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HomeMy WebLinkAbout10-27-10~~ 1505610140 REV-1500 ~` t°'-'°' PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po sox 2so6o1 INHERITANCE TAX RETURN 2 1 1 0 0 6 3 4 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 6 2 5 4 0 4 2 3 0 6 1 3 2 0 1 0 1 D 1 2 1 9 2 2 Decedent's Last Name Suffix Decedent's First Name MI S H E A F F E R E L M A K (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW ® 1.Original Return 4. Limited Estate ® 6. Decedent Died Testate (Attach Copy of Wifl) 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 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) CORRESPONDENT -THIS 5EGTION MUST 8E cOMPLEf tu. ALL curcrctsrunutnut wnu cunr~utn ~ wu I wx ~nrurulw i gun snuuLU of u~Ktc ~ to I u: Name Daytime Telephone Number R O G E R B I R W I N E S Q U IRE 7 1 7 2 4 9 2 3 5 3 First line of address 6 0 W E S T Second line of address City or Post Office C A R L I S L E State ZIP Code P A 1 7 0 1 3 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) REGISTF~RpF WILLS US~NLY c ~ ~_~ ''' ~~.-t ~.-..3 ..' ! -i- ~ --~ - -i , .. ?~ - ,.~ ~ - ~ ~ r ~ ~~. r `, t -.. - ~ ti TE FILED .. ~ ~' G ,~ Correspondent's e-mail address: Under penalties of perjury, I declare that I have examined this return, inGuding accompanying schedules and statements, and to the best of my knowledge and belief, lt is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAT~ OF PER~SO~R ~ BLE FOR FyJN~ ~ ~N o~~ A~ D~E~` /~ 2 PATTON ROA ANNV1LLt rA Lruu~ SIGNATURE O~ EP~,REfR`OTHER~T'HAN RE ESENTATIVE ATE 60 WEST POMfRF1T ST 1505610140 P O M F R E T S T R E E T PLEASE USE ORIGINAL FORM ONLY Side 1 A 17D1 1505610140 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: E L M A K• S H E A F F E R 1 6 2 5 4 0 4 2 3 RECAPITULATION 1. Real Estate (Schedule A) ........................................... 1. 2. Stocks and Bonds (Schedule B) ................................. ..... 2. 3. Cbsely 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. 1 4 0 5 1 9. 6 0 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested . ...... 6. 7. Inter-Vivos Transfers & Miscellaneous N -Probate Property ~ 1 2 9 7 5 9 9 6 (Schedule G) Separate Billing Requested . ...... 7. , 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 2 7 0 2 7 9 , 5 6 9. Funeral Expenses and Administrative Costs (Schedule H) ............ ...... 9. 2 3 9 3 6. 1 0 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ....... ...... 10. 1 0 3 3 . 4 0 11. Total Deductions (total Lines 9 and 10) ......................... ...... 11. 2 4 9 6 9 . 5 0 12. Net Value of Estate (Line 8 minus Line 11) ...................... ...... 12. 2 4 5 3 1 0 . 0 6 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. 2 4 5 3 1 0 . 0 6 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 0 15. 0. D O 16. Amount of Line 14 taxable at lineal rate X .045 2 4 5 3 1 0. 0 6 16. 1 1 0 3 8. 9 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. 1 1 0 3 8. 