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Home My WebLink About05-14-09 (2)15056041103 REV-1500 EX (06-05) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po eox zaoso~ INHERITANCE TAX RETURN ~ i Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 162-14-8081 02212009 10301918 Decedent's Last Name COOVER Suffix Decedent's First Name ALICE (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW 1. Original Return ^ 4 . Limited Estate 6. Decedent Died Testate (Attach Copy of Will) ^ 9. Litigation Proceeds Received ^ 2. Supplemental Return ^ 4a. Future Interest Compromise (date of ^ 7 death after 12-12-82) Decedent M i t i d . a n a ne a Living Trust (Attach Copy of Trust) ^ 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) MI M MI ^ 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) ~.vrcr[~arvnutn I -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number WANDA K. DIETRICH, CPA 717-264-5961 Firm Name (If Applicable) ROTZ & STONESIFER, P.C. First line of address 1134 KENNEBEC DRIVE Second line of address City or Post Office State ZIP Code CHAMBERSBURG PA 17201 REGISTER WILLS USE OY ~~ o ~' -: a "_L ~ r :~-_., -~; J r ~~~ =>=i ~ : ~ ~ ~-t~ DEFILED ~~ -_., Correspondent's e-mail address:WANDAa1ROTZANDSTONESIFER • COM Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. fl DT IAGLIC DCO C/1AI o~c+n~.~r.i n, r- ~.... ~.~ .. .... __..__ _ /1 // , ADDRESS ~`~ -J v 1134 KENNEBEC DRIVE, CHAMBERSBURG, PA 17201 PLEASE USE ORIGINAL FORM ONLY Side 7 15056041103 B W 4647 1.000 15056041103 J REV-1500 EX Decedent's Social Security Number Decedent's Name: ALICE M- COOVER 162-14-8081 RECAPITULATION 1. Real estate (Schedule A) 1, Q . 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 linealrateX.045 633050.57 1s. 17. Amount of Line 14 taxable at sibling rate X .12 17 18. Amount of Line 14 taxable at collateral rate X .15 18 19. TAX DUE 19. 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056042104 324130.61 112361.09 24551.41 185170.49 646213.60 13014.89 148.14 13163.03 633050.57 633050.57 28487.27 28487.27 Side 2 15056042104 awasas ~.ooo 15056042104 J REV-1500 EX Page 3 Decedent's CemnlPtp Orlrtracc• File Number DECEDENTS NAME ALICE M- COOVER STREET ADDRESS 143 BEECHWOOD LANE CITY STATE ZIP CHAMBERSBURG PA 17201- Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 14 2 4 - 3 6 3. InterestlPenalty if applicable D. Interest E. Penalty (1) 28487.27 Total Credits (A + B + C) (2) 14 2 4 -3 6 Total InterestlPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in box 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) 27062 • 91 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 2 7 0 6 2.91 Make Check Payable to: REGISTER OFWILLS, 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; ^ X^ c. retain a reversionary interest; or . ^ 0 d. receive the promise for life of either payments, benefits or care? ^ a 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? . ^ 0 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. Far 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. SS9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. 9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. Far dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~116(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. 116(1.2) [72 P.S. 539116(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. 5~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. B W 4671 1.000 REV.1503 EX +'(s.98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF ALICE M. COOVER SS# 162-14-8081 FILE NUMBER 21 09-0190 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1.MORGAN STANLEY ACCOUNT #410-032659 (SEE ATTACHED DETAIL OF ACCT) 198,597.09 2. MORGI~N STANLEY ACCOUNT #410-053791 (SEE ATTACHED DETAIL OF ACCT) 125,533.52 TOTAL (Also enter on line 2, Recapitulation) I $ 324 , 13 0.61 swasss 1.000 (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF FILE NUMBER ALICE M. COOVER SS# 162-14-8081 21 09-0190 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. MORGAN STANLEY ACCOUNT #410-032659, CASH & MM FUNDS (SEE ATTACHED) 41,601.82 2. MORGAN STANLEY ACCOUNT #410-053791, CASH & MM FUNDS (SEE ATTACHED) 4,847.36 3. SUSQUEHANNA VALLEY FCU (SEE ATTACHED) 6,720.73 4. GENWORTH LONG-TERM CARE BALANCE 162.00 5. THE PATRIOT NEWS-SUBSCRIBER REFUND 220.90 6. IRS REFUND, 2008 FORM 1040, PERSONAL INCOME TAX RETURN 5,662.00 7. PA REFUND, 2008 FORM PA-40, PERSONAL INCOME TAX RETRUN 834.00 8. PERSONAL PROPERTY-REATAINED BY HEIRS, IN KIND VALUE 500.00 9. COUNTRY MEADOWS-NURSING HOME REFUND (PD 1 YEAR IN ADVANCE, SEE ATT CHED) 35,916.36 10. PNC CERTIFICATE OF DEPOSIT #31300271450 (SEE ATTACHED) 15,895.92 TOTAL (Also enter on line 5 Recapitulation) $ ~ 112 , 3 61 0 9 swafin~ t.ooo (If more space is needed, insert additional sheets of the same size) REV-1509 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER ALICE M. COOVER SS#$ 162-14-8081 21 09-0190 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A, PATRICIA A. SMITH 143 BEECHWOOD LANE DAUGHTER CHAMBERSBURG, PA 17201 g, RICHARD M. COOVER 2331 MEADOW OAK CIRCLE SON KISSIMMEE, FL 34746 C. JOINTLY-OWNED PROPERTY: ITEM NUMBER IETTER FORJOINi TEN1Ni DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BAN( ACCOUNT N.MBER OR SIMILAR IDEMIFYING NUMBER ATTACH DEED FOR JOINfLV+E1D REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1. A. SOVEREIGN BANK MM #571139795 14,414.05 50% 7,207.03 2. B. SOVEREIGN BANK MM 14,536.12 50% 7,268.06 3. A. PNC CHECKING #51-4001-3113 6,785.06 33.33% 2,261.46 4. B. PNC CHECKING #51-4001-3113 6,785.06 33.33% 2,261.46 5. A. PNC MM SAVINGS #50-0492-7156 11,1.06.80 50% 5,553.40 (SEE ATTACHED DETAIL FOR ALL CCOUNTS) TOTAL (Also enter on line 6 Recapitulation) $ 24 551 41 swasAE 1.000 (If more space is needed, insert additional sheets of the same size) REV-1510 EX + (6_ggl COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ALICE M. COOVER SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY 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. DESCRIPTION OF PROPERTY ITEM NUMBE IN0.LDETFEN4MEOFTFETRANSFEREE,THEIRRELATIONSI9PTODECEDEMArD TFEDATEOFTRAN F DATE OF DEATH %OFDECD'S EXCLUSION TAXABLE S ER,ATTACHACOPYOFTHEDEEDFORREALESTATE. VALUE OF ASSET INTEREST IF APPLICAB ~ AIG ANNUITY BX203363 LE VALUE . 