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HomeMy WebLinkAbout04-15-10 (2)~ REV-1500 EX (06-05) PA Department of Revenue Bureau of Individual Taxes PO Boz 280601 Harrisburg, PA 17128.0601 ENTER DECEDENT INI Social Security Number 191-18-3761 Decedent's Last Name GRAUPNER ELIAS 15056041169 OFFICIAL USE ONLY County Code Year File Number IN R SI DENT D C DENT N 4, ~ ~~ a 7.~ O Date of Death Date of Birth 07172009 11261916 (If AppNcable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffer Spouse's Social Security Number FILL IN APPROPRIATE BOXES BELOW ® 1. Original ReWrn 4. LimMed Estate © 8. Decedent Died Testate (Attach Copy of 1nn10 9. Litigation Ptoaeds Received Spouse's First Name THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Return 4a. Future Interest Compromise (date of death after 12-12.82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) Suffix Decedent's First Name MARIA MI MI 3. Remainder Retum (date of death prior l0 12-13-112) a 5. Federal Estate Tax Return Required B. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - TH13 SEC110N MUST BE C111~LETFD. ALL CDRRESPONDENCE AND CONFWENTULL TAX INFlNtW110N BRDULD BE DIRECTED T0: Name Daytime Telephone Number DONN L. SNYDER 717-257-7524 Finn Name (HApplicable) First line of address P.O. BOX 12002 Second line of address City Of Post Office HARRISBURG Correspondent's e-mail address: MMILLI n r penalties of perjury, I declare that I have it is tie, conpct and compote. lleclaratbn of 24 CAMP HILL State ZIP Code L PA 17108-2002 ~ a ~-;-, ....~ ~r ~ G) ~.? ~L'?•rnr-i ~ r'~ C f'1 ~ C n nQ ~ ^! n ~ ~ - t'r-' ~ -v D , ~: 7 nAl'F wZi Fn .• CTS 1 . COM rotum, including accompanying schedules and statemerda, and to the best of my knowledge and belief, than the personal ropresenta8ve is based on aM information of which preparer has any knowledge. Rl N DATE I 4/~ /2010 v~v,~n~ ~n~ yr rncrnnGn v ~ nCn 1 nMrv RCrRCJCn INI IVt DATE ADDRESS 4 ~ ~ 2 010 P.O. BOX 12002, HARRISBURG, BA 17108-2002 PLEASE USE ORIGINAL FORM ONLY Side 1 15056041169 15056041169 J J 15056042160 REV-1500 EX Decedent's Social Security Number Decedents Name: MARIA GRAUPNER ELIAS 191-18 - 3 7 61 RECAPITULATION 1. Real estate (Schedule A) .......................................... ... 1. 2. Stocks and Bonds (Schedule B) ..................................... ... 2. 2 , 4 3 2 , 10 0 . 3 3 3. Closely Hek1 Corporatan, Partnership orSole-Proprietorship (Schedule C) .. ... 3. 4. Mortgages & Notes Receivable (Schedule D) .......................... ... 4. 5. Cash, Bank Deposds 8 Miscellaneous Personal Property (Schedule E) ..... ... 5. 6 7 , 3 0 8 . 8 7 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested .... ... 6. 7. Inter-~lnros Transfers ~ Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested .... ... 7. 13 0 , 8 4 6 . 8 5 8. Total Gross Assets (total Lines 1 - 7) ................................ ... 8. 2 , 6 3 0 , 2 5 6. 0 5 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. 151 , 8 9 7 . 4 2 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule 1) ............. .. 10. 15 , 0 2 0 . 3 6 11. Total Deductions (total Lines 9 & 10) ................................ .. 11. 16 6 , 917.7 8 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 2 , 4 6 3 , 3 3 8 . 2 7 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which l io 2 3 5 2 14 8 2 7 an e ect n to tax has not been made Schedule J ( ) ...................... .. 13. , , . 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. 111 , 19 0 . 0 0 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .0_ 15. 16. Amount of Line 14 taxable at lineal rate x .0_ 1g, 17. Amount of Line 14 taxable at sibNng rate x .12 17. 18. Amount of Line 14 taxable 111 19 0 . 0 0 at collateral rate x .15 ~ 18 16 , 6 7 8 .5 0 19. TAX DUE ........................................................ 19. 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 16,678.50 Side 2 15056042160 15056042160 J REV-150o EX Page 3 Decedent's Comalete Address: File Number 21- 0 9- 0 7 5 0 DECEDENTS NAME Maria Grau ner Elias STREETADDRESS Lo alton @ Creekview 1100 Crandon Way CITY STATE ZIP Mechanicsburg PA 17050 Tax Payments and Credits: 1. Tax Due (Page 2 tine 19) 2. CrediWPayments A. Spousal Poverty Cred'A B. Prior Payments C. Discount 3. InteresUPenatty ff applicable D. Interest E. Penalty (t) 16, 678 .50 Total Credits (A + B + C) (2) 15 , 7 5 0 . 0 0 Total InleresUPenalty (D + E) (3) 4. If tine 2 is greater than Line 1 + Line 3, enter the d'rfference. This is the OVERPAYMENT. Fill in box on Page 2, Line 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater Than Line 2, enter the difference. This is the TAX DUE. (5) 9 2 8 . 5 0 A. Enter the interest on the fax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58) 92 8 . 5 0 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 propeAy transferred : .......................................... ^ b. retain the right to designee who shah use the property transferred or its income : .................... ^ c. retain a reversionary interest; or ......................................................... ^ d. receive the promise for kfe of either paymeMts, tx:rrefils or care? ................................ ^ 2. If death occurred after December 12,1982, did deoederrt transfer propeAy within one year of death without receiving adequate oonsideration? .................................................... ^ 3. Did decedent own an'in trust tar" ar payable upon death bank account or security at his or her death? ..... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a benefxiary 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 For dates of death on or after July 1,1994 and before January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116(a)(1.1.)(i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (O) percent [72 P.S. §9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax relum are still applicable even if the surviving spouse is the only beneficiary. For dues 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 chid is zero (0) percent [72 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-haf (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individuai who has at least one parent in common with the decedent, whether by blood or adoption. REV-1503 EX+ (&98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER 21-09-0750 All properly joirrtty-0wrled with right of survivorship must be disclosed on Schedule F. (n moro space is needed, insert addRional sheets of the same sae) REV-1508 EX+ (8-98) SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. COMMONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER 21-09-0750 Include the proceeds of Idigation and the date the proceeds were received by the estate. All property jointly~owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Net from coin auction (see Cordier attachment 78,75 dated 12-18-09) 2 Net from jewelry auction (see Cordier attachment 817.50 dated Fall 2009 3 Net from personal property auction 12,626.35 (see Cordier attachment dated 11-22-09) 4 Misc. coins 895.00 5 Wachovia Bank-cap Acct. No. 9620344697 46,701.27 6 Diamond solitaire ring 2,100.00 7 Diamond dinner ring 965.0 8 Gold necklace 1,810.00 9 Gold circle pin set with diamonds 1,315.00 TOTAL (Also enter on line 5, Recapihdation) 3 6 7, 3 0 8. 8 7 (H more space is needed, insert addfional wheels of the same size) REV-1510 EX+ (6-96) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS 8 MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER 21-09-0750 This schedule must be campbted and tiled H the answer to any of questans 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. REM NUMBER DESCRIPTION OF PROPERTY NGAIOE il# N4ME OF THE TRANSFEREE, 71fR REUTgNSNp TO DECEOENTAND 7FEDAlEOFTRANSFER.pTrpCNACdPVOFTHEDEEDFORREAIESTATE. DATE OF DEATH VALUEOFASSET % OF DECD'S INTEREST EXCLUSION IFavrurAS~i TAXABLE VALUE t. Western National Life Insurance Co. 111,436.06 100 111,436.06 Annuity # FJ204259 2 Wachovia IRA No. 0191183761 19,410.79 100 19,410.79 TOTAL (Also enter On line 7, ReCeplhlletl0n) I f 13 0 84 6.8 5 (If moro space is needed, insert additional sheets o1 the same sae) REV-1511 EX+ (10.06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER 21-09-0750 Debls of decedent must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t• Neill Funeral 1,013.72 2 Romberger Memorial-marker engraving 230.00 e. ADMINISTRATIVE COSTS: i. Personal RepreseMatiwe's Commissrons Name of PersonalR~reseMative(s)Maronetta F Miller sreetAddress24 Victoria Way City C amp H i 11 state PA zlP 17 011 Year(s) Commission Paid: 2 0 0 9- 2 010 2. Adomey Fees 3. Famiy Facemptan: (KdeoedeM's address is not the same as claimant's, attach explanation) Claimant StreetAddress City State Relationsh~ of Claimant to Decedent 4. I Probate Fees 5. I Accamtant's Fees 6. Tax Retum Preparer's Fees ~, Elmer Magaro-Flowers for Masoleum 8 Law Journal-Advertise Grant of Letters 9 Sentinel-Advertise Grant of Letters 10 Reg. of Wills-short certs. li Post master-postage SEE ATTACHED 65,000.00 75,000.00 1,484.00 1,500.00 75.00 166.30 16.00 44.00 7,368.40 TOTAL (Also enter on line 9, Recapitulation) I ; 151, 8 9 7 . 4 2 ZIP (If men; space is needed, insert add"dional sheets of the same size) No. DESCRIPTION AMOUNT 12 Saul Ewin - sta a 28.89 13 Coble Transfer-move items from Loyalton and storage unit to auction house 1,315.00 14 Munn's Jewel a raisal 150.00 15 BNY Mellon-lost stock cert. 244.28 16 Donn L. Sn der-luncheon 87.12 17 Wachovia-checks 10.00 18 Kath Sitler-not 20.00 19 Saul Ewin -co ies, s e and Federal Ex ress 163.11 20 Camera Box-du licate hotos 106.00 21 Bo er & Ritter - re a final rsonal Income Tax Returns 2,200.00 22 Kevin M. Scott - re are Fiduci Income Tax Returns 1,000.00 23 Kevin M. Scott--review final IRS 706 for filin with IRS 2,000.00 24 Postmaster 44.00 Total $7,368.40 ~588va. ~ 1/5/10 REV-1512 EX+ (12-OB) ~ ` Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER 21-09-0750 