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Home My WebLink About08-27-101505610143 1500 Ex (01-10> REV - OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code Year File Number Bureau of Individual Taxes DEPARTMENT OF REVENUE Po Box.2soso~ INHERITANCE TAX RETURN 21 10 0642 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 171 05 3999 05 31 2010 07 03 1918 Decedent's Last Name Suffix Decedent's First Name MI ACHEY MIRIAM 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 IN APPROPRIATE OVALS BELOW X I 1. Original Return ~ 2. Supplemental Return ~ 3. pr?o io d2rlRegtzjn (date of death 4. Limited Estate ~ . _: qa. Future Interest Compromise ~ 5. Federal Estate Tax Return Required (date of death after 12-12-82) ~ g Decedent Died Testate ^ f Will ~X, ~ Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust) ) (Attach Copy o 9. Liti ation Proceeds Received ^ f 9 10. Spousal PovertY Creditl(date ;f death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and -1-95 (Attach SCh. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO; Name Daytime Telephone Number ROBERT C SAIDIS ESQ 717 243 6222 ~.. First line of address 26 WEST HIGH STREET Second line of address City or Post Office CARLISLE State ZIP Code PA 17013 _,.T s~'3 Correspondent's a-mail address: Under penalties of perjury, I declare that 1 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 has any knowledge. cir_ticTUCtF nF PFRSntJRESPONSIBLE FOR FILING RETURN ,..~'-°_`T] ~ Thomas L. ADDRESS 363 Old York g~~Ney~i Cumberland, PA 1 SIGNATURE OF P RER HE AN REPRESENTATIVE Robert C. Saidis Esq 26 West High Street, Carlisle, PA 17013 Side 1 1505610143 1505610143 REV-1500 EX ~eoedenrs Name. Achey, Miriam A. RECAPITULATION 1. Real Estate (Schedule A) ....................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3. 4. Mortgages & Notes Receivable (Schedule D) ..................................................... ... 4. 5 Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............ ... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested......... ... 6. 7 Inter-Vivos Transfers & Miscellaneous Noq-Probate Property . (Schedule G) a Separate Billing Requested......... ... 7. 8. Total Gross Assets (total Lines 1-7) ................................................................. .... g. 9. Funeral Expenses & Administrative Costs (Schedule H) ................................... .... 9. 10 Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .......................... .... 10. 11. Total Deductions (total Lines 9 & 10) ............................................................... .... 11. 12. Net Value of Estate (Line 8 minus Line 11) ...................................................... .... 12. 13 Charitable and Governmental Bequests/Sec 9113 Trusts for which . an election to tax has not been made (Schedule J) .......................................... ..... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) .......................................... ..... 14. Decedent's Social Security Number 171 05 3999 174.11 23,205.11 23,379.22 4,145.35 2,015.15 6,160.50 17,218.72 17,218.72 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 15. (a)(1.2) X .00 16. Amount of Line 14 taxable 17 , 218 , '] 2 16. at lineal rate X .045 17. Amount of Line 14 taxable ~ , 0 Q 17. at sibling rate X .12 18. Amount of Line 14 taxable 0 , ~ ~ 18. at collateral rate X .15 19. Tax Due .................................................. .............................................................. .. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505610243 1505610243 1505610243 0.00 774.84 0.00 0.00 774.84 REV-1500 EX Page 3 File Number 21-10-0642 ..........+............. .r^-- - -------- DECEDENT'S NAME Achey, Miriam A. _ __ STREET ADDRESS 20 North 12th Street, Apt. 219 CITY Lemoyne STATE 'ZIP PA 17043 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 774.84 2. Credits/Payments A. Prior Payments 736.10 B. Discount 38.74 Total Credits (A + B) (2) 774.84 3. Interest (3) - 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check box 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. (5) ~,~~ Make Check Payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :............................................................................... ^ b. retain the right to designate who shall use the property transferred or its income :.................................. ^ 0 c. retain a reversionary interest; or ............................................................................................................... ^ ^x d. receive the promise for life of either payments, benefits or care? ............................................................ ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without ^ receiving adequate consideration? .................................................................................................................... x 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....... ~^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a 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 January 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)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-1508 EX+)6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Achev. Miriam A. 21-10-0642 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM DESCRIPTION NUMBER 1 Centric Bank -Account No 1096163 VALUE AT DATE OF DEATH 174.11 TOTAL (Also enter on Line 5, Recapitulation) I 174.11 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1509 EX+(8-98) SCHEDULE F COMMONWEALTH OFPENNSVLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Ache ,Miriam A. 21-10-0642 If an asset was made joint within one year of the decedents date of death, it must be reported on schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Thomas L. Achey 363 Old York Road Son New Cumberland, PA 17070 B C. .....urn oono~orv. J V,1.1 ITEM NUMBER v -,-~.... . LETTER FOR JOINT TENANT .~. ~._ . DATE I MADE JOINT DESCRIPTION OF PROPERTY NCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSE % OF DECD'S INTEREST DATE OF DEATH DECEDENTS NTEREST 1 A 0812006 Integrity Bank -Account No. 202003476 46,410.22 50.000% 23,205.11 TOTAL (Also enter on Line 6, Recapitulation) I 23,205.11 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98) REV-1151 EX+ (10-06) COMMNHERITANCE TAX RETURNANIA RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Achev. Miriam A. 21-10-0642 vcvw v~ a~cvca.v..~........ ..... ... ~. ~. -_-. _.. __-'______ __ ITEM DESCRIPTION AMOUNT NUMBER A, FUNERAL EXPENSES: See continuation schedule(s) attached B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address Citv Year(sl Commission paid State Zio 526.00 2, Attorney's Fees Saidis Sullivan 2,750.00 3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 87.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 781.85 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 4,145.35 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Ache ,Miriam A. 21-10-0642 NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Thomas L. Achey -Reimbursement for Tombstone and funeral luncheon 526.00 H-A 526.00 Other Administrative Costs 2 Cumberland County Register of Wills -Filing fee for the Inheritance Tax Return 15.00 3 Cumberland Law Journal -Advertise Estate Notice 75.00 4 The Patriot News-Metro West -Advertisement of Estate Notice 168.96 5 Thomas L. Achey -Reimbursement for payment to have apartment cleaned and dumpster 500.00 6 Thomas L. Achey -Reimbursement for UPS expense to send clothes to the undertaker in 22.89 Allentown H-67 781.85 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 El(+ (12.08) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Ache ,Miriam A. 21-10-0642 Repoli debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 A T & T -Telephone bill from April and May 2010 98.46 2 Thomas L. Achey -Reimbursement for payment of nursing care 200.00 3 U. S. Department of the Treasury -Notice of Reclamation 1,716.69 TOTAL (Also enter on Line 10, Recapitulation) I 2,015.15 (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-OS) REV-1513 EX+ (71-08) SCHEDULE J ESTATE OF FILE NUMBER Ache ,Miriam A. 21-10-0642 NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(Sl RECEIVING PROPERTY ° ~ i (Words) ($$$) TAXABLE DISTRIBUTIONS [include outright spousal I. distributions, and transfers under Sec. 9116 a 1.2 1 Christopher Achey Grandson $4,000 4,000.00 706 N. Jordan Street. Allentown, PA 18102 2 Krista L. Achey Granddaughter $4,000 4,000.00 258 Washington Terrace Audubon, NJ 08106 3 Thomas ~. Achey Son 100% of the 5,218.72 363 Old York Road residue New Cumberland, PA 17070 4 Alisa Quinn Granddaughter $4,000 4,000.00 15 Willow Tree Court Barnegat, NJ 08005 ~ Total ~ Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet, as a ro i NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 17,218.72 TOTAL OF PART II ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) ~~.. CI c,- L 1..1 _ .~ t _~ SAIDIS -IUFP, FLOWER & LINDSAY :I U'l IV111~ KCl JtlCC~ camE/ Ei~n, ran LAST WILL AND TESTAMENT c ~~ OF L_ ( 1 i ~~ ~;' ~;; MIRIAM A . ACHEY c, .. , LL{ ,_ __. CJ~ ~~~ U ~, MIRIAM A. ACHEY, of Cumberland County, Pennsylvania, bei U of sound and disposing mind, memory and understanding, do here make, publish and declare this as and for my Last Will Testament, hereby revoking all other Wills and Codicils heretofore made by me. DEBTS AND FUNERAL EXPENSES. I direct the payment of my just debts and expenses of my last illness and funeral from my estate as soon after my death as I. conveniently may be done. II. PERSONAL AND HOUSEHOLD EFFECTS. A. Except as provided in paragraph II. B., I give bequeath all of my automobiles and articles of personal or household use, including household goods, furniture and personal effects and all family heirlooms, to my son, Thomas L. Achey, if he survives me by thirty (30) days. B. I give such of my articles of personal or household use to those persons as are named on a written list made by me during my lifetime, if any. My Executor may make whatever arrangements my Executor deems appropriate for storing and delivering articles of personal or household use to the beneficiaries, and may pay the cost thereof and any related expenses including insurance from my residuary estate. 