10,154.24 100$ 0 10 PATRICIA A. SMITH, DAUGHTER ,154.24 2. AIG ANNUITY BX202372 10,154.24 100$ 0 RICHARD M. COOVER, SON 10,154.24 3. TRANSAMERICA LIFE INSURANCE CO. 12,894.45 100$ 0 DEFERRED ANNUITY #007378488 12,894.45 PATRICIA A. SMITH, DAUGHTER 4 TRANSAMERICA LIFE INSURANCE CO. 12,894.44 100$ 0 DEFERRED ANNUITY #007378488 12,894.44 RICHARD M. COOVER, SON 5 NATIONWIDE LIFE AND ANNUITY 53,828.60 100$ 0 NON-QUALIFIED ANNUITY#07-1048566 53,828.60 PATRICIA A. SMITH, DAUGHTER 6. NATIONWIDE LIFE AND ANNUITY 53,826.37 100$ 0 NON-QUALIFIED ANNUITY#07-1048566 53,826.37 RICHARD M. COOVER, SON 7. UNION CENTRAL IRA #A61320133C 15 709 07 100$ PATRICIA M. SMITH, DAUGHTER , . 0 15,709.07 8. UNION CENTRAL IRA #A61320133C 15 709 08 100$ RICHARD M. COOVER, SON , . 0 15,709.08 TOTAL (Also enter on line 7, Recapitulation) ~ $ (If more space is needed, insert additional sheets of the same size) 8W46AF 1.000 185,170.49 REV-1511 EX+(1,0-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES ~ ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ALICE M. COOVER SS# 162-14-8081 21 09-0190 Debts of decedent must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~. NEIL FUNERAL HOME, INC. (SEE ATTACHED DETAIL) 10,169.89 2. FUNDERAL RECEPTION 200.00 B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: State Zip 2. Attorney Fees 0 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 7 0 . 0 0 5. Accountant's Fees 2, 4 5 0. 0 0 6. Tax Return Preparer's Fees 12 5 . 0 0 7. TOTAL (Also enter on line 9 Recapitulation) I $ 13 , 014 8 9 awasnc 1.000 (If more space is needed, insert additional sheets of the same size) R~V-1512 EX + (12-OB) pennsylvania SCHEDULE DEPARTNENiOF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER ALICE M. COOVER SS# 162-14-8081 21 09-0190 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. VERIZON (DIRECT PAYMENT) 2,77 2. HOLY SPIRIT HOSPITAL 100.00 3. VERIZON (FINAL BILL) 45.37 TOTAL (Also enter on Line 10 Recapitulation) ~ 3 14 8 14 BW46AH 2.000 If more space is needed, insert additional sheets of the same size. REV-1513E'X+(11-08) SCHEDULE J pennsylvania DEPARTtv£N70F REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER ALICE M. COOVER SS# 162-14-8081 21 09-0190 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 2116 (a) (1.2).] 1 PATRICIA A. SMITH DAUGHTER 1/2 SHARE OF 1. 143 BEECHWOOD LANE RESIDUE OF CHAMBERSBURG, PA 17201 ESTATE 2 RICHARD M. COOVER SON 1/2 SHARE OF 2331 MEADOW OAK CIRCLE RESIDUE OF KISSIMMEE, FL 34746 ESTATE ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 1 8 OF REV-1500 COVER SHEET, AS APP ROPRIATE. ~[ NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN A. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS B. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ IT more space Is neeoea, msen atltlltlonal sheets of the same size. BW46AI 3.000 R T ~ \ Y :~i^ ~ * "~ LAST WILL AND TESTAMENT OF ALICE M. COOVER KNOW ALL MEN BY THESE PRESENTS, that I, ALICE M. COOVER, presently residing in Hampden Township, Cumberland County, Pennsylvania, do hereby make, declare, and publish this as my Last Will and Testament, hereby revoking all former wills and codicils heretofore made by me at any time. PAYMENT OF EXPENSES i:_: ~' ''~ ~, -_ `: } ' ~'a :`~:.. . I. Payment of Expenses. I direct that my Co-Executors, hereinafter named, shall have the power, but not the duty, to pay all my just debts, expenses of my last illness, and funeral expenses from my estate as soon after my decease as shall be found convenient. II. Personal and Household Effects: I bequeath my automobiles, household and personal effects and other tangible personalty of like nature (not including cash or securities), together with any existing insurance thereon, to such of my children as are living on the thirty-first day after my death, to be divided between them in as nearly equal shares as practical. III. Residuary Estate. I give, devise and bequeath the rest, residue and :remainder of my estate, whether real, personal or mixed, and of any nature whatsoever and wherever situated to my children, in equal shares, per stirpes. IV. Powers of Appointment. No provision of this Will shall exercise any power of appointment I may have. FIDUCIARIES V. Co-Executors. I hereby nominate, constitute and appoint my daughter, PATRICIA A. SMITH and my son RICHARD M. COOVER, as Co-Executors of this my Last Will and Testament. In the event that either should predecease, not survive me, or decline the appointment, the other shall serve as sole Executor. VI. Bond. No Executor (Co-Executor) shall be required to give bond or enter security for the performance of their duties. -1- ADMINISTRATIVE PROVISIONS VII. Management Provisions. My Co-Executors shall have, in addition to the powers and authority conferred upon them by law, the following additional powers and authority: A. SelULease: To sell at public or private sale, exchange, lease, mortgage or pledge any property, real or personal, at any time constituting a portion of my estate, and upon- such terms and conditions as they shall deem wise. B. Invest: To invest any money at any time in such bonds, stocks, notes, real estate, mortgages,. life insurance, annuities or other securities, or such property, real or personal, as Co-Executors shall deem wise, without being limited by any statute or rule of law regarding investments by an Executor. C. Retain: To retain, without incurring any liability, as investments, any property owned by me at the time of my death, as long as they deem it wise, and even though such property is not the kind of property an Executor would purchase as an investment; and even though to retain such property might violate sound diversification principles. D. Title to Property: To cause any security or other property which may at any time constitute a portion of my estate to be issued, held or registered in the Co- Executors' names, or in the name of a nominee, or in such form that title will pass by delivery. E. Expenses of Estate: To pay all costs, taxes, charges and expenses in connection with the administration of my estate. F. Allocate: To determine what is "Income" and what is "Principal" hereunder, and their decision thereon shall be final; and to purchase securities at a premium or discount, and to apply or charge said premium or discount against income or principal as the Co-Executors may determine. G. Borrow: To borrow money from any person, firm or corporation, for the purpose of protecting and preserving or improving my estate hereunder; to execute promissory notes or other obligations for amounts so borrowed. H. Employ: To employ legal counsel, accountants, brokers, investment advisors, custodians, managers and other agents and employees and to pay them reasonable compensation out of the funds held hereunder to which