HomeMy WebLinkAbout03-04-11 (2) 1505610101
REV-1540 Ex `01 .1°' *'
PA Department of Revenue Pennsylvania OFFICIAL USE ONLY
Bureau of Individual Taxes OF.v~P1MENi OF Hf~FNUF County Code Year File Number
INHERITANCE TAX RETURN
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PO BOX 280601 '
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Harrisburg, PA 1128-0601 RESIDENT DECEDENT .
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ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
105-42-8672 12/06/2010 12/29/1950
Decedent's Last Name Suffix Decedent's First Name MI
PEARSON LAVONNE R
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
N!A
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
t»)b 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death
prior to 12-13-82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT - PHIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
Andrew H. Shaw, Esquire (717) 243-7135
.,
First line of address.
200 S. Spring Garden St
Secand line of address
Suite 11
Cit or Post Office State ZIP Code
REGISTER OF WIC ~E ONLY
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DATE Ft¢~D
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Carlisle PA 17013
Correspondent's a-mail address: andrew@ashawlaw.C01'Y1
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 arty knowledge.
SIGNA URE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
~n ° a ~ ~ ~
ADDRESS
6 Hartzdale Drive, p ' I, PA 17011
SIGN E OF R HAN REPRESENTATIVE DATE
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ADDRESS
200 S. Spring Garden Street, Suite 11, Carlisle, PA 17013
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PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610101 15D561D101 J
J
1505610105
REV-1500 EX
Decedent's Social Security Number
Decedent's name: LaVonne R. Pearson 105-42-8672
RECAPITULATION
1. Real Estate {Schedule A) ........................................ ..... 1. 0.00
2. Stocks and Bonds (Schedule Bj .................................. ..... 2. 0.00
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00
4. Mortgages and Notes Receivable (Schedule D) ...................... ..... 4. 0.00
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).. ..... 5. 16,560.67
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ... .... 6. 7,237.67
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested... ..... 7. 28,792.36
8. Total Gross Assets (total Lines 1 through 7) ......................... .... 8. 52,590.70
9. Funeral Expenses and Administrative Costs (Schedule H} ............... .... 9. 4,385.80
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 675.71
11. Total Deductions (total Lines 9 and 10) ............................. .... 11. 5,061.51
12. Net Value of Estate (Line 8 minus Line 11) .......................... .... 12. 47,529.19
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) .................... .... 13. 0.00
14. Net Value Subject to Tax (Line 12 minus Line 13) .................... .... 14. 47,529.19
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2} x .0 0 0.00 15. 0.00
16. Amount of Line 14 taxable
at lineal rate X .0 45 21, 506.96 1 g, 967.81
17. Amount of Line 14 taxable
at sibling rate X .12 0.00 1 ~ 0.00
18. Amount of Line 14 taxable 26 022.23
at collateral rate X .15 ~
18. 3 903.33
19. TAX DUE ..................................................... .... 19. 4,871.14
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
15056],0105 1505610105 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
DECEDENT'S NAME
LaVonne R. Pearson
STREET ADDRESS V
6 Hartzdale Drive
CITY
Camp Hill STATE
PA ZIP
17011
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
3. Interest
243.56
4. ff Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fifl in oval on Page 2, Line 20 to request a refund.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(1)
Total Credits (A + B) (2)
(3)
(4)
(5)
4,871.14
243.56
4,627.58
4,627.58
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred :.......................................................................................... ^
b. retain the right to designate who shat{ use the property transferred or its income : ............................................ ^ Q
c. retain a reversionary interest; or .......................................................................................................................... ^
d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ Q
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. ^
3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .............. ^
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? ........................................................................................................................ 0 ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994, and before Jan. 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. 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.
0.00
LAST WILL AND TESTAMENT
I, LAVONNE R. PEARSON, of Cumberland County, Pennsylvania, being of sound
mind, disposing memory and full legal age, do hereby make, publish and declare this to be my
Last Will and Testament, hereby revoking all Wills and Codicils heretofore made by me.
