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HomeMy WebLinkAbout12-30-10 (3)~ 1505610101 OFFICIAL USE ONLY REV-1500 ~` X01-10' 'L~1` PA Department of Revenue Pennsylvania (.gyp DEVARTMENT OF REVENUE 3~a £. ~~ ber Bureau of Individual Taxes County Code Year i e um PO BOX 280601 INHERITANCE TAX RETURN Harrisbur PA 1 128-0601 RESIDENT DECEDENT ~ ~ ~, J, 7 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY ame Suffix Decedent's First Name MI Decedent's Last N~ ~~~- ~~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number ::~ .:k -: ~. ~ ~; --^--Y- ~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE a~ Y .. =N~v.~~.~-~ ~-: ., _. -, _ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death O 4. Limited Estate O 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received O 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) prior to 12-13-82) O 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes O 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 DIREC~E~ T0: Name Daytime Telep a Number ' - _ ~ ~.. i r i REGIST ~ ~S USE„~NLY ~-i First line of address Second line of address City or Post Office C State ZIP ode ~~ ~ ~ ~ f cn ~" ~- ~ ;- DATE FILED Correspondent's a-mail address: J,4 t,i ~CaAe!,~' C~ ~/,~Q/, oo . Under penalties of perjury, I declare that I have exami ed this return, includ'~ig accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF ER N RESPONSIBLE FOR FILLNG RETURN DATE ADDRESS Z'7. ~ DicN. ~.~It// `~ /`a~ ~ ~ ~~ ,~Q ~~ ! ~© SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS BOG'{ ~~~ttiCl ~Od. L ~~~ ~os6ioln~ USE ORIGINAL FORM ONLY Side 1 1505610101 J r 1505610105 REV-1500 EX Decedent's Name: Decedent's Social Security Number 1 / ,L ~ 3 ~ ~ _ ~ ,~ RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. ~:. ~r 2. Stocks and Bonds (Schedule B} ....................................... 2. ~ 3. Closely Hekt Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. j 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. ~ ~~. f 5. Cash, Bank Deposits and Miscellaneous Personal Property .(Schedule E)....... 5. , Z / W Q ~~ ~~° ~ ~ 1 ~ ~-~a< ~ 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. ~- _ 7. Inter-Vivos Transfers 8 Miscellaneous Nan-Probate Property (Schedule G) p Separate Billing Requested........ 7. , ` _<y ~ ~~~9j 4 id 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ~, ~ ~ ; ::Y i'C ~ ~ ,~ ~; ~Q 9. Funeral Expenses and Administrative Costs (Schedule H} ................... 9. ~ ~ ~ ~~ ~ Z, ~,- ZM } 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule i) .............. 10. :: 3 11. Total Deductions (total Lines 9 and 10) ................................. 11. .~ ~' ~ ~ ~ c~ .~ Z ` Z.. 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. • ~ ~ ~ ~ ~ ~ ~ 0 ~ ~);~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which - ~ ~ ~"°~ ~• ~ °'~` an election to tax has not been made (Schedule J) ........................ 13. ~ ss x ~ . --~~, ~. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. ~ ~ ~ ~ ~ ~ r 1-.~ TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 ~ : ,. ~ ~ .~. , __ . ~ ~ ~... ..: ~ ~ ~~, 16. Amount of Line 14 tax le ~ ,._ ., ' '~;< ,-' ~,-.~ ~ tug`-'' ~ ~~ `k~ ~. ~ -~c ~ ;"` ° ~, I at lineal rate X .d ~.., ~ ~' ~ ~, ~ 4Q ~ ~ ~ ~1 16. ~ ~ ` _ r / ' ~ 1 7 17. Amount of Line 14 taxable ~ ~ "° `~'.~~'~ '~'`~'"~ "'~` ,~.:;y~?3~,.~.~. s„K; . at sibling rate X .12 ~ = 17. ~ ~ ~ ~ ~ ~ ~~ 18. Amount of Line 14 taxable ' `~'~ '~'~ ~ `~ ~ .•"`~ ._'~ ~'~~~°,'~ ~`- ~~,... ~ ~, ~ 4 ~`,~.~,.'~~^ r~ ~ ~ ~ ~ at collateral rate X .15 ~ 18. ~ ~ ~ ~ ~ ~_ 19. TAX DUE ......................................................... 19. 20. FILL IN THE OPAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 15U5610105 1505610105 J REV 1500 EX Page 3 Decedent's Complete Address: File Number DECEDENTS NAME STREET ADDRESS ~.