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HomeMy WebLinkAbout05-06-11J 1505610143 REV-1500 Ex(°'_'°' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania county coda veer Fila Number Bureau of Individual Taxes °~'"""~""°"~'°"~ PO 80x.280601 INHERITANCE TAX RETURN 21 10 01196 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 202 20 6116 11 21 2010 06 13 1927 Decedent's Last Name LOTZ Suffix Decedent's First Name SHIRLEY (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI 8 MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW 1. Original Retum ~ 3e82~ (date of death 2. Supplemental Retum ~ 3 P mjo dZr 1 4. Limittad Estate ~ 4a. Future Interest Compromise ~ 5. Federal Estate Tax Retum Required (date or loath artar tz-tz-ez~ ® g Decedent Died Testate ~ T pAeceder~t~yintained~ Living Truet 1 8. Total Number of Safe Deposit Boxes (ttech G of 7 (Attach Copy of Wtlp 9. Litigation Proceeds Received ~ 10. bsgo~r,~~Pt~~ ~a~t ~_da~sgr death ~ 11. Election to tax under Sec. 9113(A) (Attach Sch. 0) CORRESPONDENT • THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number JERRY R DUFFIE (717) 761 4540 First Ifne of address 301 MARKET ST Second line of address PO BOX 109 City or Post Office LEMOYNE State ZIP Code PA 170430109 .._ Correspondent's a-mail address: Under penalties of perjury, I deolara that I have examined this return, inGudinp accompanying schedules and statements, and to the best of my knowledge and belie}, it Is true, corygct and wmplete. DeGaralion of preparer other than the personal representative Is based on all information of which preparer has any knowledge. Richard S Simpson II SIGNATURE OF PREPARER OTH REPRESENTATIVE DATE JERRY R DUFFIE AD ES Market Street, Lemo ne, PA Side 1 L 1505610143 1505610143 ~_~ REGISTE~~WILLS U9~ ONLY ~ - ~ _ a- n :Z i'r1 I r ~ ~:~ -~~ ~ ur-,n c _ 1, _. w- o ~ ~~' , ' ~ _. -- : - .. _ . ~7 .- r - :, _ TAE FILED `.7 ~~ ~q~ \° o~ '~ ~~~ ~ REV-1500 EX o~oaa^r.Na^,e: LOTZ, Shirley Bennett Decedent's Social Security Number 202 20 6116 RECAPITULATION 1. Real Estate (Schedule A) ..................................................................................... .. 1. 2. Stocks and Bonds (Schedule B) ........................................................................... .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)....... .. 3. 4. Mortgages & Notes Receivable (Schedule D) ...................................................... .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............. .. 5. 3O0 , 78O . 54 8. Jointly Owned Property (Schedule F) ^ Separate Billing Requested........... . 6. 7. Inter-Vivos Transfers 8 Miscellaneous lynx; Probate Property Re arate Billin uested Se 7 70 27 230 ........... g q p (Schedule G) u . , , , 8. Total Gross Assets (total Lines 1-7) .................................................................. ... 8. 371 , 010.81 9. Funeral Expenses & Administrative Costs (Schedule H) ..................................... .. 9. 2 7 , 7 0 6 . 4 0 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................ .. 10. 6 , 5 94.67 11. Total Deductions (total Lines 9 ~ 10) ................................................................. .. 11. 34 , 301.07 12• Net Value of Estate (Line 8 minus Line 11) ........................................................ .. 12. 33 6 , 70 9 . 7 4 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............................................. .. 13. 20 , 000.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ............................................. .. 14. 316 , 7 0 9 . 7 4 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .00 15. 18. Amount of line 14 taxable 313 , 7 0 9. 7 4 18. at lineal rate X .045 17. Amount of Line 14 taxable 0 0 0 17 at sibling rate X .12 . . 18. Amount of Line 14 taxable at collateral rate X .15 3, 0 0 0. 0 0 18. 19. Tax Due ................................................. ................................................................ . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 0.00 14,116.94 0.00 450.00 14,566.94 Side 2 15D5610243 1505610243 1505610243 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-10-01196 DECEDENT'S NAME LOTZ, Shirley Bennett STREET ADDRESS Messiah Village 340 Messiah Circle CITY STATE ZIP Mechanicsburg PA 17050 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 14,568.94 2. Credits/Payments A. Prior Payments 13,000.00 B. Discount 884.21 Total Credits (A + g] (2) 13,884.21 3. Interest (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Check twx on Page 2 Llne 20 to request a rofund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) $$2.T3 Make Check Pa able to: REGISTER OF WILLS AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or inwme of the property transferred :............................................................................... ^ Q b. retain the right to designate who shall use the property transferred or its income :.................................. c. retain a reversionary interest; or ............................................................................................................... x d. receive the promise for life of either payments, benefits or care? ............................................................ x 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .................................................................................................................... ^ Q 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....... 