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HomeMy WebLinkAbout05-04-10J 15056071120 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year PO 80X.280601 ~ ~ INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 ~ ~ RESIDENT DECEDENT 21 0 9 File Number 1175 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death 175 10 7404 12 09 2009 Decedent's Last Name KELLER (If Applicable) Enter Surviving Spouse's Information Belovu Spouse's Last Name Date of Birth 06 21 191'7 Suffix Decedent's First Name MI INA M Suffix Spouse's First Name MI Spouse's Social Security Number 'THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ X 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-'i 3-82) 4 Limited Estate Future Interest Com romise 4a. 2 ~ 5. Federal Estate Tax Retttrn Required (date of death after -12-s2) it ! X '' g Decedent Died Testate (Attach Copy of Will) ~ Decedent Maintained a Living Trust (Attach Copy of Trust) 0 8. Total Number of Safe De osit Boxes p ~I 9. Litigation Proceeds Received ~ 10. Spousal Povertyy Credit (date of death b ~ ~ 11, Election to tax under Sec. 9113(A) .~ etween 1231 J1 and 1-1-95) (Attach SCh. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL T~~X INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number JOHN E. SLIKE ESQ. 717 737 3405 ~., Firm Name (If Applicable) SAIDIS, FLOWER & LINDSAY First line of address 2109 MARKET STREET Second line of address City or Post Office State ZIP Code CAMP HILL PA 17011 Correspondent's a-mail address: c~ RiEGISTER O~~LS USES LY ;_ - -0 ~~ r=te' rn ~~ .. I -- ~ ~ t r ~ `~ ~ II v DATE FILED O ~_ y ~, f.. 1 .: /~-'.1 ...' Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statement:;, and to the best of rrty knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge. SIG RE OF PERSON RESPONSIBLE FOR FILING RETURN / DATE rr ~ / ,. ~.~.,, ~--~ ..~~Z~,,-- ~leffrey P. Weaver ~~~~ ~ G~~,~'~C, _ , ADjiR675~/ / - ~ 51 a ne Drive Mecha icsbur PA 17055 SIGNA U Fy OF PREPAREP, OT R THAN EPA ESENTATIVE DATE t~ __-~~~~. Jahn E. Slike Esq. ._' ~~ / f' ~ ADDR JS` `, _ 21 9 Market Street, Camp Hill, PA 17011 L 1505607112D Side 1 1 ~i056071121D . - .._ J 1,5056072],20 REV-1500 EX Decedent's Social :Security Number Decedent's Name: Ina M. Keller 17 5 10 7 4 0 4 RECAPITULATION -- --_---- - ------ ----------____ -- - 1 . Real Estate (Schedule A) ...................................................................................... . 1. 2 . Stocks and Bonds (Schedule B) ............................................................................ . 2. 3 0 3, 2 8 5. 7 3 3 . Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)........ . 3. 4 . Mortgages & Notes Receivable (Schedule D) ....................................................... . 4. 8 , 5 0 0 . 0 0 5 Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. ~6 0 , 18 6 . 6 6 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested............ 6. .L 5 , 8 3 0 . 2 6 7. Inter-Vivos Transfers & Miscellaneous N,on-Probate Property (Schedule G) X Separate Billing Requested............ 7. 67 , 552.40 8. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 455 , 355.05 9. Funeral Expenses ~ Administrative Costs (Schedule H) ....................................... 9. 3 7 , 6 $ 0 . 3 6 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 5 8 6 . 6 7 11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 38 , 2 67.03 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 4 7.7 , 0 8 8 . 0 2 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............................................... 13. 8 3 , 4 2 6 . 3 6 14. Net Value Subject to Tax (Line 12 minus Line 13) ............................................... 14. 3 3 3 , 6 61.6 6 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 .00 15. 0 . 0 0 '16. Amount of Line 14 taxable at lineal rate X .045 0, 0 0 16. 0. 0 0 17. Amount of Line 14 taxable at sibling rate .X .12 2 7,$ 0 8. ,5 2 1 ~~ 3, 3 3 7. 0 2 18. Amount of Line 14 taxable at co--ateral rate x .15 ;? 2 2, 4 7 0. 4 8 18. 3 3, 3 7 0. 5 7 19. Tax Due ................................................................................................................. 19. 3 6, 7 0 7. 5 9 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REf=UND OF AN OVERPAYMENT. Side 2 1 50560721 , ,20 1,505607 21,20 REV-1500 EX Page 3 File Number 21-09-1175 Decedent's Complete Address: DECEDENT'S NAME Ina M. Keller STREET ADDRESS ~ 5225 Wilson Lane I CITY ---- _------- ------ STATE ----- -- Z I P Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) (1) 36,707.59 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments 38,000.00 C. Discount 1,835.38 Total Credits (A + B + C) (2) 39,835.38 3. Interest/Penalty if applicable - p. Interest E. Penalty Total Interest/Penalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) 3,127.79 Check box on Page 2 Line 20 to request arefund - 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) g, Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable ta: 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 :............................................................................... ~] ^x b. retain the right to designate who shall use t:he property transferred or its income :.................................. ^ 00 c. retain a reversionary interest; or ............................................................................................................... ^_ ! xJ d. receive the promise for life of either payments, benefits or care? ............................................................ [_] 2 If death occurred after December 12, 1982, did decedent transfer property within one ye~-r of death without (__ receiving adequate consideration? .................................................................................................................... L_1 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....... ~_~ 4. i decedent own arylndivg ual Rey irement Account, annuit or other non- robate ro eri: wh Cx l ~~ contains a beneficia desi nation ..................................... y~..................... p............p... p.... y..... ich 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)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 (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneiiciary. 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 zero (0) percent [72 P.S. §9116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.~i) 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)]. 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. Rev-1503 EX+ (Ei-98) SCHEDULE B 4 STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE N~JMBER Keller, Ina M. 21-09-1175 All propertyjointly-owneclwith right of survivorship must be disclosed on Schedule F. ITEM NUMBER CUSIP NUMBEP, DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 000375204 69 shares of ABB Ltd -Adr Sponsored 17.7750725 1,226.48 2 002824100 53 shares of Abbott Labs -Com 53.4050943 2,830.47 Merrill Lynch Acct #898-03R63 3 0o817Y108 42 shares of Aetna Inc New -Com 30.73 1,290.66 4 001084102 25 shares of AGCO Corp -Com 30.67 766.75 5 140193301 311.157 shares of American Capital Income Builder CL C - 47.97 14,926.20 Mutual Fund (as quoted by NASDAQ) Merrill Lynch Acct 898-61489 6 453320301 558.672 shares of American Income Fund of America CL C ~- '! 5.32 8,558.86 Mutual Fund (as quoted by NASDAQ) Merrill Lynch Acct 898-61489 7 03662Q105 49 shares of Ansys Inc - C:om 40.105102 1,965.15 8 037411105 22 shares of Apache CorK- -Com 92.605 2,037.31 g 037833100 25 shares of Apple Computer Inc -Com 194.2352 4,855.88 10 13 shares of Garrick Gold Corp -Com 40.8353846 530.86 11 088606108 15 shares of BHP Billiton Ltd -Sponsored Adr 72.84 1,092.60 12 242 shares of Black Rock Global -Part of Merrill Lynch Acct; 13.8941736 3,362.39 #898-79687 13 09255K108 600 shares of Blackrock E.nhcd Govt, Inc. -New York Stock 17.515000 10,509.00 Exchange Merrill Lynch Acct 898-61489 Total of Continuation Schedules See attached a es TOTAL (Also enter on Line 2, Recapitul~~tion) 303,285.73 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1503 EX+ (6-98) SCHEDULE B i ~ 4 STOCKS & BONDS continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TA.X RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Keller, Ina M. 21-09-1175 ITEM NUMBER CUSIP NUMBER _ DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 14 092517301 1,283.175 shares of Blackrock Global Allocation Fd Inc. C •~ 16.86000 21,634.33 Mutual Fund (as quoted by NASDAQ) Merrill Lynch Acct 898-61489 15 092530108 55 shares of Blackstone Group LP -Com Unit Repstg L Pint 13.3350909 733.43 16 124857202 126 shares of CBS Corp New CL B 13.6$ 1,723.68 17 172758102 174 shares of Cisco Systems Inc -Com 23.665 4,117.71 1 g 172967101 $13,000 Citigroup Inc - C:om 3.87 503.10 19 189754104 35 shares of Coach Inc -Com 35.1651429 1,230.78 20 192446102 34 shares of Cognizant Technology Solutions Corp - CL A 43.905 1,492.77 21 G2554F105 40 shares of Covidien PL.C SHS 46.895 1,875.80 22 25490A101 61 shares of Direct TV Group Hldngs CLA 32.855082 ~ 2,004.16 23 293646103 25 shares of Entergy Corp New -Com 80.6852 2,017.13 24 302316102 68 shares of Exxon Mobil Corp -Com 72.825 4,952.10 25 302445101 15 shares of Flir Systems Inc -Com 30.07 451.05 26 343498101 55 shares of Flowers Foods Inc -Com 22.92 1,260.60 27 353496805 8,243.326 shares of Franklin Income FD CL C -Mutual Funci 2.0500002 16,898.82 (as quoted by NASDAQ) Merrill Lynch Acct 898-611489 28 302941109 20 shares of Fti Consulting Inc -Com 45.345 I 906.90 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1503 EX+ (6-98) SCHEDULE B t ~ ~ :STOCKS & BONDS continued COMMONWEA'_TH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE N~JMBER Keller, Ina M. 21-09-1175 ITEM NUMBER CUSIP NUMBEF; DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 29 36962G4E1 4,000 shares of General Elec Cap Corp -Notes GLB 3.500°/~ 1.0411 4,164.40 8/13/2012 DTD: 8/13/2009 30 370334104 20 shares of General Mills Inc -Com 68.74 1,374.80 31 38141 6104 14 shares of Goldman Sachs Group Inc -Com 163.885 2,294.39 32 40414L109 475 shares of HCP, Inc. -New York Stock Exchange 31.745000 15,078.88 Merrill Lynch Acct 898-61489 33 428236103 45 shares of Hewlett Packard Co -Com 49.40511111 2,223.23 34 404280406 17 shares of HSBC Holdings PLC - Spon Adr New 57 969.00 35 647791101 50 shares of Ingersoll-Rand PLC 1,737.00 36 46625H100 87 shares of JPMorgan Chase & Co -Com 41.055057Ei 3,571.79 37 517834107 86 shares of Las Vegas Sands Corp -Com 15.375 1,322.25 38 53071M708 21 shares of Liberty Media Corp -Liberty Starz Ser A 48.31 1,014.51 39 55616P104 70 shares of Macys, Inc. 16.275 1,139.25 40 580037109 72 shares of McDermott Intl Inc -Com 22.425 t 1,614.60 41 637071101 26 shares of National-Oilwell Inc -Com 41.415 1,076.79 42 65334H102 54 shares of Nexen Inc -Com 22.771296?'