HomeMy WebLinkAbout03-0588BUREAU OF ZNDZV/DUAL TAXES
TNHERITANCE TAX DTVTSZnN
DEPT. 280601
HARRXSBURG, PA 171Z8-060!
COMMONNEALTH OF PENNSYLVANZA
DEPARTMENT OF REVENUE
ZNHERZTANCE TAX
STATEHENT OF ACCOUNT
REV-i&O? EX AFP C01-OS)
HERSHEY TRUST CO
100 MANSION RD EAST
PO BOX 445
HERSHEY PA 17055
DATE 06-01-2004
ESTATE OF OBRIEN
DATE OF DEATH 07-05-2005
FZLE NUMBER 21 05-0588
COUNTY CUMBERLAND
ACN 101
Amount: Rem'i 'l:'l:ed
JANET
HAKE CHECK PAYABLE AND REHZT PAYMENT TO:
REGISTER OF NTLLS
CUMBERLAND CO COURT HOUSE
CARLTSLE, PA 17015
NOTE: To insure proper credi~ ~:o your account:*, submi~ ~:he upper por~:ion of ~:his form wi~h your ~:ax peymen~c.
CUT ALONG THZS LZNE ~ RETAZN LONER PORTZON FOR YOUR RECORDS
REV-1607 EX AFP (01-03) ### INHERZTANCE TAX STATEMENT OF ACCOUNT
ESTATE OF OBRIEN JANET M FZLE NO. 21 05-0588 ACN 101 DATE 06-01-2004
TH/S STATEHENT TS PROVZDED TO ADVTSE OF THE CURRENT STATUS OF THE STATED ACN TN THE NAHED ESTATE. SHO#N BELO#
TS A SUHHARY OF THE PR/NCTpAL TAX DUE., APPL/CAT'rON OF ALL PAYHENTS*, THE CURRENT BALANCE,, AND,, ZF APPL/CABLE,,
A PROJECTED ZNTEREST FZGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 05-17-2004
PRINCIPAL TAX DUE: ..........................................................................................................................................................................................................................
PAYMENTS (TAX CREDITS)=
8,$41.52
PAYHENT RECEIPT DISCOUNT (+)
DATE NUMBER INTEREST/PEN PAID (- AMOUNT PAID
10-02-2005
05-17-2004
CD005078
REFUND
417.08
.00
XF PAXD AFTER THZS DATE,, SEE REVERSE
SIDE FOR CALCULAT/ON OF ADDZT/ONAL INTEREST.
( XF TOTAL DUE [S LESS THAN $1,
NO PAYHENT ZS REQU/RED.
8,000.00
75.56-
TOTAL TAX CREDZT
BALANCE OF TAX DUE
8,541.52
.00
ZNTEREST AND PEN. .00
TOTAL DUE .00
ZF TOTAL DUE 1S REFLECTED AS A "CREDXT" (CR),
YOU HAY BE DUE A REFUND. SEE REVERSE SZDE OF TH~S FORH FOR ZNSTRUCT[ONS.
PAYMENT:
Detach the top portion of this Notice and submit aith your payment made payable to tho name and address
printed on the reverse side.
-- [F RES[DENT DECEDENT make check or money order payable to: REGZSTER OF NILLS, AGENT.
-- [f NON-RES[DENT DECEDENT make check ar money order payable to: CONNONNEALTH OF PENNSYLVANIA.
REFUND (CR): A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing mn
"Application for Refund of Pennsylvania inheritance and Estate Tax" (REV-13[~). Applications are available at
the Office of the Register of Hills, any of the 23 Revenue District Offices or from the Department's Z4-hour
answering service for forms ordering: 1-BOO-36Z-2050~ services for taxpayers with specie! hearing and / or
speaking needs: 1-800-4~7-3020 (TT only).
REPLY TO:
Questions regarding errors contained on this notice should be addressed to: PA Department of Revenue, Bureau
of individual Taxes, ATTN: Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 171ZB-O60l, phone
(717) 7B7-6505.
DISCOUNT:
[f any tax due is paid within three (3) calendar months after the decedent's death, a five percent (SZ) discount
of the tax paid is allowed.
PENALTY:
The 15Z tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not
paid before January 18, 1996, tho first day after the end of the tax amnesty period.
iNTEREST:
interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of
six (6Z) percent per annum calculated at a daily rate of .000164. AIl taxes which became delinquent on and after
January 1, 198Z will bear interest at a rate which will vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2004 are:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
1982 lOX .000548 1988-1991 11Z .O0030X 2001 9Z .000247
1983 16Z .000438 1992 9X .0002q7 ZOOZ 6Z .O0016q
19B~ llZ .000301 1993-1994 7Z .O0019Z 2003 5Z .000137
1985 13Z .000356 1995-1998 9Z .O00Zq7 ZO0~ 4Z .000110
1986 log .000274 1999 72 .O0019Z
1987 9Z .000Z47 2000 8Z .000219
--interest is calculated as foI1ows:
INTEREST = BALANCE OF TAX UNPATD X NUI~BER OF DAYS DEL/NQUENT X DA'rLY 'rNTBREST FACTOR
--Any Notice issued after tho tax becomes delinquent will reflect an interest calculation to fifteen (15) days
beyond the date of the assessment. If payment is made after the interest computation date shown on tho
Notice, additional interest must be calculated.
PETITION FOR PROBATE and GRANT OF LETTERS
Estate of Janet M. 0' Brien
also known as Janet Margaret 0' Brien
Social Security No.
Deceased.
202-46-995§
NO.
To:
Register of Wills for the
County of Cumberland
Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older an the executor
in the last will of the above decedent, dated -NoYemb~r 4
and codicil(s) dated
in the
named
, ~t 2002
(state relevant circt~l~[~ilri'c"es,:~:[, renunciation, death of executor, etc.)
Decendent was domiciled at death in Cunlber] and County, Pennsylvania, with
h last family or principal residence at 321 Cascade Road
t4ochanic~hmJrn~; PR 17fl_~_~
(list street, number and muncipality)
Decendent, then 47 years of age, died July 3 ,Xlngt 2003 ,
at Hnl? g.nirif_ Hnnpital; £umberland County: Penns¥1vanii~
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
after execution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent:
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) Ail personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal prop.erty in County
Value of real estate in Pennsylvania
situated as follows: 32'[ Cascaade Road
$ 300:000.00
$
$
$ 100~UOU.UO
Mechanicsburg, PA 17055
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s)
pre~ented herewith and the grant of letters testanlentar¥
theron. (testamentary; administration c.t.a.; administration d.b.n.c.t.a.)
Robert K ~' Ix~lg-~e-i- t/
= Vice President & Irust OtficeP
Hershey Trust Company
100 Mansion Road East
Horqhoy~ PA 17fl3.~
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA '1
COUNTY OF }- ss
The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are
true and correct to the best of the ki~owledge and belief of petitioner(s) and that as personal represen-
tative(s) of the above decedent petitioner(s) will well and ~rgJ-y~admi~iscer the,,~'t~e~c~ding to law.
be~r~ ~e~his~~ day of / / ~ '' ' ~ ~ ~
~~ 1o/ / ~
Estate of Janet M. 0'Brien , Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW 19 .... in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated~ November l$, 2002
described therein be admitted to probate and filed of record as the last will of Janet M. 0' Brien
and Letters Testamentary
are hereby granted to Hershey Trust Company
FEES
Probate, Letters, Etc. b.~. $. 341.00
Short Certificates( ) ... :.¥ .... $ 30.00
AW~t~gi~t~...QCP .......... $ 10.00
$
TOTAL __ $ 381.00
Filed ...................................
Elyse E. Rogers, ID~41274
ATTORNEY (Sup. Ct. I.D. No.)
415 Fallowfield Road, Suite 102
Camp Hi 11, PA 'ADDRESS 17011
717-612-5801
PHONE
'~is is to cert iS' t~at the intbrmation here given is correctly copied from an original certificate of death duly filed with me as
l.,,,cal .Rt;gistraJ.. The original certificate will be forwarded to the State Vital Records Office for permanent ~ling.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fec fbr this certificate, $2.00
P 9331215
No.
Local Registrar
,, Janet Margaret O'Brien
COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
J i 45/12/1956 [,Wilkes-Barre p/~.~'--~
Clerk ~ist ,,.~ t. of H~lth
'"' P ' "" -.. {'~
321 ~s~de R~d ~,u~ ,,. m,. Pe=sylv~ia ,,..~ ~ ~. U~r Allen
,,. ~CS~g, PA 17055 ~
~r,~,.~ [,,. ~uise O1~
~o ~ ~u ~o ~,.-, I-~ '~ ........ ~ ...... I~'='~'~'''''~
~u ~ O{,,,.July 5~ .2003 {,,, ~te of Haven ~t
~~~" ~'~'~ ............... ~ ....... I
[*~f,~i._, ~ .......................
/ /~ ~ ..~m~,~ CJI I tm D *D/
I. g=
Las{
OF
JANET M. O'BRIEN
I, JANET M. O'BRIEN, of Upper Allen Township, Cumberland County,
Pennsylvania, do make, publish and declare this to be my Last Will and Testament,
hereby revoking all Wills and Codicils by me heretofore made.
ITEM I: I direct that all inheritance and estate taxes
becoming due by reason of my death, whether such taxes may be payable by my
estate or by any recipient of any property, shall be paid by the Executor out of the
property passing under ITEM IV of this Will, as an expense and cost of
administration of my estate. The Executor shall have no duty or obligation to
obtain reimbursement for any such tax so paid, even though on proceeds of
insurance or other property not passing under this Will.
ITEM II: I direct the Executor to pay the expenses of
my last illness and funeral expenses from the property passing under this Will as
an expense and cost of administration of my estate.
ITEM III: I may leave a written statement or list in my
safe deposit box disposing of certain items of my tangible personal property. Any
such statement or listing in existence at the time of my death shall be
determinative with respect to all items bequeathed therein. If no written statement
or list is found in my safe deposit box or elsewhere and properly identified by the
Executor within thirty (30) days after the probate of my Will, it shall be presumed
that there is no other statement or list. Any subsequent discovered statement or
list shall be ignored. I give to my son, SEAN MATTHEW O'BRIEN, all of my
household furniture and furnishings, books, pictures, jewelry, silverware,
Page I ~~
automobiles, wearing apparel and all other articles of household or personal use or
adornment not identified in the written list mentioned above and all policies of
insurance thereon. I specifically request that the Executor retain for my son, or
distribute to or for my son, his books, trucks, toys, trophies, his Christmas tree and
Christmas ornaments, all photo albums, and other items of memorabilia which he
requests. If my son has not attained the age of eighteen (18) years at the time of my
death, and the Executor thinks any property to which he would become entitled is
unsuitable for his use, the property shall be sold and the proceeds shall be added to
the share of my residuary estate held for his benefit. If my son has not attained the
age of eighteen (18) years at the time of my death, the Executor may deliver any
property to which he is entitled and which is not sold to the person with whom he
resides or who has the care or control of him (without bond), and the receipt of that
person shall be a complete release of the Executor.
ITEM IV: I give all the rest, residue and remainder of
my estate, not disposed of in the preceding portions of this Will, to HERSHEY
TRUST COMPANY, as Trustee, for the benefit of my son, SEAN MATTHEW
O'BRIEN (the "Beneficiary"), to be administered and distributed as follows:
(a) I request that the Trustee remind the Beneficiary, upon
his attainment of the age of twenty (20) years, to obtain a colonoscopy.
I request that this reminder be provided to my son every year after he
attains the age of twenty (20) years, until termination of the Trust.
(b) Trustee shall pay to or for the benefit of the Beneficiary
so much of the net income, in convenient, at least annual installments,
as is necessary, in the discretion of the Trustee, for the proper support,
maintenance, medical care and education of the Beneficiary, including
the cost of private high school and college, should the Beneficiary so
Page 2
choose. Income not distributed shall be accumulated and added to
principal.
(c) The Trustee shall also pay to or for the benefit of the
Beneficiary so much of the principal as the Trustee, in the discretion of
the Trustee, considers necessary to maintain the beneficiary in the
proper station in life, including proper support, maintenance, medical
care and education, including the cost of private high school and
college, should the Beneficiary so choose.
(d) Upon the attainment of the age of twenty-five (25) years
by the Beneficiary, the Trustee shall pay to the Beneficiary one-half of
the principal of his Trust. Upon the attainment of the age of thirty
(30) years by the Beneficiary, the Trust shall terminate and the
Trustee shall pay to the Beneficiary the remaining assets of the Trust.
However, the Trustee may refuse to make distributions of principal to
the Beneficiary should the Trustee consider the Beneficiary unable to
manage the principal of the Trust in the best interests of the
Beneficiary. The Trustee may also terminate this Trust in whole or in
part prior to the attainment of the age of thirty (30) years by the
Beneficiary, if the Trustee reasonably believes the Beneficiary able to
manage the principal in his own best interests.
(e) Should the Beneficiary die before final distribution of the
assets of his Trust, the Trust shall terminate and the Trustee shall pay
the assets of the Trust to the then living issue of the Beneficiary, per
stirpes. However, if any issue has not attained the age of twenty-one
(21) years at the time of distribution, the Trustee shall continue to hold
Page 3
the share for that issue as Custodian under the Pennsylvania Uniform
Transfers to Minors Act for the benefit of that issue.
(f) If at any time before final distribution of the assets of any
of the Trusts administered under this paragraph, there are no living
beneficiaries of the Trust, the Trust shall terminate. The assets of the
trust shall be paid to my parents, LOUISE SIRAK and JOSEPH
SIRAK, if they are living at the time. If they are not living, the assets
shall be divided into as many equal shares as there are then living
siblings of mine. My siblings are RICHARD SIRAK, RONALD SIRAK,
and JAYNE JOHNSON. One equal share shall be paid to each then
living sibling. If any sibling is not living, his or her share shall be paid
to his or her then living issue, per stirpes.
ITEM VI: No part of the income or principal of any
Trust created by this Will shall be subject to attachment, levy or seizure by any
creditor, spouse, assignee or trustee or receiver in bankruptcy of any beneficiary
prior to his or her actual receipt of income or principal distributed. The Trustee
shall pay the net income and the principal to the beneficiaries specified by me, as
their interests may appear, without regard to any attempted anticipation, pledging
or assignment, and without regard to any claim or attempted levy, attachment,
seizure or other process against the beneficiary.
.ITEM VII: In addition to the powers granted at law, the
Executor and the Trustee shall each possess the following powers, each of which
may be exercised without court approval and in a fiduciary capacity only:
Page 4
(a) To retain any investments I have at my death, including
specifically those consisting of stock of any bank even if I have named
that bank as the Executor or Trustee.
(b) To vary investments, and to invest in bonds, stocks, notes,
real estate mortgages or other securities or in other property, real or
personal, without being restricted to so-called "legal investments", and
without being limited by any statute or rule of law regarding
investments by fiduciaries.
(c) In order to divide the principal of a Trust or for any other
purpose, including final distributions, the Executor and Trustee are
authorized to divide and distribute personal property and real
property, partly or wholly in kind, and to allocate specific assets among
beneficiaries and Trusts so long as the total market value of each
share is not affected by the division, distribution or allocation in kind.
The Executor and Trustee are each authorized to make, join in and
consummate partitions of lands, voluntarily or involuntarily, including
giving of mutual deeds, or other obligations, with as wide powers as an
individual owner in fee simple.
(d) To sell either at public or private sale real and personal
property severally or in conjunction with other persons, and to
consummate sale(s) by deed(s) or other instrument(s) to the
purchaser(s), conveying a fee simple title. No purchaser shall be
obligated to see to the application of the purchase money or to make
inquiry into the validity of any sale(s). The Executor and Trustee are
authorized to execute, acknowledge and deliver deeds, assignments,
Page 5
options or other writings as necessary or convenient to any of the
power conferred upon the Executor and Trustee.
(e) To mortgage real estate, and to make leases of real estate.
(f) To borrow money from any person, including the Executor
or Trustee, to pay indebtedness of mine or of my estate, expenses of
administration or inheritance, legacy, estate and other taxes, and to
assign and pledge assets of my estate or any Trust established by this
Will.
(g) To pay all costs, taxes, expenses and charges in
connection with the administration of my estate or any Trust
established under this Will.
(h) To make distributions of income and of principal to the
proper beneficiaries, during the administration of my estate, with or
without court order, in such manner and in such amounts as the
Executor deems prudent and appropriate.
(i) To vote shares of stock which form a part of my estate or
any Trust established under this Will, and to exercise all the powers
incident to the ownership of stock.
(j) To unite with other owners of property similar to property
in my estate to carry out plans for the reorganization of any company
whose securities form a part of my estate.
Page 6
(k) To disclaim any interest in property which would devolve
to me or my estate by whatever means, including but not limited to the
following means: as beneficiary under a will, as an appointee under
the exercise of a power of appointment, as a person entitled to take by
intestacy, as a donee of an inter vivos transfer, and as a donee under a
third-party beneficiary contract.
(1) To prepare, execute and file tax returns of any type
required by applicable law, and to make all tax elections authorized by
law.
(m) To employ custodians of property, investment or business
advisors, accountants and attorneys as the Executor or Trustee deems
appropriate, and to compensate these persons from assets of my estate
or trust, without affecting the compensation to which the Executor and
Trustee are entitled.
(n) To divide any Trust created in this Will into two or more
separate Trusts so that inclusion ratio for purposes of the generation-
skipping transfer tax shall be either zero or one, in order that an
election under Section 2652(a)(3) of the Internal Revenue Code may be
made with respect to one of the separate Trusts, or for any other
reason.
(o) To allocate administrative expenses to income or to
principal, as the Executor or Trustee deems appropriate. However, no
allocation to income shall be made if the effect of the allocation is to
cause a reduction in the amount of any estate tax marital deduction or
estate tax charitable deduction.
Page 7
(p)
lifetime.
To continue any litigation instituted by me during my
(q) To do all other acts in their judgment necessary or
desirable for the proper and advantageous management, investment
and distribution of the estate and Trusts established under this Will.
ITEM VIII: The Trustee is authorized to distribute
principal and/or income in any one or more of the following ways if the Trustee, in
the discretion of the Trustee, considers the beneficiary unable to apply distributions
to the beneficiary's own best interests, or if the beneficiary is under a legal
disability:
(a) Directly to the beneficiary;
(b) To the Trustee, or to another person selected by the
Trustee, as custodian under the Pennsylvania Uniform Transfers to
Minors Act as to a beneficiary under the age of twenty-one (21) years;
(c) To a relative of the beneficiary, to be expended by that
relative for the benefit of the beneficiary; or
(d) By directly applying distributions for the benefit of the
beneficiary.
ITEM IX: The Trustee, on an annual basis, shall
provide each income beneficiary who has attained the age of eighteen (18) years,
and the Guardian of the person of any income beneficiary who has not attained the
age of eighteen (18) years, statements showing transactions each Trust established
for the benefit of that beneficiary. The beneficiary, or the Guardian of the person of
such beneficiary, may waive this right to receive an annual accounting. The
Trustee may, at any time, settle any account, or questions concerning the
administration of any Trust established under this Will, by agreement with the
then current income beneficiaries of the Trust, if legally competent, or if not legally
competent, with the Guardian of the person of the beneficiary, the legally
competent spouse of the beneficiary, or the oldest legally competent relative of the
beneficiary who would take a portion of the estate of the beneficiary were the
beneficiary to die at that time intestate under the laws of the State of Pennsylvania.
Any Settlement made in accordance with this Item shall bind all persons who have
an interest in the Trust, and shall constitute a release and discharge of the Trustee
with respect to transactions specified in the settlement.
ITEM X: In the absence of actual knowledge of a
breach of trust, or information concerning possible breach of trust that would cause
a reasonable person to inquire, a successor Trustee is under no duty to examine the
accounts and records of a predecessor Trustee, or to inquire into the acts or
omissions of the predecessor, and is not liable for any failure to seek redress for any
act or omission of the predecessor. The successor Trustee shall have responsibility
only for property which is actually delivered to him or her by the predecessor and
shall have all of the powers conferred upon a Trustee hereunder.
ITEM XI: Any person who has died within thirty (30)
days of my death, or under such circumstances that the order of our deaths cannot
be established by proof, shall be deemed to have predeceased me. Any person (other
than myself) who has died at the same time as any beneficiary under this Will, or in
a common disaster with that beneficiary, or under such circumstances that the
order of deaths cannot be established by proof, shall be deemed to have predeceased
that beneficiary.
Page 9
ITEM XII: It is my preference that JOHN O'BRIEN
serve as Guardian of the person of my son, SEAN M. O'BRIEN. In the event he is
unable or unwilling to serve, I appoint ANDREW J. O'BRIEN to be the Guardian.
ITEM XIII:
to Executors and Trustees:
I make the following provisions with respect
(a) I appoint HERSHEY TRUST COMPANY, Hershey,
Pennsylvania, to be the Executor and Trustee.
(b) My brother-in-law, ANDREW J. O'BRIEN, shall have the
power to remove any institutional Trustee serving under this Will,
provided that he first appoints another institutional Trustee to serve
as successor Trustee, and that successor Trustee has agreed to act as
successor Trustee. This power shall be deemed to be a continuing
successive power to remove and replace institutional Trustees.
(c) Each appointment of a successor Trustee shall be in
writing and shall be filed with the court in the jurisdiction which is the
situs of the Trust. The written instrument shall be signed by the
person having the power to make the appointment.
(d) The Trustee shall have the right to receive reasonable
compensation for services rendered.
(e) The Trustee shall not be liable or accountable for any loss
that may result from the good faith exercise of the authority granted in
this Will.
Page 10
(f) The Executor and Trustee are specifically relieved from
the duty of filing bond or entering security.
IN WITNESS WHEREOF, I have set my hand and seal to this, my
Last Will and Testament, consisting of this and the preceding ten (10) pages, at the
end of each page of which I have also set my initials for greater security and better
identification this f~day of~ , 20 ~.~-~.
NET M. O'BRIEN
We, the undersigned, hereby certify that the foregoing Will was signed,
sealed, published and declared by the above-named Testatrix as and for her Last
Will and Testament, in the presence of us, who, at her request and in her presence
and in the presence of each other, have hereunto set our hands and seals the day
and year first above written, and we certify that at the time of the execution
thereof, the said Testatrix was of sound and disposing mind and memory.
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA )
) SS:
COUNTY OF ~(~,~ )
I, JANET M. O'BRIEN, 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 and
Testament; that I signed it willingly; and that I signed it as my free and voluntary
act for the purposes therein expressed.
NET M. O'BRIEN
Sworn to and subscribed~before
me this ~ day of
,20 0L.
~lic
My Commission Expires:
(SEAL)
LC' NOTARIAL SEAL
CYN~T, HIA J. RULE, Notary Public
Camp hilt Boro., Cumberland County
ommission Exph ~s ,fan. 24, 2004
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA )
) SS:
COUNTY OF ~ )
We, X/z~/_~ ~ ~.~5,~//r/ and~V<-~e~c~_ \-~. ~e4r~c~ ,
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, JANET M. O'BRIEN, sign and execute the instrument as her Last
Will and Testament; that Testatrix signed willingly and that she executed said Will
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 the Testatrix was at that time eighteen (18) or more years of
age, of sound mind and under no constraint or undue influence.
Witness Witness
Sworn to and subscribed before
me this ~-~ day of f~/0'x/~
,2002_
My Commission Expires:
(SEAL)
OF
JANET ~. O~B~IEN
KEEFER WOOD ALLEN & RAHAL, LLP
Attorneys at LAW
CAMP HILL, PENNSYLVANIA 1701 I
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO.
REV-1162 EX(11-96)
CD 003078
HERSHEY TRUST COMPANY
100 MANSION RD EAST PO BX 445
HERSHEY, PA 17033
........ fold
ESTATE INFORMATION: SSN: 202-46-9958
FILE NUMBER: 2103-0588
DECEDENT NAME: O'BRIEN JANET M
DATE OF PAYMENT: 10/02/2003
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 07/03/2003
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $8,000.00
REMARKS:
TOTAL AMOUNT PAID:
HERSHEY TRUST COMPANY
$8,000.00
SEAL
CHECK# 062993
INITIALS' VZ
RECEIVED BY:
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
IN RE: Estate of Janet M. O'Brien
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISION
NO.- 21-03-00588
PETITION FOR ORDER DIRECTING
AMERICAN EXPRESS FINANCIAL ADVISORS, INC.
TO DISTRIBUTE CERTAIN ACCOUNTS TO TRUST
AND FOR TI-IF~ AWARD OF COSTS AND ATTORNEYS F~S AGAINST
AMERICAN EXPRESS FINANCIAL ADVISORS, INC.
AND MICHAEL I. SHALHOUB
AND NOW comes Keefer, Wood, Allen & Rahal, LLP, as counsel for
Petitioner, Hershey Trust Company, and states as follows:
1. Petitioner, Hershey Trust Company, is a Pennsylvania trust company
with its principal office at 100 Mansion Road East, Hershey, Dauphin County,
Pennsylvania.
2. Petitioner, Hershey Trust Company, is the Executor of the Estate of
Janet M. O'Brien, having been granted Letters Testamentary on July 22, 2003.
3. Petitioners, Louis O'Brien and Rose O'Brien are the paternal
grandparents of Sean O'Brien and reside at 3431 Alinda Circle, Camp Hill,
Pennsylvania.
4. Janet M. O'Brien ("Decedent"), died on July 3, 2003. A true and
correct copy of her Last Will and Testament (the "Will"), dated November 4, 2002,
is attached hereto and made a part hereof as Exhibit "A".
5. Respondent, Michael I. Shalhoub ("Shalhoub"), is an adult individua]
with a principal business office at 3500 Market Street, Camp Hill, Cumberland
County, Pennsylvania.
6. Respondent, American Express Financial Advisors, Inc. ("American
Express"), is a foreign corporation with a registered office at CT Corporation
System, 1635 Market Street, Philadelphia, Pennsylvania.
7. Decedent was divorced at the date of her death and was survived by a
son, Sean Matthew O'Brien ("Sean").
8. At the date of Decedent's death, Sean was 15 years old, (is now 16
years old) and is not currently suijuris.
9. Sean is currently a student at the Milton Hershey School. When not at
the Milton Hershey School, he resides with his paternal grandparents, Louis and
Rose O'Brien.
10. Sean's paternal grandparents and Sean's father, Michael O'Brien, are
currently involved in legal proceedings regarding custody of Sean.
11. In Item IV of Decedent's Will, she left the residue of her estate in trust
to the Hershey Trust Company as Trustee (the "Trust") for the benefit of Sean.
12. The Decedent's financial advisor was Respondent, Michael I. Shalhoub,
of Respondent, American Express.
13.
Express.
At her death, the Decedent owned several accounts at American
14. American Express, via its agent, Shalhoub, has taken the position that
eight of the Decedent's accounts are "Transfer on Death" accounts with Sean,
individually, as the beneficiary. This position is stated in a July 31, 2003
correspondence from American Express Financial Advisors, Inc., to Hershey Trust
Company. The July 31, 2003 correspondence is attached hereto as Exhibit "B" and
made a part hereof as though fully set forth herein.
15. The eight accounts which are alleged to be "Transfer on Death"
accounts are listed below with their current balances as of August 31, 2003
statements:
ACCOUNT NUMBER,
BAI~ANCE
010100226611 002
01010022671 0 002
01010022672 8 002
01010022673 6 002
01010022674 4 002
01010022675 I 002
01010022679 3 002
01449156233 7 002
$28 096.77
$25 559.93
$19 244.29
$19.855.10
$21 667.39
$ 8 941.52
$ 9 781,12
$ 286.35
A true and correct copy of an American Express statement setting forth these
August 31, 2003 balances is marked at Exhibit "C" and made a part hereof as
though fully set forth herein. The above-listed accounts are collectively referred to
as the "AMEX Accounts."
16. On May 23, 2003, Respondent Michael I. Shaloub, called Decedent's
attorney, Elyse E. Rogers ("Rogers"), of Keefer Wood Allen & Rahal, LLP, and
requested advice regarding the proper titling of accounts which he was opening for
Decedent. Rogers advised him that the accounts were to be opened as individual
accounts, because Decedent had created a trust for her minor son under her Will,
and her assets were to pass to that trust upon Decedent's death.
17. Decedent, with the assistance of Respondent Michael I. Shaloub,
completed a number of Investment Applications with American Express, which are
attached hereto and made a part hereof as Exhibit "D ", and made a part hereof as
though fully set forth herein.
18. Each Investment Application is, on the first page thereof, under the
heading "Account Registration," designated an "Individual" account and not a
"Individual with TOD" account.
19. Decedent signed each Investment Application on the forth page
thereof. The purpose of the signature, as stated in the Investment Application, was
to certify that the Decedent: (a) provided a correct tax identification number; (b)
was a United States citizen or resident; and (c) that the Decedent was not subject to
withholding.
20. The fifth and sixth pages of each Investment Application allegedly
constitutes a "Transfer on Death Account Agreement." The fifth page is not
completed, and Decedent did not sign the alleged "Transfer on Death Account
A "
greement.
21. Transfers on death accounts are permitted under Pennsylvania
Estates and Fiduciary Code, 20 Pa. C.S.A. §6401, et seq., under certain
circumstances.
22. An account may only transfer on death when the beneficiary form
constitutes a valid contract. 20 Pa. C.S.A. §6409.
23. The beneficiary form must indicate in writing the intention of the
owner to transfer ownership of the security to a selected beneficiary upon the death
of the owner. 20 Pa. C.S.A. §6401.
24. The Investment Applications do not indicate any intent by the
Decedent to create a Transfer on Death Account. The Decedent did not sign any
portion of the Agreement allegedly creating a Transfer on Death Account, and it
does not constitute a legally binding contract.
25. Under Pennsylvania contract law, a signature does not ratify text and
agreements found after the signature.
26. Respondents American Express and Shalhoub have agreed to
distribute the AMEX Accounts to the Trust if the distribution is approved by the
Court.
27. Respondents American Express and Shalhoub have caused the Estate
to incur unnecessary attorney's fees and costs by insisting on distributing the
AMEX Accounts pursuant to an unexecuted and clearly ineffective "Transfer on
Death Agreement."
28. Respondent Shalhoub was clearly negligent in seeking the advice of
Rogers, Decedent's estate planning counsel, and then taking action (or attempting
to take action) directly contrary to that advice.
WHEREFORE, Petitioners, Hershey Trust Company and Louis O'Brien and
Rose O'Brien, respectfully request that the Court direct the distribution of the
AMEX Accounts to the Trust created under the Decedent's Will and further order
Respondents Michael I. Shalhoub and American Express Financial Services, Inc. to
pay the fees and costs incurred by Petitioner, Hershey Trust Company, in bringing
this Action.
Dated:
KEEFER WOOD ALLEN & RAHAL, .LLP
By: C~
~lyse ~. Rogers, t~quir~
Attorne~y ID #41274''~-~
Elizabeth J. Goldstein, Esquire
Attorney ID # 73779
415 Fallowfield Road
Suite 301
Camp Hill, PA 17011-4906
(717) 612-5800
Attorneys for Petitioner
VERIFICATION
I, Robert K. Reitzel, an authorized agent of Hershey Trust Company, do
hereby verify the statements made herein are true and correct to the best of my
information, knowledge, and belief. I understand that false statements made
herein are made subject to the penalties of 18 Pa.C.S.A. § 4904, relating to unsworn
falsification to authorities.
DATED:
Ro~bert K. lieitzel ~
VERIFICATION
We, Louis O'Brien and Rose O'Brien, verify the statements made herein are
true and correct to the best of my information, knowledge, and belief. I understand
that false statements made herein are made subject to the penalties of 18 Pa.C.S.A.
§ 4904, relating to unsworn falsification to authorities.
DATED: ~.( '.~
/ --) · ,- ~. ;,~
Louis O'Brien
Rose O'Brien
CERTIFICATE OF SERVICE
I, Elyse E. Rogers, Esquire, attorney for Petitioner the Hershey Trust
Company, hereby certify that I have served the Petition for Order Directing
American Express Financial Advisors, Inc. to Distribute Certain Accounts to Trust
and for the Award of Costs and Attorney's Fees Against American Express
Financial Advisors, Inc. and Michael I. Shalhoub, upon the following individual by
depositing a true and correct copy of the same in the United States mail, first-class
postage prepaid, addressed as follows:
American Express Financial Advisors, Inc.
c/o CT Corporation System
1635 Market Street
Philadelphia, PA 19103
and hand-delivered to:
Michael I. Shalhoub
3500 Market Street
Camp Hill, PA 170111
KEEFER WOOD ALLEN & RAHAL, LLP
By
lyse ~. Rogers, ~squi~
Attorne~ ID #4127~-~
Elizabeth J. Goldstein, Esquire
Attorney ID # 73779
415 Fallowfield Road, Suite 301
Camp Hill, PA 17011-4906
(717) 612-5801
EXHIBIT A
JANET M. O'BP~IElk~
I, JANET M. O'BRIEN. of Upper Allen Township. Cumberland County,
Pennsylvania, do make, publish and declare this to be my Last B~ill and Testament,
hereby revoking all Wills and Codicils by me heretofore made.
ITEM I: I direct that all inheritance and estate taxes
becoming due by reason of my death, whether such taxes may be payable by my
estate or by any recipient of any property, shall be paid by the Executor out of the
property passing under ITEM IV of this Will, as an expense and cost of
administration of my estate. The Executor shall have no duty or obligation to
obtain reimbursement for any such tax so paid, even though on proceeds of
insurance or other property not passing under this Will.
ITEM II: I direct the Executor to pay the expenses of
my last illness and funeral expenses from the property passing under this Will as
an expense and cost of administration of my estate.
ITEM III: I may leave a written statement or list in my
safe deposit box disposing of certain items of my tangible personal p¢'operty. Any
such statement or hsting in existence at the time of my death shall be
determinative with respect to ail items bequeathed therein. If no written statement
or list is found in my safe deposit box or elsewhere and properly identified by the
Executor within thirty (30) days after the probate of my Will, it shall be presumed
that there is no other statement or list. Any subsequent discovered' statement or
list sha~l be ignored. I give to my son, SEAN M--ATTHEW O'BRIEN, all of my
household furniture and furnishings, books, pictures, jewelry, silverware,
Page 1
automobiles, wearing- apparel and ali other articles of' household or persona] use
adornment not identified in the written list mentioned above and ali ~Jolicies of
insurance thereon. I specifically request that the F, xecutor retain for my son. or
'distribute to or for my son. his books, trucks, toys. trophies, his Christma,~ tree and
Christmas ornaments, all photo albums, and other items of memorabilia which he
requests. If my son has not attained the age of eighteen (1S) years at the time of my
death, and the Executor thinks any property to which he would become entitled is
unsuitable for his use, the property shall be sold and the proceeds shall be added to
the share of my residuary estate held for his benefit. If my son has not attained the
age of eighteen (1S) years at the time of my death, the Executor may deliver any
property to which he is entitled and which is not sold to the person with Whom he
resides or who has the care or control of him (without bond), and the receipt of that
person shall be a complete release of the Executor.
ITEM IV: I ~ve all the rest, residue and remainder of
my estate, not disposed of in the preceding portions of this B~fll, to HERSHEY
TRUST COMPAi~, as Trustee, for the benefit of my son, SEAN 1VIATTHE~
O'BRIEN (the "Beneficiary"), to be administered and distributed as follows:
(a) I request that the Trustee remind the Beneficiary, upon
his attainment of the age of twenty (20) years, to obtain a colonoscopy.
I request that this reminder be provided to my son every year after he
attains the age of twenty (20) years, until termination of the Trust.
(b) Trustee shall p ay to or for the benefit of the Beneficiary
so much of the net income, in convenient, at least annual installments,
as is necessary, in the discretion of the Trustee, for the proper support,
maintenance, medical care and education of the Beneficiary, including
the cost of private high school and college, should the Beneficiary so
Page 2
choose. Income no; distributed shall be accumulated and added
principal.
lC) The Trustee shall also pay to or fbr the benefit of' the
Beneficiary so much of the principal as the Trustee. in the discretion of
the Trustee, considers necessary to maintain the beneficiary in the
proper station in life, including proper support, maintenance, medical
care and education, including the cost of private high school and
college, should the Beneficiary so choose.
(d) Upon the attainment of the age of twenty-five (25) years
by the Beneficiary, the Trustee shall pay to the Beneficiary one-half of
the principal of his Trust. Upon the attainment of the age of thirty
(30) years by the Beneficiary, the Trust shall terminate and the
Trustee shall pay to the Beneficiary the remaining assets of the Trust.
However, the Trustee may refuse to make distributions of principal to
the Beneficiary should the Trustee consider the Beneficiary unable to
manage the principal of the Trust in the best interests of the
Beneficiary. The Trustee may also terminate this Trust in whole or in
part prior to the attainment of the age of thirty (30) years by the
Beneficiary, if the Trustee reasonably believes the Beneficiary able to
manage the principal in his own best interests.
(e) Should the Beneficiary die before final distribution of the
assets of his Trust, the Trust shall terminate and the Trustee shall pay
the assets of the Trust to the then living issue of the Beneficiary, per
stirpes. However, if any issue has not attained the age of twenty-one
(21) years at the time of'distribution, the Trustee shall continue to hold
Page 3
th~, share fbr that issue as Custodian under the Pennsylvania Uniform
T'ransfer,~ to Minors Act fbr the ene~t of that issue.
(fl If a~ any time befbre final distribution of the assets of any
of the Trusts administered under this paragraph, there are no living
beneficiaries of the Trust, the Trust shall terminate. The assets of the
trust shall be paid to my parents, LOUISE SIRAK and JOSEPH
SIRAK, if they are living at the time. If they are not living the assets
shall be divided into as many equal shares as there are then living
siblings of mine. My siblings are RICHARD SIP~kK, RONALD SItbacK,
and JAYNE JOHNSON. One equal share shall be paid to each then
living sibling. If any sibling is not living, his or her share shall be paid
to his or her then living issue, per stiles.
I_TEM l_q: No part of the income or principal of any
Trust created by this Will shall be subject to attachment, levy or seizure by any
creditor, spouse, assignee or trustee or receiver in bankruptcy of any beneficiary
prior to his or her actual receipt of income or principal distributed. The Trustee
shall pay the net income and the principal to the beneficiaries specified by me, as
their interests may appear, without regard to any attempted anticipation, pledsing
or assignment, and without regard to any claim or attempted leeds, attachment,
seizure or other process against the beneficiary.
ITEM VII: In addition to the powers granted at law, the
Executor and the Trustee shall each possess the following powers, each of which
may be exercised without court approval and in a fiduciary capacity on]y:
Page 4
la: To retain any investments I have au mx- death, inciudin~
specifically those consistin~ of stock of any bank even if ~ have named
that bank as the Executor or Trustee.
(b) To vary investments, and to invest in bonds, stocks, notes.
real estate mortgages or other securities or in other property, real or
personal, without being restricted to so-ca/led "legal investments", and
without being limited by an), statute or rule of law regarding
investments by fiduciaries.
(c) In order to divide the principal of a Trust or for any other
purpose, including final distributions, the Executor and Trustee are
authorized to divide and distribute personal property and real
property, partly or wholly in kind, and to allocate specific assets among
beneficiaries and Trusts so long as the total market value of each
share is not affected by the division, distribution or allocation in kind.
