HomeMy WebLinkAbout03-17-111505610101
REV- ~ 50o tX (oi-io) Yi
enns lvarria OFFICIAL USE ONLY
PA Department of Revenue PEO.A,~E Y
Bureau of Individual Taxes ~ ~' wE~E"u` County Code Year File Number. ICI
POBOx28o6o1 ~ INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601 RESIDENT DECEDENT Z I ~ ~ ~ v U Z~
Date of Birth MMDDYYYY
Qm ~ I 1
Decedent's First Name MI
C o~ r o~ I T~T
~ n~~
Spouse's First Name MI
~~~® ! 1
~ ^ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Return O 2. Supplemental Return
O 4. Limited Estate O 4a. Future Interest Compromise (date of
- ~ death after 12-12-82)
O 6. Decedent Died Testate O` 7. Decedent Maintained a Living Trust
(Attach Copy of Will) (Attach Copy of Trust)
O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
O 3. Remainder Return (date of death
prior to 12-13-82)
O 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
O 11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
5~, ,- !~ ~s cow 7179~19a16
REGISTER OF WILLS USE ONLY
First line of address ~
~. O 11'1 ; w ~ _~ ::_
Second line of address j _~C7 ~
-- , r-
~J') -~~-- yf
City or Post Office State ZIP Code m~¢ ~ ED
P~ ~ ; `_
a r ~ s ~ ~ ~J s7.d, ~ 4 1 ~~ =
~. ~~ C~
Correspondent's a-mail address: t+p ~
Under penalties of perjury, I declare that I have examined this re m, including accompa ing 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 ofyw~hic~h preparer has any knowledge.
SIGNAT_~RSON' ES~OR FILING RETURN '. "/'~~ DATE~6 /J
!'~ 5F
ADDRESj
SIGNATURE OF PREPA R OTHER T AN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610101 1505610101 J
T
1505610105
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: ~ '~ ~ ~ ~ '{ ~ Q
RECAPITULATION
1. Real Estate (Schedule A) ...:.....:.:......................:..... ....: 1. ~ % / ' 'Y ~ ~ ~ • Q u
2.
Stocks and Bonds (Schedule B) ..................................
..... 2. ~.
~ `~ ~ ~{ 9 • ~ '~
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages and Notes Receivable (Schedule D) ...................... ..... 4. ~ • ~
.i
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).. ..... 5. / ~ .,~ Z Q ~ .: 6 ~~
6. Jointly Owned Property (Schedule F) p Separate Billing Requested .. ..... 6. 3 / q 9 , f 0 .~
~
7. Inter-vvos Transfers 8 Miscellaneous Non-Probate Property - 1`
'~ ° ` -
(Schedule G) O Separate Billing Requested... ..... 7. ~ 3 ~ ~~ - b ~. d
8.
Total Gross Assets (total Lines 1 through 7) ........................
..... 8. v . ,,
~ ~ ? ''f / 7 • ~ ~
9. Funeral Expenses and Administrative Costs (Schedule H) .............. ..... 9. /~! 3 g ~ ~ b O
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ......... ..... 10. . 0
11. Total Deductions (total Lines 9 and 10) ............................ ..... 11. ~ .3 g 5 , b
12. Net Value of Estate (Line 8 minus Line 11) ......................... ..... 12.
13. Charitable and Governmental BequestslSec 9113 Trusts for which - ' "
an election to tax has not been made (Schedule J) .........:...:..... ....... 13, rf ~,
14. Net Value Subject to Tax (Line 12 minus Line 13) ................... ..... 14. }f Z 3 O 3 ~ . 5
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116 ~ ~ ~ ~ ~ ..~r- ,
(a)(1.2) X .0_ . 15. ~~
16.
Amount of Line 14 taxable -
at lineal rate X .0 ~ ~ 4 ~
~ 6 ~. ~ ~
16 _A f ~ ~ .
, -
17. ;
Amount of Line 14 taxable '"' ~ ~=' ` "`` " ` ~~"' ° ~` `~ " ~" "'
~
at sibling rate X .12 ~,
~ ~~ ~ 17
~
~ -
'~~
a.~p~
tp`r~~C ~
`
~
~
18. AmountotLinel4taxable ~
~= "" '
~ .`
,
~
"
~
at collateral rate X .15 ;~ ~ 18 +.