. i 1,229.65 i Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA••1500 Schedule B (Rev. 6-98) Rev-1503 EX+ (6-98) t , COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS continued ESTATE OF FILE NUMBER Keller, Ina M. 21-09-1175 ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 43 670738106 720 shares of Nuveen Multi-Strategy -New York Stock 7.31500 5,266.80 Exchange Merrill Lynch Acct 898-6'1489 44 682189105 143 shares of On Semiconductor Corp -Com 8.165035 1,167.60 45 683940886 840.593 shares of Oppenheimer Rochester National Muni FD 6.97000 5,858,93 CL C -Mutual Fund (as quoted by NASDAQ) Merrill Lynch Acct 898-61489 46 68389X105 97 shares of Oracle Corp -Com 21.82 2,116.54 47 695156109 38 shares of Packaging C:orp American -Com 22.0705263 838.68 48 713448108 60 shares of Pepsico Inc -Com 61.575 3,694.50 49 717081103 205 shares of Pfizer Inc -Com 18.0650244 I 3,703.33 50 693390445 961.601 shares of Pimco 'Total Return FD CL A -Mutual 10.89000 10,471.83 Fund (as quoted by NASDAQ) Merrill Lynch Acct 898-61489 51 742718109 75 shares of Procter & Gamble Co -Com 62.0550667 4,654.13 52 747525103 30 shares of Qualcomm Iric -Com 44.525 1,335.75 53 758766109 92 shares of Regal Entertainment Group - CL A 13.99 I 1,287.08 54 759351604 30 shares of Reinsurnce Group America 45.955 1,378.65 55 780259206 21 shares of Royal Dutch Shell PLC Spons ADR A 59.4152381 I 1,247.72 56 78388J106 54 shares of Sba Communications Corp - CL A 31.84 ~ ~ 1,719.36 Copyright (c) 2002 form software only The Lackner Group, Inc. Forrn PA-1500 Schedule B (Rev. 6-98) Rev-1503 EX+ (6-98) f 4 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TA;K RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS continued ESTATE OF FILE N~IMBER Keller, Ina M. 21-09-1175 ITEM NUMBER CUSIP NUMBEF; DESCRIPTION UNIT VALUE ~ VALUE AT DATE OF DEATH 57 827048109 19 shares of Silgan Holdings Inc -Com 53.9 1,024.10 58 855030102 45 shares of Staples Inc •• Com 23.94511111 1,077.53 59 874039100 217 shares of Taiwan Serniconductor Manufacturing Co - 10.875023 2,359.88 Adr Sponsored 60 880779103 79 shares of Terex Corp IVew -Com 18.65 1,473.35 61 881624209 44 shares of Teva Pharmaceutical Industries Ltd -Adr 52.505 2,310.22 62 883556102 43 shares of Thermo Electron Corp -Com (Thermo Fisher 47.7851163 2,054.76 Scientific} 63 H8817H100 21 shares of Transocean LTD 79.97 1,679.37 64 907818108 22 shares of Union Pacific Corp -Com 63.14 1,389.08 65 912909108 20 shares of United STS Steel Corp New -Com 45.44 908.80 66 92927K102 42 shares of Wabco Holdings, Inc. 24.47 1,027.74 67 941053100 30 shares of Waste Connections Inc -Com 32.96 988.80 68 949746101 95 shares of Wells Fargo ~& Co New -Com 26.0850526 2,478.08 69 698255105 105 shares of XL Capital L.td - CL A 17.7550476 I 1,864.28 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1503 EX+ (6-98) SCHEDULE B STOCKS & BONDS continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Keller, Ina M. 21-09-1175 ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 70 05565QBH0 $500,000 BP Capital Markets PLC -Company Guarnt GLE3 1.048428 ~ 5,242.14 03.87% 3/10/2015 Merrill Acct 898-03R63 New York Bond Exchange Dtd: 3/10/2009 Mat: 3/10/2015 3.88% Accrued interest on Item 70 through date of death 47.90 71 172967CQ2 $600,000 Citigroup, Inc. -Subordinated GLB 05.00% .9747033 5,848.22 9/15/2014 Merrill Acct 898-03R63 New York Bond Exchange Dtd: 9/16/2004 Mat: 9/15%x014 5.00% Accrued interest on Item 71 through date of death 70.00 72 263534BN8 $500,000 E.I. DU PONT DE NEMOURS -GLB 04.875% 1.086624 5,433.12 4/30!2014 Merrill Acct 898-03R63 New York Bond Exchange Dtd: 4/30/2004 Mat: 4/30/2014 4.88% Accrued interest on Item 72 through date of death 26.41 73 31398ADM1 $400,000 Federal Natl Mtg Assoc -NOTES 5.375%; 1.1376575 4,550.63 6/12/2017 DTD: 6/08/2007 Accrued interest on Item '73 through date of death I I i I i 105.71 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-'1500 Schedule B (Rev. 6-98) Rev-1503 EX+ (6-98~ . ., COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX. RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS continued ESTATE OF FILE NUMBER Keller, Ina M. 21-09-1175 ITEM NUMBER CUSIP NUMBER DESCRIPTIION _ UNI f VALUE VALUE AT DATE OF DEATH 74 428236AG8 $400,000 Hewlett Parkard Co -GLB 06.00% 7/01/2012 1.00 4,000.00 Merrill Acct 898-03R63 New York Bond Exchange Dtd: 6/26/2002 Mat: 7/01/2012 6.50% Accrued interest on Item 74 through date of death 114.11 75 58013MEE0 $400,000 McDonald's Corp - SER MTN GLB 05.350% 1.0856375 4,342.55 3/01/2018 Merrill Acct 898-03R63 New York Bond Exchange Dtd: 2/29/2008 Mat: 3/0112;018 5.35% Accrued interest on Item '75 through date of death i 58.26 76 1AN7 58933 ° $300,000 Merck & Company, Inc. -GLB 05.00 /° 6/30/2019 1.0593067 i 3,177.92 Merrill Acct 898-03R63 New York Bond Exchange Dtd: 6/25/2009 Mat: 6/30/2019 5.00% Accrued interest on Item 'l6 through date of death 68.33 77 59156RAU2 $500,000 MetLife, Inc. -GLB 06.75% 6/01/2016 1.145906 5,729.53 Merrill Acct 898-03R63 New York Bond Exchange Dtd: 5/59/2009 Mat: 6/01/2016 6.75% I i Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1503 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAY, RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS continued ESTATE OF FILE NUMBER Keller, Ina M. 21-09-1175 ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 78 74432QBJ3 $500,000 Prudential Financial, Inc. - Ser Mtn 4.75%; 5,097.23 9/17/2015 DTD: 09/15/2009 Accrued interest on Item 78 through date of death 55.42 79 912828LQ1 $1,400,000 U. S. Treasun~ Note - 2.375%; 9/30/2014 1.015 14,210.00 DTD: 9/30/2009 gp 912828LR9 $1,100,000 U. S. Treasun/ Note - 1.375%; 10/15/2012 1.0071873 11,079.06 DTD: 10/15/2009 Accrued interest on Item']`~'through date of death 63.94 Accrued interest on Item 80 through date of death 22.85 81 United States Savings Bands (HH Series) i 14,000.00 TOTAL (Also enter on Line 2, Recapitulation) 303,285.73 Coaynght (c) 2002 form software only The Lackner Group, tnc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1507 EX+ (6-98) t 4 1 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TA): RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF FILE NUMBER Keller, Ina M. 21-09-1175 All property jointly-owriedwith right of survivorship must be disclosed on Schedule F. (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule D (Rev. 6-98) Rev-1508 EX+ (6-98) SCHEDULE E i ~ ~ CASH, DANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TA:{ RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Keller, Ina M. 21-09-1175 Include the proceeds of litigation and the date the proceeds were received by tie estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Merrill Lynch Primary Acct 898-03R63 5,650.00 2 Merrill Lynch Primary Acct 898-61489 971.16 Accrued interest on Item 2 through date of death 7 50 3 PNC Certificate of Deposit 8/13/2010 - 25 Month Fixed Rate of 3.73%; Investment 16,897.23 #31400240679 Accrued interest on Item 3 through date of death 44.91 4 PNC Checking Account #50-7007-5801 8,860.21 Accrued interest on Item 4 through date of death 0.27 5 PNC Money Market Account #50-0096-2,h-44 15,521.45 Accrued interest on Item 5 through date of death 5.16 6 Bethany Village -Refund from Asbury Communities, Inc. 949.52 7 Bethany Village -Refund from Asbury Communities, Inc. 13.50 8 Highmark Prescription Drug Plan -Premium Refund 36.01 9 Penn Treaty Network America Insurance Company -Claim #P231272!1 3,240.00 Policy #P231272 Reimbursement for Care at Bethany Village Retirement Center 9/22-9/30/X109 $810.00; 10/1 -10/3/2009 $270.00; 1018-10/31/2009 $2160.00 10 Penn Treaty Network America Insurance Company -Policy #P231272 '~ 4,500.00 Reimbursement for Care at Bethany Village Retirement Center Total of Continuation Schedule See attached page TOTAL (Also enter on Line 5, RE~capitulation) 60,186.66 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1:100 Schedule E (Rev. 6-98) Rev-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY continued ESTATE OF FILE NUMBER Keller, Ina M. 21-09-1175 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1~~00 Schedule E (Rev. 6-98) Rev-1509 EX+ (6-98) ~ i 4 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER Keller, Ina M. 21-09-1175 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 ADDRESS RELATIONSHIP TO DECEDENT A. Jean Ream 1145 Pheasant Drive North Niece Carlisle, PA 17013-1252 B. Michael Weaver 107Haire Avenue Nephew Lewisburg, PA 17837-9204 C. Larry Bistline 217 East Garfield Street Nephew Shippensburg, PA 172572001 JOINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE: OF ASSE o/o OF DE:CD'S INTEREST DAVALOUE OF TH DECEDENT'S INTEREST 1 A 1/2/2008 PNC Certificate of Deposit 02/02/2010 - 25 10,639.03 50.000% 5,319.52 Month Fixed Rate of 3.73%; Investment #31800163927 In Trust for Jean Ream 2 B 7/20/2008 PNC Certificate of Deposit 08/20/2010 - 25 10,511.25 50.000% 5,255.63 Month Fixed Rate of 3.73%; Investment #31400177692 In Trust for Michael Weaver 3 C 08/01/2008 PNC Certificate of Deposit 9/01/2010 - 25 1!0,510.21 50.000% 5,255.11 Month Fixed Rate of 3.73%; Investment #31400255537 In Trust for Larry 13istline TOTAL (Also enter on Line 6, Recapitulation) I 15,830.26 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1;100 Schedule F (Rev. 6-98) Rev-1510 EX+ (6-98) SCHEDULE G 4 INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTI~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Keller, Ina M. 21-09-1175 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY THE DATE OF RANSFER.SATTACii ACOP OF TIHOE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET °i° OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 Allstate Advantage Plus Annuity - GA 18295261; 35,096.80 100.000°/a 35,096.80 Beneficiary--Elizabeth Beers, Sister 2 MetLife Investors USA -Fixed Annuity; Beneficiary-- 32,455.60 100.000% 32,455.60 Jeffrey P. Weaver, Nephew TOTAL (Also enter on Line 7, Recapitulation) I 67,552.40 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA~-1500 Schedule G (Rev. 6-98) REV-1151', EX+ (10-06) ,' SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAXRET~RN ADMINISTRATIVE COSTS RESIDENT D~CEDEN ESTATE OF FILE NUMBER Keller, Ina M. 21-09-1175 Debts of decedent nnust be reported on Schedule I. ITEM DEE~CRIPTION AMOUNT NUMPER A, FUNERAL EXPENSES: See continuation schedule(s) attached B. ADMINISTRATIVE COSTS: 'I . Personal Representative's Commissions Name of Personal Representative(s) 7,368.29 Street Address 512 Wayne Drive city Mechanicsburg state PA zip 17055 Year(s) Commission raid 14,740.00 2. Attorney's Fees SaIdIS, Flower & Lindsay 14,740.00 ~;, 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 4. Probate Fees 373.50 5. Accountant's FeE~s 6. Tax Return Preparer's Fees 7. Other Administrative Costs 458.57 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulai:ion- 37,680.36 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATI`/E COSTS continued ESTATE OF FILE NUMBER Keller, Ina M. 21-09-1175 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Jeffrey P. Weaver -Reimbursement for Funeral Luncheon 312.36 2 Jeffrey P. Weaver -Reimbursement for organist at funeral service 50.00 3 Jeffrey P. Weaver -Reimbursement for IntermentlService--Interment No. 205-2009 1,030.00 4 Musselman Funeral Home, Inc. -Invoice dated December 18, 2009 5,863.62 5 Pealer's Flower Shop 112.31 H-A 7,368.29 Other Administrative Costs 6 Post Master -Registered mail 33.39 7 Professional Tax Advisors, Inc. - 2009 T'ax Preparation Fees 205.00 8 The Patriot News Co -Add Order #0002034229 220.18 H-B7 458.57 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 EX+ (12-08) SCHEDULE 1 i , ~ ~ DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIEN~- COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Keller, Ina M. 21-09••1175 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08) REV-1513 EX+ (11-08) "~ SCHEDULE J COMMONVVEALTFI OF PENNSYLVANIA BENEFICIARIES INHERITANCE Tq~ RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Keller, Ina M. ~ 21-09-1 175 NAME AND ADDRESS OF RELATIONSHIP TO SHAf~E OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) Do Not List Trustee s I TAXABLE DISTRIBUTIONS [include outright spousal . distributions, and transfers under Sec. 9116 a 1.2 1 Elizabeth Beers Sister Eighlt and one- 27,808.52 825 North Hanover Street thircl percent (8 Apartment 111 1/3°/~) Carlisle, PA 17013-2041 2 Larry Bistline Nephew Twelve and one- 41,713.44 217 East Garfield Street half percent (12 Shippensburg, PA 172572001 1/2°/~) 3 Barbara Cone Niece Eight and one- 27,808.52 307 Tappan Street #2 third percent (8 Brookline, MA 024455382 1/3%) 4 Cheri Keller Niece Eight and one- 27,808.52 7022 NW 92nd Place third percent (8 Gainesville, FL 326537843 1/3%) of the resiclue. 