-- [.c CITY STATE ZIP ~ ~ Q I Tax Pa ments afnd Credits: Y 1. Tax Due (Page 2, Line 19) 2. CreditsJPayments 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. Fitl in oval on Page 2, Line ZO to request a refund. Total Credits (A + B) (2) (3) (4} 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) ~ I ~ / ~ , T~" 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 :.................. ^ b. retain the right to designate who shall use the property transferred or its income : .............i~SJ.~~................... ,~] ^ c. retain a reversionary interest; or .......................................................................................................................... ^ fl d. receive the promise for life of either payments, beneftts or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a benefciary 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 survivirxl spouse is 3 percent [72 P.S. §9116 (a} (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the .surviving spouse is 0 percent (72 P.S. §9116 (a) (1.1} (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory. requirements for disclosure of assets and Bing a tax ietum 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 chid is 4 percent [72 P.S. §9116(a}(1.2)]. • The tax rate imposed on tt~e 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 decedents siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. e REV-1508 EX + (1.97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT _ ESTATE OF FILE NUMBER Include the proceeds of litigation and the date the proceeds ere received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~ yQ~y.~. /~ 1 .~y,~ ~S:'~/~//CY(JJ'~l NGItiJ ~, z ~ ~,*~~~q~/~i A~~T~ ,?1 0o39~9Z3SOloL 9~~~a 30 000. o0 ~ ~~~-~A,~k /~~rT~ .3~0o3919z382.78~ y~Z,l~ ~,oooo. °~ /,vo,~ 2µ,~~ ~` ~~.~,~ T~~A« owT l S 13 S~ Z. 3~ SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY TOTAL (Also enter on line 5, Recapitulation) I $ ,~ 10 '7~ c1' g~. (If more space is needed, insert additional sheets of the same size) ~. ~, ~~ Q~ ~.~ `~~ ~ti~~ ~~ Morgan Stanley Smith Barney 4507 N. Front Street Second Floor Harrisburg, Pa. 17110 To whom it may concern, September 20, 2010 Please accept this letter of authorization as the distribution instructions of our father's estate account. We would like to equally distribute the Cash in this account to the two beneficiaries of the estate. Transferred half of the estate account into the Morgan Stanley Smith Barney AAA # 410- 057962 in the name of Alan C. Myers. The remaining amount should be in a check made payable to Jay A. Myers that may pick up at your office. Thank you, Alan C. Myers r 1 i ~~- ~7 /Y ~ C vvt.^.J Jay A. Myers ' REV-1510 EX+(1-97) • COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF _ ._ This schedule must be completed and filed if the SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY FILE NUMBER any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET 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. /~ /,~ ~,J C~ ~ e ~ ~, ~~ .~~~~~~ ~~ L~Q~~ P~ 7 ~ ~ 1 0 Z.S" ~o~,~ ~,~g fro O~~ . ~ 9 ~Q~ ~ ~~~ ~~~ ~~~ TOTAL (Also enter on line 7, Recapitulation) I $ ~©Q ~j ~ 9 , (If more space is needed, insert additional sheets of the same size) Page: 1 Document Name: untitled STET 1 THE TRANSACTION STMT FORMAT 10/12/27 9.34.38 STMT CO 96 OP EBRN MS 50861 LAST PAGE OF TRANSACTIONS ACTION COID PROD CODE REA ACCT 3 5 0 0 4110 0 9 3 8 8 4 SHORT NAME MYERS ARZ~iiJR R CURB CODE PAGE 3 SEARCH FROM 106/10/02 THRU 110/11/19 ACTH POST EFFECTIVE CHECK NUMBER IRAN AMOUNT D/C B,ALANCE TRACE ZD DESCRIPTION 12/31 158.34 C 60,154.89 I-GEN109123100030992 INTEREST PAYMENT GENERATED 11/19 534.69 C 60,689.58 I-GEN110111900000001 INTEREST PAYMENT' GENERATED 11/19 323721578 60,689.58 D .00 EPSDCAR CLOSEOUT - DECEASED .. PF: 1-HELP 3-PLVL 6-INQ 7-SB 8-SF 9-ASUM 11-CUTO -STSM ~-X ~~ ~ ~ r -~r Date: 12/27/2010 Time: 9:35:00 AM r--~ ~ F F ~ ~ ~- ~ ~~~ ~ F ~~-~ ~r~ ~ ~- u~1-~~ ~~~~,~. ~~~ ~ ~~ ~ o~ ~ F l~ © r1~&TBc1Y11~ IRA / OTH IR /SEP IRA DESIGNATION OF BENEFICIARY _---= Manufacturers and 'iYaders Trust Company as Trustee for: /I `~ I; ;I;' '~nr:,, ~11h;; ~~ .ii ;,.