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Home My WebLink About07-30-10 1505610101 REV-1500 EX `°'-1°' ~ ni PA Department of Revenue pennsylva a DEP~RlMENT OF REVENUE Bureau of Individual Taxes INHERITANCE TAX RETURN PO Box 280601 RESIDENT DECEDENT Harrisburg, PA 17128-o6oi ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth 383-10-3515 10/30/2009 04/15/1918 OFFICIAL USE ONLY County Code Year File Number V J ~.~ MMDDYYYY Decedent's Last Name Suffix Decedent's First Name Mt Rae Dr. George R (If Applicable) Enter Surviving Spouse's information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Sociai Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Retum (date of death prior to 12-13-82} O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust C 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 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 Thomas Rae (717) 532-4735 First line of address 114 N Prince Street Second line of address City or Post Office Shippensburg State ZIP Code PA 17257-1318 REGISTER QF•~VILLS USE ONLY( ~ ,:-.:.~ f F . .. `.^~ ,.~ r r_Y[-Jl [ ,_1, -_a ~ C.~ ,:>~, _ _.. ~ ~' ~. ~ -_ -..~.:. DAT~~FIL~D "" .~ ..`_ . -, -, , ~ ~. ~ ~_i_.1 -'7 {" ~) I<7 Correspondent's a-mail address: Thomas.RaB@P4box.com Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my 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 Yeas any knowledge. SIGN9TU E OF PERSON~PONSI FOR FILING RETURN ~ ~ ~ ANTE .c..-c__ J t~~ ~ D ADDRESS ^~- 114 NPrince Street, Shippensburg PA, 17257 SIGNAT R OF PREPARER OTH THA PRESENTATIVE DATE ADDRESS 114 N Prince Street, Shippensburg PA, 17257 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: George R. Rae 383-10-3515 RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 112,170.00 2. Stocks and Bonds (Schedule B) ....................................... 2. 210,910.65 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 228,903.84 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 551,984.49 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 23,800.36 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 6,206.63 11. Total Deductions (total Lines 9 and 10) ................................. 11. 30,06.99 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 521,977.50 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 26,098.88 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 495,878.63 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 taxable at lineal rate X .0 45 495,878.63 16. 22,314.54 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. 22,314.54 20. FILL IN THE OVAL fF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Q, Side 2 1505610105 1505610105 J J 1505610105 REV-1500 EX Decedent's Social Security Number decedent's -yame: George R. Rae 383-10-3515 RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 112,170.00 2. Stocks and Bonds (Schedule B} ....................................... 2. 210,910.65 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 228,903.84 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 551,984.49 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 23,800.36 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 6,206.63 11. Total Deductions (total Lines 9 and 10) ................................. 11. 30,a~6.99 12. Net Value ofi Estate (Line 8 minus Line 11) .............................. 12. 521,977.50 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 26,098.88 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 495,878.63 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 45 495,878.63 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610105 1505610105 22,314.54 22,314.54 O J REV 1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME George R. Rae STREET ADDRESS _ - ---- 114 N. Prince Street - -------__-------- -- ---- --------------- __ -T---- CtTY T--- Shippensburg (STATEPA z1P17257-1318 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments __ B. Discount 3. Interest 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. File Number Total Credits (A + B) (2) (3) (4) (5) Make check payable to: REGISTER OF WILLS, AGENT. 