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HomeMy WebLinkAbout08-24-09J REV-1500 Fx (DB-D5) PA Deperhnent of Revenue Bureau of Individual Taxes Po Box zeo5ol Hardahuro. PA 17128-0501 15056051058 OFFICIAL USE ONLr County Coda Year FNe Number INHERITANCE TAX RETURN ENTER DECEDENT INFORMATION BELOW Social Sacudty Number Date of Death Decedent's Last Name IfSuflix_ -----_ ..._. -........~ l~l L i ~~ r: air. (N Appliubls) Enter SurvWing Spouse's Information Below JD~ate of Blrth 7 „her z3.r.12 ~9 ii Decedent's First Name MI EVL'LYIJ ~ In Spouse's Lest Name Suffix Spouse a First Name MI Spouse's Sobel Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW ~ 1. Orig{nal Retum O 2. Supplemental Retum O 3. Remainder Retum (data of death pnorb 12-13-82) O 4. limited Estate O 4e. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required death ether 12-12-82) O 8. Decedent Died Testate O 7. Decedent Maimeined a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O iD. Spousal Pavony Credit (date of tlealh O 11. EVeGlon W tax under Sec. 9113(A) behveen 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CARRE8PONDENCE AND CONFIDENTIAL TAx INFORA4ITION SHOULD SE dRECTED T0: Name Dayfime Telephone Number L ihIDS A" 1~• aAifZD 7/7- Z43-5732 Firm Name AItz.D LAW Flret line of address 3T .~oLCTH uzrnoycr S~rcc+ Second Tine of address _ 1 City or Post Office State ZIP Code ~rII'she _ ~l 17013 Correspondent's a-mall address: I~Ci 1 rGl. Lc-{ W ~' Y/J_ . N E' REGISTER OF~ILL8 USE ON~ ~ ' >~ n SJ ~ r- G7 G:_~ J .?i - t ~, . c ~O-n ~ OC - . r I w -; '~ Under penaltles rN perjury I declare that 1 have examined tlrla realm, induding acampenying eohedulea end eletemenle, end to the beet of my knowledge and Ireller, tt le true, correct and mmplsle. DaUeletlon of preparer other than fhe personal repreeentetNe ie Deeed on all Informetbn of which preperer hea arty knowledge. S NATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE m 9~a~,.,.r.at~. ~6 - 5 - x-009 516 ~~lrn s k~ blc ~letci . ~~Ir ri she ~A I~I•~ SIG PREPARER OTHE RE SENT THE DATE ~?'~ 1~t ~ ^ ~~S ' -1 7" ~ cL n o~~yrnn O/ 7 !/$~L ~'~R{ ~ Yd7~ PLBASE U81B ORIGINAL FORM ONLY Side 1 L_ 15056051058 15056051058 REV-1500 EX Decedent's Social Seedy Number RECAPRULATION 1. Real estate (Schedule A) ............................................. 1. 1 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Carporatlon, Partnership or SolaPropdetorehip (Schedule C) ..... 3. 4. Mortgages 8 Notes Reoetvable (Schedule D) ............................. 4. 5. Cash, Bank Deposits 8 Miscellaneous Personal Propeny (Schedule E) ........ 5. Z I 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 8. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 3 I~ I 6 8. Total Gross Aueb (total Lines 1-7) .................................... 8. / . 4 ! Z r ~ Z I 9. Funeral Expenses 8 Administrative Costs (Schedule H) ..................... 9. f Z 4 Z 10. Debts of Decedent, Mortgage Liabilitles, 8 Liens (Schedule I) ................ 10. 11. Total Dadutdons (total Lines 9 8 10) ................................... 11. ' 4. 2 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. ~ 9 ~} 3 13. Charitable and Govemmentel Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 14. Nat Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 1F 4 7 3 TAX COMPUTATION • SEE INSTRUCTION3 FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax refs, or 15. 16. 17. 18. 19. TAX DUE ......................................................... 19. transfers under Sec. 9116 (a)(1.2) X .0_ 18. Amount of Line 14 taxable at lineal rate X .0 S 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Llne 14 taxable at wllaterel refs X .15 20. FILL iN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1505b052048 15056052048 Side 2 1505605248 O J REV-1500 EX Page 3 Flle Number Decedent's Complete Address: z ~ ~ j Q~~ `{- DE E NTS NAME I L V~~~-t 11. Lt tie o I - ZO- t 60 CSSnr STREET ADDRESS ^, CITY STATE ZIP Cclr~cs~£ ~(~ ~~01~ Tax Payments and Credits: /, 1. Taz Due (Page 2 Une 19) (1) I + ~ 3 . ~}. 2. CreditslPaymenls A. Spolrsal Poverty Credit B. Pda Payments C. Discount TotalCredits(A+B+C) (2) Interest/Penaky if applicable D. Interest E. Penalty Total InterestlPenafry (D + E ) If Line 2 is greater than Line 1 + Line 3, enter the diRerence. This is the OVERPAYMENT. FIII in oval on Page 2, Wrre 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. Eller the interest on the tax due. B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (3) (4) (5) ~ 1843, G 1 (5A) (~, 1 ~ 4 3.41 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a Varlsfer and: Yes No a. retain the use or income of the property transferred :.................................................................................... ...... ^ m b. retain the right to designate who shall use the property transferred a its income : ...................................... ...... ^ c. retain a reversionary interest; or ................................................................................................................... ....... ^ d. receive fhe promise fa Iffe of either payments, benefits a cere? ............................................................... ....... ^ 2. If death occurred after December 12, 1982, did decedent transfer property wdhln one year of death without receiving adequate consideration? ....................................................................................................... ....... ^ 3. Did decedent own an'in trust for' a payable upon death bank account or security at his or her death? ....... ....... ^ 4. Did decedent own an Individual Retirement Acceunt, annuity, a 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 R AS PART OF THE RETURN. Fa dates of death on a after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or fa the use of the surviving spouse is three (3) percent (72 P.S. §9116 (a) (1.1) (i)]. Fa dates of death on a after January 1, 1995, the tax rate imposed on the net value of transfers to or fa