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HomeMy WebLinkAbout05-03-11 REV-1500 (F>, PA Department of Revenue Pennsylvania OFFICIAL USE ONLY DEPU+TNENT Of NEVENU[ County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 28o6oi ~ (,r Harrisburg, PA 1128-o6oi RESIDENT DECEDENT ,~'j ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY Decedent's Last Name Suffix Decedent's First Name MI Walsh Ms Mary Frances L (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name 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 ® Original Return O Supplemental Return O Remainder Return (Date of Death Prior to O Limited Estate O 4a. Future Interest Compromise (date of O f=ederal Estate Tax Return Required death after ~ Decedent Died Testate O Decedent Maintained a Living Trust ~ "total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O Litigation Proceeds Received O Spousal Poverty Credit (Date of Death O f=lection to Tax under Sec. 9113(A) Between and (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Dumber Ronald J. Walsh ~ ~ %z ~C7 RECa1STER O ? ~~rnE ONLY' t ~ t.,~ ' , a>~~ _ . First Line of Address ~ Belden Street ~ ~ 1 - - Second Line of Address . U ~'~p ~ Q C„ . City or Post Office State ZIP Code DATE FILED Philadelphia Pa Correspondent's e-mail address: walshjauera~aol.com Under penalties of perjury, I dedare that I have examined this return, induding accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Dedaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PE SO RESPONSIBLE FOR FILING RETURN DATE . ADDR SS .?plc ~ ~~.c/ SI'~2~'~'~, ~N/c LP~f~-~ ~ ~ i'y'~/r SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 J REV-1500 EX (FI) Dec:edent's Social Security Number Decedent's Name: Mary Frances Walsh RECAPITULATION Real Estate (Schedule A) Stocks and Bonds (Schedule B) Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) Mortgages and Notes Receivable (Schedule D) Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... Jointly Owned Property (Schedule F) O Separate Billing Requested Inter-Vivos Transfers ~ Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ Total Gross Assets (total Lines 1 through Funeral Expenses and Administrative Costs (Schedule H} Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) Total Deductions (total Lines 9 and Net Value of Estate (Line 8 minus Line Charitable and Governmental BequestslSec Trusts for which an election to tax has not been made (Schedule J) Net Value Subject to Tax (Line minus Line TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES Amount of Line taxable at the spousal tax rate, or transfers under Sec. (a)(1.2) X Amount of Line taxable at lineal rate X _ Amount of Line taxable at sibling rate X Amount of Line taxable at collateral rate X 1 g TAX DUE FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~ Side 2 REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Mary Frances Walsh STREET ADDRESS _ _ _ _ _ _ _ _ Hillcrest Court _ _ _ - _ _ _ _ _ CITY _ STATE 'ZIP Camp Hill Pa Tax Payments and Credits: Tax Due (Page Line Credits/Payments A. Prior Payments _ B. Discount Total Credits (A + B) Interest If Line 2 is greater than Line 1 + Line enter the difference. This is the OVERPAYMENT. Fill in oval on Page Line to request a refund. If Line 1 + Line 3 is greater than Line enter the difference. This is the TAX DUE. Make check payable to: REGISTER OF WELLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred ? ~c b. retain the right to designate who shall use the property transferred or its income ? c. retain a reversionary interest ? d. receive the promise for life of either payments, benefits or care? ? If death occurred after Dec. did decedent transfer property within one year of death without receiving adequate consideration? ? Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ? Did decedent own an individual retirement account, annuity or other non-probate property, which contains a benefaary 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 and before Jan. the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent P.S. (a) (i)]. For dates of death on or after Jan. the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent P.S. (a) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disdosure 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 • The tax rate imposed on the net value of transfers from a deceased child 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 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 benefiaaiies is percent, except as noted in 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 percent P.S. §9116(a)(1.3)]. Asibling is defined, under Section as an individual who has at least one parent in common with the decedent, whether by blood or adoption. • REV-1503 EX+ SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STACKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~ ~ FILE NUMBER All property jointly-owned with right of survivorship mus# be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH i . t, ~ ~ S ~l1r'N,~ $i G'' C./C /~.L C"•:,~ ~.1.~~t.~ ~''o`r ~c',4~G~,1~1~_s"f~?~~~:~~..5~'3'1!9'ef /.~fj!'.'.'~:~ '~S~r~~ 'f~'~;~.,~. , ~Gt(~ .,,5.~-j!A/C~ S~ L3!' CQrn.~i''14:~,l l L'r C•Ik ~ i,3~/tll~ d,~'' ,~~~~i t~.e~ L° Ul''+~' • • ~.Sttj~;~s' cr cc.~:n~.~=u~" ..si~c`i~~,~~i C~:~~:~ ~y`r~u~.• C~ ~cI` ,5~r9k-C. a~~~~5 ,~'Yi~:,~~~ Ste'"a.~:,j'~ Z ~ c; :~~t~'s e.~= C- ~j::,c! _.S;'.:cf~' S y ~i/~C ?~~'S` r ~/t/,~~i.' ~ L. 1 c.M. s ~ ` ~~fi'~~;! ~'yr~; ~J Vii' r/~y r L: ~ ' x.'73 f'~~' :...Syf~n-~: s, F' c~..~ ~ ~ ~G;ir~~i-'I ~ 'u Gt./~"" f ~~t= -1~v~S~h.~`r~;! e L.v':'~ ~ I,~,7 ~ ~ ~ ~ L! = G. ~C~ ~ Gf f' ~.~mt3!L/~ -.f! ~ ~ " CL'i ~ 3~,~J ~ Gr J~V ~~Iri ~ , '°f G' is .s~t"~~~ = ~~j~ ,~y f,~:ti'~,~r:~,~c~~,~,! :~t,r.~~ ~ ~~~zY~ cam, TOTAL (Also enter on line Recapitulation) $ ~ ~c~f ~ (If more space is needed, insert addfionaf sheets of the same size) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. AU property jaint~r-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ,r ~ ~ _ ~~~~f f ~t~~ ~~~~.i~ TOTAL (Also enter on line Recapitulation) $ I~• <Y..~ (If more space is needed, insert additional sheets of the same size) R'cV-t544 EX • (t-9n SCHEDULE G INTER-VIVOS TRANSFERS & COM~OERITANCECTAXERETURNANlA MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER This schedule must be completed and filed 'rf the answer to any of questions 1 through 4 on the reverse side of the REV-9500 COVER SHEET is yes. DESCRIPTION OF PROPERTY % OF ITEM INCLUDE THE NAlAE OF THE TRANSFEREE, 7kEfR RELATSCNSHSP TC DECEDENT AND THE DATE CF TRANSFER. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE ATTACH A CCPY CF THE GEED FCR REAL ESTATE . NUMBER VALUE OF ASSET INTEREST 1FAPPLfCA6LE ~ err v'.~F ~ i `7r ~ ~'~:c` v:~t..'r' .~1~!~1~c~t' ~/d ~v~T~ .S'J, J L• , j. TOTAL (Also enter on line Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ SCHEDULE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL_EXPENSES: _ ~ ~ i G~ ~X ~S~%.:v'~' cry :s•~ i>~ B. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative{s) Street Address City State Zip Year(s) Commission Paid: Attorney Fees 4 Family Exemption: (If decedents address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent Probate Fees ~ ~ • -J~ ~ Accountant's Fees Tax Return Preparer's Fees ~ J ~ z. ,jt ~ ~ .i t:: ~ 4 ,~~,f~c~' ~ s i ~ t'} r? f'~ f R3 ~ j-~, f~/•~~if 3 .C. ~'Cs c: t ~ / ~r ~°j~~'~J}l~/ts,r~.' ~ G;~4y~ tSlll+°. L+' ~ I.C~~ L 1"t'~'~ ~.'C:,, Lf T 7 ~Y ~y~Ln. p~~'-g2~•~ `s ~ ~sf~ c; ~.cl~ 1n.,~ . C Y / ~jl ~ i` . l1 f ~f ~ f r7~ ~~lZ 51:.x? ~r /"'c r3. ~`'~G .;"S ~v t`3, ..~~'p~~1! J'. TOTAL (Also enter on line Recapitulation) ~ ~ F"~,• (If more space is needed, insert additional sheets of the same size) ' REV-1513 EX+ SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. (a) (1.2)J ~?r~~l~.~}~~;. , d `vr c~ ~ ~ ,~'~e i f~<= Jib t-~rc~..~ ~-~Ls~~v~~~-~-1, .nf T a ; ~L i;'k ~ ~ ~ ~ t:%%C T~ S i ~C,~}jE1 T~r~1 ~ Zi'k; ~i1'?G'S r'~ E-~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES THROUGH AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION FOR WHICH AN ELECTION TO TAX IS NOT BEIN(a MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE i3 OF REV COVER SHEET $ (If more space is needed, insert additional sheets of the same size) IYIARY FRANCES WALSH ? ' -1=1LE NO 2-:10-W ~~NAL LAST WILL AND TESTAMENT of MARY FRANCES WALSH BE IT REMEMBERED, that I, MARY FRANCES WALSH of Hillcrest Court, Apt. Camp Hill, PA being of sound mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making null and void any and all Wills and Testaments and writings in the nature thereof by me, at anytime heretofore made. ARTICLE BACKGROUND INFORMATION: The following is background information pertaining to myself and my family: (A) I was born on September (B) My social security number is XXX-XX-8631. (C) I am single and have no children. (D) I have 2 brothers, Ronald J. Walsh and James V. Walsh. (E) My brother, Ronald J. Walsh, has two children: Kathleen Tomczuk and Sean Patrick Walsh. (F) My brother, James V. Walsh, has two children: Kimberly McCormick and James J. Walsh. ARTICLE DEFINITIONS AND MISCELLANEOUS TERMS: The following definitions and miscellaneous terms shall apply to this my Last Will and Testament: (A) Issue: The terms "issue" means the immediate and remote lawful, lineal descendants by blood or adoption of the person referred to, who are in being at the time they must be ascertained in order to give effect to the reference to them. (B) Personal Representative: The term "my Personal Representative" means the Executor or Executrix of my Estate, or any other title of like import which is used to describe such a fiduciary. (C) Residuary Estate: The term "my Residuary Estate" means all the rest, residue and remainder of my Estate remaining after payment of all of my last debts, funeral expenses, taxes and administration expenses and any other expense, or expenditure required to be made as the result of my death and after distribution of the Tangible Personal Property and any special bequests specifically set forth herein. (D) Per Stirpes: The term "per stirpes" means that whenever a distribution is to be made to the issue or descendants of any person, the property to be distributed shall be divided into as many shares as there are living children of the person, and deceased children, who left descendants who are living, of the person. Each living child, if any, shall take one share and the share of each deceased child shall be divided amongst his then living descendants in the same manner. Page 1 MARY FRANCES WALSH •FILE NO 2-10-W (E) Survive: The term "survive me" means that any person or organization herein named or referred to shall be deemed to have survived me only if such person or organization shall in fact survive me for a period of at least thirty days. Any person or organization named or referred to herein who shall not survive me by a period of thirty days shall be deemed to have died before I do. (F) Gender and Number: Where appropriate to the context, pronouns or other terms expressed in one number or gender shall be deemed to include the other number or gender, as the case may be. (G) Percentages: Where a gift, bequest or devise is expressed as a percentage in the following Articles, it refers to the percentage of that portion of my estate available for distribution unless a contrary intention appears in the Article. (H) Priority: Priority for distribution of the gifts and bequests herein made shall follow the Article number with the lower numbered Article taking priority over any Article appearing subsequently unless a contrary intention appears in the Article. (i) Encumbrance: When encumbered property has been specifically devised or bequeathed, it shall pass under the terms and conditions of this Will subject to said encumbrances, provided however, that any installment payments, current or past due, on either principal or interest on such encumbrances may be paid by my Personal Representative in his/her sole discretion. (J) Partial Invalidity: If any provision of this Will shall be declared inoperative or in violation of any rule of law, such invalidity shall not affect the remaining provisions of this Will and they shall remain in full force and effect. ARTICLE DEBTS AND FUNERAL EXPENSES: I direct that all my just debts and funeral expenses appropriate to my station in life and custom of living (including appropriate monument or marker for my grave) be paid as soon after my demise as may be convenient. ARTICLE ADMINISTRATION EXPENSES: i direct that all of the expenses of the administration of my Estate including, but not limited to, probate and other Court fees and reasonable commission for my Personal Representative and any attorney retained by my Personal Representative, be paid as such expenses are incurred and as soon after my demise as may be convenient. ARTICLE PAYMENT OF TAXES: I direct my Personal Representative to pay all inheritance, estate, succession and legacy taxes of whatsoever nature and kind, to which my Estate or any person receiving the transfer of any property passing hereunder or otherwise passing by reason of my demise, may be subject and to charge such taxes against my Residuary Estate, it being my intention that none of the aforesaid taxes, either federal or state, or any property required to be included in my gross estate, under the provisions of any state or' federal law now in force or hereafter enacted, shall be prorated among the persons interested in my Estate to whom such property is or may be transferred or to whom any benefit accrues. ARTICLE TANGIBLE PERSONAL PROPERTY: I give and bequeath all tangible personal property owned by me at my death and all insurance policies on such property as follows: Page 2 MARY FRANCES WALSH ' •FILE NO 2-10-W (A) Memorandum: To those individuals who survive me and who are designated on a list, memorandum, or Bequest of Personal Property form signed by me which refers to my Will or is found with a copy thereof, I give and bequeath the items listed beside his/her name. (B) Remainder Distribution: The balance (including any items to be distributed under this Article, the bequest of which has lapsed) shall become part of my Residuary Estate and distributed to the beneficiaries and in the proportions herein provided. My Personal Representative shall have the right to dispose of said remaining items of personalty, either in kind or in cash as a result of liquidation thereof as my Personal Representative, in his/her sole discretion, deems appropriate under the circumstances. It is my intent, however, that should any beneficiary of my Residuary Estate desire to receive a particular item in kind which was not specifically bequeathed to that beneficiary, to the extent reasonably possible, my Personal Representative shall attempt, but not be obligated, to follow that beneficiary's request. (C) Safekeeping: If any beneficiary of any item of tangible personal property aforesaid has not yet attai red the age of twenty-one at the time of my death, I direct that my Personal Representative, hereinafter named, to hold said items in safekeeping for that beneficiary and to deliver the same to that beneficiary upon he or she reaching age twenty-one or at such earlier age if my Personal Representative deems the beneficiary to be of appropriate age and maturity to receive said items of personalty. For these purposes my Personal Representative shall be entitled to use or set aside from my Estate sufficient funds to provide for that safekeeping. ARTICLE SPECIAL BEQUESTS: i make no special bequest in my Will other than those to be made pursuant to Article herein. ARTICLE RESIDUARY ESTATE: I give, devise and bequeath my Residuary Estate to the following persons and in the following percentages: (A) to my brother Ronald J. Walsh, provided he survives me. If Ronald J. Walsh fails to survive me, then his share of my residuary Estate shall be distributed instead to such of his issue who survive me in equal shares per stirpes. (B) to my brother James V. Walsh, provided he survives me. If James V. Walsh fails to survive me, then his share of my residuary Estate shall be distributed to such of his issue who survive me in equal shares per stirpes. (C) to my grand nephew, Luke Tomczuk, provided he survives me, and subject to the Trust set forth in Article 9 herein. ARTICLE THE LUKE TOMCZUK TRUST: In the event Luke Tomczuk should become entitled to any interest in my Estate, his share shall be held in Trust by my hereinafter named Trustee in separate Trust for the following uses and purposes and subject to the following terms and conditions: (A) Name of Trust: The Trust shall be known as the "Luke Tomczuk Trust" (hereafter referred to as the "Trust"). Page 3 MARY FRANCES WALSH • •FILE NO 2-10-W (B) Beneficiarv: The Trust shall be held for the benefit of Luke Tomczuk, (hereafter referred to as the "Beneficiary"). (C) Appointment of Trustee: The following shall apply to the appointment of the Trustee of the Trust: Trustee: I appoint Kathleen Tomczuk as my Trustee. 1 St Alternate Trustee: In the event Kathleen Tomczuk should predecease me, die, fail to qualify, cease to exist or act, or renounce the appointment as my Trustee, I then appoint Carl Tomczuk as my Trustee. 