ONE. I direct my Executor or Executrix, as the case may be, to pay all of my
debts, funeral and administrative expenses as soon as convenient after my decease. Furthermore,
I direct that all state, inheritance, succession and other death taxes imposed or payable by reason
of my death and interest and penalties thereon with respect to all property composing of my gross
estate for death tax purposes, whether or not such property passes under this Will, shall be paid
by the Executor or Executrix from my estate, and that none of the aforesaid taxes shall be
prorated among those persons or entities named herein or otherwise beneficiaries hereunder.
TWO. My Executor or Executrix may, at his or her discretion, compromise
claims, borrow money, retain property for such length of time as he or she may deem proper;
lease and sell property for such prices, on such terms, at public or private sales, as he or she may
deem proper; and invest estate property and income without restriction to legal investments
unless otherwise provided hereunder. I authorize and empower my Executor or Executrix to sell
any realty and/or personalty owned by me at my death and not specifically devised or bequeathed
herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale
therefor, in fee simple, as I could do if living. My Executor or Executrix is authorized and
empowered to engage in any business in which I may be engaged at my death, for such period of
time after my death as seems expedient to said Executor or Executrix.
Initial
THREE. I give, devise and bequeath all of my estate of whatever nature and
wherever situate to my father, HAROLD J. YOUNG, to be held in trust by the hereinafter
mentioned Trustee according to the following terms and conditions:
A. Upon the creation of this Trust, the Trustee, as well as my Executor or
Executrix, as the case may be, is hereby authorized to retain, unconverted, any property,
real or personal, that I may own at my death and shall be under no duty to convert it into
legal investments. The Trustee shall have the power and authority to sell, transfer,
convey, invest and reinvest and to pay over the net income of the trust property, to or for
the use of my father, or to accumulate it in the sole discretion of the Trustee. The Trustee
is also authorized and empowered to pay over to, or for the use and benefit of my father
such portion of or all of the principal of the trust estate as in the Trustee's sole discretion
seems proper for his continued support, maintenance, education, or medical care. My
primary objective is to insure the support, maintenance, and medical care of my father.
Notwithstanding the above purpose of this trust, the Trustee, in the Trustee's sole
discretion, may distribute any of the trust principal or income for the benefit of any of my
father for any such purpose as the Trustee deems reasonable under the circumstances such
as but not limited to the purchase of real property, or any other purpose which would in
the Trustee's sole discretion advance the best interest of my father. Any payments made
hereunder may be made by the Trustee directly to my father, if in the sole opinion of the
Trustee he is of such age and ability to properly handle the funds so paid, or payment may
be made by the Trustee directly to the person having the custody and care of my father, or
Inih'al~~ 2
may be made by the Trustee directly to any institution entitled to such payment by reason
of services rendered or to be rendered to my father.
B. Upon the death of my father, then in that event, the rest, residue, and
remainder of the trust property shall be distributed in accordance with Paragraph Four
below.
FOUR. If my father, HAROLD J. YOUNG, does not survive me by a period of at
least sixty (60) days, then I give, devise, and bequeath all of my estate of whatever nature and
wherever situation to my friend TERRY L. MIDDLEKAUFF, absolute. If my friend, TERRY L.
MIDDLEKAUFF, does not survive me by a period of at least sixty (60) days, then I give, devise
and bequeath all of my estate of whatever nature and wherever situate to my friend, TROY D.
MIDDLEKAUFF, absolute.
FIVE. In the event of a common disaster causing the death of my beneficiaries
named in Paragraphs Three and Four above, all within a period of sixty (60) days, then I give,
devise and bequeath the rest, residue, and remainder of my estate to the CHRISTIAN LIFE
ASSEMBLY, anon-profit church organization principally located at 2645 Lisburn Road, Camp
Hill, Pennsylvania, or its successors or assigns, for its general religious and charitable purposes.
SIX. I nominate and appoint, TERRY L. MIDDLEKAUFF, to serve as Trustee
of the Trust created in Paragraph Three hereof. If she has predeceased me, failed to qualify or is
not able or does not serve for whatever eason, I then appoint, TROY D. MIDDLEKAUFF, to
serve as Trustee of the Trust created in Paragraph Three hereof.
