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Home My WebLink About04-14-111505607121 REV-1500 a (~, ~~Y PA DeprbrontdgjreAb BnanloftndNdiWTaiaes ~hhC~ Yer FbtflmEx Poeox2~oeot INHF.RfTANCETAxRETURN 2, 1 1 D 0 5 7 2 t~~raun PA t717tb6S01 RESIDENIT DEI~DENT t7liER DECENT SIFORMATiON 8t10Y11 3odU Security Number Date d Death Dib of Batll 1 7 1 2 8 0 4 1 9 0 5 2 5 2 0 1 0 0 2 0 7 1 9 3 5 DeaedarA's Lase NMrre slrlfac DeoedeaPs Fast Name rvll MCC 0 M B S A N N A M 1~ MP~+bN1(=~- SrevlMrrp Spalaek InRorneagoo t3aiow 3paae's Last Name Sulibr Spouse's Fast Name ~ MI Spouse'a SocW Seaarly Narrber . THIS RETURN MUST BE FlLED tN DUPLICATE WITH THE REGISTER OF WILLS FILL Sl APPROPRIATic OVAl$ tlF].OW 7.Oliparal ileben ^ 2 Suppletrlerrtai Rshsrr ^ 3. Rsrnaklder Raban (dds at daMh ^ 4. L1nr6sd Estate _ ^ 4a Fuhms Interest Compromise (dale of pbrb t2-7382) ^ 5. Federal totals Tax ItstlsT Flsquaad ® B. Decederk Dbd Testsle ^ dssAh a1Mr 12-12.82) 7.Oecederrt llaartaaNd a LMag Tnrst 8. ToW Nuaber of Safe Depose Baooss Wtaeh Capy dam) (Attadr Cagy of Tnpf) ^ 9. WOdi°e Proceatls RsaeWed ^ 70. Spousal Poverty Credk (dde of death ^ 11. tUectiaa b tarr rerder 9sa. 6173(A) behaeen 7237-01 and 1-1.63) (Attagr Sch. p) OO ~ ~PONDEIST-~TiN86Et:110N MUSE BE COi1.E7ED. ALL COOIpBICE AND fXlI~fN1. TAXStia01S61U1DN tiller DN~:fED Ttk e DaylYne TsNpirarb Number G R E G O R Y R R E E D E S B ? l 7 2 3 8 0 4 ~,4 Fam Nt:ne (it/lpplicable) ~ G=' Fkst Ikre aF address 3 1 2 0 P A R K V I E Y L N Seoard Nne of address Oily or Past pl8oe H A R R I S 8....U R G Sfale 21P Code L P A 1 7 3 1 1 Ota.Y' m ~~n ~ ~~~ ~ ~-~ c7 ~ -tr O ~ -ri `~ '-~-1 ~® c n x~ ~ "`~ r i'i i7 r; ~ C"7 ;;D _ti. i`+ ~ r'r1 -.. ~::.j ~:..: ::: -~ =_ C"~ f~ f~ ~~ SKa1MTURE OF PIiEPARER 07HFR'DiAa REPRE8B11'ATIVE ~~ ADDRESS .... .......... .. _. PLEASE USE Wll[iN1AL t~RY OItLY Side 1 1505607321 1505607123 •_ 1505607221 REV-1500 EX Decedent's Social Securky Number oeoedenrs Name: ANNA M• M C C O M B S 1 7 1 2 8 0 4 1 9 RECAPITULATION 1. Real estate (schedule A) ................................... ..... 1. 5 '8 3 6 5. 2 4 2. Stocks and Bonds (Schedule B) ............................. ..... 2. 3. Closet' Held Corporation, Partnership or Sob-Proprietorship (Schedule C) ..... 3. 4. Mortgages & Notes Receivabb (Sehedub D) ................... ..... 4. 5. Cash, Bank Deposks & Miscellaneous Personal Property (Schedule E) .. ..... 5. 1 $ 3 1 6 1 • 8 0 8. Jointy Owned Property (Schedub F) ^ Separate Billing Requested .. ..... 8. 2 7 9 2 0 . 9 6 7. Inter-Vivos Transfers 8 Miscellaneous N -Probate Property (Schedule G) ~ S eparate Billing Requested .. ..... 7. 2 8 9 3 3 , 5 2 B. TotalGroasAssets(totalLinesl-7) ,,,,,,,,,,,,,,,,,,,,,,,,,,, g. 2 9 ~8 3 8 1, 5 2 9. Funeral Expenses 8 Administrative Costs (Schedule H) ............ .... 9. 3 2 4 4 7 , 3 3 10. Debts of Decedent, Mortgage Liabilitbs, & Liens (Schedule I) ........ .... 10. 11. Total Deductions (total ones 9 & 10) ....................... .... 11. 3 2 4 4 7 , 3 3 12. Net Value of Esmte (Line 8 minus Line 11) ..................... .... 12. 2 6 5 9 3 4 , 1 9 13. Charitabb and Governmental BequestslSec 9113 Trusts for which an ebction to tax has not been made (Schedub J) .............. .... 13. , 14. Net Value SubJect to Tax (Line 12 minus Line 13) .............. .... 14. 2 6 5 9 3 4 . 1 9 TAX COMPUTATION • SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxebb at the spousal tax rate, or transfers under Sec. 9118 (a)(1.z)x.o _ D. 0 0 15. 0. 0 0 18. Amount of Line 14 taxable at lineal rate X .0 _ 0 • 0 0 18. - 0 . 0 0 17. Amount of Lkre 14 taxabb at sibling rate X .12 5 6 8 5 4. 4 8 17. 6 8 2 2. 5 4 18. Amount of L'are 14 taxabb at couateral rate x .15 2 0 9 0 7 9. 7 1 1 g. 3 1 3 6 1. 9 6 19. Tax Due ............................................ ....19. 3 8 1 8 4. 5 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505607221 1505607221 J REV•1500 EX Page 3 Fik Number Decedent's Complete Address: z1 10 os72 DECEDENTS NAME ANNA M. MCCOMBS S7REETADDRESS CITY STATE Zip Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credils/Paymenis A. Spousal Poverty Credit B. Price Payments 36,000.00 C. Discount 1,800.00 3. InteresUPenaltyrfepplicable D. Interest E. Penalty (1) 38,184.50 Total Credits (A +B +C) (2) 37,800.00 Total InteresUPenalty (D + E) (3) 0.00 4. M Line 2 is greater than Line 1 + Line 3, enter the d'AFerence. This is the OVERPAYMENT. , Fill In oval on Page 2, Une 20 to request a refund. (4) 0.00 5. H Line 1 + Una 3 is greater than Line 2, ante the ddference. This is the TAX DUE (5) 384.50 A. Enter the interest on the tax due. (5A) B. Enter the total of Une 5 +5A. This is the BALANCE DUE. (56) 384.50 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: Y~ ~ a. retain the use or income of the property transferted : ...................................................................... ^ b. retain the right to designate who shall use the property transferred or its income : ............................... ^ Q c. retain a reversionary krterest; a ................................................................................................ ^ d. receive the promise fa I'rfe of either payments, benefits a care? .................................................... ... 2. If death txxx,rted after December 12,1982, did decedent transfer properly within one year of death without receiving adequate consideration7 ........................................ 3. Did decedent own an'in trust for" a payable upon death bank acxount a security at his a her death? ......... ^ ^X 4. Did decedent own an Individual Retirement Accrount, annuity, a other non-probate property which contains a benefidary designalion? .................................................................................................. ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. .j' T . ~ r Fa dates of death on a after July 1,1994 and bore January 1,1995, the tax rate imposed on the net value of transfers to a fazthe use of the surviving spouse is three (3) percent p2 P.S. §9116 (a) (1.1) (i)]. Fa dales of death on a after January 1,1995, the tax rye imposed on the net value of transfers to a fa the use of the surviving spouse is zero (O) percent [72 P.S. §9116 (a) (1.1) pi)j. The st~ute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements fa disdosure of assets and filing a tax return are still applicable even if the surviving spouse is the anry benefiraary. Fa dates of death on a after July 1,2000: The tax rate imposed on the net value of transfers from a deceased child twenty-0ne years of age a younger at death to or fa the use of a natural parent, an adoptive parent, a a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the n~ value of transfers to a fa the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) I72 P.S. §9116(a)(t)]. The tax rye imposed on the net value of transfers to a fa the use of the decedent's siblings is twelve (12) percent ]72 P.S. §9116(aN1.3)). A sibling is defined, under Section 9102, as an Individual who has at least one parent in common with the decedent, whether by blood a adoption. REV-1502 EX + (8.98) SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANW INHERITANCE TAX RETURN RESIDENT DECEDENT OF ..