2"d Alternate Trustee: In the event Kathleen Tomczuk and Carl Tomczuk both should predecease me, die, fail to qualify, cease to exist or act, or renounce the appointment as my Trustee, I then authorizes any court o~ competent jurisdiction to appoint a successor Trustee to act in Trustee's stead. No Bond: All Trustees hereunder shall serve without bond, unless otherwise determined to be appropriate by a court of competent jurisdiction. (D) Management and Administration of the Trust: Subject to the provisions of Paragraph (E) of this Article my Trustee shall have, hold, manage, invest and reinvest the principal of the Beneficiary's share of the Trust, and during the continued existence of the Trust, pay to or for the Beneficiary's benefit, all or so much of the net income and all or so much of the principal of the Beneficiary's share of the Trust, even to exhaustion, and without liability to any remainderman, with any unused income and principal to be accumulated, as my Trustee in his/her absolute and sole discretion, may deem necessary, proper and/or appropriate to maintain the Beneficiary in the proper station in life including, but not limited by way of specification the payment of expenses relating to or associated with: Support and Maintenance: General support and maintenance; Room and Board: Room and board (including the rental or purchase of a home for the beneficiary, home maintenance, repair and/ar improvement, utilities, telephone, food, and other general living expenses; Taxes: Real estate, income, personal and other taxes; Transportation: Transportation and vehicle expenses (including the purchase of a vehicle or vehicles, airline fees, public transportation costs and the like); Education: Educational costs and fees including, but not limited to, tuition charges for college, university, post graduate sehool or post-secondary vocational or technical training and trade schools and all expenses which the Trustee deems necessary and desirable in connection therewith including, by way of illustration, room and board, clothing, travel expenses, books and supplies, and reasonable sums for personal and other living expenses; Insurance: Life, health, vehicle and homeowners insurance; and Page 4 MARY FRANCES WALSH ' 'FILE NO 2-10-W Medical: Expenses for medical, hospital, dental, optical, and psychological/psychiatric care. (E) Special Needs Provisions: If during the pendency of this Trust, the Beneficiary becomes disabled or incapacitated, and during the period of that disability or incapacity, the following shall apply: The Trust for the benefit of Beneficiary shall be held and used to the Beneficiary's needs other than support and maintenance which may be unavailable to Beneficiary except through this Trust. The Trust is intended to satisfy those non-support needs, as deemed appropriate in the absolute discretion of the Trustee. This Trust is not intended to displace any source of income otherwise available to the Beneficiary for his basic support (such as food and shelter), including any governmental assistance program to which the Beneficiary is or may be entitled. It is not intended to be a resource of the Beneficiary. It is not available to the Beneficiary. It is intended to be a discretionary spendthrift Trust created for non-support purposes. No part of the corpus of the Trust shall be used to supplant or replace any public assistance benefits received by or through any County, state, federal or other governmental agency. Trustee shall hold and distribute the principal and income ~of the Trust as follows: (a) During the lifetime of the Beneficiary, to the extent that benefits are not made available to Beneficiary for other than basic living expenses, including food and shelter, Trustee in Trustee's absolute discretion, may distribute from income and principal to or for the benefit of the Beneficiary for his needs other than basic support. For the purposes of this provision, non-support purchases include, but are not limited to: dental care; unreimbursable medical expenses, including plastic and reconstructive surgery, diagnostic work and treatment, rehabilitative training and experimental medical services; the differential in cost between shelter for a shared and private group home or room; supplemental nursing care; recreation, cultural experiences, outings and travel, including payment for others to accompany the Beneficiary; telephone and television, including cable television; reading and educational materials; exercise equipment; and unreimbursed therapy. Trustee's discretion in making distributions authorized hereunder is absolute with regard to distributions form the'Trust estate, and shall be binding on all interested persons or parties. (b) As this Trust is specifically not intended to provide basic support and maintenance needs for the Beneficiary, if the Beneficiary is unable to maintain and support himself from his own resources and sources of income, Trustee shall seek such support for the Beneficiary from public sources. This Trust has specifically not been created to supplant or replace public assistance benefits. Trustee should therefore seek Page 5 MARY FRANCES WALSH • FILE NO 2-10-W entitlements which are available to members of the community who are experiencing disabilities that are substantially similar to those that the Beneficiary experiences. Trustee shall deny any request made by an agency or governmental entity requesting disbursement of the Trust funds to satisfy the Beneficiary's support needs. (c) Trustee shall take whatever legal steps shall be necessary to initiate or continue any public assistance program for which the Beneficiary is or may become eligible. Trustee shall bring such action in any court having jurisdiction over the matter, to secure a ruling or order that the Trust is not available to the Beneficiary for support purposes. Any expense of the Trustee, including reasonable attorney's fees, in connection with matters relating to determination of eligibility of the Beneficiary for public support, shall be a proper charge to the Trust. (F) MISCELLANEOUS TRUST PROVISIONS: Separate Account: I direct my Trustee to maintain a separate account for the property bequeathed and devised to the Beneficiary. Distributions: The amount to be paid for the benefit of the beneficiary from the Trust shall be determined by my Trustee, in my Trustee's absolute and sole discretion, and from time to time, after consideration of the beneficiary's needs, other income and assets, including any income payable for the benefit of the beneficiary from other sources, including but not limited to, other trusts, social security benefits and/or other governmental benefits. Under no circumstances can the Beneficiary compel a distribution from the Trust for any purpose. Trustee's discretion in making distributions is final, even if Trustee elects to make no distributions at all. Further, Trustee may be arbitrary and unreasonable. Trustee's absolute and independent judgment, rather than any other party's determination, is intended to be the criterion on which distributions are made. No court or any other person should substitute its or their judgment for any decision or decisions made by the Trustee. Distribution-Person or Institution: The payments to be made from the Trust may be made, as my Trustee deems appropriate, directly to the beneficiary if the beneficiary is, in the sole opinion of my Trustee, of an age and ability to handle the funds so paid; or directly to the person having custody and care of the beneficiary; or directly to any institution entitled to such payment by reason of services rendered or to be rendered to the beneficiary. Death of Beneficiary Before Final Distribution: If the beneficiary should die before final distribution the beneficiary's share of Trust, then the beneficiary's share of Trust shall be distributed to the Beneficiary's issue in~ equal shares per stipes and if none then amongst the then surviving beneficiaries of my Residuary Estate and in the proportions herein provided, subject to the terms and conditions of this Trust, if then applicable. Termination of Trust Due to Size: Should the principal of the Trust herein provided for be or become too small in my Trustee's discretion so as to make Page 6 MARY FRANCES WALSH • •FILE NO 2-10-W establishment or continuance of the Trust. inadvisable, my Trustee or Personal Representative may make immediate distribution of the then-remaining assets, principal and any accumulated or undistributed income outright to the person or persons and in the proportions they are entitled, and if any such person is a minor then to the Guardian of the Person of that minor beneficiary. Rule Against Perpetuities: In the event that any proposed distribution hereunder shall violate any rule against perpetuities or rule against accumulations my Trustee is directed to cause a sooner termination of the Trust and to make distribution as specified above in such shorter period that will not violate any such rule or law, any other provisions in my Will to the contrary not withstanding. No Alienation: No income or principal shall be assignable by a beneficiary or available to anyone having a claim against a beneficiary before actual payment to the beneficiary. No part of the Trust, shall be subject to the claims of the Beneficiary's creditors, or specifically the Beneficiary's voluntary or involuntary creditors for the provision of care and services to the Beneficiary during his lifetime, including payments for residential care and maintenance by any public entity or private creditor. (G) POWERS OF TRUSTEE: In addition to the powers conferred by law or under previous provisions of my Will, my Personal Representative and m~y Trustee shall have the following powers: General Powers: In general, to exercise all powers in the management of the Trust Estate which .any individual could exercise in his or her own right, upon such terms and conditions as it may reasonably deem best, and to do all acts which it may deem reasonably necessary or proper to carry out the purposes of the Trust. Receipt of Property: To receive property bequeathed, devised or donated to the Trustee by the Testatrix or any other person, to receive the proceeds of any insurance policy which names the Trustee as beneficiary; to execute all necessary receipts and releases to Personal Representatives, donors, insurance companies and other parties adding property to the Trust Estate. Retention and Exchange of Property: To retain in the form received any property or undivided interests in property donated to, or otherwise acquired as a part of the Trust Estate, including residential property donated to, or otherwise acquired as a part of the Trust Estate, including residential property and shares of the Trustee's own stock, regardless of any lack of diversification, risk or nonproductivity, as long as it deems advisable, and to exchange any such security or property for other securities or properties and to retain such items received in exchange, although such property represents a large percentage of the total property of the Trust Estate or even the entirety thereof. Investment of Property: To invest and reinvest all or any part of the Trust Estate in any property and undivided interests in property, wherever located, including bonds, debentures, notes, secured or• unsecured, stocks of corporations regardless of class, interests in limited partnerships, real estate Page 7 MARY FRANCES WALSH 'FILE NO 2-10-W or any interest in related estate whether or not productive at the time of investment, interests in trust, investment trust, whether of the open and/or closed fund types, and participation in common, collective or pooled trust funds of the Trustee, insurance contracts on the life of any beneficiary or annuity contracts for any beneficiary, without being limited by any statute or rule of law concerning investments by fiduciaries. Sale of Assets: To sell either at public or private sale any real or personal property and to consummate said sale or sales bysufficient deeds or other instruments to the purchaser or purchasers, conveying a fee simple title with special warranty, free and clear of all trusts and without obligation or liability to the purchaser or purchasers to see to the application of the purchase money or to make inquiry to the validity of the sale or sales; and to make, execute, acknowledge and deliver any and all deeds, assignments, options, or other writings which may be necessary or desirable in carrying out any of the powers conferred upon my Trustee in my Will or otherwise; Purchase of Property: To purchase property, real or personal, from the Testatrix's general estate upon such terms and conditions as to price and terms of payment as the Testatrix's personal representatives and the Trustee shall agree, to hold the property so purchased as a part of the Trust Estate although it may not qualify as an authorized trust investment except for this provision, and to dispose of such property as and when the Trustee shall deem advisable. The fact that the Testatrix's personal representative and the Trustee are the same shall in no way affect the validity of this provision. Retention: To hold and retain the principal of the Trust Estate undivided until actual division shall become necessary in order to make distributions; to hold, manage, invest, and account for the several shares or parts thereof by appropriate entries on my Trustee's books of account; and to allocate to each share or part of share its proportionate part of all receipts and expenses; provided, however, the carrying of several trusts as one shall not defer the vesting in title or in possession of any share or part of share thereof. Cash: To keep, at any time and from time to time, all or any portion of the Trust Estate in cash and uninvested for such period or periods of time as it may deem advisable, without liability for any loss in income by reason thereof. Liquidation or in Kind Division: To make payment in cash or in kind, or partly in kind upon any division or distribution of the Trust Estate (including the satisfaction of any pecuniary distribution) without regard to the income tax basis of any specific property allocated to any beneficiary and to value and appraise any asset and to distribute such asset in kind at its appraised value; and when dividing fractional interests in property among several beneficiaries to allocate entire interests in some property to one beneficiary and entire interests in other property in another beneficiary or~ beneficiaries. Banking and General Financial Powers: To have the following banking powers: (a) Deposits: To deposit any funds received for mein my accounts in such bank or trust company or other depository as my Trustee may select. Page 8 MARY FRANCES WALSH 'FILE NO 2-10-W , (b) Withdrawals: To withdraw from and to draw any check or other draft against any monies held my the Trustee for the Trust Estate at any bank, saving fund or other place of deposit. (c) Endorsements: To endorse notes, checks and other instruments which may require endorsement. (d) Borrow Money: To borrow money and to mortgage or pledge any property, real or personal, now or hereafter owned by the Trust as security therefor, and to satisfy of record any indentures of mortgage now or hereafter standing in the Trust name or acquired for Trust account. (e) General Banking: Generally, to any and all business for the Trust with any bank, trust company or other depository. Stocks, Bonds, Securities and Investments: To have the following investment powers: (a) Sales and Exchanges: To sell, exchange, pledge, assign, transfer and deliver to any person, at my Trustee's discretion, all or any part of any stocks, bonds, notes, mortgages, interests in partnerships or other securities, and any and all personal property standing in the name of the Trust or belonging to the Trust, or over which the Trust may have any power of control; and to make, execute and deliver on my behalf all necessary deeds, assignments or transfers. (b) Registration: To register any or all of my securities in the name of the Trust. (c) Votin To refrain from voting or to vote shares of stock which are a part of the Trust Estate at shareholders' meeting in person or by special, limited, or general proxy and in general to exercise all the rights, powers and privileges of an owner in respect to any securities constituting a part of the Trust Estate. (d) Investment: To invest in any form of property, all funds and securities held by or received for the Trust, keeping such cash reserves as, in my Trustee's discretion, are necessary or desirable to meet conditions as they may exist from time to time. In the exercise of this power, my Trustee may invest in any variety of real and personal property as in my Trustee's discretion appears to be prudent investments, and my Trustee shall not be liable to me for any error of judgment in the making or continuation of any investment. (e) Reorganization: To participate in any plan of reorganization or consolidation or merger involving any company or companies whose stock or other securities shall be part of the Trust Estate, and to deposit such stock or other securities under any plan of reorganization or with any protective committee and to delegate to such committee discretionary power with relation thereof, to pay a proportionate part Page 9 MARY FRANCES WALSH ' 'FILE NO 2-10-W of the expense of such committee and any assessments levied under any such plan, to accept and retain new securities received by the Trustee pursuant to any such plan, to exercise all conversion, subscription, voting and other rights, or whatsoever nature pertaining to such property, and to pay any amount or amounts of money as it may deem advisable in connection therewith. (f) General: To transact all business in relating to any stocks, bonds, securities or other property in the nature thereof; to deposit the same under agreements of deposit; to participate in any plan of lease, mortgage, merger, consolidation, exchange, reorganization, recapitalization, liquidation, receivership, or foreclosure with respect thereto; to exercise any rights to subscribe to new issues thereof; and generally to exercise all rights of management and ownership with respect thereof. Real Estate: To have the following powers regarding real estate: (a) Sales: To sell, exchange, pledge, assign, transfer and deliver to any person, at my Trustee's discretion, all or any part of my real property, standing in the name of the Trust or belonging to the Trust, or over which the Trust or my Trustee may have any power or control. (b) Subdivision and Development: To subdivide, develop, or dedicate real property to public use or to make or obtain the vacation of plats and adjust boundaries, to adjust differences in valuation on exchange or partition by giving or receiving consideration, and to dedicate easements to public use without consideration. (c) Mana ement: To manage real property, separately or jointly with others. (d) Leases: To lease for any term any real property