Loading...
HomeMy WebLinkAbout09-10-091505607121 REV-1500 E>< (D6-D5, PA Department of Revenue '~ Bureau of IntlNidual Taxes Count' Cade Year File Number PO BOX 280601 INHERITANCE TAX RETURN 2 1 0 9 0 2 2 0 Harrtsbum PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 6 5 2 6 7 3 6 2 1 2 1 5 2 0 0 8 1 2 3 1 1 9 3 2 Decedent's Last Name Suffix Decedent's First Name MI S M I T H P H Y L L I S I (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS © 1. Original Retum ~ 2. Supplemental Return ~ 3. Remainder Ratum (date of death 4. Limited Estate ~ 4a. Future Interest Compromise (data of prior to 12-13-82) ~ 5. Federel Estate Tax Retum Required 6. Decedent Died Testate ~ death after 12.12-82) 7. Decadent Maintained a Living Trust 1 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (data of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTUIL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number D A V I D H S T O N E E S Q U I R E 7 1 7 7 7 4 7 4 3 5 Firm Name (If Applicable) _ ___ _ ~' REGISTER OF WILLS USEONLV S T O N E L A F A V E R S H E K L E T S K First line of address 4 1 4 B R I D G E S T R E E T Second line of address City or Post Office State N E W C U M B E R L A N D P A Correspondent's a-mail address: A ZIP Code ~__._ 1 7 0 7 0 C ~ rv ° Q i i I'C~~ ~ c i y I ~Arr?_ ~71~ n--- 'rnp i •~j r( ~ ~ ~,G I D -h- r..7 ~ r -- -p ?7 S ti IV f , ~-,T c.. ~., -~ Cp ~n _..__ ,_.._.__ _. ,_.,_.,, ..w,,,,o „a, , ,,,,o o,,,,,,,,~„ wa iewrn, mGUCing aocompanying schedules and statemenh, arM to the best of my knowledge arM belief, d u true, coned and wmplate. Dedarefbn of reparer other than the personal representatlve to based on all infortnatlon of which preparer has any knowledge. SIG UR OF PERS RESPONSIB OR FILING RETURN `r~~ ~E/ a 9 ADD ESS 16 COURTLAND ~ AD CAMP HILL PA 17011 SIG EP E ER THAN REPRESENTATIVE DATE ADD S 414 BRIDGE STREET NEW CUMBERLAND PA 17070 PLEASE USE ORIGINAL FORM ONLY Side 7 1505607121 1505607121 J 15D5607221 REV-1500 EX Decedent's Social Security Number Deeeoent's Name: PHYLLI$ I• SMITH 1 6 5 2 6 7 3 6 2 RECAPITULATION 1. Real estate (Schedule A) ................................. .... . . . 1. 2. Stocks and Bonds (Schedule B) ........................... .... .. . 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . , ... 3. 4. Mortgages 8 Notes Receivable (Schedule D) ................. .... ... 4. 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) .... ... 5. D , D 0 B. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .... ... 6. 4 7 7 6 2 , 5 7 7. Inter-Vivos Transfers 8 Miscellaneous N -Probate Property ~ (Schedule G) Separate Billing Requested .... ... 7. 7 8 3 5 , 2 7 8. Total Gross Assets (total Lines 1-7) .................... .... ... 8. 5 5 5 9 7, 8 4 9. Funeral Expenses 8 Administrative Costs (Schedule H) ......... .... ... 9. 9 7 3 6 . D 4 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ..... ..... .. 10. 2 5 6 7 , 2 5 11. Total Deductions (total Lines 9 8 10) .................... ..... .. 11. 1 2 3 D 3, 2 9 12. Net Value of Estate (Line 8 minus Line 11) .................. ..... .. 12. 4 3 2 9 4 , 5 5 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) ........... ..... .. 13. , 14. Net Value SubJsct to Tax (Line 12 minus Line 13) ........... ..... .. 14. 4 3 2 9 4 , 5 5 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(tz) x• D D. 0 D 15. D. 0 D 16. Amount of Line 14 taxable at lineal rate x• D 4 5 4 3 2 9 4. 