The Executor and Trustee are each authorized to make, join in and
consummate partitions of lands, voluntarily or involuntarily, including
giving of mutual deeds, or other obligations, with as wide powers as an
individual owner in fee simple.
(d) To sell either at pubhc or private sale real and personal
property severally or in conjunction with other persons, and to
consummate sale(s) by deed(s) or other instrument(s) to the
purchaser(s), conveying a fee simple title. No purchaser shall be
obligated to see to the application of the purchase money or to make
inquiry into the validity of any sale(s). The Executor and Trustee are
authorized to execute, acknowledge and deliver deeds, assignments,
Page 5
options or other writings as necessary or conveniem to an~.- z'
o~ the
power conferred uj)on the Executor and Trustee.
(e)
To mortgage real estate, and to make leases of rea~ estate.
(f) To borrow money fi'om any person, including the Executor
or Trustee, to pay indebtedness of mine or of my estate, expenses of
administration or inheritance, legacy, estate and other taxes, and to
assign and pledge assets of my estate or any Trust established by this
Will. -
(g) To pay all costs, taxes, expenses and charges in
connection with the administration of my estate or any Trust
established under this Will.
(h) To make distributions of income and of principal to the
proper beneficiaries, durins the administration of my estate, with or
without court order, in such manner and in such amounts as the
Executor deems prudent and appropriate.
(i) To vote shares of stock which form a part of my estate or
any Trust established under this Will, and to exercise all the powers
incident to the ownership of stock.
(J) To unite with other owners of property similar to property
in my estate to carry out plans for the reorganization of any company
whose securities form a part of my estate.
Pa~e 6
(k! T'o disclaim an~- interest m property which would devolve
to me or my estate by whatever means, including- but not limited to the
following means: as beneficiary under a will, as an appointee under
the exercise of a power of appointment, as a person entitled to take by
intestacy, as a donee of an inter vivos transfer, and as a donee under a
third-party beneficiary contract.
(1) To prepare, execute and file tax returns of any t~vpe
required by applicable law, and to make all tax elections authorized by
law.
(m) To employ custodians of property, investment or business
advisors, accountants and attorneys as the Executor or Trustee deems
appropriate, and to compensate these persons from assets of my estate
or trust, without affecting the compensation to which the Executor and
Trustee are entitled.
(n) To divide any Trust created in this WiLl into two or more
separate Trusts so that inclusion ratio for purposes of the generation.
skipping transfer tax shall be either zero or one, in order that an
election under Section 2652(a)(3) of the Internal Revenue Code may be
made with respect to one of the separate Trusts, or for any other
reason.
Page 7
(o) To allocate administrative expenses to income or to
principal, as the Executor or Trustee deems appropriate. However, no
allocation to income shall be made if the effect of the allocation is to
cause a reduction in the amount of any estate tax marital deduction or
estate tax charitable deduction.
lit%nme.
continue any litigation instituted by me during- mx
(q) To do all other acts in their judgment necessary or
desirable for the proper and advantageous management, investment
and distribution of the estate and Trusts established under this Will.
I__TEM lrfI~I: The Trustee is authorized to distribute
principal and/or income in any one or more of the following ways if the Trustee, in
the discretion of the Trustee, considers the beneficiary unable to appty distributions
to the benefieiary's own best interests, or if the beneficiary is under a legal
disability:
(a)
Directly to the beneficiary;
(b) To the Trustee, or to another person selected by the
Trustee, as custodian under the Pennsylvania Uniform Transfers to
Minors Act as to a beneficiary under the age of twenty-one (2 l) years;
(c) To a relative of the beneficiary, to be expended by that
relative for the benefit of the beneficiary; or
(d) By directly applying distributions for the benefit of the
beneficiary.
I~TEM_ I~: The Trustee, on an annual basis, shall
provide each income beneficiary who has attained the age of eighteen (18)years,
and the Guardian of the person of any income beneficiary who has not attained the
age of eighteen (18) years, statements showing transactions each Trust established
fbr the benefit, of' that beneficiary. The beneficiary, or the Guardian of' the person of'
such beneficiary, may waive this right to receive an annual accounting. The
Trustee may. ar. any time. settle any account, or questions concerning the
administration of any Trust established under this ~Vfll. by agreemen~ with the
then current income beneficiaries of the Trust, if legally competent, or if not legally
competent, with the Guardian of the person of the beneficiary, the legally
competent spouse of the beneficiary, or the oldest legally competent relative of the
beneficiary who would take a portion of the estate of the beneficiary were the
beneficiary to die at that time intestate under the laws of the State of Pennsylvania.
Any Settlement made in accordance with this Item shall bind all persons who have
an interest in the Trust, and shall constitute a release and discharge of the Trustee
with respect to transactions specified in the settlement.
ITEM X: In the absence of actual knowledCe of a
breach of trust, or information concerning possible breach of trust that would cause
a reasonable person to inquire, a successor Trustee is under no duty to examine the
accounts and records of a predecessor Trustee, or to inquire into the acts or
omissions of the predecessor, and is not liable for any failure to seek redress for any
act or omission of the predecessor. The successor Trustee shall have responsibility
only for property which is actually delivered to him or her by the predecessor and
shall have all of the powers conferred upon a Trustee hereunder.
ITEM XI: Any person who has died within thirty (30)
days of my death, or under such circumstances that the order of our deaths cannot
be established by proof, shall be deemed to have predeceased me. Any person (other
than myself) who has died at the same time as any beneficiary under this Will, or in.
a common disaster with that beneficiary, or under such circumstances that the .
order of deaths cannot be established by proof, shall be deemed to have predeceased
that beneficiary.
Page 9
~_TEII[ Nil: I~ is my preference that JOHA- O'BRIEN
serve as Guardian o~~ the person of my son. SEAN M. O'BRIEN. In th~, even~ he~ is
unable or unwillin~ ~o serve. I appoin~ ANDREW g. BRIEN ~o be the Guardian.
ITEM XIIt:
to Executors and Trustees:
make the following provisions with respect
(a) I appoint HERSHEY TRUST COMPARry, Hershey,
Pennsylvania, to be the Executor and Trustee.
(b) My brother-in-law, ANDREW J. O'BRIEN, shall have the
power to remove any institutional Trustee serving under this Will,
provided that he first appoints another institutional Trustee to serve
as successor Trustee, and that successor Trustee has agreed to act as
successor Trustee. This power shall be deemed to be a continuing
successive power to remove and replace institutional Trustees.
(c) Each appointment of a successor Trustee shall be in
writing and shall be filed with the court in the jurisdiction which is the
situs of the Trust. The written instrument shall be signed by the
person having the power to make the appointment.
(d) The Trustee shall have the right to receive reasonable
compensation for services rendered.
(e) The Trustee shall not be hable or accountable for any loss
that may result from the good faith exercise of the authority granted in
this Will.
Page
(f! The Executo:. and Trustee are specificalh- ~'eiieved f~om
the duty of£iling bond or entering security.
IN WITNESS WHEREOF. I have set my hand and seal to this, rny
Last Will and Testament, consisting of this and the preceding ten (10) pages, at the
end of each page of which I have also set my initials for greater security and better
identification this ~z'Y~day of,~/,~r', , 20 ~-~--~ ~
M. 0 BRIEN
(SEAL)
We, the undersigned, hereby certify that the foregoing Will was signed,
sealed, published and declared by the above-named Testatrix as and for her Last
Will and Testament, in the presence of us, who, at her request and in her presence
and in the presence of each other, have hereunto set our hands and seals the day
and year first above written, and we certify that at the time of the execution
thereof, the said Testatrix was of sound and disposing mind and memory.
AC~C~OYVLED GME
COMMONWEALTH OF PENNSYL~i~NIA
£
SS:
I, JANET M. O'BRIEN, Testatrix whose name is signed to the
attached or foregoing instrument, having been'duly quahfied according to law, do
hereby acknowledge that I signed and executed the instrument as my Last Will and
Testament; that I signed it willingly; and that I signed it as my free and voluntary
act for the purposes therein expressed.
NET M. O'BRIEN -
Sworn to and subscribed before
me this %k~-k day of
,20
My Commission Expires:
(SEAL)
AFFIDAITT
COMMONwtBALTH OF PENNSYLVANIA
£
COUNTY OF ,._.~~
SS:
the Witnesses whose names are signed to the attached or foregoing instrument,
being duly qualified accor~ng to law, do depose and say that we were present and
saw Testatrm, JANET M. O'BRIEN, sign and execute the instrument as her Last
W~ and Testament; that Testatrix signed willingly and that she executed said W~
as her ~ee and volunt~y act for the purposes therein expressed; that each of us in
the hearing and sight of the Testatr~ signed the Will as Bqtnesses; and that to the
best of our knowledge the Testatrm was at that time eighteen (18) or more years of
age, of sound mind and under no constraint or undue influence.
/ '~-" - i?
Witness <2
Sworn to and subscribed before
me this ~Lek day of
,2002
My Commission Expires:
(SEAL)
EXHIBIT B
July 3 L 2003
IDS LIFE INSURANCE COMPANy
AMERICAN EXPRESS FUNDS
AMERICAN EXPRESS CERTIFICATE COMPANY
AMERICAN EXPRESS BROKERAGE
70100 AXP Financial Center
MinneaDolis, MN 55474
ROBERT K RErTZEL
I-IERS~4_Ey TRUST COMPANy
100 MANSION RD EAST PO BOX 445
HERSHEY, PA 17033
Dear ROBERT K. REiTZ~I.,:
[/pon a reccm review of om-pond/rig s~ttlement records, we ~scovered ou~mn~ng
req~~ for ~e acco~ wher~ JANET M 0 B~N ~ eider ~ o~, ~cd, ~ui~t
or tidal.
IM-PORTA.NT R-EMINDER(S):
- In.accordance with various regulator}, agencies, American Express Financial
continue to mail monthlv/quazterlv statemez-*~ c__ ,~. ...... Advisors w/II
-- - . - , - ,~ ~u~ mu acceasell to tiaa rteceased's address of
record, 'Ina only individual(s) gra.rtted authorization to change ~e address of the deceased
and thus, redirect the mailmg ad&ess of the s~atemem, s, is the Executor(s) of the Es~at~ of the
decease& .
Account Information
Mutual Funds
01010022661 1 002
01010022671 0 002
01010022672 8 002
01010022673 6 002
O] 010022674 4 002
01010022675 1 002
01010022679 3 002
0~069156233 3 002
01099156233 0 002
01129156233 5 002
01249156233 1 002
012691562.-t3 0 002
01439156233 8 002
01449156233 7 002
01729156233 2 002
,Account Number
00030473789 3 021
individual. TOD
Individual - TOD
Individual - TOD
Indiv/duaI - TOD
Individual - TOD
Individual - TOD
Ind/v/dual - TOD
IRA - b~eficiary des/g~ated
ZKA - beneliciary designated
IRA - beneficiaW designated
ZRA - beneficiary designated
~R A - beneficiary de.qlgnatecl
ZRA - benclSciary dmsiL~mated
Individual - TOD
l'R_&, beneficiary designated
O wn._____er___s~E
Individual
Document_q Received
insurance and annuities are
issued by IDS Life Insurance
Campanv. ~q American Ex~ress
co~pom,,, Amorica~ ~x. pm~:
~x~rem~ Financial ~viso~ In~.
Arum loan ~pre~ F~naneal
Advisors ~nc,
American ~res~ ~0m~
F, Ud
We have received and approved these documen.ts for setllememt processing:
Certified Letters of Testamentary/Letters of Administration
(For accounts: 00030473789 3 021i
Documents Not Received
The documer, t(s) listed below have not been received and are needed ro process the settlement:
Certified Death Certificate
(For aeeotmrs: 00030473789 3 021, 01010022661 I 002, 01010022671 0 002, 01{110022672 8
002, 01010022673 6 002; 01010022674 4 002, 01010022675 1 002, 01010022679 3 002,
01069156233 3 002, 0109915§233 0 002, 01129156233 5 002, 01249156233 I 002, '
01269t56233 9 002. 01439156233 $ 002, 01449156233 7 002, 01729156253 2 002)
The death certificate must be an original document that bears certification from the heal~.
department or local registrar and imrludes the cause of death.
Estate Settlement Form (3248F)
(For accounts: 00030473789 3 021, 01010022661 1 002, 01010022671 0 002, 01010022672 8
002, 01010022673 6 002, 01010022674 4 002, 01010022675 1 002, 0101.0022679 3 002,
01069156233 3 002, 01099156233 0 ~02, 01129156233 5 002, 01249156233 1 002,
01269156233.9 002, 01439156233 8 002, 01.449156233 7 002, 01729156233 2 002)
To process a settlement on a Mutual Fund, Cer~icare or Brokerage account~ we need a
completed Estate Settlemem Form 32481: ~om each.claimant.. A separate form should also be
/~cludcd £~ each ownemt~ type. Sections I, 2, 4 and 10 must be completed. For instructions
on ¢orrrplet/ng this form, please see page 6. Incomplete information would cause delay.
An Obituary or Statement listi~tg ail children of the decedent
(For accounts: 01010022661 I 002, 01010022671 0 002, 01010022672 8 002, 01010022673 6
002, 01010022674 4 002, 01010022675 1 002, 01010022679 3 002, 01069156233 3 002,
01099156233 0 002, 01129156233 5 002, 01249156233 I 002, 01269156233 9 002,
01.439156233 8 002, 01449156233 7 002, 01729156233 2 002)
Because thc beneficiary designation is living lawful, children or children per stirpes, we require
either a~ obituary or a statement signed by either thc advisor or a~ adult child, listing ail
children at'the decedent (both living aM deceased). Ifa child is deceased, we require a certified
copy of his or her death certificate. Ia addition m tl~s, other req~fireme-ats may be needed.
Letters of Guardianship/Conservatorship
(For accoums: 0]0]002266! 1 002, 01010022671 0 002, 01010022672 8 002. 01010022673 6
002, 01010022674 4 002, 01010022675 ! 002, 01010022679 3 002~ 01069~$6233 3 002~
010991562~3 0 002, 0! 1291562~ 5 002, 01249156233 ! 002, 01269156233 9 002~
0143-0156233 g 002, 01449~562~2 7 002, 01729156233 2 002)
A~ least on~ &the named beneficiaries .is a minor. Therefore, we require court-certified papers
designating the legal guardian/conservator of the mi-_or's estate. This document vet/ties who is
authc)rized m take receipt of the assets on behalf of the m/nor.
OR
Court Order
(For accmmts: 01010022661 1 002. 01010022671 0 002, 01010022672 8 002, 01010022673 6
002, 01010022674 4 002, 01010022675 1 002, 010100226'79 3 002, 01069156233 3 002,
01099156233 0 002, 01129156233 5 002, 01249156233 1 002, 01269156233 9 002,
01439156233 8 002, 01449156233 7 002, 01729156233 2 002)
Dis~'/bution/Court Order must be a courr-certilSed copy, l/st the AmerJcan Express FmanciaI
lnsuran:e and annuities ere
Lssued by IDS Lif~ Insurance
Company, ar~ American Expr~
~cm~ny. ~erimn ~re~
~roke~ge is pr~{d~ by Am~rlcan
~re~ ~nanciaj Ad~so~ i~c.
/merJcan ~xpre~S
Ad,sots Inc. Ma~r NASD.
Amer~ca~ ~res~ Company is
Advisors accounts being claimed and indicate to whom the assets should be distributed.
The 1-RA beneficiary designation ~[or the IRA plan you requested is enclosed,
Please contact the Amer/c~ Express financial advisor, MICHAEL SItALHOUB. at (717) 975-
5555 for forrm and assistance.
Please contact us ffyou have any questions, or if you need another copy o£dae imtial
correspondence. Thank you,
Sincerely,
Laura Martmez
Death Settlements Processing Team
70310 AXP Financ/al Center
M~nneapolis, MN 55474
1-800-862.7919, Optiun 5, 1
MICHAEL IBRAH]]VI SI-LtkLHOUB
DSO 149
Rep 038655
Company, an American ~pr~
company. ~n ~Drflss
Brokerage is provld~d by ~rican
~pres.s Fi~ncial A~/som ine,
American E~press RnancJal
~vJso~ lnc, M~mber NACD.
American ~pre~ Compang is
se~amr~ from ~rimn ~Dm~
EXHIBIT C
Statement Mailed to
MS JANET k4 0 ItRIEN
;321 OASL;A, DE ROAD
MECitANI£SBURG PA 11055~5518
Statemeht.~i:'Of-iFinaficiai:::IAd~o'unts:i!:!.i...'..'.?.i~-:;..-' ~.. i.~
O~oup Number 0915 6233 0 001 Check Your Accaunls
Automaled Telephone Service
Client Number 1949 3925 2 001 a00-S62-7919
MS JANET M O BRIEN
On~na
hom~2.a~erlcanex~ess,~micacc
DJracl yeur s. erv!c..a and Investmenf quesllQns to
MICHAEL SHALHOIJB
American Express Financial Adv
3500 Market St Sle 200
Camp Hill PA 170l l-,4353
71
l'rotect your family's
tinancia! sectmty_ ~
Ensuring your family's fina~nclal ~ecurit¥
involves more than simply saving money
or Inve~ting it, II ~equi~ aa averall
=lralegy ~ help you meal your ~tt.e
goals and a contlngen~ plan i~ Ilia lakes
an unexpccled turn. The right life
insurance is a ~rnerslone Io a secure
financial plar~ and can help prolec[ your
lam~l~ and prov~e ~laancial s~curJl~. Call
y~}r advisor Ioday ~or grmre In~rmalio~_
American
Where your assela
are invested
by pveducl
Express
Portfolio Summary
Percent of
all cl.~rren l
producls
~J
Prnducl type
Money Market Funds and Cash
Vailre Value
one year ago last sfalement Cmrant valm
FI0t applicable $0.14 $0.0{
[~ 100% Mutual Funds
~. 0% Securllies
[~ 0% Annuities
[~hl 0% Cerlificales
'J~I~ 0% Insurance
[] 0% Limited Partne,'t~hips and REITs
[] 0% Additional Producls
100% Total value gl all accounls
$33,134.4t $207,718.07 $166,440.91
Not applicable Not applicable Not appficabl~
Nol applicable Nol applicable [lot applicabh
Not applicable Nol applicable Not applJcabl,
Not applicable Not applicable . Not applicabl
Not applicable Not applicable Not applicabl
Not applicable Noi applicable Not applicabl
$33,134.41 $201',718.2! $166,440,1)
001GG091~623~0000~0~ 08129/2~3
A~count Service iot~rmetiul~ '" ' ..... - .... "' - ' ~-.~-~:~.-~='-:,.,.~.:':.:h.:-.,c'='.,. :-.,.~ --,~.:.:~. ~:.-.A~::-..,.,-...::. -~ ... :. . ...: ..~.
available lhFo~g~ American ~e~s Financial Ad~isors irc.
For more (omplele informatioo on ar.y proWL'Ct or sec.'ice.
prospeclus, Please read il carefully before y~u iBve~l you~
~o~e.j.
Dlr~cl inquiries I~:
?01~ ~p Financial
~lin~eapoli~ MN
you ~o /a/er than 6D days alier we ~ent F~u fha FIRSF
notify us ~iihln 60 day=, we wi/I ended;tend I~at ~ou aoree
wilh the alatemenl, If you have ether concerns ~ Complaints
reaa~din~ yo.r a~Coun:/, please contact us at the address abo~e.
WJ~en conlacfing us, please provide Ihe fail.lin
Your name and accounl or group ~Umber.
TI~e I~sue, ~rror or transfer ab~ul which you ale unsure.
c~cern or ~hy y~u ~e~ more irformati~n
The dolor amom~ of Iha suspend error
seciion5 of your slala~Enf relaJe~ I0 ~erican
Con[uriah ~an~, we will inwstigale your complal~l
any Error prernp[ly. I[ your Yeq~e~t lakes rncre Ihan 10 business
days, we will crEdll your accoufli lot the amounl
be in error, uniil t~ tim~ Ihal we can complele o~r in~sliga.
gallon
To de~ernUne wheiher pleaulhorjzad Iranslel~ have been ~ade
Io your account, call us al 800.297-7378.
~ investor br~.hure describing Ihe PubEc Disclosure Program
is available ~n Ihe IJASD Web Silo (N~D~com)
or by ~allu~g a~ 180-9990.
For more Complela informalloa [m any prod~cl or saY.ce.
i~-cludln9 associated teas a~d e~penses,, coalacl ~ financial
a~is~ Jar a pr~ect~s. Please rand it carefully before ~u
~elican E~ress Rnancial ~s0rs Irc., IDS Lile Insd~a.ca
Compaey, IDS Ll~e Insurance Company al H~/York, and
Certificate Core.ny am rot banks..and the securities I~ey
are riel ba~k~ ~ guaranle~ by any b~k ~r ara ~, I~su~ed
b~ Ihe FDIC. '
IDS ~le Ir,~urance Company I~ r~t, and is ~ol ~equl~d Io be a
~embe~ of Ihe Se:a~lies Invellor Prote~on Cor~alion {SIPC).
~e~ica~ E~esi Company I~ ~pa~le from America:~ Express
Financial ~isms lac., member IIASD and SlPC and :~ not a
b~o~r-dealer. '
~me~kcan EXpress Financial ~sors uses and
In~ormalio~ con.ming Inves(~em, insurance an~
accounts thai mambos el a pumary household group have wi~
~e~can E~ss Financial ~'~sors and ils ~(dlates
pxo~de a ca~solidaled slalemenl 0[ accounls and, for ~dakn
p~0ducts and sauces, advanl~eous pdcin9 or f~s. A prima~
household g/oup conslsls of a~ ia~i~dual ~ient. his or her
spouse or domestic pa~ner, a~O/er their UR~r~md children
uader age 21 who reside at Ihe sams address. I~ ~u ~r
ha~ a sta{emenl covering only a~ounls Iha(you own and nol to
padicjpala ia hou~hold ne, call t~,e se~lce ~urn~r aa ~Ur
slstement c~ your financial adais~.
Values {or accoanls summarized I~ Ibis stalemenl mayva~/
because al mar~t fluctualJoaL ~count ~cti~[y ~
Ioaas. ~ome valu~ may be stbjecl ~o ~rrender cha~es, market
value a~uslmenls er olher [e~.
The F~tces used lo provide ~es, ~elds a~d Income
*estlmate~ obtained frol~ oul~ide se~'l¢es believed Io be reli-
able The values do eel necessar~ repVeseht pd~s al which
Ihe $ecuvJlies could ha~ been purchased o~ sold. Because Ih~
ties lhal do ~01 have phis a~3ilable al I~e time al lbo
slatemer, t a~ n~ iecluded in Ihe tolal accouRt value.
(AEFA). Mernbe~ NA'~D arm $1PC In~$tmen.,t proOJcls are hal
Insured I~, tqe FOIC. am n0( ~sils or oblioa~ons al or
gUaranleed by a finarc~al insli&ulion. ,nv~ inveslme~,[ risks
Including ~sible los5 of ~rlacipll ar, d may fluctuate in val~e.
~encan Exprest C~lurio~ ~g (A~CB),
ce~a~n ban~ng fealuras le AEFA for Ihe ~mican E~ess dUE
Rna~c~al a~ounl and Sire[agio ~Hlelio Se~ce ~a~tase vAl'h
ONE (ealu~ -A~ ~poslt Pl~ucls ara FDIC.In~u~o up
lt~.00a pe~ cusle~e~ The ~e~can ~press Ins~d Mcn~ Marks
.~c~t Is an FDIC-insured proaL:t ~ovidad by
~Er~ Is a ~oker-deale~
Becmlllee ProtecUon
Securl II es are prol~ecled by 8ecu rid es I nve$1or p rolecli0n ~r-
po~alio~ (SlPC) up Io a maxl~ ol 4~,0~0 ~ ~ustomer Which
incluaes a ~1~.~ IJmil on claims fcr cash held
We ~a~ oblai~ed ~cess C~age or, Id[al brokerage ac~u~l
assets up to ~4.5 million. Assels w~h IDS LI[e Iff lurarce
Company, asaets wllk olher aflillated i. suranca C~nies and
mulual fund aSsels h~d oulsi~ o~ y~r b[o~regeaccounl
hal ~by SIPC.
DPP and REIT Securities Dladolure
Positions held In dir~cl PadiolpalioJ'l H'Ogram sec~.ritles (e.g,
Perlnerl~hipL llmiled Iiabili~ ~mpames, and real ~(ale
in~sfmenl ~usts which are hal listed on I~a national
or (he Nasdaq) ale ~enerally illiquid; aa fo.~al trading market
exlst~ lot these secu~ties; and Ihelr ealues will ~ dU~erenl
then Ihe pumhaae p[ice. UMess olh~wlse Ihd~lE~. t~e values
0~ units owred leal are shown h~eln for such ~ecu~ities h~
been pro~ded ~ and represent eHl~les of Ihe In~sl3~'s in[eresl
in tl~e eel a~se[s ~' Ilo prog[am. Unless olrer~ise indicated,
num~r of LnJis ~aned shmvn herein Pa~ been Pgaviodsly Pl~ided
by lbo managemenl ~ each program and mig~l n~ ~ecessarily
retied subsequenl acl.~iig' T~ere/ore, the animated va:uae show~
herein may hal nec~aiiJy be realized ~oo~ Ihe sale d sec~rilies
and Ihe RUbber of Units sh~ mayrol necess~rit~ re, ecl youl
curreql hold nos.
Statement of Financial Accounts .... -. -'..'..:' :..- .:-.: ... . 7~' '..-~0~i~'Y~4,,i~n~'~co · '.'"
" - - ". · . - ' : :.'-' ...... : aoo:851i:?¢19 ~ ~.~.~' :' -.: - ..
St mmary
~Mone¥ Mar~,et Funds and Cash
AMERICAN EXPRESS BROI(ERAGE ACCDUNI
of Accounts by Product
Mulual Funds
AXP PARTHERS VALUE FUND CLASS A
AXP NEW DiMENSiONS FUND CLASS A
AXP GROWTtt DIUENSIONS FUND CLASS A
AXP EC}UiT¥ SELEC'i FUND CLASS A
AXP PARTNERS SMALL CAP GRQWTH FUND CLASS A
AXP SIIOI~T DURATION U.S. GOVERNMEN'[ FUND CLASS A
AXP DIVERSIFIED BOND FUND CLASS A
AXP NEW DIMENSIONS FUND CLASS A, iRA
AXP GLOBAL BALANCED FUND CLAS~ A, IRA
AXP DIVERSIFIED B.DND FUND CLASS A, IRA
AXP SttDRT DURAIION U.S. GOVERNMENT FUND CLASS A, IRA
AXP MANAGED ALLQCATION FUND CLASS A~ IRA
AXP DIVERSIFIED E(~UI'IY INCOME FUIID GLASS A, IRA
AXP INSURED TAX-EXEMPT FUND CLASS A
AXP PARTNERS SMALL CAP VALUE FUND CLAss A, IRA
- Toial et mulual funds [rom brckerag~ account{s) held cae year ago
or last statement, bu{ not hDId this slatemenl.
Symbol Accoun! number
Value one year ago
Value last ~lalemanl
00~0 3047 3789 3 021'
AVL.AX 0010 1002 2661 1 002
IF/NB)( 0010 t0~2 2071 0 C02
AXDAX 0010 1002 2~72 6 ~2
INVPX 0010 1002 2673 6 002
AXaCX 0010 1002 21~74 4 002
IFINI{ 0010 Ifl~ 2075 1 002
INBNX 00tO 1002 2879 3 ~2
INNDX 0010 8915 6233 3 ~2
IDO~ 0019 ~15 D~ 0 002
INBNN ~11 2915 6~ 5 002
IFINX 0012 49~5 0~33 1 ~2
IMRFX 0012 ~15 ~33 g 0~2
INDZN ~014 3915 ~33 8 002
IINB~ 0014 4915 ~33 7 ~2
ASVAN 00IT 2B15 ~33 2 ~2
Not applicable $0,14 $0.00
N et applicable 10,14 li~acljve
.$33,!34.41 $207,718.07 $1r~6i44o.9,,
Not applicable $24,701,84
Not applicable $24,60~,88 ~6,869.93
Not applicable $ t8,4?4.52 $19,244.21)
Not apl~lcable $18,525.52 $1g,8~a.10
Not applicable ¢19,~72,28
Nol applicable $g,022.01 ~8,~11
Not applicable $9,030.14 $8,7S1.1~
$2,g10.O3 $3,076.44
~ 1 ,g68.26 ~2,118.28
$8,451,88 $9,118.58 ~8,887.04
$?,370.45 $7,566.03 ~'7,496.46
ll4,242.41 ~4,5G7,84 ~4,586,g3
I;5,~54.71 $5,~2,33
Not applicable ~2~6.73 ~6.35
S2,036.~ $3,256.00
Not applicable ~46,315.56
CESA Plan Contributions
Plan JANET M 0 BRIEN
OWfier IRA Plan
Plea k!ade for 2003 Ii0.00
Coni¢lbu[tons Rullover 2C03 I0,00
Summary of Accounts
J.__ANE.T M Q BRI£U
AXP PARTNEI~S VALUE FUND CLASS
Symbol Account I~umber
60fO 1002 2661 1 002
O010 1002 2871 O 002
00i0 1002 ~672'8 002
OOlO 1002 2673 6 002
0~)10 1002 2674 4 002
0010 1002 2675 I 002
0010 100~ 2879 3 002
0~14 ~915 6233 7 002
0~0 3047 3789 3 Q21'
AVLAX
AXp NEW DIMENSIONS FUND CLASS A ItdNDX
AXP GROWTH DIMENSIONS FUND CLA3~ A 'AXDAX
AXP EQUITY SELECT FUND CLASS A INVPX
AXP PARTHERS SMALl_ CAP GROWTH FUND CLASS A AX$CX
AXP SHORT DURATION U,-=. GOVERNMENT FUND CLASS A IFl#X
AXP DIVERSIFIED BOND FUND CLASS A INE~X
AXP IHSURED TAX-EXEMPT FUH[3 CLASS A IINSX
AMERICAN EXPRESS BROi<ERAGE ACCOUNT
Valua ~na y..~ear ago
Cutreql value as of 08/29f20C~
Value last alalemenl
C,~rrent vaiue
Not aP-.L~_cable $17~ 2~,~42.8 E ~30~432.4}'
Not applicable !~24,?01.64 '- $'26~
Not applicable ~24,~03.86 ~28,559.93
Hol 'appll Cablu ~18,474,.52 II19,244.29
Hot applicable !;18,525.5~ ~10,66&.1~
Hot applicable ~ 19~,272:28 $21,667.;~)
No! applicable $0,022.0l ,,~!,641..5-~
Nol applicable $fl.030.14 ~8,781.12
Fiot applicabl~ 5'2,9,6.73 {206.3~
Hot applicable ~18,315.70 inacttve
_JANET M O BRIEN IRA
AXP' ~EW Di'MENSIONS FUI4D CLASS A INNDX
AXP GLOBAL 13A/AHCED FUHD CLASS A IDOA~
AXP DIVERSIFIED 8OND FUND CLASS A INBNX
AXP SHORT DURATION U.S. GOVERh'MENT FUND CLASS A IFII~X
AXP MANAGED ALLOCATION FUND CLASS A IMRFX
AXP DIVERSIFIED E(~UITY IHOOME FUND CLAS~ A INDZX
A~P PARTNERS SMALL CAP VALUE FUND CLASS A ASVAX
0010 6915 ~ 3 ~02 ~2,910.03 $3,0~..44
~3,19~,98
0o10 ~t5 6233 0 ~2 ~1,960.26 ~2,116.28 S2,141.16
0011 ~15 6233 5
0012 4015 6233 1 ~2 ~Z,370.45 ~7~6~.~ $7,498.4~
0012 ~15 ~33 6
0014 3015 ~33 8 ~2 '~5,254,71 ~5,802.33
0017 2915 6233 2 ~2 ~.2,936,65 ~3,256.09 ~,570.~
Mutual P'unds
AXP Partners Value Fund
Account owner(s) Dale accounl opened 05/27/2003
,JANET M O BRIEN'TOD -
Your accounl performance
AcccuM ~edorrnance bfforlnalion is ~o! provided f<~r I~cc, ounts thai al'e leas than one
},ear ~ld
There ~re no transactions lo repo;t tot {his $1alemenl period.
Accourlt number
Current account value
er~ 0812912003
Class A shares owned
Current price per share
Eslimaled average cost per share'
Cash Invested to date*
Reinvested dividends
Cash dividends
Accrued dividends
Market gain (loss)"
Cash withdrawn'"'-
Account Value
0010 1002 2661 1 002
$26,096.77
5,812.198' '
$4.490
$4.30
$25,000.00
$o. oo
$0.o0
$o.oo
$1,096.71
$o. o0
$2~-9-6.7 7'
This number is an eslimale aqd ,.houl.'l not be used in -~o3r lag
calculalions. Cons~ll a p~lesSl~al la~ a&vito~ when (alculMin9 laxes.
Inclu6es ~alized gain (loss), unmali~d market appr~ialioa
{depreciation), alld $ale~ charge~.
Include~ redenpflens, exchanges, cash di~dends, laxes w~lhheld.
~uslodJal leas and c~lsions to class A
AXP New Dimensions Fund
Account owner(s)
J~,~T U o aR~ TOD
Your accoun! performance
Dale account apened 05/27/2003
old
AcCOUlll Aclivttl/: There: are no tfar~sacli8ns to report for Ibis statement period.
0010 1002 ~2671 0 po2
Current accouter value
on 08129t20D3
Class A shares owned
Currenl price per share
Eslimated average cost per share"
Cash Invesled 1D date'
Reirwesled dividends
Cash dividends
Accrued dividends
Market gain (Iossl**
Cash withdrawn* "'*
Accounl Value
$25,559,!)3
1,151.867
$22.190
$21.7O
$25,000.00
$o. oo
$o. oo
$o.00
,$559.93
$o.0o
$25,559.93
Tlds number ts eh estimate and should no( be Used i. y<'ur lax
ca)culallens. ~sult a Prefessionai ta~ ad'~or whe[ ~lculall~ laxes.
Includes realized gai~ (loss), unrealized ~m~.el apprec,~tion
(depr~lMion}. and sales charges.
Includes r~empllons, e~haa~s, cash ~i,~ideeds, la~e~ ~'ithheld.
cu~ial lees a~d con~rsi~s to class A '
.statement of Financial Accounts
.July 1, 2003 . August 31, 2003
:i ': :~' -::":': :} :. ~'''' ' .... .'- . . '
AXP Growth Dimensions Fund
Accoun! owner[~)
,JANET M 0 BRIEN TOD
Dale accoun! opened 0§/27/2003
Your account Periormance ' *..
· . : .:: .:: :. :! ~;:: ;:~;;;~:; :[.il~t::.:~! .::.!i~i :.i; i~.i? :;i!5!i~i'L:::~/i:!i~; .:~::;'~/F'":.:~':~iF*i:::;~::tiz.::..:".;~;~:..;. *
~ear old.
Accouilt Activity: 'll~e~u are no lrafisacllons lo repot Icg ll~is ~late~enl period,
~ccq. unl number
Current account value
on 08129/2003
Class A shares owned
Curren! price per share
Esllmated average eosl per share'
Cash invesled to dale'
Relnvesled dividends
Cash dividends
Accrued dividends
cMaar.kel gain (loss)"
sn wllhdrawn*"
OOlO !002 ~672 8. 002
$19,244.29
8,553.019
$2.250
$2. t9
$18,750.00
$o. oo
0,00
0,00
$494.29
$0.00
Account Value $1§,244.29
This number is an eslimale and rd*.ould nol he used in yo~r lax
calculaliene. CoReull a P~ofessional lax aclbfso~- When cetculating luxes
Includes realized gain {loss}, unrealized market appreciation
(dep~iaclafion). and sale~ charges.
Includa~ redempllons, e~changa$, cash dividends, luxes wllh~eld.
ceslcdlal fees and conversiaes tc "lass A
Accouni owner(s)
,JA~wr u o eRIE~ Too
A_XP Equllv 8elecl Fund
ccou ! bet 0 10 1002 2673 6002
Date account opened 05/27/2003
Your accounl performance
are no Iran~acllons lo reporl lot Ibis slalemeni: periocl.
Current account value
on 08/2912003
Class A shares owned
Current price .per share
Estimaled avera[/e cosl per share'
Cash Invested Io dale'
Reinvested dividends
Cash dividends
Accrued dividends
cMaar,ket gain (loss)'"
sn withdrawn*'*
Accounl Value
$19,855.10
1,772.777
$11.200
$18,750.00
$o. oo
$o. oo
$o. oo
$1,10§.10
$0.00
$19,855. I0
This number is a~ eslimale amd should not be used in ~,Our
c~lculalions. Consult a professional 1~ a~sor when -'~lC~la,qng lanes
Includes ~all~d ~aln {loss). unrealized ma~kei apprec ~{Ion
(~pmclati~), and sales
tncludss ~4empllons. exchanges, cash dividends.
~sl~ial lees and ~rsions to class A
: SlQtcmento[ Financial Accounts ..... · .... ~ · ..:.: · ~....a..mtpho.es.ha~e . .- -
· : ':': · -. :" .. '5: .- 8004tB~;~1~'i@ ": ..:": · ",'.' .; ' .'. ?:.' ..
~ulv l, 2~3L. August 31, 2~a ' - ..... -"" ' ~ .... ' ....: oi~i~': :-.... · .
' * ..,.~r~up Number..-05~ q~;o.0~!....::
.... ' :- ."':- :~'~,'2 ::'?h~y--:.~.~:.)~:.¥;'~.':. !:..~:~;-..'~:?:
AXP PartPers Small Cap Growth Fund
Accounl owner(s) Date accounl opened 05/2712003
JAIIET M O BRIEN TOD
Y~ur accounl perlormal~ce
:"' '~' ~' ': '%' ''';~: ""~ ..' '- ~-- ::' -. ::" .... F' "~ '"'' ":':'~:'~" -
Accmml perlo~mance intormation is not plovided lot accounls ihal ate less than erie
¥.ear old
gccouil| AclJvjt¥; Tl~ere are rm transactions to reporl Ior Iltis stalement period,
, .. Account numb-er ..0010 1002 26.74 4 002
Current account value
on 0813912003
Class A shares owned
Current price per share
Eslimaled average cost per share'
Cash invesled ~o dale'
Reinvested dividends
Cash dividends
Accrued dividends
Markel [lain (loss)'*
Cash Wilhdrawn""
Accounl Value
$~1,667.39
5,570,022
$3,890
$3.37
$18,750.00
$0.00
$0,00
$0,O0
$2,917,39
$0,00
821,667,39
This etleber is ar, eslJmale and should nol I:e used in ~:,u! lax
calculMions. C~suU a pro{essl0nal lax ad~or when cal:ulaUng laxes
Inclu~s maliz~ gait. {loss], u~realiz~ m~{ appmciahon
(debr~clalion). and sales cb;~es.
lecludes redemptions, exchanges, cash distends, laxes wllhheld,
¢usl~'-al tees and c~q~rsi~s ~ class A
AXP Short Dt~ralion U.8, Government Fund
Accounl owner(s)
JANET M O BRIEN TOD
Date account opened 05/27/2003
Your accounl performance
:';:F q !: !?;?;;~!: '¢;:i ;~ ;i !!;~;!i ;'*;':;;!!';;;~;i;;!;;:: '";! ;i!; i:.~:il;' ;! :::. :": ?::!'.q ;i?.:':i ::'::::?:; ;:' !:: !'-: :.;J ::.:: ::;:;i :! i:: !. :·:! ;~:-..:·
Ac¢otmt paJf~rrnance informalion is aa( provide(l for a¢cou~.s II~al are less Ihan one
old
Account ac¢ivity
07/24/2003 Relnvesled dividend
Class of Number Price
shares of shares Xper ;hare
A 3,000
$4,000
$4.870
al $0.0081 per share
01i/22/2003 Rei~vesled dividend
at $0,0080 per share
A 3.029
Dollar
amoun!