the use of the surviving spouse is zero (0) percent [i2 P.S. §9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still appliceble evenrf the surviving spouse is the ony beneficiary, Fa dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child lwentyone years of age or younger at death to a 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 a 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 a for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common wiN the decedent, whether by bbod a adoption. REV-1508 EX+ (6-98) COMMONWEALTH Of PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT scNEOU~E ~ CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY 7 ESTATE OF FILE NUMBER v'e 1~ n R . ~i'~er~~~}oY 21- O9- o l4~- Indude the proceeds d lilipation end Me date iha prOCeeda were received h1'the estate. All proiwrty jdntryowrwd rMll right of aurvlvashlp must a dbdosed on Schelde F. REV-,5,0 IXi (698) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEptIL! 6 INTER-YIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER ~YetYn 12. Li~er~+oY 21 -09-OILF4 This schedule must be comdeted end Aled'rf the answer W any of queaaorre 1 brough 4 on the reverse sMe of tl~a REV-1500 COVER SHEET is yes. ITEM NUMBE DESCRIPTION OF PROPERTY ixawe nos ruac oc nlErarHSrrasr:, nlem eaunoxexivrosacsoerrrnro TMean:a*au/s~a ~,rncMncgvror,r~gsso roa xEU esrn,e. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST EXCLUSION it nsr~ TAXABLE VALUE ZNG USA ANNU't'FY 19,38° /~~ma t~. C~arr+~n- t~~jh}er 2.0 3~y76• Zj~v id L- l.i~era}or- ~n 20 3 ,Ll76 L1~er~1 A. I~e,pet~-l~ita~h~er Zp 3,G76. [2cx-1er L. L.,~er.~~ot'-SOh 20 3,-47• l:ic~arc~ r• ~"lev,~~er-Sph 10 1,73$, `a~ov~`C ~~• I~t°,~-~'xer - ~h1cr 10 (,-1 8$• /~~ma rl. C~c7htr,2A» - lldl~gilteY ~ `J"-rJj~~.i t~avicL L. L, her-a'~or-.$~r~ 1.0 2,70$, C~er~(I /~• ~e t per - L~zTLrl?~~ev 2O 2.70g I:o~j~r ~_ L. ~Pr~{Or -~cir. zo z_ log. vo ~O DO DO db 00 7 d9 og oq TOTAL (Also enter on line 7 Recepkulation) S I ,31 9 16 . 9L~ (If more space H needed, insen adddional sheets of Me same size) REV-7511 EX~ (70-08) scN®du~e x COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES S~ INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF ` FILE NUMBER l.' Ve.1~ rt ~, L't ~aera}nv Z 1 - Oq- OI 44 Debh of thadent must N roported on &heduh L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: L ~ We~Fmiv~is}er'Ceme{-d'r~l- Mc7YKer i~~7EiG 8 2~1b`•vo Fuy,ervrl Rsc~.~a~.vn - S7• PduAi c1.uv'cl, l QQ , 5Z SC.r~}1h~~ (10'4teC - ~}{ec o T~ant:.5 .S.S'~~ rltx..~s-C~v~-o»~C~~ f~b~tce - l.~~er d~ 1~eThY.S q•00 Sr.P,~ui s Cl.urcl,- - L~w.~.~+w,~ -loti {x.xtneraPt 1 0 0.0 0 e. I ADMINISTRATIVE COSTS: 1. Personal Represenfatlve's Commisaions Name of Personal Representative(s) Street Address Gty Year(s) Commission Paid: 2. Attamey Fees 3. I Family Exemption: (If decedent's address h not tna same as daiment's, attach explanation) Claimant Street Address Gty Relel'ronahip of Caimant to Decedent State Zip Zip 4. ProbaC~ al-,-~.- I.ma Coza..ti~~r ~ ~ si e•r ci va I Ul s 5. AxaumanYS Fees 8. Tex Retum Preparer's Fees ~. Prvo~ o~ PubltcN~ta;, -~.~ (lo~tct -Cca.,,,,herl~r•J l.aW JoL~YYIa~ Pr,~ ~ ~ubltexs}ton, gs4~}e (bl ice- 1'4.~ 5~~•.-4t v`el 8~ / 00 83- 00 1 ~, no a. t a-qa TOTAL (Also enter on line 9, Recapitulation) I S IS27 ~ 'T (If more space is needed, insert edtlidonal sheets of ins same size) LAST WILL AND TESTAMENT OF EVELYN R. LIBERATOR KNOW ALL MEN BY THESE PRESENTS, that I, Evelyn R. Liberator, of 516 Barnstable Road, Carlisle, Cumberland County, Pennsylvania, being in good Health and of sound and disposing memory, do hereby make, declaze, and publish this as my Last Will and Testament, Hereby revoking all former Wills and Codicils heretofore made by me. FIRST: I direct that all my just debts and expenses of my last illness and funeral expenses shall be paid by my Executrix, hereinafter named, from my estate as soon after my decease as shall be found convenient. SECOND: I give, devise, and bequeath all the rest, residue, and remainder of my estate, ~~ ,~ whether real, personal or mixed, of any nature whatsoever and wherever situated, including any lapsed l`.i or void legacy, to Abna M. Garman, 516 Barnstable Road, Carlisle, Pennsylvania. `~ ~-=' '}> THIRD: I hereby nominate, constitute, and appoint Alma M Garman, as Executrix of this ~, ~' my Laet Will and Testament. If my Executrix fails to serve, or for any reason fails to continue to y~Y serve, I then appoint Lindsay D. Baird, Esquire, 37 S. Hanover Street, Cazliale, PA to serve as Executrix. FOURTH: I direct that my Executrix, oz her successor, shall not he required to famish `~'° any bond or other security for the faithful performance of her duties, notwithstandingsny provisions ~ ~. of law to the contrary. ~`'~~. FIFTH: My Executrix shall have, in addition to the powers and authority conferred upon her by law, the following additional powers and authority: 1. To sell at public or private sale, exchange, lease, mortgage, or pledge any property, real or personal, constituting a portion of this estate, at any time, and upon such terms and conditions as she shall deem wise. 2. To invest any money at any time in such bonds, atoclxa, notes, real estate, mortgages, lie insurance, annuities, or other securities, or such property, real or personal, as she shall deem wise, without being limited by any statute or rule of law regazding investments by the Executrix. 3. To retain, without incurring any liability, as investments, any property owned by me at the time of my death, as long as she deems it wise, and even though such property is not the Izind of property she would purchase as an investment, and even though to retain such property might violate sound diversification principles. 4. 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 hex own name, or in the name of a nominee, or in such form that title will pass by delivery. 