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Home My WebLink About04-14-10 (2)J ],505607121 REV-1500 EX 06 ( -05) PA Department of Revenue OFFICIAL USE ONLY _-_____ Bunaau of individual Taxes PO BOX 280601 INHERITANCE TAX RETURN County Code Year File Number Harrisburg. PA 17128-0601 RESIDENT DECEDENT 2 1 0 9 0 7 4 0 ENTER DECEDENT INFORMATION BELOW _ -~ '---- SoGal Security Number Date of Death Date of Birth 2 9 2 2 8 1 8 1 8 0 7 2 1 2 0 0 9 0 5 1 9 1 9 2 6 Decedent's Last Name Suffix Decedent's First Name MI W E R N E R R U S S E L L A A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW © 1.Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death 4. Limited Estate [~ 4a. Future Interest Compromise (date of prior to 12-13-82) ~ 5. Federal Estate Tax Return Required ® 6. Decedent Died Testate (Attach Copy of Will) [] death after 12-12-82) 7. Decedent Maintained a Living Trust 2 8. Total Number of Safe Deposit Boxes 9. Litigation Proceeds Received ~ (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number H E A T H E R D R O Y E R E S Q 7 1 7 2 ~4 2 4~ 1 Firm Name (if Applicable) ~_.... Q ::~~Mr J ~ S M I G E L A N D E R S O N & S A C K S REGISTER Of"~3iy~l. .~ S USE ON~ ; :: . T i " .,, First line of address t -' ~~ ~ ~ ~~-- 4 4 3 1 N F R O N T Second line of address 3 R D F L O O R City or Post Office H A R R I S B U R G S T R E E T State P A ZIP Code 1 7 1 1 0 . _ ~ .. w - .~ _. ~ ; ~, ~ ~ .~ ~ :~ < ~ DATE FILED ~'`~ Correspondent's a-mail address: HROYERCc~SASLLP.COM Under penaltles of perjury, l declare that I have examined this n~tum, including acoompanying schedules and statements, and to the best of my knowledge and belief, h is true, ooneq and complete. Declaration of preparer other than the personal representative is based on ail information of which preparer has any knowledge. SIGNATURE OF PER ON R PONSIBLE FOR FILING RETURN DAATE J ADDRESS y/ /~ / ~ ~ 0_N. COURT MOON TOWNSHIP PA ],5108 'RE ER ~TNF eu wcooecc~~TwT~...- 431 N• FRONT ST•;~3RD FLOOR HARRISBURG PA 17110 PLEASE USE ORIGINAL FORM ONLY Side 1 1505607121 1505607121 J REV-1500 EX nA~p~p-,r~ Namp~ R lJ S S E L L A A• W E R N E R Decedent's Social Security Number 2 9 2 2 8 1 8 1 8 RECAPITULATION 2 5 8 0 0 0. D D 1. ........................................ Real estate (Schedule A) 1. 5 4 8 7 9. 4 6 2. .................................. Stocks and Bonds (Schedule B) 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages 8 Notes Receivable (Schedule D) ........................ 4. 1 6 2 4 4 0 7. 4 2 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property 1r 3 3 2 3 1, 2 4 (Schedule G) ~ Separate Billing Requested ....... 7. . 8 2 0 7 0 5 1 8, 1 2 8. Total Gross Assets (total Lines 1-7) ........................... . 9 9 0 4 3 9, 1 4 9. Funeral Expenses & Administrative Costs (Schedule H) 3 3 6 1 . 2 6 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............ 10. 11. Total Deductions (total Lines 9 8 10) ........................... 11. 9 3 8 D 0. 4 0 12. Net Value of Estate (line 8 minus Line 11) ......................... 12• la 9 7 6 7 1 7 . 7 2 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) .................. 13. J, 9 7 6 7 1, 7 . 7 2 14. Net Value Subiect to Tax (Line 12 minus Line 13) . 14. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 0 D 0 15 (a)(1.2) X .0 . 16. Amount of Line 14 taxable 1 9 7 5 7 ], 7 7 2 1 s at lineal rate X .045 . 17. Amount of Line 14 taxable D ~ D 0 17 at sibling rate X .12 . 18. Amount of Line 14 taxable ], D D D 0 D 18 at collateral rate X .15 . 19. Tax Due .......... ............................. .. ..... ..19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 1505607221 1,505607221, Side 2 0. 0 0 8 8 9 0 7. 3 0 0. D 0 1 5 0. 0 D 8 9 0 5 7. 3 0 Lsos6o~2z1 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 09 0740 DECEDENT'S NAME RUSSELLA A. WERNER ____ STREET ADDRESS --- - ------------_------ --- -- - ---- 310 LAMP POST LANE CITY ---- _- - -- STATE ------ ZIP - - ----- CAMP HILL PA 17011 Tax Payments and Credits: ~• Tax Due (Page 2 Line 19) (1) 89 057 30 2. CreditslPayments , . A. Spousal Poverty Credit B. Prior Payments 84,000.00 C. Discount 4,420.92 3. Total Credits (A + B + C) Interest/Penalty if applicable (2) 88,420.92 D. Interest E. Penalty Total InterestlPenalty (D + E) (3) 00 0 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. . Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 636.38 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 636.38 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : ...................................................................... ^ 0 b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q c. retain a reversionary interest; or ................................................................................................ ^ d. receive the promise for life of either payments, benefits or care? ....................................................... ^ Q 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ^ Q 3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? ......... ^ Q 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................. 0 ^ 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 (0) 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 return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 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 (4.5) 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 individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX + (6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER RUSSELLA A. WERNER _ 21 09 0740 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real roe which is int -owned with ri ht of survivorshi must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATN 1. 310 LAMP POST LANE, CAMP HILL, HAMPDEN TOWNSHIP, CUMBERLAND 258,000.00 COUNTY, PENNSYLVANIA. SEE HUD-1 ATTACHED. TOTAL (Also enter on line 1, Recapitulation) ~ a 258,000 00 (If more space is needed, insert additional sheets of the same size) ~ ~ ~^ REV-1503 EX + (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER RUSSELLA A. WERNER 21 09 0740 All property jointlyowned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. BONDS - VARIOUS E AND EE 54,879.46 SEE ATTACHED CALCULATED VALUE OF BONDS PER TREASURYDIRECT.COM 2. OMEGA FINANCIAL STOCK - 1,890 SHARES -TRANSFERRED TO HERITAGE 0.00 BROKERAGE ACCOUNT 09/05. 3. PENN STATE INVESTORS CORP. STOCK - 200 SHARES -DEFUNCT COMPANY AS OF 0.00 1971. TOTAL (Also enter on line 2, Recapitulation) ~ $ 54,879 46 (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. IN RESI DENT DECEDENT N PERSONAL PROPERTY ESTATE OF FILE NUMBER RUSSELLA A. WERNER 21 09 0740 Include the proceeds of litigation 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 1. CITIZENS BANK CHECKING ACCOUNT #610068XXXX 2. CITIZENS BANK MONEY MARKET ACCOUNT #622398XXXX 3. CITIZENS BANK CHECKING ACCOUNT #622398XXXX 4. INTEGRITY BANK MONEY MARKET ACCOUNT #20101XXXX WITH INTEREST ACCRUED TO DATE OF DEATH 5. ORRSTOWN BANK SAVINGS ACCOUNT #1541XXXX WITH INTEREST ACCRUED TO DATE OF DEATH 6. WACHOVIA BANK CHECKING ACCOUNT #XX~:XXX6787 WITH INTEREST ACCRUED TO DATE OF DEATH 7. WACHOVIA BANK SAVINGS #XXXXXX84227 WITH INTEREST ACCRUED TO DATE OF DEATH 8. M & T BANK MONEY MARKET ACCOUNT #XXXXXX84695 WITH INTEREST ACCRUED TO DATE OF DEATH 9. PNC BANK SAVINGS ACCOUNT #51-1200-4025 WITH INTEREST ACCRUED TO DATE OF DEATH 10. HERITAGE WEALTH ADVISORS- MONEY MARKET ACCOUNT, EQUITY ACCOUNT, MUTUAL FUNDS #SHT115060. 11. WACHOVIA BANK SAFE DEPOSIT BOX -SEE ATTACHED INVENTORY LIST. SAVINGS BONDS REPORTED ON SCHEDULE B 12. CITIZENS BANK SAFE DEPOSIT BOX -SEE ATTACHED INVENTORY LIST. 13. CREMATION SOCIETY OF PENNSYLVANIA -BENEFIT TOWARD CREMATION. 14. PENNSYLVANIA STATE EMPLOYEES RETIREMENT PENSION 15. PSECU MONEY MARKET ACCT. #292XXXXXXX 16. PSECU REGULAR SHARES VALUE AT DATE OF DEATH 96,296.55 98.04 56,283.38 13,629.98 104.65 11,355.89 54,014.87 144,648.51 1,208,805.40 0.00 0.00 2,170.00 1,655.60 6,735.86 217.49 TOTAL (Also enter on line 5, Recapitulation) ~ ~ (If more space is needed, insert additional sheets of the same size) 1,624,407.42 Continuation of REV-1500 Inheritance Tax Return Resident Decedent RUSSELLA A. WERNER 21 09 0740 Decedent's Name Page 1 File Number Schedule E -Cash, Bank Deposits, & Misc. Personal Property ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 17. PERSONAL PROPERTY -SOLD AT ESTATE AUCTION 1,020.40 18. REFUND -TRAVELERS HOMEOWNERS INSURANCE 373.00 19. REFUND -COMCAST 5.58 20. REFUND -FLOOD INSURANCE 86.00 21. REFUND - Q & T PHONE LEASE 7.44 22. AMERICAN EXPRESS TRAVELERS CHECKS 670.00 23. 2009 INCOME TAX REFUND 156.00 SUBTOTAL SCHEDULE E 2,318.42 GRAND TOTAL SCHEDULE E $ 1,624,407.42 REV-1510 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER RUSSELLA A. WERNER ~ i ne man 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 INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE GEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1. PENTAGON FCU SAVINGS ACCT #51-1200-XXXX 5.10 100. 5.10 BENEFICIARIES: SHARON ROSE, DAUGHTER; STEVEN WERNER, SON; AND PAMELA DAVEY, DAUGHTER 2. PENTAGON FCU MONEY MARKET #0-4252465-XX-X 81,341.20 100. 