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH i. Donn L. Snyder-POA fee for June-July 2,125.00 2 Wachovia-credit card- 102.95 3 Louise Donivan-hair stylist 16.00 4 Omnicare-pharmacy 50.47 5 Bon Ton 181.09 6 Pinnacle Health 161.75 7 Saul Ewing-legal fees June-July 12,367.10 8 Louise Donivan-hair stylist 16.00 TOTAL (Also enter on Une 10, Recapitulation) I; 15 , 020 .36 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (11-OS) ~ : Pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERRANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER 21-09-0750 RELATlONSHiP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. Vivian Enders cash and Jewelry $4.,875 cousin 54,875 2 Dorothy Smith - Jewelry $1,315 cousin 1,315 3 Elmer Magaro none 20,000 4 Groupner Long Mausoleum Maintenance Fd none 10,000 5 Arthur Long cousin 25,000 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV•1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUT10N5: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 fOR WHICH AN ELECTION TO TAX IS NOT TAKEN None 0 1 B. CHARITABLE AND GOVERNMENTAL DISTRIBUT10N5 1. see attached 2,352,148.27 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON UNE 13 OF REV-1500 COVER SHEET. # 2 , 3 5 2 , 14 8 . 2 7 If more space is needed, insert addltlonal sheets of the same size. The (Pine Street) Presbyterian Church of St. Michael's Evangelical Lutheran Church Danette Blank, Ex.Director Harrisburg for Downtown Daily Bread Office of Pastor Tri-County Association for the Blind Third and Pine Streets 118 State Street 1130 South 19'~ Street Harrisburg, PA 17101 Harrisburg, PA 17101 Harrisburg, PA 17104 5% of the residue 10% of the residue 2.5% of the residue The Harrisburg Academy Attn: Arthur Moore Zion Lutheran Church 10 Erford Road Oj~ce of the Pastor WormQeysburg, PA 17043 15 South Fourth Street 10 /o of the residue Harrisburg, PA 17101 35°6 of the residue Following Receive the Percentage Noted of the remalnhtg 37.5% of the Residue American Heart Association Capital Region David J. Morrison Harrisburg Symphony National Bequest Center Derek Dilkes c/o Mr. Bruce Darcus Attn: Betsy Bloch, Bequest Administrator Historic Harrisburg Association ParenteBeard LLC P.O. Box 22249 Post Office Box 1843 P.O. Box 625 St. Petersburg, FL 33742 Harrisburg, PA 17105 Harrisburg, PA 17108-0625 2% 2% 25% General Council of the Assemblies of God For Benefit of Richard Wislocky #244964 Arta: Frederic S. Gore, CPA Harrisburg Area Community College Harrisburg Boys and Girls Club Assistant Administrator Attn: Nancy M. Rockey c/o Morton Spector Division of the Treasury One HACC Drive P.O. Box 60784 1445 N. Boonville Avenue Harrisburg, PA Harrisburg, PA 17106-0784 Springfield, MO 65801-1894 4% 5% 4% Mercersburg Academy Rejoice! Inc. Office of the Headmaster Tanya Williams-Bell, President pine Street Presbyterian Church 300 E. Seminary Streef 1800 State Street Dr. Russell Sullivan -- Menxrsbutg, PA 17236 Harrisburg, PA 17103 310 N. Third Street 3% 4% Harrisburg, PA 17101 IS% Central Pennsylvania Food Bank Lafayette College Thon Express Inc Kendall Hanna, Executive Director Dean Hannah Stewart-Gambino, Ph.D. , . c/o Henry An m~c III President 3908 Corey Road 200 Scott Hall o , 232 Spanglers Mitl Road Harrisburg, PA 17109-5929 Easton, PA 18042 New Cumberland PA 17070 10% 3% , 2% EWI-Harrisburg Chapter American Red Cross of Susquehanna Valley Bethesda Missio Nancy E. Varricchio, President Gannett Fleming Inc Capital Region Office K h n Attn: Scott Dunwoody , . Post Office Box 67100 at y Felker, Executive Director 1804 N 6t° Street 2101 N. Front Street Harrisburg, PA 17106-7100 . Harrisburg, PA 17110 Bldg # 1, Suite 301 Harrisburg PA 17110 4 /0 2% , IS% Westerr National Life Insurance Company vENOOR N0. 'P OAS OFJ204259 P.O. Box &71, .Amarillo, TX 7 91 05-08 7 1 *** ONE HUNDRED ELEVEN THOUSAND FOUR HUNDRED THIRTY-SIX Western National Life Insurance Company P.O. Box 871, Amarilb, TX 79105-0871 NAME: POLICY: TRANSACTION: OWNER: FEDERAL WITHHOLDING TAX STATE WITHHOLDING TAX AMOUNT OF CHECK TAXABLE INCOME S 109,658.72 S 204.46 - 5 62.77 - S 111,436.05 PLEASE DETACH AND KEEP THIS STUB FOR YOUR RECORDS 14575981 _6z-35_ 311 BNV Mellon TruS[ Ot OtliMlare NEWARK,DELAWARE PAY THIS AMOUNT and 05/100 DOLLARS *** $ «. « «...111,436..09 CHECKD 14575961 INTERNAL REFERENCED 2200841350 TRANSACTION STATEMENT MARIE ELIAS September 14, 2009 FJ204259 PARTIAL WITHDRAWAL MARIE ELIAS Janney Montgomery Scott LLC August 26, 2009 Law Offices of Donn L. Snyder PO Box 12002 Harrisburg, PA 17108-2002 RE: Estate of Marie G Elias Dear Mr. Snyder, ~e ~ ~ $1Z7,o ~jS I In response to your letter dated August 19, 2009, Marie G. Elias maintained account number 3017-8810 at Janney Montgomery Scott LLC since November 7, 1983. There were no registration changes within the last two years. The following checks were issued from the account; these amounts represent dividends and interest paid to the account: 05/22/09 $ 789.63 06/05/09 $1,000.00 06/26/09 $ 200.57 07/31/09 $ 196.82 05/29/09 $ 