HomeMy WebLinkAbout04-14-111505610143
REV-1500 Ex (01.10,
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OP REVENUE
PO 80X.280601 INHERITANCE TAX RETURN 21 10 0900
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
165 36 4052 08 24 2010
Decedent's Last Name
EPPLEY
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name
Date of Birth
06 22 1923
Suffix Decedent's First Name MI
SARA M
Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise
death after 12-12-82)
(date of ~ 5. Federal Estate Tax Return Required
g Decedent Died Testate
(Attach Copy of Will) ~ r~
~• AttacdheGopy Hof Trust)a Living Trust 8. Total Number of Safe Deposit Boxes
9. litigation Proceeds Received
~ 4 YY
1 ~• between 14 31 ~J1 antlt (datge5~f death
Z T
~
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
JAN M WILEY 717 432 9666
First line of address
3 N BALTIMORE ST
Second line of address
City or Post Office
DILLSBURG
Correspondent's a-mail address:
REGISTER OF WILLS USE ONLY
C'a f.-'
~~ ~ ~ ~
DATA f~L a
-
-~-r
State ZIP Code ~ , ; -- ;` ~ r _~
~
PA 17 019 ``~ ~ ~,+; -
7 t
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 othe than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSO ESPONSIBL OR FILING ETUR DATE
/~,2~~y~~ ~,~''z~ ,~,~,fi Nancv Grove Nichols ~,f - ~ 2 " 1
ADDRESS //
5 S. (/Baltimore St. Dillsbur PA 17019
SIGNA RE OF PREPARER OTHER THAN RE ESEN TIVE DATE
~ ~ ~~ , Jan M Wiley ~ -- ~2 -
.Church Street, Dillsburq, PA 17019
Side 1
L 1505610143
1505610143
~~'
PA Inheritance Tax Return
Signature of Additional Fiduciaries
ESTATE OF FILE NUMBER
Eppley, Sara M 21-10-0900
Under penalties of perjury, I declare that 1 have examined this return, including accompanying schedules and statements, and to the best of
my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all
information of which preparer has any knowledge.
Signature #2 .~
Name
Address1
Address2
City, State, Zip
Date
Sara Jane K WjEkard
29 Montsera Rd.
Carlisle, PA 17015
f(
J
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedents Name: Eppley, Sara M 165 3 6 4 0 52
RECAPITULATION
1. Real Estate (Schedule A) ....................................................................................... 1,
2. Stocks and Bonds (Schedule B) ............................................................................. 2. 6 0 , 62 8 . 7 3
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3.
4. Mortgages 8~ Notes Receivable (Schedule D) ........................................................ 4.
5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 15 5 , 2 4 9.71
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 2 6 , 071.62
7. Inter-Vivos Transfers & Miscellaneous Nnq Probate Property
Requested
arate Billin
Se
7
............
g
p
(Schedule G) ^ .
8. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 2 41 , 95 0 . 0 6
9. Funeral Expenses 8 Administrative Costs (Schedule H) ....................................... 9. 2 6, 4 5 0. 2 5
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10.
11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 2 6 , 4 5 0 . 2 5
12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 215 , 4 9 9.81
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ............................................... 13. 37 , 885.64
14. Net Value Subject to Tax (Line 12 minus Line 13) .........................................:..... 14. 17 7 , 614.17
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
15 0 . 0 0
(a)(1.2) X .00 .
16. Amount of Line 14 taxable
0 • 0 ~
16. 0 . 0 0
at lineal rate X .045
17. Amount of Line 14 taxable
0 0
0
17
~
0. 0 0
.
at sibling rate x .12 .
18. Amount of Line 14 taxable
614.17
17 7
18.
2 6 , 64 2.13
,
at collateral rate x .15
19. Tax Due .................................................................................................................. 19. 2 6 , 642.13
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^
Side 2
1505610243 155610243 J
,.,
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-10-0900
DECEDENT'S NAME
Eppley, Sara M
STREET ADDRESS
Chapel Pointe
770 S. Hanover St.
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
3. Interest
24,937.50
1,312.50
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box 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.
Make Check Pa able to: REGISTER OF WILLS., AGENT.
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(3)
(4)
(5)
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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 ............................................................................................................... ^ ^x
d. receive the promise for life of either payments, benefits or care? ............................................................
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without ^ ^
receiving adequate consideration? .....................................................:.............................................................. x
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....... ^ ^x
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.
