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Home My WebLink About05-06-09 (2)May 4, 2009 Glenda Farner Strasbaugh Register of Wills County of Cumberland 1 Courthouse Square Carlisle, PA 17013-3387 Dear Ms. Strasbaugh: I am the administrator of my bother Patrick J. Fitzgerald's estate (#21-2008-1246, Social Security #174-40-3320.) Enclosed are duplicate copies of the Pennsylvania estate tax form, related schedules, and documents. Also enclosed is one original estate tax form. Since I had only one of these forms, I had earlier phoned your office to obtain another, (The bottom of page one advises the filer, "Please use original form only.") I was told that copies were OK and, therefore, used your office's online fill-in form in the interest of legibility. I have enclosed the original form in case it too is needed. Also enclosed are the estate's check in the amount of $33,162.85 in payment of the estate N tax a separate check for $15.00 to cover the filing fee. c o ~ _ ,_ , >~ _ ~~'D Zs c_ Si erely, a I=~ ~ _ .N `til C ; a C~' ~`. ) Gerald Fitzgerald ~ ~ ~ 3 202 North Walnut treet ~ -a°- cn ~; Ridgewood, New Jersey `'' 07450 e 15056041046 REV-1500 EX (05-04) , - PA Depattmeht of Revenue Bureau of Individual Taxes o-,_ nsE ~.Y Coun Code Year File Number ~' Dept.28oso1 INHERITANCE TAX RETURN _ Hamsburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth Decedent's Last Name Suffilx Decedent's First Name MI (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Retum THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS O 2. Supplemental Return O 3. Remainder Retum (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INfORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number ~c~~~~ ~ ~~~z~~RtA~~ ~~ g~~ ~- ~q F N If A I b i irni ame ( pp ica le) First line of address ~~~ ~~Q~~ Second line of address WA{-1~(~7 sTRCE~" Cit or Post Office IBS o-74So `~:. _.~ E .:~ _'T .3 ~~; ~J ~.~ ,. ~:~ -1 r7 Correspondent's a-mail address: Unde allies of perjury, I declare that I have exam ed this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is t ,correct and complet$ Dec~_af~tion dF~~er other than the personal representative is based on all information of which preparer has any knowledge. SIG TORE OF PER /(ESI(~1NSIBL~FO~b'KyDIG RETURN // I neTC y ~ ~/ ~ - / - ~ ~ v A S 1,, e Y SIGNATURE OF P P/jy~ER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY ZIP Code REGISTER WILLS USE~YLY - Q ? -~ ~r'i-T C7 .a3 :"t 1 r~ 3a ~-. t ~~rn r ~; :>~~ 4~1 rz C-'C-~~-~ t ~ c°- ~ t7 ~ :T: ATE FILED I Side 1 15056041046 15056041046 J J 15056042047 REV- ~0 E pecedent's Number RECAPITULATION A d l 1 ~ ~~ g _ c '' ' x ~j ' 1. ) ........................................... u e Real estate (Sche .. . a: F ., ,.,;, ~ i-sK e 2. Stocks and Bonds (Schedule B) ..................................... .. 2. ~ x ~ ,. ., 3. Closely Held Corporation, Partnership or Sole-Proprietorship {;Schedule C) ... .: S: ~ • 4. Mortgages 8~ Notes Receivable (Schedule D) ........................... .. 4. 5 r ~ r 5. Cash, Bank De osits & Miscellaneous Personal Pro ert Schedule E . 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ..... .. 6. +f 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) C Separate Billing Requested...... .. 7. _ ~ C ,~. 8. Total Gross.Assets (total Lines 1-7) .................................. .. 8. I "G 1 G s 1 r - , 1 9. Funeral Expenses & Administrative Costs (Schedule H) ................:. ... 9. ~ + 1 ~ 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10. ~ ~• 11 ...................... l Deductions (total Lines 9 & 10) T t ... 11. ~ ' ~r ~~~ . .......... o a 4._,~,.. v , 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. p~ ~~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ..................... ... 13. 14 ±_, ~~~ ,~ t/ 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... . ~r 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 _ 16. 17. Amount of Line 14 taxable ~ ~/ ~ ~ ~ ~ Q 17 at sibling rate X .12 . (() r 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE .........................................................19 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 3~r1: ~~~.iS~ 3~~ l ~~~" O Side 2 15056042047 15056042047 REV-1500 EX Page 3 Decedent's Complete Address: File Number DECE E~ I /~ ------- / J`~ - ~~~ STREE A D S __ ~~L1 CITY STATE ZIP Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) a 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. 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. 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)j. 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. (3) (4) (5) a (5A) (56) (~ 1 15056051058 REV~1500 E>< c06-OS, o~,c~,~E our PA Deperlrner-t d ReYerele ~' °~ ~' INHERITANCE TAX RETURN ~ code Y~ ~ rtrmber PO eox 2aosot Herrisbtllg, PA i7126OS01 RESIDENT DECEDENT ENTER DECEDENT MIFORMATN)N BELOW Social Security Number Dale of Death Dale of Birth 174-40-3320 1112M2008 03J16/1949 Decedent's Last Name Sufix Decadence Frst Name MI Fitzgerald Patrick J (If Applicable) Enter Surviving Spouse's Mtforrns6fon Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social SewrUy Number Tells r~TUR~I Ma~sT eE Fl~ED a ouPUCA~E rrrrll n~ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ L Original Return 2 Supplemental Return 3. Remainder Return (date of death prior1012-13-02) 4. Limited EsfaOe 4a. Futwe Interest Compromise (date of 5. Federal Es#ate Tax Return Required death oiler 1212-82) 6. Decedent Died Testate 7. Decedent Mairrtairled a Lining Tnrst 8. Tote) Number of Safe t~poeit Bamas (Attach Copy of 1Nii) (Attedt Dopy of Tnet) 9. l'IOgetiDn Proceeds Received 10. Spousal Poverty Credti (die or death 11. F_lection m tax under Sec. 9113(A) belvveen 1231-91 and 1-1 95) (Attach Sch. O) CORRESPONDENT - ilfi8 SECTION MUST ~ t.OMPLE'rED. ALL AND CaNRDENTIAI. TAX INFORM/tTtON SHOULD BE DtttEC'1ED'i+o- Name Daytime Telephone Number Gerald E. Fitzgerald (201)857-2189 Firm Name (NApp6r~bls) _ _ _ _ ~ _._ ~r REGISTER t)SE - _~,. ~ T. ~ t--. F~sl Nne of address ~7 ~ rte- "~ t~~, 202 North Walnut Street ~ :~ c.