5. To consent to the reorganization, consolidation, readjustment of the {financial structure, or sale of the assets of any corporation or other organization, the securities of which constitute a portion of my estate, and to talze any action with reference to such securities which, in the opinion of my Executrix, is necessary to obtain the benefit of any such reorganization, consolidation, readjustment or sale; to exercise any conversion privilege or subscription right given to her as the owner of any securities constituting a portion of my estate; to accept and hold as a portion of my estate securities resulting from any reorganization, consolidation, readjustment, sale, conversion, or subscription. 6. To pay all costs, taxes, chazges and expenses in connection with the administration of my estate. 7. To transfer, sell, exchange, partition, lease, mortgage, pledge, give options upon, or otherwise dispose of any property at any time held by her, at public or private Bale, or otherwise. 8. To employ legal counsel, accountants, brolxere, investment advisors, custodians, managers, and other agents and employees and to pay diem reasonable compensation out of my estate or out of any fund held hereunder to which said compensation is attributable. 9. To do all other acts in her judgment necessary or desirable for the proper and advantageous management, investment, and distribution of my estate. SIXTH: I duect that all transfer and inheritance taxes, state or federal, assessed because of my death, whether the fords, property, or insurance proceeds to which ouch taxes are attributable pass under this Will or not, shall be paid out of my residuary estate just as if they were my debts and none of those taxes shall be chazged against any beneficiary; that my Executrix pay, or provide fox payment, of all such taxes at such time or times and in such manner as my Executrix deems best. SEVENTH: All questions as to the validity of this, my Last Will, or the administration of the Will shad be governed by the laws of the Commonwealth of Pennsylvania. EIGHTH: Should Alma M. Garman, fail to survive me, then I give, devise, and bequeath all the rest, residue, and remainder of my estate of whatsoever nature and wheresoever situate to my three children, David Liberator, Cheryl Peiper and Roger Liberator, Jr. NINTH: Except as otherwise provided in this Will, I have intentionally failed to provide for any other relatives or other persons, whether claiming to be an heir of mine or not. Insofar as I have failed to provide in this Will for any of my other issue now living or later born or adopted, such failuze is intentional and not occasioned by accident or mistalze. IN WITNESS WHEREOF, I, Evelyn R. Liberator ,the Testatrix to this, my Last Will and Testament, typewritten on three (3) sheets of paper which I have identified in the mazgin of each page by my signature, hereunto set my hand and seal this 10th day of July, 2007. U ~,~~ C-= ' r G~ Evelyn R. Liberator ~', ~='~ , (J The preceding instrument, consisting of three (3) typewritten pages, each identified by the signature of the Testatrix Evelyn R. Liberator, was on this day and date signed, published, and declared by her, the Testatrix therein named, as and for her Last Will, in the presence of us, who at her request, in her presence, and in the presence of each other have subscribed our names as witnesses. / ~ /.~ , / \ ~_C. t I d ~' nu)fl4T,.atyF .~eVVxu wne. ..x=w ~..... . _... _. COMMONWEALTH OF PENNSYLVANIA ) S5: COUNTY OF CUMBERLAND ) I, Evelyn R. Liberator, Testatrix, whose name is aigned 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 on the 10th day of July, 2007; that I aigned it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. -~ ~~ ~~"~ E yn R. Liberator Sworn or affirmed to and acknowledged before me, by Evelyn R. Liberator , the Testatrix, this 10`~ day of July, 2007 . Notary Public COMMONWEALTH OF PENNSYLVANIA Notsdal Saar Nlven J. Baird, Notary PubYc Carlisle 8oro, Cumbedpnd Camry MY Commesion Expires Nov.2, 2010 Member, PennsyNanie Aasoeletion of Notaries COMMONWEALTH OF PENNSYLVANIA ) SS: COUNTY OF CUMBERLAND ) We, the witnesses whose names aze aigned to the attached or foregoing instrument, being duly qualified according to law, do depose and say drat we were present and saw Evelyn R. Liberator sign and execute the instrument as a codicil to her Last Will; drat sire signed willingly and that sire executed it as her free and voluntary act for the purposes therein expressed; that each of us in the c )searing and sight of Evelyn R. Liberator signed tlse codicil as witnesses; and that, to tlse best of our knowledge, Evelyn R. Liberator was at tlse time eiglsteen (18) ox more years of age, of sound mind, and under no constraint or undue influence. 77 ~n f ., ~iy C= Sworn or affirmed to and subscribed to before me by tlse above-named witnesses, this 10th day of July, 2007. I ~~~"?~ Notary Public COMMONWEtiLI'N OF PENNSYLVANIA Notarel Seat Niven J. Baird, Notary Public Carlisle Bab, Cumherland County My Commissbn E~ires Nov. T, 2010 Member, Pennsylvania Association of NotaAes 5 ~ .. _. ~ ?? ti ~~ !-! ^ ~.. ,:V ~.,~ ~,1 ~ ~ ~ ~i 4 _ © ~.. ~~. 1'M ~f ~ ~ ~ r F'n .. ~ ~,C~ i l E _ ~ }~/ e~ r ~~r ~,t _ ~:~ ~ ~ ~. i p,-~ R S h{ i~ ! YG1 `~~ ~jG~ i ~J WS?C.S-1. J~' ~--4~.til~ G~ _ ~ ~ / ~F~'G ~ :~- ~ U i ~~~~,.,~., :,.~.:~,.:v.:,..:, roul uoslaN s¢woyj,® E Q ^ 'V'S'(1 u!aP~'W ~~,~ ~I~~nI'{~~~ 6'9b05-1991'D N9SI £OII seley siuuea ,(q Rydel6olot{d OIG~" %~~ IN MEMQRY OF . ~? _ n ,(J , . _.L. IS GYiAT~FULLY ACKNOWLEDGED. 7l° LINDSAY DARE BAIRD, ESQUIRE 37 S. Hanover Street Carlisle, PA 17013 (717)243-5732 Fax: (717)243-8110 STATEMENT FOR LEGAL SERVICES RENDERED To: Ms. Alma Garman RE: Estate of Evelyn R. Liberator DATE SERVICE RENDERED DATE: July 14, 2009 UNITS OR HOURS RATE TOTAT. 