<.
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,. ... .,. . ~ °A...; "a,:., r .... P:.. 5; F, ,.... F<?r x~, ..,. ~"J .Y'. b~` E ,_, _.,-x >,?. ".e'~: ~ns. r5,~..0~ ~.... ~ ..~. ~ .. < ;..n.. . '... .?:
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 January 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.
(1)
26,642.13
26,250.00
392.13
Total Credits (A + B) (2)
Rev-1503 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF FILE NUMBER
Eppley, Sara M 21-10-0900
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER CUSIP
NUMBER
DESCRIPTION
UNIT VALUE VALUE AT DATE
OF DEATH
1 Laporte Asset Management Securities (see attached): 58,845.41
2 44 shares of MetLife Trust shares. ~ 40.530 1,783.32
TOTAL (Also enter on Line 2, Recapitulation) 60,628.73
~Ir more space is needed, additional pages of the same size}
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98)
Rev-1508 EX+ (8-98)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Sara M
FILE NUMBER
21-10-0900
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with the right of survivorship must be disclosed on schedule F.
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98)
(If more space is needed, additional pages of the same size)
Rev-1509 EXf (6-98)
,~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF FILE NUMBER
Eppley, Sara M 21-10-0900
Han asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
A. Nancy G. Nichols
B. Sara K. Wickard
C.
518 S. Baltimore St. Niece
Dillsburg, PA 17019
29 Montesera Rd. Niece
Carlisle, PA 17013
JOINTLY OWNED PROPERTY:
ITEM
NUMBER
LETTER
FOR JOINT
TENANT
DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT
NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR
JOINTLY-HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSE % OF
DECD'S
INTEREST DATE OF DEATH
DECEDENT'S NTEREST
1 ABzB 11/24/2009 Sovereign Bank Account #2895551592: 26,071.62 100.000% 26,071.62
TOTAL (Also enter on Line 6, Recapitulation) I 26,071.62
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-98)
REV-1151 EX+ (10-06)
COM INI~ERIIDAENT DECEDN$.RN ANIA
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Eppley, Sara M 21-10-0900
Debts of decedent must be reported on Schedule I.
ITEM
B R DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
See continuation schedule(s) attached
1,526.42
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Nancy Grove Nichols Sara Jane K. Wickard
Street Address 518 S. Baltimore St.
City Dillsburg State PA Zip 17019
Year(sl Commission paid 2011 12,000.00
2. Attorney's Fees The Wiley Group, PC 12,000.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills: 369.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 554.33
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 26,450.25
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Eppley, Sara M 21-10-0900
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Ex e
1 Nancy Grove Nichols (misc. funeral expenses):
1,526.42
H-A 1,526.42
2 Other Administrative Costs
Cumberland Law Journal (advertise estate):
75.00
3 Pharmacy: 97.52
4 PSERS (Reimbursement): 59.31
5 Register of Wills (filing fee): 30.00
6 Sovereign Bank (date of death letter fee): 20.00
7 The Sentinel (advertise estate): 272.50
H-B7 554.33
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
REV-1513 EX+ (11-08)
COM~O~yvEgALN~EDECE D~N~RNVAN IA
SCHEDULE J
BENEFICIARIES
ESTATE OF FILE NUMBER
t le , Sara m ~ 21-10-0 900
NAME AND ADDRESS OF RELATIONSHIP TO
SHARE OF ESTATE
AMOUNT OF ESTATE
NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT (Words) ($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal
• distributions, and transfers
under Sec. 9116 a 1.2
1 David E. Eppley Nephew 18,942.82
12506 Musket Trail Drive
Cypress, TX 77429
2 Richard E. Eppley Nephew 18,942.82
335 Harbor View Blvd.
Somerset, MA 02725
3 Marian Fears Niece 18,942.82
PO Box 36
Durant, FL 33530
4 Lois Ann Hoffman Niece 18,942.82
1055 Hickory Lane
Indiana, PA 15701
5 Carol Knisely Niece 18,942.82
1759 W Lisburn Road
Carlisle, PA 17015
See continuation schedule attached Continuation 82,900.11
Total 177,614.21
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 150 0 cover sheet, as a r o riate.
