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HomeMy WebLinkAbout10-18-101505610140 REV-1500 EX (01-10) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 0 0 6 6 3 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYW Date of Birth MMDDYYYY 2 3 4 3 6 7 1 6 8 0 6 0 8 2 0 1 0 0 8 2 1 1 9 2 3 Decedent's Last Name Suffix Decedent's First Name MI SCOTT R E B A C (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 Q 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) 0 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number JOEL R. ZULLINGER 717 264 6029 First line of address 1 4 NORTH MAI N STREET Second line of address S U I T E 2 0 0 City or Post Office State C HA M B E R S B UR G P A Correspondent's a-mail address: ZIP Code REGISTERt,Q.~ VHILLS USE~U~LY _-_ _ t_ ..-~ ~-T , _ :;~~3 :> 4a; ~ -~ -~_r.~~ ~--- _ c-:~ ~ _; _ ,_, ,_ - . ~, _, > --~ ~ ~~ t3ATE"IFILED __ - 1 1 7 2 0 1 t ~., _..~ _, r f ...~ i . , _'t ..:~- 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 mplete. Declaration of preparer n the personal representative is based on all information of which preparer has any knowledge. SIGNATURE ~ER~S~ON~ RESPONSE'!/ OR FILI C)~TE~ ~~~~1/lid/ ~+ Iw /'/~ tliu iJ1 ADDRESS 85 HANNA ROAD NEWBURG PA 17240 SIG F PREPARER ATIVE ADDRE ~ /~ / ~ 14 RTH MAIN ET, SUIT 00 CHAMBERSBURG PA 17201 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 150561014() J r -~ (~~~ J 1505610240 REV-1500 EX Decedent's Social Security Number Decedents Name: REBA C. SCOTT 2 3 4 3 b 7 1 6 8 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. • 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).. ..... 5. 8 9 3 • 6 8 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .. ..... 6. 6 IJ 6 8. 7 4 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested .. ..... 7. 6 '~ 9 3 . 8 8 8. Total Gross Assets (total Lines 1 through 7) ...................... ..... g, 1 3 ~ 5 6 . 3 0 9. Funeral Expenses and Administrative Costs (Schedule H) .... ....... ..... .. 9. 1 2 ,3 3 0. 7 5 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ...... ..... .. 10. • 11. Total Deductions (total Lines 9 and 10) ................. ....... ..... .. 11. 1 2 3 3 0 . 7 5 12. Net Value of Estate (Line 8 minus Line 11) .............. ....... ..... .. 12. 1 1 2 5 . 5 5 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. 1 ,' 2 5 . 5 5 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 0 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .045 1 1 2 5. 5 5 16, 5 0. 6 5 17. Amount of Line 14 taxable at sibling rate X .12 0 0 0 17. 0. 0 0 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 18. 0. 0 0 19. TAX DUE ........................................ ....... ..... ..19. 5 0 • 6 5 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^ Side 2 1505610240 1505610240 J REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME REBA C. SCOTT STREET ADDRESS 98 Qui le Road CITY Newburg STATE PA ZIP 17240 Tax Payments and Credits: ~. 