The URL can be used to link to this page

Home My WebLink About08-31-10 505610101 REV-150 Ex ~O1.1°' ' PA Department of Revenue Pennsylvania OFFICIAL USE ONLY DEPARTMENT OF REVENUE County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 Harrisburg, PA 1yi28-o6oi RESIDENT DECEDENT ~ l ~ a !~ 0 ~ Z ~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY ~~~ oq 78J ~ o~o~~c~ ~o Q'~~I 19t S Decedent's Last Name Suffix Decedent's First Name MI ~A~'V ~~' JA~~ s ~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number I G g ! ~ ~ 7 ~ ~ 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 Return (date of death p 4. Limited Estate ~ 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received O 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) prior to 12-13-82) O 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes O 11. Election to tax under Sec. 9113(A) (Attach Sch, O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number r--,.7 First line of address 70? So. at sr 5T Second line of address City or Post Office CA~f~P ~~ ~ ~- State f' ~ ZIP Code ~ 1 70 / ~ REGISTER A _LS USE ~Ll' _ }.~ ,, . , :, ~~ t..: ; (7 (;;) ~ _, r- - ~ -..y !`T"6 C.~ r tti ~_ --~ .~ . ;=~ `- _~ r ~ ~~~ ::~ DA`T'1" FILED F`O ~. _.. , .::~ ~~ ~ •, .- :. ,, Correspondent's a-mail address: 1-•1' M ~} fZ V ~ ~ y /4 f-,f'O c~ ~ O /YJ 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 has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ~~-DATE ., ADDRESS U ; , _ ~~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS 1505610101 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 J .~ i 1 1505610105 .J REV-1500 EX er Decedent's Social Security Numb Decedent's Name: ~./ ~" ~ ~~ !1 !'7 /~~c1 ~ }~ l ` ~ °~ ~~ ~ ~ ~ / RECAPITULATION 1. Real Estate (Schedule A) ..:......:.:................. ~.....:.......... 1. • 2. Stocks and Bonds (Schedule 6) ....................................... 2. ^~ ~ .~ ~ • q 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. l CI ~" ;~ O • 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. • 7. Inter-Vivos Transfers ~ Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. • 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ~ 2 ~j 7 9 • Z 9. _- Funeral Expenses and Administrative Costs (Schedule H) .................. . 9. ~ ~, G? ~ ..~ 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. . 10. • 11. Total Deductions (total Lines 9 and 10) ................................ . 11. 12. Net Value of Estate (Line 8 minus Line 11) ............................. . 12. j 5 7 " `7 ~ . ] (~ 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. f j ~ 7 ~ ~ (p 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~ I `j 7 7 ~ , 7 (0 15. (,.;~ C 16. Amount of Line 14 taxable at lineal rate X .0 _ • 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 .............................................:.......... . 