22,314.54 22,314.54 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ c. retain a reversionary interest; or .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 0 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .............. ^ [x] 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 Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 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 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 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 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 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+ (11-08) ~ pennsylvan~a SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER George R. Rae 2009-010 i'9 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 property that is jointly-owned with right of survivorship must be disclosed on Schedule F. If more space is needed, insert additional sheets of the same size. PAYABLE TO: CAROL A CARMACK, TAX COLLECTOR PO BOX 282 SHIPPENSBURG, PA 17257-0282 TEMPORARY RETURN SERVICE REQUESTED ESC: ASSESS.NO - 33000046 MAP NO: 33-33-1867-043 114 N PRINCE STREET ACRES .100 DEED 0022W 00090 LAND LESS THAN 1 ACRE Residential Building RESIDENTIAL Y~ SH PPE~~BUR~PA 17257ET JFF~CE THURS 2:30-5:00 (717-530-7505) iouRS: JAN-FEB BY APPOINTMENT OFFICE ~ 111 N. FAYETTE ST PLEASE SEE INSERT FOR ALT. HOURS TAX PAYER COPY Blil No: 2009 Statement of Real Estate Taxes control Noy oss - nncma~ ca... n~~e 1021 Assessed Land Values :_5,000 Homestead Exclusion Improvement 97,170 Mineral 0 Total 112,170 12 106- SH~PEN88URti AREA S.D. Discount Faa Rates .01321000) .01321000 SCHOOL R/E 198.151 1 283.62 2 $ 1 481.77 10 $ Homestead Credit 15 ,~9,2- TAX AMOUNT DUE -> i1,299~.4'i ,~~" =1,321.85 #1,454.04 _! Baid Oa or ]1tt~r If Bsid Oa Or S~tora 7 O1 2009 8/31 2(109 9 10 31/2009 ii 01 2009 12/31 2009 IF NWT PAID BY 1?!31/2001f THIS BILL ILL BE RETURN ED TO T1)c ClJ-Bli BUREAU FOR COLLECTION AND FlUNG OF A UEN A~iAINST YOUR PROPERTY. CASH, MONEY ORDERS ONLY AFTER 1?l1QIb9 ~,~ ~ < - ~ ~:~ (~ . ~ ~,~ Cotlector Signature -/ /_ $ Retum IBilt with Payment. For a Receipt, Date Paid Amount Paid Enclose +a self-addressed stamped envelop+ REV 1503 EX+ (6-98) SCNEDt~LE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE; NUMBER George R. Rae 20CI9-01079 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~~ BLACKROCK MUNIYEILD PA INSURED FUND INC (CUSIP: 092556107) 100.0000 @ $13.1900 1,319.00 2. FIVE STAR QUALITY CARE INC (CUSIP: 33832D106) 4.0000 @ $3.4500 13.80 3. FRANKLIN TAX FREE TR PA TAX FREE INCOME FDA (CUS{P: 354723801) 7,915.5350 @ $10.1900 80,659.30 4. GOLDMAN SACHS TRUST GROWTH & INCOME (CUSIP: 38142V654) 3,119.0340 @ $9.4800 29,568.44 5. GOLDMAN SACHS TRUST STRUCTURED SMALL CAP (CUSIP: 38143H282) 3,394.4790 @ $18.7800 63,748.31 6. HRPT PPTY TR SBI (CUSIP: 40426W101) 200.0000 @ $7.0300 1,406.00 7. ING EQUITY TR MIDCAP OPPYTYS FD CL A (CUSIP: 44978A509) 1,114.4300 @ $13.0200 14,509.87 8. MOTORS LIQUIDATION COMPANY (CUSIP: 62010A105) 500.0000 @ $0.5890 294.50 9. MUNDER FDS INC TR INDEX 500 FD CLA A (CUSIP: 626129761) 46.9390 @ $18.9200 888.08 10. OSHKOSH CORP (CUSIP: 688239201) 400.0000 @ $31.2600 12,504.00 11. SENIOR HOUSING PPTYS TRUST SHARES (CUSIP: 81721M109) 20.0000 @ $19.2800 385.60 12. SPARTAN MOTORS INC (CUSIP: 846819100) 1125.0000 @ $4.9900 5,613.75 TOTAL (Also enter on line 2, Recapitulation) ~ 210,910.65 (If more space is needed, insert additional sheets of the same size) s4ir N a~ O N 'd S f1 ~ ~o 1X ~ am N 7Nl"„i ~ ~ ~, y ` v~+ o S 'C3 N "' N t4 ~ ~ ^. y~{ ~ N ' L/ ~ d (d r d ~, ,~ ~ o 4 d ? r ~~ a ~~ R, C ~' ~ ~ ...` ~ p N ~ ~r 'rr1. j 'tt • ±~ ^ O~ r-~ 3 L.. ~N 4 7 ~ 1~ ;~ ~, m ~. O N ~/ G 7 ~u..+ I`~ ~...-_-... r}...i V"~ w~ ~- '^..~ r•~ ~r~..~{ `~^, (''~/ y~ rWr i~ ~,1 l v ~.r r N 1 o J 0 _--~_..._-_...~.