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HomeMy WebLinkAbout09-17-10 (3)1505610148 REV-1500 EX (D1-1t)) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po Box 2sosol INHERITANCE TAX RETURN 21, 10 0 4 4 6 Harrisburg, PA 1 7 1 28-060 1 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 31,8-01,-3843 D3232DI,D 03307~9Z5 Decedent's Last Name Suffix Decedent's 1=first Name M I LARSEN ANN G (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name M I Spouse's Social Security Number THtS RETURN MUST BE FIl_EO fN DUPLICATE WITH THE - - REGISTER ~~ WILLS FILL IN APPROPRIATE BOXES BELOW ® 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-82) ^ 4. Limited Estate ^ 4a. Future Interest Compromise (date of ^ 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust I 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) ^ i ^ 10 ^ 1 9. Litigation Proceeds Rece ved . Spousal Poverty Credit (date of death 1. 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 TO: Name Daytime Telephone Number GREGORY S • CHELAP, ESQ - 717-233-1,000 r~ First tine of address 1,7 S • 2ND STREET Second line of address SIXTH FLOOR City or Post Office HARRISBURG State ZIP Code PA 171,01, REGISTNILLS US~NLY .""' ' ;~ -~ ' t,~ 4 ~ -~ ~r~ ~ 1'""- -- -_: -r~ ~ ~.. .~ `5~ - DATE FILED Correspondent'se-mail address: GCHELAPa~SKARLATOSZONARICH-C0~1 Under penalties of perjury, 1 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. SIG RE OF PERSON RESPONSIBLE FOR FILING RETURN D E w _ '~ -~~.~,~~' JEAN WALTERS - ~Q ESS 2 81 DART UTH S CAMP HILL, PA 7,707,], SIGNATURE PREPARER O ER REPRESENTATIVE TE GREGORY S - CHELAP ~-/~ -/d ADDRESS 1? S - 2 6TH FLOOR HARRISBURG, PA ],71,01, PLEASE USE ORIGINAL FORM ONLY Side 1 15D561D148 9M46474.000 1505610148 ,~ ~-'` J 1505610248 REV-1500 EX Decedent's Social Security Number 318-D1-3843 Decedent's Name: L A R S E N ANN G RECAPITULATION 1. Real Estate(ScheduleA)--- 1. D.00 2. Stocks and Bonds (Schedule B) . 2 D • ^ [] 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) , 3. [] . 0 D 4. Mortgages and Notes Receivable (Schedule D) _ _ 4 D • 0 0 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) 5, 3 2 3 , 6 9 7 . D 0 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested - - g. 8 , 8 3 3.0 0 7. Inter-Vivos Transfers ~ Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested 7. 16 , 9 4 7, • 0 0 8. Total Gross Assets (total Lines 1 through 7) • g. 3 4 9 , 4 71.0 0 9. Funeral Expenses and Administrative Costs (Schedule H} , - _ , g 3 3 , 3 0 9.0 D 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I} 10 1, , 5 2 5.0 0 11. Total Deductions (total Lines 9 and 10) , - 11, 3 4 , 8 3 4 - D D 12. Net Value of Estate (Line 8 minus Line 11) - 12_ 314 , 6 3 7 . D 0 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) • _ , 13, 0 • ^ 0 14. Net Value Subject to Tax (Line 12 minus Line 13) _ _ , 14. 31, 4 , 6 3 7 • D 0 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers un~er Sec. 9116 16. Amount of Line 14 t xable ~ at lineal rate X .0 4 D • 0 0 16. 17. Amount of Line 14 taxable at sibling rate X .12 14 4 , 4 3 2 •0 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 1, 7 0, 2 0 6 -0 0 18. 19. TAX DUE 19. 