~ ~ --~_ % ~;~ second Nne of address ~ p ~,~ a' ~' ' c~c = ~__~ ~' ~ ~ O r - City or Post Olfioe State ZIP Code B~d7E RL® ~ , '.. > Ridgewood NJ 07450-2629 Comeepondenrs e-rrla;l addresg: 9~~~sn.corrt under d psrjrey,l declero that 1 have exarninsd this retran, ir-dudkg Mne sa,eautes am stsbmerNa, and to e,e best or my knowledge and txNet, N is true, and oonlplsb. than iha pereonel represerMsave rs based on a1 irMommOan of which prepaiar Fms any knoMAedge. siG RE N ~ O~' _ '- G v°` r ` [ ~• l JV SIGNATURE OF PREPARER O R REPRESENTATIVE DATE ADDRESS PLEASE UtiE ORIOIgAL FOAM ONN.Y Side 1 15056051058 15056051058 J 15056052059 REV-1500 EX Decedent's Social Security Number Patrick J Fitzgerald , 174-40-3320 s ~~: oecedenc _ _ _ __ RECAPITULATION 1, Real estate {Schedule A) ............................................. 1. 50,000.00 2. Stocks and Bonds (Schedule B) ....................................... 2. 54,372.83 3. Closely Held Corporation, Partnership orSole-Proprietorship {Schedule C) ..... 3. 4. Mortgages 8 Notes Reoeivade (Schedule D) ............................. 4. 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ........ 5. 190,088.34 8. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & MisceNaneous Non-Probate Property (Schedule G) Separate Bring Requested........ 7. 6. Totsi Gross Assets (total Lines 1-7) .................................... 8. 294,461.17 9. Funeral Expenses ~ Administrative Costs (Schedule H) ..................... 9. 17,531.14 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 BequestslSec 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 (ax1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate x .12 276,357.09 17, 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE .........................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 572.94 18,104.08 276, 357.09 276,357.08 33,162.85 33,162.85 15056052059 RE1~1500 IX Page 3 Decedent's Complete Address: rye Nun6sr DECEDarrs nuwE DEC~oerrs socw. sECUtmr rnx-eBt Patrick J Fitrgerald 174-40-3320 sT>~rADORESS 334 Third Street CITY New Cumberland STATE PA ZP 17070 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 33,162.85 2. (]editslPayments a spouse PoveAy Credit B. Prior Payments C. DisoouM Total Credits (A + B + C) (2) 3. IrderestlPenally iF appficabie D. trrterest E. Penalty Trial~(D+E) (3) 4. N tine 2 is greater than Une 1 + Line 3, ever ~e differerroe. Tt~ is the OVERPAYMENT. F61 in o~ on Page Z, Line ZO !o raqueet a refund. (4) 5. ff Late 1 + Lure 3 is greater Than Lyre 2, enter fire dilfererrce. Tics ~ the TAX DtiE. (5) 33,162.85 A Enter the merest on Ure tax due. (5A) B. Enter the tom of thre 5 + 5A. This is the l~-u-ticE DUE. (5Bj 33,16? 85 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOIMNG QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Old decedent make a transfer and: Yes No a. retain lire use or income afi the property transferred :.......................................................................................... ^ b. retain the rigid to designate who shall use the property transferred or its ~oome : ............................................ ^ c. retain a reversionary ink or ..........................•--•----........................................................................................ ^ d. receive The prarise for Gfe of either payrrreMs, benefits ar caxe? ...................................................................... ^ 2. ff death ocaxred after December 12,1962, did der~dent transfer properly witlrtrr one year of doh wi~out receivtrg ~? .................._....................._...---............................................................. ^ 3. Did decedent own an'~r trust for" or payable upon death bards aooourd or security at his or her dead? .............. ^ 4. Did decedent own an Individual Retirement Aooount, annuity, or other non-probate properly which . cordains a benefiaary dest9nafior-? ........................................................................................................................ x ^ ~ THE ANSIIYER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND Fq.E R AS PART OF THE RETURN. For dates of death on a alter July 1,1994 and before January 1,1995, the tax rate imposed an 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 a after January 1,1995, ttte tax rate on the net vie ~ transfers to or far the use of the surviving spouse is zero (0) peraerrt [72 P.S. §9116 (a) (1.1) ('I~]. The statute a transfer to a surviving spouse from tax, and the stabrtay regkrrerrts for ~sdosrxe of assets and 1iCmg a tax velum are still applicable even if the surviving spouse is the only beneficiary. For dates ~ death on ar after July 1,2000: The tax rate on the rte vaNie of transfers from a dek~aised cldld iwenty-0ne years of age or younger at death to or for the use of a na4tr~ parent, ~ adoptive parent, or a stepparent of the child is zero (0) percent p2 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value ~ bansfers to ar for The use of the dekx3dent's benefidaries is four and one-half {4.5) percerd, except as noted h 72 P.S. §9116(1.2) [12 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use ~ the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an indnddu~ who has at least one parent in common with the decedent, whether by bbod ar adoption. REV-1502 EX+ (11-08) pennsylvarria SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER Patrick J. Fitrgerald 2008-01246 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with rioht d survivorship moat be dkrdoaed on Sdreduk F. If more space is needed, insert additional sheets of the same size. reyovs r_dimpCyare obsolete form HUO-7 (3/86) re( Handbook 4305.2 Settlement Statement U.S. Department of Housing and Urban Development _ H Tyoe of LoaD _ rov O -O 6 e 'res 1 0 FZNAL I ^FtiA '. ^FmHA 3. ^Com•. Unins. 