1 S. " 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1,50561,0105 15D5610105 J REV-1500 EX Page 3 ~ File Number Dec~edent;~s Complete Address: ~ ~ - ~ .~~ _ ~' ~ g~~`-7 DECEDENT'S NAME STREET ADDRESS - -_ _- CITY STATE n ~n T ZIP 1' /~ ,~ ~ ~~ // Tax Payments and Credits: 1., Tax Due (Page 2, Line 19) 2. Credits/Payments 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. 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 : ............................................ ^ r-~ c. retain a reversionary interest; or .......................................................................................................................... ^ Lv~1/ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ [~1 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? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which ~,r contains a beneficiary designation? .................................................................................... ^ L~ .................................... 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. Total Credits (A + B) (2) (3) (4) (5) REV-1503 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER All property Jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size} REV-1508 EX + (1-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ~jc~G~7 ~u rc~ ~-E ~Ar3~~C ~d~1~ Vil>,~ ~ lG ~fl~P~%~K$~U'~~ ~ ~J,c~ c1~, ~o 5 ~ ~' ... ~ c~ I,~C; ~,( .3 3 c; 1.t1 ~ 1~ l,L.) , C K ~-'~ U ~ ~5 ~ .~ /I ~~ 7~ ~ ~~ ~7~ ~A~u'`j 1 tv5u>z~~vcr~= ~'~f ~~ 1l /~7~5c%.~3 ~ ~ ~ .cam ~ 1~~5G~~ ~ ~~~ ~ -11~w i -~ nJ ~. rl C~ c f< iUc ~ ~ ~ 5 / 7 ~~~~- w~ ~ ~~ /~7~i~ ~TR~ u~ ~,z ~ s ~t~e c ,~s ~ ~~~~ ~~ ~ l~i~a .~~ _ ''1 ~~ ~ sue--=~ _ TOTAL (Also enter on line 5, Recapitulation) $ ~--~--r ~-~ (If more space is needed, insert additional sheets of the same size) 999015443 LYLA HARVEY REORDER 805 • U.S. PATEP•!T P.O. 55:!6..^.90, 5575588, 5647183, 5785353, 5964364. 683; CHECK NUMBER 7 6 8 5 6 3 DATE 0 8~ l 3~ 10 INVOICE NUMBER DATE DESCRIPTION GROSS AMT. DISCOUNT NET AMOUNT 73010VA 07/30/10 JHarvey-Burial 100.00 0.00 100.00 ,~ CG Lam.-~.-~~ County of Cumberland TOTALS 10 0. 0 0 0. 0 0 10 0. 0 0 PLEASE ADDRESS ANY CORRESPp'JDEhCE REGARDING THIS VOUCHER OR TRANSACTIO.~' TO THE OFFICE OF THE CONTROLLER, CUMBERLAND COUNTY COURT HOUSE, CARLtSLP.. PA. 1701 J. Please Note: The "Check Date," noted below, represents the settlement date of this transaction. Under normal market conditions, sale transactions are traded 3 business days prior to the "Check Date". BNY M E LLON SHAREOWNER SERVICES Login ~~ Investor ServiceDirectR~ nr. www. bnymel Ion.comishareowner/isd RETAIN FOR YOUR RECORDS SHAREHOLDER OF REINSURANCE GROUP OF AMERICA, INCORPORATED INVESTOR !D CUSIP ACCOUNT KEY 806722874455 001 314 75935160 HARVEY---LYLAJ0000 SHARESlUNITS SOLD PRICE PER SHARE (S) 21.0000 45.7928714 GROSS PROCEEDS TAX WITHHELD $961.65 $p.OQ NET PROCEEDS SHARES HELD BY PLAN $944.13 0.0000 DESCRIPTION SHARES SOLD CHECK NUMBER CHECK GATE CHECK AMOUNT 7396747 08/25/2010 $944.13 TRADING FEES PAID BY SERVICE FEES PAID BY COMPANY SHAREHOLDER COMPANY SHAREHOLDER $0.00 $2.52 $0.00 $15.00 PLEASE DETACH BELOW CHECK NUMBER: 73967 V\i 11 A/~JJI\ ~\il IL/ ~ J~ i~..l/ \iJ -------------------------------------------------------RETAIN FOR YOUR RECORDS-------------------------------------------------------- ...... .. . ': :SHAREHOLDER OF TRANSACTION DESCRIPTION _ REINSURANCE GROUP OF AMERICA, INCORPORATED DMDEND dNVESTOR !D CUSIP ACCOUNT KEY ISSUE/CLASS OF STOCK RECORD DATE PAYABLE DATE _ 806722$74455 001 314 75935160 HARVEY--LYLAJ0000 CONNIAON STOCK 08/04/2010 08/25/2010 DATE PER SHARE CERTIFICATED SHARES BOOK-ENTRY SWARES GROSS AMOUNT TAX WITHHELD CURRENT DIVIDEND _ $0.1200000 0 21.0000 $2.52 $0.00 $2.52 DIVIDEND PAID YEAR TO DATE TAX WITHHELD YEAR TO DATE TAX IDENTIFICATION NUMBER ,_ $2.52 $0.00 ON FILE please detach and retain this form for our records. y .._ - _---_._-- ---- -- _-_ __ _._ _...- -. -. __ __ _-_-------___-.- --PLt_ASE DETACH BELOW ._ __ __- __ ._ _-.- - --_ -- _ _---._ _ __ __._ ----CHECK_NUMBERw 76_64515+4 - ~ ~~~'a' ~'C1~'1t1~S, IBC. '85 Delaware Avenue. Suite 2000 9uffalo, NY 14202-1885 800 724 7788 - ~ paperless Ask about e-del~ver~ i1 TDII ~xAn.D Li iA i'O PRCAIVA Y~R TR11Dt CUNR7100tTIiMR OM.It$, vs.e~ crnn•>.cr lOOR nNtstimrt PAOffBffid01L 6A PINIINCI711. OACJttiItJ~TIaII. PAGE: 1 of 2 iMAIL T0: C O N F I R M A T I O N li~ll~~i~~ill~~il~~iillll~~,~I~~il"„~ii~i~~~l~if~~lil„I~~~~~i~ "k 00018529 01 MB 0.382 01 TR 00081 XPVL1 MT2 JAMES K HARVEY 707 SOUTH 21ST STREET CAMP HILL PA 17011-7402 FOR THE ACCOUNT OF: JAMES R HARVEY 70? SOUTH 21ST STREET e1000UNT NUMBER: AZD-351039 ACCOUNT TYPE: 1 YOUR ACCOUNT BXECUTIVE: M&T SECURITIES A.E. NUMBER: U4E PHONE NUM88R: 717-241•-7787 YOU SOLD: TRADE DATE: 08-20-10 RITE AID CORP PROCESS DATE: 08-20-10 SETTLEMENT DATE: 08-25-10 CUSIP NUMBER: 767754-10-4 SYMBOL: RAD WE CONFIRM THE BELOW TRADE(S), SUBJECT TO THE TERMS AND CONDITIONS SET FO ~ _--_ RTH ON THIS CONFIRMATION 'BADE QUANTITY PRICE PRINCIPAL ~ INTEREST ~ COMMISSION SERVICE TRANS. FEE NET AMOUNT CPTY _UMBER COMM EQUIV CHARGE USD OCN34 2,000 0.933 1,866.00 80.00 2.50 0.04 1,783.46 0 UNSOLICITED ORDER MB1-ESTATE PER3HING LLC MAKES A MKT IN THIS SEC & ACTED AS PRINCIPAL ALLOCATED ORDER YOUR BROKER ACTED AS AGENT NVESTMENTS*ARE NOT FDIC INSURED*HAVE NO BANK GUARANTEE*MAX LOSE VALUE OTALS 2,00 - 1,866.0 80.0 2.5 0.0 ~ 1,783.4 THIS CONFIRMATION IS AN ADVICE NOTAN INVOICE. REMITTANCE OR SECURITIES ARE DUE ON OR BEFORE SETTLEMENT DATE. SEE TERMS ANO CONDITIONS AND EXPLANATION OF COOED SYMBOLS RELATING TO THIS CONFIRMATION. ON OTHER THAN ROUND LOTS (NORMALLY 100 SHARES), IF"DIF" Department of the Treasury N ~ Financial Management Service ~ $ Philadelphia