81,341.20 BENEFICIARIES: SHARON ROSE, DAUGHTER; STEVEN WERNER, SON; AND PAMELA DAVEY, DAUGHTER 3. PENTAL FCU MONEY MARKET #0-4260199-XX-X 34,854.72 100. 34,854.72 BENEFICIARIES: SHARON ROSE, DAUGHTER; STEVEN WERNER, SON; AND PAMELA DAVEY,DAUGHTER. 4. PSECU IRA CERTIFICATE 17,030.22 100. 17,030.22 BENEFICIARIES: SHARON ROSE, DAUGHTER; STEVEN WERNER, SON; AND PAMELA DAVEY, DAUGHTER TOTAL (Also enter on line 7 Recapitulation) I $ 133 231 24 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS __ - ESTATE OF FILE NUMBER RUSSELLA A. WERNER 21 09 0740 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. PARTHEMORE FUNERAL HOME 4,215.62 2. FUNERAL FLOWERS 227.90 3. FOOD FOR FUNERAL LUNCHEON 776.70 4. MEMORIAL EXPENSES 7S7.S9 B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) SHARON A. ROSE Street Address 117 COTTONWOOD COURT City MOON TOWNSHIP Year(s) Commission Paid: 2010 State PA Zip 1 S 108 2, Attorney Fees SMIGEL, ANDERSON & SACKS, LLP 3. Family Exemption: (If decedents address is not the same as claimant's, attach explanation) Claimant 4. 5 6 7. 8. 9. 10. l 1. 12. 13. 14. 1 S. 16. 17. 18. Street Address City State Zip Relationship of Claimant to Decedent Probate Fees REGISTER OF WILLS, CUMBERLAND COUNTY Accountants Fees Tax Return Preparers Fees FINAL PERSONAL AND ESTATE 1041 SENTINEL -LEGAL ADVERTISEMENT CUMBERLAND LAW JOURNAL -LEGAL ADVERTISEMENT HUNTINGTON BANK -ESTATE CHECK FEE D.A. POTTS -APPRAISAL OF HOME DIRTY DOG HAULING -REMOVING TRASH FROM HOME WILLIAM F. DAVEY -REPAIRS TO HOME (REPAIR WALLS/PAINTING) HAMPDEN TOWNSHIP WATER/SEWER PP&L -ELECTRIC BILL RESIDENCE SELLING COSTS -SEE HUD-1 SHEET ATTACHED COMCAST -PHONE BILL VERIZON HUNTINGTON BANK -WIRE TRANSFER FEES S 1,335.40 12,500.00 1,195.00 750.00 198.16 75.00 18.95 375.00 1,425.00 65.74 277.30 676.30 9,995.00 177.30 220.SS 72.00 TOTAL (Also enter on line 9, Recapitulation) ~ 90,439.14 (If more space is needed, insert additional sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent RUSSELLA A. WERNER 21 09 0740 Decedent's Name Page 2 File Number Schedule H -Funeral Expenses & Administrative Costs - B7. ITEM NUMBER DESCRIPTION AMOUNT 19. POSTAGE 60.62 20. AMERICAN WATER 89.35 21. CUMBERLAND COUNTY REAL ESTATE TAXES 1,832.96 22. ROBERT MYERS - LANDSCAPE/YARD WORK 1,240.00 23. TAX CERTIFICATION FEE PAID OUTSIDE CLOSING 5.00 24. SHARON A. ROSE -MILEAGE/TOLLS 1,876.70 SUBTOTAL SCHEDULE H-B7 ~ 5,104.63 REV-1512 EX + (12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ~ ESTATE OF FILE NUMBER RUSSELLA A. WERNER 21 09 0740 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. SMIGEL, ANDERSON & SACKS, LLP -FEE BALANCE FOR ESTATE PLANNING SOS.00 2. VILLA ST. JOSEPH OF BADEN -BALANCE FOR PERSONAL CARE HOME 1,705.99 3. DENNIS LACKMEYER -CHECK CLEARED AFTER DATE OF DEATH 100.00 4. BARBARA WERNER -CHECK CLEARED AFTER DATE OF DEATH 100.00 S. VALLEY AMBULANCE AUTHORITY -MEDICAL SERVICES 180.00 6. AARP HEALTH CARE PREMIUM 16.95 7. VERIZON 220.SS 8. QLT -PHONE LEASE AUTOPAYMENT 16.36 9. PA STATE EMPLOYEES RETIREMENT SYSTEM -REFUND OF OVERPAYMENT 496.68 10. AMEX CREDIT CARD 19.73 TOTAL (Also enter on line 10, Recapitulation) I $ 3,361 26 (If more space is needed, insert additional sheets of the same size) REV-1513 EX + (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER RUSSELLA A. WERNER ~ ~ nn n~ n n ". vi viTv RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)l 1. SHARON A. ROSE Lineal 648,572.58 117 COTTONWOOD COURT MOON TOWNSHIP PA 15108 2. PAMELA J. DAVEY Lineal 648,572.57 17138 WOOD ACRE TRAIL CHAGRIN FALLS OH 44023 3. STEVEN A. WERNER Lineal 648,572.57 12743 PLATEAU CIRCLE NW SILVERDALE WA 98383 4. CHRISTA LAUBACH Lineal 5,000.00 503 SKYPORT ROAD MECHANICSBURG PA 17050 5. ANGELA M. ROSE Lineal 5,000.00 5714 NORTH 6TH STREET ARLINGTON VA 22205 6. DENNIS LACKMEYER Lineal 5,000.00 12323 NE 9TH ST., UNIT Q KIRKLAND WA 98033 7. KATHERINE R. WERNER Lineal 5,000.00 4456 N. KENTON AVENUE CHICAGO IL 60630 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET ~ fir more space is neeoea, insert additional sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent RUSSELLA A. WERNER 21 09 0740 Decedent's Name Page 3 File Number Schedule J -Beneficiaries -1 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS (include outright spousal distributions) 8. TERESA A. ROSE Lineal 5,000.00 50 PADDLEBOAT LANE, APT. 602 HILTON HEAD ISLAND SC 29928 9. JULIA ROSE Lineal 5,000.00 117 COTTONWOOD COURT MOON TOWNSHIP PA 15108 10. ROBERT LACKMEYER Collateral 1,000.00 1025 SENECA TRAIL ST. CLOUD FL 34772 Continuation of REV-1500 Inheritance Tax Return Resident Decedent RUSSELLA A. WERNER 21 09 0740 Decedent's Name Page 3 File Number Schedule J -Beneficiaries -1 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS (include outright spousal distributions) 8. TERESA A. ROSE Lineal 5,000.00 50 PADDLEBOAT LANE, APT. 602 HILTON HEAD ISLAND SC 29928 9. JULIA ROSE Lineal 5,000.00 117 COTTONWOOD COURT MOON TOWNSHIP PA 15108 10. ROBERT LACKMEYER Collateral 1,000.00 1025 SENECA TRAIL ST. CLOUD FL 34772 REV-1500 Discount, Interest and Penalty Worksheet Discount Calculation Total Amount Paid within three calendar months of the decedent's date of death: _-____ _____ __ -_8410_00.00 Discount: _ __ ___- __ _ _____4 420.92 Interest Table ~ Year ~ Days Delinquent this time period Balance Due Interest this year this period -- - -- ---- -r-. -------- - '~ 1987 ---- -- - - - --- 1988 throu~h_1991 __ ~ _ 1992 ' -- --- i-1993 through 1994 -- - _ - ---- _1995 through 1998__ j 1999 -- ---- ---~ --- -- - - -- '~ 2000 2001 2002 2003 2004 --- ---- - -- --t----------- ~- - - -- -- 1 - 1- - --- Penalty Calculation If the decedent's date of death was on or before March 31, 1993, insert the applicable amount: Total Balance Due on January 17, 1996: ___ _ ______ Penalty: 8960-1-5/Will/HDR/crm 6/13/06 4:05 F LAST WILL AND TESTAMENT OF i RUSSELLA A. WERNER I, RUSSELLA A. WERNER, presently of Cumberland County, Pennsylvania, declare this to be my Last Will and Testament hereby revoking all Wills and Codicils previousl made Y by me. MARITAL STATUS I declare that I am a widow. CHILDREN I have three (3) children, now living, whose names and dates of birth are as follows: PAMELA J. DAVEY born January 24, 1951 SHARON A'. ROSE born December 7, 1955 STEVEN A. WERNER born February 3, 1958 All references in this Will to my children include only the children named above. I have six (6) grandchildren, now living, whose names and dates of birth are as follows: CHRISTA J. LAUBACH born Apri122, 1980 ANGELA M. ROSE born February 22, 1983 DENNIS R. LACKMEYER born April 24, 1983 KATHERINE R. WERNER born December 11, 1983 TERESA A. ROSE bom November 28, 1985 JULIA P. ROSE born June 20, 1989 All references in this Will to my grandchildren include only the grandchildren named above. SPECIFIC BEQUESTS ARTICLE I A. I give the sum of Ten Thousand ($10,000.00) Dollars to ROBERT J. LACKMEYER, presently of Cleveland, Ohio, provided he survives me by thirty (30) da s. Y If ROBERT J. LACKMEYER does not survive me by thirty (30) days, then this gift shall lapse. B• I give that portion of my net taxable estate that exceeds the federal estate tax applicable exclusion amount in effect at the time of my death to the ROSWELL PARK ALLIANCE FOUNDATION located in Buffalo, New York. PERSONAL PROPERTY ARTICLE II I give all of my household furnishings and tangible personal property to my children and "' my bru+i4viiiiur~ll tV V~ ulvlu~;d Qil 11111 L11G111 C1J 111Gy a1G 2dU1C iu agree. ii They are unable to agree, then said property and furnishings shall be sold and the proceeds added to my residu ~' estate. Page 2 of 9 Pages RESIDUE ARTICLE III I give the rest, residue and remainder of my estate not disposed of in the preceding portions of this Will to my children and to my grandchildren in equal shares. If a child of mine should fail to survive me by thirty (30) days, then his or her share shall be divided and distributed in equal shares to my surviving children. If a grandchild of mine should fail to survive me by thirty (30) days, then his or her share shall be divided and distributed in equal shares to my surviving grandchildren. If all of my children fail to survive me by thirty (30) days, then their respective shares shall be divided and distributed in equal shares among my surviving grandchildren. If all of my grandchildren fail to survive me by thirty (30) days, then their respective shares shall be divided and distributed in equal shares among my surviving children. If all of my children and all of my grandchildren should fail to survivie me by thirty (30) days, then I give the rest, residue and remainder of my estate not disposed of in the preceding portions of this Will to ROSWELL PARK ALLIANCE FOUNDATION. EXECUTRIX ARTICLE IV A. Appointment. I appoint my daughter, SHARON A. ROSE, as the Executrix of this Will. In the event of her death, resignation, renunciation or inability to act in that capacity, then I appoint my brother, HARRY W. ADAMITZ, presently of Mount Vernon, Washington, as the Executor of this Will in her place and stead. Page 3 of 9 Pages B. Bond. No bond or other security shall be