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HomeMy WebLinkAbout10-14-101505610140 1500 EX `°'-'°' -"' REV - OFFICIAL USE O~Ll( PA Department of Revenue County Code YeaY File Number Bureau of individual Taxes INHERITANCE TAX RETURN PO BOx 280601 2 1 1 0 0 6 2 9 Harrisburg PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 9 1 1 8 4 4 6 7 0 4 0 9 2 0 1 0 0 9 2 9 1 9 2 3 Decedent's Last Name Suffix Decedent's First Name MI C O U L S O N J E A N E (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW 0 1. Original Return 4. Limited Estate QX 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE V~IITH THE REGISTER OF WILLS 2. Supplemental Return ~ 3. Remaind•rr ~eturn (date of death prior to 12-1 -$2) 4a. Future Interest Compromise (date of ~ 5. Federal ~st~'te Tax Retum Required death after 12-12-82) 7. Decedent Maintained a Living Trust 1 8. Total Nurj (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death ~ 11. Election between 12-31-91 and 1-1-95) (Attach CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRE Name B E N J A M I N J B U T L E R First line of address 5 0 0 N T H I R D S T R E E T Second line of address P O B O X 1 0 0 4 City or Post Office H A R R I S B U R G AND CONFIDENTIAL TAX INFOI Daytime Te 7 1 7 State ZIP Code ~ P A 1 7 1 0 8 of Safe Deposit Boxes x'under Sec. 9113(A) a) MI n i turf a~nuut.u tse uinec i eu ~ u: th,~nt# Number ~~ 6 1 4 8 5 N O WILLS U LY Y` ~ +a p -T, r,r..t ~ ,;. ~'J ~) -. ice- ~ r 1~J t %~ .yiC~4^1 T ~ _ `.~~ C"j -_' ~A E FILED `'`~ ~ "'ti I ~ Correspondent's e-mail address: LAWYERS UTLERLAWFIItM.COM Under penalties of perjury, I declare that 1 have examined this return, including accompanying schedules and statements, and to the of my knowledge and belie) it is t tract and complete. Declaration of p ter other than the personal representative is based on all information of which p pa erihas any knowledge. IGN F PERS01FF2ESP SIB R FILING ET ~ BATE ~D ~/Z~~ ~{DDRESS 2D80 B D RO ENOLA P 17025 SIGNATU OF P O HE REPRESENTATIVE DATE -fit L ~ ADDR SS 500 N THIRD STREET, PO 80X 1004 HARRISBURG ~IP ~4 171D8 PLEASE USE ORIGINAL FORM ONLY ~ ii 1505610140 rv 1505611]14,0 J 15D561D240 REV-1500 EX Decedent's Social Security Number Decedenrs Name: JEAN E• C O U L S O N 1 9 1 ~ IB 4 4 6 7 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 and Notes Receivable (Schedule D) .......................... 4. ~ ~ 12 3 2 . 1 9 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous N -Probate Property ~ Separate Billing Requested ....... (Schedule G) 7. • 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. r3 '~ 2 3 2 . 1 9 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9. 5 I1O 6 3. 3 5 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. 3 I~ ~I 2 1 8 . 4 3 11. Total Deductions (total Lines 9 and 10) ............................... 11. 4 3 ' 2 8 1 . ? 8 12. Net Value of Estate (Line 8 minus Line 11) ............................ 12. - 3 5 '' 0 4 9 . 5 9 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. - 3 5 ! Q 4 9 . 5 9 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.o _ 0 0 D 15. 0. D 0 16. Amount of Line 14 taxable ', at lineal rate X .0 _ O. D 0 1 s. ! D. 0 0 17. Amount of Line 14 taxable 0 0 0 0 0 0 . at sibling rate X .12 17. . 16. Amount of Line 14 taxable at collateral rate X .15 D 0 0 18. ', 0. 0 0 19. TAX DUE ............................................... ....... 