0 ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ~ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: . The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0 percent [72 P.S. §9116 (a) (1.2)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted In 72 P.S. §9116 1.2) (72 P.S. §9116 (a) (1)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-7608 EX~IB•88) SCHEDULE E CASH, BANK DEPOSITS, 8 MISC. PERSONAL PROPERTY COMMONWEALTH of PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER LOTZ, Shirley Bennett 21-10-01196 Include the of litgIpation end the date the proceeds were rsgivstl by the setets. All pmpsrly n8y-owned vAM Ma rlyht of survivorship moat W dbcloudon eehsdule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH Ameriprise Annuity Accounts - -Beneficiary: Estate 1 Ameriprise Annuity Account No. 00088783808 8 021 (IRA) -Cash Account -Beneficiary: 30.990.27 Estate 2 Ameriprise Annuity Account No. 00086763808 8 021 (IRA) - Trans Short Tenn Bond - C Trans 10,208.89 America Funds Beneficiary -Estate 3 Ameriprise Annuity Account No. 93107812969 5 004 (IRA) -IRA Annuity Account 100,843.38 Beneficiary: Estate 4 Social Security -Payment of benefits 1,098.00 5 Sovereign Bank Checking Account No. 1051070287 13,853.08 6 1995 Oldsmobile Ciera SL Sedan 4D -Kelly Blue Book valuation IS attached 2,675.00 7 Lady's 18K Yellow Gold Diamond Engagement Ring -Appraised by Joseph James Jewelers 5.250.00 Appraisal is atgched to this Return Beneficiary: Dyane V. Smith 8 Personal Property appraised by Chuck Bricker -Appraisal by Chuck Bricker, Auctioneer 970.00 AU084-L Beneficiary: Dyane V. Smith 9 2010 Federal Individual Income Tax Return 958.00 10 Allstate Insurance Refund -Refund on Renters Insurance 52.00 Beneficiary: Residue of Estate 11 Allstate Insurance Refund -Refund on Automobile Insurance 51.00 Beneficiary: Residue of Estate Total of Continuation Schedule Sea attached page TOTAL (Also enter on Line 5, Recapitulation) 300,780.54 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1b00 Schedule t: (Rev. 6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNBVLVANIA INHERITANCE TAx RETURN continued RESIDENT DECEDENT ESTATE OF FILE NUMBER LOTZ, Shirley Bennett 21-10-01196 ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 12 Freedom Blue Premium Refund 132.80 13 Holy Spirit Hospital -Refund on Account 75.00 14 Home Shopping Network (HSN) Refund on Account 5780-9795-3235-0958 - Benefliciary: 163.74 Residue of Estate 15 Kay LLC d/b/a Home Instead Senior Care -Refund -Beneficiary: Residue of Estate 1,787.52 16 Pinnacle Health System Refund -Beneficiary: Residue of Estate 50.00 17 Reimbursement from The Law Offices of Pratz and Wallace - Error in billing 75.00 18 Reimbursement/Refund of Retainer Check from Law Offices of Pratz and Wallace LLC - 2,990.00 Beneficiary: Residue of Estate 18 Ameriprise Annuity Account No. 93002115662 3 004 15,415.73 20 Ameriprise Annuity Account No. 93002407024 3 004 -Beneficiary: Estate of Shirley Bennett 38,753.33 Lotz 21 Ameriprise Annuity Account No. 93003403326 4 004 -Beneficiary: Estate of Shirley Bennett 27,568.38 Lotz 22 Ameriprise Annuity Account No. 93004115867 2 004 -Beneficiary: Estate of Shirley Bennett 47,059.41 Lotz 23 Hartford Annuity 382.20 TOTAL (Also enter on Line 5, Recapitulation) I 300,780.54 Copyright (c) 2002 form software only The Lackner Group, Inc. Forrn PA-1500 Schedule E (Rev. 6-88) aw-yam Ex. (a-ael SCHEDULE 6 INTER-VIVOS TRANSFERS 8r MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNBVLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER LOTZ, Shirley Bennett 21-10-01196 7hie schedule must be completed end tiled T the answer to any of questions 7 through 4 on the reverse aide of the REV-7500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY THE DATENOF TROAFNSFER SATfACIiTA COP OF TIRE DEIEU FO EREAL ESTATE. DATE OF DEATH VALUE OF ASSET % of DecD~s INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 1,597.231 shares of Columbia Inflation Protected 18,914.68 18,914.88 Securities Fund B - Transfer on Death Account to Estate of Shirley Bennett Lotz Ameriprise ONE Financial Account No. 00064103922 7 021 2 CNL Lifestyle Properties - Ticker: CNLIDI -Real Esta 5,240.00 5,240.00 Share 3 Corporate Property Associates -Ticker: WP15DI - 5,350.00 5,350.00 Real Estate Share 4 Inland American -Ticker: INAMDI -Real Estate Share 6,080.32 6,080.32 5 Ameriprise Certificate of Deposit Account 8,207.12 8,207.12 00804724475 4 001 - Transfer on Death Account to Estate of Shirley Bennett Lotz 6 Ameriprise Certificate of Deposit Account 8,646.22 8,646.22 00804838762 0 001 - Transfer on Death Account to Estate of Shirley Bennett Lotz 7 1,040.192 shares of Ameriprise Mutual Fund Account 7,832.65 7,832.65 No. 01013181525 7 002 - Transfer on Death Account to Estate of Shirley Bennett Lotz 8 Ameriprise Mutual Fund Account No. 01133915297 4 5,091.39 5,091.39 002 - Transfer on Death Account to Estate of Shirley Bennett Lotz Total of Continuation Schedule ee attached page TOTAL (Also enter on Line 7, Recapitulation) ~ 70,230.27 (If more space is needed, additional pages or the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-7500 Schedule G (Rev. 6-98) Rev-1670 EX+ (8-88) SCHEDULE G INTER-VIVOS TRANSFERS 8 MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN continued RESIDENT DECEDENT ESTATE OF (FILE NUMBER LOTZ, Shirley Bennett 21-10-01186 ITEM NUMBER DESCRIPTION OF PROPERTY THE DATENOF TRANSFE~RSATTACH A COPY OF THE SEED ~OREREAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 9 981.889 shares of Infl Prtct Services Secs B - 6,867.88 6,867.88 Ameriprise Mutual Fund Account No. 01013480119 9 002 - Transfer on Death Account to Estate of Shirley Bennett Lotz TOTAL (Also enter on Line 7, Recapitulation) I 70,230.27 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) REWN67 E7h (70-06) COM I ~tl 1~ V FV ~~ANIA ESTATE OF FILE NUMBER LOTZ, Shirley Bennett 21-10-01196 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT A, FUNERAL EXPENSES: B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Richard Simpson serest Aadress 426 South Third Street city Lemoyne state PA zio 17043 Yearfs) Commission paid 2011 2, Attorney's Fees JOHNSON, DUFFIE, STEWART & WEIDNER 3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zio Relationshio of Claimant to Decedent 9,000.00 9,000.00 4. Probate Fees 194.