9 5 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610240 1505610240 Continuation of REV-1500 Inheritance Tax Return Resident Decedent ELMA K. SHEAFFER 21 10 0634 Decedent's Name Page 2 File Number Correspondents Name R O G E R B I R W I N Daytime Telephone Number 7 1 7 2 4 9 2 3 5 3 First line of address 6 0 W E S T Second line of address City or Post Office C A R L I S L E P O M F R E T S T R E E T State ZIP Code P A 1 7 0 1 3 Correspondent's a-mail address: 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 oompk~te. Declaration of preparer other than the personal representable ~s based on all infom-ation of which preparer has any knowledge. SIG TU F PERSON RESPONSIBLE F LING E RN /,~ DATE 120 ALTERS ROAD CARLISLE PA 17015 REV-15U0 EX Page 3 nee~erlc-n!'c C_mm~latp 0[ilc~rpac~ Fife Number 21 10 0634 DECEDENTS NAME ELMA K. SHEAFFER STREET ADDRESS 3 TODD CIRCLE APT E CITY STATE ZIP CARLISLE PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments 10,000.00 A. Prior Payments B. Discount 551.95 (1) 11,038.95 Total Credits (A + B) (2) 10, 551.95 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fiil in oval on Page 2, Line 20 to request a refiund. (3) (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 487.00 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS t . Did decedenl make a transfer and: Yes No a. retain the use or income of the property transferred : ...................................................................... ^ ^ b. retain the right to designate who sha{{ use the property transferred or its income; ............................... ^ 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 propeRy within one year of death ^ without receiving adequate consideration? ....................................................................................... h? ^ 0 ......... 3. Did decedent own an 'intrust for" orpayable-upon-death bank account or security at his or her deat Did decedent own an individual retirement account, annuity or other non-probate property, which 4 . contains a beneficiary designation? .................................................................................................. © ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE {T 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, and Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX+ (8-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER ELMA K. SHEAFFER 21 10 0634 Include the proceeds of litigation and the dath the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. 17EM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. M&T BANK -CHECKING ACCOUNT #436453 3,853.86 2. ~M&T BANK -SAVINGS ACCOUNT #15004200063094 3. 1M8~T BANK -CERTIFICATE OF DEPOSIT #31003917741968 4. ICORNERSTONE FEDERAL CREDIT UN10N -SAVINGS ACCOUNT 5. CORNERSTONE FEDERAL CREDIT UNION -CERTIFICATE OF DEPOSIT 6. IPERSONAL PROPERTY 7. (CASH ON HAND 37,830.29 75,825.79 25.10 20,474.56 1,750.00 760.00 TOTAL (Also enter on line 5, Recapitulation) ~ ~ (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ (08-09} Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESfDENTDECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER ELMA K. SHEAFFER 21 10 0634 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. DESCRIPTION OF PROPERTY ITEM INCLUDETHENAMEOFTHETRANSFEREE,THEIRREIATIONSHIPTODECEDENTAND DATE OF DEATH %OFDECD'S EXCLUSION TAXABLE NUMBER THEDATEaFTRANSFER.ATTACHACOPYOFTHE~EEDFORREALESTATE. VALUE OF ASSET INTEREST nFaPPUCA~ VALUE 1. ALLSTATE 33,528.33100.00 33,528.33 ANNUITY CONTRACT #GA0751946 BENEFICIARIES: C. EDGAR & KENNETH H. SHEAFFER 2. M8T BANK (NATIONWIDE 96,231.63 100.00 96,231.63 ANNUITY #75566658 BENEFICIARIES: C. EDWAR & KENNETH H. SHEAFFER TOTAL (Also enter on Line 7, Recapitulation) { S 129,759.9E If more space is needed, use additional sheets of paper of the same size. REV-1611 EX+ (10-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ELMA K. SHEAFFER 21 10 0634 Decederh's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOFFMAN-ROTH