~;11, ,.,,,,; ~, :~ , Name /_ S a S~urlty~-~ ~/ /~ Addres / `__ / ~ / Jr Date rt /~~. cny % ~ /~D /~ zi%~D /~ ~~ `yi ut~r `~ ~a,~~+}L- .i i,~r+ 'T.r ~.:i/ r. ~r.;i c _ .~~Li .~ : i~ ~ r r {!+~ •F t~. r r ~' 'ir' ;,~ ' 'i " r } r- ~' tr °:rt; t '~r. .' ~}~r. ~ r ~ ii : ~~~" 1 hereby elect to: (check one} ~~.C~HANGE BENEFICIARY ~ I ~de'Signate the individual(s) named below as my primary and contingent be~ ~ _ ffdiary(ies) to receive the benefits of my IRA/ BOTH IRA I SEP IRA Plan that may become due upon my_death. This change of beneficiary m revokes and replaces all~prior beneficiary(ies) selected by me, and encompasses all accounts'unde'r my IRA / ROTH IRA /SEP IRA I - " " , G ADD BENEFICIARY TO MY NEW IRA/ROTH IRA/SEP IRA PLAN In addition to the beneficiary designations made on the attached Application d Adoption Agreement, I designate the individual(s) named below as my primary and contingent beneficiary(ies). _ `~_ j~; ,?i. •r:t"='I.t~.>;K'~.i`• .y :S ...+~i`. d~' _ "::"s_'I~',, `• }.:~: •.~:;:... ~ ~. .;~ -..... ~•y,j,J,.iL.~. `:r .:,.~ _ r.~, ..I;~,rf .,:r~~• '.l:'. •'..:+~.. rl:~,:t'$k:~':: 'til ~., y.~w y:;.!;:' .}_ • This section should be reviewed if either the rus ~' ence of I ac wledge that I have received a fair and reasonable disclosure of the IRA/ROTH IRA/SEP IRA holder is located in a community or my use's property and financial obligations. Due to the important tax marital property state and the IRA/BOTH IRA/SEP IRA holder is con uences of giving up my interest in this IRA/ROTH fRA/SEP IRA, married. Due to the important tax consequences of giving up one's I ha been advised to see a tax professlona!. oommuniry property interest, Individuals signing this section should + consult with a competent tax or legal advisor. I he e y give the IRA/ROTH IRA/SEP IRA holder any interest I have in the f ds or property deposited in this IRA/ROTH IRA/SEP IRA and C~JRRENT MARITAL STATUS con nt to the beneficiary designation(s) indicated above, I assume full ~ ('~ Am Not Married - I understand that 'rf I become married in the res o sibility for any adverse consequences that may result. No tax or ~ future, I must complete a new IRAlROTH IRA/SEP IRA Designation leg I deice was given to me by the Trustee. Of Beneficiary form. U 1 Am Married - 1 understand that if I choose to designate a primary Sig t re of Spouse Date beneficiary other than my spouse, my spouse must sign below. I am the spouse of the above named IRA/ROTH IRA/SEP IRA holder. Sig a t re of witness Date .. . .- . •,...' ... . ,.. :. . ...' . .... .;~ -{. I hereby Instruct MBtT Bank, as Trustee of my IRA/ROTH IRA/SEP IRA Plan to all sums pursuant to this designation to the primary beneficiary(ies) if he or she survives me, and to the contingent beneficiary(ies) only ff all my mary beneficiary(ies} predecease me. If nq primary or contingent beneficiary exists at the time of my death, or no designation is made, payment i I be to my estate. I have the right to change this designation at any time by filing another IRA/BOTH IRA/SEP IRA Designation of Beneficiary form th the Trustee. ~~ X ~ 1 ~, .~,aJ .~ .~- d y~G ~ y/g ccount Holder Slgnaturel. D to Customer Identificatio / / ranch Representative Name (Please Print) Authoriz ig lure arch ~ Ernployee Number ~~ 1,4Jhnn• r7anl.r.,,,r, valln,~~~ r`~ic~nmq• rr,.,,, ! ~~~~--~ ~eV VerffV ~// (! ~ BR-395 (3103) `. ~ M&T Banlc IRA DISTRIBUTION TO BENEFICIARY FORM AND AFFIDAVIT ^ TRAD ^ ROTH ^ SEP. PLAN (FOR QUALIFIED PLANS COMPLETE FORM BR-594) ~~1 DECEASED :ACCOUNT HOLC~ER ~ ~`u ~' .,' Name ARTHUR R MYERS Date of Birth 4/8/21 Social Security # 203 - - Date of Death* 9114/10 *Attach death cert~cate ,. ~;:~~. -8E~11EF1C1A-RY 1I~iF~3R(1~11~'~'ION ; ~ -; , ;~, x. ~ ,: Name ALAN C. MYERS Mailing Address 4064 DARIUS DRIVE City, State, zip ENOLA, PA 17025 Legal