a
k - ~::'
19. TAX DUE .................................................... ... ,_,, ~,~
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~
- - -
Side 2
L 1505610105 1505610105
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
DECEDENT'S NAME }'
_ Ca'r' V~t~1
STREET ADDRESS (
- - ~ ~ ~ J0.M es S `-- -- -
CITY
tc. ``__
~glAcc.S1UU1' STATE ~ ZIP _
J~O~J '~~~
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments -_
B. Discount
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill 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> r 9 0 3 G. y~
Total Credits (A + B) (2)
(3)
(4)
(5) ~ ~t 0 c~ la . ~ ~
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred :.................................................................................... ...... ^ .~
b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ [~,
c. retain a reversionary interest; or .................................................................................................................... ...... ^
d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ........................................................................................................ ...... ^
3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ........ ...... ^
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? ................................................................................................................. ....... ~ ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the 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)j. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
~,
REGISTER OF WILLS
CUMBERLAND COUNTY
PENNSYLVANIA
No . 2011- 00023
Estate Of: CAROL HHAYES
CERTIFICATE OF
GRANT OF LETTERS
PA No . 21- 11- 0023
/First, Middle, Last)
Late Of : MECHANICSBURG BOROUGH
CUMBERLAND COUNTY
Deceased
Social Security No : 147-16-4408
WHEREAS, on the 5th day of January 2011 an instrument dated
UNDATED
CAROL H HA YES
/First, Mule, Last/
late of MECHANICSBURG BOROUGH, CUMBERLAND County,
who died on the 18th day of December 2010 and
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wills in and
for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby
certify that I have this day granted Letters TESTAMENTARY to:
SHARON E BROWN
who has duly qualified as EXECUTOR(R/X)
and has agreed to administer the estate according to law, all of which
fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE,
CARLISLE, PENNSYL VANIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my office on the 5th day of January 2011.
egister o liHs
.~ C ~.~ 1~ ~ 1 ; tZ/L~~
eputyr
* *NOTE* * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST)
~'
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LAST WILL AND TESTAMENT OF CAI20L H. NAYES ~ ~'~ -'
t:
I, CAROL H. I?AYES, of the Borough of :Mechanicsburg,
County of Cumberland and State of Pennsylvania, being of sound
and disposing mind, memory and understanding, do make, publish
and declare this to be my Last Will and Testament, hereby re-
voking and making void all former i*lills by me at any time
heretofore made.
1.
I direct the payment of all my just debts and
funeral. expenses as soon as conveniently may be after my
decease.
2.
All the rest, residue and remainder of my estate,
real, personal and mixed, whatsoever and wheresoever situate,
I give, devise and bequeath to my daughter, Sharon E. Brown,
and r.?y son, Robert E. Hayes, in equal shares.
3.
i,A'~?'L~", I nominate, constitute anel appoint my daugh-
ter, Sharon E. Brown and my son, Robert E. Hayes, to be the
Executors oz this, m_y Last Will and Testament. I further
__ ._ direct.~~at they shall not be required to file bond or other
., ,, ,.,,,,~Y~*,, ._ _. _ .~
l
purpose of settling my estate.
IN WITNESS WHEREOF', I have hereunto set my hand
and seal this day of February, A. D. 1973.
~,f-u.~ e ~t~ ~ ~:.~~, {SEAL j
3
Signed, sealed, published and declared by the
above-named CAROL H. FIAYES, as and for her Last Will and
Testament, in the presence of us who have hereunto sub-
scribed our names at her request as witnesses thereto, in
the presence of the said Testatrix and of each other,
_..._____._.~%,~d ...5~ . ~~ .~
P'
-~
~`~.~
~..~ri._
RENUNCIATION
REGISTER OF WILLS
CUMBERLAND
COUNTY, PENNSYLVANIA
C~~p~
Estate of CAROL H. HAYES Deceased
I~ Rob Haves , in my capacity/relationship as
(Pant Name)
son and desienated co-executor of the will of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
Sharon E. Brown
i 1~ ~ ~ ~ ~G
(Date)
~.
(Signature) Robert E. Hayes
1953 Marlene Avenue
(Street Address) -'
Redding, California 96002
(C~t~; State, Zrp)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of
Deputy for Register of Wills
Form RW-06 rev. 10.13.Ob
Executed out of Register's Office
Before the undersigned personally appeared. the
party executing this renunciation and certified
that he or ~ executed the renunciation for the
p oses stated within on this ~~ day
of~( .Q~ ~~ ~.e,Y 2~ t o
v.~t,1~l.t.'~`~'''
Notary Public
My Commission Expires: f ~~~c~l~T S i ~2n 11
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission..)
D. BURNS
Commfsslon # 1755905
y Notary Public - California ~
= Shasfa County
Comm. Expires 5, 20i ~
• DECEASED '
~~ DeparimentofiheTreasury- IntemalRevenueService
1040A U.S. Individual Income Tax Return (~) 2010
Name, R
Address, I
and SSN "r
c
See separate L
instructions. E
A
R
L
Y
CAROL H BAYES -DECEASED 12/18!2010
~ SHARON H SROI~liT
504 JAMES ST
bIECSANICSBURG, PA 17055
IRS Use Only - Do not write or staple in this space.