~~ ovmvcrc ANNA M. MCCOMBS 21 10 0572 AU real property owned eoleltr or as a tenant N common moat be reported ffi fa& market value. Fair market value Is defined as the price at which exchanged between a wiNng buyer and a wiMirlg seller, neither bei rwrrl property would be ng peYed to buy or seN, bosh having reasonable knowkidge of the rekrvant fads. RealorooeervrwW,ieMiNM..u.....n ... .vu _._.._.~___.,-_---.. _ EM NUMBER DESCRIPTION VALUE AT DATE t. Real estate located at 413 Third Street, Enola, Pennsylvania. OF DEATH Sold through a real estate agent. See copy of settlement sheet attached as Exhibit "1". 58,36 (Net amount) _ TyrA1(Also enter Ori line (K more space b needed. kareA additlonal sheets of the same sim) m,..,._....M._..w_._„.~_... ....,......~,.,,.~..,,,,,....~... ., . REV-1508 EX + (8-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. IN RES DENT DECEDENTRH PERSONAL PROPERTY ESTATE OF FILE NUMBER ANNA M. MCCOMBS 21 10 0572 IncNrde theproceedy of litlgatbn and the date the Proceeds were received by the estate. ~ PrePeKY Iol~Yowned with right of surr'norshlp must be disckrsed on Sehadule F ITEM . , NUMBER DESCRIPTION VALUE AT DATE t• PSECU savings account OF DEATH (see copy of letter attached as Exhibit "2") 12,047.67 2. US Savings Bonds (see copy of reporting form attached as Exhibit "3") 7,999.50 3• Sovereign Bank (56,872.55 less 3326.58 in checks written before death but cleared after death) 6 545 97 (see copy of letter attached as Exhibit "4") , . 4. Wells Fargo (see copy of letter attached as Exhibit "5") 89,349.18 5• Wachovia IRA (see copy of letter attached as Exhibit "6") 41,572.70 6. John Hancock Annuity (see copy of letter attached as Exhibit "7") 16,695.20 7. Manulife Stock - 246 shares @ $16.45 per share (see copy of document attached as Exhibit "8") 4,046.70 8. United Health Care Inpatient Hospital Stay: 6/9/10, 7/17/10, 7/17/10, 1,845.11 9. Verizon rebate 2 89 10. Manulife financial dividend 25 74 11. Private sale and liquidation of household furniture and furnishings 900.00 12. I Patriot News Refund I 21.75 13. Comcast Refund 86.39 14. Harrisburg Gastro Refund 15.00 15. US Savings Bonds 2,008.00 (see copy of bonds and reporting form attached as Exhibit "9") TOTAL (Also enter on line 5 Recapitulaation) I S 183 161 80 (H more apace b needed, hL9ert addtlbnal slmefs of the yams ylzel .._.,:.,.. ,w.d,,..._....._..,....,,_.._r..,.,.,_..,~._,_,w.,,...._.,_. ..__,.._,~,..,............._...,..._~..~~._..._.~.._....~_ REV-1508 F>(+ (6.98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERffANCE TAX RETURN OF ANNA M. MCCOMBS 21 10 0572 k an asset was made joint within one year of the decedents date of death, k must be ropotted on Schedule G. A. SURVIVING JOINT TENANT(S) NAME Hill Road, New ADDRESS Sister TO DECEDENT c JOINTLY-OWNED PROPERTY: REM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANGAL INSMUTIDN AND BANK ACCOUNT NUMBER OR SIMILAR I~NTIFYING NUMBER ATTACH DEEP FOR JOINTLY+IELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT S INTEREST 1. A. unknown Wachovia account 55,841.91 50. 27,920.96 (See copy of bank statement ending 5/26/10 attached as Exhibk "10'~ _ TOTAL (Also enter on line 6, Recapitulation) I S 27 920 96 (H more space b needed, tn9ert addihortal sheets of are same size) REV-1510 EX + (rrgg) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN DF SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ANNA M. MCCOMBS 21 10 0572 This schedule must be complebd and filed fi the answer to arty of questions 1 thrrngh 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM DESCRIPTION OF PROPERTY ~' u° NUMBER ' E'"E"u~°""E'"""~E,n°""g'v'°'~s"°T°°EC~°wT"'a '"E4N~OFTRAN°~~'"n"q1^C0P1'0fT1E0~f0R1~~T"TE• DATE OF DEATH %OFDECD'S EXCLUSION TAXABLE 1. Sovereign Bank IRA - Gwendoyn H. Miller, sister, beneficiary VALUE OF ASSET 8 335 12 INTEREST 100 ~"rw~ VALUE (see copy of bank letter attached as Exhibit "3'~ , . . 8,335.12 2. IRA Annuity -Gwendolyn H. Miller, sister, beneficiary 20,598.40 100. 20 598.40 (see copy of Lincoln Benefit Life letter attached as Exhibit "11'~ , 3. PSERS Account -Gwendolyn H. Miller, sister, beneficiary 36,643.96 0. 0 00 (see copy of letter attached as Exhibit "12'~ . Exempt by statute TOTAL (Also enter on line 7 Recapitulation) I i 28 933 52 (If more space is needed, irmert additlaial eheeb of the same size) REV-1511 EX + (10-08) COMMONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN SCHEDULE H• FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ANNA M. MCCOMBS 21 10 0572 Debts of decedent must bs reported on lidreduk i. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t. Neill Funeral Home 7,680.87 6. ADMINISTRATIVE COSTS: 1. Personal RepresentaMre's Commissions Name of Personal Representatlve (s) Gwendolyn H. Miller 12,000.00 streetAddre~ 626 Paipe Hill Road t;lh New Bloomfield smte PA zlp 17068-9235 Year(s) Commission Paid: 2011 p, Attorney Fees Gregory R. Reed, Esq. 10,480.00 3. Family Exemption: (Kdecedents address is not the same as claunant's, attach explanatbn) . Claimant Street Address CtiY State Zip Relationsh~ of Claimant to DeoedeM 4• Probates Fees Register of Wills 399.00 5. Aocounhanrs Fees 6. Tax Retran Preparers Fees 7. Cumberland Law Journal -advertisement 75.00 8. The Sentinel -advertisement 1 ~ ~ 9. Members 1st -check fee 13.95 10. Donegal Insurance Group 303.00 11. Diller -trash removal 69.95 12. PPL Electric (May-October) ~ 129.87 13. PA American Water (May-October) 95.17 14. East Pennsboro School Tax 392.08 15. East Pennsboro Township -water/sewer (April-September) 230.00 16. 