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HomeMy WebLinkAbout02-24-11 1,5056],03,0, REV-1500 Ex fo'-lo, PA Department of Revenue pennsylvania OFFICIAL USE ONLY r„Wr,«~• ~. ^-,E~.,~E County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po Box z8o6o1 21-10-0853 Harrisburg, PA 1~i28-o601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW - Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 199-03-4390 08/12/2010 02/14/1918 Decedent's Last Name Suffix Decedent's First Name MI McMILLEN JR. THOMAS W THIS RETURN MUST BE FILED IN DUPLICATE WITH THE; REGISTER OF W{LAS FILL IN APPROPRIATE OVALS BELO-l1i ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return {date of deate~ prior to 12-13-821 O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-821 ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 1t). Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A: between 12-31-91 and 1-1-95) (Attach Sch. O) (If Applicable) Enter Surviving Spouse's Information Belovv Spouse's Last Name Suffix Spouse's First Name Mi N/A Spouse's Social Security Numt7er CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED Tt{: Name Daytime Telephone Number ROBERT R. BLACK (717) 243-3727 REGISTER OF 4~IL~.S USE UNLY`~. ,' First line of address ~ C.- ~t~7 ~~' '- t? ~~ 36 South Hanover Street r-n ~~ ' ~ x ~ ~ i Second line of address ; `_r:> '`~' ~ f ~~ ~.._ (`~ `~ _ City or Post Office State ZIP Code ~ DATE F~6--1 ~ ~ ~ r.r `,.~ ~~ ~. r ,; --rte Carlisle PA 17013 °~~'`- Correspondent's a-mail address: robtrblack@embargmail.GOm Under penalties of perjur,!, 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 info . rmation of which preparer has any knowledge. SI TURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRES'S 60 Co way t., Carlisle, PA 17013 2624 Walnut Bottom Rd., Carlisle, PA 17015 SIGN U E F R P ~E EPR NTATIVE DAT=. ADa Es. 36 South Hanover Street, Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY 155610101 Side i 15~561a101 ~~ r t ' ~~ ~JSQ~~y~~i35 RE1i-150Q Ems' pecedent'sJOCIa! SeCUritV NUmt)e" Decedent's Name: THOMAS W. MCMiLLEN, JR. 199-03-4390 RECAFiTtJ!`ATiOk 7. Real Estate fSchedu!e A; ............................................. 1. 0,00 2. Stocks and Bondsl;Schedu!e B? ....................................... G 1,702.26 3. GlosQ!y Held Ccrporat!on, Partnership or Sole-Pr©prietorship {Schedule C! ..... '3. 0.00 4. Mortgages and Notes Receivaf~!e {Schedu!p D! ...... . ............ .. a 0.00 `~. 4:~ash, rank bPpnsits and Mlscpllaneo=us Personal Prr?pprty (SchPdctle E?..... 5, '122,262.01 6. Jointly Owned Property (Sc!-te-du!e F) Q Separate 8iliir7g Requested ....... 6. O.OO 7. Inter-Vrvas 1~ransCers & Miscellaneous Non-Probate Property tScheduie G~ C~ Separate Bil!inG Requested.. , ..... 7. 0.00 8. Total Grass Assets ttataf E,ines 1 thrnurJh 7? .. . ............... . .... . .... 3• 123,964.27 9. i=i.Jneral ttr)Ftr18B~ artd Artm!rricfrati~e ~nsts ;Sc~t~wrliyl~a H? ................... ~. 12.782.72 ~~. Debts ryf PiecedenF~ Mortgage - ?ab:!it;as; ~r;d LiArrs rSCtts:iu!e l? .... , . ... - - 1n- 1 200.00 'l1. Total i~etluc~lcrn~ {t~tsl Cities ~ ~.~s X05 ................. . ............... 1 ~. '13,982.72 12. iVet Value of Estate (Liras ti min~.~s Ling 11 > , , ..... ..... ... .. , , , ~ z. 109.981.55 13. C;! ~aritab#e atlrt rOVeritrtlettt3l Set]~~eStS~Sec 9113 Trusts iur w`r+~r; , an 81BCtIGn tG tax Peas not beer made i5chedu;e J1 ............ . ........... 13, 0.00 14. htet Vatua StJb~ect to Tax. (trine 12 rrtin,as Line 1:~? .. 1~"~. 109,981.55 TAX CA1.Ct!l.ATiON - S!~>r tNS'CRt1CTlONS l~qR AFFI.t+GAB4E RATi i5. Anil^,Unt cat sine lw taxably at the st~ousal tax rate. or transfers under SP,C. 9i1:=i ?~. .~f""!r.t~!'tt f`~ ~ 1!'Sp Z.