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610248 9M464H 4. WO 1505610248 D•00 0.00 ],7,332.OD 25,531.OD 42, 863.00 J REV-1500 EX Page 3 1'lnrnr~ant'c (:mm~lcatr~ 1~rlrirPCC- File Number ai, ~,n n44~, DECEDENTS NAME S ANN G STREET ADDRESS U BERLAND CITY ~1ECHANICSBURG STATE PA 21P 1,7050- Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 2. Credits/Payments A. Prior Payments 4 0, 0 0 0• D 0 e. Discount 2 , 0 0 0.0 0 Total Credits (A + B) (2) 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in box on Page 2, Line 20 to request a refund. s (4) 42, 863.00 42,000.00 (3) 0.0 0 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 8 6 3 • 0 0 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLAC{NG 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; i d i ^ 0 ncome; or ts b. retain the right to designate who shall use the property transferre ^ c. retain a reversionary interest; or ^ d. receive the promise for life of either payments, benefits or care? . 2. tf death occurred after Dec. 12, 1982, did decedent transfer property within one year of death ^ without receiving adequate consideration? . " " ^ or payable-upon-death bank account or security at his or her death? in trust for 3. Did decedent own an 4. Did decedent own an individual retirement account, annuity, or other non-probate property, which ® ^~ contains a beneficiary designation? IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 1=or 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 benefiaaries 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. 9M4671 2.000 REV-1508 EX + (6-98) COMMONWEALTI-t OF PENNSYLVANIA ' INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER ANN G. LARSEN 2110 0446 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 Jewelry - see appraisal attached hereto 1,940 2 Metro Bank - Cash found in Safe Deposit Box (see Inventory attached hereto) 23,951 3 Metro Bank Checking Account No. 513180000 3,137 4 Metro Bank Checking Account No. 833086358 75,515 5 Metro Bank Savings Account No. 616092657 30,308 6 Belco Savings Account No. S1 5 7 Belco Money Market Account 44,039 Interest accrued to 3/23/2010 74 8 Belco Certificate of Deposit 1,005 Interest accrued to 3/23/2010 3 9 Household goods and personal property 500 10 PA Life Insurance - Refund of policy premium 40 11 National States Insurance - Refund of health insurance 355 12 The Patriot News - Refund 191 13 PA Department of Revenue - '09 Tax Refund 275 14 Country Meadows Associates - Refund 5,510 15 Citizens Bank Checking Account No. 620938-705-9 2,659 16 Citizens bank C/D No. 6255-533213 51,790 17 Citizens Bank C/D No. 6245-023241 56,475 18 Citizens Bank C/D No. 6255-533191 25,925 3W46AD 1,000 TOTAL (Also enter on line 5, Recapii (if more space is needed, insert additional sheets of the same size) 323,697 F2El/-1509 EX+ (0 . -10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN R~SIUENT DECEDENT SCHEDULE F JOINTLY OWNED PROPERTY ESTATE OF: FILE NUMBER: ANN G. LARSEN 21100446 ff an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVNING JOWTTENANfT(S) NAMES) ADDRESS REtAT10NSHIPTO DECEDBJT A Walters, Jean JOINTLY OWNED PROPERTY: 2081 Dartmouth Street, Camp Hill, PA 17011 Niece ~~ NUMBER LETTEa FOR JOINT TENANT DATE MODE ,JOINT DESCR~TION OF PROPERTY INCLUDE NAWE aF FlNANCwL INSTITUTK7N AND BANK ACCOUNT NUMBER oR SIMUIR IDENTIFYING NUMBER. ATTACH DEED FCR JgNTLY HELO REAL ESTATE. ~~ ~ DEATH VALUE OF ASSET °~6 OF DECEDEtJT'S INTEf2EST DIATE OF DEATH VALUE OF DECEDB~fT'S BYTB~EST 1 A 3/22/2002 Metro Bank Savings Account No 616307600 17,667 50.0000 8,833 - TOTAL (Also enter on Line 6, Recapitulation) 3 8 , 833 ywasAE 2.00o If more space is needed, use additional sheets of paper of the same size. REV-1510 EX + (08-09) SCHEDULE G pennsylvania DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER ANN G. LARSEN 21 100446 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBE DESCRIPTION OF PROPERTY MICUDE TFE NOME of TFE TRANSFEREE, ThEIR RElAT10NSMP TO DECEDENT AND TFE DATE of TRArSF6t ATTAC!