6. File Number 7. Loan Number 8. Mortgage Insurance Case Number a ^v - ^ 0 -03- 4 This form is famished to give you a statement of ecru settlement rests. Amotmis (saki to and by the satl eM agent are shown. C. Note: Uems marked "(p.o.e. )° were pakl outside the ebshg: they ere shown here for Infnrtnation purposes and are rtot irtcluded in the totals. T[UeEXpresS Settlement System WARNING: U is a rsime to knowingly make fWsa statameMs to the United States on this rx any other simUar form. Penalties upon ~...,..ini..., ~~.., t..r•A~d.. ,. rrv. anri imaisaaneM_ For details see: Tine 18 U. S. Code Section 1001 and Section 7010. ~ NnME or• t~oRaoweR: 7'immark Properties ( Nnnne aF sla.t.ra Estate of Patrick .i. Fitzgerald (= Nnn~[c or t.F.NOtle __~poR [=SS c, httoPCKTY nDD2rss: 334 Third Street, New Cumberland, PA 17070 New Cumberland Boroueh tt seTTLrn-IFNT Ac~NT Precise Settlements, Inc., Telephone: 717-635-2050 Fax: 717-635-2055 - _gl.~~cl- c?r ~r~-r1.J~t~tr:N~~ 241 I N. Front Street_ I-Iarrisburg_ PA 171 10 J SUMMARY OF BORROWER'S TRANSACTION' K SUMMARY OF SELLER'S TRANSACTION- ,nn rRr1SR AMAI IAtT r~11F FR[)M RARRO\NER 400. GROSS AMOUNT DUE TO SELLER tOt. ntract sales o1i~e 50 000 _ 00 50 000 _ 00 7 r Settletnen t03 1 204.25 . t04 t05 Ad'ustme is for 'ems aid b seller i n adva ce Ad'tts a is for items aid b se ter i n advance 03 13 09 12 31 09 446.83 03 13 09 12 31 09 446.83 tD~`~choo( Taz(e~ 03/13 09 06 30 09 314.79 03 13/09 06 30 09 314 _ 79 ito . i 1 BOSS AMOUNT D M 51 965.87 420 N T L 50 761.62 2Qt], AMQyL1T$ PAID~.~' QR ON BE LF F 8 R O R 500 TI IN A T T R p0wt or eameSLmOl1SSL..---__~.._ 500.00 501- Excess Deposit (see instr ~_t+nns) -- 500.00 500.00 ~ taken gybj&Gt tp _ 4 0 7 Ad ustments or items un std se t er Ad'ust s or ire sun aid b se! er 554.75 T 1 Y R 500.00 520. T A D TI T D 1 554 _ 75 300. A ~TLI,~MENT F~C~M OR TO~QgI2s?W R 60 A T T R F tER s amount 51 965.87 50 761.62 ass amounts paid bvltor btxrovver [line 500.00 1 554.75 303._~$H FROM BO R WER 51 465 _ 87 603. T 49 206.87 SUBSTITUTE FORM 7t~j SELLER STATEMENT: The intormaton contained herein 15 important tax information and is being twnished to the Internal Revenue Service. It you are requ'sed to file a rewrn. a negligence penalty or other spnctio wilt bo imposed on you if this item is required to Ue reported and the IRS determines that it has not bean reported. The Comract Sales Price desvibed on tine 407 above constitwes the Gross Proceeds of this transaction. SELLER INSTRUCTIONS: IT this rest estate was your pdrxipol residence, ilia Form 2179, Sale or Exehango 01 Principal Resklence, for any gain, with your income lax return: (or other transactipns, complete the applicable pans of Fonn x797. Fonn 6252 and/or Schedule D (Porto 7040). you are required by law to provide the se111pment agent (fed. Tex ID No: )with yow correct taxpayer tdeMificatfon number. IT you da rwt provide your correct taxpayer idantilicatlon nwnber. you may be sut>jac! to civil or criminal penalties imposed by law. n ertT ~ Tyer)ury. 1 certify that the number shown on this statement is my corced taxpayer identification number. TIN_ SELLER(S) SIGNATURE(S): SELLER(S) NEW MAILING ADDRESS: '~ev~ous ediliatia•erc obsolete U.S. DEPARTMENT OF HOVSING AND URBAN DL•VELOPMENT File Number: 09-03-04 term HUD-1 (3!861 roT HarWbook x305.2 FINAL PAGE 2 PAID FROM PAID FROM BORROWER'S SELLER'S FUNDS AT FUNDS AT SETTLEMENT SETTLEMENT x~ ~e~rtity Ut1l 11mv~e~reosetved a copy of tlb HUD-t ~3 mail mtanembelief. 6 S a Vue mW eearate stmement of ~ receipts erW daM~rsert~ngs made an my exam! ar by me L_.~ WARNWO: IT IS A CRMtE TO KNOYNNGLY MAKE FALSE STATEMENTS TO THE The HUD-1 SetBenterri vrhidt 1 hove prepared is a true aid sxvala accawK of tlMs tranaaellort UNITED STATES ON THIS OR ANY SIMILAR FORM. PENALTIES UPON CONVICTION 1 have cetuada fie ~aMj1o ba d}abvsed in aFcards~ca wiM 9da statement. CAN INCLUDE A FINE AND IMPRISONMENT. FOR DETAILS SEE TRLE t8: //~ U.S. CODE SECTION 1001 ANO SECTION 1010. Sy ~ (~ (7~ c RE1F1503 EX+ (6-9e) COMMONNIEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ~N~~~~ B STOCKS & BONDS ESTATE OF FlLE NUMBER Patrick J. Fitzgerald 2008-01246 AN proPwh- jointly~awlsd wdgr right or smvivarsldp must be disdoad as Scirsd~is F. iTEM VALUE AT OJ1TE NutaeER DES(~'iION of DEATH t. Verimn ~ co^~on ~odc 18,614.60 626.122065 shares ~.529.73/share (See atlfadled dttl~B of death sta6afrrlerlt) 2. Fairpoird ComrrtunitxtGons wlnrllorl slack 12.0867 shares ~2.2?Jstl~ls (Ses agadled daka of death s>aksmerrt.) 28.43 3. U.S. Satrirlgs Bonds'EE' (l2edelrlption vaktes as of 11124/2008 yes af~tted 1st) 18 729.80 ' 4. U.S. Satrirlgs Bonds'I" (Face values as of 11/24/2008-wee a~ciled i~.) 17 000.00 TOTAL (Also enter on Grle 2, Recapitulation) I i 54,372.83 (IF more space is needed insert additiorud sheets aE the same see) Calculate the Value of Your Paper Savings Bond(s) Page 1 of 2 ~TreasuryDrectr yon?e ~ Indi_v_id4al ~ ~f00~$ ~ Calculate the Value of Your Paper Savings Bonds i Calculate the Value of Your Paper Savings Bond(s) SAYIN6l5 BOND CALCOIATOB -- Instructions ----------~ Value N ot: H.,w ho l..,e the Sa v+r.3s 8crd HROOa I tJPOATE :,. ~~, fdl<ularcr -- Notes Description -----.~~ Balrs: DeOOaJnattoa: B1ad Serb! Naafber: Issue Date: EE BOfIdS .500 - -.. ~.. ~ ! NI Not Issued . -:~. NE Itot eligible for payment - ~. P5 Indudes 3 month - NOW TO SAYF YOUR IN VENTORY ~ intarast panafty ~_.. __. __ .