19. D . D 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~ L I ^ Side 2 1505610240 150561O~41b REV-1500 EX Page 3 I~pr_'edent's Complete Address: Flle Number 21 10 0629 DECEDENTS NAME JEAN E. COULSON STREET ADDRESS ', 700 WALNUT BOTTOM ROAD CITY CARLISLE STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount (1) 0.00 3. Interest Total Credits (A + B) (2) ' 0.00 3 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Une 20 to request a refund. (4) 0.00 5. If line 1 +Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ' 0.00 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPR(~P~t1ATE 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; ............................... II ry c. retain a reversions interest; or ................................................................................................ d. receive the promise for I'rfe 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? ....................................................................................... 3. Did decedent own an 'intrust for" or payable-upon~eath bank account or security at his or her death? ......... l!,.J '' ^X 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a benefiaary designation? .................................................................................................: IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE Ili A$ DART 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 ort fort 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 surviviing pouse is 0 percent (72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transferto a surviving spouse from tax, and the statutory requirfem~nts 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 ffhe ~-se of a natural parent, an adoptive parent or a stepparent of the child is 0 percent 172 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, $xc~pt 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. §91 ~6(~)(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 adoptionl REV-1508 EX+(6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER JEAN E. COLJLSON 21 10 0629 Indude the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM ' VALUE AT DATE NUMBER DESCRIPTION !, OF DEATH 1. Citizens Bank -Checking Account 2. ~PSERS -Final Retirement Payment 3. ~ Highmark -Refund TOTAL (Also enter on line 5, (If more space is needed, insert add'dional sheets of the same size) 7,758.50 145.41 328.28 8.232.19 REV-1511 EX* (i0-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER JEAN E. COULSON 21 10 0629 Decedents debts must be reported on Schedule L ITEM NUMBER DESCRIPTION ' AMOUNT A. FUNERAL EXPENSES: 1. i B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Carolyn J. Leventhal 1 Street Address 2080 Brigade Road City Enola State PA ZIP 17025 Year(s) Commrsslon Paid: 2010 ', ', 1,500.00 Z, Atbmey Fees: Butler Law Firm 2,520.00 3, Fatuity Exemption: (If decedents address is not the same as daimanYs, attach explanation.) Claimant Street Address i ~, City State ZIP Relationship of Claimant to Decedent _ 4. Probate Fees: 106.00 5. Accountant Fees: 6. Tax Retum Preparer Fees: 2010 1040 and PA-40; 2010 1041 450.00 7. Cumberland Law Journal -Estate Advertising 75.00 8. The Sentinel -Estate Advertising 219.40 9. Executrix Expenses 103.15 10. Citizens Bank -Lost Key Fee 25.00 11. Photocopies 0.80 12. Cumberland County Register of Wills -Filing Fee ~I 30.00 13. ProSeries Charges ', 34.00 TOTAL (Also enter on Line 9, Recapitulations Z 5.063.35 If more space is needed, use additional sheets of paper of ffie same size. _ _ _._. _. _.. _ _ _ _. T T I REV-1512 EX+ (12-08) Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, Si LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER JEAN E. COULSON 21 10 0629 ' Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbutjsed medical expenses. ITEM ~' VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Commonwealth of Pennsylvania/Department of Public Welfare -Class 3 Claim (20 Pa. C.S.A. 3392(3)) 27,430.34 2. Commonwealth of Pennsylvania/Depardnent ofPublic Welfare -Class S.1 Claim (20 Pa. C.S.A. 3392(5.10 9,002.46 3. Forest Park Health Center ', 1,691.84 4. Graham Medical Clinic, PC 55.58 5. Pinker & Associates I 38.21 TOTAL (Also enter on Line 10, Recapitula~don~ I ; H more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-i0) pennsylvania ~ SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: JEAN E. COiJLSON 21 10 0629 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS Qndude outs' ht s usal distnbutlons and transfers under Sec. 91 f6 (a~1.2)J 1. Insolvent Estate Lineal ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVE S EET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: L A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. I TATAI AC DADT T< _ CAITCD Tl1TA1 AIl1A1 TAYA DI C f11CTG1O1 ITIl1AIC rlAl I I\IC ~O nc r~fw ~rnn nnvrn n~ Irrr ~'. ~ . v..-.rv • i-.. ~. u - ~.~. ~,~ ,vI~V I\vl\-IIVYlu4.V Vlvll~lVV I Ivl\V vi\ L11\L IJ VI- nGY-I~JW VVYCn J(iGCI. I .~ If more space is needed, use additional sheets of paper of the same size. ~' ---~-- o LAST WILL AND TEST MFNT ~ .oa~rr l~ QE ~ `:~~ ~ JEAN E. COLn~SON '~ c ~ ~~ "~ ~ UO'T1 -~ ~~ N I, JEAN E. COULSON, now of Franklin Township, York County, Penns~l Iaru~ declare= this to be my Last Will and Testament and hereby revoke all prior Wills and Codicils made by me. ITEM I. I direct that all of my just debts and funeral expenses, incluc~in~ the cost of my gravemarker, if any, shall be paid for from my residuary estate as soon as practical a~te~ my decease as an administrative expense of my estate. ITEM II. I give and devise all of my estate of every nature and whe~evjer situate as follows: A. Two-thirds (2/3) thereof to my daughter, CAROLYN J. LEVINTH~L, or her issue, per stirpes. B. One-third (1/3) thereof to my son, ROBERT F. ENSMINGER Shoull3 hle predecease me or die on or before the thirtieth (30th) day following my death, the share given him shill lapse and the same shall be paid to my daughter, CAROLYN J. LEVINTHAL, or her issue, pjerlstirpes. ITEM III. If any income or principal shall be payable to any person whp shall be under the age of twenty-one (21) or who shall be incapacitated for any reason, my personal ~e~resentative, as trustee, shall hold such income and principal for such beneficiary until the age of twe$~ty-one (21) or during incapacity and shall be entitled to apply such income and principal to the health, maintenance, support and education of such person without the appointment of any guardian or corkir~ittee or any I ~ :C _ ~.;. ,r`- r -^. ~~= f--i ,7 c=' _~ Coulson authority of court, and shall be entitled to make direct application hereunder or to make application by payment thereof to the parent or other person in charge of such person, or to his ar her guardian or to a custodian under the Uniform Transfers to Minors Act. Any remaining incom$ aid principal to which such person shall be entitled shall be paid and distributed to such person updn attaining the age of twenty-one (21) or upon the termination of incapacity. ITEM IV. I appoint my daughter, CAROLYN J. LEVINTHAL, E~eclutrix of this my Last Will and Testament. Should she fail to qualify or cease to actin such capacityp I then appoint my son, ROBERT F. ENSMINGER, Contingent Executor of this my Last Will and '~e~tament. No bond shall be required by my personal