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Home My WebLink About02-10-11150561D140 ~ REV-1500 ~` ~°'-'°' R# OFFICIAL U,~ OtIILY I PA Department of Revenue Courtly Code Year!, File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po Box 2801 2 1 1 0 0 9 4 8 Harrisburg PA 1712&0601 RESIDENT DECEDENT _ ENTER DECEDENT INFORMATION BELOW Social Seauity Number Date of Death MMDDYYYY Date of Birth MMDDYYYY, 2 1 0 1 6 7 4 1 3 0 7 2 1 2 0 1 0 1 0 1 2 1 9 2$ ', Decedent's Last Name L U P O L D Suffix Decedent's First Name MI J E A N E (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI N I A '' Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICA~T~ WITH THE REGISTER OF VWILLS I i FILL IN APPROPRU-TE OVALS BELOW ', 1.Original Return ~ 2. Supplemental Return ~ 3. Remai d Return (date of death prior ~ 1213-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federa~ E taite Tax Return Required death after 12-12-82) ® 6. Decedent Died Testate ~ 7. Decedent Maintained a Uving Trust 8. Total I~um~er of Safe Deposit Boxes iew.,..ti r....., s unu~ /A4f~nh r`.nnv of Tnis4\ r ~~aaoaw ~ wM~ v~ . m~~ ~....,..... --„~-~ ... .. ~~ y 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Electio tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (A S .'O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFO SHOULD BE DIRECTED TO Name Daytime T Number R M A R K T H O M A S E S Q D I R E 7 1 7' ~~ q 6 2~ 0 0 ~ ~ 'r' REt'al$ LL$U$@~HLY ~< ("t'1 II3 f. ~ i` ~ First line of address _ ~ p r~ :i r 1 0 1 S O U T H M A R K E T S T R E E T ~p ~, ~~ f c _- c ~ r Secorrd line of address ~ ~p D I c.aJ Y-~E FILED """ =~ State ZIP Code City or Post Office M E C R A N I C S B U R G P A 1 7 0 5 5 Correspondent's e-mail address: rmarldho mail.com Urxier penslUes of perjury, I dsdaro tl~at I haw examined Uds netum, Including accomparrying schedules and stafemsrKs, and to pf my knowledge and beUef, it is true, and complete. DscliuaUon of preparcr other than the personal roprosentaUve Ls based on all Ir~fomiaUon of which r has any knowledge. SIG OF PERSON RES R FlLI RN DA ADDRESS ~ ~ ~ 2021 LINCOLN REET CAMP HILL A 17011 Sl A REPRESENTATIVE D TE ~S ~ A 101 SOUTH MARKET STREET_ MECHANICSBURG ~ A 17055 c~_4... "~ .~ n ski ~-1 .s PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 15056]~0~40 1505610240 ~ ' REV-1500 EX Decedents ~Sodial Security Number Decedern~s t~+e: JEAN E• L U P O L D 2 1 0', '1 6 7 4 1 3 RECAPIITULATION 1. Real Estate (Schedule A) ........................................... 1. 2. 3. 4. 5. 6. 7. 8. Stocks and Bonds (Schedule B) ...................................... Cbsely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... Mor~ages and Notes Reosivable {Sd~edule D) .......................... Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... Jointly Owned Property {Schedule F) ^ Separate Billing Requested ....... Inter-Vivos Transfers d~ Miscellaneous N Probate Properly (Schedule G) ~ Separate Billing Requested ....... Total Gross Assets (total Lines 1 through 7) ........................... 2• 3. 4. 5. 8. 7. 8. I I y'' 1 I' '~ ~ ~ 3 ~ ~ ~ ~ ~ 3 2 1 ? ~ 9 0 3 • 7 • 3. 8 . 9 . 0 7 9 7 6 5 0 1 9. Funeral Ex enses and Administrative Costs Schedule H ......... P ( )......... 9• ~ 2 7 7 . 8 1 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. ', ~ 5 4 8 • 4 9 11. Total Deductions (total Lmes 9 and 10) ............................... 11. ~ ~ 8 2 6. 3 0 12. Net Value of Estate (Une 8 minus Line 11) ............................ 12. 3 ~' ~ 9 1 3. 4 1 13. Charitable and Govemmentaf BequestsiSec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... 13. 0 . 