required of any Executrix or Executor appointed in this Will. C. Compensation. The Executrix or Executor shall receive reasonable compensation for her or his services performed as determined by the Court in which this Will is admitted to probate. EXECUTRIX POWERS ARTICLE V I give my Executrix in addition to and not in limitation of the powers given by law or by other provisions of this Will, the following powers with respect to settlement of my estate, to be exercised from time to time in the discretion of my Executrix without further order or license of the Register of Wills or of any Court: A. Investments. To retain any property, pending distribution hereunder, to invest in or purchase any property without restriction to legal investments for fiduciaries, to compromise claims, and to sell any property at public or private sale; B. Securities. To hold shares of stock or other securities in nominee registration form, including that of a clearing corporation or depository, or in book entry form or unregistered or in such other form as will pass by delivery; C. Litigation. To engage in litigation and compromise, arbitrate or abandon claims; Page 4 of 9 Pages D. Distributions. To make distributions in cash or in kind at current values, or partly in each, allocating specific assets to particular distributees on a non-pro rata basis, and for such purposes to make reasonable determinations of current values; E. Tax Return. To make elections, decisions, concessions and settlements in connection with all income, estate, inheritance, gift or other tax returns and the payment of such taxes, without obligation to adjust the distributive share of income or principal of any person affected thereby; F. Loans. To pay off any loans I may have taken against life insurance policies owned by me that remain unpaid at the time of my death; G. Borrowing and Encumbering. To borrow money from any person including any fiduciary acting hereunder, and to mortgage or pledge any real or personal property; H. Property Management. To manage, control, repair and improve all personal and real property; I. Insurance. To procure and carry at the expense of the estate, insurance of the kinds, forms and amounts deemed advisable by the Executrix to protect the estate and the Executrix against any hazard; J. Employment of Attorneys, Advisors and Other Agents. To employ any attorney, investment adviser, accountant, broker, tax specialist or any other agent deemed necessary in the discretion of the Executrix; and to pay from the estate reasonable compensation for all services performed by any of them; Page 5 of 9 Pages K. Business Operation. To conduct alone or with others any business in which I am engaged or in which I have an interest at my death, with all the powers of any owner with respect thereto, including the power to delegate discretionary duties to others, to invest other property held hereunder in such business and to organize a partnership or corporation to carry on such business; L. General. To do all the acts, to take all the proceedings, and to exercise all the rights, powers and privileges which an absolute owner of the property would have, subject always to the discharge of her fiduciary obligations. The enumeration of certain powers in this Will shall not limit the general or implied powers of the Executrix. The Executrix shall have all additional powers that may now or hereafter be conferred on the Executrix bylaw or that maybe necessary to enable the Executrix to administer the provisions of this Will, subject to any limitations specified in this Will. NO ALIENATION ARTICLE VI No interest of any beneficiary under this Will or any codicil hereto shall be subject to anticipation or voluntary or involuntary alienation. Page 6 of 9 Pages NO CONTEST ARTICLE VII If any beneficiary or remainderman under this Will in any manner, directly or indirectly, contests or attacks this Will or any of its provisions, any share or interest in my estate given to that contesting beneficiary or remainderman under this Will is revoked and shall be disposed of in the same manner provided herein as if that contesting beneficiary or remainderman had predeceased me without issue. LEGALITY OF ARTICLES ARTICLE VIII If any provision of this Will or of any codicil thereto is held to be inoperative, invalid or illegal, it is my intention that all of the remaining provisions thereof shall continue to be fully operative and effective so far as it is possible and reasonable. TAXES ARTICLE IX All estate, inheritance and succession taxes, together with any interest and penalties thereon, payable as a result of my death and imposed with respect to any property, whether or not disposed of by this Will, shall be paid out of the residue of my estate. Page 7 of 9 Pages IN WITNESS WHEREOF, I have hereunto set my hand and seal and caused this my Last Will and Testament, consisting of nine (9) typewritten pages, including this attestation clause, to be executed, declared and published this ~`~ ~1 day of ~ ~~~~~ , 2006, at River Chase Office Center, 4431 North Front Street, Harrisburg, Pennsylvania. ~I ~ ~ n-^z~.~~~~~ (SEAL) RUSSELLA A. WERNER Signed, sealed, published and declared by the above named RUSSELLA A. WERNER, Testatrix, as and for her Last Will, in the presence of us and each of us, who, at her request and in her presence and in the presence of each other, have hereunto subscribed our names as witnesses thereto the day and year last above written. Residing at 1 ~l~ ~T~d~~L~ / -, .~ 0~ '? ,~. Residing at ~~ ~. R ~ n ~~+ ~ ~ , t ~ Residin at 1,,~. g _~(f _~~:-~ Page 8 of 9 Pages COMMOI~fWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN SS. We, RUSSELLA A. WERNER, the Testatrix, and -~- ~ ~ r ~_ ? and ~ ~~ ~ ~ the witnesses whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will; that the Testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testatrix signed the Will as a witness and that to the best of his or her knowledge the Testatrix was at that time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. ~~~~~- •it~ Q L~4 RUSSELLA A. WERNER 5 Witness S Witness Witness Subscribed, sworn to and acknowledged before me by RUSSELLA A. WERNER, the Testatrix, and subscribed and sworn to before me by ~ `~~- ~ .. ~: ~- '~-~ ~ ~ . ~ and ~ ,witnesses, this i, ~~, ~~~~ day of ~ ~,~ , 2006. ~` Nota y Public ' My Commission Expires: Page 9 of 9 Pages ~9G0-1-~/Codicil/N DR/tmc 7/8/U9 12:7 PM FIRST CODICIL TO THE WILL OF RUSSELLA A. WERNER I, RUSSELLA A. WERNER, presently of Cumberland County, Pennsylvania, having made my Last Will and Testament dated June 14, 2006, do hereby make, publish and declare this ~~ ~~:~ _ to e a First Codicil to my said Will. ~? ~; , : ~; ~; n r ,, ~~, c ~:. ,r'..... ..~ ~' Y _-y --) Substitution of Provision `~'' -' c~ -~ ~- -, r ; _-r3 _~ - ; _:~'- - - , Article I on Page Two of the aforesaid Will is hereby revoked and the foll~ving is w = ~=` ':~ ~ ~, .c- substituted in its place: SPECIFIC BEQUESTS ARTICLE I A. I give the sum of Five Thousand ($5,000.00) Dollars to each grandchild of mine who survives me by thirty (30) days. B. I give the sum of One Thousand ($1,000.00) Dollars to ROBERT J. LACKMEYER, presently of St. Cloud, Florida, provided he survives me by thirty (30) days. If ROBERT J. LACKMEYER does not survive me by thirty (30) days, then this gift shall lapse. C. I give that portion of my net taxable estate that exceeds the federal estate tax applicable exclusion amount in effect at the time of my death to the ROSWELL PARK ALLIANCE FOUNDATION located in Buffalo, New York. Article III on Page Three of the aforesaid Will is hereby revoked and the following substituted in its place: RESIDUE ARTICLE III I give the rest, residue and remainder of my estate not disposed of in the preceding portions of this Will to my children in equal shares, per stirpes, such that any issue shall represent and take their deceased parent's share. If all of my children fail to survive me and leave no surviving issue, then I give the rest, residue and remainder of my estate not disposed of in the preceding portions of this Will to ROSWELL PARK ALLIANCE FOUNDATION. Article IV on Page Three of the aforesaid Will is hereby revoked and the following is substituted in its place: EXECUTRIX ARTICLE IV A• Appointment. I appoint my daughter, SHARON A. ROSE, as the Executrix of this Will. In the event of her death, resignation, renunciation or inability to act in that capacity, then I appoint my daughter, PAMELA J. DAVEY, presently of Chagrin Falls, Ohio, as the Executrix of this Will in her place and stead. Page 2 of 4 Republication of Will In every other respect, I hereby confirm and republish my Last Will and Testament dated ,tune 14, 2006. IN WITNESS WHEREOF, I have hereunto set my hand and seal and caused this First Codicil, consisting of four (4) typewritten pages, including this attestation clause, to my Last Will and Testament dated June 14, 2006 to be executed, declared and published this ~ ~~day of 2009, at ~ v ~ ~ _._.P,a'~__,.,~~:.r ~ -~-. ~ !~ ~~~-~4.~0~. ~:r, ~....,rv~..