~, t^RY?hec at ~~rea, ra=~ X p 45 105,981.55 ~t; 4.949.17 t;. ~~t,~,~r,t r;r ~~~~~ ~~ ~x~~,~~: : asi ; ~: : 1R. ... ,. . ,u ... . ,~ . f?trlot3!1t fJf L!ne ~~ tr3Xat7lE' ~. :3i C~?fit°rat r3tP, i<.. !'^. k t.'. ~ ~ T,~x ~ttir -~ 4,949.17 ~.;. i=ft_~. ih1 Tt~i~ C3VAL tF ~t7u ~,Rr~ #~~t~t,l~~`~'lltit3 A ~.>~i='U'~~ ~~ ;~t'~ GV>`k€~AYtVt i*AtT ~ 1.~4-4~~1. .l 4 Decedent's Gom~lete Address: r`~r~ ~{~m~~r 21-i 0-0853 ut~;tu~rr;.a ~vAr~~ THOMAS W. McMILLEN, JR. __ _ __ STREET ADDRESS 2624 Walnut Bottom Road __ C! T Y STATE 2iP Carlisle PA 17015 Tax Payments and Credits: ~ . Tax Cue (gage 2, Line 1 g} 2. Credits(Pavrn2nt~. A. Prier Payments 3,500.00 B. Discount 184.21 3. interest 4. If tine 2 is greater than tine 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in ova! on Page 2, tine 20 to request a refund. 5. If line ! + Line 3 is Greater than Line 2, enter the difference. Thisss the TAX DUE Mike check pa~~ble ~o: REGISTER OF WILLS, AGEN ~. 4,949.17 3,684.21 0.00 1,264.96 PLEASE Alt'SWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN TFiE APPROPRIATE BLOCS 9. Did decedent make a transfer and' Yes Na a, retain the use or income of the property transferred :............................................................. ~+ i!.x b, retain the right to designate who shall use the property transferred or its income :.................................... ........ j !z c. retain a reversionar<r interest: or .................................................................................................................. ........ 1_ i ?x' __~ . o. receive the promise for Irfe of either payments, benefits or care% ................. ..,....... .,.,.... ~ ;xi 2. If death occurred after Dec. 92, X982, did decedent transfer property within one year of deatr; without receiving adequate consideration? ............................................................................,,.............. ~ [ic' 3. Did decedent own an "in trust for" orpayable-upon-death bank ac~:ount or security at his ar her death? ...... ........ Sri h ~. Dix decedent own an individual retirement account, annuity or other non-probate property. whit;h contains a beneficiar,~ designation? ................................................................................................................ ........ i l1 fx~; IF THE ANSWER TO ANY 01: 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 rats imposed on the net value of transfers to or for the use of the surviving spouse is 3 perrertt [72 P.S. §911 (a) c1.3~ (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 su^~iving spouse is ~ percent [72 P.S. §9116 (a) (1.1) (ii)j, The statute does not exempt a transfer to a surviving spouse from tax, and the statutor,~ requirements for disciesure of assets and fling a tax return are still applicable even if the surviving spouse is the only benefrian~ For dates of death on or after July 1, 209t~ • 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. ar adoptive parent or 2 stepparent of the child is Q percent j72 P.S. §9116(x)(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. §9196(1.2) j72 P.S. §9116(x)(1}; The tax rate imposed on the net value of transfers to or far the use o`r the decedent's siblings is 12 percent j72 P.S. §9116(a)(1.3)j. Hsibling is defned, under Section 9102, as an individual yvhc has at least one parent in common with the decedent, whether by t;iood or adopticr:. (11 Total Credits f A * B j (2 (31 ~Q~ 15) i`•. COf:9hA~N~A~EA! T!