FUNERAL HOME 8,309.70 2. SUNSIDE RESTAURANT -FUNERAL LUNCHEON 402.70 3. WESTMINSTER CEMETERY -OPENING & CLOSING OF GRAVE 1,970.00 B. I ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Paid: State ZIP p, AttomeyFees: IRWIN & McKNIGHT, P.C. 3. Family Exemption: (If decedents address is not the same as claimant's, attach explanation.) Claimant Street Address Cry State ZIP Relationship of Claimant to Decedent 4. I Probate Fees: REGISTER OF WILLS 5. I Accountant Fees: 8,600.00 265.50 6. Tax Retum PreparerFees: PATRICIA A. ROSENDALE, CPA 350.00 7. REGISTER OF WILLS -FILING FEE 30.00 8. CUMBERLAND LAW JOURNAL -ESTATE NOTICE 75.00 9. THE SENTINEL -ESTATE NOTICE 198.16 10. HARRISBURG TRANSFER COMPANY -TRANSPORT 1,039.43 11. BUDGET -RENTAL TRUCK TO MOVE FURNITURE 139.30 12. KRUGERS RENTAL 1,053.12 13. TRAVEL FOR GRANDCHILDREN 1,302.19 14. C. EDGAR SHEAFFER -REIMBURSEMENT FOR TRAVEL & MEALS 201.00 TOTAL (Also enter on Line 9, Recapitulation) 3 23 936.10 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, ~ LIENS ESTATE OF FILE NUMBER ELMA K. SHEAFFER 21 10 0634 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH. 1. MEALS ON WHEELS CARLISLE 2. ICENTURYLINK -TELEPHONE 4. (SARAH A. TODD COTTAGES -NURSING 5. (WEST SHORE EMS -AMBULANCE 6. 2 CHECKS OUTSTANDING FROM M&T BANK CHECKING ACCOUNT WEST SHORE EMS - $46.52 - DDS HUFF - $20.00 TOTAL (Also enter on Line 10, Recapitulation) ~ $ If more space is needed, insert additional sheets of the same size. 60.00 20.85 793.00 93.03 66.52 1 REV-1513 EX+ (01-10) Pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT OF: ELMA K. SHEAFFER ~~ ~n na~n .,~-. 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 [Indude outright spousal distributions and transfers under Sec. 9116 (a) (1.2).) 1. C. EDGAR SHEAFFER Lineal 117,655.03 2 PATTON ROAD 1/2 REMAINDER ANNVILLE, PA 17003 2. KENNETH H. SHEAFFER Lineal 117,655.03 120 ALTERS ROAD 1/2 REMAINDER CARLISLE, PA 17015 3. AMY SHEAFFER GREGG Lineal 2,000.00 1335 WEST GILBERT STREET MUNCIE, IN 47303 4. CLARK E. SHEAFFER Lineal 2,000.00 1232 SYNER ROAD ANNVILLE, PA 17003 5. KENNETH H. SHEAFFER, JR. Lineal 2,000.00 PO BOX 26 INTERIOR, SD 57750 6. KACI SHEAFFER HARVEY Lineal 2,000.00 PO B OX 26 INTERIOR SD 57750 7. SCOT R. MURRAY Lineal 2,000.00 695 SOUTH HIGBEE AVENUE IDAHO FALLS, ID 83401 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS 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. E It more space Is neeoea, use aooitlonal sheets o1 paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent ELMA K. SHEAFFER 21 10 0634 Decedents Name Page 1 File Number Schedule J - Beneficiaries -1 NUMBER NAME AND ADDRESS OF PERSONS RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS pndude outrigh ~spou j ;distributions and transfers under Sec. 91 6 al 1.2 . 8. BONNIE M. SHEAFFER Lineal 2 PATTON ROAD PERSONAL PROPERTY ANNVILLE, PA 17003 9. VONNIE K. SHEAFFER Lineal 120 ALTERS ROAD PERSONAL PROPERTY CARLISLE, PA 17015 LAST WILL AND TESTAMENT I, ELMA K. SHEAFFER, of West Pennsboro Township, Cumberland County, Pennsylvania, declare this instrument to be my last will and testament, hereby expressly revoking all wills and codicils heretofore made by me. 1. I direct my executors to pay all of my debts, funeral and administrative expenses as soon as may be done conveniently after my decease. 2. I authorize and empower my executors to sell any realty owned by me at my death, at either public or private sale, and to give good and sufficient deeds therefor, in fee simple, as I could do if living. 