said compensation is attributable. ~ ~ /-! "~ ~ ~ / ~ '' ''y~_-- -2- I. Other: To do all other acts in the Co-Executors' judgment necessary or desirable for the proper and advantageous management, investment and distribution of my estate. VIII. Protective Provision: To the greatest extent permitted by law, before actual payment to a beneficiary no interest in income or principal shall be (i) _ assignable to a beneficiary or (ii) available to anyone having a claim against a ..beneficiary. IX. Death Taxes: I direct that all transfer and inheritance taxes, state or federal, assessed because of my death, whether the funds, property or insurance proceeds to which such taxes are attributable pass under this will or not, shall be paid out of my residuary estate; that my Co-Executors pay, or provide for payment of all such taxes at such time, or times, and in such manner as my Co-Executors deem best. X. Tax Options. I authorize my Co-Executors to exercise any options available in determining and paying death taxes in my estate. IN WITNESS WHEREOF rit enIon three O(O` heetshof paperrwhichhI shave Last Will and Testament, typew identified at the bottom of each page by my signature, hereunto set my hand and seal this . `day of ~ > 1997. ALICE M. COOVER The preceding instrument consisting of this and two (2) other typewritten pages, each identified by the signature of the Testatrix, ALICE M. COOVER, was on this day and date there of signed, published and declared by, ALICE M. COOVER, the Testatrix therein named, as and inrther resents lof each othernhave us who, at her request, in her presence, ~ subscribed our names as witnesses. , ~ -~- ~ } ~ ; ~ ,. ~_ /` t -3- COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN I, ALICE M. COOVER, 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 the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. -_ ,. +_, . _ - ALICE M. COOVER Sworn or affirmed to and .acknowledged before me, by ALICE M. COOVER, the Testatrix, this_3%'-~~ day of,~;~~; ~ ;,~,~;~' 1997. 1~ (SEAL) 7 Notary Publi~~ Notarial Seal Gloria A. Cuddington, Notary Public Harrisburg, Qauphin County, PA Nty Commission F~cpires Feb. 14, 1998 ... -. -s A,r. COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN We, Catherine Moran Betty J . McClure ,_ and Richard E ..Connell the witnesses. whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testatrix sign and execute the instrument as her Last Will; that she 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; and that to the best of our knowledge Testatrix was at that time eighteen or more years of age, of sound mind and under no constraint or influence. k~=~~'~~~~ dl) ~ -~~t y ~... t Sworn and affirmed to and subscribed to before me by Catherine Moran and Betty J. McClure and Richard E. Connell ,witnesses, this 3rd day of September , 1997. (SEAL) i Notary Public Notarlai Seal Gloria A. 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N 1 f N N N' iN N ' N N+ N ~, l ~. 1 N 1 1 3 N N 1 N , 1 1 N, ~ 1 1 t 1 N N 't N . :I N 1 N. '1 N i N '. I Y i l 1 1 1 1 1 1 I 1 t „ . ~,, .n ~n .o ~D ~O ~O ~O . ~O .n ~D ~ ~O, .. ~ . O ~- ~ , '~ c~ ~ O O+ m ~ m O~ Y r r r r r Y N W N • ~ J `r r N r ~ tp W ~ m a w W W - W lT ~ , ~j +ln W W In 4 -o o o o o o o N lit ' o fo o n m ~ v ~ ~ ~ '~ V v 'o o~ 4. ID ~ ry ' ' ; a r ~ ? : V i : r - w i U u i 0a c Vj p O o .O ; ! O 0 0 O O O~ N r N o ~ o- o, +.0 to V O o O N iT' bi p O O (~ O O : i N ~ fn 0 0 N ~ N ~: A ~ O W r N: .~ N r W ~ In i W F+ N N+ W Q,' tJl 1 (Z '. O~ O W W O ~ O O` ~ N W N W F+ .F T ~0 ', r .F p N : .t` V 1-~ ,, ' lii + o f p D Q^ tN In lT -•, .'.. ~ N In In r ~ . - N o In w :. V r .n .o ~ ~ d ' .F ~~ C W m o• m ~ .n o ql ~: to ro W o w, 0 0 ~:. '~ Q D D D ' D D a D D D. D A. A O y J . J O : tD . N ~ N y 3 ~ w N ~ ,,, () . Q ' (p r r ~ ~-+ N W W 1-' In N N W O~ N Ilf ~ N ~ V V V ~O 1~ !n r, Y r W t+ W.' ' O - V J ~ W ~ O~ lT• O m V l11 ~.p V F o W V. N ~O c~ ~ .1~ ~ ' ~ to .fi . • V O In !n V V o ~ - " o ' ~ :~ W ! lT -: Cn lT (p 't71 O '' O O ~.. of IIt - O VI O O m x ~ a a m 3 ;' a o J ` N ~ ~ ~~- V , O - W , , VI ~O. O~ . ' W W ~p 1~ ' W Q+ ' N lT : ' " W ~` h+ -. H Q~ -. W W'. l7t . ~ N . ~ ~ N ~ .D Y N F o -.. o o o .r Y ~ a ' .. tit In w w. o w ., o 0 ~ ara r nr Dr ra 'rai-nr ar•a ~ aj- ar b Cm C m Cm Cm W C m Cn Cm Cm :C m Cm Cm: N ~ t'n ~ N ill: ~ " N. N N Vl N N 1 --1 -1 -i =1 -i -i -i ~ ~ ; ~ 1 -i -1 -1 -1 -1 -i 1 ~ -i -1 • m • ms m• • m • • m• S " ~o m • m. m• , v -i o-i o~ ~ q ~ u -s v-s o~ v ~ va v-i: ~ 3- 3' 3 - 3 3 :: 3 3!' 3 3 3 3 3'. o -- o ~ ~ O O ' O 'O o -0 O O N N \ \ ,\ \I ~ \ \ \ N \ ~ \ N N N N' N N N N • N i rn m m m rn rn m o+ ;o~ . m; m ~" ~', N N N r N r '~ 1 o i ?1 O I o - ~O ~ ~ ~O 7 Q ~ N O~ V O' N . O~ ,'CQ ~ ` ;o 0 0 1 ~ 0 rn +{o ;O 0 o 0 O ~ `' '~ Ob I W Y O •~ Cl , i V N W N ~D O ~ N O~ ~ In t-a ~O ~ ~., O fn ' !~ I ~~ l ~ ~ ~ D " ~ : '. d INTI lit ~I + ' n m :o w ~ N 1 I N F ~ Q I o ~ I ar a'r Dr ~ va Cm vo Cn vo ~ "C ~b ' ~ D m m t n m o'Q i c 4 o l m s C l o~ vz o~ o` w~ i 3 :_; 3 @ N ppt ~~+ ~Z~ N N ` ~ N ~ : N \ -N '~ 061 : " . m ~ ~o ~ w ,c .o ~ I ?i i O n r~ 1~1 ~ C Z Z ~ Z ~ ~ ~"+ O n [ ro 0 °m v D m W O 0 ~•1 v N ti m n c D 77 m A~ 7 Q N fD (7 (D N ~~ ~ ~_ Q ~ .-. 7" ~ ~ C ~ ~ ~ ~ (Q ~~ ~ ~ ~ ~~ ~~ -~ N n O 7 n O O N (D ~_ n 0 A W m .~ Z Z ~- . ~ ,~ .~ ~I- -~ : ~. o I ~ O -~ i~ O' .. N D O O O O D - :. 7C m ~ m 7~ D 7~ - F 7C I Q O' C` O Z O '-1 O m O H (7 D ~ r n ~ ' H ~ Z H ~ a H o m ~ C7 n c a ! ; ~ ~ ~ ~ O ~ ~ ~ ~ ~ ID ~ `~ ~ m : r ~ ~ a ~ ~ ~'. c-C ~ :v ~ r a ` ~ o o ~ n! pr ~ ~ ~ ~ '0 ~' m Q ~, n ~ ~ n ~~ ~ O 4 C ~ ~ ~ O fn ~~ ~ ~ t 3 ` ° °' ~ y ~~ x; ~ c _. m ~. _ c m Z1 • d i ~ ~ N`~ D t i , t t t ~ 4, :. ; i : ,~ t y O f ~ r ~ V o '. .NO V r Oo . '': T' V Np .p r r. ~ N .n N r H ~ H p1 ' 'p, t fD, fm ~ CY ~ n t '~ ~ O irn r i 1 ~' [ ^n n y' o N o N b, i N : o' N i o o o b N N N N o n7 0 N 0 N 0 N 0 o t N N t ti O t q ~^ : ~'' f N 1 N . "1 ~. N, 1 N i 1 I t q I ` 1 N N '~ N N i it " N I N 1 N 1 N 1 ± 1 N N ~ OJ ; "* N `G ~ ~ H. H H, ~ H. H H,; r H ' ' H 1 r 1 N I r 1 H ~r- 1 ' 1 . p ~lA ~ ~ 1 O ~O I O .O f o ~O 1 0 ~O r I l t O ;O oO ~O -~O ~O ~O :O ~O O ~0 o ~O O ~O : O !O ~O . f~0; '. Tj ^ A ,p t . : ~~ 1 ; ~ ~ ~.. `G } Dl r-.. ~ " ~ i ~ '. ~ ~ ~ , ~ d ~ M H H D ~ 3 N N N N ' 0 r 0 H 1~ O~ 1` it 0~ m ( ~ ~' 27 ~ s tr In In W !~O .n . m . ~ .O c0 r H H r; ~ _ ~ 0 : q . `'~ ` ^~ ! Q o o ~ O~ O O IO o '.. o ~ ' t lf1 ! ~ ' Ln ~ ~ t O)'. W H H H ~ (~ ' i ' ~ N N N i V V V V V : V ~1 ~O ~ i0 " ~D QD } ' OD VI O~ In ~O U7 ~O ~O Oi 1J7 AI ~• Q 3 Q tD ~ y " ~ f ~^ ~ O O 4 O O' ! ' O ~ O O 0 O O O O O ~ Q . o O O O . lit F+ In ~ In O (TI 4.H ~ o : W O O ~. y i . .. M ~ y .j G o o . o 'O O „ O o o O zV 111 O i V VI o '. 