---^-- Ct ~ C n G n N M ~ ~ n 7 ~ ~ a P ~ C ~ ~ n N ro< a a a ° o cs m ~ O n ~ ~ - s +o ~ c ti oGi Q O- ~ 7 D' >' c9 ~ ("0 (mil P 3 N 0. ~ O ~ n ~ ~ O 'V r n ; ~ ~ ~+ r -i 'o A ~ r N ~ ~ ~ 'a~ a'' p in V+ O Q ~~ 0 N~ m O ° n ~ p O ~ ~ n ~ c 3 m n c ~ ~ +a. 3 w, c c O n s v "q w a .. tD co !! 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(~ r t /, f U~ 4 C~ ~n i- ~~ Z I1_ ~•• n, Z n ~~~ ~ ~r~ ly 1.B ~i 1 ~,y ~r: ID• _ N (31 O Ut O ja IV _ ? w rn _ _'` ~ w Z Z N °~° Z _ g° Z chit chit o ~ ~ D D ~ ~ D awo D N O tT O O Cn O W W V O O N Cn N OD A -• ~1 V 0 ~° V ~ A ~ O ~o CA N 0 0 0 0 0 0 0 0 0 0 0 o o D O o v o o ~ D (D D A D (D 7i (D C7 A~ m Q r ?~ r ?t r ?~ r ?i ~' 7D~, aim ~~ ~~, a ° m m m m ~ co co to 7D m co 7D ~ cO 17 m ~ m ~ ~ co my my ma my -~°' ci sv m v, m ~ v V ~ 00D ONi O cA0 ~ ~ ~ A ~ N OD o N N ~ ~ D V D N ~ A S A < V w W ~ c 0 ~ O ~ ~ ~ ~ N A 00 O ~ O 0 co n C'7 C7 n n n n n n n n n D D D D D D D D D D D D ~ 2 ~ = ~ 2 ~ S ~ S fn = ~ S ~ 2 ~ S ~ S ~ S ~ 7: REV 1508 EX+ (6-98) SCHEDVLE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER George R. Rae 2009-01079 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointty-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Members 1st Federal Credit Union, 5000 Louise Drive, PO Box 40, Mechanicsburg, PA 17055 Checking Account 001153189 14,041.02 2. Members 1st Federal Credit Union, 5000 Louise Drive, PO Box 40, Mechanicsburg, PA 17055 Savings Account 000053189 1,667.37 3. Members 1st Federal Credit Union, 5000 Louise Drive, PO Box 40, Mechanicsburg, PA 17055 Money Management Account 000553189 1,481.68 4.. LPL Financial- AXA Advisors, LLC, 1290 Avenue of the Americas, New York, NY 10104 Brokerage Account 87573704 Cash 4,645.18 5. LPL Financial- AXA Advisors, LLC, 1290 Avenue of the Americas, New York, NY 10104 MONY Custom Master NQ Interest Account 2VA0013205 197,583.59 6. 2000 Chrysler Cirrus, 73281 miles, fair conditon 2,100.00 7. Household Items, Upstairs (see Inventory page 1) 4,095.00 8. Household Items, Parlor 8~ TV Room (see Inventory page 2) 865.00 9. Household Items, Dining & Kitchen, Miscellaneous (see Inventory page 3) 2,425.00 228,903.84 TOTAL (Also enter on line 5, Recapitulation) S (If more space is needed, insert additional sheets of the same size) 5t O MEMBERS 1St FEDERAL CREDIT UNION :~enr1 Inquires to 5000 t.auise Drive PO Box 40 Mechanicsburg, PA 17055 www.memberst st.org Main Switchboard: (800) 283-2328 EZ Call: {r'1I- 691-4372 or (8001 283-431? TDD: (717J 697-5312 or X800) x83-2;328 ext 531? TeleBranch: (800) 237-72813 Statement of Accc-unts Oct 25, 2009 thru Nov 24, 2009 Account Number : 53189 Balances at a Glance Checking : 0. 00 Savings : 0. 00 Certificates: 0. 00 Loans: 0. 00 Money Management : 0. 00 Swipe 5 YTD Reward : 0. 00 it>e.StQ ~ N1I-~ i~. ~u c,Y~l(i-~t>f-,y,p I~~I~III~~~I~~I~~I~I~II~~~~~~i1i~l~~~~l~i~l~~lll~~~~l~i~~l~~li __._ __ GEORGE R RAE ,,,, = C/O THOMAS RAE, EXECUTOR ~~""' 505 NELSGN STREET P4B3221 '`" ~ ROCKViLLE M MC) 2084 r' W -~~ _._ ~- K~ Page : 1 of 3 Your current Member Loyalty Rewards level is Gold. Your aggregate balance as of November 1st is $17,416.49. An aggregate balance of $35,000 and having 3 products will rnove you to the Platinum level. Need the perfect gift for someone on your gift list? Give them a Visa Prepaid Gift Card. For more information visit www.members1 st.org/promotions.aspx. CHECKING ACCOUNTS 0011 -CHECKING Date Transaction Description __, _i___-_._ _ ___._- _ ._______ -_ ____ ._-.Additions __~Subtr~~ctions_-_.