2010 1040 Income Tax on US Savings Bond Interest 444.00 TOTAL (Also enter on line 9, Recapitulation) i 32 447.33 (N more space is needed, insert additional sheets of tire same size) REV-1513 EX+ (11-OB) Pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RES1DENi DECEDENT esrare OF FILE NUMBER ANNA M. MCCOMBS .,, ,~ ~~~„ NUMBER NAME AND ADDRESS Of PERSON 5 RECEIVING PROPERTY () RELATIONSHIP TO DECEDENT Do Not List Trustee(s) c,-,V-VV/G AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1 • Gwendolyn H. Miller, 626 Paige Hill Road, New Bloomfield, PA 17068-923 Sister All of Schedule F & G 2. Gregory Rowe, 11 South Market Street, Shiremanstown, PA 17011 Nephew 1/11 th of the residue 3. Brian Rowe, 300 Catherine Street, Ashland, PA 17921 Nephew 1/11th of the residue 4. Michael Rowe,153 N 2nd Street, 1st Floor, Frackville, PA 17931 Nephew 1/11th of the residue 5. DeAnn McCombs, 6324 Old Hgb. Road, York Springs, PA 17372 Niece 1/11 th of the residue 6. Sarah Shreiver (McCombs), 326 4th Street, Enola, PA 17025 Niece 1/11th of the residue 7. Duncan McKenzie, clo Dee McKenzie, 7824 Tanglerod Ln, La Mesa, CA Nephew 1/11th of the residue 8. Daniel McKenzie, c/o Dee McKenzie, 7824 Tanglerod Ln, La Mesa, CA Nephew 1/11th of the residue 9. Jeffery Weaver, 606 3rd Street, Enola, PA 17025 Nephew 1/11th of the residue SEE ATTACHED ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 1B OF REV-1500 COVER SHEET, A S APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 fOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ~ Ir more space is neetled, Insert atlditional sheets of the same size. 10. Tammy Bixler (Miller), 472 Falling Springs Rd, Landisburg, PA 17040 11. Gregory Miller, 12 lhigans Mill Rd, Duncannon, PA 17020 12. Janice Shadle (Homer), P.O. Box 472, Gratz, PA 17030 Niece 1/11 s' of the residue Nephew 1/11th of the residue Niece 1/11'x' of the residue A. Settlement Statement (HUD-1) OMB Approval NO.2502.0285 ~ ~~ 1. ^ FHA y, ^ RHS 3. ~X Conv. Unins. 6. FNe Number: 7. Losn Number d. Mortgage Inwronce Ceae Number: 1 i-03 1101004214 4. ~ VA 5. ^Conv. Ins. C. Nob: Thu faun d Nmlftwd b pw you • flaYmarrt of ectwl tenement wrf. AmouMa ek b and tM sstlhmf r P by ' n Warne ere fhown. INmf marltad (D.o.oY wfn paid owfwa Ilia d0311p~ tMY N fhoww lien /or iMtnmalbnel purPONf end an nol krehldad b IM IolaH. D. Name a Addreaa d Borrower E., ~IM 4 AAdrase d Seger: qyn q. ~hw~ R7ibn4C.1~kMM,ar., A,eu WeMCQerttee } F. Name d Adtlroas of Lender. wsbn 8brlyape CapOr 820 West Oemwnbwn Pore, SuOe J50, PIManM Mestlny, PA 19482 G. Properly Location: H. Settlement Agent: 413 3rd Seer P.R.O. Sererrern Sermius I. Selfle,rtsnt Dale: 02/25/2011 Ends, PA 17025 TelepMre: 717.2443785 Fac 717-2140344 Disburaament Date: 02725/2011 Em Pemnboro Ttnmahip Plans o1 Seltbment: T1tleE>~ren 424 Wen PMn Street, Carde, PA 77013 100. CwwsMauntgueMomeamwr 101. Catrep err Price 400. 6renAntouMOwbSNir 102. Patxorui 85,000.00 101. CgNad aaW pke 65.000.00 103. SeRanenteher btarrowar ~ Oyw 1/00) 3.922.97 102 Pweonr m e 403. 1a. 1os. 404. 4os. uebnerrb brldnre d eelhrlnaMence 108 CByAoee LLxn uetrnerefor Rerm d ee0er in eavrta . b 108. CtlrMm lien b 107. ~~~e b 407. Court' la7tn b 1~• ~~ ~ 01/258011 b 0890/2011 203.03 408. Scholl Wcn OZ25I2011 b 081382011 109. 109. 203.03 110. Sewer e1n1 Trash 0?I2N2011 b 0313112011 53.87 410. Sewer and Trash 02258011 b 0313772011 111. 111. 53..x7 112. 112 120. gran Amour Due hem Borrower 09.179.17 . 4M. gron Amount Due b Sear 200. Amotrra Prd orM Brtrid Borrotvar i8,286.f0 800. RaduWons In Aetour Arab Bant 201. OepoWaeaner mmley 1.000.00 er 501. Eacae depttdl (aN Inrruc0ona) 202. Prirrjpr anPmtdnew brya) 83,050,00 502. SeMemeM Chargeebae0er (One 1400) 203. E s liken b 4,910.00 503 I 201. . a liken b 205. 504. Payo9dOrr mMgfpe ben 20d Seerr AOWWICe 505. PayolldaewM morlpage loan 1.950.00 207. CumbMrel Court' Grad 500. Se6er AfdeWrp 1.950.00 3,118.21 507. 208. 508. 209. 509. A ebIlMh7r Bemeu eW erllr A h 210. CityAuwl larva b e neMafor Rant rd erlar 211. County Wes OtA12011b0112512011 31.46 510. Ctlyrtown lean b 511. CounlT Wtes 01A18011 b02852011 212. Sehod tees b 31.46 512. Scholl lath 213. 00 513. 211. 514. 215. 515. 216, 516. 217. 517. 219. 518. 279 220. Totr Peid Borrower 69,170J7 519. 820. Tofr Reductlon Amount Due SNMr 4091 Al 700. Cash r BeWanant koedlo Bomowr 301. (loss annum due from hOnOww Ohw 120) 000. Ceeh r tiettlrrwrtt 1Mrorrr SrW 89.179.87 J02. Leas amants prd b'AOr borrower 91N 220) 801. f,Yosa emotmt due b setler (Wie 420) r 85,256.'„ 89.779.87 802. Less redoGtiont in amount due seller (9ne 520) 707. Ceeh Q From ~ To Bonovnr 0.00 - 6,891,46 007. Cafh 0 To ~ From &qer 80 --ra w wrr~m, . ,~,,,... -.,.rm,.r..uw.r..rwnw~waoxerow~..,s.,,«,,,w",.,..."...'"'..'_~.~~.w..amw.~a u,~..~ro.rv,.w,,.q,~. a. ,766.24 r.. i....o.~~,. m..,....,_..__~_-____. ••••i Yw~v e.M-N.NF~/.[W.x]FVwaawM Ham.lw,./^q II..MM1nw. Ikevbus tedltbM an obsolete Paya 1 d 4 HUD-t 700, iolNt4eyEeW &olurFen 33.900.00 I)Kldondtormtleibn 700 asfc8ows: 701• 51.950.00 m Prudmed liomeaab Servhai Pald From Borrower's Funds at Pafd From Seller's Funds at 702 51950.00 b CeMuy 2l Phrdareri Realty lne. 703. Cdnenbeion paid at aNarmnt 701. &uka Fee b PngenOal Fimnesale Sevres 705. Traliactlal Fee b Century 21 Piadoneri Reeky Inc. Settlement 195.0 Settlement 3,900. 0 225. 100. acme ebb In Cennesson sAN Loan BO1. Oaafynelbn chaps OncNrdx OdgnaBon Pdd %a 50.00) 5598.20 (from GFE #1) 802 Ya-aedll a eh#rye (peiMS) tOr Om speti0c NOereat ra0e chosen f (from GFE #2) 003. Yoa aa)ugad aipnatlon ahagea (from GFE AI ~. ~~ ba b aiid $avite (hen GFE #3) BOS. Cred'A repel b Krd FaeWal Gala (hen GFE #3) 808. Taz servie b Ban GFE #3 596.20 385.00 13.19 807. Flaad ceNMatlon b KrW Fachul Data (hen GFE et31 8.00 808. 5Ye Mae Cbahp Fee m NSial C (from GFE #3) 100.00 900• Mrne tared b M PeW In Adveaa 901. Deiy bbrep charyn Dom hen OL25R011 b OL0112011 ~ 37.BB13/daY (ban GFE #10) 902. Matyege Im. Prmrdum for rrbnMS ro Y~sbn Mat Sal (ham GFE #3) 903. ylomeowMls bsaance for maphs ro Reamsrolm Mulual Insurance C 3303.00 P.O.C. 'loom GFE #1 t) 31.53 904. mondts ro from GFE #11 1000. Reserves teak WMer 1001. Ilisal depotilfor your etaay axouM 0rom GFE ~) 1002. ItomeombYS inwrenq 3 mdaha S 25.25hnoMh 575.75 1003 Mapa e 1lturane IOI.BO . p e moMhi S 38.18hnaMh 50.00 1000. CK1'PropMy Tea monMi f O.OOnnoNh 50.00 1005. County WoDartY Tea 2 nroalu S 17AOInbMh 339.80 1006 Seh d 4 . o aei f0 snake S 19.01hna11h 5490.10 1007. Aggeqale AdlushneM 3195.85 1100. Tilb Ch 1101. Tsb serviw and bndefs 81b auuranca than GFE #41 1,018.75 1102 Settlamemaebibg tee b 5 1103. Oamer's Wb insaenee (hen GFE #51 1101. LerideVe tltle biurance 564&75 1108. Lan0eya 91b pa0ey Bnet 583,060.00 1108. Owrw'e Y9e poky twit 585,000.00 11 W. Agent's portbn d tlv! tDW doe iniurme pradan 3531.87 1108 Undamlrya por0on dlne laal alb iroaawe premium 311678 1109. Doaenerd PmpaaBon fas b P.R.O. Settlement SerNCes 5100.00 1110. Carbr FM ro P.R.O. SealemeM SerMeea 520.00 1111. tJOtary Fee b Cash 555.00 f0. 1112 Deed FnpamOan b Cen 21 P4ebneri Re Int. 128 1113. 100 No VnK100 b Fast Amedcan Title Insurance 350.00 1114, 3003urwylt00 bFWt American Tib lrlwrax:e 550.00 1115. 900 EPL•Rea78.1 b Fast American Tltle Insuralce 550.00 1118. Cbairg6vclelCL bFhM Arnedran Tiee lnaaaas f75.D0 1200. Goaemmrtl Record) end Trenefa C s 1201. GoveneneM recording ehergei (fran GFE #71 186.50 1202 Deed 552.00 374.00 Rebase 50.00 1203. TranaMr Was (from GFE #8) 680.00 i2M. CIglCoady tazlatamps Deed 5850.00 50.00 1205. Stall Taabtanpa Deed 5850.00 50.00 650. 