representative in any jurisdiction. ', ITEM V. In addition to the powers given by law to my personal repre~enltadive(s) and trustee(s) [hereinafter fiduciaries] in the administration of my estate and of any trust(s) ~'Icr~alted herein, they shall have the following discretionary powers applicable to all real and persona p~gperty held by them, including property held for minors, effective without court order until actua distribution. A. To retain any property owned by me at my death and to invest an~ filnds held by them in any stocks, bonds, notes or other securities or property, real or personal, inclpd~ng common trust funds, mutual funds and money mazket deposit accounts operated or offered b~ nhy corporate trustee, if any, or any affiliate of it. B. To sell or otherwise dispose of any property, real or personal, at an~ t~me forming apart of my estate or the trust estate, for cash or upon credit, in such manner and orl s1~ch terms as they see fit, and no one dealing with the fiduciaries shall be bound to see to the application ot~any monies paid. I Jean E. Coulson j 2 ~ r C. To manage, operate, repair, improve, mortgage or lease for any term Cevien if beyond the duration of the trust(s)] any real estate at any time held or owned by them as fiduciaries. D. To hold investments in the name of a nominee and exercise and dispps~ of warrants. E. To engage in litigation and compromise, azbitrate or abandon ciaimis property. F. To conduct any business in which I am engaged or in which I have ~n interest at the time of my death for such period as the fiduciaries deem advisable, with the power to barrow money and to pledge the assets of the business and to do all other acts which I, in my lifeti~id, could have done, or to delegate such powers to a partner, manager or employee. without liabil~tyl for any loss occurring therein. G. To allocate items of receipt or disbursement between principal an~ income as the fiduciaries deem equitable regardless of the character given such items by law; to distribute in cash or kind or partly in each at valuations fixed by the fiduciaries. H. To borrow money, including the right to borrow from any corpotrpstee, if any, and to mortgage or pledge as security or to hold its own stock if a corporate trusted. I. To join in any merger, reorganization, voting trust plan or other c~n~erted action of security holders, and to delegate discretionary duties with respect thereto, J. Should the principal of any trust herein provided for be or become too in trustee's opinion so as to make establishment or continuance of the trust inadvisable, my trust~e(~S) may make immediate distribution of the then remaining principal and any accumulated or undis~ril~uted income outright to the person or persons and in the proportion they aze then entitled to inco~ne~ Upon such Jean~E. Coulson 3 termination, the rights of all beneficiary(ies) who might otherwise have an interest as sucdeeding income beneficiary(ies) or in remainder shall cease. K. In general, to exercise all powers in the management of the assets ~f my estate or the trust estate which any individual could exercise in the management of similar pro~e~±ty owned in his own right, upon such tenors and conditions as the fiduciaries may deem best, and Igo e~cecute and deliver all instruments and to do all acts which the fiduciaries may deem necessary or ~rbper to carry out the purposes of this will or any trust(s) created herein. ', L. To apply income or principal to which any beneficiary is entitled, directly for his or her comfort, maintenance and support, should