-T_.. ,. Ma Maturod and oat eeming interest Calculator Results for Redemption Date ii/2008 - --- ----- Total Price Total Value Total Interest YTD Interest #28,500.00 #38,806.60 #10,306.60 #1,457.80 floods: 1-63 of G3 Serial # Series Denom Issue Ne:t Finat Iuue ~e~ IMerest Vatue Note Date Accnfal ~ Maturity Prke Aate ~ D27142892EE EE 5500 10/1992 04/2009 10/2022 E250.00 5345.60 4.00% :595.80 _ D27144375EE EE 5500 1211992 12/2008 12/2022 5250.00 ;333.80 4.00% 5583.60 _ j D27145829EE EE 5500 03(1993 03/2009 03/2023 5250.00 5235.00 2.73% 5485.00. - D2714729SEE EE f500 05/1993 05/2009 05/2023 ;250.00 ;229.20. 2.65%. 5479.20 _ D27148730EE EE 5500 07/1993 01/2004 OJ/2023 f250.00 ¢223.40 2.45% 5473.40 _ D29863073EE EE 5500 10/1993 04/2009 10/2023 ;250.00 ;223.40 2.45% #473.40 - ` D40489475EE EE 5500: 12/1993 12/2008 12)2023 ;250.00 ;212.00 2.79% 5482.00 _ D40491053EE EE ¢800 02/1994 02/2009 0212024 5250.00 ¢212.00 2.79% 5482.00 _ D90492566EE EE 5500 04/1994 04/2004 04/2024 ;250.00 5212.00 2.79% 5482.00 _ D40494117EE EE 5500 07/1994 01/2009 0712024. ;250.00 $202.40 2.83% 5452.40 _ D40445660EE EE ;500 09/1994 03)2009 09/2024 ;250.00 5202.40 2.63% 5452.40. _ D42753417EE EE 5500 11(1494 05(2009 11/2024 5250.00 ;198.00 2.48% 5448.00 _ D42755111EE EE E500 02/1995 02)2009 02)2025 ;250.00 ;192.40 2.60% 5442.10 - + D42756774EE EE 5500 04(1995 04)2009 04/2025 ;250.00- 5192.40 2.60% 5442.10 - D42758412EE EE 5500 06/1995 12(2008 06(2025 5250.00 5167.00 2.58% 5417.00 - D427600001EE EE 5500 09/1945 03/2009 09/2025 5250.00 5167.00 2.58% 5417.00 - D42761721EE EE ;500 11/3995 OS/2009 11/2025 5250.00 5161.40 2.65% 54IL40 _ D4Z763438EE EE E500 01/1496 01)2009 01/2026 E250.00 5156.20 2.58% 5408.20 - D43912221EE EE 5500 08/1996 0212004 06/2026 5250.00 4147.00 2.58% #397.00 _ D427b6698EE EE 5500 06)1996 12/2008 06/2026. ;250.00 5147.00 2.58% 5397.00 _ D42765078EE EE 2500 03/2996 038009 09(2026 5250.00 ;156.20 2.58% 5408.20 _ Dd3913830EE EE 5500 10/19% 04/2009 10/2026 ;250.00 5147.00 2.58% 5397.00 _ D43915408EE EE 5500 01/1997 01/2009 01/2027 5250.00 4136.20 2.58% 5388.20 _ D43916952EE EE f500 03/1997 03)2009 03!2027 5250.00 5138.20 2.58% 5388.20 - i D43918437EE Ef 5500 0511997 12/2008 05/2027 ¢250.00 5150.80 2.80% 5'.408.80 - D43919B62EE EE 5500 08/3997 12/2008 06(2027 E250.00 5148.00 2.74% 5398.00 _ D48473334EE EE 5500 10/1997 12/2008- 10/2027 5250.00 5146.20 2.74% 5396.20 _ D48474844EE EE 5500 12/1997 12/2008 12/2027. 5250.00- 4138.60. 2J4% 5388.60 _ ! D4B476267EE EE 5500 01/1998 12(2008 01(2028 5250.00 ;137.80 2.74% 5387.80 _ D48477644EE EE 5500 05/1998 1212008 05/2026 $250.00 5129.20 2.60% 5379.28 - 1 D48476936EE EE 5500 07/1998 12/2008 07(2028 ;250.00 5127.40 2.74% 5377.48 - {4 D50544239EE EE f500 09(1998 12(2008 09/2028 5250.00 5125.80 2.74% 5375.50 - D50545604EE EE 5500 12/1998 12/2008. 12(2026 5250.00 5118.60 2.74% 5368.60 - DS054b935EE EE 5500 02(1999 12(2008 02/2029- 4250.00 ;116.80 2.74% 5366.80 - I D50548208EE EE ;500 04/1999 12/2008 04/2029 5250.00 5115.20 2.74% 5385.20 - D50549495EE EE 3500 07/1999 12/2008 07/2029 f250.00 5110.00 2.74% 5360.00 - D50550665EE EE 5500 09(1999 12)2008 09(2029 5250.00 5108.40 2.7d% 5356.40 _ D50551612EE EE 5500 11/1999 12(2006 11)2029 5250.00 5103.60 2.60% 5353.60 - D51096954EE EE 4500 0112000 12/2008 01/2030 f250.00 4102.00 2.J4% 5352.00 - D5109B029EE EE 4500 04(2000 12/2008 04/2030 ;250.00 ;99.60 2.74% 5319.60 _ D51099143EE EE 5500 06/2000 12)2008 06(2030 5250.00 594.20 2.74% 5344.20 _ ! 051100167EE EE 4500 08/2000 12/2008 06/2030 5250.00 592.80 2.74% 5342.50 _ ' D51101133EE EE 5500 11/2000 12(2008 il/2030 4250.00 SB5.00 2.80% 5335.00. - D51102060EE EE 5500 01/2001 12/2008. 01/2031_ 4250.00 ;83.40 2.74% 5333.40 _ 051102987EE EE 5500 03/2001 12/2008 03/2031 5250.00 ¢82.00 2.74% 5332.00 051I03923EE EE 5500 06/2001 12/2008 068031 5250.00 575.20 2.74% 5325.20 - M001168359F 1 51,000 118001 12/2008 11/2031 51,000.00 5392.80 6.97% 51.392.80 - M001168479I I t1,000 04/2002 12/2008 04/2032 51,000.00. 5354.00 6.89% 51,35.4.00 _ M001168617I I 51,000 06/2002 12(2008 08/2032 51,000.00 5340.00 6.89% SL340.00 - ' Calculate the Value of Your Paper Savings Band(s) ~ M001168747t 1 51,000 0112003 12/2008 01/2033 53,000.00 5300.OD 6.18% ;17dB.00 ~ M0011689021 t 51,000 05/2003 12/2008 05/2033 51,000.00 5253.60 6.05% ;1,2S3.W ~ F10011690581 I f1,000 1012003 12/Z008 10/2033 51,000.00 5223.20 5.97% u.223•m E M0011692161 1 51,000 0312004 1212008 03/2034 51,000.00 5184.80 5.97% ;11Y4J0 PS j M001169547t I 51,000 07(2004 12!2008 07/2034 51,000.00 5177.60 5.86% 51177.f0 F's M0011698]41 1 S1,OD0 128004 128008 12(2034 51,000.00 f164.00 5.86% ;1,1NAD PS M0011702021 1 ~ f1,000 04/2005 12/2008 04!2035 11,000.00 5144.80 5.86% ;1LM.80 t'$_ M00117097bI I 51,000 09/2005 12/2008 09/2035 51,000.00 5134.40 6.07% ;1131A0 S?5 M001171745I t 51,000 02/2006 128008 02/2036 51,000.00 5106.00 5.86% ;1186.00 PS M001171002I i SIAQQ 06/2006 128006 06/2036 SI,000.00 589.60 6.27% 61,081.10 RS f M0011712M1 i 51,000 11(2006 12/2008 11/20 S1A00.00 582.00 6.35% ;1.88100 PS 1 140011715071 1 51,000 03J2007 12/2008 03/2037 f1A00.00 562.00 6.27% ;106.88 P~ M00t171742! 1 51,000 08/2007 12/2008 OB/Z037 SIA00.00 541.20 6.17% ;1.041.20 PS. ~ M001171974I 1 51,000 01(2008 12/2008 01/2038 51,000.00 526.80 6.07% ;1026.80 r!E F ff,! f111 TFk btll}l'HLf+ Si+v.}t~ Survey..... _. _.__.. How weab yon rste th4 Loi7 --' Exoell~t .' Good .' Fair ~: Voor Pag Frecdo i Incomwtic-q Ar,Y ~ 1 ?-•.&-GuiAarcc ~ P,..c•-,cy .4 Eegat wot c~:.. ~ Wrbte TermshC i!iens ~ <. _-.~ib~IitY ~ Da[a, (;ualit~ t c. t,•..~,,.r.-,...,~ r' ti,., Tn•~r.~u•.,. flurnaE+ r..i ib~ Public psb~ REV 1506 EX+ (698) SCMEp11LE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & IMISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT --__ ESTATE OF FlLE NUMBER Patrick J. Fitzgerald 2008-01246 Include the proceeds of Irtigation and the date the proceeds were received by the estate. IU property jointly-0wnad with ripM or survivorship must bs disdosad on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Pennsylvania State Employees Credit Union (savings account#174-40-3320) See aifached. 80,254.00 2. Members 1 st Credit Union (savings account #263469-00) Ses attached. 