179.17 06/19/09 $1,110.23 07/17/09 $3,097.72 08/21/09 $ 552.59 The remaining information you are requesting will be included in the Date of Death Valuation which I should be able to forward to Maronetta Miller sometime next week. The Estate account has been open and all assets have been transferred to Estate account number ~ 128-1111. If I can be of further assistance in the handling of Mrs. Elias' Estate, please feel free to contact me at 717-731-2103. Sincerely, Daphne L. Williams Branch Operations Manager/ Assistant to Alan S. Meminger 20 Erford Koad, Suite 315, Lemoyne, PA 17043-1109 • 717.731.4400 Eax: 717.731.4411 www.jmsonline.com Member New ti~rk Stock Exchange, Inc. and other principal exchanges Member Securities Investor Prcaection Corporation Estate Valuation Date of Death: 07/17/2009 Estate of: Marie G. Elias Valuation Date: 07/17/2009 Account: 3017-8810 Processing Date: 08/26/2009 Report Type: Date of Death Number of Securities: 16 File ID: Marie G. Elias DOD 071709 Shares Security Mean &/or Div & Int Security or Par Description High/Ask Low/Bid Adj'ments Accruals Value 1) 100000 PENNSYLVANIA ST Financial Times DTD: 01/15/2001 07/17/2009 Int: 07/15/2009 G.O. BDS (709141QF5) Interactive Data Mat: 01/15/2021 5.125$ 107.59200 Mkt 107.542000 107,542.00 to 07/17/2009 28.97 2) 25000 STATE PUB SCH BLDG AUTH PA SCH SCH LSE R (857322PZ8) Financial Times Interactive Data DTD: 09/10/2003 Mat: 06/01/2033 5~ 07/17/2009 113.95900 Mkt 113.959000 ;.28,989:75 Int: 06/01/2009 to 07/17/2009 159.72 3) 25000 LEWISTOWN BORO PA GO BDS (528699CR0) Financial Times Interactive Data DTD: 05/15/2003 .Mat: 12/15/2025 9.68 - 07/17/2009 100..03800 Mkt 100.038000 25,009.50 Int: 06/15/2009 to 07/17/2009 102.22 4) 15000 PENNSYLVANIA ST Financial Times DTD: 03/01/2001 07/17/2009 Int: 06/01/2009 TPK COMMN TPK TURNPIKE (709223NP2) Interactive Data Mat: 12/01/2030 5$ 101.12500 Mkt 101.125000 15,168.75 to 07/17/2009 95.83 5) 15000 HARRISBURG PA AUTH RES RECOVER REF REV B (91973EES6) Financial Times Interactive Data DTD: 06/04/2003 Mat: 09/01/2039 5$ 07/17/2009 95.33100 Mkt 95.331000 14,299.65 Int: 03/01/2009 to 07/17/2009 283.33 Page 1 This report was produced with EstateVal, a product of Estate Valuations ~ Pricing Systems, Inc. Janney Montgomery Scott LLC assumes no responsibility for accuracy or completeness of the information provided, the Date of Death and the specific securities, which are valued. While we deem this information to be reliable, we do not warranty or guarantee its accuracy. This service is not intended to constitute legal or tax advice. You should consult with your tax professional and attorney to discuss estate settlement and any legal matters. Date of Death: 07/17/2009 Estate of: Marie G. Elias Valuation Date: 07/17/2009 Account: 3017-8810 Processing Date: 08/26/2009 Report Type: Date of Death Number of Securities: 16 File ID: Marie G. Elias DOD 071709 Shares Security Mean &/or Div & Int Security or Par Description High/Ask Low/Bid Adj'ments Accruals Value 6) 50000 GNMA PASS-THRU X SINGLE FAMILY (36205BM58) Financial Times Interactive Data Mat: 05/15/2024 7.000$ Fact: 0.01571928 07/17/2009 109.32238 A/B 109.322384 859.23 Int: 07/01/2009 to 07/17/2009 2.45 7) 150000 GNMA PASS-THRU M SINGLE FAMILY (36202CJZ7) Financial Times Interactive Data Mat: 09/20/2025 7.5008 Fact: 0.0117818 07/17/2009 111.11434 A/B 111.119341 1,963.69 Int: 07/01/2009 to 07/17/2009 5,g9 Int: 06/01/2009 to 06/30/2009, payable 07/20/2011.21 Prin: 06/01/2009 to 06/30/2009, payable 07/20/2009 27.07 8) 50000 GNMA PASS-THRU M SINGLE FAMILY (36202DD57) Financial Times Interactive Data Mat: 10/20/2029 7,0008 Fact: 0.02174522 07/17/2009 109.52152 A/B 109.521520 1,190.78 Int: 07/01/2009 to 07/17/2009 3.38 Int: 06/01/2009 to 06/30/2009, payable 07/20/2006.94 Prin: 06/01/2009 to 06/30/2009, payable 07/20/2009 16.58 9) 25000 FHLMC REMIC SERIES 2647 (31394GC76) Financial Times Interactive Data Mat: 07/15/2033 5.0008 Fact: 1 07/17/2009 97.38751 Mkt 97.387510 29,346.88 Int: 07/01/2009 to 07/17/2009 55.56 10) 25000 FNMA REMIC TRUST 2005-115 (31394VUT5) Financial Times Interactive Data Mat: 10/25/2033 6.0.008 Fact: 1 07/17/2009 101.42122 Mkt 101.421220 25,355.31 Int: 07/01/2009 to 07/17/2009 66.67 Int: 06/01/2009 to 06/30/2009, payable 07/25/2125.00 Page 2 This report was produced with EstateVal, a product of Estate Valuations & Pricing Systems, Inc. Janney Montgomery Scott LLC assumes no responsibility for accuracy or completeness of the information provided, the Date of Death and the specific securities, which are valued. While we deem this information to be reliable, we do not warranty or guarantee its accuracy. This service is not intended to constitute legal or tax advice. You should consult with your tax professional and attorney to discuss estate settlement and any legal matters. Date of Death: 07/17/2009 Estate of: Marie G. Elias Valuation Date: 07/17/2009 Account: 3017-8810 Processing Date: 08/26/2009 Report Type: Date of Death Number of Securities: 16 