II NON-TAXABLE DISTRIBUTIONS:
. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FO R WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1 The Bethesda Mission 18,942.82
2 The Salvation Army 18,942.82
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 37,885.64
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08)
SCHEDULE J
BENEFICIARIES
(Part I, Taxable Distributions)
ESTATE OF:
Sara M Eppley 08/24/2010 165-36-4052
Item Name and Address of Person(s) Share of Estate Amount of Estate
Number Receiving Property Relationship (Words) ($$$)
6 Nancy G. Nichols Niece 31,978.64
518 S. Baltimore St.
Dillsburg, PA 17019
7 Elaine Palmer Niece 18,942.82
5 Dougherty St.
Indiana, PA 15759
8 Sara Jane K. Wickard Niece 31,978.65
29 Montesera Rd.
Carlisle, PA 17015
Total 82.900.11
1
~-- ~ r-:
~,.
~.~ - _ E .'
r~~k ~~~ ~i~~ ~~~k~~~~rtt
OF
SARA M. EPPLEY
I3E IT REMEMBERED, that I, SARA M. EPPLEY, of 102 South 22nd Street.
Camp Ilil}, Cumberland Count~~, Pennsylvania, being o1~ s~~und mind, memory and
understanding, do make, publish ~~nc declare this as and for !ray Last Will and Testament,
hereby revoking and making nul[ and void any and all Wills and Testaments and writings
in the nature thereof by me at any ti~r.e hereofore made.
ITEM 1: I direct that all my ju,~t debts and funeral expenses be paid as soon
after mV demise as may be convenient.
ITEM 2: All the rest; residue and remainder of my estate, of whatsoever nature
and wheresoever situate, whether it be real, personal or mixed, including property over
which I have a power of appointment, I give, devise and bequeath my entire residuary estaic
as follows:
(A} I give ten percent (10%) thereof to THE SALVATION ARMY, 1 122
Green Street, Harrisburg, Pennsylvania.
(B) I give ten percent (10%) thereof to THE BETHESDA MISSION, 61 ?
Reily Street, Harrisburg, Pennsylvania.
(C) I give the remaining eighty percent (80%) thereof to my nieces and
nephews, DAVID E. EPPLEY, RICHARD E. EPPI_.EY, LOIS ANN
HOFFMAN, MARIAN FEARS, ELAINE FOSTER-PALMER,
NANCY GROVE NICHOLS, CAROL KNISFLY and SAR,4 ,1ANE K.
WICKARD, in equal shares, per capita.
ITEM 3: I direct my hereinafter named Co-Executrixes to sell all of my
property, both personal and real, converting the same to cash, and distributing the same in
accordance with this my Last Will and Testament.
1 of 4
ITEM 4: I direct m~ hercinafi~er named Co-Executrixes to pay ail inheritance,
estate, succession and legacy taxes of whatsoever nature aid k;nd_ to which my estate nr
the transfer ofany property passinf':~~ereunder or otherwise r,,,.:~~n~~ h~- reason o' i7~v dem;se.
may be sub?ect and to charge such taxes against my residuary estate. it being my intentic,r
that none of the aforesaid taxes; either federal or state, nn ai:v property required to re
included in my gross estate, uncle; the provisions ofany state or ';:deral law now in force
or hereafter enacted, shall be pror;aec among the persons ir'ere~cd in my estate t~ wh.^-
such property is or may be transferred er to whom any benefit accrues.
ITEM 5: 1 appoint 'IANCY GROVE NICHOLS and SARA JANE, K.
WICKARD, as Co-Executrixes e:`th.is my Last Will and Testan~en~.
ITEM 6: I direct that m,v Co-Executrixes or their successors shall not be
required to give bond for the faithfu; performance of their duties in any jurisdiction.
ITEM 7: My Personal Representatives shall have the following powers in
addition to those vested in them by L.aw and by other provisier.s of this, my Last Will and
Testament, exercisable without court approval, and effective until distribution of all
property:
I. To retain any or ail of the assets of my estate; real or personal,
without restriction to investments authori~:ed for Pennsylvania
fiduciaries, as they from time to time may deem proper, without
regard to any principal of diversification or risk.
2. To invest in all forms of property without restriction to investments
authorized for Pennsylvania fiduciaries, as they from time to time
may deem proper, without regard to any principa' ~f diversi f ication
or risk.
3. To sell at public or private sale, to exchange, or to lease foi- any
period of time, any real or personal property and to give options for
sales, exchanges or leases, for such prices and upon such terms or
conditions as they from time to time may deem proper.