Initial. ~; 3
SEVEN. I nominate and appoint my friend, TERRY L. MIDDLEKALTFF, to be the
Executrix of this my Last Will and Testament. In the event she has predeceased me, failed to
qualify or is not able or does not serve for whatever reason, I then appoint my friend, TROY D.
MIDDLEKAUFF to be the Substitute Executor of this my Last Will and Testament, whereby the
said substitute personal representatives shall have the same powers as are given to the original
Executrix hereunder.
EIGHT. No person(s) shall benefit hereunder unless such beneficiary shall survive
me by sixty (60) days.
NINE. No Executrix, Executor, or Trustee acting hereunder shall be required to
post bond or enter security in this or any other jurisdiction.
TEN. No beneficiary may assign, anticipate or pledge his or her interest in any
income or principal held or distributable hereunder, and no beneficiary's creditors may levy,
attach or otherwise reach any such interest.
ELEVEN. The validity and administration of any trust established hereunder and any
questions or disputes relating to the construction or interpretation of any said trusts shall be
governed and construed in accordance with the laws of the Commonwealth of Pennsylvania.
[THE REMAINDER OF THIS PAGE HAS BEEN INTENTIONALLY LEFT BLANK]
:,
Initial
,; 4
IN WITNESS WHEREOF, I have hereunto set my hand and seal this _ ~. r;°~ '`"day of
.~~ ~ s-,. ~.~, ~-,~ ~°~. , 2009.
-~ - i
~. ~~~~~ `~ ---' ~' SEAL
LAVONNE R. PEARSON
Signed, sealed, published and declared by the above-named person as and for a Last Will
and Testament, in our presence, who at said person's request, in said person's presence and in the
presence of each other have hereunto set our names as subscribing witnesses.
__
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ACKNOWLEDGMENT AND AFFIDAVIT
WE, LAVONNE R. PEARSON, TRACI D. SMITH and CHERYL L. CLELAND,
the testatrix and witnesses respectively, whose names are signed to the foregoing instrument,
being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed
and executed the instrument as her last will and that she had signed willingly, and that she
executed it as her free and voluntary act for the purpose herein expressed, and that each of the
witnesses, in the presence and hearing of the testatrix, signed the will as a witness and that to the
best of their knowledge the testatrix was, at that time, eighteen years of age or older, of sound
mind and under no constraint or undue influence.
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
~.'} ; ;.
LAVONNE R. ARSON
TRACI D~ SM,,~TH -, -!
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CH R L L. CLELAND
SS:
Subscribed, sworn to and acknowledged before me by LAVONNE R. PEARSON, the
testatrix herein, and subscribed and sworn to before me by TRACI D. SMITH and CHERYL
L. CLELAND, witnesses, this-"~~-^J day of~ l~jU~j~ ~~~'"~ , 2009.
,.
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Natary Public
COMMONWEALTH OF (~ERlNSYLVAI~I/~
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!Notarial Sea _.u..P..- __,~..__ _
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M1y Con-±~~ission E~ires Dec. 8, 2011 '- ~ ~ _ _ ._
Member. ~ennsyivania Association of Notaries S _
REV-1508 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
LaVonne R. Pearson 21-11-0030
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
(if more space is needed, insert additional sheets of the same size)
'HETRO
BANK
Metro Bank
3801 Paxton Street
Harrisburg PA 17111-1448
1_888-837-0004
mymetrobank.com
>[ID962 6738537 OD1 D92140
LAV4NNE R PEARS4N
fi HARTZDALE DR
CAMP HILL PA 17011
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Ws4s tra+e 7 days a wNk~ 2~ Marrs s day at 1-888-937-000.
Interest Summary
r
Total OvN+drsR FNS Yoar to ~ SOAO
Total Roturnid lesrnn Fess YNr fo Dats ~pAO
For your convenience, a summary of overdraft and returned item fees appears on your monthly statement. Pisses note that the overdraft fee
summary includes non-suf(iccient funds fees, uncollected funds fees and unavailable funds tees. The summary does not reflect refunded or vraived
items credited to your account.