0 0 14. Net Value Subject to Tax (Une 12 minus Line 13) .. .. .. ..... ...... 14. ~ 1 (~ 9 1 3 . 4 1 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (ax1.2) x.o _ 0. 0 0 15. ~ 0. 0 0 16. Amount of Line 14 taxable ' at lineal rate x .045 3 1 6 9 1 3. 4 1 16. 11, 4 2 6 1. 1 0 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, ' ~, D. 0 0 19. TAX DUE ...................................................... 19. 1!, 4, I 2 6 1 • 1 0 20. FILL IN THE OVAL IF YOU ARE RE4UESTING A REFUND OF AN OVERPAYMENT ~~ ide 2 ', '~ i I ~ 1505610240 1505610~40~ ~, REV-1500 EX Page 3 Decedent's Complete Address: FII~ Number 21 10 0948 DECEDENTS NAME JEAN E. LUPOLD STREET/~DDRESS ~ 2021 Lincoln Street Cry Camp Hill STATE PA ZIP 17011 Tax Payments and Credits: 1• Tax Due (Page 2, Line 19) (1) ' ~ _ 14.261.10 2. CreditslPayments A. Prior Payments B. Discount Total Credits { A + B) (2) ' 0.00 3. Interest ', {3) , 4. ff Line 2 is greater than Line 1 + line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page T, Line 20 to request a refund. (4) ~ ~ 0.00 5. ff Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 14261.10 Make check payable to: REGISTER OF WILLS, AGENT' PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APP~tO~RIATE BLOCKS 1. Did decedent make a transfer and: ' Y~,s No a. retain the use or income of the property transferred : .................................. ............................... b. retain the ri ht to des' pate who shall use the transferred or its income: 9 r9 PfOPeny ~ c. retain a reversionary interest; or d. receive the promise for Iffe of either payments, benefits or care? ....................................................... 2. If death occurted after December 12,1982, did decedent transfer property within one year of death without receiving adequate c~nsideration? ....................................................................................... ....... 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 cerement account: annuity or other non-probate property which contains a benefiaary designation. , ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE ~ /~S 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 $r fir the use of the surviving spouse 3 percent [72 P.S. §9116 (a) (1.1) O]. 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 survi~rin I spouse is 0 percent [T2 P.S. §9116 (a) (1.1) (ii}j. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requ~rer~nts for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficlary. 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 fie use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent p2 P.S. §9116(a)(1.2)j. I j • The tax rate imposed on the net value of transfers to or for the use of the decedents lineal beneficlaries 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. §91~~16(~}(1.3)). A sibling is defined, undr Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption's REV-1508 EX + (6-98) SCHEDULE E COMMONWEALTH OF PENNSriVANIA CASH, BANK DEPOSITS, St MISC. INHERRANCETAxRETURN PERSONAL PROPERTY ~ RESIDENT DECEDENT ESTATE OF FILE NUIMBE JEAN E. LUPOLD 21 10 0 Include the of Ntlpation and the date the proceeds mere reoeNed by the estate. AN properly f~owned with right of survhrorsh~ must bs dlscbsatt on ScheduN F. ITEM VALUE AT DATE NUMBER DESCRIPTION ' i 4F DEATH 1. 