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HomeMy WebLinkAbout10-06-10 (2)1505607121 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po Box 2aosol 2 1 1 0 0 1 3 7 Harrisburg PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 5 8 4 8 1 1 4 8 0 1 1 4 2 0 1 0 0 2 0 6 1 9 1 1 Decedent's Last Name Suffix Decedent's First Name MI G R A Y L O U I S E A (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI N / A Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ^X i. Original Retum 4. Limited Estate 0 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 2. Supplemental Return 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust} 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 3. Remainder Retum (date of death prior to 12-13-82) 5. Federal Estate Tax Retum Required 8. Total Number of Safe Deposit Boxes 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 T0: Name Daytime Telephone Number D A V I D R G E T Z E S Q U I R E 7 1 7 2 3 4 4 1 8 2 Firm Name (If Applicable) W I X W E N G E R First line of address & W E I D N E R 5 0 8 N O R T H Second line of address P O B O X 8 4 5 City or Post Office H A R R I S B U R G S E C O N D S T R E E T State ZIP Code REGISTER OF WILLS USE ONhY ._] ~p ~a -~ ~ c- _~ ~. ~_ ~ I r-r~i I s ~ ~ c~ -- J ` \ '"'7 ~:~ ~ - r7 Ca ,. - _~-,. (LED "-' _ __ _ L ~3 P A 1 7 1 0 8 0 8 4 5 ~'`~ Correspondent'se-mail address: DGETZC~WWWPALAW.COM 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 infgrmation of which preparer has any knowledge. SIGNATURE OF 5~N RESPONSIBLE FOR FILING RETURN DATE /1V /fILJJ SEE ATTA HED SIGNATURE OF R(q ARER ENTATIVE DATE IU 508 NORTH SECOND ST/P~0 BOX 845 HARRISBURG PA 17108 PLEASE USE ORIGINAL FORM ONLY 1505607121 Side 1 1505607121 Estate of Louise A. Gray SSN 158-48-1148 Estate No. 21-10-0137 Date of Death: January 14, 2010 Under penalties of perjury, we declare that we have examined this return, including accompanying schedules and statements, and to the best of our knowledge and belief, it is true, correct, and complete. N. Cornell Gray, Co- c or 147 Manthorne Road, Unit West Roxbury, MA 02132 ATTACHED David A. Gray, Co-Executor 43 Summer Drive Dillsburg, PA 17019 Dated: ~~ • ZZ } , 2010 Estate of Louise A. Gray SSN 158-48-1148 Estate No. 21-10-0137 Date of Death: January 14, 2010 Under penalties of perjury, we declare that we have examined this return, including accompanying schedules and statements, and to the best of our knowledge and belief, it is true, correct, and complete. attached N. Cornell Gray, Co-Executor 147 Manthorne Road, Unit #2 West Roxbury, MA 02132 ~~ David A. Gray, Co-Executor 43 Summer Drive Dillsburg, PA 17019 Dated: ~ ~ Z , 2010 J 1505607221 REV-1500 EX Decedent's Social Security Number Decedent's Name: L O U I S E A• GRAY 1 5 8 4 8 1 1 4 8 RECAPITULATION 0 • 0 0 1. ................................... Real estate (Schedule A) ..... 1. 7 2 7 3 9 8. 9 4 2. ............................. Stocks and Bonds (Schedule B) ..... 2. 0 ' 0 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0 ' 0 0 4. Mortgages & Notes Receivable (Schedule D) ................... ..... 4. 1 2 5 7 7 6 • 3 0 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .. ..... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .. ..... 6. 7. Inter-Vivos Transfers & Miscellaneous N -Probate Property (Schedule G) ~ Separate Billing Requested .. ..... 7. 8. Total Gross Assets (total lines 1-7) ...................... ..... 8. 8 5 3 1 7 5. 2 4 9. Funeral Expenses & Administrative Costs (Schedule H) ........... ..... 9. 9 5 3 8 . 4 6 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ....... ..... 10. 3 0 0 6 . 6 7 11. Total Deductions (total Lines 9 & 10) ...................... ..... 11. 1 2 5 4 5 . 1 3 ,~ 8 4 0 6 3 0. 1 1 12. Net Value of Estate (Lme 8 minus Line 11) ........... . 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) ... • • • • • ........ • - • • ... • • • • • • ....... 13. 14.. 8 4 0 6 3 0 . 1 1 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 0 0 0 15 0. 0 0 (a)(1.2) x .o _ . . 16. Amount of Line 14 taxable 8 4 0 6 3 0. 1 1 3 7 8 2 8. 3 5 at lineal rate X .045 16. 17. Amount of Line 14 taxable 0 0 0 17 0 • 0 0 at sibling rate X .12 . 18. Amount of Line 14 taxable 0 0 D 0 • 0 0 at collateral rate X .15 . 18 3 7 8 2 8. 3 5 ....................... 1 s. Tax Due ............... ... ...... .19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^ Side 2 1505607221 1505607221 J REV-1500 EX Page 3 ne~o~ia~nt'c [`nmr~lptp Oddress: File Number 21 10 0137 .........~.~..- - -----r---- - --- - DECEDENT'SNAME LOUISE A. GRAY STREET ADDRESS 735 OAK OVAL CITY STATE ZIP MECHANICSBURG PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 37,828.35 2. Credits/Payments A. Spousal Poverty Credft B. Prior Payments C. Discount Total Credits (A + B + C) (2) 0.00 3. InteresUPenaRy if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 0.00 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. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 37,828.35 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 37,828.35 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APP ROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : ............................................................ ......... . ^ ^ 0 X ^ b. retain the right to designate who shall use the property transferred or its income; ..................... ......... . ^ ^X c. retain a reversionary interest; or ...................................................................................... ......... . ^ d. receive the promise for life of either payments, benefits or care? ............................................. ......... . 