1208. Deed 50.00 30.00 1207. UPI CeakeOOn Fee S2p,gg 1208. Graa Apeemenl 27.00 1209. AESigiment of Mortgage 540.50 1300, AddabnM Sealement Ch a 1301. Required servkes Mm you can slap for (hen GFE tt6) 1302 Survey ro S 1303. b 1301. Grant Rebell Fes ro Cumhedand Cou M 27 00 . 1305. 2011 Caaiyrtwp. Tazes ro DebMe L d Tyr CWecw 250,pp 1 : . 1 ~~ . .r. 1 .. enM n~ ..... .. 'Paid oulaide dtbaag M' (BKarower, (3)elbr~ ILbnder. ONryesbr, Bro(Kkr. Prevbus adlUOra are obsolete Gaga 2 of 4 MUD-1 aan of Good FaNh Eallmab GFE and M1M1 Ch a ~ Cannotlnreaaa Good FWh Eatlmab HU61 NU0.1 Lim Numbr Ow dlpinslbn ohr~ #801 Your aedlrcheryp (poiMSl forth specific bbreslrab dtomn 596.20 598'20 Your equslad #rignati0n rilsrges #803 0.00 Translr lases # 1203 596.20 598.20 650.00 650.W Ch a That Cm Chan IMOd depaaNfor yea eferaw account # 1001 flood Fdtl1 EatlmaN NUO.1 OaY iM i 1,209.00 IOI.BO y e2tt c wpeB Boni #901 57.86131day 31 52 Nomeownera Mtwance #903 . 31.53 TNN aendcea and lenders tltla insurance # 1101 420.00 303.00 OwrorstlW lMUranq # 1103 1,063.48 1.019.'5 0.00 0.00 # # Your irtANl ban amount N 563,050.00 Yaw ban mnn k ~ ~~ Yow IMIiA irdwut rate 4 4.5000% Yow IM091 moMNy amount OwNd for pAnGpal, InbrmL and arty morbape s319.4T irrhdm insuance Is O Ri~pd X^InWeat Natgape IMwanee Can your iM4mm ram rim? X^ No. ~ Yea. N can dse b a niaaknian d %. The Ant chmrge v4A ba On I I ant tan charge agrn every years albr I f ,Every change dale YOw bNreat rate can inaufie a decrous by 7L Over the Ala d the ban, yow Inbrest ra0e ie gurmumdbnmer be bunt tlmn %wNghrMan X Evan N you make vapne,rb m tlme. can yow ban balenm dmT X^ N0. ~ Yu, A can dm b a meakrarm d S EvM N you make paymm~ts on tNr1e, tan your montlay amount Owed for ~% No. ~ Yu, the Aral incream can bean I I and Om madily prirwga4 blared, fad mor~ape Nuuranca dm7 amount Owed can dm b S The madmum it can ever dm b u 5 Daea yow Ian have a prpaprmrd Pan+NY+ ^X W. ~ Yes, YOw madmum PreP+Ynent DendlY b S Does yow ban have a ba9aon paymrda ^X No. ~ Yas, you have a batlo0n payment dS d b ue yera on I I Towl madly amount awed Nwludkq escrow acwwq paynwda ~ Yau d0 n01 have a montMy escrow payment hK Nuns such s property taau and homeowners Inswanm. Ya must pq them Nems dmcay yourmN. X^ You have an addNbrml rrpnWy eurow payment d 5128.N Ihm resWts in a total Initlal moMMy mquM awed d 5047.91. This Indudas principal, inleram, arty mOripage IMUfante and any Items checked bebvr. I'rapenY mse6 ~ Naroowner9lMUrence u-._. u._..._._ -.. _ .. ... _ . Flood insurance -•s vw.,M.~N wuu. uw uausnnera unarges arp Wan I BmI611Stetl al 0110 bml, phase contact your lender. Prevbus adlrbns aro obwkte Pape 3 Of a Nt1D-1 PSEC~ June 7, 2010 Account # 0171 XXXXXX GREGORY R REED 3120 PARKVIEW LANE HARRISBURG, PA 1711 I Dear MR REED: The following is the status of ANNA MCCOMBS's account with PSECU as of the date of death. Joint Owner's Name NONE Date of Death 05/25/2010 Date of Birth 02/07/1935 Share Description Open date Balance Accruod Dividend S 0l Regular Shares 01/15/1976 $12,042.66 $ 03.17 S 04 Moneyhandler 01/15/1976 0.00 0.00 Loan Description Open Date Balance Accrued Interest L O1 PSL Loan 07/23/1984 $ 0.00 $ 0.00 The dividend earned from January I, 2010 through the date of death was $19.00. We do not have safe deposit boxes for our members. If you have any questions, please call 234-8484 in Harrisburg or our toll-free number, (800) 237-7328. At the menu prompt, enter 6 and then extension 2227. Sincerely, ,~ ~'va~1 Sue Walter Member Service Representative Finance Support Unit Pennsylvania Sfafe Employees Credif Union Main Address: 1 Credit Union Place, Harrisburg, PA 171 10.2990 • 717.234.8484 • 800.237.7328 Mailing Address: P.O. Box 67013, Harrisburg, PA 1 71 06-701 3 • 717.777.2100 (TDD) • 800.472.1967 (TDD) Thfe crodit union is fademlly insured by the Nationol Credit Union Adminislrorion. E ual O pSeCU.t0111 q pportuniy Lender ~~~~~Soverei n Bank .,,,~,. g PZ 92 ~ Processed SAVINGS BOND REDEMPTION INTEREST REPORTING FORM Date Redeemed 08/28/2010 TRANSACTION DISBURSEMENT ^ Cash TYPE(S) NUMBER OF #58 X Check ^ Sovereign Acct Credited Account #: TOTAL REDEEMED $7999.50 Ensure that the following information applies to the NAME on BOND/80ND OWNER. TOTAL 1099 INTEREST TO BE REPORTED IS $6,599.50 SOCIAL SECURITY NUMBER OR EIN 27-8651338 EIN NAME on BOND/BOND OWNER ESTATE OF ANNA I DATE OF BIRTH 02/07/35 STREET ADDRE33 of NAME ON BONDlBOND 626 PAIGE HILL RD OWNER CITY, STATE 3ZIP CODE NEW BLOOMFIELD COUNTRY OF CITIZENSHIP ::_:._~ ..._. Complete the Information below about the person cashing the bond(s) ONLY If NOT the NAME on BOND/BOND OWNER named above. _ NAME OF PERSON CASHING BOND(S) RELATIONSHIP TO NAME on BOND/BOND OWNER: GWENDOLYN H. MILLER, EXECUTRIX ^ ParenUGuardian ^ Trustee ^ Conservator X Executor ~Q: u::canvns ms~rucirons: You must cross out item 2 below if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. I certify under penalties of perjury, that (1) that the number shown above is my Taxpayer Identification Number and is my correct TIN; (2) I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all Interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. person (inGuding U.S. resident alien). Signature Legal Representative Title (if any) Date /mportantl By signing above, you certify that either 1) Your TIN is being used to report the interest earned on the savings bond(s) OR 2) You are authorized to sign on behalf of the registered holder/TIN reporter whose TIN is being used to report the interest earned on the savings bond(s) {i.e. you are the parent/guardian, trustee executor/administrator or conservator) Refer below for additional Federal Reserve Bank redemption resource Information. '~ Via telephone: 1-800-245-2804 8 Via the Internet: httpalwWwsavineshnn~le .,..., BRANCH USE ONLY Provide copy to customer, Retain copy in branch files. ngs Bond Redemption Forms special use enveloee the 1099 PROCESSING TEAM USE ONLY UTJ SBR001 REPORT DATE PZ 250 REPORT DATE o~ ~~ Effective 12/10/2008 Revised 07/15/2009 ~~~/// Calculated Value of Your Paper Savings Bond(s) Page 1 of 2 Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 08/2010 Total Price Total Value Total Interest YTD Interest 1 400.00 7 999.50 6 559.50 64.17 Bonds: i-58 of 58 ~o.~,~ "" Series Denom +ssue Next Final Issue Interest Maturity Price Interest Rate Value Not NA E _..._,_$25. 12/1975,Accruai_12/2005,_,....•,.$18.75 .,$116.00 ~_ ~ , $134.75 MA E .........$25._1.0/1975........ ..,....10/2005,..........$18.75_.. $.114.40` . .......- $133.15. , MA ...NA .E...:......$?5,07/1975 ..................._07%2005 .................,...... ..__..$18 75„ $114 40 , ... . _$133.15 MA .......$25 09/1975... _ :09/2005 - __$1875_..