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Home My WebLink About04-0691 Register of Wills of Cumberland County, Pennsylvania PETITION FOR GRANT OF LETTERS Estateof VeronicaJ. Stupak No. --0q-0(cql also known as Deceased Social Security No 191-18-0211 Carol Ann Marshall Petitioner(s), who is/are 18 years of age or older, apply(les) for: (COMPLETE 'A' or 'B' BELOW:) ] A Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the execut r ix named in the last Will of the Decedent, dated 07/07/1987 and codicit(s) dated None N/A ? (; C~ '%: ~ State relevant circumstances, e9· renunciation, death of executo~.------~ ~ 4:~ ~;i] -'[ Except as follows, Decedent did not marry, was not divorced and did not have a child born or adopted aff~r'.>:~execution~-the__ documents offered for probate; was not the victim of a killing and was never adjudicated incompetent: ~ ~L~ ' ~' " N/A ;7= Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and I Name Relationship Residence (COMPLETE IN ALL CASES:) Attach additional sheets if necessary Decedent was domiciled at death in Ctzmberland County, Pennsylvania with his/her last family or principal residence at 4030 Seneca Avenue, Lower Allen Township, Camp Hill, PA 17011 (list street, number, and municipality) Decedent, then 81 years of age. died. 07/05/2004 at Carlisle Re~ional Medical Center, PA (Location) Decedent at death owned property with estimated values as follows: (If domiciled in PA) Ali personal property $ 7,800.00 (If not domiciled in PA) Personal property in Pennsylvania $ (If not domiciled in PA) Personal property in County $ Value of real estate in Pennsylvania $ 95,000.00 situated as follows: 4030 Seneca Avenue, Camp Hill, Cumberland Co. , Pennsylvania Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of letters in the appropriate form to the undersigned: I Signature Typed or printed name and residence I ,¢ Carol Ann Marshall ~/~/z~./¢ ,L/,~/,~ . 6 Spruce Drive, Carlisle, PA 17013 Prepared by the Pennsylvartfa Bar Assocfation Copyright (c) 1996 form software only CPSystems, [nc Form RW-111991) Oath of Personal Representative Commonwealth of Pennsylvania County of Cumberland The Petitioner(s) above named swear(s) or affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that as personal representative{s) of the Decedent, Petitioner(s) will weft and truly administer the estate according to raw Sworn to or affirmed and subscribed _¢./~/~/'"/,~ .~. ~..~-~'~. ~ ~ ~ Carol Ann Marshall before me this ~ 9 day of (~ ~'¢ r For the Register ¢ ~ '~' Estate of Veronica J. Stupak Deceased Social Securi~ No: 191-18-0211 Date of Death: 07/05/2004 AND NOW, ~b ~i ~ ~]~ ~i , in consMeratJon of the Petition on the reverse side hereon, satisfactoW proof having been presented before me. IT IS DECREED that LeEers ~ Testamentary ~ Of Administration (cra: d b.n.c ta: pendente lite; durante absentia; durante minoritate) are hereby granted to Carol Ann Marshall in the above estate and that the instrument(s) dated 07/07/1987 described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES J ~', ~egister of Wi.is Short Certificate(s) ..... $ ' ~ ~;~.) , r- [/ Renunciation ..... $ Attorney: ~e~n~e~ ~. Affidawts ( ) $ ID. No: Extra Pages( ) .... $ ~-- ~ ~ Address: One West Main Street Codicil ........... $ Shiremanstown, PA 17011 Inventow ......... $ Other . . $ TOT, ..... Zq5O Prepared by the Pennsylvania ~a¢ Association Copyright (c} 1996 formsoftwareonly CPSystems. [nc Form ~W-~ (1991) his is to ccrtJ~ that this is a true copy of' thc record whict~ is on tile in the PennssIvanla DMsion of Vital Records in ac<o;dance ~ith Act 66, P.L 304, approved by the General Assembly, June 29, I953. WARNING: It is illegal to duplicate this copy by photostat or photograph. Calxin B. )oJu)son, M.D., M.P.lt. ~ 5ecretaU' of Health ~ ~ (~harics Hardestcr ~i State Rcgisnar L)ate LAST WILL AND TESTAMENT OF VERONICA J. STUPAK ~>? ~ ~ I, VERONICA J. STUPAK, of Camp Hill, Cumberlan~County, /lvania, declare this to be my Last Will and TeStament, and revoke any and all Wills and Codicils made by me. ITEM I: I direct that all my just debts and funeral expenses, including my grave marker and all expenses of my last illness, shall be paid from my residuary estate as soon as practicable after my decease, as a part of the expense of the dministration of my estate. ITEM II: I give, devise and bequeath the rest, residue and remainder of my estate of every nature and wheresoever situate to my daughter, CAROL ANN MARSHALL. In the event my daughter does not survive me, I give, devise and bequeath the rest, residue and remainder of my estate of every nature and wheresoever situate in equal shares to my then living grandchildren; PROVIDED, that if any grandchild entitled to distribution shall be under age twenty-seven (27), the share of such beneficiary shall be held by the Trustee, hereinafter named, IN TRUST, for the following uses and purposes: A. If the beneficiary is under age eighteen (18), to expend and apply so much of the net income (any income not lexpended or applied to be accumulated and added to principal) and so much of the principal of each trust as the Trustee, after 2onsultation with the guardian of said beneficiary, shall consider advisable for the support, maintenance and education (including college education, both graduate and undergraduate). B. After the beneficiary attains the age of eighteen (18), thereafter to pay to such beneficiary the net income together with so much of the principal thereof as Trustee shall consider advisable for the support and education (including college education, both graduate and undergraduate) of such bene- ficiary, after taking into consideration his other readily avail- able assets and sources of income. C. Up to thirty-three and one-third (33-1/3%) percent of the then-remaining principal and accumulated income at age twenty-one (21) on the request of the child shall be distributed to that child at or after age twenty-one (21); an additional fifty (50%) percent of the then-remaining principal and accumulated income at age twenty-four (24) on the request of the child shall be distributed to that child at or after age twenty- four (24); and up to the entire balance of principal and accumulated income then remaining on the request of the benefic- iary shall be distributed to that child at or after age twenty- seven (27). Distributions at or after these stated ages shall be made only in the event the child requests such distribution by a writing intended to take effect during his lifetime, executed by that child upon or after attaining each of the stated ages and delivered to the Trustee. 2 ITEM III: Ail Federal, state and other death taxes payable ~e of my death with respect to the property forming my gross estate for tax purposes, whether or not passing under this Will, including any interest or penalty imposed in connection with such tax, shall be considered a part of the expense of the administration of my estate and shall be paid out of the residue of my estate, without apportionment or right of reimbursement. ITEM IV: I appoint CCNB BANK of New Cumberland, Pennsyl- vania, to serve as Trustee under this Will. ITEM V: I direct that no executor or trustee or their successor serving hereunder be required to post bond or enter security in any jurisdiction. ITEM VI: I appoint CAROL ANN MARSHALL of Carlisle, Pennsyl- vania, Executrix of this my Last Will. Should CAROL ANN MARSHALL fail to qualify or cease to act as Executrix, I appoint ALLAN STEPKOVITCH of Jermyn, Pennsylvania, Executor of this my Last Will. ITEM VII: I appoint CAROL ANN MARSHALL guardian of the estate of my minor grandchildren. In the event that said CAROL ANN MARSHALL fails to act or ceases to serve as guardian, I appoint ALLAN STEPKOVITCH guardian of the estate of my minor grandchildren. ITEM VIII: I direct my personal representative to employ HOWARD B. KRUG as attorney for my estate. This provision 3 ~s made solely at my request and without urging or suggestion by the said HOWARD B. KRUG. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~.7~ day of QT-~/.~ 1987. (S AL) VERONICA J. S~K The preceding instrument, consisting of this and seven )ther typewritten pages, was, on the date thereof signed, published and declared by VERONICA J. STUPAK, the Testatrix therein named, as and for his Last Will, in the presence of us, ~t her request, in his presence, and in the presence of each other, have subscribed our names as witnesses hereto. _ residing at ~.~.~.., ', ~'~ residing at ~--' / ,~ ~- ~ .~ > · ,/~/~ 4 [~ALTH OF PENNSYLVANIA : SS: OF DAUPHIN : ? , the testatrix and the witnesses, ely, whose names are signed to the attached or fore- 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 willing- and that she executed it as her free and voluntary act for purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the will as es and that to the best of their knowledge the testatrix ~as at that time eighteen years of age or older, of sound mind ~nd under no constraint or undue influence. VERONICA J. STUgAK Witness Witnessf - Subscribed, sworn to and acknowledged before me by VERONICA J. , the testatrix, and subscribed and Sworn to before me by witnesses, this ~/ day of " _, 1987. 5 CERTIFICATION OF NOTICE UNDER RULE 5.6 (a) Name of Decedent: Veronica J. Stupak Date of Death: July 5, 2004 Will No. 21-04-0691 Admin. No. To the Register: I certify that notice of estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on July 23, 2004: Name Address Carol Ann Marshall 6 Spruce Drive Carlisle, PA 17013 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: None Date: -i/~/0~ Jen~i'fer B. Hipp, Esquire ~ One'West Main Street "- Shi · . remanstown, PA 17011 ~ (717) 737-8761 <~ Capacity: Personal Representative ~4 X Counsel for Personal .~ ~· ~ .~ Representative JAMES D. BOGAR ATTORNEY AT LAW ONE WEST MAIN STREET SHIREMANSTOWN, PENNSYLVANIA 17011 e-mall mall@bogarlaw.com TELEPHONE (717) 737-8761 JAMES D. BOGAR FACSIMILE JENNIFER 13. HIPP* (717) 737-2086 *Also admitted to New Jersey Bar Direct e-mall Jhlpp@bogarlaw.com October 5, 2004 V~A HAND DELIVERY Glenda Farner Strasbaugh Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 RE: The Estate of Veronica J. Stupak No. 21-04-0691 Date of Death: July 5, 2004 Dear Ms. Strasbaugh: I represent the Estate of Veronica J. Stupa~-.~ Enclosed f~ a check made payable to the Register of Wills in t~?amou~t of"' ": $22,307.55, same constituting a prepayment at discount ~.on account of Pennsylvania inheritance taxes in the above-captzon~ estate. The prepayment is determined as follows: $521,814.05 ~k~ltiplied by 4.5% or $23,481.63, less discount in the amount of 5% or $1,174.08, resulting in payment of $22,307.55. Pleasei~rovide me with the appropriate receipt in this matter. Your time and consideration in this matter are greatly appreciated. Very truly yours, ER B. HIPP JBH/blw Enclosure cc: Carol Ann Marshall, Executor (w/o encl.) COMMONWEALTH OF PENNSYLVANIA REV-11 62 EX(11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT, 280601 HARRISBURG, PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 004467 MARSHALL CAROL ANN 6 SPRUCE DRIVE CARLISLE, PA 17013 ACN ASSESSMENT AMOUNT CONTROL NUMBER ........ fold 101 $22,307.55 ESTATE INFORMATION: ssN: 191-18-o211 FILE NUMBER: 2104-0691 DECEDENT NAME: STUPAK VERONICA J DATE OF PAYMENT: 10/05/2004 POSTMARK DATE: 10/05/2004 COUNTY: CUMBERLAND DATE OF DEATH: 07/05/2004 TOTAL AMOUNT PAID: $22,307.55 REMARKS: MARSHALL CHECK# 1003 INITIALS: CCP SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS Register of Wills of CUMBERLAND County, Pennsylvania INVENTORY Estate of Veronica J. Stupak No. 21-04-0691 Date of Death 07/05/2004 also known as ,Deceased Social Security No. 191-18 - 0211 Carol Ann Marshall, Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. I !We verify that the st~tements made in this Inventory are true and correct. (!We understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Name of Attorney: Jennifer B. Hipp Esquire Personal Representative Signature: ~,,/t?L..n .W4~a:/L_t'"jJ Carol Ann Marshall I.D. No.: 19475 Signature: Address: One West Main Street Address: 6 Spruce Drive Shiremanstown, PA 17011 Carlisle, PA 17013 Telephone: 717/737 - 8761 Telephone: 717/697 - 8446 Dated: Description (See continuation page(s) attached) ;- (Attach additional sheets if necessary) Total: 131,602.15 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory. Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems, Inc. Form1lRW-7 (1992) Estate of: Date of Death: County: INVENTORY Veronica J. Stupak 07/05/2004 Cumberland CASH: Conseco Senior Health Insurance Company - Refund of Premium 963.47 PNC Bank, N.A. - Checking Account No. 5003645093, date of death balance $5.00, accrued interest $0.00 5.00 PNC Bank, N.A. - Checking Account No. 5140063014, date of death balance $6,496.88, accrued interest $0.64 6,497.52 PNC Bank, N.A. - Savings Account No. 5003645237, date of death balance $899.41, accrued interest $0.00 899.41 Rite Aide Corporation - Pension Payment 106.46 Shippensburg Health Care Center - Refund 6,588.35 15,060.21 PERSONAL PROPERTY: Contents of home and personal property - Appraisal is attached hereto and incorporated herein 1,070.00 l,070.00 -1- BONDS: United States Savings Bonds - Values per attached listing REAL ESTATE/PA: All that certain piece or parcel of real estate having erected thereon a dwelling house being known and numbered as 4030 Seneca Avenue, Camp Hill, Pennsylvania. - The property was acquired by Thomas H. Stupak by Deed dated December 21, 1951 and recorded in the Cumberland County Recorder of Deeds Office, a copy of said Deed being attached hereto and incorporated herein. The said Thomas H. Stupak died on December 31, 1982, whereupon full and complete title became vested solely in Veronica J. Stupak, the Decedent herein. The property was conveyed to the sole beneficiary of the Estate by Deed dated November 11, 2004. A copy of the said Deed being attached hereto and incorporated herein. It is respectfully suggested that the fair market value of the real estate is as follows: $95,810 (county assessed value) x 1.11 (common level ratio factor) = $106,349.10 -2- 9,122.84 106,349.10 9,122.84 106,349.10 TOTAL RECEIPTS OF PRINCIPAL.... ........... -3- 131,602.15 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT MARSHALL CAROL ANN 6 SPRUCE DRIVE CARLISLE, PA 17013 nnn__ fold ESTATE INFORMATION: SSN: 1 91 -1 8-0211 FILE NUMBER: 2104-0691 DECEDENT NAME: STUPAK VERONICA J DA TE OF PAYMENT: 02/23/2005 POSTMARK DATE: 02/23/2005 COUNTY: CUMBERLAND DATE OF DEATH: 07/05/2004 NO. CD 004979 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $368.47 I I I I I I I I TOTAL AMOUNT PAID: $368.47 REMARKS: C MARSHALL CHECK# 0096 SEAL INITIALS: VZ RECEIVED BY: REGISTER OF WILLS GLENDA FARNER STRASBAUGH REGISTER OF WILLS \~ REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT REV -1500 EX + (6-00) CAPB HpRL EplO CRAC KoTK ES C P o 0 R N R D E E S N T Z. Supplemental Return 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach copy ofT rust) Spousal Poverty Credit D 11. Election to tax under Sec. 9113(A) (date of death between 12-31-91 and 1-1-95) (Attach Sch 0) ~.I~lg~.I:IIj;i,$jj\@Qe~gQl~iii1~~il~.IDeWMQel~It.I~IQg'l4.gltl'.~II'IIN!$H~'a1iiJlIlBgQ~j,~;. NAME COMPLETE MAILING ADDRESS D E C E o E N T COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Stu ak Veronica J. DATE OF DEATH (MM-DD-YEAR) 1. Original Return 4. Limited Estate X 6. Decedent Died Testate (Attach copy of Will) o 9. Litigation Proceeds Received 0 10. Jennifer B. -Hi FIRM NAME (If Applicable) uire N i\fJ 0 OFFICIAL USE ONLY FILE NUMBER 21-04-0691 NUMBER COUNTY CODE YEAR SOCIAL SECURITY NUMBER 191-18-0211 THIS RETURN MUST BE ALED IN DUPUCATEWlTH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER o 3. date of death . Remainder Return prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes One West Main Street Shiremanstown, PA 17011 1. Real Estate (Schedule A) Z. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or Ll 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Oedudions (total Lines 9 & 10) 1Z. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subjed to Tax (Line 12 minus Line 13) TELEPHONE NUMBER (1) (Z) (3) 15. Amount of Line 14 taxable at the spousal tax rate, ortransfers under Sec. 9116(aX1.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate 19. Tax Due ZOo :::!Pfl~q~:~~~~:.F:OCQi:I,:~"~:~~~~$,1.!.M;!A!:t.l~F~~l)::~:~::~~Jt~~~~~j1:::: ~liiill!\:~_..~fil~i~.B.~1i~~iJ~~i;t,~e8!1f1li;~ua;lfj$il~jBiv~~e.e~JNQtI~fjg~~QliM"Tiji.f(.m;~~t4%B~wl;jil;[~;!ij1jjj~~i R E C A P I T U L A T I o N (4) (5) (6) C o M P T U A T X A T I o N SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 530,002.22 Copyright (c) 2000. form software only The Lackner Group, Inc. r'-",) 106,349.10 9,122.84 None None 16,130.21 13 , 951. 23 (,") (., : 402,866.52 18,417.68 None (a) 548,419.90 (11) 18,417.68 (1Z) 530,002.22 (13) (14) 530,002.22 x x x x .0 0 .0 45 .12 .15 (15) (16) (17) (18) (19) 0.00 23,850.10 0.00 0.00 23,850.10 Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: STREET ADDRESS 4030 Seneca Avenue CITY I STATE I ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) Z. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 23,850.10 0.00 22,307.55 1,174.08 Total Credits ( A + B + C) (Z) 23 ,481. 63 3. InterestlPenalty if applicable D. Interest E. Penalty TotallnterestlPenalty ( D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. . Check box on Page 1 Line ZO to request a refund (4) 5. If Line 1 + Line 3 is greate.r than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B) Mlike Check Payable to: REGI.S.TER . OF WILLS~ AGENT . 0.00 0.00 368.47 0.00 368.47 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; . . . . . . . . . . . . . . . ~ ~~x b. retain the right to designate who shall 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? . . . . . . . . . Z. If death occurred after December 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 beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. o o []] []] D Under penalties of perjury, I declare that I have examined this return, Including accompanying schedules and statements, and to the best of my knowledge and belief, It Is true, correct and complete. Declaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN Carol Ann Marshall ---~_?P-~~~~--~~~-~~--------------------------------- Carlisle, PA 17013 Jennifer B. Hipp Esquire One West Main Street ----------------------------------------------------- Shiremanstown, PA 17011 DATE ~k""'./I t?.v ,0 f;/Ahh~"t!../ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ~.. (q-t'i'" DATE For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. 9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [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 twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [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%, except as noted in 72 P.S. 9116(1.2) [72 P.S. 9116(aX1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 9116(aX1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Copyright (c) 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) REV-1502 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Veronica J. Stupak SS# 191-18-0211 07/05/2004 21-04-0691 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is iointly-owned with riClht of survivorship must be disclosed on Schedule F. ITEM DESCRIPTION VALUE AT DATE NUMBER OF DEATH 1 All that certain piece or parcel of real estate having erected 106,349.10 thereon a dwelling house being known and numbered as 4030 Seneca Avenue, Camp Hill, Pennsylvania. The property was acquired by Thomas H. Stupak by Deed dated December 21, 1951 and recorded in the Cumberland County Recorder of Deeds Office, a copy of said Deed being attached hereto and incorporated herein. The said Thomas H. Stupak died on December 31, 1982, whereupon full and complete title became vested solely in Veronica J. Stupak, the Decedent herein. The property was conveyed to the sole benefic!ary of the Estate by Deed dated November 11, 2004. A copy of the sa~d Deed being attached hereto and incorporated herein. It is' respectfully suggested that the fair market value of the real estate is as follows: $95,810 (county assessed value) x 1.11 (common level ratio factor) = $106,349.10 SCHEDULE A REAL ESTATE TOTAL (Also enter on line 1, Recapitulation) $ 106,349.10 (If more space is needed, insert additional sheets of the same size) Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1502 EX (Rev. 1-97) FEE-SIMPLE-Typewrlter ID4t5~,lI~tuturtf :!Whtilr IDqr DEe 211951 c1Av 01 December ... the lIe..r 01 our Lord 0... Tk01....nd NI..e Hundred ..nd FlftlI -one (1951) titttuttn RQY A. HOLLINqER and ELIZABETH A. HOLLINGER, h~s wife, of the City of Harrisburg, County of Dauphin and State of Pennsylvania, Grantors, hereinafter called the parties of the first part; and THOMAS H. STUPAK and VERONICA J~ STUPAK~ his wife, of Lower Allen Township, Cumberland,County, Pennsylvania, Grantees, hereinafter called the parties 01 'h. ..cond pliTt. Bifntssetq Th,.e ,he...1d perl ies 01 the firet pliTt. 101' ..nd ... couId.....tio.. of',.....mof One ($1.00) Dollar, and other good and valuableconsidera- tions IIalDCilI', ",...ful mOftev of the Uftlted State. of America, ...ell ..nd trulV pIIid bv ,he ...Id pliTt i e s of 'he ..cond paTt to 'h. ...Id pliTt i e s of the font perl, ..t ..nd b.