~ (SEAL} RUSSELLA A. WERNER Signed, sealed, published and declared by the above named RUSSELLA A. WERNER, Testatrix, as and f-or her First Codicil for her Last Will, in the presence of us and each of us, who, at her request and in her presence and in the presence of each other, have hereunto subscribed our names as witnesses thereto the day and year last above written. Residing at ~ \ ~ ~ ~p~ ~ P~ l _ Residing at ~3 (,V~`~Y~`J.Q,~ ~r``f,~ _. ~ Residing at Mc~ees R,oc~s, ~A ~ 513 b ~o n3 V~ ~N~~V ~. ~;v~ McI~Es ~~ks ~ isl3~ Page 3 of 4 COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF c We, RUSSELLA A. WERNER, the Testatrix, and and N ,the witnesses, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as the First Codicil to her Last Will; that the Testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testatrix signed the First Codicil as a witness and that to the best of his or her knowledge the Testatrix was at that time eighteen (18) years of age or older, of sound mind and under no constraint or undue influence. 1 / 1~~.~1 J1 i J~ J j ~ . Vl .iL I /~~ M A /'7 RUSSELLA A. WERNER Witness - Witness Witn Subscribed, sworn to and acknowledged before me by RUSSELLA A. WERNER, the Testatrix, and subscribed and sworn to before me by v and ~~ day of -Tj.~,~ witnesses, this ~~~ Notary Public (SEAL) c:c~,~i~.tc; y iii: ~~,L ~ ~L1 c~ P ~J~vsYLV~~via i`,Ic~rf~:il ~e~l Vl~~i!i~m N~. F.G~:;, Paacary ~'u~iic r. i f f.Jf 'lii~)l ir~.'.i. ,•'1i;F~ilwf{y CCUniy Page 4 of 4 1hy C`,o;;;tYr~;',~,~1~ ~ i_;,, w f~nrii 2~i, 201 ~ b~am5~r, r~~r~aylvania Associa'.ion of Ncta; fes Hula Nn ~an~_n~as A. _- - - .. B. TYPE OF LOAN: U.S. DEPARTMENT OF HOUSING r4 URBAN DEVELOPMENT 1.OFHA 2. QFmHA 3. QX CONV. UNINS. 4. QVA 5. QCONV. INS. SETTLEMENT STATEMENT 6. FILE NUMBER: LEPLEY 7. LOAN NUMBER: 6800285212 8. MORTGAGE INS CASE NUMBER: C. NOTE: This form is /urnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown . Items marked "(POCJ" were paid outside the closing; they are shown here for inlormational purposes and are not included in the totals. 1.0 3/99 (LEPLEY PFp/LEPLEY117) D. NAME ANO ADDRESS OF BORROWER: E. NAME AND ADDRESS OF SELLER: F NAME AND ADDRESS OF LENDER: CHARLES C. LEPLEY and MEMBERS 1ST FEDERAL STEPHANIE S. LEPLEY SHARON A. ROSE, Executrix of the CREDIT UNION Estate of RUSSELLA A. WERNER 5000 LOUISE DRIVE MECHANICSBURG, PA 17055 G. PROPERTY LOCATION: H. SETTLEMENT AGENT: 20-1624913 I SETTLEMENT DATE: 310 LAMP POST LANE . CAMP HILL, PA 17011 GUARANTEED ABSTRACT SERVICES, INC. N HAMPDEN TWP, CUMBERLAND CO. PLACE OF SETTLEMENT ovember 30, 2009 PRUDENTIAL THOMPSON WOOD REAL ESTATE 3813 Market St, Camp Hill, PA 17011 J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION 100. GROSS AMOUNT DUE FROM BORROWER: 400. GROSS AMOUNT DUE TO SELLER: 101. Contract Sales Price 258 000.00 401. Contract Sales Price 258 000 00 102. Personal Pro ert 402. Personal Pro ert . 103. Settlement Char es to eon-ower Line 1400 8,361.23 403. 104. 404. 105. 405. Ad Lstments For Items Paid B Seller in advance AdLstments For Items Paid B Seller in advance 106. Count !1"w Taxes 11/30/09 to 01/01/10 46.05 406. Count fTw Taxes 11/30/09 to 01/01/10 46 05 107. Cit Tax to . 407. Cit Tax to 108. School Tax 11/30/09 to 07/01/10 1 069.65 408. School Tax 11/30/09 to 07/01110 1 069 65 109. 4TH QTR SEWER/REFUSE $138.6511130109 to 01/01/1 48.23 409. 4TH QTR SEWER/REFUSE $138.6511/30/09 to 01/01/ , . 48 23 110. 410. . 111. 411, 112. 412. 120. GROSS AMOUNT DUE FROM BORROWER 267,525.16 420. GROSS AMOUNT DUE TO SELLER 259,163.93 200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER: 500. REDUCTIONS IN AMOUNT DUE TO SELLER: 201. De osit or earnest move 5,000.00 501. Excess De osit See Instructions 202. Princi al Amount of New Loans 206,400.00 502. Settlement Char es to Seller Line 1400 9 995 00 203. Existin loans taken sub'ect to 503. Existin loans taken sub ect to , . 204. 504. Pa off of first Mort age 205. 505. Pa off of second Mort a e 206. 506. 207. 507. De osit disb as roceeds 208. . 508. 209. 509. Ad'ustments For Items Un aid B Seller Ad ustmenfs For Items Un aid B Se/!er 210. Count /Tw Taxes to 510. Count /Tw Taxes to 211. Cit Tax to 511. Cit Tax to 212. School Tax to 512. School Tax to 213' 513. 214. 514. 215. 515. 216. 516. 217. 517. INHERITANCE TAX ESCROW to GUARANTEED ABS 10000 00 218. 518. . 219. 519. 220. TOTAL PAID 8Y/FOR BORROWER 211,400.00 520. TOTAL REDUCTIONAMOUNT'DUE SELLER 19,995.00 300. CASH AT SETTLEMENT FROM/TO BORROWER: 600. CASH AT SETTLEMENT TO/FROM SELLER 301. Gross Amount Due From Borrower Line 120 267,525.16 : 601. Gross Amount Due To Seller Line 420 259 163 93 302. Less Amount Paid By/For Borrower (Line 220) ( 211,400.00) 602. Less Reductions Due Seller (Line 520) ( , . 19,995.00 303. CASH (X FROM) ( TO) BORROWER 56,125.16 603. CASH (X TO) ( FROM) SELLER 239,168.93 i re unt7ersigned hereby acknowledge receipt of a completed copy of pages 1 &2 of this statement & any attachments referred to herein. Borrower CHARLES C. LEPLEY Seller SHARON A. ROSE, -- Executrix of the Estate of RUSSELLA A. WERNER STEPHANIE S. LEPLEY Page 2 L. SETTLEMENT CHARGES 700. TOTAL COMMISSION Based on Price $ 258,000.00 2.5000 °16 6,450.00 PAID FROM PAID FROM Division of Commission Tine 700 aS FO//O WS: 80RROVYER'S SELLER'S 701. $ 6,450.00 to PRUDENTIAL THOMPSON WOOD REAL ESTATE FuNOSAr FUNDS AT 702. $ to PRUDENTIAL THOMPSON WOOD REAL ESTATE sErnEMENT SETTLEMENT 703. Commission Paid at Settlement 6,450.00 704. SETTLEMENT DEPT MGMT FEE to PRUDENTIAL THOMPSON WOOD REAL ESTATE 200.00 200.00 800. ITEMS PAYABLE IN CONNECTION WITH LOAN 801. Loan Ori ination Fee 1.0000 °r6 tD MEMBERS 1ST FCU 2,064.00 802. Loan Discount % to 803. Appraisal Fee to 804. Credit Report to 805. Lenders Inspection Fee to 806. Flood Cert Fee to 807. Tax Service Fee to 808. Document Prep Fee to MEMBERS 1ST FCU 305.00 809. Application Fee MEMBERS 1ST FCU $375 POC 810. Underwriting Fee to MEMBERS 1ST FCU 150.00 811, 900. ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 901. Interest From 11/30109 to 12/01/09 $ 28.666700/day 1 days %) 28.67 902. Mort a e Insurance Premium for months to 903. Hazard Insurance Premium for 1.0 ears to POC 904. 905. 1000. RESERVES DEPOSITED WITH LENDER 1001. Hazard Insurance 3.000 months $ 43.00 r month 129.00 1002. Mort a e Insurance months $ er month 1003. Count !Tw Taxes 10.000 months $ 42.90 er month 429.00 1004. Cit Tax months $ r month 1005. School Tax 6.000 months $ 152.75 per month 916.50 1006. months $ r month 1007. months er month 1008. AGGREGA?E ADJUSTMENT months $ er month -558.69 1100. TITL'':'!IA.. ~~ES 1101. Set; ~ ,'.iosin Fee to 1102. E-M. _;c,;,:ment Retrieval to GUARANTEED ABSTRACT SERVICES INC. 50.00 1103. Title Examination to 1104. Title Insurance Binder to 1105. Document Pre ration to SMIGEL ANDERSON 8 SACHS DEEDIPOC 1106. Nota Fees to NOTARY CLERK 30.00 1107. Attorney's Fees to includes above item numbers: 1108. Title Insurance to GUARANTEED ABSTRACT SERVICES INC. GA8.09-140 1 648.75 includes above item numbers:1101 1103 -BASIC RATE 1109. Lendefs Coverage $ 206,400.00 8230738-79333159 1110. Owner's Coverage $ 258,000.00 8222638-79333215 1111. PA EN0:100, 300, 900 to GUARANTEED ABSTRACT SERVICES, INC. 150.00 1112. 1113. Insured Closin Letter to LAWYERS TITLE INSURANCE CORPORATION 75.00 1114. Overni ht Fee/packa a to GUARANTEED ABSTRACT SERVICES, INC. 12.00 1115. Tax Cert Fee to GUARANTEED ABSTRACT SERVICES, INC. 5.00 1116. 1117. 1118. 1200. GOVERNMENT RECORDING AND TRANSFER CHARGES 1201. Recordin Fees: Deed $ 62.00 ;Mort age $ 90.00; Releases $ 152.00 1202. Ci /Count Tax/Slam s: Deed 2,580.00 MoR a e 2,580.00 1203. State Tax/Stam s: Revenue Stam s 2 580.00; Mort a e 2,580.00 1204• RECORDER OF DEEDS 1205. RECORDER OF DEEDS 1300. ADDITIONAL SETTLEMENT CHARGES 1301. Surve to 1302. Pest Ins action to POC 1303. RADON MITIGATION to ENVIROQUEST 760.00 1304. 1305. 1400. TOTAL SETTLEMENT CHARGES (Enter on Linea 103, Section J and 502, Section K) 8,361.23 9,995.00 Certified to be a true copy. GUARANTEED ABSTRACT SERVICES, INC. Settlement Agenl (LEPLEYlLEPLEY/17) Calculated Value of Your Paper Savings Bond(s) Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 07/2009 http://www.treasurydirect.gov/BC/SBCPrice Total Price Total Value Total Interest YTD Interest $19,106.25 $54,879 47 $35,773.22 $895.22 Bonds: 1-190 of 190 Serial # Series Denom Issue Date Next Accrual Final Maturity Issue Price Interest Interest Rate Value Note L378764100EE EE $50: 08/1988'., 08/2009 08/2018 $25.00 $46.18 4.00%' $71.18. L351692039EE EE $50 06/1988 12/2009 06/2018. $25.00 $47.60' 4.00% $72.60 L351663840EE EE $50 05/1988 11/2009 05/2018 $25.00 $47.60. ._ 4.00% $72.60: L351625694EE EE $50 03/1988 09/2009. 03/2018' $25.00 $47.60. 4.00% $72.60 L227225169EE EE $50 01/1986 01/2010. 01/2016' $25.00 $64.14,. 4.00% $89.14: L214223738EE EE $50 05/1985; 11/2009 05/2015: $25.00: $65.94; 4.00% . $90.94. L214230337EE EE $50 06/1985 12/2009 06/2015.., $25.00 $65.94: 4.00% $90.94 L217625150EE EE $50 06/1985 12/2009 06/2015 $25.00 $65.94 o 4.00 /o $90.94 L217633165EE EE $50 07/1985 01/2010 07/2015 $25.00 $65.94 4.00% , $90.94' L217541125EE EE $50 07/1985 01/2010 07/2015' $25.00 $65.94 4.00% $90.94' L182469339EE EE $50 08/1985: 08/2009 08/2015 $25.00 $64.14 4.00% $89.14 L226736431EE EE $50' 08/1985 08/2009 08/2015: $25.00' $64.14 4.00% $89.14 L226744465EE EE $50 08/1985 08/2009 08/2015; $25.00 $64.14 4.00% $89.14 L226752490EE' EE $50 09/1985... 