3. I give, devise and bequeath all of my estate of every nature and wherever situate as follows: (a) My iron bed to Vonnie K. Sheaffer, (b) My grandmothers clock to Bonnie M. Sheaffer, (c) The sum of $2,0.00.00 to each of my grandchildren; Amy, Clark, Kenneth, Jr., Kaci and Scot, and (d) All the rest, residue and remainder to my two sons, C. Edgar Sheaffer and Kenneth H. Sheaffer, share and share alike, the child or children of any deceased son taking the ~ ~ J a shaze their pazent would have if living. 4. I nominate and appoint C. Edgar Sheaffer and Kenneth H. Sheaffer, to be the executors of this my Last Will and Testament, they are to serve as such without bond. 5. I hereby suggest that my personal representative retain the services of Irwin, McKnight & Hughes as attorneys in the settlement of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 23RD day of April 1997. J Q~ ~~ (SEAL) ELMA K. SHEAF Signed, sealed, published and declared by ELMA K. SHEAFFER, the testatrix above named, as and for her Last Will and Testament, in the presence of us, who, at her request, in her presence and in the presence of each other have subscribed our names as witnesses hereto. 2 Z M ACgNOWLEDGMENT AND AFFIDAVIT WE, ELMA K. SHEAFFER, CHERYL L. CLELAND and MARTHA L. NOEL, the testatrix and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her Last Will and that she had signed willingly, and that she executed it as her free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the Will as a witness and that to the best of their knowledge the testatrix was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. COMMONWEALTH OF PENNSYLVANIA . SS: COUNTY OF CUMBERLAND Subscribed, sworn to and acknowledged before me by, ELMA K. SHEAFFER, the testatrix herein and subscribed and sworn to before me by CHERYL L. CLELAND and MARTHA L. NOEL, witnesses, this 23RD day of April, 1997. ~, ~, Notary Public Ropger BNlrwinal~ Carltsie Boro, Cumberl~ ~ my My Commission Expires Oct, 3, 2000 Member: Pennsylvania Association of Notaries ~~ ~~ . ELMA K. SHEAF R a V iV L VVVi( VVV4 L 1.JV Mlrchal~ 1~02d MAlsbolo, DE 19866 Mall Dade DE-M&12 Phone: 88&602-4349 i~x: 302.934.2966 Fax To: Roger B Irwin p n~~rs~ Frvna Sue Kimble iFa~c 717-249-8354 Date: July 1, 2010 ills: Estate of Elma K SheafFer Pages: 3 •Carnanents: Attached, please find the irYFormation ynu requested for the Estate of Elma K Sheaffer, as of June 13, 2010. ff I can be of further assistarx~, please do not hesitate to call me at888-502-4349. Thank y!ou and have a great day! Sue Kimble ~ M ~ T Bank This eommunlcaUon oontalns Information Hfi~h may be confldentlal and ptnprletary. You may not use, dlssemlr:ete, distribute or mP7+ al or any part of this oommunlcation wldwut the express consent of M 8 T Bank, AtiArst Fhanclal Inc. or their riespective subsldterles or aflfllates. In addtilon, If you are not the addressee (or are autliorized fA receive this Ir~om~atlon by the addressee), yrou are rat authorized to receive or review the contents of this c~anmunkatlon. If you have received This communication in error, please return it th M 8 T Bank at P.O. Box 1596, Baltimore, MD 212tJ3 and delete any tapy of this vommunicatiarr frtxr- your systems. Thank you. 1. Type o/'Aaount Checking AcCOUn[ Ac~unt Number 436453 - .+vrraa,, iva~yu Ownership (Names ojJ Elmal;'Shea„(jer Openir~ Dare 09/0!/67 Balance vn Dare ofDearh ,$3,553,82 Accrued Int¢red $ . (~ Tukd ~i3,853.1t6 2. 