12/08-7/09 Attorney fees 1.00 850.00 850.00 0.00 _ - 0.00 i -- 0.00 ~ 0.00 Thankyou,Alma. 0.00 0.00 0.00 0.00 0.00 0.00 i --- _ ----- -- -------- 0.00 TOTAL UNITS OR HOURS ].00 SUBTOTALi SSO.OO I Less Retainer 2!3!09 750.00 BALANCE DUE $100.00 PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (iJnder Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Joumal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Cazlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regulaz editions and issues of the said Cumberland Law Journal on the following dates, vlz: February 20, February 27 and Mazch 6, 2009 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. Marie Coyne, TO AND SUBSCRIBED before me this Liberetor, bbelyn R, deed. Late of Weat Pennsboro Tovm- ahip. Executrix: Alma M. Garman c/o Lindsay D. Baird, Esquire, 37 South Hanover Street, Carlisle, PA 17013. Attorney: Lindsay Dare Baird, Esquire, 37 South Hanover Street, Carlisle, PA 17013, (717) 243- 5732. 6 day of Mazch, 2009 Notary NOTARIAL SEAL DE30RAH A COLLINS Notary Public CARl13LE BORO, CUMBERLAND COUNri My CommNSfon Explras Apr 28, 207 0 CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tels: (717) 249.9188 Fex: (717) 246-2888 March 6, 2009 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Lindsay Dare Baird, Esquire Evelyn R. Liberator Estate RE: Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on the following dates: February 20, February 27 and March 6, 2009 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 0 .00 Total Amount Due $ 75.00 Payment received by, ., .. ~. ~ _„w,.. PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Erica Peterson, Classified Manaeer, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13~, 1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following day(s): February 14, 2009, February 21, 2009 and February28,2009 COPY OF NOTICE OF PUBLICATION Affiant further deposes that helshe is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of publication are true. Sworn to and subscribed before me this a~ ~ '~Yl anc~ aoo9 . -~ Notary Public My cornrnission expires: COMMONWEALTH OG= PENNSYLVAI'ilA ._, NOTARVAL SEAL BAMBI ANN HECKENOORN. Notary Public Camp HRI Boro., Cumberland County My Commis. s ,ion Expires J~ ~ 2010 RETAIN THIS PORTION FOR YOUR RECORDS TFIE SSNTZNEL - LEGAL BAIRD LAW OFFICES P.O. BOX 130, CARLISLE, PA 17013 AD NUMBER CLASS SALESPERSON BILLING DATE LINES 364690 10 PUBLIC NOTICES wolfs 03/01/09 40 * 2 AD DE CRI ION START DATE STOP DATE EXECUTRIX NOTICE LETTERS TESTAMENT 02/14/09 02/28/09 PUBLICATION INSERTIONS RATE NE7 AMOUNT GROSS AMOUNT 3 THE SENTINEL - LEGAL 3 LGL 212.40 TOTAL AD CHARGE 212.40 3 PROOF OF PUBLICATION ~O1PRF ~ 7.00 PAY THIS AMOUNT I z19.4o I 263.28* Est.E.Liberator „~_, ~~,a MESSAGE: Thank you for advertising with The Sentinel. Deadlines for in-column legal advertisements: Monday is Thursday at 5 p.m; Tuesday is Friday at 5 p.m.; Wednesday is Monday at 5 p.m; Thursday is Tuesday at 5 p.m; Friday is Wednesday at 5 p.m Saturday is Wednesday at 12 Noon; Sunday is Wednesday at 5 p.m. If you have any questions regarding your Legal bill please call Classified Manager at 717-240-7176 Fax your legals to 717-243-3754 attention Classified Manager You can also EMAIL your legal to Classified ads: classified®cumberlink.com Please send a cover letter including your name and address as an attachment DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT THE SENTINEL -LEGAL Est. E. Liberator .,.. wan Pn~l ICS G DA ~'f/lg2 r AD NUMBER CLASSO START DATE STO DATE 364690 PUBLIC NOTICES 02/14/09 02/28/09 AD DESCRIPTION BI LING DATE TEL PHONE NU BER EXECUTRIX NOTICE LETTERS TESTAMENT 03/01/09 717-243-5732 GROSS AMOUNT OF 263.28 DUE AFTER 03/31/09 TOTAL AMOUNT DUE 219.40 ENTER AMOUNT ENCLOSED BAIRD LAW OFFICES 37 SOUTH HANOVER ST CARLISLE, PA 17013 I,.~lll~~~lll,~„„II„II~{~~I~1 20200000003646900000000000000002632800000219401 . ,... ... w„R, „.a ..,~,,...~,.... .,,,....w_ ..a .. .,~. , ? zoo The Sentinel ~~ ~ E ~ r :a ~ Sox 130, Carpals, Pa. 17073 Received from: Jr~,~/w J`l~ /h'!(.n, g ~ ,p d ~H~~.~ac~ For; Cla~/ '/ Circ. Retail Legal Other /~ Irnoice No. ~G57 Initialed by ~•//~ THE NEWS-CHRONICLENALLEY TIMES-STAR - 5 7 H 9 7 P.O. BOX 100 1011 RITNER HIGHWAY SHIPPENSBURG, PA 17257 (717) 532.4101 FAX (717) 532-3020 Dnr6 ~ ~-3 ~ tE1VFD FROM ~ ~ ~~C~ /LGP ~ ~, i i DOLLARS MWN7OF gCCpVNT • {~/~ CASH, ~' .9 THIS PAY ECK (( BAIANCE DUE BY M.C. ti~a~~~~ ~~-- if ' ~ -c..A.~_ c.~-~~° "~ 7-f~.~.-A.~ w~. ~- ~~~,~ Q.P,tit- .k. ~~,e.ka+.~ s~- ~ 'tau-, 1 vL ~3"" ~. ',.c . ~.c-'~ .C~-~-~' /d--L.~1-.~1r1" ~.L~,-''~-~`'1 '~`"W 'sue ~.r._.- Q-' N. Lc<a+.*`.~---. 4~-~- ~E:,.:.u, ~~,~.~:- ~ atis-1~,~ r ~~ ~~ C E it # `7 {3_5-7,5 Y V ~~~ ~ Commerce Benk/Harrisburg N.A. P.O BOX 4998 ank Harrisburg, Pennsylvania 17111.0999 1•Ba8-937-0004 J~~~` ESTATE OF EVELYN R LIBERATOR 518 BARNSTABLE RD CARLISLE PA 77015 We're here 7 days a week, 24 hours a day at 1-888-937-0004. ESTATE CHECKING 0537512923 _, ,. Statement Bounce as or oaso(os slo,tnasl Plus 0 Deposits and Other Creel"Rs .50.00 Less 0 Checks arM Other Debits 30.00 Statement Balanceas of 05/31/98 510.878.21 DOB Cycle x Page 1 of 1 NOTE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION Member FDIC ...~' _ , ;,~v ~ ~ curt: ':. _ c~~' ~G~ ~'~ ~u;e l ~~ ~# l~ ~ -~la~lo~ ~~~~ ~M~ _~ MARY E BROWNEWELL WILLIAM J BROWNEWELL PH. 717.7767628 F 7s cARUSUZ RoAo i NEWV~u-E, PA 17247 __ ~,.,A ~ ~~ un~;~ -~ ~~~39 1215 oA~ ',(~ 8" a 9 i g3~pppo~: MgT - --_sG~t~~LLARS 8 ."'~. 4 ©~,~ M@NO I / /.!-++L"~~L!-_. /~Y C.n'Li'SbL~li}•C~ .. ~:0 3 i 30 29 55~: 98 3 29996691. 1 2 15 Commerce Bank 0180021NY7N00009TOR ESTATE OF EVELYN R LIBERATOR 576 BARN9TABLE RD CARLISLE PA 17015 Commerce BanklHarNsburg N.A. P.O BOX 4999 Harrisburg, Pennsylvania 17111-0999 1-88M937-0004 We're here 7 days a week, 24 hours a day at 1-888-937-0004. ESTATE CHECKlN6 0537512923 Statement BaMneeas of 0381/08 37,87 - Plus 1 Deposits and Ot11er~Credds ,000 Less 0 Ghecks MW OfheYDebits 50.00 ~~ Statement Balance as of 04/30/09 510.876.21 Transactions By Date Dab Daurip0on Debit Crcdk Balance 0429/08' DEPOSIT= 53,000:00 510,876.21 009 Cycla ~ Page 1 of 1 NOTE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION Member FDIC ~ -- m ~ ~'` ` M ~ ~ m ~ ~ s ~ ~ ~= c CJ 1= ~ Q .