-VA coPV OF TFE DEED FOR REAL ESTATE DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION F APPLJCABLE TAXABLE VALUE ~~ Ameriprise Account No. 60321155 16,941 100.0000 0 16,941 (transferred at death to decedent's niece, Jean Walters) TOTAL (Also enter on line 7, Recapitulation) $ 16 , 941 If more space is needed, use additional sheets of paper of the same size. 9VV46AF 2.000 REV-1511 EX+(10-09) SCHEDULE H pennsylvania DEPARTMENT OF REVENUE FUNERAL EXPENSES AND ` INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF r ~~~ ~vv~no~R ANN G LARSEN 21 10 0 4 4 6 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1 Auer Cremation 1,640 Total from continuation schedules . 171 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 13 , 000 Name(s) of Personal Representative(s) Jean Walters Street Address 2081 Dartmouth Street City Cam Hill State PA ZIP 17011 Year(s) Commission Paid: 2 010 2. Attorney Fees: 17 , 100 3. Family Exemption: (If decedent's address is not the same as Gaimant's, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 14 7 5. Accountant Fees: 6. Tax Return Preparer Fees: 800 7. 1 Register of Wills (Dauphin Co.~ - Oath of Office Fee 20 2 Register of Wills - Additional Short Certificates 12 Total from continuation schedules ~ 419 TOTAL (Also enter on Line 9, Recapitulation) ~ $ 33 , 3 0 9 9w46AG 2.000 If more space is needed, use additional sheets of paper of the same size. Estate of: ANN G. LARSEN Schedule H Part 7 (Page 2) 21 10 0446 3 Cumberland I~aw Journal - Estate Notice 75 4 The Sentinel - Estate Notice 219 5 Mountz Jewelers - Appraisal Fee 105 6 Skarlatos ~ Zonarich - Costs 20 Total (Carry forward to main schedule) 419 REV-1512 EX + (12-08) pennsylvania SCHEDULE I DEPAI2TMENTOF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER ANN G. LARSEN 21 10 0446 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. STEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1• Dept. of Treasury - '09 Tax Due 79 2 Country Meadow Associates - Pharmacy Charges 20 3 Discover Card - Balance Due 30 4 Country Meadows at Home - Balance Due 1,150 5 Country Meadows at Home - Check #1424 cleared after DOD 185 6 West Shore EMS - Check #1423 cleared after DOD 61 - TOTAL (Also enter on Line 10, Recapitulation) ~$ 1 525 8w46AH 2.000 If more space is needed, insert addftional sheets of the same size. REV-1513 EX+(01-10) SCHEDULE J pennsylvania DEPARINIENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ANN G. LARSEN 21 10 0446 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [Indude outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1, Julia Borzok 151 N. 21st Street Camp Hill, PA 17011 50~ of Residue: 144,432 Sister-in-law 144,432 2 Walter Borzok 42 S. Railroad Avenue Frackville, PA 50~ of Residue: 144,432 Brother 144,432 I ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. __ TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ~ $ 0 If more space is needed, use additional sheets of paper of the same size. swasAi 2.000 ,Estate of: ANN G. LARSEN Schedule J Part 1 (Page 2) 21 10 0446 Item No. Description Relation Amount 3 Jean Walters 2081 Dartmouth Street Camp Hill, PA 17011 Ameriprise Account No. 60321155 Inventory Value: 16,941 Metro Bank Savings Account No 616307600 Inventory Value: 8,833 Niece 25,774 Last Will And Testament Of - - ~~- ANN G. LARSEN I, ANN G. LARSEN of the 'T'OWNSHIP OF HAMPDEN, COUNTY of CUMBERLAND, COMMONWEALTH of PENNSYLVANIA, being in good bodily health and of sound and disposing mind and memory, and not acting under duress, menace, fraud, or undue influence of any person a-homsoever, merely calling