· ~ 14.70
$14.75
Accounl number
0010 !002 2675 1 002
Cufren( accounl value
on 08129~2003
Class A shares owned
Currenl price per share
Accrued dividends
Eslimated average cosl per share'
Cash Invesled 1o date"
Reinvesled divider~ds
Cash dividends
Accrued dividends
Market gain (loss)"
Cash withdrawn**'
Account Value
$8,941.52
1,835.363
$4.870
~,3.3a
$5.13
$9,375.00
$42.95
~o. oo
$3.30
($479.73)
$o.00
$8,941.52
~[hls number is an e~tima~e a~d should ~el be used in your [ax
calculations· C0fls~-II a professional lax ad~¢~or when (~lculal;.9 ta~s.
Includes r~iz~ ga[~ (l~s). unrealized markal appr~lplion
(dentition), and soles cha~es.
Inclades re~mplions, exchange3, cash di'~dar, d~, t~es vABheld,
cuslo¢ial fees and conva/~ions to class A.
Statement of Financial Accounts
J.uly 1, 2003 - AuguSt Sl, 2003
AXP Diversified Bond Fund
Accounl owner(s)
JANET M O BRIEN TOD
Dale accounl opened 05/27J2003
Your accou~fi performance
Ac¢oul]l petla;mance thin,mellon is nol provided for accounl; thai are less lhan ore
geaw ~ld
Account activily
Dale Activity
07/24/2003 Reinvesled dividend
al ~0.0125 per share
08/22/2003 Reinveslad dividend
al $1:),0117 per share
shares
A
A
Nulltber
of shares
4.736
4,495
Price Dollar
X. per share = amount
$4.840 $22.92
$4.770
.. p Number 0~5 62330 001 · 'home2 ' ~ ¢ * '
$21.44
Account pu~ber
0010 1002 2,67'9 3.002
Currenl account value
on 08~29~2003
Class A shares owned
Current price .per share
Accrued dividends
Estimated average cost per share'
118,781.12
1,836.144
$4.760
$4.35
$5.14
Cash invesled to date'
Reinvested dividends
Cash dividends
Accrued dividends
Market gain (loss)*'
Cash wl]hdrawn"""
Account Value
~9,375.00
$64.26
$o,~
$4,35
($662,49)
$0.00
$8,781.12
r~.ls number Is aa eslimat~ aecl should r. ol be us~ In yocr tax
calculations. Con=uli a professional la)~ a~tvisor when csXulaliag taxes.
Includes reatized Dam (loss). unrealized manet appreciation
[deprecialloR), and sales cha~es.
lacludas redemptions, exhales, cash di~dands, la,es wilhheld.
Cusi~al fees and con~sions la clas~ A.
Date account opened 0a/20/20D2
AXP New Dimensions Fun_d, IRA
Accoun! owner(s)
AlViERICAN EXPRESS TRUST COMi~ANY
CIO JANET M 0 llRIEN
AS CU$'fD FOR Tile JANET M 0 itRIEN lEA
Your account performance
Account PeH0tmaaca hlormalioa is ~ot ~ro,.'idad Ior a~our, t~ that are less Ihan oas
Account Activity; There are nO transac/ien~ 1o roper[ for (bis stateme.t p~lod.
Account nu bar 0010 6015 6233 3 002
Current account value
on 0B/29/2003
Class A shares owned
Current price per share
Eslimaled average cost per share"
Cash invested to dale*
Reinvesled dividends
Cash dividends
Accrued divide rids
Marks! gain (In?s,),**
Cash wilt]drawn
Account Value
$3,195.98
144,028
$22,190
$21.99
$3,162.3 I
$4.86
$o.oo
$o.oo
$28.81
$o,oo
This natal:er Is an esll.,r, ate acd shotlld not be u~ed in .~cur lax
calculations. Consull a pt~e~siara/la~ ad~sor 'when calculating laxes
Includes ~ali~ gain (Ios~). unreallced ma(ke.I apprec al o~
(dep~aclalionJ. and ~le, chatty.
InclEdes mdampl OhS, ~chang~, c~h dividends. [a~ will, held,
cusl~ial leas and coa~rs~ns ~ class A
:' Slatement of Financial ACCounts
....July 1, 2003, 7 Augusl 3t, 2003
AXP Global Balanced Fund, IRA
Account owner(s)
AIdERICA~I EXPRESS TRUST COMPANY
CIO JANET M O BRIEN
AS CUSTD FOR '['HE JANET M O BEIEN .IRA..
Dale accounl opened 08/20/2002
Accoun! pedorrnance inlorrna:ion is nol pcevided Ior accounts Ihal are less than
year old
Account Acllvity: There are no transaclions to reporl [or {his sis'lament period,
Accnu~lt nun,~b~r . 0010 9915 6233 0 002
Curren~ accounl value
on 08t 29120D3
Class A shares owned
Currenl price per share
Estimated average cost per share'
$2~141,76
46g.685
$4.00
Cash invested to date'
Reinvested dividends
Cash dividends
Accru ed di vidends
Market gain (loss)"
Cash withdrawn'"
$2,t08.24
$4.33
$0.00
$o.00
$29,19
$o.oo
Account` Value $2,141.76
· This number Is an estlrnale and should .'~ot be used In ¥'ot.r lex
calculations. Consult a Fro/ess(oriel te~ advisor whes] csb(Ulating taxes
~ Incl~ides reali~d gain (less}, tm~eaflzed markel app;eci~ican
(dsp;ecJalion), and sales charges·
IRcludes redemplions, exchanges, cash di~dends. (aXes ~ilh~etd,
cusl~iel leas and ~n~tslon s 1o class A
~AXP Diversified .Bond Fupd, IRA
Account owner(s)
AMERICAN EXPRESS TRUST COkiPANY
C/O JANET M O BRIEN
AS CUSTD FOR THE JANETM O BRIEN IRA
Your a~ounl performance
year old,
Account aclivit¥
Date ~
07/24/2003 Reinvested dividend
at $(i.0125 per share
08/22/2003 Reinvested dividend
al ~0.~117 per share
Dale accoun! opened 08/20/2002
Class o! Number Price
~hares at,hares X~are
A 4.756 $4.840
A 4.541 $4,770
Dollar
amounl
&23.02
Accoun,{ qurq.ber 0011. 2915 6233 5 002
Curren¢ account value
on 08/2912003
Class A shares owned
Currenl price per share
Accrued dividends
Esllmated average cosl per share'
Cash Invasled lo dale'
Rehlvesled dividends
Cash dividends
Accrued dividends
Market ~lain (loss1"*
Cash wilhdrawn-V,
Account Value
$6,867.04
1,854.106
'$4,780
$4.41
$4,94
$8,786.22
$371.40
$0.00
$4.41
($294.99)
$0.00
$8,86,7.04
TH$'numl:er Is an eslima.,e and shouid r,0t bt use,-J lo ~our lax
ca:culaiions. Censull a Professional la): advisor when ¢&lculadn.3. la,(es.
Includes ~'eatized gain {loss), unrealized ma~rkel appseCalion
{depreclaboe), ard sales charges.
Includes lac~ernp ohs excha~,ges, cash divlden:Js, taxe~ Withheld.
cuslodlal fees mid conversions Io class A
Statement iof Financial Accounts
July 1.3003 August 3t, 2~oa
AXP Short Duration U.S. Governmenl Fund IRA
A counf um er 0012 491 6233 1 002
Account owner(s)
AMERICAN E×PRES$ TRUST COMPANy
CIO JANET M 0 BRJEN
.AS CIJSTD FOR_ THE JAHET M O BRIEH iRA
Date account opened 08/20/2002
Your account performance
i :i-i i!;~ i :.: :ij~, i:i::/::':;;:t :~ '::;:~:~: ~ :: ~:,:.::. ;:: =:....,::,:.:.., .. ..........
t~:: "':""'~':'~":"::':';:i!'~' ~..";::'J~;!;::;;:':.:;'~' .:H~!i~;~.':::!~ ;':'::~'~
A~.era e ann I. ret .....
. - . . .q~ urnasol. Bi .............
~ .. J.Yeat ....... ~ Yea .............................. ' .......
...... N/A ;~"NtA' ":::" ........ ' ........... ~' ................... ~-"
Accuu~t perl'~rmance iM3rmolior, is no! p~o~ded tot accounts [hal are less II, an Dba
yea~ old. .
Account activily
Dale AcllvJ/~/_
07/24/2003 Reinvested dividend
al $0,0081 per share
08/22/20(/3 Reinvested dividend
at $0,0080 per share
Claes of
,sharns
A
A
Number.
of .aharea
2.533
2.509
Price
X~ ahare =
$4.900
$4.870
Dollar
a~moont
$12.41
$12.22
Current account value
on 0812912003
Class A shares owned
· Current price per share
Accrued dividends
Estimaled average cosl per share'
Cash invesled to date'
Reinvesled dividends
Cash dividends
Accrued dividends
cMaar.kel gain (loss)"
ah withdrawn'"
Accounl Value
$7,4§8.4B
1,539,156
$4,870
$2.79
$5.15
$7,730.09
$194,67
$o, o0
$2,79
($429.07)
$o, o0
$7,498,48
This number Js an estimate a~l should n01 be used in your lax
calc~alaiions. Consult a prolestJo~al lax ~'Asor w~en calculal,~p taxe~.
IncI-jdes ~ealized gain {loss). u~raalize~ market appreciation
(depreclalio~l, and sale~ the;gas.
lacludes ~amplions. e~anges, cas~ di~dends, taxes wiih~old,
AXP Mananed AIIocalion Fund, IRA
Account owner(s)
AMERICAN EXPRESS TRUST COMPANY
C/O JANET M O BRIEN
AS CUSTD FOR THE JANET M O E, RIEN IRA
Your accoun{ perlormance
Date accounl opened 06i20/2002
Ac¢oul:l pmformauce i~[o[maljon is no! olovided {or accotlnls Ute{ am less lhan one
yaar old
Accounl Aclivll¥: There are rio I~am)sactions to rcperl lot [his statement period.
Accoupt number 0012 6915 6233 9 i102
Curren! account value
or, 0BI2912003
Class A shares owned
Current price per sham .
Esl]mated average cost per share"
Cash hwested fo date'
Reinvesled dividends
Cash dividends
Accrued dividends
Market gain
Cash withdrawn*"'
Accounl Value
$4,566.93
581,774
$7.850
$8.00
$4,567.78
$84.77
$o. oo
$o. oo
($85.62'
~;o. oo'
This number is aa esllma[e a~d should aol be used in ¥o~ la:,:
calculalion$. Consull a P~otesslonal iax a~r when calculabng taxes.
InclUdes ~al~ gain {loss), unmaliz~ market app~eclalion
(depreciation}. and sales
Includes ~edempi~ons, exchanges, cash dividend~ m. ay~s wil~held,
~uslodlal lees and co~versions to class.
Statem¢llt of Financial Accounts ' . * - .. i.--.:..-.. · .?::: ..... )'.'.':.-~o~.,~.::~e!e~i~h~..s.~:~:~ ....:? ..
. . Jul/ t, 20~ - Augusl 31, 2~3 . · .' · .'::.
AXP Diversified Eqully I=come Fun_d, IRA .,
Account owner(s) Date account opened 08/20/2002
AMERICAN EXPRESS TRUST COMPANY
CIO JANET M 0 BRIEN
A,S CUSTD FOR TIlE JANET M
Accuunt Acllvity: There are no transa~;lions to report for this s!alement peri~d.
Accounl ~umber D014 39!5 62._3_8 002
Current account value
mt 0812912003
Class A shares owned
Currenl price per share
Estimaled average 'cosl per share*
$6,167.30
744.843
$8,28O
$7.67
Cash Invesled to date
Reinvemed dividends
Cash dividends
Accrued dividends
Market gain
Cash withdrawn ·
Account Value
$5,621.88
$91.21]
$0.00
$0.00
$454.14
$0.00
$6,167,30
This ntmber is an estlnlale ard should ~ol be used In youg le0~
calculations. Coe'~sult a professional lax a~lvlsor wl~en celculaling taxes.
latitudes Fealized gain [loss), unrealized market apprecialien
{dep~eclalion). a~,d sales charges·
Includes federations, exchanges, cash dividends, laxes wJlhheld.
cuslod,al fees apd conversions lo class A
AlP Insured Tax-E~em t Fund
Account oWner(s)
JANET M O BRIEN TOD
Date accounl opened 12/26/2002
Your accoun! perlormance
Accoufll Performance J~lotlllaliofl is riel ~ro~de~ Ior a~ounls lhat are less {b~n one
year
Account aclivilt/
Dale ~
b¥/¥4/2003 Reinvesled dividend
al $0.0162 per share
08/2212003 Reinvesled dividend
al $0,01~5 per share
Ciasa of Number Price
shares of shat_es ~XXper aha_______re
A 0.163 $5.470
0.158 $5.380
Dollar
~l~OUllt
$0.89
$0.85
Account umber 0014 4915 623 7 002
Currenl accoun! value
on 08/2912003
Class A shares owned
Current price per share
Accrued dividends
Estimaled average coal per share'
Cash invesled ~o dale*
Reinvesled dividends
Cash dividends
Accrued dividends
Market c~ain (Io-~.~'-
Cash wi~hdra'wn";7~
Account Value
$286.35
53.087
$5.390
$0.21
$5,77
$300.00
$6.08
$0.00
$0.21
($1~9.94)
$0.00
$286,35
This qumber is an aslimale and ~l'-ould r, al be used ia y:ur lax
calculaiiens. Cons~l{ a ~ofessional la~ a~isor v/hen c/Iculalin9
I.clt~es ~ealized gain Iloss), unrealized ~arkel
{depr~ialionL and ~ales charge.
Inclt~es ~ed~pll~s, exchan9~' cash ~dends, la~as~vlU~he~d
cust~ial roes and conversions ~ class A.
AXP Parlners Small Cap ValUe Fund, IRA
Account owrmr(s) Dale accounl opened 08/20/2002
AMERICAN EXPRESS TRUST COMPANY
CIO JANET M O BRIEN
AS CUSTD FOR TIlE JANET M O BRIEN IRA
Your accounl performance
.,~,ccoulH peHormance lntormatior~ is not p~ov~ded for accoufils thai are less llla~ one
year old
AccouIl| Ac||I/ily; There are r~ Irar~sacliens to report lar this statemen! period.
,Accoulll number .0.017 29!,5 623~ 2 002
Current account value
on 0812912003
Class A shares owned
Currenl price per share
Esllmaled average cost per share'
Cash invesled 1o date'
Reinvested dividends
Cash dividends
Accrued dividends
Markel gain (loss)'"
Cash withdrawn""
Accounl Value
$3,570, g9
629,804
$5.670
$5,05
$3,162.31
$16, 62
0.00
0,00
$392.06
$o. oo
$3,570.99
This number Is an esUmaie and shou'.d nat ~ used in yc~,tf lan
caAculaltons Coa]ull a pr~essJonal [~ advisor when calculating la,es.
Ir, eludes r~lized gain (lost), tRmall~d mar~l app~eciall~
(depreclalioaJ, and sales charges.
Incluaes ~edempUons. excha~g~s~ cash ~ividends. la~s ~lhheld,
cds~ial fees and C0n~rsior s Io class A
Americar~ Expresa Brokerage Account
"':'"~' "* ~ _.:.2d~h *?j~b~,,~,:-j~ n'~:.~ H~ J~'~, ~, · :, "~f,~ ~ -~x.
summary [rom July 26, 2003 to August 29, 2003
$0.14
0'00
Nel tolal income
Asse! aclivity debt!
Assel aclivit¥ credit
Clasing money markel and cash balance
Dividends alid Interest summary
Taxable dividends
Taxable i~!eresl
Non-laxable interest/dividends
Net total Income
Ope~iing ~no.ney marke! and cash balance
Cash deposits
Cash withdrawals
bet OOD 3047 3789 3 02
Curre~l Year-to-dale
$0.00 $103.15
$o, oo $0.14
$0,00 SO, DO
~~.6d '---~0~
Review ol account on August 29, 2003
Value last slalement
Money market and cash
Tolal porllollo value
Value change from last stalernerll
$48,315,70
$o,o0
($48,3t5,70)
Portfolio Holdinga
Maae¥ Mmket a~d Cash
Value ~1 Mouey Market and Cash
Estlmaled Est/maie~
m a~rk_.9_eLvalue Estima!ed annual
"-'4--V-ia I d income
$0,00
Actiully
Cash Deposits
D~a!e_ ..... _D es___c.r_ipti on
Cash Withdrawals
Date . .D. es_c_ri~liun,
DJ~ide~ds ~l~d hlleresl
~_aLe ....... A~i~y Description
Amount
c~:edlt'ed Date
Descrlj~on
Tolal Cash
Arnot~t
credll_ed..
$0.00
Amount
debited Date Desc.rj~ion Amoun{
{ ${ ${ ${ ${ ${ ${ ${ ${ $~0. ~ 3,) - debiled
Total Cash Withdrawals ($0.14) *
A~nount Amount
debited credited
Asset Acllvity
~_aLe ........ A_.c_LivilL_ ~_e.~_c. rip lion
68/14/2003 Delivery LIB SELECT VALUE - A
LIBERTY FUNDS GROUP
DELIVER TO 309784561
08/14/2003 Delivery VAN KAMPEN GRW & INC -A
VAN KAMPEN FUNDS
DELIVER TO 309784561
01t/14/2{)03 Delivery AMER WASH MUTUAL - A
AMERICAN FUNDS GROUP
DELIVER TO 309784561
Quantity
(953.289)
(1,230,991)
(378.5a6)
Total Dividends and Inleresl
$0.00
Estimated
Estimated realized Amount .Amount
Price cosl basis' gain I~)'~ debiled credited
$0,00
Tolal Asset Acllvlly $0.00
number Is an eslimale mad shDuld hal be L;secl i~] your la){ calculations Co, evil a ~o/essional lax advisor when calculallng laY, es. Es(treated cosl basis is not available fo~ all posi';~o~s.
Amou,lt debited and Amour, l clrediled includes aj:@l'lCable commissions and fees. Fo~ bonds and CD'e, Amount debilec~ an(I Amou~l. crediled may include acc~ted inleres~. Please see you~ (rede conllrmalio~ tor dele. ils.
~,~co~nl~ carried by
A~'nerical~ E'nlerprise inveslmenl SErvices
704~ ~ Fmanclal Cen~er
American Enterprise i~slme~l Se~ce Inc. v/ill r~l~
remuneration for dl~clihg ~de~s ~oa ~agic~lar brewer o~ ~aler.
lhro~gh ~ich 'l~[ Iransac~on is a~ealed Such ~mu~era[Ion
considered ~ ba com~'hs~G~n fo ~s '~d' I~e '[our~ and a~ounl
any co~pensaCon w~lJ be disclosed upon request
Dela~ls aboL, I commissions a~d ~t, er cha~e= rela~d Io oplion~
Iransac(lons in you~ accounl ha~ bean ~ided iff confUma#~s
pm~Jously ~1 Io ~. This i~[mmalion will be ma~e available
~u prom~d~ upon req~es~ P;~se a~ise us immed alely of any meier.
~al change In ~ur ink.meal ebj~oti'~s or Ilnanclal
Acli~ For this Pe~od
A transac~un may co: appear on IhJs s(a(emenl if
date is after q~e ~te ~('our -' ....... ' setlle~e~
appear on your ~e~ ~alemenl.
Fr~ Credil Balance
In general, a free c~edit balance repte~enls [ands payable
demand which, althoLgh properly a~unled teton our bo
~? :?gteg2led ?~ m~ b~used iff fha co~ducl of fl~ flr~ s. are
.usmess ~ will pny ~u ~nteresl on available fre~' credj~
balances, and as pn~ of c~ensalion in seducing yOUr
we may ear~ income grozn the balances:
American Express W~llh Manaaemenl Se~ces
American E:~ess Firancial Ad~sors is lbo broke~ dealer ~ mc~d
aaa egect~ ~1 Ilades for your Weatlh Manage~enl Se~ices
as agen~ Tra~es se(gte through Am~ican E~rass Enle~prise
Inveslmenl Se~ces, Inc ar, a/fillale of American E~tess
F~nancial
American E~tass Brokerage will n~. provide, upo~ mquesl.
lionel In(or~tio~ relaled to orde~ ~ecal~ons including delalls
on whom an~ when ~ders were e~ecu~ed. A~e~caR
8roke:age will also matte a~aHable a qua~e[I m off
ln[orm~lo r a · Y P priding a. ~ fdJng order rouging deslinallans. To
me~e m~o~ please comer an American E~Fress Brokerage
rep~esen.ali~e al 1-~3 ~P.~RV_ -
Margin Accouul Customere Using American Express Credil
This stalo~nenl is a combined elaleme~l of ~aur ma~i~ sub*
accoum earl special memorandum sub.accupril male~Jne~ for yOU
undez ~ction 4ff)(G) ~ Regulation T issued by [he a.am
Go.mots o¢ Ihe Federal Rese~,e ~lem. The ~ma~enl te~rd
el the separate sub-ac~unl, as ~:~ired ~/Regulalio~
a~tla~e (or ~ur las~icn upoa mquesL
Securities purchased on ma~in am ~e f:tm's coil~ral
Ieee Ip ~u. II (he s~fldiies in ~ur aceoer, t decUne i~ value, .
so aoe~ IP~ val~e ollhe collateral suppodieg your lean.
a ~esull, Ihe hrm cap ~kE action, sdch as IssUe a ma~ia
with Ihe ~embar i- ~-- ,- _L~ ..... ~ Is he d
~ , -. -,~m ,u e~mma n I~a requl~ed ujl
acccfln,. I~ Is i - ~ y
involv~ n ,.~/lahJ j~ yOU tally u.derslaed (he risks
the foil~ln~~mg sacurlues on marwn. ~ese hsk$ include
You can lose more ~nds lh~c ~u d~asil In lhe ma~gi~
The/irm ~an [or~e the sale ~f s~ud~es or ether assets iu
your ~counl(s).
The/irm can sell your JecurJl~s or ~he~ assets
cenlacling ~u.
You a~e ~oJ eel I ed ~o ohcose which s~Urjlies el ol~er assels
In your accounl{s) are tJquida~ or sold lo mee~ a margin call.
The li~ eaj~ inoea=e its *~ous~ m~elenance margin require,
menls al any time a~d is eel required Io prm~iae you advance
You a~e Roi untilled to ~n e~sion ef lime on a ma~in call.
Im~oria~l Feelers Io Consider
~e~lc~n ~press finenci~ a~som pay c~arges ~ Some mulual
Jund and securily sales, purchases and ~anges Tra
g~a~es}. The ~ale cqaraed va~i .... a ~ _L_,, ( n. aclion
J0. Iransacl~en lo ~ransa~lan. Transaclion ~harges
de(ernlined by a vaHe~/el l~l=~s such ~ the · el
~VlSO~ qo ~ Pay/r~nsaclion C'harges o~ eerla¢~ &ansa~i~Ons
associated with mulaal funds ~dictpaliro ia Salecl Group
Progfanl including ~ ~unds. ~cmdi~gly Be fransaeljon
¢harges In~rred by W~-r adwsol ~11 va~. For more infer-
~alJae 0h these tranaacllon charges, ptea~a ask ~LV a~isor.
Diddead and Inleresl ~umme~ -
lepotlanl Informal{oa rot iRA Clients
you are an I~ cllanl, lhe Inletcsl and dividends descend
Finan=lal InleresI ia Pmducls
American E~p~ess Financial Corpolatlo~ has a hnancial InJeres~
the s~es of pmprlela~ produ~s Ihs: are manafac~uf~ by hs
al/iliates. AE~ and lis a~llal~s receive selling ¢o~mJssions ar
o{her comport salion for In~m~ls. firancJal &~d i~su~a ce
. you purchase. Reid lead.s lec~ve a sale ~o~us a
bio ~or an o~rali~ bu .... ,__ _ ~ , nd are
d epe~all~g ~udga varies d~--~,-- - '-- . .hi et Ihe bonui
you purchase. Reid leaders mav~e~i~ higher co~pensahon when
pvopnela~ ~roducls and mulua[f~ds In Ihe
a~e pu~hased Fina~*ial a~.~ .... ~_ ~. ~cup er~zam
P~opriela~ muk. al funds us. hah-p~opriela How~e
pensalio~ sbuclares va~ b~ ploduct tyne ~- ...... ~ ~ecause com.
insu~nce ralher Ih~ Ofhers~ ~ ~cHam ~ypes of ~oduc[s, such
on m~rgin w thoul ~kJn~ aa~ 4~ ...... ~ Sa ~cufilies
pOWer ~sUally e~uals ~uble the amou,~l el Free Cash.
D~I~ · Uo~me~l of ass~ls oul ~ a brokerage acceder
w]l~0ut
F~ Cash -Amoun[ thai can ~e boffo~ on ma~gin
inc~asi~j col ale~aL The a~.oual can ~ wilha~,~n G~ used
Io purchase nen-ma~ginable s~uril~as.
JouJ~aJ. Mo~menl of sisals wll~ie a brokerage acco~l or Jo
differenl brokerage account.
Margin -AbUjty 1o ~o~ ~mn a bm'~Er usina l~e ~lue of iecu~.
itjes qwaed as collateral baseG oe an approved margin agreemenl.
agreemanl.
Margin Balance Oet~lending - Leas [debl0 amount fo~ sec~d[ies
purehas~ uslag margin.
Mulual Fund C0al Basis - The a~rage basis, sirr~le
melhad Il use4 Ia calculate ~sl ~sis tot muJual fund[
R~ejpl - M~meal of asse~ or cash ingoa b~okirage aCcounl.
Plier Y~r Dlviden~. A dividend d~clared by a muiual ~e~d o~
~E[~ I~ ,~lobel, N~mber er Deceaber is consi - .
Dy tea snareholde~ for la~ hLi~. ~ ...... ~r~ r~eived
dl~dend is ' ~ ~-~ uy -~emoer ~1, a~an ~ Ihe
July 1, 2003. Augusl 31, 2003 . - Group Number :oalp 6233 0 oaf - . Onlln ..: .. '" '. i' .
This page tnlenlionally le~t blank
· .'. "';-..':"' ;'~,~' .~.-'~ ?'..~.;.' "' - ..... ~:.- . ,:' ' -U' - '. : ' ....;':',.-.:.Z-.,,~:!-~.~:;;~.~';:~, ~..'¢.'~":':~?.:'-'7'!~ ~;~%-..:~,f;.~:.-.*.,57..' ' ..~s ?--::~.~.~:~:.,,~.;?.,....':~:.~.r.-..-.: ...... ~._., ......
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:,: .::. :._;;ll~.-'j~.:, .,:..july 1, 2000. lull.,t al, ~003' ,. ": :',:-',:',' ,,~,;', `~..::~.~`~`.~.~:.*....`~.~`:~:.~.:~.~`.:`:..i~¢~.~..~:.~;~~i~..~;.~:..!:...`.:~`.::~.:`-.'. --,."--.';:,', :':-i
· :; ' .' ¢ '.: :~. ;,~:::' :::" - .::.' : . · :' · .... -' . ; - '"' '..-'..,~:":i.',.:-¢~: '.' ::. 7.-'.:'.2:-?% ':-" ":'¢-.,:¢;-:-~i.i%..:{*~'~"&\'}rt.::"::*7{".~?,':z.-~,,":;.'-' ";.';:.':5':.::-*'~-,=;-' ......
· -~~ ............ · .- .-.--. · Croci Num er. ' ~$' ~.~ n'~i~'.~.'- .......-- · ,:-~lh~' .,.,.--.'., ........ ;..- ...... ' -
... . p.'. 8 .. . .... -.~ ....... . ...... . .
Automated Telephone Service Service Information
Enler your social sezdritV gumber
Enter your four-digit Pitt
Clmose the option for Ibp !n~orma. tion Ihal 7ou'd like lo heat
For accounl values press I. ' '
For accounl aclivity, press 2.
For Amellcan [xp~ess proddc( plies ra~es e~ pe~otm~R~,
press 3. ' '
Fo~ PiN Maintenance. press 4
F~ document requesls, press 5
For assistance, press 0.
EFFECTIVE ON OR AROUNO JUNE 27, THE FOLLOWING AMERICAN
~[4~1~) ~R~s VAH[~LE PORTFOLIO BOHD
. WILL CHAHGE THEIR NAME8 TO THE FOLLOIMH~:
~P Bored F~nd will cha~ga le ~ Di~-'sified Bo~d Fund. ~p E~a
In~me Fuhd will change lc ~ ttlgh Yield Bond Fun~. ~p Federal
Ig~ma Fund ~11 change io ~ 3~oH Du~alion U.S. G~ar~meni Fu~d.
~ VF-gohd Fu~d will Change Io ~ ~'-Dl~siliod Bond Fund. ~p
~-E~e' I~roma Fuad will cl,aaga to ~F VP-Hioh Yield Bc~d Fun~. ~p
~-Fedaral Income Fu~d will change lo ~ VP-SAa~ Du~allon U.S
G~*n-men{ Fund,
EXHIBIT D
200Z31GhI12G79.00~ 0~2 ! I/IZ/~OOZ ~2.'D~'~3 /~t/
' pv nt Appliemion I
CORPORATE OFFICE USE ONL'Y
I (~ ELEN~ AliT BA
.J
· ' An approved Cber~ Profile Form 200152 for eu~ cifafn mUST be imbmmed prior to ,L,~mhlminm~ an a~ou n~ L
· For address Changes tmblmt From 618
SecUon A-- ~lent IBfummhon
~ IndMdml w~ TOD(A~ach TOO
l"l temms m Cmu~ [~] UGMA/MTM~ ir'J E.:ale_
Trg~J~lr~j~ Owo~l~N,~s '
Reqe~es Addmmm] Forms- (Refer m investment Appl~ahon ~ Ins~on FoTm ~ 1 tn trams cabinet on A~vtsor Cora~ct}
Semen B -- I~e~ Selecflon- (Refer ~o Invest~em Applicanon Y'586 Insm.,~on Fora F................~ ] Jn forms cabinet an AdvLsor Conr~
[] CHEC3C HERE IF i~S IN LP/RF. IT ATTACH FORM 232AND SUBAGREEMENT
B~qk Autt~rm~mon ,
Month -
..~_[ Corpome I)ffr~e u.
OO2
Product (Imm A
c
L-] I
ODm~Oepo~
Secuon F-- ~ OoI~.C~ A~,ng (Or.A) and~o~ Stma..,mo eayoK ~ (SPOs)----"---
Pert I _ Dollar-Cost Avenging
Ff~luency(chectrone) ~lV~nthiy E3(iuarte~ r~Sem~an~uafly ~A~nually (Wdldeiauhlommlthiydln~tlencT,sllOtlndlcKed)
OatelMM/DO/YPPf)l.~e~echo. F,~ Slordofnua.d~~ ~
Part 2 -- gPO Payuut Oplmn [Mmimm of ~ for payouts lea~ng.~m~e~c~n Ex~'e.~ F '" - S-
l-lA Cbecktocllell~,, r'lo ~. ...... } ecl:A Bore '
~ ~Expianaa~ efln~e,Jzment
.._.__~_ -- -, u - ,u,,uwmg.~mment. sana s,gmngThrs apphcatm youamowJedge thet'ollaw~j
3. lame.US Pmmm:itm:imtnlgaiJS ~.demekee)
TaxpByer 1~ :
z__._.._ L_._. L_._._L
I~lJlMIvl/~C)A'YYY]
I ] IL I IL I ~ ' t
Pu~h~se ~am
Funct and/or Cemf~:_~,~ Name{s)
Account Numbed$) (Fun~s CertJfJcatesorSecuntss OniW
J ~ undersigned owner at the above ~,:toun~$) desoto to estabhsh a Transfer on
Dea'dl ~OO) demg~n purlin m ~a Mm~ Un~ TOO ~r~
P~g~s~mo ~Hthe ~) U~n~(or~ me~of~ia~r
~ Amen~n ~p~s ~ml ~ ~c ~rJ~A
I~nt Sew~ Iflc an~ tho fufl~ m ~
(m~ua~jy or col~m~ly core.ny )~14 d~s~um ~ a~ ~rd~ m
~maon s P~ml pl~ of bum~m In Mmn~hs Mm~m
~eq Ben~m~ I m~r~nd ~t
mdca~d m ~ ~O reD--on any ~s
pr~ ~ m dea~ wdl be ~M ~ ~ ~
~cbang~
for e~an9~ a~ ~flg comm~ r~aM~ of ~emer
~ a~ h~ a d~m or no TeD r~
(b) I ~e ~d ~r~ ~t ~s TOD ~on
8~ou~ e~l~ ~ me ~ m a ~ or ~ exc~
re~ ~th ms~t ~e ~ou~ h~ m
~J~g TOO r~j~ pronely ~
TOD ~ ~ ~ ~ ofl~ on e ~er
Ag~nt '
~m~O ~J~o~ Iec~leOgaana~e~aTany~O
to ~ ~s~t~ m here~
~ucmn~ I un~ a~ a:~l~~ ~m no ~t a~n~ m f~t
change ~e b~:m~ ~ dall~ m P~ A~ ~memor
W cou~ o~ ~s ~mlon ~all n~ ~h~b~t ~e ~le or pl~ge of my
acmunt ~ a~ ag~: a~m~ m ~c: come.mr or g~an
Pl~ o[~D Ace~m f ~mmnd aha ~~ ~c tf si) ~ ~ of
my ~m has ~n pl~g~ ~ ple~ ~
b~q ~ul Cbddmn I undem~ end a~J~ge
~ddre~ ~s fmlud~ m my TOD feg~uon ~ ~Qon ~aff be
~emed to m~uOe ~ IN~ leg~ c~Jldmn bom m ~ ~fd~ I~ally
~op~ ~ me a~er Lhe ~m of O.s ~m~t ~ or ~ h~ ~ na~
~ ~s ~mem~t S~ chriSTen and ~nd:hlld~n am ~ ~md under
· JS d~gna~en
11
12
~3
14
9 Pawnemaf Onndond~ If eppl=able i ar.~owmdgeaM a0ree ~t~
m~rd ~ fir ~ ~T of a d~d f~ ~ a~) ~er ~n
a~ ~mer a~ ~mcular ~M~ sha~ ~ to ~
fl~ce of my ~ at ]~ prJnapaj ~ of
any ~rmn c~mg ~ ~ an ~t m my a~s~ ~te
~ ~ ~e ~ s~ll ~ a~ ~ t~ ~ ~
Um~ TOD ~ ~l~ ~t ~d I ~r a~ m m~l~ me
ce~apj~ ~ hold ~e m~ny ~le~ ~ any
~e pr~s~ ~ ~ ~ ~lJ ~ b~mg u~ ~ hmm
~nefician~
any c~ obj~g ~ ~ ~r of S~ P~T
~e p~lSlOm of ~ Mmn~m ~de~ TOD ~ a~a~ Am The
~h=aw op~s ~ be am~ ~ mm~ m ~ t,~
(~] da~ mtf~ mm~ m me at my a~m~ m ~ ~ ~ ~ mmp~
:ompa~ u~ S0 d~ n~e ~1~ m me at ~ m
~ com~
G~mml ~w ~mm ~Jl be ~ ~ ~e t~
of Mmn~o~ a~ s~ll ~ to ~ ~eflt of ~e m~ an~
admm~m p~nal m~re~n~ ~ a~
Uff~nal and ~ S~~ UA~J or~l shams held m a
bm~mge ~oum ~lch ~n n~ $ dwded ~1~ among ~e
b~j~ will ~ t~qu~ ~ ~ pr~ t~r~e~bu~ m ~e
b~mmnes
'l
me or ~ mear~ zfle ulcflV~lL~l Q~' individuals s~gnmg thJs Agreement
I C°rporata Off=a Apl~r~'a~ ' IOar~ ~campe~
~O0231b'M126 79. 001. 00 7 !1/I2/2002
mo proceed~ provlcl~d however That ~t~ ~ll~l of the ownerhasflm~ ~m ~
OWller ~ ~m whmh ~e ~J~ ~uid ~v~ re~ ~ be ~ ~e ~d ~e ~er ~ll ~ eq~Jly O~ a~~ ~e ~mg ~l~ (~
~ D ~ ~r'8~ ~ ~ ~e [~1 ~of ~e ~ ~ual& ~ ~ ~1~ or ~ ~l~ ~ ~ ~ ~f a ~l~ of ~e
~er has d~ ~om ~ o~r ~ ~are wh~ t~ ~,ld ~u~ ~ rece~ ~he or ~ ~d ~ ~n~ ~11 ~ ~ m his er ~r JlV~g ~ul c~reA or
~ ~.ls agn~ ~ ~ ~ the ~dsJ
* ~11 N~me of ~l · ~laaonsflfp of mdw~l ~ ~e ~ Tm~
S~aW(~ · ~an~hon or to ~r * ~de nm~r ~ wJlJ
~e ~l~} %' ' ~T~ · ~re~ of o~n~ forTe~nm~Tm~ D~of B~ SSN~N
Primary and Secmldary must_p, qAje! 100%
Sectm~s ma~ed as Required am required for proces~ng me form
Thts Sectmn Must Be Completed In Full by Ali I~wners
Ch~ap~opnateboxtomcJu:ateMarj~j$1~tus) [:]Single L--IIV~(SB6 CoIlS6rlTOfSpoLl~e }
Consem of ~pouse
Th~s co~ser~ of spouse must be s~ane~ if alt d t~ follQwmg r. oAd~ons ere pre~nt (a) The spouse of lhe ewnm' is }ivmo ih) Is notlhe ~ma~' benef~cmq,
name~aj~ [tithe owner and slzA~e are re~dem~ of 8 commumtl, pmper~ tAnzone Cal~foml~ idah~ Nevada ~ ~o T~ Wmh~n a~
~ ) ml~u~h all ~ ~mt~ or ~er n9h~ ~erem
I~ Applicati0"
I~-~W~--,~t ~ ' :d~PORATE OFFICE USE ONLY
~ ~ ~ BENE-ACg7 BA SP0
A~er N~b~ ~ ~ A~iser Nam~
An approved Client Profile Fo~ 200152 for each client must be submi~ed prior to establishing an account/.
For address.changes, submit Form 518
1. Client Information ............
Account Holder Name [First, Middle Initial, Last_) '
Co-Account Holder Name (First, Middle initial, Last)
n Express Funds
[] American Express Certificates
Social Security N'um~
[] Limited Partnership/EEIT (include Form 232 and Subscription agreement)
3, ~)count Reois~al;on
[~Jndividual [] Tenants in Common
I"1 UGMA/UTMA [] Estate
[] Individual with'rOD [] Community Property Relationship to Minor.