4. To allocate receipts and expenses to principal or income or partly to
each as they From time to time may deem proper.
5. To borrow money from persons or institutiotls,themselves included,
and to mortgage or pledge any or all real or personal property as
they in their sole discretion shall choose, without regard to the
dispositive provisions of this instrument.
2 0= 4
6 To compromise any claim or controversy as<erte.i ~, ~~r against my
estate or trust estate.
%. To make distribution in cash or in hind or r ar~i~ ~; c:.~h and partly
in kind, and in such manner as they rrav ~ercrrnine, and at
valuations finally to be fixed by them.
IN WITNESS WHEREOF, 1 have hereunto set m~~ h~:. ~;~c; seal this i 1 ~ day c~i
November, 2009.
WITNESS:
SARA M. i:;l'PLEI'
.cam/ ~S.
3 of 4
COMMONWEALTH OF PENNSYL.~'AN1A
COUNTY OF PORK
SS
We, SARA M. EPPLEY, DA~'1D J. LENOX, ESQliIRE and M. SUSAN
McMICHAEL, the Testatrix and the wimesses respectively, whose Humes are signed to
the attached or foregoing instrument, be:.gig first duly sworn, do hereby declare to the
undersigned authority that the Testatrix signed and executed the instrument as her Last Wili
and Testament and that she had signed w^iiingly (or willingly directed another ±o sign fnr
her}, and that she executed it as her free a:.d voluntai~• act for the ;;ur~:oses therm
expressed, and that each of the witnessc~. ~n the presence and hearing of the Testatrix..
signed this Last ~~%ill and Testament as winless and that to (he best c~ft}~~eir knowledge the
Testatrix was at the time eighteen (18) years of age or older, of sound mind and under no
constraint or undue influence.
SARA M. EPPLEY
WITNESS
WITNESS
Sworn to and subscribed before
me this 1 I `h day of November, 2009.
NOTARY PUBLIC
MY COMMISSION EXPIRES:
4 of 4
SARA M EPPLEY
Account Market Value
Stock Price as of
11/09/2010 Total Market
Value
$40.530 $1,783.32
The aggregate amount paid to all
Trust Beneficiaries in this distribution
is $165,579,185.12.
Investor ID 8064 31 96 741 5
2010 Dividend Summary
Record Date Total Trust
Interests Dividend per
Trust Interest Current
Distribution
11 /09/2010 44.0000 $0.74 $32.56
Payable Date Tax Withheld Net Distribution Prior Year
Distribution
12/14/2010 $0.00 $32.56 $32.56
For inquiries about your account, you may visit www.bnymellon.com/shareowner/equityaccess, or call 1-800-649-3593.
Trust Beneficiary Information
You may purchase or sell shares of MetLife, Inc. common stock through
the MetLife Policyholder Trust (the `Trust"). free of any commissions or
other fees, under the MetLife Purchase and Sale Program, as amended. A
copy of the brochure describing the program is available on the Internet
at www_metlife.com by selecting Investor Relations and then the
Shareholder Services Information page, or by calling the number listed
above- You are permitted to transfer your Trust Interests only in the
circumstances described in the brochure. You may also instruct that all
(but not less than all} of your shares of MetLife, Inc. common stock held
by the Trust be withdrawn from the Trust. Information regarding your
withdrawal rights may be found in the Purchase and Sate Brochure or by
calling the number listed above.