5 5 1 g. 1 9 4 8. 2 5 17. Amount of Line 14 taxable et sibling rate X .12 D. D D 17, D. D D 18. Amount of Line 14 taxable at collateral rate X .15 D. D D 18 D. D D 19. Tax Due ................................................ 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1 9 4 8. 2 5 Side 2 15D5607221 15D56O7221 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 os o220 DECEDENTS NAME PHYLLIS I. SMITH STREET ADDRESS ----... ----- ---------- 502 SECOND STREET, APT 2 ITY 1 ---;STATE------ -- ZIP----- NEW CUMBERLAND i pA 17070- Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Interest/Penalty ii applicable D. Interest E. Penalty 4. (t) 1 948.25 1.800.00 94.74 Total Credits (A + g + C) (2) 1 894 74 If Line 2 is greater than Line 1 +Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 +Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tau due. (3) 0.00 (4) 0.00 (5) 53.51 (5A) B. Enter the total of Line 5 +5A. This is the BALANCE DUE. (5B) 53.51 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : ............................................. ^ ................... b. retain the right to designate who shall use the property transferred or its income : ........................ ...... ...... ^ ^X c. retain a reversionary interest; or ............................................................. . ^ . ........................... d. receive the promise for life of either payments, benefts or caret ................................................. ...... ...... ^ 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 'intrust for' or payable upon death bank account or security al his or her death? .... ..... ^ ^X . 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation7 ............................................................................................. ..... 0 ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT A3 PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) pecent [72 P.S. §9116 (a) (1.1) (i)J. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (O) percent [72 P.S. §9116 (a) (1.1) (ii)J. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even N 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 a for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (O) percent [/2 P.S. §9116(a)(1.2)j. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in n Ps. §s11s(1.2) [/2 Ps. §s11s(a);1)J. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent (72 P.S. §9116(a)(1.3)J. Asibling is defned, under Section 9102, as an individual who has at leas) one parent in common with the decedent, whether by blood or adoption. Total InterestlPenalty (D + E ) REV-1509 EX ~ (e-98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN PHYLLIS I. SMITH 21 09 0220 k an aeeet was made Jolnt wkhln one year of the decedeM'a date or death, k moat he reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. DEBRA ANN LANSER 18 COURTLAND ROAD DAUGHTER CAMP HILL, PA 17011 C JOINTLY•OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIALINSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FORJOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECDS INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1. A. 101304 Allied Irish Banks stock joint w/Debra A Lanser 1206 sh 6,512.40 50. 3,256.20 $5.40 per sh 2 A 100797 M&T Bank-Checking Acct #81353065 joint 2,268.10 50. 