the fiduciaries deem such beneficiary incapable of receiving the same by reason of age, illness, infirmity or incapacity, or to pay the samd to'such person or persons as the fiduciaries select to disburse it, whose receipt shall be a complete acqui~ta#ice therefore without the intervention of any guardian. ', M. To assume continuance of the status of any beneficiary with refe~e~tce to death, marriage, divorce, illness, incapacity or other change in the absence of information dlee#ned reliable without liability for disbursements made on such assumptions. N. All principal and income shall, until actual distribution to any beneficiary, be free ofthe debts, contracts, alienations and anticipations of any beneficiary, and the same inlay not be liable for any levy, attachment, execution or sequestration while in the hands of any bene~ic~ary, and the same may not be liable for any levy, attachment, execution or sequestration while in tl~e hands of any fiduciaries. ~~ ~, Jean .Coulson '~ 4 ~T"~ IN WITNESS WHEREOF, I have hereunto set my hand and seal this day of /~8 ~ P YK IE7;~G~ ? , 1998. -~ Jean E Coulson the preceding instrument, consisting of this and four other typewritten pages, identified Iby tl~e signature of the testatrix, as on the day and date thereof signed, published and declared by Jean E. Coulson, the testatrix nam as and for her last Will, in the presence of us, who, at her requests ' her presence and in th rese ce of ea h they, subscribed our names as witnesses hereto, '. ~ y ~ ~, ~~. ~~ s ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA: COUNTY OF DAUPHIN . SS. I, JEAN E. COULSON, testatrix whose name is signed to the attache o~ foregoing instrument, having been duly qualified according to law, do hereby acknowledge that~I s~gned and executed the instrument as my last Will, that I signed it willingly, and that I signed it ~,~y free and voluntary act for the purposes therein expressed. Jean E.~Coulson Sworn affirmed to and acknowledged before me, by Jean E. Coulsdn, ~estatrix, this day of _ QK117f1~ , 1998. J II t~-~ I~ ' otary Public My Commission E ~s~ ' N T 1~1. SEAt '._" AFFIDAVIT ~ "S• b K'; Nofa-p Publlc ~ MY Cor~xnlasi $' Count COMMONWEALTH OF PENNSYLVANIA: ~-' 15,1999 . SS. COUNTY OF DAUPHIN _ ~ ~' We, C u ~~ ~ ~ ~ C~t.a, Q ~ n ~ ,the witnesses whose names are signed to the attache or foregoing instrument, b ng dul q alified according to law, do depose and say that we were present and saw testatrix sign and a ce ute the instrument as her last Will; that she signed willingly and that she executed it as her end voluntary act for the purposes therein expressed; that each of us in the hearing and si ht~Of the testatrix signed the Will as witnesses; and that to the best of our know e slat at that time 18 or more years of age, of sound mind and under no consti~ai a nfl Sworn to and subscribed before me this 7 ' ~' day of brt f'Y1 ~ ~~ , 1998. My Commissior~Exp pY~ ~.~~~ My Cornmlasion Fob,15,1999 ~ pennsylvania DEPARTMENT OF REVENUE August 9, 2010 Benjamin J. Butter, Esq. 500 N. 3rd Street, 12`" Floor Harrisburg, PA 17101-1146 Deaz Attorney Butter: '!, Pursuant to your request that a representative of the Pennsylvania Department of R~ve~nue appeaz and inventory a safe deposit box in the name of Jean E. Coulson deceased, author~za~ion is hereby given for attorney of the estate to access the safe deposit box without the pr s nce of a representative of the Pennsylvania Department of Revenue. You aze hereby authoi~z~d to access the safe deposit box on or after Angu~t 20.2010. You should present this letter to i ' ens Bank as evidence of your authority pursuant to 72 P.S. § 9193. This authorization is made only to Beniamin J. Butter. Esq. and may not be deleg~t~d to any other person. In granting this authorization, Beniamin J. Butler. Esq. agrees to pr~ep~re and submit an inventory of all contents of any safe deposit box accessed and to submit 5ai~d inventory on the form provided by the Pennsylvania )department of Revenue, to the Pennsylviania Department of Revenue within seven (7) days, from the access date, by mailing to:' Pennsylvania Department of Revenue Harrisburg District Office 1825 Stanley Drive Harrisburg, PA 17103-1256 Sincerely, C% ~~ Anthony Rovito Acting District Administrator Attachments Cc: Cititzens Bank 4 S. Baltimore Street Dillsburg, PA 17019 Department of Revenue ~ 1825 Stanley Dr.~ Harrisburg, PA 17103-1256 ~ 717.425.7700 ~www.revlen4eatate.pa.us _...._._ SAFE DEPOSIT BOX : PLEASE (PRINT OR TYPE t iST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTIC)N WHERE SAFE DEPOSIT BOA IS LOCATED AND ~} .....•...._.___________..._.___,__,___.__ ___ RETURNED TO ABOVE ADDRESS ` 1~CaU1~4~.__~:~~ 2. _ . ~ -~ ~~I~(~~~R~_,_. . - 3: SOCI;4L SEGU~11'Y,`:01~' DE-igTN CER~fII~tCATE NUMBE 21 .__._._ 121 10-0629 191 18-4467 .~ 4, DECEQ~Iy_T`ivl~- LASTFIR~ T~MCDE3 E .. ~-- R; , i _ , _ ,, ~ .. .~___--~ Coulson; Jean E -_- '" _ { - H ' _ __ .. _ .. _ _. , ,,.. _ , ., .. , , 0 /09/10 w~ `- SI` TE . ZtP ~Qb'E 700 Walnut Bottom Road ~ -- ~ _-"~ -~~°__°~- ~~-~----~ ---~-._~. - -- -.----- ;Carlisle ----°-- - ~ ATCORIVEY tst4TuFE --_._ _-_ - ~ _ _- .---._.~~~_~_~__.~.,.,sPA ;17013 `-' 3enjamin J. Bulter _.._._._._._____--~_.__.._ __~... .~,..~ .._.._ ._._._. .~.~_.. .~_.,~._,~~ ~- ____._ iTF2EET'i4DDRESS"•~..-_.~___.~ -- - C1T1" ~.v`'' . , ~' X00 N. 3rd Street ~-___. 12th Floor ~ ~ "*-' ,_.^ S~r~r ~}ZaPCO E , Harrisbur 9 .NAME ADDF~I=SS f~ND RELATIC7NSFtlI~:_(IF ANY TODEC PA 17101-1146 ,ED~hI.T,D~~EF~SQ ; ISS~~'RESENT_i~T-'r --1~~nY~ .~ ~ r~.~ _~ u~ r~vv-:vr r~r[ .~I~tbIf~CL t ~, ~. itizens Bank S. Baltimore Street - ~ _ DATE OF COWTR/kCT~Tb'REN7BOX, ~-3 Ni>1hitRGR wz~~av VAM,E. A ME)_ ,~_ "=STATE :`~ IP CODE V ~~ -, ___. SAFE DEPOSIT BOX INVENTORI~ - INSTRUCTIONS CASH: REPORT TOTAL ONLY. ,~) STOCKS: LIST IN DETAIL EVERY COMMON OR PREFERRED CERTIFICATE, WARRANT OR ~T~iER RIGHTS FOUND IN BOX. STOCKS ARE TO BE DESIGNATED BY NAME OF COMPANY, CERTIFICATE NUNIIB R, DATE OF CERTIFICATE, NAME IN WHICH STOCK IS REGISTERED, AND NUMBER OF SHARES AND CLASIS F STOCK. - (3) OBLIGATIONS OF U.S. GOVERNMENT: NUMBER OF ITEMS, DATE OF ISSUE, FACE VALUE, N MES IN WHICH REGISTERED AND TYPE OF OWNERSHIP, ie.. JOINTLY HELD, PAYABLE ON DEATH, ECT. (4) BONDS: DESIGNATE BY NAME, AMOUNT, SERIAL NUMBER, OR OTHER DESIGNATION. (BEAR R BONDS) (5) BANK AND SAVINGS AND LOAN PASSBOOKS: STATE NAME OF DEPOSITOR, NUMBER OF ~OIOK, LAST DATE APPEARING IN BOOK, NAME OF BANK AND BRANCH, AND BALANCE. (6) JEWELRY, COINS, STAMPS, MANUSCRIPTS, ECT: LIST AND DESCRIBE AS FULLY AS POSS~B E. ;7) DEEDS, MORTGAGES, CURRENT INSURANCE POLICIES OR OTHER EVIDENCES OF INDEB'~E~NESS: LIST AND DESCRIBE AS FULLY AS POSSIBLE. :8 _ALL OTHER CONTENTS. _ _ --r- - ----- .__.....___ __.__._...__.__... _ _ ; TEM NOS _ _~ ~~ ~ _ ___.__- ~, f~•__J' ITEM DESCRIPTION ~~~ _~- ~ --~ jr' •_ _._._.__._.~. N~~r,j /~ ~n .f~+i,l~,~ _ i q B/ ~'aci~i t LY--~--~r P-~4.S~I.e.~---~I~--*I'-~ n~/1 --r•--- ~ °'- /s"'7/ ~../fi»..t Otd ~®, %/,Sbo~~ ~ f' P ~n a:F ~s71~ 13.E .. -. ~ ._l.._____ ~~~ -r ! s7L 6 ~ l~- R d -1 r ------------------r----_ _.._...._.._... ---..-...~_.._....._..... ~..._.--- _.__..._. _ .._ __ _ __._._ ~ .. _..._..