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 225.00 7. Other Administrative Costs 9,286.90 See continuation schedule(s) attached TOTAL (Also enter on line 8, Recapitulation) 27,706.40 SCHEDULE H FUNERAL EXPENSES 8 ADMINISTRATIVE COSTS Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1600 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER LOTZ, Shirley Bennett 21-70-01196 ITEM NUMBER DESCRIPTION AMOUNT 1 Other Administrative Costs Chuck Bricker, Auctioneer -Appraisal of Decedent's personal property 120.00 2 Cumberland County Register of Wills Office -Additional Short CertiRcates for Ameriprise 24.00 Accounts 3 Cumberland County Register of Wills Office -Filing Fees for Inheritance Tax Return and 30.00 Inventory 4 Cumberland County Register of Wllis Office -Additional Probate Fees 225.00 5 Dyane Smith - Relmbureement for expenses associated with gathering Decedent's pereonal 751.65 property and Uhaul storage 8 Joseph James Jewelers -Appraisal of Decedent's Diamond Ring 150.00 7 Messiah Village -Resident Account No. 90913 -Final Balance Due 4.569.20 8 Nancy and Jim Rickard -Moving Expenses of Decedent's personal property to Storage Unit 520.00 9 Neill Funeral Homes Inc. -Remaining Balance 1,043.28 10 Reserves: Filing of Formal Account with Advertising and other Miscellaneous 650.00 Administrative Expenses 11 Sovereign Bank Checking Account No. 1051070287 -Bank Service Fees 12.00 12 Sovereign Bank Checking Account No. 1051070287 -Bank Service Fees 12.00 13 Sovereign Bank Checking Account No. 1051070287 -Bank Service Fees 12.00 14 The Patriot News Co. -Notice of Estate Administration 189.75 Copyright (c) 2002 form software only The Lackner Group, Inc. Fonn PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER 21-10-01186 ITEM NUMBER DESCRIPTION 15 Verizon 18 Vital Records -Additional Death Certificates 17 Wiedeman 8 Douty, P.C. -Accountants pertorming Audit of Power of Attorney Records H-B7 AMOUNT 48.02 90.00 840.00 9,286.80 Copyright (c) 2002 form software only The Lackner Group, Inc. Forrn PA-1600 Schedule H (Rev. 6-98) Rav1672 E7t~ (12-0a) COMMONWEALTH OF PENNBVLVANW INHERITANCE TA% RETURN RESIDENT DECEOEM SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, S LIENS ESTATE OF FILE NUMBER LOTZ, ShiMey Bennett 21-10-01196 Report debt Iricumd by the decedent prior to death that rortlalned unpaid al the data Or death, Including unrolmburosd medical a:psneu. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Alert Pharmacy 113.18 2 Allstate Insurance -Final Payment on Account 51.00 3 Bon Ton Credit Card Account No. 2116-0410-1033-1511 -Turned over to HSBC for Payment 55.61 4 Dr. Cohen -Final payment 19.80 5 Messiah Village -Home Care Assistant Fees (Final) 68.00 6 Messiah Village -Payment for November -Check Clearing after Date of Death 4.165.00 7 Messiah Village Home Health Care -Payment for November -Check Clearing after Date of 339.25 Death 8 PA Department of Transportation -Duplicate title for Automobile 22.50 9 Sears Credit Card Account No. 5121-0719-7237-9139 442,85 10 Social Security -Return of benefits 1,096.00 11 Uhaul -Mechanicsburg -Payment for Decedent's Storage Unit of Personal Property 121.85 12 West Shore EMS -Final Invoice 99.63 TOTAL (Also enter on Line 10, Recapitulation) I 6,594.67 (If rrwre apace is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA•1500 Schedule I (Rev. 12-08) REV-161 EX. (11-08) SCHEDULE J coM~~'€L~~ANIA BENEFICIARIES ESTATE OF FILE NUMBER w~c, ~mne ttennett 21-10-0 1196 NUMBER NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE PERSON(S) RECEIVING PROPERTY (Worts) ($$$) I ' TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 a 1.2 1 Susan Fulginiti Friend $1,000 Specific 703 Robert Street Bequest Mechanicsburg, PA 17055 2 Mary Louise Shatter Friend $1,000 Specific 838 Bosler Avenue Bequest Lemoyne, PA 17043 3 Dyane V Smith Daughter Tangible PO Box 723 Personal Danbury, CT 06810 Property; 10% of Residue 4 Lisa Starner Friend $1,000 Specific 132 Ridge Drive Bequest Dillsburg, PA 17018 Total Enter dollar amounts for distributions shown above on lines 1 5 throw h 18 on Rev 150 0 cover sheet as a ro riate. II NON-TAXABLE DISTRIBUTIONS: . A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 Grant Foundation Hopital Albert Schweitzer Haiti io,ooo.oo 2 Presbytery of Carlisle' Presbyterian Church (U.S.A.) io,ooo.oo TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 20,000.00 Copyright (e) 2009 form software only The Lackner Group, Inc. Fonn PA-1500 Schedule J (Rev. 11-OB) ESTATE OF SHIRLEY BENNETT LOTZ SCHEDULE OF EXHIBITS EXHIBIT A Last Will and Testament for Shirley Bennett Lotz signed and dated May 26`h, 2010. EXHIBIT B Date of Death Valuation from Ameriprise Financial for IRA passing to the Estate. EXHIBIT C Date of Death Valuation of Account for Sovereign Bank Checking Account EXHIBIT D Kelly Blue Book Valuation for Decedent's 1995 Oldsmobile Ciera SL Sedan EXHIBIT E Appraisal of Decedent's Personal Property by Chuck Bricker, Auctioneer AU094-H EXHIBIT F Appraisal of Decedent's Yellow Gold Diamond Engagement Ring by Joseph James Jewelers EXHIBIT G Date of Death Valuation from Ameriprise Financial for Annuities passing to the Estate. EXHIBIT H Date of Death Valuation from Ameriprise Financial for Transfer on Death Accounts passing to the Estate. 440612 ~.~c~t ~~YX ~c~~ ~e~t~cn~er~t OF SHIRLEY BENNETT LOTZ '~ I, SHIRLEY BENNETT LOTZ, of Upper Allen Township, Cumberland County, Pennsylvania, declare this to be my last will and revoke any will previously made by me. 1. I direct that all my legal debts and funeral expenses including my gravemarker and all ,expenses of my last illness, shall be paid from my residuary estate as soon.as practicable after my decease as a part of the expense of the administration of my estate. 