Financial Center rn o PO Box 51318 Philadelphia, PA 19115-6318 AWARD STATEMENT IN REPLY REFER TO: 310/295 FILE NUMBER: V 3175023 3 RETURN CORRESPONDENCE TO Department of Veterans Affairs P.O.Box 7208 Phila., PA 19101-7208 AUGUST 6, 2010 LYLA J HARVEY 707 S 21ST STREET CAMP HILL PA 17011-7402 WE ARE AUTHORIZING PAYMENT OF S 1.320.28 TO YOU FROM GOVERNMENT LIFE INSURANCE POLICY V 3175023. A PAYMENT FOR S 1,320.28 IS ENCLOSED UNLESS YOU ASKED TO HAVE THE PAYMENT DEPOSITED DIRECTLY INTO YOUR BANK ACCOUNT. *THIS IS A ONE TIME PAYMENT. **THIS REPRESENTS 33 DAYS INTEREST PAID FOR THE PERIOD FROM THE DATE OF DEATH UNTIL AUGUST 8, 2010. AMOUNT OF THIS ADDITIONAL YOUR SHARE YOUR SHARE DEDUCTIONS FROM YOUR SHARE AMOUNT AMOUNT OF THIS INSURANCE POLICY INSURANCE AMOUNT LOAN LOAN INTEREST LIEN INSURANCE AWARD (PAID-UP) 1,308 ALL 1,308.0 S 1,308.00 AMOUNT OF EACH NO. INSTALLMENTS NO. INSTALLMENTS NO. INSTALLMENTS NO. INSTALLMENTS AMOUNT ACCUMULATED INSTALLMENT (ORIGINAL) PREVIOUSLY PAID THIS PAYMENT REMAINING PAYMENTS * 1,308.00 ADDITIONS PREMIUM REFUND DIVIDEND DIV. INTEREST TOTAL DISABILITY P M OTHEA PLUS ADDITIONS AY ENTS 6.04 ** 6.24 12.28 PREMIUMS DUE LIEN LIEN INTEREST PRIOR PAYMENTS TOTAL DISABILITY LESS DEDUCTIONS DEDUCTIQNS OVERPAYMENTS 10 THE TREASURY DEPARTMENT WILL ISSUE A PAYMENT FOR THIS AMOUNT 1 , 3 2 0 . 2 8 ~ti QUESTIONS ABOUT YOUR INSURANCE? CALL US TOLL FREE AT 1-800-669-8477 • '" ~, Department of the Treasury N ~ Financial Management Service o Philadelphia Financial Center rn o PO Box 51318 Philadelphia, PA 19115-6318 AUGUST fi, 2010 LYLA J HARVEY 707 S 21ST STREET CAMP HILL PA 17011-7402 AWARD STATEMENT IN REPLY REFER TO: 310/295 RETURN CORRESPONDENCE TO: Department of Veterans Affairs P.O.Box 7208 Phila., PA 19101-7208 FILE NUMBER: V 3175023 2 wE ARE AUTHORIZING PAYMENT OF S 771.00 TO YOU FROM GOVERNMENT LIFE INSURANCE POLICY V 3299010. A PAYMENT FOR $ 771.D0 IS ENCLOSED UNLESS YOU ASKED TO HAVE THE PAYMENT DEPOSITED DIRECTLY INTO YOUR BANK ACCOUNT. *THIS IS A ONE TIME PAYMENT. **THIS REPRESENTS 33 DAYS INTEREST PAID FOR THE PERIOD FROM THE DATE OF DEATH UNTIL AUGUST 8, 2010. AMOUNT OF THIS ADDITIONAL YOUR SHARE YOUR SHARE DEDUCTIONS FROM YOUR SHARE AMOUNT AMOUNT OF TH13 INSURANCE POLICY INSURANCE AMOUNT LOAN LOAN INTEREST LIEN INSURANCE AWARD (PAID-UP) _ 765 ALL 765.0 S 765.00 AMOUNT OF EACH NO. INSTALLMENTS NO. INSTALLMENTS NO. INSTALLMENTS NO. INSTALLMENTS AMOUNT ACCUMULATED INSTALLMENT (ORIGINAL) PREVIOUSLY PAID THIS PAYMENT REMAINING PAYMENTS _ ~ 765.00 -DDITIONS PREMIUM REFUND DIVIDEND DIV. INTEREST TOTAL DISABILITY P OTHER PLUS ADDITIONS AYMENTS _ 2.36 ** 3.64 6.00 PREMIUMS DUE LIEN LIEN INTEREST PRIOR PAYMENTS TOTAL DISABILITY LESS DEDUCTIONS IEDUCTIONS OVERPAYMENTS 10 THE TREASURY DEPARTMENT WILL ISSUE A PAYMENT FOR THIS AMOUNT QUESTIONS ABOUT YOUR INSURANCE? CALL US TOLL FREE AT 1-800-669-8477 (1DCD A Tf1DC ADC f1R1 I"11 ITV ~A(1R1(1 A V TUDr11 1/':LJ CDIf'1 A V O.'2 A A RA Tr1 C DI-A C A CTCDI~I T111AC 771.00 ~,~ MetLife Metropolitan Life Insurance Company 500 SI::HOOLHOUSE ROAD •JOHNS-f OWN, PA. 15915 Notice of Claim Payment BrlDist. Agency Date of Notice c75-oo0 08/05/201 NAME OF DECEASED DATE OF DEATH DIST PHONE NUMBER JAMES K HARVEY 0 /06/2010 (610) 398-0100 LYLA J HARVEY 707 SO 21ST ST CAMP HILL PA 17 O 11 Please See Important Notice on Reverse Side Policy Number Codes Refer to Messages Below. 1 14724687 A 130281675 A Items Payable Policy Amount 218.80 183 .69 One-Year Term Insurance Additional Insurance 553.87 462 , 98 Dividends With Interest Dividend to Policyholder Terminal Dividend Premium in Advance Interest on Claim Deductions Premium in Arrears Loan Loan Interest TOTAL PER POLICY 772.67 646.67 This claim has been approved for the total o the amounts appearing in the boxes below. Items determining these amounts are listed to the left. Amount Held for Deferred Payment Check Iss»ed by Ciutomer Service Center A. Your check for the balance due has been sent to our local office for delivery to YOU. THEIR PHONE NUMBER IS (610)398-0100. ~. are . ~l.Cr':~UNT NO. .ACCOUNT TYPE 41651731 M8T SELECT MITH INTEREST "` '- JAMES K HARVEY __ 707 SOUTH 21ST ST -- CAMP HILL PA 17011 INTER~:ST PAID YEAR TO DATE 1.23 00 0 06113M NM 017 13662 Af'P'fl11NT CIIMM~RY STATEMENT PERIOD PAGE JUL.10-AUG.11,2010 1 OF 1 HIGHLAND PARK BEGINNING 6~-LANCE DEPOSITS $. OTHER ADDITIONS CHECKS PAID OTHER SUBTRACTIONS CURRENT INTEREST PD ENDING: BALANCE N0. AMOUNT N0. AMOUNT N0. AMOUNT 11,806.73 0 0.00 0 0. 0 O 0.0 0.10 11,80b.83 Q['['Cl11NT Q('TTVTTY POST NG -DATE TRANSACTION DESCRIPTION DE SI S,INTEREST. ~ OTHER-ADDITIONS ... NECKS & O HER SUBTRACTIONS DA LY BALANCE 07-10-10 BEGINNING BALANCE 511,806.73 08-11-10 INTEREST PAYMENT 0.10 11,806.83 ENDING BALANCE 511,806.83 ANNUAL PERCENTAGE YIELD EARNED = 0.00 THIS IS A REMINDER THAT IMPORTANT REGULATORY CHANGES THAT COULO IMPACT YOUR M8T CHECK CARD AND ATM TRANSACTIONS GO INTO EFFECT AFTER AUGUST 13, 2010 FOR ACCOUNTS OPENED PRIOR TO JULY 1, 2010 AND ARE CURRENTLY IN EFFECT FOR ACCOUNTS OPENED ON OR AFTER JULY 1, 2010. IF YOU MOULD LIKE TO LEARN MORE ABOUT MHAT THESE CHANGES MEAN TO YOU AND THE CHOICES YOU HAVE, PLEASE CALL US AT 1-877-378-1289 OR VISIT US AT MNW.MTB.COM/MANAGEMYACCOUNT. REV i'S11 EX+ (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCI~IEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: is ~ ~',~ r~ J ~ ~ r,/ ~ ~ T~ ~' ' C ~ ~' ~ cf ~- ~; .~ C r~ ~ ~ 7 N F" X10 ~' £" l~u N ~' ~ ~ L `- ~. ~Q~~ ~~ i`si ~- l.~ ` C-t ri'! f3 C h' C J~ !/ ~~ , ~ C; j7 C ~ v' G r? ~ U ~" c~ ~ ~~7 ~_ ~ ~ ~2 ~ /~ s 5,w ~ ~ o . Qo' a ~ C~ L l9 ~ J O !~r ~ L ~? ~ ~ G ~l m c n1 c.