-{ OF PENNSYLV,~NiA ST4~KS ~ Bt~t~DS~ INHERITANCE TAX RETl1P.N RESIDENT DECEDENT ESTATE OF FILE NUMBER THOMAS W. McMILLEN, JR. 21-10-0853 All property jointly-owned with right of survivorship must be disclosed on Schedule F, t~f more space is neeoed, insert additional sheets of the same size} i ~ p~ennSyLvania DEPARTMEN? OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ~~~~~~~~ t CASH, BANK DEPOSITS & MASC. PERSONAL PROPERTY E5TATE OF: _ i FILE NUMBER: THOMAS W. McMILLEN, JR. 21-10-0853 include the proceeds of litigation and the date the proceeds v~rere received oy the estate. All property jointly owned with right of survivorship must be disclosed or: Schedule F. ITEM ~ VALVE AT DATE fJUMBER DESCR~PTIQN ( OF DEATh 1. j Orrstown Bank -Checking Account #108006373. See attached letter. s Principal - $83,076.61; Interest- .79 I ~ 83,077.4Q 2_ I Orrstown Bank -Certificate of Deposit #400032458. See attached letter. I Principal - $32,045.67; Interest - 2.63 32,G48.30 3, M8~T Bank -Checking Account #9833004782. See attached fetter. Principal - $776.36; Interest - 0.00 ~ 77C gC 4. ~ Hoffman-Roth Funeral Home -Refund ~ 1 QO QQ 5. Household Goods -See appraisal attached hereto. ~ 2 1 QQ Qp i g ~ 2401 Volkswagen Jetta Sedan Per attached Blue Book s . . . ~ 3 375 QO 7• PSERS - Final Retirement Pa men - Y t i I 78•.95 TOTAL (Also enter on Line 5, Recapitulation) $ ~ 122,2b2.01 If more space is needed, use additional sheets of paper of the same size. ~ ~CHE~ULE ~ `~ ~ . ~ p~nlnsylvarr~~{ DEPARTMENT Or REVENUE ~ FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS $ RESIDENT DECELIENT ESTATE ~F FILE Nt1M8ER THOMAS W. McMILLEN, JR. 21-10-0853 Decedent's debts must be reported on Schedute 1. ITEM I NUMBER ~ DESCRIPTION 1 AMOUNT p. FUNERAL EXPENSES: ! 1' ~ Hoffman-Roth Funera{ Home -Funeral Expense j 2.583.4, 2. ~ Gail M. Black -Funeral Luncheon Supplies 43C.22 3. ~ Judy Welles - Minister at Funeral ~ 500.00 a. j Unitarian Universalist of Cumberland County -Church 8~ Luncheon i SQQ.OQ 5. I ~ David Geasgow -Organist ~ 200.00 n. f ~ ADMI viSTRATIVE CGS T S: j 1, ! Persona( Representative Commissions: 1` f ~.~~ Name(s) of Personal Representative(s) Street Address _ 4 City State ZIP __ Year(s) Commission Paid: _._ __..___ _. __.._ _ _ I' 1. Attorney Fees: I 4.On0.00 I 3. ~ Family Exemption: (if decedent's address is not the same as ciaimant's; attai,h explanatian.) 1 ~ 3'~~~'~~ Claimant Charlotte PJ!. Klein __ Street A ddress 2624 V1/alnut F3ottom Road City (;ar1151e__ __ _ _ State PA ZIP 1 (U"I5 ___ _ _ _ , i ! Relationship of Claimant to Decedent Daughter f { 4. ~ f Probate l=ees: ~ 513.04 5. ~ Accountant Fees: 5. Tax Return Preparer Fees: %• Lindstrom Household Appraisal ~ -i4.B,g0 $. ~ ~ { Reserve for Closing ~ ` i 3u0.1~u TOTA! (Also enter on Line 9, Recapitulationl ~ $ 12, ~~Z• ~ 2 !f more space is needed, use additional sheets of paper of the same size, i~ p~~nnsytv~n~a bEPARTMENT OF REVENUE INHERITANCE TAX RETURC! RESIDENT DECEDEPIT DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER THOMAS W. McMILLEN, JR. 21-10-0853 Reps>rt dents incurred by the decedent prior to death tha# remained unpaid at the slate ~f death, including unreimhursed medical expenses. Rx=1~ 1513 tX+ tU'_- ~•±j pennsyLvan~~ SCHEDULE ~ CJEF'AP.Th1Et~'T GF nEJEULIE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: THOMAS W. McMILLEN, JR. 21-1 t)-0853 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal diskributions and transfers under Sec. 9116 (a) (1.2).J 1- Gail M. Black, 60 Conway Street, Carlisle, PA 170113 Daughter 24,Qt}O.GO SSN: 176-34-7909 +50°,~~ 2. Charlotte M. Klein, 2624 Walnut Bottom Road, Carlisle, PA 17015 Daughter 50°i~ SSN: 291-40-8430 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. G.Oq 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: o.aQ TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ 0.00 [f more space is needed, use additional sheets of paper of the same size. LAST WILL AND TESTAMENT OF THOMAS W. McMILLEN I, THOMAS W. McMII,LEN, of Penn Township, Cumberland County, Pennsylvania, declare this to be my Last Will, hereby