01 o o : O O 1 ' ~ ~ W : i ~ 0 y .~ t' N h ~ ~ N ~ QD N t - ~ T N W S W - .H' 1-' .O N N .~ 41 t:_ : ; Q.' N to H o O to V j W t ~ fT t,W R` W U1 O+ V ~O N ~ W N :Q W *! G1 W H lIT H ~0 ~O 1n V : o~ '.F W O ~G ~ ^- (~ ~ ~ Q O tD ,' O:' QD N N ~ VI ~ ' 1~ o , :o W -4~ !~ o VI 1~ .L~ v ~ N .~ N m VI VI V H ~ O~ VV : ~I -0 ~O W 4 r .O r Wv -~ x~ „y, . ~y Q ! A D ~ D . '0 ~ 'D 'V ~ D ~~ D 'O D D ,, ~ ~ O y ~ ~ Ip° ~ `N ~ ID 1 ~ p Q•;~ ~ N tN~ ~ N ~ ~ UI N W !N H F+' I~ "N i N ~ -~, pr b O .O H m Un V U1 p+. W N P. .y ~ ' o V W ~ ~W !Q1 x. I W N o O~ N W +~0, N D W H O O, . 1 ~ .F' - o .1T1 Or W N Q ~ H VI N ~ D W t0 ~ .L~ ! 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O ' ~ W V ~ O7 ' V1 O V1 ; N .. N 171 OD lT N V r lJt .~ j o , W .o , , r-! V ,1-+ r , ; O` + : m r to W m r r .o ou fA ~ ~N ~ ~ V O b~~ a O O ~ : W ~ W Q~ ~N ~ 1~ V N : + W ': W N V ~ V Oi N Q) N lT tn. N : lst m V O O+ ~ .~ y X : l ~ d~ 'i O I a+ r -~ w m r-+ r r r r N 1-! . N ~ r N i s : O T i .~O : 1~ ~ O O+ W W: O+ V VI N r N ~ h + _-. W 07 ~:. V N ~O V ~. F-' ~ ' ~ - F+ 1-1 1~ ` ': O ~ O~ lJ1 F+. W . - W : O~ - N , ttA , .~ O~ F 171 l71 .A V o ~ V O + •- O O± N rnrar arnrar ~ ra r r nr rnr 0 00 00 0 00:00 o 0 0 0 00 o ao o ~.o ~~ ~.L~ ~o L ~:t_ ~ L~ Lb ~ L~ m Cn m cm Nm Cm ~ m .gy m m; Nm .m m ~ N _ N _ i ,~ -_ V "'1 -'1 -1 --i -~ m• mm m•: =-1 1 -1 -1 --t -'t • m• m• mm -1 -'1 • m -'1 • ' ~ -'1 • -- '--1 m• 1 ~-~ -~ 1 •:mo ~ 7 O~ 07 ~ O-~ 0'1 v 'i'O ~ ~ z Oy ~1:0~ '3 = 3 3 3 ~ 3 3! 3 3 -: 3 3 -' 3 I_ O O N N O .O~ p O -- N, N N :O 'N ~ pI. N~ -q N I N N ~ N, N N N •" N: N 0 0 o 0 0 0 ::o o! o. ,. r E. I 1 i N m m, ~ n 3 n' 0 0 r m o ~ A?: v, l to ,O ~ [~/~ Q ~ ~' i~ r N ! 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H o IYi. - O:. 4 ~~ ~ C - ~ ~ ~ ~" ~ ~o ° ? ~: ,~` ~ ~ n t ~ ~ ~ t ~~ ~ ~ ,. ~ ~ T l/ z, ~-° ~^ ~ ~ pJ ~? ~ , ~ ~ to P V ~ o ~-+ ~ W N Q1 F-~ F W T~ O~ '. ~~-+ lT~ I ? _. ~ N V~ '' f ~~O N W 0~ lT1 (~ ~ N . , O .'., j u~ . : s f t ~ ~ 01 ~ r`. `y' . ' a N o N 0 N 0 o N N 0 N 0 0 N N 0 N _ 0' o; ~o` N N'6'N J' , o~ o' N N t J ~ °, ,,C ~ ° Jai N i N ~ N i ~ N !N ~ N ~ i N N i N: i ~.r: a; N -N'. N ° i ~ ~J. N N i a •~ r r r ~ r ' r ~-+ r ~ r t+ +¢~ ; t-+ l r r ' ~.~• j: o io. >o o .n o ~n o o ~n .o o ~n +o.-o w .a :o ~n o+ o o .n w± ~a o o ~n .o ~ r. ~ " ~ ~ 4t ~ ~ ' '. ,. t i '. . ' ' °w ~ O` ` ~ ~ , w w ~ t ~ ~ a va+ : vi ~ I ~ i ~ ~ t `~; ~ . ~ ~ ~ ~ o a u i , i ~ . , . Vt vt j R 'a •'~ O N N N Q? ~ i~ 0 .~ ~ ~ ~ ' Q+ O, O~Ji Q+! OVt N s N ;N 3 " '.~ t 0 a~ Q ID 1~ ; ;y, ~` D -t~ O r , cq, a o m o m:;w O l i i0 ~ U1 au O+ m m O~ lT~ o b o O o ,cat ot O k O ~ O B Eio I L? . o;o O i~ O 1 Ew ' ~~ ~ t, . < fA - b O : O k O o b O V 01 O O O O OO I O ' O O` r O t ~~~ ~ Jn =o O O. 'O q QO Y V O o O O O" O O .O O !O , ~' f~0 t O ~ O " A w ~ , ~ a .? t ~ ° ' 0 ~ ~ C ~ r ~ Oi N O W t r V 4~ r ' 4J7 Or W ~--~ W '. N N ~ N V O~ Q~ N N N j ~ ~ N 'V' .~ O+ '01 N ~ i-+ V O) ` . aR p ~ '-7 • 1 t Q. ~O W W ~ O` V N - 1~ V ~ O) t t 4T7 '. O~ Q+ V N .O W W ~ as , -0 N W O ~ ~ ("~ O (D ~ :~"' ~ W : N O~ 0 17I `1` 01 ~ 1~ .n P o o F m 1~ o O+ ~ y 1 y ~ ut QY o m o (t1 ~ t .~ O Q~ W N O O O O O o o O ~~ °;. ~-. .r. Q a a; a p' n a a a a n a n b » ~ O'y. J ~ ' ~ ' ~ ~ tp G' t'p d 1 ~ E " ~ ~ ~ ` C ~. N Q O ~- ~ N ~ W ~ ~ ~ ' N ~ V V N N ~ ~ ~ n ~ ' O ,. W ~ V 7i l W '. ~ •A~ r .~O V V ~-' . W W V ~O lTl ~ . W N 1~ V ~ 1~ b A ~-+ t+ U i ; O` N ! O+ SAD ~ A C'1 w ~ ~ D1 .F ~ N W ~ q ~ ~O U~ W OD V V 1 O W I W .4~ ~ Y fi ~:. O ~ ~ O ~ r 1 o: ~ ~ V o l7~ 0 U 0 n W T; C~ U1 V1 V C ~ x n ~ ~ ~, c~ c ° o '~. c ~ w ~ _ W _ W _ t+. _ F+ •• ~ U1 N N N• W F+ W W .4~ f+ ~ W ~ , 1-' N N ~ . ++ r r~ ~-+ ~-+ , W 4 W !. ~ ~ F+ ~ W ~ U1 0 $ U1 I W W V ~. O W W ~ O'.. 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' Q y ~ p O N ~' ~„~ Q Y . C 0 O ; , , ' p ~! 0, C 61. ,~ ;,,o' ~ 4 ~ t t ~! t O ~ ~ 7 3 h ,; ~' n; t t ' l i :i ~ ~ I m a i S' (D ~ t c ~i ; ~ ~ ~ , m; , ~a ; ~. W ~ ' pl ti, ` ~ ~ ~ ~ N ' W r 1-'' lJl OD N ~ .fi "F ~ -0 ~ 7 l t-~ ~ 1T r W ' Cp 31-+ ~ Sy M ~ . ~ , ~ ;G Y : N , J VS N ~O W i ~ ; 91 V,1 . , P 1 lTl ~ 1'j ~ {; , ~ is '~. ~+ ~ , I N ~ j y, y^I Q ! O O ID O; ~O O a ~O O, Q i 1 O' O t . t O t i a ~ O' O t i s ~ ~ n C ': to ~~ N i - N t N N N N N. N~ t N N N-. i N N: N 0 t: n1 ~ .~. = ,~.-. . ~ { 1 ~ `N ;- 1-' Y N. F+ 1 N 1-' 1 N Y 1 N r 1 N h' 1 1 N N 1-+ I--' 1 N L; t q 1 l iIV N , , F-~ r 1 1 1 N ~N N 1-+ F' 1-+ I N I-+ Ili ~ '.~ ` W i ' y 1 ~',. : ~ o O vp P ~ ~o O ~o t~ O .Ip o .o 0 .o 0 0 .n .n O .n a: O ! ~o .p O O o .o . { ! a .p o .n - ~ ~ , ~ ~~p : t t ;, ~ , t R ~ " " i ~ r ° r t ~ (D (D , j ~ n~ pl -~ p ~ ~! ' : V V N N i N ` N N N W 0~ t -L~ ! ~. 1~ ~ t! IN Q ~ N i N N 0~ ~ Q do N W 0 ,~ tq ~ ^ t Q _ a ~ ~ ~ . 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' . j,' ID ,- W N ~~ N N T j o ~ ~. ,a w r fi to r trir W ~W ~. ~ W -V-~ p 4 Dp t ;,ss 'ap n n cn cn c cn a o° N a Ul N m ® : (/1 m ' N ma ~°' °O' ~ ~ ~ ~ ~ 's 7 q p1 ~ Wj b 9 3 O H,O 3 o C 3. ~~ : 'al Zi CO N N N "-\ \ \ ~ ~ N N ` ~ N ~ N ~ - 0 .O ~p .p .p .p, ~ ' 1 ~: I I ' rr ^O ~n..,L 7~/ e--F- )..~1~ 'fi '~ ~ n 1~1 o~y lCry 4, ~_ ~n c ~ n z N O tQD m .A 0 -17 N N ~ en o r w ~ ~ vi ~ o ~ cn ~ ~ ~ ~ ~ ~ ~ ~ ~, ~ x ~ ~ + p : ~ O o ~ o a1 o I ~ 7~ O 7C , Q~ 7C ~ m~ 7~ D 7C Z m ~ ~ ~ ' k C °- cn °i- ~ o °+- ` ' off- ~ ' m , ~ ~,~ C ; ~ H r . gM : :. ~ , , ~~~ ~, " lO ° ~. -~ $ c-- ~ ~ o ~ O 1 ~ ti ~ z ~ , o ~<~~ m ~C n ~' ~ x ~ a ~ v ~ su :> ~ o o r ~ , ~ ~ , ': rn ~ ~' ' j m p ~ ~ Q b ~ ~ ~ n' Z N , I C'~ C ~! ^ o "~ H n ~ n ~ tr. r D V' ~ ~' ~ yy F`v q C ` O . C ~ , , i , ~ ~ , ! , , U1 ~ ~.~/ , 3 1 I ! i~ ~ ~ n n I . ""1 ~ ~; Q ~ O : r <n ; l y . .4 ~ Q V z n lT -4~ q ~ O~ ~C .F -. 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'tl .~ O n [ z ro Q ~' p' r+ p ' ~n p t ~ n ' m „ ' ' o c r m o ,~ x ~ ~ i ~ ~ v ' t - ~ A ~ " m o"Q" ~ a ;N p : ~ o ( ~ o ~ o r ~ ern :: m m: z ,m, + 'a :m D >m --i ' ~~ D nm~ } ~ 0 ~ 3 ~ O; + mO "' ~ ~ ~' . z ~ I~ Q r " ~ t cC , ICn ' ~ o ~ v ~ cn ' m ^1 ;: , ' ~ ! .~. ~ i , ; `~ r ~ , ~ i , ~Q"; ry ,~ ° ,~ `'oI o ~ fD ~ r.. f. 67 ~ ' i ~ ~ ~ ~I ' ; ° C + ~ / ~ a ~i ~ a H ~~ ~ ~` ~ ~ " .. r " i ~ ~ a i 1-' ~ N .o V w w + to r N w ; w ~ fD y cp ~ + , + i 1 Q c7 ~ ~. + i ~ ~ ~ ~~' ~ O R ~ ' O b o Q ~ ~ O O l~ O + o O O , d! O i ~ ~. p C n N N N N N N -~ N' IV N N t N N! N p C~~ (pI '~ ~ ~ N w; ~N' ' r N r N r N++N w w t N w N+-N w w AT ~ N~ + r r i N N+, w w .