1 direct my Executor to pay all inheritance, transfer, estate, income and similar taxes (including interest and penalties) assessed or payable by reason of my death on any property or interest in property which is included in my estate for the purpose of computing taxes. My Executor shall not require any beneficiary to reimburse my estate for taxes paid on property passing under the terms of this Will or otherwise. IIL. I .bequeath my automobile, household goods, jewelry, including, but not limited to, my. yellow gold diamond. ring and my platinum diamond ring, and other tangible personal property of a like nature (not including cash or securities), together with any insurance thereon, to my daughter, DYANE VALERIE SMITH. Should my daughter, DYANE VALERIE SMITH, predecease me, then I direct that my' Executor shall liquidate said items of personalty and the net proceeds therefrom shall be a~:~ed t.s my r~si~iuary esat~. IV. I bequeath the sum of One Thousand ($1,000.00) Dollars to my friend, MARY LOUISE SHETTER, provided she shall survive me. v. I bequeath the sum of One Thousand ($1,000.00) Dollars to my friend, LISA STARNER, provided she shall survive me. VI. bequeath the sum of One Thousand ($1,000.00) Dollars to my friend, SUSAN FULGINITI, provided she shall survive me. VII. I devise and bequeath the residue of my estate of every nature and wherever situate as follows: . A. The lesser of five (5%) percent of my residuary estate or' the "sum of Ten Thousand ($10,000.00) Dollars to GRANT FOUNDATION, P.O. Box 81048, Pittsburgh, Pennsylvania 15217, for the benefit of Hospital Albert Schweitzer Haiti. I further direct that this residuary bequest shall be paid by GRANT FOUNDATION to the governing body of Hospital Albert Schweitzer Haiti and to be used as part of the general operating fund. B. The lesser of five (5%) percent of my residuary estate or the sum of Ten Thousand ($10,000.00) Dollars to PRESBYTERY OF CARLISLE, .PRESBYTERIAN CHURCH.(U.S.A.) to be given to the Presbyterian Church of which I am an active member at the time of my death. Further, I direct that the bequest be given to the Presbyter7an Church of which I am an active member at the,time of my death to be invested and reinvested by the Church's governing body in a separate fund and the principal ,arid income in said fund to be used by the Senior Pastor in service at said. Church in said Pastor's discretion to assist women and families in financial difficulty because of domestic abuse or abandonment. C. The balance thereof to my daughter, DYANE VALERIE SMITH. Should my daughter, DYANE VALERIE SMITH,. predecease me, I devise and bequeath a residuary to my grandson, TAYLOR LELAND SMITH, subject to the provisions of Paragraph VIII. 2 vul. Should any of my issue, including my grandson; TAYLOR LELAND SMITH, entitled to a share of my estate not attain the age of twenty-five (25) at the time of distribution to him or her, I devise and bequeath the share of each such issue to MID PENN BANK, Camp Hill, Pennsylvania, IN SEPARATE TRUST, to hold, manage, invest and reinvest the shares so received, and the accumulation of income thereon, and to use and apply the income and principal, or so much thereof as, in t'rustee's sole and absolute discretion, may be necessary or appropriate for such issue's support and education (including trade school and college education, both graduate and undergraduate) after taking. into consideration his or her parent's ability to provide for such support or education, or to make payments for these purposes, without further responsibility, to such issue or to such issue's parent or to any person taking care of such issue. Any principal or income not so applied shall be distributed to such issue absolutely when he or she attains the age of twenty-five .(25). If he or she dies before attaining the age of twenty-five (25) the Separate Trust shall terminate and such share shall be distributed to his or her personaPrepreseritative: IX. The interest of the beneficiaries hereunder shall. not be subject to anticipation or to voluntary or involuntary alienation. X. I nominate, constitute and appoint, RICHARD S. SIMPSON II, Executor, of this, my last Wili.. Should RICHARD S. SIMPSON II fail to qualify or cease to act as Executor, I appoint MID PENN BANK, of Camp Hill, Pennsylvania, Executor, of this, my last Will. a XI. direct that my Executor, and his successor, shall not be required to post bond in any jurisdiction for the faithful performance of his or her duties. XII. My corporate fiduciary shall be entitled to compensation based on its regular schedule of fees for such services in effect from time to time during the period over which. the services are performed. 3 / ~~ IN WITNESS WHEREOF, I have hereunto set my hand and seal this 2G "" -day of 2010. ~.~ir.n ~ a-F~h- ~.o'~i (SEALj SHIRLEY B NNETT LOTZ Signed, sealed; published and declared by the above-named Testator, as and for his Last Will and Testament, in the presence of us, who, at her request, in his presence and in the presence of each other have hereunto subscribed our names as witnesses. ACKNOV COMMONWEALTH OF PENNSYLVANIA . ss: COUNTY OF CUMBERLAND I, SHIRLEY BENNETT LOTZ, Testatrix, whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. ~« lau ,r~nesi~- C. o'f'i.. SHIRLEY ENNETT LOTZ Sworn or affirmed to and acknowledged before me, by SHIRLEY BENNETT LOTZ, the Testatrix, this f197 f~ day of _ , 2010. ~~d~~ ~ Notary Public COMbfONWEALrH OF PENNSYLVANIA NOTARIAL SEAL Gai17. Mahoney, NotaryPublie Lemoyne Borough, Cumberland County 4 My commission expires Feb 19, 2014 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND . ss. We, ~t°. Pry! 2 . ~~C~f l ~ and {~ a. J' ~0..fe ~ ~• I`-~° ,the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say.that we were present and saw the Testatrix sign and execute the foregoing instrument as her Last Will and Testament; that she signed willingly and that she executed it as her 'tree and voluntary. act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix signed the Will as witnesses; and that to the best of our knowledge, the Testatrix was that time at least 18 years of age,. of sound mind and under no constraint or undue influence. Sworn or affirm/_ed to and subscribed to before me bey" ~~~~( r~ ~ ~~i `~- and (~G.V'P-,~I~X`E~T ~ • ~ ~t~ ,witnesses, this o~(y~~ day of Y~h 2010. 