[] Joint Tenancy I'WROS) [] Guardian/Conservator [] Sole propdetorship
State Governing UGMA/UTMA: I. 1 I
'l'ru-~'~in~s Ow~i~hips: Reqnims Additional [-~$- [Refar to lnvesi.,ent Appli~tion 51~ Instruction Fo~ E8~-1 in forms ~abinet on Advisor Cenaect}
[] Corporation (01~ [] Partnership (02) [] Trust [95 [] Tax-Exempt Corporation (05} F'I Pm~ional Associa~on [02)
Name ~f Comorat[on, Pemerehip or 7~ust
Name of Trustee(s) [Trust) or Authorized Signer (corporation/Parmership) l~usiness, rrmst TIN
Sa'eat Address (For Business Only ~ Include City, State and ZIP)
! I.._L_.I I_LLLJ., I lllilllllll_j
Date of Trust (mm/dd/yyyy)
~. Investm__ent Selection
· American Express Mutual Funds/Cert~icates dividend and interest will automatically default to Reinvest. To select other options, complete Form F140.
Produc: ~breviation Share Class/Term/Participation Initial Amount Monthly BA Amount BA Date Imm/dd/yy)
Product Abbreviation Share Class, q'erm/Participation Initial Amount Monb~ly BA Amount BA Date (mm/dd/yT)
Product Abbreviation Share Dass/Term/Participation Initial Amount Mohthly BA Amount BA Date imm/ddlyy)
Product Abbreviation Share Class/Term/Participation Initial Amount
ilk/,? P!)(,J ..1_ _1 I I~J
4x~cx ~
IFlux ~r
5m u
BA Date (mm/rid/W)
Page 1 of 5
Monthly BA Amount
Ig~ ~O. go
qt, _~'7 s-. 00
5. Account Funding
Indicate which method you are
using to fund the account initially.
Bank Authorization
[~he lc authorize'don
ck enclosed
[] American Ex'press -[ransfer/F-xchan.~e/Redemption
(at-~ach Form Fll 9 or Form 33442}
F-~ W~re transfe,~ .
[] Ex[ernai account ~nsfer (attach transfer form(s)i
From Fund
Start Date {MM/DD/YYYYY
[] Add. to existing bank authorization. Bani: account number: . . :
[] Set up new bank authorization. Use attached initial investment cheo~ or a voide~ check. 7ace a voided ct~eck to 8~ x 11 paper and return with application.
If no s[ar~ date is specified, ~ve will use a date 7 business 0ays after receipt of the ap~licai on.
For savings bank information, complete Form 1748 '
7. Wire Transfer and Direct Deposit AuthorJzatio~
I authorize American Express Enancaal Advisors to establish the abil~ to transfer future redemptions/surrenders via electronic transfer to my bank. iThese arrangements
ma,/only be established if ~e American Express Rnanciai Advisors account and banl~ accounts have identical ownerships.}
[] Use bank information from SemJon 6 for fur. ute redemptions or surrenders into my bank account.
8. Authorization for Dollar-Cost Averaging (DCA)
DCA Doliar-Co~ Averaging/Intema! Transfer Option
Payout plans moving irrmmally will be subject to minimum requirements of the receMng accounts.
Frequency (check one} ED Monthly [] Quarmrty [] Semiannually ~ Annually (Will default to monthly iff]'eqeency is not indicated)
Amount
ToFund
From Produc~.
Market Sb-ategy Certificate Participation Terms (minimum $1,000 to new term or $5D to existin[7 term)
Frequency (c~eck one) ~ Weekly _ml Monthly ~] Bi-Monthly [] Quarterly [] Semiannual [] irregular (check contribution months):
Amount (DoJlar~}
$
End Date (Required)
l'-IJ ElF DM []A ~M r-Id ~j r-iA ~S []0 E3N ~'-ID
Start Date {MM/DD,NYYy)
[] Check if the last te~m is tc iocl-de the requested dollar moont.~lus all interest i~ the fixed sub-a~count.
6. Explanation of Invesl~em:
Your American Express financial advisor is required to review this investment with you. Please read
foli~t., emerge and signing this application, you acknowledge the following: the prospectus as it contains details about the investment. By checking the
~ Adequate Information. You understand the investment obje~ves and risks for each investment specified in this application. There is no guarantee that the
objectives will be achieved.
American Express Rnanciai Advisors Inc. is nat a bank and the securities offered by it am not backed or uam
,n,~., .re they insured by the FglC, g nteed i~/any bank,
/ Yields and Values. if appJyin§ for mLCuaJ fund shares, you understand that share values fluctuate daily. When you redeem year shares, you may receive more or Jes~
" then you paid for them. Dividends and interest may fluctuate up and down and are no~ cuaranteed. If a ' - ·
i,,~ is decJarerl and when Jt is added to your amount. - PPt~nI~ for e face amount ~eraficate, you understand when
~ .Ch~,~es and Fees. We receive fees es explained in the prospectus. You may have to pay sales or su~Ten
.,/~_. ~. ants should be held for a number of years der charges. These are some of the reasons most
~ Telephone Redemptions or F. xchanges.
· The ability to do transactions by telephone is an automatic service provided with all mutual fund and certificate amounts.
· We ar~ept zelephone redemption requests up to $50.O0g from a single owner on multiple owner accounts. The account into which funds are being transferred must
have the same ownership as the account providfnl~ the funds. Some forms of ownemhip prevent telephone transactions.
· We reserve the right tu refuse any telephone request that does not appear to be authentic. American Express Financial Advisors and its affiliates accept no liability
for any action resulting from a telephone redemption/surrender or exchange request that appears to be authentic.
ccept redemption and transfer requests without regard to the impact such changes wiIl have on named beneficiaries.
g/Cl[en~;,Slatements. We periodically send our ciients e statement covering all accounts owned by members of
./~spouses or dome~c parmers, you will receive consol dated statements for all acm ........--J- ........ the .sa.m.,e hou~e~Jd. You understand ~hat by applying
~ Drafts are a'~=~ --" ...... · ,.,,~u~, Wll~'ulur Ir~OlYlOUally or jointly ownen.
o,=,,,u~ u, ~asn Iwanagement Class A and Tax-Free Money Class A accounts w~th most ownerships. Drafts will be honored with just one signature even
on jairrdy owned attaint trusteed a~counts.
u F/o~) Page 2 of ~
1 ecJaretiou and Signalures --' ~
U ~n~ler penalties of perjury, J cattily that '~
1. ~°i'he number shown on this form is my correct taxpayer identJfiaation cumber, and
2. ~_ om cot subject to backup withholding because (a) | am exempt from backup witbboJdin§, lb) J have not been notified by the internal Revenue
~S, ervice (IRS) that ] am subject to backup withholding as a result cf failure to report all interest or dividends, or (c) the internal Revenue Service has
~--notified me that I am no longer subject to backup withholding, and
3. i am a U.S. person (including a U.S. resident aJieuJ.
The internal Bevanue Service does not require your consent to any provision of this document other than the certificalions required to avoid backup
withholding.
'~bu must cross out item 2 above if y~u have been notified by the iRS that you are currently subject to backup withholding because you have failed to report ali interest
and dMdends on your tax return.
Sign here with your correct name spelling
Print First []liem's Name ,, Print Second Client's Name
T~payer ID Taxpayer ID
Second Client Signature
~X
Team ID Ser~i:i~ ~lvi~ignat~,)e~ ////
Comp %
Area 0~ce Nu~
Team ID Se~i~i~g Ad~r Si¢~a~re
111111
Camp % ~ Office Number
1. I
.... L ....... 1
UGM~VUTMA Designation o~ Su~.ces-s~/~us~odian
Advisor Number
Phone Number Ext. -
Advisor Number
Phone Number Ext.
To be completed out7 by Custodian. Must be withered by person other than successor ousmctian, lThi~ designation is not valid in the ~mm of Ohio.)
Successor Custodian Name
Signature
Date (mm/dd/yyyy)
Signature of Witness
I I
---- L_I I L_L_I L_L__Lj
Acceptance Approval
I Corporate Office Use Only I~
Purchase Date
Page 3 of 5 ~
.?Transfer ~o~ :Death Account ~greement
Account Identification IComplete this section exactly as it appears on our records.)~
Name of Clientis)
Fund and/or Ce~ficate Name(s}
Account Number(s) - (Funds, Certificates cr Securities 0nly)
L the undersigned owner ofthe above accountfs} desire to establish a Trarmfer on
Death f[OD) designation pursuant to the Minnesota Uniform TOD Security
Registration Act Ithe ActJ. Upon my dea~ (or upon the death of the last survivor of
us), American E~press Financial Corporation. American Express Certk'icete
Company, American Express Financial Advisors Inc., American Enterprise
investment Services inc., and the funds in the Amedcen Express Funds lindMdually
or collectively "company") shall distribute my account according to the terms and
conditibns of this Agreement, filed at American Express Financial Corporation's
principal place of busirmss in Minneapolis, MJnrze~ote. In consideration of company
acceptance of my TOD registration, [* agree
as follows:
1. Joim Tenancy. Iflwo or more individuals sign this Agreement, they shall be
the owner~ of the account(s) as joint tenants with rights of su~vomhip.
2. Secondary Beneficiaries. I understand that if no survivorship provision is
indicated in my TOD regLv~ration, any fonds earmarked to a beneficiary who
precedes me in death will be paid to my estate.
3. ,~r~change~.
{a) J authorize rte company to accept instructions by telephone or in writing for
exchanges among existing company accounts, regardless of wb~er the
accoun,,s have a different or no TOD registration.
(b) I acknowledge and agree that this TOD registration shall appiy to any new
accounts ascmblishad by me pursuant to a written or telephone exchange
reques~ with respect to the accounts listed in this Agreement.
4. ChanDe of Beneficiary. J aclmowledge and agree that any changes to an
existing TOD registration previously created by me, and/or any newly created
TOD registrations may be made only on a Transfer on Death
Account Agreement_
5. Previous TOD Re§istratio,,. I aclmowledge and agree that any ~20D
registration or Declaration of Revocable Trust previously created with respect
to the accou~s) listed, is hereby revoked.
§. Rduciades. I understand and acknowledge that no agent, attorney-in-fact,
conservator, guardian, or other person acting in my behalf may name or change
the beneficiaries, except [f allowed in Power of Attorney document or by court
order. This provision shall not prohibit the sale or pledge of my account by any
agent, attomey-in-fac'~ conservator or guardian.
7. Pied§e of TOD Account. I understand and acknowledge that if all or part of
my account has been pledged, the pledgee has the right to change the
registration of the portion of my account that has been pledged, includino the
fight to cancel the designated TOD beneficiary. ~
8. Uving lamr[ul Children. i understand and acknowledge that if"living
lawful children" is included in my TOD registration, such registration shall be
deemed ts include any living teg/dmate children bom to or children legally
adopted by me after the date of this Agreement whether or not iisted by name
on this Agreement Stepchildren and grandchildren are ,at covered under
this designation.
9. Payme"t °f Dividend~ if applicable, I acknowledge and agree that the record
data forthe payment of a dividend from my account(s), rather than the da~ of
declare'don of such dividend, shall determine with reference to my deat~
whether any particular ~ividend shall belong to me otto a ben~r, iar~/*, provided,
however, that all dividends may properly be paid to me mT[il the issuer ofthe
secufftias on which a dividend is being paid has received wrilZ~ notice of my
death at its principal place of business.
10. Effect of Other State Laws.** I aokn awledge and a~ree that if tran~r on
death registration is not permitted under the laws of the jurisdiction where I am
domiciled at the time of my death, the ~mpany may, absent notice from any
person claiming to have an interest in my acoou~s}, distribute the account(s)
pursuant to my TOD registration. In the svent of such distribution, I agree that
the company shall have all of the protections of the Mirmesota Uniform TOD
Security Regisumtion Act, and I further agree to indemn~ the company again=
and hold the company harmless from any and all claims, and the provisicr~s of
this paragraph shall be binding upon my heirs, Jegateem, execute,
administrators, pa.monal representatives, assigns and baneficiariss.
11. Revocatio~ of Benoficia_5, Designation ~y Will. J understand and
acknowledge that a revocation of this beneficiary designation in my will is not
binding upon the company unless the company receives written notice from
any claimant object2ng ts the transfer of cecurfties pursuant to this Agreement
before such transfer is made.
12. Amendment of Tatum. I undemtand that this Agreement shall be subject'to
the provisions of the Minn~ota Un,arm TOD Security Registration Act_ The
terms of this Agreement, with the exception of the terms des~bing beneficiary
options, may be amended bythe company at anytime upon thi~(30i days'
notice mailed to me at my address in the records at the compaq. The
availability of TOD designations may be terminated at any time by the company
upon §0 days' notice mailed to me at my address in the records of the company.
I3. Govemi~§ l~w. This Agreement shall be governed bytbe laws of the State of
Minnesota and shall inure to the benefi~ of the company and its successors and
assigns, and shall be binding on me, my heirs, legatees executor~,
administrators, personal representatives, assigns and benaficiades.
14. U~eq.,al and Fractional 8hare~. Unequal or fractional shares held in a
brake."age account which can not be divided equally among the designated
beneficiaries will be liquidated, and the proceeds thereof distributed to
the beneficiaries.
*'I.' "me" or "my" means the individual or individuals signing this Agreemem.
--TOD provisions are not available for residents of the stem of Louisiana.
Corporate Office Approval
Date Stamped
0/021
Page 4 of 5
,~ BpneficJary Designatior~*'* (Choose only one option.) (Se~'"rdnt'# 8.of this form for a.q explanation of "living, lawful children.")
-- [3~A. Spouse if Living, if not, Living, Lawful Children ith Rich*ts ~f Survivorship. Beneficiary is; Owner's spouse,"
~ if Jiving, if not, the beneficiaries are the living lawful children of the owner and they will receive equal shares of the proceeds; provided, however, that if
I:~ a child ortho owner has died l~efore 1he owner, the share which the child would have received if he or she survived the owner will be equally divided
~ among the surviving children,
! [] B. Spouse and Per Stirpes. Beneficiary i-~: Owner's ,spouse,"
," [f living, if not, the living lawful children of the owner
· equally, the survivors equally, or the survivor; provided, however, t~t if a chili'of i~e owner'~,s died before the owner, the share which t~e child would
m ~,_.~,. ve received if he or she survived the owner will be paid to his or her living lawful children or their direct descendants Jn equal shares.
~'! C~C. Children Jiving, Lawful, Equally With Rights of Survivorship. Beneficiary is: the living lawful children of the owner and they will receive equal
~ I shares of the proceeds; provided, however, that if a child of the owner has died before the
'= owner, the share which the child would have received if he or she survived the owner will he equally divided among the surviving children. (Sea General
I~' Instructions.,
,.. [] D. Children Per Stirpe-~. Beneficiary is: the lawful children of the owner equally, the survivors equally, or the survivor; provided, hoWever, that if a chil~
of the owner has died before the owner, the share which the child would have received if he or she survived the owner will be paid to his or i~er living
lawful children or their direct descendants in equal shares. (See General Instructions.]
[] E. Other. Be sure that Primary and Secondary designations eaCh-t~t'al i0'0%. If an attachment is required to complete toe beneficiary designation, make
sure that the attachment is signed and dated by the owner{si.
Primary/
Secondary -Full name of individual 'Relationship of *Date of trust
(check one .Organization or Individual to owner -Article number of will
~. per line) Percent* · Name of Trust -Address of organization for Testamentary Trust Date of Birth SSN/TIN
Required Required Required Required Required NR NR
uPc s I._,t _L_II t l L__ I
~,,DPDS L.~I; L I ~ [
J i *Both Primary and Secondary must equal 100%.
Sections marked as Required are required for processing the form, Sections marked as NR are not required for processing the form, but may provide useful
"information in the event of a claim.
.~a~l~ea~teS;~a~ dme~.~ohftsouta~,:oO~ii:~!s_d_~!gna,tion is.subject to. the approval of the corporate office.
~ p.) ~f an a~zacnrrmnt.~s required to complete the beneficial, designation,
make sure that the attachment is signed and dated by the owned(s).
This Section Must Be Completed in Full by All Ow ners
Chesl( appropriate box to indicate Marital Status i~ [] Single E2 Married (See "Consent of Spouse.") ~dowed or Divorced.
Consent of Spouse
This consent of spouse must be signed if all of the following conditions are present: (a) the spouse of the owner is IMng, Lb) is not the primary beneficiaq~ named
and (c} the owner and spouse are residents of a community property state fArizona, California, idaho, Nevada, New Mexico, Texas, Washington and Wisconsin).
I have reviewed the above beneficiary designation and, es the spouse of the ownec J consent to the beneficiary designation and all co~ibutions of money or
property to be used for the purchase of such accounts to be issued in my spouse's name, whether heretofore, now or hereafter and I relinquish
other dghts thereto, all my statutory or
Date Spouse's Signature
~B u 17/02J
Page 5 of 5 ·
CERTIFICATION OF NOTICE UNDER RULE 5.6 (a)
Name of Decedent: Janet M. O'Brien
Date of Death: July 3, 2003
Estate No. 2003-00588 State File No.
To the Register:
I certify that notice of beneficial interest required by Rule 5.6 (a) of the Orphans' Rules
was served on or mailed to the following beneficiaries of the above-captioned estate on
November 6, 2003.
Name
Sean M. O'Brien
Hershey Trust Company
Address
c/o Louis O'Brien, 3431 Alinda Circle, Camp Hill, PA 17011
P.O. Box 445 Hershey, PA 17033
Notice has now been given to all persons entitled thereto under Rule 5.6 (a) except
Date
Sil~n~ture ' " ~,/
Robert K. Reitzel
100 Mansion Road East
P.O. Box 445
Hershey, Pa. 17033
Telephone No. (717) 520-1109
Capacity: X Personal Representative
__ Counsel for personal representative
~~E. Estate of Janet M. O'Brien
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISION
NO.: 21-03-00588
ORDER OF COURT
Upon consideration of the Petition for Order Directing American Express
Financial Advisors, Inc. to Distribute Certain Accounts to Trust and for the Award
of Costs and Attorney's Fees Against American Express Financial Advisors, Inc.
and Michael I. Shalhoub, and any response thereto, the Court ORDERS:
1. American Express Financial Advisors, Inc. shall pay to the Hershey
Trust Company, as Trustee of the Trust Created Under Article IV Janet M.
O'Brien's Last Will and Testament dated November 4, 2002 all funds held by Janet
M. O'Brien in the following accounts numbers:
010100226611 002
01010022671 0 002
01010022672 8 002
01010022673 6 002
01010022674 4 002
01010022675 I 002
01010022679 3 002
01449156233 7 002
2. Michael I. Shalhoub
shall reimburse to Hershey Trust
with this matter.
and American Express Financial Services, Inc.
Company its fees and costs incurred in connection
BY THE COURT:
Date:
Jo
IN RE: Estate of Janet M. O'Brien
IN THE COURT OF COMMON PLEAS
ORPHANS' COURT DIVISION
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 21-2003-00588
CITATION
WE COMMAND, you that laying aside all business and excuses whatsoever, you be and appear in your
proper person before the Honorable Judges of the Court of Common Pleas, Orphans' Court Division at a
session of the said Court there to be held, for the County of Cumberland to show cause why __
1. American Express Financial Advisors, Inc. should not pay to the Hershey Trust Company, as Trustee of
the Trust Created Under Article IV Janet M. O'Brien's Last Will and Testament dated November 4, 2002 all
funds held by JanetM. O'Brieninthefollowing accounts numbers:
01010022661 1 002
01010022671 0 002
01010022672 8 002
01010022673 6 002
01010022674 4 002
01010022675 1 002
01010022679 3 002
01449156233 7 002
2. and why Michael I. Shalhoub and American Express Financial Services, Inc. should not reimburse to
Hershey Trust Company its ~es and costs incu~ed in connection with this ma~er. Returnable 20 days
~om service.
- SHERIFF' S RETURN - REGULAR
'" 200 x
CASE ~,p,; 3-00588 0 ~
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
O'BRIEN JANET M ESTATE OF
VS
SHALHOUB MICHAEL
CPL. MICHAEL BARRICK , Sheriff or Deputy Sheriff of
Cumberland County, Pennsylvania, who being duly sworn according to law,
says, the within PETITION AND CITATION was served upon
SHALHOUB MICHAEL the
RESPONDANT
at 3500 MARKET STREET
, at 1434:00 HOURS, on the 9th day of January
CAMP HILL, PA 17011
TARA KNORR, SUPERVISOR,
a true and attested copy of PETITION AND CITATION
by handing to
OPERATIONS TEAM LEADER
together with
, 2004
and at the same time directing Her attention to the contents thereof.
Sheriff's Costs:
Docketing 18.00
Service 9.66
Affidavit .00
Surcharge 10.00
.00
37.66
Sworn and Subscribed to before
me this I~ day of
,/ Clerk of Orha~s {ourt {
So Answers:
R. Thomas Kline
01/12/2004
KEEFER WOOD ALLEN RAHAL
By: ~p=~ut, y~_~_~r l~f~j
IN RE: Estate of Janet M. O'Brien
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNT~~,
PENNSYLVANIA
ORPHANS' COURT DIVISION
NO.: 21-03-00588
;ELIMINARY DECREE
AND NOW, this~ day of ~~_~ ,2003, upon
consideration of the Petition for Order 'irecting American EXpress Financial
Advisors, Inc. to Distribute Certain Accounts to Trust and for the Award of Costs
and Attorney's Fees Against American Express Financial Advisors, Inc. and
Michael I. Shalhoub, it is hereby ORDERED and DECREED that a citation is
awarded, directed to American Express Financial Advisors, Inc. and Michael I.
Shalhoub to show cause why:
1. American Express Financial Advisors, Inc. should not pay to the
Hershey Trust Company, as Trustee of the Trust Created Under Article IV Janet M.
O'Brien's Last Will and Testament dated November 4, 2002 all funds held by Janet
M. O'Brien in the following accounts numbers: -
010100226611 002
01010022671 0 002
01010022672 8 002
01010022673 6 002
01010022674 4 002
01010022675 I 002
01010022679 3 002
01449156233 7 002
2. and why Michael I. Shalhoub and American Express Financial
Services, Inc. should not reimburse to Hershey Trust Company its fees and costs
incurred in connection with this matter.
BY THE COURT:
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY
HERSHEY TRUST COMPANY, :
EXECUTOR OF THE ESTATE OF JANET:
M. O'BRIEN AND TRUSTEE OF THE :
TRUST CREATED UNDER ARTICLE IV :
JANET M. O'BRIEN'S LAST WILL AND :
TESTAMENT DATED NOVEMBER 4, :
2002, AND BY LOUIS O'BRIEN AND :
ROSE O'BRIEN, GRANDPARENTS OF :
SEAN O'BRIEN, :
Petitioners, ·
MICHAEL I. SHALHOUB AND ·
AMERICAN EXPRESS FINANCIAL ·
ADVISORS, INC. ·
Respondents. ·
ORPHANS' COURT DIVISION
NO. 21-03-00588
ENTRY OF APPEARANCE
TO THE PROTHONOTARY:
Kindly enter the appearance of Joshua Horn, Esquire on behalf of the respondents, in the
above-referenced matter·
JOSH WA HORN, ESQUIRE
I.D. 1 o. 71799
FOX ?~OTHSCHILD LLP
2000 Market Street, 10th Floor
Philadelphia, PA 19103
(215) 299-2000
Attomey for Respondents
Dated: January 29, 2004
CERTIFICATE OF SERVICE
I hereby certify that I served a tree and correct copy of the foregoing entry of appearance
via first class mail upon the following:
Dated: January 29, 2004
Elizabeth J. Goldstein, Esquire
Elyse E. Rogers, Esquire
415 Fallowfield Road
Suite 301
Camp Hill, PA 17011-4906
Attomeys for Petitioner
JOSHUa HORN, ESQUIRE
REV-1500 EX (6-00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIN_USE ONLY
FILE NUMBER
21
COUNPf CODE
-- 2003 0588
DEC, EDEN'PS NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
~ O'Brien, Janet M 202-46-9958
z
I,LI DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-OD-YEAR) TI-IS RE33JI~I M U~T BE FILED IN DUPLICATE WITH THE
lU 07/03/2003 05/12/1956 REGISTER OF WILLS
III IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
¥ ----.e31~ 1. Odginal Return
~ ~'~ f I I 4. Limited Estate
9. Litigation Proceeds Received
Z
O
I--
[~2. Supplemental Return ~--~ 3. Remainder Return (date of death prior to 12-13-82)
[~] 4a. Futura Interest Compromise (date of death after 12-12-82) ~ 5. Federal Estate Tax Return Required
[~7. Decedent Maintained a Living Trust (Attach copy of Trust) 8. Total Number of Safe Deposit Boxes
[~] 10. Spousal Poverty Credit date of death between 12-31-91 and 1-1-95) r-~ 11. Election to tax under Sec. 9113{A) (Attach,S~ O)
NAME COMPLETE MAILING ADDRESS
HersheT' ?ruet Ccaap&ny PO Box 445
FIRM NAME(IfApplicable) 100 Ma33,~'ion l~,oed l~a.~t
Her,,hey, P~ 17033
TELEPHONE NUMBER
1. Real Estate (Schedule A)
2.
(1) 111,769.22
Stocks and Bonds (Schedule B) (2) 173,807.87
3. Closely Held Corporation, Partnemhip or Sole-Proprietorship (3) 0.
4. Mortgages & Notes Receivable (Schedule D) (4) 0.
5. Cash, Bank Deposits & Miscellaneous Personal Property 2~, 195.8:5
(Schedule E) (5)
6. Jointly Owned Property (Schedule F) (6) 151.13
~] Separate Billing Requested 0.00
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) ~,,~
(Schedule G or L) i,; .
8. Total Gross Assets (total Lines 1-7) (8)
9. Funeral Expenses & Administrative Costs (Schedule H) (9) 4 0,3 4 6.4 5
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 8 4, 4 3 5. 5 2
11. Total Deductions (total Lines 9 & 10) (11 )
12. Net Value of Estate (Line 8 minus Line 11) (12)
13. Charitable and Governmental Beq uests/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)
OFFIClN. USE ONLY
309,924.07
12~,781.97
185,1~2.10
0.00
185,142.10
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax 0.0 0 0.0 0
rate, or transfers under Sec. 9116 (a)(1.2) x .00 __ (15)
185,0~5.69 8,327.06
16. Amount of Line 14 taxable at lineal rate x .045 (16)
17. Amount of Line 14 taxable at sibling rate 0o00 x.12 (17) 0.00
96.41 1~.46
1 8. Amount of Line 14 taxable at collateral rate x .15 (18)
8,341.52
19. Tax Due (19)
20. el el ~ I~l · ~ II ~ ~
2W4645 1.000
Decedent's Complete Address:
STREET ADDRESS
321 Cascade Road
Cl~
Mechaniceburg
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
0.00
8,000.00
400.00
0.00
0.00
Interest/Penalty if applicable D. Interest
E. Penalty
STATE
(1)
ZIP
17055
8,341.52
Total Credits (A + B + C) (2)
Total Interest/Penalty (D + E) (3)
8,400.00
0.00
58.48
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 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)
A. Enter the interest on the tax due.
(5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check Pa able to: REGISTEROF~S, 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; ......... r~ ~
c. retain a reversionary interest; or ................................ r~ r~
d. receive the promise for life of either payments, benefits or care? ................. E~ r~
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? r~ ~
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.
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the bast of my knowledge and belief, it is true, correct and complete.
Declaration of preparer other than the pemonal representative is based on all information of which preparer has any knowledge.
SIGNATURE OP'~----'~N RE~P~O~FOR FILING RETURN ~ DATE
SIGNATUREOFPREPARERO~ER~ANREPRESE~A~VE
ADDRESS~O ~u~ ~5 100 ~o~
Hershey, PA 17033
DATE
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 3%
[72 P.S. § 9916 (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 0% [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 ratum are still applicable even if
the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent,
or a stepparent of the child is 0% [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 4.5%, except as noted in 72 P.S. § 9116(1.2) [72 P.S. § 9116(a)(1 )].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% (72 P.S. § 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.
W4646 1.000
REV.1502EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF FILE NUMBER
O'Brien, Janet M 21-2003-0588
All mai property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which propeffy would be exchanged
between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable know~edge of the relevant facts. Real property which is jointly-owned with
right of survivorship must be disclosed on Schedule F.
ITEM DESCRIPTION VALUE AT DATE
NUMBER OF DEATH
1. 111,769.22
(per
Residential real estate located at 321 Cascade Road
Mechanicsburg, PA, U~per Allen Township, Cumberland County
attached settlement statement)
Gross amount due seller :
Zess settlement costs:
Net value=
$120,766.22
(8,997.00)
$111,769.22
TOTAL (Also enter on line 1, Recapitulation) $ 111,7 69.22
2w4695 2.000 (If more space is needed, insert additional sheets of the same size)
I B. TYPE OF LOAN:
'~ .... 1.[]FHA 2.DFmHA 3. E~CONV. UNINS. 4. DVA 5. E]CONV. INS.
U.S. DEPARTMENT OF HOUSING & URBAN DEVELOPMENT I 6 FILE NUMBER 7. LOAN NUMBER:
SETTLEMENT STATEMENT I ' 03150CAP I 47640967
8. MORTGAGE INS CASE NUMBER:
C. NOTE: This form is furnished tn give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown.
Items marked "[POC]" were paid outside the closing; they are shown here for informational purposes and are not included in the totals. 1.0 3/98 10315OCAP PEP/03150CAPI1 S)
D. NAME AND ADDRESS OF BORROWER: E. NAME AND ADDRESS OF SELLER: F. NAME AND ADDRESS OF LENDER:
JOHN F. PIERCE SR. ESTATE OF JANET O'BRIEN Countrywide Rome Loans, Inc.
211 E. Locust Street 681 Anderson Dr., Bldg. 6, 2nd Floor
Mechanicsburg, PA 17055 Pittsburgh, PA 15220
G. PROPERTY LOCATION:
321 Cascade Road
Mechanicsburg, PA 17055
Cumberland County, Pennsylvania
Upper Alien Township
H. SE'i-ELEMENT AGENT: 25-1722090
Capital Region Land Transfer, Inc.
PLACE OF SETTLEMENT
3310 Market Street
camp Hill, PA 17011
I. SETTLEMENT DATE:
December 18, 2003
J. SUMMARY OF BORROWER'S TRANSACTION
100. GROSS AMOUNT DUE FROM BORROWER:
101. Contract Sales Price
102. Personal Property
103. Setllement Charpes to Borrower (Line 1400)
104.
105.
Adjustments For Items Paid By Seller tn advance
106. City Taxes to
120,000.00 401. Contract Sales Price
K. SUMMARY OF SELLER'S TRANSACTION
400. GROSS AMOUNT DUE TO SELLER:
120,000.0~
6,345.04 403.
107. County Taxes 12/18/03 to 01/01/04 10.91
108. School Taxes 12/18/03 to 07/01/04 740.09
109. Sewer 12/18/03 to 01/01/04
110.
111.
112.
120. GROSS AMOUNT DUE FROM BORROWER
Personal Property
404.
405.
Adjustments For Items Paid By Seller in advance
, Taxes to
Taxes 12/18/03 to 01/01/04 10.91
408. SchoolTaxes 12/18/03 to 07/01/04 740.09
15.22
15.22 409. Sewer 12/18/03 to 01/01/04
410.
411.
412.
127,111.26 GROSS AMOUNT DUE TO SELLER
200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER:
201. Deposit or earnest money 1,000.00
202. Principal Amount of New Loan(s)
203. Existing Ioan(sI taken subiect to
20.4.
205.
206.
207.
.~06.
209.
Adjustments For Items Unpaid By Seller
210. City Taxes to
211. County Taxes to
212. School Taxes to
213.
214.
215.
_~16.
217.
218.
219.
22~. TOTAL PAID BY/FOR BORROWER
300. CASH AT SETTLEMENT FROM/TO BORROWER:
301. Gross Amount Due From Borrower
302. Less Amount Paid By/For Borrower (Line 220)
303. CASH ( X FROM) (TO) BORROWER
REDUCTIONS IN AMOUNT DUE TO SELLER:
501. Excess Deposit (See Instructions/
502. Settlement Charges to Seller (Line 1400)
504. Payoff of first Mortgage to BSI Financial Services
f of second Mort,sage
506.
508.
Adjustments For Items Unpaid BF Seller
Taxes to
/ Taxes
512. School Taxes
513.
514.
515.
516.
i18.
319.
120,059.00 520. TOTAL REDUCTION AMOUNT DUE SELLER
120,766.22
8,997.00
72,115.28
81,112.28
600. CASH AT SETTLEMENT TO/FROM SELLER:
601. Gross Amount Due To Seller (Line 420) 120,766.22
602. Less Reductions Due Seller (Line 520) 81.112.2e?
7,052.26 603. CASH( X TO).( FROM j SELLER
The undersigned hereby acknowledge receipt of a completed copy'of pages 1&2 of this statement & any attachments referred to herein.
Borrower ,~ ~L..~ Seller EST/~JANETo'B//~
~IN F. PIERCE SR. BY'-/~'~1' ·
39,653.94:
L. SETTLEMENT CHARGES
700. TOTAL COMMISSION Based on Price $ 120,000.00 @ 6.0000 % 7,200.00
Division of Commission (line 700) as Follows:
701. $ 3,625.00 to The Homestead Group Realtor, Inc.
PA~D FROM
aORROWER~S
FUNDS AT
SETTLEMENT
PAJD FROM
SELLER'S
FUNDS AT
SETTLEMENT
702.$ 3,575.00 to HOWARD HANNA DETWEILER REALTY
703. Commission Paid at Settlement 7,200.0(
704. to
800. ITEMS PAYABLE IN CONNECTION WITH LOAN to
ination Fee %
802. Loan Discount % to
803. Appraisal Fee to Roland Johnson Appraisals 350.00
804. Credit Report to Countrywide Home Loans, Inc. 35.00
805. Commitment Fee to Countrywide Home Loans, inc. 100.0(
). Fee to
807. Assumption Fee to
).Fee
809. Rood Check Fee to Landsafe Rood 25.O
810. Reinspection Fee 75.00
to Countrywide Home Loans, Inc.
811. FHA (OTMIP) to Countrywide Home Loans, Inc. 1759 fin/.50 cash
1,759.50i
900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE
901'lnterestFrom 12/18/03 t° 01/01~)4 @ $ 19'980000/day ( 14days %) I 279'72J
e Insurance Premium for months to .
903. Hazard Insurance Premium for yearn to
904.
905.
1000. RESERVES DEPOSITED WITH LENDER
1001. Hazard insurance 3.000 months @ $
30.17 per month
s Insurance months @ $ per month
Taxes months @ $ per month
,Taxes 12.000 months @ $ 23.23 per month
1005. SchoolTaxes 8.000 months @ $ 112.86 per month
1008.
1007.
1100. TITLE CHARGES
months @ $ per month
months @ ~ per month
months @ $ per month
90.51
278.76{
-304.08
1101. Settlement or Closing Fee
1102. Abstract orTitle Seamh to
1103. Title Examination to
1104. TitJe Insurance Binder to
1105. Document Preparation to
/ Fees
1107. Attorney's Foes .to
(includes above item numbers:
to Lisa Rowe
1108. Title Insurance . to Capital ReRion Land TransferI Inc.
(includes above item numbers:
1109. Lender's Coverage $ 119,059.00
1110. Owners Coverage $ 120,000.00
10.00
958.75
11. 100,300,8.1 to Capital Region Land Transfer, Inc. 150.0(
12. Deed Preparation Capital Region Land Transfer, inc.
13. Overnight payoff 16.00
1114. Closing Protection Letter
to Capital Region Land Transfer, Inc.
to Stewart Title Guai'anty Company
1115. Sewer (Oct 1-Dec 31 ) to Upper Allen Township Municipal Authority Acct. 530027
1116.
1117.
1118.
35.00
100.00
1200. GOVERNMENT RECORDING AND TRANSFER CHARGES
1201. Recording Fees: Deed $ 38.50; Mortgage $ 50.50; Releases $
1,200.0O
1,200.00; Mortgage
1203. State Tax/Stamps: Deed 1,200.00; Mod,~a~le
1204. Recorder of Deeds
1205.
1300. ADDmONAL SE'R'LEMENT CHARGES
1302. Pest Inspection to Biechler & Tillery tnc. 35.00
1303. Home Warranty to HSA Home Security of Amedca
to Joseph M. Greer
1305. Home inspection to Biechler & Tiltery Inc. 275.00~
1400. TOTAL SETTLEMENT CHARGES {Enter on Lines 103, Section J and 502, Section K). 6,345.04I
Capital Region Land Transfer, inc. ~
Settlement Agent ·
8,997.00 ~
(03150CAPIO3150CAP/19)
REV-1503 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF FILE NUMBER
O~Brien, Janet M 21-2003-0588
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
10
11
DESCRIPTION
953.289 shs Liberty Select Value Fund: Cusip 53054M709, $20.37
per share
1,230.991 shs Van Kam~en Growth & Income Fund~ Cusip
92113H103, $15.84 per share
378.586 shs Washington Mutual Investment Fund: Cusip
$25.79 per share
939330106
5,812.198 shs AXP Partners Value Fund Cusip=00246Y307 $4.28
per share
1,151.867 shs AXP New Dimensions Fund Cusip:00245V106 $21.57
per share
1,772.777 shs AXP Equity Select Fund Cusip:00245H107 $10.57
per share
5,570.022 shs AXP Strategy Fund Cusip:00246C792 $3.54 per
share
1,829.334 shs AXP Short Duration US Government Fund
Cusip:00245K100 $4.93 per share
1,826.913 shs AXP Diversified Bond Fund Cusip: 00245B100 $4.92
per share
52.766 shs AXP Special Tax Exempt Series Tr Cusip: 00246A101
$5.61 per share
VALUE AT DATE
Of DEATH
19,418.50
19,498.90
9,763.73
TOTAL (Also enter on line 2, Recapitulation) $ 173,807.87
2w4696 3.000 (If more space is needed, insert additional sheets of the same size)
19,717.88
9,018.62
8,988.41
296.02
18,645.58
8,553.019 shs AXP New Dimensions Fund Cusip: 00245V403 $2.18
per share
18,738.25
24,845.77
24,876.21
~ REV-1508 FFr. X + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
O'Brien, Janet M 21-2003-0588
Include the 3roceeds 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
2
3
4
5
6
7
8
9
10
11
12
13
14
PSECU - account # 9605960690
PSECU - account # 8102193912
Cash - miscellaneous coins and currency
Schmidt, Ronca & Kramer - balance held in escrow account
PEBTF - medical insurance reimbursement
US Treasury - child tax credit tax relief check
Susquehanna Oil Company - reimbursement
Comcast - refund received
Erie Insurance - reimbursement of homeowners policy premium
Household items - Bombay Co. sideboard and mirror and china
closet sold at auction (see attached statement)
Diamond Solitare Ring
Rowe's Auction Service - proceeds from sale of personal
property
1999 Toyota Corolla Sedan VIN#1NXBR12E9XC133806 - per sales
proceeds
Child support payments owed to decedent by Michael O'Brien.
Amount due at death $6,475.42. Collection efforts to date
have failed and recovery of any funds appears unlikely.