~ ~ ~ ~ y ~ 1 1 1 I , 1 1, 1 1 i 1 p 1 1 1~ (; 1 k (n ._ C j' O O o o O~ ;O O O O 4 i0 O ~d O t. i I S1? ~ ', ; ..,, .O ~O ~O ~O ~O i AO ~O ~O ~O ~O :O +O' ~O ~O } CD ~ ~" ~ ~ Q ` t i ~ + { o N ~ n~ 3 ' °' + " + 1 ~ _ p1 ~ ~ ~ W V ~ V ~ V ~ V 0/ V 1? N w k' N' ly r N w W N, w H ~ SM W+ . O w w w W b ~ b o W rW + O! O ~ p0 ~ Q- ~ 'a : ~ o, m m o+ 1 ; , m ~ c+ a+ o: ' , m ao ~ " 00 ` pS 41 W 'i1 ' W W m au 3 ~,. 7" Q~ ~ A O r Q r O `O i + r 0 "O V ~++iN 7 ~ AV ~{P W ~ ~ } ~ "+ < ~ , ~ o O ; +O O ib i r O O O O ~ ` O ; O , N 7 : O i ~ Vn N + l1 . V7 O F+ V7 IO }O+: O Ot O mo } O~ y r..- 'i~ ' 'O O O+ O O O ~ : ~ Ot O O O+ i O-; Q+ b . E O ''vQ +~ O Q'+ O=i ~ . w, < ~' 0 M1i _ ~ i t 4 j 3 ~I r* Q ~. Vl ' I t ~ O '. O + 0 W 3 ,~ t t i ~ ~ '7, i rn ~ ~ ~~ ~ 7 O ~ 1~p C j N W ~ W ~ N N ; ~0 N w ": w ~O N tT1 w ~. V7 . W N " . ~ ~ ., + ; 7 = $ ; N V U7 0 W 01 lTl 0 W V O~ N ~Q W ? O ti W fi 0+ N ~ W+. N T W .4~ W 'V N V ; W w W + 4~ ~; In : O V + V : 0~ ~I ~ ~ ~ y ~' + ; ,~ i + , ~ ~ ~ ~ 1 ~ O tD ~ fi1 i O~ O~ V Oi 1` In V m p~ .n 01 W .~ V O ~ Q+ N T AD N S ~ V to W , d ' y~ ; k+ W ! N A ~ + 'O~ N O . ~ + ; o ~ I ~ i , w i O 7 tIf o + O + ~ ~ ~ c, O ,"~ i. 1 S?°I ~N 'O.. ~ ! 1. ... , ~ O i ~. ' ~ N ~ Z ~' n ~ N ~p W .L~ W ".L~ '. 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O y ~ ~ ~ ~~ I ~ ~ W A) n N ~ In In r w .n w W W W In 7 1 J: Q T Ot ' W .171 ~O ~ F+ O~ N ~ ~O W 1-+ V 111 r V V F+ V N W (n ~ ~O tD y ~` . r :1~ ~ V ' N In m !~b - v ~o ~ to ~ ~ 7, '1 H ~. o C ~ N t!i o -.. _ W o W O~ N m .O o ~ I '. pl -.$. Q D D. D D ~ D D D D ~; ~ py 3 ~ ~ ~ 0 Cif o- O~ ~ N ~ y h i ,~~ ~ ~ O Q O+ ~ l71 'r ~ ` W , .p W w W 0 171 o N V a N W m o W ~ ~ , j p'+. - : . O - t ~ ~ p O , ~ O i Q 1 V1 ~ OD .~ ~ ~ O O W N OD -Q~ l71 - ~ : 61 ' ~ W 171 O 171 O O p1 ~ ~ .~ O (D ! y K N b fD b m 3 °; ~ ! .,. 0 m~ ~ , ~~ N ~':i 1~ V N ~ :r .:. r N !-+ O ~O nl - - ~ :F V N. U7 ~O~ O 1~ o O o i F+, N O N O' W CD V 07 In o I ~ X Dr 0 0 ~ rA O Q rD O ~ r O ra O' 0 rD~'r 0 ~~0 ayr p 0 ' ~7 7 7~ '7 L 7'U 7't:7.: L'7 N O t0. N tl N m ~ ID __ 1C FA _N..IG , . 7C IQ ~ 1 -[ ~ -i ~ 1 1 ~ 1 ~ ~ 1 1 -i'-i 1 =1 mm oz o m z o m m ~s o m -7 m m ~ o o mm -s oz mm v~ 3 ~ 3 3 :. 3. 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O O fN W O O U1 O W C O O W V Q O~ O V ~' ~~ O '•~ ~ OOf00.0 VOQfOON Wf•~O~D i•~+O W=O,O l111t10 WOH _ O (~ 1 1 i 1. ~ ~ O < ~ ~ ~`n; ~~A~C.f7~~W O~X~t~tA~DCC'1Z2~r~~~Z C~ ~ a -+ ,~ (V ~~ ~ ~ to N C Z 2 Z ZZZ ZZ ,'~ Z ', Z N ~ i "~ • r • m• r iD r r '• r p x x x xxX xX'' x X x o O O OpO q~' C] p q µ µ 1+• Y•µµ'µ M•~µ '.µ W - a a s aaa as a a a ap. r r r rr® ow w r r, a a s aaa-aa a a a o~ a a a aaa as a a a p r r r m r r r r r r r ~rt r r r rrr mr ~ r r in z, s s r m r w m r o s r 0 0 0 000- oca.'o o r °~' gAj ~ ~ ~ °:~~ ~~ ~ ~ ~ m 0 0 0 ooa o0 o Q o ~ .a ,n .\o .o ~a .o .o ~o w ~o; ~o o Q ~ ~ ~J - N QUEHAN L-L ~~ate escription i- --- 04~08~0 Estate of Alice M Coover User: admmwf Date: 04/08/09 .Code: tck DeptTELLER Check: 82917 Term: 192.168.1.16 Time: 13:30 Voucher: 436550 Account# Type Cert# Amount Name 1171 00 0 ****6,720.7 i Alice M Cpover ~ I ~_ I ~ Country Meadows West Shore 4905 East Trindle Road Mechanicsburg, PA 17050 Telephone: (717) 761-8880 Resident Statement Date: 04/01/2009 Re: Alice Coover Account#: 48988 Balance Due: .00 Patricia Smith 143 Beechwood Lane Amount Enclosed Chambersburg, PA 17201 eking Statement f ~ ~ ~'°"~ ,nur in_ formation, sign on to P Bank Online Banking f~com. ~ ~~ ;r number: 51-4001-3113 -cued , PNCBANK For the period 03/06/2009 to 04/06/2009 RICHARD M COOVER PriMa~ y .^.,.,C^~-;nt n~imhar' 51-4001-3113 Page 3 bf 4 Account Summary Patricia A Smith punt number. 50-0492-7156 Please see the Activity Detail section for -- alance Summary additional information. Be innin Deposits and 9 9 Checks and other deductions Ending balance balance other additions 11,108.97 15,908.52 5,000.00 22,017.49 . Average monthly Charges balance and fees 21,396.54 .00 'ransaction Summary Checks paid/ Check Card POS ansactions d t Check Card/Bankcard POS PIN transactions r withdrawals ~ signe 1 0 0 Total ATM PNC Bank transactions ATM transactions Other Bank ATM transactions 0 0 0 As of 04/06, a total of $50.54 in interest was Interest Summary ~ paid this year. Annual Percentage Number of days In interest period Average collected balance for APYE Inthlsst nod P Yield Earned (APYE) 0.67% 32 21,396.54 12.60 Activity Detail There were 2 Deposits and Other Additions '~ Deposits and Other Additions totaling $75,908.52: Date Amount Description om CDA 040 # 3 it I+ 1300271450 r 03/11 15,895.92 Depos 04/06 12.60 Interest Payment checks and Substitute Che Dks Reference Check Amount paid number number 106 5,000.00 03/18 osa~4si 7s There is 1 check listed totaling $5,000.00. Daily Balance Detail Date Date Balance Balance Date Balance 017.49 04 06 22 / Date Balance 97 03/11 27 108 06 11 ,004.89 03/ 18 , 22,004.59 . , 03/ FORM953R-1005 ,3~rr l09 G ~ -~a fl•oo l~~/ 1 5 ~ ~8() ~ 59 Y ([hl 1 5 • 33 15q£i9~3-9~ 0.Ofl ~~` Sovereign Bank Your account is currently at a zero balance. If your account remains at a zero balance for two entire statement periods with no activity; your account maybe closed. Please deposit funds into this account quickly to prevent it from closing. if this account is not meeting your needs, it would be our pleasure to discuss:other options with you. -- _ _ _ ~~an~en4 Reried 88fA7199 TA 9214b199 1-877-SOV-BANK (1-877-768-2265) www.sovereignbank.com MONEY MARKET ~: ~::,_, , ALICE M COOVER PATRlClA A SMITH ' i Balances - E~`x ~ '~aia.~t' ,,~.~_~ 3 ~~+fii ~ ~~~s~~~u~,"r, ~~'a~ ,*,~ ""r~ ~'v++~'.r~~cl~~ ~~;`,;x ~` . 00 ~- ~ ~""$0 ~ CtlCre ~$a ~ ~d x+3 i irii B r 05 ~B 19nC ~' n ~¢ , ., r -,. , ., . ; . eg ng a e . DepositslCre~its ~ + SG.00 Average Daily$alance ~ ~ $14,408.19 V1littidrawalsrDebits ''~"`' : $1~ 4~1~ Oar` y` ` Interest Paid thEs`~'ertod' ~ ' ~ ' " ~ ,: `~~ 00.' Apn~at~.en4ageYreltl~~~indd"``} { •°b 00°!~ :~ - r ti moo. rJ Y .Y ~:.._. ,..i .; ~ -...s-~. _.... .. ~..~ i. ~,:~.=. _:- .. c.~., _ _ i Earned this Period $ 0.00 Paid Last Year $63.68 r .Paid Yeaf To ate } ~ 2 K >;,~kw -.~s11 36` '' ,~, -. ' ' '.~53 '~ttv~'.~~'~'i-'m,.+3...~'..~'.a^sY"~iw'ifiF.S~.,,~. aR3ul^s-'.~.~w...JAC".d..Y,kf.';..~,`.7R.xe5~"fiz ar~.~t3~_.~,!>,ev ._ .. f~.37ky'4S.'~P3.Y3.^A'l.na~.4 uir-x5'~t .. a,e:fwaRt~,e~.~:+,.KS .~ ~" - - ..~ ~ "The: interest earned and the-interest paid-may differ depending on_when interest is_Gr_edited to your account~~ _ -~ Account Activity Date Description Additions Subtractions Balance ~. 02-17 Beginning Balance $14,414.05 'rtX1~.