revoking all prior wills and codicils. FUNERAL EXPENSES FIRST: I direct the payment of my funeral expenses, including my gravemarker, as soon as may be convenient after my death. PAYMENT OF DEATH TAXES SECOND: I direct that all taxes that may be assessed in consequence of my death, of whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a part of the expense of administration of my estate. DISTRIBUTION OF PERSONAL PROPERTY THIRD: I give all my personal property, household goods and automobiles, in equal shares, to my two daughters, Gail M. Black and Charlotte M. Klein, or their issue, per ,stirpes. BEQUESTS FOURTH: I give the real estate, amounts or items to the following individuals: A. To Gail M. Black, my daughter or her issue, my real estate in Milroy, Mifflin County, Pennsylvania, being mountain land and containing forty- two (42) acres, more or less, my cabin property in Pine Grove Furnace, Cook Township, Pennsylvania, which I lease from the Commonwealth of Pennsylvania and the sum of Twenty-four Thousand ($24,000.00) Dollars; and B. To Charlotte M. Klein and Thomas S. Klein, or their issue, all of my interest in certain real property, together with the improvements thereon erected situate in Penn Township, Cumberland County, Pennsylvania, containing five (5) acres, more or less. 'tials v DISTRIBUTION OF RESIDUE FIFTH: I give the rest of my estate, in equal shares, to my two daughters, Gail M. Black and Charlotte M. Klein, or their issue, per stirpes. MINORS AND INCAPACITATED BENEFICIARIES SIXTH: If any income or principal shall be payable to any person who shall be a minor or who shall be incapacitated for any reason, my executor as trustee shall hold such income and principal during minority or incapacity and shall be entitled to apply such income and principal to the health, maintenance, support and education of such person during minority or incapacity without the appointment of any guardian or committee or any authority of court. My executor as trustee shall be entitled to make direct application hereunder or to make application by payment of income and principal to the parent or other person in charge of such minor or incapacitated person, or to his or her guardian or to a custodian under the Uniform Transfers to Minors Act. Any remaining income and principal to which such person shall be entitled shall be distributed to such person upon the termination of minority or incapacity. My executor as trustee shall have the same powers as my executor. POWERS OF EXECUTOR SEVENTH: I confer upon my executor the right to sell or otherwise convert any real or personal property at public or private sale, at such time or times, in such manner, and for such price or prices, and on such terms and conditions as my executor shall determine, and to execute and deliver good and sufficient conveyances, assignments and transfers of the property, without liability of any purchaser for the application of any consideration; to borrow money and to secure its payment by mortgage of real or personal property, pledge of investments, or otherwise, without liability on the part of the lenders to see to the application thereof; to retain any investments at discretion; to invest and reinvest at discretion, without restriction to so-called "legal investments"; to make distribution in cash or in kind; to allocate and distribute different kinds or disproportionate shares of property or undivided interests in property among beneficiaries, in cash or in kind, or partly in each; and to do all other acts and things necessary or appropriate in the management, administration and distribution of my estate. APPOINTMENT OF GUARDIAN OF ESTATES OF MINORS EIGHTH: I appoint my executor as guardian of the estates of minors with