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. File Number 21 10 0663 50.65 Total Credits (A + B) (2) 0.00 (3) (4) 0.00 (5) 50.65 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 : ...................................................................... ^ ^X b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q c. retain a reversionary interest; or ................................................................................................ ^ d. receive the promise for life of either payments, benefits or care? ....................................................... ^ Q 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ^ Q 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ......... ^ ^X 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? .................................................................................................. ~ ^ 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 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, undE 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 COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, 8c M~$C. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER REBA C. SCOTT 21 10 0663 Include 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. Account #332038, Orrstown Bank 513.88 2. Account #801461, Orrstown Bank ( 379.80 TOTAL (Also enter on line 5, Recapitulation) I $ 893.68 (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: REBA C. SCOTT _ 21 10 0663 SCHEDULE F JOINTLY-OWNED PROPERTY If an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RFI ATIC)NSHIP T(1 f1F(:Ff1FNT A. George W. Scottq 85 Hanna Road Newburg, PA 17240 son B C JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET °~o OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. Account #6900166907, Invesco Van Kampen Capital 1,150.38 50. 575.19 Growth Fund - CL A, 104.0130 shares @11.0600 2. A Account #672124382, Invesco Van Kampen Senior Loan 10,987.09 50. 5,493.55 Fund, 1,749.5360 shares @6.2800 TOTAL (Also enter on Line 6, Recapitulation) I $ 6,068 74 If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+ (08-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER REBA C. SCOTT _ 21 10 (l~iF~3 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 NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY of THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1. Account #01122407664 3 002, Ameriprise Financial, titled 6,493.88 100.00 6,493.88 Reba C. Scott, transfer on death to George W. Scott, son, and Phyllis Hershey, daughter, equally TOTAL (Also enter on Line 7, Recapitulation) I $ 6,493.88 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER REBA C. SCOTT 21 10 0663 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Fogelsanger-Bricker Funeral Home, funeral services 10,938.14 B ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Paid: State ZIP 2, Attorney Fees: Joel R. Zullinger 1,250.00 3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address 4 5 6 7 City State ZIP Relationship of Claimant to Decedent Probate Fees: Letters - 45.00; will 15.00; short certificates 16.00; JCS fee - 23.50; automation fee - 5.00; filing return 15.00 Accountant Fees: Tax Return Preparer Fees: Mailing fees for account liquidation 119.50 23.11 TOTAL (Also enter on Line 9, Recapitulation) I $ 12, 330.75 If more space is needed, use additional sheets of paper of the same size. REV-1513 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: FILE NUMBER: REBA C. SCOTT 21 10 0663 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 [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. George W. Scott Lineal 85 Hanna Road Items 1 &2, Sch. F Shippensburg, PA 17257 1 /2 of Item 1, Sch. G 2. Phyllis Hershey Lineal 126 Neil Road 1 /2 of Item 1, Sch. G Shippensburg, PA 17257 _ I ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. jj, NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B, CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET, I ~$ If more space is needed, use additional sheets of paper of the same size. TD r7 ~ ~ n ?