1,134.05 w/Debra A Lanser Princ. $2,266.03, Int. $.07 3 A 040398 Sovereign Bank-Cert of Deposit #2335251001 joint 25,050.34 50. 12,525.17 w/Debra Ann Lanser Princ. $25,000.00, Int. $50.34 4 A 062298 Sovereign Bank-Cert of Deposit #2335251068 joint 25,074.68 50. 12,537.34 w/Debra Ann Lanser Princ. $25,028.93, Int. $45.75 5 A 072899 Sovereign Bank-Cert of Deposit #2335251423 joint 26,346.23 50. 13,173.12 w/Debra Ann Lanser Princ. $26,298.16, Int. $48.07 6 A 012396 Sovereign Bank-Checking Acct #0571126243 joint 8,121.99 50. 4 061.00 w/Debra Ann Lanser Princ. $8,117.10, Int. $4.89 , 7 A 012396 Sovereign Bank-Savings Acct #0574117214 joint 2,151.38 50. 1 075.69 w/Debra Ann Lanser Princ. $2,145.76, Int. $5.62 , TOTAL (Also enter on line 6, Recapitulation) (lf more space is needed, insen additional sheets of the same size) REV-7510 EX * (a-96) COMMONNIEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON•PROBATE PROPERTY PHYLLIS I. SMITH 21 09 0220 This schedule must be completed and filed If the ansvrer to any of questlons 7 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM NUMBER INLLpDE THE NAME OETXEiPNA9{£pEE, iNEIR REU-ON6HIPTO OECEOENTANO THE DATE OF iRM1EFER. ATTACHACOPV OFTHE GEED FOR RFAL EbiATE. DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE VALUE OF ASSET INTEREST I iIFMPLICABIE VALUE 1. Jackson National Ins Co-Opimax 4 Annuity 7,835.2 7 100. 7 835.27 benef-Debra Ann Gill nka Debra Ann Lancer , - TOTAL (Also enter on line 7 Recapitulation) ~ S 7 835 27 (If more space is needed, insert adtlitional sheets of the same size) REV-7517 Ex + (70.08) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAx RETURN PHYLLIS I. SMITH 21 09 0220 SCHEDULE H FUNERAL EXPENSES 8 ADMINISTRATIVE COSTS Debh of decedent moat W reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1 Parthemore Funeral Home-funeral expenses ($4365.07 & $888.00 Lewisberry United Methodist Church-services rendered Baughman Memorial-engraving on stone Funeral dinner Emanuel Cemetery-grave opening & closing B. ~ ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) 5,253.07 200.00 185.00 250.00 225.00 SVeet Address city state zp Year(s) Commissbn Paid: 2. AdomeyFees David H. Stone, Esquire 2,500.00 3. Family Ezemption: (If decedents address is not fhe same as claimants, attach ezplanation) Claimant Street Address City State Zip Relatbnship of Claimant to Decedent 4. Probate Fees 5. I AxountanYs Fees 6. I Tax Retum Preparers Fees 7. Checks written by dec. but not cleared by bank 181 40 2 Aetna-return of check . 278 73 3 Space Mart-storage usage 99 64 4 Space Mart-storage for 3 months . 298 92 5 Space Mart-storage charge 99 64 6 Space Mart-storage charge . 99 ~ 7 Register of Wills-filing inheritance tax return 15 00 8 Reserve for closing expenses . 50.00 TOTAL (Also enter on line 9, Recapitulation) S 9 736.04 (If more space h needed, insert additional sheets of the same size) REV-1512 EX + (12-03) COMMONWEALTH OF PENNSVIVANIA INHERITANCE TAX RETURN SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS PHYLLIS I. SMITH 21 09 0220 Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, Including unreimbureed medical ezpensea. ITEM I VALUE AT DATE NUMBER DESCRIPTION OF DFATH 1 IEIm AI Dillsburg Operations LLC-debt of decedent 2,496.00 Pennsboro Ambulance-services rendered more space is neeAed, TOTAL (Also enter on line 10, Recapitulation) of the 71.25 REV-1513 EX. (9.00) SCHEDULE) COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT PHYLLIS I. SMITH 21 09 0220 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS pndude outright sppoousal dBtdbutions,and transfers under Sec. 9116 (a) (11)I 1 DEBRA A LANSER Jackson Annuity $ 7,835.27 Lineal 25,564.91 16 COURTLAND ROAD 1/2 residue $17,729.64 CAMP HILL, PA 17011 2 PAMELA J EICHELBERGER Lineal 17,729.64 108 SUNSET VIEW DRIVE NEW CUMBERLAND PA 17070- ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 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 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART I[ -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 9 pi nio~e apace la nee0e0, Insert a001tI00al Sheets Of the SaRle Size) STONE LeFAVER &SHEKLETSKI wrroarvere wr uw ela eKloee araecr MVID H. aTON! POaT OF/ICE a0% a OeMLD J. 6HtKLETaKI New Cvwaaaiwxn. PA VO70 eurwaerH s. scone wWwS[OMIiwTCI January 28, 2009 Pennsylvania Department of Revenue Harrisburg District Office Lobby, Strawberry Square Harrisburg, PA 17128-0101 Re: Estate of Phyllis I. Smith Date of Death: December 15, 2008 Social Security No. 165-26-7362 Greetings: or courvsn ervwalJ<s H. scone JON K I..vwvea re~erHOne 1>Irl no~us FwDelMiie 1>I>I»4aaep Please find enclosed an original Safe Deposit Box inventory for Box No. 1308. Thank you for your attention in this matter. Should you have any questions, please feel free to contact me. Very truly & SHEKLETSKI DHS/jam Enclosure ec: Debra A. Lanser 48500041046 REV385 EX (7-071 SAFE DEPOSIT BOX INVENTORY PA Oemlimanl el Rwwxw ~,...~~..~,z.l~:~zi.31.61z] ~~~'#~~~~(~~~la(g,~ N~~~ I...101 d~.~~~ DacedenYa L881 Neme _ MI A ..... ~ ~ jjaama '''7a ~FiPrsl~Nan~ ~~~~'''~''''T ©ADDREtt OF DECEDENT STREET. CITY: STATE: ZIP CODE: ~~ Second Street Apartment 2 New Cumberland PA 17070 ~ NAME `°° °' .cnaON REQUEBnNp THE OPENIND OF 1NE SAFE DEPOtR BOX ' .__._J2a-visl-H,,_StQne,_Esqur..e_ __ STREETADDRESS: - _._____. _.._- _. -.. __ .w • .. ~ _. CITY: - -- -- ST1TF ne nnne. ' a. NAME Debra A, Lanaer RElAT10N9NIP: __.._ _ _-_.___. -______ __ _ _d3u4hxs~ STREETADDRESS. ___ CITY: ____ ----------- -- -._L6.-.Cnurtland_ROad... __ __.- b N -Camp. Hi1L_--- STATE: 21P CODE: P~ 1Z011 . AME -- RElAT10NSNIP: --.- __ _- STREET ADDRESS. '' -''- CITY: --- - -~-~------ STATE: ZIP LODE: P. NAME - _.---.__-- _____ RELATIONSNIP~ ....- _ - _._-__ __ ~~ _ ' BTREETADDRESS - CITY ----- -- ---- STATE 21P CODE: NAME AND ADORE88 OF FINANCIAL INSTRUTION WNERE THE SAFE DEP O8A BOX M LOCATED M8T Bank - West Shore Plaza -___ ',~ STREETADDRE9S: ~-- - Llry:-~ - - I - 1 0 Market Street Lemo ne STATE PA ZIPCODE: 17093 NAME OF PER80N MANMp LABT ENTRY DATE AND TIME OF lABT ENTRY GATE OF CONTRACT TO RENT BO% NUMBER OF BOX 1 TITLE UNDER WNICN BOX RI REGIBTEREO Or NAME AND ADORE88 OF PERtONl8) NAVINO ACCE9t TO 80X a. NAME: '~ b. NAME: - -PhYliis I. Smith _- _ .--... __.. STREET AODRE38 Dahra-.A...Lanaec _ _ -- -- 502 Second Street,. APt M2 __.. ~ -- STREETADDRESS: 16 COUrtland Road ; CITY: STATE ZIP CODE: New Cumberland PA 17070 _ CITY: -- - -- STATE ZIP CODE: 'i Cam Hill PA 17011 NAME AND TRLE OF EMPLOYEE TAKN10 THE INVENTORY David H. Stone, Esquire WAS A WILL IN THE BO%T ^ YEa ]~ NO N Yaa. a. OaM of wlll: b. Nama mtl atltlrpa o/ Panonal rapnxnMfha, N namatl In Ow will - - -- - - _. __-_-_. ' NAME: i STREET ADDRE99: - CITY - - -- STATE: ZIP LODE: i e. Nama aM aatlmR b a0omay, N arty _.. - ____ ''. NAME: ii STREETAODRE53: - CITY : STATE ZIP