}..... ,he ....u..g ..nd dell"lrl/ of th... pr.._. the receipt ...h...eof b ,.....bl/ acJm.owI.dg.d, ha v e Qrll..,.d. b..rl1..I..ed, .old, ..1I...ed.l ...f.ofled. r.I....ed, c....".l/ed. and COftfirmed ..nd 1>11 ,h... pre._ do Qrllftt. bar.,...... ..11, ..II.... ...feou. r.I...... COftvev. ..nd COftfirm "..to the ...Id perl ies of the ..cond paTt their heIre ond ualgu. All that certain piece or parcel of land situate in the .Township of Lower Allen, Cumberland County, Pennsylvania, more particularly bounded and described as follow~,to-wit: BEGINNING at a po~nt on the northern side of Seneca Avenue, one hundred four 'and seven one-hundredths (104.07) feet west of the northwest corner of Seneca 'Avenue and Oneida Road, said point also being at the dividing line between Lots Nos. 24 and 25 on Plan of Lots hereinafter mentioned; thence South fifty-eight (58) degrees forty (40) minutes West along the northern side of Seneca Avenue, sixty-four (64) feet to a point on the dividing line between Lots Nos. 23 and 24 on said Plan; thence North thirty-one (31) degrees twenty (20) minutes West along said dividing line, one hundred ten (110) feet to a point on the dividing ltne between Lots Nos. 24 and 26 on said Plan; thence North 'fifty-eight (58) degrees forty (40) minutes EaS~ along said dividing line, sixty-four (64) feet to a point on the dividing line between Lots Nos. 24 and 25 on said Plan; thence South thirty-one (31) degrees twenty (20) minutes East along said dividing line, one hundred ten (110) feet to a point, the place of BEGINNING. BEING Lot No. 24 on Plan of Lots known as "Keewaydin", re- corded in the Office of the Recorder of Deeds in and for Cumberland County in Plan Book 4,. Pages 42 and 87. HAVING thereon erected a, one story frame dwelling house. I "" .1.", BEING part of the same premises which E. Vickery, Widow, by deed dated May 10, 1951, and recorded in Deed Book "R", Vol. 14, Page 599, Cumberland County records, granted ~ndhconveYed unto Roy A. Hollinger, one of the parties fiereto or t e rir~t pa:tt . record. 1.:,,1.: . d'''; " r. ~r.t.,; ,~4. !.,. UNDER AND SUBJECT to reservations and restrictions of ~ , ~ I .r l' , I r-; t \ " I "'T{! j' IDngdlttr 1Dtm .u .M .mgulll... tha """""'''. h.......rltamem. aM .ppun....""... to /ha .....a balmlgi.., or l1\ ...ploa appenaml.ftg. .M th. ..""enloft aM r."............ ......aM.... .M ........iM...... ..em.. la...... aM Pf'ofiea th_f; Aub mil .u the .atIIt.. ""ht. titl.. i..cer.at, prop,,"'" claim .llII d.....M ...haeao....er. both 1ft III... aM aquit". of the eald pani e 5 of the fim pan. of. .... to or out of the ..id ",.....ia.... .M ""..." pan ...I 11M pa.....1 theraof " mn lIlaUt attb to ]\{nIb the ..id ",.....10... ....uh,.U aM ....guIA.. th. .PJIun....""a.. ....to the .aid pan i e s of tha ..eatul pan. the i r hdr. 11M ..algou. to aM for the ....1" prIlpft' .... .M b.hoof of the ..id pan ies of tha ,.coM part. their hdr. 11M all"", for""..... i\ttb THE SAID Pan iesof the firat pan for themselves, their haI.... _.....tor. .M admt..Wr.con. do I b" t"".a pr..em.. Hid parties of tha .acoM part, their they th. Mid Parties of the "r.t part their """...II..t. gra..t lI..d """.. to 11M ...Ith the hdr. 11M III""",. t'..., het... all 11M .."""lIIr the her.dttomem. .M ",.....10.. herd...&o". d..erlbad' .M gra..t.d or m...tl....~d. AM t.... tmded eo to b.. UJith .ppurt....""... ....co the Mid pan ies of the ..eatul pan. their hair. .M'....lg..a. .gam.t the Mid panies of the firae pan.M their helra aM .gat_ IIII.M ."""" oth.... p........ or per...... ...homao""..... 11I...,..11" cllllml.ftg or to clllim the ....... or _II pan ther.of. .hall .M ...11I b" th... pr.....ea. WARRANT AND FOREVER DEFEND 1Jtt .UtttSS .lttrtof h.........to.et th e ir haM s the ..id part i e 5 of the firet part ha ve .;:.- ,.M .....1 S , " the "II aM """" "r.t .b..... ......tt..... ?f:. ...0)... .."..::.....eQ.....,...~,/' ,..,~~.........".,,(SEAL) ".~.Q..~/-e&/...,(SEAL) ............ ...'........ 0................................. .(SEAL) ......................... ............ .......... ...... .. . .. (SEAL) :).U'::I;:.;;..~;'.~I.'j,....:......... :......:................. . (SEAL) , '~""'I.\"" h..... h h. h........ h:.... .{....J ,.... ........ .... .. .. .. ... ..'..... ... (SEAL) , , ~....................., ....., .. .. (SEAL) .. :~i:.: .," :":; h h ....( ................ ,(SEAL) "', ,(SEAL) (SEAL) ................................................... ,(SEAL) \ COMMONWEALTH OF PENNSYLVANIA } SS: COUNTY OF ...........D.A.UP..H.IN...........~........................... 0.. thia, cr.. ....... P.~~..zJJ~.~............. .De.camber ........... ... ........ .., 19 ..51. before me a. .N.otar.y.. Publi.c~..in. and. for.. .said. .S.tate. and. .C.o.unty .............. th. ..M....algfted offic...., per".....II11 .PJI..red .. .ROl. ..(1,.... J:JQLL.I~GEa. ~md.. .EJ..IZ./I.B.ETH. ../1... . HOLLINGER, ,.his. . .w.i.fe,__ ................................................................................... --........... ................ ................................................................................. Ic""w.. to m. (.... "lIlbfllctorilll prov...) to be th. peno... S.. .whoae _me s...... are......... ....b.crtb.d to the wltht.. lnalt'um...t, IInd lIclcftOtDledg.d thot ...:t. he .y. . . . ..,.euted the ..m. for the purpoae /heret.. COftlllmed. IN WITNESS WHEREOF,I h.........to ".t mil haM ~~.~~4..~., Mil eommllalOft ."",\r." ....:..... ..My..Cnmmission. Expires.... January 29, 1955 I '....e&1I c""lfll thal1'" P,..eIo. Realdmc. 0 the G.....t.., \.. the ...Uh\.. Deed. la ........ . . . . . . . . . . . .....Lf.d..1...a.....z;.e.')Jec-:~....., . . .. ....... ...Low .. Alle.n.. Township,.. . Cumberland. C.un~y.. .P.BDD;tv \' IQ ~ ~ ~ .. ~ 'd. ...t s:=: 'd cd. l>> .-{ .. III !f $.t: 'g&l ..-f ....4 GI: , 'd.d GI. 1 1lIt:.! ~ '" GI :z; cd .. 0' ~. : H ~ ~ 0: ...:I .. ft.i .. cr.:...:IGI ~~ .. 0 8 0: 1iI0r..t 0; ~=i ~E-4 . .:,' Q .. 0 tl)Gl CIS ..-i: H . .., . E-4 . r..t ~: ..-i s:i .... ...:1< III tI).~ P1 .. ..:l ..-f ~ , . .. GI cd: giS..d . 0 ~ .-( Po.: =< 0; ..-i iii 0 P "lI:i: < .. ~ <~ tl)H l>-i ~~ .., I-{ ..,. li 1 N 01 o. GI !f 1 l>-tH ~~ ..:l :c ~ ~~ ~ .. 0 0: t:. ...:I 0: u III ... ,: ~: "-.: )..: ,,: ~ : ~ I -~ 1 . .-~)~'~7~11.1.~~:':-~~~ .~,:;.-r),F0:;:,- ~;;" ~.--_.'----'-"-' " t: ;','-"-_"_~:::~ ','~~Hf.' ~:+\I ".1\' t.,',,',...'.~.::\\-'lit~.~~ "I _, 'tt.n. ":"1 . .. '.: I .,' , . . ,. .: ~ "'\"""'')'' .......~::~;.~,;.~~.~~.~:~:~J..; 0'" (l ilttoril,il In the Office for Recording of Deeds, Mortgages, etc. in. and for the County of ........99M.~.r;gJ"l~~!L.........in Deed Book .......w,.........Vol ......J..!t.......... Page .....M~5......... .Uurss, . 22ND My Hand and Seal of Office, this....................................................................................day of ..............................................D.ECEMBER....................................Anno Domini 19 51 " ~~dL h/~~ tf ; z;r/ ~. ROBERT r:: '7r;':'t'I'-;f I. L.I_~~C.I\ F j:" r () D r't ~ - r,... -, r"" ~ r. '. \..... tJ U I dJ _ n d r L'r. c '.:.:;, C ~ ' F/ D :-- F: :_ r ~ I ::; ~~, -j ~ r.:'1~!J j'\,i.n. U 17 LL~ I 'v Prl 1 32 Tax Parcel No. 13-23-0555-096 THIS INDENTURE, MADE THE \\-1-"" day of ~O\) rc.,VY\~ct.R. two thousand four (2004) BETWEEN. CAROL ANN ~~SALL, Executrix of the Last Will and Testament of Veronica J. Stupak, late of Lower Allen Township, Cumberland County, Pennsylvania, party of the first part, and CAROL ANN ~~SFJlliL, of Carlisle, Cumberland County, Pew~sylvania, party of the second part: WHEREAS, the said Veronica J. Stupak by her Last Will and Testa- ment, duly proved and recorded in the Cumberland County Register of Wills Office, Pennsylvania, in Docket Book 2004-00691, Letters Testamentary being issued on July 23, 2004, provided, in perti- nent part, as follows: ITEM II: I give, devise and bequeath the rest, residue and remainder of my estate of every nature and wheresoever situate to my daughter, CAROL ANN MARSHALL.... ITEM VI: I appoint CAROL ~~ MARSHALL of Carlisle, Pennsylvania, Executrix of this my Last Will.... NOW THIS INDENTURE WITNESSETH, that the said party of the first part, by virtue of the power and authority aforesaid, in said will contained, and in consideration of the sum of One Dollars ($1.00) to her paid by the said party of the second part, at and before the ensealing and delivery of these presents, the receipt whereof is hereby acknowledged, has granted, bargained, sold and conveyed, and does hereby grant, bargain, sell and convey to the said party of the second part, her heirs and assigns forever: ALL THAT CERTAIN piece or parcel of land situate in Lower Allen Township, Cumberland County, Pennsylvania, bounded and described as follows, to wit: BEGINNING at a point on the northern side of Seneca Avenue, one hundred four and seven one-hundredths (104.07) feet west of the northwest corner of Seneca Avenue and Oneida Road, said point also being at the dividing line between Lot Nos. 24 ~~d 25 on Plan of Lots hereinafter mentioned; thence South fifty-eight (58) degrees forty (40) minutes West along the northern side of Seneca Avenue, sixty-four (64) feet to a point on the dividing line between Lot Nos. 23 and 24 on said Plan; thence North thirty-one (31) degrees twenty (20) minutes West along said dividing line, one hundred ten- (110) feet to a point on the dividing line between Lot Nos. 24 and 26 on said Plan; thence North fifty-eight (58) degrees forty (40) minutes East along said dividing line, sixty-four (64) feet to a point on the dividing line between Lot Nos. 24 and 25 on said Plan; thence South thirty-one (31) degrees twenty (20) minutes East along said dividing line, one hundred ten (110) feet to a point, place of BEGINNING. BEING Lot No. 24 on Plan of Lots known as nKeewaydin", recorded in the Office of the Recorder of Deeds in and for Cumberland County in Plan Book 4, Pages 42 and 87. HAVING thereon erected a one story frame dwelling house. BEING the same premises which Roy A. Hollinger and Elizabeth A. Hollinger, his wife, by deed dated December 21, 1951 ~~d recorded in the Cumberland County Recorder of Deeds Office in Deed Book "W", Volume 14, Page 495, granted and conveyed unto Thomas H. Stupak and Veronica J. Stupak, his wife. The said Thomas H. Stupak died December 31, 1982, whereupon title to the within described property became vested solely in Veronica J. Stupak. The said Veronica J. Stupak died July 5, 2004. TOGETHER with all and singular the rights, liberties, privileges, hereditaments and appurtenances whatsoever thereunto belonging or in anywise appertaining, and the reversions and remainders, rents, issues and profits thereof, and all the estate, right, title, interest, property, claim and demand whatsoever of the said Veronica J. Stupak at and immediately before the time of her decease, in law or equity or otherwise howsoever, of, in, to or out of the same: TO HAVE AND TO HOLD the said granted premises to the said party of the second part, her heirs and assigns forever. AND the said party of the first part, does covenant, promise, grant and agree, to and with the said party of the second part, her heirs and assigns, by these presents, that the said party of the first part, has not done, committed, or ~~owingly or willingly suffered to be done, any act, matter or thing what- soever, whereby the premises aforesaid, or any part thereof, is, are, shall or may be charged or encumbered, in title, charse or estate, or otherwise howsoever. IN WITNESS-WHEREOF, the said party of the first part has here- unto set her hand and seal the day and year above written. Signed, Sealed and Delivered ~n the Presence of /f7ll/r? p~~.!.,.f' ...