6 G No ary Publi ',399609 COMMONWEAL1Ii OF PFAIIdSYLVAbIIA NOTARIAL SEAL t3si1 J. M~cY, Notffiy Public Lemoyne BorougL, (~mbedand County . .. • - - conmiisva~n F 19, 2014 5 DEC-7-2010 07:50 FROM:RMERIPRISE FINANCIAL 7613686 __ _ s_ -. , „.~ ~ . T(J:7745075 P.2 3-entsCommun(Caf ~ent Ta Susan H Fulginiti/Field/AMPF@AMPF '!AMPF 'c ,,"* •' ~thea"J :" , wx~ _ yW.." w ~~' ~" •" - Subject_ 13654712 2 001 SHIRLEY BENNETT-LOTZ - dEATH 10 06:56 t?M~i ti. ~" r. • • ~"~ " SETTLEMENT AEQUIREMEN75 -PLEASE DO NOT ~,~ ~' - -~~,.,,^, DELETE Rlver3ourca Llfa Insurance Company R[verSouroe Funds Amarlprfss CertiRcato Company . Ameriprlse Brokerage 70100 Amerlprtse Flnanclal Center Mlnnaaaolls. MN 55474 December 3, 2010 SUSAN HORNEI2 F[JI.OINITI 214 SENATE AVE STE 604 ~:~1hfP HILL, PA 17011-2382 Dent SUSAN HORNER FULGINITI: We have received notification of SHIRLEY HENNETT-LOTZ's death. The deceased's name appears on the following accounts. Accouat values as of 11/21/2010 are listed below. AE the end of this leticr, you will find a list of beneficiaries shown in our initial review of the accounts Account Information Mutual Funds Account Number _ 01013191525 7 002 01013480119 9002 01014370072 1002 01133915297 4 002 Certitlcates Account Number 00804724475 4 001 00804836762 0 001 Annuities -Post 1985 Account Number 93002115fi6"e 3004 93002407024 3 004 93003403326 4 004 93004115967 2 004 93107812969 5 004 weer hi Individual - TOD Individual - TOD Individual - TOD Individual - TOD Ownership Individual - TOD Individual - TOD Ownership ndividual Individual Individual Individual IRA -beneficiary designated DEC-7-20i0 07:50 FROM:AMERIPRISE FINANCIAL 7613686 Account Number Ownership 00066763806 8 D21 IRA -beneficiary designated Amcriprise ONE Finan cial Account Account Number Ownership OODfi4103922 7 021 individual - TOD a~=1Vlutual Funds :.. 70:7745075 P.3 Account Number Total Value # of shares Asset Value Per Share 01013191525 7 002 $7,832.65' 1,040.142 $7.530 01013480119 9 002 $6,867.89 +~ 961.889 $7.140 01014370072 1 002 $ 16,914.68 ~ 1,597.231 $10.590 ,09. ~ ,091.3 `.Certificates ..;.-~, ,~ Account Number a lue 00804724475 4 001 $8,207.12 v 00804836762 0 001 $8,646.22 ~ Annuities .~ Post 1985`--F ;.;: ~ - _ Account Number Total Value 93002215662 3 004 $15,415.73 .~ 93002407024 3 004 $38,753.33 d 93003403326 4 004 $27,568.38 + 93004115967 2 004 $47,059.41 y' 93107812969 5 004 $100,843.39. -~~~~ •ise Brokerage'AccounQ ~s Account Number Total Value ~A 000667638_ 06 8 021 $41,199.16 Arttct`iprise ONE'F'Inanciaf:Account.,~ AGCOUnt Number Total Value d_,,, ~ ~ , -t ~. 0006a 103922 7 021 $16,670.32 ~ ~~~ tir~.l~..l f j~,r~{~.; ~Yl ~~~„~ ~'~'~' 1~~ Acct Name:Ameriprise t3rokerage Account, AMERIPRISE TRU57 COMPANY GO SHIRLEY BENNETT-L•'bTZ AS CUSTD FOR THE SHIRLEY BENNETT-LOTZ IRA Acct No:0006fi763806 021 AcctType:INDNIDUAL IRA Asset Name Ticker l3roed ~ Mjjt Narni Quantity Pries tSl Vaiw jfj CASH C~QUIH~/pLEMT3 30,99027 1.00 3„ J~FFsO^27`~r/ TRANS SHORTT?P6~BOND-C~ RACX S1iORT-TERM TitANSAMERIC 9TSA6 1nQ to2f.'8.65~/ . - FlXED INCOME . A FUNDS .. .. . .- ~~~ r'l ~ ~j ~ ~ ~ - Aecaum TolaL 541,199.1fi DEC-7-2010 07:52 FROM:AMERIPRISE FINANCIAL 7613686 Account Number: 93003403326 4 004 Designation: PRIMARY BENEFICIARY ESTATE OF SHIRI.EY BFNIYETT-LOTZ Account Numbcr: 9300-1115967 2 004 llcsignatian: PRIMARY BENEFICIARY ESTATE OF SH[RLEY BENIJEI"1'-LOT2 Account Number: 93107812969 5 004 Designation: PRIMARY BENEFICIARY ESTATE OF SHIRLEY BENNFfT-LOTZ \ccnnnl 'Numbcr: 00064 103922 7 021 Designation: PRIMARY BENEFICIARI'~ ESTATE OF SHIl2LEY BENNETT-LOTZ -~ Account Number: 00066763806 8 021 Designation: PRIMARY BENEFICIARY . ESTATE OF SHIR.LEY BENNETT-LOTZ 100.00"~0 100.00% T0: 7745075 .' P.9 ~~' 100.00% 100.00% ~~ 100.00% Sovereign Sank. ESTATE OF Shirley Anne Bennett-Lotz SOCIAL SECURITY #: 202-20-6116 DATE OF DEATH: November 21, 2010 Account #: 1051070287 Type: Checking Open date: 11/27/1996 In the name of: Shirley Anne Bennett-Lotz (Richard S Simpson II, POA) Date of Death Balance: $13,852.68 Int.(YTD) from 1/1/2010 to 11/9/2010 $6.50 Accrued interest to date of death: _ $0.40 Other Info:. Account #: Type: _ In the name of: Date of Death Balance: Int.(YTD) from to Accrued intere§t to date of death: _ Other Info: Account #: Type: _ In the name of: Date of Death Balance: Int.(YTD) from to Accrued interest to date of death: _ Other Info: Account #: -Type: _ In the name of: Date of Death Balance: Int.(I'TD) from to Accrued interest to date of death:. _ Other liifo: Open date: Open date: Open date: Page 1 of 1 I X95 Oldsmobile Ciera -.Private Party Pricing Report -Kelley Blue Book Page 1 of 3 - _ R ply s~~1 /~yy~ ('~~~ _ _ _- I1GIlC~ BIp81 YO VA I -_-i 1 SEARCH THFTRUSTFpRE50URCE - I --' - n Home New Cars Certi£ed Pre-Owned Used Cars Research Reviews tk News Dealers ~ Inventory Used Cars Far Sate Loans & Insurance UsM Car Values I Search Used Car Clas5i0ed5 ~ CertiOed Pre-Ownetl I Compare Vehicles ~ Pertect Car Finder I Mos[ Researched Vehicles ~ CARFAX Vehlde History Welcome Back Sign in ~ Create Recount ~ My KBB ZIP Code: 17055 ~ Recently Viewed You Might Also Like Free Dealer Price Quote NBWfi More Car News -_ ~ 10 Coolest Ce:5 Under $18,000 Tips for Holiday Delving - AOL Autos llltmS > rs5;,,.;;,~- > 3995 > Oldsm°blle > LktS > SL sedan as @ Save Vehicle ~ Print ~~ Email 'C7 BOOKMRRK :r'{~©_~ 1995 Oldsmobile Ciera SL Sedan 4D .,.. . Trade-[n Value __.. . ._ _ _- . I ~ mated Psymenfa PYivate Party Value BLUE BOOK® PRIVATE PARTY VALUE '{ G`_' ~ $fi0 !mo O 3.99% APR - Suggested Retail Value ~ ~•*~+»Na erovalDe Condition.a:~~rs.,~:, Value ' -.