Address (if different than mailing address) City, State, Zip SS# or Estate Tx ID# Phone # (717) 919-3236 Date of Birth* 11/14/1950 Relationship to Depositor* SON Percentage of Plan 100% Customer Identification PA DRIVERS LICENSE Customer Identification** 14032725 Current Employer or Nature ofSelf-Employment** HOFFMAN FORD *Not applicable if the beneficiary i:. not an individual, such as the estate or a trust. **Two forms of identification are required if customer is new to M&T Bank and an ff not an individual, attach appropriate Legal documentation. Inherited IRA Beneficiary or Transfer to Spouse Account is being established. ,, a 1S'1''RI~UTfON E~ECTlaN ,;(Cc~mplete~~~tidn 34 or~B)` ~ ; Q ~~ ~ `~~~~ .. _. H ... SECTION A: OWNER DIED ON OR AFTER THE REQUIRED BEGINNING DATE (April 1 of the year after owner attained age 70'/z) 1. If the beneficiary IS an individual or qualified trust, select one of the following: a) ® Lump Sum -Distribute account in a single lump sum b) ^ Inherited IRA -Single Life Expectancy -Make periodic distributions based on single life expectancy of the beneficiary's or owner's remaining single life expectancy c) ^ Transfer To Spouse -Designate entire account as spouse's own (Available only if the spouse is named sole beneficiary). d) ^ Spouse Rollover -Rollover spouse's interest in account to spouse's own IRA (Available whether or not the spouse is named as sole beneficiary) 2. If the beneficiary tS NOT an individual or qualified trust, or if NO beneficiary is named, select one of the following: a) ^ Lump Sum -Distribute account in a single lump sum b) ~ ^ Inherited IRA -Single Life Expectancy -Make distributions periodically over the owner's remaining single life expectancy SECTION B: OWNER DIED BEFORE THE REQUIRED BEGINNING DATE (April 1 of the year after owner attained age 70'/z) 1. If the beneficiary IS an individual or qualified trust, select one of the following: a) ^ Lump Sum -Distribute account in a single lump sum b) ^ Inherited IRA -Single Life Expectancy -Make distributions periodically based on single life expectancy of the beneficiary's remaining single life expectancy , c) ^ Inherited IRA -Five Year Rule -Distribute entire account by December 31 of the year containing the fifth anniversary of the IRA owner's death d) ^ Transfer to Spouse -Designate entire account as spouse's own (Available only if the spouse is named sole beneficiary). e) ^ Spouse Rollover -Rollover spouse's interest in account to spouse's own IRA (Available whether or not the spouse is named as sole beneficiary) 2. If the beneficiary iS NOT an individual or qualified trust, or if NO beneficiary is named, select one of the following: a) ^ Lump Sum -Distribute account in a single lump sum b) ^ Inherited IRA -Five Year Rule -Distribute entire account by December 31 of the year containing the fifth anniversary of the IRA owner's death ,. .fEC3ERAL .IWGOME TAX V1ffTHHOLDlNG []Check~x To Indicate a Change In Prior,llnstruc~ons ~ .: a:.~~~ ~`'~` Amounts distributed from your IRA may be taxable as income to you in the year received. These distributions are subject to federal income tax withholding at 10% unless you elect not to have tax withheld. If you elect not to have withholding apply to your payments, or if you do not have enough federal income tax withheld from your payments you may be responsible for payments of estimated tax. You may incur penalties under the estimated tax rules if your withholding and estimated payments are not sufficient. You must check one and only one of the following boxes: ^ I elect not to have any federal income tax withheld from the distribution(s) ® I elect to have 30 % of each distribution withheld as federal income tax. (You must elect a percentage greater than 10%.) ^ I elect to have a fixed dollar amount of $ from each distribution withheld as federal income tax. Copy to Pension Services & Customer BR~69 (9/08) w 'S PAYN~ENT M, ETHOD, OF