~', ,~i//_,,-. .1'.-' c../ ~~:/-" , (S~..L) . Carol Ann Marshall, Executrix of the Estate of Veronica J. Stupak COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND On this, the !J+~ day of i\/:vdnb..":..;2.. , 2004, before me, the undersigned officer, personally appeared CAROL ANN ~~SF~L, Executrix of the Estate of Veronica J. Stupak, known to me (or satisfactorily proven) to be the person described in the forego- ing instrument, and ac~~owledged that she executed the same in the capacity therein stated and for the purposes therein con- tained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. .----:- ) "_'::,:. -', /-:J ~ -. ~ r r . L L--._......'<-(' :A" "\..- .. (SEAL) Notary Public My Commission Expires NOTARIAL SEAl BONNIE L WILLIAMS, NOTARY PUBLIC SHIREMANSTOWN BORO., CUMBERlAND CO MY COMMISSION EXPIRES APRIL 18 2005 CERTIFICATE OF RESIDENCE I do hereby certify that the precise residence and complete post office address of the within named grantee is 6 Spruce Drivel Carlislel PA 17013.** ~OoJ~~ 1\ 12004 71 (J. (' Jennifer B. HiPPI Esquire, N.T.S. Attorney for Grantee **PLEASE RETURN RECORDED DEED TO: Jennifer B. HipPI Esquire One West Main Street Shiremanstownl PA 17011 COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND RECORDED on this day of 200_1 in the Recorderls Office of the said CountYI in Deed Book I Page Given under my hand and the seal of the said officel the date above written. I Recorder. REV-1503 EX + (1-97) SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Veronica J. Stupak SSII 191-18-0211 07/05/2004 All property jointly-owned with right of survivorship must be disclosed on Schedule F. FILE NUMBER 21-04-0691 ITEM DESCRIPTION UNIT VALUE VALUE AT DATE NUMBER OF DEATH 1 United States Savings Bonds - Values per attached 9,122.84 listing TOTAL (Also enter on line 2, Recapitulation) 9,122.84 (If more space is needed, insert additional sheets of the same size) ,..__....I_L....I_\ 1aaJ:: ~_.._ __~u....._ __I... ,..DC,._+__.. I....... IOn.... R~V_1~n~ !:'Y'Dftu 1 ".." M (.0.., o ...... ~ o o ~ lI"l "- 00 Q eo ~ ~ ~ .... o N Q eo ~ Q.. ~ o o ~ !Q 00 I IJ -~ 11 [I II .~""':-- lEI ...~~, :~1 f"'l II ;............ 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N ...... ...... ...... 0 0 0 ca -:-: 00 00 00 00 00 00 00 00 00 00 00 00 00 00 u ~ ~ ~ - - In > ...... ...... ...... ...... ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ c:l Z CI) Q. :d ~ ~ ~ ~ z ~ a: t: t1 :>M-wW. ..c: ~ .... o M ~ eo as Q.. ~ o o ~ I.I"l - 00 ... 0 0 ! ! ~Q. ~ Q) ~ :J II) r... :J o ... ~ .- OJ "' '. i c::LL i: - e 00 .Q :J II) e 't:l .a 0 '._'. 0 , , Q) C) .- .Q Q) >- OJ Q) "' c= Q. ::l .!! en - - .c:: c 'E - .!! Q) .a :a Q) '. ! ::l "' U en II) x r... W ~ c:: ... "' 0 - - .s .!!! r... ::l Q. ~ Q) "' ~ III (.) C,) "' 'C Q) 't:l Q.. - c e:- O u OJ ~ ell III CZl C'I - U u .:;: c ... ':;: E8 ell "' > en en 0 eo ui ... as ::> e - ~ - '5 .... .0 (.) ~ ~ "'0 :.) C,) .- ~ ::0 ... :3 5 Q. ::::l rII rII j eo c: ;> as -:-: ~ Q. t: ..c: ---- .~ . -- " 'I W \I :.. J _- ~--- " . _- . - t . ". _- : f 'I I :_ ~~~~~~~~~~~ ",ve ye..It. AND TeN MONTHS IPROM THe Is.ue OATC MeRCOII" WIUo ~..y !:J~~~~~ *181-20-5726 JAN. 1971 000 -00-0 OOOMONT"~:::: :,-~~-- /SVG BO'NO / , 670 3750 .' 'SlIU1:z.~S .. : 1-31-1971: \ CATlNO ST~ " , / , , I II "'- -' '"'----.. 1'1 SERIESE ~-=.=:Eer:;:;~ L 803 252643 [I I~~:i:~~-:::'-~~~~ !!!~~; iii;iiiii;; !i~~.--:; ~~i B~~~~~~'('::J\&I " :..,.~ 'I~-,_~;::..-::-i~:~: i "'-:>€~~~~~~~~! NTHOMAS M STUPAK OR MRS'VERONICA J STUPAK 4030 SEMECA AVE CAMP HILL PA 17011 ~1.~ ~!.f!lJ!Q)$I~~ @,.~'flESlt<lt~ JPtvc VUltS AND TEH MONTHS ~M THe Issue DATE HI:RCOII' WILL. 1'14'1 ~~~~nTt~~Sj hrHOMAS M STUPAK OR MRS VERONICA'~ STUPAK SEMECA AVE'<~-' HILL PA 17011 *181-20~5726 FEB. 1971 00 O~OO-O 00 O-(-..o.;m..~::= ::,-,f:!i5r"I-- >S'VG : BONtl - . 670: 3750: " . :7~'" 1 . " 'I~~' :2-28-1971 : I I \ c.TI""*3 ST~ " , / , , "'...... ,,' -...--... II, 'I II \I :>4 J _- _ \I: _- -. . '. _- : I ~~~~~~~lI~~~ 1'I'Y1f: YURS AND nH MONTHS I'WOM THe 15.5 ua DATI: HIERIEO~ WILL "AY 1 '~lr~~I~~~~~ ISSUE DATE -:-=~'- ~ .....:. . WHICH IS THE FIRST DAY OF II NTHOMAS M STUPAK *181-20-5726_(~B_::~_W,__ ~ i OR MRS VERONICAJ STUPAK 000-00-0000 _,,/- "'l!S ~-I " SVG BONQ !I' ! 4030 S EMECA, A V E .670 3750 :/ I.....q.~ ~ I~ _ CAMP HILL PA l7O11 \~~~~y k ""sf"RIESE . ~-====tlf'=~~ L 805323881 [ . ,6~~+~=+-=~~~~~,:., ~':~:~:i~:S:~'i'~~;:i1 >t:~ ~~~:~:~::-~~~~=~.I 'I W \I :,. J _- _ \I. _- -. · '. _- : , 'I I ' ~~~~~_iNlmf~ IfIVC "...... AND TeN MONTHS P1tOM TH" IS.UC OATC MCltCO' Wtu. ~AY ~~~~~E~~ *181-20-5726 APR 1971 000-00-0 OC<r~~::=:::~m-- :' S VG BO~W 670 3750 .' 1--1~ '. , ' : 4-30-197l " \ CSATfNG ST...... , ' \ ,'.1 " I ;, . - I _......__~_~.ICT.M-.......... .. I ".,'fltn.c~~~ s.,.... . ". ~ .. ____ 0-..'" " OUU' 1- ;:w I ==:=-_... ~ ~ ~:~ L 810 735 512 E. I II!f~iii;:'0~.:,i~,i_-=~~~~. To THOMA S M STUPAK OR MRS VERONICA J STUPAK 4030 SEMECA AVE CAMP HILL PA 17011 ~~~!mm~.~~~ . I'IVC .,lIAII. AND TaN MONTHS ~M THe ISSUE OATC NCltICO... WIt.L, ,.AY ~~-!t~~n~~-' NTHOMAS M STUPAK OR MRS VERONICA J 'STUPAK "_ II- ,.Ii II I'll, ' IIS~ 11-_-- ii" r'SE~IESE .,' -.-=-:- -' - ~~__j--=-L'810B.b6 507 E ' Rfil '" "II' ~.:","" . I . ..~."" " . ,~ ~~~+=iL~=~~'" '( , 'J \II " :-.,. , '1--' ~ :>i :.,. " : i '" ~~~~~~,;; ,', '. " ....-..... _.~.:--:. 4030 SEMECA AVE,..:_ CAMP HILL PA 17011 " , .::::::- ..- ~- - "-", -.-- - ~. -- - .. : :,;a.. 'I I ... u;.. _ ::.... ~ _ *181-20-5726 'MAY:~1971 00000 0 ooaMO.......r:==:-'!fS-~ '.._--~~~;~=-:~~,'. ,'--' ~~~:S~~;":~ONQ"< -6 7ci'"E~:3:f5o;:;"'/:":;;~~':~.,,: -'C:': -t;5~31";;191i: ..u .\..'~;':~~T1"" ~~ .:_~;--;:.. :." . .:: '\ . ~-: '.:'<\ ~~~'- . , . - ,. ~~~_.. ~~'.:'~~': -.. ~.~.::~:'. -.. :~::. ---. -.. -.. , 11111\1:,., _- ,- , '" :>1-- _- _ , . : -, 'II 7Jl:l'.!~~~f!.~~~~ ,",VI: .,URS A"O TEN MONT)4S ~M THe ISSUK DATe relE"I:O'" WILL. ~AY ~IW,"~~n~~Sj To THOMAS M STUPAK OR MRS VERONICA J STUPAK I i ,II I I __.___.,~.......__.._ I ' - S~RIES E- ~~-=-~.. '~-:~~~~~ 1~1, -- .. ~"-' I ~~~=-=..~~... '( I ~ ~ " :.,.. ~ '1_-' ~ :>i : ~ .. : i '" ;;;tI~ ~-= ~ "1:...J..1 4030 SE MECA AVE CAMP HILL PA 17011 *181-20-5726 JUNE 1971 000 -00 -0 00 aMO;:m.~:: ==:.-~~S-- /SVG Bo'ND , 6 7J 3750 ", ,.....1-:.JJr. ... : 6-3D-1971,: ., QA.T1NC1 ST...... , , ' , " ----..... ,. . 'I W \I :.. I _- ~~~~~~~~..Rmm<I~ '.. '.~ . ~"e yc.o..s ....D TCN OOO..TMS l'lOOM TM" Issue DAn "CJtCO" WI"" "AY ~:::r" ~, r,THOMAS M S~~81-20-5126 ~~Yf~~fi 11 OR MRS VERO"lICA J STUPAK OOO-OO-OOOOMC~~:::=.-,-_-~~--II~. /SVG BOND .' 4030 SEMECA AVE 670 3750 " 7-31 " I.'~" I ISWUINa AGCNT"s ' CAMP HILL P;' 17011 :,7-31-,-1971) 'I'~ 04TINCI lIT...... ~ '- " '1- , " IJ ~IESE ~~~~~ L8163~'~-~~'~-E, L I~ f~' ~~fi ~~. ~ ;':.~- ~'~:~ ~ ~ ~~~~+~~~~'( I "! ~,,:~. "1_-' ~:..:~ ~;.;.., ~"!(~=~;~~ II I W \I :.. I -' . \I: _- _-.' '. _- : , 'I I '" - , ~. . -.' ~.- ...... ",.-.'. . . - ',. ... ..... ,- ~ , ,. ~.!.~~il~.J~~.~~ Jl'IVC TEARS ....0 T'l;N1 MONTHS JrROM THe Issue DATE HalEO'" WILl.. "AY :!f!~~~~~n~ *181-20-5726SEP<:1971 000-00-000 dWl",":2::: ::_~~D'S'- ~ /SVG'80N'Q .670 3750."," I..;;;z.-~' >- ':9-30":1971': ,. ',. QATtNO~ ,. .' ... ... _:. .... __ r " - .... . . .' .. ,:"c~:~.;~D~{~~2:;.;,~L:.:~:; ,~~ -_._-_..~_..__.... .... ',' II .~ S~RIES E. ~-=--==,V ~.;;;.;:;:;~: ~~8-2,3__5Q9287[" I Il~~~~=~=~~~,(. ~ \II":",, ''f_;:':~:'':-#s'':'' "" :1!~~_~T;~1I1 ~, JQTHOMAS M STUPA K 'of'", OR MRS VERONICA J 'STUPAK' 4030 S EMECA AV E CAMP HILL PA 17011 . . W \I :.. I _- \I -- t "._-:"1. ~.!~~~~~'IV~~~ ~vc 'tU"S AND TaN MOMTM. ~M. THe 'ssue aAT& HCIICO,.. W'I.L "AT 1. ~~~~~~R~ WHI~~~~HiF1~~~;;or ~ To THGMAS M S TUP~K- * 181-20-5726___9_<;!___J.~_'n__ I OR M~~~. VERONICA J STUPAK OOO-OO-OOO~>----'~01'S.! ,. ,/ S VG BON-Q I 4030 SEMECA AVE 670 3150 " ,~~s '. I , . I i C A to' P Hill PAl 7 0 11 \1 0:.~2; :~? 11; I .11' \ :'.1 :at ..,...... ,~ I ~ . .' '.' . .' . . - -- - - - . I II ~s';IESE ~-=::;:;ae~~~ L 826149159 E '. ~! 111~~~", ~ 't: ",":p" ~-,~.,. r....~~.i , . W \I :,. I _- . - \I : _- _- t . "~_- : -, ',. ISSUE DATE _ . WHICH IS THE.-FI.RST DAY OF.. . -.. ':":<,:--; ';'j.::-,:t ~~~!mI!~~~~m~ "VI: YUltS AMD TaN MONTHS JORON THe Issue DATe Hell.OIl' WIU,.. ftAY ~~,!t!r~ltd&~ To THOMAS M STUPAK *181-20-572~1~;tl,~~~~ OR. MRS VERO~lCA ..J ; STUPAK 000::"00-0900 :)<~:0+f}~.vs:~~:; ,",~. :::';:" . . ,~c.,~..,./...SV. G :~BON:O.) 4030 SEMECA AVE~;':~': - 670 . 3750":'~f~:::~'>~ ii CAMP HILL PA 1701 I." ...~ :::-....>~11~iO~.i..9fi"i II!' .~-:'.- ; \;:--. J..':-:"....<>/.::.:~ . I .:---.., - __.:.........;.:.:-. .:.:....:. -',.~ :-'.:-". ~ _. SERIES E ~~~k~~T 828~9~,~-:~o~~E ,I ,1I~rt.~4[c?'~'~'=X~ '( , '!. ~ " :4> "" '1_-' :; :>t : ~ ~ : . ~: ~~~~=~~~.! ~~~~~~~m~~ "va yeA'" AND 1"1:" MO""", J'JtOM THe ISSUE DATe HI:ItCOIl' Wtl.L ""V ~~!t~~n~~ *181-20-5726 DEC 1971 000-00- 00 0 dMCN~~::= = :_-~1f~-- /SVG BOND , 4030 SEMECA AVE 610 3750 " I~""" \ CAMP HILL PA 17011 _ 12-31-1971; .1 < --< <CC .." \, ~=:.'/ -, I. ...........................,.""IM-..cr. &8..--......... - ~I. _"'____....:::. '..._..__...-..._ 4 I " ~ ==:==-:.......~ tfA:~:; L 831196 645 E ~';.i.'1 I~ '"..... ~"~"""''''~~WT........,; . " _ . . .- "" . ,--...............~....._,._-..._="'"" ~9.f ~~~.""" _~_...:;.....___._<='.=-::r-:lI.... {. J ~ " .4>"" 1_' ~ ... ,-#S " ... ,,>lIIlIlE'J!;i',=o,:;,C-____,.__._____,~ .. 'JI To Tn OMAS M STU P AK OR MRS VERONICA J STUPAK . ,I ~,~~~~,~;~~:~. II * 181- 20- 572 6. -li.O~!II\l~==~~l. .6-,--1 ~ml. OOC- co-oeco /~ -'-u s . ,/ S VG B 0 1\:0 ~ : 1 \: I 670 3750 ' 1.....~N....' ~. :, 1-.J,1..-..L~7 2J I'~ i \ / "'. " ,. i , , : I ~.....-. =-:.~~ ..........== ..u.-. II ,i . SERIES E __:::==UT l If!!..!::--:'J-- L 833 873 393 E, ' I '!;~~~~=iia;~~~::I~~~~i~~s'~--~_~~:~::~:~' ~'iT~=:~~ii=i=~5.' ToTHCMAS M STUPAK OR MRS VERONICA J STUPAK 4030 SEMECA AVE CA~P HILL PA 11011 \I : _- _- ~ t - . ..:' ,,-0__ '0- _. _~ .' *181-20-5726 FEB~"1972:~~ 000- 00 - 000 Qi.ONf;,2:: ~=. :_-~~ -::- /SVG 'S'ONQ.} 670 3750 " l~~'\'::. : 2~29-1912::~ \. . _~TI~..T~" _':, .'",' .~ . '~, :"'~~:>..:.-" ", ~.. -.>'. :'.~ . .' '~'~'~,~~;-.:<-<:'~~. ..-~ -' .lO THOMAS M STUP AK OR MRS VERONICA J STUPAK. I~: . . '!It '\' I !I ...... " . ; . . 1& ~~~ __....dtlltOC..~Of'fJ).ACr'.................._.. II -~ ~101'MC,....__COlIOrf1OIIS 51'.... . . ". -a..1I 'f.....~" If' ou.,.y I_ I __OIMl'U.__IM\NUC..._ _~0#-.uu"'UlU'M. Is SERIES E -=-=-- '..... R!..!:-~(~ L 836 258 326 E .' ~l1~%~~=~=-~... '( I. ~::~:~ ~~~~~~~!~~! ~:~ :~. ~~:~~=?!::::..~~=~~~== 4030 SEMi:CA AVE CAMP HIll PA 11011' --.:.- ~~~~~l!]>~~~I1l!~~ "VI: VeAItS AND TaN IWOHTHS II'ROM THe ISSUI: DATe HERCO' WILL ".'1 ~lW1!'~~!r~0Jn~~ -----........ -- ~~ ~ ;::o;iI *181-20-5726 MAR 1972 ~'I 000- 0 0- 00 0 di.ONT"~:: =: ~---~-:tfs-- , . " I /SVG BON-Q . I 670 3 750 " ,......1. ~ '.' : 3-31-1912) I \ a4T1fo1C:J .-TNwI", I , ' , ' ,. ' To THOMAS M STUP AK OR MRS VERONICA J STUPAK 4030 S EMECA AVE CAMP HIll PA . 17011 Ii .. "'J'."" ;., -:' _______..;.' __...___.._ --~---<. . --.!. ' .f~ESE ~-= it{~.:::; L838588282~ 11j~.(.~~~-,;;'i5:~,~.~j:i~.1 II "t .. \I :.. I _- \I - - :a: ''';r.' : , 't I ".:_I~ ~1~~~.J~~~.t~~ . ~..,. ~ AT THe ORIGINAL. MATURITY MIEJICO'" WILl. "..Y 11' '''"lilrl-4~I~N'''D.0lR~'B~ ISSUE DATE ,,''; ===~~. ::81-20-5726 -;p':~':~~;' . ~..,:,.':,: J STUP AK 000-00- 000di.O~2::==:--r:tfs-- I; /SVG BONQ I 670 3 7 50 " ......1.7cJJ.... \ ".' :\ 4-0A~9..:.1;..~ 7 ~J ~ " ,,' ~ " -ii' II SE"R~I' ES E ~~~~z:~ L 1 0 00 80~.~.;2 E ~ . /';;:';"".'--r - - ~ ~ !li~;:+=1~+=Ii:~~~ ,{~::~:::i~~:T~::~ -"';;~~~:~~~~::~:=~:::~j~+=-~~+=~: ~~'~ 4030 SEMECA AVE CAMP HILL PA 17011 ...........y.,~~~~._~--""--.._--~: '-. , 't I_ ;'-:' ' ~~~M!lJ!~~~~~JrJilil~IDm~ AT THE ORIGINAL MATURITY HPeO'" WILL. PAY' . !:..~~~~n~~S} _':'.~'/;'~.:.., ,','''''...' ~ M STUPAK *181-20-5726 ->-j-tAY-:.i:197i':-.:~ 2 OR MRS VERON I CA J STUP AK: . 0()Q'::"bo-oQ6o~~2:'~~~:~-~~~~':"< ~ ~~~ ~i~EC~/V~7011 . _ 6;~'3750;;j.(~~~*~y~" I \ . :".OATlNO .,....... I '\ _ ,_ . .)'--- &i ........_~..., ;" -.... ij 'ii"'SE;IESE ~=:=;;tr~~~L 1 06Q~~~~~i~~.~E" I It~~~=T~~+=~a~ '( 1 ~ :~ \I :~. ~ '1:::-' ~. :>t::~::~::~::..::~~~_~~~=+~~~1I . .._-- -~_.....--_.'.__._-._--- . t"\I:ofl_- \I . _- -! ' ..., _- : f '.>> ISSUE DATE WHICH IS THE FIRST OAY OF ~~~~~@lhlJ~~~ AT THE ORtGlNAI. MATURITY HCJltCO,. WIU", "ay ~.m:.~~n~lf"BJ *181-20-5726 JULY 1972 000- 00- 000 OMONTi-<2:: = =:_-~'eS-- /SVG BO'No 670 3750 /,-:I.~'" :-7-31-1972) , c:lATlNCI ~ , , , " ,. I ",. , ~ - I " .___-~ ,:. I ~=E"-=~~~L 1 006160 777 E " I .~~~~..~" w .,~""__. ~~~:::r~~mi MTHC~AS M STUPAK CR MRS VERONICA J STUPAK SEMECA AVE HILL PA 17011 . "'." \I :of I _- " _- -..' ~. _- : t "t. ~~~~~~.~~~ AT THe O"'GlNA&. MATURITY MUCC)ll' WI1..&.. ,.,.y ~~~'JilSj ISSUE DATE WHICH IS THe: FIRST DAY OF HTHOMAS M STUPAK OR MRS VERONICA J STUPAK 4030 SEMECA AVE CAMP HILL PA 17011 * 181- 20- 5 726 _--4U1'i___L9.12.__ (WONTMI ____ t"f'1CAllll 000-00- 0000 /~ -'-US ,/ SVG BON'O , , 670 3750 : t_.?a ~ '. : 8-31-1972: \ elATING aT....... I \ " , " , ......--.... -."" \;';.fl: ..~-_. \I . _- _-, . '. _ : -,) '. 1 -. ...-- ... ":'" .." .. .' .... ~;I~~!tl~~!1B~~~!!~~ AT THe OlllGlNAI. MATURITY HCReop' WILL FlAY ~.!t~~nnA~SJ *181-20-5726 SEP.' 1972 000- 00- C 00 CioO,,":,~:: =::.-~:tfS-- . /SVG BONO, , , . 403C SEMECA AVE:':;:::-.-':", , _ 670,-3750,' 1...u1~,'.. it C A ~ PHI L L P A .. 170 11 :, 9- 30- 19 72J Iii" '::-::~:.--: '. DATlNO.,....... " Ii " ~I 1m! .SE~~EsE ~~e~~L1013P;'~';-;~t. I~~x~+~~...~... ,(, ~ \AI " :~.~ '!--' :>> :.. :~ ~ :=~:~:::>tI~~:Z~~;:J HTHCMAS M STUPAK CR MRS VERCNICA JSTUPAK . ." \I :.. I _- 1o.a.. - - . ......_ .... - .- ~ . - : t 't t .....:.-=:0 --...--. ~~~~~~~I~ AT TNII OlllGlNAI. MATURITY HU.O'" W.u.. ,.,.y ~~~~"1r~~ .---. ~ ~ HTHOMAS M STUPAK OR MRS VERONICA J STUPAK 4030 S EMECA AVE, CAMP HILL PA_ 17011 * 181-20- 57 2 6___0J:J____1.9].,__ 000- 00-0 0 0 d....'"'":'~~ ~ --'. ~Jj~ ,/ SVG BO'N-O ,670 3750 " I~""'~ .. . . :]. 0- 3 1..; 1 9 7 ~ \\ ICaAT1NC1 .,......... " , ' , ' _.....___.-.-no_ _cr._~.....__ .....,.'nIC__~..-at . "...........OM.YMI'o.u',.... SFRIESE ~_.... - ~~L 1021955583 E .~~=~~... '( . 'J \AI " : ~ '" '1_-' ~--:.. i.~~ : ~ .':!.. ~!~~=~~~+~.I _._-- " . -- -. . '. _- : , 't I ~m~~~~~ AT THe ORIGINAL. MATURITY HCRCOl' WIU,.. "..., H THCMAS M STUP.lK OR MRS VERO~rCA J STUPAK 4C30 Si:MECA AVE CA~P HILL PA 17011 670 3750 " I~~\ , . :11-30-: <;7~ \\ CtATlNG .,........ I \ , ""'.. ;~~~ ....--...... ---_.............,........ .Mn',.."'c~__~S'I'.... __ _.o.na.....______ -- -- - II... t II " :... I _-. ". - - . .. - _.. . - : , 'II . .._', . ,I::';';. ~,~ ,j .I_~""._~." > ~~~~ltrmm>~,~~~~~ AT TNe ORIGINAl. MATURITY ""COP Wlu., PAY ~~!t~~Dn&U8J 7iJ THOM AS M STUPAK, -, . * 181-2 0-5 726...c.....A~C;=:}.(~?-- OR MRS ,VERON reA ,J STUPAK '. 000-00-0000 ,/. "':-::~.vS. ,/ SVGBON9 670 3750 :' '--'f~' ~ .' :12~~1~' 072- \ a..-rf...o ST~ ' I " . . , I; . '- '"....,' I ~s=EsE ~~-=t#~~L102728-~-~~~:'E 'I ~~~=+=~~=~~... '{ · ~ \II " :~. S~~ -, ~ :.. : :,,'5 ~~?!:::~~~::+~~.1 40 30 SEM ECA A VE--:;'~:::~: .:"-' ,,:,.:',' CAMP HI LL PA' 17011. .. II, . W \I :Jof I _-I ! \I. _-. -..' ~. _- : ( I ~~~~~@>>~ AT THe O'"GlN..... MATURITY. HeReOF WILL "AiY ~~!t~~~~& , STUPAK *181-20-5726 JAN.' 1973 CR MRS VERONICA J STUPAK OOO-OO-OOC~;m.~:::::.-~~1-- /SVG BOND . , , 4030 S ~ M E C ,A A V E 670 3750 " ,--Z ~ ... CA~P HILL PA 17011 ~ 1-31-1973: \ I:llA.T1NCI S'1"AhIP / . . SERIESE ~-==-__-~~L10298:;-~7~-;/~ .:' , ~"d " .y!!li a~'~~~~=~~~ '{ · ".J ~ " :"^ .... 'J_-'~~::~~~~::~~~:::~i~~=+=)!=+=~~ ~~: ~ ISSUE DATE r;;; WHICH IS THE FIRST DAY OF ,oti ~ *181-20-5726 FEB. 1973 S 000 00 COOO-'woNiW------------- ~..'. - _. ..~-"'----~:es.. i /S VG B Cl\i'(; I: ~ , \ ~ 670 3750 " l...lo-~.ln. " ~ ~ 2-28-1973: ~~ \ OAT1NO STAM" / ~j \, / ~ " ! ! ~EsE ~~ ~~L1029889-~-~-OE:~ : I~~~~}+;~;-+=~~~~ '{ · :;' \II -. :~. ~~'~~ ~~~.~:::.. : ~~!.:!:::.~::~~]~~.iE;;+:&:+~&I '., ~~~~~Q1t~~~ AT THe O.IGlN.... M"TUItIT"r NIERKO' WI""" "AY ~t~~~n&'BS ToTHOMAS M STUPAK OR MRS VERONICA J STUPAK 4030 SEMECA AVE C AM PHI L L P A 1 701 1 " 'I W \I :... I -, ..' . \I : _- _-. I , ~-~ ~I ,*181-20-5726 MjR ~ 1973:~ I OOO-OO-COCO~~:::=:.~"if'S--: ,I /SVGaONQ '. , I 67C 3750,: ,.....1~..., ~ I :, 3:~~~7~J, ,'j \, ~' ..1 , , ' "-----' F; I I .SF-RIESE ~-====e~L 1036930688 E II .~ '( . ~ \101 -. :..,. ~" 'I_-t :.I :>t :"" ~ : ~ " ;>otI~~~~~~.1 ~~~~~~~~~mm!\ AT THC ORIGlNA'" MATURI"" H.RCOP' WII.I. "AY l:~.!t~~~Sj ToTHC~AS M STUPAK CR MRS VERONICA J STUPAK' 4G3C SEMECA AVE _ CA~P HrLL PA '11011 .., : -- _-. . '. _- I ) " I ~~~~~~.~~It~ AT TH. ORIGIN..... "ATURlTY HIEJn:OI" WIU. "AY ~lt~.lPY("'lil:.0l&~~ - -- '="'''-'' ..: SEMECA AVE HI L L P A 17011 I$! ISSUE DATE '!il:l WHICH IS THE FIRST DAY OF ~ j!j *181-20-5726 APR 1973 i~""~ , 000-00- COOO(....~~:::=:"-~!fS'--, /SVG BOi~m 670 3750 .: I-...:z.~ .. \\~J.C!.-l.27~) ~. , ' II ~~~;Z~L 1 0:<t0 04~--~~'~'E ~: .n'~: ToTHCMAS M STUPAK OR MRS VERONICA J STUPAK' ~SF.RIES E :.. If-. 1 III \I :.. I _~ \I . _~, ~ ~ _- : I 'I) ~~~~~~:~~~~ AT THe O"IGlNA"" MATU"''''' MOCO'" WIU. ~AY ~S~~~"Thn&~ . NTHOMAS M STUPAK * OR MRS VERONICA J --..---.".,..,...., ".,,.fttC.,........~Sl'MD JCaMa~ lMftlI",....______ "...,... ~CIIY' . -- -- ~ ... ....--..-..... '~~~t.l 040109639 E :-i, ~ 'I_-~'~:'" :~ ' ::~:=~:::~!m;~~:-=~5= ~~t '..--.... ~i ;J' ,,~ ~ ~' ~ ~ l1,~,'. ~ ~. ~ ~~ ~ STUPAK * 181-20-5726___~A'L__}._973 o CC-oo-oood...."'7~~.--._~~~-- ,/ SVG BONO I~~S" , 5-31-1973: a.TtHQ S'1".......,. " I , , 610~_ 3750 , , , , I \ , , , , 4030 SEMECA AVE CAMP HILL PA 11011 ~\I YAUDA TIN& STAMP rTI'T\..I: 0,. O,....'CE'" UNITED STATES SAVINGS BOND-SERIES E TERMS AND' CONOITIONS THIS BmID IS ISSUtD JlURSUAHT TO DEPARTME10IT OF THE TREASURY CIRCUUR NO. &53 III FURCI: all ITS ISSUE DATE. IT 15 SU80lECT TO THE TERMS ANa caNDmaNS OF THAT CIRCUUR AHll OF THE savUlIllIG RUUlAnONS (L... CIRCULAR lIa. 5301. 10lH AS CUR- IEIfTL T REVISED. AS FULLT AS IF IIEl1EIII SET FURm IT IS lIaT TIlANSf'ER':'LeJ AI1 MA 'f NOT IE IISED AS caUATEIlAL. THE ORIGINAL AHD EXTDIDEa MATURITY. ni'E lilvES'I'MEHT TID.D (IIClOESTI. THE IIITEREST ACJ:llUAL DATES. AHD THE REDEMPTIDN YAl,\/ES aF ,lHIS laND. WHICH ARE IlETERMlllED IT ITS ISSUE DATE. ARE SHOWN IN CIRCUUR .JI. &S3.i'HIS CIRCULAR IS AYAlLUU FIIaN AII'f FEDERAL RESUVE "UNit OR IRANCH. OR FIIOM THE IUIlEAU IlF THE l'U8UC DEBT.DEPAJrTMEMT OF THE TREASURT. WASHINGTON, D. C. ZDUS. IIlFOllMAnOIl AS TO THE CURREJIT REDEMPTlaN VALlIE OF THIS IOND MAT IE OBTAINED FIIaM JtKf F1IWIcw. II5T11UT1DM llUAUFlED Ta PAT SERIES E IOH!'S. U PAYMENT INF'ORMATION Pa'tMIIfT Of THIS _ MAr lIE OITAlI ;JJ lIT THE IWlISUlED DIIIIEIl (lr A JlATIIUI. PUSONIhJR EI'THEll _",.un TDCAfTDllWO ~ FIIlIM ISlIIlE DATE. '" .un 1oUIK. lIUSf CDMP.un. ASSQCIAnON. III DTHEII IIlSII1VrIlN 1lUALlllC0 AS A PATUIG A8EIlT. AlTER TIlt: _NTEI IIUl.Y EST_a HIS IllElmTT AIlO THEM SHillS Tilt: IllQUEST IlIR ""TMENT. PaTMEICT OF .un ;uJG , _a MAT ALSO IE OBTAINED fROM A _'iDU~ IlESER'If. IAIlIt DR ....NCH, DR TH( OffICE Df THE TREASUIIU Df THE: UIGl[Jl STATU.SEClIIIMS llMSIDIl. wASHlIGTDlL D. C. . ClISTOMEll Aa:r.lIa. A DATE ESTABUSHED 10Z2D. _II PIlUEIITA~ _ SUlllllNOtR Of Tm _ WITH l'H( 01nlER'S HOUEST llULr S1GIlEIl AND CUTlFlED. 1'1:_ AlllHDRIZEII TO CEIlTIN REDUESTS IlICLIIllE Dff1ClALS _ lIESI&IlATm EMP\JJTEES OF PAT11l8 A6DlTS. AND OF POST Dmca, IN CASE Of DlSA8lLlrt. IlEATH. ETC... OF A Il[GIS- 1EIlED DlNU aR 10TH C/1DWHEIl". AlMCE SHalLa lIE IlEDUunD FROM DH( 01 THE S UllCES cm:D A8lIY[ 8UtIRE THE lIEIIUEST FlIIl'"J1ATMCor IS EXECUTED. Iz.JlooaCJ D RECUEST FOR PAYMENT I AM THE QWNER OF THIS BOND. AND HEREBY REQUEST PAYMENT. ICITT. ..TATe. I CERTIFY 1lIAT THE ASOVE-HAMED PERSON. WHOSE IDt:NTlTY IS WELL- KNOWM 011 PROVED TO ME. SIGHED THE AIIDVE RmUEST 1M MY PRESENCE. ACXHOWLEDGING THE SAME TO BE HIS FREE.ACT AHD DEED. ON IIESD'IO FDR 1llEJmflCA~ _DTAT1DtlS . llDCUJoIElntsHlESl:llIPTIDN IDATe CJfI' ttCQuc.sTI OfFICIAL SEAl. '.'IIN..TU.C Q" O""'CJ;JlI DR . IDDtTIF1ED aT (ILU4E , ADOAEssl llESEllYEO FDIl S1GlIATUIlE OF PERSONAL lDElmF1Ell. If .un REV-1508 EX +(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Veronica J. Stupak SS# 191-18-0211 07/05/2004 21-04-0691 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ITEM NUMBER 1 DESCRIPTION Conseco Senior Health Insurance Company - Refund of Premium VALUE AT DATE OF DEATH 963.47 2 PNC Bank, N.A. - Checking Account No. 5003645093, date of death balance $5.00, accrued interest $0.00 5.00 3 PNC Bank, N.A. - Checking Account No. 5140063014, date of death balance $6,496.88, accrued interest $0.64 6,497.52 4 PNC Bank, N.A. - Savings Account No. 5003645237, date of death balance $899.41, accrued interest $0.00 899.41 5 Rite Aide Corporation - Pension Payment 106.46 6 Shippensburg Health Care Center - Refund 6,588.35 7 Contents of home and personal property hereto and incorporated herein Appraisal is attached 1,070.00 TOTAL (Also enter on line 5. Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 16,130.21 o PNCBAl\K September 29, 2004 Jennifer B. Hipp One West Main Street Shiremanstown, P A 17011 RE; Estate of Veronica 1. Stupak. deceased SSN: 191-18-0211 DOD: 7/5/2004 Dear Ms. Hipp: In response to your request for Date of Death balances for the customer noted above, our records show the following: Checking Accounts Account #5003645093 Established 04130/200 1 VERONICA J STUP AX. DOD balance: $5.00 + SO.OO accrued interest Account #5140063014 Established 09/0111968 VERONICA J STUP AX. DOD balance: $6,496.88 + $.64 accrued interest Savings Account Account #5003645237 Established 04/30/2001 VERONICA J STUPAK DOD balance: $899.41 + SO.OO accrued interest The decedent maintained Line of Credit (ReA #4003048002238082) for further information please call 1-888-762-2265. Select option 1, then option 3, and then 0 (zero) this will connect you to a Loan Service Representative. Page lof 2 Please note that this office only provides date of death balances for deposit accounts (IRAs, CDs, Cheeking and Savings accounts). We do not proeess any financial transactions or provide statements. If you need assistance with any of these items, please call1-888-PNC-BANK (1-888-762-2265) 01" stop by your local PNC Bank branch office. Sincerely, ~UWh Rachelle Wells 1~800-762-1775 P7-PFSC-04~F 500 first Ave. Pittsburgh PAl 5219 Page 2 of2 Member FDIC To: James D. Bogar Attorney at Law One West Main Street Shiremanstown, PA 17011 From: William G. Rowe, Appraiser 211 Old Stone House Rd. Carlisle. PA 17013 Re: Personal Property Appraisal Veronica J. Stupak Estate 4030 Senaca Avenue Camp Hill, PA 17011-6747 Date: October 6, 2004 LINDEN ~LL ANTIQUES 211 OLD STONE HOUSE ROAD CARLISLE, PA 17013 717-249-1978 LIVING ROOM Old T.V. Desk Sofa I chair - worn - no value Hide-a-bed - no value Coffee table Lamp stands Lamps Wall hangings / prints Knick knacks Music center - not working DINING ROOM Dining room set Lamps China Stemware Radio Knick knacks Cuckoo clock KITCHEN Refrigerator - old model Table 14 chairs Washer / dryer - old models Microwave - old Dishes / housewares Pots I pans I flatware Dishes Sweeper Bookcase in hallway BEDROOM File cabinet Lamps Stupak Appraisal $10.00 $20.00 $0.00 $0.00 $5.00 $10.00 $10.00 $15.00 $25.00 $0.00 $100.00 $10.00 $20.00 $10.00 $5.00 $10.00 $15.00 $10.00 $50.00 $30.00 $10.00 $10.00 $25.00 $15.00 $5.00 $10.00 $10.00 $10.00 1 - 10/6/2004 Small cabinet Upholstered chair - worn Hall bookcase Books $15.00 $0.00 $10.00 $10.00 BEDROOM Bedroom set Miscellaneous household Sweeper Portable potty $30.00 $30.00 $50.00 $5.00 BEDROOM Bedroom set Jewelry case Costume jewelry Miscellaneous household Wall hangings $100.00 $35.00 $35.00 $30.00 $10.00 OUTSIDE Picnic table - damaged Mower Garden tools Weed eater Spreader $0.00 $30.00 $40.00 $10.00 $5.00 BASEMENT Single bed Garden tools Workshop tools, etc. Hardware Hand tools Compressor Cart Stool $5.00 $20.00 $40.00 . $10.00 $15.00 $75.00 $5.00 $5.00 TOTAL $1,070.00 \......- 31.--< William G. Rowe - "j2- Stupak Appraisal 2 ~ 10/612004 REV-1509 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Veronica J. Stupak SCHEDULE F JOINTL V-OWNED PROPERTY SS1ft 191-18-0211 07/05/2004 FILE NUMBER 21-04-0691 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. A. SURVIVING JOINT TENANT(S) NAME Carol Ann Marshall ADDRESS RELATIONSHIP TO DECEDENT Daughter 6 Spruce Drive Carlisle, PA 17013 B. c. JOINTL V-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial Institution and bank DATE OF DEATH DECO'S VALUE OF account number or similar identifying number. NUMBER TENANT JOINT Attach deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTERES 1 A 02/13/87 New York Life Insurance 27,902.45 50.00% 13 ,951. 23 Company - Mainstay Account No. 43-79312637 TOTAL (Also enter on line 6, Recapitulation) $ 13 ,951. 23 T (If more space is needed insert additional sheets of the same size) DI The Company You Keep. www.newyorklife.com New York Life Insurance Company 26 Early Lane Annville, PA 1 7003-8623 Bus. 717 838-9691 Res. 717 838-0580 August 09, 2004 Henry J. Wagner Agent Jennifer B. Hipp: RE: Estate of Veronica J. Stupak Social Security #191-18-0211 Annuity Contracts #51 019 863 1158 008 714 #58 093 238 MAINSTAY Account #43-79312637 Jennifer B. Hipp Attorney At law One West Main Street Shiremanstown, Pa. 17011 Life Insurance Policy #42 627 457 With regard to your letter of July 23, 2004, we have enclosed the information on the above accounts as Mrs. Stupak was the owner of these accounts. The Mainstay account was owned jointly with her Daughter, Carol Ann C. Marshall. We will need the W9 form and a letter of instruction as to her plans to continue the account in her name. We will need three Certified Death Certificates for these accounts. There is also a Long Term Care Policy, number 252017 with CONSECO Senior Health Insurance Company with the premiums paid to September 3, 2004. The address is: CONSECO SENIOR HEALTH INSURANCE COMPANY 11815 N. Pennsylvania St. Carmel, Indiana 46032-455 Tel: 1-888-754-3401 Please return the above requested forms to our office to h~ve processed...... should you have any questions, do not hesitate to give our office a call. Sincerely, ~d P. f{:-~--<-- Henry J. Wagner HJW / jww Enclosures ......FE for Financial Products & Services Registered Representative for NYLlFE Securities Inc. Member NASD/SIPC 3401 North Front Street Harrisburg, PA 17110 717 232-2555 New York Life Insurance Company New York Life Insurance and Annuity Corporation III nOlllllAllllrO rl"lrl"lnrlllti,.,nl :~&fMIIJI~~j~~@~;r~~~~~ilIIIjmim~~]Im~~~jmiIm:j~if~~fnn:i~I:i~mrifMN$Wj&lFmmV~J5.i::Eb.R6.s.m@@~~il~WB~~ml~iliI@~@il~ilt~~:Ii:@@~mi~Iii~II~:j:~I~iiimmi:~m:~:~~i Tax Identification Number: 191-18-0211 Valuation Date: 0713012004 . [m5.iTiQmQ.::~\%1ili1~1i~~i1111ili~m:~:1:]1:1:[1m::~~~1:]:)~:1~1I~:I:1~:~~:::1:1ml~:I:1mH~tI~t11l:Imm:)::~:I:::;:::tUiI~:::ii~::::]):~:~iit~l::i:1I~:I1:I1)[[1i)1:l1i::):i:~::Il:~~miilml:l~:iim::~:::: ::;:~~~~Iiii:tm~:~:::l1:::1;:~~ Rezistratlon: Veronica J Stupak Carolann C M&rshaII Jt Wros 4030 Seneca Ave Camp Hill Pa 17011-6747 Account # Fund Date Est. Total Shares Price Account Value 79312637 High Yd B 02/13/1987 4,536.9830 6.1800 28,038.55 Total Portfolio Value: 28,038.55 {Xeaatiif~:aPiiQN$.:m~~:mm\::~f~:~~l%::::~:Im~~III~II:ItIIIIil:ErI;~IIIIIiHrrr:I:i:Ir:~r:;I~irFrIiII1ImIl:~II~II:IIIIIJ~i::~:I::::~~:~::EEJ:I{l{{I::t:JIIIIIIImI:~::~11::::1:~ Rezistratlon: Veronica J Stupak. . ................................ Carolann C Marshall Jt Wros 4030 Seneca Ave Camp Hill Pa 17011-6747 Account Nwnber: 79312637 Fund: HIZb Yd B OPEN 05/01/1923 CASH REINVEST NO Automated Clearing House: Listbill: Expedited Redemption: Expedited Exclw1ge: Certificates Issued: Pre-Au1borized Checks: Letter of Intent: Systematic Withdrawal Plan(SWP): Beneficiary Name NO NO NO YES NO NO NO NO Account Status: Date of Birth: Dividend Option: Capital Gains Option: Check Writing: Rights of Accumulation: Letter of Intent Amount: Account Type: Relationship JOINT TENANTS Deslznation Carolann C Marshall Jt Wros 4030 Seneca Ave Camp Hill Pa 17011-6747 Account Nwnber: 79312637 Contributions Current Year Prior Year Fund: High Yd B Year To Date Summary CurrentYear PriorYear Employee: InterestlDividends: 960.96 2021. 72 Employer: Short Term Capital Gains: Long Term Capital Gains: Total: 960.96 2,021.72 Dividends Reinvested to Account Number: i:i:XaCaQNil~Xerio.Ns::mn]~~:tt~:~:]n:::~:in::::n:~:]~~:ttt]r:::::ttttt:rrrrr:ttttt]r:ttttt]r~]~:~:ttl:r~]:::]:]:::]r:tt]r:~:t::]~::]~~:t~:ttt~:t]ir:::It]:]:It]:]lirrI:]::;~:U:::~:~:~r:]r:~:~:i:~r:]r uu:::]UUUr Rezistratlon: Veronica J Stupak ..................................... Carolann C Marshall Jt Wros 4030 Seneca Ave Camp Hill Pa 17011-6747 Account Nwnber: 79312637 Trade Date Transaction Fund: HIZb Y d B Shares Price Total 06130/2004 OS/28/2004 04130/2004 03131/2004 02/27/2004 01130/2004 12/17/2003 11/28/2003 10131/2003 09130/2003 INCOME DIV 0.0353 CASH INCOME DIY 0.0353 CASH INCOME DIY 0.0353 CASH INCOME DIV 0.0353 CASH INCOME DIY 0.0353 CASH INCOME DIV 0.0353 CASH INCOME DIY 0.0353 CASH INCOME DIV 0.0353 CASH INCOME DIY 0.0353 CASH INCOME DIV 0.0353 CASH 160.16 160.16 160.16 160.16 160.16 160.16 160.16 160.16 160.16 160.16 A/llrrlnMM:liotll ",../161..1. Account value on July 5, 2004 $27,902.45. Securities distributed by NYLIFE Di.tributon Inc., mcmberNASD IMPORTANT INFORMATION: This is not the official MainStay confinnation. All informalion is .ubject La verification. Valuations are based on the prior day'. closing price. Shares may be subject La Contingent Dcfcm:d Sales Charges upon redemption. Printed On: 0713012004 Page: 1 REV-1510 EX +(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Veronica J. Stupak SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY SSf! 191-18-0211 07/05/2004 FILE NUMBER 21-04-0691 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes. DESCRIPTION OF PROPERTY %OF ITEM RELAW8~M~I~ t~b~~~5~Ur~J~~~1fA~~~~ t~XWSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE NUMBER ATTACH ACOPYOFTHE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) 1 New York Life Insurance 122,798.38 122,798.38 Company - Annuity No. 58093238, date of death value $122,798.38 2 New York Life Insurance 179,373.90 179,373.90 Company - Annuity No. 58008714, date of death value $179,373.90 3 New York Life Insurance 100,694.24 100,694.24 Company - Annuity No. 51019863, date of death value $100,694.24 TOTAL (Also enter on line 7, Recapitulation) $ 402,866.52 (If more space is needed, insert additional sheets of the same size) II The Company You Keep. www.newyorkliie.com New York Life Insurance Company 26 Early Lane Annville, PA 17003-8623 Bus. 717 838-9691 Res. 717 838-0580 August 09, 2004 Henry J. Wagner Agent Jennifer B. Hipp: RE: Estate of Veronica J. Stupak Social Security #191-18-0211 Annuity Contracts #51 019 863 #58 008 714 #58 093 238 MAINSTAY Account #43-79312637 Jennifer B. Hipp Attorney At law One West Main Street Shiremanstown, Pa. 17011 Life Insurance Policy #42 627 457 With regard to your letter of July 23, 2004, we have enclosed the information on the above accounts as Mrs. Stupak was the owner of these accounts. The Mainstay account was owned jointly with her Daughter, Carol Ann C. Marshall. We will need the W9 form and a letter of instruction as to her plans to continue the account in her name. We will need three Certified Death Certificates for these accounts. There is also a Long Term Care Policy, number 252017 with CONSECO Senior Health Insurance Company with the premiums paid to September 3, 2004. The address is: CONSECO SENIOR HEALTH INSURANCE COMPANY 11815 N. Pennsylvania St. Carmel, Indiana 46032-455 Tel: 1-888-754-3401 Please return the above requested forms to our office to have processed...... should you have any questions, do not hesitate to give our office a call. Sincerely, .~9~~~ Henry J. Wagner HJW / jww Enclosures IlVUFE for Financial Products & Services Registered Representative for NYLlFE Securities Inc. Member NASD/SIPC 3401 North Front Street Harrisburg, PA 17110 717 232-2555 New York Ufe Insurance Company New York Life Insurance and Annuity Corporation fA Delaware Corporation) Policy Date: OS/26/1998 Owner: Veronica Stupak Policy Status: Premium Pay Plan: Lifestages Variable Annuity-l Prepared On: 07130/2004 Tax Status: Non-qualified Im;ficy~y_:_y::i!:!m:fII[~:@!:::i[![iII:iI:i[i::U:[~::l::[~:@::iU~:i:f:~~lII!:II!:::~::Ut::::[[:~:I!ml:!t:~::~:[::~:~::::[!:i:i::~i::i::~::::::[![::):::!:!:~t~[:::::[:j[:[:::[~::::[llf!:~:I!:!:it[[:! lfII!tm~[i~!:f[~~f[i~tit:f@~[it~tm[:[~:::~lll~[::~:::i::g .. .... Total Current Values Basis and Gain Infonnation ... ...... . .... .. . Quote As Of: 07130/2004 Pre- TEFRA Cost Basis: .00 Accumulation Value: 122.557.81 Post-TEFRA Cost Basis: 75,000.00 Surrender Charge: .00 Total Cost Basis: 75,000.00 TSA Loan & Interest: Federal Taxable Gain: 47,557.81 Net Surrender Value: 122,557.81 State Taxable Gain: 47,557.81 Surrender-Free Window Surrender Free Window: Amount Used: Amount Remainin:: 0.00 23,411.04 ImmnmMHD.eONEBiTAIiilis.H1:I::IIjH::H[::::::~:::~:[HHH[I~:[::~:[:::~I:I[1:[:I::IIIII::[:::::::::m::[:[[:::[:~~:::[::::[I[ImIII:::::::::[III[:I:~~:II:I:II:::::~:III:1::~H~I[:~m[:::::~:[[II:~:[::~1m~mH I1iII Quote As Of: 07/30/2004 Net Surrender Value: 122,557.81 Total Accumulation Value: 122,557.81 Investment Option Account Value MAINSTAY VP S&P SOO INDEX MAINSTAY VP HIYLD CORP BOND ACCOUNT MAINSTAY VP VALUE ACCOUNT I-YEAR FIXED ACCOUNT 19,440.59 42,633.50 20,679.87 39,803.85 tiiiMiU$.i:s.