N
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~ CycN Pages 1 of 4 ~aerRO-c~~
PERS STATEMENT-~
Fees Summary
'~ETRO
BANK
>08324 673853? 001 D9214D
LAVONNE R PEARSON
fi HARTZOALE DR
CAMP HILL PA 17011
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Metro Bank
3801 Paxton Street
Harrisburg PA 17111-1418
1-888-837-0004
mymetrobank.com
Webs here 7 days a week, 21 hoots a dry at 1-888-~3]'-0001.
PERS STATElIAENT
a
a
Fees Summary
N
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O
ti
a
3~ crde Palls 1 of 4 METRQ-fiOLL
For your convenience, a summary of overdraft and returned item fees appears on your monthry statement. Please note that the overdraft fee
summary inckxtes non-sufifc~M funds fees, uncollected funds fees and unavailable funds fees. The summary does not reflect refunded or waived
items credited to your account.
ZASt 3895
ZtMMERMANS AUTO SALES
2234 S MARKET STREET PH. 717.788.7656
MECHANICSBUR(3, PA 17055 BO-8224/2313
DATE ~ '•~Ct/~
PAY /~ _. .
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'--"""'- J~ B~ DOL~4RS 8 ~.
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MEMBBRS i"
~auta~u. c~,®n~ v~nQx
FOR
i~fC~~3895u' f:23L38~24~~: ?7?26 7 ta~,n ??
REV-15og EX+ (oi-io)
~ pennsylvania
` DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF: FILE NUMBER:
LaVonne R. Pearson 21-11-0030
]OINTLY OWNED PROPERTY:
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
]DINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FOR )DINTLY HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET % OF
DECEDENT'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
1. A. 07/01110 Metro Bank Savings Account # 410143668 7,733.28 50 3,866.64
2. A. 07/01/10 Metro Bank Checking Account # 512035171 6,742.06 50 3,371.03
TOTAL (Also enter on Line 6, Recapitulation) I $ 7,237.67
If more space is needed, use additional sheets of paper of the same size.
If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G.
°^'HETRO
BANK
>119U3 6724598 001 092240
LAVONNE R PEAFtSON
OR HAROLD J YOUNG
6 HARTZDALE DR
CAMP HILL PA 17011
_.._._.
Metro Bank
3801 Paxton Street
HatTtsburg PA 17111-1418
-aes-a37-ooa4
mymetrolfank.cam
tMNe~+. Her. ~ drys a z~ Horns. day.t ~-aes-~~~-ooo~s.
11124/10 VISA THE OLNE GARD00 =18.39 ~ ;3,518.71
RFtW41tI21 11123 023644 MECHANICSBURQyPA
12101N0 CREDR MEMO :1,300.00 :7,816.06
12103M0 METLIFE PAYMENT t-36.17 :7,733.28
LAVONNE R PEARSQN
12/07/10 VZ itY1RELESS ARC ARC x.90 ST,630.20
SERIAL NUMBER: 0114032001882000001
1210TH0 CRI ACCT PYMT PURCHASE x667.38 ;7,002.82
SEAL NUMBER: 121 TERMINAL CRY: CAMP STATE: PA
12/10V1 p CHECKS 117 ;13,pp ~~S23,pp
12/16Nb Unify Financial Ut=LIC ;48.83 ~7sp,~
uvoNNE R PEAI~soN
12/23110 INTEREST PAYMENT x,83 ~T~.p6
Check Transactions
Numbar Oat Amount
Number Date Amount Number Dab Amount
116` 12!07 x40.00
718 1?106 :47.18 120 1Z/O:i x26.61
flame denoted with en 'E' aro elecr~or~ entries and wiM not have a duck 4rape. hems denoted with an "'indicate processed cr~edcs out of sequenos.