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ............................................................................. h? " ......... . ^ ^ or payable upon death bank account or security at his or her deat 3. Did decedent own an "intrust for ........ . Did decedent own an Individual Retirement Account, annuity, or other non-probate property which 4 . contains a beneficiary designation? ....................................................................................... .......... . ^ 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1,1994 and before January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exemot 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 twenty-one 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 zero (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 four and one-half (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 twelve (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. REV-1502 EX + (6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER LOUISE A. GRAY 21 10 0137 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real orooerty which is jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. NONE 0.00 TOTAL (Also enter on line 1, Recapitulation) ~ $ 0.00 (If more space is needed, insert additional sheets of the same size) REV-1503 EX + (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT OF FILE NUMBER LOUISE A. GRAY 21 10 0137 All property jointly-owned with right of survivorship roust be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. STOCKS HELD AT MERRILL LYNCH (ACCOUNT NO. 826-12S87) 727,398.94 SEE ATTACHED ITEMIZATION TOTAL (Also enter on line 2, Recapitulation) ~ $ (If more space is needed, insert additional sheets of the same size) REV-1504 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT 'ATE OF SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP FILE NUMBER LOUISE A. GRAY 21 10 0137 Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporationlpartnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. NONE 0.00 TOTAL (Also enter on line (If more space is needed, insert additional sheets of the same size) REV-1507 EX + (6-98) SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE FILE LOUISE A. GRAY 21 10 0137 All property jointty-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER NONE DESCRIPTION VALUE AT DATE OF DEATH 0.00 TOTAL (Also enter on line (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER LOUISE A. GRAY 21 10 0137 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned vnth right of survivorship must be disclosed on Schedule F. VALUE AT DATE ITEM NUMBER DESCRIPTION OF DEATH 1. METLIFE TOTAL CONTROL ACCOUNT #4031504328 34,102.48 VALUATION STATEMENT ATTACHED 2 MERRILL LYNCH "BANK DEPOSIT" PROGRAM/CASH 20,120.74 . INCLUDED ON MERRILL LYNCH DATE-OF-DEATH VALUATION STATEMENT 3. PNC BANK CHECKING ACCOUNT XXXX8744 9,009.67 DOD BALANCE: $9,009.64 ACCRUED INTEREST: $.03 17 204 56 4. PNC BANK SAVINGS ACCOUNT XXXX5885 , . DOD BALANCE: $17,197.79 ACCRUED INTEREST: $6.77 815.85 33 5. MESSIAH VILLAGE REFUND , 6. ESTIMATED REFUND FOR 2009 FEDERAL INCOME TAXES 1,564.00 7. ESTIMATED REFUND FOR 2009 STATE INCOME TAXES 99.00 8. ORDINARY HOUSEHOLD GOODS AND FURNISHINGS 3,153.00 SUMMARY ATTACHED 9, JEWELRY 6,707.00 SUMMARY ATTACHED TOTAL {Also enter on line 5, Recapitulation) ~ $ 125 (If more space is needed, insert additional sheets of the same size) REV-1509 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULEF JOINTLY-OWNED PROPERTY FiCJIUCIV I UCIiG UCIY I -- FILE NUMBER ESTATE OF LOUISE A. GRAY 21 10 0137 ff an asset was made joint within one year of the decedents date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME A. B C JOINTLY-OWNED PROPERTY: ADDRESS LETTER DATE DESCRIPTION OF PROPERTY ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH NUMBER TENANT JOINT IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET A, ~ NONE TIONSHIP TO DECEDENT °~ OF DATE OF DEATH DECD'S VALUE OF INTEREST DECEDENT'S INTEREST TOTAL (Also enter on line 6, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) REV-1510 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF LOUISE A. GRAY 21 10 0137 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM ~~ THE w+ME ~ THE TRANSFEREE, THEIR RELATIONSHIP To DECEDENT AND NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. NONE DATE OF DEATH I % OF DECD'S ~ EXCLUSION TAXABLE VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE TOTAL (Also enter on line 7 (If more space is needed, insert additional sheets of the same size) REV-1511 EX+(10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ATE OF SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER LOUISE A. GRAY 21 10 0137 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES: 1. FOLSOM FUNERAL SERVICE, INC., ROSLINDALE, MA 2. WOODLAWN-NORTH PURCHASE CEMETERIES ASSN, ATTLEBORO, MA 3. RUDY'S RESTAURANT, HACKENSACK, NJ (FUNERAL LUNCHEON) 4. CREMATION VESSEL (ESTIMATED) 5. ORGANIST 6. PASTOR g, ~ ADMINISTRATIVE COSTS: AMOUNT 2,602.70 250.00 690.00 600.00 175.00 250.00 t. Personal Representative's Commissions Name of Personal Representative (s) Street Address City State Zip Year(s) Commission Paid: 2 AttomeyFees WIX, WENGER & WEIDNER (ESTIMATED) 3,000.00 g. 