- r o (1 ~ o r 7 '7 (1 2 Ul\LJ _. J . _... :~CCt~ .~~ ~..C ~ob~. 1_ ~ , ~~0~ LAST Y~ILL ANI3 TESTAi~2ENT ~ ' ~ ~ _. J , ~~ _ ~ 11 I, Reba ~. Sc®tt of 98 Quigley Road, Newburg, Penn~~ylvania, being of sound and disposing mind, memory and understanding, do 1-~orol-,~r ~r~rl ~rc~ ~l~i c f-n be m5r ;.;ill 1-ier~l~tr rc~tvnirinr-r anZr any ~l l 1 1 \.... 1 V J.J 1 \A V \... 1 l.il 1 V 6. 11 1 ~...+ ..~ v , ~... A/ V > .L 1 1 ~n 1r - V. 1 1 former wills and codicils thereto by me heretofore made. r i ~... . r` __ _ ~ _ _ -.: ~ ~- ~ ~ - - ,- - - -' ~ ~ i ~ ~ ;~ ._ ~ tL, i -- i - -~ _ _ _, . . , _S`~ti~_-~ -= ~GC1~ ~_S .a~:t-! Cam ~, -~ ~ _~ 'a'.i ~._..~1.8= ~_ =_ _ ____, i~: _I1~ ~~,~ -- - ~; '` ~.~~ ~,~~ e `~ } ~;•.: ~` .~ 1~ll I give, devise and bequeath the -residue of my estate of =very :1 ~-.. ,~ nature anal wrierever situate to ~~y son, George V~1, Scott, ;~rov:iding .. ~.~ he shall survive me by thirty days . Should my son predecease ~~:ne or .` die on or before the thirtieth day following my death, I give and ~ ~. \° , ., devise the residue of my estate to his ~aife, Janet KridE~r Scott . Should both the said George W. Scott and Janet Krid.er Scott predecease me or die on or before the thirtieth day following my death, I give and devise the residue of my estate to my grandsons, Travis W. Scott and Tyler P. Scott, in equal shares. i i i Any fiduciary under this will shall have the following powers in addition to those vested in them by law and by other provisions of „-, 1' tAr, 11 appl ; rahl e to all property whether principal or income, including property held for minors, exercisable T~ithout Court apprc,-,ra l and ~f fect i ve until actual di stri buticn of all property _~ _ _. ~ ~ -t t ~ . 1-~ -- _ _ ~ L __ _ _ . _. i _ i. l U _ v !~ a I iZ ~ 11 / a ~ 1 ~.t ~ .~ _ '.J L L. 11 C: d iJ ti v ~__ ~ J 1 . e l ~~ ~ i._. L ~ : _ `. ~, i ~ d. L .~ L _~ __ ,_- O lp ~ _ y-~ 1 C _~ 1 C' la ~_ ~ ° ~~ a r'd t C ~ Z 1?1J l/ ~'~ i 1 ~ ~ . 1_ i.~ i ~ '~ 1 _ ~ _ - - - _ - _ ~ ~l _ ., -. -. - -- - -- - - _ _ - --, ~~`t:....~_! -- __- - -~-~_-~-,i~- ~-~C1. iii;~_ --G _ _~:~- ~U` .!__:~ - ------._.~_ ;~~~ _!"!C~-~.~_, -- - `- !_ r - ~" ~ (.' 1 . _ `~ - ~ "' . r v ~ t Yl r' 1 _ '~ ~ ~ ~ i_ ` 1 ~_ ~' l - °_ C~j- _ ~i i _. _ _. ; i ti'7 TV' .l'J ~~.. n ~ d ^~ - ic~uc i a~_ ies as thev deem grope ~~ . Irv i t t~_out re~a-_ d to an~j °~ ~~ r 1 r v L ~ t 1017 O L z 18 }L . p_inczp_e o_ di ersiL_ca \ C. 1o sell at public or private sale, ~o exchange or to `~~~! lease for any period of time any real or personal ~~ ~~~ ~~~~,~; property and tc give options for sales, exc~-angel or leases , for such prices and upon such terms or c:ond~.tions ~ ~, ~v `~ as they deem proper. ~~~; D. To allocate receipts and expenses to principal or income 4 ~ ,t or partly to each as they from time to time think proper . J E. To compromise any claim or controversy. F. To distribute in cash or in kind o_r partly in each, Page 2 G. To hold property in their names without designation of any fiduciary capacity or in the name of a nominee or unregistered. Iv. I direct that all taxes that may be assessed ;n consequenr_.e of my death of ~njhatever nature and by ~~~hatever jurisdiction imposed, shah- ';e _~ai d from my resi duar,,T estate as a ~~.rt of the e:xpen,~e of ' ~ r - - - - l. 11 e ~ i~ i l t ~ 1"]_ i a =L ..