~yI::I:f::~~::[:~:f[I:~[[[[:::[::::I:ff::[:~::I:[:f~~~r[~}f:rr[f~[r::I:~::r::~:::r::::::r[::[:}fff}fff::}}ff:r:::f~:~f[r::r:[:::f}fff}fI:r::II[[::::r[ff}ff::~r:[:}:rrI:[r:::f[:f:::rI[~:: ::::[:m::fff:::[f: Premium Mode: Total Premiums Paid: 99,146.77 Premium Amount: Extra Credit Amount: .00 Last Premium Activity: Total Withdrawals: .00 Paid To Date: TSA Quarterly Loan Repayment: Next Bill Date: IiRiMIDMIALLoCinoN:DE.TAmS~t::::[:::I:I[~[:[::II:mII:::::[:::::I:::I:IIIII[:t~:~:I:)m::::~::::::[:I[:I~:[::::~:I[:~H:~I:IUI[:::II::[~III:[::UI:I:::::[:[I:::III[:tII[:H~l::[:~:::~:~I~~::::::~[:~:t[:I: :I::II[:H:[l~ . InvestmentOption.... .... . ...... .... .. Allocation O/e .. . ... ... .. I-YEAR FIXED ACCOUNT 30.00 MAINSTAY VP S&P SOO INDEX 20.00 MAINSTAY VP HIYLD CORP BOND ACCOUNT 30.00 MAlNSTAYVPVALUEACCOUNT 20.00 timnatti&:la.ET*ms.I:::[r[:::I::[f::f::~::[[:::::::[:f[rr:[::::::[:r:::[::::~:r:IIIIIII::[rr::::[:::::[IIfII~::[:Ir:::::II::I:I:IIIIfIIfII[:~r:~::r:::IItf:::::I::::::::II:[:ffIf:II::[f[IrI[ffff[rI:~: f:rrr::m:[:[:[:I:~[: As Indicated In The Application File. Contact The Variable Products Service Center For More Infonnation ClientID: 003967385 HouseHoldID: 9811100007929331 Sex: F Address: 4030 Seneca Ave Phone: DOB: 05/01/1923 Camp Hill, PA 17011-6747 Henry J Wagner Tnn-rta 100% Harrisburg 092148 717-838-%91 Policy Receipt Date: 12/31/1998 Commission Option: 01 $ 99,146.77 was a 1035 Exchange from Annuity number N3 157 332 which had an Investment of $ 75,000.00 opened 05/08/91 $ 122,798.38 Cash Value 07/05/04 These are not the Final Figures only Estimates. ISSUED BY NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION DISTRIBllTED BY NYLIFE DISTRIBllTORS INC. (MEMBER NASD) The informalion contained hen: is as of the prior business day's close ofbusincss. This report is not the official record of your policy. All information contained hen:in is subject to verification of the issuer against ils official policy records. If you have questions about your policy, please contact your registered representalive or call our Variable Product Service Center at 1-800-598-2019. Printed On: 0713012004 Page: 1 Policy Date: 06/06/1996 Owner: Veronica Stupak Policy Status: Premium Pay Plan: Lifestages Variable Annuity-I Prepared On: 0713012004 Tax Status: Non-qualificd rimICii;y6Ei:~i:i:f:!!!:))):~i:)ml)I~~!r):~ffil)!~;f)~il;Ii))~:frm:tll)tII~)i;):tI:i:iI)ltm!)ilii:)!i);::;:t:;::::~:::!;iii;t:::::::ii::;:::))~:f;:)i~:);f)!~rit:i~t:::r:JJtI::IIlrII:IIl1:)i:~:~::i):I :i:;I!::!i:I))ll:I!III))lI!:)II!Jl Total Current Values Basis and Gain Information ..- ....................................... Quote As Of: 07130/2004 Pre- TEFRA Cost Basis: .00 Accumulation Value: 178,129.73 Post-TEFRA Cost Basis: 76,480.05 Surrender Charge: .00 Total Cost Basis: 76,480.05 TSA Loan & Interest: Federal Taxable Gain: 101,649.68 Net Surrender Value: 178,129.73 State Taxable Gain: 101,649.68 Surrender-Free Window Surrender Free Window: Amount Used: Amount Remainin:: 0.00 60,944.97 flN.yiSimNT:D.MSlo'!ft9I"I!j~jji):IIIIIIIIiII:III)iim)'I:I;):II!'Ii!II):IIi!I):IIiI;i:':mI1I):iiI)I:;:):I):IIiiIII:I;)mI:iIi:)IiI):iIII;'i:iI:IIiIIIImiIi!Im!~:::!IH) Net Surrender Value: 178,129.73 Total Accumulation Value: 178,129.73 Investment Option Account Value MAINSTAY VP CAP APP ACCOUNT MAINSTAY VP S&P SOO INDEX MAINSTAY VP BOND ACCOUNT MAINSTAY VP HIYLD CORP BOND ACCOUNT MAINSTAY VP VALUE ACCOUNT 27,122.n 37,328.43 17,076.79 62,378.50 34,223.24 tp:ii$mif:~):Ii)IIil:I:II::mliIii!]lIIII:IIIII:IIIIIIIIIIII::;::;~:::::iiI:;):):Ii;:;:;:;;!i:::::::iI:IiiIIIIIII):II:II'II:::'I);;I:II)I:IIiIIiI:)II'i):III::lII:I:i:)i::;IIIIIImIIm:]l Premium Mode: Total Premiums Paid: 117,184.76' Premium Amount: Ell.1ra Credit Amount: .00 Last Premium Activity: Total Withdrawals: 3,135.00 Paid To Date: TSA Quarterly Loan Repayment: Next Bill Date: MAINSTAY VP CAP APP ACCOUNT 20.00 MAINSTAY VP S&P Soo INDEX 20.00 MAINSTAY VP BOND ACCOUNT 10.00 MAlNSTAYVPHIYLD CORP BOND ACCOUNT 30.00 MAINSTAY VP VALUE ACCOUNT 20.00 Ii.aei.XR&JfiExAmi:i:::::ir::i::i:r:tt:::i::::!i:ir:::::::i:::i::~:::::::::::::::::::::~;::;:r::I;:::;i:i::::t:::I::::;:;::::lirri:;:;rI:r:::~:;:!;:::;::I:~:r;::::!:::::::;;:;:::::::::;:!I:rr!i::::;i ;;:;i::::;::r::;;:;IiI;::i!::::;;::::::::i::::::ri:::::i::;;!::;::::;::i!::::::::::;;i;i!tr::II~:;i:::i:;:::::::::;::::::;;:;:::::r;i:::::iI As Indicated In The Application File. Contact The Variable Products Service Center For More Information I:cme;mQmTIB.N:::ii:i:)::r:;;:::rI:IIl!:i;::::ij:::~:;:::::::;:::;irr::;:::::::~i:::):i:::::::r:r:::::ir:::II:i:l:::rIrr::::::::~:::~::I:r:;':r:::::i::::~:::::;::::::::::ir:::i::r:ri::r;:::!:I::::!!: ::::::::::::::::~;:;::rr:::::r:::rI:t::::::::::::::::::;i::::i::::r::i:::::::i:r::i::~:::::::::::::;IIIt:;~ Name: Veronica Stupak Role: OWNER/ANNUITANT SSNlTax ID: 191-18-0211 Client ID: 003967385 HouseHold ID: 9811100007929331 Sex: F Address: 4030 Seneca Ave Phone: DOS: 05/0111923 Camp Hill, PA 17011-6747 Henry J Wagner Trm-rta 100% Harrisburg 092148 717-838-9691 Policy Receipt Date: 06130/19% Commission Option: 01 $ 117,184.76 was a 1035 exchange from Annuity number N3 157 332 which had an Investment of $ 75,351.70 opened 05/03/89 $ 179,373.90 Cash Value 07/05/04 $ 180,505.47 Death Benefit Reset Value These are not the Final Figures only Estimates. ISSUED BY NEW YORK UFE INSURANCE AND ANNUITY CORPORATION DISTRIBllTED BY NYLIFE DISTRIBlll"ORS me. (MEMBER NASD) The information contained here is as of the prior business day's close of business. This report is not the official record of your policy. All information contained herein is subject to verification of the issuer againsl its official policy records. If you have questions about your policy, please contact your registered representative or call our Variable Product Service Center at 1-800-598-2019. Printed On: 0713012004 Page: 1 (:~\!~mMt\~t1wi1J:~mti:;:\:HII::;!fdmm@imm!IMjMIiifiIliiIi:t:iim~~mMit:t:trmmm::m_~m!::mi:!Imm;j:::ak~~~~~~~~~~~ili~l~~~~~~~~~~~~~~I~~~~~~i~~~~Il~i~~~~~~~~~~~~~i~~~~i~~~~tf~i~~~~~~~l~fi~~~~~~~~~~~~t~ t&~~fj~f~~~~~~ll~~~~~~~ Policy Number: 51019863 Annuitant: Ms Veronica J Stup Policy Date: 12/22/1994 Owner: Ms Veronica J Stupak Policy Status: Inforce Plan: Single Premium Retirement Annuity - 2e Prepared On: 0810512004 Tax Status: Non-qualified tmmaf.1mSS~GEs~::jHi::::M~~H;Il:!:i\@J!:!~\\:!;::!r::\!!!\~:H:::llr\::::!:!l\m!I:H:;l~I!:::I!l:::In:;i[@[:;mm::m:::::::tm:m[:mm~:mt~\t~~:@r~i@)\;\:@;Mmn:m!@;@W;HiI;;l~~[:m::j::@II:rMMl:!im[!:1:~: 1) 825-33 POLICY 'RECEIPT RECEIVED OAS ::~maIDi~yrmm;:$_~m~:\:!,!,::!,f,@\))Ir:::~Il:::~1:~f~~:~~:~:!1l:~m:):!l\Itm:l:)1:::!:!:)!!::\:~~il~:::::~::~:rit\:\t:::1::;:1:11::::l~:::::::m:'~:::t~::::~!~t:j:~:Ni.iI~:ml::;llj1lr~~~!\:\m~)ml:[tl~ mmmlm!\!~i:Ilf:::!~~:1:::1!I~~:;!::::~: .... . Total Current Values Basis and Gain Infonnation .. ...... ..... . ..."...." """. Quote As Of: 08105/2004 Pre- TEFRA Cost Basis: Accumulation Valuc/Death Benefit: 100,936.38 Post-TEFRA Cost Basis: Surrender Charge: 0.00 Total Cost BasIs: TSA Loan & Interest: Federal Taxable Gain: Net Surrender Value: 100,936.38 State Taxable Gain: 46,006.81 46,006.81 54,929.57 54,929.57 Surrender-Free Window Surrender Free Window: 100,936.38 Amount Used: .00 AmoWlt Remainin:: 100,936.38 Premium Amount 73,833.99 Extra Credit Amount: Last Premium Activity: 12128/1994 Total Withdrawals Current and Prior Year: Paid To Date: TSA Quarterly Loan Repayment: Next Bill Date: I::ii{i~:)iETm:\:::::\!;\::!\~1:!\!;M::::::nl~:r;r:::::!:::mmm::mr:::~![::!;:!rI:W~:I~~0::i[l:Il:[:~:[m\::::l.f:Mttrl:fI:Ii:f:lrJ[i@I!l:~:~:~J!H~n:~:):11\::1:1;I:::!::II:@l::~:m:li;;::I::::~:!Im::mmm M~rti:t.ll.!~[::JiMI~i Policy Date: 12122/1994 Premium: 73,833.99 Additional Premiums Cash Value as or 0810512004 Current %: 3.00 Source Date AmOWlt Current e;. tiSi.aCfAiitiiExAnf$.I:~tijtm::~:::~[:mil!t~m::mt::I:m:;lm:mMm:~!:!~!:l:~~rll:~:::~l:::!:::::::mi:::!:~~!!::r:!:r:!:!!!:m::::::::!:::r::::l!~rm::m~:::t:::i~mj~:IIj:r@t:::::~[@::I~I:::t::::\g:limm:::; ::m::ml:li@\[iK@!~I%lII~l:~m Ist-<:arol A.marshall Dghtr Rev. Nicole M.& Jesse C.grandchlm ~ Ist-acc To Foil Provisions:, Trstees Last Witl Dtd 070887 ICniEN.T:lN'F.OmTIQN1I:1::@~:lm:!I:I~1:::;:!:!:!:!i:r:::::!:r:r:f::::!I:::!:!:::!:!:r:!:!:::~!:!I:!:::I!:!::i::::l:~::!;nI:::t::[I~ff[mr:rtm~~ml.::::I:!~j:j::::::l:::::~I:::::1m:::~:I:~::rm!~:~m:1mr: I~lill;Hr:@W;::~1iI~~~:~:::!!:!!:m1::::::1::n::!:!:!~fmm!if Name: MsVeronicaJStupak Role: OWNER/ANNUITANT SSNlTaxID: 191-is..o2iT""'"'' Client ID: 003967385 HouseHold 10: 9811100007929331 Sex: F Address: 4030 Seneca Ave Phone: DOB: 05/0111923 Camp Hill, PA 17011-6747 Henry J Wagner Original Trm-rta 100%. Harrisburg. 092148 717-838-9691 Policy Receipt Date: N/ A Commission Option: 03 $ 73,833.99 was a 1035 exchange from Annuity number 52 564 061 which had an Investment of $ 50,000.00 opened 11/14/86. $ 100,694.24 Cash Value 07/05/04 These are not the Final Figures, only Estimates. NEW YORK UFE INSURANCE AND ANNtJITY CORPORATION (A DELAWARE CORPORATION) Values reflect transactiolll proc:cued by the Company up to the"A$ Of" Dale. Values may vary due to W\pnlCcssed transactions. For further details, call your New York Life Agent or your New York Life Service Center. Printed On: 08/0512004 Page: 1 REV-1511 EX +(1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Veronica J. Stupak SSlft 191-18-0211 07/05/2004 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s) I EIN Number of Personal Representative(s) Street Address City State Zip B. 2. 3. 4. DESCRIPTION 1 FUNERAL EXPENSES: Four Seasons Florist - Funeral Flowers 2 Michael P. Glinsky Funeral Home - Funeral 3 Red Lobster - Funeral Luncheon 4 Snyder Granite Company - Headstone Year(s) Commission Paid: Attorney's Fees Jennifer B. Hipp Esquire 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 Probate Fees Register of Wills 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1 Comcast - Cable Bill-Final 2 Linden Hall Antiques - Appraisal Fee 3 Pennsylvania American Water Company - Water Bill-Final 4 PPL - Electric Bill-Final 5 Recorder of Deeds - Recording Deed and Statement of Value 6 RESERVES: Costs to conclude administration of Estate including filing fee for PA Inheritance Tax Return, Inventory and First & Total of Continuation Schedule(s) FILE NUMBER 21-04-0691 AMOUNT 450.50 7,109.00 165.00 485.00 8,695.00 275.00 35.85 65.00 42.87 69.24 39.50 850.00 135. 