~~ ~ ~~~ ~ ~ m R w x a 2° fa^ ~ o ~~i ~Z~ aGa m ~ Jb~ 4mv U w' O s ,~ T ao" 1 ~ .~ ~i 4 ~~ V 4 N N fT7 N J ru i ~ •. c0 J a . a N w° a ^ .. ~. Westminster Cemetery ~ DuriPl ~ ~9q 1159 Newville Road Carlisle, PA 17013 ~-{~', coNTRncT No. 717449-2029 Propcny D<eJ No. INTERMENTIENTOMBMENT AUTHORIZATION AND INDEMNIFICATION - Tnday'F Dele: 12(21//44 1 -DATA ON DECEASED- NAMII: {{~~ LI ~ A I•-V DO. g. DOU. 1'MEOP IIFnTH -.-~ $5X M F AGE MARITPLStATVS ADORPS9 V Y LL/1 II P ~ ~ WAR RECOPD ~ 1 JN IDLAAIy ' I PLAfe OP DEATH'. -DATA ON NEXT OF KiN OR REPRESENTATIVE - NAME: A PNON$_ ADDAB4H: 5I -DATA ON PROPERTYOWNER- NAMR: TIONSNIP: PHONE'. ADORlg9: -INTERMENT/ENTOMBMENTRNURNMENTDATA- uu cerveD DAre: nME I eY. FUNEML AOOPB[!'. Z PNONg: PUNEMLXDME ACT: PIINIML UIRHCPOR: 2 DAy`.. V AI- MTROP URIA' Iz 'Z S PIMEML ~_F MLHOEflt _CNULCN _CEMITERV: 58RVICR AT'. TWe: ~M 051'. ARNVALAT CHMHTFAY -MAUSOLEUM- TEM~._ MAUSOIEUM HAMR: SECTION tq_ PEAM:~ IPVPLHO, QYPfRM1CH8N0. LSITERMO: CRYM PLATE YES/NO MCIEMO/SCROLLDPATN Wre NFlO60: VESIIq PHLIOIW 011UTNER: • BUIUAL- pAROHN NMAp/ off No. LOTNO. OMVF.19) !1 ' MOL Dp TYPI OP DIRER BUNCAL C~OMAMER O D ' ~Tti . VfE0. BNUAL<ON1'AMERGD~. S EMQF _CNAPeL flCRVICH L31D0 OTP~0. OO@0. flPEClALM5T0.UCf101155PEG1At&}U@MEM: PNMdONAL n9FALLep !9l Ji SCMLL DEATX DATTIINO NeIDIO: 89 Ip ~~-A ZvYO ScRO{~'~g1TTH£kAis -CURRENT CHARGES AND PREPAIDINFORMA710N- PRCN66D CONTMCF. DATE NUMBER 96LLMG PRICE AMOUNT DUE OPENTi01CLOSTNO VAtrtTNwULT MSTALL comer MARKERIBALE PROPERTY OTHEA _ I_ =-( -1 f .OD 'S .!/D wMOUNT DUR T056PUHNLD FlIOM~ IAMILY _PUNLMLDIR[LTOL MTALDUL: TM1C mdmiPetl M1emby ttNIRH IReY Imve Ilk full IePi auNmtry m dirtn No Inkmlenl.2namMmt m Inummmlof Ue mmaiv of the denaW. and M1Heby aulM1m~ ze Ue [nnel<ry m mke dipoailbn D(NC rtmins o(IM tlettMW a indinud. TNe undmiPd benby R^IM1^nni(Y eM repnnnt Vul R.ey art aWMrys)m wNn- IizN rtprearnmdve0) o(Ue awm[[) of Ile above dcecribW Intmmnt RigM1b and M1emby aolM1ariu uM N Mid Inmmmml RI9M1b Of IM1C Inkmenl. Emombmem, m Mmnmeau ahhc rtmHax of Ibe Mein mmeB de[PPd, TM omrerzry'n Aertby dlrtH<tl l0 eupcmrz inamllnion or imm any oumr buntl cmmincr, m Ibe eamnl mquirtd by Iew, pnmMUtl in cmnnlion wirb IM1is Intmrtnl aM Nc Inkmem RiAbb deuribM Mein. TM1e undersignetl bHeby egme to iM[mniry antl IwIE Iwmkaf Ne nm[kry, ib agrnu anE emFloyees Gom any end aU LIADIWTY, incWdiM mnwrubk Xtomey's tm, ud aPMH NYtw hw Day Illy awlHnNmmNmim wiM OH lnlenmmRSlmmDmmS nNmnllmtwppiu]MRwdH. TMdnMCylek4 pA[['vero vaitl ertma, WI In Hk cumn an ImdVeHHIT nra tlom w[w, DN wmelmy ebR love UN riHM b [OII![I aaY mar M Ue Innmmm4 C mmLmml m InummrnL rt ib own eRpenm, wilRnl my liebiliry for rv[M1 <mn. NOTE3: Flawen wlll be removM i ari IkOm bOrlal. ~~i~ >r S mily Smvi[eCwnkbr SiPamm of tua Oxrn/AUtM1Orittd Repeaenmlive OFFICE 0360 V SPACE VERIFICATION -AUDRAND EECORDKE[PIN6 Inkmmt ,/ (InitiH aaan[b NaO is wmPlHed) CM1Hk /• PamllY VerlaW: MfERM5HT OROpA C'HIIXeD ~,~ 1 2 ; Eurv< B: INiF.RLIlNTCARD COMPLETEDAMI FILED , q Yad Y 1 MASTER TARO UPDATED /~ CAMedB: PLAT BOJRANO LOT MAPS UPDATED __ - s•I PUNALIggMR RECEIVED AND iILEO _ _ MNEP WUNa~AdmMYHnlIaTCaMry-AdMnilrttlonPM4~MaMHmM PevyW rt`L~.~~l C~ 12~ ~~ZvaB' Baird Law Offices 37 South Hanover Street Carlisle, PA 17013-3307 (717) 243-5732 Fax: (717) 243-8110 E-Mail-bairdlaw@pa. net FAX TRANSMISSION COVER SHEET Date: 2111!09 To: Cumberland Law Journal Fax: 249-2663 Re: Executor's Notice, Evelyn R. Liberator Sender: Lindsay D. Baird YOUSHOULD RECEIVE 2 PAGE(S), INCLUDING THIS COVER SHEET. IF YOUDO NOT RECEIVE ALL THE PAGES, PLEASE CALL (717) 243-5732. Good afternoon! Please run the attached Notice in the Journal once a week for 3 consecutive weeks. We would appreciate receipt of Proof of Publication. Please send the invoice to Lindsay D. Baird, Esq., 37 5. Hanover Street, Carlisle, PA 17013. And thank you for your assistance. Conlldentiality Note The informadoa cootalned in end with Wb facsimile message is legally privileged and confidential intormadoo Intended only for the use o[ the individual or entity Domed above. If the reader otthia message is not the intended recipient, you are hereby notified that any disaeminadon, distribution or copy of this telecopy is strictly prohibited. It you Gave received this tekcopy in error, please immediately notify ua by telephone and return the original meaeage to us at the address above via the United States Postal Service, Thenk you. FOR CUMBERLAND LAW JOURNAL: Letters Testamentary on the Estate of EVELYN R. LIBERATOR, late of West Pennsboro Township, Cumberland County, Pennsylvania, deceased, have been granted to the undersigned. All persons knowing themselves to be indebted to said Estate will make payment immediately, and those having claims will present them for settlement to: Alma M. Garman, Executrix c(o Lindsay D. Baird, Esquire 37 South Hanover Street Cazlisle, PA 17013 (717) 243-5732 Lindsay Daze Baird, Esquire 37 South Hanover Street Cazlisle, PA 17013 (717)243-5732 Baird Law Offices 37 South Hanover Street Carlisle, PA 17013-3307 (717) 243-5732 Fax: (717) 243-8110 E-Mail-bairdlaw@pa. net FAX TRANSMISSION COVER SHEET Date: 2/11/09 To: Classified Department Fax: 243-3754 Re: Executor's Notice, Evelyn R. Liberator Sender: Lindsay D. Baird YDUSHOULDRECEIVE 2 PAGE(S), INCLUDING THIS COVER SHEET. IFYOUDO NOT RECEIVE ALL THE PAGES, PLEASE CALL (717) 243-5732. Good afternoon! Please r1ln the attached Notice in the Sentinel once a week for 3 consecutive weeks. We would appreciate receipt of Proof of Publication. Please send the invoice to Lindsay D. Baird, Esq., 37 S. Hanover Street, Carlisle, PA 17013. And thank you for your assistance. Conadenriallly Note The Information coohined in and with this 6aimile message fs legally privileged and confidential informarioe intended only for the use of the individual or eority named above. If' the reader of this message is not the intended recipient, you arc hereby notiaed that any dissemination, distribution or copy of this telecopy is aMctly prohibited. I[ you have