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HomeMy WebLinkAbout08-24-09J 15056051058 REV-1500 EX (O6-OS) PA DepaMlent of Revenue OFFICIAL USE ONLY Bweeu of Inrbvidual Taxes County Cade Year File Number Po eox zea6ol INHERITANCE TAX RETURN Harrisburg, PA 1712&0601 21 09 0486 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Severity Number Date of Death Date of Birth 186-30-5772 05/15/2009 07/19/1918 Decedent's Last Name Suffiz Decedent's First Name MI COHICK EARL E (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI N/A Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE __ _ _'' REGISTER OF WILLS FILL IN APPROPRWTE OVALS BELOW C~ 1. Original Retum C.7 2. Supplemental Retum c~~ 3. Remainder Retum (date of tleath prior to 12-13-82) t""') 4. Limited Estate G:::. 4a. Future Interest Compromise (date of ~;:::::a 5. Federal Estate Tax Retum Required death after 12-12-82) C~ 6. Decedent Died Testate r; ~ 7. Decedent Maintained a Living Trust __i__ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) t~ 9. Litlgation Proceeds Received C'""r 10. Spousal Poverty Credit (date of death ':°.: ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 end 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ,ROBERT R. BLACK (717) 243-3727 Firm Name (If Applicable) ' ~, REGISTER OF USE ONLY fJ LANDIS & BLACK y, ~.; ~ , ~ ~ First line of address -i '.. ~ ~ ~~ 4 _ ~ u _ 36 South Hanover Street z ~ r ! r' '' Second line of address -"~ <7 C7 -q ! :O-n ~ "- = ~ ,, ~ GJ) n City or Post OffICe State ZIP Code ~__ DATE ~ED ,Q. ~ ' -'" '_` Carlisle O PA 17013 correspondent's a-mail address: rObttblBCK((~embargmaiLCOm Under penalties of perjury, I declare that I have examined this velum, including accompanying schedules and statements, and to the best of my knowledge and belief it U true, correct and complete. DeUaretlon of preparer other than the personal representative Is Dased on all information of which preparer has any knowledge. SICaNATUIM: OF PFJ2SON,RESPDNfISLj FOR FIIJNG RETURN DATE ADDRESS/'r~.~~L. /iLT7 CC/O~wQ -`iw~` 150 Cherry Street, Carlisle, PA 17013 330 E. Orange St., Shippensburg, PA 17257 SIGNATURE EPA R O R TH EP SENTATIVE `~~~ /JI~~ ~/Q DAT i / ADDRESS _~,_,~ J/~v ~'/'~ 36 Sout Street, artist PA 17013 (/ PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 REV-1500 EX Decedent's Name: EARL RECAPRULATION 15056052059 E COHICK Decedent's Social Security Number 186-30-5772 1. Real estate (Schedule A) ............................................. 1 2. Stocks and Bonds (Schedule B) ....................................... 2. 0.00 0.00 3. Closely Hekl Corporation, Partnership or Sole-Propdetorship (Schedule C) ... .. 3. 0.00 '. 4. Mortgages 8 Notes Receivable (Schedule D) ........................... .. 4. 0.00 " 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... .. 5. 360,384.40 '.. 8. Jointly Owned Properly (Schedule F) r~ Separate Billing Requested ..... .. 6. '. 0.00 '. 7. Inter-Vrvos Transfers 8 Miscellaneous Non-Probate Property "~"" """'° ~~ "''. (Schedule G) C~7 Sepamte Billing Requested...... .. Z -....... 35,074.69 S. Total Gross Aaseta (fatal Unes 1-7) .......... . . . . . . . . . . . 8 395,459.09 '.. 9. Funeral Expenses 8 Administrative Costs (Schedule H) ............... ...... 9. 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) .... .... ..... 10 ......... . . 11. Total Deductions (total Lines 9 & 10) ... ........ ... . . . ..... _ . . 11. 12. Net Value of Fatale (Line 8 minus Line 11) ........ .......... ... ..... 12 13. Charitable and Governmental Bequests/Sec 9113 Tmsts 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. ®________.___.. __,.__...~,.._..__..w._.._.,_.