to mind the frailty of human life, and being desirous of disposing my aTorldly goods while I have the strength and capacity so to do, I do make, publish and declare this my LAST WILL AND TESTAMENT. I hereby revoke, cancel and annul all my former Wilis and T estaments, including codicils thereto, by me at any time made, and deciare this alone to be my LAST w'iLL ANi~ TESTAMENT. AS TO SUCH ESTATE IT HAS PLEASED GOD TO ENTRUST ME WITH IN THIS LIFETIME, I DISPOSE OF THE SAME AS FOLLOWS, VIZ: ITEM 1. I direct that my Executors hereinafter named, pay and discharge all of my just debts, funeral and testamentary expenses. ITEM 2. I order and direct that my bodily remains be cremated. My cremation has been prepaid. ITEM 3. All the rest, residue a~1d remainder of my entire estate, wheresoever situate, and whatsoever it may consist of, I give, devise, and bequeath, absolutely, and in fee to my dearly beloved husband THORKILD R. LARSEN. In the event my dearly beloved husband dies ~=ith me in a simultaneous disaster, or fails to survive my death by thirty days, then I give, devise, and bequeath my entire estate:, wheresoever situate, and whatsoever it may consist of, to the following named individuals, share and share. alike, per stirpes: (1) JULIA BORZOK (2) WALTER BORZOK ITEM 4. I nominate and appoint THORKILD R. LARSEN as Executor of this my LAST WILL and TESTAMENT. Should the Executor herein named fail to qualify or cease to act as Executor, then I appoint JEAN WALTERS as Executrix in his stead. i ANN G. LARSEN Page 2 of 4 ITEM 5. I hereby direct that all my personal representatives, as well as their successors, shall not be required to give bond for the faithful performance of their duties in any jurisdiction. ITEM 6. I order and direct that my Personal Representative(s) named herein use the legal services of JAMES M. BACH, as Attorney for my Estate. ITEM 7. I direct that all estate, succession, legacy, inheritance or other transfer taxes, however designated that shall become payable by reason of my death in respect of all property comprising my gross estate for tax purposes, vrhether or not such property passes under this LAST WILL, shall be paid by my Executor out of my residuary estate. ITEM 8. I grant to my personal representatives herein named, in addition to., but not in limitation of those powers vested by law, to be exercised arithout prior- application to or approval of any court, the power and authority to retain --- indefinitely any property, to invest and reinvest any assets or the proceeds derived from the sale of assets, although said investments may not be of the charactei- prescribed by law, to sell, convey, assign, transfer and encumber any property, to pay, settle or compromise all claims, to make distribution or divisions in cash or in kind, and in general to exercise all powers in the management of any property hereunder which any individual could exercise in the management of similar property owned in his own right, anei to execute and deliver any and all instruments and to do all acts which may be deemed necessary and proper. _:% ~~~ , ANN G. LARSEI\r -~ ~. I ~ WITNESS i' !_ ~'~~;.-.~ .~~ ,_~:, .'' ~V~ ``r_.~~~- J WITNESS .