OMB No.1545-0074
Your social security number
147-16-4408
Spouse's social security number
Make sure the SSN(s}above
j and on line sc are correct.
Checking a box bebw will not
change your tax or refund.
~raa.uana ~.ar . a..r1C{:K Here R u Or Ur Ot1Se g TItMt OR7 want t0 t0 this fund - YOU $ S@
Filing 1 R Single 4 Head of household (wilh qualifying person). (See instructions.)
g~t~ 2 Married filing jointly (even ff onlyone had income) a the ualit m
q y' g person is ach ild but not your dependent, enter th is
Check only 3 Married f fling separately. Enter spouse's SSN above 8 f ull name below. child's name h ere. -
one box. - 5 QuaHfving widow(er) with dependent child (see inswctions)
Exemptions 6a U Yourself. If someone can claim you as a dependent, do not check box 6a. a oxen
checked on
~~ Ba and Bb 1
N f h'la~--
If more
man six
dependents,
see instructions.
c Dependents: _ -
(1)Frstname Last name (2)DependenYssocial
securitynumber (3)DependenYs
relationship to you 4 if chili
underage 1'
qualifying ti
hild tax cr.
see 16
o.oci
on sc w h o
' ~livedwith
r you
did not live
with you due
to divorce or
separation
(see inst r)
Dependents
on Bc not
entered above
Add numbers
on lines
above -
Income
Attach
Form(s) W- 2
here.Aiso
attach
Form(s)
1099- R if tax
was withheld.
If you did not
get a W - 2, see
page 20.
Enclose, but~o
not attach, any
payment. Also,
please use
Form 1040- V.
7 Wages, salaries, tips, etc. Attach Form(s) W- 2. 7
Sa Taxable interest. Attach Schedule B'rf required. Sa 2 0 , 14 9 .
b Tax exempt interest Do not include on line Sa. Sb
9a Ordinarydividends.AttachScheduleBrfrequired. ~ 805
b Qualified dividends (see instructions). 9b 8 0 5 .
10 ital ain distributions see trlstnlctrons . 10
11a IRA 11b Taxableamount
12a Pensions and
13 Unempbymer
14a Social security
13,794.
12b Taxable amount
11b 4
12b 8,405.
14b Taxable amount
15 Add lines 7 through 14b (far right column). This is your total income - 15 4 3 , 310
Adjt,isted
gross t 6 Educator expenses (see instructions). 1 s
InCOrtle 17 IRA deduction (see tlstructions). 17
18 Student krarl interest deduction (see instructions). 18
19 Tuition and fees. Attach Form 8917. 19
20 Add lines 16 through 19. These are your total adiustmerris. 20
21 Subtract line 20 from line 15. This is your adiusted arose income - 21 4 3 , 310
KBA For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040A (2010)
1040A 52010) FD1040A-1 V 1.18
Form So tware Cepvrirht 1946 - ?011 HR9 Tax G~onp, he
Form 1040A {2010) CAROL H HAYg S 14 7 16 4 4 0 8 Page 2
Tax, Credits, 22 Enter the amount Nom line 21 ad'usted roes income . 22 4 3 310 .
and 23a Check X You were born before January 2,1946, Blind Total bones
I~yrrtentS ~- SpousewasbombeforeJan
~,arYz 1x46. Blind checked - 23a 1
b If you are married filing separately and your spouse itemizes
d eductions, see page 29 and check here r~-~
- 23b 1 1
24 Enter your standard deduction (see instructions) 24 7 , 10 0 .
25 Subtract line 24 from line 22. ff ime 24 is more than line 22 enter - 0- . 25 3 6 210 .
26 Exemptions. Multiply $3 650 by the number on line 6d 26 3 , 6 5 0 .
27 Subtract ire 26 from lute 25. If Ikte 26 is more Phan line 25,enter - a .
This is yourtaxable income,
- 27
3 2 ,
5 6 0
28- Tax, including anyattemative minimum tax tees instrucions). 28 4 , 3 4 8
29 Credit forchikt and dependent care expenses. Attach Form 2441. 29
30 CredRfortheelderlyorthedisabied.Attach
Schedule R. 30
31 Education credits from Form 8863 lire 23. 31
32 Retirement savings contnbutionscredit.AttachForm8880 32
33 Child tax credit (see instructions). 33
34 Add lines 29 through 33. These are your total credits. 34
35 Subtract line 34 from i'me 28. >f line 34 is more than line 28 enter - 0- . 35 4 , 3 4 8 .
36 --Advance earned incomecredftpaymentsfromForm(s)W-2 ,box9 36
37 Add lines 35 and 36. This is wurtotal tax. _ - 37 4 3 4 8 .
3B Federal in~me tax withheld from Forms W- 2 and 1099 38 1, 9 0 7 .