31,672.31 3. M8T Bank {checking aocount #33342598) See attached. 22,528.54 4. ANstate Annuity (tIGA18416966) See attached. 45, 596.87 5. 2005 Chevrolet MaNbu (Blue Book value) 8,465.00 6. Gold bullior- (1.85 oz. ~5822.50/oz. 1,521.62 7. Silver Bulion (4.0 oz. X512.50/ot. 50.00 TOTAL (Also enter on line 5, Recapitulation) i 190,088.34 (If more space is needed, insert additional sheets of the same s¢e) REV-1510 EX+ (&99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT scNEOU~E ~ INTER-VIVOS TRANSFERS S MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Patrick J. Fitzgerald 2008-01246 This schedule must be completed and filedrf the answer to any of questions 1 through 4 on the reverse side of the REV 1500 COVER SHEET ~ yes. ITEM NUM DESCRIPTION OF PROPERTY SiCLUDE THE XAWE OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACHACOPY of THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION FAPPLICABI.E TAXABLE VALUE 1. Alianz High Five (~fDAD45096-09775) This IRA was funded with a quaified 111,660.03 100 0.00 transfer of funds from Patrick Fitzgerakt's Pennsylvania stabs pension funds. Distributions from beneficiaries AlNanz death benefits are 100%taxable by the IRS. See attached paperwork involved in the rolbver of these funds.. TOTAL (Also enter on line 7 Recapitulation) S I 0.00 (If more space is needed, insert additional sheets of ltTe same size) ~ , ".-,~_ Contract Profile Contract Number. DAD45096-09775 Initiallnvestment: $111,660.03 Contract Effective Date: 03/19/2008 Product: Allianz High Five Plan Type: Qualified Representative Information Name: GARY CORDON Address: ONE CREDIT UNION PLACE Dealer: CUSO FINANCIAL SERVICES L P HARRISBURG, PA 17110 Contract Owner Information Name: PATRICK J FITZGERALD Address: 334 THIRD ST NEW CUMBERLAND, PA 17070 Date of birth: 03/16/1949 SSNITI N: 174403320 Annuitant Information Name: PATRICK J FITZGERALD Date of birth: 03J16/1949 Address: 334 THIRD ST SSN/TiN: 174403320 NEW CUMBERLAND, PA 17070 Investment Information 100% AZL MONEY MARKET Product Features GUARANTEED MINIMUM INCOME BENEFIT ENDORSEMENT GUARANTEED ACCOUNT VALUE BENEFIT ENDORSEMENT GUARANTEED WITHDRAWAL BENEFIT ENDORSEMENT TRADITIONAL GUARANTEED MINIMUM DEATH BENEFIT ENDORSEMENT TELEPHONE AUTHORIZATION -REPRESENTATIVE "If this is an Individual Retirement Account (IRA) and you will be age 70 12 or older by December 31 of this year, you may need to take your Required Minimum Distribution (RMD) by December 31. Regardless of age, a RMD may also be required by December 31 if this is an inherited or beneficial IRA Please contact your tax advisor or Registered Representative if you need to determine your status regarding RMD . A Required Minimum Distribution form is included with your contract for your convenience." Beneficiary Information Type Name Relatanship Percentage Please refer to the enclosed Beneficiary Clarification Form to make ner~ssary changes to your beneficiary designations(si. For questions, contact the Alliana Service Center at 1-800-6240197 Date Prepared: 3/202008 o.,..., ~ .,c ~ Allianz Service Certter PO Box 1122 Southeastern, PA 19398-1122 r .. REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEp11LE M FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Patrick J. Fitzgerald 2008-01246 Debts of decedent must be reported on Setlsdub L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Mct,ongle Funeral Home and Crematory, Inc. (See attached detailed bill.) 9,768.90 2. Headstone (Gealy Memorials) 1,650.00 B. ADMINISTRATNE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Gerald E. Fitzgerald Soaal Security Number(s~EtN Number of Personal Representative(s) _ street address 202 North Walnut Street City Ridgewood . stata NJ zip 07450 Years} Colrl--ission Paid: N/A 2. Attorney Fees 2,051.00 3. Family Exemption: (H decedent's address is not the same as claimants, attach explanation) Claimant Street Address City .State .Z'ip Relationship of Chaimant to Decedent 4. Probate Fees 422.00 5. AocountanYs Fees B. Tax Return Preparer's Fees ~. Probate bond (required by Register of Wills) 1,860.00 8. Required legal notices 174.66 s. Postage, registered mailings, overnight delivery t~targes 221.37 ~ o. Pennsylvania automobile title transfer fee 22.50 ~ ~. Real estate fiansfer tax (334 Third Street, New Cumberland, PA) 500.00 ~ z- Mt?lirrtenance of 334 Third Street from 11 /24!2008 to 3/1312009, plus property cleart-0ut for sale 860.71 TOTAL (Also enter on line 8, Recapitulation) ; 17,531.14 (tf more space is needed, insert additional sheets of the same size) 1090 East State Street Sharon, Pennsylvania 16146 724-347-7575 www. McGonigleFuneralHomeandCrematory. com January 7, 2009 Dennis Fitzgerald 771 McClure Avenue Sharon, PA 16146 The Funeral Service for ~..~ ,.~~C~~~0~22~~G Funeral Home and Cremates ,Inc Patrick Josebh Fitx~erald PROFESSIONAL SERVICES Professional Services MERCHANDISE SELECTED Casket: Adams 20 Gauge Outer Burial Container Eagle Sentinel Acknowledgement Cards Register Book Prayer Cards Temporary Grave Marker Cross Crucifix DVD Video copies (10) AUTOMOTIVE EQUIPMENT Out Of Town Transporation CASH ADVANCES Certified Copies of Death Certificate Clergy Honorarium Newspaper Notice Herald Newspaper Notice New Castle Flowers Opening Grave Organist/Vocalist St. Joseph Ladies Guild Mr. D's Luncheon TOTAL OF SERVICES LESS: Payments Made 08302 J. Bradley McGonigle III FD, Supervisor Timothy M. McGonigle, FD Karen McGonigle Murphjy, FD J. Bradley McGonigle Sr., FD. $ 3950.00 TOTAL PROFESSIONAL SERVICES $ 750.00 TOTAL AUTOMOTIVE EQUIPMENT $1,725.00 $1,350.00 $ 30.00 $ 30.00 $ 25.00 $ 25.00 $ 25.00 $ 100.00 TOTAL MERCHANDISE SELECTED $ 60.00 $ 100.00 $ 201.60 $ 175.00 $ 200.00 $ 600.00 $ 75.00 $ 50.00 $ 297.30 CASH ADVANCE TOTAL $3,950.00 $750.00 $3,310.00 $1,758.90 $9,768.90 9,768.90 PAID IN FULL $0.00 REV-1512 EX+ (12-DB) ~ pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAx RETURN MORTGAGE LIABILITIES 8t LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Patrick J. Fitrgeraid 2008-01246 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medicat expenses. If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (11-08) pennsylvarria SCHEDULE ~ DEPARTMENT OF REVENUE ,~ T,,,~ BENEFICIARIES RESIDENT DErx~tr -- ESTATE OF FILE NUMBER Patrick J. Fitzgerald 2008-01246 RELATIONSHIP TO DECEDENT ANOINT r OR SHARE NUMBER NAh~ ANO ADDRESS OF PERSON(S) RECEIVING PROPERTY Do qst List Tnsttee(s) OF ESTATE I TAXABLE DISTRIBURONS [Include alright spousal distributions and transfers under Sec. 9116 (a) (1.2).) 