Z3 Ctimbinad
a
3
Pap! 1 of 8 +~-rno•aa~
Transactions By Date
Dais Pin Debit Credit Balance
REV-1510 EX+ (08-09)
pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INT/ER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
E5TATE OF FILE NUMBER
LaVonne R. Pearson 21-11-0030
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND
THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET
°!° OF DECD'S
INTEREST
EXCLUSION
(IF APPLICABLE)
TAXABLE
VALUE
1• Highmark Investment Plan to Teny Middlekauf, beneficiary
28,792.36 100 0.00 28,792.3E
TOTAL (Also enter on Line 7, Recapitulation) $ I 28,792.36
If more space is needed, use additional sheets of paper of the same size.
YOUR RETIREMENT SAVINGS STATEIIAENT
Highmark Investment Plan
01K75 OpE1T13M 11~11~57
I ~„I l 1, s, I l l ~,,, ~, l 1, ~, i l l„~ I I, I„i 1,,,1,,,1 1 1„~, 11,,,,, I l i
~ LAVONNE R PEARSON
...~ 6 HARTZDALE DR
~~'r° CAMP HILL PA 17011
~~
..........
~~
ACCOUNT SUMMARY
binning f8alance on 10/01/2018
Dividends & Interest
Unrealized Gain/i_oss
Ending Balance on 12/3112010
~-IIGHM/~RIC_
10/01/2010 to 12/3912010
Page 1 of 6
News About Your Ptan
X27,476.01
661 38 8?~Contributl9n Umits
id you know you can save a total of
254.97
61 x16,500 in your empbyer sponsored
,
:28,792.38 retirement plan during 2011(uniess your
plan has a lower contrlbu6on limit)? And, if
51,316.35 You are age 50 ar okter you may be able to
:28,792.38 make "catch-up contnbutions," and put
~ ~ aside an adoritional 65,500. Inaease your
contribution rate today to take full
4.79°k advantage of these great ways b save for
retrrement.
Net Change
Vested Balance
Year to Date Contr~wdons
You Personal Rate of Rehm
ACCOUNT GROWTH
~.°°° ~,
~~~..
i
2o,aoo e/
10,000 -
0BI09 12!09 06110 12N0
^ At~oount Balance
Your Personal Rate of Return
From 01 /01/2010 to 1213112010: 9.44°~
06/30/2009 12!3112009 0t313W2010 1213112010
$18,819.57 x24,522.19 $25,415.15 $28,792.36
Thee of yow accaunt cars be inlPuenced by a nam6er of factors, including the specific investment options selected
the ificatlon of your investment am asset classes and the contribufians to your account. Past performance does
not guarantee future results. !f you would like b make charufes to any of these areas, contact a representative or go online
t0 WiMW.WellSfa-gO.COrNmyretlreplan.
CONTRIBUTION SUIIAMARY
By saving througi~ your plan you can
add to ftre frnancisJ nest egg you wi1J
need in the future. All Contribution Sources
EE PreTax
Safe Harbor Employer Match
Contribution
Rate This Period Year to Date
O.OO~b $0.00 $27.27
n1a $0.00 $27.27
Total Coniributians
60.00 $54.54
lAVONNE R PEARSON 682583
ODE1T13M 016575 0132208450! 1 NYNNN NNNNN NN NNNNN NNNNN NNN 000001
101,291
10101/2010 to 12/31/2010
Page 2 of 6
VESTING INFORMATION
Vested balance is the amount that fs
aheady yows based on the amount of
time have heart w~orkbtg !br this
em , as detlired in the ves~ng EE PreTax
s of your plan. My r~ilference EE PreTax Supplemental
6efween ~ ~~,~~ and Post 86 After-Tax
your vested balance tail/ be forfeited If Safe Flarbor Employer Match
you leave your employer belbre you Employer Match
aro fully vesteo'. Pre 87 After-Tax
Balance on Vesting Yested
12131!2010 Percentage Balance
242,836.41 10096 $12,836.41