~ . ~ l.. -! O 1 _ ~ t i l t ~y/ .., ~.~ l~ ~ ~l~ ~ .. ., r. " i ~ ~,~ app01~1t ~.c":Ilet Krlder SCOtt as el~ecut ~~i s Of t~~18 l~ty x,'111 jhOU ~ Ci ~~• ` ` Janet Krider Scott predecease me, fail to qualify or cease to act, ,, ~ ~ t ~ '..~' I appoint. noel R. ~ullinger as executor of this my will. ~. ~~ l ' '1 1-. .--~ n r No ,pond hall b~ L equired of any fiduciary .~ v. hereund~~L lr~ any jurisdiction. Page 3 ~a~ :~~~~vF~~~ €~i~~~'©~', I here~anto set my hand ar~d seal to this my last will and testament, consisting of five typewritten pages, the first three of which bear my signature in the margin for the purpose of identification this _ :~',~_ c~<~y of ~_ --- .-- ~- --~~ ~' ~ _ j ,. - _.. __ _ _ ,.. n ,: \ .=~r'~' .f ~-z~' ~ ~-! ~ w/ ..~ ~~ ~z _ t~: (~ SAL ) 5~~~~-r; :sealed, published and decla-red ~v the above-named - - -~ r, %c~'~1_^ ~__!_~J_ Y. ..~~ a~ld i_v i,- i~~ _ ~ o ~ ~ ~iv~.i_. and _ ~~tcailiF,,--;t _=.. _ .'_Y ~~~v':~~~T=c'c~ - ~ _.~ ~ - _~ - ~r,L. ~ l-- ~~ !-, ~t ~ ~ ~ < ~ ~ °~ ~ ~ ~ ~.~ tt f _ ~` @ i ;.. . !P f / . ~ ~~ _ /~ ,~ ~ ,~~ 4' ~ % W e f ~ ~b a C . S c ~ t t , ~f f --~~~~~~ ~ ~ /) ~ ~/f~~°`- ~ --- and ~~~~~,~, ~~~'~~.' ~ . ~~6 f~..~ the testatrix and the ~,~itr~esses respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declaz~e to the undersigned authority that the testatrix signed and exE~cuted the instrument as her last will and testament and that she e~cecuted it as her free and voluntary act for the purposes therein expressed and that each of the witnesses , in the presence and hearing of the Page 4 said testatrix, signed the will as witnesses and to thE~ best of their knowledge, said signer was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence . _ _ ,, ,. .-- _ ,~ - _.__. ~~ - ~--~:_ s `_ . ~ ~ - ~/C~ /~ ~ Witne~~ ~. r~ ,, ; n. ._ r ,; _._ _ .< i F ~ .. i ~~-i='ilr-; S s .~~e ~ ~~~_ _ _ - ~ r _ _i~_~ .,-.%__-~~a~<<ed ~ _an~_ a_ ~~, ll .~ 1 ~ ~ / 9 TSvtca~~y rubiiC COMMONWEALTH OF PENNSYLV14NfA Notarial Seal Card J. Weitt~er, Notary PUbfio Se-~tf~ampton Twp., Cexnbe~and Cexrky My Commission Expires Sept. 3, 20Q7 .'Member, Pennsylvania A,ssociatiGC~ Of Notaries Page 5 _ 6/8/2010 Customer Information File Inquiry 09:49:08 Reba C Scott CIF number: 5023406 98 Quigley Road Short name: SCOTT REBA C Newburg PA 17240 Tax ID number: 234-36-7'_68 Class: Personal Language: ENGLISH Messages 1 of 1 Num Deposits Avg' Rate Num Loan Bal. Avg Rate Other Direct 2 893.68 .00570 0 .00 .0000% 0 Indirect 0 .00 .0000% 0 .00 .0000% 0 Related 0 .00 .0000% 0 .00 .0000% 0 Opt Account No Type Relationship Balance Remarks A/A _ 332038 50+ Int 513.88 _ 801461 MMAAcct 379.80 _ 234367168 FNIC .00 Bottom F1=Addl func F3=Exit F5=Customer F6=Messages F9=Profitability F:L1=Related Cust F12=Previous F14=Liability F15=Credit Line F16=Tax Reporting ]~18=Guarantors Slyn Out Coniaee U/ 0 Administrative O Nelp l~sset5 Clients Statements Plans Cllenr List Gient Households rtece~nt Transactions As~et~ & Prices pate Extract Clirclts ~ C,ILent AccQl~ncs r ACCO~nt Oetells Account Value by Date Atxount a: 69001907 Mpm! CO: INVESCO ~'~~~CQ itegiabpt~oA: REBA p $CQTT d vvAO Name: ~/ESCO YAN i(AMPEN CAPITAL QApWTH FUND - CL A GE-0RGE W 6COTT JT T!N Vicw F~nq~,Qtall9 