~ 2010 estimated tax payments and amount
applied from 2009 return. 39 4 , 9 8 0
If you have '~ Makino work pav credit Attach Schedule M 40
a q uali(ying 41 a Earned income rxedft (EIC}. 41 a
Cfllld, attach b Nontaxable combat pav election. 41 b
Schedule DC. ~ Additionaichild taxcredit. Attach Form 8812 42
43 American opportunitlrcreditfrom Form 8863 line 14 43
44 Add lines 38.39, 40, 41 a, 42 and 43. These are your total Da vrnerrts. - 44 6 , 8 8 7
Refund ~' ff line 44 is more than Ikte 37, subtract Tine 37 from line 44.
2,539.
Direct 46a Amount of Tine 45 you want refunded to 1rOU. If Form 8888 ~ attached check here - ~ ~ 46a 2 , 5 3 9
depot? - b Rotrting
See instructbns number X]CXXXXXXXXXXXXXE - c Type: ^ Cptt~tjc ~ 9a~pt8
and fill in
46b,46c, - d Account
and 46d or number X]CXX]t:X]CXRXICXXXXXXXXXXXXXX$XXX
Form ~' 47 Amount of I'Ine 45 you wan# applied to your
2011 estimated tax. 47
ArnOUrlt ~ ~~ Y~ ~• ~~ ltrte 44 from line 37. For deta~s on how
you OWe _ to pay, see instructions. - 48
Third party Do you want to albw another person to d iscuss this return with the IRS fee instructions)? X Yes. Complete the foNowing. No
deSlgrlee Designee's name Phone no. Personal ID number
- 8R BLOCK - (717) 243-6868 (PIN)- 6924 ~_
.S• rl Under penalties of Perjury, I declare thffi I have examined this return and axompanying schedules and statements, and to the best of my
knowledge and belief, they are true, correct, and accurately list all amouMS and sources Ot income I received during the tax year. DeGaration
~~ of preparer (other than the taxpayer)is based on all information of which the preparer has any knowledge.
Jointrettun? Yoursignature Date Youroocupation Daytnrlephonenumber
See page 17. TIRED
fo~ ur~py Spouse's signature. N a joint return, both must sign. Date Spouse's occupation
Paid Pnnf/Typepreparer'sname Preparel'ssignature Date Check -~ 'rf FTIN
ROBERT WALLACE 2/25/2011 ~'~nPbYed P00531960
preparer Fan's EIN- 2 5 -17 6 9 6 31
use only Firm's name - 8 AND R BLOCK
Firm's address - CAROI SL8 PA 17 013 Phone no. (717) 9 6 0 - 0 0 0 6
Form to4oa(2a1o)
1o4oA~2o1o> Fnlo4oa-2v1.1S
Form So twareConyright 19~- 20+f HRl3 Tar Grnvp, Inc.
SCHEDULE B Interest and Ordinary Dividends OMBNo.1545-007tt
(Form 1040A or 1040)
Department of th a Treasury - Attach to Form 1040A Or 1040. - See Separate Instructbns. Attachment
Internal Revenue Service (99 U e ~S
Name(s) shown on return Your social security number
CAROL H BAYES 147-16-4408
1 list name of payer. If any interest is from aseller- financed mort
a
e and th
b
d
Part I g
g
e
uyer use
the property as a personal residence, see separate instructions and list this
Interest interestfirst.Ado,showthatbuyer'ssocialsecuritynumberandaddress -
(See separate CITIZENS
instructions and CITIZENS
theinstructions
for Form 1040A, or SOVEREIGN BANK
Form 1040,1ine8a.) SOVEREIGN BANK
Note. If you
received a Form
1099- INT, Forrn
1099-OID,or
substitute
statementtrom
a brokerage firm,
fist the firm's
name as the
payerand enter
the total interest
shown on that
form.
2 Add the amounts on line 1 _ _ _ .
3 Excludable interest on series EE and I U.S. savings bonds issued after 1989.
Attach Form 8815. .
4 Subtract line 3 from line 2. Enter the result here and on Form 1040A, or Form
Part II
Ordinary
Dividends
(See separate
instructions and
the instructions
for Form 1040A, or
Form 1040, line 9a.)
Note. If you
received a Form
1099- DIV or
substitute
statement from
a brokerage firm,
list the firm's
name as the
payerand enter
the ordinary
dividends shown
on that form.
5 List name of payer -.
14,140.
1 880.
a sls.
1,314.
20 149.
ao 149.