1. Francs N. Fitzgerald, P.O. Box 393, Sharon, PA 16146 m'bing (bnoltrer) 20% 2. Mary EIerL Flarrdo, 394 AAcCkrre Avenue, Sharon, PA 16146 sii~htg (sts4ar) 20% 3. Gerald E. Fitzgerald, Z02 Nash Waknit SUeet, Ridgewood, NJ 07450 sibirg (brdher) 20% 4. Dennis J. Fitzgerald, 771 McClure Avenue, Sharon, PA 16146 sibfKtg (brotlter) 20% 5. Susan T. Pappajotxt, P.O. Box 1440, Magerrlowrt, WV 26505 arbirrg (sislsr) 20% I~fTER DOLLAR MtOIN(TS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVrBt SHEET, A S APPROPRIATE. II NON-T,'UiABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDBt SECr10N 9113 Fri WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE MID GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - HfIER TOTAL NON TAXABLE DISTR®UTIONS ON LINE 13 OF REV 1500 COVER SHEET. ~ If more space Ls needed, i~rt addit~nal sheets d the sane size. ~omputershare Computershare Imrestor Services 250 Royail Street Canton Massachusetts 02021 www.computershare.com GERALD FITZGERALD 202 NORTH WALNUT ST RIDGEWOOD N] 07450 February 12, 2009 Company; VERIZON COMMUNICATIONS INC. Registration: PATRICK 7 FITLGERALD Hok~r Account Number: 00012246943 Our Reference: VZN/0002886173/9/wt/20138 Dear Sir/Madam: Thank you for contalling Computershare, the transfer agent for Verizon Communications Inc. We appreaate the opportunity 6o be of service bo you. Please accept this letter as confirmation that the transfer of shares has been processed as instructed. An account statement confirming this transaction wilt be separately mailed to the address shown above. On November 24, 2008, account number 00012246943 held 626.122065 shaves. On that date, the dosing price was X29.73 per share. Should you have other account related questions, please call us at (800) 631-2355. Our telephone representatives are available during regular business days between the hours of 8 a.m. to 6 p.m. Eastern Time. For certain routine infonration,-you-may calF us 24 hours a day, 7 days a week and access our automated telephone service. sincerely, Service Representative Enclosure: Norte BNY Mellon Shareowner Services P.O. Box 358333 Pittsburgh, PA 15252-8333 April 8, 2009 GERALD E FITZGERALD 202 N WALNUT ST RIDGEWOOD NJ 07450 RE: ESTATE OF PATRICK J FITZGERALD Dear Investor: BNY M1rI.LflI~ SkAR~OWNER SERVICES Company I FAIRPOINT :Name j COMMUNICATIONS, ~ INC. ~ `Account ' FITZGERALPITSJ0000 { 'Key ~ ! -------- '- Control ---------- _-- _ _--__-- -- - 200904070003854 Number ( j Telephone 877-295-8608 Number j Thank you for your inquiry requesting information for this account. Please be informed that closing on 11/24/08 was $ 2.2200. You will find included an account transcript containing the requested information. This report will show: • Account Profile-general account status • Account Certificate Listing-debit/credit of certificates • Account Payment List-details cumulative dividend payments • Dividend Reinvestment Account Summary-details shares purchased with reinvestment We hope you find this information helpful. As a reminder, you may access our Investor ServiceDirect Web site at www.bnvmetlon.co~n/shareo~rner/isd or call our automated voice response system at the above number for account information and to initiate certain transactions. You may also choose to speak with one of our Customer Service Representatives who are available from 9 a.m. until ? p.m. on Monday through Friday. Sincerely, BNY Mellon Shareowner Services c ~sEC~ January 26, 2009 Account # 0174XXXXXXX GERALD FITZGERALD 202 NORTH WALNUT ST RIDGEWOOD , NJ 07450 Dear MR. FITZGERALD: The following is the status of PATRICK J. FITZGERALD's account with PSECU as of the date of death. Joint Owner's Name NONE Date of Death l 1.24.2008 Date of Birth 03.16.1949 Share Description Open date Balance Accrued Dividend S O 1 Regular Shares Ob.19.1981 $ 5,197.96 $ 4.06 S 04 Moneyhandler 0.00 0.00 C50 12 Month Certificate-1 04.02.1999 1b,145.56 38.97 C51 24 Month Certificate 04.17.2007 43,352.55 142.60 C52 12 Month Certificate 04.04.2008 15,335.29 37.01 The dividend earned from January 1, 2008 through the date of death was $3,023.85. The decedent had no loans with us. We do not have safe deposit boxes for our members. If you have any questions, please call 234-8484 in Harrisburg or our toll-free number, (800) 237-7328. At the menu prompt, enter 6 and then extension 2227. Sincerely, L, ~! ~" (~,~ Meacie Fairfax Member Service Representative Finance Support Unit Qennsylvcxnia Sta#e Employees Credifi tJa~ios-~ Main Address: 1 Cn~it Union Place, Harrisburg, PA 1 71 1 0-2990 • 717.234.8484 • 800.237.7328 St MEMBERS 1St FEDERALCREDtT t1amN REGULAR SAVINGS ACCOUNT: Account NumbedSuffix 263469-00 Date Account Established 04/20/2005 Principal Balance at Date of Deatfi $76.95 Accrued Interest to Date of Death $.05 Total Principal and Accrued Interest to Date of Death $77.00 Name of Joint Owner None CERTIFICATES OF DEPOSIT: Account Number/Suffer 263469-00 263469-42 Date Account Established 04/05/2007 03/06/2008 Principal Balance at Date of Death $10,726.05 $10,235.15 Accrued Interest to Date of Death $18.65 $22.83 Totat Principal and Accrued Interest to Date of Death $10,744.70 $10,257.98 Name of Joint Owner None None CERTIFICATES OF DEPOSIT: Account Number/Suffer 263469-43` Date Account Established 08/12/2008` Principal Balance at Date of Death $10,566.46 Accrued Interest to Date of Death $26.17 Total Principal and Accrued Interest to Date of Death $10,592.63 Name of Joint Owner None 'Rollover from cert~cate 263469-41, originally established 09/13!2007. M , BERS 1sT FEDE L CRED UNION Danielle A. Kline Insurance Services Specialist February 3, 2009 Estate of PATRICK FITZ.GERALD Date of Death: November 24, 2008 Social Security Number. 