TOTAL (Also enter on line 5, Recapitulation) $
13.71
12,526.76
13.67
150.00
1,990.50
400.00
183.89
53.32
175.00
1,500.00
537.00
1,522.00
5,130.00
0.00
24,195.85
2W46AD 2.000 (If more space is needed, insert additional sheets of the same size)
428 Hockersville Rd.
Hershey, Pennsylvania 17033
(717) 533-3147
This is to certify that we are engaged in the jewelry business, appraising watches, jewelry
and precious stones. We have carefully examined the following item and estimate the
value as listed for ESTATE purposes at FAIR MARKET VALUE. In making the
Appraisal we DO NOT agree to purchase or replace the item.
FOR THE ESTATE OF JANET O'BRIEN
Item
A lady's ring, in 14kt yelloTM gold, set with a marquise shaped stone, held in a
white gold prong setting (worn out prongs). The marquise is a diamond
measuring approximately 7.67x3.17x approximately 2.26mm and having
a calculated weight of.36cts. The quality grade is VS and the color grade
is estimated (in the setting) to be H.
FAIR MARKET VALUE
$537.00
July 24, 2003
ROWE'S AUCTION SERVICE
(RH 79L)
Bill Rowe (AU 1538L)
Ben Rowe (AU 1092L)
.f
2505 Ritner Highway' · Carlisle, PA
249-2677 697-4794 249-1978
Auction Js Action Call '~Rowe" For Satisfaction
OTHER
AUCTION DATE/LOCATION ~.~ ~ %,q ~~
Bob Rowe (AU 2276L)
Dave Rowe (AU 2295L)
AUCTIONEER
DESCRIPTION OF MERCHANDISE
I Commission the Auctioneers to sell the merchandise to the highest bidder by Public Auction. Merchandise
to be sold as is & grouped as necessary to obtain bids. I certify that I am the owner or authorized represen-
tative of the merchandise, goods and or property and have good title and the right to sell and that they are free
from all incumbrances. I agree to accept all responsibility for providing merchantable title and for delivery of
title to the purchaser. I agree to hold harmless the Auctioneers against any claims of the nature referred to in
this agreement. .
AUCTION .SIGNATURE
Total Sales (Clerking Tickets Attached)
Less Sale Expense:
?-~-~ b ~'~ % Commission Auctioneer
% C omm ssion
OTHER:
SELLERS SIGNATURE
TOTAL SALE .EXPENSE DEDUCTED
SELLERS NET
'~[-UCTI 0 N~'I G NATURE
SELLERS SIGNATURE
"~Bill Rowe (AL~_%~38L)
Ben Rowe (AU 1092L)
ROWE'S AUCTION SERVICE
· 2505 Ritner Highway · Carlisle, PA
· '~ "2.49-2677 697-4794 249-1978
Auct~on'~I}'~et~on Call '~Rowe" For Satisfaction
ADDRESS ]~ ~. ~.~, .~., ~.. ~
DESCRIPTION OF MERCHANDISE
(RH 79L)
Bob Rowe (AU 2276L)
Dave Rowe (AU 2295L)
PHONE
AUCTIONEER
%
I Commission the Auctioneers to Sell the merchandise to the highest bidder by Public Auction. Merchandise
to be sold as is & grouped as necessary to obtain bids. I certify that I am the owner or authorized represen-
property an&have good title and' the right to sell and that'they are'free
accept all responsibility for providing merchantable title and for delivery of
~L~'L¥21~i':v~?~ti~le~to' the purchaser. .... I agree to hOld harmless the Auctioneers against any claims of the nature referred to in
this agreement.
AUCTION SIGNATURE
Total Sales (Clerking Tickets Attached)
Less Sale Expense:
.......................... /~..,,~ % Commission Auctioneer
% Commission Clerks
OTHER:
SELLERS SIGNATURE
TOTAL SALE EXPENSE DEDUCTED
SELLERS NET
SELLERS SIGNATURE
REV-1509 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
R~SIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF FILE NUMBER
O~Brien, Janet M 21-2003-0588
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 ADORESS RELATIONSHIP TO DECEDENT
A. McGovern, Julia Aunt
B. O'Brien, Sean M
C. O'Brien, Michael
133 Holland Street
Wilkes-Barre, PA 18702
3431 Alinda Circle
Camp Hill, PA 17011
19 Houston Drive
Mechanicsburg, PA 17055
Son
Friend
JOINTLY-OWNED PROPERTY:
~ DATE ~SCRI~ON ~ ~OPER~ % ~ DATE OF DEATH
ITEM FORJO~ MADE Include name ~ fin~cial in~itufi~ and bank ac~nt numb~ ~ DA~ OF DEATH DECUS VALUE OF
NUMBER TEI~ddT JOINT similar identi~ing numar. Attach dm ~r jdntl~d mai ~t~ V~UE OF ASSET INTEREST ~CEDE~S INTEREST
1. A 08/20/1987 $50 face value US Series EE 58.60 50.00 29.30
Savings Bond #L288388148EE
issued August 1987 Joint
with Julia McGovern
2 B 04/30/2001 $200 face value US Series 109.44 50.00 54.72
EE Savings Bond
#R167639055EE issued April
2001 Joint with Seao
O~Brien
3 c 12/18/1998 $100 face value US Series 61.08 50.00 30.54
EE Savings Bond
#C660253154EE issued
November 1998 Joint with
Michael O~Brien
4 A 11/05/1984 $50 face value US Series EE 73.14 50.00 36.57
Savings Bond #L176551144EE
issued November 1984 Joint
with Julia McGovern
TOTAL(Alsoenteronline6~Recapi~lati~) $ 151.13
2W46AE 2.000 (If more space is needed, insert additional sheets of same size}
!- , /~:'/:":. i:.OOOOqOOO ?i:O ~
Franldin First Fe. deral Saving.-
Loan ASsoCiatio~ ,,
~ 1987 ,
_-;~JA'NET O~BR'IEN '- ' ---'
.: IdA:3:'L ,TO..: '
JUL]:A
.a_a_a_a_a_a_a_a_a~ Lm ~J~ ~ ~'~,;~U m~ .:SERIES
:.2'0-9 1,6 6006 ~ ~i, 041 .20'0~1i"
' - ~L-- J~-'/,: .... ::?- ~7., . '-~: ' .....
HCGDV. ERN ............ -' 0 q--~.O'-D'l 'X
WHICH IS THE FIRST gAY OF
' 'Nov. 1984
, ~o .Gift~209-16' 600.6 -,~ i:: -- 33 i~_~, - -
Janet O'Brian ~T..~.~".
· 35'..HOlland Street ~.~. ~
?':~-. ~ ~iWilke's-~Barre,' .Pa.. 18702 . ' ..........
~:__" ~'='==~ ==¢2~[~ ~ ~L 1'7 6 5 51 14.4 E E
SER~S
Inventory Report
Active Inventory
Print Date: 03/27/2004
Bonds: File Pricing Date: 07/2003
Issue Next Interest l~'m~l-~-~uht~ ......
No. Series Denom Serial Number Date Price Interest Value Rate Yield Date Date Note
1 EE $50 L288388148EE 08/1987 $25.00 $33.60 $58.60 4.00% 5.57% 08/2003 08/2017
2 EE 200 R167639055EE 04/2001 100.00 9.44 109.44 3.25% 4.05% 08/2003 04/2031 P5*
3 EE 100 C660253154EE 11/1998 50.00 11.08 61.08 2.66% 4.34% 08/2003 11/2028 P5*
4 EE 50 L176551144EE 11/1984 25.00 48.14 73.14 4.00% 5.89% 11/2003 11/2014
Inventory Totals:
Price Interest Value
$200.00 $102.26 $302.26
· MN- bond is
Untitled 1
· cI- bond was Cashed n · EX- bond was E changed for an HH bond · ME- bond is atured and Exchangeable for an HH bond
atured and Not exchangeable for an HH bond · NE - bond is Not yet Eligible for payment (it's < 6 months old) . NI - bond has Not yet been ssued
· P5 - bond is a Series I or EE, was issued in or alter May 1997 and includes a 3-month-interest ? enalty until the bond is $ years old
· * bond is a Series I or EE, was issued in or after January 1990 and may be tax exempt if used for post-secondary education
· 0 bond was Cashed In or EXchanged for an HH bond, but is being priced on a date prior to the cashed or exchanged date
Page 1 of 1
REV-1511'EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
O'Brien, Janet M 21-2003-0588
Debts of decedent must be reported on Schedule I.
R'EM
NUMBER DESCRIPTION AMOUNT
A.
8,300.50
2
3
5.
6.
7.
8
9
10
11
pRALF_.~PF...NSES: .
ezz~ Funera£ Home
8 Market Plaza Way
Mechanicsburg, PA
professional services
Office of Catholic Cemeteries - internment exl0enses
Lord & Taylor - purchase of funeral dress for
decedent
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s) See Schedule attached
Social Security Number(s) / EIN Number of Personal Representative(s)
Street Address
City State __ Zip
Year(s) Commission Paid:
Name.. Keefer Wood Allen & Rahal
Attorney Fees
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
Probate Fees
Accountant's Fees
Tax Return Preparer's Fees
The Jewelers Bench Inc - appraisal fee
The Patriot News Co - estate advertising
PP&L Electric Utilities - utility expenses at 321
Cascade Road Mechanicsburg (August 2003 to sale)
Cumberland County Law Journal - estate advertising
expense
United Water Pennsylvania - utility expense at 321
from continua=ion pages ....
TOTAL (Also enter on line 9, Recapitulation) $
950.00
78.39
11,320.00
10,000.00
0.00
381.00
0.00
0.00
20.00
241.15
125.83
75.00
38.07
8,8i6.5i
40,346.45
2W46AG 2.000 (If more space is needed, insert additional sheets of same size)
Estate of: O'Brien, Janet M
Schedule H, Part A -- Funeral Expenses
Item
No. Description
0
5
Rose O~Brien - reimbursement for funeral expenses
incurred
Anita Sirak - reimbursement for funeral expenses
incurred
Page 2
21-2003-0588
Amount
139.93
665.65
TOTAL. (Carry forward to main schedule) ...... 805.58
Estate of: O'Brien, Janet M
Schedule H, Part B -- Administrative Costs
Item
No. Description
11
Cascade Road Mechanicsburg, PA (August 2003 to sale)
12
P. Scott Archibald - real estate appraisal at 321
Cascade Road Mechanicsburg, PA
13
Vet1 Williems - trash removal at 321 Cascade Road
Mechanicsburg, PA
14
Erie Insurance Oroup - auto insurance premium
15
Federal Express - package shipped to Bank One
16
Upper Allen Township - utility expense at 321 Cascade
Road Mechanicsburg, PA
17
Jay R. Braderman, Esq - legal fees incurred in child
custody proceedings per Item VII(p) and Item XII in
resisting Michael O'Brien's custody claims for Sean
O'Brien
18
Register of Wills Cumberland County - PA Inheritance
Tax return filing fee
19
Reserve - miscellaneous filing and settlement fees
Page 2
21-2003-0588
Amount
300.00
440.00
54.00
13.28
100.00
6,888.65
15.00
200.00
TOTAL. (Carry forward to main schedule) ...... 8,010.93
Estate of: O'Brien, Janet M
Schedule H, Part B -- Personal representatives' Commissions
Item
No. Description
1
Name: Hershey Trust Company
Social security number: 23-0692150
Address: PO Box 445
100 Mansion Road East
Hershey, PA 17033
Year(s) commissions paid:
Page 2
21-2003-0588
Amount
11,320.00
TOTAL. (Carry forward to main schedule) ...... 11,320.00
REV-1512 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGELIABILITIES,& LIENS
ESTATE OF FILE NUMBER
O'Brien, Janet M 21-2003-0588
Include unreimbursed medical expenses.
ITEM
NUMBER
3
4
5
6
7
8
9
10
11
12
13
14
15
DESCRIPTION
BSI Financial Services - mortgage secured by residential real
estate located at 321 Cascade Road Mechanicsburg, PA (Schedule
A, item 1)
PSECU - checks ~070507, 071201, 072304, 072502 outstanding at
time of death
PSECU - automatic payment withdrawal PP&L Utilities 7/9/03
U~per Allen Township - balance due on utilities
Fleet Credit Card Service - balance due on credit card account
PP&L Electric Utilities - balance due per statement
United Pennsylvania Water - balance due per statement
Susquehanna Breast Care Center - balance due per statement
Citi Cards balance due on credit card account
Bank One - payment on car loan #00519900001957
Jay R. Braderman - legal expenses incurred prior to death
Bank One - payoff of car loan #00519900001957
West Shore EMS - services provided 6/28/03
Quantum Imaging & Therapeutic services provided at Holy
Spirit Hospital 6/30/03
West Shore EMS - services provided 2/4/2003
TOTAL (Also enter on line 10, Recapitulation) $
AMOUNT
71,997.14
805.54
43.30
100.00
69.48
57.82
39.43
1,568.00
54.61
270.56
3,805.50
4,130.64
881.25
205.00
407.25
84,435.52
2W46AH 2.000 (If more space is needed, insert additional sheets of the same size)
REV-1513 EX+ (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF FILE NUMBER
O'Brien, Janet M 21-2003-0588
NUMBER
2
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLEDISTRIBUTIONS[indu~outrights~usadistd~tions, and ~nsfem
underS~.9116(a)(1.2)]
O'Brien, Sean M
3431 Alinda Circle
Camp Hill, PA 17011
J O'Brien Trust fbo Sean O'Brien
C/O Hershey Trust Company
PO Box 445
Hershey, PA 17033
McGovern, Julia
133 Holland Street
Wilkes-Barre, PA 18702
O'Brien, Michael
19 Houston Drive
Mechanicsburg, PA 17055
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
Son
Aunt
Friend
AMOUNT OR SHARE
OF ESTATE
54.72
184,990.97
65.87
30.54
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II.
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON UNE 13 OF REV-1500 COVER SHEET $ 0.0 0
2W46AI 1.000 (if more space is needed, insert additional sheets of the same size)
WHEREAS, on the 22nd
dated November 4th 2002
Register of Wills of CUMBERLAND County, Pennsylvania
Certificate of Grant of Letters
No. 2003-00588
ESTATE OF
a/k/a
Late of
Deceased
Social Security No. 202-46-9958
day of July
PA No. 21-03-0588
O'BRIEN JANET M
O'BRIEN JANET MARGARET
UPPER ALLEN TOWNSHIP
~U~_-q..ND COUN'I'~,
2003 an instrument
was admitted to probate as the last will of O'BRIEN JANET M
(~'±', ~'l~'±',
a/k/a O'BRIEN JANET MARGARET
late of UPPER ALLEN TOWNSHIP , CUMBERLAND County, who died on the
3rd day of Jul-y 2003 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, DONNA M. OTTO , Register of Wills in and for
the County of CUMBERLAND in the Commonwealth of Pennsylvania, hereby certify
that I have this day granned Letters TESTAMENTARY
to HERSHEY TRUST COMPANY
who has duly qualified as Executor.(rix)
and has agreed to administer the estate according to law, all of which fully
appears of record in my Office at CUMBERLAND COUNTY COURT HOUSE,
CARLISLE, PENNSYLVANIA.
IN TESTIMONY WHEREOF, I have hereunno set my hand and affixed the Seal
of my Office the 22nd day of July 2003.
**NOTE** AT,T, AIAMES ABO~-E APPEAR (LAST, FIRST. MIDDLE)
Las
OF
JAbYET M. O'BRIEN
I, J.A_NET M. O'BI~IEN, of Upper Allen Township, Cumberland Oounty,
Pennsylvania, do make, publish and declare this to be my Last Will and Testament,
hereby revoking all Wills and Codicils by me heretofore made.
ITEM I: I direct that all ~mBeritance and estate taxes
becoming due by reason of my death, whether such taxes may be payable by my
estate or by any recipient of any property, shall be paid by-the Executor out of the
property passing under ITEM IV of this Will, as an expense and cost of
a~m~stration of my estate. The Executor shall have no duty or obligation to
obtain reimbursement for any such tax so paid, even though on proceeds of
insurance or other property not passing under this V~ill.
ITEM II: I direct the Executor to pay the expenses-of
my last ~]]~ess and funeral expenses f~om the property passing under this Will as
an expense and cost of a~m~stration of my estate.
ITEM III:. I may leave a written statement or list in my
safe' deposit box dispo.sing of cert.aiu items of my tangible persona] property. Any
such statement or listing in existence at the t~rne of my death shall be
.determinative with respect to all items bequeathed therein. If no written statement
or list is found in my safe deposit box or elsewhere and properly identified by the
'Executor within thirty (30) days after the probate of my Will, it shall be pres~ume[[
that there is' no Other statement or list. Any subsequent discovered statement or
.list shall be ignored. I give to my son., SEA_N MATTHEW O'BRIEN, all of my
household furniture and furnishings, books, pictures, jewelry, silverware,
Page
automobiles, wearing apparel and all other articles of household or personal use or
adornment not identified in the written list mentioned above and all pohcies of
insurance thereon. I specifically request that the Executor retain for my son, or
distribute to or for my son, his books, trucks, toys, trophies, his Christmas tree and
Christmas ornaments, all photo s/b~ms, and other items of memorabilia which he
requests. If my. son has not attained the age of eighteen (18) years at the t~rne of my
deat]~, and the Executor'thinks any property to which he would become entitled is
unsuitable for his use, the property shall be sold and the proceeds shall be added to
lhe share of my residuary estate held for his benefit. If my son has not attained the
age of eighteen (18) years at the time of my death, the Executor.may deliver any
property to which he is entitled and which is not sold to the person with whom he
resides or.who has the care or control of him (without bond), and the receipt of that
person shs]] be a complete release of the Executor.
ITEM IV: I give all the rest, residue and remainder of
my estate, not disposed of in the preceding portions of this Will, to HEP~SI-tE¥
TRUST COMPANY, as Trustee, for the benefit of my son, SEAN MATTHEW
O'BttIEN (the "Beneficiary"), to be administered and distributed as follows:
(a) I request that the Trustee rem~nd the Beneficiary, Upon
his att~m ent of the age of twenty (20)years, to obtaJ_u a colonoscopy.
I request that this reminder be provided to my son every year after he
attains the age of twenty (20) years, until termination of the Trust.
~) Trustee shall pay to or for the benefit of the Beneficiary
so much of the net income, in convenient, at least sn~us/insts]]rnents,
as is necessary, in the discretion of the Trustee, for the proper support,
maintenance., medics/care and education of the Beneficiary, includ~n g
the cost of private high school and college, should the Beneficiary so
Page 2
choose. Income not distributed shall be accumulated and added to
p rincip al.
(c) The Trustee shall also pay to or for the benefit of the
Beneficiary so much of the principal as the Trustee, in the discretion of
'the Trustee, considers necessary to maintain the beneficiary in the
proper station in life, including proper support, maintenance, medical
care a_nd education, including the cost of private high school and
college, should the Beneficiary so choose.
(d) Upon the attainment of the age of twenty-five (25) years
by the Beneficiary, the Trustee shall pa~ to the Beneficiary one-half of
the principal of his Trust. Upon the attainment of the age oftB~rty
(SO) years by the Beneficiary, the Trust shall terminate and the
Trustee shall pay to the Beneficiary the rems~g assets of the Trust.
However, the Trustee may refuse to make distributions of principal to
-the Benefici~y should the Trustee consider the Beneficiary unable to
manage the principal of the Trust in the best interests of the
Beneficiary.- The Trustee may also terminate this Trust in whole or. in
part prior to the atts~ment of the age of thirty (SO) years by the · ·
Beneficiary, ffthe' Trustee reasonably believes the Beneficiary able to
manage the principal in 'his own best interests.
(e) Should the Beneficiary die before f~ual distribution of the
assets of his Trust, the Trust shall terminate and the. Trustee' Shall Pay
the assets of the Trust to the then living issue of the Beneficiary, per.
stirpes. However, ff any issue has not atta~ued the age of twenty-one
(21) years at the t~rae of distribution, the Trustee shall continue to hold
Page 3
the share for that issue as Custodian under the PennsYlvania Uniform
Transfers to Minors Act for the benefit of that issue.
(f) If at any time before final distribution of the assets of any
of the Trusts administered under this paragraph, there are no living
beneficiaries of the Trust, the Trust shall terminate. The assets of the
trust shall be paid to my parents, LOUISE SIP~6_K and JOSEPH
SIRAK, if they are living at the time. If they are not living, the assets
shall be divided into as many equal shares as there are then living
siblings ofm~ne. My siblings are'RICHARD SIRAK, i%ONALD SIRA_K,
and JAYNE JOHNSON. One equal share shall be paid to each then
living sibling. If any sibling is not living, his or her share shall be paid
zo his or her then living issue, per stirpes.
ITEM VI: No part of the income or principal of any
Trust created by this Will shall be subject to a~tachment, levy or seizure by any
creditor, spouse, assignee or trustee or receiver in bankruptcy of any beneficiary
prior to his or her actual, receipt .of income or principal distributed. The Trustee
shall pay the net income and the principal to 'the beneficiaries specified by me, as
their, interests may appear, without regard to any attempted anticipation, pledging
or assignment, mad without regaxd to any claim or .a~empted levy, attachment,
seizure or other process against the beneficiary.
ITEM VI!: In addition 'to the powers granted at law, the
Executor. and the Trustee shall each possess the following powers, each of which
may be exercised without court approval and in a fiduciary capacity only:
Page 4 ~--~/
(a) To retain any investments I have at my death, including
specifically those consisting of stock of any bank even if I have named
that bank as the Executor or Trustee.
(b) To vary investments, and to invest in bonds, stocks, notes,
real estate mortgages or other securities or in other property, real or
personal, without being restricted to so-called "legal investments", and
without being lir~ted by any statute or rule of law regarding
investments by fiduciaries.
(c) In order to divide the principal of a Trust or for any other
purpose, including final distributions, the Executor and Trustee are
authorized to divide and distribute personal property and real
property, partly or wholly in ]~d, and to allocate specific assets among
beneficiaries and Trusts so long as the total market value of each
share is not affected by the division, distribution or allocation in kind.
The Executor and Trustee are each authorized to make, join in and,
consummate partitions of.lands, voluntarily, or invol~zntarfly, including.
giving of mutual deeds, or other obligations, with as wide powers as an
individual owner in fee simple.
(d) To sell either at public or private sale real and personal
property severally or in conjunction with other persons,-and to
consummate sale(s) by deed(s) or other instrument(s) to the
purchaser(s), conveyin§ a fee simple .title. No purchaser shall be
obligated to see to the application of the purchase mone~ or to make
inquiry into the validity of any sale(s). The Executor and-Trustee are
authorized to'execute, acknowledge and deliver deeds, assiE~ments,
Page5 ~~
options or other writings as necessary or convenient to any of the
power conferred upon the Executor and Trustee.
(e) To mortgage real estate, and to make leases ofreaJ estate.
(i) To borrow money f~om any person, including the Executor
or Trustee, to pay indebtedness of mine or of my estate, expenses of
administration or inheritance, legacy, estate and other taxes, slnd to
assign and pledge assets of my estate or any Trust estabhshed by this
Will.
(g) To pay all costs, taxes, expenses and charges in
connection .with .the a~m4~stration of my estate or any Trust
estabhshed under this Will.
(h) To make distributions of income and of principal to the
proper beneficiaries, during the administration of my estate, with or
without court order, in such ma~er and in such amoUnts as the
Executor deems prudent and appropriate.
(i) To vote shares of stock which form a p art of my estate or
any Trust established under this Will, and to exercise all the powers
incident to the ownership of stock.
(j) To unite with other owners of property similar to property
in my estate to carry out plans for the reorganization of any company
whose securities form a part of my estate.
Page 6
(k) To disclaim any interest in property which would devolve
to me or my estate by whatever means, including but not limited to the
following means: as beneficiary under a will, as an appointee under
the exercise of a power of appointment, as a person entitled to take by
intestacy, as a donee of an inter vivos transfer, and as a donee under a
t]~rd~p arty beneficiary contract.
(1) To prepare, execute and file tax returns of any type
required by apphcable law, and to make all tax elections authorized by
law.
(m) To employ custodians ofprope.rty, investment or business
advisors, accountants and attorneys as the Executor or Trustee deems
appropriate, and to compensate these persons from assets of my estate
or trust, without affecting the compensation to which the Executor and
Trustee are entitled.
(n) To divide any Trust created in this Will into two or more
separate Trusts so that inclusion ratio for purposes of the generation-
skipping transfer tax shall be either zero or one, in order that an
election under Section 2652(a)(3) of the Internal Revenue Code may be
made with respect to one of the separate Trusts, or for any other
reason.
'(o) To allocate administrative expenses to income or to
principal, as the-Executor or Trustee deems appropriate. However, no
allocation to income shall be made if the effect of the allocation is to
cause a reduction in the amoUnt of any estate tax marital deduction or
estate tax charitable deduction.
Page 7
lifetime.
To continue any litigation instituted by me during my
(q) To do ali other acts in their judgment necessary or
desirable for the proper and advantageous management, investment
and distribution of the estate and Trusts established under this Will.
ITEM VIII: The Trustee is authorized to distribute
principal and/or income in any one or more of the following ways if the Trustee, in
the discretion of the Trustee, considers the beneficiary unable to apply distributions
to the beneficiary's own best interests, or if the beneficiary is under a legal
disabilitY:
(a) Directly to the beneficiary;
-(b) To the Trustee, or to another person selected by the
Trustee, as custodian under the Pe~sylvs~a U~form Transfers to
M~ors Act as to a beneficiary under the age of twenty-one (21) years;
(c) To a relative of the beneficiary, to be expended by that
relative for the benefit of the beneficiary; or
(d) By directly applying distributions for the benefit of the
beneficiary.
ITEM IX: The Trustee, on an annual basis, shali
provide each income beneficiary who has attained the age of eighteen (18) years,
and the Guardian of the person of any income beneficiary who has not attained the
age of eighteen (18) years, statements showing transactions each Trust established
for the benefit of that beneficiary. The beneficiary, or the Guardian of the person of
such beneficiary, may waive tlmis right to receive an annual accounting. The
Trustee may, at any time, settle any account, or questions concerning the
administration of any Trust established under this Will, by agreement with the
then ctu-rent income beneficiaries of the Trust, if legally competent, or if not legally
competent, with the Guardian of the person of the beneficiary, the legally
competent spouse of the beneficiary, or the oldest legally competent relative of the
beneficiary who would take a portion of the estate of the beneficiary were the
beneficiary to die at that time intestate under the laws of the State of Pennsylvania.
Any ~ettlement made in accordance with this Item shall bind all persons who have
an interest in the Trust, and shall constitute a release and discharge of the Trustee
with respect to transactions Specified in the settlement.
ITEM X: In the absence of actual l~nowledce of a
breach of trust, or information concer~ng possible breach of trust that would cause
a reasonable person to inquire, a successor Trustee is under no duty to examine the
accounts and records of a predecessor Trustee, or to inquire into the acts or
omissions of the predecessor, and is not hable for any failure to seek redress for any
act or o~ssion of the predecessor. The successor Trustee shall have responsibility
only for property which is actually dehvered to him or her by the predecessor and
shall have ali of the powers conferred upon a Trustee hereunder.
ITEM XI: Any person who has died within thirty (30)
days of my death; or under SUch circumstances that the 'order of our deaths cannot-
be established by proof, shall be deemed to have predeceased me~ Any person (other
than myself) who has died at the s~me time as any beneficiary under thisWill, or in
a common disaster with that beneficiary, or under such circumstances that the
order of deaths c~unot be established by proof, shall be deemed to have predeceased
that beneficiary.
Page9
ITEM XII: It is my preference that JOHN O'BRIEN
serve as Guardian of the person of my son, SEAN M. O'BI%IEN. In the event he is
unable or unwilling to serve, I appoint ANDREW J. O'BRIEN to be the Guardian.
ITEM XIII:
to Executors and Trustees:
I make the £ollowing provisions with respect
(a) I appoint HERSHEY TRUST COMPANY, Hershey,
Pennsylvania, to be the Executor and Trustee.
(b) My brother-in-law, ANDREW J. O'BRIEN, shall have the
power to remove any institutional Trustee serving under this Will,
provided that he first appoints another institutional Trustee to serve
as successor Trustee, and that successor Trustee has agreed to act as
successor Trustee. This power shall be deemed to be a continr]ng
successive power to remove and replace institutional Trustees.
(c) Each appointment of a successor Trustee shall be in
writing and sh~l] be filed with the court in the jurisdiction which is the
situs of the Trust. The written instrument shall be signed by the
person having the power to make the appointment.
(d) The Trustee sh~11 have the right to receive reasonable
compensation for services rendered.
(e) The Trustee shall not be liable or accountable for any loss
that may result from the good faith exercise of the authority granted in
this Will.
Page 10
(f) The Executor and Trustee are specifically relieved from
the duty of filing bond or entering security.
IN WITNESS WHEthEOF, I have set my hand and seal to this, my
Last Will and Testament, consisting of this and the preceding ten (10) pages, at the
end of each page of which I have also set my initials for greater security and better
identification this ~f/~ day of~ , 20
(SEAL)
We, the undersigned, hereby certify that the foregoing Will was signed,
sealed, pubhshed and declared by the above-named Testatrix as and for her Last
Will and Testsment, in the presence of us, who, at her request and in her presence
and in the presence of each other, have hereunto set our hands and seals the day
and yes_r first above written, and we certify that at the t~r~e of the execution
thereof, the said Testatrix was of sound and disposing mind and memory.
/
Residing at 'b~g ~ ~)~.
ACKNOWLEDGMENT
COMMONTvVE~TH OF PERTNSYLVANL4 )
) SS:
I, JANET M. O'BttIEN, Testatrix, whose name is signed to the
attached or foregoing instrument, having been duly qusHf~ed according to law, do
hereby ac]ruowledge that I signed and executed the instrument as my Last Will and
Testament; that I signed it w~]]~ugly; and that I signed it as my free and voluntary
act for the purposes therein expressed.
O'BRIEN
Swm:n to smd subscribed, before
me this ~ day of ~k/o~/~
,20 bL.
~blic
My Commission Expires: [ NOTARIAL SEAL 't
CYNTHIA J. RULE, Not, ary ,P~blic.
Csmp Hili Bore., Cumber~ano uount¥
(SF.J~L) My c,,omm!ssio_ n Expires Jan. 24, 2004
AFFIDAVIT
COIVIMONWEALTH OF PENNS~rLVANIA )
) SS:
COUNTY OF ~ )
the Witnesses whose names are si~ned to the attached or foregoin¢ instrument,
being duly qualified according to law, do depose and say that we were present and
saw Testatrix, JAN-ET M. O'BRIEN, siEn and execute the instrument as her Last
Wi]J and Testament; that Testatrix signed wi]]~ngly and that she executed said Will
as her free and voluntary act for the purposes therein expressed; that each of us in
the hearing and sight of the Testatrix si~ned the Will as Witnesses; and that to the
best of our knowledge the Testatrix was at that time eighteen (18) or more years o£
age, of sound mind and under no c°nstrs~nt or, undue influence.
Witness -/ Witness C)
Sworn to and subscribed before
me this ~ day of ~Cr~q.4a,_.Ja~
,2002_
My Commission Expires:
(SF_3_L)
YNIHiA o. '
Bore, Cumberland Counl~t /
. · i-. s~an 24,2~
~omm~ssion
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 180601
HARRISBURG, PA 17118-060!
HERSHEY TRUST CO
100 MANSION RD EAST
PO BOX qq5
HERSHEY
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLO#ANCE OR DZSALLOHANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
'04 f~i.?~ E4
PA 1705~~i~
DATE 05-Zq-ZOOfi
ESTATE OF OBRIEN
DATE OF DEATH 07-05-2005
FILE NUMBER 21 05-0588
"~i;('~OUNTY CUMBERLAND
ACN 101
Amoun~ Remi~ed
RE¥-lSq? EX AFP (01-05)
JANET
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF OBRIEN JANET MFZLE NO. 21 05-0588 ACN 101 DATE 05-Zq-ZOOq
TAX RETURN HAS: (X) ACCEPTED AS F/LED ( ) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAZSED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
$. Closely Held Stock~Partnership Interest (Schedule C) ($)
q. Mortgages/Notes Rece/vable (Schedule D)
5. Cash/Bank Deposits/M/sc. Personal Property (Schedule E)
6. Jo/ntly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Tote1 Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expanses/Adm. Costs/M/sc. Expanses (Schedule H) (9)
10. Debts/Mortgage Liab/1/t/es/Liens (Schedule I) (10)
11. Total Deduct/ohs
12. Na~ Value of Tax Return
1111769.22
1731807.87
.00
.00
2q~195.85
151.13
.00
(8)
qO,3q6 .q5
8q~q35.52
(11)
(12)
15.
NOTE:
NOTE: To /nsure proper
credit to your account,
submit the upper port/on
of th/s form with your
tax payment.
309,92q.07
]24.781.q7
185,1q2.10
Charitable/Governmental Bequests; Non-elected 9115 Trusts (ScheduZe J) (15)
Nat Value of Estate Subject to Tax
Zf an assessment ,as issued previously, lines 14, 15 and/er 16, 17,
reflect ~igures that include the total o~ ALL returns assessed to date.
(15) .00 x O0 =
(16) 185,0q5.69 x Oq5=
(17) .00 x 12 =
(18). 96.ql x 15 =
(19)=
ASSESSMENT OF TAX:
15. Amount of L/ne lq at Spousal rata
16. Amount of L/ne lq taxable at L/neaZ/Cless A rata
17. Amount of L/ne lq at S/bl/ng rata
18. Amount of Line lq taxable at Collateral/Class B rata
19. Pr/ncipal Tax Due
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT
DATE NUMBER INTEREST/PEN PAID (-)
10-02-2003 CD003078 ~17.08
05-17-200~ REFUND .00
AMOUNT PAID
ZF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATZON OF ADDITIONAL INTEREST.
8,000.00
75.56-
.00
185,1q2.10
18 and 19 will
.00
8,327.06
.00
lq.q6
8,3ql.52
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
8,3ql.52
.00
.00
.00
( ZF TOTAL DUE ZS LESS THAN $1, NO PAYMENT ZS REQUIRED.
ZF TOTAL DUE ZS REFLECTED AS A 'CREDIT' (CR)~ YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR ZNSTRUCTZONS.)
RESERVATION:
PURPOSE OF
NOTICE:
PAYMENT:
REFUND (CR):
OBJECTIONS:
ADNIN-
ISTRATZVE
CORRECTIONS:
DISCOUNT:
PENALTY:
INTEREST:
Estates o{ decedents dying on or before December 12, 1982 -- if any future interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration o{ any estate for
life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class B (collateral) rate on any such {uture interest.
To ~ulfill the requirements of Section gl40 of the Inheritance and Estate Tax Act, Act 25 of ZOO0. (72 P.S.
Section 9140).
Detach the top portion of this Notice and submit with your payment to the Register of Rills printed on the reverse side.
--Make check or money order payable to: REGISTER OF NZLLS, AGENT
A refund of a tax credit, ehich was not requested on the Tax Return, may be requested by completing an "Application
for Re{und o{ Pennsylvania Inheritance and Estate Tax" (REV-iSIS). Applications are available at the Office
of the Register of Rills, any of the 25 Revenue District Offices, or by calling the special 24-hour
answering service for forms ordering: 1-800-562-2050; services {or taxpayers with special hearing and / or
speaking needs: 1-800-447-5020 (TT only).
Any party in interest not satisfied with the appraisement, allowance, or disalloeance of deductions, or assessment
of tax (including discount or interest) as shown on this Notice must object aithin sixty (60) days of receipt of
this Notice by:
--eritten protest to tho PA Department of Revenue, Board of Appeals, Dept. 281021, Harrisburg, PA 17128-1021, OR
--election to have the matter determined at audit o{ the account of the personal representative, OR
--appeal to the Orphans' Court.
Factual errors discovered on this assessment should be addressed in eriting to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Raviee Unit, Dept. 280601, Harrisburg, PA 17128-060!
Phone (717) 787-6S05. See page S o{ the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-iS01) for an explanation of administratively correctable errors.
I{ any tax due is paid within three (5) calendar months after the decedent's death, a five percent (SI) discount of
the tax paid is alleged.
The 152 tax amnesty non-participation penalty is computed an the total of the tax and interest assessed, and not
paid before January 18, 1996, the {irst day after the end of the tax amnesty period. Thls non-participation
penalty is appealable in the same manner and in the the same time period as you would appeal the tax and lnterest
that has been assessed as indicated on this notice.
Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of
six (623 percent per annum calculated at a daily rate of .000164. All taxes which became delinquent on and after
January 1, 1982 mill bear interest at a rate which will vary {rom calendar year to caIendar year aith that rate
announced by the PA Department of Revenue. The applicable interest rates for 1982 through Z004 are:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
~ lOX .000548 ~-1991 1XZ .000501 ~ 9X .000247
1985 XSZ .000458 1992 92 .000247 ZOOZ 67. .000164
1984 Ill .000501 1995-1994 7Z .000192 Z005 52 .000157
1985 157. .000556 1995-1998 92 .000247 Z004 42 .000110
1986 102 .000274 1999 7Z .000192
1987 107. .000274 2000 77. .000192
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
--Any Notice issued a{tar the tax becomes delinquent will reflect an interest calculation to fi{teen (lB) days
beyond the date of the assessment. If payment is made after the interest computation date sheen on the
Notice, additionat interest must be calculated.
IN RE: THE ESTATE OF JANET M.
O'BRIEN
IN THE COURT OF COMMON
PLEAS, CUMBERLAND COUNTY,
PENNSYLVANIA
:
: ORPHANS' COURT DIVISION
:
: FILE NO. 21-03-00588
CONSENT ORDER
1. On October 13, 2003, Petitioners, Hershey Trust Company, Executor of
the Estate of Janet M. O'Brien, and Louis O'Brien and Rose O'Brien, who have sole
legal and physical custody of Sean O'Brien, filed a Petition for Order Directing
American Express Financial Advisors, Inc. to Distribute Certain Accounts to Trust
and for the Award of Costs and Attorney's Fees Against American Express
Financial Advisors, Inc. and Michael I. Shalhoub (the "Petition").
2. The Respondents to the Petition are: American Express Financial
Advisors, Inc. ("American Express"), and Respondent, Michael I. Shalhoub, Janet
O'Brien's financial advisor.
3. The dispute arose regarding whether the following American Express
accounts held by Janet M. O'Brien at the time of her death were held as "Transfer
on Death Accounts":
ACCOUNT NUMBER
010100226611 002
01010022671 0 002
01010022672 8 002
01010022673 6 002
01010022674 4 002
01010022675 I 002
01010022679 3 002
01449156233 7 002
(herein collectively "the Accounts").
4. The parties agree that the Accounts will not be treated as Transfer on
Death accounts but instead the Accounts will be paid to the Estate of Janet O'Brien
by American Express issuing a check to Hershey Trust Company as the Executor of
the Janet O'Brien Estate for the aggregate amount the Accounts are worth on the
date of liquidation.
5. The Estate of Janet O'Brien will complete American Express's Estate
Settlement form (attached hereto as Exhibit "A" and made a part hereof as though
fully set forth herein), and Mutual Fund and Certificate Redemption, Exchange
and/or Transfer of Investment form (attached hereto as Exhibit "B" and made a part
hereof as though fully set forth herein).
6. The Estate of Janet O'Brien will complete Exhibits "A" and "B" and
return them to American Express's undersigned counsel.
