ~~~ (t (t H L]. C'r ~l L' .~ ~ O' ~' row "+7 O ro ro n r•O ~• ~ n 3 m~ z w o ro ~ - ro c+ n •• cr n c~ r- tt ~' ~7 n r• a tr1 ro ro ~ ~ r- 7C ;b n y W () H ct' W O ro n z ao ~o ~• ~--~ w w o o ~n o o00 rno N O O O O O O O f•3 ~ ~ ~ r• r G ~ ~ J ~-' U1 Gr N J (.Jl ,~,,[~ W W O "~ 1 O~ O~ O N N O 0 d m 0 Cr7 z an H H •~ r~ x 2 a W N O O REV-485 EX (1-07) 48500041046 SAFE DEPOSIT BOX INVENTORY PA Department of Revenue Social Securi or Death Certificate Numt~er Date of Death PLEASE USE ORIGINAL FORM ONLY County Code Year File Number Decedent's La~ /' 1 ~ ~y t Name x~" ~. u.~ .u"' s ffl~ K .. N - °~ , w - ; , --._> ame ,. >~. 3} ~ 1 ©ADDRESS OF DECEDENT STREET: ~ a_, ~~ -` `~ ( ~~ ~ t f~ CI - _. '~~5 _ _ 1 STATE ZIP CO NAME AND DRESS OF PERSON REQUESTING THE OP NING OF THE SAFE DEPOSIT BOX ' NA.b1E: it ~ ll ,, ~lr~ STREET ADD ~ _ ,r ~ ~ CITY: -- • NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT OF PER e / S / •Zj Cp '/ , a. NA ON(S) PRESENT THE BOX OPENING t TIONSHIP: l STREJ~p ESS. -- ~/'~ ~ ~ CI T T ' _ E: ZIP C E: b. NAME: `" - `' J l ~ ( ~~ ~- ~~~ REtATIONSH+ ~ j ~ kr ~'- STREET ADDRESS: -- CITY: - _ STATE: -ZIP CODE: c. NAh1c: -- -- RELATIONSHIP: -- STREET ADDRESS: - ------ - CITY: STATE: ZIP CODE: NAME AND ADDRESS OF FINANCIAL INSTITUTICIw wuce+~ c SAFE D EPOSIT BOX I S LOCATED NAME ~- ~_ ~~ STIjE , 7 O RESS: __ _ - _ CITY- a -- j 1 L ~ S TE: ZIP CODE: N , O PE SON MAKING LAST EN RY . . / ~ ~ DATE AdD T ENTRY ' DAT OF N T T BOX NU OX Q TIT E U ER W BO IS R ISTERE NAME AND ADDR S OF PERSON(S) HAVING ACCESS TO BOX ~ a. NA r /~ 1 ~ b. NAME: ..~ ~ ' ST D ESS;, - STREET ADDRESS: __ '-- GTY- i TE: IP CO '/ ! ~ / ~ CITY: STATE: ZIP CODE: N A TI O OY TAK G THE INVENTO ' ~ 4 WAS WILL IN THE BOX7 ^ YES NO If Yes, a. Date of will: b. Name and address of personal representative, if named In the will NAME: STREET ADDRESS: _ CITY: STATE: ZIP CODE: c. Name and address of attorney, if any NAME: ~ STREET ADDRESS: ! CITY; STATE: ZIP CODE: i L 48500041046 4850004 1046 p REV-4g5EX SASE DEPOSIT BOX INVENTORY Pa9e- --°f----- INSTRUCTIONS ~ , (4) (5) (6) (~) (8) (9) ITEM NO. (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certficate, name in which stock is registered, and number of shares and class of stock. (3j Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank and branch, and balance. Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. All other contents. Return completed form to: ITEM DESCRIPTION DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG, PA 17128-0601 I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECEIVING CORRECT AND COMPETE TO THE BEST OF MY KNOWLEDGE AND BELIEF SAFE DEPOSIT BOX JIUIVAI Ujl6 j / / , PRINT PRINT BOX BELOW: ] - - r,~y.r~rrKV1'KIAiE BOX: -'--------- ~,/ ^!EV/xecutor(trix) ~ Administrator(trix) i Q g ^ Estate Representative ~ Joint owner of safe deposit box NOTE: Attach additional 8'/:" x 11" sheet(s) if cess ry or use duplicates of this page of form. The Department is authorized by law, 42 U.S.C. §405 (c)(2)(C)(), to require disclosure of Social Security numbers in connection with administering state tax laws. The Department uses the Social Security number to identify the decedent and personal representatives of the estate The Canmonwealth may also use the infom>ation in exchange of tax information agreements with Federal and local taxing authorities. The state law hibits the Commonwealths personnel from discbsing confidential tax information except for official ournncac