CODE L 48500041046 46500041046 J REV-085 EX SAFE DEPOSIT BOX INVENTORY Page Gf INSTRUCTIONS (t) Ceah: Report total only. (2) Stocks: List in tletail every common or pre(erted certi(rcate, wartant or other rights fountlanAbnumber otshares entl clalss of stack. in which stack is registered, fi cate. name name of company, certigcale numbet data of certi names in which registeretl and type of ownership, face value f i , ssue, (~) Obllgatlom M U.S. GovarnmenC Number of items, tlale o i.e., pintly heM, payable on tlealh, etc. (<) Bonds: Designate by name, amount, sepal number, or other designation. (Bearer Bonds) Peasboob: Stale name of depositor, number of book, last tlate appearing in book, name of bank d L oen (a) Bank end Savings an and branch, and balance. (8) Javnlry, Coins, Stamps, Manusorip4, etc: List and describe as fully as possible. Cumnt Inaurenea Policies or other avldeneea of Indebtedness: List and describe as fully as passible. rt M gages, o (T) Deeds, (B) Atl other contents. (9) Return completed Torm te: ~ AX DIVIMON NNERRANCE PO 00X Ye0801 HARRISBURG, PA tT12t1-0Bm ITEM ITEM DESCRIP(ION EMPTY _ __ .__-__ - __ .. _ ___.__. __ I CERTI FY UNDER PE Of ERJURY THAT THE ABOVE RECORD 18 DOE AND BELIEF PERSON RECEIVING COPY OF SAFE DEPOSIT BOX INVENTORY: CORRE CT AND C T . E BEST OF MY NNOWLE SIGNATURE S PRINT NAME ANO CHECK APPROPRIATE BO% 9ELOW'. T 90% y ~ j ~` . E OATE CNECN APPROPRIA PRINTTfILE m,~a pi ~ ( ~ ~~ nxre~a .aem» " ~ESine RgPre en ~~Vl(~ NOTE: Attach additional 8'/~" : 11" sheet(s) if necessary or use duplicates of this page of form. F a the Oepadmenl Is aulMMZed by law. J2 U.S C §a051v112`ACpil. !o regli a disclosure pl5oc al Secunry numbers H can eLi pn w N adm nlsrenng slates a s Tne pnpanme I uses t the formation w aaCP n e of roe nlwmata greements l ' so se $atldl Scanty number b dantrfy the decedent and personal repreeenlatiuee of the e5late. The Cort'.monweailh ay a o„fnnm al a rlormaticn accept ror !eGal purposes. aN FederM and local to%i mes Tle aw In IIm ,r" ~'- __ _- ___ Pg nu arv es____._ ____ _ _ _ Allied Irish Bks Depository Receipt (AIB) -Stock chart, Index chart -MSN Money Page 1 of 2 money Voaaa mart, na.. a9,:snx cwwaa. Ramon sues Cana ~~ H1q~1 R~.Tla,a naa~. `-3 sne9ra n e~nm sesfwm}a S•Sj } S•r~.~ ~ sm-~laa AraMC Ratiiws fm Yal Rtsults ew Taelw Meaux PmeE 9NMIY aa.e.wn Reea,2N wN.~ ~• a 651 a-~=a= ~~InG (.tl~~ ~~ .~~ M~a,T,w.Nelq.9w,MM9N~, dvnM,eM,n 5.93 ~+a.17 +2.97% Open: 5.90 Nglc 9.95 bx: 891 p2HWa aoRe~. s9s va~ae: sa9,n9 rsaan mme •9W IrIM 9b 9paWney IEp9t ,. na. m.. :~ µst0ck ly-. ch9ab ¢ ~a5c .,~ o~aw mM<Iw am '~~ W.vnlm] p2 MSN MMIy ImeaRlwN TMbm mum rmnn http://moneycentral.msacom/investor/charts/chartdl.aspx?PT=B&compsyms=&D4=1 &D... 8/13/2009 fGN)7gM ®]W9Twnswi IhuMe, CILi N ReafixCgry. Qigltl s,K{/ky ER ImwZtke Np, SIW V[e Nw pw~bal Oy Nwnwn ReYZrc)1ImNN,h. Lb. pM® aepypl }0 minite. iaj[ gvtl%M 8~1]~}W91 JO VM Ea51pT Tnrt m~ ~~ 8' a 's a r ~ 3 s< ^ P~ T gT i $~ f~ ~~~~ ~~~~ , „, ' ~s ~`r;~ ~~w ~.r,~ *~ `~ `~ . ,~, t w M 9 O Y N P C o q N ©M~TBank 499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12 Phone (888)502-4349 Fax (302)934-2955 March 12, 2009 Stone LaFaver & Sheklestski Attorneys At Law 414 Bridge Street Post Office Box E New Cumberland, PA 17070 Re: Estate of Phyllis I. Smith Social Security: 165-26-7362 Date of Death: December 1 S. 2008 Dear Sir or Madam: Per your inquiry dated March 