09/2009 09/2015._ $_25.00 $64.14 4.00% $89.14 L226760424EE EE $50' 09/1985 _ 09/2009 09/2015 $25.00 $64.14: 4.00% $89.14' L228369299EE EE $50' 10/1985 10/2009 10/2015' $25.00 . $64.14 4.00% $89.14 L228377081EE EE $50 _ 10/1985._, 10/2009' 10/2015 $25..00 $64.14: 4.00% $89.14 L228385141EE EE $50 1.1/1985 11/2009 11/2015' $25.00: $64.14 .. _. 4.00% _ $89.14 L227185928EE EE $50 _ 11/1985. 11/2009 11/2015 $25.00' $64.14 4.00% $89.14 L227193710EE EE $50 12/1985 12/2009 12/2015 $25.00 $64.14'. o ,_ 4.00 /o' $89.14. L227202342EE EE $50. 1,2/1985 12/2009 12/2015.;. $25.00:. , $64.14 4.00%' $89.14- L227209888EE EE $50' 01/1986, 01/2010 01/2016 _ $25.00 $64.14 4.00% .. $89.14' L227217524EE EE $50 01/1986 01/2010 01/2016.: $25.00: $64.14 _ o _ 4.00 /o _ $89.14, L263768807EE EE $50 0.2/1986 08/2009 _ 02/2016 $25.00 $62.40 4.00% _ $87.40 L263776726EE EE $50 02/1986 08/2009. 02/2016 $25.00; $62.40'; 4.00% $87.40 L263784520EE' EE $50 03/1986 09/2009 03/2016 . $25.00': . $62.40: o 4.00 /o $87.40 L263792175EE EE _ $50 03/1986. , ___09/2009 _ _. _, 03/2016; $25.00 _ $62.40 4.00%; $87.40' L263799727EE EE $50 04/1986 10/2009 04%2016' $25.00 $62.40 __ , 4.00% _ _ $87.40 L263807272EE EE $50 04/1986 10/2009 04/2016 $25.00 $62.40 4.00% $87.40 L263814844EE EE $50 05/1986 11/2009 05/2016 $25.00 $62.40 4.00% $87.40 L263822217EE EE $50 05/1986 11/2009 05/2016. $25.00 $62.40 _ 4.00% __ $87.40 L263829698EE EE _ $50 06/1986 12/2009 06/2016'_ _ $25.00' $62.40 ; 4.00% $87.40 L263837039EE EE $50 06/1986 12/2009 06/2016'. $25.00: , .. ,$62.40. _ 4.00% ._ ___ $87.40 L267610498EE EE $50 07/1986 01/2010 07/2016' $25.00 $62.40 4.00% $87.40: L276672647EE EE $50 07/1.986 01/2010 07/2016 $25.00 $62.40. 4.00% $87.40 L276680724EE EE $50 08/1986 08/2009. 08/2016 $25.00' $60.68' 4.00% $85.68 L276688810EE EE $50 08/1986'. 08/2009 08/2016; $25.00 $60.68 4.00% $85.68 L284825587EE EE $50 11/1986' 11/2009 11/2016: $25.00: $52.04: 4.00%: $77.04 L276697567EE EE $50 _ 08/1986 08/2009. 08/2016'... $25.00; $60.68: 4.00% $85.68 L276706651EE EE $50 09/1986, 09/2009 09/2016' $25.00. . _ $60.68. ° 4.00 /o $85.68 L276716266EE EE $50_.._ . , 09/1986 ,.._, 09/2009 _ _ 09/2016 $25.00: $60.68 4.00% $85.68 L276725809EE' EE $50 10/1986: 10/2009. 10/2016: $25.00 $60.68 _ 4.00% $85.68 L276735115EE EE $50 10/.1986 10/2009 10/2016; $25.00. $60.68 4.00% $85.68 L284816788EE EE $50 11/1986 11/2009 11/2016 $25.00 _ $52.04 4.00% $77.04 L284834930EE EE $50 _ 12/1986 12/2009:,. 12/2016' $25.00 $52.04 4.00% $77A4 L284844303EE EE $50 12/1986 12/2009 12/2016' $25.00 _ $52.04 _ 4.00% $77.04 L284853404EE EE _ $50 01/1987.. .01/2010 01/2017 $25.00' $52.04 4.00% $77.04 L284862675EE EE _ $SO __ 01/1987 _ _.,01/2010 01/2017: $25.00 $52.04 4.00% $77.04 : 1.291559180EE EE $50_ 01/1987 01/2010 01/2017: $25.00:,__ $52.04 4.00%' . ._... $77.04 L291568412EE EE $50 02/1987 08/2009 02/2017 $25.00' $50.52 4.00% °° $75.52 L291577254EE EE $50 _ _ 02/1987 08/2009 _ _ 02/2017... $25.00 $50.52. 4.00% $75.52 L315665240EE EE $50 06/1987 12/2009 _ 06/2017 $25.00 $50.52 4.00% $75.52 L291586360EE EE $50 03/1.987 09/2009 _ .03/2017,.;.,_ $25.00 $50.52' _ 4.00% $75.52 L291595109EE EE $50 03/1987 09/2009 03/2017. $25.00 _ $50.52' 4.00% $75.52: L291603478EE EE $50 _04/1987 10/2009 04/2017 $25.00' ...$50.52: 4.00% $75 52 L291612418EE EE $50 . 04/1987 10/2009. 04/2017 $25.00 _ ___ $50.52 4.00% . $75.52 L315639920EE EE $50 05/1987 11/2009 05/2017 $25.00 $50.52 4.00% $75.52: l_315658653EE EE $50 _05/1987 11/2009' 05/2017' $25.00,.__ $50.52 4.00%: $75 52' L315656742EE EE $50 06/1987' 12/2009 06/2017- $25 00 $50 52 4 00% . $75 52 1 of 3 9/4/2009 10:52 AM Calculated Value of Your Paper Savings Bond(s) http://www.treasurydirect.gov/BC/SBCPrice L315676429EE EE $50 07/1987 01/2010 07/2017. $25.00 $50.52 4.00% $75.52' L315682850EE EE $50 07/1987 01/2010 07/2017 $25.00 $50.52 4.00%' $75.52' L35169144EEE EE $50 07/1987 01/2010. 07/2017 $25.00 $50.52 4.00% $75.52'. L315700136EE EE $50 08/1987 08/2009 08/2017 $25.00 $49.04 4.00% $74.04 L336748191EE EE $50 09/1987 09/2009 09/2017. $25.00 $49.04 4.00% $74.04 L336767606EE EE $50 09/1987 09/2009 09/2017 $25.00 $49.04 4.00% $74.04 L336767832EE EE $50 10/1987 10/2009, 10/2017 $25.00 $49.04 4.00% $74.04 L336777419EE EE $50 10/1987 10/20.09 10/2017 $25.00 $49.04 4.00% $74.04 L336787437EE EE $50 11/1987 11/2009 11/2017 $25.00 $49.04 4.00% $74.04 L336797194EE EE $50 11/1987 11/2009 ..11/2017 $25.00 $49.04 4.00% $74.04 L336817343EE_ EE $50 12/1987 12/2009., 12/2017 $25.00 $49.04 4.00% $74.04 L336807533EE EE $50 12/1987:, 12/2009 12/2017 $25.00 $49.04 4.00% $74.04 L336827105EE EE $50 12/1987 12/2009 12/2017 $25.00 $49.04 - 4.00% $74.04 L336836970EE EE $50 01/1988 01/2010; 01/2018 $25.00 _ $49.04 a 4.00% $74.04 L351596508EE EE $50 .01/1988, _01/2010: 01/2018 $25.00 $49.04 4.00% $74.04 L351606836EE: EE $50 02/1988 08/2009.. 02/2018 $25.00 $47.60 4.00% $72.60 L351515377EE EE $50 02/1988 08/2009 02/20.18 $25.00 $47.60 4.00% $72.60 L351635142EE' EE $50 03/1988- 09/2009 03/2018 $25.00 $47.60 4.00% .,__, __ $72.60 L351644792EE EE $50 04/1988 10/2009 04/2018 $25.00 $47.60 4.00% .......... $72.60 L351654382EE EE $50 04/1988 10/2009 04/20.18 $25.00 $47.60 4.00% $72.60 L351673448EE EE $50 0,5/1988, 11/2009 05/2018 $25.00 $47.60 4.00% $72.60 L3516$2990EE' EE $50 06/1988: 12/2009 06/2018 $25.00 $47.60 4.00% ... ...... ........... $72.60 L351704357EE EE $50 07/1988'_ _0.1/2010- _07/2018 $25.00 $47.60 4.00% $72.60 L378737758EE EE $50 07/1988 01/2010 07/2018 $25.00 $47.60 4.00% . . ........... $72.60 L378746886EE EE $50 07/1988 01/2010:_ .07/2018 $25.00 $47.60 4.00% $72.60 L378755504EE EE $50 _08/1988 _.08/2009;., 08/2018. $25.00 $46..1.8 4.00% ........... $71.18 L378772684EE EE $50 09/1988' 09/2009 09/2018 $25.00 $46.18 4.00% $71.18 L378797560EE EE _ $50 09/1988..:. 09/2009., 09/2018 $25.00 $46.18 4.00% $71.18 L378782286EE EE $50 . 10/1988 10/2009_;, 10/2018 $25.00 $46.18 4.00% _ $71.18 L378790491EE EE - $50 10/1988 10/2009 10/2018 $25.00 $46.18 o 4.00 /o _ _ __. $71.18 L378807228EE EE _ $50 11/1988 _ 11/2009 11/2018 $25.00 $46.18 4.00% $71.18 L378815658EE EE $50 11/1988 11/2009.; 11/2018 $25.00 $46.18 4.00% . _. $71.18' L378824159EE EE $50 12/1988' 12/2009 12/2018 $25.00 $46.18 4.00% $71.18 L37$832242EE' EE _ $50 12/1988:.. _12/2009,:,, 12/2018 $25.00 $46.18 4.00% $71.18 L378840669EE EE $50 12/1988.;... _ _12/2009,:., 12/2018 _ $25.00 $46.18 4.00% $71.18 L378848907EE: EE $50 01/1989 01/2010 01/2019 $25.00 $46.18 o _ 4.00 /o _. $71.18 L404617139EE EE $50 - 02/1989.. 08/2009 02/2019 $25.00 $44.78 4.00% $69.78 Q6135730134E .. ...E $25 11/1976,.. 11/2006 $18.75 $118.90 $137.65 MA Q6135741397E E $25 1.1/1976 11/2006 $18.75 $118.90 $137.65 MA Q6135752734E _ E $25 _ 12/1976 _ 1,2/2006 $18.75 $119.29 #138.04 MA Q6135763761E E $25, 12/1976 _ _ 12/2006 _ _ _ _. $.18.75. , _ $119.29 _ _ $138.04 MA Q5126828858E E $25 02/1974, _ 02/2004_ $18.75 $109.73 _ _ _ $128.48 MA Q5126846423E E $25 - 02/1974 _ 02/2004 $18.7 5 $109.73 - $128.48 MA Q5126855678E E $25 03/1974;,, _ _ 03/2004 . $18.75 $109.73 $128.48 MA Q5125865575E E _ $25, 03/1974' _ 03/2004. $18.75 $109.73 - $128.48 MA Q5140748863E E $25 04/1974 04/2004 $18.75 _ $109.73 _ _._ ... .. $128.48 MA Q5140753930E _ E _ $25 _ 04/1974 04/2004_ $.18.75 . $109.73 - ,. $128.48 MA X2409060EE EE $10,000 02/1993 _ 08/2009;_ ,02/2023_: $.5,000.00_ $6,912.00 4.00% $ 11,912.00 Q5140761434E E $25' 05/1974 05/2004; $18.75 $110.96 $129.71 MA Q5140772353E E $25 05/1974 __05/2004- _ . __$18.75, $110.96 $129.71' MA Q5176341422E E $25 _05/1974 _ .05/2004.._ _ $18.75 $110.96 _ _ $129.71:; MA Q5176354229E E _ $25 06/1974 06/2004: .$18.75.: $111.27 _ $130.02. MA Q5176363365E _ _E $25' 06/1974'.. 06/2004 _ .. $18.75 .... ... _ $111.27 _ $130.02. MA ~5176375648E. E $25 07/1974... ,, __ .. _. 0.7/2004.' _ _ __ .$18.75: . $111.27 _ $130.02:: MA 5176385089E - E _ $25 07/1974 _ _ _ .07/2004' $18.75.. $111.27: _ .. $130.02; MA 5176397622E E _ $25 08/1974 _ 08/2004.: _$18.75 $111.27 . ........ , . . $130.02 MA 5176406973E E _„ $25: 08/1974 08/2004; .....$18.75'.._ - ....$111.27 : - _ _ $130.02 MA Z5192567956E: E $25; 09/1974 09/2004 $18.75 ....... $111.27 ......... .. $130.02 MA 5192577843E _ E $25 __ 09/1974 __ _09/2004 $18.75 $111.27 $130.02 MA 5192587244E E $25 10/1974 _ 10/2004._.. _ $18.75. $111.27 _ ,- $130.02 MA 5192596433E E $25 10/1974 10/2004 $18.75, $111.27 $130.02 MA 25192618755E E $25 11/1974 11/2004.;. $18.75 $112.51 $131.26 MA 5192628511E E $25 11/1974 11/2004 $18.751_ _ $112.51 _ $131.26; MA 5192634652E E $25 11/1974 11/2004 $18.75; _ __ $112.51: X131.26 MA 6084281937E E $25 07/1976__ 07/2006;_ $18.75,_ $117.57' $136.32 MA 6084292930E E $25' 07/1976,.__, _... 07/2006 - $18.75 $117.57 _ _ _ $136.32 MA 6107884262E E $25' 08/1976 08/2006 $18.75 $117.57 ... $136.32' MA 16107895825E E _ $25' 08/1976'_, 08/2006 $18.75 $117.57 $136.32 MA 16107905585E E $25 09/1976__ _ 09/2006_„ $.18.75 $117.57' $136.32 MA !6113930914E E $25 09/1976' 09/2006 $18.75.' $117.57 $136.32 MA !6124073538E E _ $25' 10/1976 10/2006;. $18.75 $117.57 $136 32' MA !6124083601E E $25 1.0/1.976: 10/2006 $18.75 $117.57 . $136.32' MA 6124092553E E $25 10/1976 10/2006 $18.75 $117.57 . $136.32- MA ,6135776721E E $25 01/1977 _ _01/2007: _ ...