$58.18 10096 $58.18
6113.56 10096 $113.56
$28.14 10096 $29.14
615,345.18 100% 515,345.18
6309.89 10096 x309.89
Total 628,792.38 128,792.36
ASSET ALLOCATION
Current Asset
Allocation
Future Investment
Direction
~AVONNE R PEARSON
~a~,7e2
ouoo oaoo 7 ~ iie~ v~
Current Asset Future investment
Allocation Direction
0 Bond
PIMCO Real Rehm Fund (Admin}
PIMCO Total Return Fund (Adrnin}
4896 3096
1996 2096
29°6 3096
~ Domestic Stock
Artisan SmaA Cap Fund (Invests)
Large Cap U.S. Equiiy Index N!. Fd (CI F)
Mid Cap U.S. Equity Index NL Fd (Ci F)
3696
5°~6
2096
1196
3396
596
20°~
10%
® lnternatlonal Stock - 1896 1596
MFS Inst International Equity Fund 16°~ 15°~
This table shows how your investments are cwrently allocated among the asset dosses b help you determine iiyou need to make
adjustments b your albcation. The asset class inkxmation is taken ~ reliable sources, incgxbong the mutual kind companies, but
is not gu~-+erlteed by Weis Fargo as to completeness a aaxvacy. Wells Fargo shah not be liable for any errors in content, or for any
actions taken in re~anoe thereon. Please read each fund prospectus carehdty fnr more inlformatiorc
fi82583
REV-1511 EX+ (10-09)
~ ~ ~ pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
LaVonne R. Pearson 21-11-0030
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES: .
1' Zimmerman Auer Funeral Home, Inc. 171.00
2. Rolling Green Cemetery 1,395.00
s. Pastor Smith for funeral 200.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Names} of Personal Representative(s) Terry Middlekauff
Street Address 6 Hartzdale Drive
City Camp Hill State PA ZIP 17011
Year(s) Commission Paid: 2011
2. Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant
Street Address
4.
5.
6.
7.
City State ZIP
Relationship of Claimant to Decedent
Probate Fees:
Accountant Fees:
Tax Return Preparer Fees:
Miscellaneous Postage
TOTAL (Also enter on Line 9, Recapitulation) I $
If more space is needed, use additional sheets of paper of the same size.
1,500.00
1,000.00
104.50
15.30
4,385.80
~r~~~
FUNERAL H ME. II~iC.
41b0 Yoneota~n~ct ~ PA 1?l04
~.Q114 C~
DeC 1p, 2p1Q
Harold J. Young
B20 Li.ek~urrx Road, #408
C1mp I3i11, FA 17011
LaVonne Ruth Pearson - Deceased
SPECIAL CHARGES
Direct Gremat it~rn
Forwarding Remains
Receiving ~.exnains
Zmmed3,ate Burial
Nationwide Guarantee Fro~ram
worldwide Travel Protect~c~n
TOTAL S PECxAL CHARf3$S ~ 0.0 0
PROFESSIpNAL SERVICES
X Sexvices of Funeral Director & Staff $1.,595.Q0
X l~mbalmin $725.00
X pxee~in~~Cosmetizing/Casketing 220.0
X Facilities & Staff fc~~' VievriYl t$Z00/ha-ur) 2p0 . UO
Facilities & Staff for Funera~ Se~'vice
Facilities & Staff far Memvria.l Service
St a f f & 8qu~.pment for ~7i.er~rirl ( $ 2 0 0 /hour ~
X Staff & 8quip~tttMf for Funeral service $50.00
Staff & Bquipmeet for .Memorial Service
Privatc3 Family Viewing
i
i
i
W
tness
n the Cremat
on
PaGkac~ing~Forwardingg of Cremated RemaY~ns
Personal Delivery of Cremated ReanaiMs
Scattering 4f Cremated ~temaing ..~
TOTAL PROFY;SSI011TAL SERVICES $3 , 290 .00
ATJTOMOTIVL EQ~IIPMSI3T
X Removal. Vehiel~e $25U . 4Q
X Casket CoaGYi $250.OQ
Flower Car
X Lead Car/Clergy Car $175.QQ
Serv3.c+~ Vehf cle
Familyy Car
TOTAL AUTU~IOTIVE EQUIPMENT $675.00