Amount
6 Add the amounts on line 5. Enter the total here and on Form 1040A, or Form
1040, line 9a - 6
Note. If Ime 61s over $1,500, u must Dorn fete Part III.
Youmustcompletethispartifyou(a)hadover$1,500oftaxableinterestorordinarydividends; (b)hada Yes NO
Part III for ' n account; or c received a distribution from, or werea rantorof, or a transferorto, a fo ' n trust.
Foreign 7a At any terse d wring 2010, d id you have an interest ~ or a signature or other authority over a financial
Accounts account in a foreign country, such as a bank account, securities account, or other f~ancial account?
and Trusts See separate instructions for exceptions and filing requtrementsforForm TD F 90-22.1 _ _ _ g
(See b B •Yes,' enter the name of the foreign country -
In~astructieons 8 During 2010, did yrou receive a distribution from, orwere you the grantorof, ortransferor to, a
) for ' n trust? if •Yes • u ma have to file Form 3520. See arate instructions . ~[
KBA For Pa Red ion
perwork uct Act Notice, see your tax return Instructions. Schedule B (Form 1040A or 1040) 2010
1040- Sch B (~2010~ FDB-1 V 1.6
Potm SCfTwar? : npy uhf 139@ - ?Ott HnR T.as Gr•.~ap, tic.
REV-1503 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCNEp1~LE B
STOCKS & BONDS
ESTATE QF ` ' '-- '"""'---
Ca„t~ol t1 . ~aye.s ~(- l~ -o ~a 3
All properly jointly-owned with right of survivorship must be disclosed on Schedule F.
VALUE AT DATE
ITEM OF DEATH
NUMBER DESCRIPTION
,. ~~y 50.,-e own~~ ~.~s;~~s 4 ~ ~, 6 ~a. al
` ~ 6 6, a7g. qa
~e.c s Vie. ~,cx't.~ c~~c
~ 9. ~6~ ?6
~x~.~ ~ ~ob,~ ~.
Y ~(y~ `~
02. v- S. JQUth g ~'nd$ Ca~ack6~~ ~60~ooO.~D
TOTAL (Also enter on line 2, Recapitulation) I $ ~ 'J~, 1 `f Q . $'
(If more space is needed, insert additional sheets of the same size}
421301 000318 0012144
Pays 1 d
BNY M):LLON
sHAaEOVVNeR st:RYlcrs
P.O. Box 358035
Pittsburgh, PA 15252-8035
oooasie of as o_ss7 ••evto r~ o easy moss-s9TSOa col aswt -i -
i...I11...111....I.t..i.I...11.I.I..I...t.ll..ll....l..l..lirl
CAROL H HAVES
504 JAbES STREET
MECHANICSBURG PA 1776
THE HERSHEY COMPANY
INVESTOR SERVICES PROGRAM
STATEMENT PRWT DATE: 12/20/2011
~~; ~1-750278661 ~
SYMl30L.: HS'
ACCOUNT KEY: HAVES--CAROHOOOi
INVESTOR Ip; 80634747322:
VISIT NiTP-JIYYYYW. ANY.COIMR FOR bIVESTOR
RELATIONS MFORbiAT10N. ARE YOUR NAME Ate ADDRESS
CtJR~NT Sr OUR RECOROS't C/LLL800-851-4216 OR 600539.0261
FOR ASSISTANCE.
Year-To-Dai+e Account Summa Save this Statement for Tax Purpose:
AsoP t>ytslayfo cASH olvol~ms NETAMOINdT
TOTAL Id1R10:t VALUE ~ CLOSIIKi PRICE (~ a1VE511IB115 (:) TOTAL (S) __. TAX YNTIa~.Dt>:) . AYOUNTTO aIVEST (s) RtVESTED (i)
17,60221 48.0800 460.94 460.94 460.94
TRADMIC F~ PAD gy I~ SBtVICE FB3 PAID BY ~) SALE OF PLAN SlNRES ~ CIOt71RCAT® SHARES HELD SHARES Nf3D BY TOTAL
CO~ANY cOIIPANY ~g pR0~0S TAx p HELD BY YOU BY PLAN OTHER PLANr3) sHAREs
0.45 3662548 366.2546
42130100033160012142
Form 109 9-DIV Divide nds And Distributions ~ o
to Total ordinary d-ividends 1b QuaiBsd diriderlds
94
#460 ~
Copy B for ReCipitartRs OMB No. 1345-0110
_ -
$460.94 .
ain distr
l
ild
T
2
t ffi t>rrrecap- Sec-125D 9al^ 2c Section 'IaD2 gain 2d CoMeables (28%l 9~ pt aided)
.