~4:k. , Q~il~i~Tit~AtJSACT1C~t;1~~, r .r ~ - ,4 o Y w v-< f r .;• ryv g ~,' ' ~.$ 03-15 `Ending,Balance $0.00 I _ _ _._._ _ w ~ ~.4~a.*.~Q a4 ~y '_'1 AbbottVascular ICJ (800)222-6883 _I Y~.b., ., ~ ., - -ter STATEMENT OF ACCOUNTS Account #571139795 CASHI_ER'S CHECK Ch :128431 From Member: 1171 Date: 8, 2009 Remitt Fe Ins Proceeds-Alice Coover Payee: X Richazd M Coover ~~ Check Amount 1,250.00 Fee Amou t: .00 .__._.-_._-.__._ _. ____- _- ....-..J '----- YtIVI`IJTLYAIVIA llVtltKl IAIVI.t IAJI . ,~ INFORMATION NOTICE BUREAU Df INDIVIDUAL TAXES AND F I L E PD Box 280601 TAXPAYER RESPONSE ACN HARRISBURG PA 17128-0601 DATE REV-1543 E% 4FP (BB•BB7 NO. 21 09-0190 09122300 04-06-2009 PATRICIA A SMITH 143 BEECHWOOD LN CHAMBERSBURG PA 17201-1489 EST. OF ALICE M COOVER SSN 162-14-8081 DATE OF DEATH 02-21-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT SAVINGS ® CHECKING TRUST CERTIF. PNC BANK NA provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call (717) 787-6327 with vuestians. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 000005140013113 Date 07-01-1959 To ensure proper credit to the account, two Established copies of this notice must accompany Account Balance 6 785.06 Payment to the Register of Wills. Make check ~ payable to "Register of Wills, Agent'•. Percent Taxable X ],6.,r.6.(.~ .33 1 ~~ ~~~~ ~~ NOTE: If tax payments are made within three Amount Subject to Tax months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. ~~~ ,I ~ Any Inheritance Tax due will become delinquent Potential Tax Due $ nine months after the date of death. PART TAXPAYER RESPONSE ~ FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMEtJT A. ~ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to oht ain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. C ONE B L 0 C K 0 N L Y B. The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return to be filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART 2~ and/or PART 3LJ below. PART a TAX LINE If indicating a different tax rate, please state relationship to decedent: RETURN - COMPUTATION Date Established Account Balance Percent Taxable Amount Subject to Tax Debts and Deductions z 3 4 5 6. Amount Taxable 7. Tax Rate 8. Tax Due PA OF TAX ON JOINT/TRUST ACCOUNTS PAD - 1 2 3 X 4 $ 5 - 6 +~' 7 X 8 $ =~iGIAt USF ONLY ~ AAf PARTMENT OF REVENUE i 2 3 4 6 7 8 ---- PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID IuIAL itnter on Line 5 of Tax Computation) S Under penalties of perjury, I declare that the facts S have reported above are true, correct and com lete to the best of my knowledge and belief. t _ '~ } HOME C 1 ! ~) ~ r~ • ~ .. ~;~ ,:`~ f ~ f :€,-C.2t ~c ~'~ i WORK C __..~ _,_._.,, F~ ;c' ~. t ~;' TAYPAVCD cTr_un IIDC TCI CpLIfIAIC AIIIMRCD TATC INFORMATION NOTICE BUREAU DF INDIVIDUAL TAXES A N D PD Box 280601 TAXPAYER RESPONSE HARRISBURG PA 17128-D601 eEV-1543 EX AFP COB-BB) FILE N0. 21 09-0190 ACN D9122301 TATC ~T-vv-~vD i3 RICHARD M COOVER C ~O n~ 1~~7H1I~CRJIID'RO °^ 1 ~~ni Y.~~-rD 02 33 t /j'I ~ar,~o~ Oc~ Cif EST. OF ALICE M COOVER SSN 162-14-8081 DATE OF DEATH 02-21-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 TYPE OF ACCOUNT ^ savlNGs ® CHECKING ^ TRUST ^ CERTIF. PNC BANK NA provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of Pennsylvania. Please call C717) 767-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 000005140013113 Date 07-01-1959 To ensure proper credit to the account, .two Established copies of this notice must accompany Account Balance 6 785.06 payment to the Register of Wills. Make check , payable to "Register of Wills, Agent". Percent Taxable )( 11~-s-s733.33 NDTE: If tax payments are made within three Amcunt Subject to Tax $` 1-e-1-~$-.r~7 ~ (,(!~ months of the decedent's date of death, Tax Rate s~o~ S deduct a 5 percent discount on the tax due. Any Inheritance Tax due will become delinquent Potential Tax Due yF 169"S3 6 •~~ nine months after the date of death. PART TAXPAYER RESPONSE ~ FAILU EWy RESPOND WIRE ULT. IN AN Off' AL TAX ASSESSMENT A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue C ONE B L 0 C K B.~The above asset has been or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to be filed by the estate representative. C. The above information is incorrect and/or debts and deductions were paid. Complete PART 2^ and/or PART ~ below. ~ ~ PART If indicating a different t~lC ~~ej„p~as~ ~[6~e~ / OFFICIA€US,E CINLY~ I _j prAF f relationship to decedent: f•• Gtl cJ y ~~ TAX RETURN PA DEPARTMENT DF REVENUE - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE I. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due PART DATE PAID PAYEE DESCRIPTION AMOUNT PAID Un pe omp e al ies of perjury I declare that the facts I t the b/s~p]F m knowle a and belief. V J have reported bove are tr(u~e, c /re t and HOME (~0~ ) ~J ~~~r~ G1 , i/ r, l WORK C p ) ^ a ~ TA PAYER SIGNATURE TELEPHONE NU BER ATE TOTAL CEnter on Line 5 of Tax Computation) $ rCl\1\J1LYN.1\ih il•r7G Ri1M1\i,.C IMA - ,' INFORMATION NOTICE BUREAU OF INDIVIDUAL TAXES A N D Po Box zso6B1 TAXPAYER RESPONSE HARRISBURG PA 17128-0601 REV-1543 EX AFP (OB-08) FILE N0. 21 09-0190 ACN 09122302 DATE 04-06-2004 EST. OF ALICE M COOVER SSN 162-14-8D81 DATE OF DEATH 02-21-2009 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: PATRICIA A SMITH REGISTER OF WILLS 143 BEECHWOOD LN CUMBERLAND CO COURT HOUSE CHAMBERSBURG PA 17201-1489 CARLISLE, PA 17013 TYPE OF ACCOUNT ® SAVINGS CHECKING TRUST CERTIF. PNC BANK NA provided the Department with the information below, which has been used in calculating the potential tax due. Records indicate that at the death of the above-named decedent, you were a joint owner/beneficiary of this account. If you feel the information is incorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax laws of the Commonwealth of ?e nnsylvan:a. Please tail i7i7) 757-8327 wit.. questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 000005004927156 Date 01-1$-2006 To ensure proper credit to the account, two Established copies of this notice must accompany 11, 106.80 payment to the Register of Wills. Make check Account Balance ~` payable to "Register of Wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 5,553.40 months of the decedent's date of death, Tax Rate X .045 deduct a 5 percent discount on the tax due. 2 4 9 .9 0 Any Inheritance Tax due will become delinquent Potential Tax Due ~` nine months after the date of death. P~T TAXPAYER RESPONSE ~ FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT.: A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or