-..-----------.--- ~-- ~~------....._- . Gets Pre-owned loan from Photo Gallery _ EXCBIIAflt $Z,STS ~ 3.99°.6 APR .Cars For Sale raw) Good $2,675 Get Yaur Credit Score Now Compare vehicles I Get a Free insurance Quote Review _ ... _ ...: .. Fair .. $2,2QQ:.,_. Consumer Ratings - More Photos ~ ~~ aCverFJSement - Find Your Nexr car . Specifications ~BUYA USED CAR '. On Blue Book GassMedd° S Oldsmobile ~_ Ciera ''I 75 Mlies ! ,'Near ZIP 17055 To Vlew Ads, Gick raa Sfioppirig Tt1ob . -I CARFAX Record Check Auto Loan from 3.99°b APR Get Your Credit Score Now Compare Insurance Rates ' wide Progressive - Payment Calculator !~. Extended Warranty QUa[e r, • Print For Sale syn ~.$ 'i S • share with Friends 17QOf-, it . Get uD-to-date Uw Vs1ua5H Get Your Toolkit Find Tito R1gf* for Compare Used vs. New '; under f5,00o Both New and USetl ,' ' ''Sedan To Vlew List, Cllok VlawNaotlterVehkJe r j ~ ~ ~~ ~ ~ SEARCH LOCAL LISTINGS - , JJJ.-M1. 111>:r a.:<~r:,:s~r..ewf,se,", ~r~i~.,1,s-~_-.. CARFAX Record Cheek Powered by !A+ VIN: No VIN7 No Problem) j News, Revtews & ToP 105 '. 10 Gooiest Cars Under $18,000 2011 Best Resale Value Award Winners Unconventional Winter Beaters - AOL Autos 2011 Best Redesigned vehicle How To Keep Your Headlightr Bright For Winter - AOL Autos - _zY~.Sa.~'Y+s?~;3tl:dW21'SaF~25t9r.d+SwZ+tiYw ec. ~.-. ~rz,'.;S'r Average Consumer Rating (175 Reviews) Read Reviews ' 4.2 ou[of5 ~~~ 1 Review the 1995 Oldsmdbile Gera :i:.E` .dZ.'iilYGlw+ .fop,-3.1•'kR'J<!s°_°d.. Y~ti"^e.~ x^K'v.•..'e•: •.: ~•~; ' Vehicle Highlights Mileage:- 20,000 Engine:. V6, 3.1 Liter - ... - ..... ,,.. ' - Transmission: XUtanfatic "' ' DrIVeValn: FWD '. Selected Equipmenk Change Equipment staneera Air CondfUOning Power Door LorkS AM/FM Stereo Power Steering Tilt Wheel Cassette Power Windows Uuise Control Steel Wheels GET YOUR FREE QUOTE SOW ~ ~. 1 APPR~4ISAL. Personal Property of 5'y/~L~ y /~E,vN~Tr ~DTa .ESTATE /~c5s/.~/% U/LL 5~ Appraised by Chuck E. Bricker AU094-L Date /~- ~~- j~ ITEM VALUE ITEM VALUE 3 j'~ /~/f/~Tr~ ~s ~ 0 da p,~ 00,~lcs}-S~'.s 90' 'c (y 0, UU L 5s Tu co-FEE"T LE D,UD ss ~~ s~ ~ - eU~ D, a o Ct! t~ c~cz a e ~ ~v~T ~o, o0 y/ c cv Lv ,30 Qo G L, ~ , .SU ~ ~DD, OU CU i G /3/niE7- I~LD,oa S E c /R 1 b o i U 7`,~ rs ~2o,oa JFWER~Y C ~"S"- 30 OD UP ,' cU D,eo icJU c i .5 o ao 5s piSd/~S- L sS- DTs -P NS lDD D0 `~70, ev ~~~ ~, P/' is L w - ~ - v ~OSEpIi JAMES JEWELERS TO WHOM IT MAY CONCERN: This is to certify tlut we ere engaged in the jeweby business, appraising diamonds, watches, jewelry snd praious stone of all dauriptiom. We herewith certify the we hive this day carofuliy aamined the folbvring listed end described amides, the proputy oP. NAME: Estate of Shiley Ann Bennett-Lott ADDRESS: 301 Market Street Lemoyne, PA (7043 We esdmue the value u listed for insurance or other purposes u Ne artmt retail valuq eaduding Federd oral other tees, la making this Appraisal we DO NOT sgne to purdtese or replete the srtiolea , try iuf,uwmg hems were evaluated for estate purposes: DESCRIPTION Lady's 18K yellow gold, diamond engagement ring. The round old European cut diamond measures approximately 830rnm x 8.32mm and 4.48mm deep. This diamond weighs approximately 1.98ct. The clarity is VS . The color is N. The table is approximately 64%. The depth is approximately 53.9%. The shank is hand engraved "Cartier 18K Serial #88559." The integrated crown is 14K white gold with four prongs. This is constructed from a die struck shank with a cast crown. Value: $5,250.00 '~ January 7, 2011 D. DAVIS P.G. The foregoing Appraicd is mode whh the undereranding that the Appnis¢ assumes no liability with rcspea to uy a¢ion the may be taken on the basis of the AppnisaL 301 East Main 5tr•eet • Mechanicsburg, PA 17055 • (717) 795-9224 DEC-7-2010 07:50-- FRDM:RMERIPRISE FINANCIAL 7613686 .. a • " -S :~ 1u.~3:• • . ~•~ : .: - ,, v December 3, 2010 T0: 7745075 P.2 r:~SQL`IfeEventsComrnu icat Cent To Susan H Fulginiti/field/AMPF@AMPF ~'Se~nt tiy~Rhea-J '-" ~, xx;:3 cc . rt co/Cti /AMPF.*,~r ~~~ W ~Cl~ !' ba: ~~~ "~ ~ ~' Subject. 13654712 2 001 SHIRLEY BENNETT-L0T2 - dEATH 12103!2010 06:56 PMT' ti. +-.r.;~ ~• =-• • ~~ SETTLEMENT REQUIREMENTS - PLEASE d0 NO7 ~•-~r3'^~~ ~`'~' - DELETE RtverSource L1fe Insurance Company R1verSouree Funds Amorlprlse Cortificato Company Amarlprise Brokerage 70100 Amerlprlse Finanelal Canter Mlnneapotis, MN 55474 SUSAN HORNER FULGINITI 2]4 SENATE AVE STE 604 G:'lMP HILL, PA 17011-2382 Dear SUSAN HORNER FULGIIJITI: We have received noti8catian of SHIRLEY DENNETT-LOTZ's death. The deceased's name appears on the followutg accounts. Account values as of 1 112 1/20 10 are listed below. At the end of this letter, you will find a list of beneficiaries shown in our initial review of the accounts Account Information Mutual Funds Account Number Ownership _ 01013 } 91525 7 002 Individual - TOD 01013480119 9 002 Individual - TOD 01014370072 1 002 Individual - TDD 01133915297 4 002 Individual - TOD Certificates Accoun[Number Ownership 00804724475 4 001 Individual - TOD 00804836762 0 001 Individual - TOD -~ Annuities -Post 1985 Account Number Ownership 93002115662 3 004 Individual 93002407024 3 004 Individual 93003403326 4 004 Individual ' 93004115967 2 004 individual 93107812469 5 004 IRA -beneficiary designated .~neriprise Brokerage Account DEC-7-2010 07:50 FROM:AMERIPRISE FINANCIAL 7613686 Account Number Ownenhio 00066763806 8 021 1RA -beneficiary designated Amcriprlse-ONE Financial Account Account Number Ownershio OnOC4103922 7 021 Tndividual - TOD ~- Mutnal Funds. . 