File ID: Marie G. Elias DOD 071709 Shares Security Mean &/or Div & Int Security or Par Description High/Ask Low/Bid Adj'ments . Accruals Value 11) 25000 FHLMC REMIC SERIES 2724 (31394NAT5) Financial Times Interactive Data Mat: 12/15/2033 5.500 Fact: 1 07/17/2009 98.75942 Mkt 98.754420 24,688.61 Int: 07/01/2009 to 07/17/2009 61.11 12) 13000 FNMA REMIC TRUST 2005-21 (31394CTV4) Financial Times Interactive Data Mat: 03/25/2035 5.000 Fact: 1 07/17/2009 98.33045 Mkt 98.330450 12,782.96 Int: 07/O1J2009 to 07/17/2009 28.89 Int: 06/01/2009 to 06/30/2009, payable 07/2 5/2059.17 13) 18000 FHLMC REMIC SERIES 3075 (31396ET48) Financial Times Interactive Data Mat: 11/15/2035 5.750 Fact: 1 07/17/2009 98.93597 Mkt 98.935970 17,808.97 Int: 07/01/2009 to 07/17/2009 46.00 14) 21000 FHLMC REMIC SERIES 3081 (31396FXS7) Financial Times Interactive Data Mat: 12/15/2035 5.7508 Fact: 1 07/17/2009 98.83461 Mkt 98.834610 20,755.27 Int: 07/01/2009 to 07/17/2009 53.67 15) 25000 GNMA REMIC TRUST 2007-50 (38375K3X8) Financial Times Interactive Data Mat: 01/16/2037 6.000 Fact: 1 07/17/2009 100.93044 Mkt 100.930440 25,232.61 Int: 07/01/2009 to 07/17/2009 66.67 16) 103075.55 Cash (CASH) 103,075.55 Page 3 This report was produced with EstateVal, a product of Estate Valuations b Pricing Systems, Inc. Janney Montgomery Scott LLC assumes no responsibility for accuracy or completeness of the information provided, the Date of Death and the specific securities, which are valued. While we deem this information to be reliable, we do not warranty or guarantee its accuracy. This service is not intended to constitute legal or tax advice. You should consult with your tax professional and attorney to discuss estate settlement and any legal matters. Date of Death: 07/17/2009 Valuation Date: 07/17/2009 Processing Date: 08/26/2009 Total Value: Total Accrual: Total: $449,869.34 Page 4 Estate of: Marie G. Elias Account: 3017-8810 Report Type: Date of Death Number of Securities: 16 File ID: Marie G. Elias DOD 071709 $498,612.66 $1,256.68 This report was produced with EstateVal, a product of Estate Valuations & Pricing Systems, Inc. Janney Montgomery Scott LLC assumes no responsibility for accuracy or completeness of the information provided, the Date of Death and the specific securities, which are valued. While we deem this information to be reliable, we do not warranty or guarantee its accuracy. This service is not intended to constitute legal or tax advice. You should consult with your tax professional and attorney to discuss estate settlement and any legal matters. Wachovia ,62a As of Date: 01/08/2010 2009 FORM 5498 MARIE GRAUPNER ELIAS C/0 MARONETTA F MILLER 2 N 2ND ST FL7 HARRISBURG PA 17101-1619 Wachovia Bank, N.A, as Custodian Customer Service: 80069-2136 Partkipant's Name and Address: MARIE GRAUPNER ELIAS C/0 MARONETTA F MILLER 2 N 2ND ST FL7 HARRISBURG PA 17101-1619 5498 -IRA Contribution Information Copy B For Participant ISSUer's Name and Address: WACHOVIA BANK, N.A. 401 SOUTH TRYON STREET CHARLOTTE, NC 28288-1164 Issuer's Federal Identification No: 56-1354525 Participant's Social Security Number: 19118~3761 Your Account Number: 0191183761 OMB No. 1545-0747 IRS Box No. Description 1 IRA OONTRIBUTIONS (OTHER THAN AMOUNTS IN BOXES 2-4 AND 8.10) 50,00 2 ROLLOVER CONTR~Ui10NS ~.~ -~ 3 ROTH IRA CONVERSION AMOUNT ~.~ 4 RECHARACTERIZED CONTRIBUTIONS ~ ~ 5 FAIR MARKE7 VALUE OF ACCOUNT _ 519,410.79 - 8 LIFE INSURANCE COST INCLUDED tN BOX i ~ ~ 7 IRA ~ SEP ~ SIMPLE ~ ROTH IRA _ 8 SEP CONTRIBUTIONS 50.00 _-_-9-.- -SIMPLE CONTRIBUTIONS ~.~ - 30 ROTH IRA CONTRIBUTIONS ~ ~ 11 _ `_ IF CHECKED. REQUIRED MINIMUM OISTRIBUTN)NS FOR 2010 ~ 12a -- ' _ _ _RM_O Date - - _12b _ _ RMD Amount ------- ---- -- - ----- - _ --- _ f0.00 The above is important tax information and is being furnished to the Internal Revenue Service. See instructions on reverse. 134193011165044123 YYNN NNNNNNNN OW00'd NZYSR2TA Wachovia Retirement Statement 134193 azwz1o11 MARIE GRAUPNER ELIAS C/0 MARONETTA F MILLER z 2 N 2ND ST FL7 HARRISBURG PA 17101-1619 e1 For Customer Service Call (800) 669-2136 Or write to: WACHOVIA BANK, NA 401 SOUTH TRYON STREET CHARLOTTE, NC 28288.1164 18 Pian Overview -IRA Asset & Earnings Summary ?_ Balance as of Balance as of Earnings paid* Earnings paid* ~ Type of asset 0],/01/2009 12/31/2009 this period this year _ ~.r. Time Deposits $ 20,758.25 $ 19,410.79 $ 814.85 $ 814.85 Total ----- -- $20,758.25 $19,410.79 $ 814.85 $ 814.85 *Eamings are shown to help track how your IRA is performing. You are not required to report these as taxable earnings on your tax return. I~ Tax Information: Contributions. & Distributions ~ Contributions ~ For tax year 2008 $ 0.00 For tax year 2009 $ 0.00 ~ Rollover Deposits $ 0.00 2009 Distributions Amount (gross) Federal tax withheld Net amount Smarter Retirement Planning With Wachovia IN 2010, THE RULES FOR A ROTH CONVERSION ARE CHANGING. YOU MAY HAVE AN OPPORTUNITY TO CONVERT YOUR RETIREMENT ACCOUNTS TO A ROTH IRA, AND MAY BENEFlT FROM TAX-FREE