5 Jane Lawrence Niece Eight and one- 27,809.52 108 Main Street third percent (8 PO Box 21 1/3%) Francestown, NH 03043-3026 See continuation schedule attached Continuation 97,330.48 Total 250,279.00 Enter dollar amounts for distributions shown above on lines 1 5 throu h 18 on Rev 150 0 cover sheet, as a r o riate. NON-TAXABLE DISTRIBUTIONS: I1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO Tf~X I~~ NOT -I-AKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 Bethany Village Endowment Fund 33,370.54 2 Shriners Hospitals for Children 33,370.54 3 The Knights Templar Eye Foundation, Inc. 1s,s85.2s TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET' 83,426.36 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) SCHEDULE J BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: Ina M. Keller 12/09/2009 175-10-7404 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) 6 Jean Ream Niece 1145 Pheasant Drive North Carlisle, PA 17013-1252 7 Jeffrey Weaver Nephew 512 Wayne Drive Mechanicsburg, PA 17055-4984 8 Michael Weaver Nephew 107Haire Avenue Lewisburg, PA 17837-9204 Twelve and one-half of 41,713.44 the residue. Eight and one-third 27,808.52 percent of the residue Eight and one-third 27,808.52 percent of the residue. Total 97.330.4 1 a.-- LAST 'WILL AND TESTAMENT of INA IY.C. I~~+"LLER I, INA M. KELLER of Lower Allen Township, Cumberland (~ounty, Pennsylvania, declare this to be my Last Wi11 and Testament, hereby revolving any will previously made by me. I. I direct the payment of a11. my just debts and funeral expe:uses out of my estate as soon as may be practical after my death. II. I bequeath certain items c-f my tangible personal property, not includizzg cash and securities, in accordance with a writtE;n list made by me during my lifetime. Ire the absence of such a list or designation on such a list, I direct my executor hereinafter named sf;ll said articles and that the proceeds be added to ,the residue of my estate. III. I devise and bequeath all the rest, residue and remain~~er of my estate of whatever nature and wherever situate unto the following individuals and entities in the proportions indicated: A. Ten percent (10%) of said residue shall be distributed to the Shriners Crippled Children's Hospitals to be used for such purposes as they shall ~.IDIS ~; FLOWER f I'~DSAY p 1-lilt, PA deem. appropriate. B. Five percent (5%) of said residue shall be distz-ibuted to the Knight's Templar Eye Foundation, Inc. to be used for such purposes as they shall i deem appropriate. 1 ~s .. __..._._.__...~r........~....-,_ _..._.....~.,~_..._-----. _ C. Ten percent (10%) of said reside shall be distributed to the Endowment Fund of Bethany Village, Mechanicsbl~rg, PA. D. The remailung seventy-five percent (75%) of said residue shall be divided in nine equal shares among my two living sisters, Elizabeth Beers and Dorothy Bistline, or if they are deceased, to, their issue; my niece and nephew, Jean Ream and Larry Bistline, or if they are deceased to their issue; and my deceased husband's nieces and neph°ws, Barbara. Cone, Jeffrey 'Weaver, I~ichael Weaver, Jane Lawrence and Clzeri Reiier, or if any of them is deceased, to their issue. VI. I appoint Jeffrey P. Weaver Executor of this, my Last Will anti Testament. Should he fail to qualify or cease to act as such, then I appoint Roberta L. Weaver as Executrix to act in this capacity. None of my personal representatives sha11 be; required to post bond in this or any jurisdiction. IN WITNESS WHEREOF, I Dave hereunto set my hand acid seal on this, the ~~,~ ~~ day of _, 2004. ~- ~~~ ~ ~~~ (SEAL) INA M. KELLER ~~ ~.IDIS ~, FLOWER INDSAY JE1'S~A'f•LALI~ 9arleel Slreel p hill, PA Signed, sealed;, published and declared by INA M. KELLER herein named, on this anal two (2) other sheets of paper as and for her Last Will and Testament, in our presence, who, in l~.er presence, at her request, and in the presence of each other, have hereliuto subscribed our ~. names as attesting witnesses. COMMOI~TWEALTH OF PENNSYLVANIA } COUNTY OF CUMBERLAND } WE, the undersigned, the Testatrix and the witnesses, respectively, whose names are sio led to the foregoing instz-ument, being first duly sworn, do hereby dec:Tare to the undersigned authority that the Testatrix signed and executed the instrun-lent as her Last Will and Testament and that she signed willingly (or willingly directed another to sign for her), and that she executed it as her free will and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix signed the will as witnesses and that to the best of their knowledge the Testatrix was at that: time eighteen years of age or older, of sound mind, alld under ilo constrain or uizdue influence. INA.~~`V1. KELLER, Testatrix Wltn Witness Subscribed, sworn to and acknowledged before me by the Testat;:•ix,an~d~subscribed and sworn to before me by both witnesses, this , '`~~ day of ~~~~,s-~ -' 2004. ~ . ;. ~/~ ~ , COMMONWEALTH OF PENNSYI.,VANIA - Notary Public Notarial seal Sallie Allsbouse, Notary Public Cfurrp Hitl i3oro, Cumberland County My Commission Expires Mar. 29, 2008 IRIS F,LObt~ER ~1DSAY 1'S•nT• LnIV ric?I Stree( nni, ~n 3 ~ ,~ ~ - O ~ O CO O '~ CO r O N O O ~ M W MM ~ /~ ~ } - (n ~ O , ((') ~' - ~ ~' ~;p i.A . ~ ~ . ,~ i .. • L ' . f6 U ' > a ~ ~ - ~ - o .. .. . .. T N ~ O ~ O `O O O z ..,. .p O, ::0; _ i ; - : , ,: ~ E ,,- ~,- ~ ~ N ~ :cfl ~a r . L {-! r . -~-! . ][ Y c c L W ~ ~ , O 0 .: ~. O CO O N _ O. O r- . N O ' I` , O cfl O O. ~• 'N ~ ~. Ch O ;;j co ' p ~ O. r Cam, r ~~ -. ~ . .T : . , - N Q ? 