7,~pe ofAccvunt SavutgsAccount Acrwunt Ntomb~• 150042UUi163094 Owne~:ship (Names n~ Eima !C Shea,~er Openirt~DaGe 11/Ol/70 Balance on Dare ofDearh ~37,824?3 Ac~.rued In[e-xsr ~ d.06 lure! ,37,830.29 3. 7~pe of Accrnmr C.FlTiftl:Rtp. Qf F)pp(dSit Account Number 310D3917741968 Chvnershr,'p (Nconcs q~ Elma K Shc~(fer OpeningDate 06/22/10 Balance un Date ufDeafh X7(1,000.00 Accrued Interest S 5,825.7.9 Total .67,S,82S.7.9 i c.`s iu t IfJ I0 YJG1 IO rU MJ [. i' 1UU Far fiicWer nccoual iufornmlioa, dosurce and/or rdn~u~eW of fowls pkaaie roll 16e 1~ Slrtet Cede Oll'ire et iH717•Z404.~6. We were enable to Ioeate any safe deposit box for the above-tneatloned deeedent. Suicemely, Suzanne M Kimble Adjunt Services CORNERSTONE P.O. Box 1181, 5 East Gate Drive, Carlisle, PA 17015 ,~ Federal Credit Union Telephone (717) 249- 166 I FAX (717) 249-8208 Member founded -Service based www.cornerstonefcu.coop July 6, 2010 Irwin & McKnight Attn: Roger B Irwin ~ ~~ ,, West Pomfret Professional Building 60 West Pomfret Street ~1;t~~~i~~' _ ~ ~~ ~~~°~;~. Carlisle, Pa 17013 --~ - ~~=- RE: Estate of Elma K. Sheaffer Roger, At the time of her death, Elma Sheaffer was a single owner of a savings and a certificate of deposits. Listed below is the information requested per your letter dated June22nd: 1) Elma K. Sheaffer, single owner 2) Savings and certificate of deposit were established on June 9, 2009. 3) Not Applicable 4) Not Applicable 5) Interest accrued for: Savings account - $ .28 Certificate of Deposit - $243.32 6) Date of Death balances for: Savings account - $25.10 Certificate of Deposit - $20,474.56 If you require any additional information, please do not hesitate to contact me at 717-249- 1661 ext 240. Sincerely, Donna J. Mickey Financial Services Administrator MEMBER SAVINGS ACCOUNTS FEDERALLY INSURED TO $2SO,OOO BY THE NATIONAL CREDIT UNION ADMINISTRATION cep ... ,~~ m ~9 __.:~~~~' ~°~--M--.~_..._ ___ _~..._ _~..~~..._.~.~.a... - -- Q; v ~...~ _.~-_--_.____..___..~.. ~..~..__v_....._...~_----- 50 ~ a ~ ~__._.~..-.--__- G L ~ M ~-~~~ r ,~~ ~D ~ o ~5 ,~o 3 0~ •°° 7 ~-- ~5_ ao e 00 ~~ bi6w ~ t gIRME 'des a~ Od ~- b _ .~. Contract Details Contract Details For policy: GA0751946 ~ Policy owner(s): Sheaffer, Elma K. Contract Information Product name: Status: Policy owner name(s): Insured/annuitant name(s): Payor name(s): Tax qualification: Iesue date: Replacement: Cost basis {On term policies, this equals the total premiums paid.) as of 06/14/2010: Pre-TEFRA cost basis: Post-TEFRA cost basis: Allstate Select 2000 Active (Inforce) Sheaffer, Elma K. Sheaffer, Elma K. Sheaffer, Elma K. Non Qualified 07!11/2002 No $30,839.50 $0.00 $30,839.50 Values as of 06/14/2010: Policy Value: $33,528.33 For information on surrender charges, market value adjustments and loan balance, click View Additional Values. View Additional Values Page 1 of 1 * This "As of" date shown above can mean: • Fixed life and annuity products -the value as of the date shown. • Variable and indexed life and annuity products -the fixed funds are reflected as of the date shown. Variable and index funds are shown as of the market close for the previous business day. Fund Information Fixed Funds Fund Value Value Ailoc. Rate nt Guaranteed Untii* Fixed 5 Year Fund $33,528.33 100.00 °!0 3.25 % 07/11/2010 *Note: The amount displayed in the Current Rate field may be higher than the actual interest rate paid through this stated guaranteed period due to bonus amounts paid in the initial year(s) of