- $114.40...... _ . NA E ... _.._.__$25:06%1975.:...... __;.06/2005. 18.75._. , ....$133.15; MA NA E _ _._.$25 05/1975 __$.- . $114.40 ....-.... .~...~133 15_ MA 05/2005 . ,. ~- $18.75.._._, $114.08....__ 132.83. MA NA __ E....: __.$25 ;.3/1975. .. , 03/2005 .. _. ._ -18 75 $112.82 _ $131.57. Mq Nq E _ ... _. -.. ..... $25 02/1975 '..02/2005 _ „$18 75_ _ $112.82 __ X131.57 Njq _..NA ., ...E_........$25 01/1975........ ..~ 01/2005 .......$18 75....... $112.82.. ........ . ......::....$131.57.-- MA .... „.$25 11/1974. .11%2004. 18 76 _ $.. .... $112..51 .... , ....$131.28 MA, -.NA E... _ ..$25.10%.1974_._,_ 10/2004 $18 75 .... $111.27; ,_$130.02 MA _ NA. E_ $?5.08/1974 08/2004 .. -$18,75 _ $111.27 . NA_ E _ _ $25 07/1974..._... _ 07 2004 _ _. $130.02 _ MA _.. -.$i8 75.... $111,?7 ...- NA E __._$25 06/1974,_._... _. _ :..130.02 ..MA _.. _06/2004.._ ...$18.75.;..._$111.27..,.____.._... ;.. ..$.130.02...~"1A. .. NA E ._..$25x04/1974...._ ! 04/2004 . __.$18..75.:......$109.73 ............. ._:..$128.48 MA _~.... A E _... _ ... $25.03/1974... _. .~-03/2004... _......$18.75 _.. $109.73 _ . ,.... NA _ E ._ _ ..... $25 12/.1979._._..._ ...!.12/2009 .....:.. $128.48... MA ...._$18 75 _ -......$91,87, ....... _.....'......$•110.62... MA ... NA E.. ...._.$25 01%1980......... ..01/2010........_$18.75_.._.. $91.87._......... ...$110.62 ,MA NA E _...$25.1.1%1979 ! 11/2009....,, $18..75... _ NA ...E $91.87 ._.. _ .. . x.110.62 MA NA E . _ $25 09/1979 _ 09/2009.. _. _ _ -_ ,..$18.75__,_ $90.84. ,._,$109.59 ~MA ._.,.$25 06/1979 06/2009 -~ NA - _ E _ . _ _ $25 ,08/1979 ., $18.75 $90..84. .._ $109.59. MA .... ...08/2009......... $18 75_... $90,84..-._ ...._ . _.....$109.59....MA NA E $2.5 .05/1979 _ ' 05/2009. $18.75 90.58 $ ; _ $109.33 MA NA E..... _. $25 04/1979 ... :04/2009•.. $18 75 • NA E $25 03/1978 03/2008 ~$18 75_...... $89,53 .. _ ..............•..~108.28...MA NA E _ __ _ $89.79. ..... $25 02/1978 _ 02/2008 __ X108.54 MA $18.75 ~ `~ NA E $25',12/1977 12/2007 $109.70 $128.45 MA NA E _ __$18.75......._$1.09,70._...._.........- -$128.45_ MA $25 11/1977 11/2007 $18.75 $109.34 $128.09 MA NA E_... $25...07/197.7 07/2007 $18.75 _NA E $25 08/1977 $120.92 _$139.67 Mq 08/2007 __ $18.75. $120.92 _ :" $1.39,67 MA NA E -. _ $25 1,0/1977 10/2007.., .$18.75__.._. $120.92 _ NA E _ $25.06/1977 06/2007 - ... ...$139.67 ..MA NA E $18.75 $120.95 $139.70 MA $25 04/1977. 04/2007 $18.75 NA. E $25 03/1977 03/2007 $119.2.9 $.138.04_ MA NA E .. $25 01/1977 $18.75, $119.29 $138.04 MA .01/2007 $18.75. ,$119.29 _ _$13804 MA NA E $25.12/1976,., 12/2006 $18.75_ NA E _ _ $119.29 $1.38.04... MA _ $25 02/1979_,. 02/2009 NA E _ _ .$18.75._. $89.53. - _ ..~.108..28...MA _. $25 •01/1979„ _ 01/2009_ „ $18.75.. $89.53 _ $108.28 MA NA E __$25 11/1978 _ 11 2008_,. 18.75 NA E ._.... / _ $ $89.2.3..... $107.98 MA $25 10/1978. ,_.,.10/2008 $18,.75. $88.22. _ ~_ -.$106.97 Mq Court Ordered Processing \ Decedents - MAI-MB3-02-10 - P. O. Box 841005 -Boston, MA 02284 June 17, 2010 Gregory R. Reed, Esquire Attorney at Law 3120 Parkview Lane Harrisburg, PA 17111 RE: Estate of: Anna M. McCombs Date of Death: May 25, 2010 Dear Mr. Reed: Per your request, enclosed please find the account information as of the date of death for the above-named decedent. For your information, accrued interest is not included in the date of death balance. Please feel free to contact me if I can be of any further assistance. Very truly yours, .UT~ iti.~"-_ Linda Spavento Team Leader 617-533-1789 Sovereign Sank ESTATE OF SOCIAL SECURITY #: DATE OF DEATH: Anna Mae McCombs 171-28-0419 May 25, 2010 Account #: 0921710658 Type: Checking Open date: 4/12/1997 In the name of: Anna Mae McCombs Date of Death Balance: Int.(YTD) from 1/1/2010 Accrued Interest to date of death: Other Info: $6,872.55 to 5/25/2010 ; $0.00 $0.00 Account #: 0928119866 Type: IRA Open date: 3/31/1998 In the name of: Anna Mae McCombs Date of Death Balance: $8,335.12 Int.(YTD) from 1/1!2010 to 4/30/2010 $45.18 Accrued interest to date of death: $3.56 Other Info: Beneficiary: Gwendolyn Miller, sister Page 1 of 1 Willa Fargo Advisors, LLC Three Lemoyne Drive Lemoyne, PA 17043 Te1717-761-7344 Fax 717.975-8426 800-468-8685 Member FINRA/SIPC June 7, 2010 Gregory R. Reed Attorney-at-Law 3120 Parkview Lane Harrisburg, PA 17111-1356 RE: Estate of Anna Mae McCoombs Date of Death: May 25, 2010 Account No. 5711-8512 WY38 Established December 16, 1997 SS# 171-28-0419 Dear Mr. Reed: Enclosed please find a copy of the correspondence previously sent to Gwendolyn H. Miller the executor of the above estate. At your earliest convenience please send to me an original Certificate of Grant of Letters Testamentary, affidavit of domicile and a federal identification number for the estate along with supporting documentation. Your prompt attention to this matter is greatly appreciated. 4 ~ ~ :. -~,. Very truly yours, Bruce D. Mulvey Associate Vice President Investments _~~ i ~~ ~~t ~ ~:, - ., :~~..: BDM: le Enclosure Page 2 The Estate of Anna Mae McCombs Account No. 5711-8512 WY38 SS# 171-28-0419 Date of Death: May 25, 2010 Amount Security Price Value Closed End Mutual Funds: 668 VI{M Penn Value Municipal Income Fund 13.515 9,028.02 (13.60 - Hi, / 13.43 - Lo) Municipal Bonds: 25,000 Philipsburg Osceola Area Sch Dist GO 100.304 25,076.00 1.375% due 10/15/2012 acc int 37.67 25,000 Greencastle Antrim Sch Dist GO 101.193 25,298.25 2.50% due 10/01/2016 acc int 94.18 Open End Mutual Funds: 2203.880 Eaton Vance PA Lirnited Maturity 10.12 22,303.26 Municipal Income Fund -Class A 7,511.80 Bank Deposit Sweep 1.00 7,511.80 Total = 89,349.18 "This report has been created solely for informational purposes and does not supersede the proper use of your Wells Fargo Advisors client statement which is regarded as the only accurate record of your account. If you discover any discrepancies, please call your local branch manager." res-ncsilsmrfx2-16 6/16/2010 12:25:22 PM PACE 1/002 Fax Server ~'1~.