received this hlecopy in error, please immediately notify us by telephone and return the original message to ns N the address above via the United Shtea Poshl Service, Thank you. EXECUTOR'S NOTICE Letters Testamentary on the Estate of EVELYN R. LIBERATOR, late of West Pennsboro Township, Cumberland County, Pennsylvania, deceased, have been granted to the undersigned. All persons knowing themselves to be indebted to said Estate will make payment immediately, and those having claims will present them for settlement to: Alma M. Garman, Executrix c/o Lindsay D. Baird, Esquire 3? South Hanover Street Carlisle, PA 17013 (717)243-5732 Lindsay Daze Baird, Esquire 37 South Hanover Street Carlisle, PA 17013 (717) 243-5732 ING. ING USA Annuity and Life Insurance Company P.O. Box 9271 Des Moines, b4 50308-9271 Pho na: 7-800-368.0068 Fax: 7-815.888.2034 {ntemet: www.inoannuftlas.com "•••`"""''AUTO"3-DIGIT 170AUT0 000000022000005384 EVELYN R LIBERATOR 516 BARNSTABLE RD CARLISLE PA 17015-9413 ur(~~ur~~~uuu~(r)r(r~r(nr~u~ur(~u(~nu(~r~~un(r Page 1 of 4 Quarterly Statement AS Of December 31, 2008 All displayed end of quarter values are as of the dose of business of the New York Stock Exchange on Me lest business day of the quarter. Your Financial Representative BARBARA ANN BISTLINE AIG FINANCIAL ADVISORS INC 301 S HANOVER ST CARLISLE, PA 17013-3933 717-249-4441 Contract Information Contract Number: 1025096-OD Owner: Evelyn R Liberator Product: ING GoldenSelect DVA Plus Joint Owner: None Contract Date: February 2,1998 AnnuilaM: Evalyn R Liberator Qualified Type: Non Qualified Contingent Annuitant: None Death Benefit: Standard Death Benefit Primary Beneflciary(ies): Robert(Shorty) M Mentzer Alma M Garman Cheryl A Peiper David L liberator Richard K Menfzer Roger L Liberator Investment Summary Current Quarter Year-To-Date Since Contract Date 10101/2008-12/31/2008 01/01/2008-12/3112008 02/02/1998.12/31/2008 Beginning Accumulation Value: $19,866.16 $24,106.44 $0.00 Premium Payments: $0.00 $0.00 $40,000.00 Net Withdrawals: $200.00 $1,100.00 $22,620.00 Net Investment Results' ($3,894.98) ($7,235.26) ($1,608.82) Accumulation Value: $15,771.18 $15,771.18 $15,771.18 tThe amount by which your Accumulation Value has changed is due to Investment resutLa during the pedod, induding eny market value adjustment, g applicable, and adjusted by certain charges, Induding any surrender charges, es oudlned in your con0ad and prospectus. < ~ ~;r. ING. Your future. Made easler.BM ozss7s oooot 00004 oooooa ooooao ooooao ING , ING. Your future. Made easler.S1A ING USA Annuity and Life Insurance Company Information Guaranteed Minimum Death Benefit: Death Benefit:l 1The Death Benefit is Me anwunt of the Death Benefit under your contract plus Information Owner Name: Contract Number: Contract Date: Annuttant Name: Statement As Of: As Of 12/31/2008 $17,380.00 Evelyn R Liberator 1025096-OD February 2, 1998 Evelyn R Liberator December 31, 2008 Page 2 of 4 As Of 08/30/2008 $19,866.16 Multiplier Death fit, if applicable, as of the date shown. As Of 12/31/2008 As Of 09/30/2008 Accumulation Value 15,771.18 19,866.16 Surrender Charges $0.00 $0.00 Market Value Adjustment (MVA) $0.00 $0.00 Annual Administration Charge $40.00 $40.00 Cash Surrender Value $15,731.18 $19,826.16 Investment Options At a Glance Important Messages Large Cap Value Balanced ~% 50% Starting with 3/31/09 statements, if you did not have transactions in the prior quarter, you will not receive a printed statement but will be able to view your statement on www.ingannuities.com. Sign up to receive electronic notification for your account documents. You will need a PIN to access this information from our website. Your PIN was mailed to you after you purchased your contract. If you have misplaced it, please call 1-800-366-0066. Investment Options By Objective As IN 12/31120081 As Of 10/01/20081 Accumulation fro Unit Accumulation of U 1 Investment Ootbn2 ana er Value Units Value Value Units ya ue Balanced ING TRowe Capital T. Rowe Price $7,912.80 218.9643 36.1374 $9,942.68 221.8489 44.8173 Appreciation (S) Large Cap Value ING Van Kampen Van Kampen Growth and Income (S) $7,858.38 354.6161 22.1602 $9,923.48 359.2817 27.6203 ozssa0 oooaz o0ooa 000000 000000 000000 ING INQ. Your future. Made easier.s"" ING USA Annuity and Life Insurance Company Owner Name: Evelyn R Liberator Contract Number: 1025096-0D Contract Date: February 2, 1996 Annuitant Name: Evelyn R Liberator Statement As l'N: December 31, 2008 Page 3 of 4 Investment Options By Objective (continued) As Of 12i31M0081 As Of 10/01/20081 Accumulation ggf r~lfl Accumulation a4 yQlt Investment Ootfon2 Manager Value n s Value Value nl Value TOTALS 515,771.18 519,868.18 1The value for # of units is calculated using flue decimal places and the value of each unit IS calculated using up to eight decimal places; however, both values are truncated to tour decimal places for display purposes. 2A symbd following en Investment Opdon indicates that the share dass is sutlJed toe 12b-1 distdbutbn or service See. See your prospectus for more Information. Transactton History 10/01/2008 to 12131120081 Effective Date Transaction Tvoe # of Units2 Unit Value2 From To 10/15/2008 Automatic Withdrawal ING TRowe Capital Appreciation (S) 1.3901 35.9682 $50.00 ING Van Kampen Growth and 2.2584 22.1397 $50.00 Income (S) 11/15/2008 Automatic Withdrawal ING TRowe Capital Appreciation (S) 1.4946 33.4542 $50.00 ING Van Kampen Growth and 2.4072 20.7700 $50.00 Income (S) 1The uensadlon history may contain transac0ons with effedive dates prior to the current quarter if the processing occurred during the arrant quarter. =The value for # of units is calculated using flue decimal places and tha value of each unit is calCUlated using eight dedmal places; however, both values are truncated to four decimal places for display purposes. y ~:< 020991 00003 00004 000000 000000 000000 ING Page<of< ,. , Owner Name: Evelyn R Liberator ING. Your future. Made easier.sa Contract Number: 1025096-OD Contract