174-40-3320 p ~s~ 499 Mitchell Road, Millsboro, DE 19966 Maio Code DE-MB-12 Phone (888)502-4349 Fax (302) 934-2955 March 4, 2009 Gerald Fitzgerald 202 North Walnut Street Ridgewood, New Jersey 07450 _ _ 1>'e: Estate of Patrick Jaseph Fitz eg rald-- __ _ _ _. --_ Social Security: 174-40-3320 Date of Death: November 24, 2008 Dear Sir or Madam: Per your inquiry dated January 24, 2009, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type of Account Account Number Ownership (Names o~ Opening Date Balance on Date of Death Accrued Interest Tota! Checking Account 33342598 Patrick JFitzgerald* 11/28172 Closed 1/22/09 $ 22, 527.77 $ 0.77 ___ _ $ 22, 528.54 Please be advised, there was no safe deposit box found for the above decedent. * If upon reviewing the information above, you believe there are additional accounts not referenced, please provide us with an account number and/or name of any possible joint account holder. For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds, etc., please contact our Capital Harrisburg Office # 717-233-6435. Sinc ly, ~~ ~~--~- Tracie Hare Adjustment Services Allstate Life Insurance Company P.O. Box 94212 Palatine, IL 60094-4212 Telephone: (877) 499-6418 Facsimile: (866) 635-4523 T~ecember 10. 2008 Gerald Fitzgerald 202 N Walnut St Ridge~~rood, NJ 07450 Re: Patrick Fitzgerald Contract No: GA18416966 Dear Mr. Fitzgerald: ~~ A~lskate You're in good hands. We received a request to complete IRS Form. 712 for the above referenced contract. The purpose of Farm 71.2 is to provide an estate or donor with the value of a life insurance contract or its proceeds as of a certain date (usually the owner's date of death or date of transfer of the contractj. Because this contract is an annuity, it is not reportable on IRS Form 712. I can, however, provide the followin/~ information for estate purposes: Date of Death: November 24, 2008 Annuity Value as of Date of Death: $ 45,596.87"` Cost Basis: $ 40,000.00 Named Beneficiary: Estate of Patrick Fitzgerald, deceased *The actual amount paid may differ due to Market Value Adjustments and/or any applicable Surrender Charges. If you have any questions, please contact me at 1-877-499-6418 Ext.. 86184. Sincerelti•. Donna Gray Sr. Claim Examiner ` ~ r~. ~~ ~GAraNFo Qualified Transfer Reques~~" ~ " ~ 4~' AS E~'~ Use this form to transfer tax qualified accounts, including IRA transfers and direct rollovers to Allianz. Enclose copy of your most recent statement from the firm from which you are transferring. Allianz ili contract O Existing contract number DA 1) Transferring arm informatioi~jQT~( (Company from which proceeds Owner s name are being requested) l SERS/Commonwealth of PA 30 North Third Street +ne Transferring firm's account/contraa number P.O. Box 1147 Harrisburg, PA 17108-1147 State ZlPcode 800-633-5461 2) Transfer authorization Mail completed form to Allianz Service Center (~dr~ esxs_'bglgw„~ ~ ~~n J PAI~ ~Y w~1 ~~/w Expected amount transferred: $ Qualified plans: Authorization to transf funds directly to Allianz Service Center. Certain states will require a state replacement form. Please call 800.624.0197 with questions. Liqul Lion selection: choose one option only wish to liquidate all of the above mentioned account ^ 1 wish to liquidate only a portion of the above mentioned account, totaling $ Current p{an type: ^ Regular IRA ^ Roth IRA O 403(b) ^ 401 D SEP iRA (At transferring) ^ Inherited Roth IRA ^ Inherited Traditional 1RA ~Do not check these boxes if this is a spousal continuance O One -Person Defined Benefit Plan ^ Roth conversion (The IRA at the transferring firm maybe converted to a Roth IRA at Allianz) Roth conversion federal taxes: ^ Do not withhold ^ wthhold % I understand that Allianz Life Insurance Company of North America (Allianz) does not maintain administration on my 403(b) account. The administration of this 403(b) account is my or my employer s responsibility. If this tax qualified account is currently invested in an annuity, check one of the following: ~ Contract is attached O Lost contract certification - I declare that the contract has been lost or destroyed and will not claim any right if found in the future. I direct the institution named above to convert to cash the assets held for the owner in the account listed above and to transfer this money directly to Allianz. I have completed the application for the issuance of an Allianz variable annuity contract in exchange for these assets. I understand the exact amount of the proceeds may vary ending upon thendat9e of liquidation and that funds will be sent directly to Allianz. Owner's name (print) - - OwnerrSsigna'fure O d~ Date Day telephone Evening telephone Representative's name Repre ntative's day telephone Registered representative -Plea se moil rms (no checks) to: ~rz wing ~irrrr orregistered repre sentative- Please mai~orms with checks to: Rgaular mail Overnight mail Regular mail Overnight mail Allianz Life-Allianz service Center Allianz Life-Allianz Service Center. Allianz Life-Allianz Service Center Allianz Life-Allianz Service Center 824240 PO Box 1122 300 Berwyn Park PO Box 824240 cJo PNC Bank Lockbox Southeastern, PA 19398-1122 Berwyn, PA 19312-1179 Philadelphia, PA 19182-4240 312 W Route 38 and East Gate Drive Moorestown, Nl 08057 All checks should be made payable to Allianz Life FBO contract/account owner name and contract/poliq number (if known). USA-375 (R-4/2007) ~~ ar~ .