g
sap
o
a
a Dl~1.ICATE
K dwdai)__ _
__
3 Nonditiidertd dielribeone 4 ~~ teeuaee tax 6 Foreign tax paid paFasess+otlY Or U-S.
8 Cash -
Distribt/Bom 9 Noneaslt
D
By wlwla t~ THE HERSHEY COMPANY -
To Whottl Paid
CAROL H HAVES
S STREET Payers Federal Ider4ificaLion Number
23-0691590
504 JAME
MECHANICSBURG PA 17055-3976 ~~ oescnptwn
COMMON
---
--
-- - -- - --
Re~orted By The Bartle d New York
Halloo
ReTapienCs Ideluilkkxtion Nurttber )C)CX XX-4408
OIt Fie ~w ~
.brsey City NJ 07310
Account Key
HAVES-CAROH0000 001 750 42786610 (600) 651-4216
www.erhmiewn.
•_* tMPOFrTANT TAX NATION "*
of imposed orr you ~utoonr is faowbla attha 1 de4eraline tt>Iet it h been rsFwrled. a ~BM~
ACCwaIt Nupnber: Tuley show an account or other raY+que numbs. the payer Box 2d Shows 28% rye gan from aalea or wrdierrges of oo~edibtes. M required.
~ ~ Y~ acoour4. use this amanrt when oornpletng the 289L Bale Cain 1Morloheet-Line 18 in 11==
Box 1 a Shows tnfat ortBrler~r nd~vidends that are leomble. include this ~nourd Ora ~ Sd~sdul° D (Form 1040).
,,., ~:..., o• ..s ~...,. +nsn ... ~ e er•...anr..r e M S~~ dw a rFevm 1n4rA Box 3 Shows the Dart dthe daUibutiorr tl18t ~ rwntaxabie because 3 is a teller
It is import~t to retain this staterrl~rt for tic reoortirlo Q and for use as a referer~
when you aaxss your account onOne at ow~ wetrsite or when cartacdrrg CargrrRersliare. ~~ Account Number: 00000819701
If you want to make an optional cash purdmse at this lime, please make you check payable to Computershare. Please writes your Holder Accotmt
Number and the Catlpar-y name on the c~tecit or on your txwer~etter. Please send your c~ecic to: Corrlputershare, P.O. Box 6t~6, Carol Sfiream, IL
60197-6006.
- ACCOUNT SUM~IIARY
As of close of stock market on 10 Dec 2010
- Sbodt Class. I `Gertlficated Shares! ~ Di[ect Registr~on: - Imp-Plan. Toth
~ Closing Pace"
~ -Market
Descr~tion) ~ !!rite- tieki by 'you I , Book SiiaresNn9s ~ .Book Sllares~Flrtits I Sl>areaJtlr~its Per SttarelUnit (Sj Valet ($)
DSPP - Canrnon Stock 0.000000 0.000000 95.302003 95.302003 72180000 6,878.90
Dividend Reinvestment Activity As of record date
This section indtrdes information only for shareshmits ~ wfach are retrnies~d.
RecordI Payment Dividend Stock CNass Divklend ReimesiJmerrt Gross ! Taxes Net
_~__ Date-1_- _~ L_ ~~) _ --@escri~on ( ---- Sharesitlnits-Dividend (s} t Yltitidtetd (S) ! Dir_idend (~-
12 Nov 2010 10 Dec 2010 0.440000
94.719678 41.66
41.s6
Transaction History From: 01 Jan 2010 To: 10 Dec 2010
This sedior- pertains onry tobode-entry sharestunks.