__vw...w__.. __.,wn. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Llne 14 taxable at the spousal fax rate, or transfers under Sec. 9118 (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable ~ '.. `""""" """' at lineal rate X .0 _ 18, '. 17. Amount of Line 14 taxable 18,300.71 1,794.80 20,300.71 '', 375,158.38' 10,000.00 365,158.38 at sibling rate X .12 365,158.38 17, 43,S19.U1 19. Amount of Line i4 taxable ~~~~.~ ~ ~ `~ "" "."""" '.. et collateral rate X .15 19. ' 19. TAX DUE ......................................................... 19. '. . 43,819.01._'.. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 sWt 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: ..........._ ... Fha Neml?ar... I 21 i' 09 !!0486 ECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER FrARL E COHICK 186-30-5772 STREET ADDRESS 121 Walnut Bottom Road CITY Shippensburg STATE PA ZIP 17257 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit 35,000.00 B. Prar Payments C. Discount 1,842.05 Total Credits (A+ B+ C ) 3. InteresVPenalty if applicable D. Interest E. Penalty Total InteresVPenalty (D + E j 4. If Line 2 is greater than Lure 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. (i) 43,819.01 (2) 36,842.05 (3) (4) (5) 6,976.96 (SA) (58) 6,976.96 Make Check Payable to: REGISTER OF WILLS, AGENT ~1)6f??~'H=~~kl~.,., ;!~ ..';~w ~~ii~kitl€~i'iN1~~Yl~~~fl')tiN~°l;,}~~sw~(li~'??!~q,:'1i=:'=114(~u„9,N1ti;~j.=<')ik~1f6€t,~11~~i'P„~'~~=„'S)flS4~''~4;n°+~,sl=',tE~a~`n~"9~,a(t"b~,~dii4+f;~{'.,I!,.,t.!, PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes Nc a. retain the use or income of the progeny trensferted :.................................................................................... ...... ^ b. retain the dght to desynate who shall use the property transferred or its income :..................................... ....... ^ c. retain a reversionary interest; or ................................................................................................................... ....... ^ ^ d. receive the promise for life of either payments, benefts or care? ............................................................... ....... 2. If death occurred after December 12,1982, did decedent transfer properly within one year of death without receiving adequate consideration? ....................................................................................................... ....... ^ 3. Did decedent own an "in trust for" or payable upon death bank account or seadly at his or her death? ....... ....... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate properly which contains a bene8dary designatlon? ................................................................................................................. ....... © ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. '11~ ,. ~a r ~~tt~e,~+":in~,fh~5.~ri;i'~a.11?i`.k,~(~1+~'`ply;ti;)IS'!!NI~4li"1~i,iI~~P:?I.~',.~j1i;~'i~fi'iI" krtit4't~!'n(~. i'Iti~uttptl: 4itt i,",.°tr~>£i411d~1tt,htt~tsC,~il»ti3.ti~?4`,.,1„~t~=i),iil.~'~4~!r,~i'.;ztt]Sl~ml~.', ,t, t .. ';~,f.. 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 [/2 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 trensfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (n)]. 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 deaN on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-0ne 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) [/2 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 [/2 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. 