INCOME IN RETIREMENT. CONTACT YOUR FINANCIAL SPECIALIST TO SEE IF THIS STRATEGY MAY BE SUITABLE FOR YOUR SITUATION. $ 2,162.31 $ 0.00 $ 2,162.31 01/01/2009 thru 12/31/2009 WACHOVIA BANK, NA Page 1 of 3 1341930111G5044123YtNNNNNNNNNN 000001 fiZY5R2TA Wachovia ~ez~ Retirement Statement 01/01/2009 thru 12/31/2009 MARIE GRAUPNER ELIAS Time Deposits These deposits are FDIC inwred up to $250,000 per depositor. Ask us about our added coverage IRAs for addiUonai inwrance coverage. SUMMARY Certificate Balance as of Maturity Interest Interest paid Interest paid Account Number Type 12/31/2009 date rate this statement period this year 257410090511804 60 MO AND l~ = 19,410.79 03/19/2012 4.170 X f 814.85 S 814.85 Total S 19,410.79 S 814.85 S 814.85 ~'T~IPLI\I Account Number. 257410090511604 ~ Date Descrlpt(on Add Subtract Balance 01/01/2009 Opening Balance S 20,758.25 03/31/2009 Interest 214.52 S 20,972.77 03/31/2009 Payout Distrilxrtion 2,162.31 S 18,810.46 06/30/2009 Interest 196.57 S 19,007.03 ~_ 09/30/2009 Interest 200.82 S 19,207.85 12/31/2009 Interest 202.94 f 19,410.79 32/31/2009 posing Belanoe - --- -- ------ S 19,410.79 1NACHOVIA BANK, NA Page 3 of 3 134193071165044123 YYNN NNNNNNNN 000002 RIYSR2iA ~- MUNN'S diamond gallery JEWELRY APPRAISAL ESTATE PURPOSES FAIR MARKET VALUE LISTINGS We estimate the value(s) as listed for estate purposes only using fair market value guidelines. The following item(s) have been carefully examined and verified as accurately as possible within the normal and reasonable gemological ranges without the use of gemstone removal or damaging tests. Carat weights are estimated by volumetric formula unless otherwise noted. Prepared For: Estate of Marie Elias 1tt~~ ~'~s ~,~^ 1. Item Description: Diamond Anniversary style ring, Platinum mounting with 14 round single ~- cut diamonds *.20 cttw. SIl -SIZ/GH quality. (Double row, prong set) Metal wgt 23 dwt Fair Market Value of this Item ............... $ 240.00 ~2. Item Description: Diamond Engagement ring, Platinum mounting with one major round ~~ diamond *.77 ct. VS 1/GH quality, six minor round diamonds *.10 cttw. SI2-Il/GH quality, metal wgt. 2.1 dwt, sz. (Rd ctr., three graduated small stones each side) Fair Market Value of this Item ............... $845.00 3. Item Description: Lady's fashion style ring, nine diamonds, Platinum mtg with round major center *.71 ct. SII/F quality, eight round minor diamonds *.56 cttw. SI2/GHI quality, 1203 Market Street metal wgt. 3.6 dwt. (Low profile, filigree, confer prongas on ctr stone) Lemoyne, PA 17043 Fair Market Value of this Item ............... $965.00 ~4. Item Description: Diamond eternity style ring, Platinum mounting with 23 round diamonds *.46 cttw., metal weight 1.4dwt. (Diamonds all around) `~" Fair Market Value of this Item .................$ 225: -7 5. Item Description: Diamond engagement ring, 14k white gold mounting with 1 d *1.26 ct. SIl/G quality, metal weight 1.7dwt. (Single stone ring) Fair Market Value of this Item.. 00 ` `: / ;:~.. , ~ V 6. Item Description: Lady's wedding band, 14k yellow gold 2mm. wide snK~t~~ ; metal weight 1.Sdwt. (No stones) Fair Market Value of this Item........ t. x ,.f~ ~~ .~ M U N N'S Appraisals: Marie Elias, (con't.) diamond g a l l e r y 7. Item Description: Lady's Diamond Circle Pin, 14k yellow gold with 6 round diamonds, major stone *.86 ct. SI2/G quality, (5)minor stones *.57 cttw. SIl-I1/G quality, metal wgt, l ldwt. Fair Market Value of this Item .................$ t,315.00 8. Item IDeacrlption: Diamond Necklace, 14k yellow gold necklace with 26 diamonds, major stone Round shape * 1.05 ct. SI2-Il/EII quality, 23 minor round minor stones * 1.15cttw SI2-I1/H-I quality, 2 baguette diamonds *.12 cdw. SI2-I1/HI quality, metal wgt 3.8dwt. Fair Market Value of this Item .................$ 1,810.00 ~. Item 1Deacripiion: Diamond fashion ring, Platinum mounting with 9 diamonds, one round major stone *.40 ct. SIl/I-J quality, (8) round shape diamond minors *.72 cttw.SIl-SIZ/I-J quality, metal weight 2.8 dwt. (L.ow profile, beaded edging, eight prong center setting) Fair Market Value of this Item .......:........$ 535.00 ~' ,~ 10. Item Description: Lady's Diamond and Sapphu+e ring with (9) diamonds and (8) sapphires, ~11` maja~ stone one round diamond: *.62 ct. VS1/G-H quality, (8~inor stones *.21criw SI1/GH 9~itY, ~PP~ modified square cuts *.15 cxtw. A quality metal wgt. 2.6 dwt (Filigree) Fair Market Value of this Item .................$ 1,480.00 Date of Appraisal(s): October 16, 2009 leted by, Christopher C. Munn 1203 Market Street Lemoyne, PA 17043 Note: Precious metal market price: $1047.00%z('1~ Platinum $1341.00%z('I') *unless noted, canR weight is estimated by formula, no stone removal. Value excludes tax. Photo of item attached to original document. 'T'his is not an offer to purchase or replace articles. 1T17)- ~~-7 7-87`I=..QI Prudential September 1, 2009 Maronetta F. Miller, Executrix 24 Victoria Way Camp Hill, PA 1701 I Re: XXXX-7820 Marie G. Elias Dear Maronetta: rn~a s.