72 $ 18,417.68 TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insert additional sheets of the same size) Estate of: Veronica J. Stupak Soc Sec #: 191-18-0211 Date of Death: 07/05/2004 Continuation of Schedule H-B7 (Other Administrative Costs) Item II Description Amount Final Account; preparation of Personal and Fiduciary Income Tax Returns 7 Verizon - Telephone Bill-Final 135.72 135. 72 REV-1513 EX +(9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIAR IES ESTATE OF Veronica J. Stuoak SSII 191-18-0211 07/05/2004 FILE NUMBER 21-04-0691 RELATIONSHIP TO DEC~DENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116(aXl.2)] 1 Carol Ann Marshall 6 Spruce Drive Carlisle, PA 17013 Daughter Rest, residue and remainder ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) 0.00 LAST WILL AND TEST~~NT OF VERONICA J. STUPAK I, VERONICA J. STUPAK, of Camp Hill, Cumberland County, IPennsylvania, declare this to be my Last Will and Testament, and revoke any and all Wills and Codicils made by me. ITEM I: I direct that all my just debts and funeral expenses, including my grave marker and all expenses of my last illness, shall be paid from my residuary estate as soon as practicable after my decease, as a part of the expense of the administration of my estate. ITEM II: I give, devise and bequeath the rest, residue and remainder of my estate of every nature and wheresoever situate to my daughter, CAROL ANN MARSHALL. In the event my daughter does not survive me, I give, devise and bequeath the rest, residue and remainder of my estate of every nattire and Iwheresoever situate in equal shares to my then living IgrandChildreni PROVIDED, that if any grandchild entitled to jdistribution shall be under age twenty-seven (27), the share of i Isuch beneficiary shall be held by the Trustee, hereinafter named, IN TRUST, for the following uses and purposes: A. If the beneficiary is under age eighteen (18), to expend and apply so much of the net income (any income not 'expended or applied to be accumulated and added to principal) and so much of the principal of each trust as the Trustee, after I I II consultation with the guardian of said beneficiary, shall consider advisable for the support, maintenance and education (including college education, both graduate and undergraduate). B. After the beneficiary attains the age of eighteen (18)! thereafter to pay to such beneficiary the net income together with so much of the principal thereof as Trustee shall consider advisable for the support and education (including college education, both graduate and undergraduate) of such bene- ficiary, after taking into consideration his other readily avail- able assets and sources of income. c. Up to thirty-three and one-third (33-1/3%) percent of the then-remaining principal and accumulated income at age twenty-one (21) on the request of the child shall be distributed ) to that child at or after age twenty-one (21)i an additional Ififty (50%) percent of the then-remaining principal and accumulated income at age twenty-four (24) on the request of the child shall be distributed to that child at or ~fter age twenty- four (24)i and up to the entire balance of principal and accumulated income then remaining on the request of the benefic- iary shall be distributed to that child at or after age twenty- I seven (27). Distributions at or after these stated ages shall be made only in the event the child requests such distribution by a writing intended to take effect during his lifetime, executed by that child upon or after attaining each of the stated ages and delivered to the Trustee. 2 I ITEM III: All Federal, state and other death taxes payable !because of my death with respect to the property forming my gross :iestate for tax purposes, whether or not passing-under this Will, !inclUding any interest or penalty imposed in connection with Isuch tax, shall be considered a part of the expense of the ! jadministration of my estate and shall be paid out of the residue I 10f my estate, without apportionment or right of reimbursement. IT~~ IV: I appoint CCNB BANK of New Cumberland, Pennsyl- vania, to serve as Trustee under this Will. ITEM V: I direct that no executor or trustee or their successor serving hereunder be required to post bond or enter security in any jurisdiction. IT~~ VI: I appoint CAROL ANN MARSHALL of Carlisle, Pennsyl- vania, Executrix of this my Last will. Should CAROL ANN MARSHALL fail to qualify or cease to act as Executrix, I appoint ALLAN STEPKOVITCH of Jermyn, Pennsylvania, Executor of this my Last Will. ITEM VII: I appoint CAROL ANN MARSHALL guardian of the estate of my minor grandchildren. In the event that said CAROL ANN MARSHALL fails to act or ceases to serve as guardian, I appoint ALLAN STEPKOVITCH guardian of the estate of my minor grandchildren. IT~~ VIII: I direct my personal representative to employ HOWARD B. KRUG as attorney for my estate. This provision 3 I I I~s made solely at my request and without urging or suggestion by IFhe said HOWARD B. KRUG. i I Ilthis II I IN WITNESS WHEREOF, I r day of 0t.,/Y / / have hereunto set my 'hand and seal , 1987. I I The preceding instrument, consisting of this and seven other typewritten pages, was, on the date thereof signed, published and declared by VERONICA J. STUPAK, the Testatrix therein named, as and for his Last Will, in the presence of us, at her request, in his presence, and in the presence of each other, have subscribed our names as witnesses hereto. d (-;' i~' . , :" ....,. _ I ;/J- j. I '...:V'-4'-"~.-LlJ' ,,/~/~ (SEAL) VERONICA J. STUPAK ;; " " i ': /' . i . (Ir; , 1. /,: /1 / J' I f...11 , /, J '/0-' i Ii l;t, - ,fy J / " /. v ~ 'I' , ._{A. '-- l...- residing fl ,~ '. , i in j I,ll} i Y' .' ili'~ /'1/ j'l/ at ,/,1 L. ..,' t LJ '1/' roLe.!.."...", (-.l T/" 1-'t)/hIL, /) I j I' I I /}. -, 1/", / r, ,-{ . I' . r I t 1 :___ ~f t I l' .. /1" res i ding at C//1 /r '.,.,.;,,'/Yi> r. rl/ ,,' \.J 4 bO~10NW~ALTH OF PENNSYLVANIA I ,COUNTY OF DAUPHIN '! ss: ,f il I , ',I .' '. Ii ,.Llf'''; hi //'; 1;1/'""1/.' ..'" :1 / :lrespecti vely, whose names are signed to the attached or fore- IlgOing instrument, being first duly sworn, do hereby declare to jthe undersigned authority that the testatrix signed and executed Ithe instrument as her Last Will, and that she had signed willing- Ily and that she executed it as her free and voluntary act for jthe purposes therein expressed, and that each of the witnesses, I lin the presence and hearing of the testatrix, sLgned the will as I II itnesses and that to the best of their knowledge the testatrix Iwas at that time eighteen years of age or older, of sound mind , I and under no constraint or undue influence. WE, VERONICA J. STUPAK, 'i / -\/~_'i':- /,' -(1;Z1-~1. -4- ;}. J j. 7. ). 1:... I .-e./ t:' _ ~. 1(;. 6...L.L~U' ~nd / / ..; , the testatrix and the witnesses, d~~o...~ VERONICA J. STUPAK ; /; -/i;1 t j I j /j I ~.J ,J! :'",'" ~~ ,,:"! / / f..__' / I...~' r /' _ .-' /./~ "~_~~:.., Wi tness /1 ~' /! .' ..11, ,~,; ~ i ~It ' Wi tness{ i.I /11'~ ~ nJ:;i....:.;t r "Le. Subscribed, sworn to and acknowledged before me by VERONICA J. rTuPAX, the testatrix, Ct4vf'dL ,4, t[l~ witnesses, this ~ and subscribed and sworn to before me by and 'V1 \ / ;4 f / .., \ .. ~J , 1987. ,P( (! / 'I ' ~~, Lfj/ ?a~ Notar-3y' Public, 'Z, .,~ '}. ~I,,(',jTAi\i rui;.. I J"'''~' H' \ J MOl 1'., "'.~o:._,. '-....:~s ~a!)t. 4. l~ day of BUREAU OF INDIV~,j'AXE'V T'r;:: INtERITANCE TAX 01\'.1'$10.1.'; ':,,_<'. ,>__'L PO BQX 280601 HARRISBURG PA 17128-Q6Ql~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEKENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ....n"t' ....,.''! ""'0 LLf,~0 t'l.i f L Pli i2: l.2 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 05-16-2005 STUPAK 07-05-2004 21 04-0691 CUMBERLAND 101 Amount Reni tted C E~'/ ~~ I c" ,'c L l ):~, \.). ~R~H" ,,~ {'(V"'T JENNU ;,B:)'tlRi?'.t~; 1 W M 'ST SHIREMANSTOWN PA 17011 *' REY-lS47 EX AFP (03-05) VERONICA J MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ I1n~-.t!C,.'ft.~.'r1f!~1.'MI1tWJ!.!II!'.!WtA'rf4M!'t.'IW.lWl1lTftMMf~.'ll'C[W4M:'\!'.lITt.............. ... DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF STUPAK VERONICA J FILE NO. 21 04-0691 ACN 101 DATE 05-16-2005 TAX RETURN WAS: I X) ACCEPTED AS FILED ) CHANGED I~ an assess.ent was issued previously, lines 14, IS and/or 16, 17, 18 and 19 will reflect ~1gures that include the total ~ ~ returns assessed to date. ASSESSMENT OF TAX: 16. Aaount of Line 14 at Spousal rat. (15) 16. ~ount of Line 14 tax8ble .t Lineal/Class A rat. (16) 17. AIIount of Line 14 .t Sibling rat. (17) 18. Amount of Line 14 taxable at Collateral/Class Brat. (18) 19. Principal Tax Due RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule AJ 2. Stocks and Bonds (Schedule B) 3. Closely H81d stock/Partnership Int.rest (Schedule C) 4. Hortgage$/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property ISchedule F) 7. Transfers (Schedule SJ 8. Total Assets III (2) (3) (4) (5) (6) (7) 106,349,10 9.122,84 ,00 ,00 16.130,21 13.951.23 402,866,52 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adn. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governnental Bequestsi Non-elected 9113 Trusts (Schedule JJ 14. Net Value of Est.t. Subject to Tax (9) 110) 18,417,68 .00 Ill) (12) 113) 114) NOTE: .00 530,002.22 .00 ,00 x 00 = X 045 = X 12 = X 15 = NOTE: To insure proper credit to your account, ~it the upper portion of this for. with your tax p.~nt. 548,419,90 lA.~17 liB 530,002,22 ,00 530,002,22 119)= ,00 23,850,10 ,00 ,00 23,850,10 TAY CR"nIT!I: ,?, AKOUNT PAID OATE _BER INTEREST/PEN PAID 1-) 10-05-2004 CD004467 1,174.08 22,307.55 02-23-2005 CD004979 .00 368.47 TOTAL TAX CREDIT 23,850.10 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 ~. IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALtULA TION OF ADDITIONAL INTEREST. IF TOTAL DUE IS LESS THAN $1, NO PAVIlENT IS REllUIRED, IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YOU KAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORK FOR INSTRUCTIONS,) STATUS REPORT UNDER RULE 6.12 Name of Decedent: Veronica J. Stupak Date of Death: July 5, 2004 Will No. 21-04-0691 Admin. No. Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes XX No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes No XX b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes XX No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Cerk of the Orphans' Court and may be attached to this report. i' r- 0.j ~\.~ ~re Jennifer B. Hipp, Esquire Name (Please. type or print) One West Maln St. Shiremanstown, PA 17011 Address Da te: ~ -l"l"'O Co) ...-.::. N (17) 737-8761 Te 1. No. '--.- i,..__ Capacity: Personal Representative (MAH:rmf/AM3) x Counsel for personal representative %