0.00 REV-1508 EX* (6-98J SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & MISC. INHERITANCE 7AX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER EARL E. COHICK 21-09-0486 Include the proceeds of litigation and the date the proceeds were received by the estate. All pmpert/ Jokntly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE 1. M & T Bank -Checking Akxount #407666. See attached letter. Principal -11,706.96, Interest - .35 11,707.31 2. M 8 T Bank -Certificate of Deposit #31003910538669. See attached letter. d Principal - 36,000.00, Interest - 30.94 36,030.94 3. M & T Bank • CerBficate of Deposit #31003910609436. See attached letter. Principal - 70,267.82, Interest -54.20 70,322.02 4. M 8 T Bank -Certificate of Deposit #31003913025928. See attached letter Principal -15,085.30, Interest - 4.09 15,089.39 5.' M 8 T Bank - Cerfifirate of Deposit #31003917742718. See attached letter. Pdncpal -100,000.00, Interest - 22.20 100,022.20 6. Wachovia Bank -Certificate of Deposit # ......7888. See attached letter. Principal - 63,507.01, interest-109.22 63,616.23 7. Wachovia bank - CerBficate of Deposit # ......4452. See attached letter. Principal - 63,500.00, Interest - 80.57 63, 580.57 8. Senfinel Refund 15.74 TOTAL (Also enter on line 5, Recapitulation) S I 360,384.40 (If more space is needed, insen additional sheets of the same s¢e) REV-1510 EX+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 6 INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER EARL E. COHICK 21-09-0486 This schedule must he cornoleted end filed if Me answer to env of cuesfions t through 4 on the reverse side of the REV-1500 COVER SHEET Is yes. ITEM NUMBS DESCRIPTION OF PROPERTY INCLUDE THE NNAEa THETRIH9FEPEE, iIEIa REIA7~ONEHIPRI DECEDENrAND TNEDATE CFiRNiSFFR. ARACNACCPY Oi THE UFm FCa REAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST EXCLUSION (IFAPPUCAaL TAXABLE VALUE ~ Allstate Lrfe Ins. Co. -Annuity Contract No. 16147142. See attached letter. 35,074.69 100 0.00 35,074.69 TOTAL (Also enter on line 7 Recapitulation) S I 35,074.69 (If more apace is needed, insert addiaonal sheets of the same size) REV-1511 El(+(12-99) SCNEDt1LE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES 8c INHERITANCETAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER EARL E. COHICK 21-09-0486 Debta of decedent must be reported on Setledule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t' Funeral Luncheon 353.75 z. Hoffman Roth Funeral Home -Services 2,643.96 B. ADMINISTRATIVE COSTS: 1. Petsarsl Representatives Commissions 0.00 Name of Personal Repesentadve(s) Sodal Sacudty Number(s)/EIN Number or Personal Representative(s) _ Street Address City State Zip Year(s) Commission Paid: 2. AttomeyFees 12,000.00. 3. Fatuity Exemption: (If decedent's address is not the same as daimanl's, attach explanation) ctarcnam None Street Address City State .Zip Relationship of Claimant ro Decedent a. Probate Fees 650.00 5. Accountants Fees 6. Tax Retum Preparer's Fees T. M 8 T Bank -Reclaim Social Security benefits - 2 months 2,253.00 a. Reserve for closing & filing releases 400.00. TOTAL (Also enter on line 9, Recapitulation) S 18,300.71 (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-08) pennsylvania SCHEDULE I DEPARTMENT OF REVENVE DEBTS OF DECEDENT, INHERITANCE TA%RETURN MORTGAGE LIABILITIES & LIENS RESIDEM DECEDENT ESTATE OF FILE NUMBER EARL E. COHICK 21-09-0486 ]f more space is needed, insert additional sheets of the same size. REV-1513 E%+ (IS-OB) pennsylvania SCHEDULE 7 DEPARTMENT Of REVENDE INMERiTANCE TAX RETURN BENEFICIARIES RESIDEM DECEDEM EARL E. COHICK 21-09-0486 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND AODRE55 Of DERSON(S) RECEIVING DROPERTY Do Not Ltst Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. Robert