power to hold all property payable by law to a guardian appointed by my will and to use it for the minor's health, maintenance, support and education, either directly or by payment to any person selected by my executor to disburse it whose receipt shall be a complete acquittance. Guardian may, in discharge inirials ~ r of all the guardian's duties, pay any minor's share deemed impractical of administration to the parent or other person in charge of the minor or to his or her guardian or to a custodian for the minor under the Uniform Transfers to Minors Act. My executor as guardian shall have the same powers as my executor. APPOINTMENT OF EXECUTORJRIX NINTH: I appoint Gail M. Black or Charlotte M. Klein, or the survivor thereof, as Executrix of my will. WAIVER OF BOND TENTH: I direct that no fiduciary hereunder shall be required to furnish bond in any jurisdiction, and if any bond is necessary, no surety shall be required. INTERCHANGEABILITY OF LANGUAGE ELEVENTH: Words used in the singular maybe read to include the plural or the plural may be read as the singular. Similarly, the masculine form may be read to include the feminine and neuter; the feminine may be read to include the masculine and neuter; and the neuter maybe read to include the masculine and feminine. HEADINGS TWELFTH: The headings used on the various paragraphs of this will are included for convenience only and shall have no legal significance. I have signed this will this ,~~ da of Y ~ S~ , 2002. t Thomas W. McMillen Witness ;~ ~ , c J ... ~ Witness ~ i • ACKNOWLEDGMENT and AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND We, Thomas W. McMillen, the Testator in and the undersigned witnesses to the will, the attached or foregoing instrument, who have signed the instrument, having been qualified according to law do depose and say: (a) that I, the Testator, do hereby acknowledge that I signed the instrument as my will, that I signed it willingly and as my free and voluntary act for the purposes therein expressed; and (b) that we, the witnesses, were present and saw the Testator sign and execute the instrument as his will, that he signed it willingly and executed it as his free and voluntary act for the purposes therein expressed; that each of us in the hearing anal sight of the Testator signed the will as a witness and that to the best of our knowledge the Testator was at that time eighteen or more years of age, of sound mind and under no constraint or undue influence. Z'V ` ~ Thomas W. McMillen Witness ~ l:~ Witness ~, Notary Public Notarial Seal Robert R. Black, Notary Public Carlisle Boro. Cumberland County My Commission Expires Sept. 10, 2Qp5 r • r • • ^ r • t- THOMAS W MC MILLEN Account Market Value Stock Price as of 11 09 2010 Total Market Value sao.53o $1,702.26 The aggregate amount paid to al! Trust Beneficiaries in this distribution is $165,579,185.12. I~VAStOfID 8063 3219 9558 2010 Dfvid~end Summary Record Date T~vtal Trust Interests Dividend per Trust Interest Current Oistrlbution 11/09/2010 42.0000 $0.74 $31.08 Payable Date Taos Withheld Net Distribution Prior Year Distribution 12/14/2010 $0.00 $31.08 $31.08 For inquiries about your account; you may visit www.bnyme~ion.com~shareowner/equityaccess~ or call 1-800-649-3593. trust 8onofidary Irtftxtnation You may purchase or sell shares of MetLife, Inc. common stock through the MetLife Policyholder Trust (the 'Trust"). free of any commissions or other fees, under the MetLife Purchase and Sale Program, ~as amended. A copy of the brochure describing the program is available on the Internet at www.metlife•com by selecting Investor Relations and then tha Shareholder Services Information page, or by calling the number listed above. You are permitted to transfer your Trust Interests only in the circumstances described in the brochure. You may also instruct that all (but not less than a11) of your shares of MetLife, Inc. common stock held by the Trust be withdrawn from the Trust. Information regarding your withdrawal rights may be found in the Purchase and Sale Brochure or bp~ calling the number listed above. An annual shareholders' meeting to elect members of the Board of Directors of M®tLife, Inc. and for the transaction of other business is expected to be held on April 26. 