005 Buidc Century Sedan ', 5,000.00 2, vereign Bank, checking account no. 1161092501 . O. Box 841005 oston, MA 02284 3. overeign Bank, money market no. 2331031789 . O. Box 841005 ston, MA 02284 4. overeign Bank, certificate of deposit no. 2335226185 . O. Box 841005 oston, MA 02284 5. embers 1st Federal Credit Union, savings account no.179713-00 . O. Box 40 echanicsburg, PA 17055 6. embers 1st Federal Credit Union, checking account no. 179713-11 . O. Box 40 echanicsburg, PA 17055 7. fate Employees' Retirement System 0 North Third Street, Room 319 aatsburg, PA 17101 ', 8. antage Ambulance refund 9. rie Insurance refund 2,696.37 134,599.07 10,091.60 19,070.52 3,697.74 1,987.76 120.00 74.00 TOTAL (Also enter on line 5, Recapitul ';L' (N more space is needed, insert addffional sheets of the same size) ', '~ REV-1509 Ex+ (01-10) pennsylvania DEPARTMENT OP REVENUE INHERITANCE TAX RETURN _ RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY Man asset was made jointly owned within one year of the decedents date of death, R must be reportejd oil $chadule ~. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS ' ELATIONSHIP TO DECEDENT A. Corinne L. Lupold 021 Lincoln Street aughter amp Hill, PA 17011 B. I C. i JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY-HEIR REAL ESTATE. I DATE OF DEATH VALUE OF ASSET ! ~ % OF pECEDENTS INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST I. 8198 021 Lincoln Street, Camp Hiii, PA 17011 154,587.50 50. 77,293.75 assessed value of $123,670.00 x common level ratio of 1.25 = 154,587.50) i ~~ I TOTAL (Also enter on Line 6, If more space is needed, use additlonal sheets of paper of the same size. REV-1510 EX+ (08-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN ~ RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY This schedule must 6fl ODmDIBEed and tNed if the answer to any of questions 1 through 4 on page three Of the REV-1500 b yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCUIDE THE NAME OF THE TRANSFEREE, Ti18R RELATIONSF9P TO DECEDENT AND THE DATE ~ TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE DATE OF DEATH VALUE OF ASSET % OF DECD INTERES EXCLUSION PF Al TAXABLE VALUE 1. ohn Hancock Life Insurance Company 91,108.90 00.00 ', 91,108.90 . O. Box 8505 oRsmouth, NH 03802 ~~ L ~I Iii I '~ '' ~i ~I I I III TOTAL (Also enter on tSne 7, Recapitulatiol}) { i; 91,108.90 If more space b needed, use additional streets of paper of the same size. REV-1511 EX+ (10-09) pennsyivania SCHEDULE H pEPARTMENr OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMiNISTRATiVE COSTS RESIDENT DECEDENT ESTATE OF FEE NUII~E L JEAN E LUPOI.D 21 10 094 ' Dscsd~M's debts must bs reported on Schsduk L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Neill Funeral Home, Inc. 7,344.27 B. 1 2. 3. d. 5. 6. 7. 8. ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Corinne Luaold Street Address 2021 Lincoln Street City Camp Hill State PA ZIP Year(s) Commssion Paid: 2011 Attorney Fees: R. Mark Thomas, Esquire Fatuity Exemption: (If deoedenfs address is not U1e same as daimanfs, attach explanatlon.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Return Preperer Fees: Sovereign Bank (bank fee) State Employees' Retirement System (reimbursement) 3,500.00 ~ I 11,275.00 346.50 ' 20.00 ', I 1,292.04 TOTAL (Also enter on Une 9, Recapitul~tia~) I S If more space is needed, use additlonal sheets of paper of the sane? size. ~ Continuation of REV-1500 Inheritance Tax Retum Resident Decedent JEAN E.LUPOLD 21 10 0948 Decedent's Name Page 1 File Number ~ ~ Schedule H -Funeral Expenses 8~ Administrative Coats - B1 iTEM NUMBER DESCRIPTION ! AMOUNT 8. ADMINISTRATIVE COSTS: ', Personal Representative Commissions: ~i 2. Name(s) of Personal Represerdative(s) Kane Warble ~I i, 3,500.00 Street Address 5 South 16th Street i-1--- Cily Camo Hill State PA ZIP ' 1 011 Year(s) Commission Paid: 2011 SUBTOTAL SCHEDULE H-61 I~ ', ~ s,5oo.00 I ~ __ __ - REV-1512 EX+ (12-08) Pennsylvania DEPARTMENT OF REVENUE INHEPoTANCE