A. Cohick, 150 Cherry Street, Carlisle, PA 17013 Brother 50% S.S. No. 180.26-5339 2. Seldon S. Cohick, 330 E. Orange Street, Shippensburg, PA 17257 Brother 50% S.S. No. 186.30-5998 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH IB OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SDOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARTTABLE AND GOVERNMENTAL DISTRIBUTIONS 1. First United Methodist Church, 64 East North Street, Carlisle, PA 17013 10,000.00 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON L[NE 13 OF REV-1500 COVER SHEET. ; 10,000.00 If more spate is needed, insert additionalsheets of the same size. LAST WILL AND TESTAMENT OF EARL E. COHICK I, EARL E. COHICK, of the Borough of Carlisle, Cumberland County, Pennsylvania, declare this to be my Last Will, hereby revoking all prior wills and codicils. FUNERAL EXPENSES FIRST: I direct the payment of my funeral expenses, including my gravemarker, as soon as may be convenient after my death. PAYMENT OF DEATH TAXES SECOND: I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as apart of the expense of administration of my estate. BEQUESTS THIRD: I give the sum of Ten Thousand and no/100 ($10,000.00) Dollars to the First United Methodist Church, East North Street, Carlisle, Pennsylvania. DISTRIBUTION OF RESIDUE FOURTH: I give the rest of my estate in equal shares to my brothers Robert A. Cohick or his wife, Thelma E. Cohick and Seldon S. Cohick, or his wife, Roberta K. Cohick or the issue of my brothers, per stirpes, who survi~~e me for a period ofthirty (30) days. MINORS AND INCAPACITATED BENEFICIARIES FIFTH: If any income or principal shall be payable to any person who shall be a minor or who shall be incapacitated for any reason, my executor as trustee shall hold such income and principal during minority or incapacity and shall be entitled to apply such income and principal to the health, maintenance, support and education of such person during minority or incapacity without the appointment of any guardian or committee or any authority of court. My executor as trustee shall be entitled to make direct application hereunder or to make application by payment of income and principal to the parent or other person in charge ei'such minor or incapacitated person, or to his or her guardian or to a custodian under the Uniform Transfers to Minors Act. C~ initials Any remaining income and principal to which such person shall be entitled shall be distributed to such person upon the termination of minority or incapacity. My executor as trustee shall have the same powers as my executor. POWERS OF EXECUTOR SIXTH: I confer upon my executor the right to sell or otherwise convert any real or personal property at public or private sale, at such time or times, in such manner, and for such price or prices, and on such terms and conditions as my executor shall determine, and to execute and deliver good and sufficient conveyances, assignments and transfers of the property, without liability of any purchaser for the application of any consideration; to borrow money and to secure its payment by mortgage of real or personal property, pledge of investments, or otherwise, without liability on the pan of the lenders to see to the application thereof; to retain any investments at discretion; to invest and reinvest at discretion, without restriction to so-called "legal investments' ; to make distribution in cash or in kind; to allocate and distribute different kinds or disproportionate shares of property or undivided interests in property among beneficiaries, in cash or in kind, or partly in each; and to do all other acts and things