check box "A" and return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. C ONE B L 0 C K D N L Y B. ~ The above asset has been "'~~~!!! to be filed by the estate or will be reported and tax paid with the Pennsylvania Inheritance Tax return representative. C. ~ The above informs ion is Complete PART 2~ and/or incorrect and/or debts and deductions were paid. PART O below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION DF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Established 2. Account Balance 3. Percent Taxable 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rate 8. Tax Due 1 2 $ 3 X 4 $ 5 6 7 X a $ PA PAD _1 2 3 4 5 6 7 8 OFFICIAL US£ ONLY ~ AAF° DEPARTMENT OF REVENUE PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID IUIHL ~tnter on Line b of Tax Computation) S Under penalties of perjury, I declare that the facts I have reported above are true, correct and com~lete to the best of my knowledge and belief. HOME C t (-~ ) ,~'~~_~ ~-~ ~ .~~ °,.c.~'^} .,~~ ,%~ y ~ WORK C --_•,.•~.-~----- , TAXPAVFR ST6NATIIRF TFI FPNf1NF NUMBER ~nATF The Union Central 1876 Waycross Road Life Insurance Company Cincinnati Ohio 45240 (513) 595-2200 www.unioncentral.com /^ ^~~~, insurance and Investments A UNifl Company March 16, 2009 Re: A61320133C Alice M. Coover NOTICE OF PAYMENT UNDER AN ANNUITY CONTRACT, INCOME POLICY OR SETTLEMENT OPTION AT THE DEATH OF A PAYEE Name of decedent: Alice M. Coover Date of death: 2-21-2009 Residence ~f decedent: 4905 E Trirdle Rd. Apt. 97, Mechanicsburg, 1'A 1', CSC (X) Annuitant () Beneficiary under Settlement Option Date of issue of Annuity or effective date of Settlement Option: 12-19-1994 Kind of Annuity or form of Settlement Option: SPDA IRA Name of Beneficiary: Patricia A. Smith Relationship: daughter & son Residence of Beneficiary: 143 Beechwood Ln. Chambersburg, PA 17201 Method of payment to beneficiary: Richard M. Coover 2331 Meadow Oak Circle Kissimmee, FL 34746 Q Single Sum -Amount of proceeds on deposit Accrued interest Q Single Sum -Commuted value of Annuity or Installment Option (X) Single Sum Q For Estate Tax purposes the commuted value of the remaining certain installments is Other details of settlement: r By .~~~~ Dennis Peyton Second Vice President, Individual Claims UC 2791 03/95 31,418.15 Securities offered through affiliate Ameritas Investment Corp„ Member FINRA/SIPC. WADDELL ~~ ~~ Financial Services Transaction Confirmation March 24, 2009 Contract Number: 07-1048566 Investing_ With a plan'" ~~ Customer ALICE M COOVER 4905 E TRINDLE RD STE 97 MECHANICSBURG PA 17050-3653 Contract Value is $53,828.61 For Assistance Contact (717)541-9606 Your Investment Professional LEROY J JONES JR JR WADDELL REED INC 4230 CRUMS MILL RD STE 200 HARRISBURG PA 17112 Account Information Contract Number: 07-1048566 Issue Date: 06/14/2001 Nationwide Life and Annuity Annuitant: ALICE M COOVER P O Box 182021 Plan Type: NON-QUALIFIED ANNUITY Columbus OH 43218-2021 24 hr. Automated Information Line: (866) 221-1011 Customer Service: (866) 221-1100 Hearing Impaired: (800) 238-3035 Internet: www.waddell.com Beginning Contract Value on 01/01/2009: $112,303.57 Purchase Payments $.00 Withdrawals/Charges - - - ($53•,828.60) Net Investment Results` 4 646.36 Ending Contract Value as of 03/24/2009: 53,828.61 Our records indicate you have processed a total of 1 Lund transfers. After 20 fund transfers during the calendar year or more than 11 fund transfers in 2 consecutive calendar quarters, all additional transfer requests must be submitted by mail. However, Nationwide reserves the right to restrict trade activity at any time in order to stop disruptive trading practices. `This is the net amount of investment gains or losses during each period. These results include the deduction of charges as outlined in your prospectus. Variable Account Summary 4 4 Investment. Unit Value Units Owned Value Option IVYVIP MNY MKT 10.77657 4994.96268 $53,828.61 Variable Fund Total $53,828.61 Withdrawals/Charges on 03/24/2009 4 4 Transaction Investment Option Dollar Unit Fund Date Type Amount Value Units 03/24/09 WITHDRAWAL IVYVIP MNY MKT ($53,828.60) 10.77657 (4994.96175) Taxes $4,295.56 Net Amount $49,533.04 Z-- p ~.ze ~.c- If you requested a distribution from your contract, please know it will be sent to you under separate cover. WRASN 00 ID . 071048566 000000010000000300005288 OOOOR170 220200874761 Page 1 of 4 00008170 WADDELZ ~~ Financial Services® Investing. With a plan's Transaction Confirmation March 30, 2009 Contract Number: 07-1048566 Contract Value is $.00 Customer ALICE M COOVER 4905 E TRINDLE RD STE 97 MECHANICSBURG PA 17050-3653 Account Information Contract Number: Issue Date: Annuitant: Plan Type: 07-1048566 06/14/2001 ALICE M COOVER NON-QUALIFIED ANNUITY For Assistance Contact (717)541-9606 Your Investment Professional LEROY J JONES JR JR WADDELL REED INC 4230 CRUMS MILL RD STE 200 HARRISBURG PA 17112 Nationwide Life and Annuity P O Box182021 Columbus OH 43218.2021 24 hr. Automated Information Line: (866) 221-1011 Customer Service: (866) 221-1100 Hearing Impaired: (800) 238-3035 Internet: www.waddell.com Beginning Contract Value on 01/01/2009: Purchase Payments WithdraWa!slChargss Net Investment Results* Ending Contract Vnlue as of 03/30/2009: $112,303.57 x.00 ($107,654.97) 4 648.60 .00 Our records indicate you have processed a total of 1 fund transfers. After 20 fund transfers during the calendar year or more than 11 fund transfers In 2 consecutive calendar quarters, all additional transfer requests must be submitted by mail. However, Nationwide reserves the right to restrict trade activity at any time in order to stop disruptive trading practices. 'This is the net amount of investment gains or losses during each period. These results include the deduction of charges as outlined in your prospectus. Withdrawals/Charges on 03/30/2009 a a Transaction Investment Option Dollar Unit Fund Date Type Amount Value Units 03!30109 SURRENDER IVYVIP MNY MKT ($53,826.37) 10.77613 (4994.96268) Taxes $5,952.12 Net Amount $47,874.25 ~" T`'`" If you requested a distribution from your contract, please know it will be sent to you under separate cover. For Your Information Unit Values and Units are displayed to five (5) decimal places. However, all accounting is actually calculated to eight (8) places. Requests for additional information, including loans (loan interest rates, loan balances, loan activity, etc.) and market value adjustments as applied to guaranteed term options, should be directed through the Annuity Service Center at 1-866-221-1100. These options may not be available in all jurisdictions. 