T
T I
d
Dale I
I ' ~ f Amount (S) ( Amourd (#) ~ ShazefllMt~ I SharesNtits ~ esNnits
Sher
Plan Tra>sactions DSPP - Carrion Sbdc
Balance Fonrad 927T3898
10 Mar 2010 Dividend ReQtvestinent 38.97 Comp Paid Fees 0.01 36.97 66.120441 0.5379 93.36;1277
10 Jun 2010 Dnriderb Reinves6nent 41.08 Canp Paid Fens 0.02 41.08 60.621317 0.617649 94.040926
10 Sep 2010 Dividend Reirrvesbrrent 41.38 Cane Paid Fees OA2 41.38 60.964868 0.678752 94.719678
10 Dec 2010 Divider-d Rem 41.66 Comp Paid Fees 0 01 41.68 71.575163 0.562325 95.302003
Pt;3RTANT TAX-RE('URML10CUlY~NTA'ITACHED
oor~--rnx Oaec ~ami Please~see inpoRard PRNACY t10TTCE on reverse side of sfate~nent
__
E~~on Mobi 1 ~~~~ ~ fig, Dividends and Distributions
PAYER'S name, sheet address, city, stale, and ZO' code
EXXON MOBS. CORPORATION
CIO CAE
P.O. BOX 43010
PROVIDENCE R102940-3010
RECIPIFA'PS [cane, street addre~, c6Y, state. 21P code
CAROL N HAYES
504 JAMES ST
MECHANICSBURG PA 17055-3976
1a Tdel oidnary dividends tb famed dnldeMs
i [63.17 S 163.17
3 Nondiridend 4 Fedaai inware taut vritlrbeld
s s
6 Faeipn tat paid 7 r-aeigo aomfry a U.S. possession
S
E Cash Ligridaioe tksYbaim PAYER'S Fedaai idarliCatlon rgsnber
S 13-5409005
RECIPIDii'S ideM~an rg,mbar Amamt tngtr6er (see irabra~orrs)
endrg qt "'-"406 00000819701
Starrlra~r of n~otte6le iroane f Paid ardlar Reirvesled do rot
ra0ed tled<g3orts for tart vtilrheld, iFary)
Annxrl Paid 6y CherdrlEFr AngrrM Reinvested
S 0 S 163.11
Catgpanr Pad Fees ~Peny Paid Service Charges
: 0.06 S 0
Disaoud on rrretd
S 0
oMa No.1s45.0110
Zoo
Farm 1099-DN
copy s
for Recipient
71ris is impodad lar idonrr~ion
aed is being hrrnisNed b [fie
krlarral Revenge Sanice- b you
are required fo lie a re6gm, a
negiperxe penally a other
sarg:iort may be irposed on
you d !his ircorrre a taxable and
the IRS de> tral i has
apt been reported.
Form 1099-0IV (keep for your records) ollha Trtresay -- hdernal Revenue Servka
w.~~,awnm Rt'J.u4t A_i'VL.i[fNi1/LJ39_SbIMlfIp1J11/1HI42)
. ~ -S
~ I~lolder Account Number 00002949806
- ACCOUNT SUMMARY As of close of stock market on 10 Dec 2010
Stock Class Cerfifid Sues , Direct Ramon Irnresbnerlt`Plan < Total Closing Price Market
.Description ~ Held by You ~ i3ook,Shares ~ ' Book Shares I Shares ~ Per Share.:(;) ~ Value {~)
DSPP - Cortlrnon Shock 3.000 0.000 63.764 68.764 144.8'10. 9.668.76
Dividend Reirnestment Activit~r As of record date
This section ilndudes information only for shares for which dividends ate retilvested.
R Dam I P~Datet I R,~ I ~d i~ I Dividend { Gross I Taxes ~ Net
~) ption Reimrestment Shares 1 Dividend ($) Withheld ($) Dividend ($)
10 Nov 2010 10 Dec 2010 0.65 Corman 66.472 4321 -_ 43.21
Transaction History From: 01 Jan 2010 To: 10 Dec 2010
This section pert~ns Doty to boric-ea~try shares.
Date ~ Transaction + Tra-uaction ( Deduction ~ Deduction ~ Net I Price Per I Transaction ( Total
Description [Amount ($) f Descriptor Amount ($) Amourrt (S) Share (S) Shares Book Shares
Plan Trons DSPP - Corrnlon Shock
Balance Forward 62.538
10 Mar 2010 Dividend Rei~ve~neM 36.05 7ransactiort Fee 0.72 35.33 126.757 0279 62817
10 ,kar 2010 Dividend Reir-resfnnerd 4278 TransacYon Fee 0.86 41.92 127.987 0.328 63.145
10 Sep 2010 Dividend Reinvesknerd 4299 Trar>sadial Fee 0.86 4213 128.854 0.327 63.472
10 Dec 2010 Dividend ReinvestrneM 4321 Transaction Fee 0.86 4235 144.837 0.292 63.764
oo~r+-reM
it is a return of your cost {or other basis). You mus# reduce
your cost {or other basis) by this amount for figuring gain or Lass
when you sell your stock But if you get bads ati your cost
(or other basis). report future distributions as capital gains.
See Pub. 550, tnvestrrlent Income and Expenses.
aow~os ~. snot
~~ ..
r
~~ ~~~
~ . ~~~
DN vrith the IRS for each of the other owners to show their
share of the income, and you must famish a Form 1099-DIV to
eadt. A husband or wife is not required to file a nominee return
to sham amou-1is owned by the other See the current tax year
General instnrctions for Certain Information Returns.
152UDR
' t6APORTANT TAX RETURN DOCUMENT ATTACHED .