~L., ~'.L'~~ ~ : ~ll~r~-J SU~ANNE T. POWER KIMBEFZ~Y A. ROSS Page 3 of 4 ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA ) ss COUNTY OF CUMBERLAND ) I, ANN G. LARSEN, the TESTATRIX, RThose name is signed to the attached or foregoing instrument, having been duly qualified according to laa~, da hereby acknowledge that I signed and executed the instrument as my LAST WILL; that I signed it willingly; and that I signed it as my free and voluntary act for the purpose therein expressed. Sworn to or affirmed and acknowledged before me, by: ANN G. LARSEN, the. TESTATRIX this S'x day of September, 2000. ANN G. LARSEN ~~`-'°~ ~ ~~:-=~ ~~~:j-<`;~` ~.:~~. ~ J1~fi~IES M. BACH, ESQUIRE '=~~r=--~:~'` v `s~~K ~ ~ NOTARY PUBLIC Mechanicsburg, PA 17055 My Commission Expires: 05/13/03 AFF DAVIT COMMONWEALTH OF PENNSYLVANIA ) } ss COUNTY OF CUMBERLAND } We, SUZANNE T. POWER and KIMBERLY A. ROSS, the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to laaT, do depose and say that R-e were present and saw the TESTATRIX sign and execute the instrument as her LAST WILL; that the TESTATRIX signed it willingly and that she executed it as her free and voluntary act for the purpose therein expressed; that each aritness in the hearing and sight of the TESTATRIX signed the WILI, as R-itnesses; and that, to the best of our knou-ledge, the TESTATRIX a~as, at the time, 18 or more }'ears of age, of sound mind and under no constraint or undue influence. Sworn to or affirmed and acknowledged before me, by: SUZANNE T. POWER and KIMBERLY A. ROSS witnesses, this 5th day of September, ?000. \XIITNESS ';;,'r t~..-;~c,:: , ,' ~ d%'~clf-~.~.,, WITNESS ~'1 L~'Y~'1~!C.t ~~{ _ ~ 4i. SUZANNE T. POWER KIMBER~ Y A. R SS =_ / - y=:~;~ e,,.,,, -~ << F-~, J-. ES M. BACH ESQUIRE "~~~-;,~_'-R ~~;,.~",'r~~~ _ NOTARY PUBLIC ^''~`'`°- ~ ~'''.~ ~ ~ Mechanicsburg, PA 17055 My Commission Expires: 05/13/03 Page 4 of 4 ' J E W E L E R S Trust Your Special Moments To Mountz. June 8, 2010 Gregory S. Chelap, Esq. 17 South Second Street 6th Floor Harrisburg, Fh i 710 i Dear Gregory Chelap, Esq., At your request I examined the jewelry you submitted for valuation and have provided an opinion of the Fair Market Value for the estate of Arai Larsen. This report is valid only in its entirety and the final. figure excludes any applicable taxes. You may wish to take this into consideration when using the report. The value conclusions are subject to limiting conditions that are set forth in the body of the report. To the best of my knowledge and experience, I estimate the jewelry has a total Fair Market Value of $1,940.40. Photographs are included with the original report for your reference. I suggest that you keep your copy of this report in a safe place. This report was prepared in accordance with the Uniform Standards of Professional Appraisal Practice (USPAP}. If I can be of any further assistance, please call. Sincerely, ,_.~ ~, J~` ~ fs .~ 4i ~~~ // Che~-i-~Lynn Grove Certified Gemologist Appraiser, AGS Enclosures Member AMERICAN '.7 E W E7 ,F ,. S GEM 3780 Trindle Road • Camp Hill, PA 17011 • (717) 763-1199 K k~xL ' SOCIETY - www>~~it~c~uvelers,com TR E BAN K 3801 Paxton Street Harrisburg • PA • 17111 mymetrobank.com 888.937.0004 May 20, 2010 Skarlatos Zonarich LLP 17 S Second St 6th Floor Harrisburg PA 17101 RE: Estate of: Ann G. Larsen Tax Identification Number: 318-01-3843 Date of Death: March 23, 2010 To Whom It May Concern: This letter is in reference to decedent account information you requested for the individual listed above. We are able to provide the following: Account Type: Checking Account Number: 513180000 Date Opened: 04/06/2000 Primary Owner: Ann G. Larsen Date of Death Balance: $3136.93 Account Type: Checking Account Number: 833086358 Date opened: 08/24/X00 Primary Owner: Ann G. Larsen Date of Death Balance: $75515.04 Account Type: Savings Account Number: 616092657 Date Opened: 04/06/2000 Primary Owner: Ann G. Larsen Date of Death Balance: $30307.84 TRo BANK 3801 Paxton Street Harrisburg • PA • 17111 mymetrobank.com 888.937.0004 Account Type: Savings Account Number: 616307600 Date Opened: 03/22/2002 Primary Owner: Ann G. Larsen Secondary Owner: Jean A. Walters Date of Death Balance: $17666.62 Please feel free to contact me at (717) 412-6127 if I may be of further assistance. Sincerely, ~--- ~~_ _ _ -~ Diana Reynolds Metro Bank Research Associate/Deposit Services SKARLATOS ZONARICH LLP 17 South Second Street 6~' Floor Harrisburg, Pa. 17101-2039 May 27, 2010 Re: Estate of Ann G Larsen, a/k/a Ann Gerry Larsen S.S. 318-O1-3843 Attention: Gregory Chelap, Here is the information for the above referenced account. If you need any further information, please call me at 717 720 641.4. Sincerely, ,...~ -, • ~'`~~ ~` Yvonne James Finance Depart ,~-~. ~` i ment DECEDENT ESTATE INFORMATION 1. Name(s) in which the account was held: ANN G LARSEN 2. Account number: 882473 3. Balance as of date of death: $45,048.61 Balance Accrued Dividends YTD Dividends Opened Regular Savings: S1 $5.00 $0.00 $0.00 11/2/2009 Christmas Club: S2 Whatver Club: S3 Checking: S4 Money Market: $44,038.58 $73.63 $112.21 1/28/2010 Certificates: Balance Accrued Dividends Certficate Number YTD Dividends $1,005.03 $2.58 64165 $5.08 $ $ 4. Date the account was initiated: CERTFICATE 11/2/2009 5. Name(s) in which Safe Deposit Box was held: NONE 6. Date the box was initially rented: 7. Branch address at which the box is located: 8. Loan Information: Balance Accrued Interest Per Diem Int A. Unsecured Loans: N/A L14 Classic Visa Card B. Secured Loans: N/A C. Mortgage Loans: $ N/A $ $ $ $ $ $ $ $ 9. Miscellaneous: r 1-800-773-7373 Call Citizens' special, dedicated Gold Custo mer service line any time for account information, current rates, and answers to your questions. US002 BR292 ANN G LARSEN 4833 E TRINDLE RD STE 538 MECHANICSBURG PA 17050-3654 Circle Gold Summary Circle Gold Account Statement of 4 Beginning March 18, 2010 through April 19, 2010 Contents Summary Page 1 Checking page 2 CD5 page 2 Account Account Number DEPOSIT BALANCE Checking Circle Gold Checking w/Interest 620938-705-9 CDs 3 month CD 6255-533213 6 month CD 6245-023241 13 month CD 6255-533191 Monthly combined balance to waive monthly fee is Your monthly combined balance this statement period is Balance Balance ANN G LARSEN Last Statement This Statement Circle Gold Checking w~Interest 620938-705-9 2,658.97 2,659.09 51,789.51 51,802.70 56,475.22 56,511.74 25,925.14 25,990.31 Total Deposit Balance 136,963.84 20, 000.00 n Total Relationship Balance 136,902.96 136,963.84 ?d1ernb?r rDIC Q Fquo! Nousin~ l-nder Page 2 of 4 ~S v~ 3~d3~~o Acet Metite:r~rnetiprrse QNE Fr~cra! Account, AtdRt ©!~-R3~h170D AcctNo:OD060321155 D21 ALC1Type:Mon-Qualified 1~axt !#aECryc T"ecicr B~aed Mkt. N~snc ~~ntrf~' 'Priod~) Velac{$j CASH ,GASH ~©5.59 ~.C)0 X05.59 ° E'QUNRL~iYT'S ' OPP Rd fVR~ICIf~ - A K ~C?~tG- OFPE~fftEtLlEIZ 1,~7Q.47 1(}.TZ 16,835_d5 ~1NTFRNEDlAT~- FUNDS TERM Accau~tTa~t ~~ts.s~~.04 The date of death values provided are for estate tax purposes and are not a value to be paid. Accounts may be subject to market fluctuation as governed by each product. Please note that the values indicated for any Life Insurance products with the insured deceased reflect the gross death benefit at date of death and not the cash value. Values indicated for Life Insurance products with only the owner deceased reflect the cash value as of the date of death. Values for any proprietary mutual funds include accrued dividends as applicable. Values provided for brokerage products are manually calculated, and should be used as estimates only. The prices