2011. The deadline for submitting shareholder proposals for consideration at this meeting is November 23, 2010. A copy of MetLife, Int.'s annual report and proxy statement will be available free of charge on or before March 31, 2011, along with other MetLife, Inc. and Trust filings under federal securities laws, (i) on the Internet at www.Metlife.com by selecting About MetLife, Corporate Governance, under Related Links. (ii) by writing to MetLife, Inc., c/o BNY Mellon Srtareowner Services, PO Box 358447, Pittsburgh, PA 15252-8447 or (ii) by calling the number listed above. These and other SEC filings by MetLife and the Trust are also available on the fnternet at www.sec.gov. k-R~ease .Note:-~ ~r~~ortant 2010 Tax Information- -~-- _ _ . ~ __.--. __.MetLffe ~ FORM 1099-DIV. U.S. TAX INFORIIIIATION FOR 2010 OMB NO.1545-0110 DIVIDENDS/DISTRIBUTIONS COPY B FOR RECIPIENT RECIPIENT'S TOTAL ORDINARY IDENTIFlCATION NUMBER DIVIDENDS QUALIFlED DIVIDENDS FEDERAL, INCIOME TAX WITHHELD eox 1 a sax 16 sox 4 199-03-4390 $31.08 $31.08 20.00 onv~ere ILIA\1G -^' ~~ ~ ~~..r.'= I'AYtH'S FEDERAL IDENTIFlCATION NUMBER BNY MELLON SHAREOWNER SERVICES AS CUSTODIAN OF THE METLIFE POLICYHOLDER TRUST 51-6516987 SECURITY DESCRIPTI ~~ TO WHOM PAID INTERESTS ``~ THOMAS W MC MILLEN CARLISLE PA 1701 _~. ..._ - .. _.. IMPORTANT 2010 TAX INFORMATION This Is Important tax information and is being furnished to the Internal Revenue Service. If you are required to file a return, a negligence penalty or other sanction may be imposed on you if this Income is taxable and the IRS determines that it has not been reported. Box 1 A -Shows total ordinary dividends that are taxable. Include this amount on Tine 9a of Form 1040 or 1040A. Also. report it on Schedule 8 (Form 1040) or Schedule 1 (Form 1040rA), if required. The amount shown may be dividends a corporation paid directly to you as a parti- cipant (or beneficiary of a participant) in an employee stock ownership plan (ESOP). Report it as a dividend on your Form 1040/1040A, but treat it as a plan distribution, not as investm:nt income for any other purpose. F'JR INFORMATION REGARDING THE REPORTED BY THE BANK OF NEW YORK MELLON 480 WASHINGTON EVARD JERSEY CI , 4BOVE, CALL 1,800.64-3593 Box 4 - Sows backup withholding. For example, a payer must backup withhold on certain pay. merts at a 28% rate if you did not give your taxpayer identification number to the payer. See fGrrr W5, Request for Taxpayer Identification Number and Certification, for information on backup withholding. Include this amount on your income tax return as tax withheld. hflorninees. If this form includes amounts belonging to another person, you are considered a non'inee recipient. You must Pilo Form 1099-DIV with the IRS for each of the other owners to show the r share of the income, and you must furnish a Form 1099-DIV to each. A husband or wife is not required to file a nominee return to show amounts owned by the other. See the 2010 Gereral Ynstructions for Forms 1099, 1098, 3921, 3922, 5498, and W-2G. Box 18 -Shows the portion of the amount in box 1A that may be eligible for the 15% or zaro capital gains rates. See the Form 1040/1040A instructions for how to determine this amount. Report the eligible amount on Ilne 9b, Form 