-_. __.._-_ _._...__ -----~ _ __._.._._.._____-__..__-------~I----'---. - :ERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE PERSON RECEIVING COPY OF SAFE DEPOSIT OX INVENTORY: :CORD IS CORRECT AND COMPLETE TO THE BEST OF MY ~OWLED~E AND BELIEF. ~hls'TI Yd~~~x 5 v~ ~ VJ'~G / A /\ i r.w"'k `^r"J"T7'^~-~-r,~- n _ _ ~ ~ / `-. , 1. INT _ E .` `_ _ ___. _ - :P}~iN1a!;~ A/I'J~ bC : C IMP , i~•F/4.'I>`E`?BD` °SE b ~~.: ~.. ----...~ iNr TITLE -- ----- --- yn ~ L~.v, ~ ~ ~ GI ~,t~,~1P~~~1P`RtA SOX ~~` ~~~~4 _ - N ~ T~ i ~S ~ L~ i- -~r~F~C~}TpR(j~~,~~~ Y ~ ~r ~ ~ ~? . M IVI ~~2ATp --------- -.....--•--•-•-- -- I zESTi4T'l=' R'ITPE~ESI=I~TATt!iY~ ~ ~ i _._ __..._____.___.._.~_...~ _ ..... ar, : ~t~WwER of 3, .... _~ ~ ~ ~ ~ --~--• A~FE ~PC?SIT BpX )TE: ATTACH ADDITIONAL 81/2" x 11" SHEET(S) IF NECESSARY OR USE DUPLICATES OF THI~ P GE OF FORM. ___ _ _ _ ~t ~#i~~ns Bank i-800-862-fi200 .: . Call Citizens' PhoneBank anytime for account information, anent rates and answers to your questions. 05102 BR319..:.:;::•, .:: :.:.... ~~ AROLYN-JEAN LEVINTHAL EXEC 2080 BRIGADE RD ENOLA PA 17025-1472 Business Partners III Account Statement © qP 2 Beginnin~ June 21, 2010 through ~une 23, 2010 Con~eilts Sum aryl Page 1 Checking' Page 2 Business Partners Checking III Summary Account ~' 6alana ilalana ; ,, ,~ ~' Lsst Statement This Stabment ~~ ~ JEAN LEVINTHAL EXEC DEPOSIT BA-LANCE BUST !S Pi it III_ Chetiling B Business Partners Checking III ~` NOT AVAILABLE 8,727.88 Total Deposit Balance `rl ~ 8,727.88 n ', Total Relatlonsllip batanoa `TI, ~ 8,727.88 -- re-w~~ o F,~ q6~. ag nn ~~ 'V'enn OVRr~wy/~1~/1~ ~, ~\ ~~ ~~ • <~ ~n G~ Member FDIC ~? Equal Housing Lender COMMONWEALTH OF PENNSYLVANIA SCHOOL EMPLOYEES' RETIREMENT Mailing Address PO Box 125 sburA PA 17108-0125 Toll-Free - 1-888-773-7748 Building Location (1-888-PSERS4iJ) 5 North Sth Street Local - 717-787-8540 Harrisburg PA Web Address: www.psers.statepa.us May 21, 2010 CAROLYN LEVENTHA~ 2080 BRIGADE RD ENOLA, PA 17025 RE: Jean Coulson SSN: XXX-XX-4467 Dear Ms. Leventhaw: The Public School Employees' Retirement System is processing the benefit of J~arh Coulson. Please accept our condolences on your loss. ', i PSERS issued the following monthly retirement benefit(s) prior to processing the} death benefit: Check Date Check Amount May, 2010 $484.69 April, 2010 $484.69 Jean Coulson was entitled to a pro ted amou t of $145.°_ 41~e month of Ap~il.' Therefore, please reimburse PSER $823.97, ich represents the total of the ~dnthly benefit payments and debts (if applicable) lis d above minus the prorated amount. PI ale make your check or money order payable to hool Employees Retirement SyStefn. Please retain this information for preparation of the member's final tax return. If you have any questions, please contact the PSERS Member Service Center y ~alling toll-free 1-888-773-7748 (1-888-PSERS4U); Harrisburg local callers, please us~ (717) 787-8540. To contact PSERS by e-mail, use the following address: ra-ps-contactQstate.pa.us. For your convenience, the Member Service Center ~s staffed each business day from 7:30 a.m. to 5:00 p.m. You may also find additional informat orb on the PSERS website: www.psersstate.pa.us. I ~ Sincerely, ~u6Ue SekooG £~lo~peea' ,~al~e~u~d S~~ J ~~ 9 ,~8~'L v ~ I ~~ 9^~ ~e \~~~ ~f ~ c'~ o - v.. IIIIIII~IIIa11111111111NflI1111~N111 y ~. J .tl f C 4 : . ~ ~. H l~ti!~fZ ~- %~ IG . .. ~ . :. m . .. . f .r i .,. .. _ .. -_ _. .. .. ... .. ~ .. :'.:. - _. ~ ri 1 .. 0311426: ~ , .:::: ~ _ ~:::::: , ~...:::.~:~ :. ~~'03 1 14 26u' x:036076 L50~: 6 2054 5 2 58 Ln' ',~