~lCIiOiVIA Waahovia Bank Balance Confirmation Sarviaas P O Box 40028 Roanoka, VA 24022 June 16, 2010 GREGORY R REED ATTORNEY AT LAW •« Refaaae m:1a7106s SUBJECT: Verification / Confirmation of Aooolunt and Balantx In~rmation providod for: Crrtonaer: ANNA MAE MCCOMB5 (S5Nif 7QQt-XX-0419) Date of Death: May 25, 2010 Denoalt Accoaet Infornadon Acaowa Aaaourd Dak of Death Avenge Balmoe Dab Maturity LdweR Aoaued YTD Date Type Numha Halana Opa~od Dab Rab Irierd Idnet Paid Cloned IRA 70000i7tJ0000i:7871 SII,57270 SR/1997 $41.67 571.70 1F(}ALTf[7B: ANNA MAE MCCOldHB Far Bend9ciary Claim Foram 4 plane call 1(866)786-4890. Other AecoaM lnfornotatioe Acmua Aacaud Date of Bdu~oe Dab Date I.adger Collected TYPe Number Opa~od Claud BROf:ERAGE X?170C8112 BRK - Yaur requad Ira boar forwarded b the laolcer Gded bebw and will follow aepanWy. Your Finarrdal Adviaar. BRUCE D MIJLVEY Phoro:I17-761-7144 /800-468-8683 PaOe 1 of 2 Mutual Funds Operations John Hancock Signature Services, Inc. P.0. Box 55913 Boston, MA 02205.5913 (800) 225.5291 www.jha ncock.comlfu nds March 8, 2011 Gwendolyn H Miller 626 Paige Hill Rd New Bloomfield PA 17068-9235 Reference: 01109829 Account Number: 3023095 Robert C. McCombs Anna Mae McCombs Dear Ms. Miller: the future is yours' 'T'hank you for your telephone inquiry regarding the John Hancock mutual fund account listed above. The account value on May 25, 2010, was $16,695.20. This amount includes $65.72 in dividends that had accrued but had not been paid. The net asset value per share of the Bond Fund A was $15.02 and there were 1,107.156 shares in the account. Please remember that the share price fluctuates daily. We hope this information is helpful. If you have any questions, please contact our customer service center at 1-800-225- 5291 any business day between 8:00 a.m. and 7:00 p.m., Eastern time. One of our customer service representatives will be happy to assist you. For additional account and product information, please access our Web site at www.ihfunds.com. Sincerely, '/ ~/ G~r Jessica DeYoung Correspondence Associate cc: Signator Investors Inc John Hancock Signature Services, Inc., 30 Dan Road, Canton, MA 02021 00175056501R10M000MBS--ANNAM0000 6100 THE CHECK BELOW REPRESENTS A DIVIDEND PAYMENT To make inquiries or enroll your account, contact BNY Mellon Shareowner Services ® Manulife Financial Toll Free Number 800-249-7702 Outside the U S. (Collect) 201-680-6578 Hearing Impaired 800-231-5469 ~. AUTHORIZATION FOR INVESTMENT PLAN PROGRAM To particpate in the Manulife Financial Corporatbn (Manulife) Investment Plan Program, complete and sign the enrollment form and return ft in the enclosed enveklpe, or you may go to yiww 40y_rrtttll2r! com/shareovmer(jtl$ or call the toN free number above. Q This will authorize Manulife to forward to the Administrator all ar a portion of the dividends you receive on common stock to be invested to purchase additional ~~ shares of Manulife common stock. All investments made are subject to the Terms and Conditions of the Plan as set forth in the Manulife Investor Services Program brochure available online in Investor ServiceDirecte ffi vwvw.bnvmellon.comishareownerlisd ~~ This authorization and appointment are given with the understanding that you may terminate them at any time by so rtotllying the Administrator. Should you enroll and own 200 shares or greater, you may choose to invest all or a portion of your dividends paid on Manulife Common Stock. Investors who ~ own less than 200 shares well have the dividends for all of their shares reim~ested if they choose to participate. (Please check one ttebw.) ~ ~~ Reinvest the dividends on ALL shares. ANNA MAE MCCOMBS ~. 413 3RD ST ~ ^ Reinvest a PORTION of my dividends. (UnUI you ENOLA PA 17025-3t2B own 200 sheros, aN dividends INifi be roinwafed.) Please remit to me ttte dividends on shares. 1 understand that the dhldertds On my remaktirtg shares, as well as all future shares that I acquire wiq be rektvested. Signature(s) Date Ap joint owners must sign exactly as names appear above. 6100 00175056501R10M000MBS--ANNAM0000 ~ < DETACH AND RETURN ABOVE FORM RETAIN FOR YOUR RECORDS In~RQRt;A~iT ~'A~;1NF4RlugTt~~ ~:'fi~~'IGNpE'I'A44.. >: . . SHAREHOLDER OF TRANSACTK)N DESCRIPTKXJ MANULIFE FINANCIAL CORPORATION DMDEND _ INVESTOR ID CUSIP ACCOUNT KEY TYPE OF SECURrtY RECORD DATE PAYABLE DATE i?600B81BJ1I 001 750 56507 R 10 MCCOMBS-ANNAM0000 I COMuION STOCK 02123!2009 I 03/1912009 RATE PER SHARE ~ CERTIFK:ATED SrtARES BOOK-ENTRY SHARES GROSS DIVIDEND US TAX WITHHELD FOREIGN TAX WITHHELD 502085000 0 2A8.0000 ~ 551.29 50.00 57.89 CURRENT gVIDEND 115 TAX WITHHELD YTD FOREIGN TAX WITHHELD YTD ;DIVIDEND PMD YTD TAX IDENTIFICATION NUMBER i Please detach and retain Ihie 343.80 50.00 57.89 551.29 ON FILE ~ lorm for w records. PLEASE DETACH BELOW CHECK NUMBER: 80717223 tvu L..l • ' 111JW11~sA1 1 LtrtyJ ~ 1Y1Y11VlJLll'l: 1.11V own - t auvv: rwau~c rabctvtt Nsw User? Register Slgn In Help Preview Mall w/ Toolbar Yahoo! Mail Y,nHQO ~;. FINANCE Search Web Search Dow 40.7f%Nastlaq ~O.aeS HOME INVESTING NEWS d OPINION PERSONAL FINANCE MY PORTFOLIOS TECH TICKER ~~~ GET CUOTES Finencs Ssarah Mon, Ox 27, 2010, 10:11AM EST - Ue MarNab ebaa In a hn and Ia mtna Manulife Financial Corporation (MFC.TO) on Dec 2e 17.24 *o.osjo.t7x- '„ ~ FREE TRADE"' ~'' ~'. FREEOp f y! I l ,~. ~, i er~. o oars -"~"~-:. rytneot ucwrar uc Historical Prices Gat Hletwlcal Prlcea for: Set Data Range ~GO~ o Daily SIaA Date: May ~ 25 2010 Eg. Jan 1, 2010 Weakly End Dan: May ~ 25 2010 Monthly Dividends Only ~ Get Prices ~ First ~ Provioua ~ Nexl ~ Laat Prkes Date Open High Low Close Vdume Adj Clore' May 25, 2010 16.33 18.47 18.20 16.45 8,342,000 16.11 ' Clots pnca atljuatad ftN dhndaMa and aplka. First ~ Provbua ~ Nexl ~ Last w' Download to Sprudshest Curreney in CAD. COpWiOht C 2010 Yahoo! Inc. NI ripMS nNrvetl. Privacy Pdicy -About Our Ads - Tums of Service - CopyriahVlP Polky • Sentl Feetlbsck • Yah00! Newa Network GuoNS MNrid, exeapl vdtue intliutetl olMrwiu. DeNy limes m 15 mine for NASOAO, NYSE end Amex. See Nee delay times IN enter exehanpe. OueNt and Omer inlormstion wppied by inMpendeM providers itlenfilise on Ihs Yahod Finencs partner peps Oumee ero upeeted suronutiuly. but WiN De fumed oR aner 25 mmuNS vl inegiviry Ouehs an delayed sl Ins115 m,nuNS All mbrmeoan provided `as ie" for infarmalienel purposes only, not inlsnoed for trading purposes a advice Neither Yahoos nor any of independent provrden Is liabN kr any Inlomwlionel anors, Incompleteness. or tleNye, er for any anions Nken n relianp on ®1amNbn conLmed herein. By accNikla IM Yetwol wile, you earth not N fetlielribYN !hs mNmutlOn Iwntl merlin. FundsmenNl cortgaM dsN provided M Gpilal 10, Hietvdwl Ntr1 deN and dally uptlene provided M Commotliry Synems, Ina (CSp. InNmalbnN hisNrkN than dna. Giy updNee, Hntl summary, land perfamtenu, dividentl dau and MomNaaur InMx dau provided eY fAOminaeUr, Inp. http://finance.yahoo.tom/q/hp?s=MFC.TO&a=04&b=25&c=2010&d=04&e=25&f=2010... 