__ _ Balance Oct 25 Ba/ance Forward 1, 6Q2.87 Oct 26 Withdrawal ACH Shippensburg Bor 203.56- 1,3.31 TYPE: UTILITY ID: 236003094 CO: Shippensburg Bor Oct 26 Check 003255 Tracer 0003657623 90.00- 499.31 Oct 27 Deposit Transfer From Share 05 0.69 500.00 Oct 27 Withdrawal at ATM #005512 500.00- 0.00 MEMBERS 1ST FCU 401 E KING ST SHIPPENSBURG PA Oct 28 Deposit Members 1st Online Transfer From Share 05 1,000.00 1,000.00 Oct 28 Deposit by Check 15 ,000.00 16 ,000.00 Oct 29 Withdrawal at ATM #005105 80.00- 15,920.00 MEMBERS 1ST FCU 105 W KING ST SHIPPENSBURG PA Oct 30 Withdrawal ACH CHASE 171.00- 15,749.00 TYPE : AUTOPAY ID : 4760039224 CO : CHASE uct 31 veposit Ulvidend 0.1t)0"lo 0 - Z3 15 , 749.23 Annua/ Percentage Yield Earned 0.08D~ from 1D/D 1/2009 through 10/3 )/2D09 Based on Average Daily Ba/ance of 3, .ZTB. D8 Nov 02 Deposit Transfer From Share 00 1,960.13 17 , 709.36 Nov 03 Deposit Transfer From Share 00 1,041.00 18,750.36 Nov 03 Withdrawal Transfer To Share 00 1.960.13- 16,7.23 TRANSACTION DATE - 11/0212009 Nov 03 Withdrawal Transfer To Share 00 1,x41.00- 15,749.23 Nov 04 Check 003257 Tracer 0001178051 10.00- 15,739.23 Nov 04 Check 003256 Tracer 0001178050 1,3:21.85- 14,417.38 Nov 09 Withdrawal ACH FIRSTENERGY OPCO 80.12- 14,337.26 TYPE : ACH lD : 1341968288 DATA: DIRECT DEBITING CO: FIRSTENERGY OPCO Nov 16 Withdrawal ACH CHASE 297.00- 14,040.26 TYPE: AUTOPAY ID: 4760039224 CO: CHASE Nov 20 Deposit Dividend 0.76 14,041.02 Annua/ Percentage Yie/d Earned 0, 100"/o from 11/01/2009 through 11/30/2009 Based on Average Daily Ba/ance of 9, 195.22 Nov 20 Withdrawal 14,041.02- 0.00 CHECK/NG C/osed - - - Continued on following page - - - `'t `~E?rli) Itti~Uir~'~, h~ 5000 Louise Dn~e Main Switchboard: 8(i0t ?8 3 X328 ~z can: ~ 7 ~ ~ ~ 6~n -~a •3 %~> or ~ 800 ~~- ~ ~ ~; :~ Oct 25 , 2009 thru Nov 24 , 2009 Po aox ao Mechanicsburg, PA 17055 TDD: 1117) 697-5:312 or (HOO1 283 ~'a?8 ext, ~~31.~~ ~•H~~~ ~~~~~f~~ AC COUnt N~Umber: J31$9 ti1F.MBERS ( www.membersl st.org TeleBranch: 18001 ?3. T< 88 Page : 2 Of 3 Date Transaction, Descri~fian ___ __ _________ ____ __ _ Additions_ Subtractions _ __Balance "~-" "''This rs the final statement presenting information on this product" ` ' * " Please retain this fina/ statement for tax reporting purposes ' *' CHECK SUMMARY Check # Amount Date.. Check_ # _ _ __._„Amount ___ ______ _ Date ____ --- -.- 003255 900.04 Oct 26 003257 10 . C10 Nov 04 ~'~ ,.,, -- 003256 1 , 321 .85 Nov 04 ~~ ~~ ._,_ 3 Checks Cleared for 2, 231.85 ._._ ~_ _ ~-~= SAVINGS ACCOUNTS - . 0000 -REGULAR SAVINGS Date Transaction Description Additions,,. _ _ _,.__ Subtractions ___ .____Balance Drt ~5 Ba/ante Forward 185.60 Oct 30 Deposit ACH PA TREASURY DEPT 1,310.26 1,49.86 TYPE: ANNUITANT ID: 1236003133 DATA: A7010150997015011 GO: PA TREASURY DEPT Oct 30 Withdrawal Transfer To Share 05 1,310.26- 185.60 Oct 31 Deposit Dividend 0.350°i~~ 0.06 185.66 Annual Percentage Yield Earned 0.380' from JO/01/2009 through JO/3J/2009 Nov 02 Deposit ACH DFAS-CLEVELAND 1,960.13 2,145.79 TYPE: RET NET ID: 3041036004 DATA: DO SYMBOL 8522-RET CO: DFAS-CLEVELAND Nav 02 Withdrawal Transfer To Share 11 1.960.13- 185.66 Nov 03 Deposit ACH SOC SEC 1,041.00 1,226.66 ID : 3101036216 CO : SOC SEC Nov 03 Withdrawal Transfer To Share 11 1 •x41.00- 185.66 Nov 03 Deposit Transfer From Share 11 1,960.13 2 ,145.79 TRANSACTION DATE - 11 /02/2009 Nov 03 Withdrawal ACH DFAS-CLEVELAND 1,9-30.13- 185.66 TRANSACTION DATE - 11 /02/2009 MEMBER DECEASED RTN AS R15 Nov 03 Deposit Transfer From Share 11 1,041.00 1, 226.66 Nov 03 Withdrawal ACH SOC SEC 1,a~1.00- 185.66 MEMBER DECEASED RTN AS R15 Nov 20 Deposit 1,481.68 1,667.34 Nov 20 Deposit Dividend 0.03 1,667.37 Annual Percentage Yield Earned 0.3 >0"/o from J J/0 J12009 through 11130/2009 Nov 20 Withdrawal 1,667.37- 0.00 REGULAR SAVINGS Closed * "' This is the fina/ statement presenting information on this product " " * *' Please retain th/s frna/ statement for lax reporting purposes * * * 0005 -MONEY MANAGEMENT Date Transaction Description Additions ___~Subtraotions ____ Balance Oct 25 Balance Forward 1,170.97 Oct 27 Withdrawai Transfer To Share 11 0.69- 1,170.28 Oct 28 Withdrawal Members 1st Online Transfer To Share 11 1, OC-0.00- 170.28 Oct 30 Deposit Transfer From Share 00 1, 310.26 1, 4$0.54 Oct 31 Deposit Dividend Tiered Rate 1.06 1,481.60 Annual Pencentage Yield Earned 0.490"/o from 10/01/2009 through 70/31/2009 Nov 20 Deposit Dividend 0.08 1,4$1.68 Annual Percentage Yie/d Eame+d 0. 