E00/ZOQd X95=0L iIOZ ZZ q~d £V66~g5tlt xQ~ df10tA ~~1kR
MERC~YANDISE
Register Book
Memorial Cards
Thank Yau Cax'ds
Remetnbx~tnce Package
X T~Salle Casket $1,895.00
Cardboard Container
Alternative Con,ta~.ner
X Outar Su~'~.~1 Container
Liner
$~~$-p0
Veterans Flag Case
Grave/Memorial Marker
X Remembr~s'iCe Package $115.00
TOTAL MERC~~ats~
CA.sx A~vANCm rTEMs
Grave Opening
cemetery Equipment
Vault 9erwice Charge
ti
ri~
ce
o
Fatriat Netws aper
~
ice
Newspaper Na
Clergy
Church/Organist/Soloist
X FloWera - $150 + tax $155.00
Crematory charge
Cplxnty Coroner Rae
X Death CertifiCatess - 2
$1~ • 00
T4'TAL CASF~ AD`fr,ANCED ITEMS
SUMMARY QF CHARGES
Special Charges $0.00
ProfeBBional SerV1.Ce~s $3 290.00
Automotive Equ~,pmeri,t 675.00
Merchandise $3,005.00
Cash Advarieed Items $171.00
SiTB TOTAL $7 , x,41.00
CREDITS -$2,812.00
AMOL7NZ` PREPAID - $4 , 1 S8.0 0
TOTAL $171.04
AMOUZV'~' PAID Dec 22, 2010 -$171.00
$AL~-NGE DIIE $0.00
THI5 STATEMENT MAC NOT REFLECT ALL NEWSPi~iPEl~ C~~ARC3ES
$3,005.00
$171.00
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RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH Receipt Date: 1/06/2011
Cumberland County - Register Of Wills Receipt Time: 13:07:57
One Courthouse Square Receipt No.: 1063939
Carlisle, PA 17613
PEARSON LAVONE RUTH
Estate File No.: 2011-00030
Paid By Remarks: TERRY L MIDDLEKAUFF
SAP
------------------------ Receipt Distrib ution ----- -------- -------- ---
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 30.00 CUMBERLAND COUNTY GENERAL FUN
WILL 15.00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 16.00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN
-
Check# 4650 ---------------
$89.50
Total Received......... $89.50
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~~ ..
REV-1512 EX+ (12-08)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
LaVonne R. Pearson 21-11-0030
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
If more space is needed, insert additional sheets of the same size.
'~.~~ vrer~l~nt~-~e,~s
Po Box 4043 Manage Your Account & View Your Usage Details Account Number Date Due
AcwoRTH, GA 30101
invoice Number 6534464632
Quick Bill Summary .lan 02 -Feb 01
`10008937 01 AT 0.367 "AttUTO `T2 0 1201 17011-790708 1 6 E IIPHIL0104
1rrr~~~r1r~~~lrtrrr~~rrr~~Irrr~~rfrr~~rrr~rrt~~~rrrr~~rttrr~l~
LAVUNNE PEARSON
6 HARTZDALE DR Previous Balance (see back for details} $138.73
CAMP HILL, PA 1 70 1 1-7907 No Payment Received $.00
Adjustments -$109.85
Balance Forward Due Immediately 528.88
Taxes, Governmental Surcharges 8 Fees $.00
Tetat Current Charges Due by Febntary 24r 2011 S.aO
Total Amount Due $28.88
.. .- ~-_.r{~ -
~y rte.,
F ~ A ~, ~.
Save Time And Money
it's never been easier to enroll in Auto
Bill Pay. See back of Payment Coupon
below for details.
Our records indicate your account is past due. Please send payment now to avoid service disrupiian.
Pay from Wireless- Pay on the Web ~ Quesiians:
. VE
~~VIe17~tNireless Bill Date February 01, 2011
Account Number 520018820-00001
lnvaice Number 6534464632
LAVONNE PEARSON - ,Dt'c,~~..Se[{. Total Amount Due
6 HARTZDALE DR ._ ~--- -- -
CAMP HILL, PA 17411-7907 Make check payable to VerizonWireless. ~8.~
Please return this remit slip wish payment.