12/27/2010 =''=Sovereign Bank ~i~ ~ ~~~. SAVINGS BOND REDEMPTION INTEREST REPORTING FORM PZ# 00092-1001-170504 Date Redeemed 10/01/2010 Branch# 92 Processed Julie Bailey Teller # 004 by TRANSACTION DISBURSEMENT ^ Cash ^X Check ^ Sovereign Acct Credited TYPE(S) Account #: NUMBER OF #10 ~ TOTAL REDEEMED $2008.00 BONDS I Ensure that the following information applies to the NAME on BONDIBOND OWNER. TOTAL 10991NTEREST TO BE REPORTED IS $1,508.00 SOCIAL SECURITY NUMBER OR EIN 27-6651338 EIN NAME on BOND/BOND OWNER ESTATE OF ANNA MCCOMBS DATE OF BIRTH 02/07/35 STREET ADDRESS of NAME ON BONDIBOND 626 PAIGE HILL RD OWNER CITY, STATE 821P CODE NEW BLOOMFIELD PA 17068 COUNTRY OF CITIZENSHIP United States Complete the Information below about the person cashing the bond(s) ONLY If NOT the NAME on BOND/BOND OWNER named above. NAME OF PERSON CASHING BOND(S) RELATIONSHIP TO NAME on BOND/BOND ^ Parent/Guardian ^ Trustee OWNER: ^ Conservator ^X Executor/Administrator Certificatfona Instructions: You must cross out item 2 below if you have been notified by the IRS that you are currenlly subject to backup withholding because you have failed to report all Interest and dividends on your tax return. I certify under penalties of perjury, that (1) that the number shown above is my Taxpayer Identification Number and is my correct TIN; (2) I am not subject to backup withholding either because i have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. person (including U.S. resident alien). Signature Legal Representative Title (if any) Date Important! By signing above, you certify that either 1) Your TIN is being used to report the interest earned on the savings bond(s) OR 2) You are authorized to sign on behalf of the registered holderlTlN reporter whose TIN is being used to report the interest earned on the savin s bond s i.e., ou are the arenV uardian, trustee, executor/administrator, or conservator . RCICI ueiVw ivi i1VVIlIV11 G1 r'CVCI 211 RCSCI VC DQIIR ICUCnItlllVn ~65VUfGC IniVITTIaOO n. n ~ Via telephone: 1-800-245-2804 ~ Via the Internet: http:llwww.savingsbonds.govl BRANCH USE ONLY Provide copy to customer. Retain copy in branch files. Forward original in Savings Bond Redemption Forms special use envelope the same processing day. 1099 PROCESSING TEAM USE ONLY UTJ SBR001 REPORT DATE P2 250 REPORT DATE Effective 12/10/2008 calculated Value of Your Paper Savings Bond(s) Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 10/2010 Page 1 of 1 Total Price Total Value Tota! Interest YTD Interest $500 00 $2 008 00 $1 508 00 $62.00 Bonds: 1-10 of 10 Serial Series Denom Issue Next crual A Final Maturity Issue Price Interest Interest Rate Value Note # NA EE $100 Date 01/1984 c 01/2011 01/2014 $50 00, ._ $150.80 _ 4.00%, $200.80 _ 0 EE $100 01/1984 2011 . 01/ ,. __ 01/2014 $50 00 $150.80. . _.4 00% _ $200.8 00 NA ' EE .. $100. 01/1984 , 01/2011 , 01/2014. $50 00 $150.80 4 00%, _- .80 $2 _ .... NA . EE : X100 01/1984 . 01/201.1 . . _01/2014 $50 00 _ „_ $150.80 ~ _ 4 00%_, ' $200.80__ 00 - NA , ... ; EE _. ._ $100 01/1984 2011 01/ 01/2014 $50 00. ,, $150._80,. 4. 00% .80 #2 NA EE . ,._,_ $100 01/1984 _ , 1 01/201 .,01/2014 , X50.00 _..$150.80 .,,,,,,.,400%. ,. '200.80_ - NA .. _ _ EE ;._ „.,, $100 . 01/1984 ,_ . 01/2011 . 01/2014 $50.00 $150.80 „4.00%, $200.80, NA EE ,,, _ $100 01/1984 01/2011., ..__ 01/2014 _._.$50.00 . $150.80_. ...,,4.00%. ' ;200.80 NA , . EE ,,. __ . $100 01/1984 01/2011 _ 01/2014 $50.00:, ._ $15,0.80 . _ 4.00% $200.80 0 NA EE ' „ ., $100 ' , 01/1984 _ 01%2011 _-_-01/2014; -_.$50.00 , _.__.$150 80y .80_ .......4 00% -- $20 ..._. .. -- ~ -- _-- ._ . , - „ _._ . - - "T_.:;~_ s,.. , n n.,.,.1e tane_ee 51.508.00 ! $2,008.00 Notes .NI Not...Issued .....----_ -.--- _. _._.._ _ _....... _.. N-E Not. ellglble.for payment. _. _._.., ......_ _..... PS Includes 3_month,lnterest penalty, _ .__ ..-. ..... ........... . MA Matured and not earnin Interest ~ n~i nrnn 5 .. ......(. ~... • ~F a , _` Tii Anna ~~ae Grubic 199-07-930} ~ -,,,~:"~` 4803 Devonshire Rd. "'~ garrisbur~, Pa. 17109 trft' .~u~ :' or Robext G. M.oGo~bs~ Jr. . s~~gs ~~ I Firm ~an~n.uuu.No. ~"r ws°o~-ei~e wiiw n~iua. n~ua+[wv. ,M,r,,.,r,f~.., I II ISSUE GATE y/NICN If TMC FIffT DAY OF Jan. 1984 ~;,. ^z. , ~~353~ ~.• , " ~ 1rnn+a•/fALrTti ,~~ ~', ~~~~~G'~r ~oaia~ Park Qiiico C60 774 538 ~~. 7 w. ~ ~~. ~ »~~ ~ '~'~~ ~'~ ~'~iT'~~1"~•~"~l~!aI"141+~i~']~i'~~5'~°,',i1!i;~'I~d~:~lrr1~1 ? «~.y .:..r --,I rye... -r~rWr .mow-+-+~Y..d... ,ate:-..,.a N ',~' AT TM[ MATURITY N[11[O/ WILL •AY ~;,_` ~,.. -~~~y~ ~ar~ 7~ia-~R~;~ ~ Y~~~ry , - err Y. ~ ~,, _.~,; T„ Anna Mae Grubic 199-07-9304 _~ 480 Devonshire Rd. ~' garrisbura, Pa. 17109 or Robert C. McCombs Jr. . i ~~i~~'A ~'~ ~~1~ iJi1.~.1-~L~.~.~.J~ .SR~.,;~ 1M lYD3 S. 'w+it l1xYAMMRMMM t.{WLI O t.1 4 1{~'~ ~ (J {~~.~ fW~ /' ~4r LtwmWer~~xwn y+~.~i}' ,RrwYry irE-YY ISSUE DATE WNICN If THE FIRST DAT OP J ~T~l~, 4 -AMC RM 1- ~ ~R ~:R,- - ~,9U¢ta~ C.yi (i l~l~~f ~ ifli Ji ~~`\ ~ lawwo •O[NT'R . lli f ~olYe1M0 •ewM. , r ~1#k4`~:`:~1~!issr ~~ ,,,: i`.u'..y i.+fl'. C60 742 470 EE }1 ,~.~_~,,~~- C~ i ATTN(MwTVRITYNLREOPWILLtAY al't') ISSUE DATE ,i "~~.`i"~-'.. ~ \yi~31 ~i~. 1'• 4 ~~` • ;~:'9~i~,~~~, WNICX IS tNE FIRST DAT Oi '~ ~ To Anna Mae Grubic 199-07-9304 -I7~.aa.~-- ~~ F ;~, 4803 Devonshire Rd. 8~,,;; ~ Sr:t ~ ~;;.;, 4~ Harrisburg, Pa. 17109 ; r IWRINMD AeeNY'a ,: l~'a6 ~ ~ 14 ~{ w,s~ N J'."S ~ f r at k ,.. M..rt i ..s. f DATIND •TY.M , ~ or ~~~ ~ ' Robert C. PiGCOll~bB, J'r• ; f ~ H1~iLRiSre%3Z ;~; ~+~ t3eif7iiu] Pa~r!c't)f1~:~ W YNwN IW+CI.tlYW W. ~a T••~•~-•~x• •'t~~~~_~ C 6 0 7 7 4 5 3 7 E E LyyNAT•IW„ ~ ~~~ # 311 ~` MNYIWYT~W,Y~~nWn ~ ~ ..nn welt - M1~ ~~+V- 1 .._..._ x.ue A ~ ~ w ~ ~+~ ~r'~~~ ~~~1~•y'~ I ~~ •~'~- +. yl r! '^' v'1.~,~ ~ ~ 1 ~' wwY'+w- ' '"`"""~Y ~ AT TNf MATVRIIY NER[OfWLLI,AT ~ '~I(~l[~A~){y~ q~~, 'T 7~ `T a~,(y`~(, ` 1`~~} ~ ;~y~'~f Ci N ISSUE DATE WHICH Ii THE EIRST DAT Of t° _ I ~ J,,~,,. 1g~4 / .~9, Ta ,, ,,,.., O.T~bio lq?..07-a~:.4 ~ ~,~~Y....1, :, .`~;1-- ,• 4803 Devonshire Rd. ~ Ga+ arcs, w+u~ ~ ~ i~arriaburg, Pa. 17109 ` ~~ '1i ' r,rn y 1 4 i _A ~- u. ^o.#iN& sear ce,... 1 ~•~ o r , ~tobert C+ McCombs, Jr. .,,y:., ~ 1, 4:dttiilv~l ~hfrk Of5ica t MAiwo~t~iYan Wlw Wt ~~ryOp1iMOM.w1•YYWY.Y. YICilOMT111 C60 742 471 EE 4~ • S~ '~'~'EA ~'~~'~}1{~~~~~~~~nnyy~ j uOYW ~ x1YxWYl Yl lwtlxY4Y Jx.rw./MfxtW1 YtlI1M61N • .... ...:..T•-. ~1Y1.11 Ui ~TYY.~~~~tlw.i: i~ ~1 ~I~ ~~'J~~}l~~i~•Y~ AT TNL MATURITY NLRLOP WILL PAY To Anna Mae~i~G'xubic 199-07-9304 1 ~~ 4803 De~tonahire Ad. Iiarrisb;zr , : a • 17109 I ,~ :, ,4 ~~` Robert C. 1`icCombs, Jr. ~' y t'' ~~~.~Oyy/a m.::a a:•.~•a chi nsw ln..w qwn. -'~•[LtlCi~" - ueau: a .c n wroa,~xw~.E 1JA+.1Y3~'a.• ''" __.~. ww.nw«<.w°~„ nu., ,.,r~• ~T,r.,~ ~, ......y..a.,. ISSUE DATE WNICN I! THE i1R57 DAT Oi Jan. _.198_ _ -iIAa.H~ i . _ . - gsUp'~in CeAesi! ~~;.1. $ Yrusfi ICRSc ,.:MIN, aCX?'. , , IRtfikfNRi 7a.b .~:..~c Coo 774 541~.~~ _. ,..: CL:j~ AT iNE NATYRITY NLR[Oi WILL PAY To A71.na I~ae Gxubic 199-07-9304 4803 Devonshire :td. Harrisburg, Pa. 17109 or ~ Robert C. McCombs, Jr. . ~~ ~~~E~~ XM.Iyu.p.uunxulo. Txuww uw.w YXON.;,W' cruT.-Nlwa•.NCr. yppWKttlOlx.l{. ~ ~~5 w•.1MINO. I+I Iy.A;ar ..u.'/. tlw~x~ .uawrsr r.e. ;.. - .,.., AT TMl MATURITY N[R[OP WILL MV ~_. .. ~~ To Anna Ztiae Grunic 19y-u j -7)v~r 4803 Devonshire Rd. Harrisburg 1?a. 17109 or c~u'~ar-t C, i~IcCasbs, Jr. lYwxCp~il{OVW.IN M14w.F.ON4T.4 Ypxdlp. ypp WYtCI l.1NR.'f~};Mlp W I~IpOf. I ~+ ~ ~ s Aw a.