100' from J J/0 1/2009 through J 1119/2009 Nav 20 Withdrawal 1,481.68- 0.00 MONEY MANAGEMENT G/osed '"This is the frna/ statement presenting information on this product* *' "' Please retain this fina! statement for tax reporting purposes ' *' YTD SUMMARIES TOTAL DIVIDENDS PAID 0000 REGULAR SAVINGS 0.96 - - - Continued an reverse side - - - rj =+... ~~ ~J 0. \...~ Pr'i lt'~ x .f :/=, :/. 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C7H-m U> _ ?~a ~c.~ fit- O mar--m? u> v: v: Q .~ ~ - "; .; ; ~ •%~ y i rJ r Contract Information Report: Contract # 2VA0013205 Client Information George R Rae 114 n Prince Street Shippensburg, PA 17257 General Information Product Plan Contract Date Sfat11S Qualified Plan 1035 Exchange Annuity Start Date Customer Serwr;e Contract Values Values as of Fund Value Prior Year Efid f=und Value Prior Year End Date Account Summary ID Sub-Account Flexible Payment Variable Annuity Non-C)uaGfied MONY CUSTUM MASTER ND 09/03/1999 Active No Yes 09/03/2013 1-800-487-MONY (6669) 10!3012009 $197, 583.59 $175,064.79 11r3112008 Annuitant Genrge R Rae Annurtant Date of Brrttl 04;15!1918 Current Aye 91 Issue Age '31 Gender Mate Values as of 10!30/2009 Initial Payment $148.584.68 Last Payment $5,50000 Last Payment Date 09!15/?005 Total Purchase Payments $204,084.68 Total Surrenders $17,931.00 Cash Value $197,583 `.i9 Current Payment Fund Value Number of Units Unit Value Allocation TOTAL: $0 00 Guaranteed Interest Account as of 10/30/2009 lp Account Fund Value Current Payment Aliacation °t° 316 Guaranteed €merest Account $197,583.59 100..00°~, New Money Interest Rate ID Account Interest Rate Month Year 316 Guaranteed Interest Account 3.50% October 1009 Ygtar Financial Professional CHARLES SCHI ICHTFR .)R Fund Value shows the value of the sub-accor.,nts plus the Guaranteed Interest Account as of the date rrdicaled Current Ueath Benefit shows the greater of the fund value and the guaranteed rnirUmurn death benefit Cash Value shows the fund value tens the full surrender charge plus or minus any market value adjustments Surrender of a contrast may result in adverse tax consequenres Account Summary shows the fund value anti the sub-account(s) that are m effect as of the date shown, For each sub-account, number of units, unit value, and the fund value are shown. For the Guaranteed Interest Account, the fund value rs shown Fund values are subject to roundrny New Money Interest Rate, rf applrcatrle shows the General Interest Account interest rate that rs only applicable, to purchase payments as well as transfers Prom sub-accounts received by the comparry for the cr,rrrent month. It the funds are received by the General Interest Account ~n a subsequent month, that month'> rate will apply. This rate may be different than the renewal rate i;redrted to amounts currently in the General Interest Account This rs not a complete description of yoi.n contract's provtsrons Please refer to the contract and to the prosl~rectus for specific detatls of contract provisions and terminology. !n the event of a conftrr.t_ the contract will govern. The information r;ontained within this reprrrt reflects contract values as of the dates indicated It rs subject to updates and corrections Your MONY client statements are the official record of your contract TherF~fore, ~f there are any discrepancies between this report and your Ghent statements. you should rely an your clir:nt statements and contact your financial professional with any questions Contract issued by MONY L rte Insurance Company Of America, 1290 Avenue of the Americas. New York, NY 1010x-2702. Date Printed: 1112l2~09 Requested by CHARLES SCNLIt;HTER page 1 of 1 INVENTORY REGISTER OF WILLS OF Cumberland COMMONWEALTH OF PENNSYLVANIA 1 COUNTY OF Cumberland f SS COUNTY, PENNSYLVANIA File Number 2009-01079 Personal Representative(s) of the Estate of George R. Rae deceased, depose(s) and say(s) that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I verify that the statements made in this Inven- tory are true and correct. I understand that false state- ments herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. Attorney -- (Name) (Address)- (Telephone) (Supreme Court LL-. No.) DATE OF DEATH LAST RESIDENCE DECEDENTS SOC. SEC. NO. October 30, 2009 114 N. Prince Street, Shippensburg PA, 17257 383-10-3515 FIGURES MUST BE TOTALED Dad's Room Bedroom set (low bureau, tall bureau, side table) 2 Twin beds Misc Clothing Misc Jewelry 3 Lamps Library Books Records Small Bureau Lamp Model Room 4 Display Cabinets Matchbox collection (Attach additional sheets as needed) TOTAL: 150.00 100.00 500.00 500.00 15.00 500.00 100.00 25.00 5.00 200.00 2,000.00 4,095.00 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the electio^ of the personal representative include the value of each item, but such figures should not be extended into the total of the Inventory. (See 20 Pa. C.S. § 3301(b)) Form RW-09 rev. 10.13.06 INVENTORY REGISTER OF WILLS OF Cumberland COMMONWEALTH OF PENNSYLVANIA ~ SS COUNTY OF Ctunberland Personal Representative(s) of the Estate of George R. Rae deceased, depose(s) and say(s) that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I verify that the statements made in this Inven- tory are true and correct. I understand that false state- ments herein are made subject to the penalties of 1$ Pa.C.S. § 4904 relating to unsworn falsification to authorities. Attorney -- (Name) (Address) (Telephone) (Supreme Court LD. No.) DATE OF DEATH LAST RESIDENCE DECEDENT'S SOC. SEC. NO. October 30, 2009 114 N. Prince Street, Shippensburg PA, 17257 383-1C--3515 FIGURES MUST BE TOTALED Parlor Desk & Chair Rocking Chair Corner Table Writing Desk & Chair Telephone Stand 3 Lamps TV Room 36" Sharp TV TV Stand 2 LazyBoys " 3ohnson" Chair Green Chair 2 Lamps Telephone Stand (Attach additional sheets as needed) 100.00 loa.oo 50.00 100.00 zo.oo 15.00 100.00 25.00 200.00 75.00 50.00 10.00 20.00 TOTAL: ~ 865.00 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative include the value of each item, but such figures should not be extended into the total of the Inventory. (See 20 Pa. C.S. ~ 3301(b)) COUNTY, PENNSYLVArIIA File Number 2009-01079 Form RW-09 rev. 10.13.06 INVENTORY REGISTER OF WILLS OF Cumberland COMMONWEALTH OF PENNSYLVANIA ~ SS COUNTY OF Cumberland COUNTY, PENNSYL~JANIA File Number 2009-01079 Personal Representative(s) of the Estate of George R. Rae deceased, depose(s) and say(s) that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I verify that the statements made in this Inven- tory are true and correct. I understand that false state- ments herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. Attorney -- (1Vame) (Address)-, (Telephone) DATE OF DEATH LAST RESIDENCE DECEDENT'S SOC. SEC. NO. October 30, 2009 114 N. Prince Street, Shippensburg PA, 17257 383-1C1-3515 FIGURES MUST BE TOTALED Dining Room Table & 4 Chairs Sideboard China Cabinet China Kitchen Washer/Dryer Range Refridgerator Dishes, Pots & Pans, etc Miscellaneous (Attach additional sheets as needed) zoo.oo 50.00 100.00 200.00 500.00 200.00 100.00 75.00 1,000.00 TOTAL: ~ 2,425.00 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative include the value of each item, but such figures should not be extended into the total of the Inventory. (See 20 Pa. C.S. ,¢ 3301(b)) (Supreme Court I.D. No.) Form RW-09 rev. 10.13.06 REV-1511 EX+ {1Q-09) r Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER George R. Rae 2009-01079 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. 4, 735.36 2. 3. 4. 5. 6. 7. B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 15,000.00 Name(s) of Personal Representative(s) Thomas Rae street Address 114 N Prince Street city __Shippensburg _ __ __ ___ state _PA zIP 17257 ___ Years} Commission Paid: 2009, 2010 Z• Attorney Fees: 3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) 3,500.00 claimant Thomas Rae street Address 114 N Prince Street City _ h~~ensburg - ___ State __PA ZIP 17257 Relationship of Claimant to Decedent SOn 4. Probate Fees: 315.00 5• Accountant Fees: 6• Tax Return Preparer Fees: 250.00 7. TOTAL (Also enter on Line 9, Recapitulation) I $ 23,800.36 If more space is needed, use additional sheets of paper of the same size. o ~ o 0 O M M i ~"~ tt1 O . t11 0 ~ lf1 O M f M ~f1 ~ ~ ~ ~ r.. ~ w M ~ w ~-- ~ cp ~' d' '~ }1 N N l`• ~ Q ~ U '~ - d Ql N v~ O O O O Oc")000000 c a ~ ~ O o ro fx ro ~ ~ x cn a o ~ ~~ ~ o .... ooooo~.noo~ , ~ as ty ~p l~ N dl ~.., ~c1 •- O M O N O -r~ ' ~ ~ OD ~ .. N ~ .