~ ~ rn/ i ~ ~ ~ U ~' ~? a ~ K ~" i ~ ,3 v2 ~7 S. o ~ B. ADMINISTRATIVE COSTS: ~ . Personal Representative's Commissions Name of Personal Representative(s) _ _ Street Address __ City State Zip Year(s) Commission Paid: 2. Attorney Fees 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 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. /~~7~~0 TOTAL (Also enter on line 9, Recapitulation) I $ ~p (p (,~ ~j ~ ~ ~ (If more space is needed, insert additional sheets of the same size) ~ ---_ _ _. ,_._ ~~~~ 20.~ J ~----- Received from ~ ~ ~i~._._ ~ ~~~- pollars f~ 'r' ~ 100 For ~ ~~ ~rrC~~ ~ ~.-~ ~ ~ $ " ~~ RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 HARVEY JAMES K Estate File No.: 2010-00827 Paid By Remarks: LYLA J HARVEY DM ------------------------ Receipt Distribution Receipt Date: 8/12/2010 Receipt Time: 16:08:48 Receipt No.: 1062239 Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 60.00 CUMBERLAND COUNTY GENERAL FUN WILL 15.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 24.00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN --- Check# 437 ------------- $127.50 Total Received......... $127.50 ~ ~ ~ ~ ~ ~~ ~ iK °~. ~, ~ A F'amil Tradition (Jf Cann PARTHEMORE Funeral Home & Cremation Services, Inc. Mrs. Lyla J. Harvey 707 South 21st Street Camp Hill, PA 17011 i 303 Bride Street P.O. Box 431 New Cwi~berland. PA 17070 (717)774-7721 (Fax) 774-554E www.parthemorc.com Gilbert VV'. Parthemore. Founder Gilbert .1. Parthemore. Supervisor Stephetl K. Parthemore. CFSP Bruce R. Partheinore. lire-Need Coordinator, CPC Professional Memberships: NFDA • PFDA CICFDA • CCFDA ,,,~ lrgernafforeat Urdu n/tiu C.~C`a~L EN LE,, 77lc Rtl1(' 3iru i~~ltu~ti'. Tlrc° Pcv~PJr }ru %rus! -- .~`: -. ,.. _ L ~ ~ ~~~ ~.y._ 7/8/2010 We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. The following is an itemized statement of the services, facilities, automotive equipment and merchandise that you selected when making the funeral arrangements. Terms Due Date Account # Net 30 8/7/2010 2010045.11 Description Amount SERVICES & MERCHANDISE Direct Cremation 2,250.00 Navy Blue Marbleite Urn with Army Applique 203.00 Total Services and Merchandise 2,453.00 CASH ADVANCE ITEMS Death Notice, Harrisburg Patriot 276.07 Death Notice, Oil City Derrick 111.00 22 Certified Copies of Death Certificate 132.00 Cumberland County Coroner Fee, Cremation Authorization 25.00 Total Cash Advances 544.07 ~ ~ ~' ~q Q f ~ ~~ ~ ~ I Total .s~,~,o~-. Payments/Credits $o.oo Balance Due ---~- r j ~~# Z -- 7 t~ td Pd • r'n z 9 ~~ s ((~~ ~' ~ ~~ .. ~le~run~ -( xce.~e~2ce ryt ~~mo~uz~ ~eac~r. 15760 ROUTE 322 EAST • CLARION, PENNSYLVANIA 16214 Phone: 814.764.3523 / Fax: 814-764.5828 CUSTOMER NAME: Lyla Harvey 707 South 21st St Camp Hill, PA 17011 OFFICE Clarion DATE ORDERED Invoice INVOICE NO. 8/2/2010 10-290 • ~ • $1,587.50 k 7 ~ i CEMETERY /LOCATION: Clarion ~'ic.+~~° 3-~c~t~~r~ca t r>~~ i~r~~~ta{z~~ ~~hc~q `~I.-~,i~~~ ~".~w ~~tcn~~ ~.