1 III. SPECIFIC BEQUESTS. I give to such of my grandchildren, Krista L. Achey, Alisa Quinn and Christopher Achey, who are living at the time of my death, Four Thousand Dollars ($4,000.00) each. IV. RESIDUE. A. I give, devise and bequeath all the rest, residue and remainder of my estate to my son, Thomas L. Achey, absolutely and in fee simple if he survives me by thirty (30) days. B. In the event that my son, Thomas L. Achey, does not survive me by thirty (30) days, then I give, devise and bequeath all the rest, residue and remainder of my estate in equal shares unto my grandchildren, Krista L. Achey, Alisa Quinn and Christopher Achey, per stirpes. V. DEATH TAY.ES. All taxes imposed as a consequence of my death shall be paid out of the residue of my estate and considered as a part of the cost of the administration of my estate. VI. MANAGEMENT PROVISIONS. In addition to the powers conferred by law, I authorize any guardian, executor or executrix acting under this instrument, in any such fiduciary's absolute discretion: A. To retain any investments I own at my death and to SAIDIS IUFF, FLOWER & LINDSAY ~TTORNEI'S•AT•LAN~ .109 Market Street Camp !-till, PA invest in all forms of real and personal property, without being confined to investments authorized by a statutory list, without being required to diversify and regardless of any principle of law limiting delegation of investment responsibility by any such fiduciary; 2 B. To compromise claims and to abandon any property which, in any such fiduciary's opinion, is of little or no value; C. To sell at public or private sale, to exchange or to lease for any period of time, any real or personal property, and to give options for sales or leases; D. To join in any merger, reorganization, voting-trust plan or other concerted action of security holders, and to delegate discretionary duties with respect thereto; E. To borrow from anyone, even if the lender is a fiduciary hereunder, and to pledge property as security for repay- ment of the funds borrowed; SAIDIS TUFF, FLOWER n ..~ir~n n<~ ?109 Markel Street ca~» r~ run, ran F. To make loans to, and to buy property from, my spouse's executor or administrator; G. To employ and to rely upon advice given by investment counsel, to delegate discretionary authority to make changes in investments to investment counsel, and to pay invest- ment counsel reasonable compensation in addition to any fees otherwise payable to any such fiduciary; H. To employ a custodian, to hold property unregistered or in the name of a nominee (including the nominee of any institution employed as custodian), and to pay reasonable compensation to the custodian in addition to any fees otherwise payable to any such fiduciary; I. To hold two or more accounts hereunder as a combined fund (allocating ratably to such accounts all receipts from, and expenses of, the combined fund) for convenience in investment and administration; provided that any combination of 3 accounts for this purpose shall not alter their status as separate SAIDIS -TUFF, FLOWER & LINDSAY ATTORNGYS•AT•1r11V ?109 M arkei Slreel Camp Hill, PA accounts; J. To distribute in cash or in kind; K. To renew or extend the time for payment of any obligation, secured or unsecured, payable to or by any such fiduciary for as long a period or periods of time and on such terms as such fiduciary may determine and to adjust, settle and arbitrate claims or demands in favor or against them; and L. To exercise all elections which any such fiduciary may have with respect to income, gift, estate, inheritance and other taxes, including without limitation, execution of joint income tax returns, election to deduct expenses in computing one tax or another, election to split gifts and election to pay or to defer payment of any tax in all events without any such fiduciary being bound to require contribution from any other person. VII. EXECUTOR IN INVESTMENT BUSINESS. The fact that my Executor is active in the investment business shall not be deemed to be a conflict of interest, and purchases and sales of investments may be made through any firm of which my Executor is a partner, shareholder, associate or employee, or through my Executor directly or as part of my Executor's business. VIII. EY.ECUTORS. A. I do hereby nominate, constitute and appoint my son, Thomas L. Achey, to act as executor of my estate. If he is unwilling or unable to act as executor, I do hereby nominate, 4 constitute and appoint my granddaughter, Krista L. Achey, to act SAIDIS -TUFF, FLOWER & LINDSAI' ~IUJ IYIa1111C1 Ull l~l-I c,~» ~, thin, inn as executrix of my estate. B. I direct that no personal representative, guardian, trustee or other fiduciary appointed under this instrument shall be required to give bond for the faithful performance of any such fiduciary's duties in any jurisdiction. IN WITNESS WHEREOF, I, MIRIAM A. ACHEY, have hereunto set my hand and seal to this my Last Will and Testament, this 23rd day of July, 2004. MIRIAM A. ACHEY Signed, sealed, published and declared by the above-named Testatrix, MIRIAM A. ACHEY, as and for her Last Will and Testament