DISTRIBUTIO~1 ; " - ~~ ~> / ~° ~' ~~ • Transfer to Spouse -If you are the owner's spouse and elected "Transfer to Spouse" in Section 3, indicate the account number of your existing IRA or new IRA account Branch: Attach completed IRA/Roth IRA/SEP-IRA Deposit Agreement (BR-460) for existing accounts or Traditional IRA Simpli>er/Both Simplifier (BR-450/BR-666) to establish a new plan. Branch: Review with customer if changes to benebciary information (BR-395) or scheduled distribution (BR-853) are required. Complete appropriate form, if necessary. • Inherited IRA - If you selected to establish an Inherited IRA in Section 3, complete IRA/SEP Scheduled Distribution form (BR-853) with distribution instructions and submit with the IRA Distribution to Beneficiary and Affidavit Form (BR-469). Please note: !f no instructions are given Pension Services will defaulf scheduled distributions as required by IRS regulations with 70% federal withholding. Branch: Review with customer if changes to beneficiary information are required. Complete Form BR-395, if necessary. • Lump Sum - If you selected a "Lump Sum" distribution in Section 3, indicate how payment is to be made: ® Issue Check ^ Transfer to M&T Checking Account # ^ Transfer to M8~T Savings Account # • Spouse Rollover-If you are the owner's spouse and elected a "Spousal Rollover" in Section 3, indicate the account number of~your own existing IRA or new IRA account Branch: Attach completed IRA/Roth IRA/SEP-IRA Deposit Agreement (BR-460) for existing accounts or Traditional IRA Simplifier/Roth Simplifier (BR-450/BR-666) to establish a new plan. Branch: Review wifh customer if changes to beneficiary information (BR-395) or scheduled distribution (BR-853) are required. Complete appropriate form, if necessary. - }~fi BRANCH CEitTIFICATIOiN r - ~~z`"~. ~~ {7 p}2 ~-,,,,,.~ ~ 4~ ~fi... ,ly"~r+ !`'~ -C.~nF 3aky~ s'~.K.°~ 71M 5, f,.L.. 2 f ~.. ~.]4~...2,- t~5 Branch Representative Branch No. Date Employee Number IRVYLON BOLTZ 6129 11/12/2010 56027 _. ,, °~ AFF.IDAVIT _ a ~~s ~ t-f~-~ :: ;: ~. - ,, - . ;.. _ - ~ - STATE OF PA COUNTY OF DAUPHIN SS. I being duly swom, depose and say that the information presented in Section 1 and Section 2 above is accurate and complete. I request Ma facturers and Traders Trust Company to pay me the benefits due me as the named beneficiary of the deceased depositor's IRA. F r a in co sideration of the death distribution payment(s) due me, I agree to hold MST Bank, as Trustee of the IRA, harmless from ny all I~ility, costs, losses, expenses or damages of every kind whatsoever, which may occur as a result of this distribution. of Date Notary: Indicate form of Customer Identification viewed for identification purposes Subscribed and swom to before me this 12 day of NO VEMBER , 20 10 f Notary P lic _ CONiMaNWEALi'H OF pENNSYLVANIl~ Notarial Seal ~ Craig D. Rebuck, Notary Public I Lower Paxton Twp., Dauphin County i My Commission Expires Nov. 19, 2012 Member, Pennsylvania Association of Notaries Copy to Pension Services 8~ Customer BR-469 (9/08) w RE1,'-15:1 EX+ (10-09) ~ pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Dec ent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. y 1 . ~ ~r A _ 1 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) _ _ _ _ __ _ Street Address City ____ -- ___ - - __ - _ _ -- - _- - - State ZIP Year(s) Commission Paid: 2. Attorney Fees: 3. 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: ~ ~ ~ (~ ~ S. Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL (Also enter on Line 9, Recapitulation) I $ ~C/~ ~ ~. Z If more space is needed, use additional sheets of paper of the same size. _s~_! ~- ~ ~ REV-1513 EX+ (9-00) SCFIEDIJLE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. y / ~~ ~ ~ 1~~~ ~s .1~R ~~a~~ / / l~ < /74Zf ,~- / /q ~~ / ~~S / o>~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ tir more space is needed, insert additional sheets of the same size)