and to vary the terms, including rent payable, of any lease. (e) Repairs: To alter, repair, improve, mortgage, divide, exchange, join in the partition of, or give options with respect to, real property or to demolish any improvements, to raze existing or erect new party walls or building. (f) Judicial Sale: To buy in at judicial sale any property against which I hold a mortgage. (g) Execution of Documents: To make, execute and deliver on my behalf all necessary deeds, assignments or transfers„ (h) General: Generally to transact all business and to exercise all rights of management and ownership relating to real property. Page MARY FRANCES WALSH ' -FILE NO 2-10-W Personal Property: To sell, transfer,. convey, and liquidate any tangible personal property the Trust may own whenever it appears that the Trust may no longer have any use for that property and to convert the same into cash. Claims, Law Suits, Compromise and Miscellaneous Powers: To have the following powers regarding claims, suits etc.: (a) Demands and Suits: To demand, sue for, levy, collect, and give proper receipts for all sums of money or property now, or which may hereafter become due me, from any sources whatsoever, including all estates or trusts, proceeds of insurance policies, or other property of any kind whatsoever. (b) Settlement: To compromise, adjust, arbitrate, sue on or defend, abandon, or otherwise deal with and settle claims in favor of or against the Trust Estate as the Trustee shall deem best, without court approval and without the consent of any beneficiary; (c) Agreements: To make, negotiate, sign, and perform any and all agreements and contracts now in effect or in the process of negotiation, execution and settlement by me, or which may hereafter, in the opinion of my Agent, be to my interest or advantage; to effect, procure, and continue insurance of any and every kind and description; and with full power and authority to manage any real and personal property and conduct my affairs generally. Business Operation: To continue and operate any business owned by the Testatrix at the Testatrix's death and to do any and all things deemed needful or appropriate by the Trustee, including the power to incorporate the business and to put additional capital into the business, for such time as it shall deem advisable, without liability for loss resulting from the continuance or operation of the business except for its own negligence; and to close out, liquidate or sell the business at such time and upon such terms as it shall deem best. Rents and Profits: To collect, receive, and receipt for rents, issues, profits and income of the Trust Estate. Insurance: To insure the assets of the Trust Estate against damage or loss and the Trustee against liability with respect to third persons. Loans to Estate: To borrow money and to encumber;, mortgage or pledge any asset of the Trust Estate for a term within or extending beyond the term of the trust, in connection with the exercise of any power vested in the Trustee. Loans from Estate: To lend funds to the Testatrix's general estate upon•such terms and conditions as to interest rates, maturities, and security as the Testatrix's personal representatives and the Trustee shall agree, the fact that they may be the same in no way affecting the validity of this provision. Self Dealing: In buying and selling assets, in lending and borrowing money, and in all other transactions, irrespective of the occupancy by the same person of dual positions, to deal with itself in its separate, or any fiduciary capacity. Page MARY FRANCES WALSH -FILE NO 2-10-W Employment: To employ and compensate agents, accountants, investment advisers, brokers, attorneys-in-fact, attorneys-at-law, tax specialists, realtors, and other assistants and advisors deemed by the Trustee needful for the proper administration of the Trust Estate, and to do so without liability for any neglect, omission, misconduct, or default of any such agent or professional representative provided such person was selected and retained with reasonable care. Power to Delegate: To substitute one or more Agent or Agents under my Agent, to carry out any of the general of specific powers hereby granted. Payment of Cost and Expenses: To pay all costs, taxes, expenses and charges in connection with the administration of the Trust. Tax Matters: To prepare, execute and file on behalf of the Trust any and all income tax declarations and returns, and any other tax returns and reports (including, but not limited to, protests, claims, elections, consents, closing agreements, waivers of statutes of limitations and extensions), and to represent the Trust before the Internal Revenue Service of Treasury Department and: any state or local taxing authority with respect to any claim .or proceeding having to do with tax liabilities, federal, state or local, for any and all tax years. Determination of Allocation: To determine what shall be fairly and equitably charged or credited to income and what to principal. Combination: To combine assets of two or more trusts if the provisions and terms of each trust are substantially identical, and to administer them as a single trust, if the Trustee reasonably determines that the administration as a single trust is consistent to the Testatrix's intent, and facilitates the trust's administration without defeating or impairing the interests of the beneficiaries. Division: To divide any trust into separate shares or separate trusts or to create separate trusts if the Trustee reasonably deems it appropriate and the division or creation is consistent with the Testatrix's intent, and facilitates the trust's administration without defeating or impairing the interests of the beneficiaries. (H) Fee for Trustee: I direct that the commission or fee to be paid to my Trustee for the administration of any trust herein provided shall be the annual rate of one-half of one percent of the value of the assets in the Trust, payable in monthly installments at the end of each month the Trustee administers and manages the Trust, which fee shall be based on the value of the Trust assets as of the end of the month for which the payment is due. ARTICLE PERSONAL REPRESENTATIVE: The following shall apply to the my Personal Representative: (A) Appointment of Personal Representative:_I hereby appoint the following as my Personal Representatives: Page MARY FRANCES WALSH -1=1LE NO 2-10-W Personal Representative: I appoint Ronald J. Walsh and James V. Walsh, or the survivor of them as my co-Personal Representative. 1 St Alternate Personal Representative: In the event both Ronald J. Walsh and James V. Walsh above should predecease me, die, fail to qualify, cease to exist or act, or renounce the appointment as my Personal Representative, i then appoint Kathleen Tomczuk as my Personal Representative. (B) Powers of Personal Representative: My Personal representative shall have the following powers: Law/Will: All powers conferred by law or under previous provisions of my Will; Powers Given to My Trustee. All powers conferred upon my Trustee, as referenced in Article 9 (G) herein, incorporated by ~~reference hereto; Disclaimer: To disclaim any interest in property. (C) Fee for Personal Representative: I direct that the commission or fee to be paid to my Personal Representative for the administration of my Estate shall be at the rate of five percent of the gross value of the assets in the Estate, which fee shall be based on the value of the Estate assets as reported on the Pennsylvania Inheritance Tax Return. ARTICLE NO BONDING REQUIREMENT: I direct that my Personal Representative, my Guardian of Minor's Property and my Trustee., or their successors, shall not be required to give bond for the faithful performance of their duties in any jurisdiction. ARTICLE EXCLUSION: It is not my intention to make provision iri my Will for any relative or any other person not expressly provided for herein, except for children born to or legally adopted by me after the date of this instrument. If any such person has not been expressly mentioned herein, he or she has been omitted by me intentionally and with full knowledge of his or her relationship and existence, and not by any oversight or neglect. ARTICLE WILL CONTEST: In the event that any person, including a devisee, legatee or beneficiary under my Will shall either directly or indirectly seek to establish or assert any claim to my Estate, or any part thereof, not authorized by my Will, or seek to impair, invalidate, or set aside the provisions of my Will, or to have any of the trust provisions or estate distributions limited, declared void or diminished or to defeat or change any of the diapositive scheme of my Will, or shall endeavor to secure or take any part of my estate in any manner other than through or under my Will, I hereby give, devise and bequeath to such person or persons the sum of Ten Dollars and no more in lieu of any other share or interest in my estate. Provided further that nothing in this Article contained shall prevent any beneficiary hereunder from bringing an action against any fiduciary hereunder, for an accounting, nor from enforcing any statutory share to which the heir may be entitled. INTERCHANGEABILITY' OF LANGUAGE: Words used in the singular may be read to include the plural or the plural may be read as the singular. Similarly, the masculine form may be read to include the feminine and neuter, the feminine may be read to include the masculine and neuter; and the neuter may be read to include the masculine and feminine. Page MARY FRANCES WALSH -f=1LE NO 2-10-W HEADINGS: The headings used on the various paragraphs in this Will are included for convenience only and shall have no legal significance. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~ day of ~ , WITNESS: . ~l ' . ~ {SEAL} MARY FRANCES WALSH Page MARY FRANCES WALSH -FILE NO 2-10-W ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA • SS. COUNTY OF CUMBERLAND : We, MARY FRANCES WALSH, ~ 1 d Sl J~'tak~.1~2 Or t'riu.l'!~ the Testatrix and the witnesses respective y, whose names are signec~to the attached or foregoing instrument, being first duly sworn, do hereby declare to he undersigned authority by /rtC~K~n~ ~tr /'M.arK that the Testatrix signed and executed the instrument~as ~festatrix's Last Will and Testament and that Testatrix had signed willingly (or willingly directed another to sign for the Testatrix), and that Testatrix executed it as Testatrix's free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as witnesses and that to the best of their knowledge the Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. { } SEAL MARY FRANCES WALSH TN SS WITNESS Sworn to and subscribed to before me this 1~~'day of , UBLIC My Commission Expires: COMMONWEALTH OF PENNSYLVANIA Notarial Seal Diane G. Raddiff, Notary Public Camp Hill Boro, Cumberland County My Commission Expires Jan.11, Member, Pennsylvania Association of Notaries Page INHERITANCE TAX FORM DISTRIBUTION OF ASSESTS FOR ESTATE OF MARY FRANCES WALSH Gross Assets $ Funeral & Administration Expense Net Value of Estate & Value Subject to Tax Less Tax Paid Value of Estate after Taxes Paid Tax Refund Including Discount Total Amount to be Distributed $ Luke Tomczak @ _ $ James V . Walsh @ _ $ Ronald J. Walsh @ _ $ Total $ . . i• y ~c .E~..:a; ::::•,r::~ .........................W, . ~ , ~ ~~'EL 12l ,a.-1.9c~u' :~ic~:`• . ' O1-o2-ooo2s82 r~C~~-~~:~ MARY FRANCIS WAI.SH HILLCREST COURT St1I"1'E CAMP HILL PA I I I,,,111,„I 11,,,,,,11,,,111„I, I I,,,,, I, I„11,11„~,,, i i t„I Record Date Share Position of T~•co International Distribution Date Book-Entn~ Share Position of Ltd. Common Stock on Tyco Electronics Ltd. Common Stock an ti/25/2007: Certificate Shares: Book-Entry Shares: Total Book-Entry Shares: 238.OOOU Total Record Date Sharzs: PLEASE RETAIN THIS STATEMENT FOR YOUR :RECORDS You have been issued shares of Tyco Electronics I,td. common stock in connection with the Tyco International Ltd. spin-ot~ of "lyco Electronics Ltd., a company traded on the New York Stock EYChange under the symbol "TEL". Or.~ June you r~ ere issued 1 share of "fVco Electronics Ltd. for every 4 shares oil Tyco International Ltd. based on the total number of shares ot~ned b}j you a:nd .:recorded on T~•co International Ltd's stock record on the record date for the spin-ofT, June This statement reflects the Tyco Electronics Lid. shares registered in your name on Tyco Electronics Ltd's shareo~;~ner records, maintained by Mellon Investor Sen~ices, Tyco Electronics Ltd: s transfer agent and registrar. 'I~hese shares are maintained for you under the Direct Registration System, which means theti~ are held for you to an electronic, book-entry account maintained by Mellon Investor Services (see enclosed brochwe, "What Individual Investors Should Know About Holding Securities"). Please retain this statement for yow perrrranent record. Cash will be paid in lieu of your fractional share interest, and a check will be mailed separately to you. NO ACTION IS REQUIRED if you choose to keep your shares in book-entry form. Questions? Contact Mellon Investor Services To access your accowit, use your Investor ID Number that is located in the box above on the top right hand corner of this statement. You can contact Mellon Investor Services in one of the follorr~ing ways: By Internet: Visit www.melloninvestor.com/isd for access to }'our account. Phone: Bi~ il: Toll Free Number Tyco Electronics Ltd. Outside the U.S. (Collect} c/o Mellon Investor Services Hearing Impaired P.O. Box IVR system available hours/7 days a meek Pittsburgh, PA Representatives are available 9 a.m. to 7 p.m. Eastern Time weekdays Historical Price Lookup -Tyco Electronics Page 1 of 1 ' Tyco Electronics Searc ~ by keyti~rord Part # ~s~ Who We Are Home > Lnye_stors > Stock Information > Historical Price Lookup Products Investors Investor Relations Financial Information Shareholder Information Historical Price Lookup Proxy SEC Filings Stock Quote I Stock Chart I Historical Prime Lookup I Investment Cal<:ulator Financial Reports Quarterly Earnings $ymb01 Stock Information Analyst Coverage TEL (Common Stock) Tearsheet Lookup Date Corporate Information August - - - News Releases Management Team UP Board of Directors Webcasts & Presentations Results Calendar of Events Investor FAQs Date Requested E-mail Alerts CIOSInq PNce X26.81 Request Information Volume Investor Kit Split Adjustment Factor News Room Open ' Suppliers Day's High 7 ~ ~ ~ ~ 3 Day's Low 7 Careers i`lJTE: The Closing Price, Day's High, bay's Low, and Day's Volume have been adjusted to account fcr any stock splits and/or dividends which may have ocarrred for this security since the date shown above. The Actual Prce is not adjusted for splits or dividends. The Split Adjustment Factor is a cumulative factor which encapsulates all splits since the date Shown above. The closing price above is not necessarily indicative Gf future price pe:rfiormance. ~j View printer-friendly version ~ ®E-mail this page ~ ~ RSS Feeds ~ Receive E-rnail Alerts ~ View contacts Corporate Information Quick Links Customer Support Who We Are Check Distributor Inventory Email or Chat with Us Investor Relations Cross Reference Products Find a Phone Number Newsroom Find Documents & Drawings Search Knowledgebase Supplier Porto! Product Compliance Support Center Manage Your Aca~unt Careers Site Map © Tyco Electronics All Rights Reserved ; Privacy Policy Provide 'ti^lebsite Feedback http://investors.tycoelectronics.com/phoenix.2html?c=209396&p=irol-stockLookup&t=His... att.:"~..°.::: ~~tA~~~~ ~ ~~~:.~:~:~t-~ • ~ .a HS'~~~ 1 X81 ~ 'ti4:aLS1~----iViARYF0000 INTERN,~?TIONAL LTD. k::--.-:.::..:......:>•~::::.:.:<:-:.::::.:~:~.::;.~~ .:::.::.:::.:.:<.:::.::;.::.>:.::.:::-.:_:.:::.:>:::.::.:~~.:::.:.:>::<:::::.:...:.:::::::;:::::.>::.::.::.::::. TYCO ~:;«::::::::;<<:::::..:..~ :.:........::::<::::::::~:::::::::::>::<:::<:>:~:::<:::::::::...:..........~:::::::<:~::;::::>:::::~:::;: ~I~YC 1 1-I~3~-1988 EXCHANGE O1-OS-0009337 MARY FRANCES WALSH HILLCREST COtiRT SUITE CA1'~iP HILL P.A ~•:L1::.:{:.~.. • Y:..:: :Y..Y:: • •:•:N L:•:\1 . • • N:.~ ..........:y . t... k : .r.~. :k~• • kt•. . r..:. . i:• ti~ ~I~.~• •b:; • •:r. ~ :t=2v r:.w.vv ~ .vn x:: •'::v ' •M: •:v :::ti : ti •ti•' . . 1 .ti~ t ~ . ~ - GQ04---- _ _ - _ ~ PLEASE RETAIN THIS STATEMENT FOR YOUR RECORDS Your common shares of Tyco International Ltd. (Bermuda} are now common shares of Tyco International Ltd. (Switzerland) as a result of Tyco's recent change of jurisdiction of incorporation from Bermuda to Schaffhausen, Switzerland ("the Change of Domicile-'). Each outstanding share of Tyco International Ltd. as a Bermuda company now represents the same number of shares of Tyco International Ltd. as a Swiss company. The transaction became effective on March and as a result of this transaction Tyco's CUSIP Number has changed to the number referred to above. This statement reflects the Tyco common shares registered in your name on Tyco's shareowner records, maintained by BNY Mellon Shareowners Services. Tyco's transfer agent and registrar. These shares are maintained for you under the Direct Registration System, which means, they are held for you in an electronic, book-entry account maintained by BNY Mellon shareowner Services. Please retain this statement for your permanent record. :mow. :•.~xw. ~t 1JIlr~.Vt fiA?.3[MN1 O ACT,.IYWON+I IS~~•.vR~E~.yyQ.yyUIRED ~•a~9s~[~y>Yo~~us'r shares will re~nian in book-entry form. hff.Y.a:V.WI.YN.!1A~iI~fV.. .'~S.lYNfl.YIfJHNN.'SY "I. .4•IG•AL1`•:'y..~.•1J1:',Nl.~.•ri'•Y,N.'. `..nS'~f..•V.•.•f.{Vd.CWMN.fJfiiVFjICx1FA.WY.'.¢.'.YM•~.,N/.`.....X.Yi..':~`:~.i~?.%~r:>::9?:'is~ir.'+.?''.'?'C.{ik'}7S''r.'y.Lid.~:i•'r.`iri3"'r.•..`!/.?'/f.•g?i.''•~,.5?''•`.~%r/.'~/~.+%7.'.RJs`::?~?:::v •'.^s`•uiii9~.~:•'~,~r.x;}? ~:::~f'rr,'?.•,~•:•.5 Questions? Contact BNY Mellon Shareowner Services To access your account, use your Investor ID Number that is located in the box above on the top right hand corner of this statement. You can contact BNY iViellon Shareowner Services in one of the following ways: ~i. Internet: Visit www.bnpmellon.com/shareowner/isd for access to your account. By Phone: By ~'Vhl: Toll Free Number Tvco International Ltd. Outside the U.S. (Collect) c/o BNY Mellon Shareowner Services Hearing Impaired P.O. Box IVR system available hours/7 days a week Pittsburgh, PA Representatives are available 9 a.m. to 7 p.m. Eastern Time tiveekdays SL ~ ~C\. ~ 1 c.