in the presence of us, who have hereunto subscribed our names at her request as witnesses thereto, in the presence of sai Testatrix and of each other. ADDRESS i ~~ r ~~.,~,~ ADDRESS G c, c,,,~> -1-(~ ( / ,A- COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS. WE, the undersigned, the Testatrix, and the witnesses, respectively, whose names are signed to the foregoing instrument, 5 being first duly sworn, do hereby declare to the undersigne authority that the Testatrix signed and executed the instrument as her Last Will and Testament and that she signed willingly (o willingly directed another to sign for her), and that she execute it as her free will and voluntary act for the purposes therei expressed, and that each of the witnesses, in the presence an hearing of the Testatrix signed the will as witnesses and that to the best of their knowledge the Testatrix was at that time eighteen years of age or older, of sound mind, and under constraint or undue influence. MIRIAM A. ACHEY ~--Q Witness , W ti Hess Subscribed, sworn to and acknowledged before me by the Testatrix and subscribed and sworn to before me by both witnesses, this 23rd day of July, 2004. Notary P~Ilic SAIDIS HUFF, FLOWER & LINDSAY ..IUI IYIIII IICI Jll cCl Cdrnl) l~ll~l, I'A Notarial Seal Sara J. Ensinger, Notary Public Camp Hi11 Boro, Cumberland County My Commission Expires Oct. 17, 2005 Member, Pennsylvania Association of Notaries 6 Integrity B A N K Jo Ann Seker Saidis Sullivan Law 2109 Market Street Camp Hill, PA 17011 RE: The Estate of Miriam A. Achey Jo Ann, My name is Ronak Patel and I am writing you in reference to your request for a date of death balance on the above entitled customer. The customer only has one checking account with Integrity Bank. The account is a joint checking account with Thomas L Achey. The account had a balance of $46,410.22 on 05/31/2010 which is the date of death according to the death certificate. The account was paying an interest rate of 1.19%. If you have any further questions on the account please contact me at the information below. Sincerely, Ronak R. Patel Customer Service Representative Integrity Bank 3345 Market Street Camp Hill, PA 17011 (717; 920-4900 (717) 920-4904 Fax rpatel@integritybankonline. com AUG Q 4 2010 _3~Y7 Market Street, Camp Hall, Ifl 17011 • Phone: 717-920-4900 • &77-I-HAI/EIT • Fax: 71? 920-4)04 • tuu~tu, integrity6rrirkoitlruc.com For Paperwork Reduction Act Statement and Burden Estimate Statement See Reverse 60009301 OMB NO.: 1510-0043 Side "Notice to Account Owner" Copy Expiration Date: 114/3U/211o3 r DEPOSIT FROM I ELECTRONIC FUNDS TRANSFER U.S. DEPARTMENT OF THE TREASURY FEDERAL RECURRING PAYMENTS FINANCIAL MANAGEMENT SERVICE AUSTIN RFC PO BOX 149058 8714-9058 S NOTICE OF RECLAMATION 5 2 342~7300 I IIIIII VIII VIII ~illl VIII VIII VIII VIII VIII IIII' VIII' II I IIII DATE 07/08/10 20395489 RECIPIENT AND/OR BENEFICIARY NAME CLAIM NUMBER DATE OF DEATH ~~~~~~~~ ~ nnuw ~n/n1An_7n_~4~rn n~_ni_in AGENCY DATE OF AND/OR TRACE TYPE OF DEPOSITOR AMOUNT PAYMENT TYPE OF NUMBER ACCOUNT ACCOUNT NUMBER PAYMENT 06-01-10 RRB 03173607 0141053 C 202003476 1716.69 OUTSTANDING TOTAL 1716.69 NOTICE TO ACCOUNT OWNERS FROM THE GOVERNMENT The Government has received information that person named on this notice is deceased. The purpose of this notice is to inform you that by law entitlement to Government benefits for this person ended at death. Therefore, the Government must recover all payments made after the date of death. If there has been an error and this person is not deceased, or if the date of death is wrong, this notice explains how to correct the mistake. If you do not understand this notice, please get help either your financial institution or the Government agency that was making payments. PAYMENTS TO THIS PERSON HAVE BEEN STOPPED Your financial institution has been asked to return the payments shown on this notice to the Government because they were issued in error. The Government has asked your financial institution to send this notice to you, the account owner. Your financial institution must notify you if it has taken action to recover these funds from the account. Contact your financial institution immediately if you do not understand its actions. If the Government is unable to collect from the financial institution the full amount of the payments made after death, you may be contacted by the agency which made the payments IF THE PERSON IS NOT DECEASED If the person is not deceased, immediately contact both your financial institution and the agency that made the payments to correct the error. The Government regrets any inconvenience this error may cause. Your financial institu- tion can correct the collection action if it is given satisfactory proof that the person is alive. NOTE: YOU MUST CONTACT THE AGENCY THAT MADE THE PAYMENTS BECAUSE THIS ERROR HAS STOPPED FURTHER PAYMENTS. ONLY THE AGENCY CAN RESTART THE PAYMENTS. NOTICE TO ACCOUNT OWNERS ~~ ~V~.~ t r, n y y O. V'i (~ m m o ~ a nu, u, ~'~ ''' r a~pnT' xm ~\ m *amxx r':u 1.3 a ~ y G)H ^Uil .-~ Go » r~c,mm . L V T. ~ mroc, .. 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