AA OuIGI-~' ROAG N~WDURG PA 17240.9972 Fune C04m; 1785 Statements / TiMter: ACVAX Total3har~a: 104.0130 TeX Forms i~ho>w0 +l>: Not On Rip CUSfA: 00143nn778 ACOOrAt Vale: 51.19.09 yl~iCtlent~epup•eg Account Type: 03 • JOINT TENANTS ~L1;aX Fprms Enter d DrfCe dax Uo n-trleve an account value h9m a prevrous day. TransaCtipe>s ~ •, •- P~Ice Dace: O6/O$/2070 ~8aaie~• 1:X+CEa>I19,e MaintGnanee Cup-~vnt Drlee Oece: 08/aW2010 Price Daee: 06~08~2010 Rio A~~,~ Cu-r~¢nt Net ABeQt Ve1ue: y10.7300 l'IVe A88et Vel~e: $11.0600 Current Total Shares: 10x.07$0 TOtel Shares: 1G4.01a0 Details Cu~ent Vaiuo= 51,11B_OS value. 51,'150.38 Bcet_Qltooi3mr. Acct Value try Datp Transaction His•Qpty l~SiL~11~e?• Charge Galculat0! ~reakpoln[ Genter~ $19~S~41 Accum~Qatl v n ~~~o/~ ~ ~~~ ~~ ~~~o Jest' ~ , 2010 INVE.SCO ContaSc ua. I la.L~talmar Copyright ®2010 DST Systems, InC• All Rlg~t/ ReearreC, CovcrcG et' u5 Pat9nc No• 7,275,046 --- ~ ~zl P _~' /©. ~ ~~ ~ 7 ~ ~~` ~~~ ~ J -~. hrips ://www3 .financialtrans.tom/tfNision/~ccountValueByDateSearchEvent I00 'd ~~OOZ9ZL IG ~ X~~ x~I~g ~I~IO,~SHHO '7/1!2010 U~Ib ~~~ ~ l l (1H,~ OIOZ-lO-Z(1 Sign O..C COnCaci Ys O AGminlstraGve ~ Hcip 0 Assets Clients Statements Plans Qlent LISt Client Mousahoida Recent Trensac[lons Assets 8c PrfcQS Data ldxtract ~e~t V6:11:i~i:;iL.Ci11C0.C5 > f ~llsnt nccount~ > Account Derails Account Values by Date Account at: 672t242B2 t~lymt Co: INVSSCO f n~ e~ ° iteglstra4on: RESA C SCOTT e. Fund Namer INVQSCO VAN KAMPlN 3eNIOR LOAN FUNO .CLASS IB / -~. Ct GlORGlwSC0TT.ITTEN ~~, F~ntl D,fl~jS, 86 QUI6LlY ROAD NEWBURG PA 178~0~9972 Fun4 CO4~: a9P7 Statements / TCkmre XPaTx Totsl Shares: 1,7a9.SS60 T8x FOr1nS Phone ar: NO{ pn Rte CUSIP: •81910x08 Account valuer 3109~>'.10 j~atements /Tax Yl¢1n..~liAtll,Af000ugl9 Acw~nt Typer 0®- JOINT TlNANTS •EsiCOrs Enter a pNcc date to nptrltrvo do iCCOUnI ~81rd from a previous day. Details Price Gate: oaro8rao~a ~+:~ Actd`QY.ecxitnr Acet Value sir DaDe N Cunene prlw Oaty: 06/30/2010 Price Date: 0908/2010 lstorv Transactlan Current Nat Aosee Val„v: 86.2400 Nei Asset Value: 36.2800 Current Tow! 5harefa: 1,749,5$80 Total Eheres: 1,7x8.5360 e,~eli; Eea,ss.~os tenant vales: $10,917.10 vawe: 810,987A9 ~-i~a.~lll~.iLl~~e ~~~eAia Io.D..of,gaye 2A~09 ~ax,SMn~ma..7c 2010 Tax 3urnn~~ 8reakOeinlCe~Der .R ncs or Aae~n-~ulAt;~on GcnsaclLUS• I .Rlliclaftet~e~ Copyriflht ®2010 057 Systems, inc. All Rl9hts Reserved. Covered by US Datent No. 7,275,046 hops://www3. financialtrans.comltflVisionlAccountValueByDateS eaz~chJEvent ioo~iao ~~ ~~OOZ9ZLIL ~kd~ ~I~Idg NMOZS~HO July 1, 2010 ~nrvesco 7/1/2010 U~Ib I~~ ~ I l flH,~ OIOZ-IO-Ztl Ameriprise Financial July 21, 2010 ZULLINGER-DAMS 14 NORT MAIN ST, SUITE 200 CHAMBERSBURG, PA 17201 Dear Joel Zullinger: RiverSource Life Insurance Company RiverSource Funds Ameriprise Certificate Company Ameriprise Brokerage 70100 Ameriprise Financial Center Minneapolis, MN 55474 W~ have received notifi~~ation of REBA C SCOTT's death. Please accept our condolences on your loss. The deceased's name is associated with the following accounts. Account values as of 06/08/2010 are listed below. At the end of this letter, you will find a list of beneficiaries shown in our initial review of the accounts. Account Information ~~Iutual Funds Account Number Ownership 01 122407664 3 002 Individual - TOD Mutual Funds Account Number Total Value # of shares 01 122407664 3 002 $6493.88 1,314.937 Asset Value Per Share 4.93 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 fluchiation 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. Ameriprise 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. 