TAX RETUf2N ~ RESIDE9IT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIAR{L{TIES, 8~ LIENS TATE OF FILE 1 AN E. LUPOLD 21 1 Report debts incurred by the decedarrt prior to death that remained unpaid at the date of death, including ITEM NUMBER DESCRIPTION 1. Ides Living Center -West Shore . O. Box 644407 ittsburgh, PA 15264 2. embers 1st Federal Credit Unfon, visa no. 4672090000193862 . O. Box 4517 rot Stream, IL 60197 3. ershey Kidney Specialists, Inc. . O. Box 517 azleton, PA 18201 4. peciaf Event Emergency Medical Services . O. Box 726 wv Cumberland, PA 17070 5. vantage Ambulance 33 Firehouse Lane arrisbura. PA 17111 TOTAL {Also enter on Line 10, If more space is needed, insert additional sheets of the same size. ~uilsigd medical expense:. VALUE AT DATE OF DEATH 480.00 48.49 I 60.00 I 70.00 i 890.00 i I _ _ _..._-- _.-_ _._ _ _.. _. 1 _ REV-1513 EX+ (01-10) Pennsylvania DEPARTMENT OF REVENUE INHEPoTANCE TAX RETURN ~ RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE 13F: FILE NUMBER: .,, ., ~~ ~n noels RELATIONSHIP TO DECED NT' AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Lbt Trustee(s) '~ OF ESTATE I TAXABLE DISTRIBUTIONS pndude ought I distributbns and transfers under S 91 ~6 1 2 ', (a ( . ~.] ec. 1. Joy Anderson Lineal , 12.50 12380 Fourth Street, #22 ', Yucaipa, CA 92399 ~~ 2. Nancy Daimler Lineal I, '~~ 12.50 950 South SOth Street Harrisburg, PA 17111 ~ 3. Mary Vaughn , I Lineal 12.50 99 Buttonwood Drive '~ Dillsburg, PA 17019 4. Reynold Lupold Uneal 12.50 331 Main Street Marysville, PA 17053 5. Kaye Warble Lineal ' 12.50 5 South 16th Street ~I Camp Hill, PA 17011 ', 6. Corinne Lupold Lineal 12.50 2021 Lincoln Street Camp Hill, PA 17011 7. Lawrence Lupold Lineal ' 12.50 102 Salt Road '' Enola, PA 17025 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 CO E S EET, 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. '' i TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. 'i 0.00 u uww ~Nwa w nv~, vac. pvunw~ ia~ ~~~ .~cw vi ram, v~ u,a um nv mw. ',. I . -____. _I~ -~--- -. _... _._.__ _._.- - _ _ ___ -_ __ _.. __ __ _ __ _.T. Continuation of REV-1500 Inheritance Tax Return Resident Decadent JEAN E.LUPOLD 21 10 0948 Decedent's Name Page 2 File Number Schedule J - Benefiiciariss -1 NUMBER NAME AND ADDRESS OF PERSONS RECEIVING PROPERTY RELATIONSHIP TO OECED N Do Not List T s) ~ ~! AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS pndude p~ght s I distributions and transfers under 91 fib 1 S 2 (a ( . ec. ).J 8. Randall Lupold meal ~ 12.50 15 Robert Paul Drive ' ' Etters, PA 17319 ~~ ~~:. , ~ ~ LAST WILL AND TESTAMENT BE IT REMEMBERED THAT I, JEAN LUPOLD, a resident of Cumberland~~ ,,County, Pennsylvania, being of sound and disposing mind, m~,en~dry and i understanding, do make, publish and declare this to ble~''~my LAST WILL and TESTAMENT, hereby revoking any and all Wills an~il~Codicils previously made by me. ', I I declare that I am not married, my husband LAMAR ~,.',LUPOLD, having predeceased me, and that I have eight (8) chil'Fd~~n, JOY I, ANDERSON,. NANCY. DEIMLER, MARY VAUGHN, REYNOLD LUPOLD, KA~LEI~ WARBLE, CORINNE LUPOLD, LAWRENCE LUPOLD and RANDALL LUPOLD. II I I direct that all my .just debts and funeral expensed Ishall be paid from my residuary estate as soon as practicable' ~fter my decease. III I direct that all taxes that may be assessed in cq~nsequence of my death, of whatever nature and by whatever ju~i'sdiction imposed, shall be .paid from my residuary estate as a p~lri~ of the expense of the administration of my estate. I V ', ~'~ '~ I give, devise and bequeath all my property, wheth~r real or personal, wherever situate, including any property ove.