necessary or appropriate in the management, administration and distribution of my estate. APPOINTMENT OF GUARDIAN OF ESTATES OF MINORS SEVENTH: I appoint my executor as guazdian of the estates of minors with power to hold all property payable by law to a guardian appointed by my will and to use it for the minor's health, maintenance, support and education, either directly or by payment to any person selected by my executor to disburse it whose receipt shall be a complete acquittance. Guardian may, in discharge of all the guardian's duties, pay any minor's share deemed impractical of administration to the parent or other person in charge of the minor or to his or her guazdian or to a custodian for the minor under the Unifotm Transfers to Minors Act. My executor as guardian shall have the same powers as my executor. APPOINTMENT OF EXECUTOR/RIX EIGHTH: I appoint Robert A. Cohuk and Scldon S. Cohick, or the survivor thereof, as Executors. WAIVER OF BOND NINTH: I direct that no fiduciary hereunder shall be required to furnish bond in any jurisdiction, and if any bond is necessary, no surety shall be required. V D ,.1~/V. initials INTERCHANGEABILITY OF LANGUAGE TENTH: Words used in the singular may be read to include the plural or the plural may be read as the singulaz. Similarly, the masculine form may be read to include the feminine and neuter; the feminine may be read to include the masculine and neuter; and the neuter may be read to include the masculine and feminine. HEADINGS ELEVENTH: The headings used on the various paragraphs of this will are included for convenience only and shall have no legal significance. I have signed this will this ~ day of /VQ~~~t I? > 2002. ACKNOWLEDGMENT and AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND We, Earl E. Cohick, the Testator in and the undersigned witnesses to the will, the attached or foregoing instrument, who have signed the instrument, having been qualified according to law do depose and say: (a) that I, the Testator. do hereby acknowledge that 1 signed the instrument as my will, that I signed it willingly and as my free and voluntary act for the purposes therein expressed; and L .zit" ' U..~ ~ ,za~ Eaz•! E. Cohick ~.~ ~i~a- (b) that we, the witnesses, were present and saw the Testator sign and execute the instrument as his will, that he signed it willingly and executed it as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testator signed the will as a witness and that to the best of our knowledge the Testator was at that time eighteen or more years of age, of sound mind and under no constraint or undue influence. ~ ~~~:~~ Earl E. Cohick, Testator J~ ~ ~-c~ Witness _...~ Witn ss Notary Public . t.~,n;MUi~rVEALTH OP P V Notari81368t '?nAerl R. Sleok, Notary Publb .arUS!e Soro, Cumt»Aelyd CowUy '_ ,. ~ ^.missfcm Expires Sept. 28, 2U08 48500041046 REV-485 EX (1.07) SAFE DEPOSIT BOX INVENTORY PA Department of Revenue ath Cer88ca N u ber Sodel Security or D e t e m Date of Death Col ~ ~ 'J '~ ~~ j ~ ~ rt (/~ f 9 H [~r/~; ~ ~ .. ~ +li Decedent's Lest Name Suffix First ~ ,Y/ V MI C TY: ~ STATE: i® ADDRESS OF DECEDENT STREET ~ Z~pfrpD ~ ~ Td G j Uf~STING THE OPENI G OF THE SAFE DEPOSR BO% 4 NAME AND DORESS OF PERSO~f EO ~ NAME: / •/~/f0 ~ /< ,/v~~ t F L CITY: STATE: STREET D ESS: ZIP CODE: C a NAME, ADD SS AND RELATIONSHIP (IF ANY) TO DECED NT, OF ERSON{S) PRE9E AT T E BOX OPENING a. NAME: -n~ ,/1 ONSHI~ STREET RESS: CITY: STATE: !~b Gl~l?RU ST LtSC,~ %70{,~ ~ l --s - Z~CODE: LATIONSHIP: FTE J b. NAME: ~ ~ ~~~~,~ s ~~~~ ~~li~~-.