$18.75. $119.29. $138 04 MA 6135786156E E $25 01/1977 01/2007 . $18 75 $119 29 . 1138.04 MA 2 of 3 9/4/2009 10:52 AM Calculated Value of Your Paper Savings Bond(s) Q6135799959E E $25 02/1977. Q6145852690E E $25 02/1977 Q6145865499E E $25: 03/1977: Q6145874245E E $25 03/1977 Q6170855246E E $25 04/1977 Q6170862822E E $25 04/1977 Q6170871263E E $25 04/1977 Q6170881988E E $25, 05/1977 Q6170892784E E $25 05/1977 Q6170905211E E $25 06/1977 Q6170914385E E $25 06/1977' Q6179242570E E $25 07/1977 Q6179250105E E $25 07/1977 Q6179266289E E $25„ . .08/1977.. _ Q6179277069E E $25 08/1977 Q6197925935E E $25 09/1977 Q6197939304E E _. $25. 09/1977 Q6197937064E E $25, 09/1977:. Q6212982340E E $25 _ __ 10/1977.: ._ Q6212993483E E $25 10/1977.. Q6213004543E E $25 _. 11/1977: Q6213013983E E _ $25; _ 11/1977: Q622ti377527E E _ $25_ ,,_ 12/1977 Q6226388160E E $25 .. .. 12/1977 . Q6233928602E E _ . $25 .01/1978: Q6233937923E E $25 01/1978:._ Q6233951219E E $25; 02/1978' Q6233961728E E $25 02/1978 Q6233971066E E $25 0.3/1978:,_ Q6233981211E E $25 03/1978' Q6233989322E E $25' 03/1978: Q6233999584E E _ $25 _ _ 04/1978 _ Q6256702019E E $25 04/1978 Q6256710929E E $25 05/1978: Q6256721282E E $25 05/1978 Q6256733260E E $25 06/1978 Q6256743427E E $25' 06/1978 Q6256755972E E $25 07/.1978 Q6256765973E E $25 07/1978 Q6217881510E E $25 08/1978 Q6271890342E E $25 _ 0.8/1978 Q6271905458E E $25 09/1978 _ Q6288885603E E $25 . .. 09/1978 Q62881388047E E $25.:._ _09/1978 Q6288898280E E $25 _ 10/,1978 Q6288908551E E _ _ $25 _ 10/1978 Q6288918590E E __ $25: _ _. 11/1978' Q6288928683E E $25 11/1978;_ Q6288941040E E __ $25' 12/1978 Q6288949950E E _ $25' 12/1978 Q6306975256E E _ $25:. 01/,1979 _ Q6306985003E E $25: 01/1979. Q6306998572E E $25 02/1979': Q6307007791E E $25 02/1979:...... . X2409061EE EE $10,000: 02/1993: 08/ X2409060EE EE $10,000 02/1993. 08/ http://www.treasurydire;,t.gov/BC/SBCPrice 02/2007. ..._ $18.75 $119.29 _ _$138.04 MA 02/2007 $18.75. $119.29 $138.04 MA 03/2007 $18.75 $119.29 $138.04 . MA .03/2007 $18.75 $119.29 $138.04 MA 04/2007 $18.75 $119.29 $138.04 MA 04/2007 $18.75 $119.29 $138.04 . MA .04/2007 $18.75 $119.29 _ $138.04 MA „05/2007 $18.75 $120,65 $139.40 MA _05/2007. $18.75 $120..65 $139.40 MA _ _ 06/2007_ $18.75 $1.20.95 _ $139J0 MA __06/2007 $18.75 $120.95 $139JO MA 07/2007 $18.75 $120.92 $139.67 MA .07/2007_: $18.7.5 _ $120.92 _ $139.67 MA ,08/2007: $18.75 $120.92 $139,67. , MA 08/2007 $18.75 $120.92 $139.67 , : MA 09/2007 $18..75 $120.92 _ $139.67 ' MA 09/2007. _$18.75 _ $120.92 _ __ _ $139.67 MA 09/2007. . _ _ ., $18.75 _ _ _ , $120.92., . _ . .., $139.67; MA ,,._.10/2007. ___.$18.75. ___„$120.92,...,, _,___ _ $139.67: MA .....10/2007: ...... $18.75 _ $120.92:. __ $139.67. MA _ _ ....11/2007.:. ........$18.75:. .. ...... $109.34:.._ - $128.09 MA __„ 11/2007 :_ _ $18.75: .. $109.34 ; _ _ $128.09: MA ,_12/2007. _.$18.75. $109.70 __,_$128.45 MA _ _ 12/2007.., _ $18.75 $109.70 $128.45 MA _ _ 01/2008 $18.75 $109J0 $228.45 MA „01/2008.' $18.75 $109.70 _ $128.45 MA 02/2008 $18.75 $109.70 $128.45 MA _ 02/2008 _,_,$18.75 __$109.70 $128.45 MA _.....03/2008: . $18.75 $89.79 $108.54 MA _ _03/2008 $18.75'_.. $89.79 $108.54' MA 03/2008 $18.75. $89.79 $108.54 MA „04/2008 $18.75 $89.79 $108.54' MA 04/2008 $18.75 $89.79 $108.54. MA ........ _ .05/2008 :. $18.75 __ __ _ $87.92. $106.67. MA 05/2008__ _ $18.75 $87.92' $106.67;_, MA .06/2008 _$18.75: $88.19: $106.94 MA 06/2008_ $18.75. $88.19 $106.94 MA _07/2008.:. $18.75 $88.22 $106.97: MA 07/2008 $18.75 $88.22 _ $106.97: MA _ 08/2008 . .. $18.75. _,_$88.22 $106.97 _. _ MA , _ - 08/2008 $18.75;. $88.22:. _ $106.97 MA ...09/2008, $18.75 $88.22 $106.97 MA .09/2008, $.18.75 $88.22 $106.97 MA _ __09/2008' $18.75, $88.22 _$106.97_ MA .,10/2008_, ,$18.75_ ,,,_$88.22_ _ _,:,,.,_$106.97 MA 10/2008 $18.75 $88.22 $106.97 : MA _: _ ......11/2008 $18.75 - ...$89.23: _ . $107.98 MA ..1.1/2008 '_ $18.7,5_. __$89.23 __ $107.98' MA 12/2008 __ __ .$18.7.5,. _...$89.52 $108.27 MA ' 12/2008 .......$18.75 $89.52 $108.27 MA 01/2009 _ _ _ $18.75'. _ .. _ $89.53 _. . __ $108.28 MA. 01/2009 $18.7.5_ $89.53: $108.28 MA 02/2009. _._$18.75',. $89.53 _ _ $108.28 _ . MA _ _...02/2009 .$18.75_.;,, _ ___ $89.53 $108.28 MA 009: 02/2023 $5,000.00:. $6,912.00: _ 4.00%; $11,912.00 009 02/2023._:. _. $5,000.00. $6,912.00 4.00% $11,912.00 ils for 190 Bonds x19,106.25.5 35,773.22 ..... S54.879_d7 2 2 ...... Notes NI ;Not Issued _ __ __ _ _ NE Not eligible for payment _ _ _._ P5 :Includes 3 month interest penalty MA Matured and not earnin interest 3 of 3 9/4/2009 10:52 AM From: Neff, Maynard (Wayne) (IFC) [mailto:mwayne.neff@investfinancial.com] Sent: Thursday, September 17, 2009 5:43 PM To: Amy L. Haines Cc: SHARANNROSE@aol.com Subject: RE: Werner Estate Hi Amy, Sharon was correct about the Omega Financial stock. Omega Financial was acquired by F.N.B. Corp in 2008 & the stock was exchan ed for shares of F.N.B. Cor ella's account. However, the Penn State nvestors s oc our digital files show copies of the 4 certificates that you reference) is a different story. Our contemporaneous note system shows that Russells brought theses certificates to us on 9/7/05 (prior to her trip to Australia), we copied them for reference and returned them to her. She indicated that she believed the company to be "defunct." Our Broker Dealer cor orate research de artment tol us Se t. 1995 that the company merged . iyv th Penn Pacific (possibly a Delaware corp.) in 1971, that the shares were now considered "wort ess an would not be eligible for safe keeping in her brokers a account. I suggested that she could either es roy em or ave em rame as memen os. ope that this has helpe . ase let me know if I can be of further help. M. Wayne Neff, CFP Heritage Wealth Advisers, LLC 635 N 12th Street, Suite 102 Lemoyne, PA 17043 717-614-6100 Ext. 214 (Voice) 717-614-6220 (Direct Fax) Securities and Advisory Services offered through INVEST FINANCIAL CORPORATION (INVEST), member FINRA, SIPC. A Registered Investment Advisor. INVEST is not affilliated with Heritage Wealth Adviser, LLC. 9/18/2009 Aus. 24. 2x09 11:52aM a~ Citizens Bank Smigel, Anderson & Sacks LLP Heather D. Royer, Bsquire 4431 Narth Front Street 3"~ Floor Harrisburg, PA 17110 To Whom It May Concern: No. 2389 P. 1 2001 Market Street Suite 600 Philadelphia, PA 19103 August 24, 2009 This letter is in response to your request dated August 11, 2009 in reference to Lstate of Russella A, Werner. Please be advised that at the time of her death of July 21, 2009 the balance in her accounts were as folla~rs: 6100683559 - $26,072.78 6223987'335 - $96,296.55 6223987378 - $98.04 The accounts were all titled as Russella A. 'Werner and vsrere individual accounts. The accounts were established on the following dates: 6100683559 - 06/06/1966 6223987335 - 01/02/2009 6223987378 - 01/22/2009 There is one safe deposit box listed in the customers name located at branch #291. Should you require further information pertaining to this situation, please contact our office at {717) 540-7314. rdially Andy f,. A r Branch Manager DOE RBS Integrity B A N K August 17, 2009 RE: Estate of Russells A. Werner Heather, A r.. ~£.:. 5 ia+ Syr '" °S ~+ t ~ 77 . ._~,~. ~u q~ ~7 ems. 0'l1 ~~~~ Here is the information which you request about the late Russella A. Werner's account. 1) The registered owner(s) of the account is only Russella A Werner. 2) The account was established on March 31, 2006. 3) No changes in the ownership of this account have occurred. 4) The Year-to-Date interest accrued as of 07/21/2009 on the account is $583.23. 5) The Date of Death balance is $56,283.38. ~' 6) The customer had no safe deposit boxes with our bank. If you have any further questions please call me at the phone number below. Sincerely, `' ~~ ~~ ~~~-'~ r Ronak R. Patel Integrity Bank Customer Service Representative 3345 Market Street Camp Hill, PA 17011 Phone: (717) 920-4900 3345 Market Sireet, Camp Hill, PA 17011 • Phone: 717- X20- X900.877- I- HAVEI T • Fax: 717-920- 4904 • www. integritybankonline.com ~elS RRSTO~Vw BANK A Tracdition of Excellence August 18, 2009 To: Smigel, Anderson and Sacks 4431 North Front Street 3rd Floor Harrisburg Pa 17110 From: Traci Yohe Orrstown Bank Customer Service Center PO BOX 250 Shippensburg, Pa 17257 Re: Estate of Russella A Werner Date of death July 21, 2009 ':: OS- ~9~'~2-~ IT IS HERERBY CERTIFIED THAT THE ABOVE NAMED DECEDENT, ON THE ABOVE DATE, HAD THE FOLLOWING ACCOUNTS WITH ORRSTOWIV BANK: CHECKING ACCOUNT Account # Title of Account Date o ened _Principal Accrued Interest,/ 15412864 Russella A Werner 09/ 14/06 13623.3 8 6.60 Int. YTD 12.63 SA VINGS ACCOUNT Account # Title of Account Date opened Principal Accrued Interest CERTIFICATE OF DEPOSIT Account # Title of Account Date Opened Principal Accrued Interest P.O. Box 250 • Shippensburg, PA 17257. 717.530.3530. 