a policy issuance. Refer to the policy contract for more details. ! Print this page • Contract value is not necessarily the withdrawal value. • The information shown is for informational purposes only, presented without express or implied warranties and is provided as is, This information is believed to be accurate and reliable when posted. However, due to the nature of the Internet, Allstate cannot guarantee that the information shown is accurate, complete, and current at all times, nor can Allstate guarantee the suitability of such information for any purpose. https:/1www.accessallstate.com/Secure/SrvcAccounts/ConsumerApprovedPolicyDetails.aspx 6/1412010 (~~~~~~~ 04034 I~TAT I OI~iI DS L 1 FS Y 1~8tIR1~NCS C0,1[PlINY H045739 03 10999!99 t0 PS INTERfACEO LUMP SUM PAYMENT DESCRIPTION CURRENT YEAR TO GATE GROSS PAYMENT AMOUNT 548,118.82 548,115.82 FEDERAL INCOME TAX 50.00 50.00 STATE INCOME TAX 50.00 50.00 NET PAYMENT AMOUNT 548,115.82 S48,t15.82 ~cua ~ c ~'°°~'~ N r ~ YEAR TO GATE AMOUNTS ARE INFORMATIONAL. PLEASE OO NOT USE FOR TAX REPORTING. M O O 4 aD +D a Q e- cxECtc ~ .1030313046 ` DATE OF ISSUE: 07/14/10 FOR INQUIRIES CALL:1-800.452-7126 a. ~" .w FUNERAL HOME 8t CREMAT(JRY, INC. 214 North HanoverStreet Carfiislee, Pennsylvania 17013 717.243.4511 toll free 1.866.451.4511 fax 717.243.3723 www.hoffmma-xoth.can info~hoffrnanrothc~rn June 23, 2010 Kenneth Sheaffer 120 Alters Road Carlisle, PA 17015 Statement of Funeral Expenses-for: Elma K. Sheaffer Date of Death: June 13, 2010 Account Id: 15969-143 PACKAGE: Traditional Funeral Service TRADITIONAL FUNERAL SERVICE PACKAGE $ 4,550.00 Sub Total: $ 4,550.00 MERCHANDISE: Casket: Atlantic $ 2,090.00 . Outer Container: Monarch -Concrete Vault $ 1,220.00 Sub Total: $ 3,310.00 TOTAL FUN'~RAL HOME CHARGES: $ 7,860.00 CASH ADVANCES: 12 Certified Death Certificates at $ 6.00 each $ 72.00 Newspaper Notice -Sentinel $ 112.70 Flowers $ 159.00 Additional Flowers $ 106.00 Sub Total: $ 448.70 Total Funeral Expense:. $ 8,309.70 Balancer S 8.309.70 IO2S-sl-~ lid 1G.6y le Rick T ~ X67231 No. wc-~ ECTINO Vf,D, sureaa ro ~. N~a. hdef and Hyugapns L+cNlwnO all N~ PeeteQ of arae,pea , ~ or an ms iewrsiB sus IltteW fn e1Nci on vu aBa of ieau o/ 1lNB 1~1 o117tlhg, 'E OATS s~/2~/1 fl CONSIGNED TD - <r j,F!_,,,{a` y,,w Ess #2 Rr'1ttOn.-R~3 C'rell S07 1601yg AoDREte 1325 Wee1; C~l~;ne m a^ ~- t ltFV. .,~~ $ i7 H ~~~ F100R O.HV. Ttl. ~1'iI1V1 ~ ~ P, _ COUNTY TE+~nnr+ STATE _D9 't 7pt1 W77~llbL+'iP , eDUe1TY[lo,larr~m sr~re Tn d7~Ad ep ~ ---- - dw1TE 0 ' .. ' 2~-8/24/1 ~ /1 t) - - $/23/1 , ~it aov>fol~llPs~ Oa~N Aucwwanee .. .R RECUEBTS hIOT1FICATION OP ACTUAL CHARGES TO ~ Tai(1 12A OlAt. REW®GH Gt~oes PARTY SF~IAM 6ELOW ,~ . Ss~uon Na 1 X00 s Tom. ~ tdNi. tNt `.` ~ OF aff{~Y, QR iF CNARaE! E7R:EED ESTIMATE aY MORE THAN f orb I Coneahlela•P a • !s TEI.. 1lansroolml~.an MUes 810 nt In CrA a Oiltlrd Chld~, Molloy ORl~ lialllettt Clfeok et Cheok Tian . Cho e - •Dest. . iG fNFORMATtON C • 7b Whae From whs® Mi B Transit From To • sAOtlre N Bsnra or iwelies; ND. 8 :ss Eletra I,bar Men Man Nls. .M ~ ~~ t7isterlce Ca Fast Ihlwtio n TIDN a~ Piano HandN ICE: the chipper aodares Ms acasll each value of ele st,ipmenl ro ae 5 8an+iri , Rare !