- 6l r- ~ N N d Q, ~ py U2 U CT' _ _ ~ v lA •rl ~ U} tJ} U} th U} UT V} V} U} t/} U} t/} o v tr ro ~ .s~ s~ ~+ q a m °1 v o o f:. 0 ~ H z a ~ ~ ° ti~ t.A v N d' •'~ c •r•! •rl !y •rl .~ O a, ~ ~ =ro - f~os~o ~vtro •~ a. ~ > E •rf Z O U RC W v• ~„ ~ ~ w o ~ ~ ~~ v~ob ~~ ~ ~ ~ a? cG .... O a •~ v •~ •~I ~ ~ ~ ~ `~ ~ 8 u E av ~cn~~rt~3£3 r+ v y+ ~ ~ Q ~ Z w E° ~ O a s U ~ ti ri ~ `n U :+ O .r-I ~ ~A I`I N r-I N S•1 ~ 3.1 G4 ~ C7ZU000U~pU D ORIGINAL ~' 1 1 Q ACCT. NQ. _~ ~wEa~~ r--~` Funeral Services ~ ~~ /~ ~Hd.~ - - -_ -- --- - . __ -- -_ _____ --- _-- Name of Deceased ', [_~•c~cfc ~ -_----- _-__ - . _- --___ FOGELSANGER-BRICKER [~ CREDfT FUNERAL HOME, INC. CARD _ -- -- ^OTHER _ ~- -~~- ~. , ~T,Ea-,~F ~aC,,i LAST BALANCE $ X135 ~ ~~ r-_ , ;INTEREST LATE PAYMENT .- ,~ l~IiAR~ SUB TOTAL CREDITS _J F, LESS PAYMENT '~ ~ ~ ~ r NEW BALANCE g ,._. ~, 07313 REV-1512 EX+ (12-Of3) ~ pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER George R Rae 2009-01079 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, insert additional sheets of the same size. RESIDENT STATEMENT FROM GREEN RIDGE VILLAGE SWAIM HEALTH CENTER 210 BIG SPRING ROAD NEWVILLE, PA 17241-9486 717-776-8256 GEORGE R RAE c/o GEORGE RAE 206 E SURD ST SHIPPENSBURG, PA 17257 Statement Date Due Date ACCOUNT NUMBER 10/31/2009 Upon Receipt 61617GRV $2,818.99 AMC)UPJT RAID $ Please make check payable to GREEN RIDGE VILLAGE Remit To: GREEN RIDGE VILLAGE PO BOX 34309 NEWARK NJ 07189-4309 Plc~sr, l~E:i~3t,l~ Ulu f~,itlill ii~us }ivfulili vviill'yUUI ii:iiiiitiltiGi: iii ii'i.~ ~~llui(~S51.it30JG. Comments If you have any questions regarding your statement, please contact the Business Office at (717)776-8256. __.____._ .____ _ _. ~ ._ _ - __ _ _ _._ ____ ___ _ _ ___ ---_ -_P__ _-.- Date Descri lion Balance Forward 10/03/09 - 10/12/09 Roam/Board-Self Pay 10/04/09 - 10/04/09 Wipes 10/04/09 - 10/04/09 Cannula EZ Wrap 10!04/09 - 10/04/09 Milk of Mag Lax 10/04/09 - 10/04/09 Brief Promise Ultra Ig 10/06/09 - 10/06/09 Syr Ins Safty 1 CC 29gx1/2 10/07/09 - 10/07/09 Milk of Mag Lax 10/08/09 - 10/08/09 Glucose 10/08/09 - 10/08!09 SUPPOSITORY BISACODYL 10M 10/08/09 - 10/08/09 Syr Ins Safty 1CC 29gx1/2 10/11/09 - 10/11/09 Cannula EZ Wrap 10/11/U9 - 10/11/09 Cannula (72 7'TBG 10/11/09 - 10/11/09 SUPPOSITORY BISACODYL 10M 10/11/09 - 10/11!09 Neb Sml vol w/Mask & Tube 10/12/09 - 10/12/09 Opsite Drsg. 10 X 12 10!12/09 - 10!12/09 Body shampoo royalmed 8 oz. 10/29/09 - 10/29/09 Telephone r _ - Days1 l~ --- ~ -- ..___.__. _ _. Rate _ _..___ _.. ---_ .. .-_.__. _ -_ __ ___ _. Charges/ ~~ Payrrrents Units _ ~ _ _ i i (Credit). _ ~~ $29.46 10 $267.00 $2,670.00 1 $7.26 $7.26 1 $1.16 $1.16 1 $0.78 $0.78 1 $50.04 $50.04 1 $0.96 $0.96 1 $0.78 $0.78 1 $0.99 $0,99 1 $0.33 $0.33 1 $0.96 $0.96 1 $1.16 $1.16 1 $1.50 $1.50 1 $0.33 $0.33 1 $4.71 $4.71 1 $17.94 $17.94 1 $2.97 $2.97 1 $27.66 $27.66 TOTAL BALANCE DUE: ~ Balance $2,818.99 F AGILITY NAME _ ~_. _- RESIDENT NAME ACCOUNT NUMBER SWAIM HEALTH CENTER ~ GEORGE R RAE ~ 61617GF;V 1 Millennium Phcy. Systems Mechanicsburg 5020 Ritter Raad, Suite 110 Mechanicsburg PA, 17055 Due by 3!312010 Billing office hours: Man-Fri gam - 5pm T'olt Free. 1-666-466-7779 INVOICE 02!01/2010 Account Number: Gf2VN1457 GEORGE RAE 61617GRV RAE, GEORGE 206 E KURD ST MCA _~ SHIPPENSBURG PA, 17257 _~~_ Amount Due: d3.5~ Amount Paid: Please Detach Here and Return Top Portion With Your Payment ~` _ Invuice Date:U2l01/2010, Arct#~GRVN1457, RAE, GEORGE, Green Ridge Village NC -PHI, A, HAMMETT, JAMES Prey Bal Last Pymt Last Payment Finance Cha. YTD Fin Cha. Other_ RX OTC IVSP IVPR Total $ 0,00 $ c) (l0 $ 0.00 $ 0.00 $ 43.54 $ 0.00 $ 0.00 $ 0.00 $ 0.00 43.54 ama~on.eom~ Statement Date. 09/26/09 - 10125/09 ~j Manage your account online: ~~,,.