~~which I may have a power of appointment to my children, JOY IA~TpERSON, NANCY DEIMLER, MARY .VAUGHN, REYNOLD LUPOLD, KAYE WARBLF~,GORINNE LUPOLD, LAWRENCE LUPOLD and RANDALL LUPOLD, in equal sha~es, per stirpes. ~' ~ V ', ~' I nominate, constitute and appoint my daughters, KP1Y~ WARBLE I and CORRINE LUPOLD as Co-Executrixes of this LAST WILL,' ~p serve without bond. If either daughter is unable or unwilling'',t act in that capacity, then the other alone may serve as Executrilx I r~ , ~ : IN WITNESS WHEREOF, I, JEAN LUPOLD, have set my ha,~c~ to this ,/ c LAST WILL this ~~~ day of ~P7~ , 1998 . ! ~ I l ~. D i~ ', Signed, sealed, published and declared by the albr~ue-named JEAN LUPOLD, as and for her Last Will and Testamen~, in the presence of us; who, at her request and in her presen e and in the presence of each other, have hereunto subscribed ou~ names as witnesses. ~ .. (,Qiyt. R_ ~ .. ~« ~ , ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA I ss. COUNTY OF CUMBERLAND I, JEAN LUPOLD, Testatrix, whose name is sig~he to the attached or foregoing instrument, having been duly'' qualified according to law, do hereby acknowledge that I signed a d executed the instrument as my LAST WILL; that I signed it as y free and voluntary act for the purposes therein expressed. Sworn or affirmed to and acknowledged before me by Testatrix, this ~1/`~~'~- day of ~ ~~ i 1998. r"" . AFFIDA COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND We, and the witnesses whose names are signed to the .attached os~ instrument being duly qualified according to law, do I~ say that we were present and saw Testatrix sign and d: instrument as her LAST WILL; that JEAN LUPOLD signed wi~ that she executed it as her free and voluntary act purposes therein expressed; that each of us in the h~ sight of the Testatrix signed the Will as witnesses; a~: the best of our knowledge, the Testatrix was at the tip of age or more, of sound mind and under no constrain] influence. . w ~ ;.'~I , .•:'• ~~ r -~.~ 4~ ~ ~, ;~ Sworn or a~firmed to nd~,a~knowledged be ,,;~ this / ~/~ day of ~~4 _" 1998. c LUPOLD, oregoing pose and cute the .ugly and for the ring and that to 18 years or undue me Wotarlel seed Medter~ 'C My Commis on Expkes Mar. 11, _I -_ - I ~__ tea. APPRAISAL r Sutliff Suzuki Appraisal 2005 BUICK CENTURY SEDAN Custom (VIN #2G4WS52JX51121682) Owner: kay Warble Phone: Email: 2005 BUICKOENTURY-:SEDAN Custom color: GRAY Mileage: 35,114 VIN #2G4WS52JX51121682 EQUIPMENT OPTIONS: APPRAISED VALUE: $~,OOO Thia appnaal is ~sfid ,mar 92Il1 d or ~ b0 mdea. APPRAISED BY: Don Barnes APPRAtSAL'DATE: 9/10/10 1:43 PM SALESPERSON: Book Values: ~~~~ ~~~~ Average: x4,950 Vehicle Flood Damage ^ Yes ^ No Frame Damage ^ Yes ^ No Accidlen~ ^ Yes ^ No Representation: The owner of this vehicle herby affirms that it has not been damaged by flood oi• had frame damage. Vehicle Owner Sales Manager Appraiser ', Sutliff Suzuki 6643 Carlisle Pike Mechanicsburg, PA 17050 (717)796-1111 DATE: t~ dMIEr exphsa aMsr 0 50 mr7es PAV ~~ ~~~ ~Rt~~ ~ kay Warble Trade In value for purchase of a vehicle. VIN# 2G4WS52JX51121682 Not a draft SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner CHECKING ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death. Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner VISA ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Current Balance as of 09/24/2010 Name of Joint Cardholder MEMBERS 1't FEDERAL CREDTT [JNION 179713-00 10/31/1998 $19,067.39 $3.13 $19,070.52 None 179713-11 10/31/1998 $3,697.54 $.20 $3,697.74 None 4672090000193862 09/25/2003 $48.49 $0.00-Closed out None MEM ERS 1ST FEDERAL C C;~. ~ Leigh- nne Stallings Lending Insurance Support September 24, 2010 Estate of: Jean E. Lupold Date of Death: 07!2112010 Social Security Number: 210-16-7413 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 • UNION wwmemberslst.org 4 coztfa n ru r a O C 3 fU 'O pro r = r ey H H ~ rz rnn 00 rz vzH a z Vl Z 6-+ -~ 1*i o r tr+ w w ~ ~ m r a to z m 0 PAP-582-A-0 a n~~ r*~ a .n a -1 3 LL! Z c v..om /~ Z S E H a r H r r r*1 r z 3 ~ ~ C H < ~r H . v r n a rn r*t m -~ a J a ~r ~ ~r~ ~ a -a a c ~ x r ~ y n -i O r~ r d r r n 0 ~ ~° g •• xZO'~ o.. ~ ~pn m aZ~ ~Z o ~ zoaa~g~~,a ~~~ ~~~~J -i V f'~- r. ~~~~ ~ m r v O .a.2-'Z~ ?ar ~~ ~~e-r ~ p ~ O 3 ~m r~ Cr ~D"~m ~ ~z D c~- i N m _ $z ~-+ a ' ~m o ~-•m m~ m ~ O Z-+ +~n $ N ~ m O ~ ~ n z n z n D o ~ Q ~ ~ r" ~ ~ m < o I w m .. Irn II I~ I ~ ~. O ~~ii ~ ~ $ _ ~ N ~ ~ ~ ~`- T IN N ~ ~ 0 J o G~1 ~~pp O r ~ ~ O N ~ ~ i U O ' ' O J f= ~ M fD N ~ fA O z V ~ ~ S i t 0 ~ H fat ~ ~ ~ ~ ~ ~ ~ O O~m~ mfg=0 ~_~~~ ~~aj ~ N ~ N ~ D V NaNm f0 ~ { N l• ~ S fil Z O $ O ~~ /~~ John Hancock Life Insurance Company (U.S.A) John Hancock Annuities Service Center 164 Corporate give, Portsmouth, NH 03801-8815 Mailing Address: PO Box 9505, Portsmouth, NH 03802-9505 (877) 543-2363 ' wwwtjhannuities.com November 10, 2010 Mark Thomas Attorney at Law 101 South Matket St Mechanicsburg, PA 17055-3851 ~~ he future is yours Dear Mr. Thomas: Re: CONTRACT/CERTIFICATE # GP07287275 This letter is in response to the inquiry recently submitted for the annuity contract referenced albovle. The date of death value as of 07/21 /2010 was $91,108.90. The Tax Cost Basis for this policy is $66,608.0' If you have any questions or concerns about this letter, please call us at 877-543-2363. Our Claims Service Representatives are available on weekdays from 9:00 a.m. to 5:00 p.m. EST. Sincerely, John Hancock Annuities Ufe inaixence armulUes, including group anra~itles, aro produeb fswsd by Jahn Hancock Lice Insurance Company (U.SA)', aloantield HiBa, MI 'not ~Iliclnsed in New Ywic ~ I Neill Funeral Home, Inc. 3401 Market Street ' Cam{: Hill, i'A~170114428 (717) 737-8726 Supervisor: Kevin~J. Shillabeer The following is a detailed bill for the professional services and/or merchandise arranged for . Jan E. Lupold Date of Service :July 27, 2010 Corrine Lupold Statement Date July X8,12010 2021 Lincoln Street Contract Number 7411 0000182 Camp Hift, PA 17011 Arranger Name 1 Stepnenj J Wilsbach Initial Selection Final Selection ', Difference Funeral Director and Staff Services Basic Professional Service Fee $2,680.00 $2,680.00 ' - Total Funeral Director and Staff Services $2,680.00 $2,680.00 ', I - Care and Preparation of Remains Embalming $795.00 $795.00 ' - Dressing and Casketing of Deceased $395.00 $395.00 ' - Total Care and Preparation of Remains $1,190.00 $1,190.00 ' - Use of Facilities and Related Services Visitation $495.00 $495.00 - Religious Facility Funeral Ceremony $495.00 $495.00 - Total Use of Faclities and Related Services $990.00 $990.00 - Transportation Transferring Remains to Funeral Home $495.00 $495.00 - Funeral VehicfelHearse $395.00 $395.00 - Service Vehicle $395.00 $395.00 ' - Total Transportation $1,285.00 $1,285.00 - Other Goods and Services Memorial Package $175.00 $175.00 - Fiowers $451.00 $451.00 - Total Other Goods and Services $626.00 $626.00 i - Cash Advance Clergy ! Re'~igious Facility Musicians or Singers Certified Copies Hairdressing Newspaper Notice Total Cash Advance Total Services, Merchandise and Cash Advance Total Charges (Total Services +/-Allowances + Taxes) less Cash Received Unpaid Balance Due Initlal Selectian $150.00 $100.00 $90.00 $45.00 $385:00 $7,156.00 $7,156.00 Final Selection $7,344.27 Difference $188.27 $188.27 $188.27 $188.27 Page 2 of 2 RECEIPT FOR PAYMENT GLLNDArF'ARNER STRASBAUGH Receipt Da'~t~: 9/15/2010 Cumberland County - Register Of Wills Receipt Time: 13:08:41 One Courthouse Square Receipt No'. 