~ `~yiJ ::~.Q. J.R's.' 1 1 ..ti J.~: i J •.L•~ J:{• `.•~.T.•.7 T.: ~s:~..~`i~i~:?~i2~`?'•: ~Sh'4+~h`~~a:s.`:~'x. ~.:':.~rT'.:w~s^$a.. t.r. `.`~`s`~r'~S'....... ?....•a~..>. c. - ~::+:.':"~C4`sv`•`.:...~:.``s, r~•`3>'.. ~.`.t.... n;.•~t.-5....•....•~.,t'<c.'.rAti~. i:..:iv=r:......~......-:...h.......\.:ds. d:.. 4 i~i~. •..i Tyco -Investor Relations -Historical Price Lookup Page 1 of 1 tyro vita~r! t.~tari ul ~+crur wtr i! kf Home Careers Contact Us Site Map SEARCH ABOUT TYCO OUR BUSINESSES i. INVESTOR RElAT1ONS + NEWSROOM ~ CORPORATE CITiZENSNtP > CAREERS ~ ABOUT TYCO Go To: Home Im~estor Relations Historical Price Lookup HISTORICAL PRICE LOOKUP :Th..~ . ~.:d.~,~;~~ ~~~e~._...~~:~ Investor Tool Kit Symbol ~ Stock Intarmation TYC (Common) ® t _ Lookup Date August - ~ ~ : Eod~'K~?.' , ~ ~~,enr Results Date Requested 08/t U Closing °rice Volume 2,F>$4,6U0 Split Adjusbnent Factor t Open y~' Day's High ~ , / ~a, /I J Day's Low 4f ` s~ T IV:~TF: The Closing Price, Day's High, Day's Low, and Day's Volume have been adjusted to account for any stack splii and`or dividends which may have occurred for this security since the date shown ahove. The Actual Pace is net adjusted for splits or dividends. The Split Adjustment Factor is a cumu4ative factor which encapstAates alt splits ah?ce the date shown above. The closing price above is not necessarily indicatwe of future price performance. Cnpyrighi. ~ 201G i yco. Alf Rights Reserved. 5ubscr7be http://investors.tyco.com/phoenix.zhtml?c=112348&p=irol-stockLookup&t=HistQuote&c... ~.3L 7J,G1?.1V v. .L . ~ I?j ' C ~ ? ~ rtv.«;':''~:~: LLB', .ti: v+•~'ti :h '~~ti~:~, ~;.t:.•.••, 6/2~~~/2UC)7_____---___--~------- ~~-PINOFF • O 1-02-Op02621 MARY FRANCES WALSI-I HILLCREST COURT SUITE ~O1 CA [MP HILL PA 170{i11-8jj023 ii tt tt!! ~Itl~l~il/'~~111l11'~//i'1{{1'II~tliit'R'ii~lif~ifllt!llt~lli' Record Date Share Position of T~~co International Distribution Date Book-)dntn~ Share Position of Ltd Common Stafik on Co~~idien Ltd Colxtmon StocL• an bf29/200~: - . - Certit~cate Shares:_ _ Book-Entry Shares: Total I3oak-Entr~~ Shares: Total Record Date Shags: PLEASE RETAIN THIS STATEMENT FOR YOt1R RECORDS ~ You have been issued shares of Covidien Lid. common stack in connection t~~ith the Tycc7 Intcrnativnal I,td. spin-ot~ of C'vvidien I..td., t ' compamr traded vn the Ne~v York Stack Exchange under the symbol "Ct)V". On June 2t~p7 you ~~tere issued I share of Cuvidien Ltd. fai even ~ shares of T}~ca InternationaI Ltd. based on the total number of shares ot~~ned b}' you and recorded an T}~co International Ltd's stocl~ record on the record date for the spin-old, June This statement ret7.ects the C'avidien Ltd. shares registered in your name vn Covidier Ltd's shareo~~ner records, maintained by Mellon Im~esior Services, Covidien I..td's transfer agent and registrar. These shares are maintainer for ~~ou under the Direct Registration System; ~~~hich means they are held for you in an electronic, book-entrS~ account maintained by Ivlellar Investor Services (see enclosed brochure, "What Inditifidual Investors Should Kno~~~ About Holding Securities"). Please retain this statemen for your permanent record. Cash ~~~ill be paid in lieu of your fractional share interest; and a check will be mailed separate)}~ to you. NO ACTION IS REQUIRED if you choose to keep your shares in book-entn~ form. Questions? Contact Mellon Investor Services To access }your account, use your Investor ID Number that is located in the bo~c above on the top right hand corner of thi statement. You can contact Mellon Investor Services in one of the folio«-ing ura}~s: Br„ Internet: Visit ~ywyy.me lq?ninvestQr.comfisd for access to your account. B ~ F o e: Mail: Toll Free Number Covidien Ltd. Outside the U.S. (Collect) c/o Mellon Investor Services Hearing Impaired l P.O. Boy. IVR s~~stem available hours/7 days a ~~-eek Pittsburgh, PA Representatives are available 9 a.m. to 7 p.m. Eastern Time weekdays CO~iT: C~OVIDIEN PL Historical Prices Page 2 of 3 E _(~~),~/p{~y/~~ y~ yp. ~'Jy ~,"y 3if~'( E~x'~lderyd Hot~el!lmt 0$li3~j,(~ ~ +s t7f v4.v~ M ELT o~ c9'*•ia+2QtQ in (NYSE aefay_ miris_) as PM EDT an M RE~lated Resouroes M M rT `G7 ~ ~r ~ ~ 0 ~ M j -'~~f ~ ~ ~ ~ M 'v / 7 M M M . M M M 08131/i0 M M M M M M M Splits None Available for the Sebct Timeframe Dividends None Available for the Select Timeframe Download Options Choose the format in which you would like this data to be downloaded: © TaD separated values ('.tsv) Comma separated values (`.cav) Quicken ('.qif) Metastodc (•.asc) DOYYnIOad H1stoNcal Performance: COV valuation....... _ _ _ Calculate the value of a shares of ,since Serod oats ~Calcxilstie SptxTaorod Unks - If you awe less than a729k you probaby qualify for Obama's Refi Penny Stock Picks Soaring Up To 80396..Very Consistent Gain Program For Free! www.SeeRefinanceRatas.com www.BestDamnPennyStocks.com Unbeibvable penny stock plays. Rare stocks just being Discover mikxocap stocks. 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Also cash. Memo: Above items distributed at discretion of Executor Ronald J. Walsh. Clothing was donated to Salvation Army, Camp Hill, Pa. See attached. Automobile given as gift. See attached. cash was used as part of expense for gift in recognition of nurses care in hospital. See attached. ' THE SALVATION A?It]"VIY RECEIPT FOR DONATED GOODS rte- t ' ~ Date: To. ~ ~~L 1 J i This wilt acknowledge, WIT THANKS, the donation of the listed articles or goods to The Sah~ation Army to assist in tl~e furtherance of its rehabilitation program for men and women. - Description of Articles: ~ c.= y r) ~ ~,y_ ~ ° ~ ~~~r~' ~ ~ ~ ~T.~ e' Condition: f J Valuation of gifts in kind are the privilege and responsibility of the donor. A Salvation Army Valuation Guide {;~1S-36B) fc?r fair market value will be supplied on request. Contributions are deductible for income tax purposes to the extent alloy+~ed b~ la~~.* ,r HARRISBURG, PA ~ --,f~ Address of Center Signattire of Administrator or Representatiti•e • `QTE: Due to the record keeping and reporting requirements imposed b~~ the Internal Revenue Service. the Sa1~~ation Arm~~ requests all donor, ttiht~ w-i1) require the Sal~-ation :~rm~~ to execute a Farm "\'on-cash Charitable Contribution." for contribution oti er to present such forms for txecudoe at the time of the donation. the Sai~~ation Arm~~ «ill not be able to execute such forms at am time thereafter if the donated proFcm cannot br traced. The Salvation .army is required to report to the~tnternal Revenue Service the sales proceeds of am~ aingle item for ~~hich the d~~n~yr cisime~i 1 deduction of more thsn S~0{) and or ~~hen the donor has contributed more than S~.UOt~. THE SALVATION ARMY RECEIPT FOR DONATED GOODS - ~ Date: ~o: ~ his will ackno~t~ledge, WITH TH~1ti'K5, the donation of the listed articles or goods to The Satiation Arrn~~ to assist in the "urcherance of its rehabilitation program for men and women. description of Articles: ~os,7 ~o ondttta tar/ < ~ r~: ;~~`=~'/~y' .~S~y ~ ~ r'~'-l `S C n c. ~ ~ r 4 Valuation of gifts in kind are the privilege and responsibility of the donor. A Salvation Army Valuation Guide CMS-~bB) far fair market ~•alue will be supplied on request. Contributions are deductible for income tat purposes to the extent allo«~ed b~~ 1a1~.* ;fiARRISBURG, PA ---'`J Address of Center Signature of Administrator or Representative ' tiOTE: Due to the record keeping and reporting requirements imposed b}• the Internal Re~~enue Ser~iet,'the Sal~~ation Arm~~ requests al! dorton i~ho «~il{ require the Sal.ation .~rm~- to execute a Form "\'an-cash Charitable Contribution." for contribution o~~er SS,ooo to present such forms for execudoe at the time of the donation. the Sal~~ation Army ~~~il! not be able to execute such forms at am' time thtteafter it'the donated propem cannot be traced. The SaI~-anon .-~rm~~ is required to report to the Internal Revenue Sertiic:e the sales proceeds of attm' single item for ~~hirl't the don~~r ct:~imed a deduction of mor; than. S~00 and or ~~hen the donor has contributed more than S~.t)oU. THE SALVATION ARMY RECEIPT FOR DONATED GOODS . To: L Date: This ~tirilt ackno~~•ledge, WITH THANKS, the donation of the listed articles or goods to The Salvation Arm~• to assisi in il~e furtherance of its rehabititaiion program for men and women. Description of Articles: r~ ~U6~ L~ L r ~ G. - Condition: Valuation of gifts in kind are the privilege and responsibility of the donor. A Salvation rm~° Valuation Guide {Tuts-3~B) ft+r fair market value will be supplied on request. Contributions are deductible for income t purposes to the extent allo~~-ed b~~ [a~~.* / HARRISBURG, PA Address of Center Signature of Administrator or Representati4~e ' tiOTE: Due to the record keeping and reporting requiremtnts imposed b}~ a Intzrnal Rc•tnut Sen~iee.'the Sat~~ation Arm~~ request; ail donor; ~Sh~~ ~~~ill require the Sale-anon :~rm~~ to execute a Form "'on-cash Charitable Contribution." for contribution o~~er S5,40{} to present such form; for execudot at the time of the donation. the Sal~~ation Arm~~ ~~-ill not bt able to exzcute ;uch form; at am' time theresfttr if the donated propcm cannot he traced. Thz Salvation .~rm~ is required to report to the Internal Rt~enue Stn ice the ;alt; proceeds of am' ,inglt it{m for ~~hich the dorn~r ciairntd s deduction of more eh~n an.i or ~~htn the donut ha; contributed more than 5`.OOt1. R. ~ x - ~ T of Sfi t F {A/C,No,Ext): 570-,622..-y_4~ 9 _ COMPANY NAME ANDAClDRESS ~ Dd:R~^ . - Donald E. Davis Agency, Inc. Travelers I7b6 t~Test Market Street {t ' Pottsville, PA ; ` - ~ ~ f +i . - 1 f,1,.~1 i F ~ t._~. 1 ~ ~ { ~ SUB CODE• POLICY ' ' ~f? _ TYPE AutomQ"t3 ile ; istJR£DNAMEaNDaooRESS CANCELLED P(JLlCY tNFORMATi N ' ; ,.t. • . Mary ~alshr ~ ~°uMeeR 1 : _ ~ ills est Ct ~r401 Cam HI11, PA -caNCeu.anof+o~T::' _ ; ~ P EFFECTIY~ DATE AND , HOUR 4F CANCELtATiQN k2.:.f1:1_._._.._.~. - - EFfECTNE'DATE.: - . - ~ POLICY TERM - i . _ :o~~~0110~ of/2o•~? _ - CANCELLATION REQUEST (Policy $ttachedj-'. ° POL(CY RELEASE (Cempiete Statement Section Beta~~u) . PQLICY .RELEASE STA'LEIUIENT ' ~ The undersigned afirees trot: - - - . The at7ove referenced policy is Post, destroyed or being retained. - Naclaims of any type wits be made against the Insurance Company, its agents or its representatives, _ under this policy for losses which occur after the date of cancellation shown above. " - ' Any premium adjustment will be made in accordance with the terms and conditions of the policy. ~ s Mfl+IESS M D~i~ TE_~ /~IGNATURE OF.I~AMED 1N E ~ . . - ~ - - r a sl ...,t DATE SIGRiATURE OF NAMED lNStIREO ~ ~ ~ ~ ~ i t....~_ ; gam:` ~ ~ 'WEN HOLDER MORTGAGEE LOSS PAYEE j~AU-TNO-RIZED StG14ATURE i - y. r - S " L - .LAN BOLDER MORTGAGEE _ LOSS PAYEE AUTHORlZEO'SIGNATURE s i_' ~ .~~~i i IF r a n n l ` ~R At~ENCY/COMPANY USE - ; : . , . ~ , : _ , , - t REASON FOR CANCELLATION ~ METHgO {~F~CANCELLAI'!~' _ Y_.. NQT TAKrN OTHER (IdentitYl - ~ : _1~Qtl~STEO BY lNSURCD FLAT - _ ~ N Insured Deceased. _ ~ SHOEtT RATE. , . ,PREMtUh€ 3 CQrIP~fY - -PRS~R'~K" ~.x~-.ice:; . _ .,_....v, - F - UNEARKEC FACT; ~ - ....x.~...~.--~ EFFECTIVE OATS 5t } ~ t ~ t.~ ~'~~~ir{ , s ~ - NUAIBER,-. ' / PREMIUM CALCULATION RETURN ~ I ~r ~ t SUBJECT TO AUDIT PREMIUM ~ _ y ' _ _ Please send any return to: Ronald Walsh, Belden_Street_ - - - Philadelphia, PA ~ _ -r# . :Nekv Yctfk 4n! if ou do not k e y y your auto insur nc~ in force during9 he entire r lstratigtl- penal - r - is lion wtC~ be suspended. i~ our vehicle is stli~unrnsured after 9v ~a s octr:~ uer's llce~se ~.=t: xy~. ~E~ ro.. `~r sYbid These enalties, ou ust ~rrender our re ~stration certtfic to ~ ~ m a andy la es be~ore our tns~r,~1-~e.-ef.~ Ki t-~+re must re ~rt the terrr~inatlon of auto insurance cog era a to the De artment o~ Motor Vetiicies. ' - =NANIEAND ADDRESS • ~ REQUESTIRELEASE D1STRl8UTlON #r= ( - INSURED LOSS PAYEE .i _ . htORTGAGEE LIEl+i HOLDER r - . _ - ~ - COMPANY F{N11NCE COMPANY . _ ` x f ,.,i PROCUCER'S SIGNATURE _ -~J _ Ei.ECTRONiC LASER FORI,iS, t:'^tC. • - ~;w~ ~ i~ ~ DEPARTMENT 4f TRANSPQRTAT#QN y- ~RTI FICA'~'E QF TtT`LE FQR A VEHICLE - s r 1 j +n~~ the lRi "~~tt~ ~ ~ ~ - _ a} a i ~ _ - ~ i ~ - s _s 1NG~~S~~X~~1:1:~~~"?`~ N~N€lA ~7'?3243BQ;~ WA j ;~_it:~E_E'7_iT, .,.tT,C ~4\._:~i~C~ ~ 'fc:,R ~ :'KanELFVE~i±i,Ln ~ T7E.Et;Ufi;BER j ~ Q z~ ' -,:rf s ti=E ~ 3'>r`. ~ . ihT _ttF , ~ ....~~rE?~F `.rc~+iT ~ Gb'4'r'n ~ :s!."rln - ~ ~T4Ti,E or~fA;CS `5~31l94 ; , sJ~~?/~4 i 5f3:~/94 ~f1001~ Q' a~ ~~A.c=~•TtTLEt~ +?-.TE:1: ~ Fn::3RTi?lE's'n E i~C+~.'.4.PRt~::t~.C.~TE Cif3v^':3,Alt~EB ~ C3Qt3?,i.STi~TItS s . ~ L'^QO?r1ETER $i4Tt+? :+T - - "r, - ~ _ FGfEtAt"R._R:~ t - - ~ ~ ~ a ltq'~GE E~£t'S -}tE 6tEK:Gr:: Ai. } ~ - ~ - - - - , ' 3 a t;;STeXTF~9Ei~ aAC.TTl:~4L tA"rsAG.:L'£5•,.f,4FTE~ s TiT? E $PlirJgS ; Rrr-f`af~icREO ~ lr:~RtS! =.L'~TC;:E :'E.'ipGtE ~i [j ~l~~ v l~. T / _ MARY F ~laLSM ``e ~r~ _I ~ ~ ~ ~ .c 3 ~ x.4;3'4 t ~4D. r~'t't~-:SS -pi a L. ' ~ ~ 't " :tZ3.'~'tFl.S!=s~J {~JtL ~ ~~:C ; j ~ FCr?bteE$.'? ~ crs rL LCF'r<CiLE'. ~ ' ~r a ~ ~ i f ~ ~ fir. 1 ~ ! ~ .:T - ? ~ n=C y'!S: ; nti:Tcu i ~ $ _ ~TRE~7 rr-„C _ ~ a A=~~~ TFt'cFT L'+'t'f''i.= - - - Y. _ ~rR45ERzf A TAIf . + SST i .:3~i FAY3T? rF: `cCO.'.'v ! fE*3 FA'JOF, CF: p ~uL~Q~ ~a~K ~`~JL ~ t~~l 81~.NK ~ a :~_n.i Ler.'r!c~j.' is !;ste.i, tipcr ~a!istavir~n e` ?t:? t:rs; 4tE^. u_:_ •rrtt j f ~ ti j ~ ~ ~ ` s , _^~dsr ri:ssi f~~rrrz~ `,.+rz T ~tle ±o tt*? 8~lreau et t:1c!^r UeFs des tvi-~ ttt?:= w s rtR~T :~i 7ELE,arr ~ aG~r•~~3i? term ar:d fem. ' . ~ ~ t~ e~ ~ ~ - A~rfI~CRSZ~[T FEPRESfhTAFtstE~~~'~ ~EG~r3U LtEtd Rc':.E,a~~+~ _ _ i [l 3 ~ ~ ~ 7 k~.~C:,~~~~Es~ssTnTn;~ } ruLTO,~ ~~ANf~ . _ 1b95 aTAT'~ ST • E 'ETFR~~BURG ~'A 3:75~'D - ~ - i w_ _ _ . Hfl~~~~ .~Y~RllSALI~1 t cerzit~r as ~ slat? ot:?,sue 4i= ~fiEGat t~ords. a; t~ F6-tns} iv aria. C~zrtttFeiit ~S SS»~ifD~`IG 3~~27E1^3~'Sf8 4tCC'11Q3T71RVT `R_ceuxs~T{eRt+vlvtos+Txr - r ~ ICLCtQf}:~~f~#'IB,il3~0lldt~0l1 ~ ~ , s i,. ! ~ r . V1tl~etf apptyiAg [sx t~fe wih ~ tiv-o+rr+wr otltar ~rt laser spouse. scene of ~ TCl ~EFOAE &{E. ; . ~ _ ~e b(Ceks. E rr5 3:t is awed. Este ~ki9 t+e asue~' ~ `Ter.~is ct Cxcts~;'. - ~ll C3 =.io~'Ter'anTs +si~3x nt ~:n3.rr5`r~p ~r de3l,`~ c` e~ ~i>Q C~.~~e9 i •'fi the suruevk~q oe+reor#. . . ~ ~ TetuttKS +n ja^;Gear~ wI ona .,;a?r, ,crkca52 « de=E3s~ op~>r ~ ' ~ hz h~! o• h~ ise~ or ss'ate?.. - Si:ahA'i'.3H<_ ~ Pc"SG~4 AL'}.Ut3+5`Ei~t 3 QkTH ii~!d ~ rro UEt. ~-'p i L~Ai c CHECY.80X - - ti i ~ FEtST t.fErUtO . , r l J rtpr r l ~ W - . - 3TRE_7 ~ SiAT'c l y r r a f !~Si t£ fJp t ~ c~cfc pox . ' The ~ herec-~ mz+ces ' Yin }7r i:~'•xak. _f e^,ig ice- a DATE: ~ abore,:~ject so the e~r..,~sac~ gr3 os.`~ EEC a s:c f !h :.ass. sE^..et-'.a I.tG.l+flf~~L.'?Ea. ' ! ~ ~ BEET ' e - i - ~t~\~ c~Tv 1 i ~RG'fi,E tTr GC}-t~'R~T,a TiT E!'r ~.:.1Tx~~_ 55.:.k£R STAT ~ ~ ~~a - VV/ - 4 - f , a 4 - '`r1~. ~k 'YPE GR PRINTS ~~rtificate of Titie mist be subrnitt2d within days, unless the purchaser is a registered dealer holding the vehicle for resale. W~.RN~NG - To COMPLETE RTPRO >=•1NG ~ FIALSE S"fATYEA ENT~MAY RESl1LET !N FINESANDIORMPR{SONMENTTRANSFER OF OWNERSHIP: FAILURE Regirered dE>:Fys rrtst ctF^:i=fete forms MV<7A or MY27g L:>ST IR8 M.I. D• n ~IUh:. ~~lT OF TITLE= . as rec~trec b/ !aw t gi:~ehaser a NOT a reris+erec! ~:.aier, ~ , ~ Sect n D :xt tlw fr rt cf Htia f^rm r.,tisE be tx~;,oletsd. PURCHASER O FULL r< [t I _ ,C ;r.e bsst efyn!bur knc.t Edge thE::h_ od~mE,_: r.._dirto_ is BUSINESS NAtiE 4 ~ m ~~/''J~ TENTHS ~+-Z'J.-Ld~ X ;'.O-PaRCH.iSEF P^~ miles aid r'"~:ts th. z:tu_I miieage of the ~:ehic!E r .,.,!ess cne o! 'iie fo. C':::-:c boxes is check>d• ~ STREET - ~ ~ • rDDRESS - Reflects the a-cent ^<'.'eaae is Pt OT the actua' mileage i CJ7 in excess cf its r*eo~ann ca; arm's I_~ Yti`ARN't!G: Odometer dEscrEpanCy CITY I :;'e further certify the < s `roe cf any er>.:umbrarK ^nd 'hEt rnvnership is hereby PURCHASE PRICE L 2nsfsrred to the per~ar ` a - apr I!stEd. _ STATE , Z!P OR DIN SUBSCRIBED AND Sl'/^^r.'-.` f _ "_"r- _ n C TO BEFORE ME' hs0._ DRr' YEAR C ~ 5`G.eATt3iE CF PEREOt-0 AO! i:NlSi ER1N~~ OATH ~ CO-PU CHASER SIGNATURE - Q FURCY.ASER AND,'OR J Z CO-PURCHASER MUST ~'V y - } HANORR1117 NAME HERS t-`c 'r- Ycs6? E It;S~.. t i ~ t~"~~~,~rT a 1 ~ ~ j ~ ~ r • a - ! s ^ t^ 4 ~ "'i z SIGNATURE OF SELLER SIGNATURE OF CO-SELLERC - - SELLER AND/OR ~ j~ f ` ~ ~ ST - - - - ' - ~ CON PA ET MU fi'~/ Ifr t ~ _ „ L ~ m 1l We certify, to the hest of mylour kno•.vledae that the cdcmeter rending is LAST FIRST M.I. O T-vas D E X -rilae a.-n r-fi>: is tnE a^tu ,,^.iiEage of th=_ •:ehicte. BUSIN ESSEN ~EFULL ~ unless one of the following boxes ~s •c^EC<=_~. N Reflects thil aT L'r`t n n ec;e ti JT +fte a':`.Ual mile3~e CC-PURCHASER fTl in excess O` tts r^eC~a ."'ts C_J t':Ai~t.! `r,: Oi.mefar d~screpanCy STREET ~ ~ - I!Y;e further Certify that tie i=F. c'e `'<e c` z'ry erc;rn~r=nca a'~d thz` ovmerstup i5 he2hy ADDRESS Vansferred to the psrsa:n~s} cr t^? deadsr ist<_,. ~ CITY Z SUBSCRIBED AND S."10FN TO BEFORE ME: srarE ZIP PtlRCHA3E PRICE z 4fi~. DAY TEAR OR DIN r- S~3': ATU'n c' CF aRS.~tI A81::1'viST_RR;C• OnTH ~ - PURCHASER SIGNATURE •.Z - - - ~ - s~,t _ ~ c is f i e, s-- ' t tl ~t.:i ~ - CEO-PURCi-LASER S+GNATURE m U CHASE N / ~ Q £ ~ l.m. "tf `..`f' l~ i : s. `~-t-e,,~e f4 y~~ ~ CO~ PRCHASERMHST ~ -f ~ ~ l.lra irpr ~ i e~4:' Z - - - s- k ; ( a ~ - _ i _ SIGNATURE OF SELLER m SELLER MUST 0 HANDPRINT NAME HERE. 1't ~ ~ C ~ ~ ~ D Z IIN/e certify, to the best of myfour knowlecge thrt the odometer ra:.ding is LAST FIRST M.I. T'cN ~ ~ - O X mfeS and reliECtS the aClUEI mileag@ Cf the ~'eh C(e. PURCHASER OA FULL 'n ~ BUSINE33 NAME unless one of the follov:ittg bares is checker: r1't CO-RUACHASER Reflects the amount of m;leags Is t•!OT the actual mileage ~ !n excess of its mechanlcal limits y/ARNIflG: Odometer discrepancy STREET fll IrNle further certify that the vehicle is free of any sn~imbrer~e'dnd that ownershi+~ is hereby ADDRESS transfem_d to the persenls) or the deaSer Gstsj. ~ CITY SUBSCRIBED AND SWORN PURCHASE PRICE TO BEFORE ME: srATE ZIP ~ fv10. DAY YEAR OR DW f1'1 - i ~ - SlutdATURE CF PERSON ACR!ItDSTEPING OATH. ~ PURCHASER SIGNATURE O - ~ k a ( t ~ ~ r _M•. k 1 .z f~ C t`i -~=j~ f r e CO-PURCHASER S!GNATUAE - O U HA AN ~ E t t~ i~v r s <i' +y„ }t ~o ~ l'9' ` " ; CO-PURCHASER MUST z Q x~i3:. r - _~I ! ~ ~i- ~ 6 >F ~ drys HANDP ME HERE - ~ ~ (n ; ,t=-€ iii.