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'; ~' VJ:... ... .. .~ .,. _, . ,. ~.' :. ~~ N. `:p i ~. :, ~`' , Q'} ~-: ~, ,0. , 4:":, .. t..: ~'. ~• ~..V Y ~'>, .Q ~J = m 1 ~„ ~ J >~ Q :~~`~~ U O.::: a :O O ~~T..; ~_. .. .. Q ~.:~... rn r ca u n 0o a a~ d' C' ~ i ~ V R V ~ Q w RY ~ ~ ~"' a~ ~ a~ U (~U N O N > .B ~ ~ ~ '~'' ~ Q C ' i O O '~", ft7 > ~ ~ (~0 ~ O 'Q ~ .~ ~ C IC O . ~ ~ • ~ ~ E ~ ~ ~ Q .~ OC ~ C ~ N 2 ~ ~ ~ E ~ ~ a ~ ~ >, U ..O CQ f4 L O fl- Q1 , ~ ~ d F -a -tea "p- -~ o ~ a. ~ Q ~ ~ ~ a~ ~ ~ ~ o U Q ' ~ c V Z7 ~ U ~ o ~' ~ ~ ._ c~ E ai .c ; a I- ~ ..C U ~ ~ ~ O ~ ~ '% In N L O ~ ~ V N ~ p ~ (U (U ~ ~ ~ N ~ ~ ~ ~ (TS ~ N ~ ~ .C U O U ~p L ~ ~ ~ 41 C N ~ ~ O ~ ~ ~ ~ E p O R O ~ ~ ~ (SS 0 ~ V ~ ~ ~ ~ ~ p O ~ ~ C1 N (D -C ~ O ~ ~ O ~ ~ ~ •~ (NII "C7 N _ N ~ O _ U ~ ~ n. N °' a ~ o N ~ ~ O ~ ~ ~ ~ ,G `Z w" U c ~ o L ° ~~ c Q {/7 ~ ~ ~ ~ a~ W , a ~ o ~ ~' ~ N ~ ~ ~ U Q ~ « N ~ ~ O N U > ~ N ~ !C O O .G~ L ~ ~ RT •.. O ~ 'Q p tQ ~ ~ C O _ ~ >~ ~` (II U U N G1 ~ ~ L O L ~ ~ Q ~ ~j .~ ;~ ~ N p y+ ~ '~ ~ Q . ~~ ~ In >> 7 ~ L ~ W (Q ~ U ~ o ~~ L: Q ~ ~u ~ ~, ~ 'V O N ~ ~ _ E _ ~ _ +- oU N o ~~ ~ ~ Fr ~ U ~ ~ U ~ _ N U SI r t9 Q O <~ ~ S1 L .(!J (UII ~ O U ~ CJ O N S .N . ^ .~.~ (ti ~ ~ ~= J U A ~ a ~ ~ ~ N U ~ _ ~ Oj ~ ~ ..O . O L-n ~ d1 L .Ll '~ ~ ~ ~: Gc, ro LL ~ ..L. N ~ N N ~ C C~ O ~ U ~ 1. C"T C II C .~-~ O O ~~ 'D (~ Rl ~ ~ ~ 'CJ U - ~ . ~ N ~ ~ ~: ~ N ~ +- L ~ i .O C ~p ~ ~ O ~~ ~ ~ ~ ~.. ,~` ' .~ G ~ ~ ~ O ~ C 3 ~ ~ O N ~ ~ O N U ~ ~ ( ~ > ~ ~ C C ~ ~ ~ ;~ , N ~ N v ~ c a ° ~ ~ u~ o ~ ..~ 0 cn ~ Q Q LL ~j U Qr ~ ~~ Q IRA Value for The Estate of Ina M. Keller Merrill Lynch Account #898-79687 Balance in account as of 12/09/2009: Cash $ 293.46 Black Rock Global $ 3,362.39 242 Shares at 13.89417355 YNo. .... 4TJilliamsport, Pa., . ~ C'f;Ober 1, 1960 ..............196,... Ho~n~r L. Kelley Or I,p,~, ~!~~ On d~~and we promise to paY to the order of , .. , .. ! Iiellex', h1S ~+11_e --.--.,-~~wo"Thousand--~_..__,:_.::.W~_:.__~:~~~~_...... ..... ........ 2:~oooaoo ' ........ ....................... Dollars Without defalcation or stay of execution, for value received, with interest at . •1.{. I00 ~va;iving inquisition and exemption laws, and confess ud %, per annum, interest and costs of suit, and with five ~ gment for above sum without offset, with per cent for collection fees. ' - ,:*80ARD OF N.C[SSIONS of 'rHE CENTRAL PENNSYEVANIA C%ONI'ERENCE O T'~HE EVANG ~ LICAL UNITED BRETHREN CHURCH Attest :.. ' ~,, . ~'•j?~ ~~~ ..~Cp~. ~r~~.•-, t._" /C~ . //' ~~~ Secr tars .. ... , ...,`L~~`..~~.'~C-~ .. . - ----. _ _ . President U GDES L37 ~ ~ ~` ~~1~~~s° , f . No . , . _ Williamsport, Pa. ~Febr17.~~r~r l ~ 1: 962.91 9~ ; ~'~ - ~~ On demand we promise to payao the order-. - .. _ . -- - ~ ~ ... of - ~ - ' ~ ..;~ ..a,;~: ~ -~ ~mEr- ~~ Yeller -ors Ina 1~9o Keller. hip ws:fe _ - ~;; O:eQ.O. - - •. .. ~`~ - ._..,. -'~ov:r Tl~o~a~d.~, ~.~.....~ .~.: ~,~ n.,. `~ ~,~ -.~.,- ~ „--~~.~,~.:~ 'Dollars ~ ~` r ~~`; oVithout defalcation •or: stay of execution, for ::valve;received, with interest.,:at ~.~. _ go; ~_per,_annum ~, ~~, + - - - ~• ~ ~ ~E~ .svaivmg •inquisiton and ~-exemption~aaws, and .:confess judgment for .above _sunr:~vithout o - ~ ~~tA~~'~. .~~ ,h. _ set, with - ~ ~6~ ~~~ ~ ~~~~~ ,~ interest and-costs. of suit, andt_withfive per Dent for collection fees -- ~ t?h' ~^:^ _ _ BOARD. OF `NSSIONS .of THE OENTRAL :P:ENNSYLVANL9. ~OIVFERENCE _ ;~ ~~~~ ~r -,~~ -. _-__~ OFTHE:•EVANGELICAL :UNITED ERETH:ILEN C CEE ;~~,~~ ~ ~ Attest . /.. ~ ... ~ ~~. -~ •~ - - - . F ' ~~.' ~~~~• L~ ._ . -•• - ~ 4,~' - , , Secr cry __ _ _ Pes~dent'= '~ a.~~ RKd~ c~,e,~~~ ~, ~ ~1~~f? G ~ ~ 'fit IPf~ a. ~ ~ - ~- ~I ~~- y.. i I3~~.y^° ~'~ ~ ~ `S' 4...~ .?./.', 4~'?'l~' s'f-~5' KP~~f tier°t ~T ~,~+ ~"f ,d l~n• ys _f. ~S, i W ~1~ ,n,+-f E,~¢:~~~iv.~ Kyv~`~`. i~~, ~ '''~y~~~ ,T. /'::`~ p';kP.`..':~` /~"`;~s~p~3~~~,, -i t ' •N~, '~~ 1 Ef, r.~~'~ :t.. ^u'-r~ '`'•'y~~.~~ r ~!~ NW 1".'x'1 VY, L'~'5;~1~/~-: ~ . ©GOCL h3] ~~ 1_ LITH O.I~v U.9.~.. .-. No. ... .. WilLfamsport, Pa.,Januar~" 1, 1963 .196. Homer L. I~e11er or Ina I'~1. On demand we promise to of I~elJ..er, his wife Pay to the order ...................................................... $..2:,5.00..00. ... . -,-- .--~'.wo..Tk~s~us.grad,..~'1ve..~:Iu~dred.......-. - - _ _ _ .- -. _ _~ . ........ . ..... Dollars xao Without defalcation or stay of execution, for valve received, with interest at . ~ .. qo, per annum, waiving inquisition and exemption laws, a:nd confess judgment for above sum without offset, with interest and costs of suit, and with five per cent for collection fees. BOARD OF MISSIONS oP THE CENTRAL PENNSYLVANIA CONFERENCE OF THE EV GELIGAL UNITED BRETHREN CHURCH ~, 7 Attest:. ~ ~.i. :. ..~j......../.~ ^-'". _ /~~. ~'S retary President U GDES (i,7 ~~ t~~ ~~~ ~t~,Y Dee~nrir,~r =~©, ~U09 $p~ic~ 1_, Snyder PN~ ~~nl; I I .Hampden ~xa~~ch RF.; Ina Nq. Keller Slit: 1 IS- ~ a-7404 Don: 1 ~-09-2004 Dear IBS, ~nydcr: In respon~c~ to your Te,que~t for Date of D~rxtk~ (D~I~} balances for the customer ~~ted above, our r~cord~ sho~~v the f~Ilawin,g: ~;e~tiac~a~ ml' i~~:~osit Acc~ui~t,'# 31400240b79 Es~tablishcd: OS-1 -~i)04 :C~tA M K~LI.ER DQD ba3~ncc: ~ 16,87.23 + 44.91 ~ccxt~ed interest Aceau.nt ~ 3 I44U'~555~7 Es+.a~11s1~$d: OZ-0~-20US INA NS K~[.LER 1~l'F L1?~ItY ~ ~~TL~YE DOD balance: $ i0.510_ZI + $.60 aGCnied ixiterext A~cotu~t ~~ 3 l 4D01'T7692 Established: Ol -2C)-2D00 .1N1~. M K.ELLER ITF MI+~HAFL 'WL:~tV1~:R . DDD halAnce: $ l U,51 I.25 + 20.41 acc:n~~3 interest Account ~ 3 a 8001 b3927 E3inblished: uy-02-1999 TINA M K.F,T,LER 1"~ k' rE.AN .REAiI!t DOD ~alaucc. ~ l O,G34_d3 -~- 7.13 n~csucil interest ~h~cking .A~ccoaant Account # 507007S801 E~t~~biished: 05-28- i 9g3 I)'~1A M. K.ELLER I)DD l~lanc~: $ 8,860.21 -f- 0.2~ t~ccrued izit~re~i - Page 1 a~ ~ ~~~'d J_~b~l_~Z~I~=O1 :wo.