used to provide values are estimates obtained from outside sources believed to be reliable. Ameripnse Financial provides these values~as a service to its clients. Actual values used in preparation of tax returns or for planning purposes should be verified by your legal and accounting advisors. Account Disposition Account disposition is based on how an account is owned (the ownership type). The following information will help you understand the process that will be used to settle the accounts. Accounts may be subject to market fluctuation as governed by each product. Disposition for Individual - TOD ownership Upon the death of the owner, all accounts registered as individual-transfer on death pass to the named beneficiaries. Although the assets do not become part of the estate for distribution, we understand they should be included for inheritance and/or estate tax purposes. If the brokerage account holds limited partnership or REIT investments the general partners must be contacted directly by the beneficiaries for the transfer of ownership instructions and paperwork. Required Documents In order to take appropriate steps to settle the accounts we will need these documents Certified Death Certificate (For accounts: 00060321 155 8 021) The death certificate must be an original document that bears certification from the health department or local registrar and includes the cause of death. Estate Settlement Form (3248) (For accounts: 00060321 155 8 021) To process a settlement on a Mutual Fund, Certificate or Brokerage account, each claimant must complete an Estate Settlement Form (Form 3248). This form includes separate sections for qualified and non-qualified accounts as well as sections at the end of the form to be signed and dated by all new account holders for all accounts. The account level suitability information requested on the form is required if you intend to retain the investments you receive through this process. If suitability information is incomplete will not delay settlement, however, activity allowed on any accounts created through settlement will be limited to liquidation only- We will not contact you to complete the suitability information. Instructions for completion of the Estate Settlement Form are available as Form 3248-INST. I3oth forms are available through an Amenprise Financial Advisor or online at http://www.amer~prise.com/amp/global/customer- service/account-service. asp under the list heading "Estate Settlement". hops://webmail.advisorcompass.com/whalecom3edc1568260bc822a659c8dd2cba9491 e4/... 5/19/2010 ~.~ a~C-s ~~~ 5o~tnd_,~:dvice. S~nartet-.~7~~cisio~-~s. 17 South Second Street, 6t" Floor Harrisburg, PA 17101-2039 717.233.1000 Voice 717.233.b740 Fax www.skarlatoszonarich.com September 26, 2010 Register of Wills Office Cumberland County Court House One Courthouse Square Carlisle, PA 17013 RE: Estate of Ann G. Larsen To Whom It May Concern: Sharon K. Shaffer, Estate Administrator sharon a~skarlatoszonarich.com Enclosed for filing is an original and one copy of the Inheritance Tax Return and Inventory for the above-referenced estate as well as a check in the amount of $$63.00 representing inheritance tax. Also enclosed is a check in the amount of $30.00 in payment of the filing fees. Please time-stamp the extra signature pages and return to me in the envelope provided. Thank you. Sincerely, r- ~r Sharon K. Shaffer Estate Administrator Enclosures ~ ~ - O ~ (~~ rn (: -~ :~?~ ~, ~ ~ - f- ~ <" _.. ; ~j _ „C1 .._...~ ~ ,rte, _ .. __ :.,. r...~ A Member of LawPactTM - An International Association of Independent Law Firms