~.~ 7` A~i,~, ..:a.C~.1: W^ :Mwxa,a: ..rn .\y ,~ ,~ 7R.w, ISSUE DATE WNICX IS THE /LSt DAY Oi '1 al$gly'~~;1 it ~1Tl~3Sif 1$an~; & 7nl'sx Co. , I..M.`p wI~OT.MTt• II Il• ~~•T~PI~ i~ c~~.„~.i a.,~ crt„Y. C60 774 540 EE ISSUE DATE WNICX IS tNE IIRST DAY Oi pauph;nT3a~a's!4 ~; ~ ~~ Trst Cq. ap I I..MIN. Ae[NT7• _: ,~; . ,.,. Ceto>•~) Puk Coca C60 774 539 ES AT TN[ wivnltt NLRmf wILL rAv TH Anns iiaa ura'ais 199-07-9304 I 4803 Devonshire Rd. Harriabur~, Pa. 17109 or ....Robert C. ;wicCa~bs, Jr. Y ~ {111.YYw V.l LL WfMi{Y. TYSYiN.ITWY WYI.IV(W T.YCGYM{YCt MY{M. Wig- µpM1YIWCT tYIX{fi -'~.ma~ryy'1 ~: :~ ~+.~.'- r..,,.:>..a..;~. ,:.. .. .. ,.:... .,. .. .. .. ~.. ,.....:.. .. I _______ II~~ n r { i 1~ ~ ~i 'I~~ wTYPoTr Nnuor WILL rAr 1 f ~_ ~; T, Anna Mae Grubic 199-07^9304 4303 D4Tronsh~ro R~. Yiarris`aYarg, !a. ,17109 I £ ( , Y I vv~^•. ~r ";~ Robert C. McComles, Jr. ~zr 'V-Z(ja~my'~ \wrwsa~uwa~wu{un .m.uTauea.anw.. u.n rvr{n(.N{n ~~~ n..- Yn{ulY{,. eITq TI{YY+{. ~~ .{W+N ..Y..YIm ~ ISSUE DNTe WNICN IS THE fIgST OAT OF ~ Iw7+IN1}I.I Aeerrrl. ,`` 1 I -~ 1~ i~O.r1Yl0 (.... n'f.' I _ r.. r:v.„.. C60 742 469 EE ISSUE DATE WNICN IS THE FIRST OAY Of i ... ,..;,. - ~„ ~:~: ~?,,. I .... ... I.WINO •OLNT•. 1 ._. 1 -~ttii ~yf~~/~ 1 11\ V I~~~~~ 11 .~ \ ..:, w '~,~ca'VI~aV I7P'd4k~~iSEa ~:: G•60 742 467 EE y ' ~' > '1' "' AT TNt wTURITr Nuwr wlu -Ar 1 .... .~ -~,•-ti._:,- ,~S~'~slWj ~:Il~~~~`.I7,I~D ,Y310'~ ' ~l~'CI ~ y;, Ann: P~Iae Gru'mic 19y-07^9304:. E ,w ~ 48L`3 ~3VOi::::2i~? ~{4ia I ..i ~ T 1710 or liobcrt C. NioCoab3,Jr. 1 L9WKTlYIM({M1I (I {YG...I I.VInI{{CI.S (~p ~~~JLYV ~.J~JY~ MI{NM1II.I.SYKICMIned{I Jp~ylf/MR.LIY~I ISSUE DATE WNICN IS THE fIRST OAY OF IMONTM^ ~ 1'IZQnI :i v - - `"" r ~ ~ xl ~ ~ T',...... Y I J ~..':S~ I.W~NO AOLNT'L 1 111 1 Iy~ 1 111{~~Y~;*I'~"'i;~t •+,:G~~d~i~'~~iac t~,rg~ C60 742 466EE wacxovr.4. Consolidated Statement 01 1000613955473 752 30 0 118 18,082 0000294 I~~~III~~~III~~~„I~I~I,I~~~II~~~~II,~I~II~~I~~~~II~~II~I~~,II ~~ ANNA MAE MCCOMBS ~~ GWENDOLYN H MILLER pB 413 THIRD ST WEST FARIVIEW PA 170253128 4/29/2010 thru 5/26/2010 Summary of Accounts Checking & Swings Account number 1000613955473 257410066697871 Total Account CUSTOM CHECKING IRA 30 MONTHS Balance 55,841.91 41,572.70 $97,414.61 As o! Inlerest Maturity ~ rate date 5/26 ~ 5/26 0.70% 5/07/2012 ~_ L WACHOVIA BANK , HARRISBURG CAPITOL page 1 0( 5 Consolidated Statement iii 02 1000613955473 752 30 0 118 18,083 wacxovrA 4/29/2010 thru 5/26/2010 Custom Checking Account number: 1000613955473 Account owner(s): ANNA MAE MCCOMBS GWENDOLYN H MILLER Account Summa Openinst balance 4/29 $53 913 00 Deposits and other credits 2 258 74 + Checks 313.86 - Automated Checks 15.97 - Closing balance 5/26 $55,841.91 Deposits and Other Date Amount 4/30 1,188.74 5/03 1,070.00 ota Checks Credits Description AUTOMATED CREDIT PA TREASURY DEPT ANNUITANT CO. ID. 1236003133 100430 PPD AUTOMATED CREDIT US TREASURY 303 SOC SEC CO. ID. 3031036030 100503 PPD Number Amount Date 4341 59.10 4/29 4342 41.62 5/04 4343 125.29 5/05 * Indicates a break in check number sequence Automated Checks Number Amount 4346 15,87 ota 1 g Number Amount Date Number Amount Data 4344 16.00 5106 ota 4345 56.85 5/11 4347* 15.00 5/24 (checks could be fisted under Automated Checks) Date Description 5/t7 AUTOMATED CHECK DISCOVER ARC PAYMENTS CO. ID. 5510020270 100517 ARC MISC 4346 WACHOVIA BANK , HARRISBURG CAPITOL page 2 of 5 Lincoln Benefit Life Company P.O. Box 94212 Palatine, IL. 60094-4212 Telephone: (877) 499-6418 Facsimile: (866) 635-4523 June 17, 2010 Gregory R. Reed Attorney at Law 3120 Parkview Lane Harrisburg, PA 17! 11 Re: Ann Mae McCombs Contract No: LBCA020571 Dear Mr. Reed: LINCOLN BENEFIT LIFE A N A L L S T A T H C O M P A N Y We received a request to complete IRS Form 712 for the above referenced contract. The purpose of Form 712 is to provide an estate or donor with the value of a life insurance contract or its proceeds as of a certain date (usually the owner's date of death or date of transfer of the contract). Because this contract is an annuity, it is not reportable on IRS Form 712. I can, however, provide the following information for estate purposes: Title of Annuity: Date of Issue: Date of Death: Annuity Value as of Date of Death: Cost Basis: Named Beneficiary: Anna Mae McCombs October 3, 1997 May 25, 2010 $ 20,598.90* $ 0.00 Gwendolyn Miller *The actual amount paid may differ due to Market Value Adjustments and/or any applicable Surrender Charges. If you have any questions, please contact me at 1-877-499-6418 Ext. 24597. S' rely, Je fifer vans Sr. Claim Examiner LINCOLN 131:NEFIT L[FE C(]M I'ANY .7 AlrurGav~u/'r1/Gr.ur /•irtrurr~i.t/ (ntru/r Lincoln Benefit Life Company PO Box 80469 Lincoln NE 68501-0469 ANNA MAE MCCOMBS 413 3RD ST WEST FAIFtVIEW PA 1 7025-3 1 28 November 3, 2009 Telephone: 1-800-LBL-WAYS Fax: 1-877-525-2669 www. accessallstate. com Your Representative FRAN GORMAN GORMAN INSURANCE AGY 19 KENSINGTON SQ MECHANICSBURG PA 17050-2365 (717)766-9052 RE: Saver's Index Annuity #LBCA020571 Contract Value as of 11/02/09 Gross Withdrawal Amount Federal Withholding Deducted Electronic Transfer Amount Remaining Contract Value $21,502.36 $903.46 X903.46 __ ~ 0 4 $813.12 Please retain this information for your financial and tax records. 520,598.90 We value our relationship with you and look forward to helping you achieve your long-term financial goals. GENERAL' ANNUITY INFORMATION Owner: Anna Mae McCombs Annuitant: Anna Mae McCombs Tax Qualification: IRA 1 R260N683.N01 mass •..°°wroww.+w.wsmm COMMONWEALTH OF PENNSYLVANIA STATE EMPLOYEES' RETIREMENT SYSTEM , 30 NORTH THIRD ST STE 150 HARRISBURG, PA 17101-7716 1.800.633.5461 www.sera.atate.pe.us June 18, 2010 GWENDOLYN MILLER 626 PAIGE HILL ROAD NEW BLOOMEIELD PA 17068 Re: ANNA M MCCOMBS SSN: 171-28-0419 Dear Beneficiary: We are writing to you regarding the above named account. SE ~5 The enclosed forms must be completed by you, according to the printed instructions, before we can proceed with the processing of this account for payment. Please note: The Retirement Code does not provide for the payment of interest on the principal sum of a death benefit. Please read the enclosed information pertaining to the recent change in the Federal tax law. Also, please complete and return all applicable forms to our office as soon as possible. To aid you in making selection decisions, the following information is provided: Death Benefit Payable to you: Taxable Portion: Non Taxable Portion: $36,643.96 $36,643.96 $0.00 If you have any questions or need assistance, please contact the field office nearest you at 1-800-633-5461. Sincerely, ~~ ~~~ Debra G. Murphy, Director Benefits Determination Division Enclosures BEN85