70:7745075 P.3 Account Number Total Value # of shares Asset Value Per Share 01013191525 7 002 $7,832.65' 1,040.192 $7.530 01013480119 9 002 $6,867.89 ~ 961.889 $7.140 01014370072 1 002 $16,914.68 ~ 1,597.231 $10.590 ,091.43 ~ 5,091.3 Certificates :; ~', : a ~{gcoupi Number atue 00804724475 4 001 $8,207.12 00804836762.0001 $8,646.22' Annuities =Post 1985 . ; ; - Account Number lE• 930021 15662 3 004 ~ 93002407024 3 004 1~, 93003403326 4 004 -14, 93004115967 2 004 93107812969 5 004 Total Value $15,415.73 ,~ $38,753.33 $27,568.38 { $47,059.4t w •ise• Brokerage Account,: Account Number Total Value r/LA 00066763806 8 021 $41,199.16 ~: Amcriprlse ONE`T'inanciaYAccaunk:, Account Number Total Value r. I W0641039227021 $16,670.32`~~~j ~,.'~(~,•~ ~kf~~i„y:~ 9i'i ~' •~. ~''~~?` Acct Name:Ameriprise Brokerage Account, AMERIPRISE.TRIlST COMPANY GO SHIRLEY BE NNETT-ClOTL AS CUSTD FOR THE SHIRLEY BENNETT-LOTZ 1RA Acct No:00066763806 021 AcctType:INDNIDUAL IRA Ataet Name Ticker Hand ~ MOL Narne Quantity Pries lSl Value (sl CASH CASH 30,9902! 1.88 3J,S&8171~ EQUIVALENTS TRANS SHORTT=Pt.'BOND-.C rTACX.- ~ SHORT-TERM TRANSUIMEliIC 9TSA8 1007 18,2Q8.65I _ ..: FO(ED INCOME . A FUND.; ~q 2 ~ ~ ~1 ~ ('} ~ Account Tofal' 811,199.16 DEC-7-2010 07:52 FROM:AMERIPRISE FINANCIAL 7613686 ^ -- Beneficiary Information We have the following beneficiaries on record for the deceased's accounts Account Number: 00804724475 4001 Designation: PRiMAR.Y BENEFICIARY ESTATE OF SHIRLEY BLNNL•T'.'-LOTZ 100.00% Account Number: 00804836762 0 001 Designation: PRIMARY BENEFICIARY ESTATE OF SHIRLEY BENNEIT-LOTZ 100.00% Account Nnmber: 01013191525 7 002 D~a1,;naKon: PRIM:4RY Br"i1Eg`ICIARY'._ .. ..... _ .... __ _ ESTATE OF SHIRLEY BENNETT-LOTZ 100.00% Account Number: 01013480119 9 002 Designation: PRIMARY BENEFICIARY ESTATE OF SHIRLEY BENNETT-LOTZ Account Nnmber: 01014370072 1 002 Designation: PRIMARY BENEFICLARY ESTATE OF SHIRLEY BENNETT-LOTZ ESTATE Account Number: O] 133915297 4 002 < Designation: PRIMARY BENEFICIARY ESTATE OF SHIItLEY BENNETT-LOTZ ESTATE .~(~ Account Number: 930021 15662 3 004 Ilesignatlon: PRIMARY BENEFICIARY hSTATE OF SH.P.2L.EXBENNETT-I.OTZ ~ Account Number:, 93002407024 3 004 Desi~na lion: PRIMARI' BENEFICLARY ESTATE OF SHIRLEY BENNETT-LOTZ 100.00% 100.OD% 100.00% 70:7745075 P.8 100.00% , . ..,_ _......_..,..._. 100.00% DEC-7-2010 07:52 FROM:AMERIPRISE FINANCIAL 7613686 Account Number: 93003403326 4 004 Designation: PRIMARY BENEFICIARY ESTATE OF SHIRLEY BENNETT-LOTZ I OO.OQ"~o -~ Account Number: 93004115967 2 004 Designation: PRIMARY BENEFICIARY ESTATE OF SHIRLEY BENiVETT-LOTZ 100.00% Account Number: 93107812969 5 004 Designation: PRIMARY BENEFICIARY ESTATE OF SHIRLEY BENNETT-LOTZ 100.00% lccnunl Number: 00064103922 7 021 Designation: _ _ PRIMARY BElEFICIARY ESTATE OF SHIRLEY $ENNETT-LOTZ 100.00% Account Number: 00066763806 8 021 Designation: PRIMARY BENEFICIARY ESTATE OF SHIRLEY BENNETT-LOTZ 100.00% 70:7745075 P.9 DEC-7-2010, 07:50- FROM:AMERIPRISE FINANCIRL 7613686 70:7745075 P.2 .t.: 3•y?r~ , .+SDL`libEVentsCommu (Cat Gent To Susan H Ful initi/fieldlAMPF AMPF er/ $P/AMPF '`~~_ ~"`.~ 9 @ 2~:' _ _ a:5e~~y`~Rhea"J ~s .!._ ~ ;:.-~,=1 CC ~"~ ~ CO/Co`p/AMPF%~` ~" bcc . :. ,ors,, ~ '' `,~L' ••~+ ~?~.%•a i?103/2010Q6:S6Pl,M~i'~yr •~ Subject. 136547122001 SHIRLEY BENNETT-LOTZ-DEATH lr ;~;; ~ ,,. ' •:•:~' `" " •,~ ~~ SETTLEMENT REQUIREMENTS - PLEASE DO NOT :.~ . .,- •. ~. .~.__ DELETE RiverSource Life Insurance Company RlverSouroe Funds AmarlpAsa Cartlfteato Company , • Amerlprlaa Brokerage ' 70101! Amartprtae Finanelal Center • M(nnaapolle, MN 55474 December 3, 2010 SUSAN HORN&R FUI-GINTfI 2l4 SENATE AVE STE 604 Cf'~MP HIIrI., PA 17011-2382 Dear SUSAN HOIiNER FULGIIVITI: We have received notification of SHIRLEY DENNETT-LOTZ's death. The deceased's name appears on the following accounts. Account values as of l ]/21/2010 are listed below, At the and of this letter, you will find a list of.baneficiaries shown in our initial review of the accounts Account Information Mutual Funda Account Number _ fit, 01013191525 7 002 -~, 01013480119 9 002 ~, 0]0143700721002 -'/c 01133915297 4 002 Certificates ~. AcceuntNumber 00804724475 4 001 ~0080483b762 0 001 Annuities -Post 1985 Account Number 93002115662 3 004 43002407024 3 004 93003403326 4 004 93004115967 2 004 93107812969 5 004 Ownership Individual - TOD Individual - TOD Individual - TOD Individual - TOD Ownership Individual - TOD Individual - TOD Ownership Individual Individual Individual Individual IRA -beneficiary designated r' .timeripriae brokerage Account DEC-7-2010 07:50 FROM:AMERIPRISE FINRNCIAL 7613696 Account Number Ownerslua 00066763806 8 021 IRA -beneficiary designated ~ Antcriprlse ONE Finan cial Account Account Nwnber Ownership Onp(,4103922 7 021' individual -TOT) ~~ Mutual Funds :..:._ ,:, ~.Y 70:7745075 P.3 ~ ~ Account Number ~ " Total Value # of shares Asset Value Per Share 01023191525 7 002 $7,832.6SJ 1,040.192 $7.530 ~ 01013480119 9 002 56,867.89 ~ 961.889 $7.140 ~c 01014370072 1 002 $16,914.68 J 1,597.231 $10.590 91. 3 y 5,091.39 5' . ~. Certificates', .~-:,> ;.;, Account Number to ]u ~ 00804724475 4 001 $8,207.12 ~ `~, 00604836762 0 001 $8,646.22 ~ ,. Ariiiult~e9-Post-1985::., W .... _._. .. .. _ Account Number . ota Value ' 93002115662 3004 515,415.73 d 93002407024 3 004 $38,753.33 93003403326 4 004 $27,568.38 ~ 93004115967 2 004 $47,059.41 w 93107812969 5 004 $100,843.39.y ~~~~ . : €__ ... _M _ ~lmerfprise'Brokerage'Account,,~ _ ~ Account Number Total Value ~A 00066763806 8 021 $41,199.16 ~~. Amcriprise ONE'F3nancial.-Accaunt:~ :~~7U ~. f ~ Q ~~ F ~-~. Account Number Total Value 0006a 10392_' 7 02! $16,670.32 ~ ~~ ~#~,#('~,,~ ~j~,0~{,~:i ''~ 1~~„~ ~ e • Acct Name:Amerlprise i3rokerage Accounf, AMERIPRISE.TRUSTOOMPANY GO SHIRL£Y BENN£7T-COTZ AS CUSTD FOR THE SHIRLEY BENNETT-LOTZ IRA ~ - Acct No:DO058783806 021 AcctType:INDNIDUALZRA Asant Name Ttcker Broad ~ Y MQL kan-% Quamlgr Prtas (~ Value (Sl CASH CA5H 30,99037 1.00 30,59037V~ EQUIVALENTS TRANSSHORTT=P6~gOND-,C~ ITACX.