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 CUMBERLAND COUNTY REGISTER OF WILLS 677.50 5 Accountant's Fees 6. Tax Return Preparer's Fees 7. SENTINEL -ADVERTISING 251.26 8. CUMBERLAND LAW JOURNAL -ADVERTISING 75.00 g. MOUNTZ JEWELERS -RING APPRAISAL 95.00 10. N. CORNELL GRAY -MILEAGE REIMBURSEMENT/MEALS 872.00 TOTAL (Also enter on line 9, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (12-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER LOUISE A. GRAY 21 10 0137 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. MESSIAH VILLAGE, GRANTHAM, PA (RENT) 2,602.70 2. PPL ELECTRIC (UTILITY) 55.65 3. AAA FIN. SERVICES (LIFE ALERT) 43.00 4. AT&T (LONG DISTANCE) 62.20 5. VERIZON (PHONE) 31.04 6. BRIGHAM AND WOMENS HOSPITAL (MEDICAL) 82.36 7. FAULKNER HOSPITAL (MEDICAL) 129.72 COPIES OF INVOICES FOR THE ABOVE-METIONED DEBTS OF DECEDENT HAVE NOT BEEN ATTACHED, BUT ARE AVAILABLE FOR INSPECTION IF REQ ESTED. TOTAL (Also enter on line 10, Recapitulation) I $ 3,006.67 (If more space is needed, insert additional sheets of the same size) REV-1513 EX + (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF LOUISE A NUMBER I. 1. 2. 3. 4. 5. 6 II. .GRAY NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outri ht spousal distributions, and transfers under Sec. 9116 (a~ (1.2)] MARILYN LOUISE GRAY 8936 BEVERLYWOOD STREET LOS ANGELES, CA 90034-2418 JANICE MARGARET GRAY 220 MILLBURN AVE. MILLBURN, NJ 07041 JONATHAN DAVID GRAY 30 EMMA LANE GORHAM, ME 04038 DAV I D A. GRAY 43 SUMMER DRIVE DILLSBURG, PA 17019 N. CORNELL GRAY 147 MANTHORNE ROAD, UNIT #2 WEST ROXBURY, MA 02132 TODD M. GRAY 612 NW 70TH ST SEATTLE, WA 98117 Lineal Lineal Lineal Lineal Lineal Lineal 25,218.90 25,218.90 25,218.90 369,877.25 369,877.26 25,218.90 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ FILE NUt 21 10 ~TIONSHIP TO DEC Do Not List Truster iUNT OR SH OF ESTATE (If more space is needed, insert addftional sheets of the same size) LAST WILL AND TESTAMENT OF LOUISE A. GRAY I, Louise A. Gray, of Mechanicsburg, Upper Allen Township, Cumberland County, Pennsylvania, being of sound and disposing mind and memory, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils by me at any time previously made. Provision for Taxes ITEM I: 1 direct that all inheritance and estate taxes becoming due by reason of my death, whether such taxes may be payable by my Estate or by any recipient of any property, shall be paid by my Executor out of the property passing under this Will that is not specifically devised or bequeathed as an expense and cost of administration of my Estate. My Executor shall have no duty or obligation to obtain reimbursement for any such tax paid by my Executor even though on proceeds of insurance or other property not passing under this Will. Dispositive Provisions ITEM II: I give and bequeath all my household furniture and furnishings, automobiles, books, pictures, jewelry, china, I'inen, silverware, wearing apparel and all other like articles of household or personal use and adornment to my sons, N. Cornell Gray of West Roxbury, Massachusetts and David A. Gray of Dillsburg, Pennsylvania, or if deceased, to their issue, per stirpes, to be distributed between them in as equal shares as practicable and as they may agree. If they are unable to agree, my Executor shall make such decision as to distribution. ITEM III: I give, devise and bequeath all of the rest, residue and remainder of my property, real, personal and mixed, as follows: (a) Three percent (3%) thereof to my granddaughter, Marilyn Louise Gray of Los Angeles, California; (b) Three percent (3%) thereof to my granddaughter, Janice Margaret Gray of Milburn, New Jersey; (c) Three percent (3%) thereof to my grandson, Jonathan David Gray of Falmouth, Maine; Page 1 of 6 (d) Three percent (3%) thereof to my grandson, Todd M. Gray of Seattle, Washington; and (e) The remaining portion thereof shall be distributed in equal shares to my sons, N. Cornell Gray and David A. Gray, or if deceased, to their issue, per sfirpes. ITEM IV: If at the time of my death I am not survived by any of the beneficiaries named herein, I direct my Executor to distribute all of my property, real, personal and mixed, to those persons who would receive my estate had I then died intestate, a resident of the Commonwealth of Pennsylvania. Appointment of Fiduciaries ITEM V: I nominate, constitute and appoint my sons, N. Cornell Gray and David A. Gray, or the survivor of them, to be my Co-Executors (herein collectively referred to as "Executor"). ITEM VI: If at any time any minor child or legally incompetent person shall be entitled to receive any assets hereunder, I hereby nominate, constitute and appoint my Executor to serve as Guardian of the assets. Said Guardian may receive and administer all assets authorized by law and shall have full authority to use such assets, both principal and income, in any manner said Guardian shall deem advisable for the best interest of such person, including college, university, post-graduate or other education, without securing court order. Said Guardian shall have all the rights and privileges as to the Guardianship and the assets thereof as are herein granted to my Executor as to my Estate and the assets therein. ITEM VII: My Executor and Guardian are specifically relieved from the duty or obligation of filing any bond or bonds. Powers of Fiduciaries ITEM VIII: In the settlement of my Estate, my Executor shall possess, among others, the following powers to be executed for the best interest of the beneficiaries: (a) To sell either at public or private sale and upon such terms and conditions as my Executor may deem advantageous to my Estate, any or all real or personal estate or interest therein, whether owned by me severally or in conjunction with other persons or acquired after my death by my Executor, and to consummate