1040 or 1040A. SEP,-2~-2010(WEp) 14:54 ...... FINAT~7CIAI~: SER'VYS-, .ANC. ' ' ~ ~: d 7"rai~'tio~.af ~llrnue . ' '... . Robert R. Black, Esq. Landis & Black 36 South Hanover Street Carlisle, PA ~ X013 Fax 24 ~. -4829 September 29, 2010 Re: Estate of Thorx~as W. Me1Vlilllen, ~Jr. Social Secuz i,ty Number 199-43-4390 Date of DEath August 12, 2010 lT IS ,F~ERERBY CEI~`I'IFIED T,KAT THE ABO~ClE NAND D,ECEDEIVT, ON THE ABOVE DATE, FIA.D THE FOLLOWING ACCOUNTS VIIIT~l' O.RRSTOWN BANK: CHEC~NG ACCOUNT Account No. - Account ~`ype Date Opened - Joint .A,ccount (name/date) - Balance -- Accrued Interest - CEI2'1'IFICATE OF DEPOSIT Account No. - Account Type - Datc Opened - Joint Account (name/date) - Balan.ce - Accxued Interest - 108006373 5~0~- Interest Checking ~.~,/C/02 hone ~83,n76.d 1 $.79 c000032458 3-5 Month Growrth 4/8/'09 I`jone $32, X45.67 X2.63 est Regards, P. 001 /001 '~icki L. Gullixon Cus~orrner Service Specialist 77 East King Strcct~ Shippensburg, Ptnn~ylv-~ni~ 17257 R • M~TB~ 499 Mitchell Road, Millsboro, DE 19966 Adjustment Services Phone 888-502-4349 F ax (302) 934-2955 October 6, 2010 Landis & Black Attorneys At Law 36 South Hanover Street Carlisle, PA 17013 Re: Estate of Thomas W McMillen. Jr Social Security: 199=03-4390 "----~ " ~~ -~ ~ ~~ Date of Death: August 12, 2010 Dear Sir or Madam: In response to your request, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following accounts: 1. Type of Account Ci~aecki ng Account Account Number 98'33004782 Ownership (Names o, f) Tomas W McMillen Jr Opening Date 0'/10%?3 Balance on Date of Death $;'76.36 Accrued Interest $ O.GO Total $?76.36 *We were unable to locate any safe deposit box for the above-mentioned decedent. **For further account information, closures and/or reimbursement of funds please call the Stonehedge Office at #717-240-4524. **'"This letter does not include any accounts in which the deceased may have been listed as Power of Attorney, Custodian of Uniform Transfers, Representative Payee, or Trustee under a Written Agreement S' rely, Suz e M Kimble Adjustment Services Lindstrorn's Furniture 1172 Ne~~wille Rd. Carlis le,Pa. l ~ 013 1-(717) X43 -5115 ~~,T ~ ~~ '~,~/• ~ 12/26/10 Clients :Gail Black Charlotte Klein 2624 Walnut Bottom Rd. Carlisle,Pa.17013 The Estate of The deceased Thomas W. McMillen 1) Dining Room Suite Jacobean Style C-1920s The condition is poor 6 chairs ,1 Table 1 china closet Estimated Value $300.00 2) Pine Roll Top Desk C-1970s ; Large ralltop desk solid notty pine 3 over 9draws . Estimated Value $400.00 3) Walnut Blanket Chest C-1930s ;Jacobean Style with glazed paints cedar lined It is in need of refinishing. Estimated Value $135.00 4) Solid Cherry Tall Chest of Draws C-1940-SOs ;Good condition 5 draws . Estimated Value $275.00 5) Shaving Stand Mirror C-1920s-30s Estimated Value $35.00 6) Nite Table Solid Cherry C-1940s -s-Os The condition is poor and it is in need of a complete refinishing. Estimated Value $45.00 7)Solid Cherry Writing Table C-1940-COs ~'he condition is poor Estimated Value $120.00 8) Wood and Brass Clothes Tree . Estimated Value $40.00 9) Poplar Jelly Cupboard C-1860s 2 draws over 2 doors the condition is very good Estimated Value $750.00 • w ~ ~, 1111111 G`E•R71FtCATE O~a!'Tl~'', . _ ,. ,.• ,. , ... ,.I,, ~~~ ! ~ M.NI~NNrww;rrywi'wrliiN Ni~ 1 % 1 I I. t % 1 UN •ggrlrN,pMK q N-ry ry bN00N h ~N D N Nin d NwNtrN•1x•Nwn w 1 w0~ N N x x NNl9 N •rla www4 r. a ry1 rxr•11.npuvndid•icv~nwernvwnN..nn N rlwt x N N ry gOnl ry ry 01 N q 1•aiF ry IN NN w. _ rinei•~iiw<. 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C,S , , 9 = NOT'THE A>~TUAL MILEAGE-0DOMF~TER r r ]# ;~. :TAMPERiH(iVERIFIED ' '1.~ J ~~~t ~ F ~ ~ td a4 ~ EXEMPT FROM ODOMETER bISCLOSURE .. _ (I:. , ~ REGISTERED OWNER(S) .