~~~•~_ [iti~titr~~ I~€~~~-~tdr~~~ ~~trr `! ~it~r 12cc~i7~~~f~ DETAIL OF INVOICE TRASACTION I Balance Due Bronze: 44" x 14", light finish, Mapleleaf Rockedge Base for Bronze: 4-0 x 1-6 St. Albans Pink Company Installed Foundation Charges Misc. Cemetery Charges James and Lyla HARVEY memorial ~;, sr J ~G ~~o ~~ ~:~~ ~ ~-- ~ `~ ~~ ,-~, ~ , ~~ J TIIc~IZ~J t>~~tf~ tc~,r;t;,?I111'14~ ~ ~ t/Ic' ~:~I+tvtlcl~c' tt% Sc~y-~;t'_~'~,~~~,' Total ~jC' c~~~~.11"~'t~lt?Ic.' l t,l~,,' {~=~Il.`~~yl~'S.> !lxlt~ talc' L7`tfSl ~'~?l~ ~rlcl~•~d' 1~t~r°C't't~ ,~J'1 lt.~. Payments ~f 1~1~~' C:td11 t.l.~:~l`~~" ,'>Il tltr`t~lt'~.~~ I~Z cll'IZ' ~1'CI~', ,~~I~'t-lSt' i~'Cilll~li~t GAS. - ~ 8/20/2010 1 I 2,953.00 1 0.00 1 302.00 1 20.00 $3, 275.00 $-1,687.50 $1,587.50 Accounts over 30 days past-due are subject to a finance charge of 1.5% (18% annually). ~ ,9 PURCHASER LYLA HARVEY ~__..-. ADDRESS 707 SOUTH 21st STREET CAMP HILL, PA 17011 15760 ROUTE 322 EAST • CLARION, PA 16214 • PH: (814)764-3523 PHONE 717-761-1763 cm~ClarionMonuments.com EMAIL lyharv2@yahoo.com Clarion Monuments agrees to sell to purchaser a memorial described below with lettering as specified, terms and conditions as indicated. Ail workmanship and materials provided by Clarion Monuments are guaranteed. TYPE FLUSH MEMORIAL SIZE 44" x 14" BRONZE MATERIAL BRONZE ON GRANITE BACKER fINISH LIGHT FINISH DESIGN Mapleleaf Rockedge (no vase} BASE 48" x 18"GRANITE BACKER Single Scroll /Flat Letters OTHER SKETCH /LETTERING DESCRIPTION ~., ORDERED ^ IN STOCK ^ LITHO ^ JAMES K. July 21 July 6 1918 2010 HARVEY LYLA J. July 13 (Fu#ure 1924 Date) DRAFTING LAYOUT SANDBLAST 1st LT, U.S. ARMY, W.W.11 (Army Emblem) FOULK TEMP MKR /FLAG AT LOT ^ FOUND ORD ^ FOUND IN ^ BASE IN ^ COMPLETED ^ CONTACTED ^ ^ CORNER POSTS ^ F/N ON BACK ^ INSCRIPTION ON BACK (sEE sPECIAL NOTES BELOW} It is further agreed that this work shalt remain personal property and that the title shall remain with Clarion Monuments until fully paid. This agr®ement moreover includes the authority to enter upon said lot to erect the work and likewise to remove if not paid for in accordance with this agreement. Terms: A finance charge of 1 1 /2°~ (annual rate 18%) on all accourrts over 30 days. A fee of $20 will be charged for all checks returned by the bank for any reason. All odlection fees and attorney fees are payable by the purchaser. This order is not subject to cancellation after acceptance. This order does not include the cost of adding future lettering. CEMETERY: CLARION CEMETERY SPECIAL NOTES: BRONZE SECTION LOT I NFO : BESIDE PAUL & ELLA NORA WILSHIRE BRONZE MEMORIAL . (JAMES WAS CREMATED AND HIS ASHES ARE BURIED) FUNERAL DIR.: EST. COMPLETION: LATE SUMMER 2010 **EMAIL PHOTO WHEN COMPLETED** PAYMENT METHOD ^ Paid in full PRICE $ 2,953.00 1/2 Down, Bal. Due on Completion ~~? ~`7 Sv FOUNDATION $ 302.00 ^ Credit Card -Circle One: MC or VI Exp: / F/N ON BACK $ Ae #: CORNER POSTS ~ 3 Digit Verification # on back of card: X X Cemetery Fee $ 20.00 Name as on Card.