~o~~,~ 1 STREET~~ 33: ~ d R19'I+~Ga; Sl SfflO~E c~~~RG ~ B !T"77~ /UC 57 ~~ RELATIONSHIP: c. NAME: -- STREET ADDRESS: `CITY: STATE: 21P CODE: TITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED IN U INS NAME AND ADDRESS OF F AN C LL //~ , "p ". (/ ~ ~ NAME: ~~~ I~ . !V _ _ / _f_/! __ ____ _~ STREET ~DR 5: ~ ~ C • !~0! STATE: ZIP CDDE: DATE A TIM OF UST ENTRY NAME P RSON MAKI LA~ElI'J~' u ~(( NU B R X 1 TIT UNDER CH X I REGISTERED DA CONT TO RENT BOX i . G ESS TO BOX A N NO ACC NAME ND A DRESS OF PERSON(S ) H e. NAME: ,/~~ / ` , ~ / ~J ~ ~, `--'CIII)IL^ b. NAME~~/7Ci(~T ((' ~+C.77~~ _ • STREETA D SS~L ~r STREET Af~D.~SS:~_ ~~~~ STATE: ZIP CODE: CITY: CITY: STATE: ZIP CODE: NA DaRL~. ~P YE KIN TN INVENT Y `D~_!y G `/ n r a wi11: s, a. D a WAS A WILLL IN THE BOX? IfE8 ^ NO Nye oma In tM w{II b. Name and ed o psno n al re p r uanht W e N n d d ro s f 1 A f '` / / p / ~ ' , / ~ (/ Y~' ~^ ~ ~. l/ /s/~ i/ J ~ NAME: ~L1! / ~ y ~ 1 ('~, (,s(JTllt+9G ~~ / V J . ~(J~!//C [`~~ - ~y ~ ,/ /~ ~t STREET ADD~(~ ~/A(J!/G STATE: _ ZIP CODE: e. Name and addnu o! sNomag It any NAME: ~ • ~ /$_ ~^ ,/ (//~/ J ~ ./~~ Q- F ,( /~ ~/ STREE AD~ILl __.7 _...~L~V ~G''\ .-•^/ .~7CL/~V,~C/G 1. -7 !_• 1_~~~j~E. .. ..... ZIP CODE___J 48500041046 48500041046 SAFE DEPOSIT BOX INVENTORY Page_____of_ REV~85 EX INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certigcate, wanant or other rights found In box. Stocks are to be designated by name of company, certificate number, date of certificate, name In which stock is registered, and number of shares and class of stock. (3) Obligations of U.S. Government: Number of Items, date of issue, face value, names in which registered and type of ownership, Le., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savinga and Loan Passbooks: State name of depositor, number of book, lest date appearing in book, name of bank and branch, and balance. (8) Jewelry, Cofns, 8tsmpa, Manuscripts, etc: List and describe es fully as possible. (7) Deeds, Mortgages, Current Insurenee Polfeles or other evidences of Indebtedness: Ltst and desedbe as tully as possible. (8) All other eontsnta. (9) Ratum Completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG, PA 171211-0601 REM NO. ITEM DESCRIPTION I y ~ NK ~ ~T o r (JEPOSri ~T lZ r ,~faf~,J - oo~o GGEnlhf~s NIA rfu Ca- Sc'GEcr2oots -E~kPLCaN~u-l~/isla3-35aao_ 3 W {"~ -- G E ~. ~- `~Srr~-L~ 1~'lt/e~f- ~"~f H14 -- ~y1Y~ S/7~(i!- 63 Sal n- T _ dFFM nl- o ~ k~IEYtA~~~E -PRE-Pi9 - 2 27 - 2/ '-T S, U/Esf ISf 12 CF1r11~'fCl2 N - ~lS - LO t"cfl SEG (> l~ ~ 3 I CERTI CORRE FY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS CTA CO PL TO THE BEST OF MY KNOWLEDGE AND BELIEF. PERSON REC VINO COPY OF SAFE DEPOSIT BOX INYENTORY: SKaJATURE SIONATU PRINT NAM PRI NA ANO CHECK APP IATE BO BELO- PRINTTITr7LE r/)~~0~~(~ 1aT' ' f~1 DATE / ~(A /O ~i/ / (/ / CH1ECK PPROPRIATE BOX: D~LExecutar(iM,) ~AOministrebr(Mx) 6ESleb Rapreaen4tlve ~ Joln\ owner of e~b Oepoelt box NOTE: Attach additfonai e'ix" x 1t" sheens) if necessary or use duplicates of this page of form. The Department is eullarked by few, 42 U.S.C. §405 (c)(2KC)n, b require disclosure of Sodal Security numbers in connection with administedng state taz laws. Ths DepaNnent uses dIe Soda) SewMy nrmbB u fdantdy tl\e decedent and personal represenlativas of 71e estate. The Commonwee181 may also use the information in exchange of tax infonnelion agreements w6h Federal and oral tezina autlraidss. The slate law prohbils the CommonweaMh's pereonrlel from discbsing corlfidenfial tax informaton except for olfidal pulpose8 p~~ 499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12 Phone (888) 502-4349 Fax (302)934-2955 ]une 12, 2009 Law Offices Landis & Black 36 South Hanover Street Carlisle, Pennsylvania 17013 Re: Estate of Earl E. Cohick Social Securit~i: 186-30-5772 Date of Death: May I5. 