-,.F r ~i~r~`st~ ~ I.; ~ ; r't ~.t#.~ i ,I! j : s~..~-. ~ - SIGNATURE OF SELLER - s.- [ F SELLER MUST ~ ` - . - . , - ~ ~ r HANDPRINT NAME HERE • LAST FIRST M.I. 1/Nle certify, to the Gest of mylour knovrledge that the odorietsr reading is - TENT/HS - f miles and reflec!s the actua' mileegs of the vshicle, PURCHASER OR FULL unless one of the following bores iS checked: BUSIlJESS NAME Reflects the amount at mileags Is NC~T the actual miieags CO-PURCHASER in excess bt its mechanical limits ~ VVAR'JING: Odometer discrepancy gTREET 1/K+e further cer@fy that the ,rehicle !s free of any en~urhrance and that rnvnershi~ is hereby ADDRESS transferred to the person(sl Cr the dealer fisted. c+rY SUBSCRIBED AND SWORN TO BEFORE ME: tv10 ~CAY YEAR STATE ~p RURCHASE PRICE OR DIN - SIGNATURE OF PERSGIV ADtAi4<ISTER;NG 3A?H - PURCHASER SIGNATURE - _ i s 3 }v~~~~' f ~`l~~y,.";. F `~i t IF:{ I}te ki,~~ - CO-PURCHASER SIG NATURE _ g _ 3 Y PUR H ANDlO ~ li~ ?'~tT'¢~ ~~„-x. 9r~~ ~c !"~§¢-.'~Ff.s~~t i~~`~cX CO-PURCHASER MUST 2 t y y ~j j N P T H vJ ~-f'.{ ~C ~'.'.'#,T~"af It v~„ S ~ :~FIi F`1~~.- R-.:sue, 4rf ~~yi - a.. ~.~t~~i ~4~-I;,~~,,, ~:°i'~ r_ ~~~~i~+..«i ~-i. - ~ StGNATI'AE CF SELLER + ~ SELLER MUST - - t j _ _ HANDPRINT NAME HERE ~CHE~K~HERE I~ A~L.~CAT'ION 1=Uf~ i~EALER°1~TLElAND COMPLETE SECTION D. TITLING FEES. . . MV-39 (i0-o9) > ~ Notification of Pennsylvania Assi'gnment/Correction DEPARTMENT OF TRANSPOPTATtON ~ ~ Bureau of Motor Vehicles of Vehicle .Title S. Front Street Upon Death of Owner Harrisburg, PA For Department Use Only Please read ALL information ors reverse' side before completing form. A VEHICLE DESCRIPTION Title Number Hake ~of Vehicl Vehicle 1 ent~catitm Number Registration Plate Nu b B IN ORMANT Last Name (or Fui Business Name) First Middle Name PA DUPhoto ID# yr Bus. ID# Date of Birth f H ~ ~ Stre t A dress City State Zip • i C CHECK APPLICABLE BLO I~ ? Ownership is being tran:~rerred to or by ? Ownership is being titled in the estate. - ~ Surviving Spouse -who Is o-owner 5.'Ownership is being transferred to or by all heirs. List all heirs in Section D, ? Ownership is being tran;~~~~rred to or by a Joint Tenant wits` Righ:~ of Survivorship, ? Ownership is being transferred to or by Surviving Spouse or adult ? Ownership is being trans~e~ ed to or by child(ren) to whom vehicle is given by decedent's will which is not Surviving Spouse - who ~ ~ not co-owner. to be probated. - - D HEIRS -List name, signature (P~l~t ii only), address, relationship and age of ail heirs. (in conjunction with Assignment of Title) I NAME(S) List heirs signing attached title ~ ADDRESS RELATIONSHIP AGE I (We) certify that I (We), together with the above persons who have executed the ssfgnment block on the title constitute aN of tf~e heirs sie~ta? dent and hereby join in the transr2r ~f ownbrshrp of the above described vehicle to the person(s) indicated in the assignment 61ock tx? tree II NAME(S) Heirs not signing attached Itle SIGNATURE ADDRESS RELATIONSHIP AGE ' X X X . X E NOTARIZATION-Required If Section D er -1f•rr F is completed. F AF IDAI~IT OF PAYMENT DEBTS SUBSCRIBED AND SWORN TO $EFORE ME: MONTH DAY YEAR . _ _ y..--, !hereby state under oath that ail debts of the SIGhfATURr OF PER" ~•N ADk11NISTERINt3 OATH decedent have been paid. s v c~ ors:? . T ~ DO t~OT NGTARIZE UNLESS X P~ •~A A $tGNED ~N PRtSjcNCE OF NOTARY store of surviving spouse or adult ' T M P t G PROO OF DEATH - ~CheCk f Original Death Certificate need not be attached if No. 3 below is completed by attending physician or funeral director. Original Certificate: of De:;::=_l~~ ~ ? !Certify that Noma or ecedent (must be attached„~ ~ died on Data Original Certificate ~f Death from Department of Defense (must be attached; Signature of AUending Phyetdan orFunerai Director Print Name Exactl As tt Ap Al~are H VE LIE INStIRANC~ ti+IF~F~MATiON tf vehicle is to be re istered in nce pan" me ~ Polic Nu er S/ P~cy Effe ~ e D$tev Palic xpir ~ n D t 1 A N 1NLEDGMENT~:ANC ~~RTiFICATIO o / Uwe state that Uwe have read and siijned thL # ~rrr; after its completion, and i/we swear or affirm that the statements made herein are true and correct, and that any statement made on or pursuant to this form is sub)ect to ::~e ~enalUes of PA C.S. Section 4903(a)(2j(relating to false swearing), which shall include punishment of a tine not exceeding or to a term of imprisonment t~f nbt m~r3 than two years, or both. In addition, it vehicle Is to be registe~ad, I/we a~,;;nowiedge that I/we may lose mylour operating privilege or vehicle registration for failure to maintain financi~il responsibility on the currently red vehfci for the p vv registration. Owner Sign H re'X ; ~"~l,i.'t` Co-owner Sign Here X Teleph~lu~ib~( MESSENGER NO. • MV-13ST w. i ~ ~ pennsylvania /01~IC~c~Vlt • OE FARThtEtJT Uf THAtISFClN7A'lUN Bureau of Motor Vehicles ©fi S. Front Street Harrisburg, PA " For Department Use Only IN°fI~l9CTION~ ON REVERE SIDE OF FORM ~~jj ~ , Title Number: oG' / VIN Number: C- ~ ~ Make of Vehicle: Model: Year: l ~ T V ,p Transferor No. t/~,/ Transferee No. ~ ~ t1 r (pte?se pHnt) (plea a prittf} Transferor No.2: Transferee No. a (PJeasa l)rtnt) (please print) Is the transferee related to the transferor? Yes No Identify all the parties and relationship (for example: fat r/son; mother/daughter; uncleh~ephew; frier~dlfriend): WARNING: FALSIFICATION OF TFIIS AFFIDAVIT COULD RESULT IN CRIMINAL PROSECUTION AND T[~E. REVOCATtOt! OI" YOUR DRIVING PRIVILEGES FOR A PERIOD OF ONE YEAR The undersigned transferor{s) hereby declare(s) under penalty of perjury that flwe have received nothing ol"v~i; either directly or indirectly, frog the transferee(s) or any other individual or entity in consideration of the transfer of the above-described vehicle, including but not limited to money, property, services or the forgiveness or waiver of any debt, obligatio or encumbrance. and that all information provided herein is true and correct to the best of mylour information n elief. ,~$r ~~'/~j,4k~~"Gf/gLf/~ C ~ 11-I-1~ Transferor ~ V _ Tnns?eror S~ig)rat~ure (ar• *z ze erso for orperatton) CLFhoto D Bus. t Dal of Biritl Cate Address: Strset E Cit State tip Code Transferor No. ~ _ Trans;eror Sionalvre (o.% Avthvrizec! Person fen Corporation) PA DUPhoto ID i! Uate of Both Date - Address: Street ~ City State ip Cede The undersigned transferee~ts} hereby declare(s) under penalty of perjury that I/we have given nothing of value, either directly or indirectly, to the transferor(s) or any other individual or entity in consideration for the transfer of the above-described vehicle, incluuinu. but not limited to money, property, service or the forgiveness or waiver of any debt, obligation or enc brance and'ti~a~ all information provided herein is true and correct to the best of mylour information and belief. fro ~ V Q 9 ~ ~ ~ ~'~U Trans e e _ ~ _ <nsfer»e Sipnahrre (rr Authoriz?d erson orn oration) PEA D/UPhotn lD ~ or Bu . Date "t Bf r Dafe Address: ~ ~i V ,reef ~ City fate Zip Code Transferee No. _ T.rans`er3e Signature (or Autt;rrize~.i Person for Con.~oration~ PA DUPhoto 1D # Dats of Birth Date Address: Street City State Zip Cede ~ SA-2C wID: Title: triVIN On-Line Registration System Pennsylvania ~epartr~ent of Transportation Applicant Summary statement Transaction: Reassign Title/New P.eg Processor: O1 OTT AND ASSOCIATES/00833630 Processed By: STACEY VINCENT Purchase Date: Nov O1, Process Date: Nov O1, Temp Reg Oate: None Prev Title No: Prev l3up Title fount: None State of Origin: PA Stock-NO: vIN: 1HGCD565xRA109379 Condition: FAIR unladen weight:' Chassis Mftr: YR/Make: 1994/HONDA Body: SDN GvwR: Body Make: Odom Reading: Fuei: G GCWR: Seat Cap: Odom Qual: ACTUA! MILEAGE Purchase Price: NO Of Axles: Brands: n KATHLEEN TOMC2UK/5 [ ] Tenant in GEICO loRETTO avE -Survivorship? PHILADELPHIA/PA/ t[ ],Tenant in . ',Common Oct Oi, 201i) - Apr O1, ) Retired [ ] ODTF - Daily Rental Mail Code: Disabled veteran: 0 pennDOT Fees VIN: None Nona Tax exempt Reason: GIFT EXEMPTION/13 Sales/U5e Tax: yR; Tax exempt No: Motor veh. Fees: Make: Taxable Sale Price: other Fees: Condition: Sales Tax Credit: Total: S6 Allowance: ~ r [ 7 ELT [ ) Local Sales Tax Override? Trade In None ' gpent Fees ° 1 i Allowance: libnHldr#2: Notary Fee: 5~.ta0 None ~ Plate Fee:10.00 Agent Member Fee: g{fent Service Fee: Assigned Tag Type: PASSENGER/O1 Class: Assigned Exp Sticker No: - Total: S4g Assigned Tag No: HPZ6375 Rey. G~w: Class Sticker No: Assi ned Exp Date: Oct/2011 Reg, G~'rd: Transferred Title No: j•riy a.>: tgnature o Person tom om rag ~s se ng trans errp Transferred Tag No: [ ]w/Renewal triY7<Pk Fet: SLR«l~" i Relation to Applicant: [ )w/Tag Replacement No of ou Reg Cards: 0 [ ]w/Ta Exchan e - Request or~0~tiona Registration At A welg t Excee ing t e GVWR (MV-1005) WARNING: The operation of a truck loadedbeyond the rsanu4?acturer's Gross Vehicle weight Rating (GVWR) may create unsafe conditions and also void:the manufacturer's warranty if damage should result from such overloading. check wiih your dealer or factory representative. You should also consult your insurer concerning possible adverse effects to your insurance coverage with respect to such overloading.'i/we request that the above described vehicle be registered at the gross vehicle weight (RRGw or RRCGw) listed above under the provisions of Section 19I6(b) of the Vehicle cods as amendtd by Act No. 8 approved I-15-80. I/we acknowledge that I have been warned by the Department of Transportation that loading ay truck beyond the manufacturer's gross weight rating may damage the truck and endanger its occupants, as well as other vehicles and their occupants and pedestrians; and i/we assume all risks=connFCted with an such overloadin of the truck. I we ac now a ge't at I we may ose my our operattng prty: ege s or ve tc a reg strat on s or a ure to matntatn tnanc a responst tty on',t a current y regtstere vehicle for ChR period of registration. I/we further ackriowiedge that i/we may be subject to a fine not exceeding f5, and imprisonment of not more than two years far any false stateraRnt that I/we make on this form, and I/wa certify that I/we have examined and signed this form after its completion; and that if an exemption from payment of sales tax is claimed, am/we are authorized to claim this `exemption. I/we further certify that all=statements herein are true and correct and make application for certificate of title for the vehicle described above. ate Su scrl a an sworn to: ature o A p canto Aut orize 5lgner: 5lgnatu otar A to at lg ture o Co-Owner Tlt e o Auto lze 5lgner: - s ' ' VIN GVWR Cert3 1 Cate On or TraC1 ng 1 s Require NCT~'~~i,~~.- Sys=~,L . . ST/~CEY L. ~.~~l~it~~~}T, ~`j~)~~('jf ~Ub~IC Place Signature of Person Verifying ViN/GVwR or the Tracing Here: i hereby certify that i have verified the viN/GVwR of A Clty Phl~ad°~n~11S, P~lil•~. CGt.liity thi 5 vehi cl a and the VIN/GVWR 1 i sted above i s correct. L ~~4y.Comr;i~s~on F;:pit_M~ ~+.~~~r-1~16.2012 . SIGN: DIN: - - tae ere Detac Here 1 0 1 - - - - _ C.OMMON~lTH OF PENNSYi:VANIA REGISTRATI~Pt sREDEN:~tAL ~ -;EXPIRY: QCT : 1 - BLAI"E _ ~ C,. NPZ63~' 5 : , . C7 - - ..''ET" TITLE;: TO i ' SIGNATURE VIN. ~.HG~.~15.5.~ttdZfl937~ ~ ~ 7 _ I hereby acknowledge this day that 1 have received p - YR/MAKE: 1it3NlJl~ ~ ~ notice of the provisions of Section of the Vehicle ~ . TYPE: ' ~flN, , u7 wIO 3.Q~OSi}~4i#4 0~548~'OQ' _ Code T,ZTLE :B~tANDS, , EMISSION INSPECTION REQUIRED%DIESEL,EXEMPT COUNTY PHILADELPHIA J , i ~ - t r, C . 1 ri KATHLEEN TOMCZUK ' LORETTO AVE ~ ' - PHILADELPHIA PA ~ t _ ~t4` Eilitdr ~:n-artgetz~erzts ! Hartzdaie Drive t. £ir~3p Hil! , f'A r 1 H~~~ ~~l~! i~ai~- ~~~01C Time PM ~3'~ckct`!°' y X365 ~ icr k rEdekah Merchandise Info C~1 ( M@rL`hattliStsti Dtsc Price Total 1 Berry Chocolate $'i G0 S1 ~'i, OG Bouquet erg 1 Balloon Butt~~le - 5y ~~J Thank you Merchand,se Cotai Ot3 Delivery G~harge: (^rtstorrter Discounr Taxi ~s;a$ Cc.rsx <~ri Payment: Net Amount: . _ Payment Status: did Cash Payment lnfa Cash Paid: trash Tendered ~ Cash :,hant}~. X3.13 Crrrr~er~3~ f3a~ment l~eclpien /ntn: tJrtenz.o Heart Center Staff Holy Spirit Hospital SAiPJ i ,;©HNS ~:HURCH RC . ?nd Floar icardio Vascuiar intGr~sive Care Ur~rita Camp Hi!! . PA , ~ 1-x,756 Delivery flare: Fndaj( 08120~t 2Q10 ~:~~nv e~~fthlt'~'''ran(~6'r71E=t1T:~ rnn~ M&T Mitchell Road, Millsboro, DE Adjustment Services Phone F ax October Estate of Mary Frances Walsh Attn: Ronald J Walsh Belden Street _ Philadelphia, PA Re: Estate of M ,Frances Walsh _ _ _ _ _ Social_S.ecurity_~_144-28-.8631_.._. _ _ _ _ _ _ _ _ _ _ _ _ Date of Death: August Dear S it or Madam: In response to your request, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following accounts: Type of Account Checking Account Account Number Ownership (Names ofd Mary Frances Walsh Opening Date Balance oti Date o, f Death Accrued Interest $ Total Type of Account Savings Account Account Number Ownership (Names of} Mary Frances Walsh Opening Date Balance on Date of Death Accrued Interest $ Total z, ***T1~is letter does not indude any accouats is which the deceased may have been listed as Power of Attorney, Custodian of Uniform Transfers, Representative Payee, or Trustee under a Written Agreement Sin rely, 1 Suzanne M Kimble Adjustment Services 4 Oz m~~~~'nnn~D~~~ -~<~~-X~Xn~XXn~ccs N Xx X xx o C'1 c N ~n~z~zzzc~c~c~c~woo*o ~~p zpm_mrnn~~-~oDVZZnv~ ~ ~ Z~C~ 0-----T7Cr T=~~oozoo~~~~~' nc~~~ D=~ DDp~r~00m~-=1C Z O z-c rrOvvmmn~c) n m ~ nZZ ~~-n ~m m r~C) 00~~7~ccnQ-~ ~ ~ ~ •~i ~ ~ n~ vvnzZCC _ ~yvvoo C ~ ~ rn ~ ~ rn ~ ~ ~ ~ O(J~N apWOC,1tONtVN--• C OC11.A ~Cii W00000000N~ OOGtO-~V WCDWIV CIO-~O,.r O OD V O ~P t0 c0 W ~ ~ CJt O c~ O v c ~ ~ I ? ~ ~ r cn c~ c ? i F. ~ da EA ~ N N W W ~A .A ifl ~fl ~ ~ N V V~ OD CTI N N V V W~ N ~ .A CD~ACJ1-~tVA~OWIVIVtWO~J N CTS tJ1 OC CO (Jt O W U1 CO N O L. O«1 `c ~ ~ ' ~ ° c o~ v ~ ~i° < ~ ~ ~ ~ w ba r~ ~ t-ra bra ~ `.i W da Vt N {~a N ~6a O ffl EA ~ ~ ~ OD N W O CO CO cC O N CC ~q cam. ~ 'ti. =d~~Aa0EA00 V O~O~_~-+tA t p~ ~p _ ~ v`~- CwlOOD~O~D~N~O~~O~OC~~ N ~ 1 . n " ~ ~ ~ 1 c' CS tr, .r _I~ 4 ~ v N ~ r ~ c ,~..e, a !ns.• : s a ~ ~ nsu r pan~~l® t lember Erie ir;surance Group Hone OSfice Erie Insurance Place Eris, Pennsylvania E Toi! free Fax www.erieinsurance.com September Ronald J Walsh Belden Street Philadelphia, PA RE: Estate of Mary F Walsh Life Policy Annuities #AY000474 & AY000475 Dear Mr. Walsh: Please accept our condolences to you and your family. The information that you requested is listed below: Life Policy - Vt~'hole Life The total ~~eath benefit was plus interest of Annuity # AY000474 -IRA The date c,f death value, August was The gross and taxable amount disbursed on September was minus Federal Withholding for a net disbursement of .Annuity # AY000475 -Non-Qualified 'The date of death value, August 20I 0 was with a cost basis of 'The gross amount disbursed on September was the taxable amount _ was-$13,999.48-r~in~s-$-2.,799,.90.Federal ~~jithholccii..ng.for_a_n~et_~i~bursement c~f___ - I hope this is helpful to you and if you have any questions, please call me at I extension or Melody Bokshan at Sincerely, Sally Austin Sr. Life Claims Specialist Life Palicy Administration Th+a ERIE is Above All !n Service`. - f-~, j E~~~ Life Y ~ r I ns~rar~~e® ~41er^ber Erse insurance Group Horne Office Erie Insurance PIac2 Erie, Pennsylvania 1653+J 814.870.2GG0 To;! free i Fax • www.erieinsurance.com September Malted via Certificate of Malting ~y~:a=~ ~ t~•?(-~ RE: Mary F Walsh, deceased "-tt?' Belden Street Life Philadelphia, PA Annuities AY000474 & AY000475 Dear Mr. V~ralsll: ;~'e cc-oulu like t© extend our sincere condolences to you and your family. Enclosed please find our check(s) which represents % of the net death benefit for the above pLlicies. The following is a breakdown of how the amounts were calculated: Policy Death Federal Interest Net Number Benefit Withholdin Check $ N/A $ AY000474 $ N/A $ AY000475 $ N/A $ Please be advised that federal law requires us to report the annuities transactions to the Internal Revenue Service on Form 1099-R. A copy of this form will be mailed to you by January Please notify us if you have an address change before that time. If you have any questions, please call me at extension or Melody Bokshan at extension Sincerely, s Sally Au tin _ Life Claims Specialist Life Policy Administration Department cc: Murdoch Insurance, AA7221 Enclosures: Check(s) The information contai~red in this letter is intended to give you a general understanding of the manner in it~hich certain Internal Revenue Code provisions apply to particular transactions involving Erie Family Life products. This information should not be construed as tax or legal advice but, instead, as informational only. The tar treatment of any particular transactions may vary depending upon yor~r individ:~al circumstances and you are encouraged to consult iti~ith your tux adviser or attorney rf yozr have any questions concerning the tax treahnent of this or any other transaction involving an Erie Family Life product The ERlE Cs Above AH in Service. check Date: Se Payee or Vendor Check No. SS837 Policy or Invoice Date Voucher ID Gross Amount ~ Withholding Paid Amount ~Y000474 SLA 1S.Sep.2010 3S,23S.64 3S,23S.64 ANNUITY PROCEEDS AY000475 SLA 1S.Sep.2010 ANATUITY PROCEEDS L1287740 SLA 1S.Sep.2010 LIFE INSURANCE PROCEEDS Payee or Vendor Name Ronald J Walsh Num r yti~• 1 16.Sep.2010 $48,79S.6S t Chick Date: ~ i 6.S Pa ee or Vendor - ~ Check No. ~ Policy or Iavoice Date Voucber ID Gross Amount Withholding Paid Amount AY000474 SLA 15.Sep.2010 ANNUITY PROCEEDS AY000475 SLA i S.Sep.2010 i ~ ANNUITY PROCEEDS L1287740 SLA 15.Sep.2010 LIFE INSURANCE PROCEEDS l J l Payee or Vendor Name James V :alsh 16.Sep.2010 _ October h~dii~~~ilhss~l~U~~~IIh~I~U~,~~~IJ~~i{,IL,~,~~il~ib~i MARiLE1GH HENSLEY ~278MS00089401• aoe-sa3 Branch Manager MARY FRANCES WALSH www.smithbarney.com CGM IRA ROLLOVER CUSTODIAN HILLCREST CT 'ACCOUNT NUAABER CAMP HILL PA IMPORTANT N4T1CE CONFIRMATION OF TRANSFER OF ASSETS iF YOU HAVE ANY QUESTIONS, PLEASE CONTACT YOUR BRANCH MANAGER This notice confirms that, on your requested transfer(s) was completed. QUANTITY/AMOUNT SECURITY DESCRIPTION CAPITAL INCOME BU{LDER FUND CLA ;S C CAPITAL WORLD GROWTH AND INCOME FUND CLASS C INCOME FUND OF AMERICA CLASS C NEW WORLD FUND CLASS C This transfer(s) was made FROM~your Morgan Stanley Smith Barney account referenced above to the following account: , / Account Number: 406-6710D ~ ,I~U~ -~'g~~'~ y' ~ Name and Address: RONALD J WALSH 'r CGM BENEFICIARY IRA CUSTODIAN 3 ,/>?rRRy afs'~~~ BEN OF MARY FRANCES WALSH ~ L L S ~ t?