said sale or sales by Page 2 of 6 sufficient deeds or other instruments to the purchaser or purchasers, conveying a fee simple title, free and clear of all trust and without obligation or liability of the purchaser or purchasers to see to the application of the .purchase money or to make inquiry into the validity of said sale or sales; also, to make, execute, acknowledge and deliver any and all deeds, assignments, options or other writings that may be necessary or desirable in carrying out any of the powers conferred upon my Executor in this Item VII I(a) or elsewhere in my Will. (b) To pay all costs, taxes, expenses and charges in connection-with the administration of my Estate. My Executor shall pay expenses of my last illness and funeral expenses. (c) To distribute my Estate in kind or in money. If any assets are distributed in kind, they shall be distributed at their respective value(s) on the date(s) of their distribution. (d) To retain any investments I may have at. my death so long as my Executor may deem it advisable to my Estate so to do. (e) To vary investments, when deemed desirable by my Executor and to invest in such bonds, stocks, notes, money markets, real estate mortgages or other securities or in such other property, real or personal, as my Executor shall deem wise, without being restricted to so-called "legal investments." (fl To_mortgage real estate and to make leases of real estate. (g) To borrow money from any party to pay indebtedness of mine or of my Estate, expenses of administration or inheritance, legacy, estate and other taxes. (h) To vote any shares of stock that form a part of the Estate and to otherwise exercise all the powers incident to the ownership of such stock. (i) In the discretion of my Executor, to unite with other owners of similar property in car .tying out any plans for the reorganization of any corporation or company whose securities form a part of the Estate. (j) To distribute my personal property directly to the Guardian of the person of any minor beneficiaries hereunder. Page 3 of 6 (k) To elect such settlement options as deemed most appropriate by my Executor with respect to any pension, profit sharing or other retirement plan in which I am a participant. (I) To do all other acts that, in the judgment of my Executor, are necessary or desirable for the proper and advantageous management, investment and distribution of my Estate. Miscellaneous Provisions ITEM IX: I hereby exercise all powers of appointment that I may have at the time of my death in favor of my Executor, and all property subject to all such powers shall be included in my Estate. ITEM X: Any person who shall have died at the same time as me, or in a common disaster with me, or who shall fail to survive me by ninety (90) days, shall be deemed to have predeceased me. IN WITNESS WHEREOF, I have set my hand and seal to this my Last Will and Testament, consisting of this page, the next two pages, and the preceding three pages this ,t~''day of December, 2006. Louise A. Gray Page 4 of 6 SIGNED, SEALED, PUBLISHED AND DECLARED by the above named Testator, Louise A. Gray, as and for her Will, in the presence of us, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as witnesses in attestation thereof. `~ ~. ~,"t ~• ;`~ 4. ~~c,~~ _.:~'~ ~, Address ;~ Address l• : ~ ~ ~ ~ Address r ~, ~, .~ ~ ~_ ~ >, C ~ ~ ~ /~ .t c-~ ~(~ ~s ~P T-T ~>/ ~~ ,~ it ~e% ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF DAUPHIN I, Louise A. Gray, the Testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by Louise A. Gray, the Testator, this !I~''day of December, 2006. `'_ _ ~!`,_~~~:? l~i ' :i• 1'6NIv5"i LVANIA 1:. ~ ......._ ..__ .. __ j i :~a~ : ~inl Sea! ~ i-iacR~~ !?~;t°i,~~;:; ~3:7ugitman. Notary Public ~.. ~f i;<i:isbur~. .i ~hhui County ivi~.~ '.'oiirrisss~~n F:xliims July !2, 2005 '~h.,,:.,.,,~.,r :;,n~i::yivania. Hssori.;,tio~ of Notaries Louise A. Gray, Testator :, /~~ „ ( r Notary Public-~ " My Commission Expires: ;;/iZjz~~: Page 5 of 6 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF DAUPHIN and ~.Jc~ n i c~ i; ~r~e 4~. ,the witnesses whose ames are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present. and saw the Testator sign and execute the instrument as her Last Will; that the Testator signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness, in the hearing and sight of the Testator, signed the Will as a witness; and that to the best of our knowledge, the Testator was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. • ~. Sworn to or affirmed and subscribed to before me by ~~CiU'.d ~ C~~~z , ~~, ~~ . ~ t ~S ~ ~2 ,and ~' ; ~ -~ ; . ~ ~~ ~ ; ,witnesses, this~~ day of December, 2006. /,I ~ ~ Witness `~.t~ ~ . Witness .- ~ ' ~~ fitness •,t s ~ ' ' ~! Notary Public My Commission Expires: •~/rz/Z~t~~ F:\dbw\Wills\GraylLouise A. - Will.doc ,..._.-,;!.!,r:~',i::ii ~.11~ I't:Ni~iSYI.V!rJll~ NC fir1~11 ~iefll ,. :)~•sri _ [3aut,inn•,n, No;~ry Public ,: up i~irrlsbi.~r:~. Dauphin County '. ~,,, ''nl~rl7;issioe f-;~;~ims iuiy 12. 2t1pS I ,~'v,??ji^, i'=•nnc•~~IVF.?t12 A~>SOCI3',IOf? Ot' PdOtafl=s Page 6 of 6 .` ~ M ~ ~ ~ O (~ ~ ~ ~ O ~ ~ N O N d' M ~ UI ~ N W O M U _C N ~ ~+ M N W C 7 m o ~ °o ~ O ~ ~ Q ~ M ~ ~ C a` } O o °~ ~ ~ e- N ~ ~~ p aN+ ° O o 0 0 ~ .. .. .. ~ ~ ~ °O °o °o 00 00 to .-. 