2009 Dear Sir or Madam: Per your inquiry dated June 5, 2009, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. 7ppe ofAccoura Checking Account Account Number 407666 Ownership (Names ofJ Earl E Cohick• Opening Date 9/1/67 Balance on Date of Death $ 11, 706.96 Accrued Interest $ 0.35 Total $11,70731 2. Type of Account Account Number Ownership (Names o~ Openrng Date Balance on Date ofDeath Accruedlnterest Total Certificate of Deposit 31003910538669 Earl E Cohick" 11/10/99 $ 36, 000.00 $ 30.94 ., -- __ $ 36, 030.94 3. Type ofAccount Certificate of Deposit Account Number 31003910609436 Ownership (Names ofJ Earl E Cohick* Opening Date 12127/94 Balance on Date of Death $ 70,267.82 Accrued /nterest $ 54.20 Total $ 70, 322.02 4. Type of Account Certificate of Deposit Account Number 31003913025928 Ownership (Names o~ Earl E Cohick* Opening Date 4/13/06 Balance on Date of Death $ 15,085.30 Accrued Interest $ 4.09 Total $15,084.39 5. Type ofAccount Certificate of Deposit Account Number 31003917742718 Ownership (Names oJJ Earl E Cohick* Opening Date 11/9/07 Balance on Date of Death $ 100, 000.00 Accrued Interest $ 22.20 Total $100,022.20 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 aceount holder. For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds, etc., please contaM our High Street Carlisle Otfice q 717-240-4536. S' c'erenly,~~ II nn Tracie Hare Adjustment Services Fax Transmission 8/15/2009 8:30:~i~ AM PAGE 1/001 Fax Server W~CHafvIA Wachovie Hank N.A. 13alanoe Confirmation Services P O 13ox 40023 Roanoke, VA 241Y22-7313 June 15, 2009 LANDIS &. BLACK ATTN: ROBERT R BLACK 36 SOUIH HANOVER STREET' CARLISLE, PA 17013 Reter~~e m: m9491 SUBJECT: Verification /Confirmation of Aocrnmf and Balance Infotmation provided for: Ctiast~er: EAnT. E coffiCx (ssx# ~oQC-~~77z~ Date of Death: May 15, ?A09 Deooslt Accoal8 information Acooum AarouoT Mete ofIleeth Average I)Qe MaturiUr IafdaY Apsued YID Detc Type Number 13alanx )3alanue• Opeaad I)a4 Rffi IAemd Laerei Paid Closed CERT[FICATEOP 7WCOOOOOOOC7888 S63,S07.01 121211999 31212011 5109.72 51,030.93 DEPOSIT IFGALTITIE: EARI,ECOffiCK CERTIFICATE OF 7p000.7iJ0000C4432 563,300.00 DI.POSCf LEOALT171E: EARL E OOHICK 12/22/1999 3l2I2011 580.37 8374.88 ' Date of death Fulao<x dace not include accrued interest • If date of death acanra on a weekend or a holiday, date of death balance does nd include any transactions that were made during that time~peri~rd...~ I.~w~' Audrey Trautt Servicenter Aaeooiate Phona: (340)363-7323 mr, er t Allstate Life Insurance Company P.O. Box 94212 Palatine, II. 60094-4212 Telephone: (877) 499-6418 Facsimile: (866) 635-4523 July 23, 2009 Robert R. Black Landis & Black 36 South Hanover Street Carlisle, PA 17013 Re: Earl E. Cohick Contract No: GAY6147I42 Dear Mr. Black: Allstate You re in good hands. We received a request to complete IRS Form 712 for the above referenced contract. The purpose of Form 712 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 contract). Because this contract is an annuity, it is not reportable on IRS Form 712. I can, however, provide the following information for estate purposes: Date of Death: May 15, 2009 Annuity Value as of Date of Death: $ 35,074.69* Cost Basis: $ 35,000.00 Named Beneficiary: Seldon S. Cohick & Robert A. Cohick *The actual amount paid may differ due to Market Value Adjustments and/or any applicable Surrender Charges. The above referenced contract was issued on 06/24/2003 with Earl E. Cohick as sole owner. If you have any questions, please contact me at 1-877.499-6418 Ext.86173. Sincerely, ~ Wendy a azr~ Sr. Claim Processor