's a M 8 o WRASN 00 ID 071048566 220200874761 Page 1 of 1 ° 00000001000000010000905000013909 00013909 ~® /~11'911UIt~/ AIG Annuity Insurance Company P.O. Box 87l Amarillo, Texas 79105-0871 800.424.4990 APRIL 7, 2009 PATRICIA A SMITH 143 BEECHWOOD LANE CHAMBERSBURG, PA 17201 RE: Contract BX203363 Dear PATRICIA A SMITH: We are pleased to advise you that we completed processing your claim for annuity benefits on April 07, 2009. In order to provide you with the benefit of flexibility in disbursing your funds, we have. opened an AIG Annuity Bridge. Account for you. The total amount of your claim proceeds is $10,154.24. The beginning balance of your AIG Annuity Bridge Account is $10,138.82, as described below: Non-Taxable Amount $10,000.00 Taxable Amount $154.24 Federal Tax Withheld $15.42 State Tax Withheld $0.00 $10,138.82 The taxable portion will be reported on Internal Revenue Service Form 1099-R. Your account will earn a competitive rate of interest and provide immediate access to your funds with no monthly service charge. Interest earnings on your AIG Anuuity Bridge Account will be reported as required by the Internal Revenue Service. State Street Bank and Trust will mail your new account kit shortly. 'The kit will include your personalized checks and a detailed explanation of your AIG Annuity Bridge Account. If you should have any questions, please call 1-800-331-4631. Sincerely, G~/~ B. M. Graves Manager Annuity Claims AIG Annuity Insurance Company MemGer ofAmericmi bvernatiam! Group, /nc. ~iG Annuity [usurnnce Company P.U. Box 871 Amarillo, Texas 791 OS-OS'. 1 800.424.4990 APRIL 7, 2009 RICHARD K COOVEA 2331 HEADOW OAR CIRCLE RISSI?4tEE, FL 34746 RE: Contract BX202372 Dear RICHARD H COOVER: We are pleased to advise you that we completed processing your claim for annuity benefits on April 07, 2009. In order to provide you with the benefit of- flexibility in disbursing your funds, we have opened an AIG Annuity Bridge Account for you. The total amount of your claim proceeds ib $10,154.24. The beginning balance of your AIG Annuity Bridge Account is $10,123.39, as described below: - Non-Taxable Amount $10,000.00 Taxable Amount $154.24 Federal Tax Withheld $30.85 State Tax Withheld $0.00 $10,123.39 The taxable portion will be reported on Internal Revenue Service Form 1099-R. Your account will earn a competitive rate of interest and provide immediate -.... .,access to your._funds with no monthly.aeryi_cg_.chasge...Interest earnilags on your. ._,. AIG Anuuity Bridge Account will be reported as required by the Internal Revenue Service. State Street Bank and.Trust will mail your new account kit shortly. The kit will include your personalized checks end a detailed explanation of your AIG Annuity Bridge Account. If you should have any questions, please call 1-800-331-4631. Sincerely, ~. B. M. Graves Manager Annuity Claims AIG Amaury lur,rnnce Gunyrury MemLer aJAmerreon lmavmnnnal Gruuy. Me. ANSAMERICA E INSURANCE COMPANY March 5, 2009 Patricia Smith 143 Beechwood Ln Chambersburg PA 17201 RE: Annuity Number(s) 007378488 Dear Patricia Smith: ID ~~iy Transamerica Life Insurance Company 4333 Edgewood Road NE PO Box 3183 Cedar Rapids, Iowa 52406-3183 We have received notification, Alice M Coover, annuitant of the above listed non-qualified tax deferred annuity is deceased. Our office wishes to extend sincere condolences for your loss. The following is the current information on this annuity: Annuitant: Owner: Primary Beneficiary: Annuity Policy Date: Full Value as of 03/05/2009: Full Value as of 02/21/2009: Alice M Coover Alice M Coover Patricia Alice Smith 50~ April 13, 1999 $25,813.96 $25,788.89 The attached document reflects the options available to the beneficiary. The full value as of the date of death is for tax purposes only and is not a guaranteed death benefit amount. Operations performed on an automatic basis when applicable have been terminated, such as; Systematic Payouts or Automatic Billing. The attached document contains general tax information based on Transamerica Life Insurance Company's interpretation and should not be relied upon for your personal tax planning. If you have questions concerning the direct tax consequences when selecting an option, you may wish to consult a tax advisor. Member of the `EGON. Group 11~, 5. . ~: }'~: ~.~. ~s. ='_ Initial Selection Final Selection Difference .fiandise REVERE SILVER $1,095.00 $1,095.00 --- Concrete Grave Liner $995.00 $995.00 --- Total Merchandise $2,090.00 $2,090.00 --- Cash Advance Cemetery $1,345.00 $1,345.00 --- Clergy /Religious Facility $125.00 $125.00 --- Certified Copies $90.00 $90.00 --- Newspaper Notice $153.90 $153.90 --- Total Cash Advance $1,713.90 $1,713.90 -- Total Services, Merchandise and Cash Advance $10,328.89 $10,169.89 -($159.00) Total Charges (Total Services +!-Allowances + Taxes) $10,328.89 $10,169.89 -($159.00) Less Cash Received $0.00 $0.00 Unpaid Balance Due __ $10,328.89 $10,169.89 ~__.i Page 2 of 2 Neill Funeral Home, Inc. /1, ("I /~ K1 3 ~.---` ~ / ~~ x 3401 Market Street ~d, o I V ~ ,~ ~ J ~,i~~?~~ ~~s, ~~' r Camp Hill, PA 170114428 ~, ~ (717) 737-8726 I D ~ ~ ~` ~ ~ ~~~ 6 t <=f~``~ ,~ . ~. `', Supervisor :Kevin J. Shillabeer '~ + ~ ~~ ~ ~~ ~ ~~ ..~'% ~ U e The following is a detailed bill for the professional services and/or merchandise arranged for Alice M. Coover Date of Service :February 26, 2009 Patricia A Smith Statement Date March 05, 2009 143 Beechwood Lane Contract Number 741100200133 Chambersburg, PA 17201 Arranger Name Stephen J Wilsbach Initial Selection Final Selection Difference Funeral Director and Staff Services Basic Professional Service Fee $2,680.00 $2,680.00 --- Total Funeral Director and Staff Services $2,680.00 $2,680.00 -- Care and Preparation of Remains Embalming $795.00 $795.00 --- Dressing and Casketing of Deceased $395.00 $395.00 --- Total Care and Preparation of Remains $1,190.00 $1,190.00 -- Use of Facilities and Related Services Visitation $495.00 $495.00 --- Chapel Funeral Ceremony $495.00 $495.00 --- Total Use of Facilities and Related Services $990.00 $990.00 -- Transportation Transferring Remains to Funeral Home $495.00 $495.00 --- Funeral Vehicle/Hearse $395.00 $395.00 --- Service Vehicle $395.00 $395.00 --- Total Transportation $1,285.00 $1,285.00 - Other Goods and Services Flowers $220.99 $220.99 --- Cemetery Equipment Rental Fee $159.00 --- -($159.00) Total Other Goods and Services $379.99 $220.99 -($159.00)