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ROXBURY, MA 02132 Re: Total Control Account # 4031504328 Metropolitan Life Insurance Company Dear Mr. Gray, MetLife In response to your request for the date of death balance, the date of death balance is $34,102.48. If you have any questions or require further assistance, please call our TCA Customer Service department at (800-638-7283) Monday through Friday 8:OOa.m. through 6:00 p.m. Eastern Time. Sincerely, TCA Administration Services Note: Metropolitan Life Insurance Company provides administrative services for Total Control Accounts issued ny its affiliates. tca.0052.rev.01 FE6.26: X010 10:5C~M PNC B4NK 412-105-ii41 ~~~ February 26, 2010 David R Pletcher PNC Bank Upper Allen Branch RE: Louise A Gray SSN: 158-48-1148 ppD; O1-142010 Dear Mr. Pletcher: Vo. ~35b P. 2 Yn response to your request for Date of Death (DOD) balances for the customer rioted above, our records show the following: . Checlfing Account Account # 5003545744 LOUISE A GRAY Established: 05-15-2002 Dap balance: $9,QOg•~ + $0.03 accreted interest Interest paid OI-O1-2010 thru 01-14-2010 $0.38 YTD 59v~ngs Account Account # 5002055884 LOUISE A GRAY Established: O l -29-2003 DOD balance: $17,197.79 + $0.63 accreted interest Interest paid Ol-Ol -2010 t 01-14-2010 $G.77 'Y'ID Please note that this ace provides date of death balances for deposit accomrts (~~ ~, Checlong and Savvngs). We do not prneess aioy 5nan~~ 1~8 762 2265} or stotp by Yom' local PNC B Bch any of these items, please call 1-888-PNC office. sincerely, National Financial Services Center PNC Bank, Iv .A. Member FDIC Page 1 oft ~~~-~¢ti esSla ~{ ~,~..; March 9, 2010 David Gray 43 Summer Dr. Dillsburg, PA 17019 Dear Mr. Gray: Continuing Care Retirement Services -Founded 1896 I am writing to you concerning the refund due for the apartment occupied by Louise Gray at 735 Oak Oval, Messiah Village. The acquisition fee paid for the unit in May 2002 was $114,630.00. The agreement was terminated February 28, 2010. Seventy-fi ~; f the acquisition fee was amortized over 94 months leaving a refund in the t of $33,815.85 (se enclosed amortization schedule). The payment of the refund will take place in six months or after the unit is acquired by another resident, whichever comes first. If you have any questions regarding the refund, please call me at (717) 591-7204. incerely, ~, n` ('~i~ c~.1~ ~ ~ Z ~Q t,tJ>'1 Michele Maglich Bro Director of Financial Operations Encl. 100 Mt. Allen Drive ~ Mechanicsburg, PA 17055-6100 (717) 697-4666 ~ Fax (717) 790-8200 ~ www.messiahvillage.org Enhancing Life Form ~ Q41 Label (See instructions.) Use the IRS label. Otherwise, please print or type. Presidential Election Campaign Filing Status Check only DECEASED Louise A Gray 01/14/2010 Department of the Treasury - Internal Revenue Service U.S. {ndividual {ncome Tax Return 2i~09 For the year Jan 1 -Dec 31, 2009, or other tax ear beginning Your first name , 2009, endin MI Last name Louise A Gra If a joint return, spouse's first name MI Last name Home address (number and street). If you have a P.O. boz, see instructions IRS Use Only - Do not write or staple in this . 20 ,..... -• -- - Your social security number 158-48-1148 Spouses social security number 43 Summer Drive Apartment no. You must en- t~~r City, town or post office. If you have a foreign address, see instructions. , social S2CUflty state ZIP code number(s) above. Di 11 sbur Checking a box below will not Check here if you, or your spouse if filing jointly, want $3 to go to this fund? (see instruction 17 019 change your tax or refund. ................ - ~ You ~ Spouse 1 Single 4 2 Married filing jointly (even if only one had income) Head of household (with qualifying person). (See instructions.) If the qualifying person is a child 3 Married filing separately. Enter spouse's SSN above & full but not your dependent, enter this child's c ~ name here . --_ name here .. - ~tuanlying wmow(er) with dependent child (see instructions) EXem~tlOtTS 6a Yourself. If someone can claim ou as a de endent Y p do not ch k , ec box 6a ............ b S Ouse ..... . Boxes cbecked . ...................... ~ .............................. on 6a and 6b .. 1 ........ c Dependents: (2) Dependent's (~ Dependent's (~~ s i l Pro. or .baarer, on sc wbo: oc a securi number ~ relationship y„al;fy;ng First name Last name to you ~ f r ~ld • lived with you .... . If more tax c edit (see instrs) a did nod ~" true wttft ou than four due to divorce dependents, o-seporation (see instrs) • , , see Instructions and check here-~ oeponaents on sc not d Total number of exemptions claimed . entered above , add numbers ---' Income .......... ............. 7 Wages, salaries, tips, etc. Attach Forms W-2 • ~ ~ • ~ • ~ ' ' ' ' ' ' ' - ' ' ' ' ' • • • • • • • () .... onltnes above • .... - 1 ............. 7 8a Taxable interest. Attach Schedule B if required .... ..........~...~........................ ga b Tax exempt interest. Do not include on line 8a .......... b 1 117 . Attach Form(s) .... L_._° 9a Ordinary dividends. Attach Schedule B if required W-2 here. Also attach Forms W-2G d ......... . b Qualified dividends see instrs ' ' ' ' ' ' ' ' ' ' ' ' • • • • • • • • • • • • • • • • . 9a ....................... ( ) ••••••••••• ~ 9b~ 7 10 Taxable refunds 907 c dit ~ ' 14 081. art 1099-R if t , , re ;. s, or offsets of state and local income taxes see instructions) ( ax was withheld. 11 Alimony received ' ' • • • • • • • • • • • • • • • ..... 10 ................ 0 If you did not 12 Business income or (loss). Attach Schedule C or C-EZ ~ • • • ~ ~ • ' ~ ' ' ' ' ' ~ ' 11 . get a W2 see instructions .. , • , , , , , • 13 Capital gain or (loss). Att Sch D if regd. If not regd, ck here ................... - ~ 14 O h . ....... t 13 er gains or (losses). Attach Form 4797 ......... 1 . ..... ............................. 15a IRA distributions ..... 