~~ ZO:ZZ 6002-0~-~~0 Sayings ~-CCbul2t Accaurrt ~ SOOO~~~S44 F,~.tabli5hed: t?3-Z9-19951 • :II~tA M I~ELLIR 1~UU balance: ~ 15,.5 1.~5 ~- 5, ~ ~ accni~cl interest Inv~atmi:e~n8 ~-ecaunt The decedent rx~ai~tained Inveatxn~nt Accoun14t5574049. ~'or further i.nforrnf-tian, you znay call ire Brokcranc Iaeparbment at I-800-'7~.1.-611 1. ~IcBCe note tlxat this office ~n-c>vidt;,s dt~te o,f~clettrkx bul~ncas for deposit ~ccflunt9 ~TRAs, (:.lls, Checking and 3aving~)_ ~e do not pt~uce~ts any fin~ccciul trmna~ctions or provide ~~temen#s, 1f you need as~~sts~ne~ with nny of~tbic:5o items, please cell 1,8X8-P~l~-$A1V~ (1-S$8-~~~ :Z~.es) or ~~~ by your lacnl ~r~c $~ bxan~h oi~cc. ~1T1CCrC1y, ~dtipn~l ~~ lIl~1C13,1JeN1C~5 C'eIlYL'T FTC }3ank, I~. A. Mt;rnber FDIC Page ~ of :? ~~~ ' d Zeb~L~~LIL ~ ~1 : wo ~.~ zF~ = Z~C 600z-0~-~~0 INA M. FELLER ESTATE REQUEST BY FIDUCIARY FOR DISTRIBUTION OF= UNITED STATES TREASURY SECURITIES Title of Security Date of Issue Fac:e Amount Identifying Number Registration Series HH Apr-02 500.00 D5869610HH SS# 175-10-7404 Ina M. Keller Series HH Apr-02 500.00 D5869611 HH SS# 175-10-7404 Ina M. Keller Series HH Apr-02 1,000.00 M8367543HH SS# 175-10-7404 Ina M. Keller Series HH Apr-02 1,000.00 M8367544HH SS# 175-10-7404 Ina M. Keller Series HH Apr-02 1,000.00 M8367545HH SS# 175-10-7404 Ina M. Keller Series HH Apr-02 1,000.00 M8367546HH SS# 175-10-7404 Ina M. Keller Series HH Jul-02 1,000.00 M8517030HH SS# 175-10-7404 Ina M. Keller Series HH Jul-02 1,000.00 M8517031 HH SS# 175-10-7404 Ina M. Keller Series HH Jul-02 1,000.00 M8517032HH SS# 175-10-7404 Ina M. Keller Series HH Aug-02 1,000.00 M8554057HH SS# 175-10-7404 Ina M. Keller Series HH Aug-02 1,000.00 M8554058HH SS# 175-10-7404 Ina M. Keller Series HH Aug-02 1,000.00 M8554059HH SS# 175-10-7404 Ina M. Keller Series HH Sep-02 1,000.00 M8613439HH SS# 175-10-7404 Ina M. Keller Series HH Sep-02 1,000.00 M8613440HH ~S# 175-10-7404 Ana M. Keller Series HH Sep-02 1,000.00 M8613441 HH ;~S# 175-10-7404 Ina M. Keller $ 14,000.00 ~{~w~,/l l~~~n~r(w1 wH7r~TIHr~Oylll~M1OHTHL AfT~IN OA1yL~,OTM~~Iaq~ltlyL~ CL~]J`A'u~` J11~U 571 I~l~lti1J~ ~A!/u ~~ I L'w 11C10~~ 175-10~-7404 ..1.. ,i nl .1. 7a __ 1. .l~ ~ ._i 1 t (i 1 1 -tie. 3 2 ~ ~' WEE ~ L Ef+Y' yD R~'~;A P T .;°3;2 2~'1 + MEtrN=A,N'T;irS1~lJRG~„ ~YP,A ~~1~~~,0:~5 ~~' ~,. ,,L~,I ' ,I ~,i ,, ~~ ~ L i,kl. i ' 1 T'. ~ r7 P 1 ~ I D~FERREb INTEREST $ n r~ ' ~ 00314102094047 (~ ~ rc ~4 ~,~,~ 200058696 ~Oii' ..~roo~ic,uw~,c.+r.~,,WU,~,a.~rau~y~c Wlll ~nT AT AHT 71ME !1N MOMTM6 A/T[a OAT[ OI IaaUC DEFERRED thTEREST $ ~~, ~ ~/~~ Hl 01 ~ 4rr ty~ .1'mnlury//6iT.~ 00314102094047 ~ 5 ~-oT<; 1000B 36 ?'.~a 3t-' ~'~' {' 4'~i4C4JQVi~Il~i'Q~Iy,•1/:~7~~V'U77Q~~idQi~U~ A IIIU S3i3I~Y1IfriDLliY INTEREST CEASES 20 YEARS FROM ISSUE DATE OF I 1 .. __. .... 04 ;;2002 i.ti~vin. .. IF".wb. _ .. 05F369~61D D586°~1.0~~H 08367543 s~~~~s ~ s~~~~s ~~ WILL -AY AT ANY TIN[ ^1% MOHTH! ATT[R OATS OI IOIY[ 175-10-7404 I. i. -.r r~~~ .. .. ., .. .. ... r: ". :..:- ..._ ,., Tri .. - 325_ W.EiSLEYI-'~.Df~ 'APT ; 3221 MECW,,ANILCS'B1~1CZC.; ~~1'A.,.170~55 ~ ;, .~ 1 R, 14 I. L -- t~T ~tlrl+ .II+~'~~III 1 - h ~ t ;1~ f ^gtill',i(_. I .. .. .... Y...:......v_.. ...... .. .. I IJTEREST CEASES 20 YEAR6 ITROM ISSUE DATE OF I _ 04 2p02 ; r.turr'iN YEAH 08367544 . DEFERRED INTEREST $ ~ ~~--- L N..a~u.......,1~ 00314102094047 L 5 '~~; 20008 3 E~ ? 5 ~. 4~-' .n~~r.vn:~T..;~:o:oaoT7.0:o,GAR:VR;014.9;~^'` ^'wMwwwwroann.f .Kn>dtre'e~llA%0.0'fill'VO'0',9',MYVAYfY'V,Iti4.'0'9~Al0An. _ ~S~+Z~~L~+~+~ DEFERRED INTEREST WILL MY AT AHT TIN[ ll% MOH THO A!T[H DATI OT Il/Y[ 175r10~-74U4 ., ~j' ..... ...... _._. - _ . ~.. .....~_ .r .. ~~ ~.-« - x .. . 325' .W EISL.EY~~-;UR aPT 3221 ~ _ M E C ~-1=~' N~ 2 C S'B.t7..1: C y. i; P'A .,,il'~7 0 '5 5 ~:; ~`. ,- ~~ r ,I ~, +i; $ 0.00 00314102094047 ~5 n..wn,n....yy.,rucrv.~Len~.aerurO:bAMICINVIxo~I;UAakVAxhO.S S%rnfvy //Af irn,nry 4000836?5~6~~° INTEREST CEASES 20 YEARS FROM ISSUE DATE OF. 0 4 _., . 2 0 0 2_-.-- ~ V.r O IJi 1: - ~' YEAR .. . 08367.546 ~~:~b~1:~~6-HN s~~~~s ~~ WILL IAY Ai ANY TINC /IX MONTHS Al iCR OAT[ 01 1/^U[ 175-1q--7404 ~... _ ., , .. . TNb"i~N9; KEiL'L~~R' r' '` :; ;, APT ' ; 3~2 2~ 1: I-~ '~± ' 1~ ME:GHr•ANIC:SBU;RG, Pal 17055 ~.. :<, 1 DEFERRED INTEREST $ .~ ,~, ~ ~~~Y ~~~, Hr rti .S'..,.n„y./if.?r.,..r,.y r3 DD314102199093 ~, ~ `~~~~ 90ooB 5 ~ ~0 3011' ..sr r..M' }rrr.ny~rrm,~1:..nn.H-s~ne~rYV.IrVLrA~!AWIA'AAwAU'OAXkU'UA;I+:^!wuvntUi<mA:Oll!AAs4;1~DAN.U~P.'U71f.D?U~T. ;IYVA:0;4N'A]P:U:UaYA'Au DEFERRED INTEREST $ ~.,,,~,,,,~~ ~{ _ .,1~,,,,,~„~,,,_ ~, Dr =4+t Tyr .S:mluryd/6r TiAUUry . . _.. _ __ - 00314102199093 ~ a.''~i . _ _. _. __.... _,_.__....,..,.,.,.~.,...._....~W.,_..~..~.,.A,.,~...A..,.,., ,,.. :,~»~IYA~~,IY~Y,H~N~~1><ID~w»ruY»I~;~xY.a~ae:~~..o~oww~aA~uu:a,AA~o~oca~AO~A:oso-A~aA:a~o-.a~agninauwdua WILL SAY AT AHY TINC /IX RONTH[ A/T[R DATL 01 I//VL 175-10-704 .~.. ; . ;_ .. ~ _._ s TNA h{:.. KE~.~LER.~ } 325 ;'W;ESL':E:Y ~'~~D~R:_ _ APT ~ ;3!2 2"1 -, „ ,;: ; . , ;:~ , ME~CHA="N T;=C;.~~B'U;RG, PA 17055 • I ~~ y rY 1~1., , ~ •,~ .. .. DEFERRED t N TE R EST $ ~,~~,, }~, „Dl,,,,,,~„Y,,,, • t~LY ur r4 .S:.nlr,y.//hr iinulry 00314102199093 ~ 5 ~, ,~ ~~ OOOOB 5 ~ r'0 3 211' -.rer ,-.~nr,awe:,,~oe~vtro-vor~r~C?,i"""AA*raAUU~t~vovovroAVro~~a+noottoA:o:ooa.~o-A:vaoAw~ooArA,w,. Irr, o.o:uo.o~ovorrao-o, INTEREST CEA6E5 20 YEARS FROM 15$UE DATE OF U? ~2Dg2 •,1.,., ~ Y~,.I, 08517030 ~~~1~10~~4~F~ mA ~taxmnerrarYNn»nrY,n»rvrnu•nn~eri~.r_r.rrn~ur.lwro INTERE6T CEASES, 20 YEARS PROM ISSUE DATE OF 07 2oaz _. .: C•L YEA^ 08517032 ~~~l~C~~~HP~ s~~~~s ~~ s~~~~s SE~I~S ~~I WILL TAY Ai ANY TIM[ 01X MOMTN• AITGR DATL 01 I[[U[ 175-10-7404 _ ,. .~ ~" 1 ...r. ~. ujI iS`. ti T n r , t ~. , .. ~. _.. _ f 4i N I l I NA'~;~M ~K~E•L L ~Ril ,~ Itr 1 ~ ,,: I ~ ); ,._ ._~::;:. Y `'D;~ ~I~V~E ' AIP Ti ~ 212 ,1 ,, , I ,.. MEGHANI~C"SBiJRiGJ;4 ~;P/~~ .17,'055, 357 - (~ DEFERRED`INTEREST $ - nn1~.~.