• TOTAL $ 3,275.00 Billing Address (if different): PAYMENT ~ --, BALANCE ~ 3,275.00 SIGNED ~-ff ~ ~; ^-' ~ - ~~, - DATE `~~ ~` ~ ,,,3.~~c~ i o ~~~ ~ WHITE-Office / YELLOW-Production / PINK-Purchaser REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF /~7~i9~P Yom, .~.~4~-y'! C~ 5 /!~ FILE NUMBER 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, and transfers under Sec. 9116 (a) (1.2)] 1. ~.~~ L,4. ~ /yA~2 ~J'E ~ ~ 5~.. /~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 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 $ (If more space is needed, insert additional sheets of the same size) c° LAST WILL AND TESTAMENT ~~ r ' - y / , ~ l ~ "1 "^,~ >.J _ .1-. O 1 y A~~ J t~ . !'Itl i~VLi' Y m n C t~ • I, JAMES K. HARVEY, of Lower Allen Township, Cumberland County, Pennsylvania, declare this to be my last will and testament, and revoke any wills previously made by me. I. I direct that all of my just debts and last expenses, i:.cluding all expenses of my last illness and disposal of my remains, shall be paid from~my residuary estate as soon as practicable after my decease, as part of the expense of administration of my estate. .E -.~ ,~ ~` r " t z II ~ t • ~ ~ ~ . ~ ~-~f ,~. I devise and bequeath the rest, residue and remainder of my estate, of every nature and wheresoever ~- - situate to my wife, Lyla J. Harvey, providing she shall survive me by sixty (60) days. IIIf Should my wife, Lyla J. Harvey, predecease me or die on or before the sixtieth day following my death, I devise and bequeath all of the rest, residue and remainder of my estate, of every nature and wheresoever situate, to my children, Paula L. Snyder, Kim A. Ray, Janet L. Harvey and Mary Ann Harvey, share and share alike. ~~ IV. I appoint my wife, Lyla J. Harvey, executrix of this, my last will and testament. Should she be unwilling or unable to act as execurix i appairit Paula L:~ Snyder and Kim A. Ray to be co-executrices of this, my last will and testament. t>; ~ V , ~,. ~ ~.~:,~ ~, . I direct that my executrix or co-executrices, or -2- ^ their successors shall not be required to give bond for the faithful performance of her duties in any jurisdiction. IN WITNESS WHREOF, I have hereunto set my hand l t .~. and seal this !~-~' day of ~ ~v , 1985. _ , i ames K. Harvey The preceding instrument, consisting of this and two other typewritten pages, identified by the signature of the testator,, JAMES K. HARVEY, who on the day and date there- of, signed, published and declared. by JAMES K. HARVEY, the testator therein named, as and for his Last Will and Testament, in the presence of us, who, at his request, in his presence and in the presence of each other, have subscribed our names as witnesses hereto: f` .~ ,~,_ 4 ~