15a 14 b 1Ba I bTaxable amount (see instrs) .. 15b 16a Pensions and annuities ... l E ... 16b 17 Rental real estate, royalties, partnerships, S corporations trustsaetc Att t r 9,432. nc ose, but do , . ach Schedule E 18 Farm income or (loss). Attach Schedule F 17 not attach, any payment Also, ...... , .. , . 19 Unempj yment compensation in excess of $2,400 ' • ' • ~ • • • • • • • • ~ • ................... 18 per recipient (see instructions) ............. •.. ....... please use Fonn 1040-V ..... ............................. 19 20a Social security benefits ........... ~ 20a~ 15, 089 ~ b Taxable amount s i 21 . ee nstrs Other i ncome _ _ _ _ _ _ _ _ _ ) .. 20 b 3 5 8 8 22 Add the amounts in the far ri ht column for lines 7 th ~ , Adjusted rou h 21. This is our total income • - 23 Educator expenses (see instructions) .............. 23 ~ 28 219 farOSS ......... 24 Certain business expenses of reservists, performing artists and fee-basis - It1COme , government officials. Attach Fonn 2106 or 2106-EZ ................. 24 ... 25 Health savings account deduction. Attach Form 8889 ...... , 25 26 Moving expenses. Attach Form 3903 ............... 27 One-halt of self-employment tax. Attach Schedule SE ........ 27 28 Self-employed SEP, SIMPLE, and qualified plans ............ 2$ 29 Self-employed health insurance deduction (see instructions) ....... . 30 Penalty on early withdrawal of savings 29 . .................... 30 31 a Alimony paid b Recipients SSN ... - . a 32 IRA deduction (see instructions) 33 Student loan interest deduction (see instructions) ............ 33 34 Tuition and fees deduction. Attach Form 8917 ....... , 34 35 Domestic production activities deduction. Attach Form 8903 .............. 35 36 Add lines 23 - 31a and 32. 35 ........... `' BAA For Disclosure ....................... 37 Subtract line 36 from line 22. This is our ad usted ross income . - _ ~ • • ~ Privac Act d P - , y , an aperwork Reduction Act Notice, see instructions ~ 28 219. . FDIA0112 09/17/09 Form 1 040 (2009) Form 1040 2009 Louise A Gra Tax and 38 Amount from line 37 (adjusted ross income) 1 9 Credits 39a Check _- e You were born before January 2, 1945, Blind. if: Spouse was born before Janua 2, 1945, Total boxes Standard I ~' 8 Blind. checked - 39a 1 Deduction _ b If your spouse itemizes on a separate return, or you were adual-status alien, see instrs and ck here - 39b for - 40 a Itemized deductions (from Schedule A) or your standard deduction (see left margin) .................... . • People who b If you are increasing your standard deduction by certain real estate taxes, new motor vehicle taxes, or check any box a net disaster loss, attach Schedule L and check here (see instructions) ..................... - 40 b on line 39a, 39b, 41 Subtract line 40a from line 38 ................... . or 40b or who ........ . can be claimed ~ Exemptions. If fine 38 is $125,100 or less and you did not provide housing to a Midwestern displaced as a dependent, Individual, multiply $3,650 by the number on line 6d. Otherwise, see instructions ........................ . see instructions. 43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- ........ , .............................................. • II others: 44 Tax (see instrs). Check if any tax is from: a Form(s) 8814 Single or Married b B Form 4972 fjliny separately, 45 Alternative minimum tax (see instructions). Attach. Form 6251 ........................ . . . $5,700 46 Add lines 44 and 45 ..................... _ .... 47 Foreign tax credit. Attach Form 1116 if required ............. 47 Married filing ;. jointly or 48 Credit for child and dependent care expenses. Attach form 2441 .......... 48 Qualifying 49 Education credits from Form 8863, line 29 ...... . . . ... . 49 $11,400r)~ 50 Retirement savings contributions credit. Attach Form 8880 ... 50 51 Child tax credit (see instructions) 51 Head of .......................... household, 52 Credits from Form: a ~ 8396 b ~ 8839 c ~ 5695....... 52 $8,350 53 Other crs from Form: a ~ 3800 b ~ 8801 c ~ 53 54 Add lines 47 through 53. These are your total credit e 55 Subtract line 54 from line 46. If line 54 is more than line 46, enter -0- .. , . - , . , . - a 56 Self-employment tax. Attach Schedule SE .......... ' ' ' ' ' ' ' ' ' ` ............................................ 5 ther 57 Unreported social security and Medicare tax from Form: a ~ 4137 b ~ 8919 ... , , , _ .. 5 TBXeS 58 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required .............. . .... 5 59 Additional taxes: a ~ AEIC payments b ~ Household employment taxes. Attach Schedule H ........... 5 60 Add lines 55-59. This is your total tax ... . Payments 61 Federal income tax withheld from Forms W-2 and 1099 ...... ~ ~ 6 61 62 2009 estimated tax payments and amount applied from 2(108 return ........ 62 63 Making work pay and government retiree credit Attach Schedule M ........ 63 2 515 . If you have a ~ 0 ... qualifying 64a Earned income credit (E1C) ...... 64a child, attach b Nontaxable combat pay election ..... -~ 64b~ Schedule EIC. 65 Additional child tax credit. Attach Form 8812 ................ 65 66 Refundable education credit from Form 8863, line 16 ........ ~ 67 First-time homebuyer credit. Attach Form 5405 .............. 67 68 Amount paid with request for extension to file (see instructions) .......... 68 69 Excess social security and tier 1 RRTA tax withheld (see instructions) ....... 69 70 Credits from Form: a ~ 2439 b ~ 4136 c ~ 8801 d ~ 8885. 70 71 Add Ins 61-63, 64a, & 65.70. These are your total mts Refund 72 If line 71 is more than line 60, subtract line 60 from Ijne 71. Thjs is the amount you overpaid .............. ' 72 Direct deposit? 