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. Insurance and annuities are issued by RiverSourcE Life Insurance Co~~ipany, an Ameriprise Financial company. Ameril_~rise Brokerage is provided by Ameriprise Financial Services: Inc. Ameriprise Financial Services, Inc. Nlember FINRA and SIPC. Required Documents In order to take appropriate steps to settle the accounts we will need these documents: Certified Death Certificate (For accounts: 01 122407664 3 002) 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: 01122407664 3 002) To process a settlement on a Mutual Fund, Certificate or Brokerage account, each claimant must complete an Estate Settlement Forni (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 tlu-ough this process. If suitability information is incomplete will not delay settlement:, however, activity allowed on any accounts created through settlement will be linuted to liquidation only. We will not contact you to complete the suitability infornation. Instructions for completion of the Estate Settlement Form are available as Form 3248-INST. Both foi7ns are available through an Ameriprise Financial Advisor or online at http://www.ameriprise.con~/amp/global/customer- service/account-service asp under the list heading "Estate Settlement". Request for Waiver or Notice of Transfer (Possible) (PA) Form REV-516 EX (For accounts: 01122407664 3 002) This document verities that the state tax bureau is consenting to the transfer of the assets. Form REV-~ 1 b should be completed by the beneficiary and mailed to the Petuisylvania Department of Revenue. A waiver will be sent to Ameriprise Financial stating that the assets can be released. Please Note: Due to State and Federal Laws, the requirements listed above are subject to change. Common situations that may require additional documentation are: minor beneficiaries, nonresident aliens, deceased beneficiaries, the claimant's marital stahis differs from the original designation (spousal beneficiaries only) an incorrect spelling or name change of the beneficiary. If any of the above situations apply, please contact our office to determine whether there may be any additional requirements necessary to settle the deceased's account(s). More information regarding the Estate Settlement process is available on the Ameriprise.com website. To view the "Estate Settlement Frequently Asked Questions'' page on the website, type "Estate Settlement FAQs" in the search field on the website homepage, press the "Enter" key and select the first item on the search result list. Please contact us if you have any questions as you work through these difficult times, and once again, you have our sincerest sympathy. Thank you. Sincerely, Judy Wiens Death Settlements Processing Team 70100 Ameriprise Financial Center Minneapolis, MN 55474 1-800-862-7919, Option 2, ask for Estate Settlements Attachment: Beneficiary Information Beneficiary Information We have the following beneficiaries on record for the deceased's accounts. Account Number: 01122407664 3 002 Designation: PRIMARY BENEFICIARY GEORGE W SCOTT SON PHYLLIS HERSHEY DAUGHTER EQUALLY, OR THE SURVIVOR