~~` " ~ BELDEN STREET LA - i-k -P`A r~=3al~- _ - , Please review the transfer details carefully. If they are correct, no further action is required. We appreciate your business. US HfGHWAY 19N • SUITE • CLEARWATER FL 337ri4 Morgan Stanley Smith Barney LLC. Member SIPC. Erie F~~i! Life ~i~, Insurance Member Erie Insurance Group Nome C?ffice Erie Insurance Place Erie, Pennsylvania Toll Tree Fax www.erieinsurance.com September Mailed via Certificate of Mailing James V Walsh RE: Mary F Walsh, deceased Merry Lane Life Hillsborough, N3 Annuities AY000474 AY000475 Dear Mr. Walsh: We would like to extend our sincere condolences to you and your family. Enclosed please find our check(s) which represents % of the net death benefit for the above policies. The following is a breakdown of how the amounts were calculated: Policy Death Federal Interest Net Number Benefit Withholdin Checlc $ N/A $ 2,31G?:22 AY000474 $ N/A $ AY000475 $ N/A $ Please be advised that federal law requires us to report the annuities transactions to the Internal Revenue Service on Form 1099-R. A copy of this form will be mailed to you by January Please notify us if you have an address change before that time. If you have any questions, please call me at extension or Melody Bokshan at extension Sincerely, / (~~,~p`~ S~%~ Sally Austin Life Claims Specialist Life Policy Administration Department cc: Murdoch Insurance, AA7221 Enclosures: Check(s) The information contained in this letter is intended to gyve you a general understanding of the mannE~r in which certain Internal Revenue Code provisions apply to particular transactions involving Erie Family Life products. This information should not be construed as tax or legal advice but, instead, as informational only. The tax treatment of arty particular transactions may vary depending upon your individual circumstances and you are encouraged to consult with your tax adviser or attorney if you have any questions concerning the tax treatment of this or any other transaction involving an Erie Family Life product The ERiE Is Above All In Service®. Cheek Date: ~ 1 b.S i 0 Pa ee or Vendor ' Check No. - - Policy or Iavoice Date Voucber ID Gross Amount Withhdding Paid Amount AY000474 SLA 15.Sep.2010 ANNUTlY PROCEEDS i AY000475 SLA 1 S.Sep.2010 - - ANNUITY PROCEEDS - - L1287740 SLA 15.Sep.20i0 LIFE INSURANCE PROCEEDS J f Payee or Vendor Name James ~ ; alsh - 16.Sep.2010 N~~rg~~~~nl~~ October I...III~~~lll~~~~~~ll~~~lll~~l~li„~~~i~l~~ll~il~~~~~~ii~ll~~i MARILEIGH HENSLEY Branch Manager "278MS00089401' MARY FRANCES WALSH www.smithbarney.com CGM IRA ROLLOVER CUSTODIAN HILLCREST CT 'ACCOUNT NUMBER CAMP Hf LL PA IMPORTANT NOTICE CONFIRMATION OF TRANSFER OF ASSETS IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT YOUR BRANCH MANAGER This notice confirms that, on your requested transfer{s) was completed. QUANTITYlAMOUNT SECURITY DES{;RIPTION CAPITAL INCOME BUILDER FUND CLASS C CAPITAL WORLD GROWTH AND INCOME FUND CLASS C INCOME FUND OF AMERICA CLASS C NEW WORLD FUND CLASS C This transfer{s) was made FROM~your Morgan Stanley Smith Barney account referencE:d above to the following account: , ~ sr~ Account Number: 406-6710D /LV/e m~~ V Name and Address: RONALD J WALSH ~ CGM BENEFICIARY IRA CUSTODIAN It~ ~ ~1~~~y ~ BEN OF MARY FRANCES WALSH i3 OCf~~ y ,yr ~ ~ s BELDEN STREET PH l LABf LPNi-A--t~A -191i ~=3a1~ _ _ Please review the transfer details carefully. If they are correct, no further action is regtaired. We appreciate your business. US HIGHWAY 19N • SUITE • CLEARWATER FL Morgan Stanley Smith Barney LLC. 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Rule R=GISTER ~~,-'iLLS ~vrn~i=>~.~.~~~ CO~~T~t; ~Eti~S~'LVA~I 1 `cC'~i~j.~. t7S Da~i4~LGi1: `l! ~ J/V i~f•" V Date of Dents:'--~C,~~r~+''..Si~`` fds ~iiz ~u.-~~e:' ~ - Date Levers G:ant~c~: ,,~.t~f'~~,~~ ~c~~ i- To ~i'le Rc'g?ster: I ~e~ :iiy that I~i~tice of Y zate A~~n:strat~~ : egLired b Pa. O.C. Rye ~.6i cr tie ~ ~~3~ans' C u: L ~ Ru'.es r~'a5 szrJed on or IIi3i~e~ to the f~I?c~,i:.:g ber~ei~~Ci:~ ai7L~~JL-c3r~~~i~d Z3t?.~ ~ - Name: A ~~res~: C~3 Z Yom, ~~?v.~~ - ~`^t~ i.~ Y fr~r ~~.~r~_ ~ ~~=~~~'7"G~ ~"9l•yv~ ;t 'J i (Ijmor~ s~ece is reefed, ar:ach se~~aie si:ee:.) notice has now been given to a;l persoZS e:?tit;e3 ti`:e~et~ L;der Pa. O.C. Rule 1.6~a) exceLt: ' J.'a°77A .'rE Of I~tJSGA ~11ir~ Ih.'S ~'Grln ~ aYacity: U~'ersonal Represertati ~ e ~ Coz:~se, ?~'.:m~ GfPtrsor. F'rlu:; this FGrrn ` .4ddr-ass ..T 1 e;t;~nent _ _ - _ ~ nq+ ~ , , . ~CC~UNT N0. ACCOUNT TYPE STATEMENT PERIOD PAGE X853110279 M&T CLASSIC CHECKING w/INTEREST MAR.02-APR.01,2011 1 OF 1 0 06117M NM 0 ESTATE OF MARY FRANCES WALSH RONALD J WALSH, EXEC BELDEN ST PHILADELPHIA PA _ _ _ _ INTEREST EARNED FOR STATEMENT PERIOD MECHANICSBURG IN'''EREST PAIO YEAR TO DATE ACCOUNT SUMMARY E~EGINNING: _ DE SITS B: OTH CU NT BALANCE OTHER ADDITIONS CHECKS PAIt1 SUBTRACTIONS _ INTEREST PO BALANCE NO. AMOUNT NO. AMOUNT NO. AMOUNT 0 0 0 ACCOUNT ACTIVITY POSTING: _ - DE I_S,INT REST CHECKS THER< A Y DATE: TRANSACTION DESCRIPTION, &-OTHER ADDITIONS SUBTRACTIONS BALANCE BEGINNING BALANCE ~ 04-O1-11 INTEREST PAYMENT ENDING BALANCE ANNUAL PERCENTAGE YIELD EARNED = LOOKING TO IMPROVE YOUR HOME? RAISE THE GREEN FLAG. MHETHER YOU'RE LOOKING TO BUY OR RENOVATE, M8T IS HERE TO HELP. EQUAL HOUSING LENDER. zooaa, {si~~} s ~ r ACCOUNT N0. ACCOUNT TYPE STATEMENT PERIOD RAGE MST CLASSIC CHECKING w/INTEREST FEB.02-MAR.01,2011 1 OF 1 0 06117M NM ESTATE OF MARY FRANCES WALSH RONALD J WALSH, EXEC BELDEN ST PHILADELPHIA PA INTEREST EARNED FOR STATEMENT PERIOD MECHANICSBURG INTEREST PAID YEAR TO DATE ACCOUNT SUMMARY BEGI15)IIN6 _ DEPOSITS 8 - _ OTHER CURRENT _ ENDING BALANCE DTHER ADDITIONS CHECKS PAID SUBTRACTIONS INTEREST PD BALANCE N0. AMOUNT N0. AMOUNT N0. AMOUNT 0 1 0 ACCOUNT ACTIVITY POSTING. AEPOSITS,INTEREST CHECKS 8 OTHER _ flAILY. DATE TRANSACTION DESCRIPTION ~ OTHER ADDITIONS SUBTRACTIONS BALANCE BEGINNING BALANCE 534,b38.55 CHECK NUMBER INTEREST PAYMENT ENDING BALANCE CHECKS PAID SUMMARY ANNUAL PERCENTAGE YIELD EARNED = kARM UP KITH SPECIAL SAVINGS THIS SPRING AT POPULAR RETAILERS MHEN YOU USE YOUR M8T CHECK CARD OR M&T VISA CREDIT CARD IN STORES, ON THE MEB AND OVER THE PHONE. PICK UP A COUPON BOOK AT YOUR LOCAL M&T BRANCH, OR VISIT MTB.COM/SHOPPING FOR GREAT DEALS ON SPRING SAVINGS. IF YOU PAY KITH YOUR M8T CHECK CARD, BE SURE TO SELECT (OR ASK TO USE YOUR CARD AS) "CREDIT". . L008A T _ _ {,yCOUNT N0. ACCOUNT TYPE STATEMENT PERIOD PAGE MST CLASSIC CHECKING W/INTEREST JAN.02-FE:B.01,2011 1 OF 1 0 06117M NM - ESTATE OF MARY FRANCES WALSH RONALD J WALSH, EXEC BELDEN ST PHILADELPHIA PA IN~T f?F!EST EARNED FOR STATEMENT PERIOD MECHANICSBURG Il+9T f:f!EST PAID YEAR TO DATE ACCOUNT SUMMARY 1~ESINNING : _ DEPOSITS B OTHER CURRENT ENDING BALANCE:. _OTHER ADDITIONS CHECKS PAID SUBTRACTIONS. INTEREST :PD ':=:BALANCE N0. AMOUNT N0. AMOUNT N0. AMOUNT 0 1 0 ACCOUNT ACTIVITY PtiS1'ING _ DEPOSE S INTERES CHECKS OTHER _ , ~3ATLY D~7E TRANSACTION DESCRIPTION: B OTHER ADDITIONS- SUB'~RACTIONS BA ANCE Ol-~~2-11 BEGINNING BALANCE CHECK NUMBER INTEREST PAYMENT ENDING BALANCE CHECKS PAID,SUMMARY ANNUAL PERCENTAGE YIELD EARNED = **M&T BILL PAY GOES MOBILE** THERE ARE NOW TWO FREE WAYS TO PAY YOUR BILLS THROUGH M8T BILL PAY: 1-WEB BILL PAY: LOG ON TO M8T WEB BANKING AND CLICK THE "BILL PAY" TAB 2-MOBILE BILL PAY: VISIT MTB.COM ON A MOBILE PHONE, LOG ON, 8 SELECT "BILL PAY'• TO GET STARTED, LOG ON TO WEB BANKING, SIGN UP FOR BILL PAY, B ADO PAYEES. THEN YOU CAN INITIATE PAYMENTS TO VIRTUALLY ANYONE, FROM AT HOME OR ON THE G0. Lf?UIiIIR - ~ _ . T - l~I&'~' ~3a~l~c ACCOUNT NO. ACCOUNT TYPE STATEMENT PERIOD PAGE MBT CLASSIC CHECKING W/INTEREST DEC.02-.IAN.01,2011 1 OF 1 0 06117M NM ESTATE OF MARY FRANCES WALSH RONALD J WALSH, EXEC BELDEN ST PHILADELPHIA PA INTEREST PAID YEAR TO DATE MECHANICSBURG ACCOUNT SUMMARY :..BEGINNING : DEPOSITS 8 0TH R : CUEtQENT :ENDING BALANCE OTHER ADDITIONS CHECKS PAID SUBTRACTIONS <INTEREST PD BALANCE...- AMOUNT NO. AMOUNT NO. AMOUNT 0 0 0 ACCOUNT ACTIVITY POSTING ;DEPQSIT INTEREST HECK 0 HE ~ DAILY SUBTRACTIONS ;BALANCE: DATE TRANSACTION DESCRIPTI01~1: ~ OTHER ADDITIONS BEGINNII~ BALANCE INTEREST PAYMENT ENDING BALANCE ANNUAL PERCENTAGE YIELD EARNED = EFFECTIVE DECEMBER THROUGH DECEMBER FDIC COVERAGE WILL BE UNLIMITED ON NON-INTEREST BEARING ACCOUNTS. ACCOUNTS THAT EARN OR ARE ELIGIBLE TO EARN INTEREST WILL BE COVERED UP TO PER DEPOSITOR. LoosA ~sro~~ _ _ D,~:~OUNT N0. ACCOUNT TYPE STATEMENT PERIOD PAGE - MKT CLASSIC CHECKING W/INTEREST NOV.D2-DEC.01,2010 1 OF 1 0 06117M NM - ESTATE OF MARY FRANCES WALSH RONALD J WALSH, EXEC 74fl4 BELDEN ST PHILADELPHIA PA INTEREST PAID YEAR TO DATE MECHANICSBURG ACCOUNT SUMMARY BEGINNING DEPOSITS & OTHER CURRENT ENDING BALANCE OTHER ADDITIONS CHECKS PAID SUBTRACTIONS INTEREST PD BALANCE NO. AMOUNT N0. AMOUNT N0. AMOUNT 3 1 0 ACCOUNT ACTIVITY POSTING D PO ITS,INTEREST CHECKS & OTHER DAI Y DATE TRANSACTION DESCRIPTION ~ OTHER ADDITIONS SUBTRACTIONS BALANCE BEGINNING BALANCE CHECK NUMBER 1i-12-10 DEPOSIT DEPOSIT 34,39b.63 DEPOSIT 12-O1-10 INTEREST PAYMENT ENDING BALANCE CHECKS PAID SUMMARY ANNUAL PERCENTAGE YIELD EARNED = BEGINNING JANUARY THE EXTENDED OVERDRAFT FEE WILL BE REINSTATED FOR MKT CHECKING ACCOUNTS. IF YOUR ACCOUNT IS OVERDRAWN, WE WILL CHARGE YOU FOR EVERY 5 BUSINESS DAYS FOR UP TO BUSINESS DAYS UNTIL YOU PAY US ALL AMOUNTS OWED. YOU HILL NOT BE CHARGED IF THE OVERDRAFT IS SOLELY ATTRIBUTABLE TO ATM AND EVERYDAY DEBIT CARD TRANSACTIONS AND YOU HAVE NOT ELECTED TO PERMIT US TO AUTHORIZE AND PAY THESE TRANSACTIONS kHEN YOU DO NOT HAVE SUFFICIENT AVAILABLE FUNDS IN YOUR ACCOUNT. REMEMBER, YOU CAN MAKE OR CHANGE THIS ELECTION AT ANY TIME. ~c~~fi.~ -o;;n; ACCOUNT N0. ACCOUNT TYPE STATEMENT PERTOII PAGE M8T CLASSIC CHECKING W/INTEREST SEP.O1-OC'T.01,2010 1 OF 1 O 06117M NM ESTATE OF MARY FRANCES WALSH RONALD J WALSH, EXEC BELDEN ST PHILADELPHIA PA INTEREST PAID YEAR TO DATE MECHANICSBURG ACCOUNT SUMMARY 8E6INNING DE I 6 .......OTHER ADDITIONS: CHECK~? PAID SUBTRACTIONS INTEREST PD P~ALANCE BALANCE NO. AMOUN7 NO. AMOUNT NO. AMOUNT 5 6 1 2 ACCOUNT ACTIVITY POS ING D PO$L S,, ER T: 'CH CKS HER DATLY OTH R ADDIT ONS SUBTRACTIONS BA~:IIt~E DATE ?RA A TION DES. BEGINNING BALANCE DEPOSIT CHECK `r DEPOSIT DEPOSIT CHECK NUMIBER CHECK NUMBER CHECK NUMBER CHECK NUMBER DELUXE CHECK CHECK/ACC. DEPOSIT ~ DEPOSIT x•08 yERI2:lN ARC CHECK PYMT CHECK NUMBER INTEREST PAYMENT ENDING BALANCE _ CHECKS PAID SUMMARY 09-17-IO ANNUAL PERCENTAGE YIELO EARNED = EFFECTIVE JANUARY THE FEE FOR EACH DAY THAT THERE IS A TRANSFER TO ANOTHER ACCOUNT TO COVER ONE OR MORE OVERDRAFTS IN THAT ACCOUNT WILL BE THIS FEE DOES NOT APPLY TO TRANSFERS TO A POWER CHECKING ACCOUNT. a= - ti _ L008A RX.O. ACCOUNT N0. ACCOUNT TYPE STATEMIENT PERIOD PAGE RELATIONSHIP CHECKING WITH INTEREST JUL.20-/~UG.19,2010 1 OF 4 0 06117M NM I17 MARY FRANCES WALSH HILLCREST CT APT 40I CAMP HILL PA INTEREST PAID YEAR TO DATE MECHANICSBURG ACCOUNT SUMMARY BEGINNING_ _ _:DEPOSITS:B - OTHER _ _CURRENT ENDING: BALANCE BALANCE: `OTHER ADDITIONS CHECKS PAID SUBTRACTIONS INTEREST PD N0. AMOUNT N0. AMOUN7 N0. AMOUNT 3 9 ACCOUNT ACTIVITY OSTIN6 . - _ ~ S, N: REST CHECKS 8 ~QTHER UAIL;Y `DATE `'~RANSi1CTZON -bESCt~IRT~01~1 :OTHER :A~~T~ONS SUBTRACTIONS_ BA ' E BEGINNING BALANCE VERIION ARC CHECK PYMT THEO'S BAR 8 GRILLE CAMP HILL THEO'S BAR 8 GRILLE CAMP HILL CHECK FIBER IMPRESSIONS SALON CAMPHILL CHECK NUMBER NINE 8 SPIRITS IE2109GAMP HILL ATG WEEKLY MON DDA TO ODA CHECK NUMBER THEO'S BAR 8 GRILLE CAMP HILL CHECK NUMBER CHECK NUMBER 07-30-I0 IMPRESSIONS SALON CAMPHILL OS-02-IO BENEFIT PAYMENTS PENSIONS OS-02-10 THEO'S BAR & GRILLE CAMP HILL ATG MEEKLY MON DDA TO DDA US TREASURY SOC SEC CHECK NUMBER 08-04-IO CHECK NUMBER OS-04-10 CHECK NUMBER OS-04-10 CHECK NUMBER ING FIN SER GALSG LIFELINE SYSTEMS ATG WEEKLY MON DDA TO DDA 08-1b-10 PPL EU ELEC SVC ATG MEEKLY MON DDA TO DDA INTEREST PAYMENT ENDING BALANCE LOA (6fa7) _ _ I1v VVVt~t t~v• AV V.V Vt?... t. t.t r :r.A?..~I...r.-..q .w.N~R~/M.... •.!lM..r. - - RELATIONSHIP CHECKING WITH INTEREST JUL.20-AUG.19,20I0 2 OF 4 T- MARY FRANCES WALSH CHECKS PgID SUMMARY 07-29-IO OS-04-10 OS-04-10 ANNUAL PERCENTAGE YIELD EARNED = THIS IS A REMINDER THAT IMPORTANT REGULATORY CHANGES THAT COULD IMPACT YOUR M8T CHECK CARD AND ATM TRANSACTIONS GO INTO EFFECT AFTER AUGUST FOR ACCOUNTS OPENED PRIOR JULY AND ARE CURRENTLY IN EFFECT FOR ACCOUNTS OPENED ON OR AFTER JULY IF YOU WOULD LIKE TO LEARN MORE ABOUT WHAT THESE CHANGES MEAN TO YOU AND THE CHOICES YOU HAVE, PLEASE CALL US AT OR VISIT US AT WWW.MTB.COM/MANAGEMYACCOUNT. . ; > . L008A - ACCOUNT NO. ACCOUNT TYPE STATEMENT PERIOD PAGE M8T PERSONAL SAVINGS JUL.22-AUG.21,2010 1 OF 1 0 06117M NM MARY FRANCES WALSH HILLCREST CT APT CAMP HILL PA _ _ INTEREST EARNED FOR STATEMENT PERIOD MECHANICSBURG INTEREST PAID YEAR TO DATE ACCOUNT SUMMARY BEGINN D P0. I: S : WI . RANa1:S HER CURRENT - _ ENDING BALANCE OtHER ADDTfIONS SUBTRACTIONS INTEREST PAID BALAI+~E; NO. AMOUNT N0. AMOUNT b, 4 0 ACCOUNT ACTIVITY T- _ _ Q ZTS_INTEREST:: N~RRA~IALS: 8'OTHER : DAI Y )AtE TRANSACTZ~1 DESCRYP''~ION < B--OTHER ADDITIONS SUBfiRACTIONS BALANCE< BEGINNING BALANCE ATG MEEKLY MON DDA TO DDA ATG MEEKLY MON DDA TO DDA OS-04-10 ATG MEEKLY MON DOA TO DDA ATG MEEKLY MON DDA TO DDA OS-20-10 INTEREST PAYMENT ENDING BALANCE ANNUAL PERCENTAGE YIELD EARNED = X EfFECTIVE JANUARY THE FEE FOR EACH DAY THAT THERE IS A TRANSFER TO ANTHER ACCOUNT TO COVER ONE OR MORE OVERDRAFTS IN THAT ACCOUNT MILL BE THIS FEE DOES NOT APPLY TO TRANSFERS TO A POKER CHECKING ACCOUNT. L00$A a _ - rr,y r` i~ _ ~~o . ~ F'A No , TM Es ~a to Of : MARY F WALSH ` iFirsf, Middle, Last} zti~ a/k/a : MARY FRANCES WALSH Late Of : LOWER ALLEN TOWNSHIP CUMBERLAND COUNTY to , _ Deceased Social Security No : 194-28-8fi31 WHEREAS, on the I s t day of September 2 0I 0 an i,~s trumen t dated August I2 th 2 was admitted to probate as the Zas t will of MARY F WALSH lr~rst, Middle Lest} a/k/a MARY FRANCES WALSH late of LOWER ALLEN TOWNSHIP, CUMBERLAND County, who died on the 18th day of August 20I 0 and, WrIEREAS, a t -rue copy of the wi as probated i s annexed hereto . TH.E,REt~QRE, GLENDA EARNER STRASBAUGH Register of Wills in and for CUZ~IBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: RDNALD ~J WALSH j~.rho has du? y dual i f.3. ed as EXECUTOR(R/X) and has agreed to administer the estate according to law, all of which fu? Iy appears of record in my office at CUMBERLAND COUNT' COURT HOUSE, CARLISLE, PENNSYL VANlA. T~~f TEST SONY WHEREOF, Shave hereunto set my hand and affixed the seal m y office an the Est day of September l 1 i } f f~ +f ~r I" r' Deputy - - - x. ~ X ~ ALL NAMES ABO~ APPEAR (FIRST', MIDDLE, LAST) _ COMMONWEALTH OF PENNSYLVANIA SHORT CERTiF1CATE COUNTY OF CUMBERLAND ~ ~ ~ - - - _ I, GLENDA EARNER STRASBAUGH Register for the Probate o.f Wi II s and Granting Letters of Administration .in and for CUMBERLAND County, do hereby certify that on _ _ ~ the 1st day of September, 'Two Thousand and Ten, Letters TESTAMENTARY in common form were granted by the Register of said County, on the estate of MARY F WALSH Late of LOWER ALLEN TOWNSHIP (First, Middle, Last) a/k/a MARY FRANCES WALSH in said county, deceased, to RONALD J WALSH (first, Midd/e, Lasi) and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the sea.Z of said office at CARLISLE, PENNSYLVANIA, this 1st day of September Two Thousand and Ten. Fi 1 e No . ~ PA Fi 1 e No . Date of Death S . S . # / r"....... ~ ! ' ci jt~~ a..~. ` ~,r t ./i~~% ~ ! .!r,; ~.~`f .ice.. ~ egrster"" f Wi! s ~ 5 f G-~~ eputy y NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL CCPv1iV":Cil`:'EA~3H OF PENNSYLVANIA REV-1162 EX(11-961 Dr?ART~~ENT^,r REVENUE BUREAU OF iNDIV;DUAL TAXES Dc?T.2&Ce"01 t HAR=,~SBURL, PA 1 7 1 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT IVO. CD WALSH RONALD J BELDEN STREET PHILADELPHIA, PA ACN ASSESSMENT AMOUNT CONTROL NUMBER f~~~ f ESTATE INFORMATION: Ssty: ~ FILE NUMBER: ~ DECEDENT NAME: WALSH MARY F ~ DATE OF PAYMENT: ~ POSTMARK DATE: ~ COUNTY: CUMBERLAND DATE OF DEATH: TOTAL AMOUNT PAID: REMARKS: CHECK# INITIALS: HMW SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF W1LLS TAXPAYER t ~ ~ 'J'am ~ ~ ~ ~ .-F ~ Sp ~ r'" n ~ N rh < ~ ~ ~ b ~ 7C' o -s 's Z ~ ~ ~ fD ~ `C N ~ m ~ r2 W O T v G O ~ ~ ~ ~ ~ ~ c~ Q m M ~ ~ ~ ~ ~ ~ o ~ ~ ~ ss v ~ ~ Z'! n ~ ~ `i z = _ c ac ~ N ~ ~ y ~ s~. b -t ~ o ~ m ~ D o0 p ~ * r ~ ~ ~ ~ Q ~ y ~ ~ Z ~ O # Q: Z Z ~ ~ ~y ~ ~ O ~ Rml 3 ~ ~a~ c D ~t ~ v d D o n ti 3 H G7 n W ~ b ~ p z: Z Oz ~ ~ v my ~ o o ~ ~ -v ~ T `dm -a ~~a... 0 0 ~ m o _ ~ k _ ~ ' G7 G7 ~ Z ° D D b o o [n Z 0 0.ce' ~ ~ ~ y ~ °o a D b _ ~ ~ 0o m ~ c ° ~ ° ° ~ ~ W o Z ~ ~ ~ ~ m D .sit;:; ° m ~ ~ a. of ~ rn rA rn 't ~ i W ~ w O ~ w fi`~ K N~ ~ ~ , ..a O D ~ ems. ~ fD O ~ Q7 ~ rp 0D O 3 v ? ~ m x (.