73a Amount of line 72 you want refunded to~rou. If Form 8888 is attached, check here . , - ~ 73 See instructions - b Routing number ........ XXXXXXXXX - c T and fill in 73b, Pe: Checking Savings 73c and 73d d Account number XXXXXX 58-48-1148 Pa e 2 ~ 28,219. `~a 7, 531. 41 20 688. 42 3, 650. ~ 17 038. ~ 951. 45 951. ~ 951 951_. 2,515. _1,564, 1,564. or XXXXXXXXXXX Form 8888. 74 Amount of line 72 you want applied to our ZO10 Amount You Owe Third Party Sign Here Joint return? See instructions Keep a copy for your records. Paid Preparer's Use Only Y estimated tax ........ - 74 75 Amount you owe. Subtract line 71 from line 60. For details on how to pay, see instructions ......... . .. . . - 75 76 Estimated tax enalty see instructions) ........ . . . . . . . 76 Do you want to allow another person to discuss this return with the IRS (see instructions . nDamenee's - Ptwne )' • • • • • • • • • . Yes. Complete the following. no. - u ~al identification - Under penalties of perjury, I declare that t have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, corcect, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. Your signature Date Your occupation Daytime phone numbe Spouse's signature. If a toint return, both must sign rreparer's signature Firms name S e 1 f - (or yours if self-employed),1 address, and homemaker Date Spouse's occupation Date 'd EIN Phone no. X No Preparer's SSN or PTIN FDIA0112 o9n nog Form 1040 (2009) ___I D9DD112178 L PA-40 - 2009 Pennsylvania income Tax Return ENTER ONE LETTER OR NUMBER IN EACH BOX. Do Not Use Your Preprinted Label 158481148 GRAY LOUISE A Occupation Occupation HOMEMAKER N Extension. N Amended Return. R Residency Status. PA Resident/Nonresident/Part-Year Resident from to S Single/Married, Filing Jointly/Married, Filing Separately/Final Return/Deceased Date of death N Farmers. School District Name M E C H A N I C S B U R G 43 SUMMER DRIVE DILLSBURG PA 17D19 2165D 1 a Gross Compensation. Do not include exempt income, such as combat zone pay and qualifying retirement benefits. See the instructions. 1 b Unreimbursed Employee Business Expenses. 1 c Net Compensation. Subtract Line 1b from Line 1a. 2 Interest Income. Complete PA Schedule A if required. 3 Dividend and Capital Gains Distributions Income. Complete PA Schedule B if required. 4 Net Income or Loss from the Operation of a Business, Profession or Farm. 5 Net Gain or Loss from the Sale, Exchange or Disposition of Property. 6 Net Income or Loss from Rents, Royalties, Patents or Copyrights. 7 Estate or Trust Income. Complete and submit PA Schedule J. B Gambling and Lottery Winnings. Complete and submit PA Schedule T. 9 Total PA Taxable Income. Add only the positive income amounts from Lines 1 c, 2, 3, 4, 5, 6, 7 and 8. DO NOT ADD any losses reported on Lines 4, 5 or 6. 10 Other Deductions. Enter the appropriate code for the type of deduction. See the instructions for additional information. N 11 Adjusted PA Taxable Income. Subtract Line 10 from Line 9. PAIA0412 12/2MO9 EC Page 1 of 2 FC 0900112178 ~ m W 1a D 1b D 1c D 2 1117 3 14D82 4 D 5 D 6 D 7 D 8 D 9 151,99 10 ~ 11 15199 09DD112],78 J J PA-40 -2009 Social Security Number 0900212186 158481148 Name(s) Louise A Gray L 12 PA Tax Liability. Multiply Line 11 by 3.07 percent (0.0307). 12 13 Total PA Tax Withheld. See the instructions. 13 4 6 7 0 14 Credit from your 2008 PA Income Tax return. 14 15 2009 Estimated Installment Payments. 15 116 16 2009 Extension Payment. 16 4 50 17 Nonresident Tax Withheld from your PA Schedule(s) NRK-1. (Nonresidents only) ] 7 0 18 Total Estimated Payments and Credits. Add Lines 14, 15, 16 and 17. , 18 0 5 6 6 Tax Forgiveness Credit. Submit PA Schedule SP. 19a Filing Status: 01 Unmarried or Separated 02 Married 03 Deceased 19 d DD 19b Dependents, Part B, Line 2, PA Schedule SP 19 b D O 20 Total Eligibility Income from Part C, Line 11, PA Schedule SP. 2 D 21 Tax Forgiveness Credit from Part D, Line 16, PA Schedule SP. 21 0 0 22 Resident Credit. Submit your PA Schedule(s) G-R with your PA Schedule(s) G-S, G-L and/or RK-1. 2 2 0 23 Tota! Other Credits. Submit your PA Schedule OC. 2 3 0 24 TOTAL PAYMENTS and CREDITS. Add Lines 13, 18, 21, 22 and 23. 2 4 5 6 6 25 TAX DUE. If Line 12 is more than Line 24, enter the difference here. 2 5 D 26 Penalties and Interest. See the instructions. Enter code: 2 6 D If including form REV•1630, mark the box. N 27 TOTAL PAYMENT DUE. See the instructions. 2 ? 28 OVERPAYMENT. If Line 24 is more than the total of Line 12 and Line 26, enter 2 8 0 the difference here. 9 9 The total of Lines 29 through 35 must equal line 28. 29 Refund -Amount of Line 28 you want as a check mailed to you. Refund 2 9 30 Credit -Amount of Line 28 you want as a credit to your 2010 estimated account. 3 0 9 9 31 Amount of Line 28 you want to donate to the fNid Resource Conservation Fund. 3 ] D 32 Amount of Line 28 you want to donate to the Military Family Relief Assistance Program. , 3 2 D 33 Amount of Line 28 you want to donate to the Governor Robert P. Casey Memorial 3 3 D Organ and Tissue Donation Awareness Trust Fund. . 