0302555 G3
An annual shareholders' meeting to elect members of the Board of
Directors of MetLife, Inc. and for the transaction of other business is
expected to be held on April 26, 2011. The deadline for submitting
shareholder proposals for consideration at this meeting is November 23,
2010. A copy of MetLife. Inc.'s annual report and proxy statement will be
available free of charge on or before March 31, 2011, along with other
MetLife, Inc. and Trust filings under federal securities laws, (i) on the
Internet at www_Metlife_com by selecting About MetLife, Corporate
Governance, under Related Links, (ii) by writing to MetLife, Inc., c/o BNY
Mellon shareowner Services, PO Box 358447, Pittsburgh, PA 15252-8447
or (iii) by calling the number Listed above. These and other SEC filings by
MetLife and the Trust are also available on the Internet at www.sec_gov-
Please Note: Important 2010 Tax Information MetLife
FORM 1099-DIV. U.S. TAX INFORMATION FOR 2010 OMB NO. 1545-0110
DIVIDENDS/DISTRIBUTIONS
COPY B FOR
RECIPIENT
RECIPIENT'S TOTAL ORDINARY
IDENTIF}CATION NUMBER DIVIDENDS QUALIFIED DIVIDENDS FEDERAL INCOME TAX WITHHELD
BOX l A BOX 16 BOX 4
165-36-4052 $32.56 $32.56 ~ ~ $0.00
PAYER'S NAME PAYER'S FEDERAL IDENTIFICATinN Nl1MBER
BNY MELLON SHAREOWNER SERVICES AS ',
~~ CUSTODIAN OF THE METUFE POLICYHOLDER TRUST 5t-6516987 II
SECURITY DESCRIPTION TO WHOM PAID
TRUST INTERESTS ~ SARA M EPPLEY
102 S 22ND ST REPORTED BY
CAMP HILL PA 17011-4606 THE BANK OF NEW YORK
MELLON
480 WASHINGTON
BOULEVARD
JERSEY CITY, NJ 07310
IMPORTANT 2010 TAX INFORMATION FOR INFORMATION REGARDING THE ABOVE, CALL 1-800--649-3593
This is important tax information ar.d is being furnished to the Internal Revenue Service.
If you are required to file a return, a negligence penalty or other sanction may be
imposed on you if this income is taxable and the IRS determines that it has not been
reported.
Box to Shoca Total ordrnary dividends that are taxable. Include this amount ;n hn-: 3a of
Form 1040 or 1040A_ Also, report it on Schedule 8 (FOrm 1040) or Schedule 1 (Form t040A).
.f requned. The amount sho'.vn may be dividends a corporaDOn paid directly to .you as a parti-
apant !6r beneficiary of a participant) ur an emoloyee stock ownership plan (ESOPI Report i1
as a drnd~nd on your Form 1040/t040A, but ;real .t as a plan distnbuUon. not as ,.m,esiment
income for any other purpose.
Box a - Sho,,s bay-.~,p :,.:,;holding For example. a pa;~r n~;,;, backup vn[i~hold on certain p:
rr:enis at a 28' rare .. , ~u 'lid not give ; cur iaxpay~r ;~?-•' capon num_~r to ine payer
form VJ 9. Requr.;t x payer Identrtr.atron i~lu:r~b=r ;~,~ .,=r~fication, fc. :r~iormauon
backup vnthholdina lnc'.J=_ ?his amount on your mcome tai r~:~;rn as tax witht;e!d
Nominees. If this form i:i~iudes amounts belonging tp anotn_r person, you ar- consider=~;
nominee rer_ipient You must hie Form 1099-DIV 'r,ith the IRS for each of the other ovmers
show their share of the income. and you must furnsh a Form 1099-DIV to each. A husband
wife rs not required to fire a nominee return io show amounts ~::ned by the other- See tt~e 2(i
General InstrucUOns fir Forrns 1099. 1098, 3921. 3922. X498. and W-2G
Box 1 B - Sh:~'ns the portion of the amount in bor, t A ghat may be eligible for the 15°•:, ~r z9ro
capral .:a~ns rotes. See ilia Form 1040''1040P. instructions for hova to determine this am:,unt
Report the eligible amount on line 9b, Form 1040 or 1040A.
Sovereign Bank
ESTATE OF
SOCIAL SECURITY #:
DATE OF DEATH:
Sara M. Eppley
165-36-4052
August 24, 2010
Account #: l OS l 074258 Type: Checking Open date: 1 1 /1 711 998
I~~ the name of: Sara M Eppley
Date of Death Balance: $71.056.69
Int.(YTD) from 1 /1 /2010 to
'.{~crued interest to date of death:
Other Info: Account closed 9/;/1 !1 - ~ 7n 774 49
Account #: 2895551584 Type: CD
In the name of: Sara MEppley - (Nancy Grove Nichols-POA
Date of Death Balance: $0.00
lnt.(YTD) from 1/1/2010 to 5/27/2010
Accrued interest to date of death:
Other Info: Account closed 5/27/1 ~ - ~~fi~ 51 ~~
Account #: 2895551592 Type: CD Open date: I 1 /24/2009
In the name of: _Sara M Eppley or Nancy Grove Nichols or Sara K Wickard
Date of Death Balance: $26.071.43
Int.(YTD) from 1 /1 /2010 to 8/24/2010 $0.00
Accrued interest to date of death: $0.19
Other Info:
$2.92
$57.98
Open date: 1 1 /24/2009
$289.76
8/9!2010
Page 1 of 1
ASSET MANAGEMENT l L C
September 9, 2010
Jan Wiley
130 W Church St
Ste 101
Dillsburg, PA 17019-1232
RE: Sara M. Eppley, Deceased
Dear Jan,
~lorman L. LaPorte
Managing Director
Senior Financial Advisor
Steven W. LaPorte
Senior Financial Advisor
Bryan T. Black
Financial Advisor
I have included with this letter the information you requested in regards to the Estate of Sara M Eppley.