Date: February 2,19se ING USA Annuity and Life Insurance Company Annuitant Name: Evelyn R Liberator Statement Aa Of: December 31, 2008 Other Important Information Information and Assistance Have questions about your Contract? Please contact your financial representative. You may also contact us by mail, phone, or on the internal as detailed bebw. In ernet Log on to www.ingannuities.com to access unit value(s) and current Accumulation Value by investment option, transfer money among investment options or review contract benefits. You will need your Personal Identification Number (PIN) to access specific contract information. P on For questions regarding your statement or to obtain additional information, please call our Customer Service Department all-800-366-0066. ING Customer Service Associates are available: Monday through Thursday 8:30 A.M. - 6:30 P.M. ET Friday 6:30 A.M. - 5:30 P.M. ET Automated voice response system: Available 24 hours a day, 7 days a week Additional Premium Payments. Service Requests. or Chances Please use one of the addresses below to send additional payments, service requests or changes. U.S. Postal Service: ING USA Annuity and Life Insurance Company P.O. Box 9271 Des Moines, IA 50306-9271 Express Mail: ING USA Annuity and Life Insurance. Company 909 Locust Street Des Moines, IA 50309-2899 Important Please review the information on this statement carefully and report any discrepancies within 30 days of receipt to our Customer Service Department. Reported values will be considered final and correct after 30 days. Annuities are issued andlor administered by ING USA Annuity and Life Insurance Company (Des Moines, IA) and distributed by Directed Services LLC. Both companies era members of the ING family of companies. 029882 00004 00004 000000 000000 000000 American Funds Transfer on Death (TOD) Registration Request To etermine M this option Is right fort you, please speak with your financial adviser. You MUST sign Se~tio~n y4 of ththhnTOD form on page 10. tea a ownnti l nn ' . `'' _ R- ~ ~' /L71'I~ OI-^ !©, ©^a ^ Cheek here If you are revising an existing account. Account number ~ ~~ 9 G_ 7/ N ~ S f ~ V Because this form~has important tax and/or legal consequences, you are encouraged to consult with your own financial or legal adviser re ~mpleting it. You should periodically review and, if necessary, update this form. Do not use this form to update beneficiaries on etirement accounts. State of residence 1 ~iCkrawledge that this account is being established under the Transfer on Death Security Registration Act ("TOD Act") of the state of residence indicated bNow, or, if my state of residence has not adopted the uniform TOD Act, I understand that this account will be established under the California TOD Act. Furthermore, 1 acknowledge that, upon my death, should there be a conflict with applicable s e law, the account will be admi er in accordance with the terms of this document. My state of residence is 2 Beneficiary designation I! you are married, please ¢ad Section 3, Spousal consent to beneficiary designation, on page 10. I revoke any prior beneficiary designation. Reserving the right to revoke or change this beneficiary designation, I elect, upon my death, that all fund accounts shall be transferred in equal shares (unless otherwise provided) to each beneficiary designated below. In the even[ a beneficiary does not survive me, such beneficiary's share shall be transferred pro rata to the surviving beneficiary(ies). If any beneficiary survives me but fails to survive transfer of his or her entire share, then the remaining portion of such beneficiary's share shall be transferred to such beneficiary's estate. Note: All stated percentages must add up to 10096. If not, transferstshall be rnade~pro-portionately on the percentages stated. ~wv~~ L ~.h~1Z~A\~Q. First name (W'^q MI Last Rdtlionship Dak d birth ImMdcyyyyyl nr~mme (prlnn MI Lazt ~©-a©-©a®r~ DaL d Oirm 1 mnVdGytyy) ~~~ l7©© a~ ~e ~-O®©~ as ~% ahvrrl 100 °6 Trust beneficiary: If you choose to name a trust as a beneficiary, please describe the trust by the name of the present trustee, the name of the trust (if any) and the date of the trust. Example: "John Davis, Trustee of [he Davis Family Trust dated December 1, 1995 Minor beneficiary: In the event the beneficiary is a minor, American Funds Service Company may transfer the proceeds to a custodian it selects under the applicable state's Uniform Transfers to Minors Act. Continued on next page 90-0050-0 Work with Customer Accounts Subset by LIBERAER00 Sequence by 2 Customer ey F4 Type options, then press Snter. 5=Display account 8=Display description 10=Work with memo/tickler 12:Customer summary 14=Work with alternate 15=Maintain relationships Opt Short Name LIBERATOR EVELYN R -' LIBERATOR EVELYN R F3=Sxit FS.Refresh Account number Balance Ael Type Prd Alt 9000173655 6,768.88 SOW SV 004 2313154 1,181.30 SOW DD 550 i (" _.. ..~' ,~~~o~ Bottom F11=IIn/Fold F12=Cancel F17=Subset F23=More options Commerce ~-888-937-0004 Bank Commercepc.com valence iMOrmation reBecta transecdore Mrau9h fi:u0 PM on that busineea day. Some deposiU mey not be avellable tar immediate withdrawal. Checks and oNwr items ere received for deposit aubleq M the proviabna M the Undortn Commeroial Code or eny appliwNe cnlleatlon apreament. 