~as7~4.. sm ova, 1 ~ t / ~ ~ rurit~ei s.~o~•tua=~ ~ CFS 3-6 ~m"1°v SC°""• L..P. Atxau-t Numtrer Rep ID "w"~ ~vseo G10 _P~ ~ ,~ o ~ o~rt_ °~t ~~~ aN ~ a G For Rep CAM: ^ vends ^ Managers-1007, 5RA (houser~+old) pMsnayers-ioox sM~ (wo-ooo~w~cJ ^ a"ea tbo~dw~ '~ ~ Doty ^ tkrified Manages A~ets (DMA) ^Exdwge Traded vend: t~ p Indnc PIu: E. ~ A~ O -~v+~~ wte 7:70664.~S~~'>. ~ Plan. T ,e QTraditional IRA Rogover 0403(b) (direct business irttrestors only) O sEP-IRA O Roth IRA OSAft SEP (tran56er of existtt-9 Pin ~N) O Benefiaary IRA - Deceased Bertefacbor Name: 4 Account Information P~rafi le. - ' O Gedit Union Member Number(s) it mole tMa one N Meatier s separate aumbps M ravens) O~ Registered/Afiifiabed Persat • O a ff5 Regfstered/Atfifialt'd Person Account Holder Retired? es O No ft Union Member Numbers} on file O Non-Member re~tion to a ff5 Registered/Affiliated Berson ~pl~• F„ploye tame Type of eusres r~etlred or a p ~«~ate amid ~~e P a•) Hartisburg BDD Address E~oY~' ~~ cp StaWPivrince 21p code Spiedfy OowNVation oca'pam" lesplhori3nployasast(yss) (lf seN-employed, pkssse Describe.) Is your employer a regtsteted broker-dealer other ttrAn ff5? If yes, SEE YOUR COhWLIANCE OFFICER My employer k not a regts0ered broker-dealer. FOR WRITTEN APPROVAL, WHICH WE MUST QYes. My empbyer is a registered broker-dealer, mY compYance ktty is attached. RECEIVE PRIOR TO OPENING YOUR ACCOUNT. Are you a director, 10% shareholder, or poficy- making offfoer of a pubfidY owned company? If O Yom 50, spedfY oottlpan s}. . AMUalIncome O<#15,000 O#15,000-24.999 O#25,000-49 90,000-99,999 Q#100,OOo-i99,999 O#T00,000+ Liquid Net Worth O<;15.000 O#29,000-49.999 100,000-199,999 O#soo,6o0-999,999 ~ (cash, soodw msrtual funds, etc.) Q #19,000-24,999 O#.50,000-99,999 O#200,000199,999 O #1,000.006+ Tax Bracket % Net Worth (exduding home) /Tax Status O<;19,000 O #29,000.49.9990 #1~~199,999 O #500.006999,999 * ~ ~ ro O #15,00624 999 O #56.000-99.999 (j1~200,000-499.999 O #1,000,000+ Inirestrrtent Experience A eonds Mud,al Funds (PlBsse speoiry b Y~ d - If ~1e. Wt~•) Margin Trading _ Options Tradrsg Artntrities ~_ Imrestrrtent Objective 0 capital PreservaHOn O Irscane & Growth O O cash (For drdkdtlons o(these trnasbrsar diedties, please refs m the Customer ApreCrserrt Porllon d tlMs applkatiar.) Risk Tolerance O~ k.rr O~ 2003-2007 (.1150 FinarKJN ServiteR LP. rr,rr ~ISac N Rlgllt4 xesenroa. •°+F ..-_.._ r._._..~ ~~ Ailianz High Five' S"""'r~ Individual Flexible Payment Variable Deferred Annuity Application tic q~ issued by Allianz Life Insurance Company of North America (Allianz Life), Minneapolis, MN ,o Countrywide except NY sfCU,; r"+f~~ s ~d"d 1 be age 80 oryounger.) ~V`l r r/~l r l.r~~ r r r r` ~ I~ ~~~~ ~ r r r r r r r r I I 1 1 i Individua~thvrrer First Name Middle IniGai fast Name (Jr or SrJ, or Ili Owner is ^ Trust ^ Qualified Plan ^ Custodian (ff Trust, please Include the date of Trust in the name Man-Individual Owner Informafion ff Trust is Owner, please -efer b Trustee Representation form. I I-( 1 1 1 1 1 1 1 ~-~ /'~• fly / ~p n r~ /~C~F'~-.,,. r I Tax IDrnumber r I r I r t r ~~ J~un~ numne i r r r r t t e r N y~:~~W I `-ty~fU~~~~/V~`tJ II + 1~ I~ 111 o I~ II~ I-t I I I I~~~j~j_ ~ I~~J_ v City State ZIP Code Daytime telephone number Sex ~~~ j _ ~~ . Arr- you a U.S. Citizen? es ^ No ff no, need W8-BEN. ^ F Date of 8irfh (mm/dd/yyyy) Joint Owner (OpBonal) (Must be the spouse of the Contract Owner except in the states of CA, NJ, OR and PA.) (Must be age 80 or younger.) r r r r r r r r r r r l Ll I r r r r r r r r r i r r r r r r r I( 1 I l first Name Mrddle Inifiat Last Name (Jr or Sr), or NI I r r r r r r r r r r r r r r r r r r r r r r r r- r r r r r r r r r r r r r Street Address I I I I I I I I I I I 1 I II I I I I {-1 I I I 1 I I I- t I I I-t I I I i City State ZIP Code Daytime telephone number Sex ^ M I I I_ I 1 1_ I I I I I( I I I_ L I I_( I I I I Are you a U.S. Citizen? p Yes p No ff no, need W&BEN. ^ F Date of Birth (mm/dd/yyyy) Soaa! Security number Ir r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r l Relafionshio to Contact Owner Annuitant (Must complete ff dffferent than Contract Owner.) (Must be age 80 or younger.) Lr r r r r r r r r r r l L! I r r r r r r r r r r r r r r r r l I I I ( Fast Name Middle initial Last Name (Jr or Sr), or Ifl Ir r r r r r r r r r r r r r r r r- r r r r r r r r r r r r r r r r r r r r l StreetAddress I I I I I I 11 I I 1 1 II I I. I I I-f I I I I) I I I- I I I I-I I I I I City State ZIP Code Daytime telephone number Sex ^ M I I I_ I I I.1 I I I (I 1 I I- I 1 I_ I I I 1 I~ 1'ou a U.S. Citizen? p Yes p No tf no, need W8-BEN. ^ F Date of Birth (mrrdddlj~y}y). Social Security number This section must be completed. Please make check payable b Allianz e. $25,000 minimum Purchase Payment required. ^ Purchase Payment endosed with application is contract wiA be funded by a 1035 exchange, Tax Qualified TransferlRollover, CD Transfer ~(p7` Purchase Payment amount $ I1D,DO0 _ or Mutual Fund Redemption. (tf checked, please indude the appropriate forms. This section must be completed b indkate how this contract should be issued. Inherited !RA's: ^ IR{3/^ Roth 1RA ^SEP IRA NonQualified: ^ Qualified IRA's: ~A ^ Roth IRA ^SEP IRA ,^ Roth Conversion New Roth or IRA contribution for tax year Qualffied Plans: ^ 401 ^ 401 One Person Defined Benefit This section must be comp/eteai. Do you have existing frfe insurance or annuity contracts? D Yes' If yes, will the annuity contract applied for replace ar change existing contracts or policies? ^ Yes' o ff yes, the Registered Representative must answer the replacement question F40429 (2-06 C Model Regulation states. ~~ IIOI~ ~~~ in section 11 of this application.'Please include the appropriate R-f0/2007 J~ ~~ 3~0.0~ 1~- 3~0 ~ ~o ~, A Pfl