Please look at the attached page, which details the date of death cost basis for the deceased account,
number 1501-9120, titled Sara M Eppley, Deceased. This account was opened on June 2, 2010 and is an
individual account registered only in her name. Since we received the death certificate, we have opened
an estate account in her name, account number 4933-6210, with Nancy Grove Nichols and Sara K
Wickard as joint executrixes. We are currently in the process of moving the assets from the deceased
account to the Estate account, using the forms you have supplied to us along with the letter of
authorization received from Nancy and Sara.
Please review the enclosed and let me know if you have any further questions.
Thank you,
-- ~~7
~~
Bryan T. Black
This report is not the official record of your account. However, it has been prepared to assist you with
your investment planning and is for informational purposes only. Your Wells Fargo Advisors Financial
Network Client Statement is the official record of your account. Transactions requiring tax consideration
should be reviewed carefully with your accountant or tax advisor.
25 N. 12th St., Suite 201 Lemoyne, PA 17043
1717-730-9631 • Toll-free 866-730-9630 • Fax 717-730-9635 • www.laporteam.com
vestment products and services are offered tf~rough Wells Fargo Advisors Financial fJetwork, LLC (WFAFN).
Porte Asset Management, LLC is a separate entity from WFAFN.
Sara M Eppley Cost Basis as of August 24, 2010
Description 1 Symbol CUSIP Date of Death uantit Unit Cost Cost Amount
ABBOTT LABORATORIES ABT 002824-10-0 8/24/2010 60 49.48 2,968.80
BANK OF HAWAII CORP BOH 062540-10-9 8/24/2010 60 45.58 2,734.80
BAXTER INTERNATIONAL INC BAX 071813-10-9 8/24/2010 70 44 3,080.00
BECTON DICKINSON & CO BDX 075887-10-9 8/24/2010 40 69.3 2,772.00
CVS CAREMARK CORP CVS 126650-10-0 8/24/2010 90 27.93 2,513.70
CHEVRON CORPORATION CVX 166764-10-0 8/24/2010 40 73.78 2,951.20
CHUBB CORP CB 171232-10-1 8/24/2010 50 53.61 2,680.50
EXXON MOBIL CORP XOM 30231G-10-2 8/24/2010 40 58.94 2,357.60
ITT CORP ITT 450911-10-2 8/24/2010 60 43.02 2,581.20
ILLINOIS TOOL WORKS INC ITW 452308-10-9 8/24/2010 60 41.22 2,473.20
AMERISOURCEBERGEN CORP ABC 03073E-10-5 8/24/2010 100 27.87 2,787.00
INTERNATIONAL BUSINESS IBM 459200-10-1 8/24/2010 20 124.9 2,498.00
JOHNSON CONTROLS INC JCI 478366-10-7 8/24/2010 100 26.87 2,687.00
MCKESSON CORPORATION MCK 58155Q-10-3 8/24/2010 40 60.32 2,412.80
MEDTRONIC INC MDT 585055-10-6 8/24/2010 80 31.21 2,496.80
NEWS CORP INC-CL A NWSA 65248E-10-4 8/24/2010 220 12.13 2,668.60
STATE STR CORP STT 857477-10-3 8/24/2010 80 35.32 2,825.60
TUPPERWARE CORP TUP 899896-10-4 8/24/2010 70 39.73 2,781.10
UNITEDHEALTH GROUP UNH 91324P-10-2 8/24/2010 90 31.04 2,793.60
WAL-MART STORES INC WMT 931142-10-3 8/24/2010 50 51.3 2,565.00
JOHN HANCOCK LIFE INS CO 41013M-Q5-2 8/24/2010 5,000 104.331 5,216.55
Total Value of Securities on August 24, 2010 58,845.05
Total Value of Cash on August 24, 2010 83,584.41
Total Value of account on August 24, 2010 titled Sara M Eppley