19 11t~1 HPI U,~~11/Uy lU #i~iGy~'J UC~iI I~PO51[ $1rN75:~1 -- x~tPlc~tQ o/1~~ 11 ltiA Cfi-h'LI$Lt i:6nMOtJS ltl ~~c' QCLOeLnT BR-i] 3MM 12108 AC ~~ 1~~,5 COUNTY NATIONAL BANK """"`"""`AUTO"3-DIGIT 170 10566 0.7520 AT 0.346 36 1 86 LnllludllnuulLldiLludulndLJLndldluuLll EVELYN R LIBERATOR 516 BARNSTABLE RD CARLISLE PA 17015-9413 SAVINGS STATEMENT Statement Date: 01/13/09 Account#: 9000173655 Page 1 801 High-interest holiday bills piling up7 consolidate your bills with a loan from us. whether or not you have collateral, we can help. To find out more or apply, visit us at www.acnb.com. Equal Housing Lender. Equal Opportunity Lender. Member FDIC. STATEMENT SAVINGS Account# 9D00173855 Account Summa Beginning Balance Activity Ending Balance Previous Statement Balance 12/09/08 56,710.69 + Deposits and Other Credits 2 55.60 - Withdrawals or Other Debits .00- - Service Charges .00- +Interest Paid 1 A3 Ending Balance S6, 767.32 Days in Statement Period 35 Account Detail Date Activity Description DepositslCredits WithdrawalslDebits Balance BEGINNING BALANCE 6,710.69 12-31 PROT LIFE KILICO INS PAYOUT 25.41 6, 736.10 EVELYN L, LIBERATOR 12-31 PROT LIFE KILICO INS PAYOUT 30.19 6,766.29 EVELYN LIBERATOR O1-13 INTEREST PAYMENT 1.03 6, 767.32 01-13 ENDING BALANCE 6,767.32 Interest Summary From 12110108 Through D7/13/0 Days in Statement Period 35 Interest Earned 51.03 Annual Percentage Yield Earned .16°h Interest Paid This Year 51.03 Interest Withheld This Year 5.00 P.O. Box 3129, GerrvssuRG, PA 17325 ~ raoNe 717.334.3161 ~ roLLFaeE 1.888.334.ACNB (2262) ~ wwwacnb.com ~~~ ~1~,5 COUNTY NATIONAL BANK ""'""""""`"AUTO"3-DIGIT 170 10466 0.7520 AT 0.346 37 1 83 IudlludllunulhLLlduJnluJlnlluulldLuJdl EVELYN R LIBERATOR 516 BARNSTABLE RD CARLISLE PA 17015-9413 SAVINGS STATEMENT Statement Date: 12/09/08 Account#: 9000173655 .Page 1 801 Brighten your holidays this year and next. open an interest-earning Christmas Club account now, to put more under the tree next year. For a limited time, when you open a new Christmas club with automatic payment deduction, you'll receive a free gift. stop by one of our offices for details or visit www.acnb.com. Equal Housing Lender. Equal Opportunity Lender. Member FDIC. STATEMENT SAVINGS Account # 9000173655 Account Summary Beginning Balance Activity Ending Balance Previous Statement Balance 11/11/08 56,653.88 + Deposits and Other Credits 2 55.60 - Withdrawals or Other Detids .00- -Service Charges .00- +Interest Paid 1.21 Ending Balance 56,710.69 Days in Statement Period 28 Account Detail Date Activity Description Deposits/Cred'Rs Withdrawals/Debits Balance BEGINNING BALANCE 6,653.88 12-02 PROT LIFE KILICO INS PAYOUT 25.41 6,679.29 EVELYN L. LIBERATOR 12-02 PROT LIFE KILICO INS PAYOUT 30.19 6,709.48 EVELYN LIBERATOR 12-09 INTEREST PAYMENT 1.21 6,710.69 12-09 ENDING BALANCE 6,710.69 Interest Summary From 11/12/08 Throuuh 12/09/08 Days in Statement Period 28 Interest Earned i1.21 Annual Percentage Yield Earned ,24°k Interest Paid ThLs Year 515.14 Interest Wdhheld This Year 5.00 P.O. Box 3129, Genrssvxc, PA 17325 FHONe 717.334.3161 ~ rou Free 1.888.334.ACNB (2262) www.acnb.com Grw ADAMS COIJNI'Y NATIONAL BANK & FARMERS NATIONALBANKOFNEWVILLE A D1uLion ofAAvmr Cowry Nariom[ Bank "'""""'AUTO"ALL FOR AADC 170 1394 0.8240 AB 0.351 91 27 L~JIh~~IIh~~~~~ILLhLh~~h~h~~ILdhuJIJL„~Idl EVELYN R LIBERATOR 516 BARNSTABLE Rp CARLISLE PA 17015-9413 801 CHECKING STATEMENT Statement Date: 01/22/09 Account #: 2313154 Page 1 nigh-interest holiday bills piling up? Consolidate your bills with a loan from us. whether or not you have collateral, we can help. To find out more or apply, visit us at www.acnb.com Equal Housing Lender. Equal opportunity Lender. Member FDIC. ESTEEM CHECKING Account # 2313154 Account Summary Beginning Balance Activity Ending Balance Previous Statement Balance 12/21/08 11,227.21 + Deposits and Other Credits 1 1, 083.00 -Checks Paid or Other Debits 1 1,083.00- - Service Charges .00- +Interest Paid .07 Ending Balance 11,227.28 Days in Statement Period 32 Account Detail Date Activity Description DepositslCredits Checks/Debks Balance BEGINNING BALANCE 1,227.21 01-02 US TREASURY 3D3 SOC SEC 1,083.00 2,310.21 EVELYN R LIBERATOR 01-12 R15 BENE/ACCT HLDR DCEASD 1,083.00 1,227.21 EVELYN R LIBERATOR 00000000002313154 01-22 INTEREST PAYMENT .07 1,227.28 01-22 ENDING BALANCE 1,227.28 Interest Summary From 12122/08 Throuuh 01/22109 Days in Statement Period 32 Interest Earned 1.07 Annual Percentage Yield Earned .OS°k Interest Paid This Year 1.07 Interest Wdhheld This Year 1.00 P.O. Box 3129, GETIYSBURG, PA 17325 ~ RHONE 717.334.3161 ~ rotiBREE 1.888.334.ACNB (2262) ~ www.acnb.com G./•w ADAMS COLiNIY NATIONAI, BANK & ~" FARMERS NATIONAL BANKOF NEWVILLE A Dimuox ojAdarxr Comry Na,iena! Bank CHECKING STATEMENT Statement Date: 12/21/08 Account#: 2313154 """'""AUTO"ALL FOR AADC 170 1387 0.8240 AB 0.351 91 27 InJI Indl Innul6Lld~Luh~hullnlhnJLllu~JJl EVELYN R LI8ERATOR 516 BARNSTABLE RD CARLISLE PA 17015-9413 Page 1 801 Brighten your holidays this year and next. open an interest-earning Christmas Club account now, to put more under the tree next year. For a limited time, when you open a new Christmas club with automatic payment deduction, you'll receive a free gift. stop by one of our offices for details or visit www.acnb.com. Equal Housing Lender. Equal opportunity Lender. Member FDIC. ESTEEM CHECKING Account # 2313154 Account Summary Beginning Balance Activity Ending Balance Previous Statement Balance 11/20/08 51,365.b8 + Deposits and Other Credits 1 1,015.00 -Checks Paid or Other Debits 4 1,153.53 - -Service Charges .00- +Interest Pald .06 Ending Balance 51,227.21 Days in Statement Period 31 Account Detail Date Activity Description Deposits/Credits CheckslDebits Balance BEGINNING BALANCE 1, 365.68 11-21 CHECK # 170 15.00 1, 350.68 11-21 WAL-MART STORES PURCHASE 35.70 1,314.98 SERIAL NUMBER: 171 TERMINAL CITY: CARL STATE: PA 12-03 US TREASURY 303 SOC SEC 1,015.00 2, 329.98 EVELYN R LIBERATOR 12-OS CHECK#172 700.00 1,629.98 12-17 CHECK # 173 402.83 1,227.15 12-21 INTEREST PAYMENT .06 1, 227.21 12-21 ENDING BALANCE 1,227.21 P.O. Box 3129, GsTrvsauxG, PA 17325 ~ rxoNe 717.334.3161 ~ ToL~ Fuse 1.888.334.ACNB (2262) ~ www.acnb.com Nel!'s - VYa;Ryt @attbM 940 Ys'$lrti:t fi9t")+~. esh>a Crrllsler Rh. ~,r,,, MARKETS "" ?`A "'" T "!' U Ci V a~ DATE D- N E Molrs • W alnut Bottom 940 Walnut Bottom Ro>•1 Gr{isle, PA 17013 .. _ ~,~...r.. t717~ Zd0.73d!4 CY~OIL cusTGMER SIGNATURE l~+f.2ts 1NV. N 6Zto~ ~ ^~" 208509 ~~~~ 1 Vii"-L-" O pDA~TE ~ ~~% JSE ONLY ~.~ + ~. ~~~~~ CUSTOMER 't]TY, DESCRIPTIONS PRICE PRICE EX7: i ~~ X S tv~~ S ~ CUSTOM 31GNAT ER - URE ~ E:~ aG • ~p~ INV. r 208511 OFFICE USE ONLY CUSTOMER