0 34 Amount of Line 28 you want to donate to the Juvenile (Type 1) Diabetes Cure 3 4 D Research Fund. 35 Amount of line 28 you want to donate to the PA Breast Cancer Coalition's Breast 3 5 D and Cervical Cancer Research Fund. Sigrurtun(s} Under penalties of penury, I (we) declare that I (vre) have examined this return, including all accompanying schedules and statements, and to the best of my (our) belief, they are true, correct, and complete. Your Signature Spouse's Signature, if filing jointly Preparer's Name and Telephone Number Self-Prepared Date Firm FEIN Preparer's SSN/PTIN 090D212186 Pa~e2o;?,~ D900212186 PA14 Furniture Master Bedroom set Rocking Chair (some repair needed) Use Leather Recliner End Tables Coffee Table (falling apart, abandoned) Captains chair 2 Table lamps (metal splitting-abandoned) 4Table lampsw shades 27 "Tube analog TV (abandoned) Secretary WW II vintage upholstered seat desk chair dinette set (7 yr old) Marble top table 2 paintings (no-name artist friends) Double bed WWII Tall boy dresser WWII House hold Vacuum Leaner hand hey mixer elect Frying pan 8 place setting every day Misc pots and pans 21 items Jewelry 10 K charm bracelet, 2.78 oz engagement ring diamond' wedding ring' Costume jewelry 35 pieces Cloi~es 164 pieces skirts blouses sweater etc.(abandoned) 2 winter coats 11 pair of shoes (abandoned) Total Unit price $1,200.00 $1,200.00 ebay $10.00 $10.00 garage sale est. $200.00 $200.00 ebay $20.00 $40.00 garage sale est. needed complete $0.00 $0.00 rebuild $25.00 $25.00 garage sale est. $0.00 $0.00 discarded $7.00 $28.00 garage sale est. $5.00 $5.00 garage sale est. $275.00 $275.00 ebay $50.00 $50.00 garage sale est. $200.00 $200.00 ebay $500.00 $500.00 ebay $5.00 $10.00 garage sale est. $40.00 $40.00 garage sale est. $50.00 $50.00 garage sale est. $40.00 $40.00 garage sale est. $3.00 $3.00 garage sale est. $5.00 $5.00 garage sale est. $60.00 $60.00 garage sale est. $2.00 $42.00 garage sale est. $1,317.00 $1,317.00 intrinsic 1/14/2010 $5,122.00 $5,122.00 appraisal Mountz $198.00 $198.00 appraisal Mountz $2.00 $70.00 garage sale est. $2.00 $328.00 garage sale est. $10.00 $20.00 garage sale est. $2.00 _ $2_ garage sale est. $9,860.00 'Appraisal figs. supplied _ _ Z E ~V ,E L E R S Trust your gpaial Moments To Mountz. August 30, 2010 Margaret Gray 43 Summer Drive Dillsburb, PA 17019. Dear Margaret Gray, At your request t examined the jewelry you submitted for valuation and have provided an opinion of the Fair Market Value for the estate of Louise A. Gray, January 14, 2010. 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, 1 estimate the jewelry has a total Fair Market Value of $5,320.00. 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, ~r" Ll..~.~--- Cherie Lynn Grove Certified Gemologist Appraiser, AGS Enclosures pMER~icpN 3780 Trindle Road • Camp Hill, PA 17011 • 717.763.1199 • (F) 717.763.8953 c EM_ _ mou~ers.com -SOC\ET`i~ -_. _- -_ Prepared For: Margaret Gray Ds~tec 8/30/2010 43 Sumner Drive Dillsburg~ PA 13019 Item 1 Ring One lady's 14K white gold diamond engagement ring. In the center is one approximately 1.64ct old European cut diamond set in a box style setting with-three beaded prongs on each corner. On each shoulder there are four approximately .04ct single cut diamonds channel set on a raised cathedral shoulder. The ring measures 7.37mm wide at the top, 2.52mm wide at the. shoulders, and 1.52mm wide at the base of the ring. The ring is not stamped; therefore, the metal content was determined through acid testing. The ring measures finger size 8.25 and weighs 2.ldwt. Note: The value listed below is for a modern 1.64ct round brilliant cut diamond. Diamond Grading Report Measurements: 7.35 x 7.31 x.4.50 mm (approximate) Weight: 1.62 Cts. (estimated) Depth: 61.39% Girdle: Thin, granular Culet: Small Finish Clarity: I-1, This diamond is chipped in three locations around the girdle. Color: J Diamond Melee Attributes Shape and cut: Round single cut Measurements: 2.2 mm Number of diamonds: 8 Total Weight: .32 cts. (estimated) Clarity: VS Color: G-H Total Approximate Value Excluding Tax: $5,122.00 Item 2 Ring One lady's platinum wedding band. The band measures 1.62mm wide domed engraved worn pattern on the outside. The ring is engraved "MTZPAH...(engraving worn away)...A. E. 9-2-34", measures finger size 6.75, weighs l.ldwt, and is stamped "10%IRIDPLAT Wood". Total Approximate Value Excluding Tax: $198.00 Total Approximate Value for All Items -Excluding Tax: $5,320.00 Five thousand three hundred twenty dollars and no cents Signature of Appraiser: -~~,~,~..~/~ Che e_I,ynn rove Certified Gemologist Appraiser, AGS Page 6 of 7 ,~ul~unt ,~u~t.erttl ~.erutrP, Jnr. W W W. FOLSOMFU N ERAL. COM 83 BELGRADE AVENUE, ROSLINDALE, MA 02131 (617) 325-0461 87 MILTON STREET, DEDHAM, MA 02026 • 649 HIGH STREET, WESTWOOD, MA 02090 (781)326-0022 (781)328-0022 May Funeral Home 85 NICHOLS ST., NORWOOD 02062 Mr. N. Cornell Gray 147 Manthorne Road West Roxbury, MA 02132 Funeral Expenses of Louise Anna Gray Contract #: 2010-0003 Date of Death: January 14, 2010 Date of Statement: February 2, 2010 Merchandise Basic Cremation Container Cremation pouch Total Merchandise Special Service $85.00 $25.00 Packaged Funeral Service Total Special Service $1,850.00 Cash Advances Certified Copies of death certificate Gratuities to crematory Burgin NJ Record Cremation Permt Medical Examiner Fees Total Cash Advances Total Original Charges: Additional Charges & Credits 01/29/2010 Payment on account Total Additional Charges 8~ Credits: $216.00 $5.00 $290.70 $31.00 $100.00 -$2,602.70 Paid In Full I ~c~~)( ~-(C~u (, L~ $110.00 $1,850.00 $642.70 $2,602.70 -$2,602.70 Woodlawn-North Purchase Cemeteries Association 825 North Main Street Attleboro, MA 02703 Date lil9i2olo Sold To Folsom Funeral Home Dedham, MA 02026 ' Sales Receipt Check No./Cash 3733 Item Description Qty Rate Amount Cremation Louise A Grey 250.00 250.00 Total s2so.oo .~ n~ ~m ~~ 0 ~~ M P O ~^ ~~ 1' ~{`" .~ '~ o ~~. 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