- SHORT-TFRIYt TRANSMAEliIC 9TSA8 7047 ~a,2L`9.s51 FtXEO INCOME A FUN0.; _ _ _.... ' .. /"~, /~ ~'~3"(p~~Z ~ AcmumTotat• - 341.199.16 DEC-7-2010 07:50 FROM:AMERIPf~ISE FINANCIAL 7613686 70:7745075 P.4 Tpf `_ _ ~ Acct Nemr:Amertpdse ONE Fnancial Account, SHIRLEY BENNEfT-LOTZ TOO ...i ~ . ACet No:Ot)064103922 0~1" ~ Acct Type:Non-Qualified ' Aaaet Ntmr'. ,:~~,. i ... ' jtL` (K ~ •~ B[QSQ rr - ~ ~• a~'MQt. Name',t. '~ :,~, QuanEtY ~ ii1Ca (~ ~ ~' Vsta1(S)' CNL t.iFE3TYLE PROPER71E5 . CTlL[DI REAL. ESTATE 524.00 t0.00 ~ 5,240.00 «f -!~, ~~ R~ PROPERTY tNP15Dl REAL ESTATE 500.00 t0 7D 5,350.00 /~ . tNLANO Ath~RICAM ~' INIU~{DI `~c 1tEAL ESTATE 75720 8.03 B,0e0.32 v Accaunt7c'~t 5}6,67032 The date of death values provided are for estate tax purposes and are not a value tr t+c paid, Accounts truly be subject to market fluctuation as governed by each product. Please note that the values indicated for any Life Insurance products with the insured deceased reflect the gross death benefit at date of death and not the cash value. Values indicated for Life Insurance products with only the owner deceased reflect the cash value as of the date of death. Values for env p~gpne*erv mun,pt Winds include ac^rned dividenda'ac applicable Valuee trovided for brokerage products are. manually calculated, anti should be used as estimates only.. The prices used to provide values aro estimates obtained from outside sources believed to be reliable. Ameriprise Financial provides these values as a service to its clients. Acttial values used in preparation of tax returns or for planning purposes should be verified by your Icgal and accounting advisors. Account Disposition Accoutrt disposition is based,~n how.an.accowrt is owned (the ownership type).. The fallowing information will help ~ ..: - you understand the process that will be hsed to setup the accounts. Accounts maybe subject to market fluctuation as governed by each product. Disposition forIndividual - TOD ownership _ Upon the deatft of too owner, all accounts registered as individual-transfer on death pass to the named beneficiaries. Although the assets do not become part of the estate for distribution, we understand they should be included for inheritance and/or estate tax purposes. Disposition for Individual ownership Upon the death of the owner and annuitant, account proceeds typically pass to the named beneficiaries. If na beneficiary is named and the contract includes a default beneficiary pravisioa the proceeds will be paid according to the beneficiary default language. In all other cases where no beneficiary was designated, the proceeds become part of the owner's estate for distribution. 17EFE1tRED ANNUITY NOTICE: If the beneficiary(s) wishes to elect an annuity payment plan, we must receive written uodce of this clecdory within 60 days of our receipt of complete requirements from any individual beneficiary. The contractvalue will remain invested in the separate account until we receive a completed claim If fliers are multiple beneficiaries, each claim will be processed separately and each benefciaries share will remain invested in the separate account until it is claimed The beneficiaries bear the market .risk during this time. _ Disposition far DZL4 - beneficiary designated ownership The deceased was the annuitant on at least one annuity account proviousiy listed. Upon the death of rho annuitant, account proceeds typically pass to the beneficiaries named at the time of death. If no beneficiary was designated the proceeds become part of the estate for distribution. DEFEKRED ANNUITY NOTICE: If rho beaeficiary(s) wishes to elect an amruity payment plan, we must receive written notice of this election within 60 days of our receipt of complete requirements from any individual beneficiary. The contract value .,>lil.remain invested in the separato account until we receive a completed claim If there are multiple beneficiaries, each claim will be processed separately and cacti beaeficiaryrs shaze will remain invested in the separate account. until it is claimed. The benefciaies hear the market risk during this time. Dispositfoa forIndividual-TOD ownership Upon the death of the owner, all accounts registered as individual-transfer on death pass to the named beneficiaries. • DEC-7-2010 07:52 FROM:RMERIPRISE FINANCIAL 7613686 70:7745075 P.B Beneficiary Information We.have the following beneSciaries on record for the deceased's accounts. Account Number: 00804724475 4 001 Des[gnaHon: PRIMARY BENEFICIARY ESTATE OF SHIRI.EY BENNET:'-LOTZ 100.00% Account Number: 00804836762 0 001 Designation: PRIMARY BENEFICIARY ESTATE OF SHIRLEY BENNEIT-LOTZ -~' Account Number: 01013191525 7 002 D~~:, nation: - . PRIIvfARY BENEFICLRY'"' .. ESTATE OF SHIRLEY BENNETT-LOTZ Account Number: O10I3480119 9 002 Designation: PRIMARY BENEFICIARY ESTATE OF SHIRLEY BENNETT-LOTZ ..~ Account Number: 01014370072 1 002 Designation: PRIMARY BENEFICIARY ESTATE OF SHIRLEY BENNETT-LOTZ ~ Account Number: 01133915297 4 002 < Designatlan: PRIMARY BENEFICIARY ESTATE OF SHIRLEY BENNETT-LOTZ Account Number: 930021 15662 3 004 1lesignatlon: PRIMARY BENEFICIARY hST.4TE OF SHTJ~I.E,Y.IIBNNET7-LOTZ Account Number;. 93002407024 3 004 Designation: PRIMAR1f BENEFICIARY ESTATE OF SHIRLEY BENNETT-LOTZ 100.00% 100.00% 100.00% ESTATE 100.00% ESTATE 100.00% 100.00% ,.....~ .3. ._ _ _...._..,_,,..... 100.00% DEC-7-2010 07:52 FROM:AMERIPRISE FINRNCIAL 7613686 Account Number: 93003403326 4 004 Designation: PRIMARY BENEFICIARY ESTATE OF SHIRLEY BENIVETT-LOTZ 100.00"~° Account iNum6cr: 93004115967 2 004 t)rsignation: PRIMARY BENEFICIARY ESTATE OF SHIRI.EY SENNETT-LOTZ 100.00% 70:7745075 P.9 Account Number: 93107812969 5 004 Designation: PRIMARY BENEFICIARY ESTATE OF SHIRLEY BENNETT-LOTZ Iccnunl 'Number: 00064103922 7 021 Designation: ~' "' PRIMARY BENEFICIARY ESTATE OF SHIItL$Y BENNETT-LOTZ Account Number: 00066763806 8 021 Designation: PRIMARY BENEFICIARY .ESTATE OF SHIRLEY BENNETT-LOTZ 100.00°/a 100.00% 100.00%