5, 2009, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: Type ojAccount Account Number Ownership (Names o~ Opening Date Balance on Date ojDeath Accrued Interest Total Checking Account 8/353065' Phyllis /Smith* 10/7/97 Closed 1/8/09 $ 2,268.03 0.07 $ 2,268.10 Please be advised, there was no safe deposit box found for the above decedent. ~~nt W~ ~~r'eL /~. La-/1SC/' * If upon revkwing the information above, you believe there are additional accounts not referenced, please provide us with an account number and/or name of any possible joint account holder. For any additional information on the above accounts, including ownership snd any changes, cbsures and/or reimbursement of funds, etc., please contact our West Shore Plaza Office # 717-2552271. S' cerely, ~~~ ~~ Tracie Hare Adjustment Services ~ M&T Bank ACCOUNT N0. ACCOUNT TYPE 01353065 MOT CLASSIC CHECKING N/INTEREST 00 0 06123M NM I17 19522 PHVLLIS 2 SMITH OR DEBRA A CAMBER 502 2ND ST APT 2 NEW CUMBERLAND PA 17070-2057 ZNTEREST PAID YEAR TO DATE 0.61 errnnuT curreov NEST SNORE PLAZA ANC A CN C T I BA ND. AMOUNT N0. AMOUNT N0. AMOUNT 2 130.70 .0 0.00 2 254.11 errn~~uT erTrvrrv D TE TRANSACT ON D SC PTION 0 ER A IONS 7 CTI ALANCE 11-21-00 BEGINNING BALANCE 02,130.70 11-21-00 CNECK MUMMER 1447 50.00 2,080.70 12-02-0 CHECK NUMBER 1440 450.00 1,630.70 12-03- US TREASURY 303 SOC SEC 775.00 2,405.78 12-OS-00 HARP NEALTH CARE PREMIUM 137.75 2,268.03 12-19-08 INTEREST PAYMENT / y 0.08 ~ 12-19-00 CHECK NUMBER 1451 14.00 2,254.11 ENDING BALANCE 02 254.11 CNECKS -AID SUMMARY 1447 11-21-00 50.00 1440 12-02-00 450.00 1451^ 12-19-00 14.00 ANNUAL PERCENTAGE YIELD EARNED • 0.04 % ~ ~' ` ~1 ,•~. ~ ~~~ t~Tv~ ~~ ~ 7 ~ ~~ L! ~'~ ~' ~ i ~~ i k ~G ~~> `'9 ~^~- -,J ~~'',~ .~ STATEMENT PERIOD PADE NOV.21-DEC .19,2000 1 OT 2 >, ~,, ~~ I ," i ~~.ene ~e,nn Sovereign Bank MAI MB3 02-t0 Court Ordered Processing P.O. Box 841005 Boston, MA 02284 March 11, 2009 Stone LaFaver & Shekletski Attorneys at Law 414 Bridge St P.O. Box E New Cumberland, PA 17070 Estate o£ Phyllis I. Smith Date of Death: December 15, 2008 Dear Mr. Stone: Per your request, enclosed please find the account information as of date of death for the above-named decedent. Please note the balances do not include accrued interest. There are no safe deposit boxes on file. If you should have any further questions, please do not hesitate to call. V~Je~ryf~t~/ru}lly yours, 1 . LT~,_.__. Linda Spavento Team Leader Court Order Processing Phone (617) 533-1789 Fax (617) 533-1931 Sovereign Bank ESTATE OF Phyllis I Smith SOCIAL SECURITY #: 165-26-7362 DATE OF DEATH: December I5, 2008 Account #: 0571126243 Type: Checking Open date: 1/23/1996 In the name of: Phyllys I Smith or Debra Ann Lanser Date of Death Balance: $8,117.10 Int.(YTD) from 1/1/2008 to 11/26/2008 Accrued interest to date of death: Otherlnfo: $4.89 $98.92 Account #: 05741 1 72 14 Type: Savings Open date: 1/23/1996 In the name of: Phyllys I Smith or Debra Ann Lanser Date of Death Balance: $2.145.76 Int.(YTD) from 1/1/2008 to 11/30/2008 Accrued interest to date of death: Otherlnfo: $5.62 $32.00 Account #: 2335251001 Type: CD Open date: 4/3/1998 In the name of: Phyllys I Smith or Debra Ann Lanser Date of Death Balance: $25,000.00 Int.(YTD) from 1/1/2008 Accrued interest to date of death: Otherlnfo: to 11/30/2008 $50.34 61 Account #: 2335251068 Type: CD Open date: 6/22/1998 In the name of: Phyllys I Smith or Debra Ann Lanser Date of Death Balance: _$25,028.93 Int.