7. American Express will liquidate the Accounts and issue a check to
Hershey Trust within (i) fourteen (14) days of the Court signing this Consent Order
or (ii) American Express's receipt of the Estate of Janet O'Brien's completed
Exhibits "A" and "B", whichever is later.
8. Petitioners Louis O'Brien and Rose O'Brien waive any right that Sean
O'Brien, his heirs and assigns would have in American Express paying the Accounts
directly to Sean O'Brien.
9. As part of their settlement with American Express, the Petitioners
waive any claims against Respondents for attorneys' fees and costs.
10. Hershey Trust Company will place the proceeds of the Accounts in
trust for Sean O'Brien as set forth in Janet O'Brien's Will, Item IV.
11. After Hershey Trust Company receives the check issued by American
Express, pursuant to Paragraph 7 of this Consent Order, the Estate of Janet
O'Brien will file a Praecipe to Discontinue the Petition.
12. The Court, in signing this Order, approves the settlement of Sean
O'Brien's rights to the Accounts and his waiver for any claim of attorneys' fees or
costs.
DATED:
DATED:
DATED:
THE ESTATE OF JANET O'BRIEN
THE HERSHEY TRUST COMPANY,
Executor for the Estate of Janet O'Brien
~o~ert K:R~it~el ~ ~
~ ~ce President and Trust Officer
Louis O'Brien, Co-Legal and Physical
Custodian of Scan O'Brien
Rose O'Brien, Co-Leg~fl and Physical
Custodian of Sean O'Brien
DATED:
AMERICAN EXPRESS FINANCIAL
ADVISORS, INC.
By:
Print Name:
Print Title:
[signatures continue on next page]
DATED:
M~chae~ J Shalhoub "~'~
THE COURT:
DATED:
EXHIBIT A
·
Estate Settlement Form
· Brokerage · SPS Advantage · Premier Portfolio Services
· Mutual Funds · Certificates · Shurgard (IRAs only)
· American Express ONE Financial Account · Direct Investments (IRAs only)
· Non-Qualified Accounts:
· IRAs:
Complete Sections 1 through 5 and 12
(Instructions on Page 2)
Complete Sections 6 through 12
(Instructions on Page 6)
3248 Page 1 of 10 G (12/03) ·
·
'Estate Settlement Form
· Non-Qualified Accounts
· Brokerage · Certificates
· Mutual Funds · Premier Portfolio Services, inc.
· SPS Advantage · American Express ONE Financial Account
American Express Financial Advisors
70100 AXP Financial Center
Minneapolis, MN 55474
Please read the instructions (shown below) completely before completing this form for submission to American Express. Failure to provide all required
information for your claim may cause processing delays.
General Instructions for All Assets:
Non-Qualified: Sections 1 through 5 of this form are used to provide instructions for non-qualified assets. Only the accounts listed in Section 1 will be settled according
to the instructions provided in Section 1 through 5 of the form. See below for specific instructions for each section. For IRA assets please refer to Section
6 through 11 of this form. For non-qualified direct investment accounts - REITs and Limited Partnerships, please contact the General Partner directly
for instructions.
IRA: Sections 6 through 11 of this form are used to provide instructions for settling an IRA to the claimant. The IRA plan(s) for which instructions are provided
must be identified in Section 6 of this form. All investments held in the IRA plan(s) identified, Including Limited Partnership Investment and REIT accounts
will be settled pursuant to the instructions on this form. If the decedent had multiple IRA plans and the claimant would like to make different elections for
each IRA plan, the claimant must complete a separate estate settlement form for each IRA plan. See Page 6 for more specific information on settling IRAs.
Purpose of Form: The purpose of this form is to re-title the deceased's assets in the name of the claimant. The assets must be re-titled before the claimant may make
any account transaction requests.
Notitv American Express Financial Advisors of the client's death before submitting this form. This will facilitate the fastest claim payment possible.
· AEFA Advisors please call (888) 723-8476 menu options 1, 3,1. AEFA
· Claimants and Beneficiaries please call (800) 862-7919 menu options 5,1
· Complete a separate Estate Settlement Form for each claimant, account ownership and type of transfer instructions.
This form can be used to provide only one set of instructions. The instructions indicated in this section of the form will be applied to all accounts indicated in this section of the form.
· Liquidation of Accounts
This form cannot be used to request liquidation of an account. Once the assets are re-titled, the claimant may contact our office toll-free at 1-800-862-7919 to request
liquidation. For at-fund proprietary mutual funds and certificates, they may attach form F119 to this form and indicate they have done so in Section 4 of the form.
· Additional Service Transactions, Bank Authorizations, Dividends, Interest and Scheduled Distribution Arrangements
The claimant may request these services by attaching the appropriate request form. For non-qualified accounts see Section 4 for complete instructions.
· Un-cashed, Outstanding Checks
Any checks issued against the deceased person's accounts may be returned to us to be re-issued to the correct payee. Checks issued after the date of death are the property of
the beneficiary or claimant. Checks issued prior to the date of death are the property of the payee's estate and may be treated as an estate asset eligible for probate and
distribution by the legally appointed estate representative.
· Outstanding Stock Certificates
If there are outstanding stock certificates issued against an at-fund proprietary mutual fund account, the certificate(s) must be returned to our corporate office before your claim
can be processed. If you are unable to locate the outstanding certificates, your American Express financial advisor can assist you in submitting the appropriate loss and
indemnity statements to our corporate office. You may also call 1-800-862-7919, menu options 5, 1.
Each section of the form has specific instructions. If in any section of the form there is insufficient space to provide the information required, the claimant may provide that
information on a separate attachment page. If an attachment page is included, it must be signed and dated by all parties who sign the Estate Settlement Form and the section of
the form for which the attachment is included must have the words "see attachment" entered therein.
Section 1 - Existing Account Identification
Use this section of the form to identify the decedent's accounts that are affected by the instruction provided on this form. Claims will not be processed for accounts that are not listed.
Section 2 - Transfer Instructions and Authorization
Please use this section to identify the amount of each account being claimed that will be re-registered in the ownership of the claimant. The instructions in this section must
correspond exactly to any beneficiary instruction that exists on the decedent's account(s).
Sections 3, 3A, 3B and 3C - Beneficiary/Claimant Information for Non-Qualified Accounts
All claimants/'oeneficiaries of nonqualified accounts must complete this section to provide their instructions for ownership registration. We are required by law to obtain certain
personal information from you which will be used by us to verify your identity. If you do not provide us the information, we may not be able to open your account. If we are unable
to verify your identity, we reserve the right to close your account or take such other steps as we deem reasonable.
Section 4 - Additional Requests
If you have attached forms for additional requests, such as liquidation, dividend or payout arrangements, etc., you must indicate so in this section of the form.
Section 5 - Supplemental Instructions for Brokerage, SPS Advantage, Premier Portfolio Services, Inc. Service and ONE Accounts
This Section must be completed for claimants of Brokerage, SPS Advantage and Premier Portfolio Services, Inc. Service Accounts. If this section is not completed, processing of
your claim may be delayed.
Section 1Z - Authorization and Acknowledgements
This section must be signed by all new owners and fiduciaries, if all new owners and/or fiduciaries do not sign this section the claim will not be processed.
3248 Page 2 of 10 G (12/03) ·
Estate Settlement Form
· Non-Qualified Accounts
· Brokerage · Certificates
· Mutual Funds · Premier Portfolio Services, Inc.
· SPS Advantage · American Express ONE Financial Account
American Express Financial Advisors
70100 AXP Financial Center
Minneapolis, MN 55474
Please Print or Type.
Account Numbers
· If any there are outstanding stock certificates issued for any American Express mutual fund account listed above, they must be returned to our office for this claim to be processed.
Decedent's Name
Decedent's Client ID Number
Decedent's Date of Death State of Residence Decedent's Social Security Number
I assign subject to the approval of the Fund or IDS Certificate Company or American Enterprise Investment Services (the "Issuer"):
Transaction Amount [] All : · Dollars O % Percent Shares
Shares or certificate described above to person or persons named in Section 3, I irrevocably appoint American Express Financial Corporation to Transfer said securities on the
books of the issuer, with full power of substitution in the premises.
I affirm that the information in Section 1 and 2 of this form is correct, and may be included in any required reports to the tax or regulatory authorities.
(Signature(s) of Joint Tenant, Beneficiary, Claimant, Trustee(s),
Legal Representative(s) for the Decedents Estate or other Fiduciarie(s) Date Signed
IX
IX
3248 Page 3 of 10 G(12/03) ·
·
· Guideline~ for Completion of Sections 3, 3A, 3B and 3C · We are required by law to obtain certain personal information from you which will be used by us to verify your identity. If you do not provide us the information, we may not be
able to open your account. If we are unable to verify your identity, we reserve the right to close your account or take such other steps as we deem reasonable.
· This section must be completed by all new owners/claimants of Non-Qualified accounts.
· For settlement of IRA Plan assets, please refer to Sections 6 through 12.
· Claimants of Non-Qualified Brokerage, SPS Advantage, PREMIER PORTFOLIO SERVICES, INC. and American Express ONE Financial Accounts must also complete Section 5 of this form.
[] Individual
[] Joint Tenancy (WROS)
[] Tenants in Common
[] Trustee-Beneficiary (certificate accts only)
[] Tenants by Entirety
[] Community Property
[] Usufructuary/Life Tenant/Life Estate
[] Guardian/Conservator/Next Friend*
[] UTMA**
[] Estate***
[] Trust****
[] Organization .....
[] Other
Relationship to Decedent in Section 1
Citizenship- Check One Option: [] U.S. Citizen [] Resident Alien [] Non-Resident Alien
Name as it appears in IRS Records
Street Address
City
Date of Birth
Social Security Number
State
Postal Code
Relationship to Decedent person in Section 3A Date of Birth
:
Citizenship - Check One Option: [] U.S. Citizen [] Resident Alien [] Non-Resident Alien
Name as it appears in IRS Records Social Security Number
Street Address
City
State Postal Code
Name of Fiduciary, Estate Representative, Trustee(s), Officer(s) of Organization, UTMA Custodian, Usufruct, Life Tenant/Estate
Name of Decedent, Trust, Organization, Minor, Naked Owner(s), Remaindermen
Street Address
Taxpayer Identification Number of Claimant or Minor
·
Date of Trust (if Trust is claimant)
:
UTMA State (minor claimant)
City State Postal Code
* If a fiduciary ownership such as Guardianship or Conservatorship is chosen, a court certified copy of the court order appointing the fiduciary must be included.
*" If UTMA ownership is selected for a Minor beneficiary or claimant, Social SecuriW Number for the Minor must be included.
*** If Estate ownership is selected, the Taxpayer Identification Number to be used for the Estate must be included as well as court certified copy of the order appointing the representative of the estate
.... If Trust ownership is requested, the Taxpayer Identification Number to be used for the trust as well as the names of ALL trustees and the complete date of the trust must be included on this form
and a copy of the title, and signature pages of the trust document must be submitted with this form.
..... If the assets are to be registered in the name of an organization, a corporate resolution identifying those officers authorized to sign on behalf of the organization must be included,
3248 Page 4 of 10 S (12/03) ·
For additional requests that are not included on this form, the claimant may attach the appropriate request form for processing after the death claim processing has been
completed. Please review the description for each item in order to determine if you need to include it with this form and identify the appropriate items using the check-off boxes.
[] Mutual Fund and Certificate Redemption, Exchange and/or Transfer of Investment Form Fl19
This must be included if you wish to request liquidation of an at-fund proprietary mutual fund or investment certificate account after your death claim has been processed.
Alternatively, for Mutual Fund, Certificate, Brokerage and SPS accounts, the new account owner may contact the corporate office by telephone to request this service after the
death claim has been processed.
[] Bank Authorization/Systematic Payout/1A/ire/Direct Deposit Request Form 200433
Use this form to request any of those services for non-brokerage accounts
[] Systematic Contribution/Distribution Request Form Form 200353
Use this form to request any of those services, including Bank Authorizations and systematic payouts for brokerage accounts
[] Dividend or Interest Delivery Arrangement Form Fl40
This form must be included to provide dividend or interest delivery instructions on new direct-at-fund proprietary mutual fund accounts and investment certificate accounts.
If this form is not included, the processing defaults described below will be exercised:
· If the assets are being transferred to a new account with a new account number, no arrangements will set up on the new account
· If the assets are going to remain in the current existing account with the ownership registration changed to remove the decedent from the account, then any arrangement
existing on the account will remain
[] Additional Account Features Form 10528
This form is required to continue any account features on your American Express Brokerage, SPS, SPS Advantage or ONE account
[] Request to Move American Express Funds Form 200344
This form must be included to transfer shares of American Express mutual funds, currently held in direct-at-fund accounts in-kind to an existing American Express Brokerage account.
Brokerage and SPS Advantage Accounts Only - Margin Account Agreement
if you do not elect to have a margin account by checking the box below, no margin account will be provided.
[] Yes, I agree to have a margin account*
* By checking this box I agree that I have received the client agreement and am bound by the terms set forth in the margin agreement therein.
Claimant Options - SPS Advantage Accounts Only - Check the box beside the option requested. If no option is elected, we will assume that the claimant's
intention is to liquidate the account within 90 days of completion of the death claim settlement
[] Claimant will hold an SPS Advantage Account and has signed and attached the SPS Advantage Service Agreement Form 23443
[] Claimant will be terminating the SPS Advantage agreement within 90 days of re-registration and agrees to the following terms:
· SPS Account Termination Fee will be waived on request at the time of complete liquidation of the SPS Account within 90 days of completion of the death claim settlement
· No SPS Advantage Services will be provided
· Account activity will be limited to liquidations and in-kind transfers only
· Claimant is responsible for submitting liquidation requests by calling 1-800-862-7919 and speaking to a trader to request liquidation or in-kind transfer of the account within 90
days of completion of the death settlement
Claimant Options - Premier Portfolio Services Accounts 0nly - Check the box beside the option requested. -
[] Claimant will maintain existing account and has completed the appropriate agreement(s)
[] Claimant will be completely terminating the PREMIER PORTFOLIO SERVICES agreement(s) after re-registration and agrees to the following terms:
· No annual fee will be charged
· No Premier Portfolio Services will be provided
· Account activity will be limited to liquidations and in-kind transfers only
· Claimant is responsible for submitting written instructions for liquidation or in-kind transfer of the account to our office within 90 days of completion of the death settlement.
Telephone requests for liquidation or transfer of this account are not accepted.
ONE High-Yield Savings Account Information
Upon receipt of proof of death of any account holder(s) and receipt of complete claim requirements at our office, all assets held in the ONE High-Yield Savings account will be
transferred to the American Express ONE Financial Account held by American Express Financial Advisors Inc., and will be settled to any beneficiaries, heirs or claimants as part of
the cash position of the American Express ONE Financial Account.
3248 Page 5 of 10 G(12/03) ·
'Estate Settlement Form
· Custodial IRA Plans
· Brokerage · SPS Advantage · Shurgard
· Mutual Funds · Certificates · Premier Portfolio Services, Inc.
· Direct Investment Account - Limited Partnerships and REITs
American Express Financial Advisors
70100 AXP Financial Center
Minneapolis, MN 55474
Please read the instructions (shown below) completely before completing this form for submission to American Express. Failure to provide all required
information required for your claim may cause processing delays,
General Instructions
Notify American Express Financial Advisors of the IRA owner's death before submitting this form. This will facilitate the fastest claim payment possible.
· AEFA Advisors please call (888) 723-8476 menu options 1, 3, 1. AEFA
· Claimants and Beneficiaries please call (800) 862-7919 menu options 5, 1
· IRA Required Minimum Distribution (RMD)
If the decedent had reached his or her Required Beginning Date (RBD) and has not yet taken their Required Minimum Distribution (RMD), please contact our office for additional
instructions before completing this form.
· Complete a separate Estate Settlement Form for each claimant, account ownership and type of transfer instructions.
The instructions elected in Section 6 of the form will be applied to all accounts in the IRA Plan(s) indicated. If a claimant is a beneficiary of multiple IRA plans and wishes to
provide different instructions for each IRA plan, he/she must complete a separate Estate Settlement Form for each IRA.
· Liquidation of Accounts
This form cannot be used to request a distribution from an IRA. This form can only be used to re-register the ownership of the IRA. Claimants wishing to take distributions after
completion of the death claims settlement may do so by contacting our office toll-free at 1-800-862-7919, or for proprietary mutual funds and certificates, they may attach the
appropriate liquidation request form to this Estate Settlement Form and indicate they have done so in Section 10 of the form.
· Additional Service Transactions, Bank Authorizations, Dividends, Interest and Scheduled Distribution Arrangements
These services cannot be requested using this form. However, the claimant may request a scheduled distribution arrangement by completing form 200433 and/or Form F-140
indicating they have done so Jn Section 10 of the form.
· Un-cashed, Outstanding Checks
Any checks issued against the deceased person's IRA may be returned to us to be re-issued to the correct payee. Checks issued after the date of death are the property of the
beneficiary or claimant. Checks issued prior to the date of death are the property of the decedent's estate and may be treated as an estate asset eligible for probate and
distribution by the legally appointed estate representative.
· Accounts involving a deceased fiduciary, such as a court-appointed Guardian, Trustee, Custodian, Controller, etc.
While the ownership of these accounts does not need to be changed because the actual owner is not deceased, it is still necessary to complete the Estate Settlement form to
update the registration of the accounts to indicate any change in the identity of the person(s) in the fiduciary role.
Each section of the form has specific instructions. If there is insufficient space to provide the information required, the claimant may provide that information on a separate
attachment page. If an attachment page is included, it must be signed and dated by the claimant(s) and the section of the form for which the attachment is included must have the
words "see attachment" entered therein.
Section 6 - Existing IRA Plan Identification
Use this section of the form to identify the decedent's IRA Plans for which instructions are provided on this form. Instructions provided on this form apply to all accounts held in
the IRA Plan(s) identified on this form.
Section 7 - Claimant Information - IRAs
All beneficiaries of IRA plan accounts must complete this section to provide their instructions for ownership registration. We are required by law to obtain certain personal
information from you which will be used by us to verify your identity. If you do not provide us the information, we may not be able to open your account. If we are unable to verify
your identity, we reserve the right to close your account or take such other steps as we deem reasonable.
Section 8 - Settlement Options for IRAs
All beneficiaries of IRA plan accounts must complete this section to provide their instructions for ownership registration
Section 9 - IRA Fee Information
Statement of Administrative and Custodial fees for IRAs
Section 10- Additional Requests
If you have attached forms for additional requests, such as liquidation, dividend or payout arrangements, etc., you must indicate so in this section of the form.
Section 11 - Supplemental Instructions and Information for Brokerage, SPS Advantage, Premier Portfolio Services and Direct Investment Accounts
This Section must be completed for claimants of Brokerage, SPS Advantage, Premier Portfolio Services and Direct investment accounts. If this section is not completed, processing
of your claim may be delayed.
Section 12 - Authorization and Acknowledgements
This section must be signed by all new owners and fiduciaries. If ali new owners and fiduciaries do not sign this section, your claim will not be processed.
3248 Page 6 of 10 G (12/03) ·
·
Estate Settlement Form
· Custodial IRA Plans
· Brokerage · SPS Advantage · Shurgard
· Mutual Funds · Certificates · Premier Portfolio Services, Inc.
· Direct Investment Account - Limited Partnerships and REITs
American Express Financial Advisors
70100 AXP Financial Center
Minneapolis, MN 55474
Please Print or Type.
· List one account number below from each IRA Plan to be settled according to the instructions provided on this form.
· If you are the beneficiary for multiple IRA plans owned by the decedent and you wish to provide different settlement instructions for each IRA plan, you must submit those
instructions for each IRA Plan on a separate Estate Settlement Form.
· All accounts in the IRA plans identified on this form will be settled according to the single instructions indicated on this form whether or not those specific account numbers are listed.
· Identify the IRA Plan(s) being settled according to the instructions provided on this form by placing a check mark or "X" in the box corresponding to the IRA Plan types listed below:
[] Traditional (Active) IRA [] SIMPLE (SRA) [] Inherited (Beneficial/Deceased)IRA- All Types [] SEP IRA
[] Rollover (Segregated)IRA [] Roth Contributory IRA [] Roth Conversion IRA
Identify at least one account number from each IRA Plan type identified above
Account Numbers
Deceased's Name
Deceased's Client ID Number Deceased's Date of Death State of Residence Deceased's Social Security Number
Guidelines for Completion of Section 7 - Must be completed by all new ownors/claimants of IRA Plan accounts.
· We are required by law to obtain certain personal information from you which will be used by us to verify your identity. If you do not provide us the information, we may not be
able to open your account. If we are unable to verify your identity, we reserve the right to close your account or take such other steps as we deem reasonable.
· For Non-Qualified Accounts refer to Page 4 of this form
· If the decedent's IRA held a Brokerage, SPS, Premier Portfolio or Direct Investment account you must review and complete Section 11 of this form.
· If Trust ownership is requested, the Taxpayer Identification Number to be used for the account as well as the names of All Trustees must be included as well as the complete
date of the trust and a copy of the title and signature pages of the trust document.
· If a fiduciary ownership such as Guardianship, Conservator or Estate is chosen, a certified copy of the court order appointing the fiduciary must be included.
· If Estate ownership is selected, the Taxpayer Identification Number to be used for the Estate must be included.
· If the assets are to be registered in the name of an organization, a corporate resolution identifying those officers authorized to sign on behalf of the organization must be included.
· If UTMA ownership is selected for a Minor beneficiary or claimant, Social Security Number for the Minor must be included.
Claimant/Beneficiary Information
Relationship to Decedent in Section 1
Name as It Appears in IRS Records
Date of Birth
Name of Guardian, Conservator, Custodian, Controller, Trustee(s),
and Estate Representative as Appropriate to the Ownership Registration
Citizenship - Check One Option:
[] U.S. Citizen
[] Resident Alien
[] Non-Resident Alien
Taxpayer Identification Number
Date of Trust (if Trust is claimant)
Street Address
State
UTMA State (minor claimant)
Postal Code
3248 Page 7 of 10 G {12/o3) ·
·
Identify whether or not the decedent had reached his or her Required Beginning Date (RBD).
The Required Beginning Date for IRA distributions is April 1st of the year following the year the decadent turned 70',~ years eld.
Did the decedent die prior to the Required Beginning Date? [] YES [] NO
[] Roll to Your Own IRA
Transfer my entire portion of the IRA Plan assets to my own IRA. I have attached IRA new account application, Form 200292'. I understand
that required distributions from my IRA must begin by my Required Beginning Date.
* Not required if you already have a non-brokerage custodial IRA with American Express Trust Company as Custodian.
[] Life Expectancy Payments
Transfer my entire portion of the IRA Plan assets to an Inherited IRA for my benefit. I understand that required distributions must beginibY
the later of December 31 of the year following the decedent's death, or December 31 of the year the Decedent would have attained 70/2
years of age. I have also included IRA Beneficiary Form 3993.
[] Five Year Rule* (Available only if decedent did not reach his or her Required Beginning Date)
Transfer my entire portion of the deceased's IRA assets into an inherited IRA for my benefit. I understand that if I elect this option, I must
withdraw the entire balance by December 31 of the fifth year after the IRA owner's death. I have also included IRA Designation of
Beneficiary Form 3993.
* This election is irrevocable as of the earlier of: (a) December 31 of the year the IRA owner would have attained age 7~//years of age
(b) December 31 of the year that contains 5th anniversary of the death of the IRA owner
[] Life Expectancy Payments
Transfer my entire portion of the IRA Plan assets to an Inherited IRA for my benefit. I understand that required distributions must begin by
December 31 of the year following the decedent's death. I have also included IRA beneficiary Form 3993.
[] Five-Year Rule* (Available only if decedent did not reach his or her Required Beginning Date)
Transfer my entire portion of the deceased's IRA Plan assets into an inherited IRA Plan for my benefit. I understand that if I elect this option,
I must withdraw the entire balance by December 31 of the fifth year after the IRA owner's death. I have also included IRA Designation of
Beneficiary Form 3993.
* This election is irrevocable as of December 31 of the year following the year of the IRA owner's death.
[] Life Expectancy Payments (Required if decedent reached his or her Required Beginning Date)
Transfer my entire portion of the IRA Plan assets to an Inherited IRA Plan for my benefit. I understand that required distributions must begin
no later than December 31 of the year following the decedent's death. I have also included IRA Beneficiary Form 3993.
[] Five-Year Rule (Required if decedent did not reach his or her Required Beginning Date)
Transfer entire portion of the deceased's IRA Plan assets into an inherited IRA Plan. I understand that if I elect this option, I must withdraw
the entire balance by December 31 of the fifth year after the IRA owner's death.
[] Check here if you are the beneficiary of an Inherited IRA
Required distributions from an inherited IRA must continue in the year following the year of the inherited IRA owner's death.
[] Look-Through Trust
If you are claiming this IRA on behalf of a trust and wish to take advantage of the IRS "look through" rules for trusts (IRS Reg. §1.401(a)(9)-
4, Q & A -6), complete and attach Form 200475.
3248 Page 8 of 10 G (12/03) ·
IRAs are charged an annual Custodial Fee and may also be charged an IRA Plan Termination Fee. Please refer to the publication "Your Guide to IRAs", available
from your American Express financial advisor.
For additional requests that are not included on this form, the claimant may attach the appropriate request form for processing after the death claim processing has been
completed. Please review the description for each item in order to determine if you need to include it with this form and identify the items you have included using the
check-off boxes.
[] Look-through Trust Documentation Form for IRAs Form 200475
This form is required if the beneficiary of the IRA is a Trust and the Trustee would like to take advantage of the "Look-Through" rules.
[] IRA Designation of Beneficiary for IRAs Held by American Express Trust Company as Custodian Form 3993
If you wish to designate a beneficiary, complete the form and attach to this Estate Settlement Form.
[] Mutual Fund and Certificate Redemption, Exchange and/or Transfer of Investment Form Fl19
This must be included if you wish to request liquidation of at-fund proprietary mutual fund or investment certificate account after your death claim has been processed.
Alternatively, for Mutual Fund, Certificate, Brokerage and SPS accounts, the new account owner may contact the corporate office by telephone to request this service after
the death claim has been processed.
[] Bank Authorization/Systematic Payout/Wirn/Direct Deposit Request Form 200433
Use this form to request any of those services for non-brokerage accounts.
[] Dividend or Interest Delivery Arrangement Form F140
This form must be included to provide dividend or interest delivery instructions on new direct-at-fund proprietary mutual fund accounts and investment certificate accounts.
If this form is not included, one of the two processing defaults described below will be exercised:
· If the assets are being transferred to a new account with a new account number, no arrangements will set up on the new account.
· If the assets are going to remain in the current existing account with the ownership registration changed to remove the decedent from the account, then any arrangement
existing on the account will remain.
[] Additional Account Features Form 10528
This form is required to continue any account features on your American Express Brokerage, SPS, SPS Advantage or ONE account.
[] Request to Move American Express Funds Form 200344
This form must be included to transfer shares in-kind of American Express mutual funds, currently held in direct-at-fund accounts to an existing American Express
Brokerage account.
[] Change of Side Account Designation for Limited Partnership/REIT Investment Form F246
This form is used to set up, discontinue or change Side Account Designations for Limited Partnership/REiT Investments. If this form is not included we will default to the side
fund designated for the deceased IRA owner.
Claimant Options - SPS Advantage Accounts Only - Check the box beside the option requested, If no option is elected, we will assume that the claimant's
intention is to liquidate the account within 90 days of completion of the death claim settlement
[] Claimant will hold an SPS Advantage Account and has signed and attached the SPS Advantage Service Agreement Form 23443
[] Claimant will be terminating the SPS Advantage agreement within 90 days of re-registration and agrees to the following terms:
· SPS Account Termination Fee will be waived on request at the time of complete liquidation of the SPS Account within 90 days of completion of the death claim settlement
· No SPS Advantage Services will be provided
· Account activity will be limited to liquidations and in-kind transfers only
· Claimant is responsible for submitting liquidation requests by calling 1-800-862-7919 and speaking to a trader to request liquidation or in-kind transfer of the account within
90 days of completion of the death settlement
Claimant Options - Premier Portfolio Services Accounts Only - Check the box beside the option requested.
[] Claimant will maintain existing account and has completed the appropriate agreement(s)
[] Claimant will be completely terminating the PREMIER PORTFOLIO SERVICES agreement(s) after re-registration and agrees to the following terms:
· No annual fee will be charged
· No Premier Portfolio Services will be provided
· Account activity will be limited to liquidations and in-kind transfers only
· Claimant is responsible for submitting written instructions for liquidation or in-kind transfer of the account to our office within 90 days of completion of the death settlement.
Telephone requests for liquidation or transfer of this account are not accepted.
Additional Information for Direct Investment Accounts- Limited Partnership Investments and REITs
· All Direct Investment accounts - limited partnerships and REITs held in the decedent's IRA will be settled pursuant to the instructions included on this form unless not allowed
by the General Partner.
· All Shurgard limited partnership investments accounts will be settled to an American Express Brokerage account.
· If Form F246, Change of Side Account Designation for Limited Partnership/REIT Investment has not been included and a side account must be established, it will be established
in the same product used by the deceased IRA owner.
3248 Page 9 of 10 G(12/o3) ·
·
The following statements apply to all accounts:
· I confirm that I am at least 18 years of age and full legal age in my state of residence.
· I understand you may use and combine information concerning accounts owned by members of a primary household group to provide members of the group with paper and/or
electronic statements of account(s) and certain account information. These accounts include: investment, insurance, annuity and brokerage accounts. A primary household
consists of an individual, his or her spouse or domestic partner, and any accounts owned for, by, or with their unmarried children under 21 who reside at the same address.
If you want to have a statement covering only accounts that you own and to not participate in household pricing, please call you American Express financial advisor, or the
service 800 number on your statement.
The following statements apply to Brokerage, SPS Advantage and PREMIER PORTFOLIO SERVICES, INC. accounts only:.
· I authorize American Enterprise Investment Services Inc. to lend to itself or to others, either separately or in common, any holding in my account that American Express
Financial Advisors may be carrying for me on margin. I understand that I may borrow against my account at the rates and terms explained in the client agreements
(non-qualified accounts only).
· I realize that the clearing agent, American Enterprise Investment Services Inc., will release my name, address and security position to requesting companies in which American
Enterprise Investment Services Inc. holds securities for my account, unless I specify otherwise to American Express Financial Advisors.
· I authorize American Enterprise Investment Services Inc. to lend to itself or to others, either separately or in common, any holding in my account that American Express Financial
Advisors may be carrying for me (non-qualified accounts only).
· I acknowledge that I have received the American Express Financial Advisors client agreements and agree to abide by their terms as currently in effect or as they may be
amended from time to time. This account is governed by a predispute arbitration clause, which is found in Section 13 of the client agreement. I acknowledge receipt of the
predispute arbitration clause.
The following statements apply to IRAs:
By signing this form you acknowledge the following:
· I appoint American Express Trust Company as custodian of my IRA and understand that the Individual Retirement Custodial Account Agreement in "Your Guide to IRAs' and my
IRA application, if applicable, comprise my custodial agreement with American Express Trust Company.
· I assume ail responsibility for any tax consequences and penalties that may result from making contributions to, transactions with, or distributions from my IRA.
· I acknowledge that if I executed the beneficiary designation on Form 3993, IRA Designation of Beneficiary for IRAs Held by American Express Trust Company as Custodian, my
signature acknowledges my understanding that this beneficiary designation applies to all investment accounts and products held in this IRA plan.
· I authorize American Express Trust Company to invest, directly or indirectly, in deposits of itself or its affiliates that bear a reasonable rate of interest to facilitate cash sweep services.
Taxpayer's Identification Number to Be Used Name (on IRS Records) Associated With This Tax Number
Under penalty of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number, and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, (b) I have not been notified by the Internal Revenue Service (IRS)
that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to
backup withholding, and
3. I am a U.S. pemon (including a U.S. resident alien).
You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and
dividends on your tax return.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
All New Owners/Fiduciaries Must Sign Here:
(Signature(s) of Joint Tenant, Beneficiary, Claimant, Trustee(s),
Legal Representative{s) for the Deceased's Estate or Other Fiduciarie(s) Date Signed
Ix
IX
Team ID Servicing Advisor Signature Advisor Number
iX
Check one: Comp % Area Office Number Phone Number ExL
~ FS
Team ID Servicing Advisor Signature Advisor Number
E:D iX
Comp % Area Office Number Phone Number Ext.
3248 Page 10 of 10 G (12/03) ·
EXHIBIT B
Mutual Fund and Certificate Redemption,
Exchange and/or Transfer of Investment
This form should be used to request full or partial sells of client's AXP Funds or AXP Certificates held direct at fund.
Do NOT use this form to request movement from an AXP Fund position held in a Brokerage or Wrap account.
Do NOT use this form to request "in-kind" or same fund share transfer to Brokerage or Wrap accounts, use Form 200344.
American Express' Funds
American Express Certificate Company
70100 AXP Financial Center
Minneapolis, MN 55474
Please print or type
Section 1 -- Account Identification
American Express Fund or Certificate Name
Client Name
Client Identification Number
001
Account Number
Name of Joint Tenant (Co-owner)
Client Identification Number of Joint Tenant (Co-owner)
Section 2 -- Redemption Instructions (Must also complete 2B) Must return outstanding stock certificates
2A -- Redemption Amount f~om Account in Section 1
Dollars Shares Percent All
$ i % []
: i ,, ~ · or or
· See Section 5 if account is any IRA plan, Keogh or TSCA
2B -- Delivery Instructions
or
[] Send check to client(s) at address of record
[] Express mail (Fee will be redeemed from the above account.)
[] Wire proceeds to my bank: (Complete Sections 8 and 9 on page 3 and 4. Wire fee will be redeemed from above account.)
[] Direct deposit proceeds to my bank: (Complete Sections 8 and 9 on page 3 and 4.)
[] Make check payable to special payee and/or special address:
CESA Ownership: Special payee is a valid member of the Coverdell Beneficiary's family. [] Yes [] No
Special Payee Name
Reference Number (if applicable)
Street (complete mailing address) City State ZIP Code
Redemptions/Transfers from American Express Certificate account:
[] Redeem certificate on (date) after interest is credited
[] Redeem certificate immediately
[] Redeem certificate at end of term (date)
F119 Page 1 of 4 · P
.0
Section 3-- Exchange/Transfer Instructions from Account in Section 1 (must return outstanding stock certificates)
TO: New Account Name* OR Existing Account Number** How Much in Each? ($, %, Shares) IRA Year or SEP
Transfer to purchase life insurance:
[] Process redemption when life policy approved
[] Process redemption to life account immediately
*Application must be attached: (1)if purchasing a new life or annuity account or (2)if new account has a different ownership.
**If the existing account has a different ownership or TOD designation than the account in Section 1 the amount transferred will be reregistered in the same ownership as the existing
account in Section 3.
Section 4 -- Dividend or Interest Instructions (Complete if creating a new account in Section 3)
A. Dividend/Interest Selection B. Delivery Instructions
[] Reinvest [] Send check to client(s) at record address.
[] Cash [] Electronically transfer to client's bank-- complete Section 9.
[] Split (mutual funds only) [] Send check to special payee name and/or address listed below.
[] Add to American Express Financial Advisors account number:
, i ~ Attach Form 443 if appropriate.
Special Payee Name
Reference Number
Street (complete mailing address) City State
If dividend/interest payout is from IRA, Keogh, SEP, SRA or TSCA account(s), indicate federal withholding instructions in Section 5.
section 5 ~ Tax:Qualified Withholding inStructiOns
IRA, Plans: (Including Traditional, Rollover, Roth, SEP, SRA) Distributions from these accounts are subject to optional withholding of 10% of taxable income.
We are required to withhold 10% unless you complete one of the following: [] Do Not Withhold [] Withhold %
Keogh and TSCA Accounts: 20% mandatory withholding is required on most distributions.
Required Minimum Distribution for Keogh and TSCA Clients over 70'£ RMD is only subject to optional 10% withholding.
We are required to withhold 10% unless you complete one of the following: [] Do Not Withhold [] Withhold %
Substantially Equal Periodic Payments (SEPP): Made over life. life expectancy, or for a period of 10 years or more are only subject to optional 10% withholding.
We are required to withhold 10% unless you complete one of the following: [] Do Not Withhold [] Withhold %
Attach Form 3996 SEPP Notification.
ZIP Code
~:119 Page 2 of 4 · P (~0/031
.0 .
Section 6-- Is there money systematically going into or coming out of the account in Section 17
A, Type [] Bank Authorization: B. Instructions [] Discontinue
[] Systematic Payout: [] Keep on old account (Partial exchange/transfer/redemption only)
[] Ltd. Partnership Distributions: [] Apply to new account
Special Instructions
If proceeds will be delivered to a new 529 plan account being established, and third party involvement is required to complete the delivery instructions, I understand by
signing below I am authorizing American Express Financial Advisors Inc. and the designated third party involved in the transaction to share and transmit the account
numbers involved as well as the information provided on this form. The third party is being asked to complete the delivery instructions in this form by providing the 529
Plan account number information (i.e. Reference number in Section 2B) and faxing this form to American Express Financial Advisors Inc. at 612-547-2640.
I understand American Express Financial Advisors Inc.'s ability to (and the timing of its ability to) transfer, redeem or otherwise act on the instructions in this form is
dependent upon American Express Financial Advisors Inc. receiving complete delivery instructions provided from the designated third party. The designated third
party may impose additional steps, requirements or documents to meet processing requirements.
Section 8-- Signatures
I (We) understand that if this account is a designated side fund, it will not be changed without specific instructions.
I (We) authorize the payment of the redemption proceeds to the payee (if requested). This redemption revokes any trust or TOD designation on the shares or account
being redeemed.
I (We) affirm the information on this form is correct and may be included in any required reports to tax or regulatory authorities.
I (We) accept responsibility for determining the eligibility for any transfer and/or redemption instructions reflected in this form. I (We) agree to hold American
Express Financial Advisors Inc. and its agent harmless for any and all situations arising from an ineligible or inappropriate transfer, or redemption.
Is this a solicited transaction(s)? [] Yes [] No
A transaction will be considered "solicited" when your American Express Advisor recommends the purchase or sale of a specific security or product.
Date
iX
Advisor Information
Servicing Advisor Signature
iX
Area Office
Phone Number
Date
Advisor ID Number
F]~9 Page 3 of 4 · P (10/03)
Section 9 -- Wire Transfer Authorization and/or Direct Deposit Authorization
[] This transaction only (Complete Section 9.)
[] Permanent Authorization (To select this option: The client's bank account ownership must be identical to the AEFA account ownership.)
(Complete Section 9.)
I (we) authorize the Fund, any other Fund offering the telephone redemption privilege to which I (we) may later transfer, and American Express Certificate Company,
to honor any request made by telephone which appears to be authentic for wire transfer(s) or direct deposit(s) from my (our) account(s). The proceeds will be credited
by wiring or direct depositing (whichever I (we) may designate at the time the transfer(s) is/are requested), directly to my (our) bank account described below. I (we)
understand that a fee and a wire service charge, if any, may be assessed for each redemption. I (we) acknowledge that the records of American Express Financial
Corporation will be binding upon all parties and neither the Fund nor American Express Certificate Company will be liable for any loss, damage or expenses arising
in connection with any direct deposit of proceeds credited through the Automated Clearing House or any similar system to credit payments or by wire transfer to
the bank described below.