(~~a D p !U = ~ ~ = O 3 . ~ D _i E~9 p o.:;: ~ ~ mU' ~ A rn ~ ~ d o 3 n n ~ ~ ` ~ ? ~ O M r~ ~ tQ - ~ Ci ~ A O v Q ~ ~ Z O . : ~ v ~ N y fD ~ ~ ~ ~ o rn ~ ~ ~ s„n v, m ~ © fD cV'n m~ o o 0 = t O ~ ; td ~ ~ s s a_ D D ~ rn ~ v a ~ ° ~ m r y z~ -r- ~ ~ ~ D v O O 3 Q w LT o. O O ~ to b ~ ~ G2 ~ ~ ~ ~ n D D D D O N _ff o m -i -ti ~ ° 't rn ~ n p o ~ ` r- «U cp 3 n C o` d~ x~ ~ D W ~ ~ ~ D o v, to D ° ~ ~ D .y ~m ea ao 3 o` b o co 3 ~ sU ~ ~ O w Q W ~ TAXING AUTHORITY: WEST SHORE SCHOOL DISTRJCT TAX YEAR: PER GAPITA TAX NOTICE PAYABLE BONNIE K. MILLER, TIC LOWER ALLEN TOWNSHIP TO: GETTYSBURG ROAD iD# GAMP HILL, PA SCHOOL ' ` ~ ~ ' s~ TAX PER CAPITA PER CAPITA oN R oRE ATE [?ATE ON OR BEFORE FACE DAT£ AFTER PENALTY DATE REBATE 4.so 4.so sr as~ov2olo s.so FACE sY 11/a1/20'i a t O.Qa PENALTY AFTER 11/a1120'i 0 11.QQ TO: WALSH MARY F. ~ HILLCREST CT #4a1 CAMP HILL PA 17x11 ` ~ ~ ~ ~ BILL DATE - BALL # ~3~~~Q # UNPAID TAXE5 WELL BE SENT Td DELINQUENT COLLECTOR oN TAXPAYER'S COPY ~ ~ s ~ • . ~ s l• L i i w 1 1 Blli No: TREASURER Office Haurs: MON,TUES & THURS OR BY APFT g{11 Date: Payable To: BONN{E K MILLER, CLOSED WED, FRI AND HOLIDAYS Control Na: GETTYSSURG ROAD ~ONNIE_MILLER~LOWER-ALLEN.PA.US CAMP H{LL, PA 1 pNpNE EXT Phone: EXT OCC Penalty { j1 COUNTY OF CUMBERLAND Discount ~~~~~~t~~1~~~~~~~~1 COUNTY PC $5.no $5.so 111~II11111~ TWP OF LOWER ALLEN ~ $5,r,0 MUN PC $OAO $o.oo FEE FOR ADDITIONAL RECEIPTS MUN OCC Tax Payer TAX AMOUNT DUE MARY F. WALSH {t Date Of Payment {s On thru thru ar Later HILLCREST CT APT CAMP HILL, PA 1 s ~ ~ . ~ ~ OR YOllR RECORDS ~ ` ~ TgXPAYER'S COPY -KEEP THIS PORTfON F ~ ,r.,, f -r-__ _ . _ . _ _ _ _ ~~f . ; ~ ~ EMPLOYEE NUMBER ORI~~~`AT1NG~ DEBIT: WIP TR S~CTI~N ~F-zss`ero~ .?i cENrEn _ j. iY AUTH~RIZATI~N .r .A ~ ~ - DATE vr•..-~ _ SUB PRODUCT ACCOUNT # CUSTOMER NAME (PRINT) . . DESCRIPTION ~ Original -Processing Work ' ~ , f ` Copy - $ranch TAY, ~ f_~ s . ~`s , ~-r`,~'i . :r~ ..C G CUSTOMER SIGNATURE ORIGINATING G/L NO. POSTING COST CTR. JULIAN DATA COST CENTER SE{~, NO. AMOUNT ' . Lhid~erstanc~ing what~s impolrt~.~ Mechanicsburg office If you have any questions, please call our Telephone Banking Center at Today's Date; Business Date; os1a8/2o Time: PM Checking Deposit Total Balance: Available Balance: Thanks for visiting us today. We are happy to assist you! m ~ n --i ~ n o --i - - sv ~ ~ coo c~ 3 m cn p, r° ~ - ~ - ~ ~ `'~cA ~o~~.y.~~ w /ham -a r~~s o ro cn m ~ r#' VJ• W w aV Q W • ~ ~J r~ i•~~Y ~ ' .J • r. VJ ~ ~ ~ O O ~ O vii .N~ w nm ca 0 0 ~~'o ~ ca o ~ can ~ na_ . 1V ~ ~ O~7 p ~ ~ CL1 ~ r+ ODD N ~ o ~ ~ ~ O N d ~ e -------r__ _ _ _ _ ' _ ~ ~ ~ ~ EMPLOYEE NUMBER ~ ~F-2ss ~aro~ OR~~i~~ ~ DEBIT: WIP T~AN,,SAC`i~Ot~~~ -r-~r _ f.i CESN~ ~ r._. `r~ AUTHORIZATION. ~ ' A / _ ~ ~ 5U8 PRODU T AGG UNT`# CUS,gTOMER NAME (PRINT) DESCRIPTION y _ _ ' ~ . . l Original -Processing Work Copy -Branch CUSTOMER SIGNATURE ORIGINATING G1L NO. POSTING COST CTR. JULIAN DATE COST CENTER SEQ. NO. , , - !a~ s 4 ~ ,AMOUNT . r _ z ~ t t©vF da . . THE CHECK BELOW REPRESENTS A DIVIDEND PAYMENT To inquire about your account, contact ' - BNY Mellon Shareowner Services TYCO INTERNATIONAL LTD Toll Free Number Outside the U.S. (Collect) Hearing Impaired BNY Mellon Shareowner Services is dedicated to providing you with the bes#shareowner experience! Did you know that you could manage your portfolio online hours a day, seven days a week? ,S~l~?pll' IOg ltt to Investor ServiceDirect®(ISD3 at www.bnvmellon.com/shareowner/isd _ _ - . . _ _ _ ; _ r - _ nc L. `runs r.. ~ •f'' P~ s'e~s~ :e: - ' ' rte. -n. r_ ~ r fiFi~r - 1 u. ' . ~ _e.._..: 't'i::a:~-z ~~~...s.. i _H_,'~t ~:itra.. a - ~ t~....~f~ u. e~ fc:i:e:4n -n_ ~ • i t ~ s'O 3..m aFsi.~, n . .E.....8_..~~.f.'...._...e._ '~(~nline ser~~ices not ~~fTet•ec~ hti• c7)J issrters. __s • _ s - . . , = - - - ~ - - - - ::-er-~ ,V ~ < 1v C S ~ ~ ~ ~ ~ a .x.N ~ ~ v ,g~ v ~.~/G s ~ ~ t - Accdv,v r QvG~GE - RETAIN FOR YOUR RECORDS _ _ _ ~n~ ~~-.tr:~-_ _ _-,ter ~ . _ _ SHAREHOLDER OF TRANSACTION DESCRIPTION TYCO INTERNATIONAL LTD DIVIDEND INVESTOR /D CUSIP ACCOUNT KEY 1SSUE/CtASS OF STOCK F2ECORD DATE PAYABLE DATE H8912810 WALSH----MARYF0~0 COMMON RATE PER SHARE CERTIFICATED SHARES BOOK-ENTRY SNARES GROSS AMOUNT 1'AX WITHHELD CURRENT DIVIDEt`JD 0 DIVIDEND PAID YEAR TO OATE TAX WiTFiHEi_D YEAR TO DATE TAX IDEP•tTIFICATION NUMBER please detach and retain this form for your records. ON FILE PLF.,.l1SE DETACH BELOW CHECK NUMBER: THE CHECK BELOW REPRESENTS A DIVIDEND PAYMENT To inquire about your account, contact . COVIDIEN PI_C BNY Nlelion Shareowner Services Toll Free Number Outside the U.S~. (Collect) Hearing Impairetd _ _ _m ~n a _ ~ _ ~ _ _ - - e your accou n~- ._r . _7s . Login r~ Investor ServiceDirect~`~I nr www.bnymeilon.comishareowner/isd Would you like your Dividend Payment Deposited into your bank account instead o~receiving checks by mail? Simply enroll in our self-service program by using the option below. Login to Investor Service Direct at www.bnymellon.com/shareowner/isd • Choose your account from the My Portfolio page which will take you to the Account Summary page. • Select Account Preferences from the menu. • Click Edit » on the Dividends and Direct Deposit box. • Select Electronic Deposit. • Click Continue » and follow the enrollment instructions. Have one of your persona! checks handy. You will need to refer to the bank information printed across the r bottom of your check. oc' .~pvivGs d~~~ - RETAIN FOR YOUR RECORDS _._~¢~~~~<-_-r:.:-._: r~ _ _ Rte,,.-~-.;~k~u~ _ _ _ .~--a `may SHAREHOLDER OF TRANSACTION DESCRIPTION COVIDIEN PLC DNIDEND INVESTOR 1D CUSIP ACCOUNT KEY ISSUE/CLASS OF STOCK F'ECORD DATE PAYABLE DATE G2554F10 WALSH----MARYF0000 COMMON . RATE PER SHARE CERTIFICATED SHARES BOOK-ENTRY SHARES GROSS AMOUNT TAX WITHHELD CURRENT DIVIDEND 0 DIVIDEND PAID YEAR TO DATE TAX WITHHELD YEAR TO DATE TAX IDENTIFICATION NUMBER P~eBSe detaCF1 retain t111S form ~Or our records. ON FILE Y PLEPSE DETACH BELOW CHECK NUMBER: .~~al~e~.zl ~'une~all.~o~ne Market Plaza Way ~chanicsburg, PA I705~ www.malpezzifimeralhome.com rem y J. Shartzer, FD Michael J. Nlalpezzi, Owner, FD Kyle C. Knipe, FD September Ronald J. Walsh Belden Street Philadelphia, PA I 1 The Funeral Service for Mary Frances Walsh We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHAI~iDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. PROFESSIONAL SERVICES: Sen~ ices of Funeral Director/Staff FUNERAL HOME SERVICE CHARGES SELECTED MERCH_~NDISE: Steel Gasketed Casket Guardian Burial Vault Prayer cards THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED AT THE TIME FL~tERAL ARRANGEMENTS WERE MADE, WE ADVAAICED CERTAIN PAYMENTS TO OTHERS AS Ai~T ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. CASH ADVANCES: Opening Grave Cemetery Equipment Certified Death Certificates Newspaper ~iotices - Fatriot Newspaper Notices -Pottsville ClergyfMass Offering $ Organist Soloist~Cantor Flog}~ers $ Clergy--Cemetery TOTAL CASH ADVANCES AND SPECIAL CHARGES CONTRACT PRICE HISTORY': Payment TOTAL AMOU:'~'T DUE w 'a s • _ 1+...j,_ .ar'; - - s ~z ~ ~ ~ = ~ ~ - 1.~pt ~ ~C ~j ~ ~ _ d r ~ ~ 1~s Tax ~ . - to Sz $ . . Ba~~~y~,ragts ~ ~ RtN1ALD J. WAISH EYELYN A. WALSH s-sisro e~.o~ sT ~~~a~ 6 e~ PHItAQELPHtA, PA is111 1G J i?ate >G Pay to the ~ / ~,/..,J~© ~I Order of k.,u,., ~v~ ~e ~'1V CBA~K. PNC Hank, NA_ phiiadeiptua, PA Fo ~;Q3 LO~~fl53~: 85?35~g3?Cl~~' v = ~rw,--r. .J _ j_ - ~ r ";7r. ~ r _ ~T =~'..i T1~f ~~:...d ~v~i E i.. f y~ ~ P+. S ~ ~ - _ _ .rte.' - `~ratc Amo~xnt ~,,.-r~c~nt I 1 4 f _ ~r I~ ~ ~ i G ~ E `'t ~d ~ Thy `Y`ou s f Please eampare with your records, if there is any difference please advise. If payment is due prompt payment would be appreciated. A SERVICE OF 1'/z % ADDED AFTER DAY~~ ~~ti~fl °G ~ ~~~~a CUMBERLAND LAW JOURNAL SOUTH BEDFORD STREET CARLISLE, PA Tele: T) Fax: ~ November Cumberland Law Journal is published every Friday by the Cumberland County ...Bar Association and. i .designated by the Court of Common Pleas as- the_afficial legal publica#ion for Cumberland Gounty and the legal newspaper for publication of legal notices. TO: Ronald J. Walsh Mary Frances Walsh Estate RE: Legal advertisements must be received by Friday Noon. All legal adwertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: October November and November Advertising Cost $ 75.D0 Proof of Publication $ Second Proof Request $ Payment received $ Total Amount Due $ Becky H. Morgenthal, Executive Director r _ _ _ _ _ _ _ t'~+~r~1 _ etatamerrl ~2te: Septnml;e~ ~ - C~foher Zu'!0 1 F-= _ _ ~ ; Ne~v Balance r _ _ ' F ~ - - - --?s)t?:~ f:~;rxt:.~t Payr,~ert '.~cae _ _ _ _ _ _ _ - _ _ _ ~#t3a1~_ i - Payment Due date NQVemberLl6*~10 F ~ i -=-;s ~ : Late Payrttent V~arninv: If we do not receive dour minimum payment icy ..~;c: the date fisted above, you may have to pay a lane i'es of up to and -,.~c` your APRs maybe increased Up io the Penalty APR of 29,99°x, Ir,t~_r ~s G-Y:: - 23.Od r~ Minirnum Paym4nt iNarning: If you make only the minimum payment j ~~i~r~:~ etch period, you will pay more in interest and ii will take you longer to pay T ~%ii C<<?ti ::-i ii off your balance: For example: ` ~I~t~713~+'.~_ :'r;~c!; ft you make nc3 s:as- ~.reti ,f !_i~ ~l additianai charges Yau vyi6i pay off the And you wilt end up Prailan!e c',~st? using this card and iaaiance shown on this paying an estimatted ' each month statement in about.,. total of... S:a:~a~nent t;icse c da' a 10/Q91i0 y0U p3u... ~ Nun; ~r of ~ja;~ b!I' ing cycle ~ Only the minimum [ payme~ 8 years . • ~ t ~ "i` 3 years $2,16tJ I r y, (Savings = X628) - . J~ ~ G j~ For credit counseling you may call ^S" .j .=?~',:~i~.-i.i f'F.i:~i t'kl....._.-,.ter Trans Date ~~~:ksE !Date Reference Number Transaction Description Amaunt FAYMENT;6 ANi Y i31~DiTS ! kE~/23 Payment Received Thankyou ( ) PURCHASES 09/2't l~I,r28 THE PATRfaT-NEWS MACT[ 7'I7-295-8237 PA il4 T EREST CHA @C~E:I'? #f,'08 INTEREST CHARt3E-PURCHASE TOTAL iNTERf:ST FOR THIS PERIOD , , t al 'v f ~R ~ - .Y - f Cu~T~,`~°.~:- S~~ !l~,_. ~ C!`Z:i:'~~r ~A;:?f L~'.l'Cc~ ~~Z~.`~ ~a~K CA~tt~ ',t'.C~S j +.J~ v~ .C's. C.^..^J~Y!~.. ~~'~v.:. ~r ~Lk.'A+'~ G:~i4 iSK'..^~....~P'1'v.':T. Lei 3 . ~ ~ ~ ~ . _ _ . Page 1 of 4 The Patriot-News Co. • Technology Pkwy ~.r Suite ~t~a Mechanicsburg, PA Now you know Inquiries - WALSH r,~` ~ f/j{/~J~J)~j ~ ~ ~ f tr / f ~ ~ ~ BELDEN ST. ~ ~ ~ PHILADELPHIA PA AI_I_ CHARGES ARE NET ACCT # NAME AD ORDER # DATE .EDITION ADDTL. INFO. TYPE OF CHARGE AMOUNT WALSH REGULAR BASIC AD CHARGE WALSH REGULAR BASIC AD CHARGE WALSH REGULAR BASIC AD CHARGE AFFIDAVIT CHARGE ~j rt ~ L ~ TOTAL: C~6? t,~ y7 ~ ~ , rj f~ ~A~,`,~ ~ ~~LL~ ~ REMiTTA1VCE ADDRESS d!1f r The Patriot-News Co. y Network PL I v G Chicago, IL ~~~'~~i V3 fir/ r Please include the Account # or Ad Order # (above) with your remittance--Thank You NOTE: This Invoice replaces the Order Confirmation which we previously sent with Proofs of Publication Please Note: The "Check Date," noted below, represents the settlement date of this transaction. Under normal market ~ conditions, sale transactions are traded 3 business days prior to the "Check Da#e". BNY MELLUN SHAREOWNER SERVICES Login ro Investor ServiceDirect~ at wvvw.bnymellon.comishareownerlisd E _ ~ . - RETAIN FOR YOUR RECORDS SHAREHOLDER OF ,DESCRIPTION NCO INTERNATIONAL LTD _ _ SHARES SG1LD ± INVESTOR /D CUSIP ;ACCOUNT KEY ~ CHECK NUMBER ~ CHECK DATE !CHECK AMOUNT i H8912810 WALSH----MARYFOF00 ! ~ SHARESlUNITS SOLD `PRICE PER SHARE ~ TRADING FEES PAID f3Y SERVICE FEES PAID BY ' GROSS PROCEEDS `TAX WITHHELD ~ COMPANY SHAREHOLDER {COMPANY ;SHAREHOLDER r ~ _ _ NET PROCEEDS SHARES HELD BY PLAN ~ PLEASE DETACH BELOW CHECK NIMABER: -,,,~,.a,~..-.~... _-.~,~..,.~....,.~..-,.~.,,,,,n.s..-...,-~.~o-._ ~ - Please Note: The "Check Date," noted below, represents the settlement date of this transaction. Under norms! market conditions, sale transactions are traded 3 business days prior to the "Check Date". BNY MELLON SHARE4WNER SERVICES Login to Investor ServiceDirect~ at wV1i'W.bnymeffon.comishareownerfisd L z - RETAfN FOR YOUR RECORDS SHAREHOLDER OF ~ DESCRIPTION _TYCO ELECTRONICS LTD SHARES SOLD _T_~ INVi:STOR 1D CUSIP ?ACCOUNT KEY ;CHECK NUMBER i (.HECK DATE 1 CHECK AMOUNT ~ H8912P10 WALSH----fiMRYFOFOd ! f-__--- _ _ SHARES/UNRS SOLD 'PRICE PER SHARE TRADING FEES PAID BY ' SERVICE FEE5 PAID BY ` _______._M____._~_________,_____. - GROSS PROCEEDS TAX WITHHELD r COMPANY i SHAREFN~LDER `COMPANY SHAREHOLDER ~ ! ---.--$x8.56`----~---_- j NET PROCEEDS SHARES HELD BY PLAN + _ PLEASE DETACH BELOW CHECK NUtd~ER: - _.-~~r.,_ _ . _ Please Note; The "Check Da#e," noted below, represents the settlement date of this transaction. Under normal market conditions, sale transactions are traded 3 business days prior to the "Check Date". BNY MELLON SHARE4WNER SERVICES Login to Investor ServiceDirect® ar www.bnymellon.com/shareowner/isd o i T; r p N ..._._.._...__._M.__._....-_,.__ _ a - RETAtN FOR YOUR RECORDS SHAREHOLDER OF DESCRIPTION COViDIEN PLC I SHARES SOLD INYES7i~R !D ~ CUStP j ACCOUNT KEY ~ CHECK NUMBER I CHECK DATE I CHECK AMOUNT ; _ *G2554F10 WALSH---MARYFOF00 i 1 SHARESIUNITS SOLO 'PRICE PER SHARE ($j ! TRADING FEES PAID BAY i SERVICE FEES PAID BY GROSS PROCEEDS TAX WITHHELD ;COMPANY ~ SHAREHOLDER COMPANY SHAREHOLDER ! ~ ' ~ NET PROCEEDS I SHARES HELD BY PLAN j ~ ~ PLEASE DETACH BELOW CHECK NUM8ER: BNY Mellon Shareowner Services p • ` PO Box ad~4~Ce • Pittsburgh, PA I~~TAIi"~ T iJiS Cg~CU~Ei+lT ~ol~ Yo~R REC°~RDS Company: TYCO INTERNATIONAL LTD Issue: COMMON Registration: Shares: 23s.oooo rm **AUTO T4 0 cot su3Ai - - CUSIP: H$912$10-4 I~~~III~I,~~~~lI~~~11~~~11,~II~I<<I„~~II~I~~111~~~~1~,11~~~11 RONALD J WALSH EX UW MARY FRANCES WALSH BELDEN STREET PHILADELPHIA PA Investor ID YourBroker-Dealer Account Key WALSH---MARYFOF00 Broker-Dealer ID Transaction Date OCTOBER Broker-Dealer Account Number Transaction Advice Number This is a record that the indicated book-entry shares have been transferred in accordance with your instructions. These shares are transferable on the books of the Transfer Agent, BNY Mellon Shareowner Services, upon receipt of properly completed transfer documents, instructions and assignment. There may be rights, privileges, restrictions and conditions attached to the securities covered by this Advice. ~ full copy of these can be obtained by writing to the Secretary of the Company. R Si u or M Lin ks"" for secure X4/7 LogiyZ to Investor ServiceDirect0 rxt ~ p.f' WWW.bnymellon.eom/shareowner/isd online access to your Shareowner documents. Manage your statements and View information Perform Transac#ions • Account Detail Change your address tax documents! Simply login to your • Book-entry history Sell book-entry shares account at Investor ServiceDirect® • Pending transactions Replace a dividend check where step-by-step instructions will • Transaction history Certify your taxpayer ID • Payment history Change your dividend election* Prompt you through enrollment. • Tax information • Historical stock price information and more! *Online service not offered b_y all issarers. s'"" BNY AIELLON ' SHAREQWNER SERVICES • BNY Mellon Shareo«ver Sen-ices ~ _ = ~ - ` PO Box So. Hackensack, NJ ~ TYCO INTERNATIONAL LTD I - i WALSH---~-MARYFOF00 rrrrrlrl,,,rrlr,,,.,rrrur.,r,rlr,r,rur~rri~~ll~rlr,r.,,rlr.n, ~ MB TR SRCQDSDI ' _ RONALD J ~~VALSIi EX UW hiARlr FRA~iCES t~V.~LSH - BELDEN STREET ~ $00-68J-4J09~ PHILADELPHIA PA ~ ',~y~, ~ October Dear Shareovvner: L 3 t,?.° y The Bank of Nei;j York Mellon (the Administrator), an affiliate on BNY Mellon Shareow~:r Services, °g adrnirusters a program offered by the issuer of your securities for shareovvners vvho would like to sell all 0 or a portion of their shares. By conducting a sale through this program, you agree that this G~nstitutes o immediate enrollment in the program All sales vvill be processed by the Administrator through BNY Mellon ~ Securities, LLC, a registered broker/dealer and member of NASD/SIPC and an affiliate of F?NY Mellon Sltareovvner Services. 0 0 o All sales under this program are subject to a transaction fee not to exceed per transaction plus per share. Fces for the respective issuer of the securities you hold are available on the online Plan Summary page at «~j~v~.brwrnellon.com/sl~areo«rner/isd or by contacting BNY Mellon Shareo~vner Ser~~ices. The tr~~nsaction fee vvill be deducted from the proceeds of your sale. TI>e Adnuivstrator vvill combine the shares you vv~ant to sell through the program with other shares that are also being sold by other program participants. Shares are then periodically submitted in bulk: to BNY Mellon Securiries, LLC for sale. Shares will be sold promptly after t1~e Administrator receives your iinstnrctions, usually vltlvn one business day, but in no event more than five business days (except where deferral is necessary under State or Federal regulations). The price per sllare for arR~ shares sold through the program vvrill equal the market price that BNY Mellon Securities, LLC receives for your shares (or the weighted average of the market prices of eac;11 sale if more tl>an one broker trade is necessary to sell all of the combined shares). On settlement date, which is three business days after your shares have been sold; the Administrator vvrill mail your proceeds by check to your address of record All sale requests are final and once received cannot be cancelled. All sales are subject to market conditions and other factors. Under the program, directions to sell shares on a specific day or at a specific price cannot be accepted. The actual sale date or price received for amT shares sold through this program cannot be guaranteed. Participants must perform their ovv~n research and must make their own investment decisions. Neither the Administrator nor amT of its affiliates vvjill provide any imTestment recotmnendations or investment advice vv~ith respect to transactions made through the program. You may sell your book-entry shares by visiting our a~eb site at mv~:bnymellon.com/shareowner/isd and then clicking Investor ServiceDirect~', or simply by calling tl~e toll flee number on your statement. OLP2017 205102H891281DWALSH----MARYFOFDO ~ ~ BNY Mellon Shareowner Services PO Box Pittsburgh, PA I~~TAIN THIS Df~~;UM~~iT' I"~R Y~UI~ R~CRDS Company: TYCO ELECTRONICS LTD Issue: COMMON Registration: Shares: Oi ~ff **AUTO T4 0 19111-3s1ao4 cat siMAI - - CUSIP: H8912P10-6 llll'~~t'iiill{~1111'lll'~11~'1111'1111~'I~II~~~ll/l~il'~111~~ RONALD J WALSH EX UW MARY FRANCES WALSH BELDEN STREET PHILADELPHIA PA Investor ID Your Broker-Dealer Account Key WALSH----MARYFOF00 Broker-Dealer ID Transaction Date OCTOBER Broker-Dealer Account Number Transaction Advice Number This is a record that the indicated book~ntry shares have been transferred in accordance with your instructions. These shares are transferable on the books of the Transfer Agent, BNY Mellon Shareowner Services, upon receipt of properly completed transfer documents, instructions and assignment. There may be rights, privileges, restrictions and conditions attached to the securities covered by this Advice. A full copy of these can be obtained by writing to the Secretary of the Company. M~.n~.gc Acc~~~n~ ~T~-~h ~~~c R Si u or M Links"" for secure Login to Investor ServiceDirec~0 at Sn p~ WWW.bnymellOn.COm/Shareowner/isd online access to your shareov~n~r documents. Manages your statements and View Information Perform Transactions • Account Detai! Change your address tax documents! Simply login to your • Book-entry history Sell book-entry shares account: at Investor ServiceDirect® • Pending transactions Replace a dividend check where step-by-step!'instructions will • Transaction history Certify your taxpayer ID prompt you through enrollment. • Payment history Change your dividend election* • Tax information • Historical stock price information and more! `Online service not offered by all issuers. i . ~ 3~F ~1ELLON i9~RECJ:kER SERVICES 'BNY Mellon Shareowner Sen-ices - - _ PO BoY _ So. Hackensack, N3 ~ TYCO ELECTRONICS LTD - •V WALSH--- T~IARYFOF00 1 = - - _ _ n~~iiii.