- 00314102221173 L5 i7..w/Lr+r~.ws~ ~~~~<M~ dy'w S•/v/I/ply//Af%rpMp/y ',~~ LD008 5 5~~0 5 711° ~ .,., ~ W ~ ~~~,~ ~~ Y/I LL SAY AT ANY TIN[ 51X NONTNO ~Aj T[R UAT[ Oj 156Y6 ~~~~~_~~ ( I~ ,~f~~~~ ~YUIf!'~l`ti"aS~ 1NTEREST.LEA~5ES 20 YEARS~~, FROM IS OF . ~,n4 -, SUE DATE 175 10 7404 - OB ~200~2 MONTH • ~•~ ~~ EUC }~ C F A~ ID IJU -• ~ ~ - - YEAR ' i ... .. t f1 ~ .~` - ..~ - _ . -~... _. _ ,. ~ .. - -_ -~ r n.1 t . ~ I' ~' ,~ I NA~i' ~:. KE`L L ERA `, t a^ r' ,- ~ ~ r -~'"'~ - - _, ; -~ -. .•: 325 (_~±1ESLE!~!'„DNR.T~VE,a,A,PT .:32211.., , ;~ ~ >a I I I _ 7 , ~= ~'-~ ~~ ~~'~ MECH~A!N ~CSBUIR~G, ~tPA 17,Q553574` , si. ~ i I 4 L_ .1 I C I ~ I! t .- _ ., , _' , • ... _ ... ~ .-. ... :..~_ ~ ~~~ ' F 1,. r.' ~'c it r r ..; ..._ _ F. r+ . - _ .._.. ..~ ~......,..__ . ~ ,.. . _....... .. K..--, -a . _ _ .. . _ _ =r _: y_~GALL"AT-IN".. - '~EFEBRED 1NTERESI $ ~ __ - -- - - - 003Z4102~221173 ~ 5 _ r 9, ~ - - - .. T. , .. _ - 085.54.0.5.8_ _ _. _. - .:_._ ~r .3n•.Y! JU.r!"iw.rui 01 `~' ~. - :~ 00008 5 50,0 5811° .=. _._ _ INTEREST CEASES 20 YEARS FROM ISSUE DATE OF X0.8 ~ 1I200.2 _..._.......~ f ..... _..._..._ ..I MUN"TH 'l F,All 085.54:0'57 ,, . _... ••INTEREST~CEAS ES ~20 YEAR5 FROM=t55UE RATE OF r !p:g. !20:0.2.:.: I•IONTH .~. YEAR I ._ .. - ~. _. ~„ t ~ ...-- ~ ~ . ~ - - - --s• --- ' F WILL 1'AT AT ANY TIM[ OIX MONTN[ AIT[q oAT[ OI I[[Y[ 175-10-7404 "r-'. , r•.. .. .__.r_.~-~.._. _.:mot -L .zv..x.. .-.-,-.-.-r.. ... 1~..._.__ .~..... ., _..T... __ ' I N A M-; ~OC E L L E~!`I .~~, ~~ ~ !_~ ~ , ry ` ~~ , 325 W;ES_Li:EI~' j"DR~IJV~E~~APT: ~32~21 -' ~~ - MECHAr~JI•C~SFiU+RiG•~;I ~PA~ Y17~~0155?-357+; _.... :._ I , ... .DEFERRED INTEREST $ _ _n_w 00314102221173 ~5 . H...rl,~.....,,,~.. 'A`"1 °' >.y .1:mlwryp'/,SrTmNwry „~ ; X10008 5 5 ~C) 5 9n° ~~ ~ ,>., ~ 0 $554.0-59:- SL~IES ~~ _. G-~J `+WILL~~71N[V ~i~:S~~pV~.l ~^..~~V14~1.1.\ 1.75-~.0-7404 TNA-.,Mr KE''L~~L~E~Ri~ ~,; I,-' ~ ; ~:' ~ ,,~ - 3 2 5 ; W E S L~ E Y .'.D'R i ~ ~' , :`: , ~! ' ' APT ; .3 2 21~ -;~~ , f'' l~` , ;; ~ ,, ., v MECHANICS,BU;RG, PAS ~70~5.5 ': r; h I 1 - ~~~~;i:l r ~, .;i~ _ .. : , ~~m ~ 1 ~ Iii,, ,.. .. :. . DEFERRED INTEREST $ n ~ n-^~--- ~[-«n.~..+.w f~..o%~~ ,,Kr or ry ,5',rnlary..//A~%munry U031410226013:~ ~` mac" ~, 5 ~ .~ ~~ 30008 6 b 3 ~ 3 911' n:nnf.nn~~e:aoco:O:b:O~A,O:DA;Q;4f1;v14'Ati. _ _ ".-,OO~YA•s4:0A ,6AkbA"''AA,~9SV.d`$pp~G~'~''~X~~ . "•• ~~~ ~~~~~s __: := 7atlllilll~l~ll1!Lf; ~- uia~ .=.l~tf~\~`I~~ .9 N/rS~~1~~ t9~...I` ;~ [ren YATC of tssu[ INTEREST CEASES 20 YEARS FROM ISSUE DATE OF ;p9 1200 _; Q8613439 N9861~~3;9H~;H ~~ WILL IAY AT ANY itYC Eti MONTHS A ~ . - i , p'tinj~l ~'~ ~ ~1' E J~'~~~ INTEREST CEASES 20 YEARS - ' )l'r1 l~ ~ FROM'ISSUE DATE OF i .., . ..~ i .. I75-.10-?4.a~4 :Q.q '20D~: . .. _ - ~ .'MOhT:H .- --7EhR- - _ ,.. .~~ SGC SLC.EIAC .. ,~, ..... r..:. .,. . To - -- ~-.., .. -- .._ ... .. - . ...3.z5 AP~.T :. ME_ _ _ - ---_ ..~~.~A,~~ ... . -' ~~l]Efi`~RR~D:INTERI=ST $ ^ -n-~---- -_ p03.1~o-102260133 WILL MY AT AMY TIN[ tl% NONTNB AfT%% OATe 0/ Il~U[ 175-10-7404 . Q _ . .. 1T _ - _" T N A , M,,...K ~,L,°L ERA ; ~ I T ` ~ ~ _, 3Z5, 41ES~EY 'DR' ~ ~ '. ~' Ir ~` ~14 ,r ,. .. MECHANT..~:S;B.U`RG,"•PA 17,05'5 ,,~ . .. _ ~, I x - ~. ~ ~.. ... - _ - . 4 ,., _ DEFERRED INTEREST $ n n n ~, H ~/~~, 00314102260.133 ~5 .~~,r1500086 ~3~4 X11' 45~~ .~7J3~+i'~i 1 nr IdruAPIt4UNV:UAIUWVAt~~,gAhA~7AVSQI+LQ~p1Q$ . 'r•• INTEREST CEAS~5.20 YEARS FROMISSUE DATE OF I 09 12D0~. MUN'H YEAH os6134~1 ~~bl~~~~1H s~~~~s ~~ s~~l~s ~~i Allstate Life Insurance Company P.O. Box 94212. Palatine, IL 60094-4212 Telephone: (877) 499-641$ Facsimile: (866) 635-4523 January I1, 2010 Saidis, Flower & Lindsay Attn: John Slike 2109 Market St. Camp Hill, PA 17011 Re: Ina M. Keller Contract No: ~A1829S261 Dear Mr. Slike: You're~~in good hands. We received a request to complete IRS Form 712 for the above referenced contras;t. The purpose of Form 712 is to provide an estate or donor with the value of a Life insurance contract or it;~ proceeds as of a certain date (usually the owner's date of death or date of transfer of the contract). Because this contract is an annuity, it is not reportable 'on IRS Form 712. We c~~n, however, provide the following information for estate purposes: Date of Death: December 9, 2009 Annuity Value as of Date of Death: $ 35,096.80* Cost Basis: $ 30,000.00 Named Beneficiary: Elizabeth Beers *The actual amount paid may differ due to Market Value Adjustments and/or a~ay applicable Surrender Charges. If you have any-questions, please contactour-office-at-1377-499-6418.-- - - --~---- - ~ = -------- ~ ---- --- ~ - - - - - -~ Sincerely, ~~ v~ Shawna M. Navik Sr. Claim Examiner Page '1 of 1 ~~~ MetLife Investors USA Insurance Company P.O. Box 295 Overnight Address Des IVloines, IA 50301-0295 4700 Westown Parkway, Suite 200 1(800) 255-9448 West Des Moines, IA 50266-2 266 ~ www.metlifeinvestors.com 1 cxn -ob4, INA I~ KELLER 512 WAYNE DRIVE MECHANICSBURG, PA 17055 BEGINNING ACCOUNT TOTAL VALUE. WITHDRAWN ~ 3 i .327.80 $ O.O~J i Vut i r dfiSQC±LIVi 1~~~ t1ul~ it.y ~ -11~ ~ta~emen~ rerioa 'Transaction Transaction(s) Date Annual Statement Issue Date Product 11/6/0' ~-'rernie~ Select II Contract Number Account Type 9400140i'4 Non-Clualifled Owner(s) nvA Iv -:E~_~.~~ Annuitant(s) INA fVl KPLLER Advisor Name Charles Little Account Summary Statement Period: November 06. 2008 -November 05, 2009 Account Value X32,455.60 Full Withdrawal Value X32,455.60 Guarantee Period ~ year(s) Interest Rate 3.60 ~o Death Benefit ~32~455.60 EPJDING ACCOUNT INTEREST EARNED VALUE $ 1.127.80 S 32.455.60 Dollar Amount of Transaction Messages: Please revie~~~ this Annual Statement carefully and notify us of any errors. All distributions reflected in the section of the statement titled "Your Transaction(s) During This Statement Perioc'" arE: gross distribution amounts. _ -:~~:~~ ~ o~ ~~ oc,-c~~,-