(YTD) from 1/1/2008 Accrued interest to date of death Otherlnfo: Account#: In the name of: to 11/30/2008 72 $45.75 2335251423 Type: CD Phyllys I Smith or Debra Ann Lanser Date of Death Balance: Int.(YTD) from 1/1/2008 Accrued interest to date of death: Otherlnfo: Open date: 7/28/1999 16 to 11/30/2008 $1,005.24 $48.07 Page 1 of 1 JAC KS ~NSM NATIONAL CIPE INSURANCE COMPANY Claims Administration February 20, 2009 Debra Ann Gill 16 Courtland Rd Camp Hill, PA 17011 Deceased: Phyllis Smith Policy No.: 0058985460 Deaz Debra Ann Gill: We are sorry to hear about the death of Phyllis Smith and wish to extend our condolences. Based on the information provided, we have established a claim for the following: Policy Number Named Beneficia_ 0058985460 Debra Ann Gill Preselected Benefit Option Please be advised that any scheduled distributions will cease and any un-cashed payments, issued in the deceased's name, have been stopped. In order to process the claim promptly, please return to us the following: Claim Form Final Certified Death Certificate Once we receive this information, we will process the claim as quickly as possible. Please be advised, any documentation submitted to our office will not be returned. Lump sumpayments of $5,000:00 or greater are distributed via a Beneficiary Access Account (not available in all states or for corporations, partnerships, trusts, estates or minors). These funds can be used immediately simply by writing one of the drafts we provide for any amount up to the total in the Beneficiary Access Account. Funds in the account currently earn interest at 1.500%, compounded daily. There are no fees or charges to keep this account or write checks. Jackson National Life Insurance Company I Corporate Way, Lansing, MI 48951 PO Box 24068, Lansing, MI 48909-4068 Toll Free Number: 888/565-4995 ., .,,.. M OPT/MAX 4 ANNUITY Statement Daq: February 4, 2008 Provided by Jacksons' For the period January 13, 2008 to January 13, 2008 www.iackson.com Prepared for: Phyllis I Smith 16 COURTLAND RD CAMP HILL PA 17011-6609 JAC K S ~ N`M NATIONAL LIFE INSUKANCE COMPANY Your Representative: FSF INS AGENCY LLC 500 GRANT ST RM 4905 PITTSBURGH PA 15258.0001 Reprosentative Phone: (201) 880-2024 Activity Summary Beginning Period Policy Value 87,835.27 + Interest Eamed for Period 8x{5,81 withdrawals for Period Ending Period Policy Value $0.00 $8,070,58 Account Information Policy Number. Annuity Type: Issue Date: Owner(s1: Annuitants): g v ~~ S~ SS also 0058985460 Nonqualiiied January 13, 1997 Phyllis 1 Smith Phyllis I Smith ~1~e1~~ Your Transaction Detai/ Date Transaction Type Transaction Amount 1/13/2009 ~ Interest Esrnsd for Period SYl5.31 Your annuity earned an annual effective rate of 3.00% during this statement period. The annual effective rate represents the average credited rate on your policy in the last year. S.L,N Congratulations! You're putting the power of tax deferral to work for you. You're saving the smart way, you don't pay taxes until money is withdrawn! Tax penalties may be levied by the Internal Revenue Service for surrender prior to age 59 1/2. Questions? Please, contact your Jackson representative, or call us at 800-777-7779 Monday-Friday, 8:00 a.m. to 8:00 p.m. (ET). Write us at IMG Service Center, P.O. Box 30386, Lansing, MI 48909-7886. Email us at CustomerCare@jnli.com. gssoa