~~iilr,..~~~n~i.~i,iii,~t.nn~~~i~~il~~1~~i~~~~i>>u, ~ - zo loop 1002.;~9ss MB TR SHCODSDI _ RONaI.D J VV.~I,SH EX L~~' \1.~R1" - ~ ~ FRANCES ~~'~LSH ~~~~~i~~~~~~ BELDEN STREET ! 866-25s-=~7=~5 ~ PHILaDELPHL~ P:~ I9I I I -ri~~ ~ ~ ~ o f October ~ ~ ~ • ~ y 7 1 l Dear Slrareo«ner: 5 ~L ~ The Bank of Nets York Mellon (the Administrator), anaffiliate on BNY Mellon Shareo~vner Sen~ces, o administers a program offered by the issuer of }Tour securities for s}rareo~vners ~vho would like to sell all or a portion of their shares. By conducting a sale through this program, you agree drat this constitutes o irmrtrediate enrollment in the program All sales Frill be processed by the Administrator through BNY Mellon ~ Securities, LLC, a registered broker/dealer and member of NASD/SIPC and an affiliate of BNY Mellon Shareo~vner Serc-ices. 0 a o All sales under this program are subject to a transaction fee not to exceed per transaction plus per share. Fees for ftie respective issuer of the securities you hold are available on the online Plan Summary page at ~j~t~v.bm~mellon.com/shareo~vner/isd or by contacting BNY Mellon Shareo~vner Services. The transaction fee «--ill be deducted from the proceeds of your sate. The Administrator will combine the shares you want to sell through the program with other shares that are also being sold by other program participants. Shares are then periodically submitted in bulk to BNY Mellon Securities. LLC for sale. Shares «~ill be sold promptl}° after the Administrator receives your in:~~tnrctions, usually ~ti~ithin one business day, but in no event more than five business days (except where deferral is necessary- under State or Federal regulations). The price per share for artyr shares sold tlrrouglt the program will equal the market price that B NY Mellon Securities, LLC receives for your shares (or tl~ weighted average of tl~ market prices of each sale if nwre than one broker trade is necessary to sell all of the combined shares). On settlement date, «-hic;tr is three business days after your shares have been sold, ttre Administrator tivill mail your proceeds by check to your address of record. All sale requests are final and once received cannot be cancelled All sales are subject to markf~ conditions and other factors. Under the program, directions to sell shares on a specific day or at a specific price cannot be accepted. The actual sale date or price received for any shares sold through this program cannot be guaranteed. Participants must perform their o«n research and must make their otivn im~estrnent decisions. r3either the Administrator nor airy of its affiliates ~v-ill provide arty irRTestment recommendations or irrvestnrent ad~rice with respect to transactions made tlrrouglr the program. You may sell your book-entry shares by visiting our t~~eb site at www.bn~~nellon.com/shareotvnerlied aril then clicking Investor Sen-iceDirect®, or simply by calling the toll free number on your statement. OLP2D1? 205102H8912P10WALSH----MARYFOF00 ~ 4 ~ BNY Mellon Shareowner Services ` ~ PO Box Pittsburgh, PA I~~TAI T~IIS Do~UM~:iVT YoUR R~CCI~~S Company: COVIDIEN PLC Issue: COMMON Registration: Shares: Ol ++AUTO ~T4 0 C02 s].a~z - - CUSIP: G2554F10-5 I~~~ill~l~~~~~il~~~ll~~~lI~~II~I~~I~~~~II,I~~III~~~~I„Il~~~il RONALD J WALSH EX UW MARY FRANCES WALSH BELDEN STREET PHILADELPHIA PA Investor ID 1 YourBroker-Dealer Account Key WALSH----MARYFOF00 Broker-Dealer {D Transaction Date OCTOBER Broker-Dealer Account Number Transaction 00010009fi4 Advice Number This is a record that the indicated book-entry shares have been transferred in acco _ th your instructions. These shares are transferable on the books of the Transfer Agent, ` n Shareowner Services, upon receipt of properly completed transfer documents, instructions and assignment. There may be rights, privileges, restrictions and conditions attached to the securities covered by this Advice. A full copy of these can be obtained by writing to the Secretary of the Company. Mangy ~ ~o~z~ cs:o€~n ~`~~~h..a~e ~ M~a~~9~ Sh~e`~'~?~~L~~'~' S~I~~~ I~Itr~e R SZ u or Mllnks"" for secure Logi~2 to Investor ServiceDirect0 at ~ p.f WWW.bnymellon.eom/shareowner/isd online access to your shareowner documents. Manage your statements and View Information Perform Transactions • Account Detail • Change your address tax documents! Simply login to your • Book-entry history Sell book-entry shares account at Investor ServiceDirect® • Pending transactions Replace a dividend check where step-by-step instructions will • Transaction history Certify your taxpayer ID • Payment history Change your dividend election* Prompt you through enrollment. • Tax information • Historical stock price information and more! Online service not offered b_y all issuers. _ _ _ _ _ _ T r ' SH:.R:OY:kER SERYlCES BNZ" I~~iellon Shareo«ner Services - _ PO Bo13~26 } COVIDIEN PLC So. Hackensack, NJ ~ s WALSH----:MARYFOF00 iliti(1(,..ti(1,,,,,Illlii„t,l(1„t'Itll'Ii("(('t(1.1,,.1(I,It, MB TR SRC~DSD1 1 RO\.-~LD J R :~LSH EX ? ~i CRY = BELDE\ STREET PHIL.-~DELPHI_-~ P.~ I ' 566-210-6J~~2 ~L•'~~ f October Dear Shareowner: ~ ~ ~i l ~ The Bank of New York Mellon (fl>e Administrator), an affiliate on BNY Mellon Shareo~vne~r Services, Q administers a program offered by the issuer of your securities for shareo~vners who would like to sell all or a portion of their shares. By conducting a sale fluough this program you agree that this constitutes o irnrnediate enrollment in flee program All sales will be processed by the Administrator through BNY Mellon ~ Securities, LLC, a registered broker/dealer and member of NASD/SIPC and an affiliate of BONY Mellon Shareo~rner Sen~rces. 0 ?n 0 o All sales under this program are subject to a transaction fee not to exceed per transaction plus per share. Fees for the respective issuer of the securities you hold are available on the online Elan Summary page at 1««v.brivmellon.com/shareo~~Tner/isd or by contacting BNY Mellon Sl~areowner Servrices. The transaction fee will be deducted from t11e proceeds of your sale. The Adnnistrator ~tiill combine the shares you want to sell through the program with other shares that are also being sold by other program participants. Shares are then periodically submitted in bulk to BNY Mellon Securities, LLC for sale. Shares ~~ill be sold promptly after flee Administrator receives your ik~.structions, usually «ithin one business day, but in no event more than five business days (except where deferral is necessary under State or Federal regulations). The price per share for arty shares sold tluough fl~ program will equal the market price that BNY Mellon Securities, LLC receives for your shares (or flee weighted average of the market prices of each sale if more Oran one broker trade is necessary to sell all of the combined shares). On settlement date, which is three business days after your shares have been sold, the Administrator will mail your proc~ds by check to your address of record All sale requests are final and once received cannot be cancelled. All sales are subject to market conditions and other factors. Under the program, directions to sell shares on a specific day or at a specific price cannot be accepted. The actual sale date or price received for arr}r shares sold flu~ough this program cannot be guaranteed Participants must perform their o«m research and must make their own imrestmern decisions. Neither flee Administrator nor any of its affiliates tivill pro~ride arty inrvestment recommendations or investment advice with respect to transactions made through the program. You may sell yourbook-entry shares by visiting our tveb site at ~'~~v bnvrnelion.com/s6areowner~sd and Oren clicking Im~estor ServiceDirect~, or simply by calling tree toll free number on your statement. OLP2017 205102G2554F],OWAL_SH----MARYFOF00 ~ ~ ~ BNY Mellon Shareowner Services s y ~ PO Box ~~n~~~ ~ ~ d4Ce • Pittsburgh, PA I~~TAII T ISIS D~C~I~~:NT ?..iR PQ~C~R~S Company: TYCO INTERNATIONAL LTD Issue: COMMON Registration: Shares: Ol t~ G.382 '*AtrrO T4 0 C02 s1MAI - - CUSIP: H8912810-4 1~~~111~~~111„~~~~11~~~111~~1~11~~~~~1~1~~11~11~~~~~~11,II~,I MARY FRANCES WALSH HILLCREST COURT SUITE CAMP HILL PA Investor ID YourBroker-Dealer Account Key WALSH----MARYF0000 Broker-Dealer ID Transaction Date OCTOBER Broker-Dealer Account Number Transaction Advice Number This is a record that the indicated book-entry shares have been transferred in accordance with your instructions. These shares are transferable on the books of the Transfer Agent, BNY Mellon Shareowner Services, upon receipt of properly completed transfer documents, instructions and assignment. There may be rights, privileges, restrictions and conditions attached to the securities covered by this Advice. A full copy of these can be obtained by writing to the Secretary of the Company. !b: 1 ys I~ ~ L 9 ~ I : a: G G C L ^+V L ~w~' V" ~~V [ 6 ~ G ~It `®C ~ ~ Oi" mss/' ® ctt Sign up for NlLinkS"" for secure Login to Investor ServiceDirect WWW.bnymellon.eom/shareowner/isd online access to your shareowner documents. Man~~ge your statements and View Information Perform Transactions • Account Detail Change your address tax documents! Simply login to your • Book-entry history Sell book-entry shares account at Investor ServiceDitect® • Pending transactions Replace a dividend check where step-by-step instructions will • Transaction history Certify your taxpayer ID promtpt ~u through enrollment. • Payment history - Change your dividend election* • Tax information • Historical stock price information Ctnd more! ~C>nline service not offered by all issuers. ~ ~ ~ ` BNY Mellon Shareowner Services ~ ~ - PO Box ~~~'~Ce Pittsburgh, PA I~~ T AI N THIS DCC~I~~~~~T SCR ~ UR RAC C:~ DS Company: TYCO ELECTRONICS LTD Issue: t~OMMON Registration: Shares: ;?3s.oooo Ol MS **AtrrO T4 0 cot s1MAI - - CUSIP: i~i$912P10-6 I~~~III~~~III~~~„~I1~~~111~~1~11~~~~~1~1~~11~11~~~~~~11,11~~1 MARY FRANCES WALSH HILLCREST COURT SUITE CAMP HILL PA Investor ID YourBroker-Dealer Account Key WALSH----MARYF0000 Broker-Dealer ID Transaction Date OCTOBER Broker-Dealer Account Number Transaction Advice Number This is a record that the indicated book-entry shares have been transferred in accordance with your instructions. These shares are transferable on the books of the Transfer Agent, BNY Mellon Shareowner Services, upon receipt of properly completed trans#er documents, instructions and assignment. There may be rights, privileges, restrictions and conditions attached to the securities covered by this Advice. A full copy of these can be obtained by writing to the Secretary of the Company. ~ ~ w: q~' ! t ~ d':. ~ ¢ ~ 6'y;Y ~ . F~ ~ y~- E~"'~`36`w r,~ z~, d w.~[ L E M e E ~i a wr""s. € ~ u' E e 3v I~ ,.Po ~ ~ F - ~ w E ~ ~ w v.v ~ ! ~ ~ ® at ,Sign u~i for ~ l1 n ks"" for secure LogiyZ to Investor ServiceDirect wwW.bnymellon.eom/shareowner/isd online access to Tour Shareowner documents. Manage your statements and View Information Perform Transactions • Account Detail Change your address tax documents! Simply login to your • Book-entry history Sell book-entry shares account at Investor Serv°iceDirect® • Pending transactions Replace a dividend check where ;step-by-step instructions will • Transaction history ~ Certify your taxpayer 1D • Payment history Change your dividend election* prompt you through enrollment. • Tax information • Historical stock price information and more! ~O~zline service not offered by all issuers. ~ e ~ ~ ~ . e~;an Sharea~rna Services r n~ ,`:v~ 3~0o3J ~k~ i~~ tl aa.~~~ - ~ ~s , n ^ PA ~ _ ~ ~ ~ ~ ~ ~ r f ~ r' .J i,i r . . R a t i,! t `~.F •rA t i 3 ~ ! ? x o.-. 3 £ - ' 'r.,.- ?.s- Company: C^VIDIEN PLC Issue: COMMON Registration: Shares: 23s.oooo l!GOG~~s^ **lAUTttO TG ~ aosz((1l!7Gi2-8GZii3G1`` coiin s~~az - - CUSIP: G2554F10-5 Ifii~'1111 " ~illitl~'itiE~liill~lli/Il~t~ll~lil'i1i111~1i~i111 MARY FRANCES WALSH HiLLCREST COURT SUITE CAMP HILL PA 1 investar ID Your Broker-Dealer _ _ Account Key WALSH----MARYF0000 Broker-Dealer ID Transaction Date OCTOBER o Broker-Dealer Account Number Transaction Advice Number This is a record that the indicated book-entry shares have been transferred in accordance with your instructions. These shares are transferable on the books of the Transfer Agent, BNY Mellon shareowner Services, upon receipt of properly completed transfer documents; instructions and assignment. There may be rights, privileges, restrictions and conditions attached to the securities covered by this Advice. ~ full cop`r of these can be obtained by writing to the Secretary of the Company. w~ z ; ' , _ ? . s e z . _ ? a e: v. - = ~ e ^e.r- e f ~ ~.a £ R r ~ dt Sia~t2 u~ for M Lin kS"" for secure Lv~iya to ins estor ServlceDirect WWW.bnymellon.cam/shareowner/isd online access to your shareowner documents. iVlanage your statements and View Information Perform Transactions • Account Detail Change your address tax documents! Simply login to your • Book-entry history Sell book-entry shares account at Investor ServiceDirect® • Pending transactions Replace a dividend check where step-by-step instructions will • Transaction history ~ Certify your taxpayer IG prompt you through enrollment. • Payment history Change your dividend election* Tax information • Historical stock price information and more! `Online senlice not offered by all icsccers. Please send all correspondence to: ~ Tyco Electronics EAA'N.~NG?5 STATEMENT Customer Service Center TYCO ELECTRONICS i Half Day Road PO Box K AMP PENSION PLAN LINCOLNSHIRE IL • • ' ~ ' ' ~ ' TYC004521 612a/TYRE On the reverse side of this document, you will find: Electronic Deposit Authorization, Address Correaion Form, Important Federal Tax Election Notice. 04REQU IR-6128/TYRE-0~1-000001941-0004660526-000000254541 NNN MARY FRANCES WALSH HILLCREST C'T APT CAMP HILL PA 1 ~1,~It,.~tltli't~llt~l~~~l'Itl'~ttl'~~~'tlitl'I~t'~~'t'Illll~tt~l BENEFIT . . CURRENT FEDERAL WITHHOLDING ELECTIONS ~ CURRENT PA STATE WITHHOLDING ELECTIONS ~ , ~ ~ ~ / i r~ 1 ~ ~ st2a~nRE 0721100004660526MMA043910 TYCO ELECTRONICS The Northern Trust Company Chicago, IL through Oakbrook Terrace, IL AMP PENSION PLAN 00045fi0526 08-01-201t~ OOOOOi941 ! TYC~4521 61281TYRE MARY FRANCES WALSH ~ ~ ~ ~ ~ ~ ~T~Ag Your deposit was sent to: • ~ ~ • Checking ;Amount Deposited This is NOT a check. This document is for informational purposes only. i lei Erie Fa~~i! Life Y Insurances Member Erie Insurance Group Home Office Erie Insurance Place Erie, Pennsylvania Toll free Fax yvww.erieinsurance.com September Ronald J Walsh Belden Street Philadelphia, PA RE: Estate of Mary F W<~lsh Life Policy Annuities #AY000474 & AY000475 Dear Mr. Walsh: Please accept our condolences to you and your family. The information that you requested is listed below: Life Policy # -Whole Life The total death benefit was plus interest of Annuity # AY000474 -IRA The date of death value, August was The gross and taxable amount disbursed on September was minus Federal Withholding for a net disbursement of Annuity # AY000475 -Non-Qualified The date of death value, August was with a cost basis of The gross amount disbursed on September was the taxable amount - _ was minus Fe-d:er~l Wit~_holdng fr~r-a net disbt~rsement~._ I hope this is helpful to you and if you have any questions, please call me at extension or Melody Bokshan at Sincerely, Sally Austin Sr. Life Claims Specialist Life Policy Administration The ERIE is Above Ail In Service. ~ A ~ n ~ ~ m as g- z ~ z ~ o~ ~ - rn a ~ a ~ , ~ c~' @ cc m ~ w H ~ ~o ~ cn 3 ~ O ~ G ~ p rt O~ ~ - A 1 r O ~ ~ ~ ~ is N u! ~ ~ ~ N !J~ ~ W as _ c, ~a a a - ' t) to ~ n' ~ n -s - ~ ~ _ _ A y ~ Z'mt"7v rn ~ a~ ~ o. 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J ~ fi f~ ~ 3 v ~ 'C. a Z October L~~III~~~lih~~~~~li~~dlhd~ll~.,~~i~l~~ihlL«<~di~U;,l MARILEIGH HENSLEY Branch Manager -278MS00089401. MARY FRANCES WALSH www.smithbarney.com CGM IRA ROLLOVER CUSTODIAN HiLLCREST CT 'ACCOUNT NUMBER 406-b7542-11-305 CAMP HILL PA IMPORTANT NOTICE CONFIRMATION OF TRANSFER OF ASSETS IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT YOUR BRANCH MANAGER This notice confirms that, on your requested transfer(s) was completed. 4UANTITY/AMOUNT SECURITY DESCRIPTION CAPITAL INCOME BUILDER FUND CLASS C CAPITAL WORLD GROWTH AND INCOME FUND CLASS C {NCOME FUND OF AMERICA CLASS NEW WORLD FUND CLASS C This transfer(s) was made FROM~your Morgan Stanley Smith Barney account referenced above to the following account: S~~E Fa{,,~ Account Number: 406-6710D ~~mrs ~ ~'~~Sr( Name and Address: RONALD J WALSH 7c~,3 /~~eRy ~Jv~ CGM BENEFICIARY IRA CUSTODIAN ~~~LS-~~~~d J~ ~ f. (~„~.~t yy BEN OF MARY FRANCES WALSH BELDEN STREET _ _ _ ,°HILAD-ELPN#~'t-P'-r1-191 r~=38I:~____._--------________._. Please review the transfer details carefully. If they are correct, no further action is required. We appreciate your business. US HIGHWAY 19N • SUITE • CLEARWATER FL Morgans Stanley Srnith Barney LLC. Member SIPC. . _ s ~ iy ~ = ~ „~`.r. vii i - ~ ~ i2: , [D ~ ~ _ ~i { - = O ~ v y _ f ~G ~ i _ _ r Q' O ~ w ~ _ O Q ~ ~ ~ 4 = 4e o az ~ ~ r o O ~ r" N k r ~ ~ C~ ~ _ i"PZ C~ r M. 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