~a~tin, u.c COMMAND Service Center PO Box 15010 New Brunswick. NJ 08906-5070 (8001235-7637 www.prudential.cem Per your request, we are confirming the balance on the above-referenced Pruco Securities Account. Our records indicate that as of 07/17/2009, the value of this account was: Investment Shares Price Value AEM 4,550 $55.57 $252,843.50 ALU 164 $2.51 $411.64 A[B 2,520 $4.64 $11,692.80 T 3,939 $23.98 $94,457.22 BP 3,813 $48.72 $185,769.36 CMCSA 661 $14.15 $9,353.15 CPO 168 $26.62 $4,472.16 COV 416 $36.54 $15,200.64 CSX 600 $37.87 $22,722.00 DPHIQ 6t $0.06 $3.69 DD 270 $27.57 $7,443.90 EXC 136 $51.42 $6,993.12 XOM - 4,362 $68.52 $298,884.24 Fes' 17 $0.57 _ $9.69 GE 1,440 $11.65 $16,776.00 MTLQQ 88 $0.46 $40.39 PPL 6,000 $32.45 $194,700.00 Q 461 $3.99 $1,839.39 TEL 416 $18.77 $7,808.32 TYC 416 $28.51 $11,860.16 VZ 918 $29.59 $27,163.62 VOD 568 $18.61 $10,570.48 W FC 479 $25.00 $11,975.00 ~~~ Securities products sad services are offered d~rough Pruco Securities, LLC, 751 Broad Street, Newark, New Jersey 07102- 3777, member SIPC, a Prudeetial Financial company. Pradeatial, Prudential ~aaneial and the Rock logo are registered service marks of The Prudential lasurance Company otAmerica, Newark, NJ and its affiliates. A registered principal of Pruco Securities, LLC. Investment Shares Price Value FANNIE MAE NOTES SEMI ANNL PAY - CALLABLE CPN 5.500% DUE 12/z6/zz 100,000 $100.034 $100,034.00 PENN ST HIGHER EDL FACS AUTH COLLEGEBc UNIV REVS TRUSTEES UNIV PA MBIA IB CPN 4.750% DUE 07/15/33 40,000 $96.124 $38,449.60 AHITX 6,384.448 $9.22 $58,864.61 ABNDX 2,167.630 $11.25 $24,385.84 CWBFX 1,458.435 $19.25 $28,074.87 EKVAX 6,387.015 $10.43 $66,616.57 ESBAX 2,942.656 $7.42 $21,834.51 VMPAX 7,238.307 $8.59 $62,177.06 AMECX 16,105.190 $13.33 $214,682.18 AFTEX 7,708.905 $11.61 $89,500.39 ACTHX 4,456.328 $8.35 $37,210.34 Money Market 47,410.560 $1.00 $47,410.56 Total Portfolio Value 51,982,230.99 This account was opened on 08/14/2008. [f you have any questions or need additional information, please contact the COMMAND Service Center at (800) 235-7637. Customer Service Representatives are available to assist you between 8:30 a.m. and 7:00 p.m. ET, Monday through Friday. Sincerely, ~~~-~ John Twomey - Registered Principal Pruco Command Operations Prut;,o Securities, LLC EJH Pnafen6al Mvesmient Management Services LLC 7516oad Sheet NewaA New Jdsey 071023772 Tel 201802624 Cordier Antiques S Fine Art 2151 Market Street Camp Hiil, PA 17011 Consignor Settlement Phone:717-731-8662 Fax: 717-731-9830 Consignor: 1014 Marie Elias c/o Maronetta Miller/Saul Ewing 2 N. 2nd St, 7th floor Hantsburg, PA 17101 Phone:717-257-7524 Auction: Variety Auction 12/18/09 Lotl/ Oesaipticn (~uanury 531 coin bt 110 Misc Lot ind 1976 3 pc 40% Silver 1.00 Proof Set,1964D Mint Set, German Coins Set, First Day Cover Medals (9 -1975,1976), 3 Sterling 1 oz,13 Empty Whitman Books, Reference Books, Much More CO #: 963 Date: 12/18/2009 Page: 1 unit Price Ext.Prioe CommlBuysar;k F_xpenses 45.00 - -r- 45.00 -11.25 0.00 Bid Card # 114 -------------------~-~---....---- .------..._..--- - 9 - --- - -------- ~--~-~--- ---- --- - - - ------------••----~--•----------- --- - --- ---- ---.._.......----~-~ 532 can bt 111 2 British L Cents (1900,1921 , 18 1.00 5.00 5.00 -1.25 0.00 Canadian Lg Cents (1897 -1920), 2 US Indian Bid Card # 167 Cents (1897,1898) 533 can bt 112 6 Silver Half Dollars (various dates) 1.00 30.00 30.00 -7.50 0.00 Bid Card # 139 534 can bt 113 2 Mo an Silver Dollars (1878-S, 1.00 25.00 25.00 -6.25 0.00 1890) Bid Card # 160 Total Duantity: 4.00 Total invoice Sale Price: 105.00 Total Commission: ( 26.25) Total Due to Consignor: 78.75 Total Payments: 0.00 Balance: 578.7 5 Positive Balance, Monies Owed to Consignor COMMISSION SETTINGS Cak;ulate Commission By: Each Commission Structure Type: Fixed Any Amount 25% Consignor Settlement Cordier Antiques 8 Fine Art 2151 Market Street Camp Hill, PA 17011 Phone: 717-731-8662 Fax: 717-731-9830 ConsMnor:1014 Marie Elias Go Maronetta Miller/Saui Ewing 2 N. 2nd St, 7th floor Harrisburg, PA 17101 Phone:717-257-7524 Auction: Fall 2009 Catalog Auction Lo#F Description Quantity 272 Jade and Enameled Gold Necklace 1.00 OESCRIPTIOPI: Rope chain neddace in tested 14K yelbw gold from which hangs a arcular carved and reticulated jade pendant connected by two enameled heart shaped pieces and a • seed. pearl.12.8 dwt (20.0 grams). Pendant 27mm wide. Chain 1 fr3/4' bng. 273 .26 CTW Diamond & Sapphire Bar Pin 1.00 DESCRIPTION: Diamond and sapphire firms bar pin in marked t4K white and yellow gold. Set with two approximately 8 point and one approximatety 10 point round diamonds and two square cut sapphires..28 ctw diamonds. 3.3 dwt (5.2 grams).3-7/8' x 5J16'. CO #: 696 Date: 7/22/2009 Page: 1 Unit Price F~d.Nrice ConuNBuyBadc Expenses 550.00 550.00 -137.50 0.00 Bid Card # 114 90.00 90.00 -22.50 0.00 Bid Card # 823 274 14KYeIbwGoklBJadeBraoeletDESCRIPTION: 1.00 225.00 225.00 -56.25 0.00 Bracelet in marked 14K yellow gold. Seven Bid Card # 114 recbrrg<rlar fiAgree Nnks ai~mating with Three round carved and reticulated jade links. 