PAYER'S name, street address, city, state. and ZIP code
IBM
coo coMPUrERSHARE
P.O. BOX 43010
PROVIDFJJCE 81029403010
t~Hii's name, address, city, state. z>P ~
c~Ra.HaYEs
CORRECTED (if checked Dividends and Distributions
to Taal ortnary dirideMs to Died dividends oMe No. 1545-0110
i 165.03 s 165.03
3 Nor~iridend drsb~butions 4 federal income fax witldtdd
s 2010
s
fi Fo~ign tmc paid 7 Forego onmlry «U.S. possession
F«,,,1099-DN
8 Cesh ~+ FIAYER'S Federalidentfiealfon rMrrlhsr
: 13-0871985
r~aPasrrrs ,arn« meal t~ l Copy B
m ~ ~-44oe ~ For Recipient
Y of renortable'sloorne rael,.~ v~:r ~w o :.......... y __. nis is ine>on~.r ra. rha~,.~:~..
'~..
' -~ C i t i z e n s B a n k® Customer Receipt Please be wre to enter this
transaction in your records.
Transaction Date Amount
Description Account Number
SAfiR ~THtS~~ t~0 ~(X875~ Ti`;Oi ~~1,0~.'~i
Funds from your deposit may not be available for immediate withdrawal. All transactions are subject to
2'1089-BUNKER BA6IMIPK veriftcation as outlined in the rules and regulations of the Bank. Member FDIC
C i t i ze n s B a n k® Customer Receipt Ply ~ wre to enter this
transaction in your records.
Ttansaction Date Amount
p~~ption Account Number
~il?"~~102718? 50~.i2 0110111 i3.44
SAAR ~dTNt~l) 30~IQi~~5'~ TC~ ~~1~6,~3.~t"~
Funds from your deposit may not be available for immediate withdrawal. All transactions are subject to
22089-BUNKER 8I061AAIPK verification as outlined in the rules and regulations of the Bank. Member FDIC
please be sure to enter this
~€ C it i ze n s Ba n k® Customer Receipt tre~~~ in your records.
Date Amount
Transaction
Description Account Number
t7t~r~`3'~JO271$'I JOJ3 41105111 13:05
Sfl/IR 4JTN~~d) ~4}O~tX9452 TI~':~2 ~30~~.58
Funds from your deposit may not be available for immediate withdrawal. Alt transactions are subject to
venfication as outlined in the rules and regulations of the Bank. Member FDIC
~.gUNKER 61061 MR'IC -.
• • 006-7615 ~ ~ ~-''~ ~~ ` ~ ~
C~t~zens Bank ~~
. l.:a r ~, t:a r ~/ f"; 7 ~.+fl 1 l
:~~ X61 •~7[*:. ~-.r ~.~ .y, 111 ~.~ ~ #_.~' . W. ~,~.,~ ~~ ~ "~`' .K ' ~.. ~.. i~
MEMNOT~ ~ c •~ ~
PAYMEndJ ~ Sn -ww,w .ra l~fr~
NON-NEGOTIABLE
• ~ C i t i z e n s B a n k° CUStomer Receipt please be sure to enter this
transaction in your records.
Transaction Date Amount
Description Account Number
t`~iT027187 ~.,~ 41IQ5J11 .t,i,14
SAfi~ ~ITN(5~? I ~I~}(88.59 TG;~ ~14a'~~,{~4
Funds from your deposit may not be available for immediate withdrawal. All transactions are subject to
~-BUNKER 8q8 1M/PK verification as outlined in the rules and regulationu of the Bank. Member FDIC
~€ C i t i z e n s B a n k° Customer Receipt Please be wre to enter this
transaction in your reeds.
Transaction Date Amount
Description Account Number
kJU~?ttG~JVtf1~ JV:J/ V11UJit1 1JwV?
SfliIR ~ITH(~7 L~F~O }~64~ TC~ ~1fi~~47,3G
Funds from your deposit may not be available for immediate withdrawal. Alt transactions are subject to
YL088-BUNKER 81D6 tMIPK verification as outlined in the rules and regulations of the Bank. Member FDIC
C it i ze n s Ba n k ° Customer Receipt please be wre to enter this
transaction in your records.
Transaction Date Amount
Description Account Number
Oc~t}~32J029187 #~ 01iQ5i11 13: ~P3
SAAR ~dTH(~7 0 ~(4'.~27 Ti'~;G2 ~14~0~3,5?
Funds from your deposit may not be available for immediate withdrawal. All transactions are subject to
22089-BUNKER EAD6 tMIPK verification as outlined in the rules and regulatiorn of the Bank. Member FDIC
C i t i z e n s Ba n k° Customer Receipt please be wre to enter this
transaction in your records.
Transaction Date Amount
Description Account Number
04ti{?~'~2J027167 ~t~ ~11(~f11 13ci~
SAIIR bITHc:~d? 40~G ~{X~Otk){2 Ti;:,~ ~14•~f0,~~
Funds from your deposit may not be available for immediate withdrawal All transactions are subject to
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