717.532.4143 fax ~ r ~~ y~ax Transmission 8/21/2009 11: 3:43 AM PAGE 1/002 Fax Server ~~i~iO~IA Wachovia Bank N.A. Balance Confirmation Services P O Box 40028 Roanoke, VA ?A022-7313 August 21, 2009 SMIGEL ANDERSON 8t SACKS LLP ATTN: HEATHER D ROYER ** Refenaroe ID: 2?73497 SUBJECT: Verification /Confirmation of Account and Balanoc Information provided for: Customer: RUSSELLA A WERNER (SSN# I~II~QC-XX 1818) Date of Death: July 21, 2009 posit Account Information ~~~rt Account Date of Death Average Date Maturity Lrterest Accrued YTD Date 'type Number Balance Halanee* Openod Date Rate Internet Interest Paid Closed CIlECKING 787 x104.65 10/24/1989 NA LEGAL TITLE: RUSSELLAA WERNER SAVINGS 4227 ~11~SS.n LEGAL TITLE: RUSSELLA A WERNER 12/111989 so.17 sa.n Uther Account Information Account Account Date of Ba]anoe Date Date Lodger Collected TYPe Number Opened Closed SAFE DEPOSIT XX}~IXXX0090 6/1/1996 BOX LEGAL TITLE: RUSSELLA A WERNER LOCATION: 5201 SIMPSON FERRY ROAD MECHANICSBURG PA 17050 7177938731 S.1VII GE L, AND ~ R S ~ N HEATHER D. ROY>yR. Es$UIRIr & SA~K~ LLr rHON3E: (7I7) 83x2401 ATTORNEYS AT LAW TOLL FREE: 1-500-822-9757 FACSIMILE (717) 234-361I X;1V~,A,~'L: hroyer(~sasIlp.com wwvr.sasIlp.com I4''ile No. 8960-2-5A M & 'Y` flank 3 8 OS Trindle Road Camp ~zxli, f'A. 17011 August 11, 2009 RE: Estate of Russells A. Werner Died: duly 21, 2009 Acct. No.: 150042132$4695 Ladies and Gentlemen: I represent the above referenced estate. At the time of her death, the decedent had at least oaze account with M & T Bank. For Inheritance x'ax purposes, we are requesting a statement from you including the following information for alI accounts in which decede t had an interest: 1. The registered owner or owners (exact title of account). ~/Z-~^~~ ~-~ 2. The date on whxcla the account was established. /~fa12~ ou-T~ 3. if there was a change of ownership or registration of the account within one year prior to the date of death, please prow de the date of such change and the title of the account prior to the change. ~ ~/~n/~ 4. The amount of any interest aecl~ ued to date of death for the c lendar year, n ~ 5~~~~~ 5. The date of death balance (plus accrued interest, if any). ~ oN ~7~~/1 ~r~ 6. Whether there were an safe de sit boxes in the decedent' name. - ~ f~ y pa s of ~ 6 ~( I am enclosing a photocopy of the I;,etters Testamentary for your records. Thank you for your assistance. HDR/alh Enclosure cc_ Sharan A.. Rose, executrix Sincerely, I-leather D. Royer Zoo 'd _44$1 North Front Street. 3~d Flr Harrisburg Ps ngvlvania 17110-177$ A PENNSYLVANIA LIMITED LIABILITY pAItTNk'It$HIP 808ZL8LGiG~Xdd XNdS-Z~ 9Z~8I Idd 6002-8I-ddS Page : 1 Doctunen.t Name : un.t i t 1 ed CUP1 1 CIS INDIVIDUAL CUSTOME~t. PROFILE 09/09/18 11.43.3' CULO CO 96 OP EBRN MS 64282 INDIVIDUAL CUSTOMER DISPLAYED CUST NO . 7 72 9 tS 4 3 CU'ST SEG S'X',piTUS - - COID 96 SSN TID: NO 292281818 CD 0 COST CENTR 4350 BRN-- 435t N ~ZUSSELLA A WERNER TIE 1 OPENED 7112 O1 OFF01 A 310 LAMP POST LN CLOSED Ok'F02 C CAMP HILL FA 17011-1460 LST MAIN 1070618 MAR STATS BRTHDATE 260519 SEX--'--- DECEASED A.DVERTIS? BANKRUPT EMPLOYEE? T EMPLOYER RETIRED OCCUP CD HH# ~ 8K ~tEL PRG HOME PHOI~TE 71 ? - 7 61- 0 3 7 6 CUST TYPE T 6 S E1VS CODE t BK SVC BUS. PHONE LANGUAGE ~tEFER? I 12 E MAR K S NATIONALZ~'Y NEXT PLACED EXF. DATE PLACED EXP. DATE LIST HIST ACCTS? N LIST' CLOSED ACCTS? Y ACTN: ACPR A,CDT A C C O U N T R E L A T I O N S H I P S NEXT: SEA- COID- FRDSF ACCOUNT---------------- OPEN ST CURR ------BAT.,ANCE------ RE] 0001 96 DD~,,9M 015004213284695 10611 99 54, 014 .87 IN],,/ I7dte: 9/18/2009 Time: 11:44:14 AM 000 'd OOOZGOGGIG~Xdd X~dd-Z'81~ 9Z~01 Idd 6002-8i-d~S Page: 1 Document Name: untitled ,ACDT 2 CIS D}~A ACCOUNT DETAIL 09/49/18 11.43.5= C~l'LO CO 96 OP EBRN MS ACTION SUCCESSFUL ACTION: INQ (INQ NXT) COID 00096 PRODUCT DDA ACCOUNT 015004213284695 ~~**** ACCOUNT CORES *****'* ~~~~**~**** ACCOUNT BALANC E DATA ~********** SUB P120DUCT CODE........ 9M CURRENCY-• ............... A000UNT ST.A~'US........., 99 LINE AMOUNT .............. 0.40 SERVICE CHG TYPE CODE... 9M OPENING DEPOSIT.......... 50,986.39 SERVICE CHG WAIVE CODE.. 00 CURRENT BALANCE.......... 54,014.87 INTEREST CODE........... 9M CURRENT COLLECTED BALANCE 54,014.87 INTEREST WAIVE CODE..... AMOUNT OF RESTRAINTS..... 0.00 LATE CHARGE CODE........ YsAST DEBIT/CREDIT AMOTJiVT. 9.1$ DATE CHARGE WAIVE CODE.. 00 ACCT RECON PROCESSING CD. SHORT NAME........ WERNER RUSSELLA A ZERO BALANCE ACTION CODE. 0 SU1~A~.RY POST CODE..._.... ******** ACCOUNT DATES ******** DRIVER PROCESSING........ 0 DATE OPENED..._...... 106/ 11/10 DATE REOPENED........ DATE OF LAST DEPOSIT. 109/09/l0 DATE OF LAST W/DRAWAL 106/12/0$ DATE OF LAST MAINT... 106/11/10 DATE CLOSED.......... Date: 9/18/2009 Time: 11:44:28 AM ~00'd OOOZLOGGiL~X~d ?INdS-Z~Ini 9Z ~ ~ I I dd 6002-8 I -d~S Sep. 8. 2009 12:23PM PNC BANK 412-705-2141 No. 8815 P. 1/1 n4r~o_2 57 ti's! ~~ i£At7iNG THE WAY September 8, 2009 Amy L I-lames Heather D Royer, Esq. 4431 N Fxant St 3`d F1 Harrisburg, FA 17110-1778 RE: Russella A Werner SSN: 292-28-1818 DOD: 07-21 ~20a9 Dear Ms. I-laines: In response to your request for Date of Death (DOD) balances for the customer noted above, our records show the following: Savings Account Account # 5112004025 Established: 09-18-2006 RUSSELLA'A WERNER DOD balance: $ 144,SS4.59 + 93.92 accrued interest Interest paid 01-01 2009 thru 07-21-2009 $ 1,371.50 YTD Flease note that this office provides date of death balances for deposit accounts (IItAs, CDs, Checking and Savings}. We do not process any fins~neial transactions or provide statements. if you need assistance with any of these items, please call 1-888-PNC-BA.N.[C (1-888-762-2265) or stop by your local PNC Bank branch office. Sincerely, National Financial Services Center PNC Bartle, N.A. Member FDIC Page 1 01' 1 Holdings by Product Type as of 07!21!2009 ~ Accfi# : 5HT115060 C.aSf1 Anrl Fnuiv~laniQ 5HT115060 5HT 72M MONEYMR FEDERATED CAPITAL RESERVES KT 5HT115060 5HT 72M USD US0999997 CASH 5HT115060 5HT 72M MONEYMR FEDERATED CAPITAL RESERVES - KT Purchase ~n~ ~ihi SHT115060 SHT115060 5HT115060 5HT115060 SHT115060 SHT115060 SHT115060 5HT115060 utual Fund SHT115060 SHT115060 5HT115060 5HT115060 5HT115060 SHT115060 SHT115060 SHT 72M PEP 713448108 PEPSICOINC 5HT 72M FNB 302520101 F N B CORP PA COM SHT 72M YUM 988498101 YUM BRANDS INC COM 5HT 72M DTV 25459L106 DIRECTV GROUP INC COM SHT 72M CMCSA 20030N101 COMCAST CORP CL A 5HT 72M MTLOO 62010A105 MOTORS LIQ CO COM 5HT 72M DPHIO 247126105 DELPHI CORP COM SHT 72M ALU 013904305 ALCATEL LUCENT SPON ADR ~. i. , ,~ `~._. • 96,989.00 8.02 964.91 .08 • -964.91 -.08 1, 785.5400 100, 704.41 8.33 5,732.0000 34,735.92 2.g7 864.0000 28,840.32 2.39 106.0000 2.641.52 22 73.0000 1,044.63 .09 366.4400 176.44 .01 263.4100 5.0000 13.96 12.45 .00 .00 5HT 72M PTEPX 746852102 PUTNAM PENNSYLVANIA TAX EXEMPT 31 085 6100 INCOME FUND CLASS A , . 271,066.49 22.42 5HT 72M FRPAX 354723801 FRANKLIN PENN TAX FREE INCOME 25 938 4800 FUND CLASS A , . 256,790.95 21.24 5HT 72M VKMPX 920902103 VAN KAMPEN PENNSYLVANIA TAX 15,421.0000 229 464 50 FREE INCOME CL A , . 1 g,gg 5HT 72M OELIX 233216100 DELAWARE TAX FREE PENNSYLVANIA 20 830 0500 FD CL A . . 159,349.85 13.18 SHT 72M ETTGX 277911830 EATON VANCE TAX MANAGED 1 100 6000 GROWTH FUND 1.1 CLASS A , . 20,471.07 1.69 SHT 72M ESBAX 299909614 EVERGREEN CORE BOND FUND 645 7800 SHT 72M CLASS A . 4,836.92 .40 PHIGX 746782101 PUTNAM HIGH-YIELD TRUST FUND 257 6500 __ CLASS A . 1,666.97 .14 otal 104,474, 5600 1,206,805.40 100.00 M. WAYNE NEFF, CFPTM SENIOR PARTNER HERITAGE WEALTH A D V I S E R S 635 N. 12TH STREET SUITE 102 ,,3 .. ~ , _ LEMOYNE, PA 17043 PH: 717-614-6100 x214 FAX: 717-G14-6200 EMAIL: MWayne.Neff@investfinancial.com I~rCilSl[.Itl-1l I~f('it1=tiEN(;\I"I\/( l)F ANII SF(:ItRITIFS ANI> i\IlVl1l.)IiY til-.ItVIC:F l)fFI_R[() I-IIRC)Ul~l-I INVEST FINANCIAL CORPORATION IIN\/I:STI MLMIII~I: INIi/\. tl l'C_. A INVEST Iti Nt )'I'r\ff li IATFf)\4~ Ht C~Iti I~F RFI> INVI-ti(-M I: N-1 AI)VI`()li. I ~ I-I . 1 FI LItI iACl f. WFnI TIi /\I)VI`f-. Rti. I"I l~. 1 PSEC January 25, 2010 Account # 0292XXXX~';X SMIGEL, ANDERSON & SACKS, LLP ATTORNEYS AT LAW 4431 N FRONT ST 3RD FL HARRISBURG, PA 17110-1778 Dear MS HAINES ~~~~od~~ 7~l>~ The following is the status of RUSSELLA A WERNER's account with PSECU as of the date of death. Joint Owner's Name NONE Date of Death 07.21.2009 Date of Birth 05.19.1926 Share Description Open date Balance Accrued Dividend S O1 Regular Shares 08.29.1984 $ 217.49 $ .04 S 07 Money Market 10.08.1991 6,732.02 3.84 C50 60 Month IRA Certificate * 01.08.2009 16,989.18 41.04 * Designated IRA Beneficiaries - STEVEN A WERNER, SHARON A ROSE, PAMELA J DAVEY The dividend earned from January 1,2009 through the date of death was $51.71. The decedent had no loans with us. We do not have safe deposit boxes for our members. If you have any questions, please ca11234-8484 in Harrisburg or our toll-free number, (800) 237-7328. At the menu prompt, enter 6 and then extension 2227. Sincerely, r w Jo lbin Me ber Service Representative Finance Support Unit Pennsylvania State Employees Credit Union Main Address: 1 Credit Union Place, Harrisburg, PA 1 71 1 0-2990 • 717.234.8484 • 800.237.7328 Mailing Address: P.O. Box 67013, Harrisburg, PA 17106-7013 • 717.777.2100 (TDD) • 800.472.1967 (TDD) psecu.com This credit union is federally insured by the Notional Credit Union Administration. Equal Opportunity Lender ,.. a=~ ~ Pentagon Federal Credit Union PO Box 247009, Omaha, NE 68124-7009 September 15, 2009 Heather D. Royer Attorney at Law 4431 North Front Street 3'd Floor Harrisburg, PA 17110-1778 Dear Ms. Royer: a ~~ 1 ~~ ~ ~ ~?