Section 10 -- Financial Institution Information
Financial Institution Account Information and Type: [] Checking (Attach voided check) [] Savings (Complete information below) [] Starter check
Note: Money market accounts may be either checking or savings, check with your Financial Institution. (No wires using star~er checks)
Savings Account Owner(s)
Savings Account Number
Financial Institution Routing Transit Number/ABA Number (9 Digits)
Name of Financial Institution
Bank Phone Number Extension
Fl19 Page 4 of 4 · P (lo/o3)
'Estate ~lement ~orm
w Brokerage · SPS Advantage · Premier Portfolio Services
· Mutual Funds · Certificates · Shurgard (IRAs only)
· American Express ONE Financial Account · Direct Investments (IRAs only)
· Non-Oualified Accounts:
· IRAs:
Complete Sections 1 through 5 and 12
(Instructions on Page 2)
Complete Sections 6 through 12
(Instructions on Page 6)
3248 Page 1 of 10 G (~2/03) ·
*Estate Settlement , rm
· Non-Qualified Accounts
· Brokerage ,· Certificates
· Mutual Funds · Premier Portfolio Services, Inc.
· SPS Advantage · American Express ONE Financial Account
American Express Financial Advisors
70100 AXP Financial Center
Minneapolis, MN 55474
Please read the instructions (shown below) completely before completing this form for submission to American Express. Failure to provide all required
information for your claim may cause processing delays.
General Instructions for All Assets:
Non-Qualified: Sections 1 through 5 of this form are used to provide instructions for non-qualified assets. 0nly the accounts listed in Section 1 will be settled according
to the instructions provided in Section 1 through 5 of the form. See below for specific instructions for each section, t:or IRA assets please refer to Section
6 through 11 of this form. For non-qualified direct investment accounts- REITs and Limited Partnerships, please contact the General Partner directly
for instructions.
IRA: Sections 6 through 11 of this form are used to provide instructions for settling an IRA to the claimant. The IRA plan(s} for which instructions are provided
must be identified in Section 6 of this form. All investments held in the IRA plan(s) identified, including Limited Partnership investment and REIT accounts
will be settled pursuant to the instructions on this form. tf the decedent had multiple IRA plans and the claimant would like to make different elections for
each IRA plan, the claimant must complete a separate estate settlement form for each IRA plan. See Page 6 for more specific information on settling IRAs.
Purpose of Form: The purpose of this form is to re-title the deceased's assets in the r~ame of the claimant. The assets must be re-titled before the claimant may make
any account transaction requests.
Notify American Exoress Financial Advisors of the client's death before submittinn this form. This will facilitate the f;~A~ claim payment p~Tble.
· AEFA Advisors please call (888) 723-8476 menu options 1, 3,1. AEFA
· Claimants and Beneficiaries please call (BOO) 862-7919 menu options 5,1
· Complete a separate Estate Settlement Form for each claimant, account ownership and type of transfer instructions.
This form can be used to provide only one set of instructions. The instructions indicated in this section of the form will be applied to all accounts indicated in this section of the form.
· Liquidation of Accounts
This form cannot be used to request liquidation of an account. Once the assets are re-titled, the claimant may contact our office toll-free at 1-800-862-7919 to request
liquidation. For at-fund proprietary mutual funds and certificates, they may attach form F119 to this form and indicate they have done so in Section 4 of the form.
· Additional Service Transactions, Bank Authorizations, Dividends, Interest and Scheduled Distribution Arrangements
The claimant may request these services by attaching the appropriate request form. For non-qualified accounts see Section 4 for complete instructions.
· Un-cashed, Outstanding Checks
Any checks issued against the deceased person's accounts may be returned to us to be re-issued to the correct payee. Checks issued after the date of death are the property of
the beneficiary or claimant. Checks issued prior to the date of death are the property of the payee's estate and may be treated as an estate asset eligible for probate and
distribution by the legally appointed estate representative.
· Outstanding Stock Certificates
If there are outstanding stock certificates issued against an at-fund proprietary mutual fond account, the certificate(s) must be returned to our corporate office before your claim
can be processed. If you are unable to locate the outstanding certificates, your American Express financial advisor can assist you in submitting the appropriate loss and
indemnity statements to our corporate office. You may also call 1-800-862-7919, menu options 5, 1.
Each section of the form has specific instructions. If in any section of the form there is insufficient space to provide the information required, the claimant may provide that
information on a separate attachment page. If an attachment page is included, it must be signed and dated by all parties who sign the Estate Settlement Form and the section of
the form for which the attachment is included must have the words "see attachment" entered therein.
Section 1 - Existing Account Identification
Use this section of the form to identify the decedent's accounts that are affected by the instruction provided on this form. Claims will not be processed for accounts that are not listed.
Section 2 - Transfer Instructions and Authorization
Please use this section to identify the amount of each account being claimed that will be re-registered in the ownership of the claimant. The instructions in this section must
correspond exactly to any beneficiary instruction that exists on the decedent's account(s).
Sections 3, 3A, 3B and 3C - Beneficiary/Claimast Information for Non-Qualified Accounts
All claimants/beneficiaries of nonqualified accounts must complete this section to provide their instructions for ownership registration. We are required by law to obtain certain
personal information from you which will be used by us to verify your identity. If you do not provide us the information, we may not be able to open your account. If we are unable
to verify your identity, we reserve the right to close your account or take such other steps as we deem reasonable.
Section 4- Additional Requests
If you have attached forms for additional requests, such as liquidation, dividend or payout arrangements, etc., you must indicate so in this section of the form.
Section 5 - Supplemental Instructions for Brokerage, SPS Advantage, Premier Portfolio Services, Inc. Service and ONE Accounts
This Section must be completed for claimants of Brokerage, SPS Advantage and Premier Portfolio Services, Inc. Service Accounts. If this section is not completed, processing of
your claim may be delayed.
Section 12- Authorization and Acknowledgements
This section must be signed by all new owners and fiduciaries. If ali new owners and/or fiduciaries do not sign this section the claim will not be processed.
3248 Page 2 of 10 G {12/03)
!Estate Sel~lement Form
· Non-Qualified Accounts
· Brokerage i Certificates
· Mutual Funds · Premier Portfolio Services, Inc.
· SPS Advantage · American Express ONE Financial Account
American Express Financial Advisors
70100 AXP Financial Center
Minneapolis, MN 55474
Please Print or Type.
Account Numbers
· If any there are outstanding stock certificates issued for any American Express mutual fund account listed above, they must be returned to our office for this claim to be processed.
Decedent's Name
Decedent's Client ID Number Decedent's Date of Death
State of Residence
Decedent's Social Security Number
I assign subject to the approval of the Fund or IDS Certificate Company or American Enterprise Investment Services (the "Issuer"):
Transaction Amount '~Aii , : 0 :~ ; ~
; · Dollars % Percent .
Shares
Shares or certificate described above to person or persons named in Section 3, I irrevocably appoint American Express Financial Corporation to Transfer said securities on the
books of the issuer, with full power of substitution in the premises.
I affirm that the information in Section 1 and 2 of this form is correct, and may be included in any required reports to the tax or regulatory authorities.
(Signature(s) of Joint Tenant, Beneficiary. Claimant, Tru.~ted~J,
Legal
Repr~(~,,~rt,~/~/~en~/er'F/~J~ciarie(s)~'""------., - . ~-.n - ~/./ Date Signed
, x/p-"/14/4' ../,/...C//'~ ~. ~ '~"-,. ,.~ o. ~ =~ t,. ,~ ~ ~ 7 "zo, ~ o o ~
IX
3248 Page 3 of 10 6 (12103)
Guidelines for Completion of Sections 3, 3A, 3B and 3C
· We are required by law to obtain certain personal information from you which will be used by us to verify your identity. If you do not provide us the information, we may not be
able to open your account. If we are unable to verify your identity, we reserve the right to close your account or take such other steps as we deem reasonable.
,aa This section must be completed by all new owners/claimants of Non-Qualified accounts.
· For settlement of IRA Plan assets, please refer to Sections 6 through 12.
aa Claimants of Non-Qualified Brokerage, SPS Advantage, PREMIER PORTFOLIO SERVICES, INC. and American Express ONE Financial Accounts must also complete Section 5 of this form.
[] Individual
[] Joint Tenancy (WROS)
[] Tenants in Common
[] Trustee-Beneficiary (certificate accts only)
[] Tenants by Entirety
[] Community Property
[] Usufructuary/Life Tenant/Life Estate
[] Guardian/Conservator/Next Friend*
[] UTMA**
[] Estate***
/,~ Trust****
[] Organization .....
[] Other
Relationship to Decedent in Section 1
Citizenship- Check One Option: [] U.S. Citizen [] Resident Alien [] Non-Resident Alien
Name as it appears in IRS Records
Street Address
Date of Birth
Social Security Number
City State Postal Code
Relationship to Decedent person in Section 3A Date of Birth
Citizenship- Check One Option: [] U.S. Citizen [] Resident Alien [] Non-Resident AJien
Name as it appears in IRS Records Social Security Number
Street Address
City State Postal Code
Name of Fiduciary, Estate Representative, Trustee(s), Officer(s) of Organization, UTMA Custodian, Usufruct, Life Tenant/Estate
Name of Decedent, Trust, Organization, Minor, Naked Owner(s), Remaindermen
Street Address
Ci~ State
* If a fiducia~ ownership such as Guardianship or Conse~atorship is chosen, a court ce~ified copy of the cou~ order appointing the fiducia~ must be included.
'* If UTMA ownership is selected for a Minor beneficia~ or claimant, S~ial Securi~ Number for the Minor must be included.
*** If Estate ownership is selected, the Taxpayer Identification Number to be used for the Estate must be included as well as cou~ ce~Jfied copy of the order appointing the representative of the estate.
**** If Trust ownership is requested, the Taxpayer Identification Number to be used for the trust as well as the names of ALi trustees and the complete date of the trust must be included on this form
and a copy of the title, and signature pages of the trust document must be submi~ed with this form.
..... If the assets are to be registered in the name of an orgamzation, a corporate resolution identi~ing those officers authorized to sign on behalf of the organization must be included
Page 4 of 10
Taxpayer Identification Number of Claimant or Minor
Date of Trust (if Trust is claimant)
UTMA State (minor claimant)
Postal Code
For additional requests that are not included on this form, the claimant may attach the appropriate request form for processing after the death claim processing has been
completed. Please review the description for each item in order to determine if you need to include it with this form and identify the appropriate items using the check-off boxes.
'~ Mutual Fund and Certificate Redemption, Exchange and/or Transfer of Investment Form Fl19
This must be included if you wish to request liquidation of an at-fund proprietary mutual fund or investment certificate account after your death claim has been processed.
Alternatively, for Mutual Fund, Certificate, Brokerage and SPS accounts, the new account owner may contact the corporate office by telephone to request this service after the
death claim has been processed.
[] Bank Authorization/Systematic Payout/Wire/Direct Deposit Request Form 200433
Use this form to request any of those services for non-brokerage accounts
[] Systematic Contribution/Distribution Request Form Form 200353
Use this form to request any of those services, including Bank Authorizations and systematic payouts for brokerage accounts
[] Dividend or Interest Delivery Arrangement Form F140
This form must be included to provide dividend or interest delivery instructions on new direct-at-fund proprietary mutual fund accounts and investment certificate accounts.
If this form is not included, the processing defaults described below wilt be exercised:
· If the assets are being transferred to a new account with a new account number, no arrangements will set up on the new account
· If the assets are going to remain in the current existing account with the ownership registration changed to remove the decedent from the account, then any arrangement
existing on the account will remain
[] Additional Account Features Form 10528
This form is required to continue any account features on your American Express Brokerage, S'PS, SPS Advantage or ONE account
[] Request to Move American Express Funds Form 200344
This form must be included to transfer shams of American Express mutual funds, currently held in dimct-at-fund accounts in-kind to an existing American Express Rrokerage account.
Brokerage and SPS Advantage Accounts Only - Margin Account Agreement
If you do not elect to have a margin account by checking the box below, no margin account will be provided.
[] Yes, I agree to have a margin account*
* By checking this box I agree that I have received the client agreement and am bound by the terms set forth in the margin agreement therein.
Claimant Options - SPS Advantage Accounts Only - Check the box beside the option requested. If no option is elected, we will assume that the claimant's
intention is to liquidate the account within 90 days of completion of the death claim settlement
[] Claimant will hold an SPS Advantage Account and has signed and attached the SPS Advantage Service Agreement Form 23443
[] Claimant will be terminating the SPS Advantage agreement within 90 days of re-registration and agrees to the following terms:
· SPS Account Termination Fee will be waived on request at the time of complete liquidation of the SPS Account within 90 days of completion of the death claim settlement
· No SPS Advantage Services will be provided
· Account activity will be limited to liquidations and in-kind transfers only
· Claimant is responsible for submitting liquidation requests by calling 1-800-862-7919 and speaking to a trader to request liquidation or in-kind transfer of the account within 90
days of completion of the death settlement
Claimant Options - Premier Portfolio Services Accounts Only - Check the box beside the option requested.
[] Claimant will maintain existing account and has completed the appropriate agreement(s)
[] Claimant will be completely terminating the PREMIER PORTFOLIO SERVICES agreement(s) after re-registration and agrees to the following terms:
· No annual fee will be charged
· No Premier Portfolio Services will be provided
· Account activity will be limited to liquidations and in-kind transfers only
· Claimant is responsible for submitting written instructions for liquidation or in-kind transfer of the account to our office within 90 days of completion of the death settlement.
Telephone requests for liquidation or transfer of this account are not accepted.
ONE High-Yield Savings Account Information
Upon receipt of proof of death of any account holder(s) and receipt of complete claim requirements at our office, all assets held in the ONE High-Yield Savings account will be
transferred to the American Express ONE Financial Account held by American Express Financial Advisors Inc., and will be settl~,d to any beneficiaries, heirs or claimants as part of
the cash position of the American Express ONE Financial Account.
3248 Page 5 of 10 G (12/03)
".Estate Settlement Form
· , Custodial IRA Plans
· Brokerage · SPS Advantage · Shurgard
· Mutual Funds · Certificates · Premier Portfolio Services, Inc.
· Direct investment Account - Limited Partnerships and REITs
American Express Financial Advisors
70100 AXP Financial Center
Minneapolis, MN 55474
Please read the instructions (shown below) completely before completing this form for submission to American Express. Failure to provide ali required
information required for your claim may cause processing delays.
General Instructions
Notify American Express Financial Advisors of the IRA owner's death before submitting this form. This will facilitate the fastest claim payment possible.
· AEFA Advisors please call (888) 723-8476 menu options 1, 3, 1. AEFA
· Claimants and Beneficiaries please call (800) 862-7919 menu options 5, 1
· IRA Required Minimum Distribution (RMD)
If the decedent had reached his or her Required Beginning Date (RBD) and has not yet taken their Required Minimum Distribution (RMD), please contact our office for additional
instructions before completing this form.
· Complete a separate Estate Settlement Form for each claimant, account ownership and type of transfer instructions.
The instructions elected in Section 6 of the form will be applied to ali accounts in the IRA Plan(s) indicated. If a claimant is a beneficiary of multiple IRA plans and wishes to
provide different instructions for each IRA plan, he/she must complete a separate Estate Settlement Form for each IRA.
· Liquidation of Accounts
This form cannot be used to request a distribution from an IRA. This form can only be used to re-register the ownership of the iRA. Claimants wishing to take distributions after
completion of the death claims settlement may do so by contacting our office toll-free at 1-800-862-7919, or for proprietary mutual funds and certificates, they may attach the
appropriate liquidation request form to this Estate Settlement Form and indicate they have done so in Section 10 of the form.
· Additional Service Transactions, Bank Authorizations, Dividends, Interest and Scheduled Distribution Arrangements
These services cannot be requested using this form. However, the claimant may request a scheduled distribution arrangement by completing form 200433 and/or Form
indicating they have done so in Section 10 of the form.
· Un-cashed, Outstanding Checks
Any checks issued against the deceased person's IRA may be returned to us to be re-issued to the correct payee. Checks issued after the date of death are the property of the
beneficiary or claimant. Checks issued prior to the date of death are the property of the decedent's estate and may be treated as an estate asset eligible for probate and
distribution by the legally appointed estate representative.
· Accounts involving a deceased fiduciary, such as a court-appointed Guardian, Trustee, Custodian, Controller, etc.
While the ownership of these accounts does not need to be changed because the actual owner is not deceased, it is still necessary to complete the Estate Settlement form to
update the registration of the accounts to indicate any change in the identity of the person(s) in the fiduciary role.
Each section of the form has specific instructions. If there is insufficient space to provide the information required, the claimant may provide that information on a separate
attachment page. If an attachment page is included, it must be signed and dated by the claimant(s) and the section of the form for which the attachment is included must have the
words "see attachment" entered therein.
Section 6 - Existing IRA Plan Identification
Use this section of the form to identify the decedent's IRA Plans for which instructions are provided on this form. Instructions provided on this form apply to all accounts held in
the IRA Plan(s) identified on this form.
Section 7 - Claimant Information - IRAs
Ail beneficiaries of IRA plan accounts must complete this section to provide their instructions for ownership registration. We are required by law to obtain certain personal
information from you which will be used by us to verify your identity. If you do not provide us the information, we may not be able to open your account. Jf we are unable to verify
your identity, we reserve the right to close your account or take such other steps as we deem reasonable.
Section 8 - Settlement Options for IRAs
All beneficiaries of IRA plan accounts must complete this section to provide their instructions for ownership registration
Section 9 - IRA Fee Information
Statement of Administrative and Custodial fees for IRAs
Section 10 - Additional Requests
If you have attached forms for additional requests, such as liquidation, dividend or payout arrangements, etc., you must indicate so in this section of the form.
Section 11 - Supplemental Instructions and Information for Brokerage, SPS Advantage, Premier Portfolio Services and Direct Investment Accounts
This Section must be completed for claimants of Brokerage, SPS Advantage, Premier Portfolio Services and Direct Investment accounts. If this section is not completed, processing
of your claim may be delayed.
Section 12- Authorization and Acknowledgements
This section must be signed by all new owners and fiduciaries. If all new owners and fiduciaries do not sign this section, your claim will not be processed.
3248 Page 6 of 10 G (12/03)
Estate Settlement Form
,, Custodial IRA Plans
· Brokerage .. SPS Advantage - Shurgard
· Mutual Funds · Certificates · Premier Portfolio Services, Inc.
· Direct Investment Account - Limited Parmerships and REITs
American Express Financial Advisors
70100 AXP Financial Center
Minneapolis, MN 55474
Please Print or Type.
· List one account number below from each IRA Plan to be settled according to the instructions provided on this form.
· If you are the beneficiary for multiple IRA plans owned by the decedent and you wish to provide different settlement instructions for each IRA plan, you must submit those
instructions for each IRA Plan on a separate Estate Settlement Form.
· All accounts in the IRA plans identified on this form will be settled according to the single instructions indicated on this form whether or not those specific account numbers are listed.
· Identify the IRA Plan(s) being settled according to the instructions provided on this form by placing a check mark or "X" in the box corresponding to the IRA Plan types listed below:
[] Traditional (Active) IRA [] SIMPLE (SRA) [] Inherited (Beneficial/Deceased) IRA- All Types [] SEP IRA
[] Rollover (Segregated) IRA [] Roth Contributory IRA [] Roth Conversion IRA
Identify at least one account number from each IRA Plan type identified above
Account Numbers
Deceased's Name
Deceased's Client ID Number Deceased's Date of Death State of Residence Deceased's Social Security Number
Guidelines for Completion of Section 7 - Must be completed by all new owners/claimants of IRA Plan accounts.
· We are required by law to obtain certain personal information from you which will be used by us to verify your identity. If you do not provide us the information, we may not be
able to open your account. If we are unable to verify your identity, we reserve the right to close your account or take such other steps as we deem reasonable.
· For Non-Qualified Accounts refer to Page 4 of this form
· If the decedent's IRA held a Brokerage, SPS, Premier Portfolio or Direct Investment account you must review and complete Section 11 of this form.
· If Trust ownership is requested, the Taxpayer Identification Number to be used for the account as well as the names of All Trustees must be included as well as the complete
date of the trust and a copy of the title and signature pages of the trust document.
· If a fiduciary ownership such as Guardianship, Conservator or Estate is chosen, a certified copy of the court order appointing the fiduciary must be included.
· If Estate ownership is selected, the Taxpayer Identification Number to be used for the Estate must be included.
· If the assets are to be registered in the name of an organization, a corporate resolution identifying those officers authorized to sign on behalf of the organization must be included.
· If UTMA ownership is selected for a Minor beneficiary or claimant, Social Security Number for the Minor must be included.
Citizenship - Check One Option:
Date of Birth [] U.S. Citizen
[] Resident Alien
:: : F-I Non-Resident Alien
Taxpayer Identification Number
Claimant/Beneficiary Information
Relationship to Decedent in Section 1
, : .
Name as It Appears in IRS Records
!
Name of Guard an, Conservator, Custodian, Controller, Trustee(s),
and Estate Representative as Appropriate to the Ownership Registration
Street Address
Date of Trust (if Trust is claimant)
UTMA State (minor claimant)
City
State
Postal Code
3248 Page 7 of 10 G (12/o3) ·
Identify whether or not the decedent had reached his or her Required Beginning Date (RBD).
The Required Beginning Date for IRA distributions is April 1st of the year following the year the decedent turned 70S years old.
Did the decedent die prior to the Required Beginning Date? [] YES [] NO
[] Roll to Your Own IRA
Transfer my entire portion of the IRA Plan assets to my own IRA. I have attached IRA new account application, Form 200292*. I understand
that required distributions from my IRA must begin by my Required Beginning Date.
* Not required if you already have a non-brokerage custodial IRA with American Express Trust Company as Custodian.
[] Life Expectancy Payments
Transfer my entire portion of the IRA Plan assets to an Inherited IRA for my benefit. I understand that required distributions must beginl~y
the later of December 31 of the year following the decedent's death, or December 31 of the year the Decedent would have attained 70/2
years of age. I have also included IRA Beneficiary Form 3993.
[] Five Year Rule* (Available only if decedent did not reach his or her Required Beginning Date)
Transfer my entire portion of the deceased's IRA assets into an inherited IRA for my benefit. I understand that if I elect this option, I must
withdraw the entire balance by December 31 of the fifth year after the IRA owner's death. I have also included IRA Designation of
Beneficiary Form 3993.
* This election is irrevocable as of the earlier of: (a) December 31 of the year the IRA owner would have a~tained age 7~,~years of age
(b) December 31 of the year that contains 5th anniversary of the death of the IRA owner
[] Life Expectancy Payments
Transfer my entire portion of the IRA Plan assets to an Inherited IRA for my benefit. I understand that required distributions must begin by
December 31 of the year following the decedent's death. I have also included IRA beneficiary Form 3993.
[] Five-Year Rule* (Available only if decedent did not reach his or her Required Beginning Date)
Transfer my entire portion of the deceased's IRA Plan assets into an inherited IRA Plan for my benefit. I understand that if I elect this option,
I must withdraw the entire balance by December 31 of the fifth year after the IRA owner's death. I have also included IRA Designation of
Beneficiary Form 3993.
* This election is irrevocable as of December 31 of the year following the year of the IRA owner's death.
[] Life Expectancy Payments (Required if decedent reached his or her Required Beginning Date)
Transfer my entire portion of the IRA Plan assets to an Inherited IRA Plan for my benefit. I understand that required distributions must begin
no later than December 31 of the year following the decedent's death. I have also included IRA Beneficiary Form 3993.
[] Five-Year Rule (Required if decedent did not reach his or her Required Beginning Date)
Transfer entire portion of the deceased's IRA Plan assets into an inherited IRA Plan. I understand that if I elect this option, I must withdraw
the entire balance by December 31 of the fifth year after the IRA owner's death.
[] Check here if you are the beneficiary of an Inherited IRA
Required distributions from an inherited IRA must continue in the year following the year of the inherited IRA owner's death.
[] Look-Through Trust
If you are claiming this IRA on behalf of a trust and wish to take advantage of the IRS "look through" rules for trusts (IRS Reg. §1.401(a)(9)-
4, Q & A -6), complete and attach Form 200475.
3248
Page8of 10 G {12/03) I~
IRAs are charged an annual Custodial Fee and may also be charged an IRA Plan Termination Fee. Please refer to the publication "Your Guide to IRAs", available
from your American Express financial advisor.
For additional requests that are not included on this form, the claimant may attach the appropriate request form for processing after the death claim processing has been
completed. Please review the description for each item in order to determine if you need to include it with this form and identify the items you have included using the
check-off boxes.
[]Look-through Trust Documentation Form for IRAs Form 200475
This form is required if the beneficiary of the IRA is a Trust and the Trustee would like to take advantage of the "Look-Through" rules.
[] IRA Designation of Beneficiary for IRAs Held by American Express Trust Company as Custodian Form 3993
If you wish to designate a beneficiary, complete the form and attach to this Estate Settlement Form.
[] Mutual Fund and Certificate Redemption, Exchange and/or Transfer of Investu~ent Form Fl19
This must be included if you wish to request liquidation of at-fund proprietary mutual fund or investment certificate account after your death claim has been processed.
Altarnativeiy, for Mutual Fund, Certificate, Brokerage and SPS accounts, the new account owner may contact the corporate office by telephone to request this service after
the death claim has been processed.
[] Dank Authorization/Systematic Payout/VVire/Diract Deposit Request Form 200433
Use this form to request any of those services for non-brokerage accounts.
[] Dividend or Interest Delivery Arrangement Form F140
This form must be included to provide dividend or interest delivery instructions on new direct-at-fund proprietary mutual fund accounts and investment certificate accounts.
If this form is not included, one of the two processing defaults described below will be exercised:
· If the assets are being transferred to a new account with a new account number, no arrangements will set up on the new account.
· If the assets are going to remain in the current existing account with the ownership registration changed to remove the decedent from the account, then any arrangement
existing on the account will remain.
[] Additional Account Features Form 10528
This form is required to continue any account features on your American Express Brokerage, SPS, SPS Advantage or ONE account.
[] Request to Move American Express Funds Form 200344
This form must be included to transfer shares in-kind of American Express mutual funds, currently held in direct-at-fund accounts to an existing American Express
Brokerage account.
[] Change of Side Account Designation for Limited Partnership/REIT Investment Form F246
This form is used to set up, discontinue or change Side Account Designations for Limited Partnership/REIT investments. If this form is not included we will default to the side
fund designated for the deceased IRA owner.
Claimant Options - SPS Advantage Accounts Only - Check the box beside the option requested. If no option is elected, we will assume that the claimant's
intention is to liquidate the account within 90 days of completion of the death claim settlement
[] Claimant will hold an SPS Advantage Account and has signed and attached the SPS Advantage Service Agreement Form 23443
[] Claimant will be terminating ~he SPS Advantage agreement within 90 days of re-registration and agrees to the following terms:
· SPS Account Termination Fee will be waived on request at the time of complete liquidation of the SPS Account within 90 days of completion of the death claim settlement
· No SPS Advantage Services will be provided
· Account activity will be limited to liquidations and in-kind transfers only
· Claimant is responsible for submitting liquidation requests by calling 1-800-862-7919 and speaking to a trader to request liquidation or in-kind transfer of the account within
90 days of completion of the death settlement
Claimant Options - Premier Podolio Services Accounts Only - Check the box beside the option requested.
[] Claimant will maintain existing account and has completed the appropriate agreement(s)
[] Claimant will be completely terminating the PREMIER PORTFOLIO SERVICES agreement(s) after re-registration and agrees to the following terms:
· No annual fee will be charged
· No Premier Portfolio Services will be provided
· Account activity will be limited to liquidations and in-kind transfers only
· Claimant is responsible for submitting written instructions for liquidation or in-kind transfer of the account to our office within 90 days of completion of the death settlement.
Telephone requests for liquidation or transfer of this account are not accepted.
Additional Information for Direct Investment Accounts - Limited Partnership Investments and REITs
· All Direct investment accounts - limited partnerships and REITs held in the decedent's IRA will be settled pursuant to the instructions included on this form unless not allowed
by the General Partner.
· All Shurgard limited partnership investments accounts will be Settted to an American Express Brokerage account.
· If Form F246, Change of Side Account Designation for Limited Partnership/REIT Investment has not been included and a side account must be established, it will be established
in the same product used by the deceased IRA owner.
3248 Page 9 of 10 G (12/03) ·
The following statements apply to all accounts:
· I confirm that t am at least 18 years of age and full legal age in my state of residence.
· I understand you may use and combine information concerning accounts owned by members of a primary household group to provide members of the group with paper and/or
electronic statements of account(s) and certain account information. These accounts include: investment, insurance, annuity and brokerage accounts. A primary household
consists of an individual, his or her spouse or domestic partner, and any accounts owned for, by, or with their unmarried children under 21 who reside atthe same address.
If you want to have a statement covering only accounts that you own and to not participate in household pricing, please call you American Express financial advisor, or the
service 800 number on your statement.
The following statements apply to Brokerage, SPS Advantage and PREMIER PORTFOLIO SERVICES, INC. accounts only:
· I authorize American Enterprise Investment Services Inc. to lend to itself or to others, either separately or in common, any holding in my account that American Express
Financial Advisors may be carrying for me on margin. I understand that I may borrow against my account at the rates and terms explained in the client agreements
(non-qualified accounts only).
· I realize that the clearing agent, American Enterprise Investment Services Inc., will release my name, address and security position to requesting companies in which American
Enterprise Investment Services Inc. holds securities for my account, unless I specify otherwise to American Express Financial Advisors.
· 1 authorize American Enterprise Investment Services Inc. to lend to itself or to others, either separately or in common, any holding in my account that American Express Financial
Advisors may be carrying for me (non-qualified accounts only).
· I acknowledge that I have received the American Express Financial Advisors client agreements and agree to abide by their terms as currently in effect or as they may be
amended from time to time. This account is governed by a predispute arbitration clause, which is found in Section 13 of the client agreement. I acknowledge receipt of the
predispute arbitration clause.
The following statements apply to IRAs:
By signing this form you acknowledge the following:
· 1 appoint American Express Trust Company as custodian of my IRA and understand that the Individual Retirement Custodial Account Agreement in "Your Guide to IRAs" and my
IRA application, if applicable, comprise my custodial agreement with American Express Trust Company.
· I assume all responsibility for any tax consequences and penalties that may result from making contributions to, transactions with, or distributions from my IRA.
· I acknowledge that if I executed the beneficiary designation on Form 3993, IRA Designation of Beneficiary for IRAs Held by American Express Trust Company as Custodian, my
signature acknowledges my understanding that this beneficiary designation applies to all investment accounts and products held in this IRA plan.
· I authorize American Express Trust Company to invest, directly or indirectly, in deposits of itself or its affiliates that bear a reasonable rate of interest to facilitate cash sweep services.
Taxpayer's Identification Number to Be Used Name (on IRS Records)Associated With This Tax Number
..... ................ ·
Under penalty of perjury, I certify that:
1, The number shown on this form is my correct taxpayer identification number, and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, (b) I have not been notified by the Internal Revenue Service (IRS)
that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to
backup withholding, and
3. I am u U.S. person (including a U.S. resident alien).
You must cross out Item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and
dividends on your tax return.
The Internal Revenue Service does not require your consent to any prevision of this document other than the certifications required to avoid backup withholding.
All New Owners/Fiduciaries Must Sign Here:
(Signature(s) of Joint T..e~m)t, Bene_ficia_ry,.,Gteimant, Tr.,uste~
IX
Team ID Servicing Advisor Signature Advisor Number
iX
Check one: Comp % Area Office Number Phone Number Ext.
[] FS
Team ID Servicing Advisor Signature Advisor Number
iX
Comp % Area Office Number Phone Number Ext.
3248 Page 10 of 10 G (t2/03) O
Mutual Fund and Certificate I edeml ion,
Exchange ;and/or Transfer of Investment
This form should be used to request full or partial sells of client's AXP Funds or AXP Certificates held direct at fund.
Do NOT use this form to request movement from an AXP Fund position held in a Brokerage or Wrap account.
Do NOT use this form to request "in-kind" or same fund share transfer to Brokerage or Wrap accounts, use Form 200344.
American Express' Funds
American Express Certificate Company
70100 AXP Financial Center
Minneapolis, MN 55474
Ptease print or type
Section 1 m Account Identification
American Express Fund or Certificate Name
Client Name
Client Identification Number
" 001
Account Number
Name of Joint Tenant (Co-owner)
Client Identification Number of Joint Tenant (Co-owner)
Section 2 m Redemption Instructions (Must also complete 2B) Must return outstanding stock certific/,tes
2A ~ Redemption Amount from Account in Section 1
Dollars Shares Percent All
$ ~ . %
........ i · · L,,~ or or
· See Section 5 if account is any IRA plan, Keogh or TSCA
_.Send check to client(s) at address of record or
Express mail (Fee will be redeemed from the above account.)
[] Wire proceeds to my bank: (Complete Sections 8 and 9 on page 3 and 4. Wire fee will be redeemed from above account.)
[] Direct deposit proceeds to my bank: (Complete Sections 8 and 9 on page 3 and 4.)
[] Make check payable to special payee and/or special address:
CESA Ownership: Special payee is a valid member of the Coverdell Beneficiary's family. [] Yes [] No
~t~cial P~e Name
Reference Number (if applicable)
Street (complete mailing address)
Cit,/ State ZIP Code
Redemptions/Transfers from American Express Certificate account:
[] Redeem certificate on (date) after interest is credited
[] Redeem certificate immediately
[] Redeem certificate at end of term (date)
F119 Page 1 of 4 · P (70/03l
Section 3 -- Exchange/Transfer Instructions from Account in Section 1 (must return outstanding stock certificates)
TO: New Account Nome* OR Existing Account Number** How Much in Each? ($, %, Shares)
IRA Year or SEP
Transfer to purchase life insurance:
[] Process redemption when life policy approved
[] Process redemption to life account immediately
*Application must be attached: (1) if purchasing a new life or annuity account or (2) if new account has a different ownership.
**If the existing account has a different ownership or TOD designation than the account in Section 1 the amount transferred will be reregistered in the same ownership as the existing
account in Section 3.
Section 4 -- Dividend or Interest Insb'uctions (Complete if creating a new account in Section 3)
A. Dividend/Interest Selection
[] Reinvest
[] Cash
[] Split (mutual funds only)
Special Payee Name
B. Delivery Instructions
[] Send check to client(s) at record address.
[] Electronically transfer to client's bank -- complete Section 9,
[] Send check to special payee name and/or address listed below.
[] Add to American Express Financial Advisors account number:
Attach Form 443 if appropriate.
Reference Number
Street (complete mailing address) City State ZIP Code
If dividend/interest payout is from IRA, Keogh, SEP, SRA or TSCA account(s), indicate federal withholding instructions in Section 5.
sectio. 5. ~:'au'~iifi'~ Withholding Instructions .......................................
IRA, Plans: (Including Traditional, Rollover, Roth, SEP, SRA) Distributions from these accounts are subject to optional withholding of 10% of taxable income.
We are required to withhold 10% unless you complete one of the following: [] Do Not Withhold [] Withhold ·
Keogh and TSCA Accounts: 20% mandatory withholding is required on most distributions.
Required Minimum Distribution for Keogh and T$CA Clients over 70~ RMD is only subject to optional 10% withholding.
We are required to withhold 10% unless you complete one of the following: [] Do Not Withhold [] Withhold %
Substantially Equal Periodic Payments (SEPP): Made over life, life expectancy, or for a period of 10 years or more are only subject to optional 10% withholding.
We are required to withhold 10% unless you complete one of the following: [] Do Not Withhold [] Withhold %
Attach Form 3996 SEPP Notification.
F719
Page 2 of 4 · P (10/03)
Section 6-- Is there money systematically going into or coming out of the account in Section 17
A. Type [] Bank Authorization: B. Instructions [] Discontinue
[] Systematic Payout: [] Keep on old account (Partial exchange/transfer/redemption only)
[] Ltd. Partnership Distributions: [] Apply to new account
Special Instructions
Section 7 -- Redemptions to 529 Plans only
If proceeds will be delivered to a new 529 plan account being established, and third party involvement is required to complete the delivery instructions, I understand by
signing below I am authorizing American Express Financial Advisors Inc. and the designated third party involved in the transaction to share and transmit the account
numbers involved as well as the information provided on this form. The third party is being asked to complete the delivery instructions in this form by providing the 529
Plan account number information (i.e. Reference number in Section 2B) and faxing th'is form to American Express Financial Advisors Inc. at 612-547-2640.
I understand American Express Financial Advisors Inc.'s ability to (and the timing of its ability to) transfer, redeem or otherwise act on the instructions in this form is
dependent upon American Express Financial Advisors Inc. receiving complete delivery instructions provided from the designated third party. The designated third
party may impose additional steps, requirements or documents to meet processing requirements.
Section 8-- Signatures
I (We) understand that if this account is a designated side fund, it will not be changed without specific instructions.
I (We) authorize the payment of the redemption proceeds to the payee (if requested). This redemption revokes any trust or TOD designation on the shares or account
being redeemed.
I (We) affirm the information on this form is correct and may be included in any required reports to tax or regulatory authorities.
I (We) accept responsibility for determining the eligibility for any transfer and/or redemption instructions reflected in this form. I (We) agree to hold American
Express Financial Advisors Inc. and its agent harmless for any and all situations arising from an ineligible or inappropriate transfer, or redemption.
Is this a solicited transaction(s)? [] Yes [] No
A transaction will be considered "solicited" when your American Express Advisor recommends the purchase or sale of a specific security or product.
iX
iX
Date '
Advisor information ........................
Servicing Advisor Signature
LX
Area Office Phone Number
Advisor fEI Number
Fl19
Page 3 of 4 · P(lO/03)
Section 9-- Wire Transfer Authorization and/or Direct Deposit Authorization
[] This transaction only (Complete Section 9.)
[] Permanent Authorization (To select this option: The client's bank account ownership must be identical to the AEFA account ownership,)
(CompJete Section 9.)
I (we) authorize the Fund, any other Fund offering the telephone redemption privilege to which I (we) may later transfer, and American Express Certificate Company,
to honor any request made by telephone which appears to be authentic for wire transfer(s) or direct deposit(s) from my (our) account(s). The proceeds will be credited
by wiring or direct depositing (whichever I (we) may designate at the time the transfer(s) is/are requested), directly to my (our) bank account described below. I (we)
understand that a fee and a wire service charge, if any, may be assessed for each redemption. I (we) acknowledge that the records of American Express Financial
Corporation will be binding upon all parties and neither the Fund nor American Express Certificate Company will be liable for any loss, damage or expenses arising
in connection with any direct deposit of proceeds credited through the Automated Clearing House or any similar system to credit payments or by wire transfer to
the bank described below.
SeCtim~ io'~'Financial institution info~afio~
Financial Institution Account Information and Type: [] Checking (Attach voided check) [] Savings (Complete information below) [] Starter check
Note: Money market accounts may be either checking or savings, check with your Financial Institution. (No wires using starter checks)
Savings Account Owner(s)
Savings Account Number
.