~ psr huttdrad aopira, pnmiwn; ts~loYitOi US • Additive nITEa sawvlea oaoeltEO aY ogler Char ea 1 `EB 06LIVLRaO ON dR BEFORE Advanced Che a6 ~ffNT COMKETELr OLStilPit"D A CY. Irl: VlNICtE !SINE YS8 OR A CU. FT. VCNICiS OrIt1ERED , Cu iT OeOaRED YATI . . aN NESER ~NOITIONtB ©WASNBR 0 S TEIE PER EI.Y RELE~ T118 9MINMEIVT TO A QdlhBUlR trNe~M or Yo(ume Chege ~ 1 OF N C~ M'E11 POiAiL1 Rte! 7~ QA~®1~ Ulf LrfABRJ'1'Y ROR LO~~ND OAYArEi~~n 1 •E 6RN1Q11'ME Titnla a Ceadhfone for Prynaat e1 TotN Chergee ~~ p w.peld O e.oo. G 8~1Y YAL,YE OiG~.A~ S1f ?ME' s>MII~El1 OII AN AMOUNT ' IlAtttdiroutl mtount to ba pald tl tllels of dollvnry to obtain 1060 96 EWlIT NI THE B111PIAENT, r0 •=1ai BAR Ems, ROUI~ID OF W . dUlvary of an aUm.hd ~O,D, >thlptnsnt •1~ ~ DitillEATiR . ~ . ~ ~ . ~ . . 'Fia1171A114L Ma1ft SIIULCT TD TN! RtRlsS ANa CaNa{TION3 O/ T11E 9At.ANCE DUE p0 WeM1de9 ibK. Chbt E,eeNsee x ReaueDao) 'S TARII~ lNIrPER NlaESr aeteASSS TNC ENTlIIE lNIPltENT eo A VALUE NOT prap^yment Celileled ay ~ 039.43 ~,~ ~ _ ~ + lIbNINC.lIAN,. ~ - cc ~prl~Ved ~At~E "0` ., tiea s~usa-!wi ~tet~ttG tN1! t~N~M1,CY Mt18T INSERT !H ~- •. . p p per VAC1~ OF 1 l~ Tii~'AS3T11ALatlldar O?M~ D 8~~.ii~ TO A NA7QMlM :u~T o>F,M>~:+~tyr ~ w rrsut~-ueo ~ vteaver 7177740774 ..,.., ..,.,., ,,vuu~.,,vl.v uuvua CIVLVr ~u1rvu HNU CfltWtt! GILL HARRISBURG TRANSFER COMPANY 165 I,AMONT STREET NEW CUM@ERIAND, PA 17070 PHONE 711-77A-7836 ' Executive Moving Service ~•~ ~f T-222 P002/002 F-601 Y L ~6~ " ~~~~~~~n - - •i 860 t Fib • ENT t~~ =ass r>~Es 8 2311 Q DATE ORL,YEg1 AGRNOwLBOaleenT: a[n~r.Cnr wAS eEC6lrCp IM A*MPeN'I D COND,no~ EXCEPT AS NOTED ON /NVEN70RY,,Np lERYtCES agp$R60 W6R RMED. RECD FOR STORAGE CONSIGNEE„ (WAREkWSE1 ar, tER 4 i Sarah A 8 Cottages 1000 W. South St Carlisle, PA 17013 Telephone: (717) 245-2187 STATEMENT Statement Date: 07/13/2010 Due Date: 07/25/2010 Amount Enclosed $ Account #: 101873 RE: Elma K Sheaffer Ken Sheaffer 120 Alters Road Carlisle, PA 17015 ter ~,f^ n . ~ i ' ~. ir"`~ ~ ~. a-_ r ~ n .. ...... Balance B/F 1,550. 1,550.00 06/01/10 - 06/30/1 ttage 30 51.67 -1,550.00 .00 06/09/10 Beauty & Barber 1 18.00 18.00 18.00 06/13/10 - 06/15/1 Cottage 3 51.67 155.00 173.00 06/01/10 - 06/10/1 10 51.67 516.67 689.67 06/11/10 -06/12/1 Cottage 2 51.67 103.33 793.00 Current 1-30 Days 31-60 Days 61-90 Days Over 90 Days Amount Due .o0 793.00 .oo .oo .oo NOTE: ***** PAYMENT IS DUE UPON RECEIPT ***** BUT NO LATER THE 25TH OF THE MONTH ***** Please remit the LAST AMOUNT your statement. Include the AQ:.'T# from the statement on the MEMO of your check. Payments after 07/9/10 do not reflect on statement. NOTE: ** fATE PAYMENTS ARE SUBJECT TO A 1.25% LATE CHARGE PER A $10.00 FEE WILL BE CHARGED for RETURNED CHECKS ** Elma K Sheaffer -Account #: 101873 Sarah A Todd Cottages 1000 W. South St Carlisle, PA 17013 Telephone: (717) 245-2187 Statement Date: 07/13/2010 Due. Date: 07/25/2010 ~.. r ~:.~ , ,,,,{ t' r L~ L ~? ~ ~ ~ ~ ~ ~ ~a rY9 C"'7 Y~ F"t CS '~ ~~.. r~ +.N-Y~t +.~ ~ "C9 L:~Z C5~ L~ '~ cc ,~ c ~ , ...~ [~} ,.. ti ~ '~ ~- L!" Y L ~~ ~ t f ./Budget. ~fTAL ACCT: LOCAL. - Business t ELOSEI 8~(lfi(20l~:28 3~! f C4iST. REF. # 011#~63f~~D7~ Custauer Infuroation Dealer Inforeation Rental Inforeation Rates and Charges Total Ast SI~AFFER UQD1 ~ ISELLER SERVIE~ STATION I Daily Rate Wkly Rate ATTN:EDGAR SF#EAFFER 8fi1 E, C1~41.ATE AVt:. { 15' DIF.SEI LIFTGATE.. , ... 43. d0 175. ~ 43. I~R5HEY, PA 17833 !7171 533-fi767 Dealer Nunber: 170-s30 Rental Reriod Due: Ofi117(ld~ 08:00 In; 06i1fit10 14:2fi Out: Ofif16110 0x:34 Oduneter In : 27255 Out ; 27161 pled ; 104 Free ~ 0 Vehicle Inforeation Veh, 410: ?74835 Fuel Esp.: I Save 15% Dff Your Next Track Rental! f For• re.ervations, ' call 1-800-4fi~2-8343 and aention coupon code RA1~ or 4isit ur at budgettruck.caa and enter proootion code RE1152 eFor taros and conditions go to a1r~.1-udgettruck.coelP,A152 #This discount does not apply to so®nercial acco~Knts ;:r contracted rates. li~ileage Rate.......