~ M~~ x ~~, ~1~ ~~ (c4- 2'-~,~' Superior Rates. Proven Service: 1-800?47--5626 www.PenFed.org RE: Russells A. Werner File # 2985359 Please find below the date of death values for Ms. Werner's accounts per your request: 4ccount Nnmher Princiaal Balance Dividend Acsruecl Tntal DnD Balance Share Sves 2985359-01-3 $ 5.10 $ 0.00 $ 5.10 Certificate 425 -4 $ 81,287.13 $ 54.07 $ 81,341.20 Certificate 4260199-56-9 $ 34,831.55 $ 23.17 $ 34,854.72 The Beneficiaries of these accounts are: Pamela J. Davey, Sharon A. Rose and Steven A. Werner. The share savings account was opened on 1/29/07. The two certificates were opened on 1/31/07. If you have any questions, please call us toll-free at 1-800-247-5626. Sincerely, Laurel Dunning ~~ Estate Accounts Specialist 48500041,046 REV-485 EX (7-07) : ~.:Y SAFE DEPOSIT ..: BOX INVENTORY PA Department of Revenue PLEASE USE ORIGINAL FORM ONLY Social Security or Death Certificate Number Date of Death - County Code Year File Number _, . . Decedent's Last Name Suffix - First Name .. MI V~1 e~ I' ~ ~ e r ~. ADDRESS F DECEDEf~T~ STREET ~iil'ti 11 An., ~ J!tiC --~ ~1~ (~~i n~ ~Y•l~ i ~ ~~E= Z~PCOD NAME A ADORE S OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX /v ' t NAME: r... ,~ ~ ~ ~ ~ t -- ._--- , STR TADDR S: ? -~-~-------• ~,,~ -c• ~ ~ CITY: ~---------•- ----- 1 (~ ~.~ ~~' ~ ~~ ~ ~ ~~ I I,~~ l.~•- T ZIP NAME, ADDRESS AND RELATIONS IP (IF ANY) TO DECEDENT, OF PERSON ~~ ' ~P~a (S) PRESENT AT THE BO PENING a. NAME: RELATIONSHIP: ----------------------,-------- -~,~t~i _..---~ ~€ STREET ADDRESS: ---'--'--~-' --~ -~-~~ l _- ~-1-~Q C1 v .._._. ' 7 ~ ~• F~ CITY: STATE: ZIP CODE: b. NAME: --- -------------- - ----~ 11-~-~-t-t-=1-' Y~-~~~ C~1.~t C~_._! I.1----` ~~ ~` RELATIONSHIP: } - ---- STREET ADDRESS: ~ --~-------"---'---- CITY: ---------- -----------STATE: ZIP CODE: c. NAME: - _____----_-_____-- ' RELATIONSHIP: STREET ADDRESS: CITY: STATE: ZIP CODE: . •~ ~~^~•~~ hrvu AuuKE55 OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME: ~ l ~^ ~/ \\ ~~((JJ_ CITY: STATE: ZIP CODE .+ ~ ~ NAME ^~ ~t,~~ y/~ OF PERSON MAKI G LAST ENTRY ~~S~LI`~- ~~~~vrY;~ DATE A IME OF LAST ENTRY DATE O F C NTR CT TO REN f/ T BOX NUMBER OF BOX ~ t TITLE UNDER WHICH BOX IS REGISTERED C~ NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX V ~ 'L~''. ~' i'~ ~ .f " a. NAME: b. NAME: STREET ADDRESS: ~ - ~ STREET ADDRESS ~~-' CITY: -- -- STATE: ZIP CODE: CITY: _-------------~-- -------------- '- STATE: ZIP CODE: NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY ~... - (y ~ tc~ ~ ~ ~= ._ R~ ~ r~ ty ~ c• j---- ~'~%'1V4~i1i1~3`~ ~'/Z. _._ _. WAS A WILL IN THE BOX? ^ YES ~ If yes, a. Date of will: b. Name and address of personal repre/sent~ative, if named in the will -`--'--'---"---- ----- NAM E: STREET ADDRESS--------------'--- ~------------ --- ^----- - ------- CITY: STATE: ZIP CODE: c. Name and address of attorney, if any ---~----------------- --------~------- ------ ----- NAM E: - --._. - STREETADDRESS: ---- `"- ---- --- CITY: STATE: ZIP CODE: ~, 48500041046 48500041046 Page REV-485 EX S~A,~E DEPOSIT BOX INVENTORI( _._.. °`. _ INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Banlc and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name 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. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG, PA 17128-0601 ITEM NO. ITEM DESCRIPTION t --- ~`~ ---- --- ------ ---------- - _ __ - J'~- ---~-~-- ---.._._.---~------ ._.._._ _ I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD tS CORRECT AN COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. PERSON RECEIVING COPY OF SAFE DEPOSIT BOX INVENTORY: SIGNATURE .- _. SIGNATURE ^` PRINT NAME ~q,~ n .` ~ PRINT TITLE ._. ~--_._._..._~... ~_ _.__. _.___ ._... _ DATE r. ~-r~-a 21~_~ r~z. ~~-~,~ ~ ~ jj~l (, ~/~ r ~ ~ ~~ ` C f ~ FrV~~ (r1.~...f'1 f ~ ,V(4 ~ l~ ~~ L PRINT NAME AND CHECK APPROPRIATE BOX. BELOW: .._.._ ---._.. _......-- CHECK APPROPRIATE BOX. ~ ~ ~_ ~ ~~-~-~-~------~~-~- '~ ---- _...___. ~ Executor(trix) ~ Administrator(trix) ~ Estate Representative ~ Joint owner of safe deposit box NOl'E: Attach additional 8'/~" x 11" sheet(s) if necessary ar use duplicates of this page of form. The Department is authorized by law, 42 U.S.C. §405 (c)(2)(C)(ij, to require disclosure of Sccial Security numbers in connection with administering state tax laws. The Department uses the Social Security number to identify the decedent and personal representatives of tl~e estate. The Commonwealth may also use the information in exchange of tax information agreements with Federal and local taxing authorities. The state law prohibits the Commonwealth's personnel from disclosing confidential tax information except for official purposes. u~ v W 2 F- z U 1= U z -~ z 0 U _Z W W m Q F- LL W O °~ w ~ I- Z Q ~ J W tL H 0 z ~ O x y Q z Q w }~ ~ N W 4 Z ~ 2woN ~~, a~o~ a~°Dj ~ a ~ Za ~ ~p Q ~ _ O U 0 X W m w 0 y ~ w` og mZ in ? Yp V W ~ 2' !- W fq F- _N W W m z F- U w J Q U W H u. O W Q W m Z p z 0 m U 4, F= W U W Q Z }. Z a 0 w W N N y V tTi _O ~ ~ _ ? ~ O OZ Z QW ,'~ REV-485 EX (1-07 Y ~; 4 8 5 0 0 0 410 4 6 SAFE DEPOSIT ~:" ,_ BOX INVENTORY PA Department of Revenue Sociat Security or Death Certificate Number Date of Death PLEASE USE ORIGINAL FORM ONLY ._ - _ Dec d t' -~ ~ ou my Code Year i ~ ~ File Number o r7~,4 e en s Last Name ... ,_ . . - - Suffix First Name MI :, . e, tr (l e. Y .... . .--, - ADD ESS OF DECEDENT TR ET: }} I~ r (~ d14 l~ !S~ I ~ Y1t) _. /~ Clj~~`~ (-~ ~t1 Ifl 11 ! ` - ~~TATE: ZIP CODE: NAME AND ADDRESS OF PERSON REQUESTING THE . OPENIN NAME: ~--- - STRE T ~ G OF THE SAFE DEPOSIT BOX A RE . ~~ - Sig Z), J -- ~~~ --------- - -•-- ------------ CIT ~ , ~ ----- --- ST E• ZIP CODE: NAME, ADDRE SS ANA RELATIONSHIR ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE X OPENING a. IVHMt: - -~~ ~ (S~ ~ ~ ~ 41 ~ s" RELATIn"~cuio. STREET ADDRESS: - ~ -- ~ ~'`"~ ( ~ /1 CITY: -~""`-- - ~ 1 ~ ~ C•~-l'1C.1_ ~ S ~ ~ ~ ` ~ ,~ n ~TATF• 7~p rnnG•, b. NAME: --~ ~~. Y 1~ '~, L~..._-- - -~~ ~~~= ~ I RELATIONSHIP: l STREET ADDRESS: --~--•--- -------- ---- ----- -------------- ---- CITY: STATE: ZIP CODE: c. NAME: ------- -•----- --- RELATIONSHIP: ------.___...----- -----.--- STREET ADDRESS:------------------- -----------•------------------------------ CITY: STATE: ZIP CODE: NAME AND ADDRESS OF FINANCIAL INSTITUTION WHC-RE THE SAFE DEPOSIT BOX IS LOCATED ' NAME: /~ '3 F Z~~15_ _~t~~ ..~~ ~~~~ ESS: Cct~<i~l~ ~~K~ NAME OF PERSON MAKING LAST ENTRY DATE OF CONTRACT T ENT BOX NUMBER OF BO~; L NAME ANO ADDRESS OF PERSON(S) HAVING ACCESS TO BOX a. NAME: STREET ADDRESS: CITY: /~ CITY: ~~ ~~STATE: ZI~OOE (~~ fj ~ II DATE A D TIME - F LAST ENTRY 1 TITLE UNDER WHICH BOX IS REGISTERED • v SSA:. ~-~. f~ - ~. 4~ ~ ~. ~~ 4.~t_.,... ,j~ -- -- I b. NAME: STREET ADDRESS: STATE: ZIP CODE: CITY: - rvf-mt AND TITLE OF EMPLOYEE TAKING THE INVENTORY ~ wA5 A WILL IN THE BOX? ^ YES NO If yes, a. Date of will: b. Name and address of personal representative, if named in the will NAME: STREET ADDRESS: ~--- - c. Name and address of attorney, if any NAME: - -- - - -- STREETADDRESS-------._ - ------- - ----------------------- STATE: ZIP CODE: CITY: ~ ~:. l.` CG;r STATE: ZIP CODE: CITY: -------------~--~--~ STATE:---- ZIP CODE: ~, 48500041046 4850041046 SASE D~p~SIT g~~ lIVVFI!-ITif~R~' Page _ _. _ ___of _ _ _ REV-485 EX INSTI~l~CT10NS - - - - - - - -- - - - ~ - _ (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name 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. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG, PA 17128-0601 ITEM NO, ITEM DESCRIP710N t . -.- --t~~ ~~1 E_C.~,..,L~,~7-.~---l~~i---..P_~~~ ~~ _c:~_~~~a ~ t.~l~-~t C f ~ C C~ u~ Nc~r~ I --! ~ ~ - ~-~_~~_ ~ 1 f~~'F-~1i1 l I ~ ~~;~.,~ ~i71 ~. ~i~4_~..._~f~-i '1C1'~--_ I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS CORREC~ AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. PERSON RECEIVING COPY OF SAFE DEPOSIT BOX INVENTORY: SIGNAT R ---"1 r SIGNATURE -.~,.~~ ~ PRINT AME PRINT NAME AND CHECK APPROPRIATE BOX BELOW: PRINT TITLE DATE ~y ~^( n l~--e~i `~J ~ ~{ ~ ~, ~, `~ C C- CHECK APPROPRIATE 60X: v ~ /'~ /j~. ~ Executor(trir.) ~ Administrator(trix) ~~~ ~ L r, ., ~ .t~.;.~~~J~ ~ Estate Representative ~ Joint owner of safe deposit box MOTE: Attach additional 8'!Z" x 11" sheet(s) if necessary or use duplicates of this page of form. The Department is authorized by law, 42 U.S.C. §405 (c)(2)(C)(i), to require disclosure of Social Security numbers in connection with administering state tax laws. The Department uses the Social Security number to identify the decedent and personal representatives of the estate. The Commcrnvealth may also t.lse the information in exchange of tax infol'mation agreemel-~ts with Federal and local toxin authorities. 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