~1'td~~~~ `,~ ;, ! it`t ~~ ~ ~ ~~'' '.TREE BRANDS t " T i+ I• ANTIQUE VEHICLE' ~'~~LJ~~~ frt. Tl~f'~~~~~Tr'"~` o i~ ~Irt{r ~or~• dint a ~? G,: "GUSSICVEHICLE~~ Tyr(;, D ~ ~ 2 "T ~ ~t ~ U i 8 ~ •T~T D ~ ' ~5 D ~ ' ~ ` ~• --' - "'. --_ ~ ---°~~C+OLLECpr-T~NVET H~IC~E ~ ._.. Ir r p ". a = oatdlwtLtaY Mt=sta. FOR NDN•us ,~ - • L1iAT1L 3 J~~ P A l+'TDb3 ~ H. AG CIUlTURALVF,HICLE . L';R WGGM4f~ VEHICLE, ~ , P::*' ISIWA$'A PQUCE VEHK(LE `A`^ RECON5TAt1CTED s'* "sTREff'f<ROR' • T'rt. AECOVE.REDrTHEFr,vEHICLE , V +.VEHICLE COrrTA1N3 REISSUED ~JMI •: •r1 • YV.1 f100D VEFIICLE •, •- .r. X ^ ISIWAtiATAXI : ~ . `FIRST LIEN FAVOR OF: SECOND UEN FAVOR OF: • _ ,. _ `t . -~ ~ ; If a second lieriholder is listed upon satisEBction 4t the first Gen, the first iienholdt3r must}onward this Title to the 9ureau'o1 Motor Veh~les with the FIRST LIEN RELEASED aFpropriate torrn`antl fee. DATE ` ~' ] ~ BY SECOND LIEN RELEASED `~' r' `, AUTHORIZED REPRESENTATIVE DATE ' MAILING ADDRESS • ~ 3 ~ ~ D ~ AUTHORIZED REPRESENTATIVE 224 WAt~t~U~ ~t7T7gM ~ ~t3 ' CAR~~S~E ~A' 1,7t~~3 •~ .. , _ - . .,. • _ , . ._ ,r • „ 1 _ _ . :;; 1 ~yy ,yx 9 t(y r ~ -0i1/61A1-f9n9fdC-Of-t~R.7`T7 I~ ~ ,' ~~i~t~`. A oCTransportation reflect that the •person(s) or company named herein is the 18 Nful owner ~ _.._ ~ ~ w{~ AMC,, :. ' •'°1'D~:,]P°. ~ • of the said vehicle. SecreWr of Tr ~ '!~' . . . •. SUBSCRIBED AND SWORN I' a co=purchaser other than your spouse is bstgd,and ygti'rv~nt`'the title tp TO BEFORE ME: be listed a9 "'.fpirlt Tenants With: Rfght!`of Survivorshi ' (On death of one ` • v owner,aitle oe9;_to sulvivin owher.. CHECK HARE 1 p ~ ~_ will be issued Ss "Tenants n Common°'`(On death. pt~ bwnarsnr the tide terest of • f '~ deceased owner goes to his/her heirs or estate).' __ . 910 ATUR F ~ER9 M NI T R ATH 1$T LIEN DATE: ~- I€ NO LIEN, CHECK ~"'' ~STLIENHOLDER_. ,. ;: . ~ W , ! ,..:.. STREET. .:: •1! - I CITY STATE ZIP :, FINANCIAL INSTITUTION NUMBER Q i- 2ND LIEN DATE: ~- 1F N0 LIEN, CHECK :The undsrslyned hereby make! applicetton for Cartiticste of Title to the veMcle des;rl0ed ~ bboye, subject to the encumtirances and plher legsl claims set forth here. ~NOtIENHOLDER - O iTREEF ..:.,., SIGNATURE OF APPLICANT OR AUTNORIIFD SIGNER ~ - N CITY `'STATE • ~ ZIP • :. _ ...: O ~ • :. FINANCIAL. INSTITUTION NUMBER SIGNATUAE OFCO•APPLICANT/TITLE OF AUTHORIZED 810NEA:- •.- •-••.. ~•_- • ,M ^,• , r; ~. r, ,.r ,..,, _•_~- _ ~~,. . X01 vottcs~rvagen .Jetta - Nrtvate tJarty t'nc~ng Keport - Ketiey rsi... rntp:~iwww.KOD.corrvusea-cars~witcswagervJena~~uu~iipnvate-pa... M ~ ~ ~-~` THETRUSTED RE~QURCE ;~ Send to Printer Ebb.co-~ adver:iser~ent X00 i ~oll~sv~rag~er~:.~etlKa G1+~ Tu r1b0 ~e~a n ~,~~ .. 13i_UE 8C3UliCa PRIilATE P~4RTY` VA-t..43E ~_~._..~~.~-_~_.---- --.._ _-- --__- Csz rid iti o n Value Excellent $3,750 ~. Good .. _.._.---. _.:... _..._..~~.~_3~ ~ .~ (Seiected) Fair $2,775 ifehicle Highlights Mileage: 118,000 Engine: 4-Cyl, Turbo, 1.8 Liter ', Transmission: Manual, 5-Spd Drivetrain: FWD Selected Equipm ent Standard .•i' ..U41ljl~i.}'•."1'_I i{i, ~~~tIC:J'I ~`1~G.y '; ~l~j -r `, ?i~b'J~r ! C?rtr- I,.;?i~r,~: t..r.~SSE'~tC' Blue Book Private Party \dalue Optional Kelley Blue Book Private Party Value is the amount ~ buyer'can expect to pay when buying a used car from a private party. The Private Party Value assumes the vehicle is sold "As Is" and carries no warranty (other than any remaining factory warranty). The final safe price may 4•ary depending on the vehicle's actual condition and local market conditior~. This value may also be used to derive Fair Market Value for insurance and ~~eh-cle donation purposes, ilehitfe Canditiory R~tirtgs Excellent .• :, .. $3,750 a Looks new, is in excellent mechanical condition and needs no I of 2 1/14/2011 12:31 PM ~