>..... 0,251ai ~.~# It9 DAPIt~ Rt5p.....,..... 22.00 f54,00 ~'~. IBASIC LIABILITY.......... 11.00 77,06 11,00# li~ioving Supplies ...................>....,............., 0.60i ICOST Rf»COVERY FEE -__ i DAY{S} @ 1.08.....>............ t.~# lENER6Y RECIIVERY FEE --- 1 DAY{5) @ 0.13 ................ 0.13# I{)Sales Tax A fi.00,{#{Rental Tax ~ $.00`x .............. 10.17 I Special Tax . ................... 2.~ P,ental Total ................... 115.3f1+ 1Topaff Fuel.,.........0 gals @ O,QOtgal ,..,...>.>,.. 0.00! ITruck Clearoing ......................................... 24.0+63#1 Itiiszing Equipoent ...................................... 0,00 iPhysical Da®age.........> .............................. 0.00 I Reason: I i T~tai Addational Charges 24.00 Iedductions: 1011 Deductions ......................................... 0>~@ IRepairs .........................................>...... 0.00 IReveniee Rdjustsents .................................... 0.00 f Reason: Etloving 5upplie:~ Returned ........ ....................... 0.001 { Total Deductions 0.~ I Total Charges .................. 139.36 { Less: Deposit/pre<<iou3 Payaent: 0.0Q+ { Araunt Due Budget .............. 135.30 1 3Pavments ApQroval 3V1 ~~e~*~~e#~fifi53 022IS5C 1 l 139.30 Hoy a truck Like the are you just rented. For sore inforeation, visit es at bsalgettrack.coaft~ytrucks or call. us at i-801'952-3897. Far any ether inquires, please call our castaaer 5ervicp dept at 1-877-45-4863. Rental Agent: I(ELLS6 Custoser Signature: Y•56A7 DAS (1210 / ,. } t ~~," Customer Receipt :., ~u ~ e ~~~~ ~ RESTAURANT 850 N. Hanover Street • Carlisle, PA 17013 (717)243-5712 Fax(717)243-8399 www.sunnysiderestaurant.com Steaks, Seafood, Crabmeat and Creative Chef Specialties Private Rooms for Business Meetings or your special occasions Date ~ ' l ~ Guest Information c Amount 3 ~ ~ / Gratuity ~ ~ ~/ Total ?ririrck, you ans s3~rs '~~ s I ~~ ~ .. ~~ ~°' ~ ~~ r ~ _ #$~ ec ~. .•r ,. cv t~ ~~. t7 o s~ v~+w ~ ~ v' ~~ ~v ~ S- ~ ~ ~ G,l N ::J '.~.. ~~ *' r rn n a ~' r ~ W ~ °~- °c -J ~", 11 cc ._ .: ~ .- d ~ s r1 .n CS; ~" -~ P- 3 C.3 Jr ~1 (A ~ 8 /. ;~,,; . i The Bestllailt! itllaierflle5ll11. Days Inn Carlisle 101 Alexander Spring Rd Carlisle, PA 17015 Tel: (717) 258-4147 Fax: (717) 25&1207 www.DayslnnCariisie.com 06-21-10 Amy L Gregg 1325 WEST GILBERT ST Muncie IN 47303 Folio No. :4684 AtR Number Group Code Company Wyndham Rewards Invoice No. Arrival 06-18-10 Departure 06-21.10 Conf. No. 72288667 Rate Code : SDf Page No. : 1 of 1 Date Description Charges Cn3dits 06-18-10 Room Charge 06-18-10 Occupancy Tax 06-18-10 Local Tax 06-19-10 Room Charge 06-19-10 Occupancy Tax 06-19-10 Local Tax 06-20-10 Room Charge 06-20-10 Occupancy Tax 06-20-10 Local Tax 06-21-10 Visa XXXXXXXXXXXX6653 Room No. 351 To become a Wyndham Rewards member, visit us at wyndfiamrewards.com or call 1-868- wYH-Rwus. 75.65 4.54 2.27 75.65 4.54 2.27 73.10 4.39 2.19 244.60 Total 2a4.6o 244.60 Balance 0.00 Guest Signature: Pisses contact the Manager about and sues with your stay. Days Inn or affiifates may contact you about goods and services unless you call 877-222-3287 or write to Wyndham Worldwide Hotels, lnc.1 Sylvan Way, Parsippany, NJ 07054 to opt out. View our Days Inn website about privacy. Thank you for staying with us. k was our pleasure to serve you.