~thC:L( ~~cSlh 1
,~,_,~._ P.O. BOX 25585
LEHIGH VALLEY, PA 18002-5545
~rrr~~~rr~r~~rrr`~rrrrr~r~r~r~re~r~r,~rrrr~rirr~rr~~
^ Check here and fill out the back of this slip if your billing address
has changed or you are adding or changing your errlsil address.
653446463201D52DD18820000010D0000000D00002888b
KEYSTQNE FINANCIAL ASSOCIATES, LLC
Toll Free: (80U) 423-2838 www.Advisars4Life.net
176 Cumberland Parkway, Suite 202 200 S Spring Garden St., Suite II 4225 Molly Pllcher Nwy.
Mechanicsburg, PA 17055 CQrllsle, PA 17013 Chambersburg, PA 17242
(717j 796-1700 (717) 218-S2b8 (717j 375-2139
INVOICE
~ BIIr.I. TO ~
LaVonne Pearson
c/o Terry Middlekauff
6 Hartzdale Drive
Camp Hill, PA 17QI 1
IIATE VOICE
12i~~ao i o 20 ~ 002
T~i ~s-
Due on Receipt
Please make check payable to:
Prof cities, fnc.
AnIOUNT DUB ENCL03ED
$450.00
Please detach top portion and return with your payment
------------------------------------------------------------------------------------------------------------
Activi uantt Rate Amount
Research & Update Beneficiaries - DouPlas DenlingerFP6:
Research & Analyze Case
1~fake Recommendation 9 hrs $75.o0/t-r $475.00
Home Visits and Discussions (2J
Conference Calls with Insurance and 401k Providers
Obtain G'omplete 8c Submit Necessary Farms
Special Client Discount -3 hrs $75.00/hr _225.00
TOTAL $450.00
Please mail your aavment to:
Keystone Financial Associates, LLC
176 Cumberland Parkway, Suite 202
Mechanicsburg, PA 17055
Thank you for allowing Keystone Financial Assocs., LLC to service your financial needs
KEYSTONE FINANCIAL ASSOCIATES, LLC
Toll Free: {$00) X23-2$3$ www.Advisors4Life.net
176 Cumberland Parkway, Suite 2Q2 • 200 S. Spring Garden St., Suite 11 4225 MnUy Pitcher Hwy.
Mechanl~sburg, PA 170SS Carlisle, PA 17x13 Chambersbarg, PA 17202
(717) 796-1700 (717) 218 5268 (717) 375 2139
INVOICE
~ BII~L TO
LaVonne Pearson
c/o Terry Middlekauff
6 Hartzdale Drive
Camp Hill, PA 17411
DATE IfNVOICE #
12/22/2010 201003
TERMS
Due on Receipt
Please make check payable to:
Prof cities, Inc.
AM011NT DUE TP7CLOS&D
$ 150.00
Please detach top portion and returo with your payment
Activlt usntt Rate Amount
La Vorsae Pearsorr's Estate •- Douglas De»tingerFP6:
Prep Tij»e and Fatuity Meeting
2
$75/hr
$150.00
TOTAL X150.40
Please mail your nayme»t to:
Keystone Financial Associates, C.LC
176 Cumberland Parkway, Suite 202
Mechanicsburg, PA 17055
Thank you for allowing keystone Financial Assoc, LLC to service yourJtnancial needs
REV-1513 EX+ (01-10)
~~
,~ ~ ,
pennsylvania
SCHEDULE ~
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
LaVonne R. Pearson 21-11-0030
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not list Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec. 9116 (a) (1.2).]
1 • Harold J. Young, 820 Lisburn Road, Apt. 408, Camp Hill, PA 17011 Father 20649.36
2. Terry L. Middlekauff, 6 Hartzdale Drive, Camp Hill, PA 17011 Friend 22252.25
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $
If more space is needed, use additional sheets of paper of the same size.