Financial Institution Routing Transit Number/ABA Number (9 Digits)
Name of Financial Institution
Bank Phone Number
Extension
Fl19 Page 4 of 4 0 P (I0/031
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA Z71ZS-0601
COMMONWEALTH OF PENNSYLVANTA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEHENT OF ACCOUNT
REV-I$07 EX &FP (01-03)
EDWARD L SCHORPP'04 ,~* 2~
MARTSON ETAL
10 E HIGH ST
CARLISLE ~.~ PA
17015
DATE 10-12-ZOOq
ESTATE OF WARNER
DATE OF DEATH 09-Z7-2005
FILE NUHBER 21 0~-0588
COUNTY CUMBERLAND
ACM 101
Amoun~ Remi~ed
JAN L
HAKE CHECK PAYABLE AND REHZT PAYHENT TO:
REGISTER OF WILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17015
NOTE: To insure proper crmdi~ ~o your account, subm/~: ~he upper por~:ion of ~his form wi~h your ~ax payment:.
CUT ALONG TH:iS LZNE ~ RETA:[N LOWER PORTZON FOR YOUR RECORDS -~
REV-1607 EX AFP (01-03) ~ INHERITANCE TAX STATEMENT OF ACCOUNT
ESTATE OF WARNER JAN L FILE NO. 21 0~-0588 ACN 101 DATE 10-12-200q
THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACM IN THE NAMED ESTATE. SHONN BELON
IS A SUNHARY OF THE PR/NC/PAL TAX DUE, APPLICATION OF ALL PAYHENTS, THE CURRENT BALANCE, AND, IF APPLICABLE,
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 08-$0-200~
PRINCIPAL TAX DUE: ...........................................................................................................................................................................................................................
PAYMENTS (TAX CREDITS):
155.96
PAYMENT RECEIPT DISCOUNT (+)
DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID
08-$1-200~ CDOO~$Z~ .96- 135.12
IF PAID AFTER THIS DATE, SEE REVERSE
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
( ZF TOTAL DUE ZS LESS THAN $1,
NO PAYMENT ZS REQUIRED.
ZF TOTAL DUE ZS REFLECTED AS A "CREDIT" (CR),
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.
15~.16
.20CR
.00
.ZOCR
PAYMENT:
Detach the top portion of this Notice and submit with your payment made payable to the name and address
printed on the reverse side.
-- If RES[BENT DECEDENT make check or money order payable to: REGISTER OF WILLS, AGENT.
-- If NON-RES[BENT DECEDENT make check or money order payable to: COMMONWEALTH OF PENNSYLVANIA.
REFUND (CA]: A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an
"AppIication for Refund of Pennsylvania Inheritance and Estate Tax" (REV-ISIS). Applications ara available at
the Office of the Register of NiLls, any of the Z5 Revenue Bistrict Offices or from the Department's Z4-hour
ensnaring service for fores ordering: 1-800-36Z-Z050~ services for taxpayers with specie! hearing and / or
speaking needs: 1-800-447-30Z0 (TT onLy).
REPLY TO: guastions regarding errors contained on this notice should ba addressed to: PA Department of Revenue, Bureau
of [ndividuaI Taxes, ATTN: Post Assessment Review Unit, Dept. Z8060I, Harrisburg, PA I7[Z8-060I, phone
(717) 787-6505.
DISCOUNT: If any tax due is paid within three [3) calendar months after the decadant's daath~ a five percent (5X) discount
of the tax paid is aiIowsd.
PENALTY: The 15Z tax amnesty non-participation penaZty is computed on the totaI of the tax and interest assessed, and not
paid before January Z8, I996, the first day after the end of the tax amnesty period.
INTEREST:
Interest is charged beginning with first day of delinquency, or nine (9) months and one EX) day from the date of
death, to the date of payment. Taxes which became deIinquent before January I, [982 bear interest at the rate of
six (6X) percent per annum caIcuIated at a daily rate of .000[64. Ali taxes which became deIinquent on and after
January I, 1982 will bear interest at a rate which wilI vary from caIandar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for I982 through 2004 are:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
198Z lOX .000548 1988-1991 llZ .go050[ ZOO[ 9Z .000247-
1983 16X .000438 199Z 9X .000247 ZOOZ 62 .000164
1984 llX .000301 1993-1994 72 .00019Z ZOO5 52 .000157
1985 152 .000356 1995-1998 92 .000Z47 Z004 4X .000110
1986 lB[ .000274 1999 7Z .O0019Z
1967 9X .000247 2000 8X .000219
--Interest is calculatad as follows:
INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DALLY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (153 days
beyond the date of the assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must be calculated.
'-...UlllUeLJ.dIlQ LOUm:y - J:<.eglster at Wills
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 6/06/2005
ROGERS ELYSE E
415 FALLOWFIELD ROAD
SUITE 102
CAMP HILL, PA 17011-4906
RE: Estate of O'BRIEN JANET M
File Number: 2003-00588
Dear Sir/Madam:
It has come to my attention that you have not filed the Status
Report by Personal Representative (Rule 6.12) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO.
103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after
July I, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by:
7/03/2005
Your prompt attention to this matter will be appreciated.
Thank You.
Sincerely,
~I'~~AJ~
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
cc: File
Personal Representative(s)
Judge
cd
-
Register of Wills of Cumberland County
STATUS REPORT UNDER RULE 6.12
Name of Decedent: Janet M. 0' Brien
Date of Death: July 3, 2003
Estate No.: 2003-00588
Pursuant to Rille 6.12 of the Supreme Court Orphans' Court Rilles, I report the following
with respect to completion of the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes 0 No ~
2', If the answer is No, state when the personal representative reasonably believes that
the administration will be complete: August 31, 2005
3. If the answer to No, 1 is Yes, state the following:
a. Did the personal representative file a :final account with the Court?
Yes 0 No 0
b. The separate Orphans' Court No, (if any) for the personal representative's
account is:
c. Did the personal representative state an account informally to the pa.."iies in
interest? Yes 0 No 0
Date:
c. Copies of receipts, releases, joinders and approval offarmal or informal
accounts may be filed with the Clerk ,of the Orphans' Court and may be
61lDI05 attached to tbisreport _ _ _ _ _ _ ~.
~ReitZel'Vice President
. .:)
Hershey Trust Canpany
Name
100 Mansion Road, P.O. Box 445, Hershey, PA 17033
Address
717-520-1109
Telephone No.
Capacity: rn Personal Representative
o Counsel for personal representative
~
COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
PENNSYLVANIA ORPHANS' COURT DIVISION
First And Final Account
FIRST AND FINAL ACCOUNT OF
Hershey Trust Company, Executor
.> For
ESTATE of JANET M. O'BRIEN, Deceased
No. 0588 of 2003
Stated by HERSHEY TRUST COMPANY, Executor
Date of Death:
Date of Executor's Appointment:
Advertisement of the Grant of Letters:
Accounting for the Period:
July 3, 2003
July 22, 2003
August 26,2003
July 21 , 2003
to September 15, 2005
Purpose of Account: Robert K. Reitzel, Vice President and Trust Officer, Hershey Trust
Company, offers this account to acquaint interested parties with the transactions that have
occurred during their administration.
The account also indicates the proposed distribution of the estate.
It is important that the account be carefully examined. Requests for additional information
or questions or objections can be discussed with:
Robert K. Reitzel
Vice President and Trust Officer
Hershey Trust Company
P.O. Box 445
Hershey, PA 17033
(717) 520-1109
SUMMARY OF ACCOUNT
Fiduciary
Current Acquisition
Page Value Value
Proposed Distributions to
Beneficiaries 13 $16,449.67 $16,449.67
Principal
Receipts 2 $315,333.90
Net Gain (or Loss) on Sales or
Other Dispositions 2 -.3 9,052.43
324,386.33
Less Disbursements:
Debts of Decedent 4 $86,807.19
Funeral Expenses 4 10,134.47
Family Exemption 4 0.00
Administration Expenses 4-5 12,460.76
Federal and State Taxes 5 8,251.00
Fees and Commissions 5 23,720.00 141,373.42
Balance before Distributions $183,012.91
Distributions to Beneficiaries 6 167,951.00
Principal Balance on Hand 7 $15,061.91
For Information:
Investments Made 7-9
Changes in Investment Holdings 9
Income
Receipts 10-11 $2,005.45
Less Disbursements 12 129.27
Balance Before Distributions $1,876.18
Distributions to Beneficiaries 12 640.42
Income Balance on Hand 12 1,235.76
Combined Balance on Hand $16,297.67
1
RECEIPTS OF PRINCIPAL
Assets Listed in Inventory, per copy attached
07/05/2003
11/18/2003
01/08/2004
01/15/2004
05/18/2004
06/08/2004
1 0/07/2004
Various
Receipts Subsequent to Inventory:
PSECU - A TM rebate
Erie Insurance Group - partial reimbursement of auto
insurance premium
BSI Financial Services - refund of escrow balance
PPL Electric Utilities - refund
US Treasury - individual income tax refund
PA Department of Revenue - inheritance tax refund
PEBTF - medical insurance reimbursements
Dividends transferred from income for reinvestment
1.76
74.00
941 .43
12.80
3,615.00
75.56
199.99
640.42
Fiduciary
Acquisition
Value
$309,772.94
5,560.96
Total Receipts of Principal
$315,333.90
2
Gain Loss
08/29/2003 953.289 shs Liberty Select Value Fund
Net Proceeds $20,028.60
Fiduciary Acquisition Value 19,418.50 $610.10
08/29/2003 1,230.991 shs Van Kampen Growth & Income Fund
Net Proceeds $19,708.17
Fiduciary Acquisition Value 19,498.90 $209.27
08/29/2003 378.586 shs Washington Mutual Investment Fund
Net Proceeds $9,812.95
Fiduciary Acquisition Value 9,763.73 $49.22
10/21/2003 1999 Toyota Corolla Sedan
Net Proceeds $5,130.00
Fiduciary Acquisition Value 5,130.00 $0.00
GAINS AND LOSSES ON SALES OR OTHER DISPOSITIONS
12/18/2003 Residential Real Estate 321 Cascade Road Mechanicsburg, PA
Net Proceeds $111,769.22
Fiduciary Acquisition Value 111,769.22 $0.00
08/04/2004 5,823.524 shs AXP Partners Value Fund
Net Proceeds $28,709.97
Fiduciary Acquisition Value 24,931.14 $3,778.83
08/04/2004 1,151.867 shs AXP New Dimensions Fund
Net Proceeds $25,945.23
Fiduciary Acquisition Value 24,845.77 $1,099.46
08/04/2004 1,772.777 shs AXP Equity Select Fund
Net Proceeds $19,943.74
Fiduciary Acquisition Value 18,738.25 $1,205.49
08/04/2004 5,570.022 shs AXP Strategy Fund
Net Proceeds $21,054.68
Fiduciary Acquisition Value 19,717.88 $1,336.80
08/04/2004 1,876.183 shs AXP Short Duration US Government Fund
Net Proceeds $9,043.20
Fiduciary Acquisition Value 9,246.59 ($203.39)
08/04/2004 1,897.743 shs AXP Diversified Bond Fund
Net Proceeds $9,128.14
Fiduciary Acquisition Value 9,331.09 ($202.95)
08/04/2004 55.48 shs AXP Insured Tax Exempt Fund
Net Proceeds $300.15
Fiduciary Acquisition Value 310.86 ($10.71)
08/04/2004 884.295 shs AXP New Dimensions Fund
Net Proceeds $19,825.89
Fiduciary Acquisition Value 18,645.58 $1,180.31
Total Gains and Losses
Less Losses
$9,469.48
(417.05)
($417.05)
$9,052.43
Net Gain
3
DISBURSEMENTS OF PRINCIPAL
Debts of Decedent
07/29/2003 Upper Allen Township - utility payment
07/29/2003 Fleet Credit Card Service - balance on account
07/29/2003 PPL Electric Utilities - balance due on utility account
07/31/2003 PSECU - outstanding checks at time of death per
statement
08/01/2003 United Water Pennsylvania - balance due on account
08/11/2003 Susquehanna Breast Care Center - balance due on
account
08/14/2003 Citi Cards - balance due on account
08/14/2003 Bank One - payment on car loan
09/10/2003 Jay Braderman - attorney fees incurred prior to death
09/11/2003 Bank One - payoff of car loan
09/29/2003 BSI Financial Services - mortgage payment
10/21/2003 West Shore EMS - services provided 6/28/03
10/27/2003 BSI Financial Services - mortgage payment
12/01/2003 BSI Financial Services - mortgage payment
12/18/2003 BSI Financial Services - mortgage payoff
12/23/2003 Quantum Imaging & Theapeutic Billing Office-
balance due for services 6/30/03
03/01/2004 West Shore EMS - BLS - services provided 2/4/03
04/14/2003 PA Department of Revenue - balance due on final life
state income tax return
Funeral Expenses
07/29/2003 Lord & Taylor - purchase of funeral dress
07/29/2003 Rose O'Brien - reimbursement for funeral expenses
07/29/2003 Anita Sirak - reimbursement for funeral expenses
08/06/2003 Office of Catholic Cemeteries - burial expenses
08/06/2003 Malpezzi Funeral Home - professional services
Family Exemption
Administration Expenses
07/21/2003 Register of Wills Cumberland County - probate fees
07/31/2003 The Jewelers Bench - appraisal fee
08/26/2003 The Patriot News Company - estate advertising
08/26/2003 PPL Electric Utilities - utility payment 321 Cascade Rd
Mechanicsburg, PA
08/26/2003 Cumberland Law Journal - estate advertising
09/03/2003 United Water Pennsylvania - utility payment 321
Cascade Rd Mechanicsburg, PA
09/04/2003 P Scott Archibald - real estate appraisal
09/08/2003 Veri Williams - trash removal from 321 Cascade Road
Mechanicsburg, PA
4
$100.00
69.48
57.82
1,119.40
39.43
1,568.00
54.61
270.56
3,805.50
4,130.64
657.99
881.25
657.99
657.99
72,115.28
205.00
407.25
9.00
78.39
139.93
665.65
950.00
8,300.50
381.00
20.00
241.15
38.21
75.00
6.75
300.00
440.00
$86,807.19
10,134.47
0.00
09/12/2003 Erie Insurance Group - car insurance premium 128.00
09/17/2003 PPL Electric Utilities - utility payment 321 Cascade Rd 30.41
Mechanicsburg, PA
09/26/2003 Federal Express - package shipped 9/11/03 13.28
09/30/2003 United Water Pennsylvania - utility payment 321 6.75
Cascade Rd Mechanicsburg, PA
10/15/2003 Upper Allen Township - utility payment 321 Cascade 100.00
Road Mechanicsburg, PA
10/21/2003 PPL Electric Utilities - utility payment 321 Cascade Rd 18.25
Mechanicsburg, PA
1 0/31/2003 United Water Pennsylvania - utility payment 321 6.75
Cascade Rd Mechanicsburg, PA
11/18/2003 United Water Pennsylvania - utility payment 321 23.28
Cascade Rd Mechanicsburg, PA
12/05/2003 United Water Pennsylvania - utility payment 321 11.07
Cascade Rd Mechanicsburg, PA
12/23/2003 PPL Electric Utilities - utility payment 321 Cascade Rd 12.80
Mechanicsburg, PA
01/06/2004 United Water Pennsylvania - utility payment 321 6.75
Cascade Rd Mechanicsburg, PA
01/06/2004 PPL Electric Utilities - utility payment 321 Cascade Rd 15.68
Mechanicsburg, PA
01/21/2004 Jay Braderman, Esq - legal fees regarding custody of 6,888.65
Sean O'Brien
03/23/2004 Jay Braderman, Esq - legal fees regarding custody of 340.50
Sean O'Brien
03/29/2004 Register of Wills - PA Inheritance Tax filing fee 15.00
07/21/2004 Jay Braderman, Esq - legal fees regarding custody of 3,061.48
Sean O'Brien
RESERVE Register of Wills Cumberland County - filing fees 280.00
12,460.76
Federal and State Taxes
1 % 1 /2003 Register of Wills, Agent - prepayment of PA Inheritance 8,000.00
Tax
09/15/2005 PA Department of Revenue - fiduciary income tax 251.00
8,251.00
Fees and Commissions
01/09/2004 Hershey Trust Company - real estate sale commission 2,400.00
04/20/2004 Keefer, Wood, Allen & Rahal - estate legal expenses 5,264.94
09/21/2004 Keefer, Wood, Allen & Rahal - estate legal expenses 1,331.04
03/11/2005 Keefer, Wood, Allen & Rahal- estate legal expenses 309.00
RESERVE Keefer, Wood, Allen & Rahal- estate legal expenses 3,095.02
RESERVE Hershey Trust Company, Executor's Fee 11,320.00
23,720.00
Total Principal Disbursements $141,373.42
5
DISTRIBUTIONS OF PRINCIPAL TO BENEFICIARIES
08/11/2004 Janet M. O'Brien Trust for benefit of Sean O'Brien - Per Item IV of the
Last Will and Testament of Janet M. O'Brien
09/17/2004 Janet M. O'Brien Trust for benefit of Sean O'Brien - Per Item IV of the
Last Will and Testament of Janet M. O'Brien
TRANSFER OF PRINCIPAL TO INCOME
07/24/2003 AXP Short Duration US Govt Fund - dividend reinvestment
07/24/2003 AXP Diversified Bond Fund - dividend reinvestment
07/24/2003 AXP Insured Tax Exempt Fund - dividend reinvestment
08/22/2003 AXP Short Duration US Govt Fund - di!vidend reinvestment
08/22/2003 AXP Diversified Bond Fund - monthly dividend
08/22/2003 AXP Insured Tax Exempt Fund - dividend reinvestment
09/22/2003 AXP Short Duration US Govt Fund - dividend reinvestment
09/22/2003 AXP Diversified Bond Fund - monthly dividend
09/22/2003 AXP Insured Tax Exempt Fund - dividend reinvestment
10/23/2003 AXP Short Duration US Govt Fund - dividend reinvestment
10/23/2003 AXP Diversified Bond Fund - monthly dividend
10/23/2003 AXP Insured Tax Exempt Fund - dividend reinvestment
11/21/2003 AXP Short Duration US Govt Fund - dividend reinvestment
11/21/2003 AXP Diversified Bond Fund - monthly dividend
11/21/2003 AXP Insured Tax Exempt Fund - dividend reinvestment
12/18/2003 AXP Partners Value Fund - dividend reinvestment
12/22/2003 AXP Short Duration US Govt Fund - dividend reinvestment
12/22/2003 AXP Diversified Bond Fund - monthly dividend
12/22/2003 AXP Insured Tax Exempt Fund - dividend reinvestment
01/26/2004 AXP Short Duration US Govt Fund - dividend reinvestment
01/26/2004 AXP Diversified Bond Fund - monthly dividend
01/26/2004 AXP Insured Tax Exempt Fund - dividend reinvestment
02/25/2004 AXP Short Duration US Govt Fund - dividend reinvestment
02/25/2004 AXP Diversified Bond Fund - monthly dividend
02/25/2004 AXP Insured Tax Exempt Fund - dividend reinvestment
03/26/2004 AXP Short Duration US Govt Fund - dividend reinvestment
03/26/2004 AXP Diversified Bond Fund - monthly dividend
03/26/2004 AXP Insured Tax Exempt Fund - dividend reinvestment
04/26/2004 AXP Short Duration US Govt Fund - dividend reinvestment
04/26/2004 AXP Diversified Bond Fund - monthly dividend
04/26/2004 AXP Insured Tax Exempt Fund - dividend reinvestment
OS/26/2004 AXP Short Duration US Govt Fund - dividend reinvestment
OS/26/2004 AXP Diversified Bond Fund - monthly dividend
OS/26/2004 AXP Insured Tax Exempt Fund - dividend reinvestment
06/25/2004 AXP Short Duration US Govt Fund - dividend reinvestment
06/25/2004 AXP Diversified Bond Fund - monthly dividend
06/25/2004 AXP Insured Tax Exempt Fund - dividend reinvestment
07/26/2004 AXP Short Duration US Govt Fund - dividend reinvestment
07/26/2004 AXP Diversified Bond Fund - monthly dividend
07/26/2004 AXP Insured Tax Exempt Fund - dividend reinvestment
6
133,951.00
34,000.00
$167,951.00
14.70
22.92
0.89
14.75
21.44
0.85
14.82
22.42
0.91
16.43
23.25
0.89
16.09
22.45
0.85
54.93
28.43
30.72
4.00
17.09
25.97
1.01
16.44
26.10
0.86
16.76
27.94
0.84
15.81
28.15
0.87
15.63
28.20
0.86
17.73
28.24
0.86
17.72
26.41
0.89
08/04/2004 AXP Short Duration US Govt Fund - dividend reinvestment
08/04/2004 AXP Diversified Bond Fund - monthly dividend
08/04/2004 AXP Insured Tax Exempt Fund - dividend reinvestment
PRINCIPAL BALANCE ON HAND
Cash and temporary investments
Diamond Solitaire Ring
Miscellaneous coins
Current
Value
As of 9-15-2005
$14,518.74
537.00
6.17
$15,061.91
INFORMATION SCHEDULES - PRINCIPAL
Investments Made
Units of Temporary Investment Fund were purchased or redeemed as
funds were available or required.
07/24/2003 3.000 shs AXP Short Duration US Govt Fund purchased through
dividend reinvestment
07/24/2003 4.736 shs AXP Diversified Bond Fund purchased through dividend
reinvesment
07/24/2003 .163 shs AXP Insured Tax Exempt Fund purchased through dividend
reinvestment
08/22/2003 3.029 shs AXP Short Duration US Govt Fund purchased through
dividend reinvestment
08/22/2003 4.495 shs AXP Diversified Bond Fund purchased through dividend
reinvesment
08/22/2003 .158 shs AXP Insured Tax Exempt Fund purchased through dividend
reinvestment
09/22/2003 3.036 shs AXP Short Duration US Govt Fund purchased through
dividend reinvestment
09/22/2003 4.626 shs AXP Diversified Bond Fund purchased through dividend
reinvesment
7
5.57
8.47
0.26
640.42
Fiduciary
Acquisition
Value
$14,518.74
537.00
6.17
$15,061.91
14.70
22.92
0.89
14.75
21 .44
0.85
14.82
22.42
09/22/2003 .165 shs AXP Insured Tax Exempt Fund purchased through dividend 0.91
reinvestment
10/23/2003 3.366 shs AXP Short Duration US Govt Fund purchased through 16.43
dividend reinvestment
10/23/2003 4.797 shs AXP Diversified Bond Fund purchased through dividend 23.25
reinvesment
10/23/2003 .162 shs AXP Insured Tax Exempt Fund purchased through dividend 0.89
reinvestment
11/21/2003 3.295 shs AXP Short Duration US Govt Fund purchased through 16.09
dividend reinvestment
11/21/2003 4.631 shs AXP Diversified Bond Fund purchased through dividend 22.45
reinvesment
11/21/2003 .155 shs AXP Insured Tax Exempt Fund purchased through dividend 0.85
reinvestment
12/18/2003 11.326 shs AXP Partners Value Fund purchased through dividend 54.93
reinvestment
12/22/2003 5.824 shs AXP Short Duration US Govt Fund purchased through 28.43
dividend reinvestment
12/22/2003 6.338 shs AXP Diversified Bond Fund purchased through dividend 30.72
reinvesment
12/22/2003 .727 shs AXP Insured Tax Exempt Fund purchased through dividend 4.00
reinvestment
01/26/2004 3.495 shs AXP Short Duration US Govt Fund purchased through 17.09
dividend reinvestment
01/26/2004 5.311 shs AXP Diversified Bond Fund purchased through dividend 25.97
reinvesment
01/26/2004 .183 shs AXP Insured Tax Exempt Fund purchased through dividend 1.01
reinvestment
02/25/2004 3.355 shs AXP Short Duration US Govt Fund purchased through 16.44
dividend reinvestment
02/25/2004 5.316 shs AXP Diversified Bond Fund purchased through dividend 26.10
reinvesment
02/25/2003 .154 shs AXP Insured Tax Exempt Fund purchased through dividend 0.86
reinvestment
03/26/2004 3.420 shs AXP Short Duration US Govt Fund purchased through 16.76
dividend reinvestment
03/26/2004 5.656 shs AXP Diversified Bond Fund purchased through dividend 27.94
reinvesment
03/26/2004 .151 shs AXP Insured Tax Exempt Fund purchased through dividend 0.84
reinvestment
04/26/2004 3.260 shs AXP Short Duration US Govt Fund purchased through 15.81
dividend reinvestment
04/26/2004 5.828 shs AXP Diversified Bond Fund purchased through dividend 28.15
reinvesment
04/26/2004 .161 shs AXP Insured Tax Exempt Fund purchased through dividend 0.87
reinvestment
OS/26/2004 3.243 shs AXP Short Duration US Govt Fund purchased through 15.63
dividend reinvestment
OS/26/2004 5.924 shs AXP Diversified Bond Fund purchased through dividend 28.20
reinvesment
8
OS/26/2004 .161 shs AXP Insured Tax Exempt Fund purchased through dividend 0.86
reinvestment
06/25/2004 3.686 shs AXP Short Duration US Govt Fund purchased through 17.73
dividend reinvestment
06/25/2004 5.920 shs AXP Diversified Bond Fund purchased through dividend 28.24
reinvesment
06/25/2004 .161 shs AXP Insured Tax Exempt Fuhd purchased through dividend 0.86
reinvestment
07/26/2004 3.684 shs AXP Short Duration US Govt Fund purchased through 17.72
dividend reinvestment
07/26/2004 5.491 shs AXP Diversified Bond Fund purchased through dividend 26.41
reinvesment
07/26/2004 .165 shs AXP Insured Tax Exempt Fund purchased through dividend 0.89
reinvestment
08/04/2004 1.156 shs AXP Short Duration US Govt Fund purchased through 5.57
dividend reinvestment
08/04/2004 1.761 shs AXP Diversified Bond Fund purchased through dividend 8.47
reinvesment
08/04/2004 .048 shs AXP Insured Tax Exempt Fund purchased through dividend 0.26
reinvestment
Changes in Investment Holdings
AXP New Dimensions Fund
07/03/2003 8,553.019 shs AXP New Dimensions Fund received at date of death
value
06/25/2004 884.295 shs AXP New Dimensions Fund received in reorganization
06/25/2004 8,84.295 shs AXP New Dimensions FLlnd held at:
18,645.58
0.00
18,645.58
9
RECEIPTS OF INCOME
Dividends
07/24/2003 AXP Short Duration US Govt Fund - monthly dividend
07/24/2003 AXP Diversified Bond Fund - monthly dividend
07/24/2003 AXP Insured Tax Exempt Fund - mon1hly dividend
08/22/2003 AXP Short Duration US Govt Fund - monthly dividend
08/22/2003 AXP Diversified Bond Fund - monthly dividend
08/22/2003 AXP Insured Tax Exempt Fund - mon~hly dividend
09/22/2003 AXP Short Duration US Govt Fund - monthly dividend
09/22/2003 AXP Diversified Bond Fund - monthly dividend
09/22/2003 AXP Insured Tax Exempt Fund - monthly dividend
10/23/2003 AXP Short Duration US Govt Fund - monthly dividend
10/23/2003 AXP Diversified Bond Fund - monthly dividend
10/23/2003 AXP Insured Tax Exempt Fund - monthly dividend
11/21/2003 AXP Short Duration US Govt Fund - monthly dividend
11/21/2003 AXP Diversified Bond Fund - monthly ~ividend
11/21/2003 AXP Insured Tax Exempt Fund - monthly dividend
12/18/2003 AXP Partners Value Fund - annual dividend
12/22/2003 AXP Short Duration US Govt Fund - monthly dividend
12/22/2003 AXP Diversified Bond Fund - monthly <jJividend
12/22/2003 AXP Insured Tax Exempt Fund - monthly dividend
01/26/2004 AXP Short Duration US Govt Fund - monthly dividend
01/26/2004 AXP Diversified Bond Fund - monthly (jlividend
01/26/2003 AXP Insured Tax Exempt Fund - monthly dividend
02/25/2004 AXP Short Duration US Govt Fund - mbnthly dividend
02/25/2004 AXP Diversified Bond Fund - monthly dividend
02/25/2004 AXP Insured Tax Exempt Fund - monthly dividend
03/26/2004 AXP Short Duration US Govt Fund - monthly dividend
03/26/2004 AXP Diversified Bond Fund - monthly Qividend
03/26/2004 AXP Insured Tax Exempt Fund - monthly dividend
04/26/2004 AXP Short Duration US Govt Fund - monthly dividend
04/26/2004 AXP Diversified Bond Fund - monthly dividend
04/26/2004 AXP Insured Tax Exempt Fund - monthly dividend
OS/26/2004 AXP Short Duration US Govt Fund - monthly dividend
OS/26/2004 AXP Diversified Bond Fund - monthly dividend
OS/26/2004 AXP Insured Tax Exempt Fund - monthly dividend
06/25/2004 AXP Short Duration US Govt Fund - mbnthly dividend
06/25/2004 AXP Diversified Bond Fund - monthly dividend
06/25/2004 AXP Insured Tax Exempt Fund - monthly dividend
07/26/2004 AXP Short Duration US Govt Fund - monthly dividend
07/26/2004 AXP Diversified Bond Fund - monthly dividend
07/26/2004 AXP Insured Tax Exempt Fund - monthly dividend
08/04/2004 AXP Short Duration US Govt Fund - monthly dividend
08/04/2004 AXP Diversified Bond Fund - monthly dividend
08/04/2004 AXP Insured Tax Exempt Fund - monthly dividend
10
14.70
22.92
0.89
14.75
21.44
0.85
14.82
22.42
0.91
16.43
23.25
0.89
16.09
22.45
0.85
54.93
28.43
30.72
4.00
17.09
25.97
1.01
16.44
26.10
0.86
16.76
27.94
0.84
15.81
28.15
0.87
15.63
28.20
0.86
17.73
28.24
0.86
17.72
26.41
0.89
5.57
8.47
0.26
640.42
Interest
07/31/2003 PSECU Account #8102193912
08/04/2003 PSECU Account #8102193912
08/13/2003 American Express Brokerage Account
08/29/2003 American Express Brokerage Account
09/01/2003 American Express Brokerage Account
Interest from temporary investment funds
2003 July
August
September
October
November
December
2004 January
February
March
April
May
June
July
August
September
October
November
December
2005 January
February
March
April
May
June
July
August
Total Income Receipts
7.49
0.70
0.14
0.07
0.21
0.11
2.18
24.37
29.21
30.56
44.87
60.56
52.06
54.91
51.64
51.36
53.38
66.56
73.38
59.11
40.89
44.21
53.27
57.04
55.98
65.24
67.28
74.93
74.59
81.91
86.82
11
8.61
1,356.42
$2,005.45
DISBURSEMENTS OF INCOME
09/16/2004 PA Department of Revenue - fiduciary income tax payment
Hershey Trust Company, income commission
DISTRIBUTIONS OF INCOME TO BENEFICIARIES
08/11/2004 Janet M. O'Brien Trust for benefit of Sean O'Brien - Per Item IV of the
Last Will and Testament of Janet M. O'Brien
BALANCE OF INCOME ON HAND
Current
Value
As of 9-15-2005
Cash and temporary investments
$1,235.76
INFORMATION SCHEDULE - INCOME
Units of Temporary Investment Fund were purchased or redeemed as
funds were available or required.
12
$29.00
100.27
129.27
640.42
640.42
Fiduciary
Acquisition
Value
$1,235.76
PROPOSED DISTRIBUTIONS TO BENEFICIARIES
Current
Value
As of 9-15-2005
PRINCIPAL:
TO: Sean M O'Brien per Item III of the last Will and Testament of Janet M. O'Brien
dated November 4, 2002
Diamond Solitaire Ring
Miscellaneous coins
$537.00
6.17
TO: Janet M. O'Brien Trust for Sean M. O'Brien per Item IV of the last Will and
Testament of Janet M. O'Brien dated November 4,2002
Cash $14,670.74
$15,213.91
INCOME:
TO: Janet M. O'Brien Trust for Sean M. O'Brien per Item IV of the last Will and
Testament of Janet M. O'Brien dated November 4,2002
Cash $1,235.76
$1,235.76
Total Distribution
$16,449.67
13
Fiduciary
Acquisition
Value
$537.00
6.17
$14,670.74
$15,213.91
$1,235.76
$1,235.76
$16,449.67
ROBERT K. REITZEL, Vice President and Trust Officer, Hershey Trust Company,
Executor under the Last Will and Testament of Janet M. O'Brien, deceased, hereby
declares under oath that said Executor has fully and faithfully discharged the duties of his
office; that the foregoing First and Final Account is true and correct, and fully discloses all
significant transactions occurring during the accounting period; that all known claims
against the estate have been paid in full; that, to his knowledge, there are no claims now
outstanding against the estate; and that all taxes presently due from the estate have been
paid.
HERSHEY TRUST COMPANY, EXECUTOR
~
By: - _______
Vice resident and Trust fficer
Subscribed and sworn to
by ROBERT K. REITZEL before
~~daYOf
. ,2005.
~~ iIl~
}Notary Public
Notarial Seal
Usa L PiergaHini, Notary Public
Deny Twp., Dauphin County
My Ccmmlssion ExpIres May 5, 2001
Member. Penl1l;yfvanla Association Of Notaries
IN THE MATTER OF THE
ESTATE OF JANET M.
O'BRIEN, DECEASED
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYL V AMA
ORPHANS' COURT DIVISION
NO. 0588 of 2003
CERTIFICATE
I hereby certify that written notice of the filing of this Account and Statement of
Proposed Distribution, and the date, time and place when the same will be presented to the Court
for confIrmation and of the last day to file written objections to said Statement of Proposed
Distribution, has been given to every unpaid claimant and to every other person known to the
accountant to have or claim an interest in the estate as creditor, beneficiary, heir or next of kin.
A copy of said Statement was included with the notice.
)
Elyse E. ogers, Esq .
Keefer Wood Allen & Rahal, LLP
415 Fallowfield Road, Suite 301
Camp Hill, P A 17011
717-612-5801
Supreme Court ill #41274
Attorney for Executor of
Estate of Janet M. O'Brien
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, P A 17013
AUGUST 15, 2003
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:
Elyse E. Rodgers, ESQUIRE
Janet M. O'Brien, 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 following dates:
AUGUST 1,8, 15, 2003
Advertising Cost
Second Proof Request
$ 75.00
$ 0.00
$ 0.00
$ 0.00
-------------
Proof of Publication
Payment received
Total Amount Due
$ 75.00
---------
--------
Payment received
by
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16, 1929), P. L.1784
STATE OF PENNSYLVANIA :
SSe
COUNTY OF CUMBERLAND :
Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, 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 Carlisle 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 regular editions and issues of the said Cumberland Law
Journal on the following dates,
VIZ:
AUGUST 1, 8, 15,2003
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.
O'Brien, Janet M.. dec'd.
Late of Upper Allen Township.
Executor: Hershey Trust Com-
pany, 100 Mansion Road East,
P.O. Box 445, Hershey, PA 17033-
0445, (717) 520-1109.
Attomeys: Elyse E. Rogers. Es-
quire, Keefer, Wood, Allen & Ra-
hal, LLP, 415 Fallowfield Road.
Suite 102, Camp Hill, PA 17011-
4905, (717) 612-4905.
---
N TO AND SUBSCRIBED before me this
15 day of AUGUST, 2003
civv
THE PATRIOT NEWS
THE SUNDAY PATRIOT NEWS
Proof of Publication
Under Act No. 587, Approved May 16,1929
Commonwealth of Pennsylvania, County of Dauphin} ss
Joseph A. Dennison, being duly sworn according to law, deposes and says:
That he is the Asst. Controller of The Patriot News Co., a corporation organized and existing under the laws
of the Commonwealth of Pennsylvania, with its principal office and place of business at 812 to 818 Market Street, in
the City of Harrisburg, County of Dauphin, State of Pennsylvania, owner and publisher of The Patriot-News and...I!llL
Sunday Patriot-News newspapers of general circulation, printed and published at 812 to 818 Market Street, in the
City, County and State aforesaid; that The Patriot-News and The Sunday Patriot-News were established March 4th,
1854, and September 18th, 1949, respectively, and all have been continuously published ever since;
That the printed notice or publication which is securely attached hereto is exactly as printed and published in
their regular daily and/or Sunday/ Metro editions which appeared on the 25th day(s) of July and the 1st and 8th
day(s) of August 2003. That neither he nor said Company is interested in the subject matter of said printed notice
or advertising, and that all of the allegations of this statement as to the time, place and character of publication are
true; and
That he has personal knowledge of the facts aforesaid and is duly authorized and empowered to verify this
statement on behalf of The Patriot-News Co. aforesaid by virtue and pursuant to a resolution unanimously passed and
adopted severally by the stockholders and board of directors of the said Company and subsequently duly recorded in
the office for the Recording of Deeds in and for said County of Dauphin in Miscellaneous Book "M",
Volume 14, Page 317.
PUBLICATION
COPY
......... ... .... . .11:... ';j)e...",,;.rr; ~..............
Sworn d subscribed before ~s 14th day of A ust A.D.
Seal / /. /~
Teny L. Russell, Notary Public
CIty 01 Han1sburg, Dauphin Col6Ily
My CommISIlOn ExpIres June 6, 2006
Member. Pemsytvania Association Of NoIalIes
NOT Y PUBLIC
My commission expires June 6, 2006
HERHEY TRUST COMPANY
ATTN: ROBERT K. REITZEL
100 MANSION ROAD EAST
HERSHEY, PA. 17033
Statement of Advertising Costs
To THE PATRIOT.NEWS CO., Dr.
For publishing the notice or publication attached
hereto on the above stated dates $
Probating same Notary Fee(s) $
Total $
239.40
1.75
241. 15
Publisher's Receipt for Advertising Cost
The Patriot News Co., publisher of The Patriot-News and The Sunday Patriot-News, newspapers of general
circulation, hereby acknowledge receipt of the aforesaid notice and publication costs and certifies that the same have
been duly paid.
By....................................................................
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PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DA TE OF DEA TH REGARDLESS OF THE ST A Tl!S OF THE ESTATE. IF
ESTATE IS NOT COMPLETED, FILE A 6.12 FORM YEARLY UNTIL COMPLETION.
ESTATE STATUS REPORT
Name of Decedent: Janet M. O'Brien
Date of Death:
07/03/03
Will No.: 0588-2003
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, we report the following
with respect to completion of the administration of the above-captioned estate:
1. State whether administration of the estate is complete: Yes --X.No
2. If the answer is No, state when the personal representative reasonably believes
that the administration will be complete:
3. If the answer to No.1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes X No
b. The separate Orphans' Court No. (if any) for the personal representative's
account is:
c. Did the personal representative state an account informally to the parties
in interest? Yes No X
Date:
d. Copies of receipts, releases, joinders and approvals of formal or informal
accounts may be filed with the Clerk of the Orphans' Court and may be
....--:- attached to this report. l ~_~__
JhNL~'LOOG . Of __ _ ~
I
Ro ert K. Reitzel, VP & Trust Officer
..-..]
Hershey Trust Company
Name (Please type or print)
P.O. Box 445
Hershey. P A 17033
Address
(717 ) 520-1126
Telephone Number
(k: \trust\admnfile\form s \es tstrp.frm)
Capacity: ~ Personal Representative
Counsel for Personal
Representative
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