6.0 dwt (9.3 grams). 7-3/8' long. 275 .18 CTW Diamond & Sapphire Bracelet 1.00 DESCRIPTION: A dianand and sapphire filigree bracelet in tested 14K white and yellow gok1. Set with three 6 point round diamonds and six square cut sapphires..18 ctw diamonds. 8.2 dwt (12.8 grams). 7-1/8" bng. 225.00 225.00 -56.25 0.00 Bid Card # 114 Consignor Settlement Cordier Antiques 8 Fine Art CO #: 696 2151 Market Street Camp Hill, PA 17011 ~ Date: 7/22/2009 Page: 2 Phone: 717-731-8662 Fax:717-731-9830 Total Quantity: 4.00 Total Invoice Sale Price: 1, 090.00 Totat Commission: ( 272.50) Total Due to Consignor. 817.50 Total Payments: 0.00 Balance: 5817.50 Positive Balance, Monies Owed to Consignor COMMISSION SETTINGS Cakxalate Commission By: Each Commission Structure Type: Fixed Any Amount 25% ~~ ~ ~COaoil A F ~ 1 .. ' p . ¢ `4yV.~ 1 ' + n-~ ~ -qe ~ ~ilV ~~1V Y11 i ~~~ .SOUTH C,,EMR'AL PAV ~' t ~' a ,r al ~~~IU., Pl~i' Q~9 °` ~ ~`7~~~3 !~'i~ 721t-~~ `' 1~U09 g, K - r G~'. ~ f P +~ ~ °+va, ~ ~ ep "~, _ y~ ~ ~ F ~ ~ ~ s -i 4" ~ C, TA ~ i a u Y "' a„" m..u°~ 'ry1 F x `fix 'dY ~ r ~ y ': ~ r T ~~" ~y+~~.. ,?,.3. gr ;g4CLar r ~flrR ~~ati•*'~: ~ ,'~ ~(R'~.~`~ rr 4 ~'. ~ #~ _ ., ~ ~,~'6e T~j_~f~ /"~O' S 1Y '.,t r r[ a.~~+1~~~~yf .~w~a5y"i 1' ~ Y ~Y av~r s..~ .'.: ~F~ }~ #r ~ 1~. .: -"~.rsi,_ 't.~. .._ ~ ~~rl!'A~. °.ihi.'S~a.'.f'. ~i c.4 ~. iJY,.... ~ 44,~i i".:fir, .5':, ~.~" 4 , ~,~~~. ~~'003.347i~• -r+:0 3 13 1 2 738: 51 i 2063367u' REWbS EX • p.p{) COMMONWEALTH OF PENNSIIVANIA DEPARTMENT OF REVENUE MINERfTANCE TAX DNISION DEPT. 280801 HARRISBURG, PA 17128-O6p1 MUST 8E COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITU T ION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS L~ r ~ _ /~ / (~ _ OROEATH>rERTIRCAiEN11118ER(oMyH38gb~eJwownl 11 J l1 8 NAME (LAST, FIRST, ) ~ D~ ' ` ~ ` ' v~~ ~ U ADDRESS OF DECEDENT (STREET) 'S ~ ~ (STA ) 1~ Y ~ 1~'-'~ S~U ~ CLIP f~OE) -NAME ANrD A~DDRE88 OF PERSOfN REgUEgTING THE °~ (NAME) V I ~ ~c~~r MI6 OF THE 8AFE DEPOSIT BOX k.J Q 1 1`? L~ c~ N . Vl t e _ NAME ADDRESS . AND RELATX~iSFNP ~ ANy) TO DECEDENT, OF PERSON(8 PRESENT AT THE BOX OPENING a (NAME) (RELATKXdSHiP) (STREET NAME) (CITY) (STATE) (ZIP CODE) b. (NAME) (RELATIONSHIP) (STREET NAME) (CITY) (STATE) (ZIP CODE). c (NAME) (RELATIONSHIP) (STREET NAME) (CIM (STATE) Ru' COOS) NAME AND ADDRESS OF FMIANCIAL WSTIi1)TgN WHERE 8AFE pEpggR BOX IS LOCATED ) r~ rd s~- tCm') ATE) r is bu ~ (ZIP CODE) - NAME of PERSON MAKM16 LAST ENTRY ~ o - DATE oP LAST ENTRY DAtE oR cDNTRACT To RENT eox NUMBER ~ eox TTfLE UNDER Box Is REQUEgTep .~ wwD ADDRESS of PeeBON(a) NAVMx~ ACCESS ~ Box a E) ~ ~ ,~ b. c~R' to a ` r u~'!~ _ NAME 71T'LE OF EMPLOYEE TANNIG THE INYENTORy WA8 A WILL Ma THE BOX? ^ YEB~ NO N ysa, a Dais of wiH: 0. Name and addn»a of psrao~wl np~seeMagve, N named M tha wNl (NAME) (STREET ADDRESS) lu ~ r) Please Print or Tvru3 (STATE) (lap COpE) C~~N7t/"lZ /UAJUJkt~~, (STREET NAME) (Cm') (STATE) RIP CODE) t Name and addnaa of akorney, N anY (NAME) SAFE DEPOSIT BOX INVENTORY (STREET NAME) (CITY) (STATE (ZIP CODE) ~~~ iw1 L+Te9e IAT~Ia.~w -~ •..v s i~v6s i [V1~i t7 -Ti The Department is authorized under federal law , A2 U.S.C_ § 4U5(c), to use the decedents Social Security number in administering this stat t t e ax aw. The Department uses Social Security numbers to establish a decedents identity and ensure proper credit for fax payments. (~) Cash: Report total only. I (~) Stocks: t.ist in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to he 1 designated by name of company certificate number date of Certiflr t i , , a e, name n which stock is registered, and number of shares and lass of stock. (3) Obilgetiorls of U.S. Govemmant: Number of items, date of issue, face value, names In which registered and type of ownership. i.e-, joirrtiy held, payable on death, etc. (4) Bonds: Designate by name, amourrt, serial number, or other designatkm. (Bearer Bonds) (~ Bank and Savings and Loan passbooks: State name of depositor, number of book, last date appearing in book, Hama of bank and branch, and balance. (6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds. Mortgages, Current insurance Policies or other evidences of indebtedness: List and describe aS fully as possible. (e) All other contents. ( No - ~ nEae oescRS+T1oH 1 1 9(~ 1~ '7~ 9 i o, ,rv,~ ~,ru5~ ~ ~~ a ,~ E,,~ '~N ~ v~. '' ~ ~~~5 , :N+rC~G! tA~ 2Rft W'R tiZCJ +L+C . . 0~.1ce~ W~c.~ ' ,t2G- W ~~ain~ 2 ~ I P +Y 3a , . ~ en e ~ U'n 5 JG ~'J10.JN TC,- 4 ,~ how ~ ,~ ` , ~ - 2f.~ti - d<~t. ~~ .. t~ - t ti'•e.,L ~. ~~~~ a a N t ~ ~~~ ~N A t t` iJ ~~ C.Ql~I 1 ~ N S 17 < ~ .. 1 CERTA~Y UNDER PENALTY OF ?ERJURIr THAT THE ABOVE RECORD IS CORRECT AMO COIi'LEiE TO~iIE BEaT OF 11Y KNOYM,EppE AND BBL ~.ns . iii - .._.. ~~..r - lMME - ~ f ~, l.I-1~e. N , ~~ ~~ ~. ^Jd.aw,.dW.ApoN16~ NOTE: Attach additlonal tl'/:" x 11" sheet(s) ne/xssary Or use duplicates of this page of foria. a,~1. "~-A ~:. ~~ ~~