~ www chases<.)nv~imazon Minimum Payment: 543.00 Payment Due Date: 11/19/09 Minimum Payment Due tur Credit Access Line Total Minmum Payment Uue Additional contact information $43.00 conveniently located on reverse side $43.00 _ACCOUI'VT SUMMARY _ Account IVumtaer: 4s4o te2o 4ooa s3s~ Prr~vious Balance $1,811.28 Credit Access Line $15.250 PaymF:ni, Crr~dits -$1.811.28 Available Credit $13.091 Purchases, Cash, Debits +$2,158.93 Cash Access Line $3.050 New Balance $2,15g.g3 Avai{able for Cash $3.050 Your next AutoPayme3nt for $A3 00 will tx; deduutdd arum your account and credited on your duC date ii your statement balance c xue;e,Kis your credit limit or your account is past due, you should make a payment that rnciudes the amount referenced plus the total ovcrlimit amount and any past due amount prior to the due date Please do not rely c)n your AutoPayment service-, to addres:~ an avfirlimit/pasi du~~ ~;ilu:~hon Prc:vioua Pointy Ba18nrt~~ 4.055 Choose from cash, travel. Amazon y~ft Points earned on alt other purchases 1,606 certificates and more! Tu redeem yc:wr lauints Pointy: ~)amF~d un Amaiun nom purchases 926 visit www chase.com/amazon or call Paints eamt3d on csveerycl~~y pun;hases 491 1-800-603-2265. Remaining points balance 7;078 Your card allows you to earn points faster than fivcsr! Earn 3 points for c>very eliyible dc.)Ilar spc,nt at Amazon.c;om. Eam 2 points fur every eligible dollar spent on gas, dining, drugstore, and office supply purchases. And (;ern 1 point far all other e6yible purchases! Choose rewards for as few as 2,500 paints! For complete program details, please refer to your Rewards Rules and REqulations ACCOUNT ACTIVITY _ _'~_M] Data of Iransactiotl fVl~rchant Name. cx Tran:~ar,Uon Ddscr~tion ~ Amount 10/ 19 Payment -Thank You 1,811.2E3 09/28 WM SUPERCENTER SHIPPENSBURG PA 81 6<f 09129 EXXONMOBIL 42118844 SHIPPENSBURG PA 32.05 09/29 SUNOCO SVC STATION MECHANICSBURG PA 21.33 09/30 WM SUPERCENTER SHIPPENSBURG PA 27 4~i 10/O1 EMgARO PAYMENT - RECURRIN 888-723-8010 KS 87 87 1a02 1 HE HOME DEPOT 4120 MECHANICSBURG PA 21.17 1a03 WM SUPERCENTER SHIPPENSBURG PA 19.64 10/02 PUBLIC STORAGE 24806 818-244-8080 MD 28i 00 10/01 SAFECO INSURANCE CO 800-332-3226 WA 96 83 1a04 WM SUPERCENTER SHIPPENSBURG PA 42 31 i0/02 21 t HAPPY OWL OF HARRISBU MECHANICSBURG PA 20 19 10/04 GIANT FUEL #5 MECHANICSBURG PA 35.69 10/04 BEDROOMVIBE.COM 818-314-6400 CA 161.99 10/06 WM SUPERCENTER SHIPPENSBURG PA 33.88 10/06 WM SUPERCENTER MECHANICSBURG PA 10 62 10/07 WM SUPERCENTER SHIPPENSBURG PA 26.50 10/08 LUWES #02816' SHIPPENSBURG PA 9.26 10/09 SUNOCO SVC STATION MECHANICSBURG PA 34.84 10/09 GIANT FOOD #061 SHIPPENSBURG PA 9.53 i0/09 WAL-MART #1850 CHAMBERSBURG PA 165.00 10109 WAL-MART # 1886 MECHANICSBUR PA 20.54 10!09 ALLE:GANY OPTICAt_-- SHIPPENSBURG PA 108.00 O(~Oe)01 FIS33336 G [ OGO fJ~ 2b e9 102b Paye 1 of :.~ Otit~E6 MA MFG a`~OBU 29810tX;tH1205;3bt)SU(11 X 04A) IN,~)392:1 REV-1513 EX+ (01-10) ~ Pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: George R. Rae 2009-01079 NUMBER I 1. 2. 3. 4. 5. 6. 7. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] George Rae, 114 N Prince Street, Shippensburg PA, 17257 Thomas Rae, 114 N. Prince Street, Shippensburg PA, 17257 Marissa Runshaw, 363 Plunkert Rd, Littlestown, PA 17340 David Rae, 347 C Street, Carlisle, PA 17013 George Rae, 347 C Street, Carlisle, PA 17013 Corinne Rae, 347 C Street, Carlisle, PA 17013 Andrew Lenahan, PO Box 2091, Harrisonburg, VA 22801 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE Son Son Granddaughter Grandson Grandson Granddaughter Grandson ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. St. Andrews Episcopal Church, 208 E Burd St. Shippensburg, PA 17257 5% ----- TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 100% 30% 30% 8.5% 8.5% 8.5% 8.5% 1% If more space is needed, use additional sheets of paper of the same size.