1062608 Carlisle, PA 17613 LUPOLD JEAN E --- Estate File No.: 2010-00948 --- MARK THOMAS R Paid By Remarks: D M ------------------------ Receipt Distribu tion ------ -----',- ------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 260.00 CUMBERLAND CO T GENERAL FUN WILL 15.00 CUMBERLAND COU1 T ,GENERAL FUN SHORT CERTIFICATE 28.00 CUMBERLAND CO $ T P GENERAL FUN D ~ & CNTR M JCS FEE 23.50 BUREAU OF R ECE . AUTOMATION FEE 5.00 CUMBERLAND COUly 7T ':.GENERAL FUN Check# 3141 $331.50 ', j Total Received......... $331.50 ~, ~J~ ~? i L _. . ~ ~~ COMMONWEALTH OF PENNSYLYAMA STATE EMPLOYEES' RETIREMENT SYSTEM HARRISBURG REGIONAL COUNSELING CENTER. 30 NORTH THIRD STREET, ROOM 319 ~ ' HARRISBURG, PA 17101 TELEPHONE: (717) 783-9065 FAX: (717) 783-9599 TOLLFREE: 1-800-633-5461 www.sa~.state.pa.us October 14, 2010 Estate of Jean Lupold Invoice # 2330 C/O Corrine Lupold 2021 Lincoln Street Camp Hill PA 17011 RE: Jean Lupold SS#: 210-16-7413 '; Dear Ms. Lupold: I We have recently been informed of the death of lean Lupold, a retired mem of this System. We wish to extend our condolences to you at this time. Since Ms. Lupold died 7/21/10 and the July & August checks were not to our office, this account has been overpaid in the amount of S 1292.04 for the~pen ~+am 7/22/10 - 8/30/10. It will therefore be necessary for our office to be reimb 'for $1292.04 to liquidate this overpayment: The reimbursement should be made payable to The State Employees' Retire ent System, and mailed with the enclosed copy of this letter to the address showrn ve. 'I Upon receipt of the reimbursement, this account will be closed. There are n~ f~i#ther benefits to be paid from this System. Should you have any questions .concerning this matter, please do not hesitat tc~ contact me at the above address or by telephone at (717) 783-9065 or 1-800-633-541.', '~ Thank you for your cooperation. sincerely, r ~~-(~N ~i ~V~ ' Linda Dolan, Administrative Harrisburg Regional Counsel Enclosure I iillil iifll IIIII 111 I~11 IIIII 1111 IIIlI IIIII1111111~ 1111 i.~.unuua~u~ GOLDEN LIVINGCENTER - WE9 T SHORE Name Facili Patient # T e Statement Date EAN LUPOLD Account 00285 42347 0001 08/01/10 BALANCE FWD CUR CHARGES CREDITS/PAYMENTS PAST DUE ENDING BALANCE n0.001- 480.00 0.00 0.00 480.00 Date/Period Covered Descri lion Q /Da s Amount 0708;10 07;13;10 ROOM CHARGE 6 480;00 Y U A AY NL1N H Y U CREDIT CARD OR A K ACCOUNT BY ACCESSING THE PAYMENT CENTER AT WWW.GOLDENLIVING.COM You can now use Visa. Mastercard or Discover to a our balance. Pa meMt d e b 15th of each Month. For Billing Inquiries Please Call: ($~~ 325-3608 Detach Here and Fietum for Timely Payment Processing ° GUEiJ~N L4~/INGi.:EN TEfR .,;:WE5 T 51'1UFi C!O NORTHEAST BILLING OFFICE >.:1500'ARDMORE DRIVE,:SUITE:401 PITTSBURGH PA 15221-4466 account# ~28~.+ Name. JEAN U 1 If address is incorrect, indicate changes below. PRE-SORT CORiNNE LUPOLD 2021 LINCOLN STREET CAMP HILL. PA 1.7011-3842 Date Date .Due Amount I~ ue Amount Paid 08/01/10 08/15/10 4 0 . 0 Namg of Cardholder ~I ca caao# zlP: Exp Date: - - t Paid: Signature: Please Make. Check or Monk3y r er Payable To: GOLDEN LIVINGCEI~T pl -WEST SHORE P.O~ BOX644407 PITTSBURGH PA 115264-4407 10499700285423473D0010807r201000D48000D000000D00( ~, M f ~ tD '~ 'C3 n, ~r 0 ~+t CA N~. N N ~ .~ cD e~ cND ~ 'a N ~ ~ ~ tD D ~. 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